LOCAL LOOK
Dr. Brian C. Schafer with Orthopaedic Associates of Southeast Missouri, PC, took time to answer questions from the Southeast Missourian.
Southeast Missourian: We are running a story about a second knee and hip surgery. The report says that one in 75 knee and hip surgery patients have to undergo a second replacement surgery within 3 years.
Dr. Brian Schafer: This is the problem with lies, damn lies, and statistics as reported to lay people without any explanation. The numbers they are reporting are for all hip and knee replacements in all comers INCLUDING unicompartmental knee replacements and hip resurfacing. The three-year revision rate for traditional unicompartmental knee replacement is higher, and has always been higher, than for total knees. The reason is that they are usually done in younger, more active people as a stop gap before total knee replacement ¿ realizing full well that it will fail. In unicompartmental knees before Oxford, we were only going to get about seven years out of a uni at best. Oxford has changed this to where we hope to get 15 to 20 years out of a uni, but that is a relatively new design and approach. The uni rate of revision of 2.8 percent at 3 years is skewing the data. Also it should be noted that one in 75 is a 1.3 percent revision rate at 3 years, which includes the 2.8 percent from the unis that is not that far off of what we tell people. That data also includes hip resurfacing with a 2.6 percent revision rate. Hip resurfacing is loaded with risk. It is done in young, healthy, very active patients who are at higher risk for failure due to their activity level and the inherent complication risks of the surgery; femoral neck fractures are not uncommon.
The data does not give a proper picture of the risk associated with traditional total hip and total knee replacement because it includes the data from two operations that are actually done as a temporizing procedure, knowing full well that it will probably not last a lifetime. Since the patients receiving these surgeries are younger and more active the surgery is designed to preserve bone so if and when it does fail, the conversion to a total hip and knee will be easier and more successful with less bone loss and better fixation and stability than is seen with the revision of a total knee or total hip.
If you take out the uni knees and the hip resurfacing then the numbers are what we tell people. Most people (greater than 90 percent, and some studies show 95 percent) will get 10 years out of their replacement; around 90 percent will get 15 years; and 85 percent or more will get 20 years. In the first three years the most likely reason for revision is infection or fracture. The risk of infection is about 0.5 percent and has been forever. That covers 0.5 percent of the rate right there.
SM: I am looking for a medical expert who can speak to the following: Do you have experience with second-time surgeries?
BS: Yes, I do revision surgery.
SM: It appears people seeking new joints increasingly are younger and more active, a second new study issues a caution about what athletic activity patients should try after recovery. What exercises are a go and which are a no? Swimming, running, what about tennis or volleyball? How active can one be after replacement surgery?
BS: The most important thing in the longevity of a total joint replacement is reducing impact. Any high impact activity should be avoided. Running, jumping, and sports or activities that require quick changes of direction should be avoided. Walking, golfing, swimming, cycling, weightlifting (within limits), using elliptical trainers all are fine.
SM: How can a person take care of their artificial joint while still living an active life?
BS: The main thing is to limit impact and stress on the joint through weight control and avoiding high impact activities. A very important component of a successful joint replacement recovery and return to desired activities is knowledge on the part of the patient. Walking is encouraged without limit but walking is no substitute for the exercises your doctor and physical therapist will prescribe.
Knowing what activities to do in the immediate post operative timeframe and the first 4-8 weeks following surgery sets the stage for maximal recovery. After that, the American Academy of Orthopaedic Surgeons notes that you can continue to walk as much as you like, and other acceptable activities include swimming, dancing, golfing, and bicycling. It is recommended to avoid activities that put stress on the knee. These activities include: tennis, badminton, contact sports (such as football, baseball), squash or racquetball, jumping, squats, skiing, or jogging.
Jacob Pattengill, Physical Therapist, Certified Strength and Conditioning Specialist and Center Manager for Select Physical Therapy had this to say about joint replacements.
Assuming you are suggesting that patients who have undergone a total joint replacement may face a second surgical procedure to replace the first artificial joint, it is possible.
Generally, total hip and knee replacement are expected to "last" 15-20 years. Surgeons generally encourage patients to make surgery the last option if conservative treatment such as physical therapy may assist in combating their pain and dysfunction. As our population increasingly battles arthritis, obesity, and other degenerative diseases, we will likely continue to see an increase in total joint replacements in younger patients. If someone undergoes a total joint procedure at 40 years of age, rare but does happen, they may face a second surgery when they are 55-60 years of age depending on their level of activity. This coupled with the fact that our society is generally living much longer today than the society 30 years ago, the likelihood of "outliving" these artificial joint will become more and more common.
In my experience, those who have undergone a second surgery have rehabilitated with equal success as compared to those who are recovering from their first surgery. If a patient has undergone a total joint replacement, hip or knee, I would discourage high impact activities including running, jumping, or plyomerics. Safe exercises usually include cycling, swimming, walking, and hiking, but always check with your physician for an optimal outcome.
WASHINGTON — One in 75 patients who gets a knee or hip replaced must get it replaced again within three years, new research finds, although the studies underscore a question: Just how much pounding can a new joint take if you want it to last?
First-time hip and knee replacements are skyrocketing, for good reason. They can be highly successful at relieving debilitating pain and helping people to walk normally again.
Also on the rise are more complex "revisions" where doctors remove the initial joint implant and put in another. That repeat operation isn't always avoidable even with high-quality care.
But new research suggests the type of joint replacement you choose and even gender can play a role in whether you need a revision. And as people seeking new joints increasingly are younger and more active, a second new study issues a caution about what athletic activity patients should try after recovery.
"I would discourage high impact activities including running, jumping or plyometrics (sports performance enhancement)," said Jacob Pattengill, a physical therapist and manager at Select Physical Therapy in Cape Girardeau. "Safe exercises usually include cycling, swimming, walking and hiking."
But you should ask your personal physician for specific guidelines.
Dr. Thomas Barber of the American Academy of Orthopedic Surgeons and a surgeon in Oakland, Calif., got tough with a patient who wanted a hip replacement so he could return to coaching basketball. Coach from the sidelines, don't play, Barber advised. "Yes, you can run up and down the court with your kids. But I really don't want you in there jumping up and down and throwing balls."
Americans are undergoing more than 478,000 knee replacements a year, a number expected to reach 3.4 million by 2030 as the population ages. The AAOS counts 234,000 total hip replacements a year, expected to more than double by 2030.
As the country ages and battles arthritis and obesity, joint replacements in younger patients will likely increase and "the likelihood of outliving these artificial joint will become more and more common," Pattengill said.
Already, 40,000 knee revisions and 46,000 hip revisions were done in 2004, the latest data available. Knee revisions are expected to increase sevenfold, and hip revisions to more than double, by 2030. Revisions are tougher operations, taking longer as surgeons hunt for usable bone. They also cost more. A hip replacement averages $35,000, compared with $45,000 for a revision, according to AAOS.
British researchers took the closest look yet at how modern joint replacements are holding up, using a registry tracking the operations in England and Wales since 2003. That overall one-in-75 revision rate is considered pretty good, they reported last month in the journal PLoS Medicine.
The U.S. has no nationwide registry, but high-volume U.S. hospitals report similar revision rates, and perhaps a little worse at less experienced facilities, said AAOS' Barber.
A bigger question is how the implants hold up at five years or longer. Some implants tend to fail early if they're going to at all, so rates may stabilize.
Nor could the study measure how much wear-and-tear patients put on new joints.
Enter the second study. Researchers at Massachusetts' Lahey Clinic reviewed the science to date and concluded there's no good evidence to guide advice on what activities are worst for a joint's life span. Among findings in this month's Journal of Bone and Joint Surgery:
* Twisting and hard landings are of particular concern.
* Surgeons generally recommend low-impact walking, cycling, swimming, golf or bowling — and advise against high-impact football, basketball, jogging and soccer. There's no agreement on others, such as baseball and singles tennis.
* Hip resurfacing is targeted to younger, more athletic patients but there's no proof that they return to sports more safely than patients with traditional hip replacement.
"People do have very high expectations. They're not always getting those results," Barber said.
Dr. Brian C. Schafer, a surgeon with Orthopaedic Associates of Southeast Missouri PC who performs revision surgery, said the numbers and studies can be skewed if they include numbers for partial knee replacements, which doctors know have a short shelf life. New designs and techniques are extending the years, he said.
"The main thing is to limit impact and stress on the joint through weight control and avoiding high impact activities," he said.
Local quotes were added using the Southeast Missourian's health community listserv.
![[SeMissourian.com]](/images/nameplate.gif)
Marketplace
Print
Email link
Respond to editor
Post comment
209
