The ins and outs of joint replacement

Close to half of hip replacements and three-fourths of knee replacements needed in the United States in 2016 will not be performed because patient demand will exceed the number of available orthopedic surgeons, according to a study presented at the recent American Academy of Orthopaedic Surgeons (AAOS) annual meeting held in Las Vegas. A major reason for predicted growth in patient demand for total joint replacement (TJR) is an increase in younger patients who need the surgery, a second study found.

More than 700,000 primary total hip and knee replacements are performed each year, according to the AAOS, and demand for the surgery is expected to double in the next 10 years as the baby boomer population continues to age. Although joint replacement usually is thought of as a procedure for older persons, more than half of patients who require hip replacements and knee replacements will be younger than 65 years by 2011 and by 2016, respectively, projections show. The number of primary total knee replacement procedures performed in the 45- to 54-year age category-the fastest growing group of patients-is projected to grow 17-fold between 2006 and 2030, from 59,077 to about 1 million.

The key to avoiding this problem, according to the researchers, is for policy makers to reconsider the rates at which reimbursement for TJR procedures is provided. The rates have decreased over the years while the costs of providing health care have increased. The possible development of new technologies also might help address the problem.

New life after 80?
Although the current trend is for a larger portion of the younger patient population to need TJR surgery, more patients at the other age extreme-octogenarians-may realize significant gains in quality of life with knee replacements, according to other study results reported at the meeting. In a study of patients older than 80 years who had undergone knee replacements, elements of physical and emotional health (eg, physical pain, social functioning, vitality, and physical functioning) were measured using the Short Form–36 and the Oxford Knee Score. In a comparison of the patients’ preoperative scores with their postoperative scores up to 2 years after surgery, their quality of life scores had risen significantly.

The researchers concluded that patients older than 80 years can benefit from knee replacements both physically and socially. They also noted that with the advent of new technologies and techniques, the replacement procedures are very safe in spite of the complications and risks that can occur with surgery in older patients.

Presurgery function questions
In another study presented at the AAOS meeting, Hispanic and African American patients were found to have poorer joint function before undergoing hip or knee replacement surgery than white patients and women had less preoperative joint function than men across ethnic groups. Researchers reviewed the presurgical joint function of more than 3500 patients undergoing hip or knee replacement surgery; the functional components of the Harris Hip Score and the Knee Society Score were used to quantify the functional ability of all the patients. Even when adjusted for patient age, African American patients and, particularly, Hispanic men had worse joint function before the surgery; Hispanic and African American women had significantly worse function before hip replacement than white women.

The researchers noted that the timing of joint replacement surgery has been shown to be an important determinant of outcome and that patients who have worse joint function before surgery do not do as well postsurgery. Therefore, they are trying to determine the reasons why some patient groups tend to wait longer before having surgery (eg, less access to care, insurance concerns, cultural or mindset issues) so that if the problem is one of outreach and education, orthopedic surgeons can help address it.

More on knee surgery
Most high school athletes who undergo anterior cruciate ligament (ACL) reconstruction surgery can return to competition at the same activity level-boys and girls at the same rate-according to another study reported at the meeting. Athletes who sustain an ACL tear are at high risk for reinjuring the reconstructed ACL or injuring the other ACL within 5 years of the original surgery, the study found, but returning to sports activity quickly does not increase the risk. About 200,000 ACLs are injured in the United States each year, resulting in about 100,000 ACL reconstructions, according to the AAOS.

In the first study to specifically address teenage athletes’ ability to return to high-level competition after ACL reconstruction, the researchers evaluated more than 400 basketball and soccer players who were 17 years or younger at the time of their first ACL reconstruction. After surgery, 87% of both girls and boys returned to basketball and 93% of girls and 80% of boys returned to soccer; the mean time to return to full participation was just more than 5 months. Twenty percent of the patients went on to compete at the collegiate level.

The results indicate that patients who feel that they can return to sports activity after ACL reconstruction should be allowed to do so, according to the researchers. They also should not be restricted to a predetermined time line.

For more information on these and other topics discussed at the AAOS annual meeting, visit the AAOS Web site at www.aaos.org. Or, contact the organization at AAOS Headquarters, 6300 North River Road, Rosemont, IL 60018-4262; telephone: (847) 823-7186.