Goal is for patients to feel as if they'd never had the surgery

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Sometimes after a traumatic injury, people may be recommended to have a joint replacement. I'm talking about what's important to know about these surgeries with Dr. Zachary Telgheder. He's an orthopedic trauma surgeon at Upstate, where he's an assistant professor of orthopedic surgery. Welcome to "The Informed Patient," Dr. Telgheder.

[00:00:32] Zachary Telgheder, MD: Thank you for having me, Amber. I'm happy to be here.

[00:00:35] Host Amber Smith: Now, which of the joints are most commonly affected by traumatic injuries?

[00:00:41] Zachary Telgheder, MD: Almost any joint in the body can be affected by a traumatic injury. We see, very commonly, fractures around the hip, especially in the elderly population and especially this time of year, in the winter. We see fractures involving the joints around the knee and the ankle very commonly as well.

A little less common, but still a large part of my practice, are fractures about the shoulder and elbow as well. And then a lot of the fractures around the wrist and fingers are taken care of by orthopedic hand surgeons.

[00:01:06] Host Amber Smith: Now, these traumatic injuries, are they from sports injuries, car wrecks, falls on the ice? I mean, what's the mechanism of injury for these?

[00:01:16] Zachary Telgheder, MD: We see injuries like this from all sorts of different mechanisms. A lot of it depends on the time of year. In the summer we see a lot of things like motorcycles and car accidents, just when the weather's a little bit nicer. We see children who may be playing on the playground or on a trampoline who injure their joints.

And then in the winter we see a lot of falls on ice, falls related to the snow, and occasionally the more rare things like snowmobile accidents are a little more commonly in the winter. But really any type of a mechanism that can cause any type of trauma, like a fall or any type of impact can injure a joint.

[00:01:47] Host Amber Smith: How are these type of joint replacements different from the regular scheduled joint replacements?

[00:01:54] Zachary Telgheder, MD: So a joint replacement after a traumatic injury is a little bit more difficult and a little more complex than, say, a standard joint replacement for something like arthritis. We do both joint replacements acutely at the time of the injury as a definitive method of treatment to help treat, say, a fracture on the hip with a hip replacement in the patient who's appropriate for that.

And occasionally, part of my practice is treating the post-traumatic effects of a joint injury. Sometimes we see what's called post-traumatic arthritis, where after an injury to the cartilage of the joint, the arthritis and the joint itself can degenerate rather rapidly. And sometimes the best option for that is a joint replacement down the line.

It's a little bit different than, say, a standard arthritic joint replacement in the sense that there's often hardware and implants in place or other large deformities. But the complexity of those and the rewarding satisfaction of giving a patient their life and function back is sometimes even greater than that, after an arthritic hip or knee replacement.

[00:02:47] Host Amber Smith: Is it harder on the patient because they've gone through this traumatic accident that they are healing from or have to heal from, but then they also have this surgery that they really weren't planning to have to have. Is it harder to heal that way, or is it easier because it's all happening together?

[00:03:04] Zachary Telgheder, MD: It certainly can be more difficult. I would say the most common joint replacement I do in the setting of a traumatic injury is a hip replacement for a fracture of what's called the femoral neck. And if you think of the hip as a ball and socket joint, it's relatively common, especially in patients over the age of 50, to break right below where the ball is. And many times, based on the fact that those fractures don't heal as reliably as other fractures in the body or even the femur itself, a joint replacement is usually the best option in terms of the most reliable outcome, and of course the fact that patients can get up and walk right away, right after they would with a standard hip replacement.

The big difference is that when you're having a hip replacement for arthritis, which is usually the most common way of having a hip or knee replacement, that's something you plan for. You can adjust your schedule. You go to preoperative physical therapy. You see your doctor. Whereas this all happens through the emergency department, so it's certainly a bigger psychological shock and recovery for patients.

One of the things I take a lot of pride in is being with patients at that time through the emergency department, getting them taken care of quickly and seeing them recover fully and have an excellent outcome as if they were to have an elective hip replacement. But it definitely is a little more traumatic and a little more challenging for patients just because it's certainly not something that they plan for.

[00:04:13] Host Amber Smith: How do you determine whether a joint needs to be replaced or if it can be re repaired or reconstructed?

[00:04:22] Zachary Telgheder, MD: It depends on both the injury itself as well as patient factors as well. Like I mentioned, fractures right below the ball of the ball and socket of the hip joint or the femoral neck... in patients who are young, generally less than 50, we often do our best to try to fix that with plates and screws. Even doing that, we find that sometimes they don't heal properly or have post-traumatic effects that need a hip replacement later.

Whereas in a patient who's, say, over the age of 50 or 60 who's pretty active, a hip replacement is much more reliable surgical option right at that point to allow them to get up, walk right away, have no restrictions or limitations, and seem to recover better.

Many fractures, especially around the knee and shoulder, we can fix with plates and screws and try to reconstruct them. And that is my first specialty -- traumatic injuries and reconstruction and fixing broken bones like that. But occasionally, like I said, we try to tailor each surgical option to each patient based on both what their fracture looks like and what their quality of life was like before the injury.

A lot of people are candidates for joint replacement, but that depends a lot on their age, their functional level, and what we can do to best get them back to their baseline level of function as quickly as possible.

[00:05:33] Host Amber Smith: Is there anything that would disqualify a person from having a joint replacement?

[00:05:39] Zachary Telgheder, MD: I wouldn't say there's anything that totally disqualifies them. Again, based on patient age, we try not to do definitive joint replacements in patients who are really young and may require another joint replacement in their life, if we can happen to avoid that.

The only thing that would absolutely disqualify a patient from a joint replacement would be an active infection near that joint, but that's very rare, especially in the setting of trauma. What we sometimes see -- and this is very rare -- is someone who's had a previous surgery around the joint and there's an infection there, and first we would, of course, treat that before doing a joint replacement. But rarely is there something that would totally disqualify a patient from a joint replacement.

[00:06:14] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with orthopedic surgeon, Dr. Zachary Telgheder about traumatic joint replacements.

So what do patients need to know about joint replacements? What are the replacement parts made of, for instance?

[00:06:31] Zachary Telgheder, MD: The replacement parts are often made of special metal alloys, most often cobalt and chrome, and in either a hip or a knee replacement between the metal components that replace the bone or resurface the bone, there's a plastic liner made of polyethylene.

The technology for joint replacements continues to evolve, and the technology we have now is certainly the best we've ever had in history, and we find that our joint replacements are lasting longer and are more functional than ever before.

[00:06:58] Host Amber Smith: Does the human body ever reject the new joints?

[00:07:02] Zachary Telgheder, MD: It's very, very rare, and it's a somewhat controversial topic in orthopedic surgery, but there have been reports of patients who have allergies to certain metals that sometimes have difficulty with joint replacements. That's very rare, and we haven't actually found a perfect way to test and evaluate for that. We do have, particularly in knee replacements, new components that are made without nickel, which is the most common allergen we see in joint replacements, and we can often use those if patients have a history of a previous nickel allergy.

[00:07:30] Host Amber Smith: How long do the joint replacements last?

[00:07:34] Zachary Telgheder, MD: With the modern technology and implants that we have now, we're finding that joint replacements are lasting longer than ever. Some of the registry data, which is where all of the surgeons throughout multiple countries in the world collect their data and submit that, show that some hip and knee replacements are now lasting 25 to 30 years.

Everyone is different, and everyone has a little bit of a different experience. Some patients last longer than that. Some patients, depending on their functional level, will have components have some wear prior to that. But we're finding that with our new components, most notably the new plastic liners that we have in place for our hip and knee replacements, that patients are having these last significantly longer than ever before.

[00:08:12] Host Amber Smith: Can they feel the device underneath the skin, or does it feel like what their bone used to feel like?

[00:08:19] Zachary Telgheder, MD: For the vast majority of patients, the goal of the surgery is to feel as though you never had a hip or knee replacement. The term we use is a "forgotten joint," and we see that very commonly with hip replacements. You can't really feel a hip replacement. The nice thing about hip replacement is it very perfectly resembles your normal hip anatomy, so patients can do very well with that. With the knee replacement, sometimes patients say they feel a little bit different when they're kneeling directly on their knee, but in general they cannot feel the implants themselves. It more just feels maybe slightly different from their knee normally prior to when they had arthritis or an injury.

[00:08:51] Host Amber Smith: Does it change a person's gait?

[00:08:54] Zachary Telgheder, MD: It can, oftentimes, especially with a knee replacement in the setting of deformity, actually improve a gait. Many times we see patients with deformity related to arthritis or a prior traumatic injury where their knee is bow-legged, or knock-kneed from the arthritis and wear in the joint. Many times in surgeries, particularly with the technology we have at Upstate where we use robotic technology and preoperative CT (computerized tomography) scan, we can correct a patient's alignment very nicely. And it can actually help improve their gait.

[00:09:21] Host Amber Smith: Do these new replacement joints set off metal detectors, like at the airport?

[00:09:27] Zachary Telgheder, MD: I have been told that the metal detectors that we have now are very advanced and can often see the joint replacement under the skin. In many airports around the country now they're creating separate lines and questionnaires to expedite the scanning of patients with orthopedic implants such as joint replacements. So I guess the correct answer is yes, they do set off the metal detectors, but it doesn't seem to cause much of a delay or any issue in that, particularly as hip and knee replacements and other joint replacements are becoming much and much more common.

[00:09:57] Host Amber Smith: If a patient had osteoarthritis in the joint, and you removed that and replaced it, does the osteoarthritis redevelop on the replacement joint?

[00:10:10] Zachary Telgheder, MD: It does not. Once we do a joint replacement, particularly a hip or knee replacement, the arthritic or traumatized bone is removed, and that's replaced with the new metal components. The idea of the metal components is to be very well fixed to the patient's normal bone so that there's no chance of arthritis developing ever again.

[00:10:29] Host Amber Smith: What are the risks of having a replacement joint that you go over with patients before the surgery?

[00:10:36] Zachary Telgheder, MD: The most common risks are, generally speaking, pretty standard surgical risks.

We always worry about infection and wound problems, which can happen after any open surgical procedure. We worry about the joint replacement wearing out or potentially needing a revision down the line. And again, that's very difficult to predict. Some patients last forever. Some patients need one in 10 to 15 years. And everyone's a little bit different with that.

With any surgical procedure we do on the bones and joints, there is a chance of injury to the nerves and vessels, but that's very, very rare with any kind of hip or knee replacement.

When we do a hip replacement, there is a risk of having a difference in the limb lengths, particularly because in the setting of arthritis, patients feel as though their arthritic or affected limb is a little bit shorter than the other limb. And we try to restore that normally. And with the robotic technology we have at Upstate, we now have the capability of matching a person's leg lengths perfectly and verifying that in surgery. And that's a very nice new technological update we have and we like to use on our patients.

Other risks we see after joint replacements are things like stiffness, particularly after knee replacements; needing some physical therapy after; and then blood clots can also happen after any surgery in the lower extremity. And we've gotten very good at minimizing that risk by working with our medical colleagues and also having patients optimize a blood thinner use usually for around six weeks after a joint replacement.

[00:11:58] Host Amber Smith: Well, let's talk about what's involved in the surgery. How do you actually attach the joint to the existing bones?

[00:12:05] Zachary Telgheder, MD: So, many times in joint replacements, particularly like what we do at Upstate, we utilize robotic technology to optimally position the components based on a patient's anatomy and to give them the best reproducible result. Instead of actually cutting away the bone, we actually resurface the bone, particularly around the knee, cutting very little bone away and just removing all of the arthritic and disease cartilage.

The joint replacement is then attached to the bone, either using metal that the body's bone will actually grow into, or with bone cement, which allows the bone to adhere. And again, the goal of both a hip and knee replacement is allow a patient to walk on it right away after surgery.

Many times in hip replacements, we rely on technology that the body grows bone into the implants as opposed to using cement. But occasionally, particularly in the setting of a broken bone, we will use cement to help fix the components, once again to avoid complications related to that.

[00:12:57] Host Amber Smith: What happens to the nerves and tendons in that area?

[00:13:01] Zachary Telgheder, MD: In the hip or knee, we often use approaches that are somewhat muscle sparing. And we try to do that to optimize and allow for quicker recovery.

Many times the nerves, tendons, and muscles in the region of the surgical approach for a hip or knee replacement are often safely retracted and mobilized to allow for exposure of the bone, and we try to do that in as minimally invasive a way as possible.

As I mentioned before, we do have what's called the Mako robot technology. And, in utilizing this we've been able to really minimize our dissection to the soft tissues, the nerves and the tendons around the hip and knee to allow us to optimally place components and hopefully give patients not only improved longevity of their implants, but also a quicker recovery after surgery.

[00:13:44] Host Amber Smith: Now, what keeps the new joint lubricated?

[00:13:47] Zachary Telgheder, MD: The body's normal joint fluid often is reproduced into the knee joint itself or the hip joint itself. And the modern plastic or polyethylene components we have actually form a very normal fluid type lubrication barrier, allowing for full range of motion.

Another thing that we tend to do, particularly around the knee replacement, is preserve all of the native ligaments that we can. We often preserve the ligaments on the inside and the outside of the knee, which helps the knee feel much more like a normal native knee. Between the normal joint fluid and joint lining, the modern polyethylene components and preservation of as much native soft tissue and muscle as possible, it allows the joint to stay lubricated and move in a full range of motion.

[00:14:28] Host Amber Smith: Well, I want to ask you about what recovery is like, and I'm assuming it's probably variable depending on what the initial injury was, but in general, how soon do people walk?

[00:14:40] Zachary Telgheder, MD: When we do a joint replacement, either for arthritis, for deformity, or for a traumatic injury, we get patients up and walking the day of surgery.

We have a very coordinated team, not only with the surgeons and the operating room team, but also our nursing staff, our recovery room staff, our anesthesiologists, physical therapists and occupational therapists in coordinating to help expedite and enhance recovery in all of our joint replacement patients.

Patients are up and walking with physical therapy the day of surgery, many times utilizing a walker or crutches to help assist with mobility. But we start range of motion and mobility right on the first day of surgery. Like you mentioned, Amber, everyone's recovery is a little bit different, but in the hospital, we have patients get up and moving right away with the goal being enhanced and expedited recovery.

Many patients for elective joint replacements, such as for arthritis, are going home either the day of surgery or the day after surgery now. In the setting of a traumatic injury, like a hip fracture, that requires a hip replacement, the recovery can be a little bit longer, especially in the acute phase, because like I mentioned before, patients don't always plan for something like that to happen.

In addition to working with physical and occupational therapy in the hospital, many patients require home physical therapy for a couple days after they get home to safely mobilize within their own home, with the goal, of course being to get patients home and in a comfortable environment as soon as possible.

Particularly with knee replacements, we often utilize outpatient physical therapy as well to work on range of motion and strengthening, and that usually starts around one to two weeks after the surgery. A lot of patients report feeling very well around four to six weeks after surgery, but continue to make progress with their recovery for up to a full year after surgery regarding strength, range of motion, and return to their normal activities that they enjoy.

[00:16:22] Host Amber Smith: So how long can people expect before they can get back to their life as they knew it before the surgery? Is it weeks or months?

[00:16:32] Zachary Telgheder, MD: It's usually weeks. A lot of patients are back doing the things they want do around four to six weeks. The joint replacement and the recovery from that tends to make very big leaps and bounds, if you will, within the first two to four weeks. Patients start really regaining their range of motion and their strength around four to six weeks after surgery. And many patients are back doing most of their normal activities around the six-week point after surgery. But of course, everyone's at recovery is a little bit different depending on a lot of different factors.

[00:17:01] Host Amber Smith: And how long do you monitor for allergic reactions or infections or any sort of problem that might come up with the joint?

[00:17:10] Zachary Telgheder, MD: I like to follow my patients for at least one year, if not longer after surgery. I often see patients back relatively routinely, during the first year after surgery, again, just to make sure there are no complications, no issues, and to make sure they're getting the full benefit of the joint replacement.

Oftentimes, if the patient's schedule allows, I like to see them back at least once a year after that to ensure no issues and make sure that they're doing everything they wanted to do after their surgery. And we tend to spread the visits out to, of course, not stress patients too much. But a typical postoperative follow-up schedule is usually around two weeks after surgery, six weeks after surgery, three months, six months, and then one year after surgery -- provided everything is going really well.

[00:17:50] Host Amber Smith: Well, Dr. Telgheder, thank you so much for making time to tell us about traumatic joint replacements.

[00:17:56] Zachary Telgheder, MD: Thank you very much for having me. It was a pleasure.

[00:17:58] Host Amber Smith: My guest has been Dr. Zachary Telgheder. He's an orthopedic trauma surgeon at Upstate, where he's an assistant professor of orthopedic surgery. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.