Replace Joints Earlier, Study Suggests

[Guest guest]

Replace Joints Earlier, Study Suggests

More Benefit When Hip and Knee Surgery Done Sooner Than Usual

Dec. 5, 2002 -- Joint replacement surgery for knees and hips damaged by

arthritis is often delayed -- reserved as a last-ditch effort for patients

with the most pain and least movement. But a new study suggests that getting

the operation before it's " really " needed may yield longer-lasting benefits.

Researchers from the U.S. and Canada report in the December issue of

Arthritis & Rheumatism that patients fare best when they get the surgery in

the early stages of osteoarthritis -- before pain reaches the severe levels

at which it is now usually performed.

" The traditional teaching of physicians, and traditional understanding

conveyed to patients, is that replacing a joint is a procedure of last

resort. You want to hold back and use it as your trump card when all else

fails -- and that implies waiting, " says study researcher N. Katz,

MD, of Harvard Medical School.

" But what we found is when you wait longer, so that patients are more

disabled, the outcome is worse. In fact, they may improve a little more

immediately after surgery because there is more room for improvement. But

they don't catch up in their ease of movement and quality of life compared

to their counterparts who were operated on at an earlier stage. "

In his study, 165 people with osteoarthritis bad enough to need joint

replacement surgery were divided into two groups prior to surgery -- those

able to still go about their day and those unable to maintain their normal

lives due to arthritis pain.

While all enjoyed similar relief in the first six months after surgery,

after two years, those with low functioning prior to surgery were five times

more likely to need assistance moving around, report the researchers.

" What this suggests is that waiting to have the surgery, if you need it, is

really going to cost you, " Katz tells WebMD. " If you wait until you have

trouble with basic activities like moving room-to-room, your outcome may be

worse than if you get your joint replaced when you begin to notice trouble

moving in recreational activities or moving about the community. "

Though hip and knee replacements are both highly popular and successful

procedures -- bringing relief to more than 90% of the 435,000 Americans who

received them each year, says the American Academy of Orthopaedic Surgeons

-- they are often done only when patients are severely disabled.

" The timing of when to do this surgery is critically important, but to my

knowledge, there are no clear guidelines on exactly when it should be

performed, " says Klippel, MD, medical director for the Arthritis

Foundation. " But often, both doctors and patients say, 'Let's wait and see

what happens.' Often, medical management and physical therapy can get pain

under control, so the arthritis doesn't progress, or patients try lifestyle

changes to improve their condition. "

But the problem with delaying surgery: " When it is finally done, it can be

more complicated and the rehabilitation process can be harder, " he says.

" Patients may have changed their [way of walking] or lost muscle mass from

avoiding using the inflamed joint. Or they may have additional damage to the

bone. "

So what's the delay in getting the procedure? Actually, Katz says there's a

lot of research into the reasons -- but no firm answers.

" Part is misinformation on the risks and benefits of the procedure; there is

a 1% or less [death] rate, and while that is very good, it's enough to give

anybody pause. Part is a failure of primary care doctors to refer patients

to see surgeons. Part is patients not bothering talking to doctors, and if

their disability problem never gets past the dining room table, they never

get surgery. But we do know that women wait longer than men, and that

minorities wait longer than whites. "

" If you look at advances in arthritis treatment, joint replacement of hip

and knee would have to be regarded as one of the most important that we've

seen in our lifetime, " says Klippel. " The surgery has been perfected. The

actual joint replacement parts have been perfected. And in almost all

patients, it brings significant benefit. "