My name is Brian Evans, I'm an orthopedic surgeon in the department
of orthopedic surgery in Georgetown.
I'm the director of the joint reconstruction center at Georgetown.
We provide total hip and total knee replacement for patients who have
arthritic conditions that affect primarily the hip and the knee joint.
We also have surgeons who can take care of any joint in the body
from a reconstructive perspective.
We have a lot of advantages at the joint center here at Georgetown.
The facility itself has "soup to nuts" in terms of sophisticated high-level physicians
to take care of patients with a wide variety of medical problems.
In addition, when you get to the specific orthopedic conditions,
we can handle anything from very simple straight forward
first time total hip and total knee replacement
to the multiply operated on, failed, infected, complex reconstruction.
So we can handle patients completely throughout that range of care
with a high level of competency and with a great deal of care and skill.
There's no question today, people are much more active,
much more mobile much further along in their lives than they ever used to be.
If I look back at my childhood, if I had a grandfather in his 70's
he really was someone who's not very active or very mobile.
Now these patients are traveling the world,
they're going and doing all different types of sporting activities,
they're climbing mountains, doing stairs and hills in Israel,
I mean, they really are a much more active population
than they ever used to be.
The most rewarding aspect of what I do is taking folks who are very impaired
and restoring them to a very mobile, functional, active life.
It's very difficult to determine exactly when the surgery should be done.
From a technical, surgical, anatomic perspective
whether the surgery's done immediately or it's done in a number of years,
it really makes very little difference. What really makes the determination is
the impact the arthritis and the pain that arthritis has for a patient
on a day to day basis, how that affects their lives.
And it's almost as though they have an epiphany. They'll wake up one day
and just say, you know, I'm really tired of limping, I'm really tired
of taking this medication, I'm really tired of having a very difficult time
going up and down the stairs or getting out of the car,
and then they're really ready for surgery.
The majority of patients are in the hospital for about 2 days.
It seems like a very brief period of time, but our goal after joint replacement is
to get patients active, functional and mobile.
We get patients fully weight-bearing as soon as we can after the surgery.
Frequently they're on a walker only for a couple of days
and then move to a cane and then getting off of the cane after just a few weeks.
We try and get the majority of patients discharged to home
and we have home services that can come out and actually interact with the family,
interact with the patient,
to make sure it's a safe, reasonable environment.
For patients who aren't quite as mobile, who have a difficult time getting
in and out of bed or in and out of the bathroom,
we may have them go to rehabilitation for a period of time.
Usually that's less than a week or just around a week,
but currently, the majority of patients are able to go home,
get back into their own bed, into their own bathroom, into their own life
very quickly.
With the current technology, the replacements are really marvelous devices.
Many of them should last 20 years or more,
some of the technology may even last further.
One of the challenges we have is we don't have clinical results
that extend out that far because as the technology evolves, we can't really...
we're more anticipating based upon past results,
but the current technology should last 20 years or more.
That's a question we get asked frequently
and it's really not a matter of chronological age, it's a matter of
to some extent what we call physiologic age.
I've had patients in their mid 90's who are very active, functional,
live independently, I had one woman who is, again, in her mid 90's.
She couldn't get back and forth to church, she was in a wheelchair,
and she had two hips that were very arthritic.
There a number of doctors told her that she was too old for the surgery
and the problem is even though she was having pains,
and she had limitations in mobility, the bigger factor was
she was having pain on a day to day basis just moving in and out of the wheelchair,
trying to sleep at night, she was in severe pain.
So we did go ahead and bring her in, we got a complete medical evaluation
but we provided her with 2 hip replacements
and she came back in over-joyed, she was able to walk
back and forth to church, she can go to the grocery store
and she's quite functional.
The oldest patient I've done primary joint replacement on was 97
and she lived to well over 100 and did very nicely.
So there isn't a strict chronologic age, it's really a matter of
if a patient is healthy, if they're in a good physiologic condition
it's very reasonable to go ahead and provide them a joint replacement
and get them back active and functional.
Patients who have joint replacement can really be quite active and functional.
Things that involve running are probably not the most encouraged
and running for sport is probably not the most encouraged
but they can hike, you can climb, you can water-ski, you can snow-ski,
you can use all the varieties of equipment in the gyms
in terms of elliptical, stationary bikes, Nordic Tracks,
they can do weight lifting, you can really be quite active and functional
after a joint replacement. Running, over the long term,
probably would shorten the longevity of the device
but even intermittently, if patients play tennis just a few times a week,
they can do that quite safely and it won't really impair the longevity of their implant.
We try to get patients up on their feet and walking as rapidly as possible
after the surgery, and while you can immediately weight-bear,
certainly it's sore, you've just had surgery and the muscles are tender
and over time as you get walking initially with a walker or crutches for about a week,
then move on to a cane, by about 2-3 weeks we're getting rid of that,
it'll still be somewhat sore, but usually by about 4-5-6 weeks
you should be walking much more normally,
by 2-3 months it's really starting to drift into the background
and by 4-6 months it really is just part of you and it just feels
like a natural part of your body.
The devices themselves, at least in the last 15-20 years,
have not changed dramatically.
The materials are relatively similar to what we've had.
What you find across all manufacturers is the devices actually look fairly similar
and the reason for that is there are certain shapes and certain sizes of implants
that just work, they're very effective and very functional for patients.
What has changed is the articulations where the parts come together
and where they actually rub or move. The materials that we use in those areas
have undergone dramatic changes in the last decade
and that alone has resulted in a significant increase
and how long we can expect these to work. The plastic is much improved,
the surfaces that they articulate against are much smoother,
the wear rates are dramatically reduced, the way we even sterilize the materials
has changed quite a bit.
The way we used to sterilize the device actually created a process of oxidation
where the material itself would start to break down and it would wear
at a much higher rate. By changing the way we sterilize the materials,
they don't oxidize that way, and that has resulted in a significant improvement
in how long the device will last.
There is pain with joint replacement. We are working on the bones,
we are working in and around muscles
with a variety of different approaches,
but whether you stretch the muscle or cut the muscle,
it still tends to swell and can be sore.
One of the greatest things we've introduced since about 2008
has been a multi-modality pain protocol
and this has been highly effective at relieving pain
and getting patients much more active, much more functional earlier.
If you can control the pain, the patient can walk faster,
they can get up better and they can move much more readily after the surgery.
The pain protocol is a multi-modality approach to taking care of pain.
It begins even before the surgery, you give patients a group of medicines
to help combat pain before we even have performed the surgery.
We use injectables right around the site of the surgery,
we have a device that will administer local anesthetic into the area of the operation
to help alleviate pain in the first couple of days
and then there are a series of medicines both anti-inflammatory medicines
as well as pain relieving medicines that we administer after the surgery
and they are gradually changed over the course of the hospitalization
and over the course of the recovery to keep the pain controlled
and yet keep the patient awake, active and functional.
The patient who's a perfect candidate for surgery
is tired of dealing, living with the pain that they're having currently.
If they're able to live and tolerate the pain that they're having
on a day to day basis, they're not really quite ready for the surgery.
What I recommend for patients is, if you in your mind,
as you envision your life and your day to day activities,
if you can go on for 2 years with your pain as it is in the current state,
you shouldn't have the surgery. You're not quite ready, you're still
too functional. Keep doing what you're doing, keep getting along, and...
Over time though, what tends to happen is the pain tends to get gradually worse
and at some point they will cross over a threshold
and if the patient thinks they don't really want to live with the pain
as they're currently experiencing, for 3-6 months,
then they're really ready to have the surgery.
The implants, the devices that we use for total hip and total knee replacement
are very different. For total hip replacement the majority of those devices
are non-cemented, in other words, there's a coding on the device
that the bone will actually bond directly to.
And so we implant it very firmly in the bone,
and the bone actually grows and incorporates the implant directly into the skeleton.
The articulation, the parts that actually come together,
are really sort of the work course of the device.
Those currently are either a metal or ceramic femoral head
and a cross-link plastic liner and it's a very very durable device.
In the knee, the nature of the bone around the knee
is not as amendable to non-cemented fixations
so the majority of knees are actually cemented onto the end of the bone.
The bone cement is a plastic that actually will adhere the device
directly onto the skeleton, and so it's immediately fixed rigidly onto the bones.
Those devices are made of cobalt-chrome and they have a plastic bushing
that fits in between.
Well, joint replacement, we do it quite commonly.
It is a big operation and it does have certain complications that can occur.
The most frequent complication is blood clots in the veins of the legs,
and one of the best ways to prevent that is to be up, active and mobile
after the surgery. We also give patients a blood-thinning medication
after the surgery. That helps to reduce the rate of blood clots,
but probably the single most important factor is activity.
Patients also may need a transfusion after the surgery.
We don't collect blood from the patients anymore, we used to do that.
What we found is, the patients who would donate blood -
because you just donated - you're anemic and as a result you would then need
the transfusion much more commonly. With the current techniques
we really don't lose as much blood, and so the likes of needing a transfusion
is really very low, and so we don't have patients donate their own blood.
The most feared complication is infection. We do many many things
around the time of surgery to minimize the risk of infection
but it is something that unfortunately can occur.
The joints can also dislocate, where the two parts of the joint
that we put in can separate. And so you may need to be careful
with how you position your body after the surgery.
The restrictions in activity we're positioning
only carry on for about 6 weeks and then after that
you can basically use your hip as you would feel comfortable and natural with.
And the physical therapists are very diligent about going over that with you
and the instructions are quite simple and very easy to maintain.
The majority of patients coming in for joint replacement
do best with epidural or spinal anesthesia.
While that is somewhat daunting for many patients,
it's not as though you're awake during surgery,
you're actually sedated and you have no awareness of being in the operating room
or having undergone surgery. But because you're not completely asleep
as you would be with a general anesthetic, when you wake up you feel much better,
you're much more awake and alert and you're much better able
to participate with physical therapy and also just interact with your family
and interact with the other healthcare professionals
that'll be coming in to take care of you.
The majority of joints in the United States that are replaced here
are the hip and the knee. Other joints that we have viable replacements for
are the ankle, the elbow, the wrist, the shoulder,
any of those can be replaced and we have specialists
at Georgetown who can do all those.