As we age, it's natural to want to preserve the level of activity we've
come to expect and enjoy. But also as we get older, our joints start to
wear out, sometimes due to arthritis, often due to plain old use, and
also injury. The cartilage in our knees and hips literally wears down,
and hips get wider and stiffer and often more painful as a result of osteoarthritis.
The orthopedic surgeons at Torrance Memorial Medical Center are, of course,
ready and willing to discuss any number of options to alleviate the pain,
including joint replacement surgery. But to a one, they will tell you
that surgery might not be their go to. It’s definitely a case-by-case
situation. And the department has some innovations and advances that will
make any orthopedic experience stress-free and satisfying.
First is the decision to have a joint replacement. Most doctors, especially
orthopedic surgeons, will advise that a patient first try to lose weight,
if that’s an issue, and exercise more, even working with a physical
therapist. Injections of hyaluronic acid, cortisone or another medication,
even actual cartilage can ease the friction of bone against bone. Some
patients find relief with acupuncture and massage therapy. And for knees,
arthroscopic surgery might be a less invasive alternative.
“It’s definitely a quality-of-life issue,” says Torrance
Memorial orthopedic surgeon Todd Shrader, MD, who initially trained in
sports medicine at the famed Kerlan-Jobe clinic. Now he specializes in
joint replacement. “Before recommending joint replacement surgery,
we determine a patient’s current pain and activity levels and make
sure they have no medical issues that could inhibit recovery,” he
explains. And if they choose joint replacement surgery, “Our goal
is to get them home the same day after surgery, if possible. Patients
do better at home.”
Age could also be a factor, but not in the way you might expect. “I
think a patient’s physio-psycho-social age is much more important
than their numeric age,” says Andrew Foster, MD, who specializes
in hip and knee reconstruction at Torrance Memorial. “No one
needs a hip or knee replacement, but once they’ve tried all the conservative
treatments and nothing is working to get them out of pain and to their
level of function, it can be a good decision even for older patients.
But it is a big production, and it takes a lot of help, socially, afterward.”
The surprise is that some doctors are concerned about younger patients
getting joint replacements too soon. “About 1 out of 10 patients
who get a knee or hip replacement might need a new one in about 20 years,”
says John P. Andrawis, MD, who started the same-day surgery program for
Total Joint Replacement at University of Texas, Austin. .“So if
a patient is under 50, that’s something to consider—that they
might need a revision surgery. But those results were using the old implants.
We believe the new implants might last 30 years or longer.”
Advances in care
One of the major developments in the field of joint replacement at Torrance
Memorial has been a new pain management protocol, Dr. Shrader explains.
“We use a combination of nerve blocks, an injection around the joint(s)
and a cocktail of three medications to help with the pain. The result
is less pain and less need for a narcotic pain reliever.”
Since opioid addiction is such a hot-button issue, Torrance Memorial joint
replacement patients will be happy to hear that narcotics are no longer
the go-to during surgery and recovery. “We have worked toward developing
a standardized, multi-modal approach to pain management, which is an alternative
to opioids and narcotics,” adds John P. Andrawis, MD, who started
the same-day surgery program for Total Joint Replacement at University
of Texas, Austin. “It’s a combo of nerve blocks, nerve medication,
Tylenol and a small amount of narcotics. It means less medication during
and after surgery, and better pain control, so patients can heal and recover
faster. “
Also being standardized are all the procedures around the surgery that
Torrance Memorial orthopedic surgeons use. For example, says Dr. Foster,
“Whether or not to use antibiotic cement—studies say it doesn’t
make a difference, encouraging patients to take a low dose of aspirin
to discourage blood clots and using special dressings that the patients
don’t have to change. It’s one less thing for them to worry
about.”
Dr. Shrader says his father, Richard—with whom Todd was in practice
for 10 years—was the first to perform a total hip replacement in
the South Bay, wherein the hip joint is replaced with an artificial part,
or prostheses, and Dr. Shrader has seen the progression toward the anterior
approach for total hip surgery. “Traditionally a total hip replacement
is done with a posterior approach, which involves splitting the gluteal
muscle and taking down or releasing tendons,” he says. “The
benefit of doing it with an anterior approach is that the procedure doesn’t
cut any muscles or tendons. You go between them, so there’s less
pain and less dislocation, and a faster recovery. Also we are able to
use and X-ray machine during surgery, allowing us to see implants go in,
in real time. This ensures proper alignment, and we can also check leg
lengths immediately. It’s a much better way of doing a hip replacement.”
Still a bit controversial among orthopedic surgeons is the concept of “pre-hab,”
meaning physical therapy before surgery, but the Torrance orthopedic department
agrees that at most, “meeting the physical therapist once before
surgery can help teach patients what to expect and teach them the exercises
they’ll be doing,” says Dr. Foster.
Dr. Shrader adds that ideally a patient should take enough time to get
into better overall condition before surgery. All agree that physical
therapy is most critical after a knee replacement—“Pool therapy
is the best,” Dr. Shrader says—but for hips, “the best
therapy is walking, and most our patients can walk out of the hospital
with a cane,” says Dr. Andrawis.
On the horizon: Robotic surgery, which the department is researching for
future use, especially for knee replacements, “but I’m not
convinced it will make a difference for hip replacement,” says Dr.
Shrader. “We already use an X-ray to get a real time view and immediate
feedback so we can make sure the replacement is in the right position.”
It’s a lot to consider, and Dr. Andrawis helped develop a website
(decisionaid.info) that can help patients learn the options they have.
“When a patient comes to their doctor’s office, they only
retain a portion of what we tell them in the five to 10 minute we have.
This site can be a good source of information.”
Dr. Foster sums it up: “When you have elective surgery, it’s
important to feel 100% certain about the place, the procedure and the
person. You should get as many ‘second’ opinions as possible
and be comfortable with the doctor. You will be seeing them a lot.”
You can contact Dr. Andrew Foster by calling 310-546-3461, Dr. Todd Shrader at 310-316-6190 and Dr. John P. Andrawis
at 310-784-2355.