Old Patients, New Joints

A tale of two joint replacement surgeries:

Baukje Cohen had been accustomed, at age 76, to jogging in a park near her Manhattan apartment, playing tennis and skiing. But she developed pain in her hip, and “slowly and surely it became worse and more difficult to handle,” she said in an interview. She had to give up running and tennis.

Baukje Cohen, at a Colorado ski resort in tk, PRIOR TO? her hip replacement surgery.

Courtesy Dr. Noel CohenBaukje Cohen at a Colorado ski resort in 2005, following her hip replacement surgery.

Missing her athletic life, she opted for hip replacement surgery at NYU Hospital for Joint Diseases. After about 10 days, spent in the hospital and then at a rehab facility, “I was walking very well,” she said. “It was not terribly painful.” She returned to jogging paths, tennis courts and mountainsides — until recently, when her other hip began to trouble her. Her surgeon will try a series of injections to relieve the pain, but if they don’t work, Mrs. Cohen, now 82, has decided to undergo a second hip replacement.

Laimonias Betins, a retired construction worker in Ocean County, N.J., had a drastically different experience after two simultaneous knee replacements at age 89. “His primary care physician said he didn’t recommend it — my father had heart disease and hypertension and diabetes that put him at greater risk,” said Mr. Betins’s daughter, Ilze Earner. “So he went doctor-shopping, saw three or four surgeons until he found one willing to do it.”

She and her brother begged Mr. Betins to reconsider; he dismissed their fears. Only months later, after seeing the inaccurate information he’d provided on medical forms and after the first of many neurological exams, did his family recognize the extent to which dementia had impaired his judgment.

“He had diminished capacity to understand what his doctor was telling him,” Ms. Earner said. By that time, however, the damage had been done. “Two days after the operation, he had a stroke, and he hasn’t walked since.”

Hip and knee replacements have increased dramatically among older patients, statistics from the American Academy of Orthopaedic Surgeons show. Between 2002 and 2007, the 65- to 84-year-old population saw a 16 percent increase in hip replacements and an almost 44 percent rise in knee replacements. Among patients over 85, the increases were higher still: 21 percent for hips, 54 percent for knees.

“As the operation has evolved, there is no age at which you can’t do a joint replacement,” said Dr. Joseph Zuckerman, chairman of orthopedics at New York University and Mrs. Cohen’s surgeon. But, he cautioned, there are patients whose medical conditions make the surgery a bad bet. “A 65-year-old with two heart attacks or chronic obstructive pulmonary disease is a very bad operative risk, worse than a 90-year-old with a little high blood pressure who is otherwise healthy,” he said.

The operation itself has grown safer, in part because regional rather than general anesthesia has become the standard. “The insult to someone’s body is much less than a decade ago,” said Dr. Michael Marks, a Norwalk, Conn., orthopedic surgeon and a member of the academy’s board of counselors. “Our surgical techniques are better, our pain medication is better, and people are recovering more quickly.”

But with so many patients at older ages — most of Dr. Marks’s are well past 65 — doctors, patients and their families have to pay close attention to assessing risks, both for the surgery and the recovery. Severe arthritis pain, the most common reason for elective joint replacement, can undermine a senior’s quality of life, making it difficult to function, to enjoy activities, and to maintain social connections — but it’s not life-threatening, like a defective heart valve. So deciding whether the potential benefits outweigh the hazards can become a complex process.

Surgeons will send candidates to internists, and sometimes also to cardiologists or other specialists, to be sure they’re healthy enough for surgery. “We’re finding more cardiac disease because we’re operating on older patients,” Dr. Marks said. Heart disease, pulmonary disease, neurological disorders and poorly controlled diabetes are all problems that need to be addressed before surgery. These diagnoses might rule out joint replacement altogether.

Dementia also rises with age, so Dr. Marks has his patients meet with a nurse, a social worker and a physical therapist before embarking on joint replacement, then asks the patients to return, preferably with family members, for a final round of questions and answers before committing to surgery.

Further, conscientious doctors want to know how a patient will manage at home in the three months required on average for older people to fully recover. Sure, Medicare may send a visiting nurse or physical therapist to a patient’s home. “But who’s going to do the grocery shopping or take in the mail?” Dr. Zuckerman regularly asks. An older patient who lives alone in a house with stairs may need to hire temporary home care or to ask family members for assistance.

(A caution about so-called minimally invasive joint replacement surgery: the American Academy warns that there’s insufficient evidence that this approach, the subject of much media attention, produces quicker recoveries or better results.)

Dr. Marks also wants to be sure that patients maintain realistic expectations. After recovering from joint replacement surgery, he tells them, the great majority have no pain, or so little that they don’t need even over-the-counter pain relievers. Most don’t feel the need for canes, walkers or other assistive devices, though doctors sometimes suggest using them anyway for safety.

But, he often finds, “they think it’s fountain-of-youth surgery, that we’re turning back the clock.” In response, Dr. Marks often points out that a new hip won’t increase their muscular strength or reaction times. “Somebody who’s 80, who thinks he can be playing tennis with 60-year-olds — we tell him he should be playing doubles,” he said.

If you or your parent has had a knee or hip replaced at an older age, I hope you’ll tell the rest of us what the experience was like and what the aftermath has been. It’s a complicated equation; we probably have a lot to learn from one another.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”