[Medical Insight 54th] The misunderstanding and truth of "artificial joint surgery" taught by orthopedic surgeons.

□ Broadcast date and time: October 18, 2024 (Fri) 10:20 pm
□ Producer in charge: Lee Siwoo
□ Author in charge: Kim Bae-jeong and Kim Hyun-jung
□ Cast: Park Young-sik (Orthopedic surgeon)
□ Broadcast channel
IPTV - GENIE TV No. 159 / BTV No. 243 / LG Uplus No. 145
SkyLife Number 90
Cable - Delive No. 138 / Hyundai HCN No. 341 / LG HelloVision No. 137 / BTV Cable No. 152

* The text below may differ from the actual broadcast content, so please check the broadcast for more accurate information.


◆ Park Young-sik: Hello. I'm Park Young-sik, an orthopedic surgeon. The story I prepared today is the misunderstanding and truth of artificial joint surgery.

◇ Voice actor Park Sang-hoon: The joint knee that we use the most in our body. Knee cartilage causes degenerative changes with age, causing cartilage to wear out and cause inflammation, resulting in pain. Is it the last surgery that should be chosen after enduring artificial joints that more than 100,000 patients undergo artificial joint surgery in Korea every year? Let's learn more about the misunderstandings and truths related to artificial joint surgery.

<Understanding Diseases>
◆ Park Young-sik: I've been an orthopedic surgeon for 25 years. However, I would like to tell you that there has been an increase in the number of outpatient questions recently. "I had artificial joint surgery, but why does it hurt so much? I can't live." I heard a lot of people say that it was good at the time. This is because doctors and patients have different concepts about the success of surgery. Doctors sometimes think that artificial joint surgery is successful because it is inserted well in place and the knee is bent and stretched well. However, no matter how well the patient is operated, it is not a success if he is sick. I think it's a success if there's no pain. That's why there's a difference in perception of success. Statistics usually show that about 1 in 5 people have pain from a slight to severe, although there is a difference in the degree of postoperative. Let me tell you what to do to reduce the pain after surgery. The total population of our country is currently decreasing. But the elderly population is growing rapidly. And arthritis is said to be the number one chronic disease among Koreans over the age of 45. Therefore, it is predicted that the total number of artificial joint surgeries will continue to increase by 2032. If you look around, more and more people will receive artificial joint surgery.

<Knee artificial joint surgery>
◆ Youngsik Park: Then if you look at why there are so many artificial joint surgery on the knee joint, the joints of our lower extremities are very structurally stable. But characteristically, the knee is very unstable. The upper femur and the tibia at the bottom are usually convex in surface. It's very unstable because the convex part is in contact with it. Ligaments, tendons, cartilage plates, and muscles continue to work to maintain this stability. Therefore, there is a lot of cartilage damage and degenerative arthritis is overwhelmingly more than other joints. Before I talk about degenerative arthritis, many people misunderstand one thing, but they think it's because of inflammation. But there's a reason why it can damage so much cartilage. For that reason, when cartilage is damaged, the damaged cartilage floats around in the knee and is secondary to the synovial or something like that, causing inflammation. Therefore, degenerative arthritis is not the cause of inflammation, but rather the result. And in the outpatient clinic, sometimes I've just been sick, but why are you suddenly telling me I'm at the end of degenerative arthritis? The reason is that cartilage doesn't have nerves, so the pain doesn't appear until cartilage damage has progressed to some extent. So, even though arthritis is quite advanced, when I examine it, there are many cases where I have no idea even though it is quite advanced. However, if you suddenly twist a little or if you hurt your knee a little due to an event, the pain will be severe, and if you go to the hospital and examine it, you are often diagnosed with the end of degenerative arthritis. So if you feel your knees are not good, you'd better take a test. Degenerative arthritis can be divided into early and mid-term. So, in the early stages of arthritis, you can do these injections, whether you use drugs, do physical therapy, or get cartilage injections in your knees, or you do muscle strengthening exercises. And in the case of mid-term arthritis, where cartilage defects have progressed to some extent, it is difficult to improve symptoms with only medicine, injection, or physical therapy. So in this case, cartilage regeneration is done. The cartilage regeneration usually has microperforation in which the bone marrow flows out by drilling a fine hole in the area where the cartilage is missing, and there are some leftover cartilage in our knees that we don't use. There is an autologous cartilage transplant, which is removed and implanted in areas with cartilage defects, and if the cartilage defect is wide, there is a limit to transplanting it, so you have to cover it with something else. Recently, there are cases of cartilage regeneration using stem cells, and if the legs are bent, the regenerated cartilage cannot withstand no matter how much cartilage is regenerated. So you can do an osteotomy that straightens out your bent legs. When the articular cartilage is completely worn out after the middle period and the bones underneath it are deformed, the results are not good if you do this regenerative surgery as I mentioned earlier. In this case, artificial joint surgery is performed. Then, how to operate artificial joint surgery thinly cuts the surface of the area with degenerative arthritis. It's inserting a special alloy artificial joint into the cut. And in between, we put artificial cartilage made of special reinforced plastic. So the goal of artificial joints is to walk painlessly. The goal is not to play sports where you kneel and run and run.

<History of artificial joint surgery>
◆ Park Young-sik: When did artificial joint surgery start? It must have been a long time since there was a problem with the knee joint and it hurt. But from the 19th century, I realized that cartilage was worn out between my knees, so I thought it would be nice to put soft tissue in between to prevent the impact, so I shaved pig bladder, fascia, or my fat, cellophane or ivory and mounted it between my knees. But at this time, there was no understanding of sterile treatment, so I got infected and suffered from purulent arthritis, and the results were bad. Since then, the understanding of aseptic treatment and the understanding of knee joint movement have increased, and artificial joints have developed dramatically. From the 1970s to the '90s, the most important thing was how to move artificial joints well because it was in the early stages of artificial joints, so I thought about how to shape artificial joints, and the important thing was how long it could be used. Therefore, a lot of research has been conducted in the direction of improving the material of special reinforced plastic between artificial joints, and the artificial joint is well equipped in the knee joint and should not come off, but it sometimes comes off. So how to fix it hard, and that's how we developed medical cement. And as these were resolved to some extent afterwards, the problem was that until the 2010s, when I saw children, the knee shapes were different for each man and woman, and the knee shapes were different according to race, such as white species and yellow races, and when I came to the East and used them, the results were not good. As interest in these things increased, developments were made in the direction of slightly changing the shape of artificial joints according to race and gender. And since then, research has been conducted and developed to improve the method of performing artificial joint surgery more accurately and without complications using navigation, biosensors, or robots.

<Timing of artificial joint surgery>
◆ Park Young-sik: Many people are curious about when is the best time to do artificial joint surgery. Usually, the hospital tested and recommended surgery if terminal arthritis and degenerative arthritis progress to the very end and the pain intensifies to the point where it is difficult to live a daily life. Recently, however, it is the same as having terminal arthritis, but the timing of recommending surgery has changed a little when the pain starts to get worse without having them perform surgery after waiting until they are in severe pain. The reason is that when the pain gets worse for a long time, the sensory nerves that feel this pain become very sensitive. Where you get sensitive is when you feel pain in the sensory nerves, you feel pain in the brain through the spinal cord nerve, and it becomes very sensitive at this stage when you go up from the spinal cord to the brain. So even though the cause of pain has disappeared after artificial joint surgery, a slight irritation causes this to feel wrong as pain. This is called central nerve sensitization, and when I investigated patients who were about to undergo artificial joint surgery, it was found in 20-30%. Even with artificial joint surgery, these people continue to feel pain after surgery, and the results are quite bad. So in this case, it's better to have surgery before central neurosensitization. Therefore, I recommend surgery a little earlier than before. And even if you are very old, it doesn't matter much these days. Diabetes, high blood pressure, heart disease, cerebrovascular disease, etc. are not a problem as long as they are well controlled, and age is not a problem as long as they are healthy even if they are old.

<Type of artificial joint surgery>
◆Park Young-sik: Artificial joint surgery is divided into two main categories. If degenerative arthritis is only present on one side of the knee, only half of it is semi-substituted or single-hyperstituted, and if degenerative arthritis is present throughout the knee, it is completely replaced. So if I were to tell you about a single replacement, which is only half done,

<Single replacement(half replacement)>
◆Park Young-sik: If arthritis is mainly only on the inside of one side, you can operate only on the inside and only on the outside. At this time, the deformation should not be severe, only the inside of the knee should be arthritis and the outside of the knee should be normal. The surgery is a little simple for a monoculture replacement. Fracture drugs and bone carving are very small, rehabilitation is fast, hospitalization is fast, and discharge is much faster. And because it keeps the anterior cruciate ligament alive, if the surgery goes well, it's so natural that you don't know if you've had surgery when walking or moving around, and you can be so comfortable that you forget that you've had surgery. According to recent papers, the survival rate is 10 years to 98%, with a survival rate of 15 years to 93%, but after 20 years, the survival rate drops to 84%. It is true that the survival rate is a little shorter than the total replacement. Single and semi-substituted surgery are estimated to have a lifespan of about 15 years. So, at a young age, I have a single department replacement, and I'm a little older, so I can change to an artificial joint in my 70s or 80s through total replacement. There are cases where it is recommended to do so at a young age, or you can use it for about 15 years, so in very old age, there are many cases where there is a little less risk than a total replacement. If you look at the picture I prepared, degenerative arthritis is severe only on the inside of the knee, and the outside is normal. In this case, you can perform a single hyperplasty in which only the inside of the knee is selectively artificial without total replacement.

<Pre-replacement>
◆ Park Young-sik: Then when should I do the pre-replacement? I told you earlier. I did it when degenerative arthritis is very severe and there is severe pain. And I do it when I'm old. Usually these days, people say after their 70s. However, in artificial joints, young people are under 60 years old, not young people in their 20s and 30s, but young people are under 60 years old. Under the age of 60, there is a lot of activity, a lot of movement, and a lot of exercise, so the life of the artificial joint is quite short. So in this case, it is a principle to postpone the artificial joint as much as possible. However, if you have rheumatoid arthritis or bone necrosis, you are forced to do artificial joints. If you look at this picture, degenerative arthritis is very severe throughout the knee joint. At this time, no other treatment can be applied, and the entire joint is replaced with an artificial joint.

<Materials of Artificial Joints>
◆ Park Young-sik: Artificial joint surgery equipment Artificial joints are made of a lot of cobalt chromium alloys and titanium. And the artificial cartilage uses polyethylene polymer, and this overall weight is about 570g, which is quite light. However, some people who have undergone artificial joint surgery sometimes say that their knees are heavy in the outpatient clinic, but this is not because the artificial joint is heavy, but because the lower body's strength is weak, so it is important to exercise hard in this case.

<Misunderstanding and Truth>
◆ Park Young-sik: Sometimes outpatients ask me some questions about artificial joints. What is a customized artificial joint? You are asking if it is tailored to each individual like perfect, but it is not that, but when inserting an artificial joint that comes out of the ready-made into the knee, it uses a device that is most appropriate for each individual. That's why we use the expression customized artificial joints. The artificial joint itself is not made separately. Then, you ask whether the robot does all the artificial joints of the robot on its own, but it's not that, but the robot enters CT data or enters knee scan data during surgery, and the doctor who performs the surgery decides to do this, so the robot can move accordingly and perform the surgery. Even then, the doctor holds the robot's arm and uses a medical saw or something to cut the knee to the area with degenerative arthritis on the joint surface. So in the end, it's a combination of the doctor's experience and the robot's accuracy. And recently, people are asking if there is a Korean-style artificial joint, but I haven't said this because I made a Korean-style artificial joint separately. However, there are some artificial joints from abroad that fit the shape of our knees, so we use them and say they are Korean, but Korean artificial joints have not yet been released. There are people who are worried about what to do when they wake up during anesthesia. However, artificial joint surgery usually involves spinal anesthesia, and the duration of spinal anesthesia is usually about 3 to 4 hours. And during surgery, we anesthetize you to sleep. Usually, when anesthesia is broken, it does not mean that spinal anesthesia is broken, but when consciousness returns while sleeping, the sound of surgery heard in the operating room is heard. Then you're worried and scared. So you don't have to worry too much because the pain doesn't come back. Some people say that the pain after artificial joint surgery is too severe and that it is scary to get surgery, but the pain management after surgery has improved a lot for a few years. In the case of painless treatment, painless injections are placed around the joint membrane and femoral nerve anesthesia is performed, so even in my experience, the person who had the surgery went to the round the next morning, and I don't know if he had the surgery. It doesn't hurt at all. There are quite a lot of people like this. Painless treatment has developed so much after surgery, so you don't have to worry too much.

<How to exercise after surgery>
◆ Park Young-sik: One of the things you ask a lot after artificial joint surgery is what kind of exercise you can do. I'll tell you based on what was announced by the American Association of Hip Joints. In general, you can exercise that requires low impact and low muscle strength. Walking fast, hiking, and trekking. It's okay to ride an indoor or outdoor bike. Swimming is good, too. Golf is fine. Bowling is good and social dancing is good. At first, all walking exercises themselves are rehabilitation exercises. At first, it would be better to start walking slowly and start walking for 20 to 30 minutes a day and do other exercises. But you shouldn't jump up and down. Then, the artificial joint machine will be shocked a lot, so you can't use it for a long time. You shouldn't jump like basketball, soccer, or volleyball. And jogging is also not good.

<Postoperative management>
◆ Park Young-sik: There is one very important thing during postoperative management, and what I want to emphasize is fall prevention. If you fall, there may be fractures around the artificial joint of the bone, and if the fracture comes, you will have surgery on that area, and the results of the surgery are not good and the surgery is very difficult. So the best thing is prevention. It is very important to adjust the living environment for this prevention. Make sure you use a walker or bed by rearranging the furniture, make sure you don't forget electric wires on the floor, so that you don't get caught walking around and fall down. Make sure to make a handle and sit in the bathroom. Be careful not to slip and fall when you wake up and it's easy to fall if it's dark when you go to the bathroom at night. So, don't forget to turn on a small light so that you can always turn on the light even at night.

<Postoperative complications>
◆ Park Young-sik: There are several complications after artificial joint surgery, and one of the more important complications is instability. What instability means is that when you walk or stand, your knees shake and you feel unstable. That's called instability, and the extension interval is wide in the early stages after artificial joint surgery. If the surgery is a little wrong or if the special reinforced plastic that goes into the artificial joint is a little thin, it can falter. In the late stages, special reinforced plastic artificial cartilage is worn out. Then, when abrasion occurs, the gap between the temples can be widened. At this time, when you walk, your knees bend sharply while walking, shaking, and walking. It's easy to fall down in real life, too. So there's always excessive tension in the tendon around the knee. As a result, the risk of fractures increases significantly as the area around the knee becomes very painful and falls. So when you think about what to do to make sure that the extension is well spaced in the beginning, you did biosensors, navigation, and customized artificial joints to reduce doctor errors, and recently you did artificial joints using robots. So I try to resolve the instability. And if it appears after many years, the artificial cartilage is already worn even when it appears, so in this case, it can be solved simply by replacing the artificial cartilage.

<artificial joint reoperation>
◆ Park Young-sik: When it comes to artificial joint reoperation, we think it's very difficult. In fact, artificial joint reoperation is more difficult than the first surgery. There is a lot of bleeding, and this is the case when all artificial joints are completely removed, and artificial cartilage. When only replacing parts, the operation time is short, there is little bleeding, and recovery is much faster. So, it's much simpler than artificial joint surgery itself, so you don't have to be too scared. I hope you see an experienced doctor if it's really unstable and the artificial cartilage is thin.

<artificial joint management method>
◆ Park Young-sik: You had artificial joint surgery before, and you have to control your weight to increase the life of the artificial joint. If you gain 1kg, the pressure in your knees will increase by 3kg when you stand still, and if you walk, the pressure will usually increase by as much as 10kg. If you gain 10kg, the pressure in your knees will increase by 100kg. You need to control your weight. And you have to do the second muscle strengthening exercise. The knee is a very unstable joint, so if the strength is weak, the knee shakes. This can also cause more wear and tear on the artificial joint and make the pain worse. So, if you work hard on your strength, your knees will be held firmly, so you can prevent additional damage to your knees and reduce pain. And it's important to correct your third lifestyle. It is important to always clean up your surroundings so that you don't fall, take good care of infection, always avoid squatting or kneeling, and correct your lifestyle.

<Medical AI Q&A>
◆ Park Young-sik: Viewers sent me a lot of questions about artificial joint surgery. Let's check it out together.

◇ Y-ON (AI Anchor): My knee hurts again and feels rattled after artificial joint surgery. Should I exercise? Do you think I need to do it again?

◆ Park Young-sik: It is important to identify the cause of the pain and the cause of the rattling. If you are experiencing pain due to a high amount of exercise and mild trauma, it is recommended to perform conservative treatment, rest a little, and exercise again. If the wear is severe, the artificial joint is missing a little and is dislocated, or if it is due to inflammation, you have no choice but to re-operate in the end. It is important to understand the exact cause of the pain.

◇ Y-GO (AI Anchor): I have to do artificial joint surgery, but I'm putting it off because I'm afraid of breaking my leg. Can't I do it under anesthesia when I bend my legs?

◆ Park Young-sik: Of course you can. However, it is difficult to anesthetize every time I rehabilitate, so I don't really do that. And lately, with the improvement of surgical techniques, it's not as difficult to bend your knees as it used to be. So you don't have to worry too much.

◇ Y-ON (AI Anchor): Two months into artificial joint surgery, I sat down I went to the hospital because I had pain when I woke up, and they said let's get a pro-lol injection. What exactly is the prologue injection?

◆ Park Young-sik: Proloh injection is called ligament strengthening injection in Korean. It is an injection that reduces pain by injecting high-concentration physiological saline into the ligament attachment to help regenerate damaged ligaments. However, it is recommended not to get an injection on one knee of an artificial joint. This is because if you get infected while getting the wrong injection, you may have to re-operate the artificial joint. If you have to get it inevitably, please disinfect it very thoroughly and get it right.

◇ Y-GO (AI Anchor): Is it true that elderly people who are in financial difficulties can receive surgery support with health centers and medical benefits?

◆ Park Young-sik: Yes, that's right. There is emergency medical support, but there are many low-income support projects from local governments or health insurance corporations. It would be better for you to find out and receive benefits. Depending on the hospital, there are places that run social work teams, so if you contact these places, you will be able to provide detailed information.

<Remember this>
◆ Park Young-sik: Many people ask if it's not good for your knee joints to squat. However, sitting with your legs crossed is not good for your lower back joints as well as your knee joints. And being overweight is also bad for your knee joints. Efforts to take care of healthy joints, why don't we start at this moment? I hope my story today helped you to live a happy life. Thank you.