Demand for New Joints Up as Population Ages, Technology Improves

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COLUMBIA - The number of joint replacement surgeries is on the rise, but a Columbia surgeon says there may not be enough experts to meet demand.

"It is a coming onslaught of people," said orthopedic surgeon David Hockman. "There's just not enough of us."

Hockman, who has been an orthopedic surgeon for ten years, said he is now performing between 10-13 replacements a week.

With advances in medical technology and an aging, but still active, population, the number of people seeking hip and knee replacements is expected to grow dramatically.

"I started, there were probably, I think, three-hundred, four-hundred thousand joint replacements done in a year," he said. "Now, there's almost a million joint replacements done, and they predict that that will double by 2016."

The American Association of Hip and Knee Surgeons say there may be a need for 500,000 hip replacements and 3,000,000 knee replacements each year by the year 2030.

"The cost in 2004 was about, I think it was $11 billion to Medicare, it will be $50 billion to Medicare by 2030." Hockman said.

Changes in healthcare are proving to be a game changer. Hockman said he and many other orthopedic surgeons will no longer be able to do bilateral (double) knee replacement, because of a reduction in reimbursement rates from insurance providers.

"Total knee replacement and hip replacements, in real dollar values have seen a decrease in reimbursement of 20 percent," he said, and the Center of Medicare Services is considering reducing the payments even further.

Hockman said he fears many medical students and residents will stay away from joint replacement surgeries, opting for outpatient surgeries instead.

"I want to help people with this surgery, Hockman said. "Unfortunately, there's not a lot of people feeling that way out of residency these days so not as many people are going into to fellowship training programs as there used to be and so there is going to be a huge supply-side problem, so wait times will unfortunately get worse and worse."

Joint replacements have the potential to change lives.

72-year old Roger Fisher said: "I was having a very difficult time walking, I was having a very difficult time doing anything, even to maintain just my daily routine, my knees hurt so bad. It's severe pain right in the knee, and then sometimes it radiates up the calf, or down the calf and up the thigh."

Fisher is three months removed from a total knee replacement in his left knee. Although he saw an improvement after the first full week at home, he initially had his doubts.

"The first week you're so sore after coming out of surgery that you just wonder whether it was worth it," he said.

Hockman said many patients face that sort of struggle. "It just takes your stamina away," hesaid. "You're exhausted after you have a knee replacement or a hip replacement and we just haven't been able to change how people physiologically just respond to a major surgery."

Joint replacements procedures are not cheap. Hockman estimates it costs between 30-50,000 dollars for someone to have a joint replacement, including charges for the physician, hospital care, physical therapy and follow up.

New technologies aim to provide the best two surfaces to wear against each other to provide a long lasting outcome for the patient. These include highly cross-linked plastics in hip replacements.

"Now they're adding Vitamin-E to the polyethylene plastic to try and keep it from oxidizing," Hockman said.

Another technological improvement is the use of trabecular metal, a porous material that simulates bone, in knee replacements. It allows the knee to be put in place without any cement.

"Your bone will grow right in to it and lock it in place and it should then be fixed for a lifetime if it works as we expect," Hockman said.

Hockman is still not convinced that newer technology improves the recovery time for patients.

He also said expectation management has become an important part in analyzing what a patient wants and what a surgeon can deliver.

"That's always my number one goal, I think, in having them in the clinic first is to educate them and make sure that it's right for them," Hockman said.

The American Association of Hip and Knee Surgeons website said the group expects most new joint replacements to still be working well after twenty years.

The problem for many people is deciding the right time to move forward with a replacement. Patients must meet certain conditions to qualify.

"They have to have bone-on-bone arthritis, and they have to have pain that is not responding to non-operative treatment, and they have to have some level of disability to where their quality of life is diminished," Hockman said.

Hockman said there is still not a good answer as to how young is ‘too young' to get a joint replacement.

"If you look at what the American Association of Hip and Knee Surgeons, they'll recommend, if somebody is 52 or older they're probably fine, you don't need to think about age as a factor," said Hockman. "If they're under 52, you better have exhausted all other options."

Everyone recovers from surgery differently. Fisher had a hip replacement seven years ago and said the recovery process was easier and quicker in comparison to his knee replacement.

"There's a certain leeway," physical therapist Greg Cox said. "Some patients progress more rapidly than others. We see some patients for a month, we see some for three, but I would say beyond the 10-12 week point it's pretty rare that we see anybody any longer than that."

Cox said the clinic he works at sees about three or four "new knees" every month.

"It sounds scary," Fisher said. "The operation is not that scary, the rehabilitation is simply a lot of hard work, but it's physically possible."

Although Fisher may have to replace his other knee, he plans to continue his therapy regiment on his own.

"I am continuing to do therapy at the ARC," he said. "Which means three times a week I come over and I exercise my knees to try to keep them from being stiff and try to keep them from getting sore."