Just like a car, our parts can wear out given too much use. Luckily, new procedures are helping to keep active adults on the move, free from pain.
Any car, no matter its make, model or year, is only as good as the parts that make it mobile. The same can be said of the human body. Regardless of age and medical condition, people are only able to work, play and live with full mobility and without pain if their skeletal joints function properly.
Joint treatment advances made in the past five years are proof that we’re becoming better attuned to taking care of our bodies, and the availability of highly trained, skilled orthopedic surgeons has grown to match our needs.
Dr. Frank Bohnenkamp, an orthopedic surgeon at Crystal Lake Orthopedics, specializes in hip and knee joint replacement/complex revisions and hip resurfacing and preservation procedures.
Bohnenkamp says some have already had their joints replaced due to end-stage osteoarthritis or rheumatoid arthritis, but still experience pain. Sometimes the solution is simple, but the problem may require a complex revision of a failed joint replacement.
“One of the most common reasons for a failed hip replacement is something called aseptic loosening,” Bohnenkamp explains. “Over time, wear and loosening can occur in the implants from multiple causes. This can lead to persistent and painful groin, buttock or thigh pain, especially with weight bearing.”
Increased wear and loosening, or even bone loss called osteolysis, can lead to a very difficult situation. Other problems with hip replacements include recurrent dislocations, chronic infections or fractures around the implants.
“These all require specialized care to manage them properly and often require repeat surgical procedures,” Bohnenkamp says. “We’re doing more and more replacements for end-stage arthritis in younger and younger patients. Yes, implants and bearing components have improved over the decades and now are expected to last 20 to 30 years, in some cases. However, with the aging population, especially baby boomers, we anticipate that the need for revision procedures will increase 137 percent during the next two decades.”
Interestingly, Bohnenkamp also sees a rise in the revision rate for previous metal-on-metal hip replacements. Many joint replacement surgeons in the recent past expected excellent results from these implants, since the bearing surfaces are smoother and harder, with less wear overall, and the ball part of the joint is bigger, preventing dislocation after hip replacement. This was thought to be an excellent alternative to the traditional metal on polyethylene plastic liner hip, but hopes were soon diminished.
“Unfortunately, not too long after the early 2000s, the orthopedic community started to see a more worrisome problem with this type of implant,” says Bohnenkamp. “It was showing evidence of increased metal ion particles in the bloodstream and metal debris locally, leading to joint and soft tissue destruction from adverse body response.”
A small number of patients formed pseudo-tumors, Bohnenkamp adds. Pseudo-tumors can eat away at the bone and soft tissue, causing muscle destruction.
“Now we’re keen at recognizing this as a real problem and usually recommend revision to a more traditional-type hip replacement,” Bohnenkamp says. “Metal-on-metal implants have fallen out of favor, and now most surgeons are using more traditional designs that have stood the test of time.”
There can be many reasons for hip or knee pain after replacement. Each patient is assessed on an individual basis to determine exactly what’s needed, so that the patient will have as much mobility as possible while reducing or eliminating pain.
Hip resurfacing is an alternate method of treating advanced arthritis in certain patients. In this procedure, the femoral head is not removed, but is trimmed and capped with a smooth metal covering. Any damaged bone and cartilage within the socket is removed and replaced with a metal shell, just as in a traditional replacement procedure.
Advantages to the resurfacing procedure include bone preservation and higher mobility. However, it, too, has fallen out of favor recently, because of concerns about metal wear debris reactions. In fact, most major companies have stopped making these implants. In certain highly active patients, this procedure can still be very successful; great skill is required to place the implants in a near-perfect position to prevent excess wear.
“In healthy males who are active in contact sports that require excessive range of motion or marathon running, resurfacing is a viable option,” Bohnenkamp says. “Patients who already have had a resurfacing on one side, with excellent results, will likely do well with another one on the other side. They also must have good bone stock and no unusual hip anatomy or excess collapse or destruction of the acetabulum, femoral head or neck. The procedure is considerably more invasive, but patients usually recover quickly.”
For most patients, hip or knee replacement is a result of osteoarthritis because of aging and excess wear over time. This condition can be managed for quite some time with conservative measures like cortisone injections or anti-inflammatory medicines, says Bohnenkamp.
“It usually deteriorates in a stepwise fashion, and can progress as fast as a few months to several years,” he says. “Patients will have painful flares and then it will get better. I tell patients they will know when they are ready for replacement because the pain-free intervals will decrease to a point when they can’t even do basic activities.”
Hip joint preservation is yet another method of helping patients to maintain their active lifestyles. Bohnenkamp explains that arthroscopic outpatient surgeries to repair or resect cartilage tears in and around the hip joint alleviate pain and correct subtle congenital abnormalities that become aggravated and cause impingement in the hip as the patient ages.
“Some patients may be born with abnormal subtle deformities of the hip and tend to develop arthritis at an earlier age, as early as in their 40s and 50s, but sometimes even younger,” Bohnenkamp says. “This occurs because the hip is not articulating normally. Like an unbalanced tire on a car, it will wear unevenly and a lot sooner than a tire that is aligned correctly. We now think that these outpatient joint preserving hip arthroscopy procedures can prevent early onset of end-stage arthritis, when they are diagnosed and treated appropriately.”
As the pivotal point in the human body, hip joints take a lot of punishment and usage. Dr. John Daniels, a board-certified orthopedic surgeon at Crystal Lake Orthopedics who’s affiliated with Centegra Hospital-McHenry, says most of his patients fall within the age range of 40 to 90, with 65 as the median.
“While the majority of hip joint replacement patients come in as the result of advanced osteoarthritis, I also see post-traumatic and sports-related injuries,” Daniels says. “The good news is that, within the past five years, tremendous improvements have been developed that help make hip replacement less painful and more effective than ever before.”
Daniels is specialty-trained in anterior hip joint replacement, which is basically the opposite of the traditional posterior procedure. Instead of going into the hip joint region from the backside, which involves cutting through major muscles, Daniels works through the front of the hip using minimally invasive surgical techniques. This minimizes muscle damage.
“In anterior hip replacement, the implants are smaller,” he explains. “Not only that, but, because the surgery is performed using live imagery, the sizing is more accurate and we’re able to restore the hip closer to its original configuration. This decreases improper limb length and recovery time is significantly reduced.”
Typically, Daniels’ hip joint replacement procedure takes about one hour, with the patient spending an average of two nights in the hospital followed by physical therapy two to three times weekly for six weeks. A lot depends on how the individual reacts to the surgical procedure. Swelling, pain and the extent of the wear and tear to the hip joint and surrounding tissue play a major role in how quickly and completely patients heal.
“One more positive result of hip replacement is that it eliminates any arthritis patients may have in their hip joints,” Daniels adds. “As far as infection goes, the national rate for this type of surgery is between 1 and 3 percent. We administer antibiotics prior to surgery, and the latest techniques developed to avoid infection allow us to proceed with confidence.”
Similar to the cancer treatment centers being developed nationwide, the Centegra Hip & Knee Replacement Center provides specialized services in a dedicated unit, which occupies an entire floor of the McHenry medical center.
“Based on the concept that joint replacement patients are ‘healthy,’ we segregate them from the rest of the hospital’s patients,” says Daniels. “The entire floor of private rooms is dedicated solely to treating post-surgical patients. The medical and service staff works only within the joint replacement unit.”
Within the dedicated unit, highly trained medical and support staff members focus on pain management, along with other issues that can occur with joint replacement patients.
“We have nurse navigators who work with our patients from the moment they come in until they are released to go home,” Daniels says. “They literally walk the patients through every step, making sure patients understand exactly what is happening and what to expect. Patients attend a class prior to surgery that is designed to prepare them for the process.”
Centegra’s joint replacement unit includes not only surgeons and nurses but also cardiologists, physical therapists and lab technicians who double-check everything to ensure accuracy and decrease complications.
“I believe Centegra has the only such unit anywhere around the region,” Daniels says. “Taken all together, this provides the finest care possible.”
Shoulder joints can be particularly painful, and tend to feel worse at night, making it difficult to sleep. The pain is sharpened by cold and often complicated by arthritis. Dr. Vishal Mehta, a board-certified orthopedic surgeon affiliated with Presence St. Joseph Hospital in Elgin, says he is using a reverse shoulder joint replacement technique that is yielding excellent results. This procedure even helps patients with rotator cuff tears, who previously had no good options.
“The reverse joint replacement procedure on shoulders has been around for between 30 and 40 years,” Mehta explains. “It was introduced by the French and received FDA approval in 2004. I’ve been able to reproduce positive results to the point where the procedure now requires just a one-night stay in the hospital, followed by four to six weeks of passive work, with the arm in a sling, to support the shoulder.”
Not only does this procedure help to alleviate true arthritis but it also restores full motion to the shoulder and arm, and eliminates pain. Patients may need up to three months of physical therapy, depending on their individual situations and ages. In some cases, the procedure even results in very elderly patients being able to elevate their arms adequately, without pain or the need for physical therapy.
“As a rule, I do a four- to five-inch incision in front and replace the joint with a ball and socket prosthesis that’s the reverse of the natural joint,” Mehta says. “I’ve had amazing success using the reverse replacement technique in situations where there really were no good options for long-term pain relief.”
Mehta describes the results as “life changing.” By using the newest in plastic sockets with metal ball joints and reversing their positions, Mehta can position the deltoid muscle to allow the patient to raise his or her arm without restrictions.
“Many patients don’t realize this option for shoulder joint replacement exists,” Mehta adds. “It’s especially helpful for older patients who have experienced constant pain and loss of mobility for years.”
Mehta performs about 100 reverse shoulder joint replacements each year. While the procedure is less common than hip and knee replacements, his specialty practice stays quite busy.
Hands are seldom weight-bearing, but they’re the hardest-working joint systems in the human body. Dr. Surbhi Panchal, a board-certified orthopedic surgeon at Lake Cook Orthopedics in Barrington, says her fellowship training in hands and upper-body joints allows her to treat patients ranging in age from 3 to 88 who have some form of hand problems.
“One of the reasons why I enjoy my practice so much is that I treat many different conditions, as opposed to hip and knee joint replacement,” Panchal says. “I see patients with everything from carpal tunnel syndrome to sprains, fractures, torn ligaments and, most of all, complications of arthritis.”
As patients age, they are prone to developing arthritis, particularly at the base of their thumbs. Panchal explains that this is caused by the varying amount of force used to do things like pinching, grasping and fine movements.
“A lot of wear and tear occurs as people use their hands to open jars, button up clothing, put keys into locks and car ignitions, and so many other daily activities,” Panchal says. “It’s possible to relieve the pain and inflammation by taking out specific bones and replacing them with tendons. Patients then have physical therapy to improve their range of motion and flexibility. The process takes about three to four months.”
Carpal tunnel syndrome is another common ailment that results in pain and loss of motion. This condition develops gradually, starting with numbness and tingling in the patient’s thumb, index and middle fingers. It also may cause discomfort in the wrist. These sensations often occur when the patient is holding the steering wheel, telephone or reading materials. Commonly, patients are awakened by pain that extends from the wrist up the arm. They tell their doctors that they try to shake out the feelings, which become constant as the condition persists. Weakness and a tendency to drop items is also indicative of carpal tunnel syndrome.
“When I treat carpal tunnel syndrome, I usually start with a wrist brace and try anti-inflammatory medications,” Panchal says. “Sometimes cortisone injections are recommended. I will try it once, but if all of these methods fail, then surgery is the next option.”
Panchal prefers traditional to endoscopic surgery, on an outpatient basis. The actual surgery takes about 20 minutes and involves relieving pressure on the nerves that travel through the ligament-like carpal tunnel in the wrist.
“The incision heals in about 10 days and the internal structure in four weeks,” Panchal says. “Patients should have recovered their power grip in about two months. But that depends on several factors, including how long the patient has had carpal tunnel syndrome, how severe the depression on the nerves has been, and age. I have performed the procedure on patients aged 35 and older.”
Many things can result in the need to replace finger joints, including sports injuries, rheumatoid arthritis, osteoarthritis, fractures and traumatic events. Panchal says replacing finger joints is similar to replacing joints in knees, hips and shoulders.
“Finger joints are replaced with metal-on-metal or silicon implants,” Panchal says. “We don’t have to worry about weight-bearing, but we do need to be certain the ligaments are all properly balanced and aligned.”
As the population ages and advances in joint replacement keep pace, many aging-related problems are being eased. We can look forward to keeping up our active lifestyles and living with more mobility and less pain than our parents and grandparents experienced.