Considering Joint Replacement? Watch this!
I am so grateful to be surrounded in my community by great surgeons like Dr. Minor.
Video Transcript
Talin Pepper 0:00Â
Iâm Dr. Talin Pepper, and weâre here with Dr. Bradley Minor. He is a local orthopedic surgeon in our region. Iâm 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 familyâŠ
Bradley Minor 0:18Â
Iâm 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 0:39Â
Nice. So, Chisholm Trail has maybe kind of expanded, growing a little bitâŠ
Bradley Minor 0:45Â
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 weâre expanding. Thereâs 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, thatâs excellent. Well, good to hear. So, I want to delve into a couple of things. Weâre 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
Yeah.
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 1:38Â
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 youâre 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 thatâs kind of one of the main criterias. We get the X-rays, make sure that thatâs what is going on and thatâs the right surgery because some people will have knee pain for other reasons than arthritis. Then once we know that you have arthritis, thereâs a couple of different options. The conservative treatment is what people usually start with, and thatâs 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. Thatâs all the conservative management. And then, typically when they decide on surgery, people would usually have tried an injection, something like that. And if itâs working for them, and theyâre feeling great for six months, well, you can keep doing those injections as long as you want. Eventually, usually, itâll stop working and theyâll start lasting a shorter and shorter period of time. Usually, I say that if it lasts for three months or more, thatâs considered a successful injection because thatâs when you can repeat it, typically. And so, if they want to keep going with injections, and theyâre getting good relief, thereâs no necessarily⊠You donât ever have to have a joint replacement. Itâs just when itâs affecting your quality of life enough that itâs worth having a major surgery for. So eventually, youâre going to be not having good enough relief, and youâre going to have too much pain in between that it affects your quality of life. And when that happens, thatâs time to pull the trigger on a joint replacement.
Talin Pepper 3:46Â
Well, they canât kneel, they canât squat, they canât do stuff. Even with their kids, theyâŠ
Bradley Minor 3:50Â
Yeah. It varies for everyone. So, if you canât do the things that you want to do in your daily life because youâre having pain from arthritis and itâs affecting your quality of life significantly, whether thatâs you want to be playing golf, or you just want to be walking around the grocery store. Itâs different for every patient, but I think when you decide, âThis is really affecting my quality of life on a daily basis,â itâs worth having a joint replacement.
Talin Pepper 4:18Â
Anybody youâd say from maybe even younger. Like, I can think of a case in my head now, she canât kneel, she canât get down, she wants to be able to be more active with their kids, and likeâŠ
Bradley Minor 4:28Â
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, theyâve had some sort of trauma or previous surgery, thatâs where we see a lot of that are younger age that people used to say, âOh, youâre too young for a knee replacement, youâre too young for a hip replacement.â We donât really say that anymore. If you have bone-on-bone arthritis, and itâs 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 thereâs no reason to suffer for more years just because youâre 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 theyâve heard itâs only going to last 10 years, something like that, thatâs not necessarily the case. I usually cite a 1% revision rate per year for joint replacement. So, in the first year, thereâs a 1% chance that something will go wrong, thatâd be some sort of complication like an infection. If you have it in for 20 years, thereâs a 20% chance. So, itâs not necessarily like they wear out at a certain time point anymore.
Talin Pepper 6:08Â
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 peopleâŠ
Bradley Minor 6:17Â
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 youâre doing some sort of⊠Like, I had a guy who wanted to do waterski jumping. Iâd 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 theyâve 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, theyâll get medial arthritis, so arthritis on the inside of their knee only. And for those patients, Iâll 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 itâs 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 youâre trying to do really high-speed cutting like basketball and even pickleball, stuff like that, you could play pickleball but itâs going to be a little bit harder with a knee replacement. Whereas, with a hip or a partial, youâre going to be more good to go. And thatâs not saying that you canât 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 8:33Â
Sure. Yeah, I could see that for sure. So, now Iâll 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. Whatâs the difference? How much do you recommend one versus the other?
Bradley Minor 8:50Â
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, youâre 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. Thatâs a perfectly fine way of doing a hip replacement. And depending on who you talk to, theyâre going to say it either does just as well, or thereâs no difference. But, on the anterior hip, you basically go in between the muscle, and so, you donât cut any of the muscle. It makes it more technically challenging than a posterior hip, so thereâs more of a learning curve. You donât want to do an anterior hip with someone who doesnât do many or hasnât 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, thereâs some other technical advantages. So, depending on the study you look at, in many studies, thereâs 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, thereâs a high risk of intraoperative fracture with an anterior hip. Thatâs 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 thatâs 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 donât 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. Thereâs 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 youâre laying on your back flat. So, itâs really easy to measure the patientâs leg length, which, historically, thatâs been a problem that patients have had is leg lengthâŠ
Bradley Minor 12:23Â
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 youâre checking their leg length is by kind of measuring their knees, theyâre kind of tilting forward and back. So, thereâs a lot more variability than a patient lying on their back and youâre holding both legs in your hand measuring them easily. So, thereâs some technical advantages to it too, but there definitely is a learning curve so thatâs why itâs not being universally adopted. So, if I had come straight out of residency without doing an extra year of training, I wouldnât be able to do anterior hips because I wouldnât have learned how to do that. And many surgeons never did. So, you could go to a course or something like that, butâŠ
Bradley Minor 13:18
Yeah, itâs better to have done a year of training on it, for sure. Not to say that you canât do a good job if thatâs not the case, but itâs just a little bit harder, basically.
Talin Pepper 13:29Â
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, theyâre super concerned about, âDid I damage it? Did I break it?â How strong is that? What would it take to damage the implant.
Bradley Minor 13:53Â
So, the implants, theyâre made out of metal. And so, theyâre very strong. You couldnât physically break them if you tried, theyâre 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 wouldnât be able to stand up and walk. And then, if itâs a recent surgery, you worry about busting up a knee incision or something like that, but youâre going to be able to see that typically. So, say a patient is six months out from surgery, theyâve healed, theyâve 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 couldâŠ
Talin Pepper 14:59
Muscle strain?
Bradley Minor 14:59
Yeah, you could strain or tear a ligament, something like that, but youâre very unlikely to actually damage the implant. So typically, if you have a fall like that, if you canât walk, you should go to the emergency room, you may have a fracture or broken bone around it. If you can walk, and itâs just really sore, Iâd probably wait overnight, Ice it, take some Aleve or ibuprofen if you can tolerate it and donât have any contraindications. See how it doesnât morning, if youâre still having a lot of pain, definitely feel free to see your surgeon that did your surgery. And weâll 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. Thatâs very rare, but itâs possible. So, if itâs pretty severely painful, itâs not unreasonable to go get it checked out. But usually, itâs 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. Itâs not like if you fall and bump it, itâs going to break. Itâs 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 16:31Â
Gotcha. That makes sense. So, essentially, talk to your professional. If youâre 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 Â
Absolutely. Thatâs good advice for that. So, I want to circle back, one last question. Iâve 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 17:17Â
So, what Iâve 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.
Bradley Minor17:36Â
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, itâs 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, thatâs 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, weâre going to start with things like injections, and physical therapy, but youâll have patients who continue to limp, continue to have issues with it. And then, oftentimes, weâll get an MRI that shows a tear. And then, in certain candidates, certain people who are good candidates for it, Iâll typically refer them to a sports medicine specialist that does hip arthroscopy because you can do an abductor repair through a scope. Itâs not a super common procedure, but itâs sort of an up-and-coming thing. Itâs becoming more popular.
Talin Pepper 19:18Â
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, âWeâre going to go in and fix your supraspinatus.â Itâs kind of almost the same thing if the⊠Those are the rotator cuffs of the hip.
Bradley Minor 19:37 Â
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 Â
Yeah. Itâs still advancing. Itâs kind of in its early stages of doing these repairs. How do they hold? Whoâs the right candidate. The older candidate who doesnât really have the capability to hold in. The integrity, the tissue integrity. The whole link.
Bradley Minor 20:03Â
Itâs 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 20:21Â
So, if you need a good hip surgeon, right here, we got Dr. Minor whoâs going to take care of you. Nice talk, I really appreciate your time.
Bradley Minor 20:27Â
No problem. Thanks a lot.