When Pain Is Severe, Joint Replacement Can Be a Boon

Imagine having so much arthritic pain in your knees that you can’t walk up or down a flight of stairs or even drive a car. Or so much pain in your hip that you rarely leave your home, even to walk in the yard. Now imagine the effect a new knee or a new hip would have on your life.

Such pain is the result of cartilage damage in the joints, and though seen more frequently in older people, it’s a problem faced by individuals of all ages. The most common cause of this type of joint damage is simple “wear and tear” (often referred to as osteoarthritis).

Normally, cartilage is very smooth, permitting the bones to slide against each other with minimal friction (and without pain). In an arthritic joint, the cartilage deteriorates and becomes rough, causing pain, stiffness and swelling when the joint is moved and the bones rub against each other.

While everyone’s cartilage gradually deteriorates with age, the process is accelerated in some people. Individuals who are overweight, for example, are at increased risk of osteoarthritis of the knee because of the additional load on their joints. A traumatic injury to a joint (such as a fracture or a ligament tear) and rheumatoid arthritis (in which the lining around the joint becomes inflamed) can also result in permanent cartilage damage.

For many people with extensive joint damage, there is a solution: surgical joint replacement. Every year, more than 250,000 Americans replace painfully crippling knee joints; 150,000 more replace hip joints. (Shoulders, elbows and ankles are replaced as well, but much less frequently.)

The majority of these procedures are done to relieve joint pain, improve mobility and permit a return to relatively normal function. The operation removes not only the damaged cartilage but also adjacent bone, replacing them with smooth plastic and metal substitutes.

Typically, joint replacement is recommended only after more conservative measures are no longer effective at relieving pain. Arthritic joint discomfort can often be adequately controlled with nonsteroidal anti-inflammatory medications (such as ibuprofen), particularly before the joint becomes too badly damaged. Physical therapy can be helpful at this stage as well. Nutritional supplements chondroitin and glucosamine are effective in about 30% of users, although it can take about 60 days before relief is noted. One recent study demonstrated that this combination may help to rebuild and restore cartilage.

But these “conservative” therapies don’t work for everyone. The effectiveness and the side effects of anti-inflammatory medications, for example, vary considerably from person to person. And even when conservative therapies work, the relief they provide is often short-lived. Although they may control pain initially, joint damage can progress to the point where they are no longer adequate.

That’s when joint replacement should be considered, but experts who treat arthritis say that many patients who could benefit greatly from this operation are not taking advantage of it. Some people choose to live with their disability instead of opting for joint replacement surgery because it’s a major operation, and several months of physical therapy are required to recover full function. They worry that the recovery will be prolonged and painful (which in some cases it is), and fear that the procedure might fail and a second surgery will be necessary. Also, it’s a strange notion--replacing living tissue with an artificial substitute; some people with incapacitating joint pain have trouble accepting the idea, in spite of the remarkable pain-relieving potential of these operations and positive endorsements by their physicians.

The issue is further complicated by concerns that the artificial joint will wear out. In fact, artificial joints do wear out over time, particularly in younger, active individuals. (The joints tend to last longer in people who are relatively sedentary, such as the elderly.) This usually doesn’t happen very quickly, however. The likelihood of a total knee replacement lasting 15 to 20 years is about 95%; the chance of a total hip replacement lasting that long, about 80%.

So when should a person with arthritis consider joint replacement surgery?

Most arthritis specialists agree: When other, simpler measures fail and the pain becomes so severe that it interferes with normal activities like standing, walking and stair climbing, joint replacement may be appropriate. Experts no longer believe that age should be a barrier to having joint replacement surgery. In the worst case, an individual might outlive the artificial joint and it, too, will need replacement with another artificial joint (some people would regard this as the best case).

It’s important to note that physical activities that place an excessive load on the artificial joint are discouraged after a joint replacement operation, to protect the longevity of the artificial joint. Such activities include jogging or running, contact sports, tennis and skiing. Activities like recreational walking or biking, swimming and golfing are generally encouraged.

Joint replacement operations are certainly no walk in the park, but for some people they offer the only hope for being able to walk in a park again. Any individual with severe arthritic pain that limits normal function should discuss this option with physician specialists who have experience with joint replacement procedures.

Additional information on this subject is available from the American Academy of Orthopaedic Surgeons at www.aaos.org and the Arthritis Foundation at www.arthritis.org.

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Dr. Jonathan Fielding is the director of public health and the health officer for the Los Angeles County Department of Health Services. Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. Their column appears the second and fourth Mondays of the month. Send questions by e-mail to: ourhealth@dhs.co.la.ca.us. They cannot respond to every query.