This article looked at this issue through the positive short-term experiences of six individuals who opted for joint replacement in mid-life.
They all seemed to be exuberantly active and have splendid outcomes after emerging from post-operative rehabilitation. The six recipients of artificial knees and hips were collectively able to engage in long-distance cycling, kite-boarding, motorcycling, yoga, pilates, strength training and basketball.
One woman reported that her pain and limitations were completely gone. “I never imagined my life could be so wonderful,” she commented.
Although several of the subjects were pushing the envelope in terms of stressing their implanted joints with high-impact activities, not a single one reported a problem, a complication, or a functional limitation when they returned to normal activity.
In a country where more than half of adults are overweight, and almost half are completely sedentary, the joint replacement patients in the Wall St. Journal article are far from the norm. It is hard to imagine that these six individuals are representative of patients who opt for joint replacement in middle age across the United States.
The story did attempt to balance the idealized view of joint replacement in the patient vignettes with cautionary notes from several surgeons. These invited experts pointed out that artificial joint recipients should avoid high-impact sports and that the durability of joints implanted in mid-life remains uncertain. Given the views of these experts, some tough questioning of the patients could have shown the reader that these individuals may be experiencing short-term benefits at the expense of long-term misery—if their implants ultimately fail.
More references to scientific studies would have been welcome. The article never reported the overall success rate of knee and hip replacement in younger patients. Or the degree to which these procedures lead to an increased level of activity. It gave short shrift to one of the key questions about joint replacement in middle-age. In terms of pain, function, and adverse advents, what are the projected outcomes of the revision procedures that appear to be inevitable for surgeries performed at this age?
And the article never got into the thorny question as to whether the surge in knee and hip replacement in younger patients might represent over-utilization of these surgical procedures—or at least premature use.
A recent commentary in Arthritis Care & Research suggested that patients and their doctors in the United States rely excessively on analgesics and joint replacement to treat osteoarthritis of the knee and hip—and are under-utilizing evidence-based treatments, such as weight loss and exercise programs, that might delay these operations. (See Hunter et al., 2011).
Hunter DJ et al., Quality of osteoarthritis management and the need for reform in the U.S., Arthritis Care & Research, 2011; 63(1): 31-38.
Although knee and hip replacement have traditionally been employed in patients 65 and older, there has been a recent expansion in their utilization in younger patients, particularly those in their 40s and 50s. Since patients this age will likely require one or more revision procedures over the course of their lifetimes, this creates uncertainty about the long-term outcomes of knee and hip replacement in this population.
There is also evidence that healthcare practitioners in the United States are not following evidence-based guidelines in the treatment of painful osteoarthritis of the knee and hip, particularly in its early stages. As a result, some patients may be undergoing joint replacement unnecessarily. (See Hunter et al., 2011).
Given the “graying” of the general population, and the rising prevalence of painful OA, these are huge public health issues. The aging of the population means that society will have trouble paying for these procedures in older individuals. Paying for expanded use in large numbers of younger patients who will then face more expensive reoperations later in life is a daunting prospect.
The story specified the costs of both primary and revision knee replacement operations.
The article did not adequately quantify the benefits of knee and hip replacement in terms of pain relief, function, or quality of life. It would have been useful, for instance, for readers to learn that in older patients roughly 90% of primary knee and hip replacement procedures result in significant pain relief and functional improvement—with low levels of complications. Younger patients might expect similar short-term outcomes but their long-term outcomes would be less predictable. (The story cited studies showing 85-90% of implants “still functioning well after 20 years” but that’s not a comment on pain relief and peoples’ functional improvement.)
The article included only general references to the harms associated with knee and hip replacement. It did not specify rates of mortality, blood clotting, infection, and other potential adverse events associated with primary and revision knee and hip replacement operations. These are important issues in this age group since early joint replacement will likely involve more problematic revision procedures down the road. Detailing the complications and adverse events that can be expected in revision procedures would have helped balance the article.
The article did not present specific outcome data on knee and hip replacement in younger patients—or discuss the quality of the studies in those age groups.
The closest the article gets is the following: “Still, there are no long-term data on how any of the latest implants will fare in actual patients.” The key point that is missing is a detailed explanation that the data quoted on long-term outcomes come from studies of much older individuals. There is the distinct possibility that when implanted in the younger and more active individuals featured in the article, these devices won’t last nearly as long as the patients may have expected. This point needed more teeth to overcome the overly optimistic patient vignettes.
The article discussed the expanding indications for knee and hip replacement. But there is no indication that this represents disease-mongering.
The article included comments from several independent sources. It was not clear, however, whether any of the expert sources had conflicts of interest with implant manufacturers. Information on financial conflicts would have aided in the interpretation of their comments. Though several of the experts made comments that were intended to curb the enthusiasm expressed by the patients, it would have been helpful to know whether any of the physicians receive payments from device manufacturers—given the widespread conflicts-of-interest that have affected this field in recent years.
The article did not discuss potential alternative treatments. This is a key question, since joint replacement has not traditionally been employed in this age group. Alternative therapies might include weight loss and other lifestyle interventions, exercise programs, activity modification, various medications, and other forms of surgery.
This is where the article could have been much tougher. Are these younger individuals exchanging short-term benefits for long-term problems with failed joint replacements? Some tough questioning of the patients would have been interesting. Were they even aware that they had other treatment options? Many individuals employ lifestyle changes and exercise to cope with knee problems for many years—and preserve a reasonable quality of life. They might not experience the level of athletic performance demanded by the patients in this article. But in delaying joint replacement they may have better long-term treatment results.
It’s clear from the story that knee and hip replacement are widely available across the United States.
The article explained that the indications for joint replacement have been gradually expanding to include younger patients, among whom knee and hip replacement might previously have been a “novel” procedure.
This story did not appear to rely on a press release.