I love to do total joint replacements. They can reliably and predictably decrease a patient’s pain and increase function, resulting in a significant improvement in a patient’s quality of life. With all clichés aside, that’s what it is all about. From a more technical perspective, they are wonderful exercises in applied 21st century orthopedics.
However, I have found that patient’s expectations can be out of synch with what a total joint can actually do. For example, young patients with a worn out knee have a hard time understanding why it might not be in their best interest to proceed with the joint replacement at that time. And one of the hardest things, as a surgeon, occurs when a patient is not happy about their outcome, especially when I would consider it a success. For example, a Wall Street Journal article about 4 months ago reported that, while surgeon “satisfaction” for a particular patient outcome was over 90%, the patient rated satisfaction was in the low 70’s. If you need to kneel to do your job as a carpet layer, or you did not know that a small area of skin might be numb, or thought you could return to running, or did not expect a scar; you might not be perfectly happy while your surgeon is trying to convince you that the outcome is “perfect”. So, there are many things to discuss with your surgeon when one is considering a total joint replacement.
There are many reasons for this. The total joint implant companies run marketing campaigns that are very effective. Remember the “female knee?” The lay media is full of anecdotal stories of wonderful outcomes that fail to capture or communicate some very important details. And yes, orthopedic surgeons are partly to blame as well. At a bare minimum, trying to digest all the information that needs to be presented during an office visit is akin to drinking from a fire hose.
So you can imagine my surprise when I stumbled upon a well-written depiction of some of the hardest concepts for doctors to communicate to patients surrounding total joint replacements in the August edition of Money Magazine. Did I mention the author did this on one page?
Despite the fact that it is a well written orthopedic article intended for mass consumption, there are some points that require further discussion.
The article’s first point is that an artificial joint does not last forever. Whether I agree with the cited expert’s opinion that the typical joint last 20 years or not is immaterial. What is important is that the author highlights the importance of non-operative treatment of arthritis. While the details change in each clinical scenario, I wholeheartedly agree with the message that “physical therapy, anti-inflammatory drug treatment, and cortisone shots … may buy a couple more years.”
There has been a veritable feeding frenzy around total hip replacements lately. If you do not know what I am referring to, type “total hip replacement” and “lawyer” into your computer’s search engine, and see what you get. Needless to say, I read the section entitled “Newer Doesn’t Always Mean Better,” with great interest. Ultimately, I thought it was a fair treatment of the issue. The truth is that any “advance” can have unintended consequences, some of which do not become apparent for several years. Using the recent total hip situation as an example, a well-respected company with a good track record produced a new total hip design that was anticipated to increase the longevity of the artificial joint. Unfortunately, too many of those hips were failing within the first five years, the reasons for which are only partially known. As a result, the product needed to be recalled. While it is necessary to adopt newer, better treatments, some new technologies do not always deliver upon their promises. One of my most trusted mentors is fond of saying “If mom’s apple pie tastes good, don’t change the recipe.” Orthopedic surgeons’ desire to be perceived by their patients as being on the cutting edge of technology must be balanced by the whether the new product or technique is in fact any better than the tried-and-true way.
Finally, the article speaks of some of those issues that make my heart sink when patients tell me about post-operatively. Specifically, the total cost of the procedure does go further than the out-of-pocket expense or the deductible. Often times, certain equipment is required post-operatively, such as walkers, crutches, and elevated commodes. While most of these are covered by most insurers, there can be exceptions. More importantly, there are hidden costs. If you are of still of working age, any total joint replacement will require a period of time away from work. Depending on many factors (the exact nature of your job, your benefits, the surgical factors, etc) your income may be negatively impacted during your recovery. Furthermore, there may be household tasks that you are temporarily unable to do and need to hire or have help to perform, such as landscaping, laundry, house cleaning, etc. None of these represent insurmountable obstacles, but all of them are best anticipated and planned for, at least to the best of your abilities. For example, give your friends who ask what they can do (no not another casserole!) some of these tasks.
This blog entry and the magazine article that I referred to, barely scratch the surface. While it is impossible to be completely prepared for a total joint replacement, more well-done and even-handed mainstream pieces like the one I found in the August edition of Money Magazine would certainly help.
-Robert J. Purchase, MD
