Frequently Asked Questions

Osteoarthritis and Joint Replacement

I get a lot of similar questions by patients and family members. You will find the answers to frequently asked questions on this page. Please feel free to contact me if there are any individual questions left.

Osteoarthritis – what is it?

Osteoarthritis is progressive destruction of joints by wear. Risk factors for osteoarthritis include obesity, previous injury to the affected joint, repetitive minor injuries by sports activities, and family history of osteoarthritis. Osteoarthritis can also develop after years of rheumatoid arthritis, which is a chronic inflammation of the joints. In most cases, however, there is no single cause for the development of osteoarthritis and it  develops after many years of use. It affects people who are middle-aged or older.

With osteoarthritis, the articular cartilage that covers the ends of bones in the joints gradually wears away. Where there was once smooth articular cartilage that made the bones move easily against each other, there is now a frayed, rough surface. In the knee joint, the meniscus wears out and is subject to ruptures. The ligaments become (relatively) to long which leads to instability. Additional bone is formed (so called osteophytes), debris accumulates in the joint, and a chronic inflammation of the inner surface of the capsule lead (synovial) leads to joint effusions.

The symptoms of osteoarthritis are quite uniform, regardless of the different causes:

  • Pain. A joint affected by osteoarthritis may be painful and inflamed. Without cartilage, bones rub directly against each other when the joint moves. This is what causes the pain and inflammation. Pain or a dull ache usually develops gradually over time. Pain may be worse in the morning and feel better with activity. Vigorous activity may cause pain to flare up. Typically, the pain changes over time, and there might be also intervals with less pain periodically changing with intervals with severe pain.
  • Swelling and effusion. The joint may stiffen and look swollen, enlarged or “out of joint.” A bump may develop over the joint. Of course, swelling is more obvious in joints with a thinner layer of soft tissue, and it can be observed easier in knee joints than in hip joints.
  • The range of motion deteriorates. Loose fragments of cartilage and other tissue can interfere with the smooth motion of joints. The joint may lock or “stick” when used. It may creak, click, snap, or make a grinding noise (crepitus).

When do I need a joint replacement?

Joint replacement is an option for all worn out joints with severe pain which can not be treated otherwise or conservatively.

Basically, joint replacement helps to restore quality of life, which can be severely affected by joint pain.  Joint replacement helps to restore morbility and enable physical acitivity, including appropriate sports.

If quality of life is deteriorated, and if physical activity has to be reduced significantly due to joint pain, the time to replace the joint has come. Other criteria have to be considered while indicating total joint replacement, including the patient’s age and general health condition. The radiologic appearance has also to be taken into account, but finally the patient’s impairment and expectations are the main criteria for the decision to undergo total joint arthroplasty.

When you consult Prof. Eingartner, all these factors will be considered and weighted carefully. But finally it is you, the patient, who has to make an informed decision to undergo surgery or not.

 

Surgery and anaesthesia – how do things run?

Prior to a hip or knee replacement there are to do the same preparations as on all other medium surgical procedures. If necessary due to the general medical conditions, the family doctor will do all examinations and measures. Medication which affects coagulation (blood clotting) has to be discontinued (e.g. Aspirin, Warfarin, Plavix and others); the same is the case for some oral antidiabetics. All other medication should be taken as normal.

One day before surgery there will be a check-up by the anaesthesist. You can discuss the right anaesthetic procedure with him, e.g. whether to do general anaesthesia or regional anaesthetics. In the latter case, a medicament is applied regionally at the spine, resulting in a temporary anaesthesia of the legs and the pelvis.

After the procedure, we will provide you with sufficient pain killers or even a regional continuous pain catheter, so you don’t have to experience too much pain from the operation. Thus, an operated knee joint can be moved passively without any pain.

During surgery, we use a so-called cell-saver, which enable us to collect, purify and give back to you all the blood you might loose intra- and early postoperatively. Thus, the preoperative collection of your own blood for retransfusion is not more necessary.

The total hip replacement

For total hip arthroplasty, both the femoral head and the acetabulum have to be replaced. There are many different methods to do that, and Prof. Eingartner will choose and discuss with you in any detail the most suitable procedure for you.

How does a total hip replacement work?

It is important to do a meticulous preoperative planning of the replacement procedure. We do this by means of digitizes x-rays and a special software for preoperative planning.

After access to the hip joint, the femoral neck is exposed and the femoral head with all deformities and lack of cartilage is cut off and removed. The new femoral head is on top of a metal body (femoral shaft), which is fitted into the bone of the femur. In normal bone this can be done without the use of bone cement, just by press-fitting the metal body into the femoral medullary canal after appropriate preparation of the canal. On the acetabular side, the bone is reamed to a certain size, which has been planned preoperatively.

The bearing of the articulation can be chosen under different materials. In most younger patients we use a ceramic-ceramic-combination, which has been shown to be the most wear-resistant and long living bearing option. In all other patients we use a ceramic-polyethylene combination, which also has been shown to yield excellent results. The combination of metal-on-metal, which has been discussed extensively in the last years due to wear problems associated exclusively with this bearing option has never been used in our hospital.

During implantation a reconstruction of the geometry of the hip joint including lever arms for the muscles is achieved, even in cases with severe deformities. Patients with a total joint arthroplasty of the hip gain back pain-free mobility rather quick (but, of course, this is also related to age, co-morbidity and preoperative mobility).

Now, for conventional uncemented total hip replacement, there are extended experiences with this type of hip replacement since more than 25 years. We use the Bicontact hip (B|Braun Aesculap Orthopaedics,Tuttlingen,Germany). Prof. Eingartner has published excellent long-term results for this prosthesis with a well-functioning hip in 97% of all cases after 20 years.

We recommend the conventional uncemented total hip replacement as a standard procedure for most patients and most ages.

 

Short hip stems – an option for me?

In this type of hip joint replacement the lateral portion of the femoral neck is retained in order to preserve bone. The short stem is fitted into the uppermost part of the femoral bone and the lateral portion of the femoral neck. On the acetabular side, the procedure is the same as in a conventional uncemented total hip. Most short hip stems are combined with a ceramic-on-ceramic bearing.

Short hip stems enable the orthopaedic surgeon to retain more bone, which is of special interest for younger patients, because they have a greater chance that revision surgery might be necessary in later life and bone loss is the greatest problem in revision.

Additionally, short hip stems are most suitable for minimal-invasive hip replacement procedures.

Experience with short hip stems is still limited and no long term follow-up data exist, since most short hip stems are on the market since 2004. The short- and mid-term results, however, are very encouraging. We use the short hip stem METHA (B|Braun Aesculap Orthopaedics,Tuttlingen,Germany), because this is the stem with the best published data (with respect to number of patients included, follow-up time and survival data).

We recommend the total hip replacement with a short stem for younger (less than 65 years) patients with normal joint geometry and bone strength.

 

So many choices – what is best for me?

We love to discuss the different options of hip replacement with well-informed patients. On the other hand, we can see more and more often that patients are puzzled by dozens of different opinions which can be found in different sources, including the internet. So much information is led by marketing interest and by economic interests of hospitals and surgeons.

In the preoperative visit at Prof. Eingartner’s office a thorough consulting will take place, including the individual anatomical situation, bone quality and age, updated scientific information and your individual needs and expectations. There are more than 1000 models for hip replacement on the world-wide market, and we have chosen a standard stem for uncemented and cemented implantation with excellent data for more than 20 years. And we have chosen the short stem with the best record to minimize the risk and to maximize the chances with a novel type of implant. All implants are manufactured inGermanyby B|Braun Aesculap Orthopaedics, Tuttlingen. Hip resurfacing has been in our portfolio for years, but we have abandoned this type of hip replacement due to increasing concerns in the literature (metal wear, osteolyses, fractures, early failures, pseudotumors).

With respect to bearing (which material glides on which material?) we have decided to use ceramic-on-ceramic in younger patients. Ceramic is absolutely inert, provides by orders of magnitudes the lowest wear rates and has the lowest sliding resistance. Our ceramic components are manufactured by Ceramtech (Plochingen,Germany), and nearly all orthopaedic companies all over the world purchase their ceramic components there. For all other patients we use ceramic heads together with cup inserts made from polyethylene. Tremendous advances have been made in the last 10 years to improve wear properties in polyethylene components. Metal-on-metal bearing has never been used in our hospital for total hip replacement, so the ongoing discussion about problems associated with metal-on-metal (wear, ion-release and allergy) has no impact on our patients.

Basically, you as a patient have to decide whom you trust. Prof. Eingartner and his team do joint replacement for more than 20 years. By his own scientific work in the field of total joint replacement and by continuous awareness to data published in the literature and presented at national and international meetings, Prof. Eingartner is able to make a well informed choice, individualized for your personal situation.

 

Minimal invasive – that’s better, eh?

Minimal invasive orthopaedic surgery has extensively been discussed an marketed in the last decade. But if you ask any expert, he will concede that the long term success of total hip replacement is not related to the length of the skin incision, but to the precision of implant positioning. Precision is the foremost goal the orthopaedic surgeon has to strive for, and it is not allowed to risk an implant misalignment due to the limited visualization through limited approaches. Implanting a total joint replacement is not building a ship in a bottle.

Scientific evidence is still lacking that minimal invasive procedures produce better results.

On the other hand, it is important, not to jeopardize the muscles around the hip joint – muscles are the “motor” of the hip joint, they get things moving, and they stabilize the joint. Thus, muscle-sparing approaches are more important than short skin incisions.

Prof. Eingartner has done some scientific work on several minimal-invasive hip approaches and teaches in national and international hip approach courses.

We use a minimized approach with a skin incision of approximately 10 cm. The hip joint is exposed by use of a interval between two muscles without any incision or detachment of a muscle (for the experts: minimal invasive anterolateral approach in the interval between M. tensor fascia latae and M. glutaeus medius).

 

Can you tell me details about the surgical procedure?

The implantation of a total hip prosthesis is the most common surgical procedure worldwide. However, meticulous planning and accurate execution by an experienced surgeon is necessary in every single case.

The operation is carried out in supine position. The incision is made on the lateral side and approximately 10 cm long and blunt preparation through preformed muscle spaces minimizes the soft tissue trauma. The femoral neck is exposed and cut with an electrical saw. Now the femoral head can be removed and the acetabulum is exposed.

Now the acetabulum is being prepared with spherical reamers and a metal shell (titanium) is fitted into the bone of the pelvis. Sizing and orientation of the metal shell is crucial in order to get a good range of motion and a stable articulation without the risk for dislocation. A liner made of ceramic or polyethylene is inserted into the metal shell.

The preparation of the femoral fitting for the metal stem is achieved by means of special broaches. The negative profile of the metal stem is cut into the bone. The stem, which is manufactured from titanium, is fitted into the femoral canal. Again, sizing, orientation and insertion depth are crucial for a well functioning hip joint and leg length.

Finally, the femoral head (made out of ceramics) is set on the femoral shaft and the joint is reduced. After testing for range of motion, tendency for dislocation and leg length an intraoperative x-ray is taken to document the correct positioning and articulation. At the end, a drain is inserted into the joint space and the wound is closed.

The overall surgical time is 45 to 90 minutes.

 

What’s about rehabilitation?

You can get out of the bed on the first day after the operation and make the first steps with your new joint. After removal of the wound drains on day 2 or 3 after the operation you can start to move for longer distances on the ward and also on stairs. A physiotherapist teaches you how to move with the new joint and how to get back to walking.

After 8 to 10 days you can leave the hospital and continue the rehab process in a specialized facility, as an outpatient or inpatient.

When you come from abroad, different schedules are possible, tailored to your individual needs. You can stay some days longer in the hospital, and part of the rehab process can be done here, until you are safe enough to travel back home. You can also stay shorter and switch directly to our rehab partner, ensuring a seamless continuation of the rehab process.

Full weight bearing is possible immediately after the operation. You can put away the crutches 6 – 8 weeks after the operation, and you will be back to work after 8 – 10 weeks (depending, of course, what kind of work you are supposed to do).

Regular orthopaedic visits with physical examination and x-rays every 1 – 2 years are recommended after all joint replacement procedures.

 

The total knee replacement

Conservative treatment and joint retaining surgery like arthroscopy or corrective osteotomy play an important role in the treatment of osteoarthritis of the knee joint. When the damage to the cartilage is limited, cartilage repair surgery like mikrofracturing or autologeous cartilage transplantation (ACT) can be an option.

However, if wear and destruction are beyond a certain point, partial or total joint replacement is the only solution to severe knee pain. Knee replacement helps to restore quality of life, helps to restore morbility and enable physical acitivity. Other criteria have to be considered, including the patient’s age, his general health condition and the radiologic. Finally, the patient’s impairment and expectations are the main criteria for the decision to undergo total knee replacement.

 

Unicondylar knee replacement – is this an option for me?

In many cases, only the medial side of the knee joint is affected by osteoarthritis: the pain is only here. Often there has been a previous arthroscopy which demonstrates, that the cartilage and meniscus of the lateral side of the knee joint are intact. If, in addition, the anterior cruciate ligament is also intact, the surgical treatment of this type of osteoarthritis can be limited to replacement of the medial part of the knee joint. The advantages include a smaller surgical approach, quicker rehabilitation protocol and the retaining of healthy parts of the joint, like the cruciate ligaments, the lateral part and the patellofemoral joint.

The components are manufactured from metal (cobalt-chromium) and a special mobile bearing is made from polyethylene. The metal components are mounted to the bone by the use of cement.