Podcast: WHAT DOES YOUR DOCTOR SAY?

Episode: When to see an orthopedist? #02

Leading: Dariusz Litera

Guest: Dr. Tomasz Góral, specialist in orthopedics and traumatology

Duration: 16 minutes

Joint disease is a common health problem among older adults. This episode of WHAT YOUR DOCTOR SAYS focuses on degenerative changes in the knee and hip joints, pain that limits daily activity, and situations where surgical treatment may be necessary.

Dariusz Litera's guest is Dr. Tomasz Góral, a specialist in orthopedics and traumatology. The expert explains the natural aging process of joints, the importance of prevention, body weight, diagnostics, and patient preparation for joint replacement surgery.

The conversation also covers practical aspects of treatment: qualification for surgery, the need to exclude inflammatory foci, the role of rehabilitation, possible pain after surgery, and preparing the patient's home and immediate surroundings for life after endoprosthesis implantation.

Full podcast transcript

[00:00:00] Why do joints fail with age?

Dariusz Litera:

More than half of Poles over 60 suffer from joint disease. According to the National Health Fund, the largest percentage of reimbursed medications is for medications prescribed for musculoskeletal disorders. Patients struggling with this condition experience pain that significantly limits their activity.

Is knee and hip replacement the only effective method for restoring mobility in seniors? Today, your doctor is orthopedic traumatologist Dr. Tomasz Góral. Hello, doctor. Why do our joints fail over the years? What's wrong?

Dr. Tomasz Góral:

This is the natural aging process of joints.

Dariusz Litera:

There's nothing natural about the aging process. Absolutely, it's poorly conceived, but I'll accept the argument. Natural aging?

Dr. Tomasz Góral:

We'll stick with it. Unfortunately, everyone born will eventually die. Our joints don't age differently than our entire body.

We can get used to a wrinkle appearing on our face, but something we can't see is difficult to understand. Nevertheless, the disease progresses. Sometimes we don't notice the symptoms.

Dariusz Litera:

We crush this cartilage throughout our lives.

Dr. Tomasz Góral:

Yes. As it loses the properties of hyaline cartilage, it is no longer as flexible. Some irregularities develop. Pain occurs when the cartilage has long since lost its luster.

We ignore certain symptoms that are visible to us. We treat them as injuries, as the consequences of a certain carelessness in performing a given movement. But let's not ignore symptoms related to the knee or hip joints themselves. It's always better...

Dariusz Litera:

Overreact?

Dr. Tomasz Góral:

That's right. Therefore, we prefer prevention over categorical solutions. If degenerative disease progresses to advanced stages, the most common treatment is joint replacement.

[00:02:00] Do we have any influence on the condition of our joints?

Dariusz Litera:

But what influence do we have to stop this process? Do we have influence?

Dr. Tomasz Góral:

Throughout our lives, we have influence over how we use these joints. Their future appearance depends on the type of injuries they have sustained, the level of activity we engage in, and whether that activity was appropriate or perhaps too low.

Dariusz Litera:

Do we spend our entire lives walking around with a thirty-kilogram backpack strapped to our stomachs?

Dr. Tomasz Góral:

Yes. On the stomach. It's often distributed quite symmetrically. On men, we more often see this backpack worn slightly forward.

However, the disease affects both women and men equally, but we must also know that in more advanced changes the female sex predominates.

[00:02:47] When does joint replacement become necessary?

Dariusz Litera:

What is the absolute indication for a surgical procedure in the field of joint replacement? A patient comes to the office and first undergoes some diagnostic and treatment process. When is the moment when nothing can be done and it's time to go to the operating table?

Dr. Tomasz Góral:

During a clinical examination, we assess the quality of a given joint. A physical examination is the most important test, later supplemented by laboratory diagnostics, ultrasound, and basic X-ray diagnostics.

Of course, we assess the range of joint mobility and any discomfort resulting from that joint mobility. This means that if pain is confined to a specific joint, we can accurately isolate it during a clinical examination. We confirm this with additional tests, and then we know what we can recommend to the patient, the stage of their disease, and therefore what further treatment should be.

[00:03:47] Conservative treatment before surgery: medications, injections and chondroprotection

Dariusz Litera:

Before this surgical treatment, there's talk of various therapies, some intra-articular injections, things like that that alleviate certain symptoms. What's the process like—spread over months and years? Do we get to the table sooner? What does it look like?

Dr. Tomasz Góral:

We have dedicated medications that protect cartilage. This is called chondroprotection. We can also use intra-articular viscosupplementation, specifically the aforementioned injections, most often containing hyaluronic acid.

However, there are specific indications for this therapy. It's not always possible, nor will it always be effective. When joint destruction is too advanced, the therapy will be ineffective, and joint replacement is required.

[00:04:36] What does preparation for knee replacement look like?

Dariusz Litera:

And during such a visit, the doctor says: "This is already an indication." What happens next? What does this process look like? How does this process work in the case of knee joints?

Dr. Tomasz Góral:

The preparation process for this procedure is multi-step. It's a very large operation, and even the patient has no idea what's happening on the operating table.

We, as orthopedists, must also prepare for this procedure by assessing the degree of bone destruction. How do we choose the right endoprosthesis? What should it be like? This includes measurements that will later facilitate the selection of the final endoprosthesis on the operating table.

But before a patient goes to the operating table, they must prepare. First and foremost, according to the guidelines of the Polish Society of Orthopaedic and Rheumatological Surgery, they should achieve a BMI below 35. This is absolutely essential. We shouldn't operate on patients whose BMI is significantly higher, meaning they are morbidly obese. In such cases, before the patient goes to the operating table, they should seek advice from other specialists, including those in the field of bariatrics.

Preparing a patient for surgery should be a multi-step process. First, the patient must also carefully assess any existing inflammatory lesions that could compromise the results of surgical treatment.

So in this case, we also ask for an assessment by other specialists to exclude existing inflammatory foci, which will consequently have a very significant impact or a possible impact on the complications of endoprosthesis.

[00:06:24] Why is a dental and ENT checkup necessary before surgery?

Dariusz Litera:

It is often necessary to go to the dentist.

Dr. Tomasz Góral:

Yes, exactly. Scientific studies have shown that the most common causes of septic complications during endoprosthetics are abscesses or periapical inflammation. Therefore, the dentist should perform a panoramic X-ray before the planned endoprosthetic procedure.

We also ask an otolaryngologist to assess the bacterial flora in the nose. Any other specialist should also comment if the patient has a specific condition.

Dariusz Litera:

So this is a really broad diagnostic?

Dr. Tomasz Góral:

Extensive diagnostics. Don't treat joint replacement like a visit to a mechanic who will swap out a new tire and keep it spinning. It might not spin for a long time if you don't prepare properly.

An allergist's evaluation is also required to determine any possible allergies to the metals from which the endoprosthesis is constructed. If allergy tests confirm an allergy to a given metal, we must be informed in advance and will prepare an appropriate endoprosthesis that we can safely implant.

Dariusz Litera:

Which no longer contains this element.

Dr. Tomasz Góral:

Which does not contain it or is covered in such a way as not to cause an allergic reaction.

[00:07:50] Does endoprosthesis surgery hurt?

Dariusz Litera:

Doctor, the most important question: does it hurt a lot? Does it hurt more than when we couldn't move before the surgery and those joints were really failing?

Dr. Tomasz Góral:

Yes, it will hurt. However, the anesthesiologist will monitor this throughout the perioperative period. These pain symptoms will undoubtedly persist once you return to activity.

We have to adapt, to prepare for the fact that we have a joint that previously moved completely differently. Of course, the healing process of the soft tissue will cause pain, but thanks to pharmacotherapy, we manage this very well.

[00:08:26] How long does rehabilitation take after knee replacement?

Dariusz Litera:

Statistically, because each case is different, how long does rehabilitation take after this type of surgery? We're talking about knee joints.

Dr. Tomasz Góral:

Rehabilitation depends largely on the patient's cooperation in the process. If someone is unwilling to improve, the treatment itself will also be poor. This rehabilitation will not progress properly, but we also caution such patients against joint replacement.

This is also one of the reasons why a patient may be disqualified from undergoing this procedure. Therefore, if we don't see a patient willing to cooperate during the rehabilitation period, we should reach the conclusion with the patient that joint replacement might not be a good option, as they won't benefit from this treatment.

Dariusz Litera:

The comfort of life will not change.

Dr. Tomasz Góral:

If he doesn't feel like getting out of bed, implanting an endoprosthesis won't make him get up.

The rehabilitation process is, of course, variable; it will be completely different for each person. It depends solely on the individual's vitality. The standard assumption is that after approximately six weeks, in a typical case, we can discontinue crutches. By that time, we hope the patient will have improved enough to be able to walk properly.

[00:09:48] Hip or knee replacement – which procedure is more difficult?

Dariusz Litera:

When it comes to hip joints, the situation is more serious in my opinion. It's probably a slightly different procedure, even more invasive?

Dr. Tomasz Góral:

From a technical perspective, the knee joint is more difficult to prosthesize. Hip joints are easier to prosthesize, but of course, these procedures require experienced orthopedists and don't always go as planned.

In reality, we can't compare hip and knee replacement procedures and say one is easier than the other. If we prepare properly, the patient is prepared, and we are prepared for the procedure, the procedure will proceed as we expect.

However, if any of these factors fail to work, complications may arise during the surgical procedure, which we also have to deal with.

So, comparing whether it's a hip or knee replacement, whether one of these procedures is easier from a technical perspective—there are differences we could discuss, but only in an academic debate and among experienced orthopedists. However, we treat every procedure as a difficult one.

[00:11:18] Who is involved in joint replacement surgery?

Dr. Tomasz Góral:

This is a procedure that requires an interdisciplinary approach. An anesthesiologist will oversee the anesthesia process. The arthroplasty itself involves many people.

Three orthopedists, that's the team, plus one or two instrument technicians. Plus the staff who stand behind us, respond, and help. That is, the instrument technician, who isn't—as we so popularly call it—"dirty," in this case, who isn't involved at the operating table, but responds to everything we ask of him.

[00:11:58] How long does it take to recover from hip surgery?

Dariusz Litera:

How long does it take to recover from hip surgery?

Dr. Tomasz Góral:

These are roughly similar times. We strive to ensure that the patient can truly use the joint after just six weeks.

Of course, most often he will still belay himself with a stick until the movement pattern is correct, so that this belaying is still there.

[00:12:20] How have endoprostheses and surgical techniques changed?

Dariusz Litera:

How do procedures performed today differ from those of a dozen or so years ago? What does it look like? Because there's been tremendous progress in all areas of medicine, something changes practically every month.

We often hear about 3D printers, patient-tailored, personalized solutions. What does this look like now?

Dr. Tomasz Góral:

It all varies technically. Starting with the first prosthetics in the nineteenth century, which incorporated ivory as a substitute, we are now in a privileged position.

These endoprostheses are already very well made. However, these are, of course, standard endoprostheses that vary in size, angle, and structure, depending on the companies supplying them.

They are tailored to the patient, but we often also deal with extensive bone destruction. For such patients, there are no standardized endoprostheses, nor are there any off-the-shelf endoprostheses.

We need to order such an endoprosthesis. We then perform a non-invasive test, a computed tomography scan, to visualize the bone defects. The endoprosthesis is then selected based on the degree of deformity thus visualized. A so-called custom-made endoprosthesis is tailored to the patient.

[00:13:54] Is patient awareness increasing before surgery?

Dariusz Litera:

What about patient awareness? Has it increased significantly?

Dr. Tomasz Góral:

Awareness is increasing. Thanks to this, we also observe that patients who manage to lose a few kilograms initially feel better. They don't strive to end up on the operating table.

This is a major overhaul of the body, and we want the patient to understand this when deciding on this treatment. But we also know that this treatment is effective. If we have exhausted all preventative and conservative measures, we must consider and choose this type of solution.

Dariusz Litera:

And here, this awareness of the patient is probably extremely important, so that he understands exactly what awaits him, what it will look like, what the process of recovery will look like.

Dr. Tomasz Góral:

Yes, this is very important. This awareness also ensures a lower rate of complications. If a patient knows what life will be like after a hip replacement, they'll be able to prepare for it.

He will also be able to prepare his surroundings, his environment, his family, and even such trivial technical matters at home as will prepare him for life later with an endoprosthesis.

[00:15:09] What surprises patients after arthroplasty?

Dariusz Litera:

What surprises patients during this process?

Dr. Tomasz Góral:

The need to adjust the bed and chair is often surprising. We don't like it if the patient initially sits in a chair that's too deep. This can lead to hip dislocations.

A patient must analyze their shower experience before entering. Apartments often still have bathtubs, which are difficult for someone with an endoprosthesis to use.

Therefore, let us look at our mothers and fathers and try to help them, also by adapting their homes to the changing conditions and quality of life related to degenerative disease.

[00:15:54] End of conversation

Dariusz Litera:

Dr. Tomasz Góral, orthopedic traumatologist, said in the podcast WHAT YOUR DOCTOR SAYS TO THIS. Thank you very much, Doctor.

Dr. Tomasz Góral:

Thank you.

Key takeaways for patients:

• Degenerative changes in joints are associated with the aging process and may develop for a long time without any obvious symptoms.
• Knee or hip pain should not be ignored, especially if it limits mobility and daily activities.
• The condition of joints is influenced by, among other things, past injuries, activity level and body weight.
• Before qualifying for endoprosthetics, a clinical examination, assessment of range of motion, imaging diagnostics and any additional tests are crucial.
• Conservative treatment, such as chondroprotection or viscosupplementation, may be used in selected patients, but is not always effective in cases of advanced joint destruction.
• Preparation for endoprosthetics is multi-stage and includes, among others, BMI assessment, exclusion of inflammatory foci and specialist consultations.
• Before the procedure, a dental, ENT and allergy check-up may be important.
• Pain may occur after surgery, but appropriate pain relief is provided during the perioperative and rehabilitation periods.
• The effectiveness of treatment also depends on the patient's commitment to rehabilitation. Lack of cooperation may limit the effects of surgery.
• After joint replacement, it is important to prepare the home, including the bed, armchair, shower or bathtub, to meet the needs of the person recovering.

Information about participants:

Guest: Dr. Tomasz Góral, A specialist in orthopedics and traumatology, he specializes in the diagnosis and treatment of musculoskeletal disorders and injuries, with particular emphasis on hip and knee replacement and foot surgery.

Presenter: Dariusz Litera, medical editor, health communications specialist, and creator of the podcast CO NA TO TWÓJ ELEKARZ. He has been involved in patient education for years, conducting interviews with specialists in various fields of medicine.

ATTENTION!

This material is for educational purposes only. It does not replace a medical consultation. If you experience any disturbing symptoms, consult a doctor.

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