Total hip replacements are on the rise in the United States, especially among adults in early middle age. And surgeons say people even in their 20s and 30s are having these procedures more often. But because younger patients live longer and play harder after joint replacement, some extra consideration goes into the surgical decision.
Playing Through Pain
Rachael Remick, 24, works full-time on the family farm in southeast Iowa, growing row crops such as soybeans and corn. Athletic, strong and conditioned, Remick keeps up with her father and brother, whether she’s driving a tractor to pull a cultivator and prepare the ground for planting, changing hydraulic lines and tires on large farm implements, pulling loaded wagons to the grain elevator, baling and hauling hay or cutting down trees with a chainsaw.
You’d never think so to see her in action, but two years ago, Remick had a total right hip replacement.
Before that, her hip hurt throughout high school and beyond graduation. Even so, Remick jumped into college basketball. “You kind of get into this mentality that you play through pain and just deal with it,” she says. Nor did pain keep her from working on the farm: “I’m pretty strong-willed, and so I just did what I needed to do.”
But Remick was having a lot of pain that especially affected her at night. “I was getting two to three hours of sleep,” she says. Finally, she went to an Iowa City doctor who referred her to orthopedic surgeon John Clohisy, director of the Center for Adolescent and Young Hip Disorders in St. Louis.
Younger Patients
In February, the U.S. National Center for Health Statistics analyzed hospital data on total hip replacements from 2000 to 2010. The number of surgeries more than doubled to about 310,000 at decade’s end. While procedures rose by 92 percent in people age 75 and older, they increased by 205 percent in people ages 45 to 54. (The researchers only focused on patients 45 and older, as they account for the bulk of procedures.)
“In general, total hip arthroplasty is being performed in younger patients,” Clohisy says. The largest group is patients between 40 and 60, he says, “and then you have the very young patient. And we’re doing more hip replacements on those patients than we have in the past.”
These young adults or even teens tend to have had childhood hip problems for which surgery didn’t help, Clohisy says. “Or they’ve had very severe problems as children or adolescents that aren’t treatable.” Over time, he adds, they can develop hip osteoarthritis — the kind known as “wear-and-tear” arthritis.
“For a teenager, a bad hip can be very disabling and really restrict their quality of life,” he says. Constant pain and reduced hip function mean they can’t even take part in social activities like walking around the mall with friends.
Hip-Preserving Option
The decision to do a total hip replacement on a young person is not made lightly. If possible, surgeons opt for alternative procedures to preserve the hip joint instead.
For instance, orthopedic surgeons may suggest a technique called the Bernese periacetabular osteotomy. Developed in Switzerland in the 1980s, it involves cutting the bones around the hip socket and repositioning them. The Bernese PAO can be a good choice for young patients with certain hip conditions, Clohisy says. One is hip dysplasia, or instability of the hip. Another is hip impingement, which involves abnormal contact or abutment between the socket and femur. Candidates for hip-preservation procedures may be showing signs of cartilage tears and possibly early arthritis.
Hip-preservation procedures tend to have “a little bit longer” recovery period than joint replacements, Clohisy says — probably a difference of one to two months as the bone heals. Patients start on crutches to help them bear weight. In contrast, after joint replacement, patients can put full weight on their hip right away.
But hip preservation offers significant advantages. “If it’s a healthy natural hip joint and we can preserve and reconstruct the hip — it’s not going to dislocated; it’s not going to get infected,” he says, referring to potential complications of total hip replacement. With successful hip reconstruction, he adds, patients can enjoy “very high activity levels.”
A major issue with total hip replacements is they don’t last forever. “Modern implants are now looking excellent at the 15-year mark,” Clohisy says. “So to assume that we get to 20 years is pretty reasonable.”
Young Adult — Advanced Arthritis
Sometimes the surgical choice is clear-cut. “The 18-year-old patient with a dysplasia and no arthritis is an excellent candidate for PAO,” he says. “A 50-year-old with hip dysplasia and advanced established or advanced arthritis — that hip needs to be treated with a total hip [replacement]. It’s just ready for that.”
With “markedly improved” materials now used in implants and refined surgical techniques, Clohisy says, “a surgeon’s reluctance to do a hip replacement on someone in their 30s or 40s is not as strong as it used to be.” They’re very successful operations, he says, so “it’s an area where a lot of patients are helped tremendously by contemporary hip replacement procedures.”
As Remick was in her early 20s, the reconstructive surgery option seemed likely at first. But her exam results changed the discussion. “I had no cartilage in the joint, and I was full of arthritis,” she says. “They think I fell and injured or bruised my hip when I was 3 to 5 years old.” She was told reconstructive surgery would only last a few years before pain and other problems came back.
‘Activity Restrictions’
In September 2013, at age 22, Remick had a total hip replacement. With four weeks of physical therapy to make sure her muscles healed, including exercises at home, her recovery went very well. “It took six weeks, max,” she says. Now she’s having “no pain — none whatsoever.” She has more stiffness in her hip than she used to, and side-to-side movements feel different, but she otherwise moves freely.
Clohisy notes that for young, very active patients, “even if they get a great result, most surgeons have a tendency to try and moderate their activities a bit” after hip replacement. For instance, by avoiding contact sports.
The barrel racing Remick still does at local horse shows doesn’t exactly count as a contact sport, nor do the two volleyball teams she plays on, the slow-pitch softball and pick-up basketball games she joins, along with coaching a fifth- and sixth-grade girls’ basketball team. Not to mention all the heavy lifting on the farm.
Remick has no regrets about her surgery. “For me, there was no downside — it’s been fantastic. I would do it 100 times over,” she says. At her age, she likely will need total hip replacement another two or three times down the road. “That’s OK,” she says, “as long as I can move and get around and still enjoy what I like to do.”
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Young and Hip: Replacements Rising for Younger Adults originally appeared on usnews.com
