Adventures in Joint Replacement Therapy
By Pamela K. Johnson
As children, we tumble and frolic without a care about how the hip bone is connected to the thigh bone, but by middle age we sometimes lose the spring in our step to decades of wear and tear, arthritis or injury.
While orthopedic surgeons can replace damaged or diseased joints from our toes to our shoulders, it’s the leg region that most frequently needs repair. More people require knee replacement surgery than any other joint, with about 600,000 such operations performed each year at an average cost about $15,000, according to the Journal of the American Medical Association. With an aging, active population, demands for knee-replacement surgery are projected to climb to 4 million a year by 2030.
“The biggest reason people get joints replaced is pain,” says Douglas Garland, M.D., the medical director of MemorialCare Join Replacement Center in Long Beach, Calif. He finds that his patients are getting younger and younger. Obesity, trauma and genetics can be the undoing of our knees, while hips are also vulnerable to dysplasia when joints aren’t in sync with one other, he said, ultimately leading to friction and arthritis.
“My grandparents’ generation accepted the pain,” said Garland, adding that they were content to walk with a cane or navigate the world in a wheelchair. But baby boomers and later generations cherish their on-the-go lifestyles, and are less likely to put up with the ravages of age. “Half the people we [operate on] are under 65,” he said
Erica Lansdown, who had hip-replacement surgery nearly eight years ago at 50, was one of Garland’s patients. “I was an obsessive-compulsive exerciser from 11 years old to my mid-20s,” said the Southern California librarian, who started out as a ballerina in adolescence, and went on to teach dance and run 4-7 miles daily. Then she added surfing to her recreational resume at 38. But one of her legs was slightly shorter than the other, and the ball of her hip was small for the size of the socket, she said, and over time, her cartilage began to wear down, causing her hips to ache.
The pain made it difficult to sleep, and she could only stand straight for moments at a time. When she exceeded that limit, she had to bend over and rest her hands on her knees, ultimately relying on crutches to get around—something of an unwelcome 50th birthday present.
She remembers the moment when Dr. Garland put her X-rays up on the light box: “Yeah, these are ugly,” he told her. “We’ll do both [hips] at the same time,” he determined, based on her upper body strength from surfing and her slim build. “You can have one surgery and one recovery, ” he told her.
After Lansdown’s operation, a home-health therapist came twice a week for about a month, and then she went to a rehab center and learned to walk again. She found rehab “intense, painful and nauseating,” but the feelings passed. These days she swims, surfs, and bikes, getting maximum mileage out of her new hips.
Her case is not typical, however, in that it’s often recommended that replacement of a pair of joints be separated, with the first done on the one that gives the patient the most problems, followed by the second surgery a few months later, as needed. That way a person has “one good leg to stand on.” This approach may also be preferable because many people have one joint that’s worse than the other, and by correcting it first, “a lot of times the other one is no longer taking all the weight and doesn’t hurt as much,” says Constance Chu, M.D., an orthopedic surgeon and director of the Cartilage Restoration Program at the University of Pennsylvania Medical Center in Pittsburgh, PA.
With patients skewing younger and younger, she’s exploring earlier, less-invasive options for treatment, some of it based on her study of horses. “What we found is that there are horses that heal very well, and horses that don’t heal very well,” she said, which can also be applied to people, and needs to be taken into consideration at the outset. Chu is also researching stem-cell transplants, cartilage transplants, and gene transfers as alternative methods to heal damaged joints.
Garland says recovery times have shrunk over the 30 years since he’s been performing the procedure; fewer patients need physical therapy, with the duration of that therapy also having been reduced.
For those in their 60’s and 70’s dealing with decreased mobility, joint replacement is the best option, Chu said. “Patients in those categories love their new knees, and it’s a very satisfying procedure for the surgeon.” But the elderly tend to have reasonable expectations of their new joints, she said, while younger patients tend to think of their new knees, hips and other factory-issue parts as they do a new car. “The difference with a joint replacement is that your next car is not a better car,” she explained. “It’s more metal and plastic, and less like a normal knee [or hip or shoulder, etc.] than the first one,” she observed.
Younger patients may also end up needing the surgery a second time, she said, as joints are predicted to last 10 or 15 years, but anything beyond that is not promised. So if you’re in your 60’s or 70’s, a prosthetic joint could walk you through to the end of your life. But if you’re a decade or two younger and/or put the joint under highly demanding conditions, you may turn out to be a repeat customer at your orthopedic surgeon’s office.
Claire Beekman put off going under the knife for as long as she could. The retired physical therapist was biking when she discovered her bum right knee could pedal no further.
For nearly a decade before her surgery at age 69, she nursed the knee with injections to subdue pain and improve function. But it was a Band-Aid measure, and did not resolve underlying issues with arthritis and a fractured patella. Then about two years ago she said, “I was out riding my bike and got a catch in my knee. I couldn’t bend it or straighten it,” she recalled.
It was a sign that she had to shift from babying the knee to taking the bold step of having it replaced. Before surgery roughly a year and a half ago, she set out her clothes and most-used items, installed a toilet with arms, and moved her bed so there was room for her walker to clear it. After surgery, she got up and ambled the length of the recovery unit on a walker that same day, and three months later her new knee was up for a trip to Southern Asia.
“I hiked in India right at the three-month mark after the surgery, just before Christmas,” she said. “We walked around temples, a mile and half here and there, up and down big sets of stairs, and I couldn’t have done it without the surgery.”