YOUR PATIENT IS NOT HAPPY WITH THEIR KNEE OR HIP REPLACEMENT. WHAT’S NEXT?

By George J. Haidukewych, MD

According to the Agency for Healthcare Research and Quality, more than 790,000 knee and 450,000 hip replacements are performed in the United States each year. While these numbers declined somewhat over the past year due to obvious reasons and events related to the pandemic, experts project a significant upward trend in medically indicated joint replacement surgeries over the next 10 years.

More than 85-90 percent of patients who undergo total knee or hip arthroplasty (TKA/THA) surgery experience a favorable outcome, with a decrease in pain, an increase in mobility and an overall improved quality of life. And with advances in technology, patients can expect their replacement joint to function well for 20 years or longer. But not all joint replacement surgeries are successful. Complications and failures can occur, and patients who expected dramatic pain relief and function after a knee or hip replacement may present with persistent pain, as well as considerable frustration and unhappiness.

About a third of patients will still have some aches and pains following knee or hip replacement. Early problems can be due to technical factors involving the surgery, inadequate rehab, or more serious problems such as infection or loosening. Problems can also occur years after surgery as the ceramics and plastics start to wear through. A joint replacement that had previously been functioning well for several years can suddenly start hurting or swelling.

The most common complaints following TKA include swelling, activity-related pain and mechanical symptoms, like a crunching behind the kneecap and even clicking when the patient walks. With THA, common painful symptoms include persistent pain around the tendon or bursa on the side of the hip.

WHAT DO YOU DO IF YOUR PATIENT EXPERIENCES PERSISTENT PAIN AFTER JOINT REPLACEMENT SURGERY?

Sorting out what is a normal discomfort for a prosthetic joint and what is a more serious problem is not always straightforward. What may seem like a minor ache or pain could be a sign of a more serious underlying problem. Problems such as instability or loosening of the knee or hip, or even more unusual problems like corrosion or metal sensitivity, can be easily misdiagnosed; ruling out infection and instability is critical.

The optimal plan of care for those patients who continue to experience ongoing joint pain after TKA or THA is an evaluation referral with an orthopedic specialist. Specialized tertiary referral centers like Orlando Health Jewett Orthopedic Institute offer expert specialist care and advanced technology, including leadingedge imaging, such as MRI scanning with metal artifacts suppression, to diagnose reasons for persistent symptoms after a knee or hip replacement.

Sometimes patients have unrealistic expectations of their replacement, because of what they’ve been told or seen on TV or social media. Expecting the joint to be normal versus artificial is a common source of dissatisfaction. They may not follow proper rehab or activity levels. These patients require a comprehensive evaluation of their overall fitness level, including other joints like the shoulders and ankles. Patients need to focus on total body fitness and understand what a replacement joint can and cannot do.

An overall aging population, a rise in the prevalence of risk factors such as obesity, and the popularity of maintaining active lifestyles not only contribute to the increasing number of joint replacement surgeries, but also the inevitable consequential increase in complications or failed joint replacements. We also have seen an increasing number of joint replacements in a younger patient population whose active lifestyles place added stress and wear on their original and replacement joints. With normal use and activity, every joint replacement implant begins to wear over time, and excessive activity or weight may increase the rate of this normal wear, causing the replacement joint to loosen and become painful.

Evaluation by an orthopedic specialist may determine that a painful knee or hip replacement does need any further surgical intervention. It may simply be something that indicates additional physical therapy, weight loss or activity modification. But there is an increasing number of patients who will require a joint replacement revision (redo).

WHEN IS REVISION SURGERY NECESSARY?

Revision, or redo, surgery is a complex procedure that involves removing and replacing the original joint implant, usually due to a complication from the initial replacement.

Overall, complication rates following TKA or THA surgery are low. Serious complications, such as a joint infection, occur in fewer than 1-2 percent of patients. Instability can occur in 2-3 percent of knee replacements, and 2-3 percent of hip replacements can have a dislocation or similar problem. These percentages are small, but given the large number of surgeries performed, it adds up to a significant number of people experiencing undue discomfort and pain.

Typically, more women than men undergo knee replacement, with hip replacements being about even between men and women. Overall, men place more wear on replacement joints than women, due both to more body weight and slightly more activity, resulting in a slightly higher need for revision surgery.

Data from Medicare shows that the average rate of revision surgery within 90 days is 0.2 percent but increases to 3.7 percent

within 18 months. These are usually due to infection or mechanical complications of the implant. While surgical techniques and implant designs and materials continue to advance, implant surfaces can wear down and the components can loosen over time. Research suggests that long-term wear and loosening affects 6 percent of people after 5 years and 12-15 percent after 10 years.

Only a handful of centers in Florida specialize in diagnosing and treating conditions associated with problematic joint replacements. Specialists with the Orlando Health Jewett Orthopedic Institute perform hundreds of successful revisions of knee and hip replacements every year for patients throughout Florida and the Southeast.

These complex, long procedures can be challenging and require multidisciplinary and subspecialty care, including infectious disease experts and plastic surgeons, as well as advanced surgical, intensive care, recovery and rehabilitation facilities that provide a higher level of care. Backed by all the resources of the Orlando Health system, Orlando Health Jewett Orthopedic Institute offers this advanced level of care. And, expected to be completed in 2023, a new, state-of-the-art orthopedic complex on Orlando Health’s downtown Orlando campus will usher in the next generation of orthopedic care.

Ultimately, the basic message for your patients is “Don’t give up hope!” An orthopedic surgeon who specializes in complex knee and hip revision work can provide a comprehensive evaluation to determine how to best correct a persistent joint replacement problem.

Internationally recognized for joint replacement surgery and trauma, George J. Haidukewych, MD, serves as Orlando Health’s director of orthopedic trauma and chief of complex joint replacement, practicing at the Orlando Health Jewett Orthopedic Institute. Dr. Haidukewych specializes in total hip and total knee replacements as well as orthopedic trauma. He brings extensive experience in the management of failed and infected total hip and total knee replacements and in reconstruction of the joints after trauma. Up to half of his practice is dedicated to solving these challenging problems from around the Southeast. Dr. Haidukewych completed his residency training at the Mayo Clinic in Rochester, Minnesota, as well as a fellowship at Florida Orthopaedic Institute

in the Tampa Bay area.. 

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Robot Assisted Surgery’s Scope in Pediatric Urology By Benjamin K. Rhee, MD

Congenital or acquired urological conditions that affect the kidney, ureter, bladder and genitourinary system can happen to anyone, including children. As a pediatric urologist, I have performed many procedures to treat and resolve these issues. Techniques have ranged from complex surgeries that required larger incisions to less-invasive manual laparoscopic procedures. More recently, robot-assisted (RA) surgeries, where surgeons employ innovative robotic technologies to enhance precision, lessen scarring, shorten (or even eliminate) hospital stays and reduce recovery time, have gained a great deal of attention.

Conversations about RA surgeries have typically focused on adult procedures, starting with prostatectomies. However, RA surgery has become increasingly common in pediatric cases, with clinical outcomes that rival traditional techniques. Because children are smaller than adults, RA surgery requires more customization in pediatric cases. That’s where the innovation comes in. Over the past couple of decades, highly experienced pediatric surgeons have created and mastered the customization of RA surgery protocols for use in pediatric cases.

ROBOT ASSISTED SURGERY: WHAT IT IS AND HOW IT WORKS

RA surgeries are not new. They have been performed for decades. But the accolades have become more transparent in recent years as technologies have become more widely used. Here, we’ll discuss RA surgery through the da Vinci® surgical system.

The da Vinci surgical system has been around for 25 years and counting. Introduced in 1997, it became the first robotic surgical platform to be commercially available in the United States. In 2000, it was cleared by the FDA for use in general laparoscopic surgery.

The system provides surgeons with an advanced set of instruments to use when performing surgery. There are three primary parts to the system: • The surgeon console: Where the surgeon sits and guides instruments while viewing high-definition 3D images of the patient’s anatomy. • The patient cart: Positioned alongside a patient’s bed, it contains the camera and instruments the surgeon is controlling from the console. The system will translate a surgeon’s hand movements in real time, bending and rotating the instruments on the patient cart, while performing the procedure with a greater range of motion than available to the natural human hand. • The vision cart: Facilitates communications between all the components and provides support for the 3D high-definition vision system.

Because RA surgeries are more sophisticated, they also can require more precise (and demanding) physical movement than traditional incision or manual laparoscopic surgeries. With traditional modes of surgery, the instruments can go in-and-out. They can rotate around the axis of how surgeons’ put the instrument into motion. They can go up-and-down and side-to-side. But the surgeon cannot articulate the wrist — there is only so much range of motion one can perform. With RA surgery, there is a greater range of motion, better articulation and better depth perception. In the urology field this is a huge benefit. When one can articulate the wrist and employ better vision, the task of sewing tissues becomes much easier.

ROBOT ASSISTED SURGERY IS ON THE RISE

At Orlando Health Arnold Palmer Hospital for Children, we currently utilize RA surgery in about 40 to 50 cases per year and have the ability to support from 100 to 120 per year.

There are a number of reasons for why the use of robotic surgery is on the rise, including quicker recovery rates and less reliance on pain medications. In fact, only 40 percent of the children we have treated with RA surgery have needed any narcotic pain relief; and, 100 percent went home just with scripts of ibuprofen for pain relief.

These two major points are also beginning to catch the attention of health insurers, nationwide. More precise surgical procedures, with reduced recovery time and lower narcotic pain relief, equate to better overall outcomes physically and financially, for patients, providers and payers alike.

ADULT VERSUS PEDIATRIC ROBOT-ASSISTED SURGERY

When utilizing robotic surgery, the procedures between adult and pediatric patients are similar, but they’re performed on a miniaturized scale. While some surgical instruments do come in sizes that can be larger or smaller, they’re not specifically designed to be applied as adult or child sized — robotic or otherwise. This means there’s a fair amount of customization that takes place when performing a RA surgery on a pediatric patient. But it’s never left to chance. Protocols have been in long use.

Early on, surgeons were concerned over a perceived change in tactile feedback when performing RA surgery. What was found over time, however, was that many experienced surgeons displayed a highly developed skill to ‘feel with their eyes;’ they were able to observe changes in tissue reaction, color and so forth through vision, which translated into tactile response and feedback.

Taking into consideration areas of adjustment that include space limitations when working in a smaller body cavity and pressure, it goes without saying that an RA surgery procedure could be customized to make accommodations based on whether your patient is an adult or a child. Pediatric surgeons took note and developed customized RA surgery protocols. COMMON ROBOT-ASSISTED UROLOGIC PROCEDURES

Historically, surgeons made larger incisions through skin and muscle to get clear views of areas of concern. More invasive incision surgeries are still performed when necessary. But, when performing RA surgery, the incisions are much smaller and the procedures are more minimally invasive, resulting in quicker healing and recovery times.

Some common RA pediatric urological procedures include: • Partial and total nephrectomy • Pyeloplasty • Cyst removal • Ureteral implantation

While the premise of RA surgery offers surgeons — and patients — enhanced precision, wider articulation and control, and better vision while performing delicate and complex procedures (and all the recovery benefits), it’s vital for referring physicians to vet the experience of pediatric surgeons. Surgeons are certified to perform RA surgery after five procedures. Because optimal precision comes with experience, it’s important to discuss experience and outcomes with the specialist you consider.

Benjamin K. Rhee, MD, FACS, is a pediatric urologist with Orlando Health Arnold Palmer Hospital for Children and board certified by the American Board of Urology. He specializes in robotic pediatric urology surgery using the da Vinci® Surgical System and has performed more than 1,000 pediatric RA surgeries. Dr.

Rhee may be contacted at (321) 843-9017. 