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Joint Liability

UCLA Health
Shari Roan

Among the myriad characteristics to admire about the nation’s 77-million-member Baby Boom generation is how they’re aging. Not content to fade into irrelevance or boredom, many Boomers are using their senior years to continue working, babysit the grandchildren, climb Half Dome or surf Oahu’s North Shore. But while the mind is willing, the body often isn’t. And so a steady stream of Americans ages 50 and older seek joint-replacement surgery to help them stay in the game.

Since 2000, the number of total-hip-replacement surgeries performed in the United States has nearly doubled while total knee replacements have more than doubled. According to the American Academy of Orthopaedic Surgeons (AAOS), hip replacements will increase by 174 percent and knee replacements by 674 percent by 2030. Today, about 645,000 total knee replacements are performed annually in the U.S., at a cost of about $9 billion, according to a 2012 analysis in the Journal of the American Medical Association. About 306,000 people undergo total-hip-replacement surgery annually.

“We have seen a progressive increase year after year,” says Benjamin Bengs, MD (FEL ’07), assistant professor of orthopaedic surgery. “It’s an amazing number. And when we add to that the population getting older, we will see a continued increase.”

Numerous studies show knee- and hip-replacement surgeries are reliable, durable and produce wide-ranging benefits to patients and society. But the cost of the operation, along with the rising demand, has made joint-replacement surgery Exhibit A in the often-contentious national dialogue on controlling healthcare costs. The authors of the JAMA paper noted that while the benefits of the surgery are clear, “the increase in [total-knee-replacement surgery] can also be viewed as yet another source of strain on government, insurers, individuals and businesses struggling with unremitting growth in healthcare spending.”

“People single out joint-replacement surgery because it lends itself to being singled out,” says Tom Rosenthal, MD, chief medical officer for UCLA’s hospitals. “It’s an expensive part of the healthcare system, although it’s a small percentage of the overall system. And, it’s discretionary. It’s not life-saving, like treating cancer.”

Moreover, the passage of the Affordable Care Act (ACA) has refocused national healthcare leaders — insurers, policymakers, medical professionals and consumers, too — on the issue of cost. “The idea behind the ACA was to expand coverage and move to universal coverage,” Dr. Rosenthal says. “The central question was how are we going to pay for it? Healthcare costs had not been talked about for the last 10 years, even though healthcare costs continued to rise. The ACA was the trigger for suddenly recognizing, ‘Oh my, we have never really addressed cost.’”

With more Americans than ever flocking to have a discretionary surgery that costs around $20,000, UCLA administrators and physicians are rethinking the logistics of joint-replacement surgery. From research on preventing arthritis to negotiating price cuts with medical suppliers, they say costs can be held down without limiting access to a surgery that dramatically improves lives.

A patient checking in for total-knee-replacement surgery — also called knee arthroplasty — generally is middle-aged or older, hobbling on crutches or sitting in a wheelchair or walking stiffly with bowed legs and a pained look. Typically, arthritis has eroded the cartilage that cushions the bones of the knees, leaving bone rubbing against bone. During the roughly two-hour operation, the surgeon makes a five-inch incision in the front of the knee and moves the kneecap to the side to expose the joint. The damaged cartilage at the ends of the femur and tibia bones is removed, along with some gentle trimming and shaping of the underlying bone. Metal replacement components are affixed into the space to recreate the joint. A plastic spacer is inserted between the metal components to create a smooth gliding surface. In some cases, the kneecap is cut and resurfaced with a piece of plastic. Before closing the incision, the surgeon tests the components by moving the knee through a range of motions.

Several days of hospitalization follow, and then a longer recovery and rehabilitation period at home begins. Most patients can resume normal activities in three-to-six weeks. Although the operation doesn’t restore a knee to a pre-arthritis function, for more than 90 percent of patients, knee pain disappears, and they are able to partake in many common activities, including recreational sports.

Claire Beaumon, 53, emerged from surgery at UCLA on June 12, 2012, with a new right knee and a much brighter future. The Burbank woman, a lifelong sports enthusiast, had worked as a physical-therapist assistant but had gone on disability due to numerous orthopaedic problems that had plagued her since adolescence, including a bad knee that was severely damaged by a post-operative infection in the 1980s.

“My knee was pretty much destroyed after that infection,” she says. “I just lived with it. I tried to stay active. I continued going to the gym, but I stopped biking and I stopped running. But my knee was getting so much worse. I went to doctors, but they said they would never operate on me because I had had a post-op infection. I basically gave up.”

Three years ago, however, Beaumon, now beset by constant pain, consulted with Dr. Bengs. “I’d had 14 procedures on that right knee prior to reconstruction. I told him I’d had this infection and all of these problems,” she says. “But Dr. Bengs said: ‘I can do it. I’m not scared.’ I said, ‘OK, well, I am scared.’”

The operation was uneventful and Beaumon devoted herself to rehabilitation. She continues to work out at the gym and has resumed swimming. “It was painful and it was hard,” she says. “But I kept going. I finally got my full knee extension back around November.“

She still has health problems, including a circulatory disorder and spinal stenosis. But, she says, “To have that one huge, painful disability gone is amazing. The surgery is worth every penny if the patient is good about the rehab.”

For all of the angst about the price tag of joint-replacement surgery, few operations are more supported by data showing their cost-effectiveness and impact on quality of life. In a 2012 analysis published in the journal Best Practice & Research Clinical Rheumatology, researchers at Brigham & Women’s Hospital in Boston conducted a cost-effectiveness review of seven studies on total-knee arthroplasty and six studies on total-hip arthroplasty. The paper concluded that the operations are highly cost-effective.

In another analysis, published in March in the journal Cost Effectiveness and Resource Allocation, Timothy M. Dall, a health economist and managing director of the IHS Healthcare Consulting Practice, argued that musculoskeletal disorders impose a huge burden on society and that scant attention has been paid to the economic benefits of treatment. He studied economic and employment data on more than 185,000 Americans participating in the National Health Interview Survey. The survey also assessed the severity of their physical limitations. Dall found that improved physical function is associated with a higher likelihood of employment, higher household income, fewer missed days of work and reduced likelihood of receiving supplemental security income for disability.

In a statement, AAOS President John R. Tongue, MD, noted that the ACA charges Americans with becoming better stewards of healthcare funds. But he argued that a missing piece of the debate is the indirect costs of illness. “The policy arguments to date have focused narrowly and relentlessly on the simple cost of procedures to patients and payers, which skews the picture,” he wrote, arguing that the definition of value can’t be based on “the sticker price of the orthopaedic procedure or treatment.”

Joint-replacement surgery “is one of the few procedures that consistently is shown to be cost-effective,” notes Dr. Bengs. “It’s been measured time and time again. It saves money per year by decreasing pain, increasing function, increasing participation in employment and activities, decreasing visits to doctors. That’s why it’s done, because it’s so cost-effective.”

Joint-replacement-surgery expenditures should be compared to the cost of not treating the patient, says Bert Thomas, MD (RES ’84), chief of the joint-replacement service at Ronald Reagan UCLA Medical Center. While medications and physical therapy are recommended for arthritis — and must be attempted before insurers will agree to pay for arthroplasty — they rarely alleviate the problems associated with severe joint damage.

“The alternative if you did not take care of the knee with surgery would be to have the patient live with arthritis. The cost of that is much higher than treating the condition with surgery,” he explains. “A patient who has severe arthritis in the hip or knee oftentimes, in addition to living in constant pain, will be unable to carry on normal work activity, will miss work or will go on disability. Society and the employer will wind up paying disability payments indefinitely. The only true cure for arthritis is surgery.”

The dramatic improvement in patients’ lives is one reason why more Americans are having joint-replacement surgery at younger ages. But that trend has ignited a fresh round of scrutiny over the costs of the procedure. The widening scope of patients seeking the procedure drives up overall costs. Moreover, while today’s artificial joints can last as long as 20 years before wearing out, a person getting a new knee at age 50 is likely to need a second surgery, called a revision surgery, later in life.

Revision surgeries are increasing, with more than 60,000 such operations reported in 2012. Of the 4.7 percent of Americans age 50 and older who have had total knee replacement, about one-third are in their 50s and 60s, according to a study by Elena Losina, PhD, co-director of the Orthopaedic and Arthritis Center for Outcomes Research at Brigham & Women’s Hospital. Demand for the procedure, which costs about $27,000, among people 45 to 64 has tripled in the past 10 years.

“The concern over costs related to revisions is very valid,” Dr. Bengs says. “But we’re seeing an improving quality of surgery and increased longevity of the components, too. That is part of the reason why we’re more comfortable doing the surgery in younger patients. We’re seeing 50-year-olds with debilitating arthritis. Rather than telling them to come back when they’re 60 and deconditioned and with illnesses related to a sedentary lifestyle, why not take care of it now?”

Despite the support for providing surgery to patients in need, responsible healthcare leaders constantly look for ways to curtail costs. For example, says Dr. Rosenthal, healthcare organizations, including Medicare, are attempting to look at why the cost of joint-replacement surgery can vary widely around the nation.

Nationwide, Dr. Rosenthal says, doctors “should be able to do the surgery on large numbers of patients without a lot of variation. Reducing variation will be good. It will end up improving care because people are following best practices, and that endsup reducing the cost of care.”

UCLA and the other University of California medical centers are addressing the issue of internal cost containment, Dr. Bengs adds. For example, each medical center performs surveillance to decrease waste. The university system is also negotiating better prices with the joint-replacement manufacturers.

“We are constantly trying to improve efficacy and quality and decrease waste,” he says. “UCLA and the other UCs are very sensitive to cost.” The medical center is also working on improving the biomaterials used in implants so they will last even longer. UCLA and Los Angeles Orthopaedic Hospital created a new plastic that has been shown to be more durable, perhaps for as long as 30 years, Dr. Bengs says.

They have also made advances in how the new joint is inserted. The standard approach is to affix the prosthesis to the body with bone cement. But the cement can deteriorate, he says. UCLA has helped pioneer an approach that adds proteins called growth factors to the implant “so there is a living interface with bone growing into the prosthesis,” Dr. Bengs says. UCLA also has assisted in the development of partial-knee-replacement surgery and resurfacing hip arthroplasty, less extensive and less costly surgeries “that we think will help conserve bone,” Dr. Thomas adds.

Currently, little can be done to help prevent the severe tissue damage that ultimately leads to the need for joint replacement. But UCLA researchers are studying potential preventive strategies, says Dr. Thomas. Obesity, for example, is a major contributor to deteriorating joints. Helping patients lose weight and maintain a healthy weight pays off.

UCLA researchers are also investigating the causes of arthritis — a term that encompasses a number of different diseases that attack joints — in an attempt to discover a technique to interrupt the disease or treat it. One investigative group is in the early stages of research on trying to regrow cartilage. “Our goal would be, if we can get a good-enough understanding of the arthritis process, to have specific therapies to cure the disease,” Dr. Thomas says. “Right now, the only cure is surgery.”

But, he notes, that’s not such a bad thing. “The popularity of the procedure tells me that it’s very successful. These hip and knee replacements are the most successful procedures in the history of surgery. The results are so dramatic. You’re taking someone from crutches and wheelchairs and within days having them walking through the community.”

Shari Roan wrote about medicine and healthcare for the Los Angeles Times.

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