Musculoskeletal Care of the Mature Patient

How long will a joint replacement last?  Should you put off surgery as long as possible to minimize the risk of needing a revision surgery or two?  It is one thing to be in so much pain that you can’t go for a walk, work without major restriction or enjoy travel. The idea of being that miserable at age 50 and delaying surgery to age 70 doesn’t make sense even though that’s how we practiced in 1973.  On the other hand, the more active the patient after joint replacement, the faster that joint will wear out, loosen or otherwise require revision.

 I encourage my patients to walk, swim and cycle. While there is not an abundance of scientific study regarding sports and survivorship after total joint replacement, research I directed in the Rush Orthopedic Research Center indicated little force across the hip joint or knee joint while cycling.  Most of the forces were absorbed in muscle groups. In swimming, 95% of the stroke is generated by upper extremity forces unless you are a very competitive swimmer.  If your goal is a successful, long-term outcome, a joint replacement recipient needs to avoid high impact sports such as jogging, running, and jumping. Personal quality of life issues are important; and even though advances in wear-resistant materials may make implants being used today last 15 years or more, it is 85% of patients who still have a functional hip or knee. The other 15% have been revised. Metal-on-metal hips were to have lasted for a lifetime; but their use is declining because of metal ion release. Ceramic -on- ceramic hips squeak with time.  A new “30-year knee” received marketing approval from the FDA based on tests mimicking 30 years of wear; it will take long-term outcomes studies to see how they faire in actual patients.

 Assume if you will the following hypothetical patient; or it may be you. The diagnosis advanced as the explanation for your limited motion, pain, and altered functional capacity after examination and X-ray by your orthopedic surgeon is arthritis of the hip or knee and you fall within the Boomeritis age group.  Should it be joint replacement surgery or rejuvenative cellular medical management?  The former is covered by insurance; the latter is an out of pocket expense.  A joint replacement will require compromise in your recreational and functional profile; successful stem cell management will not. Stem cell management holds the promise of unlimited recreation.   There is a 15% chance of needing revision surgery within 15 years after a joint replacement with a predictable marginal outcome thereafter; as contrasted to unknown data on the long-term success of rejuvinative cellular management, for now it is all anecdotal. The lack of success of stem cell management of arthritis would be the indication for a total joint replacement.  Should you first consider stem cells?

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