New technologies. Better materials. Improved pain medication. Greater coordination of care.
These are some of the reasons why older patients and those with compromised health conditions have become candidates today for joint replacement surgery that can greatly improve the quality of their lives.
Only, unfortunately, many primary care providers and patients are not well
educated on these possibilities.
“The primary care physician’s specialty is not orthopedics and patients’ hip and knee pain sometimes masquerades as different things,” says Dr. Naveen Singanamala, an orthopedic surgeon with SBH Health System. “Sometimes it masquerades as frequent falls. Or the patient says ‘I am not able to keep my balance.’ There are a slew of problems that can cause that. It can be a stroke. It can be neurological. Or vertigo. But it could also be arthritis. I would encourage the primary care physician that if somebody is falling, or complaining about not being able to walk as much, or unable to go upstairs, to get their hips and knees x-rayed and see if there is any arthritis and to examine the patient with that in mind.
“It is especially important for primary care physicians because they are often confounded with other problems that happen. For example, a patient with hip arthritis and frequent falls may have congestive heart failure or a stroke and that may be limiting their mobility independent of arthritis. They will not be able to localize the pain and discomfort coming from the hip because of the rest that is going on, and the physician will not be able to either. The way to break the tie is to get an x-ray. Often times you will see the arthritis in there and now the question becomes, can we safely do a joint replacement in this location and improve their mobility without causing harm?”
Orthopedic surgeons routinely perform joint replacement surgery today on patients in their 70s, 80s, even 90s. While people are more active than previous generations, it’s not necessarily about getting patients back on the ski slopes or running 5Ks. It’s often about allowing them to perform their daily activities of living.
“I think there is no question that the aging population today is a much more active one,” says Dr. Mark Klion, director, Division of Orthopedic Surgery at SBH. “They desire to continue their activities and there is the understanding that exercise results in better health. The development of arthritis, whether it is multifactorial from the environment, genetic, weight, you name it, causes a loss of mobility. We have better conservative management that can get patients to a certain point, but there is an inflection point where their quality of life starts to deteriorate from a physical standpoint. ‘I can’t walk to the store any more. Or I don’t like walking with a walker any more. Or, I am going to be in a wheelchair and I don’t want that.’ With a better understanding of how to manage these patients, we are able to offer joint replacement to patients who are much older than they were 20 years ago.”
Patients with comorbidities, such as diabetes, obesity, stroke, or cardiovascular issues, can be candidates for joint replacement if they can get their chronic conditions under control. “We know that uncontrolled diabetes causes bad outcomes,” says Dr. Singanamala, specifically referring to problems with infection, blood clots and greater postoperative pain. “I had a patient whose hemoglobin A1C was 11.5, and was only able to walk a block and a half due to knee osteoarthritis. I talked to her and her PCP and six months later her A1C was 7.2. We did the surgery and she did great.”
In some cases, joint replacement is now performed as same day surgery although this depends on the patient’s overall health and their home situation. “We all know that the hospital is not a great place to get better,” says Dr. Klion. “The better place is to be at home, cared for with the proper services.”Coordination of Care“I think the number one reason, certainly from the 30,000 foot view [for making more people eligible for joint replacement], is the coordination of care,” says Dr. Klion. “At St. Barnabas Hospital, we now have a ‘passport total joint program’ where there is great communication amongst all the services. We make sure the patient is preoperatively optimized to undergo surgery. We have great coordination between the orthopedic surgeons and rehab as well as post-care. In my early days of training, it was not that way. It was a disjointed system. In every step of transition, there was always a hurdle that was not met.”
The pre-planning, he says, has become a difference maker. This means explaining to patients the risks, hurdles, benefits and expectations at every step of the process. In addition, the hospital will soon be implementing an innovative presurgery nutritional program. This, for example, might promote a low protein or iron diet, or help reduce the likelihood of anemia that might increase the need for a blood transfusion, all factors that have been shown to reduce infection rates.
Implant materials have improved dramatically over the years. Studies show that the chance of survival of a knee or hip implant is 90 percent at the end of 20 years. “On the topic of implant longevity, someone who is, say, 65, is going to be way more active for the next 20 or 30 years than he or she would be if they didn’t get a joint replacement,” says Dr. Singanamala.
Postponing the operation for fear that the implant may eventually wear out,
he says, is not a good idea for several reasons. “With a joint replacement, your body will get used to the implant quicker; if you walk around with a painful joint it alters your gait mechanics. It alters your metabolism because you are not as active.” For an older patient, living wit compromised
mobility can also result in balance problems and the greater likelihood of falls.
Improvements in surgery have helped reduce the rate of complications. A newer procedure using an anterior approach has been shown to decrease the likelihood of hip dislocation, one of the most common problems. Going through the front of the hip rather than in the side or back, as with traditional hip replacement surgery, often allows the surgeon to make a smaller incision. This can also result in less muscle trauma and pain, less limping and a faster recovery.
The use of new medications, including multimodal analgesia, has helped reduce post-operative pain. This is the administration of two or more drugs that act by different mechanisms to provide pain relief while often reducing the patient’s dependence on opioids. It is a key component in enabling patients to return home the same day.
“A hospital is for sick people and the patients we operate on are not sick,” says Dr. Singanamala. “What we are offering them is lifestyle surgery. We are offering to change their everyday life from one of pain to relatively pain-free or even completely pain-free mobility.
“Primary care physicians play the most important part in the equation in whether patients consider joint replacement. They shouldn’t lose sight of this. Just because patients are older, or have comorbidities, shouldn’t preclude them from getting pain relief and mobility that can enhance their quality of life.”