text_1: Pushing Limits of New Knees
text_2: This article looked at this issue through the positive short-term experiences of six individuals who opted for joint replacement in mid-life. They all seemed to be exuberantly active and have splendid outcomes after emerging from post-operative rehabilitation. The six recipients of artificial knees and hips were collectively able to engage in long-distance cycling, kite-boarding, motorcycling, yoga, pilates, strength training and basketball. One woman reported that her pain and limitations were completely gone. “I never imagined my life could be so wonderful,” she commented. Although several of the subjects were pushing the envelope in terms of stressing their implanted joints with high-impact activities, not a single one reported a problem, a complication, or a functional limitation when they returned to normal activity. In a country where more than half of adults are overweight, and almost half are completely sedentary, the joint replacement patients in the Wall St. Journal article are far from the norm. It is hard to imagine that these six individuals are representative of patients who opt for joint replacement in middle age across the United States. The story did attempt to balance the idealized view of joint replacement in the patient vignettes with cautionary notes from several surgeons. These invited experts pointed out that artificial joint recipients should avoid high-impact sports and that the durability of joints implanted in mid-life remains uncertain. Given the views of these experts, some tough questioning of the patients could have shown the reader that these individuals may be experiencing short-term benefits at the expense of long-term misery—if their implants ultimately fail. More references to scientific studies would have been welcome. The article never reported the overall success rate of knee and hip replacement in younger patients. Or the degree to which these procedures lead to an increased level of activity. It gave short shrift to one of the key questions about joint replacement in middle-age. In terms of pain, function, and adverse advents, what are the projected outcomes of the revision procedures that appear to be inevitable for surgeries performed at this age? And the article never got into the thorny question as to whether the surge in knee and hip replacement in younger patients might represent over-utilization of these surgical procedures—or at least premature use. A recent commentary in Arthritis Care & Research suggested that patients and their doctors in the United States rely excessively on analgesics and joint replacement to treat osteoarthritis of the knee and hip—and are under-utilizing evidence-based treatments, such as weight loss and exercise programs, that might delay these operations. (See Hunter et al., 2011). Reference: Hunter DJ et al., Quality of osteoarthritis management and the need for reform in the U.S., Arthritis Care & Research, 2011; 63(1): 31-38. Although knee and hip replacement have traditionally been employed in patients 65 and older, there has been a recent expansion in their utilization in younger patients, particularly those in their 40s and 50s. Since patients this age will likely require one or more revision procedures over the course of their lifetimes, this creates uncertainty about the long-term outcomes of knee and hip replacement in this population. There is also evidence that healthcare practitioners in the United States are not following evidence-based guidelines in the treatment of painful osteoarthritis of the knee and hip, particularly in its early stages. As a result, some patients may be undergoing joint replacement unnecessarily. (See Hunter et al., 2011). Given the “graying” of the general population, and the rising prevalence of painful OA, these are huge public health issues. The aging of the population means that society will have trouble paying for these procedures in older individuals. Paying for expanded use in large numbers of younger patients who will then face more expensive reoperations later in life is a daunting prospect.