Theodore Manson, MD is an Orthopaedic Surgeon at the University of Maryland Medical Center and an Associate Professor of Orthopaedics at the University of Maryland School of Medicine.
Dr. Manson specializes in hip and knee replacements and orthopaedic trauma. Below he answers the most common questions about joint replacement.
Q. What advances have there been in joint replacements including new technologies, changes in patient-management and rehabilitation?
A. One significant advancement in the last 10 years has been around pain management and early recovery protocols. The goal is to minimize the amount of narcotics patients require after surgery. Today, we manage pain through many different types of medicines in addition to narcotics. There’s been a lot of success recently with joint (intra-articular) injections of anesthetic around the hip or knee joint at the time of surgery. This injection limits the amount of pain patients have when they first wake up from surgery. We know that if you limit that first pain sensation, it helps with the whole pain management process going forward.
Another significant advancement is infection prevention. Patients’ skin is now pre-operatively prepped with the antiseptic and disinfectant chlorhexidine both at home prior to surgery and at the hospital as well. In addition, we optimize patients’ nutrition and health pre-operatively. These two things have drastically cut down on infection rates. We did not use to address patient nutrition. Now, we assess patients’ nutritional status before surgery. If a patient is at a higher risk for nutritional deficiencies – those with chronic illness, diabetes or poor appetite, we then work in conjunction with a nutritionist so their infection rates are lower.
Borrowing from the aviation industry, there have been substantial improvements to patient safety in the hospital postoperatively as well. Standardized protocols, safety checklists and quality control monitoring have dramatically reduced untoward events in joint replacement patients.
Q. What new innovations in joint replacement surgery (hardware and techniques) are noteworthy and why?
A. There is a lot of marketing material on the internet regarding various joint replacement approaches, minimally invasive surgery, robotic surgery and use of custom hip and knee replacement parts. It is important to realize that none of these things has been shown to be of any benefit. When considering joint replacement, choose a surgeon who performs a high volume of hip and knee replacement surgeries and who you get along with well on a personal level.
While there haven’t been any substantial innovations with implants in the last five years, we do have long-term data on our current implants and techniques that shows them to be functioning extremely well.
Q. Who should get a joint replacement? What factors should a person consider? How should a potential patient decide?
A. In general, joint replacement is an elective procedure. If the patient is falling due to their hip or knee arthritis, it can be a very dangerous situation, so falls are an indication they should go ahead with a joint replacement. If a person is no longer able to climb stairs, if the hip/knee pain keeps him/her up at night, or if s/he is constantly dependent on an assistive device like a cane, then I think they should strongly consider a joint replacement. For others with less severe symptoms, a joint replacement may still be of great benefit to them, but they should consider surgery when the time is right and shouldn’t feel pressured into a surgical option.
Q. What should a patient expect?
A. Once they have scheduled the surgery, most patients undergo pre-habilitation prior to the joint replacement. Many patients find it useful to go to a preoperative joint class at the hospital where they’re going to have the surgery. This helps to alleviate anxiety about the procedure and educate them on what is to come. For those who are substantially debilitated preoperatively, going to prehab (physical therapy) to strengthen the operative leg is helpful and helps us foresee any challenges that may arise postoperatively.
If you have a body mass index (BMI) of 40 or greater, you should delay joint replacement until you can get below 40. This is because infection rates increase substantially for people who have a BMI of 40 or greater.
Q. Does the type of implant used depend on patient activity and age? How?
A. In the past, different implants were used based on age, but for the vast majority of surgeons we use the same type of implants no matter the age. Occasionally patient with poor bone quality will require different implants, but usually we use the same regardless of age or activity level.
Q. What is the target recovery period and regimen for various categories of patients?
A. Patients see the majority of their improvement six to 12 weeks after surgery. They reach their maximum improvement six to 12 months after hip/knee surgery.
Q. What is the lifespan of replacement joints and do you expect the lifespan to grow longer soon?
A. The lifespan of replacement joints have a 1-percent-per-year failure rate, so with 20 years, you have a 20 percent risk of needing the joint replacement redone. I expect this will grow longer as we get better at preventing infection rates. If you are over 60 years old, the odds are you’ll probably never need to have the joint redone.
Q. Have risk factors (infections, failures, etc.) declined or increased (and for whom)?
A. Risk factors have declined because of more critical evaluation and optimization of risk factors for infection around the time of surgery.
Q. Are revision surgeries more or less common these days and why? Do you expect that to change? How and why?
A. Revision surgeries are more common these days simply because of the number of people who have gotten a joint replacement is increasing, and the number of baby boomers having joint replacement is increasing. I expect the number to continue to go up just because the number of people having a joint replacement is going up.
To make an appointment with Dr. Manson or one of our other orthopaedic specialists, please call 410-448-6400. For more information on joint replacement or other orthopaedic issues, check out the University of Maryland Orthopaedics’ website.