Just after the new year, a group of orthopedic surgeons in Finland published the findings of a study showing that over the 25 year period between 1980 and 2006 there was a 130 percent increase worldwide in knee replacement surgeries for patients between the ages of 30 and 59, with the greatest increase occurring in patients between 50 and 59 years old. There was a time when we would have to tell people suffering from arthritis they would have to wait until they were 65 years old before surgery would be advisable. But the incremental advances in surgical technology that have occurred over these last few decades have combined to make knee, hip and shoulder replacements into three of the most successful elective surgeries ever introduced.
For one thing, the materials used in joint replacement surgery have increased the lifespan of the prosthesis dramatically. It’s hard to believe that 50 or 60 years ago people were in nursing homes or housebound just because of arthritis. They just couldn’t move around anymore. In 2009, the Agency for Healthcare Research and Quality reported that over 600,000 people in the U.S. had joint replacement surgery for osteoarthritis of the knee alone. Now even a younger adult who puts a lot of strain on a joint replacement can expect the materials to last through most of their adult life. The risk of multiple revisions due to wear over the course of the patient’s life is much less now than twenty years ago.
Some advancements have been tangential. For example, knee replacements went through a period where surgeons were using an alternative approach that made a much smaller incision. Most orthopods have stopped doing the procedure because the complication rates ultimately didn’t justify it. But my incisions are about 60 percent smaller than what they were five years ago because of the instruments that were developed for the approach.
New instruments are also contributing to a more straightforward approach for performing hip replacements in certain patients. These new instruments have been modified in a way that lets the surgeon approach from the anterior, or front, of the hip. The procedure is performed under x-ray guidance, which allows a small incision between muscle plains, so it’s really very atraumatic for the patients. You have a small incision, which doesn’t cut through any muscle and post-operatively it seems like the recovery is that much faster.
The biggest improvement of all has probably been the use of regional anesthesia, especially for knee replacements and, to a lesser degree, shoulder surgery. The anesthesiologist can now use ultrasound equipment to put the anesthesia around the nerve with a very high success rate. Regional nerve blocks eliminate the nausea or breathing complications that may occur with general anesthesia and it results in less post-operative pain for the patient because the block can last for up to 24 hours.
Here at BMH we have an excellent approach where the anesthesiologists, the surgeons and the nursing staff discuss how we’re going to treat a patient’s post-operative pain before the procedure. We agree on a very specific set of medications and a schedule that enables us to preemptively treat a patient’s typical post-operative problems with incredible results. Now patients are up the morning of surgery and are generally able to eat a light breakfast. It not only benefits the patient’s comfort but their recovery as well. The sooner you can get the patient moving the less risk they have of getting a blood clot (deep vein thrombosis). Whereas before some patients would have to sit in bed for a day or two while the nurses tried to control their pain, now we can get them up in a chair or walking more quickly. IV’s and catheters are usually out within 24 hours of the procedure.
Studies show the percentage of patients who are satisfied with hip replacement is in the high nineties. Satisfaction after knee replacement is in the low nineties and for shoulder replacements it’s in the high eighties. But there are objective and subjective measurements to any outcome. Orthopods and physical therapists have a scoring system that takes into account the patient’s range of motion, what the x-rays look like, and limb function. Most of the time, the objective measurements correlate very well with what the patient is feeling. However, some patients will have really good measurements but still experience pain and discomfort. Others will have low scores but feel satisfied with the outcome. I remember doing a shoulder replacement for an elderly woman who had severe osteoarthritis. She didn’t go to therapy so her range of motion was limited. But she was a violinist and the surgery enabled her to move her bow arm back and forth and she could once again carry her violin case. Her shoulder scores were terrible but she was happy because she could play again.
All these improvements, big and small, add up to total joint replacement being more accessible than ever before, and the number of people having the procedures will continue to increase in younger patients. There’s really nothing that a big hospital does that we can’t do here. A patient and their primary care doctor should confer with an orthopedist to decide when the time is right for an operation, but arthritis at any age no longer has to be the painful, restrictive condition that it once was.
William Vranos, MD is a board-certified orthopaedic surgeon at BMH Orthopaedics & Sports Medicine, a department of Brattleboro Memorial Hospital.