It’s a fact—people getting knee replacements just keep getting younger and younger. The number of knee-replacement operations in folks ages 45 to 64 has nearly doubled in less than 10 years. If arthritis is hurting your knees, no matter your age, the thought of knee replacement has almost certainly crossed your mind.
If you’re in your 40s or 50s or even early 60s, though, think twice. Getting a new knee or two this young might be a mistake. That’s especially true if you want to stay active now and in your later years. Even if you really need a knee operation—and not everyone with knee arthritis does—there may be a better surgical option.
We spoke with Jack Bert, MD, a nationally recognized expert in cartilage restoration who is an orthopedic surgeon at Minnesota Bone & Joint Specialists in Woodbury. Dr. Bert recently addressed his fellow orthopedists on the topic at a medical conference sponsored by the publication Orthopedics Today. He recommends that younger candidates for knee-replacement surgery consider a more conservative treatment that’s better for an active lifestyle. It used to be more widely used but has waned in popularity—it’s called high tibial osteotomy (HTO). We’ll see why—but first, what’s with all these hurting knees in people who aren’t very old?
WHY YOUNGER KNEES ARE HURTING
One reason for the rise in osteoarthritis in middle age is that more people are active and involved in high-intensity sports, putting them at increased risk for knee injuries like tears to the meniscus (the knee cartilage that cushions the joint) or damage to the joint surface itself. These injuries, and often the surgery to repair them, are linked to an increased risk for arthritis at a young age. On the other side of the equation, arthritis is becoming more common in younger people who are obese because of the extra load on their knee joints. Being overweight by 10 pounds can put an extra 30 to 60 extra pounds of pressure on your knees with each step.
In younger people, however—and by younger, we mean up to around 60 or so years old—the arthritis is often limited to one side (compartment) of a given knee, either because that’s where the injury occurred or because of gait issues, like being bowlegged or having “knock knees” deformities, which tends to put more wear and tear on the inner or outer part of the knee. If you’re discussing surgery, your orthopedic surgeon will likely recommend a “partial knee replacement” if your arthritis is confined to just one of the compartments of your knee. But here’s why even that may be a bad choice.
“When you do a knee replacement in a young person, you’ve committed that poor patient to having two or three knee revisions (implant re-dos) in their lifetime,” says Dr. Bert. That’s because knee implants wear out in 10 to 12 years. In very active people, the lifespan is on the short end of the range. “Every time you do a revision, the success rate of the implant drops significantly,” he adds. That could leave you with painful untreatable knees in your 60s or 70s when you hopefully have many more years to go!
A MORE CONSERVATIVE APPROACH TO KNEE SURGERY
So what about the alternative—the high tibial osteotomy mentioned above? At a recent medical meeting for orthopedic surgeons, Dr. Bert recommended that surgeons perform this HTO procedure, in which a wedge of bone is cut out of the shinbone (tibia) under the healthy side of the knee. The opening is either closed or opened further, and a bone graft added to fill the space to align your leg better and take pressure off of the arthritic knee joint surface. A plate is then screwed over the repaired bone. By shifting your weight off of the damaged side of the joint, the procedure can relieve pain and improve function. Studies have also shown that by reducing the load pressure on the injured part of the knee joint, HTO allows new cartilage to grow back to some extent, providing a little more comfort and protection.
The advantages over a knee replacement are obvious. You’re preserving your own knee joint and delaying, or possibly even preventing, the start of a cycle of repeated knee replacement that may not help for your entire life. Even if you eventually need a partial or total knee replacement, you may be able to hold out long enough to take advantage of new techniques being researched that use stem cells or other biological approaches to preserve the joint. Research also shows that the success of a total knee replacement, if you do eventually need one, is just as good in people who’ve previously had an HTO as in those who go directly to knee replacement.
HTO is also a better choice if you’re a runner, play competitive tennis or are otherwise very active, Dr. Bert says, because you really can’t resume high-intensity activity at nearly the same level after having a knee replacement.
LONG-TERM GAIN, SHORT-TERM PAIN
Dr. Bert admits that HTO is a tough sell to patients. The main reason is that recovery time is longer than that for knee replacement. Patients are on crutches for six to 12 weeks, or even longer in some cases, because the bone has to heal, versus only a few days after a partial knee replacement for most healthy middle-aged people. “We’re a society that wants a quick answer to everything, so it’s a challenging discussion for a surgeon to have with a patient,” he says.
You do need to be committed to the recovery phase if you’re going to do this. The operation itself has a low rate of complications, but if you put pressure on the knee too soon, the bone may not heal well.
You may be hard-pressed to find a surgeon who does HTO, too. The main reason is that partial and total knee replacements have become so successful that there’s less interest in HTO. At the conference of orthopedic surgeons, Dr. Bert asked for a show of hands of who has performed the operation. Fewer than one in 10 of the surgeons in the room raised a hand. “It’s not being taught universally in orthopedic residency training programs, so some surgeons feel very uncomfortable doing the procedure,” says Dr. Bert.
If you’re under age 60 (or even 65), and are a candidate for a partial knee replacement, consider nonsurgical options first. Exercise may help quite a bit—see Bottom Line’s You Need Exercise—Not a Knee Replacement, and The Ultimate Knee Workout. Get physical therapy, and work with your doctor, who may prescribe injections, pain meds, knee braces and other short-term approaches to help you stay active.
If it’s really time for a knee operation, though, ask your surgeon about HTO before considering a partial or total knee replacement. Each medical case is different, so it is not the best option for everyone. But it’s worth exploring. If your doctor doesn’t do HTOs, seek a second opinion. Make sure any physician you’re considering for an HTO has done at least 30 to 40 of the procedures because there is a learning curve. You may have to head to a large medical center to find an experienced surgeon.