Surgery bet­ter, but arthri­tis bur­den grows

Suc­cess rates for hip and knee re­place­ments are ris­ing, but so is arthri­tis, writes Lyn­nette Hoff­man

The Weekend Australian - Travel - - Health -

BOB Saniga hasn’t ex­actly gone easy on his body over the years. A botched at­tempt to bet­ter his own Aus­tralasian race­boat­ing record saw him hurled from a boat at more than 300 km/h, smash­ing his hip on the deck be­fore bounc­ing along the wa­ter for hun­dreds of me­tres. Some years later a ski ac­ci­dent pounded that same hip once again.

He didn’t let ei­ther in­ci­dent stop his ac­tive lifestyle, which in­cluded horse­back rid­ing, swim­ming and ski­ing, but it all started to catch up with him in his mid-50s, when car trips be­came ‘‘ ex­cru­ci­at­ing’’ and dis­mount­ing from his horse was painful.

So 12 years ago, at the age of 57, Saniga had his left hip re­placed. For the first two years af­ter­wards, he was much hap­pier, but then a con­stant nag­ging ache emerged, which lasted for four years — un­til a doc­tor no­ticed Saniga’s pelvis was tilted. His left leg was 10mm shorter than his right leg.

When doc­tors op­er­ated they found part of the hip pros­the­sis had bro­ken, send­ing a peg shoot­ing down into his fe­mur with each step he took. The years of over­com­pen­sat­ing meant he even­tu­ally needed his right hip re­placed as well.

Still, Saniga says the re­place­ments have been ‘‘ a god­send’’.

‘‘ If I do ac­tive phys­i­cal work like us­ing a chain­saw or climb­ing up and down on the trac­tor I get a lit­tle bit of sore­ness, but the next morn­ing there’s noth­ing,’’ he says. ‘‘ A per­son (with a hip re­place­ment) who doesn’t ride horses or drive a sports car ev­ery once in a while, or that sort of thing, prob­a­bly doesn’t have any prob­lems at all!’’

Joint re­place­ment surgery is still not per­fect, but it has come a long way even since Saniga first had it done in the mid-1990s.

New fig­ures re­leased from the Aus­tralian Or­thopaedic As­so­ci­a­tion’s Na­tional Joint Re­place­ment Reg­istry show that hip and knee re­place­ments have sig­nif­i­cantly in­creased since the reg­is­ter be­gan in 1999.

In ad­di­tion, the num­ber of sub­se­quent op­er­a­tions on the same joint, ‘‘ re­vi­sions’’ (a marker for the rate of joint re­place­ments that re­sult in con­tin­u­ing prob­lems) has de­clined.

Last year more than 64,000 Aus­tralians had hip or knee re­place­ments — dou­ble the num­ber from eight years ago. The num­bers have in­creased by an av­er­age of about 7 per cent each year.

A re­port re­leased by Arthri­tis Aus­tralia and Ac­cess Eco­nomics in Au­gust found that arthri­tis, by far the most com­mon fac­tor in need­ing a hip or knee re­place­ment, is sky­rock­et­ing. The num­ber of peo­ple with arthri­tis has in­creased by 700,000 in just six years and is now edg­ing to­ward 4 mil­lion.

There’s a com­bi­na­tion of fac­tors at play in the bur­geon­ing num­bers of joint re­place­ment surgery, says John Hart, an or­thopaedic sur­geon at Melbourne’s Al­fred Hospi­tal and an as­so­ci­ate pro­fes­sor at Monash Univer­sity.

Longer life­spans mean more peo­ple are reach­ing more ad­vanced stages of the de­gen­er­a­tive dis­ease, when al­ter­na­tive treat­ments are less ef­fec­tive against the pain. Our thick­en­ing waist­lines are also in­creas­ing the toll. Ath­letes are play­ing sports more vig­or­ously and at a higher in­ten­sity than they once did, lead­ing to an in­crease in younger pa­tients. And there’s an in­creas­ing aware­ness of treat­ment op­tions, he says.

Mean­while, ad­vances in gen­eral medicine and anaes­thet­ics have made joint re­place­ment surgery avail­able to peo­ple who would have been turned away a decade or two ago, says doc­tor John Bat­ten, chair­man of the Na­tional Joint Re­place­ment Reg­istry.

‘‘ It’s still a last re­sort, but we’re able to of­fer it to peo­ple who would not oth­er­wise have been con­sid­ered,’’ he says.

Once upon a time it would have been too dan­ger­ous to per­form the op­er­a­tion on pa­tients with se­vere heart or kid­ney dis­ease, but im­prove­ments in treat­ments and tech­niques mean that’s no longer the case. More peo­ple in their 80s and 90s are now healthy and well enough to ben­e­fit from the op­er­a­tion. And tech­nol­ogy that makes hip re­place­ments more durable has opened it up to younger pa­tients as well, he says.

De­spite neg­a­tive pub­lic­ity fol­low­ing a 2001 re­call of pros­thetic hips, doc­tors say the surgery is safer and more re­li­able now than ever. The longer you have a hip or knee re­place­ment, the more likely it is that you will need fur­ther surgery. In 1998, 14.6 per cent of hip re­place­ment surg­eries and 10 per cent of knee re­place­ment surg­eries were re­vi­sions.

Those fig­ures have fallen slowly but steadily. Last year 12.4 per cent of all hip re­place­ment surg­eries and 8.1 per cent of knee re­place­ment surg­eries were re­vi­sions. Over­all there were 641 fewer knee re­vi­sions and 670 fewer hip re­vi­sions — sav­ing an es­ti­mated $33 mil­lion in op­er­at­ing costs.

While an ini­tial joint re­place­ment surgery costs an av­er­age of be­tween $12,000 and $15,000, re­vi­sions are con­sid­er­ably more ex­pen­sive, cost­ing an av­er­age of $25,000 to $30,000, Bat­ten says.

‘‘ Re­vi­sion op­er­a­tions are big­ger, more com­plex and more dan­ger­ous op­er­a­tions. They need more ex­pen­sive com­po­nents. The de­vice has al­ready failed, so you’ve got to do a lot more to get it go­ing,’’ he says.

Hart says im­prove­ments in the de­sign of pros­the­ses mean the surgery is now more suit­able for younger pa­tients who will be more de­mand­ing and ac­tive, though they are still likely to wear the hip out faster than some­one who is less ac­tive.

‘‘ New ma­te­ri­als used to make the pros­the­sis have more cross-link of fi­bre so they are more re­sis­tant to wear,’’ Hart says. ‘‘ The head size of the pros­the­sis is now big­ger as well, which makes the joints more stable and dis­lo­ca­tions less com­mon.’’

Mean­while, the op­er­a­tions them­selves are also be­com­ing more ef­fi­cient and less in­va­sive. ‘‘ The changes also al­low us to approach the surgery from the back of the joint, where tis­sues are more soft and com­pli­ant — so there is less soft tis­sue dam­age and it al­lows the pa­tient to re­cover more quickly.’’

He and Bat­ten say the im­prove­ments have trans­lated to a drop in both length of surgery and the amount of time pa­tients spend in hospi­tal. ‘‘ Ten years ago the av­er­age hip re­place­ment re­quired 10 days in hospi­tal and a two-hour surgery. Now the surgery takes about an hour and you will be home in five days or less,’’ Bat­ten says.

But de­spite the im­prove­ments, com­pli­ca­tions still oc­cur. In­fec­tion is rare, but oc­curs in up to 1 per cent of cases. Deep vein throm­bo­sis, clots in the veins in the limbs, can be a prob­lem, and dis­lo­ca­tions, loos­en­ing and gen­eral wear-and-tear lead to pa­tients need­ing re­vi­sions.

In fact, Hart says that the trend to­ward de­clin­ing re­vi­sion rates will prob­a­bly re­verse again in the fu­ture.

‘‘ As more hips and knees are be­ing re­placed, we will likely see more re­vi­sions. We’re be­ing chal­lenged by the num­ber of younger peo­ple who are need­ing re­place­ments and are putting more de­mand on the pros­the­sis and wear­ing it out more quickly — and they live longer,’’ he says.

‘‘ The prob­lem of obe­sity is also grow­ing, and ex­tra weight puts more stress on the joints. Peo­ple who are mor­bidly obese have higher re­vi­sion rates and more soft tis­sues com­pli­ca­tions be­cause of in­creased load, and they don’t do as well.’’

The fed­eral Gov­ern­ment has asked the reg­istry to ex­pand its area of in­ter­est to in­clude re­place­ments af­fect­ing the shoul­der, el­bow, wrist and spinal discs.

The widen­ing of the reg­istry’s scope, due to take ef­fect later this year, will al­low suc­cess rates in th­ese ar­eas also to be tracked, yield­ing data to im­prove suc­cess rates fur­ther.

Pic­ture: David Crosling

Bro­ken: Bob Saniga with his first ar­ti­fi­cial hip joint, which failed. Re­vi­sion surgery was needed

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