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Knee replacements double in 10 years

Sunday, December 22, 2013 | 4:35 p.m. CST; updated 4:41 p.m. CST, Monday, December 23, 2013
When a patient goes in for a knee replacement it’s usually because eroded cartilage has made walking painful. There is no cure for this type of arthritis, so doctors insert an artificial knee. The doctor attaches metal alloy caps to the thighbone and shinbone, then places a plastic spacer between the metal caps. The plastic spacer acts as artificial cartilage.

COLUMBIA — It was that one-handed cartwheel Faye Bleigh did in gymnastics class when she was 13 that started all the trouble.

She dislocated her knee and had surgery to repair her ACL (anterior cruciate ligament), but the knee problems never went away. At 50, it hurt too much to walk for exercise, so she started biking instead.

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She finally went to see an orthopedic surgeon.

The doctor said that at age 50, she was too young to have her knees replaced. Getting knee replacement surgery as a younger adult (under 55) meant she might need surgery in about 15 to 20 years, when the replacement wore out.

“Don’t come back here unless you’re crawling,” Bleigh said the doctor told her.

Soon, her knee joint went past bone-on-bone contact and started cutting into the tissue, and she stopped riding her bicycle.

“It was so swollen I couldn’t even bend my knee,” Bleigh said.

When the severity of her situation finally qualified her for a knee replacement at 52, she rolled into surgery in a wheelchair because her knee had bled so much.

Bleigh is one of more than 4 million U.S. adults older than 50 who have opted for knee replacement surgery, according to an article in the Journal of Bone and Joint Surgery. The total number of knee replacements has doubled in the U.S. in the last decade.

Aging baby boomers are part of the reason for the increase, said Ajay Aggarwal, surgeon and director of joint preservation surgery at Missouri Orthopedic Institute in Columbia.

And more people are trying to get the procedure done earlier, according to Aggarwal and the journal. They're more active and they want to stay that way, but without the pain, Aggarwal said.

Unfortunately, the outcome of the surgery sometimes seems worse to younger patients because they have higher expectations, Aggarwal said. They want to stay active longer, so they turn to knee surgery to continue biking, running or playing other sports without joint pain.

Because of the potential for costly and more risky revision surgery further down the road, patients might not be approved for the procedure. 

“If they do (the knee replacement) when you’re under 60, it’s a miracle,” said Sandy Wulff, 66, who had both her knees replaced in her mid-60s. “There’s some real reason for them to do it.” 

Not getting a doctor's approval and insurance coverage for the procedure is costly.

An average knee replacement costs $57,000, including in-patient charges, according to a Healthline article published in 2012. Medicare and most private insurance plans will cover the procedure — as long as a doctor determines the replacement is necessary.

To prevent early surgeries, doctors try to exhaust all non-surgical measures first. Then, they put the potential patient through extensive screening to make sure he or she is a good candidate for a replacement, Aggarwal said. Some younger patients sometimes get lubricative injections instead of surgery.

Despite the hurdles, almost 1.5 million Americans who have had total knee replacements are between 50 and 69 years old, which puts them at risk of long-term complications and costly revision surgery later in life, according to the journal. More bone is lost with each revision, according to an article in the AARP Bulletin.

Younger patients will qualify for a replacement “only if they have bone-on-bone and have exhausted everything else,” Aggarwal said.

Complications

After Bleigh's surgery, she used a walker for seven months and went to physical therapy for a year. She saw other patients come and go, but her doctor told her to be patient. Her knee was worse than other patients’ when she went into surgery.

When she went back for a check-up two years after the replacement, the doctor said her knee had shifted. She would need surgery again.

“I remember telling my husband I would rather die than go through all that again,” Bleigh said.

She took her records with her and searched for another doctor. Bleigh was reluctant to start the process again, and she was disillusioned when it came to doctors.

She said she remembers thinking, “I don’t want to listen to this doctor. I don’t want to have anything to do with doctors anymore.”

 The possibility of complications after surgery, like bruising, nerve damage or something else, as in Bleigh's case, is less than 1 percent, Aggarwal said. The average knee replacement patient is almost 100 percent recovered six weeks after the surgery, but the recovery period is often more involved and extensive than patients expect. Aggarwal said. In particular, the first one to two weeks of physical therapy after surgery can be painful.

"I can't tell you the number of people I saw in physical therapy who had either not done what they had been told or wouldn't do it in therapy," Wulff said. "They don't bother to do anything anymore, and (their knees are) just as painful as before."

Those who get right back into high-impact exercise risk wearing on and loosening the knee.

Aggarwal said the most important factor in successful surgery is not the replacement itself or the rehabilitation, though — it's the surgeon’s experience.

"Above all, how’s the surgeon?" he said. "And it’s not a one-man show – it’s a team approach."

Bleigh chose Sonny Bal, an orthopedic surgeon at Missouri Orthopedic Institute, for her second surgery. He told her that her knee replacement had not shifted; it was the wrong size.

So Bal used a different size replacement for her second surgery, and her knee has been fine since, Bleigh said.

The aftermath

Patients need to be realistic about their expectations after a knee replacement, according to AARP. The goal of a knee replacement is to reduce pain and improve mobility, not make a patient younger or allow for high-stress activity.

Bleigh still goes to the YMCA three times a week, but she has avoided activities that would hurt her knee since having ACL surgery as a teenager. 

"I've learned one thing: Knees are just tricky," she said. "You injure a knee and boy, you've got it for life."

Now, Bleigh swims or bikes for exercise. She and her husband enclosed their outdoor pool recently so they can swim year-round.

Wulff is a consistent road racing competitor at the National Senior Games, but after she had both of her knees replaced, she made new rules for herself to keep her knees in good condition.

That meant no more Cyclocross, a bicycle training series in Columbia that keeps racers in shape during the offseason. The racers take tight turns on a makeshift course, and that's dangerous for Wulff.

She sometimes does a few laps on her bicycle before the rest of the racers get there. Then she runs the registration tent. 

Meanwhile, she continues to race and ride on paved roads. She placed sixth in the nation at the 2011 Senior National Games in Houston after having her first knee replacement, and she recently qualified for the National Senior Games again. 

"I don't ever stop completely," she said. "When you're older, you can lose it, and sometimes you never regain it."

Wulff is training now for the next Senior National Games, which will be in the Minneapolis/St. Paul area in two years.

"I have not slowed down," Wulff said. "My life has improved considerably. I think I'm busier than  ever."

Supervising editor is Katherine Reed.


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