Other Reasons for Joint Replacement

Episode Summary:
While joint pain is often the primary motivator, Dr. Bagares explores the lesser-known reasons for surgery, the compensatory movement patterns people develop over time, and the importance of timing the procedure correctly. He also discusses the long-term impact of these patterns on muscle loss, gait efficiency, and overall health. If you're considering joint replacement surgery or work with patients who are, this episode provides key insights into when surgery makes sense and when conservative treatment is the better option.

🔹 Timestamps for Key Topics:

• [00:00] – Introduction: What is rehabilitation, and why does it matter?
• [00:30] – Why total joint replacements can be life-changing
• [01:00] – Common reasons for hip and knee replacements beyond just pain
• [02:00] – How degenerative joint disease affects movement patterns
• [03:00] – The role of compensatory mechanisms like limping and foot rotation
• [04:00] – Why unlearning bad movement habits takes time and effort
• [05:00] – Muscle loss and the impact of long-term movement dysfunction
• [06:00] – Should you wait until the pain is unbearable before considering surgery?
• [07:00] – How delaying surgery can affect future health and mobility
• [08:00] – Final thoughts: Making an informed decision on joint replacement

🎧 Listen now to learn how to navigate the joint replacement decision-making process with confidence.

👉 Follow Dr. Fred Bagares on social media:

• Instagram: @drfredbagares
• Facebook: @drfredbagares
• LinkedIn: Fred Bagares, DO
• YouTube: Dr. Fred Bagares

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Transcript

0:00

What is rehab or rehabilitation? My name is Fred Bagaris, a board-certified sports and spine medicine physician in Virginia Beach, Virginia. After 10 years of practice, I still find musculoskeletal medicine both fascinating and challenging. This podcast is about the lingering thoughts and questions I've had after residency and fellowship. My hope is to spark discussion, challenge dogma, and share my experiences in musculoskeletal medicine. Welcome to the Talking Rehab Podcast. Total joint replacement is truly a life-changing procedure. For the purposes of today's talk, I'm going to limit this discussion specifically to joint replacements of the hip and knee. It is typically performed because of pain, and pain is a great motivator. Unfortunately, it also has a lot of secondary effects. Even though joint pain is the most common reason, I want to talk about some of the other potential reasons to undergo a joint replacement. When you go to see your orthopedic surgeon, they're obviously going to take a look at your x-rays to determine the severity of degenerative hip disease or the extent of degenerative changes. Aside from pain and swelling, if you have radiographic findings of moderate to severe arthritis with the right degree of symptoms, there's a good chance you will meet the criteria for a joint replacement. That doesn't necessarily mean conservative treatment shouldn't be considered, even if the surgeon thinks that you are a good candidate. I am obviously an advocate for conservative treatment because not everyone with severe findings needs a joint replacement, and a lot of people do very well. Aside from pain, I think degenerative joints can definitely change how you use your body in other ways. One of the other things that can happen, particularly in the earlier stages, is that people develop compensatory mechanisms for ambulation. These compensatory mechanisms are often involuntary, and I'm referring to the adaptations or strategies like limping or turning your foot outward. Limping is a way to offload a painful leg, reducing the pain experience. Another common compensatory pattern is externally rotating the foot while walking. This shift offloads pressure from the knee and hip while relying on passive structures like ligaments and tendons instead of the muscles and joints to take on the load of the lower extremity. It also can decrease the amount of work that the muscles have to do across the joint, which can be a trigger for pain. It can be really subtle, but it's a fairly significant finding in my population. Many people develop these compensatory patterns without even realizing it. However, if left uncorrected for too long, these patterns can become permanent. One of the goals after a joint replacement is to reverse these compensatory patterns. Patients often believe that once the pain is gone, the compensations will disappear and everything will return back to normal. But it's not always the case, nor is it always easy. If you've been moving a certain way for a long period of time, you have essentially learned that particular pattern. And unlearning it can certainly take time and effort. Additionally, once you have a joint replacement, it doesn't feel like your old knee. It's still a new part. You have to learn how to move and load your new knee and understand how it feels, how to work with it, in addition to how to unlearn the previous compensatory mechanisms from your old knee. Aside from contractures and weakness, compensatory patterns can cause these types of adaptations and affect the overall efficiency of your movement. For example, if you're limping, you are spending more time on one leg, which contributes to muscle atrophy in the affected leg. One of the biggest determinants of health is muscle mass, which is why resistance training becomes really important the older we get. The legs contain some of the largest muscle groups in the body, and they have the capacity to gain and maintain significant muscle mass. Therefore, they are major determinants of our overall health. So any factor that leads to muscle loss, whether it's aging, injury, or walking asymmetrically, it's generally not beneficial for long-term health. Another issue is gait efficiency. If you turn your foot outward while walking, you are offloading the painful areas but reducing the power of your gait. The foot that you turn outward becomes a shorter lever, leading to a less efficient movement. Instead of fully pushing off with your toes, you're actually taking shorter strides, which requires more effort to cover the same amount of distance. This can contribute to the development of pain and fatigue, especially for individuals with underlying arthritis. This brings me to another factor, overall deconditioning. When people experience pain and fatigue, they naturally reduce their physical activity. A common strategy is to sit more and move less, which makes sense if standing and walking causes discomfort. However, our modern sedentary lifestyles already make us more inactive, and avoiding movement due to pain only compounds this particular issue. Being deconditioned is never an advantage at any stage of life. The less active we become, the more difficult movement feels, creating a cycle that further limits mobility and quality of life. Another factor I often hear from my patients is, I want to wait until I'm in worse pain, or I want to wait until it's my last resort. I understand that surgery is a big decision and shouldn't be taken lightly. However, I often ask patients, how much of your life are you willing to sacrifice before getting to that point? For example, many people say they want to wait until retirement around the age of 65. That's fine, but I will ask, what does age 63 look like for you? What does that last year before surgery feel like? I've seen many people struggle for years before finally deciding to get a joint replacement, only to say afterward I wish I had done this sooner. The last thing to consider is your future health status. Some people are generally healthy and physically active, making them good candidates for surgery at any point in time. Others have medical conditions like diabetes, cardiovascular disease, or spinal stenosis, and these conditions independently can affect the way that people move, thus compounding the overall problem of knee or hip arthritis. One of the questions I ask my patient is, do you think that you will be as healthy a year from now as you are today? It's hard to predict the future, but if there's a high likelihood that your health is will decline, then delaying surgery may not be the best decision. I've seen patients who plan to get a joint replacement a year later, only to develop new health problems that prevented them from being a surgical candidate. Again, a good example is diabetes. If someone has well-controlled type 2 diabetes now, but their condition worsens over the next year, this can lead to poor blood sugar control, and they may no longer be an ideal candidate for joint replacement due to increased surgical risks. The decision to have a joint replacement is a shared decision between the patient and their surgeon. It involves balancing risks, benefits, and probabilities. If you have a lifestyle that allows you to maintain your health over the next year, then waiting may be reasonable. However, if you anticipate declining health and worsening pain, it may make sense to move forward with surgery while you're in better health today. Lastly, timing always needs to be taken into consideration. Timing is a balance of action and also not taking action. In either scenario, there is a cost to either of these options. Achieving pain relief is important, but not the only factor that should be measured. Again, you can't predict the future, but considering factors beyond just pain such as compensatory patterns, muscle loss, and overall health can make the decision clearer. Thanks again for listening. Take care. Thank you for listening to the Talking Rehab Podcast. I hope that this podcast stimulates you to question your own practice and how you approach rehabilitation. I truly appreciate your time and attention. If you enjoyed listening, make sure to like and subscribe to the podcast. I wish you a movement-filled day. Take care.