Joint replacement surgery and transitional care

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Hobbling around with a swollen knee or stiff hip may soon be passé for America’s seniors. Thanks to surgical advancements, people are seeking medical help sooner to alleviate chronic pain and receive artificial joints — some of them are in their 50s or are even younger.

Every year in the United States an estimated 1 million people undergo total joint replacement surgery to correct a damaged or arthritic joint.

A joint forms the connection between two or more bones to add support and help you move.

The knee, for example, is a hinge joint, and the hip and shoulder are ball-and-socket joints. The weight-bearing hip and knee joints see ongoing wear and tear and are replaced most frequently. The shoulder, ankle, wrist and elbow are other joints that are well-known to orthopedic surgeons.

Joint replacements are among the most common elective surgeries in the country. A study presented in March by the American Academy of Orthopaedic Surgeons found that people are seeking joint replacements earlier in life, in part because people are staying more active as they age and they want a better quality of life through retirement.

The study also noted the rise in U.S. obesity, as obesity places greater stress on aging joints. People are also living longer, and the accumulative use of joints over the years leads to joint breakdown.

Dr. Ritesh Shah, an AAOS board-certified orthopedic surgeon with the Illinois Bone and Joint Institute of metropolitan Chicago, notes that on average people receive a total joint replacement between age 64 and age 66.

Shah is seeing an upswing in total knee and hip joint replacements and says that total knee replacements are projected to increase as much as 400 percent in the U.S. by 2030 and that total hip replacements are projected to increase as much as 175 percent.

“People are enjoying activities at an older age now and want to enjoy their quality of life,” Shah said. “The ability to ambulate becomes very important to a good quality of life. Significant joint pain is a significant disruption of life and people don’t want to live that way anymore.”

Gregg Balbera, president of Right at Home Nassau Suffolk is also seeing seniors be more proactive in improving their day-to-day mobility. “For older adults who do choose joint replacement, many are now bypassing rehabilitation centers and completing post-surgery care at home,” Balbera says. “With the right care supervision, it’s encouraging to see older adults back on their feet and enjoying activities again with their families and friends.”

When Is Joint Replacement Advised?
Prominent joints in the body can become severely damaged through the aging process, everyday wear and tear, and injuries. Or conditions like osteoarthritis, rheumatoid arthritis, bursitis, fractures, gout, tumors and other diseases can comprise the connections between bones.

Joint pain can be mildly irritating to chronically debilitating. One national survey found that roughly one-third of adults have experienced joint pain within the past 30 days. Women have higher rates of arthritis than men (26 percent vs. 19 percent) and more readily elect to have joint replacements, but nationwide, more men are joining the joint surgery ranks.

So when do you know if you need joint replacement surgery? Your doctor may recommend surgery if you experience chronic inflammation, limited movement, joint deformity, or when non-surgical treatments such as physical therapy, medications and injections have not provided sufficient relief from continual pain.

Risks and Benefits of Joint Replacement
During a replacement operation, damaged cartilage that cushions the joint surface is removed. Parts of the joint are also removed and fitted with a titanium, ceramic or plastic prosthesis to replicate normal joint movement.

Total joint replacements do not last forever, and patients may eventually need a revision to their joint implants, but Shah notes that with today’s improved surgery methods and stronger, cement-less materials, replacement joints are now lasting up to 15 to 20 years on knees and up to 20 to 30 years on hips, depending on the activity level of the patient.

Each joint replacement surgery candidate is evaluated for potential risks and complications. A person’s general health and family health history are part of a comprehensive pre-surgery assessment. As with any surgery, conditions such as heart disease, poorly controlled diabetes or a weak immune system can elevate risk. Possible joint replacement surgery complications include infection, blood clots, nerve injury and the prosthesis loosening or dislocating. For the million-plus people each year nationwide who choose joint implant surgery, the benefits of pain relief, better movement and strength, and engagement in sports and social activities outweigh the possible risks.

Post-Surgery Recovery and Care Tips
Recovery and rehabilitation for joint replacement varies with each individual, but in general, following the doctor’s instructions will speed healing. Most patients will experience pain in the replaced joint as tissues heal and the body adjusts to strengthening surrounding muscles that have been weak from inactivity. For new knee joints, the doctor may prescribe a continuous passive motion (CPM) device for patients to use at home to help the knee learn to flex and extend. Cryotherapy machines and packs that employ ice to reduce pain and swelling are also used in post-surgery care. The first weeks at home may also require the use of assistive items such as handrails, a shower bench, raised toilet and long-handled reacher.

“Typically, seniors who are at home recovering from joint replacement need the initial support of a home health therapist or nurse, then transition to outpatient physical therapy,” Balbera said. “Older patients recover better when they have a family or professional caregiver present to help with medications for pain management and the specific exercises to help restore joint strength and movement. Balancing rest with activity is key.”

New Horizons for Joint Replacement Surgery
While traditional joint replacement surgery has meant months of recovery including pain, opioid medications, limited mobility and intense rehabilitation, Dr. Shah and a growing number of orthopedic surgeons are employing innovative surgery techniques to significantly advance patient outcomes.

These contemporary technologies and techniques include shifting muscles out of the way instead of cutting into them or disturbing too much bone.

Prefabricated cutting block molds from 3-D magnetic imaging help eliminate the need for more invasive bone separation, rods and pins. Digital cameras, optical navigation and robotic-assisted systems in the operating room help ensure precise positioning of the joint implants and speed total surgery time.

“We’ve really changed recovery significantly where, for example, when I do a total knee replacement or total hip replacement, that patient walks about 30 to 40 minutes after their surgery, climbs stairs about an hour after surgery, and goes home between an hour and a half and two hours after their surgery,” Shah explains. “So it’s no longer the idea that you’re going to be in the hospital and a nursing home and rehab for weeks. Week in and week out, this outpatient total replacement is a very routine process for us. The patients are happy because the recovery isn’t so long, and they are back to life much faster.”

Based on insurance coverage and upfront training and equipment costs for surgeons, hospitals and surgery centers, these advancements in joint replacements and post-surgery recovery are not yet available for every patient, but the outlook is promising.

“Surgery is really an important part of the process of having a total joint replacement, but surgery is not the only part,” Shah adds. “It is important that the surgeon builds a team that encourages appropriate anesthesia, nursing and physical therapy. My oldest patient was 81 and we’ve had multiple people in their late 70s and early 80s have outpatient surgeries. The main thing to consider with a senior is identifying safety by seeing if medical problems are compatible with having surgery and anesthesia and then making sure the home situation is appropriate.”

 

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