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Orthopedic Medicine: Joint Replacement

Many Americans are living longer and leading more active lifestyles. That’s good news overall, but it can take a toll on knees and other body parts.

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From the March 2013 issue of Columbus CEO

In spite of an aging population, Americans are living like they’re younger than ever, thanks to advancing medical knowledge and increased activity levels. But more participation in sports and physical activity is a double-edged sword. Although it keeps people looking and feeling fit, it also means they’re wearing out their joints at alarming rates. Fortunately, medical science is keeping pace with lifestyles.

“We’ve gotten better at repairing injuries, so now physically active people are continuing to do their sport long enough to develop arthritis,” says Dr. Andrew Glassman, chief of adult reconstructive surgery at the Ohio State University Wexner Medical Center.

The osteoarthritis that accounts for 90 percent to 95 percent of all arthritis occurs when the bone ends rub together. “In a normal knee, all of these surfaces are covered with cartilage, which looks just like the shiny white stuff at the end of a chicken leg,” Glassman says. “That smooth, slippery stuff doesn’t have any nerve endings, so you can run, jump and bounce on a normal knee without pain.” However, when that cartilage wears away—either because of trauma, disease or time—bones no longer glide effortlessly, but fall prey to friction. The ends break down and underlying nerve endings are exposed; bone fragments can cause further inflammation and pain.

It’s not just record numbers of marathon runners and extreme sports enthusiasts that have Americans lined up outside orthopedists’ offices. Expanding waistlines are a factor, too. “One of the biggest problems in our society is obesity,” says Dr. Steven Gaines, an orthopedic surgeon with Cardinal Orthopaedic Institute. “It’s like taking a car tire that’s meant for a Volkswagen Beetle and putting it on a Ford F-150 pickup truck. The joints are going to wear out more quickly.”

If pain and damage are severe enough, surgery may be necessary. “There are a variety of conditions that lead to the need to perform joint replacement,” says Dr. Michael Cannone, an orthopedic surgeon with OrthoNeuro. Among those are major trauma, repetitive micro trauma, cartilage injury during previous surgery, rheumatic conditions, gout and family history. Gaines also lists car accidents as a common cause, as well as bone damage caused by alcohol abuse or steroid use.

 

Knees

Knees are the most commonly replaced joint. Gaines says some patients come to him following an injury, but others are former athletes who wore out their knees in high school or college. “Maybe those people didn’t have any big injuries, and they managed to sneak through their 60s and into their 70s before it caused enough pain for them to come in,” he says.

Doctors favor conservative measures before joint replacement. They may prescribe anti-inflammatory medications and steroid injections, or viscosupplementation, an injection that replaces the lubricating substances within the joint. Physical therapy can help strengthen the muscles surrounding the joint, lessening pain and preventing further damage.

Surgeons can also perform arthroscopy, in which torn cartilage is repaired or removed, along with any fragments, spurs and other detritus found in the joint. A mosaicplasty moves plugs from a less-stressed part of the bone to a more crucial, weight-bearing section that is causing pain. “Some areas are more high-demand, and if those have loss of cartilage or bone, transferring bone plugs may be a good way to preserve the joint,” Gaines says.

There are also situations in which cartilage cells can be transferred. If the anatomy is right and the cells can be contained within a specific area, they will grow and replenish missing cartilage.

It pays to discuss all options with the orthopedist. “You should try to keep your own joints as long as you can, but if you’re 50 and you’re watching life pass you by, it may be better to get the total knee replacement and not wait until you’re 65,” Gaines says.

In the past, surgeons would encourage waiting, because implants don’t last indefinitely. But they do last longer than they used to, and the technologies are better, Gaines says. “If you’ve tried all of the conservative measures, none of those things are working and you’re just sitting on the sidelines, I’m not going to tell you to wait 10 years. Let’s get the knee fixed.”

Elizabeth Lockhart waited 22 years after an injury to get a total knee replacement. Lockhart, a registered nurse, works with teens who have emotional and behavioral difficulties. At age 41, she was kicked by a patient. Doctors found both torn ligaments and early signs of arthritis. They encouraged her to have surgery, but she declined. Eventually, her left knee caused pain and difficulty walking, and the right knee became arthritic as well.

“I was having trouble ambulating, and the pain was keeping me awake at night,” she says. Despite her profession, Lockhart was nervous about having surgery and kept putting it off. Now, she says it wasn’t as difficult as she had imagined. The surgery, which was performed at OSU in July, took only a couple hours. Lockhart spent three days in the hospital and a week in a skilled nursing facility before checking herself out (against medical advice). She took narcotic painkillers at home for three days, switching to ibuprofen two weeks later when she stopped taking blood thinners prescribed as a post-op precaution.

Lockhart underwent outpatient physical therapy and took four months off work, since her job has a high risk of repeat injury. She worked at a desk job her first month back. She plans to have the second knee done eventually, but for now is enjoying walking, sleeping and daily activities without pain.

Some patients opt for a bilateral knee replacement, where both knees are done at once. It may seem like recovery would be more difficult with two sore legs, but Gaines says that in many cases, it’s the best way to go. “If both knees are bad, it’s kind of a struggle to walk anyway,” he says. Many patients also have markedly bowed legs because of long-term knee damage, and repairing just one leg would leave the other too short to walk properly. “You almost have to have both done to rehab appropriately,” he says. “The knees recover at a similar rate, and it’s really not that bad.”

There is also a significant cost savings, particularly for those who are still working. In four to eight weeks, patients will be walking well with a cane, but it may take six weeks to get back to work. “With a bilateral knee surgery, you have one recovery, one rehab, one hospitalization and one downtime from work,” Gaines says. “It’s a huge plus economically.”

 

Shoulders

Dr. Rodney Comisar, an orthopedic surgeon with OhioHealth Sports Medicine Institute, says shoulder complaints are on the rise, though replacements aren’t as common as knees. “We walk on our knees, after all,” he says.

Common shoulder problems include tendon damage and rotator cuff injuries that result from repetitive motions in the workplace, sports or even everyday life. Falls and lifting injuries are common causes of pain, but even nontraumatic events can cause damage. Many people have rotator cuff issues and don’t realize it, particularly over age 50, Comisar says. Arthritis is also growing in prevalence. “It’s probably because we are staying active longer than we used to,” he says. “We are living longer, and we have higher expectations about what we want out of life.”

Patients may complain of stiffness, pain, decreased range of motion and weakness in the affected arm. As with knees, orthopedists will likely recommend ice, anti-inflammatory medications and physical therapy before joint replacement is considered.

“Supervised exercise helps build strength,” Comisar says. “Often the pain will recur if the underlying muscle issue is not fixed. I sometimes recommend injections, but that can give a false sense of security.” Rather than returning to the activity that caused the damage, the patient should take time to strengthen the muscle and tendon network around the joint.

A surgeon may also consider arthroscopic surgery to clean out bone fragments or repair small tears in the rotator cuff. Even in major tears, surgeons can use a device similar to a molly bolt (an expanding fastener commonly used to hang items on hollow walls) to reattach the tendon to the bone.

Even with total shoulder replacement, recovery can be fairly quick. Comisar says many patients can go to outpatient rehab one to three days a week instead of spending time in a skilled nursing facility. Normal function usually returns within three months, and strength will continue building to normal levels for about a year. The replacement joints last 15 to 20 years, Comisar says.

 

Ankles

Fragile and very necessary for walking, ankles are also candidates for joint replacement surgery. Dr. Thomas Lee, an orthopedic surgeon with the Orthopedic Foot and Ankle Center, uses the procedure to treat people who are experiencing debilitating bone-on-bone arthritis and the less-common avascular necrosis, a condition in which the bone dies.

Even as children are leaping off rocks and wiping out on their bikes, they are building their potential for arthritic ankles. “Many people repeatedly sprain the same ankle or, in their 20s or 30s, may fall and break an ankle,” Lee says. “Ten or 20 years out, that ankle will probably form arthritis.”

Lee says he sees two to three broken ankles every day, and that there are 24,000 sprained ankles reported across the country on a daily basis. Ankle replacement surgery patients are generally about 50 years old—roughly 10 to 15 years younger than the average knee replacement patient. There are thresholds surgeons prefer not to cross, however.

“If a patient is 30 or 35 years old, we tend not to move toward replacement,” Lee says. Replacement joints are thought to have a 15-year lifespan, and no one wants to go through the process at age 30 and again at 45 and 60. Instead, doctors recommend anti-inflammatory medications, physical therapy and perhaps a brace to prevent further injury. Custom-made leather and plastic braces are available, but even those sold in drugstores will protect the vulnerable joint, Lee says.

Arthroscopic surgery is another option, as is fusion, in which certain bones are permanently fused together to increase stability. However, patients who undergo fusion are no longer candidates for ankle replacement.

Prevention is the most important factor. “If you have a history of ankle sprains, visit your primary care doctor or musculoskeletal doctor and see if physical therapy would be appropriate,” Lee says. “Therapists can do wonderful things with strengthening and helping patients to regain their balance.”

Early signs of arthritis may manifest as stiffness, pain, achiness and swelling that increases with weather changes. Lee says changes in barometric pressure affect the viscosity of the joints’ lubricating fluids. “Ask your grandma how her fingers feel and listen to her when she says it’s going to rain,” he says. “She knows what she’s talking about.”

People who think they may be headed for future arthritis can modify activities. “If you have early signs, you probably don’t want to shoot for that marathon next year,” Lee says. “Ride in the Pelotonia instead.”

 

Innovation and Prevention

Cannone says surgeries are on the rise. “It is approaching an epidemic in the United States,” he says. “The projected numbers are staggering as to the future need for joint replacement, not to mention revision procedures.”

OSU’s Glassman performs 300 to 400 hip and knee replacements each year. “Both among the active and the overweight, the numbers are increasing,” he says. Between 2005 and 2030, total knee replacement procedures were projected to increase by 674 percent. “Right now, it’s exceeding that pace,” he says.

For patients who do undergo surgery, technology has changed a lot. In the past 10 years, incisions have gotten smaller, techniques have become more precise and the quality of materials has improved, though the design has remained largely the same, doctors say.

Glassman says innovation isn’t necessarily a good thing. “Billions of dollars are spent each year on joint replacement, and there is something new almost on a daily basis,” he says. “History, particularly the history of orthopedics, is littered with cases in which the newest, best, most revolutionary device is introduced, only to be recalled two years later.”

Innovation is having the most impact in technique and instrumentation. Doctors are using computerized and robotic technologies to perform highly complex procedures with ease and great accuracy. Snap-on guides are made prior to the surgery using radiological equipment and precise measurements, showing the surgeon exactly where to cut.

Aside from not abusing joints outright, the best way to keep them healthy is to stay active and lean. When walking down stairs, the knees experience seven times the force of body weight. “Twenty pounds doesn’t sound like a lot, but 140 pounds does,” Cardinal Orthopaedic’s Gaines says. “Put that in a backpack and walk around with it for a while, then take it off. Even what seems like small amounts of weight can be big for the joints.

“If you can keep your weight controlled and keep your legs strong, you are probably doing as much as you can,” he says. “Live life and enjoy it, but be smart about it.”

Kristin Campbell is a freelance writer.

Reprinted from the March 2013 issue of Columbus C.E.O. Copyright © Columbus C.E.O.