July 11, 2023 – Kathy Blackwell won’t let just a few sore joints stop her from living her life to the fullest.
The 73-year-old resident of Simi Valley, a bedroom community about 30 miles northwest of downtown Los Angeles, commonly organizes activities for her senior citizen group. The 20- to 30-member group of experienced residents, mostly women, stays lively. In the approaching weeks, they plan to see the Beach Boys on the historic Hollywood Bowl and take a cruise to Alaska.
Because of her busy schedule, Blackwell desires to postpone her second hip surgery and as an alternative opts for a cortisone injection in hopes of reducing the pain enough to enjoy her upcoming outings.
Not that she's afraid of a joint substitute. If her orthopedist offered a loyalty card just like the ones you get on the local coffee shop, hers can be nearly full. Blackwell's knee and one hip have been replaced, and her other hip can be replaced as soon as she has time.
“If you suffer from chronic pain long enough and there is no relief, you become irritable,” Blackwell said.
More than 1 million recent knees and hips
Joint substitute is becoming increasingly common, with roughly 790,000 total knee replacements and greater than 450,000 Hip substitute is performed annually within the United States, according to the American College of Rheumatology.
Experts agree that age just isn’t a consider selecting a joint substitute. Rafael Sierra, MD, of the Mayo Clinic, said he has performed hip substitute surgery on patients ranging in age from 12 to 102. Orthopedic surgeon John Wang, MD, of the Hospital for Special Surgery in New York City, performed knee arthroscopy on a patient in his mid-90s. At 73, Blackwell is an older man. Average age for hip surgery is 66 years.
“Numerous surveys and studies have shown that people, no matter what age group they are in, ultimately do well,” Wang said.
More vital than age is that older patients are prepared for therapy and treatment after surgery. For younger patientsthe largest drawback is that you just survive the estimated lifespan of a joint replacement is 25 years. Complications are rare and occur in about 2% of procedures. These include infections, joint dislocations and blood clots; every other health problems you will have aren’t vital.
Considering how difficult Blackwell's first knee surgery was, it's no wonder she ever set foot in a surgeon's office again.
After putting it off for seven years, Blackwell finally followed her doctor's advice in 2017 and had her left knee replaced to alleviate what she described as “crunching,” chronic bone-on-bone pain.
“It got to the point where there were no alternatives,” she said.
But her first orthopedic surgeon did a “bad job” and left her with a gaping, festering wound that led to sepsis and Wound vacuum therapy to shut the wound. She eventually found one other surgeon who removed her artificial knee and cleaned it before re-inserting the prosthesis. Fortunately, the sepsis didn’t spread and eight surgeries later, she was healthy again.
Blackwell's second knee substitute in 2018 was a model surgery, as was a hip substitute in late 2019.
“Your whole attitude changes,” she said.
What generalists should know
Orthopedic surgeons recommend that primary care physicians consider two things when considering joint substitute surgery: Have non-surgical treatment options been exhausted and is the pain unbearable? They also recommend treating symptoms with narcotics.
When assessing whether a patient is a candidate for joint substitute, a general practitioner must primarily ask whether the pain and imaging findings are severe enough to warrant surgery.
“You shouldn’t do it too early,” Sierra said.
Sierra likes to inform the story of the golfer whose knee became stiff after 18 holes. He recommends that these patients limit activity; on this case, using a golf cart or playing only nine holes.
Wang agrees, asking if the pain is “lifestyle-changing” and whether the patient is unresponsive to nonsurgical treatments comparable to over-the-counter medications, anti-inflammatory drugs and injections, home exercises or physical therapy, wearing a brace or sleeve, or just changing their activity.
And no addictive painkillers to treat arthritis, which may result in other serious problems.
“It's not going to heal on its own,” Wang said. “It's not going to get better on its own. That's why we don't want to cover it up with narcotics just to cover it up.”
Karen Smith, MD, has been a primary care physician in rural North Carolina for over 30 years. When she sees patients complaining about their joints, she first assesses their function and pain. From there, she investigates why they’re having pain. For example, is the issue related to ergonomics at work or because they’re carrying a variety of body weight?
“We look at those areas to determine what can be changed,” she said. “All of that is done before we even do the orthopedic treatment.”
Smith said she also considers things beyond basic medical care: What is the patient's mental state and pain tolerance? Is there support at home for post-operative care? And can they afford to remain home from work?
“We look at all of these factors together because they determine the outcome we want to achieve,” Smith said.
Great expectations
A recent study shows that older patients respond higher to knee replacements than younger patients, particularly by way of pain relief and quality of life. The reason for this might be considered one of expectations. While younger people will want to get back on the racquetball court and play like they used to, older patients may need to walk across the gym without discomfort.
“It's possible that these patients under 55 just need a little longer to be satisfied,” Wang said. “We can't really say why this happens, but it's possible that the younger patients are more active and expect more from their knee.”
Jeevan Sall, MD, is a sports medicine physician at Providence Mission Heritage Medical Group in Laguna Niguel, California. He first discusses conservative treatment for patients with arthritis within the joints. These measures include rehabilitation exercises, splints, shoe inserts, medications, and weight reduction. If these steps don’t improve the patient's pain or lifestyle, surgery is up for debate. Managing expectations is a vital factor.
“Is the patient mentally ready for surgery?” Sall said. “This includes what they want to achieve with the surgery, as well as the risks and benefits of the procedure.”
Blackwell's hip and knee pain were simply the results of a full life, with no notable marathons or life-changing accidents. She worked as a stay-at-home mom, raised her two children, and owned an elevator company along with her late husband, Robert Blackwell.
Yes, there are jokes in elevator construction.
“We have our ups and downs,” Blackwell said.
And Kathy can do the identical along with her recent joints.