Take a step. Now take another step. Now do a knee bend. Now bend over and try to touch your toes. With just those four simple movements,you have used numerous bones and joints, as well as the cartilage and ligaments that connect them to one another, enabling movement. Every day you call upon these important body parts thousands of times as you walk, run, rise, sit, stretch, carry, dance, swim and just plain move.
Yet you probably don’t think much about your skeletal system until something happens: a twisted knee from chasing your toddler around the park; a fractured wrist that time you tried snowboarding; a sprained ankle when you missed that step on the porch; a sore back after moving furniture. The reality, however, is that Americans make more than 12.8 million visits a year to doctors for back pain and 12.3 million for knee pain. In 2006, orthopedic surgeons replaced more than 542,000 knees—63 percent of them in women—and 231,000 hips, 56 percent of them in women.1 At the same time, 10 million Americans, 80 percent of them women, have osteoporosis, a bone disease that puts them at a very high risk of fractures, while 55 percent of Americans aged 50 and older are at risk of the disease.2 Meanwhile, 27 million Americans have osteoarthritis, the most common form of arthritis.3
The thing is, when your bones, joints, ligaments and other skeletal structures begin to go, it triggers a chain reaction that starts with less exercise and movement and ends with muscle loss, weight gain, social and physical isolation, depression and a plethora of chronic conditions that can significantly affect your quality of life.
The good news? Today we have a much greater understanding of skeletal-related diseases and prevention. For those of us who already experience the aches and pains of a well-used body—or even a sudden sports injury—improved surgical and nonsurgical treatments can not only restore movement, but also restore the joy of an active, involved life no matter what your age.
Oh, My Aching Knees!
When Margaret Blohm received a message about being interviewed for this article, she was sitting in the waiting room in a Dearborn, MI, hospital waiting for her 87-year old mother’s knee replacement surgery to be completed.
All her mother wanted, Ms. Blohm said, was to be able to play Wii bowling again in the retirement community where she lived. Ms. Blohm knew well what her mother was undergoing: The 60-year-old public relations executive had had both her knees replaced just four years previously.
Before her surgery, she couldn’t even stand up straight. The pain in her knees also prevented her from walking long distances. “Even grocery shopping was a pain,” she recalls. The pain interrupted her sleep and made concentration difficult. Visits to a rheumatologist led to fluid being drained from her knees, and one to a podiatrist resulted in a recommendation for orthotics. Nothing helped. Finally, Ms. Blohm referred herself to an orthopedic surgeon who x-rayed her knees and saw that the cartilage in each was gone. Her pain was caused by the grinding of bone on bone. The recommendation? A new knee.
Ms. Blohm stayed in the hospital for three days after the surgery. She began physical therapy immediately with a physical therapist and a continuous passive motion machine that moved her leg for her. By the time she left the hospital, she could go up and down three steps with a walker (the number of steps required to enter her home). A week after surgery, Ms. Blohm walked up and down the flight of stairs leading to her home office. Three weeks later, she drove herself to physical therapy.
Since then, Ms. Blohm has begun working out with a personal trainer to build strength in her legs and lose weight. She exercises regularly on a stationary bicycle and elliptical machine, uses free weights and walks up to two miles around her neighborhood.
And her mother? Turns out that surgery also went well. “The only problem,” said Ms. Blohm, “is going through airport security” because the metal replacements in the women’s knees can set off the alarm.
What Ms. Blohm and her mother show so well is that you’re never too old—or too young—for knee replacement surgery.
In recent years an alternative to hip replacement surgery called hip resurfacing has become more common. The procedures are similar, only less thigh bone is removed in resurfacing. However, this requires that the bone remain strong for years—which becomes a problem once women pass menopause and their bones weaken. That may be the reason studies find much higher complication rates in the first year than with hip replacement, particularly in women and in men older than 55.11
Before turning to any surgical procedure, however, make sure you’ve tried other, nonsurgical options, such as losing weight, using a cane, undergoing physical therapy and taking pain medications.
“For the majority of patients, (knee replacement surgery) works great,” says orthopedic surgeon David G. Lewallen, MD, of the Mayo Clinic in Rochester, MN. “Some of my elderly patients come in saying ‘I’m too old to do this.’” But I say, “I don’t care what the calendar says, it’s what the doctor says.” In fact, the median age for arthroplasty (another word for total joint replacement) in this country is mid-60s; so half the patients are younger and half older, Dr. Lewallen noted. He’s had patients in their 50s whom he turned down for surgery because of other medical problems and patients in their 90s on whom he was happy to operate. Knee arthroplasty is generally not recommended for people whose X-rays look relatively normal, those who have problems with blood circulation or people with neurologic conditions that affect the legs, he said.4
Studies find that total knee or hip replacement is cost effective, reducing overall health care costs as well as pain, disability and costs directly attributed to arthritis in people 65 and older.5,6
No wonder that knee and hip replacement are ranked among the top three operations valued by patients (the third is cataract surgery). It’s because of the impact these surgeries have on quality of life. “If you can see again, it’s a very big deal,” said Dr. Lewallen. “If you can’t walk or have difficulty walking around the house, you walk shorter and shorter distances. Then someone does a procedure and within a few weeks you get back to walking without pain—it’s a life-changing experience.” It can also mean the difference between living independently or going into a nursing home. “We keep them going,” Dr. Lewallen said. “That’s our job.”
These days, he has more tools with which to do his job, including custom-fitted knees designed to mimic the pre-arthritic knee and robotic surgery techniques designed to provide more precise alignment.
Of course, as with any surgery, arthroplasty carries risks. In addition to the typical surgical risks of anesthesia, bleeding or infection, one of the greatest risks of arthroplasty is blood clots, or deep vein thrombosis (DVT). The clots can cut off the blood supply in the affected limb and increase the risk of infection, but the greatest risk is that a clot might travel to the lungs causing a life-threatening pulmonary embolism. That’s why nearly all patients undergoing arthroplasty should receive prophylactic treatment with blood thinners like heparin and warfarin (Coumadin) after the surgery and, in many instances, for weeks or even months after discharge. Studies find this slashes the risk of DVT and complications up to 60 percent in people undergoing orthopedic surgery.7
Other potential complications include problems with the artificial joint itself that may require replacement.8 Overall, however, the risks of either procedure are relatively low and the long-term outcomes excellent. Keep in mind, however, that if you have this done while you’re relatively young, you may need another replacement down the road.9,10
Bad to the Bone: Osteoporosis
Dolores “Dee” Rudolph knew she had a high risk of developing osteoporosis because her mother had a severe form of the boneweakening disease, and family history is a risk factor for osteoporosis. So decades ago the now-78-year-old woman asked her mother’s orthopedist what she could do to protect herself. “Do you eat a cube of cheese each day?” he asked her. “Sure,” she replied. “I eat more than that!” “Then don’t worry,” he said.
So she didn’t, until she began developing a curve to her spine and a hump on her back. She was 58 when she was diagnosed with osteoporosis. Her treatment? Calcium supplements. Luckily, just a few years later the first pharmaceutical drugs for osteoporosis came on the market, and Ms. Rudolph started on one of them. The medication halted the bone loss, she said, although it didn’t improve it. Nonetheless, in the past three years Ms. Rudolph broke her hip and leg after slipping on ice and her shoulder and arm after losing her balance in her house. Today, she takes an herbal/vitamin supplement high in vitamin D and receives an annual, 15-minute infusion of zoledronic acid (Reclast), which studies show significantly reduces the risk of fractures while increasing bone density.
Doctors didn’t have any osteoporosis medications when Ms. Rudolph’s mother was alive, or even when Ms. Rudolph herself was diagnosed. In fact, they didn’t even understand the importance of vitamin D to bone. (Hint: it’s as important if not more important than calcium when it comes to building and maintaining strong bones.)
Unfortunately, even though there are now six FDA-approved medications for osteoporosis, many orthopedic surgeons still think nothing can be done once a woman (or man) breaks her hip or other bone. Indeed, studies show that just one in five people who suffers a hip or other osteoporosis- related fracture receives treatment for osteoporosis.12-14
Yet nearly a fourth of the 325,000 patients who fracture their hips every year end up in nursing homes, while half never regain their previous level of activity and independence and a quarter die within a year of their fractures. In fact, the rate of death from osteoporosis-related fractures is higher than rates for breast and cervical cancer combined.
That’s inexcusable, say experts like Richard M. Dell, MD. Dr. Dell led a team at Kaiser Permanente in Southern California that showed the risk of hip fracture could be slashed nearly 40 percent simply by instituting protocols designed to get doctors to assess and treat patients at high risk of osteoporosis, educating patients about the disease and making home visits to some patients to reduce the risk of falls.15 In one year, Kaiser’s Healthy Bones Program prevented 935 hip fractures, saving the system nearly $31 million. Similar programs have slashed fracture rates by as much as half.16
American Academy of Orthopedic Surgeons
American College of Sports Medicine
Foundation for Osteoporosis Research and Education (FORE)
Know My Bones
National Institutes of Health’s Osteoporosis and Related Bone Diseases National Resource Center
National Osteoporosis Foundation
“Most people only think of osteoporosis and fractures in the elderly,” Dr. Dell said. “But the disease can start in women who are in their 50s.” That’s when women start breaking their wrists and having vertebral fractures, which they may not even notice until they begin shrinking. “We need to start at a younger age to make people aware of the importance of bone strength and begin treating more aggressively with (medication) in older people,” he said.
The first line of medical treatment for osteoporosis is a selective estrogen receptor (SERM), such as raloxifene (Evista), or the bisphosphonates ibandronate (Boniva), risedronate (Actonel) and alendronate (Fosamax; also available generically). More serious cases of bone loss warrant more serious treatments, such as the annual infusion with Reclast like Ms. Rudolph received, or daily injections for two years of teriparatide (Forteo). However, although all the approved drugs show some benefit, the benefits may vary in individuals.
Still, prevention is key, says Dr. Dell. “Your bones are like a bank,” he explains. The bone you build during childhood and into your 30s will form the deposit from which the withdrawals come as you age and lose estrogen, a hormone that is critical to maintaining strong bone. In fact, women can lose up to 20 percent of their bone following menopause. For more on strategies you can take to build and maintain bone, see the Lifestyle Corner column.
|DEXA and FRAX
There are two acronyms you should know about when it comes to osteoporosis: DEXA, which stands for “Dual Energy X-ray Absorptiometry,” and FRAX, which stands for “Fracture Risk Assessment Tool.” The DEXA is used to assess bone-mineral density in your hip, spine and total body. Results are usually expressed as T-scores, a measure of how far your bone density deviates from the average bone density value for a young, healthy, Caucasian woman. A T-score between +1 and -1 indicates normal bone density while a score at or below -2.5 usually signals osteoporosis. A T-score between -1 and -2.5 usually signals osteopenia, or low bone density, that should be evaluated. The bone density is also compared to what is considered normal for your age, sex and size.
Meanwhile, the FRAX score, which is based on your age, weight, height, medical history and other risk factors, as well as your bone mineral density score, determines your risk of having a hip or vertebral fracture in the next 10 years.
Women with no risk factors for osteoporosis who have never smoked or had a fracture can wait until age 65 for their first DEXA scan, says Richard Dell, MD. Other women may need a scan earlier. A combination of a hip bone density score between -1.0 and -2.5 and a 3 percent or higher risk of hip fracture on the FRAX, or a 20 percent or higher risk score on the FRAX, should trigger medical treatment. Otherwise, says Dr. Dell, 1,000 to 1,200 mg a day of calcium and 1,000 IU of vitamin D supplements coupled with weight-bearing exercise should provide enough protection for the time being.