The New Hip Trend

[Guest guest]

The new hip trend

Fitness-crazy boomers are paying a price -- replacement joints at a

younger age.

By Marnell on, Special to The Times

June 5, 2006

http://www.latimes.com/features/health/la-he-

joints5jun05,1,664782.story

BRAD BUETTNER has always prided himself on his physical fitness. For

years the 49-year-old from Huntington Beach competed in triathlons,

cycling races, water skiing tournaments and horse jumping. Granted,

after he got married and had children, he slowed the pace a bit, but

he always made time for sports. " I have just always enjoyed being

active and fit. "

So the news that he needed a hip replacement hit hard.

" I didn't tell anybody for a while, because I was just so ashamed, "

said Buettner, who is a fit 6 foot 2 and 185 pounds. " I thought hip

replacements were for older people or those who had let themselves

go. "

Increasingly not. Although age, obesity and arthritis are still

leading reasons why people need new knees and hips, a growing number

of the younger and fitter are finding they need new joints as well.

" We are seeing an increasing patient base of younger adults whose

extremely active lifestyles put high demands on their joints, " said

Dr. ph C. McCarthy, a clinical professor of orthopedic surgery at

New England Baptist Hospital in Boston and past president of the

American Assn. of Hip and Knee Surgeons. These active baby boomers

may forestall heart disease, stroke and the other plagues of the

unfit, but in the process, their joints will take a pounding.

And while early joint replacement can extend an active lifestyle, it

also raises the disturbing possibility that the artificial joint

itself will eventually need to be replaced.

Today, surgeons perform 1 of 3 knee and hip replacements (34%) on

patients younger than 60, up from 1 in 4 (25%) in 1993. The biggest

growth has occurred in patients between the ages of 50 and 59; in

1993, 11% of all joint replacements were in this age group; by 2003,

it was nearly 20%, according to the American Academy of Orthopaedic

Surgeons, or AAOS.

The numbers of replacements have increased in the younger-than-50

group as well, though its percentage has remained stable.

" Running and other demanding sports don't cause arthritis, but

they're accelerators, " says Lawrence D. Dorr, an orthopedic surgeon

and medical director of the Arthritis Institute at Centinela Hospital

in Inglewood who performed Buettner's surgery. " Most arthritis

happens because, starting from early childhood, the joint wasn't

normal. "

Buettner, apparently, was one of those people whose hips developed in

a way that makes them more prone to arthritis. For people like him,

it's not a question of if, but when. Buettner's activity level just

brought it on sooner.

" No question. If I hadn't run so much, I wouldn't be in this boat, at

least not yet, " he said. Like many, he now wishes he'd run in

moderation, and done more lower-impact sports, such as swimming. " But

you know runners, we're nuts. "

The impact of exercise is one reason that the AAOS projects that the

demand for joint replacements will soar in the next 25 years. Steve

Kurtz, a biomedical engineer and consultant, directed the AAOS

projection study, which was released earlier this year. The study

predicts that the number of first-time knee replacements will

increase 673% (to 3.5 million a year) between 2005 and 2030, and the

number of first-time hip replacements will increase by 174% (to

572,000 a year).

Besides a more active population, other factors driving the increase,

said Kurtz, include a greater acceptance of the procedure, brought on

by better replacement devices and high success rates; an aging

population, which has more severe arthritis; and the prevalence of

obesity, which puts greater stress on knee and hip joints.

His findings indicate that 13 of every 1,000 people in the United

States will ultimately have a knee replacement, and 6 of every 1,000

will get a new hip. Although ankles wear out, too, they do so rarely,

and knees and hips are mechanically more prone to develop arthritis.

" Younger people tend to get angry when they get this news, " says

Dorr, " but they feel better when they find out how much company they

have. " The day Buettner had his hip replacement surgery, last April

just two days after his 49th birthday, he met another Dorr patient

having his hip replaced that day. He was also 49.

Pain that persists

Typically, the first sign of trouble comes when a patient starts

noticing pain in and around a joint. Unlike pain from an injury or

too much exercise, which goes away in a couple of days, this pain

keeps coming back. Eventually, it doesn't go away, not even at

night. " This sort of recurring and constant pain are signs you should

probably see your orthopedist, " says F. , an orthopedic

surgeon based in Minneapolis, and president of the AAOS.

Buettner started noticing that his hip hurt about four years ago. " I

thought I'd pulled a muscle from exercising, and figured the pain

would go away. " But it didn't. Friends kept asking why he was

limping. " I'm not limping, " he would defend. " I never put two and two

together. "

When the pain, which he described as low grade but constant, grew

more persistent, his wife talked him into getting it checked. Two

doctors gave him the same diagnosis: arthritis in the right hip

brought on by a combination of genetics and overuse. The condition

wouldn't heal, and would get worse.

Doctors spelled out his options: Live with it; try medication, such

as cortisone injections; or have a replacement, which would be his

best option in the long run. Buettner figured he would live with his

bad hip as long as he could stand it, and modify his lifestyle

accordingly.

He had already given up running and his beloved hunter jumper horse.

Running and riding hurt his hip. " I'm not in my 20s anymore; I was

ready to put some activities away. " He figured if he modified his

life enough, he could live with his condition. The turning point came

while he was hiking with his daughters, ages 11 and 16, in March.

" About a quarter mile in, I was looking for boulders to lean against.

I used to be able to go 50 miles. I was prepared to modify my

lifestyle, but I wasn't willing to give up hiking with my kids. "

Buettner chose Dorr to do the surgery partly because the physician is

one of a growing number of surgeons in the country doing hip and knee

replacements through smaller incisions: 3 to 4 inches as compared

with 8 to 10 inches for the standard incision. The idea of a smaller

incision and potentially less trauma and a faster recovery appealed

to Buettner.

" Smaller cuts, faster recoveries, better devices and improved pain

management are all making joint replacement a lot more tolerable, "

says Dorr, who is in his early 60s and had his hip replaced a few

years ago. Once patients have recovered, they can do just about any

activity they did before. " The only thing I tell my patients not to

do is run, " says Dorr. That could cause the joint to loosen and wear

faster.

The smaller incision, and advances in anesthesia and pain management

allow many patients to go home the same day of surgery. " Those who do

often feel better psychologically, " says Dorr, who will be next

year's president of the Hip Society and is a past president of the

American Assn. of Hip and Knee Surgeons.

Buettner did not have general anesthesia. He was given an epidural,

which numbed him from the waist down, and an IV sedative, which put

him in a light sleep. Dorr also injected morphine and cortisone into

the surgical site during surgery, which offers local pain relief for

up to 24 hours.

The day after his April 28 surgery, Buettner was managing pain with

Vicodin pills every four to six hours. Although he had the green

light to go home the day he got out of surgery, he opted to stay the

night in the hospital, in part to not worry his wife.

" I would have been anxious having him home, " said Lynn Buettner. " We

figured if something did go wrong, the hospital was the best place to

be. " Still, Buettner felt relieved knowing the choice was his.

Quicker mobility after surgery has been another big advancement in

the field of joint replacement. " Ninety percent of patients leave the

hospital within two or three days of surgery, using a walker or

crutches, " said . Very soon, they graduate to a cane.

Hip patients often graduate to a cane more quickly than knee patients

because recovery from a knee replacement is slower and more painful.

The knee, explained , is a more complex joint than the hip, has

less muscle mass around it, and needs a greater range of motion to

feel normal.

Buettner got up the day of surgery with a walker. By the next day, he

was up first on crutches, then on a cane. By day three, he could walk

40 feet around his house without a cane, but then a cane was all he

needed. That day he showered himself, climbed up and down the stairs

and took a walk around his yard. By day five, he was walking mostly

unassisted, and needed his cane only a few times.

His only rehab program is to do simple daily exercises such as toe

raises, and to walk as much as he feels able. His surgery, marked by

a 3-inch vertical incision on his right buttock, had shown no

swelling or bruising. One week later, he returned to work; he and his

brother own yacht dealerships in Southern California.

Today, five weeks after surgery, Buettner says he is pain free, and

has full mobility in his hip. He walks without a limp, and is doing

recreational activities — including fishing, swimming, boating and

taking simple hikes — with his family. When the joint is fully

healed, he plans to do more intensive exercise, but he won't run.

Dorr, who has been performing joint replacements since 1978, marvels

at the progress of medicine. " When I first started doing joint

replacements, we checked patients in two days before their surgery,

didn't get them out of bed for three days after their surgery and

discharged them two weeks later. "

A need to repeat surgeries

With current techniques, 90% to 95% of joint replacements should last

15 years or longer, according to the AAOS. But as people get joints

younger and live longer, concern is growing about repeat joint

replacement surgery.

Someone who has a joint replaced at 50 could reasonably be looking at

replacing that joint two more times in his or her life.

That possibility not only creates physical problems for people who

want to keep moving, it also raises costs, specifically to taxpayers.

Currently, Medicare pays for two-thirds of all joint replacements,

says Kurtz.

Given the costs and trends, we're going to need more orthopedic

surgeons, longer-lasting implants and fewer surgeries, " he says.

The medical community is working on all the above.

Joint manufacturers are devising better metals and longer-lasting

bearing surfaces, which says promise to last upward of 20

years. " We won't know for many years, but the progress in this area

is promising, " he said.

One way to reduce the number of repeat joint replacements, called

revision surgeries, is to make the native joint last as long as

possible, says Bert Mandelbaum, a Santa -based orthopedic

surgeon who specializes in helping patients slow the downward curve

of degenerative joint disease. The resulting arthritis is basically

the wearing away of cartilage, the slick smooth bone lining, of the

joint.

" The chondropenia curve [or the rate at which joints degenerate from

arthritis] trends downward over a lifetime, " says Mandelbaum, who is

also the team physician for the U.S. men's national team for World

Cup soccer. " The only destination is the bottom, a worn out joint.

But we can help delay or accelerate that curve. "

Sports injuries and excess weight accelerate the progression. Proper

nutrition and exercise, as well as newer medical interventions,

including medications and injections, can slow it. " If you maintain

your body weight, exercise moderately, pick good genes and avoid

injury, you have a better chance of avoiding a joint replacement, " he

said.

For people at risk of arthritis, including people who have an overly

athletic lifestyle, he recommends taking the popular joint supplement

combo: glucosamine (1,500 milligrams) and chondroitin sulfate (1,200

milligrams) every day.

The studies on the supplements, however, have been mixed. Some show

they help, others have shown they don't.

" Most doctors I talk to tell their patients to try the supplements

for a few weeks, " Mandelbaum said. " If they notice their joints feel

better, keep taking them. If not, stop. "

Regular exercise keeps joints healthy by building and maintaining

muscle that protects joints and by keeping bones strong. But exercise

can be a double-edged sword: Too much can hasten arthritis, as can

too little. For athletes older than 40, or those with a family

history of arthritis, Mandelbaum recommends cutting back on the

running.

" If you've been running 50 miles a week, run 18 and cross train, " he

says. Cross train using lower-impact equipment, such as bicycles,

StairMasters or elliptical trainers, he says. " But definitely

exercise. It's our only fountain of youth. "

Once arthritis begins to develop in the joint, doctors can help

patients relieve stiffness and soreness, and improve athletic

performance with anti-inflammatory medications, such as ibuprofen or

Tylenol, or -2 inhibitors. More recent breakthroughs have come in

the form of injectables, or knee lubricants, called visco-

supplementation.

Doctors inject the lubricant, called hyaluronan, which healthy

cartilage naturally secretes, into arthritic joints. Patients usually

have a series of injections, and relief can last six to eight months.

The injections don't help everyone, but they buy a little time,

between three and 18 months, for some patients, says .

Some people may be candidates for cartilage restoring methods. These

include transplanting cartilage from low-weight-bearing parts of the

body, such as parts of the knee that don't take much load, or using

cadaver cartilage in worn out joints. " If we can push the age for

first joint replacements out to 69 or 70, we may avoid the need for

revision, " said Mandelbaum,

Researchers are also developing a substance that could help

regenerate a person's own cartilage, he says. That product, however,

is still in clinical trials.

Once a person hits the bottom of the curve and has exhausted all

other remedies, he or she shouldn't put off replacement. " The longer

you go, the more atrophy occurs in the muscle and bone, and you don't

get as good a result as you would if you had stronger bone and

muscle, " says Dorr.

When people slow down to accommodate sore joints, they lose muscle

mass and fitness, and their overall health can deteriorate.

Better techniques

Buettner knows that his new hip won't last the rest of his life, but

he's banking on a new resurfacing technique that will extend the life

of his joint and eliminate the need for another total replacement.

" There's a good chance Brad's implant will be permanent, " says Dorr.

Thanks to the improved materials and techniques, the part of the

replacement that fuses with the bone will likely stay put. What wears

out and needs replacing is the implant's bearing surface, or lining.

Just replacing the bearing surface, or the synthetic liner, in the

knee or hip is a much simpler procedure. The approach could keep down

the revision burden.

The key is for patients to have their replacements checked regularly

and make the repair before the damage goes into the synthetic joint.

Dorr likens the wear to car brakes: Wait too long to change the brake

pads, and you have to replace the rotors, too, which costs a lot more.

" All those of us in orthopedics want to do is increase the mobility

and quality of life for patients, " says . " And because of better

joint materials, longer-lasting bearing surfaces and better

techniques, we can help patients achieve those goals sooner, better

and for longer. "

Looking back, Buettner says by far the worst part of the surgery was

the anticipation, which literally made him sick. He threw up the

morning of surgery before he had any anesthesia, which often makes

people nauseated.

" I can't blame the anesthesia; I'm afraid my nausea was self-induced.

I was just so nervous. I was thinking of them sawing off my femoral

head and implanting a titanium femur, and I just lost it. "

One week out, he was surprised at how smoothly the whole surgery

went. " The best part, " his wife said, " will be seeing him get his

life back, and walk without a limp. "

He expects full recovery after six months. " I'll be able to do most

anything that common sense dictates. " He won't subject his new hip to

anything that will wear it out faster, such as running a marathon.

But he does plan to walk, swim, cycle and surf, and maybe even water

ski. There are new activities to try as well. Recently his 11-year-

old daughter asked if he would become a certified diver with her.

" Of course, " he told her. " Why not? "