IS AN INCREASE IN THE YOUNGER POPULATION FOR JOINT REPLACEMENT LEADING TO REDUCED PATIENT SATISFACTION RATES?
Now more than ever, patients under the age of 55 are getting total joint arthroplasty (TJA). The rate of primary total hip arthroplasties (THAs) increased from 52 to 115 per 100,000 people in the population aged 45 to 54 between the years 2000 and 2014, a 2.2-fold increase, while the rate of primary total knee arthroplasties (TKAs) increased from 67 to 168 per 100,000 people, also a 2.2-fold increase (a 2.5-fold increase). By 2030, 107,700 total hip replacements (THRs) and 158,600 total knee replacements (TKRs) are projected to be performed on patients in this age group.
Surprisingly, the increased prevalence of the procedure in younger patients has led to decreased scores and higher revision rates. A review of 63,158 patients who underwent THA and 54,276 patients who underwent TKA revealed a revision rate of only 5% among those who underwent surgery at age >70, compared to up to 15% for women and 35% for men who underwent TKA in their early 50s (50–54 years)1.
This startling observation has led many researchers to ascertain a cause, and one of the major reasons has been the increased expectations post-surgery. Younger patients typically have more active lifestyles and place greater demands on their joints, and they may anticipate returning to these activities after surgery. Additionally, younger patients may have greater expectations for the cosmetic outcome of surgery. Moreover, younger patients may have greater expectations for the implant’s durability and the surgery. They may anticipate that the implant will last several years, allowing them to maintain an active lifestyle and avoid additional surgeries.
Let us first discuss the higher expectations regarding returning to sports and high-impact exercises. When Sir John Charnley considered his invention, he concluded that it could last 30 years, but not if the patient played football. Although their surgeons’ recommendations may influence them, postoperative patients are generally free to engage in whatever activities they choose. What patients achieve in intensity and duration of activity frequently differs from what they report and are advised to perform. A mismatch between expectations and outcome can contribute to the dissatisfaction of 15% of patients, despite good functional scores, with their outcome2.
One of the first steps is to counsel patients regarding the literature that reports participation in sporting activity following joint arthroplasty is common and is principally determined by the preoperative patient activity levels, body mass index, and patient age3. Similarly, it has been shown that increasing athletic activity has not been linked to an earlier failure of hip implants. Still, only a handful of studies report patient outcomes after ten years. Patients under 40 years have shown remarkable survival rates after receiving implants like the Birmingham hip resurfacing (Smith & Nephew, Warwick, UK) and THAs like the Exeter (Stryker, Newbury, UK)4.
After the procedure and gait, the cosmesis has been near normal, and most patients, especially older individuals, are enjoying a near-normal life.
This brings us to the discussion of the choice of implants, their longevity, and various surgical skills that can be modified to reduce revision surgeries.
Bone-saving hip surgery is superior in highly functioning athletes, with gait analysis reporting a return to nearly normal patterns5. Differential benefits at the high-functioning end of activity are reported in early data on bicompartmental knee arthroplasties performed with patient-specific instruments or robotic assistance. Also, compared to traditional manual total hip arthroplasty, robotic arm-assisted THA has been shown to have greater precision in positioning the acetabular component, restoring the native center of rotation, and preserving the combined offset6.
Regarding implants, the newer ones in the market are wear resistant. A study published in 2021 inferred that implant-related failure was ranked third among the risk factors associated with return to sports after hip replacement. These results shift away from the previous assumption that high-activity levels seen in younger, active patients would impact long-term wear-related implant survivorship and may reflect the improvement in implants7.
As hip and knee replacement implants get better, joint arthroplasty surgeons are becoming more open to returning to sports after hip replacement. At the same time, there isn’t much evidence about the real limits of these implants because there haven’t been any in-vivo studies of biomechanical load-bearing for 20–30 years. In turn, the surgeons who took part in our survey and the current research have only reported a few sports-related problems after THA, which adds to the idea that improved implants are safe. At the same time, surgeons and patient surveys show that patients don’t put much weight on their implants. Because of these things, people might get the wrong idea about what implants can and can’t do. Even though there are a lot of implants, materials, and surgical techniques available, there are no guidelines or recommendations for evaluating a patient before surgery, making surgical decisions, and talking to patients with high return to sports expectations.
However, the literature supports the notion that patients could be encouraged to be more active because the problems seen with returning to sports have not drastically affected their quality of life. Weighing the risk and benefits shows that a return to sports and an active approach should be preferred.
Kinomatic Custom Surgery offers a strong probability of returning to similar or greater levels of activity post-operatively due to the highly custom nature of the procedure. High-impact activities always come with a greater risk of injury and should be thought of carefully before participating.