Have you stopped playing golf because your knee hurts too much…or find yourself sitting out because of hip pain when the grandkids come by to play? Many people live with joint pain because they think their age means they can’t have any type of joint-replacement surgery. And that’s understandable—historically, the average age for these procedures has been in the mid-to-upper 60s.
But even as we age, we still want to walk, run, bike and otherwise stay active for as long as possible. Nonsurgical interventions, including physical therapy (PT), should be the first line of treatment for the majority of chronic joint pain conditions and may be the best solution for joint pain.
But if additional treatment is needed, advancements in technology that limit the time under anesthesia…reduce infection risk…and get patients on their feet mere hours after surgery make it possible even for people in their late 70s, 80s and 90s to thrive after knee- or hip-replacement surgery. In fact, in May 2022, a 102-year-old man in India underwent a successful partial hip replacement following a fracture that resulted from a fall. The surgery took 20 minutes, and he was back on his feet within just 24 hours.
Why Replacement Surgery?
Joints deteriorate for several reasons…
Arthritis is the most common reason for a knee or hip replacement—specifically osteoarthritis, painful wearing out of joint cartilage that occurs with age. According to a 2019 study by researchers at Peking University, Capital Medical University in Beijing and Harvard Medical School, the number of global cases of osteoarthritis increased by 113% between 1990 and 2019, from about 248 million cases worldwide to 529 million cases, respectively.
Obesity, an epidemic in the US, is commonly associated with osteoarthritis. Excess weight puts more stress on joints, which tends to accelerate the wear-and-tear process that eventually leads to inflammation of that joint. And obesity itself is pro-inflammatory, so it can worsen the inflammation related to osteoarthritis. Lastly, joint pain often causes people to be less active, which can increase risk for obesity.
Injury. Older adults often need hip replacement following a fall that results in a hip fracture. One out of every four US adults age 65+ will suffer a fall, with more than 300,000 of them being hospitalized for hip fractures, per the Centers for Disease Control and Prevention.
Health Trumps Age
For many older adults, knee and hip replacements can be safely performed regardless of their age. In fact, it’s less about a person’s chronologic age (the number of years he/she has been alive) and more about his physiologic age (how well his body functions thanks to lifestyle choices, genetics and existing diseases—also called comorbidities). A patient can be 55 years old and very fragile, with heart disease, diabetes and the beginnings of osteoporosis…or 85 years old and quite robust thanks to a lifetime of physical activity, healthy eating and fortunate genes. The 55-year-old patient would be a less ideal candidate for a joint replacement given his comorbidities, despite his relative youth, while the 85-year-old may have a lower risk for complications given her good health.
Regardless of chronological age, patients with no major comorbidities and who are physically active should have the stamina and health required to recover from a knee or hip replacement if surgery is required. They even may be able to go home the day of surgery (rather than going to a rehabilitation facility for weeks) and usually can recover with the help of in-home virtual or outpatient PT specifically designed for people recovering from surgery.
Advancements that made this possible…
Alternatives to full knee or hip replacements. Traditional knee replacement, called total knee arthroplasty (TKA), involves replacing three different components, or compartments, of the knee with metal and plastic parts. If a patient has arthritis in only one of these compartments, he may be a candidate for a partial knee replacement, which means that only the diseased area is replaced. This makes for an easier recovery…helps maintain the knee’s range of motion…and tends to result in less blood loss.
Similarly, some patients may be candidates for a partial hip replacement, called a hemiarthroplasty, during which the ball part of the hip joint is replaced but not the socket in which the ball sits. This is a shorter, less invasive operation than a total hip arthroplasty (THA), in which both the ball and socket are replaced.
Robotic joint replacement. No, a robot isn’t calling the shots during this surgery, but this cutting-edge technology does involve robotic equipment guiding your doctor. With the help of 3-D imaging, your doctor can “see” your anatomy and program a to-the-millimeter procedure path, meaning that your joint replacement can be positioned with more precision. Incisions are smaller, and recovery often is faster.
Regional anesthesia instead of general anesthesia. General anesthesia, during which patients “go to sleep” and need medical equipment to breathe for them, has historically been used during knee and hip replacements, but it is risky for older adults. Heart arrhythmias—quickened, slowed or irregular heart rates—can occur during and after surgery using general anesthesia, and that risk increases with the patient’s chronological age. Patients also can develop pneumonia or a collapse of the air spaces in the lungs due to general anesthesia. Additionally, there is a risk for post-operative dementia and post-operative delirium. Among patients age 65 years and older, up to 65% develop post-op delirium and 10% experience long-term cognitive decline after noncardiac surgery, according to a 2019 study in British Journal of Anaesthesiology. Most often, these cognitive effects wear off, but they can be permanent…and they hit patients with preexisting cognitive decline harder.
To avoid these complications, more doctors are using regional anesthesia, such as spinals or nerve blocks, instead of general anesthesia. The patient is mildly sedated and breathing independently, so there aren’t the same negative effects on the brain. Regional anesthesia also has been associated with less postoperative pain, shorter hospital stays and lower risk for blood clots and infections.
Boost Your Odds
Because of these improvements, there are no strict upper age limits for joint replacement. But you can improve your odds of success even further by asking your doctor what you can do before surgery to speed your recovery. Examples…
Pre-op PT (also called pre-hab) can build strength and endurance, leaving you optimized to handle the stress of surgery and even give you a head start on postoperative rehabilitation. Today’s virtual PT options allow people to do exercises in the comfort of their home.
Meet with a registered dietitian and formulate a well-rounded nutrition plan for the days and weeks prior to surgery.
Minimize narcotics. Ask your doctor to minimize the use of narcotic pain medications—they can cause confusion, nausea, slowed breathing and constipation regardless of age. While it’s often necessary to take these medications for some period after major surgery, the doses and duration should be as low and short as possible. Also: A long-lasting local anesthetic allows patients to return home sooner and more comfortably.
Caution: Patients ages 65 years and older who use benzodiazepines such as Xanax (alprazolam) and Klonopin (clonazepam)…first-generation antihistamines such as Benadryl (diphenhydramine)…and antipsychotics such as Seroquel (quetiapine) and Abilify (aripiprazole) are at increased risk for cognitive changes after anesthesia and should ask their doctors about possibly discontinuing use until after the procedure. (Never stop any medications without first consulting your doctor.)
Who shouldn’t Have Replacement Surgery?
Certain individuals are at a higher risk for complications, including people with poorly controlled diabetes, smokers and individuals with obesity.
Patients who cannot or choose not to have joint-replacement surgery can explore alternatives, including steroid injections and PT. Moving soon after surgery is critical to reduce the risk for blood clots, infections and pneumonia, so individuals with limited mobility from issues in addition to the arthritic knee or hip, such as balance problems or obesity, may prefer to explore these alternatives.
Because many comorbidities get worse with age, older patients should ask their physicians about possible concerns…consider their own personal risk tolerance…and make the decision together. The point of these surgeries is to relieve pain and get patients back to doing the things they love—gardening, traveling, playing tennis and golf, running after their grandkids—as well as functioning independently on a day-to-day basis.
