Victoria Williams remembers sitting in her car, crying after a disappointing visit with an orthopedic surgeon. She had been told nothing could be done, but if she came back in about 20 years, joint replacement surgery might be an option. Williams, only 40 at the time, was suffering from excruciating pain; the joint in her right knee was shot. An avid gardener and licensed aesthetician whose work meant she spent hours on her feet, Williams dreaded each new day. “I wanted quality of life now while I was younger,” says the Lake Forest Park resident about her decision to have surgery. “I didn’t want to live with the pain and physical limitations for another 20 years before I could get surgery.”
Younger patients like Williams—along with the Puget Sound’s active baby-boomer set wanting to stay in peak condition—are electing to have joints replaced sooner, and are driving explosive growth in joint-replacement surgeries in the Northwest. And while joint replacements for hips, knees and shoulders are more common, replacements for elbows, wrists and ankles are on the rise, too.
Some do it to keep their weekend-warrior status going. Urban athletes and extreme adrenaline sports junkies are not ready to stow the bike or give away the hiking boots when arthritis sets in or when aggressive physical activity takes its toll on their joints. Others, like Williams, who are still working have the surgery to combat severe pain and decreased flexibility and to improve the quality of everyday life. At the same time, with the demands our local, highly educated population has for an uninterrupted high quality of life, joint replacement surgery is changing. Breakthroughs in surgery, rehabilitation and patient care are designed to get us moving again—in the shortest possible amount of time.
Patients are not only younger and more active; they are also working. They need to get back on their feet and on the job as quickly as possible.
“Today’s patients have greater expectations about activity,” says Thomas Cross, D.O, a board certified orthopedic surgeon with Federal Way Orthopedic Associates, and an expert with more than 20 years of experience who has been both an associate professor and clinical instructor in orthopedic surgery. “In the past, we didn’t want to do joint replacement surgery on patients under the age of 60 to 65 because we thought the replacement joints would only last 10 to 12 years. Now we know that they can last 20 years or more.” This means doctors will consider doing joint replacement on younger patients who are in otherwise good health, but suffer from pain and a decrease in function, when conservative nonsurgical methods have failed and X-rays support it, he says.
Not only do active boomers and younger patients want the option of having replacement surgery sooner, they want to experience less pain and faster rehab afterward. This, according to William Barrett, M.D., medical director of Valley Medical Center’s Joint Center and a board certified orthopedic surgeon with Valley Orthopedic Associates in Renton, is driving the development of less- invasive surgical techniques. Barrett, one of the most sought-out surgeons in the field, performs more than 500 total joint replacements per year. “Patients are not only younger and more active; they are also working,” he says. “They need to get back on their feet and on the job as quickly as possible.”
New surgical techniques, such as what doctors call the anterior approach to hip replacement surgery, are receiving a lot of attention from experts because patients seem to recover more quickly. The name of the surgery isn’t consumer-friendly, but the results certainly are. Most hip replacement surgery is done using the posterior or lateral approach to access the hip joint, in which a surgeon makes the incision on the back or side of the hip and then cuts through and detaches the muscles to access the hip joint. With the anterior approach, Barrett makes a 3 to 4-inch incision on the front of the hip and works between the muscles (rather than detaching them) and tissue, minimizing trauma. “It is quickly replacing the more traditional posterior or lateral surgical approach in my practice,” says Barrett. Hospital stays for both types of surgery are similar, but the difference in recovery and rehabilitation time can be significant, because, in layman’s terms, there is less to heal because there is less trauma to the muscle and tissue around the hip during surgery. The difference of a day or two in the hospital and a couple of months of rehabilitation are huge when you are working, says Barrett.
Craig McAllister, M.D., with Evergreen Orthopedic Center in Kirkland, is past chief of orthopedics at Evergreen Hospital and Medical Center and is president of Operativ, a research company that develops specialized orthopedic instruments. He has spent the past 12 years developing minimally invasive surgical techniques utilizing computer-guided navigation and miniature surgical instruments (which he helped design). McAllister does 300 to 400 joint replacements per year, but he hasn’t done a traditional knee replacement since 2003. “Traditional knee replacements require large incisions (12 to 15 inches),” he says, “but our approach only requires a 4-inch incision.” Computer navigation affords greater accuracy in placement and less surgical exposure. A surgeon hits alignment between 92 and 98 percent of the time using the computer, but only about 70 percent of the time without it. There is also greater flexibility and control during surgery. Using computer navigation combined with minimally invasive surgical techniques results in less blood loss and less post-op fevers and pain for patients. They usually have surgery, are up and walking that same day and go home the next day. “Laying in bed and not moving leads to complications,” says McAllister.
These doctors were interviewed for our story. Visit Seattle mag’s Top Doctors to find more orthopedic surgeons
William Barrett, M.D.
Thomas Cross, D.O.
Craig McAllister, M.D.
James W. Pritchett, M.D.
Computers are also being used in other joint surgeries. In 2011, James Pritchett, M.D., a Swedish Orthopedic Institute-affiliated surgeon, became the first orthopedic physician in the region to perform a robotic-assisted hip resurfacing. Resurfacing is a procedure that replaces surfaces of the joint rather than the joint itself, preserving much of the bone. It is a good option for healthy patients under the age of 55 who would otherwise undergo total hip-replacement surgery. “The advantage of the robotic-assisted technique is precision,” says Pritchett. “Prior to the patient’s actual surgery, we perform a pre-operative CT scan and then [model] the surgery on the computer. We are able to precisely pick the best implant size for that particular patient, place the implant in the optimal position and verify the position. On the day of surgery, the robotic arm assists in the preparation and implant placement.” Robotic-assisted knee resurfacing, called Makoplasty, which is also done to preserve the bone in younger patients, has been available in the Puget Sound region now for a couple of years.
Before you get excited about the new surgical options, you need to know that while new procedures are demonstrating terrific results, most joint replacements are still done the traditional way. This is because surgeons are not trained in the alternative procedures, and specialized instruments and computers are not yet widely available. According to Barrett, about 95 percent of hip replacements are still done using back or side incisions, which is what is taught in medical schools, and only about 5 percent are done using the newer anterior approach. “Affecting change takes lots of time and money,” says McAllister. “I was lucky that my partners supported research efforts and that Evergreen Hospital made substantial investments in equipment and facilities, including a cadaver lab for research and training.”
Should you be concerned if your surgeon isn’t using one of the new techniques? No, says Cross, who explains that traditional joint-replacement surgeries have been around for years, and with a 90 to 95 percent success rate, they are one of the most successful surgeries performed in operating rooms today. Instead, concentrate on finding the surgeon who best fits your needs. Ask your primary care doctor for a recommendation. Do research and look for an orthopedic surgeon who does a lot of joint-replacement surgeries; someone with fellowship training (additional specialty training after residency) in joint replacement is a plus. Look for hospitals that do a lot of joint replacements; the staff is more experienced and they tend to do better rehab. “This is a big surgery, so it’s always good to get a second opinion,” Cross says. “Doctors don’t (or shouldn’t) take this personally.”
Hospitals that are leaders in joint replacement programs are also transforming the way care is delivered to joint patients, Cross says. These institutions have excellent pre- and post-operative programs and are proactive in educating patients and their families about what to expect. St. Francis Hospital in Federal Way runs a comprehensive Joint Camp, with small groups of patients going through the process together, from pre-surgical education and surgery through rehab and discharge. Evergreen’s protocol begins one to two weeks before surgery and involves the patient’s family. On the day of surgery, everyone is prepared, rehab equipment has already been delivered to the patient’s home and a family member spends the night to lend support.
Although not one of the larger medical centers, Valley Medical Center has been recognized as a leader in quality for both orthopedic surgery and joint replacement surgery and is included in HealthGrades’ list of America’s 100 Best Hospitals for both. Joint patients at Valley Medical have a new floor to themselves, including private rooms, upscale amenities and access to great food. The environment may be luxe, but the purpose is strictly medical: to create a setting conducive to a fast and healthy recovery. “Joint patients are not ill,” says Dr. Barrett. “They are healthy people with one bad part; they don’t want to be treated like sick people.” ✚