Joint Replacement for the Active Adult

How to get weekend warriors back to their daily lives faster after arthroplasty.

Joint replacement surgery no longer signals a pause in the active pursuits of energetic, Type A fireballs. Surgeons and care teams in ASCs and HOPDs are redefining the landscape of joint replacement for active adults. Through the integration of custom implants, advanced navigation systems, innovative anesthesia techniques and expedited rehab schedules, these centers are propelling individuals back to their dynamic lifestyles with unprecedented speed and precision.

When it comes to this population of patients, the challenges faced by surgeons and care teams are multifaceted. Dustin Schuett, DO, FAAOS, orthopedic surgeon at the Naval Medical Center in San Diego, acknowledges the necessity of managing expectations and the varying duration of recovery. While hip replacements often yield a swift recovery, knee replacements can take longer, requiring encouragement throughout the process. “We need to encourage and coach them and set expectations of how to get to their ultimate goal,” says Dr. Schuett. “We need to be their mentor and cheerleader along the way.”

Addressing the unique needs of active adults during joint replacement surgeries comes with its challenges. Ronald M. Kristensen, MD, director of joint replacement at St. Luke’s, emphasizes the profound significance joint replacements hold for these patients, as their future activity levels hinge on the success of the procedure. Setting early, achievable goals is crucial to prevent overly ambitious patients from pushing themselves too hard in the initial stages of their recoveries. “There’s definitely a period of activity where our aggressive go-getters try to be too active,” says Dr. Kristensen. “To counteract that, we aim to give them goals that are achievable at the right time.”

“Setting expectations of what they can and can’t do is critical, but we also have a lot of patients who can go back to being active very soon,” adds Zachary Yenna, MD, a hip and knee replacement surgeon at St. Luke’s. “I think most patients expect to go back to a certain familiar activity level, and we can help get them there as long as we set clear expectations about the timeline.”

New technologies pushing the envelope

PAIN BLOCKADE Cannon E. Turner, MD, was recruited by Knoxville Orthopaedic for his use of ultrasound-guided nerve blocks and innovative anesthesia practices at same-day total joints centers.  |  Knoxville Orthopaedic Clinic

In the pursuit of seamless recovery, some surgeons are turning to custom implants tailored to the unique anatomy and activity level of each patient. This personalized approach ensures a perfect fit and optimal functionality, addressing the specific demands of an active lifestyle.

J. Milo Sewards, MD, chair of orthopedic surgery and sports medicine at the Lewis Katz School of Medicine at Temple University in Philadelphia and an orthopedic surgeon at Temple University Hospital, cautions that while custom implants aren’t a cure-all, they have the potential to help get patients back on their feet even more quickly. This is because custom implants can help minimize the number of patients who feel that their joint doesn’t behave like their native joint.

“Custom implants aren’t always the holy grail of getting people back to what they want to do, but they can maximize the impact of getting patients back to their desired range of motion,” says Dr. Sewards.

Dr. Schuett notes that while he does not use custom implants due to their “fussiness,” higher cost and difficulty in handling, there is a benefit to being able to tailor implants to the patient — though the range of sizes offered in standard implants by most vendors today can help meet that need. “The analogy I use is that it’s like going into a store and finding things that fit perfectly for that patient,” he said. “In essence, they get a custom surgery for their body and proportions, without the excess cost and issues of custom implants.”

Dr. Kristensen notes that while the St. Luke’s team has not ventured into custom implant territory, advancements in technology and the precision of implant placement play a pivotal role. Dr. Yenna adds that robotics can allow for real-time adjustments based on each patient’s unique anatomy, creating a surgery that is more individualized — and potentially more customized — than traditional methods. “The precision with robotics and navigation systems is much more than ever before,” says Dr. Yenna. “I’m on the fence about the impact on long-term patient outcomes — hips have done universally well for a long time, for example — but I think knees will settle out in the long-term to be a little better. It might take time for that to show up in the data, but I can say it is a better intraoperative experience.”

Advanced anesthesia techniques

The journey to swift rehabilitation begins in the OR, where innovative anesthesia techniques play a pivotal role. Surgeons are now utilizing nerve blocks and other forms of regional anesthesia, and combining them with multimodal pain management strategies to mitigate postoperative discomfort. By minimizing pain, patients experience a smoother transition from surgery to rehab, allowing them to engage in early mobility and regain their active independence sooner.

Dr. Sewards underscores the critical partnership with anesthesia and pain control techniques, especially in outpatient settings. Controlling pain during surgery and in the early rehab phase is crucial for patients to regain motion and muscle function rapidly. Dr. Sewards advocates for a multimodal approach, including regional injections and short-term oral post-op pain control to optimize function while minimizing potential downsides such as motor function issues.

The use of spinal anesthesia, nerve blocks and various injections aids in pain management and facilitates a faster recovery, adds Dr. Schuett. He notes that studies indicate that spinal anesthesia leads to quicker awakening, improved mobility, reduced blood loss and lower infection rates. At his facility, patients take celecoxib 10 days before surgery to help block inflammation. They then continue taking it postoperatively, along with around-the-clock acetaminophen, pregabalin for nerve pain and oxycodone as appropriate. “We separate the narcotic from the acetaminophen so they can use the acetaminophen around the clock and the narcotic only as needed,” he says. “This gives the patient diverse options for pain medication. The old option was to take a narcotic or nothing.”

At St. Luke’s, Dr. Kristensen notes that providers use longer-acting agents, spinal anesthesia and nerve blocks to provide patients with relief and minimize pain, contributing to a more comfortable postoperative experience. “We can inject the knee and give the patients 48 to 72 hours of relief,” says Dr. Kristensen. “That’s one of the most exciting advancements we have.”

Patient-centered care

At the heart of successful outpatient total joint programs is a commitment to patients’ individual surgical needs and outcomes. Centers prioritize open communication, education and shared decision-making, ensuring that patients are active participants in their recovery journeys. From preoperative counseling to postoperative follow-ups, care teams collaborate closely with patients to set realistic expectations, address concerns and celebrate milestones, which fosters a sense of empowerment and motivation.

Dr. Schuett says he places significant importance on the initial meeting with patients, aiming to understand their goals and desires, as well as the limitations they face in their daily lives. By learning about the activities the patients wish to pursue — whether it’s biking, walking or other pursuits — Dr. Schuett customizes the joint replacement experience to align with their specific activity levels and lifestyle goals. Once expectations are set and the roadmap is laid out, patients will start with assisted devices like a walker, and then eventually a cane, and gradually progress to normal activities.

“A lot of patients — especially younger ones — want to get up and moving fast, but I tell them to wait at least two weeks and work with a physical therapist to tell them what they can and can’t do,” he says. “I recommend no biking outside for the first two months because of the potential of falling. But after that, for the most part, they can get back to their hiking, biking, swimming, et cetera.”

Dr. Sewards emphasizes the pivotal role of establishing a collaborative effort with patients in customizing their joint replacement experience. This involves understanding their goals, current activities and desired activity levels. The challenge lies in managing expectations realistically, differentiating between activities that are compatible with joint replacement and those that may pose risks to the longevity of the joint. He emphasizes the importance of tailoring the approach based on the specific activity, such as rock climbing versus cycling, and maximizing range of motion accordingly.

“Historically, when we do joint replacements, we counsel them to avoid high-impact activities or repetitive activities or anything else that causes the joint to wear out in a shorter timeframe than it otherwise should,” he says. “We manage patient expectations of what they want to do while trying not to be overly restrictive. Recent evidence shows joint replacement patients may safely be more active than we otherwise previously expected or wanted them to be.”

As the demand for joint replacements among the active adult population continues to rise, these strategies are not merely transforming recovery; they are rewriting the narrative for those who refuse to let joint issues impede their zest for life. “It’s an emerging area. I have a large population of patients who are younger, more aggressive and want more from their joint replacements,” says Dr. Schuett. “We’re doing joint replacements in younger and younger patients, and they are in turn pushing the envelope of what they’re doing with a joint replacement. I tell all my patients that six months after the joint replacement, I want them more active than they were in the two years prior. I have a colleague who says we’re in the moving business. We want patients up and moving.” OSM