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What is a biological joint and what is the expected process from a patient's perspective?


Indications

To be considered a candidate for a biological implant, you must be less than 55 years of age, have a lesion that is greater than 2 square centimeters in size, either on opposing surfaces of joints or in a single sided area, and you must have a body mass index less than 35.

Process for Biological Joint Replacement

You will go through a surgical screening criteria to be assured that you will meet the very restrictive guidelines that have been set up in order to ensure the best outcomes.  This will include an arthroscopic evaluation to prove the extent of the destruction and to assure that adequate material to reconstruct the joint is available. A cessation from smoking for at least three months prior to surgery is required.  Genetic testing is done to make sure that we have a complete knowledge on opiate resistance or sensitivity, and clotting factor deficiencies or unrecognized bleeding tendencies. If you desire additional tests of other areas of sensitivity of genetic differences such as cardiovascular and other metabolic pathways can be done. Once you have completed your surgical preoperative clearance for the biological joint replacement a massive time consuming precertification process throughout office begins.

Financial

The harvesting of biological grafts from donors is an extremely costly process.  The cost of the biological replacement usually exceeds $80,000 to $100,000. This is not because of physician or surprisingly hospital bills, but because of the expense of the graft material used to reconstruct the patient's joint.  A prolonged waiting period on certification or verification of insurance benefits by each patient's insurance company is to be expected.  We as an office are very good at what we do, but we cannot re-write your insurance plans, limitations, and/or approval process. Approval for surgery is so dependent on the insurance companies that often graft material is procured for use but goes unused because the insurance company is still balking. We will work hard for you to get your surgery approved. However, once we submit required documents, it is out of our hands.

Transplant Surgery Day

You will be tentivley scheduled for surgery or the assumption that reimbursement will be approved. Often surgery may be scheduled only to be canceled because of insurance delays. This is not only frustrating to patients but is also to me as your physician.

Assuming surgery goes forward, it is a very lengthy and tedious operation.  The procedure usually takes three to four hours.  It can be equated to a project rather than a procedure since there are so many moving parts and the intricacies that go into reconstruction success.

Recovery: Finally Looking forward!

Once surgery is complete, you will spend a brief time in the recovery room and move to the floor for activities to begin the same day of surgery.  In the morning following surgery, you once again are allowed to walk touch down weight bearing and with the same limited range to prove that you are independent. Once other bodily needs are proven to be functional, you are allowed to be discharged home after about 24 hours in the hospital.  Your first two weeks following surgery must be spent with your knee elevated to try to improve range of motion and encourage good circulation. During this time, the recommended sequential calf compression device is to be used as much as possible to promote circulation and healing.

Follow-Up Clinic Appointments

Your first appointment is at two weeks. I will see you on your first appointment and Sarah will see you on the next appointment. We then alternate for the months ahead as a team approach to ensure that we are all in this together.

Things That Go Sideways!

As with any surgical procedure, complications can occur.

  • Infection:  This is the most dreaded. Traditional statistics for total joint replacement are between 1% to 2%. Biologic joint replacements are less than that and vary between articles and surgeons.
  • Blood clots: While it is often the case that patients develop clots in the calves, these are not as significant as clots in the upper leg which can be potentially life threatening. We take any kind of clot very seriously and we use anticoagulation routines such as chemical and mechanical compression to minimize the likelihood of this occurring. Nonetheless, it is important to know the symptoms and the appropriate follow up in the event this should happen.
  • Loosening, failure and disruption of graft: The graft fixation is very fragile for two reasons. First, if one ever needs to revise it, you do not want massive hardware disrupting the graft, either from circulation or from access, but more importantly, the viability of living tissue is disrupted by any mechanical fixation device.  For this reason, we caution patients to be very gentle on their extremity until we allow weight bearing and range to be achieved in the recovery phase. This is individualized and specific to each patient but it by no means ensures that in every case there will not be issues that may arise.  If displacement or graft incorporation fails, there are constructive ways to repair this situation.
  • Arthritis development: Since this was the reason that we did the procedure in the first place, it is a reality that that will eventually occur.  The biological replacement is meant to delay or provide an alternative means of use until arthritis which is inevitable becomes more symptomatic. It is presumed and hoped that the biologic replacement not only gives a good foundation for mobility providing years of improved function, but when the day comes that a replacement is the next step, it gives versatility by providing a living joint as a foundation to implant traditional joint replacement implants without serious consequence.

Summary Educating

Biologic joint replacement is not for everyone.  Because of the time tied up with patients in selection, education and procuring approval from insurance companies, our office feels as though you have become part of our family. Failures are equally as disappointing to us as they are to you. They do occur and there are always issues lurking in the wings that we cannot anticipate. What matters most is that we are there for you; to answer questions if they exist, to lean on if times get tough, and celebrate your continued recovery!

David R. Lionberger, MD – 10/19/2016