Dr. Todd Dietrick is an orthopedic surgeon who went to Dartmouth and then studied medicine at University of Southern California. He specializes in adult reconstructive surgery, which includes hip and knee replacement. Dr. Dietrick performs about 400 to 500 joint replacements a year—60% of them being knees and 40% hips. Joints, according to Dr. Dietrick, most commonly wear down since they were not designed to last as long as we live these days. People, in general, are more active than they used to be and are active for longer throughout their lives. There can also be congenital factors, which contribute to joint issues. Dr. Dietrick commonly sees patients who mildly injured themselves when they were younger so they didn’t seek treatment but now seek help. Dr. Dietrick says it’s also very common for a patient to complain of pain in one joint witch is actually radiating from another joint. To make a diagnosis, Dr. Dietrick, says getting an x-ray of the joint in pain is the first thing to do and if he needs further information, he will then order an MRI. The main thing Dr. Dietrick looks for is the condition of the cartilage in the joint.
TODD: Uh, my name is Dr. Todd Deitrich.
TODD: I'm a practicing orthopedic surgeon. I went to Dartmouth College undergraduate and I studied medicine at USC medical school.
TODD: I did my training for orthopedic surgery at USC and then did a fellowship at UC San Diego specializing in adult reconstructive surgery which included hip and knee replacement.
TODD: I'm married. I have two kids. And I enjoy spending my weekends playing with my children 'cause during the week I'm busy, uh, replacing hips and knees.
TODD: Over the course of a normal year I will perform between 400 and 500 total joint replacements. Typically it's 60 percent knees and 40 percent hip replacements. People often ask why did this joint break down. Way back when people didn't live so long and joints weren't really necessarily designed to live and work for 70 or 80 years.
TODD: So general wear and tear over time is one of the main reasons. And people are more active nowadays as well.
TODD: People are active in sports as they get older and older. And that will tend to wear joints out.
TODD: There's been a lot of evidence that if you are an active person without injury it will actually improve the longevity of your joint.
TODD: Some hips are just destined to break down. And patients ask me all the time why did I start getting this hip pain in my 50s and I'd say, "Well, you know, there's something you can blame on your parents. It's how you were born." And, uh, I think that's really true.
TODD: Historically we thought that this was something that was not a genetic problem. But we've found out more recently that genetics do play a large role in the evolution of arthritis. It does tend to run in families.
TODD: Why did one hip break down versus another? It could be something as simple as an injury back in high school you never really took care of and you thought you bruised yourself and that led to some injury and 20, 30 years later that leads to joint breaking down.
TODD: The main reason the hip breaks down is that the-it's not exactly round on round. If the ball is not quite perfectly round or the socket isn't a perfect saucer, then there will be more stress and that will tend to wear out over time.
TODD: Often times patients will come in and they will say, you know, "My hip is really hurting. My hip's hurting." And they'll be pointing to their back. And to everyone this whole area is the hip. Well the hip joint actually is in the front of the pelvis. And so classically the hip pain is in the groin. And so there's multiple different presentations. Patients will come in and complain of knee pain. As clinicians it's our job we need to exam the whole patient to make sure that that pain is not being referred down from the hip joint. 'Cause that's a very common complaint. That happens at least once a week that someone comes in saying that they injured their knee, it didn't go away. And it's actually pain that's radiating down from the hip joint.
TODD: Our athletes okay that are you know, a little bit older and they say, "Doc, I pulled my groin, uh, exercising nine months ago and it just won't go away. And the hip is very, very stiff and I can't get up. And i-it takes a long time for me to get going after I walk. And I went to see my trainer and I've been stretching and it's just not getting better." That's a classic sign that you may have some arthritis or a problem going on within the hip joint.
TODD: We always start out with an x-ray because an x-ray gives us a lot of information about overall alignment, which will tell us how much cartilage is present between the bones. And if the patient has a narrowing of the cartilage and if they have bone spurs, typically there's no other testing needed. If a patient has bone on bone and they're painful there's no need for an additional study. The only time that we would need to order an MRI is if the diagnosis is unclear. That can give us a lot more information about the soft tissue and the bone itself. So if you have healthy cartilage on the end of your bones, you're not gonna feel pain when they rub against each other and that allows us to move around. What happens when you develop arthritis is that that cartilage breaks down and then you have bone which is exposed. That has nerve endings. That's what hurts. That's what causes the pain.
TODD: Those cartilage cells are so great because they don't have any nerve endings. Allow us to move. Are also delicate so if we injure them then it doesn't take very much for those cartilage cells to die. And the problem is they don't regenerate. We've only got really very few good cartilage cells. When they die they get replaced with sort of a poor man's articular cartilage called fibrocartilage. That does have some nerve endings. It doesn't work nearly as well. And eventually the added stress causes the breakdown of the joint.
TODD: There is a genetic component to it but there are things you can do about that. You can modify your risk factors for progression of arthritis. And that includes a good diet. You need to keep the muscles around your joints very strong. And that will decrease the load on the joints. Especially around the knee joint. If you're heavier you're gonna tend to more stress on the joints themselves. And that will lead to further and quicker breakdown of the cartilage and lead to more arthritis. You wanna have a certain amount of activity level but you don't wanna overdo it. You wanna try to avoid injury as much as possible. Any type of injury to the joint, uh, will overload it and potentially improve the chance of developing arthritis.
TODD: Patients always ask when should I have this done and when is the best time to replace your joint? If it's appropriate at that time. From our standpoint, we always want you to wait until you need to have the joint replaced. But I think a lot of people do put it off longer than they should. I think it comes down to a quality of life issue with each individual patient. I tell patients they need to make that decision. It's not something that, you know, the doctor can say, "You need to have this now." It's our job to help guide them and give them the information, uh, about, uh, what is going to happen down the road. And in the case of arthritis, you know, it's a pretty simple picture. It's going to worsen over time. And eventually it gets to the point where the joint itself is interfering with quality of life. And I think that's the main issue.
TODD: Patients often times ask, "What can I do to get ready for the operation?" And I think that being ready both physically and emotionally is critical to have a successful operation. Often times we'll prescribe physical therapy before surgery. Or simply if patients are motivated on their own, they can do exercises. We can, uh, tell them to do at the gym or just on their own at their home. If you're strong before surgery you're immediate recovery after surgery will be much, much easier.
TODD: From a medical standpoint it's really critical to have everything under control. If you are diabetic you need to make sure that your blood sugars are stable. We wanna make sure that you're on a good diet. Make sure your immune system is boosted before the operation.
TODD: This is an actual hip implant that we use. One of the types. This particular type, what we call a bone ingrowth implant which means that the biologic fixation, the bone grows into this implant. That's how it's fixed to the bone. This here is the socket. This is made of titanium. And this typical. And on the outside there is a we call it a porous surface. So the bone will actually grow into and onto this surface. Fortunately we've figure out that bone really likes growing onto titanium and so this roughened surface it readily grows onto. And how do we get this to fix into the bone. Relatively simple. We have what we call reamers. It's about the same shape as this. We sh-reshape it a little bit if it's out of round, which is why the hip probably wore out anyway, and we go ahead and insert it. One's one, about one millimeter smaller. And so it's a nice pressed fit in there. Sometimes if it's not a solid fit then we'll put a couple of screws. We have screw holes we can put in to hold the socket in place while the bone grows into the socket.
TODD: Once that incorporates we call that biological fixation. Now after the socket has been placed and is securely fixed in the proper position inside the hip, this is the plastic liner. And this will snap into place and that will be in there. After we finish that part of the operation, we go towards the femoral side which is where the stem comes in. And you've seen these. This is a typical, uh, bone [INAUDIBLE] stem. It's a wedge shape and we have special broaches which will go into the femur. The femur bone is actually hollow on the inside. And so the broach will fit in there and once we get a solid fit in the appropriate position, it sits there and the bone will grow right onto it. Once that is in there solid we put a ball on top. This is a chrome ball. Sometimes we use ceramic. Sometimes we use chrome. And that will fit right on top. And those two once we relocate the hip go in there and it articulates this way. That takes away the pain. Normally it's bone on bone grinding. This is metal on plastic. There's no more pain. And that's why patients no longer feel their hip after they've had their surgery. So that's what's called a forgotten hip.
TODD: I trained doing posterior approach in-in this country. The posterior approach is the mainstay of hip replacement. That traditionally has been the way everyone has been taught over the years. Over the past decade or so a new approach which actually is an older approach from Europe has come over and, uh, called anterior approach. And that's been popularized. It's just a different technique or way of putting the hip joint in. The same joint, we put it in. It's the same articulation. It's just a different place of putting it. Sometimes we get in there through the posterior approach, uh, on the back side of the hip joint and go through the, uh, the buttock muscle or the gluteal muscles. And the anterior approach is a different way of going through a natural interval in between muscles, uh, in the front of the hip.
TODD: I like the anterior approach because I think it's a more anatomic way of doing the operation. Because I'm not cutting through that muscle and I'm not detaching the tendons from the back of the hip, there's really nothing that needs to heal back to itself. I think that there's less pain. And the recovery is a little bit quicker in the first six weeks after surgery.
TODD: I have had the experience of doing both approaches. I think that they're both excellent procedures. And they both give great results. Patients who have had one of each have told me that the anterior approach is a little bit easier and quicker recovery. I feel it's a more accurate way of doing the operation. The anterior approach allows me to have an x-ray in the room at the time of surgery where I can x-ray both hips to make sure that they're perfectly positioned. To the surgeon that's really the key because we wanna get everything perfect every time. The anterior approach is the best way I've found to do that. And so I know that before the patient leaves the operating room, that the hip replacement is perfectly positioned. And that that's gonna lead to a great outcome. Patient's gonna be satisfied.
TODD: I think it's very important to get up and start mobilizing immediately after the surgery. We'll let you put all your weight on that leg immediately after surgery. The hip is designed to, uh, full weight bearing right away. And that allows patients to get up and get confident moving their hip joint. The goal is to get back into your normal activities as soon as possible.
TODD: You will typically have some leg squeezers on your legs to keep the blood circulating. We'll want you to move your feet back and forth to prevent blood clots. The hospital stay normally is about two nights. Some patients go home after one night. I prefer to keep patients in the hospital until they've reached certain milestones.
TODD: It's relatively simple nowadays. If you have confidence, uh, getting out of bed on your own and going to the bathroom and getting dressed and doing stairs. A-and you're taking regular pain pills after surgery and that's controlling your pain and you're comfortable, you can go home. You know, we have a saying that there is less sick people at your house than there are in the hospital and we'd like you to get home as soon as possible.
TODD: The first time you get up and walk we have a walker. You can transition to crutches or a cane, uh, depending on how confident you are. What your therapist feels that you can do safely. We don't want you to fall. You have to learn how to walk with your new joint. You know, safety is really critical. So I always err on the side of using a walker unless you're really confident then you can go to a cane or a crutch.
TODD: Uh, a therapist will typically come to the house a couple times, two or three times a week, for the first few weeks. Uh, depending on how much you really need. I try to tell my patients, "I want you to get up and move around and do things you're comfortable with but not to overdo it." And that's probably one of the hardest questions to answer. "Doctor, I'm-am I overdoing it? Am-what-how much is too much?" And each patient is a little bit different as to how much they can do. And our stock answer is if you're hurting too much you've overdone it. You know, you don't know you've overdone it until you've done too much.
TODD: When the therapist comes to the house, it's critical to just do what they say. Don't do three times as much as they say. You're not gonna recover three times faster. Time and healing occur at their own pace. And you just have to allow that process to happen. It doesn't matter if you're a great athlete or if you're a non athlete, you're gonna recover at your own body's pace. And so I think that that's a real important thing to understand.
TODD: Patients ask me all the time well, "So and so recovered at three weeks. So and so was doing this, that, and the other. And how come I'm not doing that?" And I tell patients all the time that I do the same operations on different people and the biggest difference in my practice is the patient. And everyone recovers at a different pace in these three, first three months after surgery.
TODD: Patients often ask, "What can I do after the operation? What is a reasonable expectation?" And it always starts with a conversation of what they like to do and what their goals are. I'll tell patients who are active, enjoy playing golf and tennis, I think it's realistic to go back to those types of activities probably after about the three or four month, uh, period. Most patients, uh, won't really feel like going out and walking 18 holes of golf after a knee replacement for three or four months. I think that's pretty typical for a hip as well. The hip patients will want to do things a little bit earlier. However if it's a bone ingrowth implant, I don't like them to stress that implant. Uh, really in the first three months after surgery I try to keep them from doing too much activity. But usually after about three or four months I won't restrict patients as far as doing things like that. Now, if patients wanna go back and become triathletes, we have a different conversation.
TODD: One of the most gratifying parts of my job is I get to see patients who come into my office limping and in pain and I know that at a certain timeline, whether it be two, three, or six months down the road, that I will see them back in my office walking and happy and grateful for the operation. It takes time. It takes effort on the part of that patient. It is not always pain free. It's a great operation for patients to have. And that's what I like to tell them. And you know, the bad news that you need an operation. And I say but the good news is that it's one of the best operations ever invented. Hip replacement surgery or knee replacement surgery is so great at improving function and quality of life. That's what makes my job so gratifying is that I see patients. I can tell when they come back in at six weeks or at three months or at one year after surgery, and they've forgotten about their joint. They've forgot they even had the surgery. And they're just so happy and they're able to do things that they weren't able to do before. It's, uh, it's really rewarding.
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