Kobe Bryant: Not Your Typical Knee Injury

Written by admin on January 28, 2014 – 1:11 pm -

As a result of his most recent bite from the injury bug, NBA superstar Kobe Bryant is expected to miss six weeks after sustaining a lateral tibial plateau fracture on December 19th. If you’ve never heard of this type of injury, you are not alone. Tibial plateau fractures are not among the most common injuries in sport.

The tibia is the shinbone that runs the length of the lower leg and is part of both the ankle joint and the knee joint. The tibial plateau is the top of the bone that flares out and widens to create a weight-bearing “seat.” There are two portions, one on the inner (medial) portion of the knee and one on the outside (lateral) aspect. There are many different types of tibial plateau fractures, but the main differentiating factor that determines treatment is the alignment of the fragments. In a displaced fracture, the bone is broken in two or more places and the edges are not lined up properly.

The most common mechanisms of injury are hyperextension of the knee and direct contact (say from a helmet in football, or in a car accident involving a pedestrian which has given this injury the nickname of “bumper fracture”). Replays of Kobe’s incident confirm his to be a non-contact injury. He plants and hyperextends on the soon-to-be-injured leg, which then buckles.
The injury results when the femur and tibia come into forceful contact with one, sometimes resulting in a bone bruise or, as in this case, a fracture. Tibial plateau fractures often result in acute swelling, stiffness, deformity, and inability to bear weight on the extremity. X-rays, CT scans, or MRI are used to diagnose this injury.

Often, the treatment for this type of injury is a surgical procedure which brings the edges of the fracture into close approximation and uses surgical screws and plates to hold them in place; a procedure known as open reduction and internal fixation. Smaller fractures that are not displaced often respond to conservative treatment of immobilization and non-weight-bearing on the affected leg. Kobe’s fracture is believed to be relatively minor and so his recovery spectrum is 6 weeks. More severe or complex injuries (such as those with vascular or nerve damage) or larger fractures require much longer recovery. In addition, tibial plateau fractures are often associated with injuries to the meniscus or ligaments in the knee. These associated injuries require additional treatments and rehabilitation. Fortunately for Kobe and the Lakers, this injury is (by all reports) relatively mild and with a majority of the regular season still ahead, Kobe has a chance to return and contribute meaningfully to the Lakers’ season.

Dr. Mark Galland is a Board Certified Orthopaedic Surgeon and adjunct Clinical Professor, specializing in sports medicine, practicing in Wake Forest and Raleigh. He serves as team physician and Orthopaedic consultant to the Carolina Mudcats, High-A Affiliate of the Cleveland Indians of Major League Baseball, as well as several area high schools and colleges. Dr. Galland can be reached at (919) 562-9410 or by visiting www.orthonc.com or www.drmarkgalland.com, or on twitter @drmarkgalland.

Alex Vitek is a nationally Certified, state Licensed Athletic Trainer and post-graduate Resident in training at The Galland Orthopaedics and Sports Medicine Athletic Training Residency– a 12 month immersional program allowing ATCs to maintain and hone clinical skills while developing those talents necessary to be effective in the clinical setting as an ATC/physician extender. Find out more at www.atcfellowship.com



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Dr. Mark Galland Discusses “New” Knee Ligament

Written by admin on January 7, 2014 – 1:54 pm -

There has been much consternation, if not outright titillation, recently regarding the “discovery” of a new knee ligament. Multiple news outlets breathlessly report that doctors in Belgium have “discovered” a new ligament. Reader’s comments in these online articles range from excitement to incredulity and borderline outrage “that doctors could miss such an obvious thing.”

Is this possible? Is it likely that there is an anatomical structure that has gone undiscovered despite centuries of patient, methodical, laborious anatomical research by thousands of surgeons, anatomists and students?

Certainly, anything is possible (that’s the premise behind lottery tickets, right)? Is it possible that this ligament can go unnoticed by the literally millions of MRI that have been performed over the past 30 years? Maybe a little less possible than the previous example, but for the sake of argument, let’s say “Yes, it’s possible.” Except that it’s not. You see, this ligament was first described in 1879–the same year the light bulb was invented! The ligament has never had one single name that we could all agree upon (previous monikers include: mid-third lateral capsular ligament, capsulo-osseous layer of the iliotibial band (What a mouthful!) and even the current ‘anterolateral ligament’ have been used in the past). Though, until recently, no clear anatomical description had been provided, surgeons have long been aware of it. Most Orthopaedic surgeons (particularly those specializing in sports injuries) have been aware of its significance, abeit indirectly,for decades. The Segond fracture caused when this ligament sometimes avulses a fragment of bone from the tibia when an ACL is torn, bears the name, not coincidentally, of the first physician to “discover” the ligament (he called it simply a “pearly fibrous band”). To emphasize this point, the authors of the paper that initiated this furor, do not claim “discovery” they merely proffer a standardized name for this ligament and
postulate its significance in knee stability.

Why the delay? If it was first noted in 1879, why are we only now: 1. giving it a name and 2. postulating its function? To answer, one must first understand the structure of a joint. Every joint is surrounded by a capsule. The capsule is like a balloon that surrounds and attaches to the bones that comprise a joint. Certain parts of the capsule are thin and others are thick and well defined. those parts that are well-defined and thick usually merit a name and are considered “ligaments” examples are the MCL (medial collateral ligament) and LCL (lateral collateral ligament). Some areas are slightly thicker than the rest of the capsule but not nearly as much as the named ligaments. Sometimes these get a name, sometimes not, and sometimes doctors argue over what name, if any, should be assigned to this “thickened area.” as you can imagine, doctor-scientist cocktail parties can get pretty rowdy! These in-between ligaments typically have arcane names like posterior oblique ligament and popliteo- fibular ligament–names like these can only result as the brain-chlild of the aforementioned post-party delirium–scientists! still it’s better than listening to them argue these points at a medical conference.

Additionally, with the advent and popularity of minimally invasive and arthroscopic surgery, these ligaments are no longer exposed in surgical procedures, unless the procedure is intended to specifically address an injury to one of these ligaments.

Arthroscopic surgery occurs within the joint, these “capsule ligaments” are by definition outside the confines of the joint and are not seen during routine arthroscopic surgery. anyone want to trade the 2 tiny incisions typical of any “scope” surgery for a 10’‘incision (and all the extra rehab and lost work-time attendant to such incisions) so that we can have the satisfaction of looking at all the knee ligaments? No? I didn’t think so.

What about MRI? “Why has no one mentioned this ligament before now, if we can, in fact evaluate it with MRI?” good question. the answer is simple. radiologists may see the ligament/capsular area on every scan, but until we name it and tell them that it is important, they view it not unlike like the skin and fat and gristle also well-visualized on every mri but are not worthy of mention.

Far from the discovery of a new ligament, these distinguished Belgian surgeons have provided us valuable insight into the importance of a known but previously disregarded structure, and have suggested its importance merits a standardized name upon which we can all agree. While not as earth shattering as a truly unique discovery, it is exciting to learn that we may have new insight into the inner-workings of the human knee. Now it is time for those of us who care for those with such injuries to begin developing and utilizing techniques to repair it when injured. Truly exciting news, indeed!

Dr. Mark Galland is a Board Certified Orthopaedic Surgeon and adjunct Clinical Professor, specializing in sports medicine, practicing in Wake Forest and Raleigh. He serves as team physician and Orthopaedic consultant to the Carolina Mudcats, High-A Affiliate of the Cleveland Indians of Major League Baseball, as well as several area high schools and colleges. Dr. Galland can be reached at (919) 562-9410 or by visiting www.orthonc.com or www.drmarkgalland.com, or on twitter @drmarkgalland.


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“New” Ligament Discovered in the Knee

Written by admin on January 6, 2014 – 2:18 pm -

In October, a group of physicians in Belgium released a study that gives support to the idea that there may be an additional ligament present in the knee. Ligaments, as we know, connect bone to bone and lend stability to a joint. Previously, we had only really concerned ourselves with the four largest ligaments in the knee, the lateral collateral ligament (LCL), the medial collateral ligament (MCL), the posterior cruciate ligament (PCL), and the one you’ve probably heard the most about, the anterior cruciate ligament (ACL).

Building off of the work of a French surgeon, Paul Segond, that dates back to 1879, these surgeons worked with 41 cadavers and microscopic dissection techniques to visualize a small band of connective tissue that runs from the front, outside portion of the femur to tibia and so appropriately named it the anterolateral ligament, or ALL. They were able to identify what they believe to be the ALL in 40 of the 41 human specimens. Researchers believe that this ligament could help support movements that involve pivoting and change of direction, and thus, could also be torn under these same stresses. Because the ACL is also commonly torn as a result of excessive rotational stresses, it is hypothesized that these two ligaments could be sprained concurrently. The surgeons also speculate that because no effort previously has been made to restore function in this ligament during surgery to replace the ACL, that the ALL could be to blame in cases that have less-than-optimal outcomes where patients have continued complaints of instability and lack of full function in the knee. Orthopedic experts around the world have had mixed reactions to this news, but all agree the work is intriguing and they are interested to see the direction further research will take the field.

While its location and potential role in lower extremity biomechanics are becoming increasingly elucidated, there are still many questions that remain. For instance, what is the healing potential of the ALL? Does it even have the potential to heal on its own, similar to the MCL (small tears usually heal with rest, larger or complete tears often warrant reconstruction)? If it is possible to reconstruct, what kind of graft would be amenable to this and what surgical techniques would be used? And then, a few obvious questions: Why haven’t we seen this ligament before? What about the tens of thousands of ACL tears that are surgically reconstructed every year with excellent outcomes where individuals are able to return to their daily and athletic activities? And ultimately, would it even respond to reconstruction in that it could help to restore function and thus result in better outcomes?
This “discovery” must be accorded its proper place in our current compendium of knowledge. It is important not because a “new” ligament has been discovered but rather suggests a more important role for a ligament long-ago discovered but not accorded any particular significance. More investigation into the role and healing capacity of this ligament is certainly warranted.

Alex Vitek is a nationally Certified, state Licensed Athletic Trainer and post-graduate Resident in training at The Galland Orthopaedics and Sports Medicine Athletic Training Residency– a 12 month immersional program allowing ATCs to maintain and hone clinical skills while developing those talents necessary to be effective in the clinical setting as an ATC/physician extender. Find out more at www.atcfellowship.com


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Prevention of Anterior Cruciate Ligament Injury in Athletes

Written by admin on June 9, 2013 – 7:16 pm -

A Review
Thomas Trojian, MD, Lindsay DiStefano, PhD, ATCDisclosures

Clin J Sport Med. 2013;23(2):120-121.

Abstract and Introduction

Abstract
Sadoghi P, von Keudell A, Vavken P. Effectiveness of anterior cruciate ligament injury prevention training programs. J Bone Joint Surg Am. 2012;94:769–776.

Objective: To investigate whether anterior cruciate ligament (ACL) prevention programs reduce risk of injury in athletes, and which prevention program is most effective, by means of a review of the literature and meta-analysis of the results.

Data Sources: PubMed, MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials databases were searched online using the terms anterior cruciate ligament, knee, injury, prevention, and control. The reference lists of relevant studies were searched for further trials.

Study Selection: Prospective controlled studies of humans, in any language, that reported on proprioceptive neuromuscular training techniques for ACL injury prevention compared with usual training programs were selected if they reported clinical outcomes and had an attrition rate of <20%. Three independent reviewers selected the studies and resolved differences by consensus. After duplicates were eliminated, the search identified 723 reports. Eight studies met the selection criteria.

Data Extraction: Details of the study design, participant characteristics, the intervention, the number of ACL injuries at follow-up, the duration of follow-up, and the sport played were extracted. Study quality was scored 0 to 3, according to use of randomization and blinding and adequacy of follow-up of participants. Pooled risk ratios (RRs) were calculated in random-effects models.

Main Results: Participants in the studies were predominantly women or girls who played soccer, basketball, or volleyball. The interventions included proprioceptive neuromuscular training and agility skills as well as strength, flexibility, and cardiovascular training, done either preseason or for 30 days to 12 weeks during the season. With 1 exception, the results of the interventions were positive, with the number needed to treat to prevent 1 ACL injury varying from 5 to 187 in those 7 studies. The pooled RR favoring the interventions was 0.38 (95% confidence interval [CI], 0.20–0.72). This included 34 ACL injuries among the 3905 intervention participants and 181 ACL injuries among the 6703 control participants. The pooled RR among female athletes was 0.48 (95% CI, 0.26–0.89) and among male athletes was 0.15 (95% CI, 0.08–0.28). The mean quality score for the studies was poor (mean, 1 point; 95% CI, 0.43–1.57 points). No variable such as type of intervention, timing of the program, or length of the program was clearly related to effectiveness.

Conclusions: Neuromuscular-focused exercise training programs to prevent ACL injuries were effective among both female and male athletes. Despite the poor methodological quality of the studies, the results were consistent.


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New Study Reveals the Obese More Likely to Require Knee Replacement

Written by admin on June 6, 2013 – 7:10 pm -

BMC Musculoskeletal Disorders
Obesity and Increased Burden of Hip and Knee Joint Disease in Australia
Results From a National Survey
Ilana N Ackerman, Richard H OsborneDisclosures
BMC Musculoskelet Disord. 2012;13(254)

Abstract

Background Research involving more representative samples is needed to extend our understanding of the broader impact of obesity in hip or knee joint disease (arthritis and OA) beyond clinical settings. Although population-based research has been conducted in the United States, how these findings translate to other countries is unclear. Using a national approach, this study explored associations between obesity and the burden of hip and knee joint disease in Australia (in terms of prevalence, pain, stiffness, function, Health-Related Quality of Life (HRQoL) and disease severity).

Methods

A random sample of 5000 Australians (≥39 years) from the federal electoral roll was invited to complete a mailed questionnaire to identify doctor-diagnosed hip arthritis, hip OA, knee arthritis and knee OA and evaluate the burden of these conditions. Validated questionnaires included the WOMAC Index, Assessment of Quality of Life instrument and Multi-Attribute Prioritisation Tool. Body Mass Index (BMI) was classified into underweight/normal weight (≤24.99 kg/m2), overweight (25–29.99) or obese (≥30). Multiple logistic regression was used to estimate odds of arthritis and OA, with demographic and socioeconomic variables included in the models. Associations between BMI and other variables were investigated using analysis of covariance, with adjustment for age and sex.

Results

Data were available from 1,157 participants (23%). Overweight participants had increased odds of knee arthritis (adjusted OR (AOR) 1.87, 95%CI 1.14–3.07) and knee OA (AOR 2.11, 95%CI 1.07–4.15). Obesity was associated with higher prevalence of hip arthritis (AOR 2.18, 95%CI 1.17–4.06), knee arthritis (AOR 5.47, 95%CI 3.35–8.95) and knee OA (AOR 7.35, 95%CI 3.85–14.02). Of those with arthritis or OA, obese individuals reported more pain (for hip arthritis, hip OA and knee OA), greater stiffness (for hip arthritis, knee arthritis and knee OA), worse function (all diagnoses), lower HRQoL (for hip arthritis and hip OA) and greater disease severity (all diagnoses).

Conclusions

This national study has demonstrated that the odds of arthritis and OA was up to 7 times higher for obese individuals, compared with those classified as underweight/normal weight. Concurrent obesity and joint disease had a marked impact on several key aspects of wellbeing, highlighting the need for public health interventions.

http://www.medscape.com/viewarticle/780602?nlid=31232_941&src=wnl_edit_medp_orth&uac=192786MG&spon=8


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Platelet-Rich Plasma May Have Edge in Jumper’s Knee

Written by admin on May 31, 2013 – 11:07 pm -

Reuters Health Information
Platelet-Rich Plasma May Have Edge in Jumper’s Knee
Mar 07, 2013

By David Douglas
NEW YORK (Reuters Health) Mar 07 – Platelet-rich plasma (PRP) injections might be more helpful to athletes with jumper’s knee than focused extracorporeal shock wave therapy (ESWT), according to Italian researchers.
Dr. Mario Vetrano told Reuters Health by email that both approaches “seem to be safe and promising as part of the treatment of jumper’s knee patients. However, both treatments share the same disputes: lack of hard evidence through randomized clinical trials and no standardized treatment protocols.”
To compare outcomes, Dr. Vetrano and colleagues at Sapienza University of Rome studied 46 athletes with tendonopathy due to overuse of the knee extensor mechanism.
They randomized their patients to receive either two autologous PRP injections over two weeks under ultrasound guidance, or three sessions of focused ESWT. Both groups then went on to a standardized stretching and muscle strengthening protocol.
Given minimal or no pain after four weeks, patients were allowed to gradually return to previous training activity. Complete return to sports took place in accordance with the patient’s pain tolerance and recovery.
A blinded reviewer made assessments before and up to 12 months after treatment. The findings were published online February 13th in The American Journal of Sports Medicine.
Both groups showed benefit, and there were no significant between-group differences in outcome measures at two months. No clinically relevant side effects were seen in either group.
However, at six and 12 months, the PRP group showed significantly greater improvement in Victorian Institute of Sports Assessment-Patella questionnaire and pain visual analogue scale. At 12 months, the PRP group also had significantly better modified Blazina scale scores.
Both approaches seem promising, but “given current knowledge,” say the investigators, “it is impossible to recommend a specific treatment protocol.”
Nevertheless, as Dr. Vetrano concluded, “The analysis of our study showed comparable results in both treatment groups at short term, with better results in the PRP group at six and 12 month follow-ups.”
SOURCE: http://bit.ly/Zu8fCl
Am J Sports Med 2013.


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Mystery Knee Pain Not In “Head”, But In “Rear End”

Written by admin on March 18, 2013 – 2:59 pm -

“Patellofemoral pain syndrome (PFPS) is one of the most common presentations to sports medicine practitioners. In a large study of 2519 presentations to a sports medicine clinic, 5.4% were diagnosed with PFPS, accounting for 25% of all knee injury presentations.”

“There is growing evidence to support the association of gluteal muscle strength deficits in individuals with patellofemoral pain syndrome (PFPS) and the effectiveness of gluteal strengthening when treating PFPS. ”

For more information on this topic, please view the below attachment from British Journal of Sports Medicine by Christian J Barton, Simon Lack, Peter Malliaras, and Dylan Morrissey.

Gluteal Muscle Activity and Patellofemoral Pain Syndrome


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“Platelet-Rich Plasma May Have Edge in Jumper’s Knee”

Written by admin on March 14, 2013 – 6:55 am -

By David Douglas: NEW YORK (Reuters Health) Mar 07

Platelet-rich plasma (PRP) injections might be more helpful to athletes with jumper’s knee than focused extracorporeal shock wave therapy (ESWT), according to Italian researchers.

Dr. Mario Vetrano told Reuters Health by email that both approaches “seem to be safe and promising as part of the treatment of jumper’s knee patients. However, both treatments share the same disputes: lack of hard evidence through randomized clinical trials and no standardized treatment protocols.”

To compare outcomes, Dr. Vetrano and colleagues at Sapienza University of Rome studied 46 athletes with tendonopathy due to overuse of the knee extensor mechanism.

They randomized their patients to receive either two autologous PRP injections over two weeks under ultrasound guidance, or three sessions of focused ESWT. Both groups then went on to a standardized stretching and muscle strengthening protocol.

Given minimal or no pain after four weeks, patients were allowed to gradually return to previous training activity. Complete return to sports took place in accordance with the patient’s pain tolerance and recovery.

A blinded reviewer made assessments before and up to 12 months after treatment. The findings were published online February 13th in The American Journal of Sports Medicine.

Both groups showed benefit, and there were no significant between-group differences in outcome measures at two months. No clinically relevant side effects were seen in either group.

However, at six and 12 months, the PRP group showed significantly greater improvement in Victorian Institute of Sports Assessment-Patella questionnaire and pain visual analogue scale. At 12 months, the PRP group also had significantly better modified Blazina scale scores.

Both approaches seem promising, but “given current knowledge,” say the investigators, “it is impossible to recommend a specific treatment protocol.”

Nevertheless, as Dr. Vetrano concluded, “The analysis of our study showed comparable results in both treatment groups at short term, with better results in the PRP group at six and 12 month follow-ups.”

Original Study Published in American Journal of Sports Medicine by Mario Vetrano, MD, Anna Castorina, MD, Maria Chiara Vulpiani, MD, Rossella Baldini, PhD, Antonio Pavan, MD, and Andrea Ferretti, MD.

Abstract available

__________________________

For more information on Platelet-Rich Plasma (PRP) therapy, please read my article at www.orthonc.com.


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Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete…: Journal of AAOS(February 2013)

Written by admin on March 4, 2013 – 6:19 am -

Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete: Diagnosis and Management

Jeremy S. Frank, MD and Peter L. Gambacorta, DO

Abstract

Intrasubstance anterior cruciate ligament (ACL) injuries in children and adolescents were once considered rare occurrences, with tibial eminence avulsion fractures generally regarded as the pediatric ACL injury equivalent. However, with increased single-sport focus, less free play, and year-round training at younger ages, intrasubstance ACL injuries in children and adolescents are being diagnosed with increased frequency. As in the adult, a knee devoid of ligamentous stability predisposes the pediatric patient to meniscal and chondral injuries and early degenerative changes.

Management of ACL injuries in skeletally immature patients includes physeal-sparing, partial transphyseal, and complete transphyseal ACL reconstruction. Complications include iatrogenic growth disturbance resulting from physeal violation.

In the past 20 years, sports injuries in pediatric and adolescent athletes have dramatically increased. Approximately 38 million young athletes participate in organized sports annually in the United States. Of these, nearly 2 million high school students and almost twice as many athletes aged <14 years are treated for a sports-related injury each year. This new epidemic of sports-related injuries can be partially attributed to the dramatic surge in the number of participants since the passage of Title IX, along with increased emphasis on year-round competition, single-sport concentration, and more intense training.

Summary

ACL ruptures in skeletally immature patients are becoming more common with increased single-sport concentration, year-round participation, and less time spent in free play. It is the role of pediatric sports medicine providers to properly diagnose and manage these injuries. Nonsurgical management, including activity modification, bracing, and physical therapy, is best used for patients with partial tears involving <50% of the ACL diameter. In patients with complete ruptures, chronologic, physiologic, and skeletal maturity must be assessed to appropriately address the injury. Treatment options are predicated on assessment of the patient’s maturity and include physeal-sparing, partial and complete transphyseal, and adult-type anatomic ACL reconstruction. Postoperative management includes weight-bearing and activity modifications, bracing, and a progressive physical therapy protocol emphasizing ROM, closed-chain strengthening, and a gradual and measured return to sport-specific maneuvers. Surgical complications are rare.

Journal AAOS © 2013 (February)


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Pushing Limits…

Written by admin on February 26, 2013 – 2:14 pm -

Younger Patients Choose Surgery; Some Sports Are OK, But Which Are Too Much?

(WSJ, April 19, 2011)

John Jeffries, a 49-year-old money manager in Dover, Mass., had hip-resurfacing surgery in 2008 and is now coaching his son’s basketball team and long-distance cycling.

Alex Douglas, a Wall Street software architect, had both knees replaced last year at 39 after years of sports injuries. He can’t wait to go kite-boarding this weekend. “I’ve been cleared to have fun,” he says.

Hard charging baby boomers and Generation X-ers are wearing out their joints at younger ages and turning to joint replacement surgery. But is it a quick fix? WSJ’s health columnist Melinda Beck discusses with Kelsey Hubbard.

Joint-replacement patients these days are younger and more active than ever before. More than half of all hip-replacement surgeries performed this year are expected to be on people under 65, with the same percentage projected for knee replacements by 2016. The fastest-growing group is patients 46 to 64, according to the American Academy of Orthopaedic Surgery.

Many active middle-agers are wearing out their joints with marathons, triathlons, basketball and tennis and suffering osteoarthritis years earlier than previous generations. They’re also determined to stay active for many more years and not let pain or disability make them sedentary.

To accommodate them, implant makers are working to build joints with longer-wearing materials, and surgeons are offering more options like partial knee replacements, hip resurfacing and minimally invasive procedures.

More younger people also need joint-replacement surgery due to obesity, and some orthopedists refer them for weight-loss surgery first to reduce complications later.

Even the most fit patients face a long period of rehabilitation after surgery and may not be able to resume high-impact activities.

“There is, to be honest, some irrational exuberance out there,” says Daniel Berry, chief of orthopedic surgery at the Mayo Clinic in Rochester, Minn., and president of the American Academy of Orthopedic Surgeons. “People may be overly optimistic about what joint replacement can do for them.”

One big unknown: How long will the replacement joints last? In the past, many doctors assumed implants would wear out in about 10 or 15 years, and they urged young patients to put off surgery as long as possible to minimize the risk of needing a costly and difficult revision surgery—or even two. (A total knee replacement typically costs $15,000 to $22,000. A revision can be $45,000 or more, with a higher risk of complications.)

Read more


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