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HEALTH JOURNAL            APRIL 19, 2011


Pushing Limits of New Knees
Younger Patients Choose Surgery; Some Sports Are OK, But Which Are Too                                                                    LIKE THIS COLUMNIST
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 John Jeffries, a 49-year-old money manager in Dover, Mass., had hip-resurfacing surgery in
 2008 and is now coaching his son's basketball team and long-distance cycling.

 Alex Douglas, a Wall Street software architect, had both knees replaced last year at 39 after
 years of sports injuries. He can't wait to go kite-boarding this weekend. "I've been cleared to
 have fun," he says.

                                                                Joint-replacement patients these days are
                                                                younger and more active than ever before.
                                                                More than half of all hip-replacement
                                                                surgeries performed this year are expected
                                                                to be on people under 65, with the same
                                                                percentage projected for knee replacements
                                                                by 2016. The fastest-growing group is
                                                                patients 46 to 64, according to the American
                                                                                                                           Available to WSJ.com Subs
 Hard charging baby boomers and Generation X-ers are            Academy of Orthopaedic Surgery.
 wearing out their joints at younger ages and turning to
 joint replacement surgery. But is it a quick fix? WSJ's
                                                    Many active middle-agers are wearing out
 health columnist Melinda Beck discusses with Kelsey
 Hubbard.                                           their joints with marathons, triathlons,
                                                    basketball and tennis and suffering
 osteoarthritis years earlier than previous generations. They're also determined to stay active
 for many more years and not let pain or disability make them sedentary.
                                                                                                                             Mideast Staggered
 To accommodate them, implant makers are working to build joints with longer-wearing
                                                                                                                           by Wheat Costs
 materials, and surgeons are offering more options like partial knee replacements, hip
 resurfacing and minimally invasive procedures.

 More younger people also need joint-replacement surgery due to obesity, and some
 orthopedists refer them for weight-loss surgery first to reduce complications later.
Even the most fit patients face a long period of rehabilitation after surgery and may not be
able to resume high-impact activities.

"There is, to be honest, some irrational exuberance out there," says Daniel Berry, chief of
orthopedic surgery at the Mayo Clinic in Rochester, Minn., and president of the American
Academy of Orthopedic Surgeons. "People may be overly optimistic about what joint
replacement can do for them."                                                                                  Gap CEO Tailors
                                                                                                              Urgent Revamp
One big unknown: How long will the replacement joints last? In the past, many doctors
assumed implants would wear out in about 10 or 15 years, and they urged young patients to
put off surgery as long as possible to minimize the risk of needing a costly and difficult
revision surgery—or even two. (A total knee replacement typically costs $15,000 to $22,000.
A revision can be $45,000 or more, with a higher risk of complications.)

                                                             Steven Haas, chief of the knee service at
                                                             the Hospital for Special Surgery in New York
                                                             City, says he frequently sees young patients
                                                             who are in too much pain to play with their
                                                             kids, take walks, work or enjoy traveling. "To   Recent Columns
                                                             them, the idea of being miserable in their       Helping Kids Beat Depression
                                                             50s so they might not need another surgery
                                                                                                              Solving Darwin's Medical Mystery
                                                             in their 70s doesn't make much sense," he
                                                             says.                                            Joy of Researching Health Benefits
 View Full Image
               Dominick Reuter for The Wall Street Journal
                                              Several studies of hips and knees implanted
John Jeffries, 49, had his hip resurfaced in 2008.
                                              in patients long ago have found that 85% to                     About Melinda Beck
                                              90% are still functioning well after 20 years.
                                                                                                              As The Wall Street Journal's new Health
Advances in wear-resistant materials may make implants being used today last even longer.                     Beck is returning to her love of reporting
                                                                                                              the editor of Marketplace, the paper's se
For example, many hips and knees use a combination of metal and polyethylene parts, and
                                                                                                              the Journal in 1996 as deputy Marketpla
continuous motion can wear away small polyethylene particles. Scientists have found that                      writer and editor at Newsweek magazine
irradiating the polyethylene removes free oxygen radicals that contribute to degradation, so                  dozen cover stories on topics ranging fro
the polyethylene components are expected to wear much longer.                                                 bombing to the O.J. Simpson trial to liqu
                                                                                                              long-term care. She's always found cove
"Metal-on-metal" hip parts were supposed to wear better than plastic, but their use is                        particularly exciting, as evidenced by aw
declining due to concerns that they can release metal ions into patients' bloodstreams and                    stories from the Arthritis Foundation, the
cause soft-tissue damage. Hip implants made with "ceramic-on-ceramic" components have a                       Society on Aging, the American College
disconcerting tendency to squeak.                                                                             the National Institute of Health Care Man
                                                                                                              College of Health Care Administrators. M
Last year, one manufacturer, Smith & Nephew, won clearance from the Food and Drug                             University and lives in New York City wi
Administration to market its latest technology as a "30-year knee" based on tests mimicking                   daughters.
30 years of wear.
                                                                                                              More in Health
Still, there are no long-term data on how any of the latest implants will fare in actual patients.
                                                                                                              An Electrical Jolt for Paralysis Rese
"We have to install them and see," says Robert Namba, an orthopedic surgeon with Kaiser
                                                                                                              Glaxo, Human Genome Sciences W
Permanente in Irvine, Calif.                                                                                  Drug
The biggest variable is patients themselves. As a rule, the more active they are, the faster                  Christie Seeks Tighter Limits on Me
their joints will wear out, loosen or require revision.                                                       Health Insurance Hikes Face Scruti

Most orthopedic surgeons encourage patients with hip and knee implants to walk, swim and                      Unintended Pregnancies Cost Gover
cycle as much as possible. Golf and doubles tennis are acceptable. But jogging, running,
jumping and singles tennis are out. "If your goal is a 30-year knee, you need to avoid high-
                                                                                                              Most Popular
impact sports," says John Wright, an orthopedic surgeon at Brigham and Women's Hospital
                                                                                                              Read     Emailed     Video     Commente
in Boston.
That said, some patients are determined to push the envelope, and some doctors give their            1.   Jewish Donors Warn O
blessing.
                                                                                                     2. Obama's Israel Surprise
"If you have a brand new sports car and leave it in the garage, it will last forever and you
                                                                                                     3. Circumcision Ban Goes on S.
won't have any fun," says Thomas Schmalzried, an orthopedic surgeon at St. Vincent
Medical Center in Los Angeles. A former college basketball player, Dr. Schmalzried has               4. Opinion: Simpson and Sherm
patients who play competitive sports and run marathons with artificial joints. "I know that the           Free Speech Problem
technology is capable of this level of athletic function. What I don't know—what nobody
                                                                                                     5. LinkedIn IPO Soars, Feeding
knows—is where the lines are for the average patient."

Some doctors compromise and tell patients they can ski and surf if they were good at it              Most Read Articles Feed

before surgery, (and as long as they avoid skiing moguls).

"There's a happy medium, and it's not necessarily the same for every patient," says Dr. Berry.
"One might say, 'I'm willing to take a risk because that activity is important to me,' and another
might not."

Personal quality of life issues are also important in deciding whether—and when—a patient is
ready for joint-replacement surgery.

"It got to the point where I couldn't get on my motorcycle anymore," says Paul Canter, a
picture framer from Los Angeles who had a double hip replacement at 63 last year.

Chris Schubert was kicked by a horse when she was 25, then suffered a near-fatal staph
infection from a cortisone shot. Mounting pain and inflammation over the next 14 years forced
her to quit recreational horseback riding, interrupted her sleep and interfered with her work as
a building contractor. She had minimally invasive knee replacement surgery with Dr. Haas
last year, at age 38, and her pain and limitations are gone. "I thought my path in life was set
and I'd just be miserable," she says. "I never imagined my life could be this wonderful."

Patients say that regaining function after surgery requires enormous mental and physical
effort. "Pre-hab"—building up strength before the surgery—is just as important as re-hab
afterward, they say.

"I was in the best shape of my life before I went in for the surgery," says Mr. Jeffries, the
money manager, who trained twice a day for six months before his hip-resurfacing surgery in
2008.

And staying as fit and strong as possible is also critical to joint preservation. "I made up my
mind. If I was going to go through all this surgery and rehab, I wanted to make these hips last
as long as they possibly can," says Carol Espel, 55, an executive of Equinox Fitness who
damaged both hips dancing professionally and teaching fitness for years. Now she takes
classes in cycling, yoga, Pilates and strength training weekly. "No impact ever," she says.

Mark Liszt, the owner of a wholesale meat company in Los Angeles who had double knee
replacement surgery in 2008 at the age of 60, says the first five months of rehab were very
painful and discouraging. "You're fighting to get range of motion back. You're fighting to break
adhesions. You're fighting depression and you're wondering, 'Is an era of your life over?' "
But he worked through the pain and was back playing basketball a few months later.

Now 63, he still plays basketball twice a week. The surgery, he says, "gave me my life back. I
can pivot. I can do a hook shot. And I am completely pain free."

Write to Melinda Beck at HealthJournal@wsj.com
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