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Knees and hips

Today nearly everything can be replaced

In 1800, the average life span in the United States was 40 years; in 1900, it was 49. Today, it is 82.

People, in general, are living longer, healthier, more active lives. But this doesn't mean things aren't going to give up, give out, or get old.

Whether through normal wear and tear, trauma, or disease, our joints take a beating. And now that we are asking them to serve us more than twice as long as our ancestors required, more and more of us are going to need them replaced.

The good news is that it's possible. Which doesn't mean it's as easy as replacing your running shoes, or that it should replace preventive healthcare. Moreover, thanks to our longevity, patients who undergo, say, a hip replacement in their 40s, 50s, or 60s are likely to require the procedure again, because it typically lasts only 20 to 25 years.

Every year, some 270,000 knees are replaced in this country, a figure expected to double by 2030, says orthopedic surgeon Christopher Meckel, who serves as chair of the Orthopedics division at Community Hospital. And the numbers for hip replacements are only slightly lower. Meckel himself performs an average of 10 hip replacements a month.

"This community has a lot of orthopedic surgeons," says Meckel. "As our country faces an epidemic of obesity, plus the aging of our Baby Boomers, the largest generation in history, the procedure is becoming increasingly common. Just 10 to 15 years ago, if an overweight person with arthritis asked for a hip replacement, he was told to lose weight first. Doctors are now realizing it's hard to lose weight when you can't walk. It becomes a quality-of-life issue; we need to replace the hip so the patient can exercise and protect his heart."

Although there are different approaches to hip replacement surgery, Meckel recognizes that patients have been taught to seek "minimally invasive surgery," an application borrowed from general surgery where technical innovation has made it possible to reduce the size of an incision when removing something such as the gall bladder or appendix. But it's a debatable notion in hip replacement surgery.

"The smaller the incision," says Meckel, "the harder it is to get the implant in place with the right positioning. I am a proponent of 'appropriately invasive surgery,' creating an incision large enough to do accurate work but small enough to minimize tissue damage. We can't be marketing cosmetics here; the scar is not what's most important."

Less-invasive surgery is appropriate to repair rather than replace the hip joint. Arthroscopy is available to patients suffering not from arthritis but from damage caused by an accident or the wear and tear of an active lifestyle. The most common call for arthroscopy is a tear in the labrum (the rim of cartilage that covers the hip socket), which causes friction, leading to erosion of the cartilage and, eventually pain.

Just ask Barry Manilow. After 30 years of shaking the merengue on stage, he was facing the prospect of a hip replacement to end his excruciating pain. Then he learned that he had tears in both hips. After a one-hour surgery in which the torn piece was either shaved off or sutured to the bone, Manilow was on his way home. And after four weeks of intense physical therapy, he returned to rehearsal.

When the hip joint is beyond repair, patients may consider yet another alternative to hip replacement. Called "hip resurfacing," it involves covering the ball and socket of the damaged joint with a metal cap rather than cutting them out and replacing them with an implant.

"I'm biased against hip resurfacing," says Meckel, "because it's temporary. Its longevity is nowhere near that of a total hip replacement. It does allow the patient to keep more bone, but the total replacement will come eventually. Besides, I'm not comfortable with the idea of microscopic metal particles later released in the system because of friction."

When hip replacement surgery is the answer, Meckel prefers anterior replacement, which means accessing the joint through an incision on the front of the hip rather than the side. This avoids cutting through muscle, creates a more stable joint, and enhances hip function.

"The gold standard is to go in from the side," he says, "but side access requires certain precautions after surgery, such as never internally rotating the leg or lifting it more than 90 degrees to avoid dislocating the joint. This is not a problem with an anterior incision.

"The whole point is to reduce pain and get patients back into their active lives, whether that means a return to walking or hiking, swimming or cycling, doubles tennis, or golf. Surgery should be the last option. Once a patient has tried rest and stretching, physical therapy and anti-inflammatory treatment, and, if appropriate, resurfacing or repair, then it's time for surgery."