Fifty years ago, 50-year-olds were different. Well, at least in terms of perception. Patients with terribly painful arthritis had very few options: they had to grin and bear it. Thankfully, a few decades have brought about a new mindset for the middle-aged, and more than a few innovations, according to Hari Bezwada, M.D., a surgeon at Capital Health and its physician leader for the Joint Replacement Certification Program of Excellence at Capital Health. “We have so many great options for patients, so they can really live life to the fullest,” he says.
People most frequently seeking treatment for joint pain—and ultimately joint replacement surgeries—include a range of patients, from active, middle-aged athletes to overweight patients suffering from too much stress on their joints. “We’re seeing a lot of people in their 40s, 50s, and 60s still out there doing marathons, triathlons, and just generally wanting to stay active,” according to Arjun Saxena, M.D., a surgeon and on the medical staff at Capital Health. “So they’re seeing their physicians earlier when they have aches and pains, trying to figure out what they can do to stay active and continue to participate in the activities they enjoy.”
First, patients presenting with arthritic pain—characterized by pain and stiffness due to inflammation of the joints—are encouraged to modify lifestyle and activity level for relief. Orthopedic doctors may suggest exercises to strengthen surrounding muscles, low-impact activity, anti-inflammatory medications, and Cortisone or Hyaluronan (also called viscosupplementation) injections.
For heavier patients, physicians promote weight loss and recommend getting physically fit. “For every pound of weight we have, it puts seven pounds of force on our knees. That’s a significant force if you’re 20, 30, or even more pounds overweight,” notes Dr. Saxena.
Surgery is always the last resort to treating symptoms after other interventions have been exhausted. “Once patients experience severe limitations in their life, have night pain, pain during daily activities, difficulty being able to work… that’s when we want to consider joint replacement surgery so they can move on with their lives,” says Dr. Bezwada.
Joyce Frey, a 55-year-old exercise enthusiast, knew this scenario well. She wasn’t able to move on with her life, literally. “I could hardly walk. The [groin] pain was excruciating as I limped around my office.”
Frey’s pain began early, in her 30s. Arthritis ran in her family, so she took Celebrex and continued on with her active lifestyle. “I would reason that I pulled a muscle, but I’m not one to take pain meds. I just kept thinking it would go away,” she says. “It would hurt, and I would just keep going.”
An X-ray at her family orthopedic physician revealed bone-on-bone contact in her hip. A total hip replacement was in her immediate future. After one surgical consultation, she decided to get a second opinion with Dr. Bezwada. Dr. Bezwada is a hip specialist who uses the direct anterior approach to surgery. In 2006, he went to Europe to get trained in the technique while most specialists were being schooled on the standard, posterior approach to hip replacement. The newer direct anterior model boasts faster recovery times and fewer patient limitations. Every one of his hip replacement patients now receives their new joint through this successful surgical approach.
Capital Health pioneered the minimally invasive anterior approach in this area and has the most experience doing it. The benefit is that surgeons do not violate any major muscle groups around the hip by reaching the joint from the front of the body instead of the side or back, Dr. Bezwada explains. A smaller incision made without having to detach muscles leads to faster healing time and better, easier recovery in the strengthening of the new joint.
“I know people who were laid up for months after a hip replacement. I walked into Dr. Bezwada’s office at two weeks—without a cane,” says Frey.
Michael Ast, M.D., another surgeon on staff at Capital Health, reports a similar outcome with a knee patient who received state-of-the-art pain management techniques, including novel injections in the joint, which allow for significantly less pain and earlier functioning after joint replacements. “Using this innovative protocol, many patients are able to be discharged home from the hospital 24 hours after surgery,” he says. “One patient even returned to my office recently, four days after knee replacement surgery, using no cane or walker, stating that since the time of surgery he had absolutely no pain.”
While some patients like Frey recover more quickly, Capital Health surgeons report return to daily functioning in just four to six weeks. The typical hip patient undergoes the one-hour surgery and stays in the hospital for one to two days. “We like them to use a cane or crutches for the first couple weeks, then one crutch, then no assistive device, and then begin an exercise plan about a month after surgery,” Dr. Bezwada says.
On the Mend
Physical therapists (PT) instruct direct anterior hip replacement patients how to do their rehabilitation exercises while still in the hospital; many patients do not even require formal participation in an outpatient PT program. For individuals desiring in-home PT care or outpatient sessions, these options are available and customizable based on each patient’s condition and preference.
“One of the things that sets Capital apart is that we do enough volume of replacement surgeries to do a great job and have an excellent system in place, but we are also small enough that we can individualize care for the patient. That’s why I like being a part of a hospital this size and a community like this,” says Dr. Saxena, who specializes in knee and hip replacements.
Dr. Saxena said that patients typically spend one to three nights in the hospital. The care team seeks to control pain and nausea, enabling patients to do therapy right away. “The more activity they can do, the more confidence they’ll get, the more comfortable they’ll feel being discharged to home.”
Patients start on a walker, transition to a cane, and experience a return to normal activities by four to six weeks. Likewise, post-operative care—including a physical therapy regimen—is customized for patients’ needs.
Dr. Ast highlights technology applications that allow him to individualize patient care at the point of contact. “For knee replacement surgery, I use computer navigation that enables me to precisely position the knee replacement for each individual patient. Instead of using averages for all patients, this technology allows me to individualize the surgical technique for each patient’s unique anatomy, which can lead to both improved function of the knee replacement and improved lifespan of the implants,” he reports.
“In the past 10 to 15 years, I don’t think the implants have changed all that much,” says Dr. Saxena. “What’s gotten better is the way we care for patients before, during, and after surgery that allows them to have a better, faster, and easier recovery.”
Thanks to her outstanding care and recovery, Joyce Frey has become a self-proclaimed cheerleader for Capital Health’s joint replacement program. “From the first second I entered the office, [Dr. Bezwada] answered any questions I needed answered, and I had a lot of them,” recalls Frey. “People say they don’t care about a bedside manner, as long as they have a good surgeon. I say find someone who has both. He was honest, never rushed me, and never put me off.”
Frey was also able to achieve a level of comfort preparing for her surgery thanks to a mandatory class run by Capital Health for patients undergoing joint replacement surgery. She spoke with a nurse and a physical therapist and expressed fears about anesthesia, inquiring about a spinal block instead. Capital Health’s operating room teams specialize in blocks, so patients are exposed to the lowest risks possible for the operation, according to Dr. Bezwada, who attributes their success rate to a comprehensive team approach to joint replacement.
“It doesn’t matter how old you are. If pain is problematic in your life, whether you lead an active life or a sedentary life, it’s important to take care of it,” Frey says. “It was worth it to me,” she reassures joint replacement patients who come in for preadmission testing. “I tell them, ‘The pain you’re feeling now is worse than any you’re going to feel afterward. Trust me.’ I took nothing for pain after surgery because I didn’t have any.”