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Rise in hip replacements for under 60s

The number of hip replacement operations on people aged under 60 has risen 76% in the last decade, NHS figures for England reveal.  In 2004-05 there were 10,145 hip replacements for people aged 59 and below, with 17,883 in 2014-15.  The Royal College of Surgeons says this is partly because doctors are now more confident that replacement joints will be more durable than in the past.  Patients are also said to be less willing to wait.

As a proportion of all hip replacements carried out, the rise among under 60s is small, but the Royal College of Surgeons says it is still noteworthy.  Demand for new hips across all ages has risen – there were 89,919 of the operations in 2004-05 and 122,154 in 2014-15.

Stephen Cannon, vice-president of the RCS, says as hip replacement techniques and prosthetics have improved, so have the numbers of younger patients undergoing this type of surgery.  “It’s no longer seen as a last resort.  “As surgeons, we now have more confidence about the wear rate of these prosthetics which allows us to be less restrictive on an age basis.”

‘Less arduous’

He said surgeons used to advise patients with hip pain to wait until they were 60 or 65 to have a replacement because the old-fashioned replacements had a shelf-life of about 15 years, meaning the operation might need redoing once in a lifetime – when the patient had turned 80.

“If you look at newer prosthetics, you could do the first operation at 55 and it is going to last for 20 years or more, so you would still only need one revision in a lifetime.”  He said another factor might be patient demand.  “Certainly, in my experience, patients do not get fobbed off. They don’t want to wait for an operation. They say, ‘I can’t play a round of golf or tennis and I want to.'”  Mr Cannon said concerns over the safety of a the metal-on-metal hip replacement in 2010 did not appear to have affected demand.  He said hip operations had become less arduous. Patients can be back on their feet with crutches on the same day or the day after surgery, and out of hospital within three days post-op. “They’re off crutches altogether by six weeks.”

‘Perfect storm’

Most hip replacements are done if the joint becomes damaged from arthritis or an injury. Many of the conditions treated with a hip replacement are age-related so hip replacements are usually carried out in older adults.  Mr Cannon says it’s not clear if conditions such as osteoarthritis are becoming more common and affecting people at younger ages, but it is worth exploring.  And with an ageing population, he says demand for hip operations could soon outstrip supply.  “The ageing population is a perfect storm. We are not there quite yet, but we might be in 10 years from now. It’s a continuing trend.”

A spokesman for the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man said: “The increase in numbers of under-60s undergoing primary hip surgery is entirely in line with the overall increase in provision of the operation.  “The orthopaedic sector must continue to work to get the first time surgery as right for the patient as possible – especially where younger patients are concerned as they are most likely to need at least one revision surgery in their lifetime.  “It is, of course, heartening and very encouraging that hip and knee implants are lasting ten years or more, with risk of revision lower than 5%.  “Joint replacement surgery offers significant benefits – getting patients back to their chosen lifestyle sooner, free from pain and with improved mobility.”

BBC News 3.3.2016

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Muscle Strengthening Aids New Knees

A new study suggests that a carefully focused program of muscle strengthening can make an important difference in how well patients recover after knee replacement.  Patients who underwent six weeks of progressive muscle strengthening aimed at the quadriceps did much better than patients given conventional treatment. The study appears in the February issue of Arthritis Care & Research.  Almost 500,000 knee replacements are done in the United States each year, and patients often report that they still have problems doing things like walking and climbing.  For the study, more than 200 patients were divided into groups and given different treatments about four weeks after surgery.  One received conventional treatment. Another was also given quadriceps strengthening, while a third was given the strengthening and electrical stimulation to make the muscles contract.

While the electrical stimulation did not appear to make a difference, the muscle strengthening appeared to bring the patients back to a level of functioning almost normal for their age.  One of the authors, Lynn Snyder-Mackler of the University of Delaware, said in an e-mail message that knee replacement patients and their doctors should not underestimate the ability “to really improve their function.”

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Patient and Doctor

Caring for Hips and Knees to Avoid Artificial Joints

PROTECT your joints now, or pay later.

That’s the message of today’s column, which could be headlined Joint Economics.

If you are one of the more than 400,000 people a year who have already had one or more hips or knees replaced — or someone who already has no choice but to consider joining their ranks — we offer our sympathies or encouragement or even congratulations, depending on how you are faring. But this column is for people who are not yet destined to necessarily become part of those statistics.

Although the human body has an amazing capacity to repair itself, our joints are surprisingly fragile.  When the cartilage that cushions bones wears away, it does not grow back. Thinning cartilage contributes to osteoarthritis, also known as degenerative arthritis, a painful and often debilitating condition.

Over time, arthritic joints can become so sore and inflamed that they need to be replaced with mechanical substitutes. A result: more pain, at least in the short term, and big medical bills.  Fortunately, you can act to protect your joints now, to reduce your chances of needing to replace them later.  And protect you should. The cost for a new hip or knee — the joints most commonly replaced — is $30,000 to $40,000. If you have insurance, your total out-of-pocket costs will be much less, but may still be $3,000 to $4,000. And don’t forget to factor in all those days of work you will miss before you get your new prosthetic.

Creaky joints are a growing national problem. The population is getting older, more people are overweight, and an increasing number of children and young adults are playing serious sports and getting seriously injured — all factors that contribute to osteoarthritis.

“Arthritis used to show up in people during their late 40s and 50s, now we’re seeing it earlier, like in the 30s and 40s,” said Dr. Patience White, a rheumatologist and the chief public health officer at the Arthritis Foundation.

The total national bill for hip replacements in 2007 was $19 billion, and $26 billion for knees, according to the federal Agency for Healthcare Research and Quality. Those figures are expected to rise significantly in the coming decade, Dr. White said. So protecting your joints will do more than save wear and tear on you and your budget. You could also be doing your part to curtail the national health care bill.  If your joints are still intact, or just beginning to creak, here are some ways to keep osteoarthritis at bay.

CONTROL YOUR WEIGHT The more you weigh, the more pressure on your joints, which can lead to joint damage. When you walk, each knee bears a force equivalent to three to six times the body’s weight. If you weigh a mere 120 pounds, your knees are taking a 360-pound, or more, beating with every step.

Studies have found a connection between being overweight and developing osteoarthritis of the knees, and to a lesser extent the hips. One recent review found that 27 percent of hip replacements and 69 percent of knee replacements might be attributed to obesity.  For reasons not well understood, weight is more of risk factor for women than men.

“A woman’s risk for developing O.A. is linearly related to her weight,” Dr. David Felson, a rheumatologist and arthritis prevention specialist at Boston University School of Medicine, said, referring to osteoarthritis.

“Men who are moderately overweight are not as at high a risk as a woman of the same weight,” Dr. Felson said.

But a woman can substantially lower her risk by shedding pounds. One study in which Dr. Felson was a co-author found that when a woman lost 10 pounds, her risk of arthritis of the knee dropped by half.

GO LOW-IMPACT Although no definitive link has been found between osteoarthritis of the knee and running (or any other sport), sports medicine doctors discourage their patients from running on hard pavement, playing tennis on concrete or activities like skiing over lots of moguls.

“Impact sports put too much stress on the joints, particularly the knees,” said Dr. Donald M. Kastenbaum vice chairman of orthopedic surgery at Beth Israel Medical Center in Manhattan. “These activities may lead to O.A. and they definitely can escalate the progression of the condition.”

If you run regularly, try to do so on a track or treadmill and consider swapping one run a week for something low-impact like swimming, biking, lifting weights or tai chi.

AVOID INJURY Easier said than done, of course. But major injuries, typically the type that require surgery, greatly increase your risk for osteoarthritis.  According to one big study, 10 to 20 years after a person injures the anterior cruciate ligament or menisci of the knee, that person has a 50% chance of having arthritis of the knee.

Those rates are even higher when the injury happens in your 30s or 40s, Dr. Felson said. “As you move into middle age, it’s crucial to avoid sports that predispose you to injury,” he said.  Weekend warriors, who sit at a desk Monday through Friday, and then run or play basketball for five hours straight on the weekend, are at a high risk for injury, and thus for osteoarthritis.

GET FIT It makes sense. The better toned your muscles are, the less likely you are to injure yourself (unless you are also playing football every Saturday morning).  And “building muscles up around joints acts like a shock absorber, spreading stress across the joint,” said Dr. Laith M. Jazrawi, chief of the sports medicine division at NYU Hospital for Joint Diseases. Pilates, moderate weight lifting, vinyasa yoga and swimming are all nonimpact forms of exercise that firm up your muscles without jeopardizing your cartilage.

No definitive link exists between increased flexibility and lower, or higher, rates of osteoarthritis. But some doctors interviewed said they believed that by regularly stretching your muscles you are less likely to injure your joints. It can’t hurt to judiciously stretch your muscles after a workout. And even if it won’t protect your joints from deterioration, it will certainly make your muscles feel better.

BE SKEPTICAL Don’t waste your money on specialized nutrients. Shark cartilage, glucosamine and chondroitin — popular supplements marketed for healthy joints — can be expensive and probably are of limited benefit, many specialists say.

“There’s some evidence to suggest glucosamine and chondroitin sulfate may be helpful in O.A. once it has started, but overall the results are inconclusive,” Dr. Jazrawi said. As for shark cartilage, there is no evidence to suggest that it has any benefit for treating the symptoms or the disease, he said. Joints are like car parts. With proper care and maintenance, they last longer.

New York Times

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Getting a New Knee or Hip? Do It Right the First Time

THERE is nothing like a new hip or knee to put the spring back in your step. Patients receiving joint implants often are able to resume many of the physical activities they love, even those as vigorous as tennis and hiking. No wonder, then, that joint replacement is growing in popularity.

In the United States in 2007, surgeons performed about 806,000 hip and knee implants (the joints most commonly replaced), double the number performed a decade earlier. Though these procedures have become routine, they are not fail-safe.  Implants must sometimes be replaced, said Dr. Henrik Malchau, an orthopedic surgeon at Massachusetts General Hospital in Boston. A study published in 2007 found that 7 percent of hips implanted in Medicare patients had to be replaced within seven and a half years.

The percentage may sound low, but the finding suggests that thousands of hip patients eventually require a second operation, said Dr. Malchau. Those patients must endure additional recoveries, often painful, and increased medical expenses.  The failure rate should be lower, many experts agree. Sweden, for instance, has a failure rate estimated to be a third of that in the United States.

Sweden also has a national joint replacement registry, a database of information from which surgeons can learn how and why certain procedures go awry. A registry also helps surgeons learn quickly whether a specific type of implant is particularly problematic. “Every country that has developed a registry has been able to reduce failure rates significantly,” said Dr. Daniel Berry, chief of orthopedic surgery at the Mayo Clinic in Rochester, Minn.

A newly formed American Joint Replacement Registry will begin gathering data from hospitals in the next 12 to 18 months.  Meanwhile, if you are considering replacing a deteriorating knee or hip, here are some ways to raise the chances of success and avoid a second operation.

EXPERIENCE COUNTS Choose — or request a referral to — an experienced surgeon at a busy hospital. “The most important variable is the technical job done by the surgeon,” said Dr. Donald C. Fithian, an orthopedic surgeon and the former director of Kaiser Permanente’s joint replacement registry.  Ask for recommendations from friends who have had successful implants and from doctors you know and trust. When you meet with the surgeon, ask how many replacements he or she does each year.

VOLUME MATTERS A study published in The Journal of Bone and Joint Surgery in 2004 found that patients receiving knee replacements from doctors who performed more than 50 of the procedures a year had fewer complications than patients whose surgeons did 12 procedures or fewer a year.  The researchers documented a similar trend when it came to hospital volume. Patients at hospitals that performed more than 200 knee replacements a year fared better than patients at hospitals that performed 25 or fewer.

ADJUST EXPECTATIONS Not everyone with joint pain will benefit from a joint replacement.  An implant can help reduce pain and improve mobility if the joint surface is damaged by arthritis, for instance. But a new joint will not help pain caused by inflammation of the surrounding soft tissue, said Dr. Berry, who is also vice president of the board of the American Academy of Orthopaedic Surgeons.  Some people with mildly arthritic joints, for instance, can manage well with the judicious use of medication. “Surgery comes with complications and risks, and should not be approached lightly,” Dr. Berry said.

Joint replacement is not a minor operation. If you have uncontrolled high blood pressure, chronic infection or another serious chronic condition, a joint replacement operation may be too risky a procedure for you. Seek advice from an experienced Orthopaedic Surgeon.

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New Models Of Implants Not Better, Study Finds

A new study suggests that the recent technology for artificial hips and knees did not perform any better than older, less expensive designs.

The study, which draws on data from Australia’s orthopedic registry, covered implants introduced from 2003 to 2007 and was published this week. The findings are significant for patients in the United States because many of the new designs, like so-called metal-on-metal hips, are widely used here. Those implants, which have both a ball and cup made of metal, are expected to fail prematurely in tens of thousands of patients rather than lasting 15 years or more as artificial joints are supposed to do.

The Australian study showed that not a single new artificial hip or knee introduced over a recent five-year period was any more durable than older ones. In fact, 30 percent of them fared worse. The Australian study concluded that both patients and taxpayer-financed health care programs were paying a high cost because surgeons were using newly designed implants, introduced with little test data, over existing designs that had track records.  ”Not only has the introduction of this technology been potentially detrimental to patient care, but the current approach may be an important driver of increased health care costs,” the review concluded.

Dr. Stephen E. Graves, the director of the Australian registry and a co-author of the study, said he believed that surgeons, hospitals and regulators should closely look at the review’s results. In the case of the all-metal hips, some experts say they believe that replacing them may cost companies, insurers and taxpayers billions of dollars.

”There needs to be a careful re-evaluation of current deficiencies in regulation,” Dr. Graves said in a recent e-mail.

The Australian review is part of a special issue of a medical journal, The Journal of Bone and Joint Surgery, devoted to studies that examine the benefits and the limitations of orthopedic registries. While America does not have a registry, the Food and Drug Administration is financing efforts to see whether data from sources like overseas databases and registries run by hospitals here can be used to better monitor device performance.  Many experts argue that such efforts are essential because 700,000 Americans undergo hip or knee replacement every year, and that number is expected to increase sharply as the population ages.  In a registry, information about a patient is entered into a database when he or she receives an implant. Then, when that patient undergoes surgery again to replace that device, more data is added. By looking at large numbers of patients followed in a registry, researchers can tell whether certain device models are failing prematurely at significantly higher rates.

But researchers in England, which has a registry, pointed out in another article in the same medical journal that a product-related disaster had likely already occurred before it was detected in a such a database. As a result, some experts say they believe that there must be greater scrutiny of implants either before or after they go on the market to detect problems earlier.  Another review in the same issue found that the results of published studies that accompany the introduction of new implants could bear little resemblance to registry findings about a device’s success once it went into broader use.  That problem occurs, the review by Australian researchers found, because surgeons involved in the original published reports are often involved in its development and may have a financial stake in them. In addition, such reviews tend to be short term.  Some surgeons say they believe that one type of all-metal implant known as a resurfacing device is permitting some patients to remain more active. However, data indicates that such benefits are limited to one group of patients, namely larger, middle-aged men.

This month, bipartisan legislation was introduced in the Senate that could force manufacturers to track the performance of implants like artificial hips after they have been approved for sale. Proponents of the bill acknowledge that the measure faces an uphill fight.  Both device producers and their allies in Congress have maintained that any additional F.D.A. regulations would slow the development and marketing of innovative products that benefit patients. For his part, Dr. Graves, the Australian official, said he believed that such arguments were misleading.

”The purpose of regulation is not to impede innovation but to ensure safety and effectiveness of medical devices,” he stated. ”This protects patients, but it also protects companies.”

New York Times December 23, 2011

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