Are Revisions Necessary?

I recently read an article discussing the need for regular follow-ups for patients following THA to determine the potential need for revisions. As many of you are well aware, with the shift in physical therapy practice shifting towards pain science - based, the question of the necessity comes up regarding joint replacements in the first place.

The need for joint replacement is supposed to be based on pain, disability, and loss of joint space. The issue with this is there are plenty of people with loss of joint space that have no pain or disability. It is just a sign of aging on an x-ray. Unfortunately, some in our medical community recommend getting joint replacements if pain ever occurs (even if short-lived) if there is loss of sufficient joint space. I've had patients who have come in for hip or knee pain, for prehab to arthroplasty, that I have eliminated their pain and disability, but they think they still need the surgery! Both practitioners and the patient are at fault. Many clinicians are still stuck in the biomedical model, thinking imaging dictates treatment. Many patients think it is best for them to order medical procedures as if they were on a menu at a restaurant. We must do our best to educate our patients on the potential success for conservative management.

 Given many patients end up having joint replacements anyway, we must address the question of potential revisions. Revisions typically occur due to infection or pain associated with failure of the prostheses. The article I read mentioned the potential need for long-term follow-up with patients who have had joint replacements and performing imaging to assess the integrity of the prostheses and tissues around them. Currently, patients would only follow-up with an orthopaedic doctor if pain returned to the joint. It is suggested regular follow-up should be performed to assess for potential periprosthetic osteolysis and aseptic loosening. The concern is that these findings contribute to osteolysis and potentially mechanical failure.

It is a difficulty decision to make as we often forget the risks associated with any surgical procedure at all (infection, complications from anesthesia, etc.). Even if the patient has pain, with the advancements in pain science, should we let imaging findings dictate our treatment. Honestly, I'm uncertain the best method for managing the potential need for revisions. With normal aging, all developmental processes are associated with biological components. After an arthroplasty, a foreign object is introduced to the body and its malfunction may affect normal processes. Typically the way I manage patients with joint pain with a history of replacement is the same way I treat all my patients: treat the impairments. If I find some muscles are weak, I'm going to try and strengthen them. If I find the lumbar spine is not moving sufficiently, I'm going to try and find a way to improve it. I'll try and reinforce my treatment with education of pain science, as well. However, if a patient fails to respond, I will refer them back to the physician. In summary, I'm not sure it's worth the risk of a revision in asymptomatic patients, due to the potential for infection and the role of the CNS in pain perception. But there likely is still a role for revisions in those with pain, if they fail conservative management.

-Chris

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