Who Needs a Joint Replacement?

What Your Doctor May Not Tell You About Hip and Knee Replacement Surgery
by Ronald P. Grelsamer, M.D.

CHAPTER 1

Arthritis, AVN, and Femoral Neck (Hip) Fractures

There isn't as much deception with joint replacement surgery as there is with outpatient arthroscopies (see What Your Doctor May Not Tell You About Knee Pain and Surgery, Warner Books, 2002). If your doctor has suggested a joint replacement, you are probably a reasonable candidate for the procedure. The only thing to quibble about is timing. Do you really need it now? During an arthritic flare-up, you'll agree to just about anything, including major surgery. Of course, this flare-up will quiet down, especially if it's one of the first. The unscrupulous doctor may quickly sign you up for surgery without informing you that arthritis pain typically waxes and wanes.

Here is a tip: If the doctor looks at your X-ray, throws a doleful look your way, and advises you of the need for a joint replacement, run out of there as fast as your arthritic legs can carry you! A good doctor treats patients, not X-rays! I'm reminded of the ninety-two-year-old man who came to see me a few years ago. He walked in and plopped his X-rays on my desk. They showed some of the worst arthritis I'd ever seen. The bones were so close together that I couldn't quite tell where one started and the other ended. I started to think about the risks associated with performing knee replacement surgery on a nonagenarian. Then he started his story: “Doc, I carry my own golf clubs, and after nine holes my knees are achy…” This man obviously enjoyed a great quality of life and didn't need any surgery. So much for the knee replacement. On the other hand, some people whose arthritis is barely visible on X-rays are in severe pain. So once again, I tell my students to “treat patients, not tests.” Joint replacement surgery is indicated for patients who suffer from either arthritis or avascular necrosis, also known as osteonecrosis. Certain types of hip fractures are also best treated with a hip replacement.

Arthritis

Like bursitis and tendinitis, the word arthritis is bandied about rather loosely. But it has a specific definition: the wearing out of the articular cartilage covering the ends of a bone. Look at a chicken bone. The shiny white material at the end of the bone is the articular cartilage. It is very, very smooth. Two pieces of articular cartilage gliding along each other exhibit a coefficient of friction eight times lower than two pieces of ice! When cartilage wears out, bone is exposed the way the concrete of a skating rink is laid bare by a spring-time melt. This wearing off of cartilage can be painful but, interestingly, not automatically so. People can live with arthritis for years without a day of pain. And then, one day, some event triggers the pain. Blunt trauma (hitting the knee against a hard object), for example, or a seemingly innocuous twisting injury. The triggering event isn't always obvious. You might come across the term arthrosis. For the purposes of this discussion, the term is synonymous with arthritis.

Not everybody with arthritis requires joint replacement surgery. A number of nonoperative treatment options exist, especially for the knee. And remember: As noted above (and yes, it does warrant repeating), arthritis pain flares up and quiets down. Joint replacement surgery is not indicated until the flare-ups are lengthy and frequent.

Copyright © 2004 by Ronald Grelsamer, M.D.

About the Author

RONALD P. GRELSAMER, M.D., is the chief of hip and knee reconstruction at Maimonides Medical Center, and a staff orthopaedic surgeon at the NYU Hospital for Joint Diseases/Orthopaedic Institute.