Correction to This Article
The graphic about joint replacements incorrectly labeled the calcaneus, or heel bone, as the talus, which is a bone in the ankle.

As joint replacements grow more popular, younger patients face repeat surgeries

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By Eric Niiler
Monday, January 3, 2011; 2:39 PM

Billy Poole's pain was so bad that he couldn't exercise - he put on an extra 40 pounds - and was reduced to hobbling around the Charles County Detention Center.

"It doesn't look too good in front of the prisoners," said the 37-year-old correctional officer.

When it got to the point that Poole needed his 72-year-old dad to help him tie his shoes every morning, he consulted a doctor. X-rays revealed a buildup of dead tissue around both hip bones - the top of his thigh bones had deteriorated due to disruption of the blood supply to the bone. (This may have resulted from the way a broken leg had healed after a dirt-bike accident at age 18.) His doctor ruled out steroid shots and other temporary fixes.

So, like a growing number of relatively young patients, Poole had both his hips replaced last summer. Pain-free for the first time in five years, he has finished physical therapy and built himself a gym in the garage of his White Plains home.

"I just seem to be able to do more around the house," he said.

Once considered a last-ditch operation for the elderly, getting a new hip has become a more common option for younger people who suffer pain that limits activity, disrupts sleep and causes them to miss work.

More than 277,000 total hip replacements were performed in 2008, the latest year for which the American Academy of Orthopaedic Surgeons has compiled figures; that's an increase of 78 percent since 1998. While most are still performed on people older than 65, the portion of patients ages 45 to 64 grew from 27 percent in 1998 to 40 percent in 2008.

"Younger people are less willing to accept physical disability than older generations," said Mary O'Connor, an orthopedic surgeon at the Mayo Clinic in Jacksonville, Fla., and president of the American Association of Knee and Hip Surgeons. "They simply want to remain active. They don't want to hear that they should use a cane or they can't walk or play golf or do the activities they want to do."

Risks and rewards

What the younger patients risk in exchange for increased mobility is the likelihood that the replacement will someday have to be repaired or replaced, a procedure known as a revision. Most replacement joints are expected to last 15 to 20 years, according to the National Institute of Arthritis, Musculoskeletal and Skin Diseases. So younger patients are likely to outlive their new hips - and experts say the second operation can be trickier than the first.

"If you need a new one, that surgery is a little more difficult," said O'Connor. "Usually when it fails, it fails because one of the the parts loosens ... every time you have to revise it, there's a higher risk of complications."

James Graeter, director of the George Washington University Hospital Joint Replacement Center, notes that there is always a small chance of complications with surgery, such as blood clots and infection, and these are more difficult for older patients.

"I tell patients that they should go with their hip as long as they can until it gets to the point where it hurts all the time or it wakes you up at night," said Graeter, who has been doing this kind of surgery for more than 30 years. "It shouldn't be done for a hip that hurts after you walk a half-mile, but hurts with every step."

According to the NIAMS, doctors used to tell patients to put off surgery until they were at least 60 years old, because older people, being less active, put less stress on the replacement joints. But new technology has resulted in stronger, more durable parts, and today, the agency says, a patient's overall health and fitness are more important than age in making the decision about surgery.

Several surgeons contacted for this article say they prefer newer, polyethylene ball joints for hip replacements. They say the material, which was first implanted in patients in the 1990s, is both stronger and potentially longer-lasting than earlier plastics or more recent ceramic implants, which reportedly have many patients complaining about a squeaking noise when they walk.

"At this point, we have 12 years of data on the new plastic, and it's wearing five to eight times less than old plastics," said Kevin Fricka, an orthopedic surgeon at the Arlington-based Anderson Orthopaedic Clinic. "We should reliably get 15 to 20 years on a replacement, and potentially longer."

From hips to knees

Some technological developments have not panned out. In August, DePuy Orthopaedics recalled a hip implant that had been put into 93,000 patients around the world after reports that 12 to 13 percent of them failed within the first five years. The Food and Drug Administration is reviewing the implant, which is the target of several dozen class action lawsuits.

"From the patient's perspective, the important question is how many replacement surgeries has your doctor done, what is the track record of the hospital, and how many revisions have they done," said Linda Bergthold, an independent health-care analyst based in Santa Cruz, Calif. "You also want to ask how long does the implant last and how did you choose it. Ask as many questions as possible."

Matthew Parker says the ultimate decision about when to go under the knife remains with the patient, not the doctor. Parker is both: An internist in the District and a competitive long-distance cyclist, he had both hips replaced before he turned 55. He says that he doesn't worry too much about revision surgery and that keeping fit and living without pain were more important.

"If you wait [to have surgery] until you're so miserable, the choices in your life are so limited ... then you've missed a lot," Parker said. "It's a completely different existence. It's like I wake up with birds chirping and the sun shining."

Knee replacements - far more common than hip replacements - are also becoming more popular among those 45 to 64 years old, according to the orthopedic association's figures. A major factor in this growth is a surge in younger patients with osteoarthritis, one of the later-in-life paybacks for sports-loving baby boomers. Several surgeons in the Washington area say they are seeing more patients in their middle years with hip and knee problems tied to arthritis.

The trend is evident at Sports and Spinal Physical Therapy on K Street NW, where therapist Robert Gillanders treats lots of 40- and 50-something marathoners, cyclists and triathletes recovering from hip and knee replacement surgery.

"People are more active than they were in the past. Sometimes that's good, sometimes that's bad," says Gillanders. "When you think of the mechanics of what the hip is doing on a 100-mile bike ride, hunched over in an aerodynamic position, it's taking a lot of stress, and we're seeing a lot of wear-and-tear injuries."

In Charles County, Billy Poole says he's excited about his newfound life without pain; any thoughts of a second replacement are somewhere down the road. After completing several months of physical therapy in early December, he is headed back to work guarding prisoners at the jail.

"If there's a fight on the other side of the building, I have to be able to run," said Poole. "I can't quite do that, but I'm working at it."

Niiler is a freelance writer in Chevy Chase.

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