Total Hip and Knee Replacement Expectations and Limitations

The following feature appeared in Maine Medical Center's Research Journal, INQUIRY, Volume 8, No. 3, December, 1997.

Total joint replacement for painful arthritis of the hip and knee is one of the most successful surgeries of the last century. Pain relief is achieved in ninety-five percent or more of patients, and the majority of patients who undergo surgery have greater mobility and increased function. Over the last two decades, however, physicians' and patients' understanding of the risks, benefits, and goals of total joint arthroplasty has evolved and the limitations of artificial joints are becoming more clear. Research in these areas has been one focus of the adult reconstruction service of Orthopedic Associates of Portland.

In an abstract submitted to the 1998 annual meeting of the American Academy of Orthopedic Surgeons, Drs. Brian J. McGrory and Michael W. Becker, in conjunction with Mayo Clinic surgeons Robert T. Trousdaic, M.D. and Daniel J. Berry, M.D. address "Patient Concerns Prior to Undergoing Total Hip and Total Knee Surgery."

During 1996, 266 patients undergoing first time total hip or total knee replacement surgery filled out a questionnaire asking a number of questions regarding their concerns prior to surgery. Patients responded on an analog scale (from 1 = minimally concerned to 4 = very concerned ), and concern was ranked by mean responses. The mean age of respondents was 67 years, and 56 percent were women. 114 had a total knee replacement, and 152 had a total hip replacement. 79 percent had previous surgery and 10 percent reported a major complication with previous surgery. One third of the patients said that they had discussed the risks and benefits of surgery with another physician. All but 5 percent of the patients considered themselves reasonably healthy.

The mean level of concern for any given question ranged from 1.1 to 2.6 (again, on a scale where 1 is minimally concerned and 4 is very concerned). Responses to only 6 of 54 questions averaged 1.9 or greater; pain immediately after surgery (2. 1), length of recovery (2.1), ability to walk (2.0), ability to return to recreational activities (2.0), ability to climb stairs (1.9), and risk of getting AIDS from a transfusion (1.9). Responses to only 4 questions averaged less than 1.3; ability to pay bill (1.2), chance of health insurance rates increasing (1.2), ability to get along with surgeon (1.2), and surgeon's age ( 1.1).

In 35 of the 54 questions asked, patient age significantly (p < 0.05) correlated with level of concern; in each case older patients were less concerned. Women were more concerned in their ability to do postoperative therapy, walk with crutches, take care of themselves after surgery, arranging for help at home and their ability to get in and out of a bathtub. Men were more concerned than women only in their ability to lift heavy objects after surgery. Patients who had reported a previous surgery were less concerned about surgeon age and not knowing what to expect. Patients who had reported a previous complication were more concerned with the cleanliness of the hospital, nursing care, and risk of getting an infection. There were no differences in the level of concern for any of the questions asked if the patient had discussed surgical risks with another physician.

Those patients having surgery at the Mayo Clinic considered themselves less healthy than did the patients having surgery at the Maine Medical Center. They were also more concerned with their ability to get along with their surgeon, with pain after dismissal, ability to do therapy, and risk of falling.

The information from this study is unique in that it focuses on patient expectations and concerns, rather than post-operative satisfaction. This information will be helpful in preoperative patient discussions and for developing educational materials for total joint replacement patients.

Patients' concerns about return to recreational activities after total hip and knee replacement have increased since the advent of modern joint replacement, and were the subject of a recent research effort by Dr. McGrory. In a study co-authored by Dr. Michael Stuart and Dr. Franklin Sim entitled "Participation in Sports After Hip and Knee Arthroplasty: Review of Literature and Survey of Surgeon Preferences," and published in the Mayo Clinic Proceedings, McGrory presented the opinions of a group of surgeons who regularly perform total joint replacement regarding acceptable activity in sports after arthroplasty of the lower extremity.

28 surgeons responded to the single page questionnaire canvassed their recommendation about return to 28 common sports after recovery from total hip and knee replacement. Sports in which 75 per cent of surgeons would not allow participation were identified as "not recommended," whereas sports in which 75 per cent of surgeons would allow participation were labeled as "recommended."

Recommended sports included sailing, swimming, scuba diving, cycling, golfing, and bowling after hip and knee replacement and also cross-country skiing after knee arthroplasty. Sports not recommended after hip or knee arthroplasty were running, water-skiing, football, baseball, basketball, hockey, handball, karate, soccer, and racquetball. In general, participation in no-impact or low-impact sports can be encouraged, but participation in high-impact sports should be prohibited.

In an associated study entitled "Sports Participation after Hip and Knee Arthroplasty: Differences in Opinion between Physiatrists and Orthopedic Surgeons", presented at the Mid-America Orthopedic Society in 1996, and published in Orthopedic Transactions, McGrory and co-authors Dr. Michael Stuart and Edward Laskowski address surgeon and non-surgeon opinion as to what type of sports activity is permissible after total joint arthroplasty.

Physiatrists at the Mayo Clinic were significantly less likely than orthopedic surgeons to disallow return to sports following both hip and knee replacement surgery. After total hip arthroplasty nonsurgeons were significantly less likely to disallow return to running, doubles tennis, football, handball, and ballet after total knee arthroplasty. Physiatrists were significantly less likely to disallow return to running, hiking, backpacking, doubles tennis, football, and handball.

These studies examining return to recreational sports after joint replacement underscore the need for communication between orthopedic surgeons and both patients and physiatrists regarding the expectations after joint replacement. The effect of impact sports on the longevity of hip and knee replacements has been shown to be deleterious, and this must be conveyed during preparation for modern joint replacement.

The adult reconstruction service of Orthopedic Associates Portland, which last year formed the Maine Joint Replacement Institute, is committed to teaching, research, and patient care. One of the significant research interests of the MJRI is physicians' and patients' understanding of the risks, benefits, and goals of total joint arthroplasty including return to recreational sports. These recent papers add to our understanding in these areas and will help for our education and preparation for joint replacement.