Not Too Young for Knee Replacement

Newswise — At age 33, Nick Clement’s knee pain had gotten so bad, he was seriously considering knee replacement surgery. But given his young age, he was concerned about how long a knee replacement would last.

He wanted to wait as long as possible, but four years of college soccer, a bad knee injury and three prior surgeries had taken their toll. The pain was robbing him of his ability to enjoy life. Even walking, and especially going up steps, had become very difficult. Athletic activities were impossible. So, Nick, who lives in New York City, decided to go online and searched “young people having knee replacement.” He found out about Geoffrey Westrich, MD, director of research in the Adult Reconstruction and Joint Replacement Service at Hospital for Special Surgery (HSS).

“When I read that Dr. Westrich had performed knee replacements on younger people and was doing MAKO robotic-assisted surgery for exact precision and alignment, I knew that was the way to go,” Nick said. He had the surgery four months ago.

In mid-March, Nick had a virtual consultation with Dr. Westrich via telehealth. HSS established "virtual visits" so physicians could see and talk to their patients remotely in real time. Nick was able to consult with Dr. Westrich for his follow-up appointment and even show him his knee. “I’m doing great,” Nick said. “The pain is gone. I go bike riding, work out in the gym. I couldn’t be happier and wish I had done it sooner.”

Nick is among a growing number of younger people who refuse to take arthritis sitting down, according to Dr. Westrich. The main concern in younger patients is that the implant will wear out. The standard implant used in knee replacement usually lasts a long time – generally about 20 years – but it usually doesn’t last indefinitely. When the implant wears out or loosens, patients generally need a second knee replacement, known as a revision surgery.

Dr. Westrich says advances in technology such as robotic-assisted surgery and improvements in implant materials and design could change that. “It’s old school thinking to tell a patient under 50 to wait as long as possible,” he says. “We believe advancements, such as robotically-assisted surgery and cementless fixation, could enable a joint replacement to last three decades or even longer. For some individuals, it may be able to last a lifetime.”

Nick says he was impressed when he read about the MAKO robotic system that Dr. Westrich uses. The first step is a CT scan to create a 3D virtual model of the patient’s unique anatomy to assist in planning the procedure. During surgery, a robotic arm uses computer-guided mapping software, similar to GPS, integrated into the surgical instruments. The digital tracking system constantly monitors and updates the patient’s anatomy and enables the surgeon to make real-time adjustments to optimize implant positioning and placement, and to restore biomechanical alignment and joint motion. This allows for an ultra-precise knee replacement customized for each patient.

“Studies have shown that optimal alignment and positioning are critical for the long-term success of a joint replacement,” Dr. Westrich explains. “In addition, the system enables the orthopedic surgeon to perfectly balance the ligaments in the knee. We believe that increased stability, along with pinpoint accuracy in alignment, will result in less wear and friction, and so the implant will last longer.”  

Another major advance is a cementless knee replacement in which cement is no longer needed to attach the implant to the bone. This new prosthesis, implanted with robotic-assisted surgery, should also extend the longevity of a knee replacement, according to Dr. Westrich. “The combination of these two major technological advances has dramatically changed the way I do knee replacements.”

In a standard knee replacement, the components of the implant are secured in the joint using bone cement. It’s a tried and true technique that has worked well for decades. But eventually, over time, the cement starts to loosen from the bone and/or the prosthesis. “With the new cementless prosthesis, the components are press fit into place for ‘biologic fixation,’ which basically means that the bone will grow into the implant,” Dr. Westrich explains. “With biologic fixation, many joint replacement specialists believe that loosening over time could be less likely.”

A joint replacement registry at HSS will keep up with patients for years after their surgery to evaluate outcomes, including how long the implant will last.  

About HSS | Hospital for Special Surgery

HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the tenth consecutive year), No. 3 in rheumatology by U.S. News & World Report (2019-2020), and named a leader in pediatric orthopedics by U.S. News & World Report “Best Children’s Hospitals” list (2019-2020). Founded in 1863, the Hospital has one of the lowest infection rates in the country and was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State. In addition, HSS will be opening a new facility in Florida in early 2020. In 2018, HSS provided care to 139,000 patients and performed more than 32,000 surgical procedures, and people from all 50 U.S. states and 80 countries travelled to receive care at HSS. There were more than 37,000 pediatric visits to the HSS Lerner Children’s Pavilion for treatment by a team of interdisciplinary experts. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is the world’s leading provider of education on musculoskeletal health, with its online learning platform offering more than 600 courses to more than 21,000 medical professional members worldwide. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.