DOC TALK WITH DR. PALOMERA AND DR. GIRLING: DO I REALLY NEED A KNEE REPLACEMENT?
Two of our physicians discuss TOP patient questions: DO I REALLY NEED A KNEE REPLACEMENT?
Dr. Girling: Patients come in and they say, Somebody told me I have to have a joint replacement. I always laugh. What does that even mean? You have to have a joint replacement? This doesn't make sense. Tell me your answer to patients whenever they come in saying, Somebody saw my x-ray and I have to have [my knee] replaced.
Dr. Palomera: My response isn't actually an answer. I'll immediately review what the patient has and hasn’t tried. The vast majority of patients that come in had some treatment like an injection, but many haven't failed conservative treatments or tried rehab. Maybe they tried bracing depending on the arthritis. However, they haven't tried steroid or cortisone injections, steroid and cortisone being the same thing in this case, or injections with Visco, which is a gel injection that a lot of people know as rooster comb injections. There's even injections made with biologics using the patient’s own platelets and plasma (PRP), so I'll usually go through to make sure the patient failed everything.
But, if the patient has tried a good couple of things and they’re not getting more comfortable, then it may be time to move on.
When a patient comes in with an obvious deformity on their knee because they are so worn out, that's when I do talk to them about conservative measures. But, I'll tend to refer them much more quickly to somebody like you who replaces a joint because sometimes there's so much deformity that you do want to do the replacement, if indicated. Just so they don't have continued problems and you don't make the outcome that much worse.
Dr. Girling: The mantra that I have is You don't walk on x-rays, I don't operate on x-rays. I operate on patients with knee pain. I end up sounding like a broken record to patients.
Many times it's all about quality of life. There are risks to what we do. Don't get me wrong, I love to operate and I could live in the operating room and be a happy man. With that being said, there's no benefit to me jumping in and operating on a patient who has not tried conservative treatments.
We've all seen patients that have horrible x-rays. You look at the x-ray and anticipate walking into a room with a patient in a wheelchair. Realistically, the patient is still getting in and out of deer blinds, loading up corn feeders, going on walks and hiking trails, or running a few days a week.
They say things like, I've got a little bit of soreness here. Those aren’t the type of patients I'm going to take into the operating room because it's not necessary. That type of pain is something a fluid flow chart, an amnio shot, PRP, or Visco can treat. We've got so many options nowadays [that a replacement isn’t necessary] .
No, none of them are a magic bullet. If you watch infomercials they show an x-ray and then, magically, in the next x-ray the damage is ‘fixed.’ I'm sorry, that's Photoshop. It's not going to happen.
However, our array of treatment options can work incredibly well. I've seen patients of yours that you've been following for years that come in for just the occasional injection. I look at their x-ray, and I ask you, Is that patient still walking? You respond with, Oh, yeah, they just got back from a trip to Europe.
Dr. Palomera: It's amazing that some patients with the biggest deformity will go two years, three years, four years, much better than expected with just conservative treatment like one of the injections I discussed.
I'm the same way. I was taught a long time ago, "You don't treat images, you treat patients. We follow that and we try to be honest with the patient while trying to honor what they want. I frequently find myself telling patients it doesn't look any worse. When they've been in treatment for a while they want to know how their x-rays look as time goes on. A lot of them are disappointed when I say it doesn't look better, but I educate them by informing them that I just don't want it to look worse. As long as you're functioning, we'll keep an eye on it. Even if we have to x-ray you every six months or every year, we'll keep an eye on it. And then when you really start having trouble that's when we revisit, is it worthwhile looking at replacement?
Dr. Girling: That's why I think the sports medicine model has worked so well. That is, you don't operate, I do. It gives us a natural transition where patients can make sure they've really tried all the easy things because the very last thing I'm going to do is have a surgery too soon. At the same time, you don't want to put off surgery so long that now you've given up all the things you enjoy.
Patients don't realize that even with a knee replacement, you can still be incredibly active. For example, I have folks that play high level racquetball, tennis, they still ski, they still do some jogging, and they still go to the gym.
Dr. Palomera: They most definitely still fish and hunt.
Dr. Girling: Absolutely! That's like the most common question they ask. Alright, Doc, this is when deer season is, I need to be better. I can still get out of my low blind, but I want to be in this high blind over here. You've got to make sure I can get in and out of a ladder. I say alright, we've got a plan.
Partial knee replacements, total knee replacements, different types of hips, new approaches, minimally invasive, all these things have revolutionized treatment for orthopedic issues. If you have not tried the simple things like the injections or bracing therapy, I would not recommend jumping into something as big of a replacement because once you do it, we can't go backwards.
Dr. Palomera: Good advice.
Dr. Girling: This has been fun. We're going to try to fill these types of videos where Tim and I sit down and pick out topics. We would love for y'all to send comments with common questions you've had. Maybe you're scared to ask them or maybe you've gotten conflicting opinions. Keep in mind, these are our opinions. Just because we say it, we don't pretend it's the gospel. Our hope is that we can give you some insight into what we think and how we look at things as two active physicians in the community. We'll try to keep this going for you, but thanks a lot for listening. We appreciate it.
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