By Richard P. Driessnack, MD
I have seen many patients over the years who have been helped by hip and knee replacement. In my 30+ year career, there have been many changes in the field, and I want to review some of these with you in this article.
Techniques: New surgical techniques for performing surgery are always being developed. For the hip, there are basically three ways: from the front (anterior), from the side (lateral), and from the back (posterior). Over the years, some have been claimed as being superior over others. In fact, no single approach is superior overall; each has its pros and cons. What is most important is to go to an experienced surgeon who is comfortable with his technique and has good results. The same is true for the knee: various techniques for incision placement and incision length have been tried, and none are as consistently good as the standard midline incision and medial parapatellar approach. In general, for both the hip and the knee, the newer techniques have a higher complication rate when used by surgeons who have changed from their “old” way to the “new” way. Experience is worth a lot.
Materials: Different combinations of metals, plastics, and ceramics have been used for hips replacements: metal heads on plastic cups, metal-on-metal, ceramic-on-plastic, and ceramic-on-ceramic. Different metal alloys have also been used. Different designs of stems, some with more parts than others (modularity), different mechanical designs for knees and hips, and different surface coatings for the cementless hips and knees — the list goes on and on. There have been failures of designs, and failures of materials, such as the massive recall of the Depuy ASR-XL total hip. In general, I try to stick with what I know has worked well in the past, knowing that a well-done hip or knee done in 2018 should have a very good chance of lasting 20 to 30 years, or even longer.
Rehabilitation: Recovery after joint replacement has been the greatest change I have seen in my career. In-hospital stays used to be 2 weeks when hip replacement was first developed. When I started practice in the mid-1980’s, it was common for my patients to wake up in the Recovery Room screaming in pain. Almost all of my patients then stayed for five days after their surgery. Now, it is typical that a majority of patients go home from the hospital on DAY 1 after their surgeries. Furthermore, it is now possible to perform some joint replacements on an out-patient basis, which means that one goes home the same day as their operation! This is probably the most revolutionary change that has occurred over the past 30 years.
Old news: Things that have come and gone over the years: Two-Incision technique for hip replacement: not all it was cracked up to be.
Mini-Incision or MIS techniques for hips and knees: not any better than traditional incisions. Navigation for hips and knees: adds tremendous expense with no demonstrable improvement in outcomes. Robotic techniques for doing hip and knee surgery: takes longer, thus costs more, with no demonstrable improvement in clinical outcomes. Cementless Knees: Been there, done that. Even with newer designs, they cost more, and beating the results of cemented knees will be almost impossible, since their longevity is so good. Anterior Approach Hip Replacement: Higher costs (requires in most instances a special table costing over $100,000), longer surgery time, greater blood loss, higher risk of nerve injury, possibly lower incidence of hip dislocation (though studies vary on this), with gains in recovery times of perhaps 2 weeks only. Will this become the new standard? Many of the previous items were thought to be “the new standard” and have since fallen into obscurity. Only time will tell.
My advice to patients who want the latest and the newest: be cautious, and do a little homework yourself. The internet nowadays makes it much more possible to research questions; in the decision process, though, the most important thing is having a thorough discussion with your surgeon, and having confidence in your surgeon.
For more information, contact OSF Orthopedics at 309-676-5546 or on the web at www.PeoriaJointReplacement.com. They have two locations: OSF Orthopedics — Downtown Peoria, 303 North William Kumpf Boulevard, Peoria; and OSF Orthopedics — North Peoria, 7800 N. Sommer St., Peoria.