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Joint-Replacement Surgery Gets Boomers Back in the Game

Pat Mertz Esswein, Associate Editor, Kiplinger's Personal Finance
Replacing a hip or knee can change your life -- and it doesn't have to be an arduous process.

The pain was like a "headache" in her hip whenever she walked any distance. For four years, Dorry Felton Wallof of Cannon Falls, Minn., treated the discomfort with ibuprofen and carried on. By the summer of 2016, intense pain and a cane were her constant companions.

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Wallof, 62, visited her orthopedist, who ordered an x-ray and concluded that she had osteoarthritis--damage to the joint and inflammation often caused by wear and tear--and needed hip replacement. She asked her doctor if she had a choice. "He said, 'Not unless you want to keep living like this,' and I said, 'No, I want my life back.' "

Wallof underwent surgery in early November at a local hospital affiliated with the Mayo Clinic system and "never looked back," she says. Her recovery was quick and uneventful. By January, she and her husband, Jeff, had returned to riding their snowmobiles (gingerly, on her part), and by spring, she was raring to hit the road on her Harley-Davidson.

How the surgery works

Joint replacement--known as arthroplasty--is one of the most common operations in the U.S. and the most common among patients covered by Medicare. About a million such surgeries are performed annually, and the number will rise significantly as boomers grow older and live longer. Increasing numbers of younger people need the surgery, too, because of obesity and injuries from athletic activity. Arthroplasty was introduced in the 1960s, and the basic strategy remains the same: An orthopedic surgeon removes damaged bone and cartilage from the joint and installs prosthetic components made of metal, ceramic and plastic to create a smooth-running, durable joint. Knee replacement involves resurfacing the knee's components: the lower end of the thigh bone (the femur), the upper end of the shinbone (the tibia), and the kneecap (the patella). In a normal joint, the ends of these bones are covered with cartilage to protect them and allow them to move smoothly. In an arthritic joint, the cartilage is damaged or worn away. During the operation, the surgeon cuts away the damaged cartilage and bone at the ends of the long bones, positions and secures the metal implants, and in some cases cuts and resurfaces the back of the kneecap with plastic. A plastic spacer is inserted between the metal components to create a smooth gliding surface.

Partial knee replacement is a slightly less extensive surgery than a total overhaul, with a slightly faster recovery. It may be appropriate if arthritic damage is limited to just one of the three compartments of the knee (inside, outside or front), but that's relatively uncommon. By the time most people experience pain in one part of the knee, they have damage to the other parts, too.

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In a hip replacement, the surgeon removes the damaged head of the thigh bone and replaces it with a metal stem inserted into the hollow center of the bone. The surgeon either cements or "press fits" the stem into the bone and attaches a metal or ceramic ball to the stem. He cuts away the damaged cartilage surface of the hip socket and replaces it with a metal socket, which may be secured to the pelvis with cement or screws. Finally, he inserts a plastic, ceramic or metal spacer between the ball and the socket to create a smooth gliding surface.

High-tech and a bit of hype

Joint replacement is not just a boon to hurting baby boomers; it is also a lucrative business. Surgeons and hospitals often compete for patients by touting a particular product, technique or surgical strategy.

For instance, some surgeons repeat manufacturers' claims that the replacement they use produces the "best knee for an athlete" or "best knee for a woman." In fact, all hip and knee implants have become more durable and anatomically accurate than they used to be and function more naturally thanks to innovations in design and materials, including a wear-resistant plastic that all manufacturers use. These implants come in all sizes and can be mixed and matched to create an exact fit for any patient, says Dr. Mark Pagnano, professor and chairman of the department of orthopedic surgery at the Mayo Clinic, in Rochester, Minn. "Minimally invasive" surgery, which generally means a smaller incision with less disruption of surrounding soft tissues, is also widely advertised. Although it's true that many hip and knee replacements can be done with a smaller incision than, say, 20 years ago, there are several techniques touted as minimally invasive, and the term has no universally agreed-upon definition. Ask surgeons what they mean by minimally invasive and whether you're a good candidate for the approach.

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Many surgeons vigorously advocate for one of two ways to access the hip in surgery: posterior (from the back of the hip) or anterior (from the front). A recent study conducted by the Mayo Clinic found that both approaches provided excellent postoperative recovery with a low complication rate, although the patients who had direct anterior surgery had a slightly faster recovery. The risk of dislocating the hip following surgery is low in both groups (less than 1%), but contrary to some claims, the anterior approach doesn't eliminate that possibility, according to recent data from the Michigan Arthroplasty Registry. What about using three-dimensional printing to custom-make a new joint for you? The technology is in use today, but it doesn't necessarily make implants fit better than they do with other technology, says Pagnano.

Anticipating the outcome

Surgical protocols have advanced remarkably over the past decade. Now, serious complications occur in fewer than 2% of patients, according to the American Association of Orthopaedic Surgeons. Still, over time joint implants may be damaged and loosen from normal wear and tear, a fracture, or infection (which is always a possibility because the surfaces of the implant provide a place for bacteria to take hold). If the replacement fails, you may experience pain, stiffness, instability or loss of function, and a redo, or revision, may be in order.

How long can you expect a new joint to last? "Joint replacements don't come with an expiration date, where they all suddenly start to fail," says Pagnano. There's about a 0.5% to 1% chance of a problem arising for every year after surgery. So you have a 90% to 95% chance that a joint will still work well after 10 years, an 80% to 85% chance after 20 years and so on. For many elderly patients, the replacement will likely last them the rest of their lives.

How to know when it's time

Two elements must come together for your surgeon to recommend a total joint replacement. First, an x-ray of the joint (an MRI is rarely required) has to show substantial damage from an underlying disease, such as arthritis, or an injury. Second, the damaged joint has to routinely cause marked pain and limit your activities. Age is never the major factor. Replacement may be the right choice for younger people because it will relieve them of pain or allow them to do more of what they want. And patients in their nineties who are healthy can also undergo the procedure safely.

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Everyone has a different tolerance for pain, as well as different expectations for their level of activity. If the pain and limitation you experience are more nuisance than hardship, then you're probably not ready for joint replacement. "Surgery has a very, very good likelihood of making you better and a tiny chance of making you worse. Your symptoms must be sufficient for you to take the chance of getting worse so you can get better," says Dr. Mark I. Froimson, president of the American Association of Hip and Knee Surgeons. "We want patients to say, 'I must do this. I have to do this,' " says Dr. William Jiranek, the association's immediate past president, in Richmond, Va.

If you do qualify for a replacement, keep in mind that the longer you wait and the more inactive you become, the more your muscles will weaken. "You'll have a bigger hill to climb after surgery," says Froimson, of Lavonia, Mich. You can begin rehab exercises before surgery to start rebuilding muscles. "Do what you can, but don't suffer," he says.

Christopher Jorgensen of Smithtown, N.Y., had both knees replaced in August 2016. Jorgensen, 52, played basketball and lacrosse beginning in his youth and injured the ligaments in both knees in a motorcycle accident in 1990. Over the years, he developed arthritis in both knees and had multiple arthroscopic procedures, in which the surgeon uses a fiber-optic camera inserted through a small incision to diagnose and repair any damage. Although his doctor recommended that he have his right knee replaced, Jorgensen put it off until he experienced a moment of truth: He was officiating a college lacrosse game and realized that to avoid pain he was walking; he couldn't run to keep up with the action. "That was the moment I said enough is enough," he says.

Jorgensen thoroughly researched prospective surgeons and chose Dr. Steven Haas, chief of knee services at the Hospital for Special Surgery, in New York City. Jorgensen insisted that Haas fix both knees at once to avoid a year-long delay between the two surgeries. Within three months of surgery, he resumed a normal gait. In late February, he successfully officiated his first lacrosse game. And after years of being unable to play basketball one-on-one with his son, he not only has resumed playing but also consistently wins. "He's a new man," says his wife, Lindsey.

Find the right doctor

To start your search for the right surgeon, ask your general practitioner for a referral, and visit your insurer's website to search for specialists and hospitals in your network. Look for surgeons who belong to the American Association of Orthopaedic Surgeons (go to www.aaos.org and click on "find an orthopaedist") and the American Association of Hip and Knee Surgeons (go to www.aahks.org and click on "find a doctor"). You can read patient reviews of physicians and find out where they have admitting privileges at www.healthgrades.com.

You'll be best served by an orthopedic surgeon who took an extra year of postgraduate fellowship training and specializes in joint replacement (see How to Choose the Right Health-Care Specialist). The more joint-replacement experience that a surgeon and hospital have, the less the likelihood of complications. A rule of thumb: The surgeon should perform more than 50 hip replacements or 50 knee replacements annually at a hospital where more than 250 total joint replacements are performed a year. Most high-volume hospitals offer joint-replacement programs with preoperative education for patients, a dedicated nursing unit and protocols designed to help you go home more quickly.

The federal Centers for Medicare and Medicaid Services rates hospitals based on several performance criteria, including rates of complications and readmission following hip and knee replacements (www.medicare.gov/hospitalcompare). You can also search for physicians by name, location, specialty or body part (www.medicare.gov/physiciancompare), but top surgeons who may be a good fit for you won't be listed if they don't accept Medicare patients. Your insurer will require you to be preauthorized for total joint replacement. Medicare requires your physician to document medical necessity with your medical history, the results of a physical examination and x-rays, as well as the surgeon's clinical judgment that surgery is appropriate.

Consider your cost

If your network doesn't include a doctor who is right for your case--say, you have had previous surgery on the joint, you have multiple medical problems, or you have complex bone deformities that will make the procedure more difficult--it may be worthwhile to go out of network. If that's the case, or if your insurance requires you to pay a large share of the cost, you owe it to yourself to shop for the best price as well as the best surgeon.

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The cost of total joint replacement varies in the U.S.--and even within many cities--with prices ranging roughly from $20,000 to $60,000, says Bill Kampine, senior vice president and cofounder of the Healthcare Bluebook. The company collects claims and payment data from health plans and calculates a fair price for procedures. (To see the price in your city, visit www.healthcarebluebook.com and click on "consumers.") Kampine says fees vary little among doctors but greatly among facilities. That can make a big difference in your out-of-pocket cost after any deductible.

One way to shop? The Blue Cross Blue Shield Association has created the Blue Distinction Centers+ designation (www.bcbs.com/blue-distinction-center-finder; search by location) for hospitals that deliver expert specialty care, including hip and knee replacement, and that are at least 20% more cost-effective than non-designated facilities. Call designated hospitals and ask what they charge. If it's close to the fair price, choose a highly rated surgeon who admits there. (For more on finding hospitals that specialize in certain procedures at a competitive price, see Travel Abroad for Low-Cost Care.)

Some joint replacements now are performed on an outpatient basis at an ambulatory surgery center. After surgery, you return home the same day or after a single overnight stay. This arrangement may be less expensive and more convenient than in-patient surgery, but it's not for everyone. You must be healthy and personally motivated. If your surgeon offers outpatient surgery as an option and you're covered by employer group insurance, check with your insurer to see how coverage for inpatient surgery and outpatient surgery differ. Medicare will require you to have your joint replacement performed as an inpatient procedure, under Part A of your coverage.

Road to recovery

With your new hip or knee, you'll be ready to leave the hospital when you can walk safely with a walker or crutches, you can ascend and descend a few stairs, and your pain is under good control with oral medication. Most patients will do best if they go straight home and not to an inpatient rehab or skilled nursing facility. At home, you'll lessen your risk of infection and be encouraged to return to your usual routine sooner.

If your surgery was uncomplicated, you won't need specialized nursing care, but you may need some help with normal daily activities during the first three to 10 days after returning home. Arrange for your spouse, a family member or a friend to help. (If you don't have social support, or you have multiple medical conditions, you may have no choice but to go to rehab or a skilled nursing facility.)

Most total hip replacement patients don't need a formal program of physical therapy after they return home, says Pagnano, although some doctors recommend it. Knee patients may benefit more from therapy because knees can become stiff after surgery, and bending the knee is key to achieving a good range of motion sooner rather than later, says Haas. Most patients don't need more than one session of physical therapy per week for the first four to six weeks after replacement. About 2% of knee-replacement patients will develop scar tissue adhesions on the joint, resulting in stiffness and pain that require more treatment. It's generally safe to walk, hike, ride a bike, swim, dance and play tennis after knee and hip replacement, but avoid running, which pounds the joints, as a routine exercise.

Coping until surgery

If you're not ready for joint replacement, your physician may recommend alternatives. Among the strategies that will noticeably diminish symptoms: avoiding high-impact exercise; taking nonsteroidal anti-inflammatory medications, such as ibuprofen; and losing a moderate amount of weight. Your physician may be able to help you manage joint pain, stiffness and swelling by removing fluid from the joint, injecting a corticosteroid (such as cortisone) into the joint or prescribing supervised physical therapy, which many insurance companies will require you to try before they will authorize replacement surgery for a knee or hip.

Arthroscopy, a procedure usually used to repair cartilage, ligaments or tendons in a joint, works best when it's performed soon after an injury. But it's seldom beneficial if you're suffering from moderate or advanced arthritis of the hip or knee, and it is neither a prerequisite nor a substitute for joint replacement.

The Author's Personal Story: At Last, I am Pain-Free

I suffered with knee pain for years as the result of an injury in my teens, an active lifestyle, a love of physical labor and a few extra pounds in middle age. In my late forties, arthroscopy cleaned up the torn cartilage in my left knee but failed to provide much relief. I dosed myself with naproxen and used walking sticks periodically. I always loved walking and hiking, but because going even short distances caused pain, I increasingly avoided those activities. By my mid fifties, I limped and, to my horror, became bow-legged as both knees degenerated with osteoarthritis. I imagined that I would need knee replacements someday, but I put it off. My parents were aging, my kids were growing, and I was scared.

Then, at Thanksgiving 2013, when I was 57, my right hip just "went." I'd previously suffered aches and the odd twinge, but this was unendurable pain, and it didn't go away. I began walking stiff-legged, like a penguin. An x-ray showed that I had end-stage arthritis in my hip, and the joint was bone on bone. My orthopedist referred me to a hip specialist, who recommended a hip replacement. I scheduled the surgery for after the holidays, booked my sister to help, took my required and very reassuring joint-replacement class, and got my pre-op physical.

My surgery took less than two hours, and I went home after two nights in the hospital. On my first night home, I climbed the stairs and slept in my own bed. My quick recovery so astonished me that, at my six-month post-op visit, I asked my surgeon if he would simultaneously replace (a bilateral replacement) both knees. He agreed because I was relatively young, healthy and clearly motivated. Six months later, my surgeon performed the surgery in just a few hours, and the result was equally astonishing.

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Now, I am pain-free. I can do everything I want to do, and I happily take walks and hikes with my husband and children. I feel young.

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