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Recent developments offer new options for younger people who want to continue their active lifestyles without pain
Published: Synapse, 2010 : Vol. 2
People now entering their late 40s, 50s, and early 60s -- the "Baby Boomers" -- tend to be more active than previous generations were at middle age, with no expectations of slowing down. But sometimes nature intervenes in the form of osteoarthritis, a degenerative joint disease in which the cartilage (connective tissue) joining the ends of two bones breaks down, roughens, and ultimately wears out. The rubbing of bone-on-bone can cause significant pain that worsens over time.
"With a larger number of men and women reaching their 50s and early 60s, we have seen a huge upswing in degenerative arthritis of the hip and knee," says Robert Huxster, MD, board-certified Orthopedic Surgeon and Chairman of the Department of Surgery. "We always start with conservative treatments such as medication, injections, and physical therapy. But some will continue to have pain that limits exercise and daily activities."
Historically, these younger patients were not good candidates for joint replacement surgery because artificial joints tend to wear out within 15 to 20 years -- meaning that most patients would outlive their prosthesis. Although not impossible to replace an artificial joint, it is difficult.
Today, there are newer resurfacing procedures that preserve more of the patient's own bone, making it possible for total joint replacement to be done later in life if needed. For some younger people with persistent pain, surgery has become a more viable option.
"The focus in orthopedics has been on developing surgical procedures that last longer or can be converted [to total joint replacement] later in life," notes Dr. Huxster. "We're seeing younger and younger people with pain and limitation who are running out of conservative options."
The hip is a ball-and-socket joint: the rounded head of the leg's femur bone fits into a pocket in the pelvis called the acetabulum. In a total hip replacement, the surgeon removes the entire head and neck of the femur and replaces it with a half-sphere-shaped metal or ceramic ball on top of a long stem, which is anchored deeply into the femur. The acetabulum is capped with metal and plastic. A total hip replacement can last up to two decades, but it puts high-impact activities such as running, jumping and singles tennis off-limits to reduce the risk of loosening.
Hip resurfacing is a newer approach pioneered in Europe during the late 1990s and approved for use in the U.S. by the Food & Drug Administration in 2006. Instead of removing the entire head of the femur, the surgeon shaves it into a rounded shape and covers it with a metal cap on a small spike, which is then cemented into the bone. The socket of the pelvis also is lined with a metal cap.
This approach offers some significant advantages. Because so much of the femur is preserved, a patient can have total hip replacement later in life if the implant wears out. High-impact sports and other activities are possible as well. "The ball of the joint has a larger diameter than it does in total hip replacement, which makes it more anatomically correct and allows for a greater range of motion," says Chet Simmons, Jr., MD, a board-certified orthopedic surgeon with Chester County Orthopaedic Associates in West Chester and Kennett Square. He adds that the metal-on-metal design may be more durable than the metal-on-plastic typically used in hip
Hip resurfacing is not right for everyone, however. The femur has to be strong and solid enough to support the metal cap. Dr. Simmons notes that the best candidates typically are "younger, active males" who have high bone density and plan to resume high-impact activities. He points to three of his recent cases, all men in their late 40s, including a competitive tennis player, karate instructor and basketball referee. Although he has performed hip resurfacing on women, many are not good candidates because they are smaller-framed and at higher risk for osteoporosis, or thinning of the bones.
Because hip resurfacing is still relatively new, only a limited number of orthopedic surgeons are trained to do it, and they cannot know for sure how patients will fare over the long term. But so far, studies suggest success rates in the high 90-percent range several years out from surgery. There may be some small risk of an adverse reaction to the tiny metal particles released into the bloodstream by the metal-on-metal implant.
"This is something I always discuss with patients," notes Dr. Simmons. "If there is persistent pain or inflammation suggestive of a problem due to the metal, we can always revise the resurfacing to a total hip replacement."
Until this risk is more fully understood, hip resurfacing is not recommended for those with a known metal sensitivity or kidney disease (because the kidneys filter impurities out of the blood). A study of 3,400 resurfacing patients at nine Canadian medical centers did show that three years after surgery, more than 99.9 percent of patients experienced no implant failure due to metal wear debris. There is a small risk of fracture to the femur, which could require a total hip replacement later. But for the right candidates, the benefits of hip resurfacing appear to far outweigh the risks. The recovery process for hip resurfacing is similar to that for total hip replacement, as it is just as extensive an operation. Brendan Sullivan, head physical therapist at The Chester County Hospital's Center for Physical Rehabilitation and Sports Medicine, says that patients can expect to start working with a physical therapist in the Hospital, followed by one to three weeks of in-home therapy and several weeks of outpatient therapy.
"Timing really varies depending on the needs of the individual patient," says Sullivan, who is certified in orthopedic rehabilitation. "At first there may be stiffness, weakness and balance issues. Once we address those through a progressive therapy plan, we work to get the patient back to his or her functional goals." Full recovery can take up to six months, although therapy typically does not last that long.
"The single most important predictor of how a patient recovers is their condition going into surgery," Sullivan adds. This can put hip resurfacing patients at an advantage, since they tend to be younger, healthier, and more active. But sometimes he finds he needs to "rein in" younger patients because they try to take on too much too soon.
Sullivan emphasizes that staying active before surgery can make a major difference in recovery for all joint replacement patients. The Center for Physical Rehabilitation offers a pre-surgical therapy program called "Start Strong, Stay Strong," which helps patients get ready by exercising with a physical therapist for three to six weeks before surgery.
"The most important thing is to try to stay as active as possible before surgery, as it will make the rehabilitation process easier. Get on a bike, get in the pool, do whatever you can. The worst thing is to sit on the couch and wish the pain away, because ultimately patients will have to deal with that inactivity during the rehab process," Sullivan says.
Unlike hip resurfacing, partial knee resurfacing -- also called partial knee replacement -- is not limited to younger patients. However, it has made surgery a better option for them because it too preserves more of the bone.
"We see many people in their 40s or 50s who develop significant arthritis of the knee, but it may affect only the inner or outer portion, or just under the knee cap," says Dr. Simmons. "By replacing only the damaged portion, there is less bone removal and the knee feels more natural. If the implant does wear out, it can be converted to a full knee replacement later."
The knee has three compartments: the medial (inner), lateral (outer), and patellofemoral (kneecap). Dr. Simmons notes that arthritis of the knee is limited to one of these areas in as many as 20 to 30 percent of patients. In partial knee resurfacing, only the damaged surface of the knee joint is replaced with a fitted implant. Usually this involves a smaller incision, less trauma to healthy bone and tissue, and faster recovery than a total knee replacement.
"Once the knee is resurfaced, physical therapy helps patients work on the problems they had before, such as lack of strength or limited range of motion," Sullivan says. As with hip resurfacing, the length of physical therapy depends on the individual patient, but some are able to finish within four to six weeks. Again, pre-surgical physical therapy can be a tremendous help.
Many patients are not good candidates for resurfacing procedures, but they may benefit from other recent advances in joint replacement surgery. One good example is anterior hip replacement surgery, a less invasive approach in which the surgeon accesses the hip joint through a smaller incision on the front of the hip, rather than the side (lateral approach) or the back (posterior). He or she then does not have to cut the major muscles in the buttocks and thigh that help stabilize the hip. As a result, patients are able to bend the hip and bear weight on it soon after surgery, which leads to a faster recovery. With the more traditional lateral and posterior approaches to hip replacement, patients have to limit hip motion carefully for several weeks after surgery.
Dr. Simmons stresses that each patient should work with an orthopedic specialist to determine when the time for surgery has come and what type of joint replacement will serve him or her best, given factors such as age, lifestyle, activity level, and other health conditions. Whatever procedure they choose, all patients stand to benefit from the development of increasingly more durable implants. Dr. Simmons says there has been a "marked improvement" in these materials, meaning that today's patients can expect them to last even longer than they would have in the past.
"Most patients know when medications and therapy aren't enough any more and their activity level drops significantly," Dr. Simmons says. "For some, it might be when they can't run or golf anymore. For others, it might be when they can't make it through the grocery store without pain. We care much more about the patient's experience of pain and limitation than what the joint looks like on an X-ray."
By Kristine M. Conner
Many younger patients with osteoarthritis pain find relief from medications and physical therapy. "Physical therapy can help patients re-establish as much motion and strength as they can, preventing or delaying the need for surgery," says John Gose, PT, MS, OCS, Director of Rehabilitation at The Chester County Hospital. "Often it's not just about pain relief, but getting people functional as golfers or runners, as heavy equipment operators or manual laborers. Even if they can hold off on surgery for five years, that's a good deal." Medical therapies can help, too. Orthopedic surgeons are treating some cases of knee osteoarthritis with viscosupplementation, a series of injections that place fluid directly into the knee, typically every six months. It can be a good option for patients who are no longer helped by anti-inflammatory medications such as ibuprofen.
Last Updated: 9/13/2010