SJ Magazine - The Heart of South Jersey

Joint Replacement
It’s not just for your grandmother anymore

Meredith Del Rossi’s pain was so bad she could barely maneuver around the medical office where she works as a nurse. At the end of each day, the 35-year-old would soak in a hot bath and take pain medication to dull the aching in her left knee.

"The pain was so excruciating that my knee would just buckle,” she says. "Just standing up or getting out of my car was an ordeal.”

When it got to the point that Del Rossi couldn’t keep up with her 8-year-old son or 4-year-old daughter, she talked to her doctor about a joint replacement. A series of X-rays of her knee revealed major deterioration of the tissue around her knee joint.

"I was diagnosed with juvenile rheumatoid arthritis at 4 years old and have been taking all sorts of medications, steroids and anti-inflammatory drugs ever since then,” says Del Rossi. "By the time I went to my doctor, nothing could kill the pain – not even getting it drained by my rheumatologist. My knee was just shot.”

So, like a growing number of relatively young patients, Del Rossi had her knee replaced last summer. Pain-free for the first time in years, she finished physical therapy and can now ride bikes and walk around her Medford Lakes neighborhood with her kids.

"I feel better than I anticipated I would before the surgery,” she says. "I’m on my feet and more active than ever before.”
Determining if you’re a candidate

Once considered a last-ditch procedure for elderly patients, knee and even hip replacements have become more common for younger people who suffer pain that limits their activity on a daily basis. About 10 to 15 percent of patients at his practice who are undergoing a knee or hip replacement are under the age of 50, says surgeon Gregory Deirmengian, MD, of the Rothman Institute.

Many of these patients, like Del Rossi, suffer from serious arthritis. In some cases, hip dysplasia, sports injuries or damage from car accidents may be the culprit behind the failing joints. No matter the reason, Deirmengian notes that "younger people are usually less willing to be debilitated by joint pain. They want to be able to walk or play golf or just get back to their daily routine.”

While age is no longer an inhibitor to joint replacement, Merrick Wetzler, MD, of Advocare South Jersey Orthopedic Associates, notes that there are some requirements for patients. "Of course, you first need to be healthy enough to undergo the procedure. Beyond that, the ideal candidate for joint replacement is not overweight – this can put added stress on the joint and impede recovery – and is motivated to get back to normal activity following the surgery,” he says.

Most doctors also encourage their patients to first try non-surgical procedures and lifestyle changes before opting for surgery. "For many people suffering from knee pain, the most successful way to eliminate that pain is through weight loss,” says Deirmengian. "Those who aren’t overweight can try activity modification – if you’re a runner, try switching to swimming. Acupuncture and anti-inflammatory medications can also be helpful.”

Other alternatives include physical therapy and steroid, cortisone or lubricant injections. "If you’ve tried these methods and are still functionally debilitated, it really comes down to your pain level,” says Deirmengian. "If you’re in so much pain that you can barely walk and no longer have a reasonable quality of life, then a joint replacement might be the right choice no matter how young you are.”

Wetzler agrees. "Some people might think they’re too young to have joint replacement surgery,” he says, "but I often say to these people that they’re too young not to have it.”

Advancing technology and procedures

Thanks to new and improved tech-nology, most replacement knee and hip joints are expected to last 15 to 20 years, according to the American Academy of Orthopaedic Surgeons (AAOS).

"Since every patient is different, you’ll want to talk with your doctor about finding a material that’s going to hold up, resist wear and scratching, and give you the best long-term result,” says Wetzler. He also notes that many surgeons are now offering more options, like partial knee replacements and minimally invasive procedures, to accommodate active middle-agers.

These days, several manufacturers make knee implants, and data from the AAOS shows that there are now more than 150 knee replacement designs on the market. Some use metal parts, while others use plastic or ceramic components to mimic the knee’s structure and movement. Deirmengian and Wetzler both note that they commonly use the new plastic, mobile-bearing implants because they last longer and allow patients greater mobility.

During knee replacement surgery, the lost cartilage and diseased bone of the knee is replaced with the implant. In older surgeries, the incision averaged eight to ten inches in length, while minimally invasive surgery requires an incision of only four to six inches long. Because there is less damage to the tissue around the knee, patients who undergo this procedure may expect a shorter hospital stay, a shorter recovery and a smaller scar, explains Deirmengian.

Thirty years ago, many hip replacement devices were attached directly to the bone with cement. While some doctors still perform cemented hip replacement procedures – especially in older patients – many are opting for cementless options. "These implants are wedged into the joint. The bone then grows into the prosthesis and becomes a part of the body,” explains Deirmengian.

These devices are often recommended for younger, more active patients because they have greater longevity and allow more mobility. Minimally invasive hip replacement surgery is routinely performed through one or two smaller incisions ranging from two to six inches, rather than several larger incisions.

Though technology and procedures have improved, doctors caution that what many younger patients risk in exchange for a new joint and increased mobility is the likelihood that their implant will have to be repaired or replaced at some point in the future. "The biggest variable is patients themselves,” says Deirmengian. "As a rule, the more active you are, the faster your new joint will wear out, loosen or require revision.”

For these reasons, most orthopedic surgeons encourage patients with hip and knee implants to walk, swim and cycle as much as possible. Golf and tennis are also acceptable, but running is out. "If your goal is a 30-year joint,” says Deirmengian, "you need to avoid running a marathon or other high-impact sports.”

The recovery process

All joint replacement patients must take physical therapy after surgery – no matter their age.

"Essentially, the physical therapy process isn’t different for younger patients,” says Cindy Rodgers, therapy supervisor at Lourdes Medical Center of Burlington County. "However, younger patients are most likely in good physical shape, so we can step up the recovery process a little faster and make things a bit more intensive.”

Rehab begins the day after surgery, with a physical therapist helping the patient get out of bed. "It’s a big surgery, and you’re going to be in pain. But the sooner you getting moving, the better off you’ll be in the long run,” says Rodgers.

She says the basic exercises per-formed in the days immediately following hip or knee surgery typically include heel pumps and ankle slides to improve flexibility. Walking – with the aid of a walker – is also encouraged as soon as possible.

Therapy continues after the patient goes home, typically within three days after surgery. "A therapist will come to your home, where exer-cises will continue to focus on gentle stretching.

"With knee replacements, we let gravity help the process. That process includes a lot of knee straightening and bending. You need a minimum range of motion of 90 degrees to go up stairs, but the ideal is 120 degrees.” For this reason, recovery for knee patients usually involves tackling steps on a daily basis.

The road to recovery for hip replacements is less arduous, simply because the hip joint doesn’t have as large of a range of motion, says Rodgers. "The hip is primarily there for stability. Therapy focuses more on lengthening and strengthening the surrounding muscles so that the patient doesn’t experience a limp or change in gait pattern.”

Most patients, whether recovering from a knee or hip replacement, should aim to be walking without the assistance of a walker or cane within four weeks. Hip replacement patients can expect a return to pre-surgery activity within three months, while knee replacement patients are usually back to normal activity within six to nine months.

"Of course, there are always exceptions and you don’t want to push it,” says Rodgers. "But younger patients are generally eager to get rid of their walker and cane and get back to being active as soon as possible.”