'Redo' joint replacement surgeries on rise in Western Pa.
By Luis Fábregas
Published: Sunday, Nov. 25, 2012, 9:18 a.m.
Karen Leto never bounced back from hip replacement surgery three years ago.
“I was in constant pain,” said Leto, 59, of Robinson. “It was getting worse.”
Leto found herself unable to manage her brick company, unable to play golf or exercise, and pretty much trapped in her house. Her orthopedic surgeon provided no solution, so she switched doctors and received a second implant on her right hip in August. She said she noticed improvement almost immediately, although her right leg remains weak.
“I see an improvement, but I'm too paranoid to say it's fixed,” said Leto, who undergoes physical therapy three times a week.
Leto's case highlights a growing trend in Western Pennsylvania operating rooms: revision surgery for thousands of patients who undergo hip and knee replacement operations every year. “Redo surgeries,” as surgeons sometimes call them, are a result of a surge in joint replacement surgeries in which doctors replace worn cartilage and bone with metal and plastic implants.
Nationwide, the number of knee replacements is escalating. More than 3 million Medicare patients got artificial knees from 1991 to 2010. Of those, about 10 percent were revisions, according to a study by University of Iowa researchers published last month in the Journal of the American Medical Association.
“There's a never-ending supply of patients who need revision,” said Dr. Brian Hamlin, an orthopedic surgeon at Magee-Womens Hospital of UPMC and associate director of its Bone and Joint Center. Nearly a third of the 400 hip and knee replacement surgeries he performs every year are revisions.
“Every day in clinic I see at least one patient who's had a failure in joint replacement.”
Wear and tear
Several factors contribute to the trend, but high among them is the wear on implants that causes them to loosen or break, experts said. Most implants tend to last 15 to 20 years, though like tread on car tires, their lifetime diminishes with use.
“We're definitely seeing a fair number of patients who got implants in the '90s who are starting to hit that time frame where the joint is wearing out,” Hamlin said.
Some people, however, experience implant failure within two years of surgery. In most of those cases, an infection or unstable joint is to blame. The hip, for example, pops out of its socket, Hamlin said.
Technical errors when installing the device affect the outcome of a surgery, doctors said, as in the case of Leto.
“People have subtleties to their anatomy that aren't recognized,” said Hamlin, whose patients come from West Virginia, Maryland and central Pennsylvania.
The jump in revision surgeries follows growth in first-time joint replacement surgeries, surgeons said. In Pennsylvania, 55,225 adult patients underwent total joint replacement in 2010, according to the Pennsylvania Health Care Cost Containment Council. The majority, or 66 percent, underwent total knee replacement, while 30.5 percent underwent total hip replacement and 4 percent had total shoulder replacement. The council said hospitalizations for knee replacement increased 16 percent to 34,320 in 2010 from 29,550 in 2006. Hip replacement hospitalizations increased 22 percent to 15,939 in 2010 from 13,041 in 2006.
A small but rising segment of joint replacement in the state is the shoulder — increasing 102 percent from 2006-10, records show.
The primary reason people undergo joint replacement is a high national rate of osteoarthritis, which develops when tissue cushioning joints wears down and causes bones to rub together. Doctors say the disease is prevalent among baby boomers who embrace sports such as running, which puts them at a higher risk of injuries and arthritis before age 65.
The disease is common among obese people, a group that accounts for more than 35 percent of adults in the United States, according to the Centers for Disease Control and Prevention. Experts say that group experiences more wear of cartilage in the hip's ball and socket structure, even after they have initial joint replacement surgery.
People undergo joint replacement surgery as a way to stay active later in life, surgeons said. People expect high physical function well into their 70s and 80s. They don't want to put up with pain, let alone be limited in what they can do.
“Many people have an expectation, and it's usually realistic, that they can continue to play golf by having their knee replaced,” said Dr. Julius Huebner, an orthopedic surgeon at Allegheny General Hospital in the North Side. About a fourth of the 350 cases he handles every year are revisions, which he considers a high percentage.
“That contributes to this epidemic we see of failed joint replacement.”
The use of new devices in the past decade added to the revision caseload. In the past several years, some patients opted to get heavily touted implants made with metal stems and sockets. Some of the devices were found to be defective and required surgery to replace them.
Studies showed the devices shed metal particles that caused chronic pain or infection and raised levels of metals in the bloodstream. The Food and Drug Administration reported more than 12,000 problems with the devices last year alone. Dr. Joshua Rising of the Pew Charitable Trusts wrote in The New England Journal of Medicine that metal-on-metal implants fail at a higher rate than hip implants made of other materials.
“Some patients unfortunately have not fared well with this device, with early loosening of the device, and some have had adverse reactions in their tissues to the debris that is generated from the metal surfaces,” Hamlin said.
Dr. Tony DiGioia, an orthopedic surgeon at Magee-Womens, said he selects a device based on a patient's needs and has used metal-on-metal devices selectively.
In addition to the implant, the success of a procedure hinges on factors such as how surgeons educate patients, the surgical technique and even getting patients out of bed on the night of the surgery.
“There's a whole sequence of things around the surgery that if you don't do, you're not going to have the best outcome,” said DiGioia, medical director of Magee-Womens' Bone and Joint Center.
Revisions are longer surgeries and far more technically demanding than first-time joint replacements, Huebner and others said. When surgery takes place in a part of the body operated on before, typically a surgeon finds scar tissue and less bone to work with, Hamlin said.
“The tissue doesn't look normal, and you could cause damage to nerves or blood vessels,” he said.
Joint replacement is becoming easier for patients, in part because of techniques that enable people to get back on their feet within hours of the surgery. An anterior approach to hip replacement allows the surgeon to reach the joint from the front, instead of the back or the side, which results in less trauma to muscle and less healing time as a result.
“Both of my (anatomical) hips basically froze, and I had no lateral movement,” said Clem Ferri, 66, of Peters. Damage to his left hip joint prevented him from going to construction sites managed by his contracting firm. He could not go up steps and had trouble walking.
Ferri successfully underwent left hip replacement in May, and his life changed.
“My therapists were amazed at all that I could do right after the surgery,” he said. “I left the hospital two days after the surgery.”
Doctors caution, however, that popular new techniques often come with a steep learning curve for some doctors. That can lead to technical errors that result in early failure of the replacement, Hamlin said. He listed some minimally invasive approaches, patient-specific instruments and robotic navigation as useful but not fully mastered.
No matter how cautious patients and physicians are, some redo surgeries are unavoidable, Hamlin said.
“We're working with a human body, and we're human beings performing the surgery,” he said. “We're not perfect.”
Luis Fábregas is a staff writer f or Trib Total Media. He can be rea ched at 412-320-799 8 or firstname.lastname@example.org.
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