I am so grateful to be surrounded in my community by great surgeons like Dr. Minor.
Considering Joint Replacement? Watch this!
Video Transcript
I'm Dr. Talin Pepper, and we're here with Dr. Bradley Minor. He is a local orthopedic surgeon in our region. I'm going to sit down and talk to him about some questions that people have for him. First up: tell me a little bit about you. Where did you go to school, tell me about your family…
I'm from here in Fort Worth. I went to TCU in Fort Worth for undergrad, and then did my orthopedic training at UT Southwestern in Dallas. Then further fellowship in hip and knee replacement at Joint Implant Surgeons in Columbus, Ohio, and then moved back here shortly after that, and I've been here ever since.
Nice. So Chisholm Trail has maybe kind of expanded, growing a little bit…
Yeah, our practice here is Chisholm Trail Orthopedics & Sports Medicine. We have offices in Cleburne and Fort Worth, and now a second Fort Worth office is opening up as well, so we're expanding. There are two other orthopedic surgeons who are more sports-medicine focused, and two podiatrists as well in our group.
Sounds like business is going well, that's excellent. So I want to delve into a couple of things: hip things, and knee replacements. The replacements are your specialty, right? All patients who have hip pain want to know: when is it time to go have this knee replacement, or the hip replacement? What do you tell them?
I think the first step is to get X-rays and see how bad the hip is. Then I'll typically talk to the patient — you're mostly going to be doing a replacement on someone who has bone-on-bone, or end-stage arthritis. Once we know that's what's going on, there are a couple of different options. Conservative treatment is what people usually start with: different types of injections, activity modification, weight loss in some patients, occasionally bracing. Typically when they decide on surgery, they've usually tried an injection first, and if it's working and they're feeling great for six months, they can keep doing those injections as long as they want. Eventually it'll start lasting a shorter period of time. If it lasts for three months or more, that's considered a successful injection because that's when you can repeat it. If they want to keep going with injections and getting good relief, there's no need to ever have a joint replacement — it's when it's affecting your quality of life enough that it's worth having a major surgery for.
Yeah, it varies for everyone. If you can't do the things you want to do in your daily life because you're having pain from arthritis and it's affecting your quality of life significantly — whether that's playing golf or just walking around the grocery store — I think when you decide "this is really affecting my quality of life on a daily basis," it's worth having a joint replacement.
I actually do joint replacements in younger patients pretty frequently, and younger for joint replacement is under 65: patients in their 50s, patients in their 40s, if they have bone-on-bone arthritis for whatever reason. We don't really say "you're too young" anymore. The plastic we use now — the polyethylene liner on hips and knees — wears a lot slower than it used to. I usually cite a 1% revision rate per year for joint replacement: in the first year, there's a 1% chance of some sort of complication, like an infection. If you have it in for 20 years, there's a 20% chance. It's not necessarily that they wear out at a certain time point anymore.
For a hip replacement, hip replacements will function very close to a native hip. You can do very well and do almost any activity after a hip replacement. The other two major procedures I do are total knee replacements and partial knee replacements. In younger patients, if they've had a meniscus injury and lost a large portion of their meniscus, they'll get arthritis on the inside of the knee only, and for those patients I'll do a partial knee replacement where we leave all their ligaments alone and just replace the inside of the knee. You can resume pretty high-level activity with a partial knee replacement. A total knee replacement is probably the one where it's hardest to resume really high-level activity, but you can still do a ton of activity: pickleball would be doable, but really high-speed cutting sports like basketball would be a little bit harder.
Anterior and posterior, and then direct lateral, are the most common approaches in hip replacement. Posterior is the most common; anterior has become much more popular recently. I do all anterior hips. On a posterior hip, you basically split through the gluteus maximus fascia and detach the short external rotators, then repair them at the end — a perfectly fine way of doing a hip replacement. On the anterior hip, you go in between the muscle, so you don't cut any of the muscle. It's more technically challenging, so there's more of a learning curve, but the advantages include a faster recovery in many studies, and a much lower dislocation rate than the posterior approach. There's a higher risk of intraoperative fracture with an anterior hip, mostly in surgeons still on the learning curve.
The dislocation issue plays into what we call hip precautions in the post-op period — things like not being able to sit in a low chair or cross your legs. Not all posterior-approach surgeons require those, but many do; you definitely don't need those with an anterior approach because the likelihood of dislocating an anterior hip is extraordinarily low.
Doing an anterior hip the way I do it, you have both legs to look at during surgery while lying on your back, so it's much easier to measure the patient's leg length accurately — historically that's been a problem patients have had.
I get this often: patients get concerned if they bump their knee in a hallway or doorway. How strong is the implant, and what would it take to damage it?
The implants are made of metal, so they're very strong — you couldn't physically break them if you tried. You could break the bone around it. If you fell and then couldn't walk afterward, you could have a fracture near the implant, but you'd know it. If it's a recent surgery, you'd worry about the incision, but you'd be able to see that. Say a patient is six months out, healed and recovered, slips and bangs their knee hard on something: it's extraordinarily unlikely they'd damage the implant. If you can walk and it's just really sore, ice it, take some Aleve or ibuprofen if you can, and see how it does overnight. If you can't walk, go to the emergency room. It's not like if you fall and bump it, it's going to break — it would take something like a car crash or a really big fall to damage it.
What I've seen with repairing muscles after a hip replacement: the direct lateral approach splits the abductor muscles, and you sometimes see those completely torn off later, which causes a limp. You can reattach it, but it's likely to retear. With the posterior approach, tearing the short external rotators leads to less stability of the hip, so a higher dislocation rate and potentially a limp, but less so than an abductor tear on a lateral approach. We're seeing abductor tears talked about more, especially in the sports-medicine literature. We typically start with injections and physical therapy, but for patients who continue to limp, an MRI showing a tear may lead to a referral to a sports-medicine specialist who does hip arthroscopy, since you can do an abductor repair through a scope. It's not super common, but it's becoming more popular.
More people call it the rotator cuff of the hip. That may be something that becomes more common in the future as it gets tested more.
It's still advancing, still in its early stages for these repairs.
If you need a good hip surgeon, right here, we've got Dr. Minor who's going to take care of you. Nice talk, I really appreciate your time.