Joe Mayer, a retired U.S. Army lieutenant colonel, estimates that he's played as much handball as just about anybody in the world. His left knee could attest to that. Not only did it bow out 30 degrees, the bone bore a deep groove. "Handball just wore the knee out," says the 78-year-old Angie's List member from Washington, D.C.
Mayer sought a total knee replacement from Dr. Kevin B. Fricka, a highly rated surgeon with Anderson Orthopaedic Clinic in Alexandria, Va. Before surgery, standing or walking required him to sit down every 15 minutes. Now he's back on the court. "It's been a new lease on life," Mayer says.
Knee and hip replacement surgeries becoming increasingly common
More than 1 million Americans undergo a hip or knee replacement, or arthroplasty, each year, up 85 percent from 1999, according to the Agency for Healthcare Research and Quality. Experts say the increase is due to baby boomers' desire to stay active. And like most recipients, Mayer praises the surgery, which involves removing the damaged joint and replacing it with metal, polymer or ceramic parts.
About 80 percent of members who took a recent Angie's List online poll say they're satisfied with their surgery, and more than 90 percent of reviews filed in the past three years are positive. Those figures are consistent with a national study by AHRQ showing 90 percent of total knee replacement patients report good to excellent outcomes four years after surgery.
But experts advise individual results may vary. A lot of times, patient expectations are based on Internet searches, says Dr. Mark Dolan, orthopedic surgeon with highly rated Northwestern Orthopaedic Institute in Chicago. "Really, their expectations should be shaped in a discussion with their surgeon."
For Mayer, handball is in but running and heavy lifting are out. Member Nan Garland, 55, of Watertown, Mass., says her doctor cleared her for all activities five months after total hip replacement. "Basically, he told me my only restriction was trampoline," she says.
Younger candidates for surgery, higher expectations
Expectations are rising as the average age of joint replacement recipients drops. The fastest-growing group for total knee and hip replacements is people ages 45 to 64, up 61 percent and 42 percent, respectively, since 2004, according to the American Academy of Orthopaedic Surgeons. "Patients' expectations of the kind of lifestyle they want to live is different now than 10 or 15 years ago," Dolan says. "They're more active. So they're willing to undergo the surgery at a younger age,"
What they risk is the almost certain fate they'll need another joint replacement - the average life span of an implant is 20 years, according to the AAOS. "However, giving up five good years of your life in your 50s or 60s to wait to have a joint replacement until later oftentimes doesn't make sense," Dolan says.
Regardless of age, a good outcome isn't guaranteed. Even with a 90 percent success rate, joint replacement proves unsatisfactory for 100,000 Americans each year.
Susie Bishop, 62, of North Barrington, Ill., says she has no doubt what went wrong with her total knee replacement. She blames her surgeon, Dr. Mitchell B. Sheinkop of Chicago, who operated twice on her left knee. After being dissatisfied, Bishop took X-rays of her implant to two other doctors who told her, "This needs to come out immediately," she says.
In August 2009, she used Dr. Martin Saltzman of Woodfield Orthopedics for a third surgery to replace the implant. "After eight months and three surgeries, I'm OK now," she says. "I'll always have some issues. You can't separate the muscles from the bones that many times and expect to get them back."
Sheinkop's medical record includes a fine and a reprimand from the Illinois Division of Professional Regulation for a case unrelated to Bishop, which involved leaving a draining device in a patient's knee. Although Sheinkop says federal privacy laws prohibit him from specifically addressing Bishop's case, he spoke about his track record of 40 years and more than 20,000 operations.
"There is no busy surgeon who doesn't have unhappy patients," he says. "An elective procedure is undertaken with the hope of minimizing pain, improving motion, improving quality of life," he says. "At times, it doesn't work. At times, a second operation is needed." As for the reprimand, he says although it may not have been his fault, "I was the captain of the ship, so I had to own it."
Knee and hip replacement surgery costs
Bishop says Aetna, her insurance company, covered the cost of her three surgeries. She paid only her annual deductible, $1,000. Total hip or knee replacement costs an average of $21,978 and $21,622 respectively, according to Healthcare Blue Book, which publishes the "fair prices" providers accept from insurance as payment in full - usually less than the "billed charges" amount.
Insurers like Aetna point to the rise in joint replacements as one factor pushing up health insurance costs for consumers. When there are problems with a joint replacement and a provider needs to perform a second surgery, Aetna spokeswoman Tammy Arnold says their company will cover the procedure as it would any other surgery.
In some bad joint replacement procedures, the patient has problems with the implant itself. Jane Alfieri-Wipper, 47, of Peoria, Ariz., received a right hip replacement hoping to improve her quality of life. Instead, her implant only compounded problems. It was one of the 93,000 recalled by DePuy Orthopaedics in August 2010. "The pain was worse, it was so much harder to walk," says Alfieri-Wipper, who is among the more than 1,300 patients suing DePuy.
The problems highlight an inherent weakness with U.S. joint replacements: no national database tracks implant failure rates. "Registries are critical," says Dr. Charles Rosen, an orthopedic surgeon and founder of the Association for Medical Ethics in Manhattan Beach, Calif. "[The U.S.] should have had one 20 years ago."
Tracking implant failure rates
Later this year, the AAOS will launch the first nationwide joint registry. It will have basic patient information, type of implant used and survivorship of implant, and in the next five years add data on complications and patient-reported outcomes, says Dr. David Lewallen, an orthopedic surgeon at highly rated Mayo Clinic in Rochester, Minn., and chairman of The American Joint Replacement Registry.
Rosen says it's flawed. "When you have an academy that's paid tens of millions of dollars by companies that make implants, you don't have an independent registry," he says. "The more independent, government-sponsored registry, the better." Lewallen says no one group or company will dominate the board. "The thought was to try to bring together the different groups and stakeholders that we know have an impact on influencing the quality of the outcome," he says.
Fifteen hospitals are scheduled to submit data for the pilot project. Still, its usefulness will be limited, Lewallen says. "You have to collect data for a while before you know what the performance of an implant is for two years or four years or five years," he says. "Our final goal is to try to have 90 percent of the 5,000 or so hospitals that do hip or knee arthroplasty reporting." Like similar registries in Sweden and Australia, "patients will be able to access a lot of this information and come up with a risk profile," Lewallen adds.
In the interim, the best resource is your doctor. "The patient should discuss expectations, activity and risk of complications," says Dr. Alejandro Gonzalez Della Valle, an orthopedic surgeon with highly rated Hospital for Special Surgery in New York. "There has to be a very thorough discussion of the benefits and drawbacks of each type of joint, keeping in mind that the goal is a joint that lasts a long time," he says.
- with additional reporting by Michael Schroeder