Ask the Expert

For five years, Suburban Hospital’s Joint Replacement Center has provided a unique approach to patient care that has resulted in stellar outcomes and rave reviews from patients and physicians alike. Dr. J. Patrick Caulfield, medical director of the Joint Replacement Center, explains why more and more surgeons from across the region are choosing to bring their patients to Suburban Hospital.

What is joint replacement surgery?

Joints can become painful when there is a loss of the normal cartilage between the bones that cushion the joint. Joint replacement surgery involves resurfacing or replacing the involved joint with a combination of metal, plastic or ceramic.

What are the reasons for joint replacement surgery?
The purpose of joint replacement surgery is to stop the pain and allow the individual to be more active and independent. It is a quality of life issue and usually joint replacement surgery is a last resort when other treatment options have failed, including medication.

Is there a typical patient profile when it comes to joint replacement surgery?

In the past, patients were typically over the age of 65 and experiencing end-stage arthritis. Today, with the improvement in the long-term wear of the implants and the overall success of these procedures, there is no typical patient profile. The appropriateness of this procedure is determined by how active a lifestyle the person desires and his or her current limitations based on pain and decreased function. I am seeing an increase in the number of younger patients who are opting for joint replacement surgery because we now know how long joint prostheses last. My patients range in age from 15 to 102. You are never too old for joint replacement surgery if your health and medical conditioning are good.

When do patients come to you?

As a joint replacement specialist, patients come to me after trying all non-surgical modalities, without success, and their pain is now compromising their quality of life. Patients younger than 50 usually present with a history of a disrupting injury of the knee, or knees that have been damaged from high-impact sports. A small group of patients may be born with joint abnormalities. For others, there is a genetic predisposition for the deterioration of the joints, especially if there is a blood relative with premature osteoarthritis before the age of 50.

For older patients, we see the effects of developmental arthritis. Osteoarthritis is the most common risk factor and reason for joint replacement surgery. However, any ailment that causes the breakdown of joint cartilage puts an individual at risk.

What is osteoarthritis?
Osteoarthritis, the most common form of arthritis, is also called degenerative joint disease or “wear and tear” arthritis. Almost everyone is affected by it to some extent as they grow older. It occurs most frequently in weight-bearing joints, mainly knees, hips and ankles. This form of arthritis slowly and gradually breaks down the cartilage that covers the ends of each bone in a joint. Normally, cartilage acts as a shock absorber, providing a smooth surface between the bones. But with osteoarthritis, the smooth surface becomes rough and pitted. In advanced stages, it may wear away completely. Without their normal gliding surfaces, the bones grind against one another, causing inflammation, pain and restricted movement.

What are the symptoms of osteoarthritis?
The number one symptom is pain. The pain is caused by irritation and pressure on nerve endings, as well as muscle tension and fatigue. The pain can progress from mild soreness and aching with movement to severe pain, even when resting. The second symptom is loss of easy movement, such as bending or rising normally. Morning stiffness is a problem for many people. This lack of mobility, in turn, often causes the muscles serving the knee or hip to weaken, and overall body coordination suffers.

What is rheumatoid arthritis?

Rheumatoid arthritis is an autoimmune disease, the cause of which is not well understood. It is characterized by an aggressive inflammatory arthritis and can lead to rapid joint deterioration and loss of structural stability. This can result in the need for joint replacement as well.

What types of surgery do you perform?

Hip and knee replacements make up between 90 and 95 percent of the surgeries I perform.

How do you decide if a patient is a good candidate for joint replacement surgery?

There are three factors that I take into account when deciding if a patient is a good candidate for surgery. First, I look at the patient’s medical condition to determine if there are any comorbid conditions that would preclude the patient from getting through surgery successfully. Second, I look at x-rays or MRI scans to determine if there have been enough mechanical changes in the joint to correlate with the patient’s complaint regarding the level of pain. I’m looking for a significant change in the joint. Finally, I determine if the patient has tried all conservative measures to address the pain.

Who should consider a total hip replacement?
Total hip replacements are performed most commonly because of progressively severe arthritis in the hip joint. Besides osteoarthritis, other conditions leading to total hip replacement include bony fractures of the hip joint, and death (necrosis) of the hip bone. Hip bone necrosis can be caused by fracture of the hip, drugs (such as alcohol or corticosteroids), diseases (such as systemic lupus erythematosus), and conditions (such as kidney transplantation).

The progressively intense, chronic pain — together with impairment of daily function including walking, climbing stairs and even rising from a sitting position — eventually become reasons to consider a total hip replacement. Because replaced hip joints can fail with time, whether and when to perform total hip replacement are not easy decisions, especially in younger patients. Replacement is generally considered after pain becomes so severe that it impedes normal function despite use of anti-inflammatory medications. A total hip joint replacement is an elective procedure, which means that it is an option selected among other alternatives. It is a decision that is made with an understanding of the potential risks and benefits. A thorough understanding of both the procedure and anticipated outcome is an important part of the decision-making process.

What’s involved with hip replacement surgery?

With total hip replacements, a surgeon removes the ball part of the joint and replaces it with a metal or ceramic ball attached to a stem that is inserted into the femur, or thighbone. This may be “cemented” into place with a special type of adhesive. Then a metal cup is placed firmly in the socket, which is prepared similarly to the thighbone.

What’s involved with knee replacement surgery?

With a total knee replacement, all three surfaces of the knee are removed. This includes the femur, the top of the tibia, and the undersurface of the knee cap. We then replace these damaged areas with prostheses, often cementing these areas as well. In some cases, it is determined that only a partial knee replacement is necessary. This procedure is reserved for patients who are experiencing the deterioration of only one surface of the knee.

How long do hip and knee replacements last?

Today’s hip and knee prostheses have a lifespan of approximately 15 to 25 years. Individual success rates are influenced by the patient’s activity level and expectations, as well as such factors as the patient’s weight. At Suburban Hospital, we have had tremendous success with both hip and knee replacement surgery

Are any new technologies aiding the practice of replacing joints?
Yes. Surgical advances such as stronger materials and new techniques are offering patients quicker recovery times, allowing them to return to the active lifestyles they enjoyed before their activities were limited by pain. Recent improvements to ceramic prostheses and metal-on-metal joints are especially helpful for younger patients because they’ve been shown to withstand more active lifestyles.

Most hospitals perform joint replacements. What do I need to know in order to select a high-quality program?

Surgical advances have led to new approaches in how joint replacement patients are cared for. At the Suburban Hospital Joint Replacement Center, we feature a model of care that emphasizes wellness and personal empowerment for joint replacement patients. In our model, patients are considered “sore,” not “sick,” and are encouraged to be out of bed and wearing “street” clothes by the morning after surgery. Their recovery is motivated through enhanced patient/family education, personal coaches and group activities that include physical therapy and communal meals. All activities, including therapy, take place on the same floor as the patient rooms.

From a clinical perspective, Suburban Hospital was the first hospital in the county to initiate the concept of a completely compartmentalized joint replacement center, where all staff members have a singular focus. Patients benefit from standardized clinical orders and routines designed to improve efficiency, a dedicated joint replacement nurse manager to assist patients and physicians, and specially trained clinical staff.

All joint replacement surgeries at Suburban Hospital are performed by the surgeon of record. In some cases, there are two experienced surgeons in the operating room, in addition to skilled assistants.

Suburban Hospital is currently the busiest joint replacement program in Montgomery County and one of the top five busiest in all of Maryland. When we opened our joint center five years ago, we treated approximately 400 patients our first year. We now treat more than 900 patients per year.

What kind of outcomes should I expect from a high-quality joint replacement program? 

At Suburban Hospital, minimally invasive, muscle-sparing surgery is the standard. Most of our surgeries are performed in less than 1 ½ hours and the patient is expected to be out of bed and moving by 7 a.m. the morning after surgery. Suburban Hospital’s infection rate is extremely low, nearly 1.5 percent below the nationwide benchmark. With newer technologies, better instrumentation, newer prosthesis and better pain control, our patients experience shorter recovery periods. We customize the recovery for each patient so that no individual is pushed beyond his or her comfort level. Our target recovery period is three to four days in the hospital, at which time our patients can be discharged and continue their physical therapy at home with the help of home healthcare services. The goal is for the patient to be able to resume low-impact physical activities such as walking, hiking, golf and even tennis as quickly as possible.

What can I expect with regard to the control of my postoperative pain?

With a high-quality joint replacement program, pain relief should be 95 percent successful. Immediate postoperative pain is treated by a “pain team” trained to address any issue that arises regarding a patient’s pain. If pain medication is needed after the hospital stay, a short course of a mild narcotic followed by over-the-counter medication should be adequate to control any pain the patient experiences.

If I’m considering joint replacement, what factors can help me make my decision?
Many experts say an important factor in successful joint replacement is the number of replacements a physician has performed. Also important is the number of replacements performed at a particular hospital. When the numbers are relatively high for these factors, there are generally lower rates of complications. Patients should look for a high-quality program that includes a medical team with extensive experience.

About Dr. Caulfield

Dr. J. Patrick Caulfield earned his medical degree from Georgetown University. He completed his internship at Johns Hopkins University and his residency at Georgetown University, where, in 1969, he was a member of the team that performed the first total hip replacement in the metropolitan Washington area. Dr. Caulfield performed the first hip replacement at Suburban Hospital in 1972. Since that time, more than 12,000 joint replacements have been performed at Suburban Hospital. Dr. Caulfield is board certified in orthopedic surgery and has a special interest in hip and knee replacement. He is medical director of the Suburban Hospital Joint Replacement Center.

Dr. Caulfield’s office is located in the Camalier Building, 10215 Fernwood Road, Suite 506, in Bethesda. The phone number is 301-530-1010.