Considering Joint Replacement? Watch this!
I am so grateful to be surrounded in my community by great surgeons like Dr. Minor.
Talin Pepper 0:00
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 is tell me a little bit about you. Where did you go to school, tell me about your family…
Bradley Minor 0:18
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. And then, further fellowship and hip and knee replacement at Joint Implant Surgeons in Columbus, Ohio. And then, moved back here shortly after that, and been here ever since.
Talin Pepper 0:39
Nice. So, Chisholm Trail has maybe kind of expanded, growing a little bit…
Bradley Minor 0:45
Yeah. So, 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’s two other orthopedic surgeons that are more sports medicine focused, and then two podiatrists as well in our group.
Talin Pepper 1:12
Sounds like business is going well, that’s excellent. Well, good to hear. So, I want to delve into a couple of things. We’re talking a little about hip, some hip things, and then, also about knee replacements. So, the replacements are your specialty, right?
Bradley Minor 1:23
Talin Pepper 1:24
So, we want to kind of discuss with you of like what are the trends? What are you seeing? So, one of the first questions I have is, all patients who have hip pain, they want to know, when is it time to go have this knee replacement, or the hip replacement? What do you tell them?
Bradley Minor 1:38
So, I think the first step is to get X-rays and see how bad the hip is on X-ray. And then, I typically will talk to the patient. And you’re mostly going to be doing a replacement on someone who has bone-on-bone, or end-stage arthritis. In some cases, you can do it in slightly less severe arthritis, but that’s kind of one of the main criterias. We get the X-rays, make sure that that’s what is going on and that’s the right surgery because some people will have knee pain for other reasons than arthritis. Then once we know that you have arthritis, there’s a couple of different options. The conservative treatment is what people usually start with, and that’s going to consist mostly of things like different types of injections. So, steroid injection, delayed release steroid, hyaluronic acid injections, stuff like that. And then, activity modification, weight loss in some patients, occasionally bracing, unloader braces, stuff like that. That’s all the conservative management. And then, typically when they decide on surgery, people would usually have tried an injection, something like that. And if it’s working for them, and they’re feeling great for six months, well, you can keep doing those injections as long as you want. Eventually, usually, it’ll stop working and they’ll start lasting a shorter and shorter period of time. Usually, I say that if it lasts for three months or more, that’s considered a successful injection because that’s when you can repeat it, typically. And so, if they want to keep going with injections, and they’re getting good relief, there’s no necessarily… You don’t ever have to have a joint replacement. It’s just when it’s affecting your quality of life enough that it’s worth having a major surgery for. So eventually, you’re going to be not having good enough relief, and you’re going to have too much pain in between that it affects your quality of life. And when that happens, that’s time to pull the trigger on a joint replacement.
Talin Pepper 3:46
Well, they can’t kneel, they can’t squat, they can’t do stuff. Even with their kids, they…
Bradley Minor 3:50
Yeah. It varies for everyone. So, if you can’t do the things that 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 you want to be playing golf, or you just want to be walking around the grocery store. It’s different for every patient, but I think when you decide, “This is really affecting my quality of life on a daily basis,” it’s worth having a joint replacement.
Talin Pepper 4:18
Anybody you’d say from maybe even younger. Like, I can think of a case in my head now, she can’t kneel, she can’t get down, she wants to be able to be more active with their kids, and like…
Bradley Minor 4:28
Well, yeah. I actually do joint replacements in younger patients pretty frequently, and younger for joint replacement is under 65. So, patients in their 50s, patients in their 40s, if they have bone-on-bone arthritis for whatever reason, whether they just happen to get arthritis early and have bad luck, or, in many cases, they’ve had some sort of trauma or previous surgery, that’s where we see a lot of that are younger age that people used to say, “Oh, you’re too young for a knee replacement, you’re too young for a hip replacement.” We don’t really say that anymore. If you have bone-on-bone arthritis, and it’s significantly affecting your quality of life, I think your age really is somewhat irrelevant. Although, the longer you have a joint replacement in, the higher chance you have of having it redone, but there’s no reason to suffer for more years just because you’re younger than the average patient anymore. So, plastic that we use now, so the polyethylene liner on the hips and knees, it wears a lot slower than it used to. So, everybody will come in saying they’ve heard it’s only going to last 10 years, something like that, that’s not necessarily the case. I usually cite a 1% revision rate per year for joint replacement. So, in the first year, there’s a 1% chance that something will go wrong, that’d be some sort of complication like an infection. If you have it in for 20 years, there’s a 20% chance. So, it’s not necessarily like they wear out at a certain time point anymore.
Talin Pepper 6:08
Right. And even with maybe activities, right? So, I want to play pickleball, or they want to go try to jog, like you say, these people…
Bradley Minor 6:17
Yeah. So, I think different surgeries, you can expect different things. So, 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. Although, if you’re doing some sort of… Like, I had a guy who wanted to do waterski jumping. I’d discourage something like that because if you had a fracture around the implant, that would be a problem. But any normal activity you would want to be doing is going to be okay. And then, the other two major procedures that I do are total knee replacements and partial knee replacements. So, in younger patients, a lot of times, if they’ve had maybe their medial meniscus had an injury, and they had surgery on that, maybe 10 years later, if they lost a large portion of their meniscus, they’ll get medial arthritis, so arthritis on the inside of their knee only. And for those patients, I’ll do a partial knee replacement where we, basically, we leave all their ligaments alone, we leave the outside and the patellofemoral joint alone, and just replace the inside of the knee. You can resume pretty high-level activity with a partial knee replacement, and it can feel pretty natural. So, pickleball and jogging would be definitely doable. Total knee replacement, you can still do a ton of activity also, but it’s probably the one that it would be the hardest to resume really high-level activity with. So, if you were a long-distance runner, or something like that, or you’re trying to do really high-speed cutting like basketball and even pickleball, stuff like that, you could play pickleball but it’s going to be a little bit harder with a knee replacement. Whereas, with a hip or a partial, you’re going to be more good to go. And that’s not saying that you can’t do most anything with a knee replacement as well, but really high-demand sports are going to be harder with a knee replacement in general.
Talin Pepper 8:33
Sure. Yeah, I could see that for sure. So, now I’ll just circle back a little bit to the hip replacement. You said, overall, more like a native hip. What are you seeing with… Some people ask about an anterior hip versus a posterior hip. What’s the difference? How much do you recommend one versus the other?
Bradley Minor 8:50
So, anterior and posterior, and then, direct lateral are kind of the most common approaches in hip replacement. Posterior is the most common, anterior has become much more popular recently. I do all anterior hips. So, just upfront disclaimer, I may be a little bit biased.
Bradley Minor 9:17
I definitely am a little bit biased towards it. But the difference is, so the way you enter the joint on a posterior hip, you’re going to basically split through the gluteus maximus fascia, and then up into the muscle too. And then, you detach these muscles called your short external rotators, and then repair them at the end. That’s a perfectly fine way of doing a hip replacement. And depending on who you talk to, they’re going to say it either does just as well, or there’s no difference. But, on the anterior hip, you basically go in between the muscle, and so, you don’t cut any of the muscle. It makes it more technically challenging than a posterior hip, so there’s more of a learning curve. You don’t want to do an anterior hip with someone who doesn’t do many or hasn’t done many in the past. But the advantages of it are, depending on the study you look at, a little bit faster recovery. And then, there’s some other technical advantages. So, depending on the study you look at, in many studies, there’s a higher dislocation rate with a posterior approach hip. The dislocation rate is extremely low in the anterior approach hip. There are other downsides of it, there’s a high risk of intraoperative fracture with an anterior hip. That’s mostly surgeons in the learning curve that are having that issue, but that definitely is cited in the literature. And then, the dislocation issue plays into what we call hip precautions in the post-op period. Not at posterior approach surgeons will have hip precautions. And that’s things like not being able to sit in a low chair, or cross your legs, and stuff like that. Not all posterior approach surgeons require those, but many do. And you definitely don’t need those with an anterior approach because the likelihood of dislocating an anterior hip is extraordinarily low.
Bradley Minor 11:29
Yeah, they dislocate out the back, typically. And so, when you go in through the front, the dislocation rates are extraordinarily low. Another advantage technically to doing it is the way I do and anterior hip. There’s kind of two ways you can do it, you can use a special table called the Hana table or fracture table, or you can do it with a regular table and trained assistant who manipulates the leg for you, which is what I do. And so, doing it that way, you basically have both of the legs that you can look at during surgery, and you’re laying on your back flat. So, it’s really easy to measure the patient’s leg length, which, historically, that’s been a problem that patients have had is leg length…
Bradley Minor 12:23
And the reason for that is because the patient with a posterior approach or a lateral approach is laying on their side. And so, the way you’re checking their leg length is by kind of measuring their knees, they’re kind of tilting forward and back. So, there’s a lot more variability than a patient lying on their back and you’re holding both legs in your hand measuring them easily. So, there’s some technical advantages to it too, but there definitely is a learning curve so that’s why it’s not being universally adopted. So, if I had come straight out of residency without doing an extra year of training, I wouldn’t be able to do anterior hips because I wouldn’t have learned how to do that. And many surgeons never did. So, you could go to a course or something like that, but…
Bradley Minor 13:18
Yeah, it’s better to have done a year of training on it, for sure. Not to say that you can’t do a good job if that’s not the case, but it’s just a little bit harder, basically.
Talin Pepper 13:29
Very true. I get this often, patients, they get concerned if they bumped their knee into the hallway, or doorway, or whatever. They slip and they fall, they’re super concerned about, “Did I damage it? Did I break it?” How strong is that? What would it take to damage the implant.
Bradley Minor 13:53
So, the implants, they’re made out of metal. And so, they’re very strong. You couldn’t physically break them if you tried, they’re pretty much impossible to break, the implant itself. You could break the bone around it. So, if you fell, and then, you could not walk afterwards, you could have what we call a Periprosthetic fracture a fracture near your implant, but you would know, you wouldn’t be able to stand up and walk. And then, if it’s a recent surgery, you worry about busting up a knee incision or something like that, but you’re going to be able to see that typically. So, say a patient is six months out from surgery, they’ve healed, they’ve recovered, they slip and fall, they bang their knee hard on something; extraordinarily unlikely that they would damage the implant. You could damage other things, you could break the bone above it, you could…
Talin Pepper 14:59
Bradley Minor 14:59
Yeah, you could strain or tear a ligament, something like that, but you’re very unlikely to actually damage the implant. So typically, if you have a fall like that, if you can’t walk, you should go to the emergency room, you may have a fracture or broken bone around it. If you can walk, and it’s just really sore, I’d probably wait overnight, Ice it, take some Aleve or ibuprofen if you can tolerate it and don’t have any contraindications. See how it doesn’t morning, if you’re still having a lot of pain, definitely feel free to see your surgeon that did your surgery. And we’ll take an X-ray for peace of mind, make sure it looks okay, give you reassurance. It almost never is something bad, but occasionally, it is. I had a patient who they fell and tore their MCL, basically. That’s very rare, but it’s possible. So, if it’s pretty severely painful, it’s not unreasonable to go get it checked out. But usually, it’s going to be just fine. And the force that it takes to damage the knee after a knee replacement, or the hip after hip replacement, is a very high level of force. It’s not like if you fall and bump it, it’s going to break. It’s pretty much just as strong as it was before, so it would take something like a car crash, or a really big fall, something like that, to damage it.
Talin Pepper 16:31
Gotcha. That makes sense. So, essentially, talk to your professional. If you’re seeing a physical therapist, which usually, you would for the most part at these. Talk to them, check with them. And then, have a contact with your surgeon on what to do.
Bradley Minor 16:44
Yeah, for sure.
Talin Pepper 16:45
Absolutely. That’s good advice for that. So, I want to circle back, one last question. I’ve got patients that ask about it. You mentioned the posterior hip, where they go in and they detach these external rotators, they have to go through and split the fascia. So, these people, sometimes I see they limp, they have some problems with it. It can be pretty debilitating over time. So, have you seen anything with being able to repair those? Do you know anything about that situation?
Bradley Minor 17:17
So, what I’ve seen with repairing muscles after a hip replacement. The third type of approach is the direct lateral approach where you actually split the abductor muscles. So, that is like this motion; spread your leg apart, you know this.
So, you can see abductor repair because, that approach, you basically split through those abductor muscles, and then you reattach them at the end. And you sometimes will go back in and see those completely torn off, and that will cause a limp. So, if that happens, it’s a problem. You can reattach it, but it is likely to retear again in the future. With the posterior approach, you could tear that little short external rotators, tear that repair, that’s going to lead to less stability of the hip, so a higher dislocation rate and could potentially cause a limp. But less so than if you had an abductor tear like on a lateral approach. We do see abductor tears becoming more talked about, especially in the sports medicine literature, which is sort of a different subspecialty from mine, but we do see patients who have torn their abductors. And typically, we’re going to start with things like injections, and physical therapy, but you’ll have patients who continue to limp, continue to have issues with it. And then, oftentimes, we’ll get an MRI that shows a tear. And then, in certain candidates, certain people who are good candidates for it, I’ll typically refer them to a sports medicine specialist that does hip arthroscopy because you can do an abductor repair through a scope. It’s not a super common procedure, but it’s sort of an up-and-coming thing. It’s becoming more popular.
Talin Pepper 19:18
Sure. (Crosstalk 19:19-19:22) I see it more and more. I see a lot of kind of mid-younger age, like, trying to prevent. Almost like they did a lot with the rotator cuff repairs, they go in to try to prevent you from having some of this, “We’re going to go in and fix your supraspinatus.” It’s kind of almost the same thing if the… Those are the rotator cuffs of the hip.
Bradley Minor 19:37
Exactly. More people call it the rotator cuff of the hip. So, that may be something that becomes more common in the future as that becomes tested, and things like that.
Talin Pepper 19:50
Yeah. It’s still advancing. It’s kind of in its early stages of doing these repairs. How do they hold? Who’s the right candidate. The older candidate who doesn’t really have the capability to hold in. The integrity, the tissue integrity. The whole link.
Bradley Minor 20:03
It’s more likely to be a younger patient, things like that. So yeah. I think that could be something up-and-coming in the future for sure.
Talin Pepper 20:21
So, if you need a good hip surgeon, right here, we got Dr. Minor who’s going to take care of you. Nice talk, I really appreciate your time.
Bradley Minor 20:27
No problem. Thanks a lot.