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Submitted by joel on 18 April, 2009 - 20:42
Staff writers are currently in the process of interviewing two leading orthopedic surgeons in order to write new detailed original content for publishing soon. Though, we would like your help in choosing future topics. As an Avascular Necrosis patient, what topics would you like us to research and write about in the future?
Joint Replacement Critera - Quality of Life vs. Mech. Integrity
I propose that the majority of the orthopedic surgeon community have a criterion for performing a total joint replacement that frequently works in direct opposition to the AVN patient's needs for quality of life. Based on my reading about other AVN patients' experiences and from my own first-hand experience with four orthopedic surgeons, I have come to the conclusion that these care providers require the ability to visually detect the existence of a mechanical defect in the condition and performance of the AVN-affected joint in order to proceed with a total joint replacement.
On the face of it, this might seem reasonable. And if that's all there was to it, it certainly would be reasonable. However, I have also concluded that an alarming number of orthopedic surgeons choose not to perform the replacement even when the AVN patient is describing ongoing, chronic pain that is so intense and debilitating they cannot perform their normal activities of daily living, much less earn a living by going to work. At this point, I think some OSs just don't believe that the AVN patient really is hurting that badly, and this grows full bloom into a critical unaddressed pain management situation and a significant degradation of doctor-patient trust. For example, the femoral head could still be smooth and the joint space consistent, even though 40-65% of the bone inside the femoral head is actually dead and the subjective pain experience for the AVN patient could easily be 8-9 on a 10 point scale, without changes to the joint perceptually detectable by the surgeon's very human eye when viewing the xray.
The situation degenerates along the following lines: 1) AVN patient cannot get surgery that his company medical plan would pay for only if his orthopedic surgeon would agree to replace the dying joint. 2) AVN patient cannot get pain meds from orthopedic surgeon because surgeon does not believe dead bone alone is sufficient to generate pain requiring narcotics. 3) AVN patient loses job because she cannot go to work with such debilitating pain. 4) AVN patient loses benefits and any hope of getting surgery now. 5) AVN patient gets foreclosed and evicted. 6) Orthopedic surgeon is still waiting on the AVN patient's joint to collapse.
To conclude, I believe there is a general approach amongst orthopedic surgeons to require the presence of a visually detectable mechanical defect in the AVN-affected joint prior to proceeding with a total joint replacement. In general, orthopedic surgeons do not believe the presence of AVN-related dead bone inside the joint is sufficient to warrant severely debilitating pain and the need for a narcotics-based pain management plan until the total joint replacement.
What is the orthopedic surgeon's professional assessment of my characterization? Regardless of who holds the majority approach, would the orthopedic surgeon have experiences to share concerning factors determining a total joint replacement and criteria for assessing severity of pain? What is the surgeon's thoughts on why quality of life due to debilitating pain is discounted so heavily when there is no visually detectable physical deformity in the joint itself? And what does the surgeon think about letting the patient linger without a joint replacement?
Pain Consideration
Necrofemur,
It seems most Orthopedic surgeons (OS) first take into account the degree of degradation of the bone in order to agree to perform a replacement. Quality of life/pain level is rarely a high weighting factor. I have heard many accounts of patients not being able to get a replacement even though their pain level is so high that they are literally being tortured by there own body and scream in pain day after day.
I tend to think that it's not that OS's don't believe that the patient is in pain. They simply are taught not to operate on something that is healthy or that has a chance to heal. This might be visible evidence that you spoke about or anything that does not constitute full collapse of the bone.
I can see why OS's may not consider a monitory disposition a condition may cause as this is out of the scope of medicine. I do however, believe they need to address the quality of life/pain the patient is experiencing. This is something we expect medicine to fix. The pain medication solution is not a long term solution for AVN patients because of the side affects such as addiction, organ damage, coordination etc.
The ultimate decision should lie with the informed patient. After all, It is their body. To give an example, you take your car into the repair shop. You tell them that your car is making a very loud noise. They tell you that your tail pipe is loose and it is beginning to fail. Now, do they not tighten or replace it because it is still working and that is has maybe another year of life? Should they decide even though it is still making a loud noise they are not going to replace it for the same reasons? They would tell you the cost, if there are any consequences, what they would do etc. The decision would be yours. No matter if it is your car or your body, the decision should be yours.
Thanks for this post. It is a very important issue.
Pain
Thank you for replying to my post in such a timely fashion. I find it interesting that you seem to agree, for the most part, with my characterization vis a vis pain vs. mechanical defect as criteria for joint replacement. Will you bring this topic up during your next interview with an OS? I would love to hear about the decision-making process.
Welcome to the site
New Interview in process
I am very excited to share that we have just completed interviewing Dr. Michael Bolognesi, orthopedic surgeon and assistant professor at Duke University, about knee replacement for avascular necrosis patients. U.S. News and World Report ranked Duke University Hospital as the #7th best orthopedic hospital in the US. Dr. Bolognesi's interview will help shed light on some of the amazing surgical techniques and practices being developed at Duke that will benefit AVN patients world-wide in the future. Staff writers are now hard at work creating the final article based on Dr. Bolognesi's interview and hope to publish this soon.
Alternative Medicine
I would like to know more about alternative medicine and what other countries are doing differently in AVN medicine.
Neurontin
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