Many people who suffer from debilitating knee or hip arthritis can resume normal activities after having total joint replacement. Edward Nelsen-Freund, MD, believes a conservative approach and careful follow-up are important elements of long-term success.

What makes total joint replacement necessary?

Joint replacement is for people suffering from arthritis, and arthritis can have multiple causes. It could be gout, it could be osteoarthritis or rheumatory arthritis, or it could be post-traumatic arthritis, when patients get arthritis as a result of fractures in their joints. Patients with early arthritis might have some pain, every once in a while some swelling, some limitation in their function. When that limitation becomes unacceptable to them, that's when we start to consider doing a joint replacement.

When does having a joint replacement become advisable?

It's different for each person. One example is the person who is 35 years old and has arthritis in a knee. The thing to realize is that knee replacements are not going to last forever. If you have a knee replacement at the age of 35, you are probably going to be looking at having multiple surgeries to redo it later on down the road. With someone who is younger, the indications are going to be more stringent than with someone who is 70.

You also want to look at what the patient wants to do. I don't do a knee replacement on a patient because he has pain when he plays basketball. You do the procedure mostly for getting the patient back to doing typical activities of daily living, like walking without pain. It depends on how old the patient is, what his or her demands are and how limited he or she is. It also depends on what other treatment options the patient has tried. There are other options besides joint replacements for patients with arthritis. Before I do a surgery, I'd like to try those other things first.

If you need a joint replacement, is it better to do it as soon as possible or to wait?

I try to take an individualized approach to my patients. For patients who haven't had any other treatments, I want to see them try some of the simpler things first - anti-inflammatory injections, physical therapy, maybe even arthroscopic surgery. At the same time I will follow them closely, checking them every couple of months, maybe with X-rays, to see if they are losing bone, because I can't in general make the bone come back. If a patient comes to me who has tried other options and still has problems - they can't walk where they need to go and have a lot of trouble getting around and doing the things they want to do - then that's when we start looking at a joint replacement.

I try some of the simpler things first because even though joint replacements work very well for most people, they don't work well for everybody.

Can total joint replacement be performed using "minimally invasive" surgery?

With a minimally invasive knee procedure, you try to go through less of the muscle with a smaller skin incision. Since you are only seeing parts of the knee at a time, it takes a little bit more work and you have to move the knee around a bit more. The minimally invasive hip procedure is very similar.

My personal view of the minimally invasive approaches is that they are worth looking into, but they do have a higher risk of earlier complications. I look at a joint replacement as a 20-, 30-, or 40-year solution to a problem. If you don't get your components in correctly because you can't see exactly what you're doing, you could sacrifice long-term function. I think the benefits you get from having a potentially quicker rehabilitation do not outweigh the potential risk of sacrificing the longevity of the component.

If a patient really wants a minimally invasive procedure, I will do that, but I let them know that if I'm having a tough time seeing what I want to see or making sure I'm putting the joint where I want to put it, I will extend the incision. I want to make sure I can get the implant in properly, because that's my first goal. My first goal is to get in a joint that will last a long time. My second goal is to try to improve the rehab.

Can both knees or both hips be done at the same time?

For most people, I recommend against it. The complication rate is more than double if you do two hips or two knees at the same time. And those complications can be significant - it can be wound complications, it can be blood clots, stoke, heart attack. However, I have done bilateral knees on a couple of patients because they had overwhelming reason for it.

If a patient wants to have both knees done, I will do them four weeks apart. That way, if their first knee gets stiff, I can actually do a gentle manipulation during the second procedure to get that joint moving again. For the hips, I like to spread them out a little further.

The biomechanics are a lot different in the hip, and I like to have my patients walking with a pretty smooth gait before we force their replacement hip to be the "good side." So hip replacements are usually a couple months apart.

What are outcomes like for these procedures?

If you look in the literature, generally 90 to 95 percent of people do very well with hip or knee replacements. These are some of the more reliable procedures we do. Still, I like to try the conservative things first because there can be significant complications.

How do you know when your joint replacement is wearing out?

What is likely is that you will start to develop pain in the hip or knee. That shows you have a lot of wear and the plastic bearing needs to be replaced or that things are starting to come loose. That's why I feel it is very important to get checked every year or two, because the surgeon can see the wear occurring on the X-ray and it can be fixed before it's too late. If you wear completely through your bearing, particularly in the knee, you likely will need to have everything changed. But if you get in there before the plastic is completely worn through, you just pop the bearing out and pop the new piece in. We refer to it as an "oil change." It's very simple. Same thing with the hip.

Now if you get a big cyst forming around the bone, it will pop the components loose, and that would be completely asymptomatic - you don't have any pain until things pop loose. But, again, you can see it coming with X-rays. I follow my patients and check them out every year to two years to make sure cysts aren't forming, because that's not something you feel.