For this month’s Blog I wanted to take on a toughie. I wanted to try to unravel the truth behind the effectiveness of joint replacements. Why? Because after 14 years I’m even more interested, intrigued and perplexed by the subject than ever before.
Sometimes they work just amazingly and sometimes they just don’t. How can it be so different from one person to the next? To investigate this properly I thought the best way to do this would be to put myself in the shoes of someone considering a hip or knee replacement. Would I choose to go under the knife or not?
Why Should You Listen To Me?
Over the course of the last 14 years I have seen hundreds of people diagnosed by the medical profession with Osteoarthritis. Not proclaiming to be the Messiah or anything in the vast majority of cases I can normally get these people feeling better. How much better depends on the person and the condition. My experiences led me to write one of my most popular Blogs: Is Osteoarthritis Really To Blame For All Your Pain?
For me it is clear that the wear and tear on your joints is not solely to blame for the pain that you feel. Pain way too complex for that as we explore in our post Just What Is Pain. In my experience it’s possible to get most people moving much freer and with considerably less pain – often with no pain at all. Obviously the people with more severe arthritis considering a joint replacement are more challenging. In most cases we still see a significant change. In some we don’t. What is the difference?
It’s the same question when it comes to replacements. Many people fair very well and the joint replacement gives them a new lease of life. Some people end up not much better than they started and in rare occasions worse than where they started. If I was considering a joint replacement I’d want to know the numbers…
According to the National Joints Registry 105,000 hip replacements were carried out in 2017. 60% of whom were women and the average age was 67.5 for men and 69.9 for women. For knees the numbers are 112,000. 56% of whom were women and average age was 69.2 for men and 69.4 for women. Interestingly the average BMI for hip replacements was 28.8 (Overweight) and 30.9 (Obese) for Knees. Maybe this is due to the increase load going through obese people’s joints? I doubt it would be that straightforward though.
What The NHS Says
My first port of call researching whether I’d be having a joint replacement would be the NHS hip replacement page. It says that ‘Most people experience a significant reduction in pain and some improvement in movement.’
Ever since I discovered that the NHS trust funding is based on the amount of operations they do I have become a bit cynical. If this is my joint they’re going to be messing around with I’d like to know what percentage of people ‘most’ means? And how much improvement is ‘some’ improvement in range of movement? If we’re talking a few degrees here I’m not too bothered!
What The Research Says About Effectiveness Of Joint Replacements
There is a surprising lack of good research on such things. As with all research there are large discrepancies in the numbers. In this review piece we see that the percentage of people reporting ‘unfavourable’ long-term pain ranges from 7-23% for hips and 10-34% for knees.
Another review piece suggests that ‘overall response to hip replacement was good but 14-36% of patients did not improve or were worse. This research here would back this up which say that 31% of patients had minimal or no improvement. Studies with numbers in the 30% ball park are starting to make me feel twitchy about going under the knife!
Let’s lighten the mood with some more positive research which reports a 71% and 53% reduction in pain for hips and knees respectively. A reduction in stiffness of 55% and 43% and improvement in physical function of 68% and 43%. These numbers are across all people in the study. Which is a little more cheery than the previous data. However, I’d still be concerned about being one of the people who respond in a negative manner…
Will It Work For Me?
So what makes it more or less likely any operation is a success? One of the articles cited above suggests that younger, obese, employed and better educated people fair better. Does this mean if I’m old, skinny, unemployed and stupid things are less likely to go well?
Certainly the age factor is well documented. People who have them younger fair better. But equally you don’t want it too soon as the replacements wear out. Generally considered in the range of 20 years these days.
Education is an interesting factor and would make sense. With a lack of knowledge comes fear which can increase pain levels. Equally I think it can go the other way. If you want too much knowledge and information then you can over think things. This is why medical people are harder to fix then the general public!
Another factor is having other ‘stuff’ going on at the same time. Stuff being a very technical term obviously. In medical terms they use the phrase co-morbidity. I think stuff sounds far less threatening!
So what other ‘stuff’ reduces your likelihood of a good result from the operation? We’ve already touched on age. Diabetes is another. If you have OA in your other side this also suggests you might not fare as well. I guess the more wonky or more compensation patterns you have the harder it is to get you into a good functional position where you don’t feel pain.
If you have low back pain apparently you tend to fair worse too. This makes a lot of sense to me. Firstly our good old friend psoas (the main hip flexor) acts across the hip joint and also attaches to all lumbar vertebrae and discs. We find it at fault in many people with long standing low back pain. It can also contribute to compression forces across the hip joint. Secondly, there is a high correlation between low back pain and stress…
Stressed or traumatised people simply feel more pain as we discuss in our Blog: Do You Think Stress Causes More Pain? Is major surgery likely to calm or reduce those stress levels? Interestingly the more pain your report pre-operation is an indicator of a poor result. Lots of pain can come from being sensitised through the whole body. Again suggesting stress levels are a huge factor – as they are in any condition.
This is further backed up by another piece of research which suggests anxiety and depression are factors in poor responses to surgery. The more worried about pain you are the more severe the avoidance movement patterns.
So there really is a lot to consider here. Not just what the x-ray is showing us.
What Are The Potential Complications
My final consideration before making a decision if I would have a replacement or not is what are the potential complications? Just how bad can these complications be? The percentage risk of complications maybe low… but how severe are the outcomes?
First let’s consider what does and doesn’t happen post surgery:
- You have to avoid bending your hip more than 90 degrees, twisting, swiveling or forcing the hip to places it doesn’t want to go
- It takes at least a year to gain the full benefit
- Hip replacements are not designed for sport!
- Legs may be different length post surgery
- Altered movement patterns are inevitable at least in the medium term
And now some of the possible complications from the NHS website.
- Blood clots in legs and lungs
- Stroke / Heart Attack
- Nerve or blood vessel damage
- Bone breakage
Some pretty big stuff in there. Even if thankfully the risks are low. I couldn’t find detailed enough research as to how likely any of these are in particular. However a large American study suggests 8.94% of people are back in hospital within 90 days of hip replacement. Interestingly this number goes up to 21.14% for partial hip replacements. This says to me if you’re going to get it done you may as well get the whole thing done!
What You Can Do To Avoid A Hip Replacement
So there’s all the information for anyone considering a joint replacement. I hope it was all useful food for thought and help make your decision simpler. If you are contemplating surgery or simply want to avoid surgery in the future here’s our top tips to dodge the knife:
- Sort Your Stuff Out! – As we discuss above your mental well being is a massive factor in the pain you feel. Just think back to a really painful phase. Chances are it was a really stressful time in life too. Don’t be afraid to get help with the mental side of things and you might be surprised just how much that can reduce your pain.
- You Gotta Live Before You Die – This is probably the most negative piece I’ve written. It wasn’t my intention it’s just the way it came out. I’m hoping I’ve not made anyone more fearful I just wanted to be honest. Whatever you do don’t live in fear. If you do you’ll be in more pain and if you have the op it will be less likely to work!
- Be More Snail – Ties in with the mental side of things in the last 2 points. Slow things down. You may not feel stressed but chances are if you’re living life at a million miles an hour then it will be affecting you in ways you don’t appreciate.
- Nutrition – You are what you eat. If you’re overweight do everything you can to lose it. If you’re a decent weight anyway review what you eat. Some food are more inflammatory than others. Get advice from a good dietician who can teach you a less inflammatory way of eating.
- Don’t Soldier On – Get things sorted when they happen. It’s much easier for us to tidy you up when you start feeling things rather than years down the line. most severely arthritic joints come about as long term compensation patterns from old injuries. Do what you can to get those old injuries as good as you can.
- Sort Your Movement Out – Or any other health care provider. There are lots of different approaches to making you feel better. We have quite a few. But others do exist. Some might even work! If you’ve not been helped by previous try something different. You might be pleasantly surprised.
So Would I Go Under The Knife?
In short no. I wouldn’t. I would have to be completely at the end of my tether to even contemplate it. However, I do appreciate as a theoretical exercise I can’t put myself in that position. You can all laugh when in 25 years I’m going to the NHS begging for a new hip!
If I had done all I could for my mental health, if I had made sure my weight was good and my nutrition was optimal for joints. If genuinely I believed I couldn’t be less stressed. If I had tried everything that Brighton Sports Therapy and a host of other health care providers have to offer and still I was in abject pain. Then, and only then, would I consider going under the knife.
This article first appeared on our Brighton site.