I will get many emails asking simply, “Am I too old for hip replacement or your treatments?” “What age should I consider hip replacement?” “Do you think my doctor is right when he is telling me to wait for a few years to get a hip replacement?” My long standing opinion has always been, if you can avoid surgery, avoid it. That is why my practice is dedicated to non-surgical, regenerative medicine treatments. HOWEVER, there are some patients we do recommend that they seek out a hip replacement. These are people that we have examined and in our opinion they would be a very poor candidate for our treatments. They would be better served with a hip replacement.
Age has shown no effect on hip replacement outcomes in some studies
Most people who ask about hip replacement with age related concerns are of two types: “My (mother or father) is 80-something years old, the doctors want to do a hip replacement,” or “I am (30ish or 40ish) my doctor is telling me to wait until I am older so I will not outlive the replacement.”
A number of different studies make different recommendations as to what is the best age for a hip replacement? The answer to this question is better asked, what is the best age for a hip replacement so I do not need a second one later in life.
A July 2022 study (1) examined the research on what is the best age for a total hip replacement. In some studies the researchers found that “age has shown no effect on outcome in some evaluations, while others have reported higher functional improvement in younger patients.” The aim then of their study was to determine if outcome after total hip replacement varies based on patient age.
- Prior to surgery, younger patients (less than 55 years) reported worse pain, function, and quality of life than other three patient groups.
- 55-64 years [older adult],
- 65-74 years [early elder],
- and more than 75 years [late elder])
- At one year after total hip replacement, younger patients ( less than 55 years) reported slightly worse pain and quality of life but better function scores than the three older patients’ groups.
- Younger patients (less than 55 years) achieved higher baseline to one year pain, and function score changes when compared to the older patients’ groups.
- The quality of life score changes was not different among the four age groups.
- Conclusion: “Although there are statistically significant differences in pain relief, functional improvement, and quality of life between younger and older patients among different patients’ age groups, there is no clinically significant difference. Total hip replacement provides an improvement in quality of life by decreasing pain and increasing function in all four age groups, with large improvements in Patient-Reported Outcome Measures scores without clinically significant age-related differences in Total hip replacement outcome at 1 year.”
People get hip replacements so they can get back to work
A January 2023 paper (6) describes the problems both patient and doctor have in understanding whether or not a patient can and when they can return to work. The paper notes that about 20% of total hip replacements are performed on people under 60 years of age when people are still of realistic working age. Return to work would be considered an important component of their hip replacement success. The problem this paper describes is that outcomes describing patients getting back are not routinely reported by doctors. Most patients who are working pre-operatively do intend to return to work post-operatively and will need advice about when they can expect to return to work. Patients may also need advice regarding specific demands of their job e.g., physically demanding activities and/or loading or driving. Unfortunately, guidelines for clinicians are lacking.
The concern of the survivorship of a total hip replacement in younger patients
A July 2022 study (2) examined the concern of the survivorship of a total hip replacement in younger patients. The primary concern is the subsequent need for revision surgery in later life. This study included 2,461 patients (2,814 hips) with minimum 2-year follow-up who underwent primary total hip replacement. There were 561 patients (643 total hip replacement; 23%) aged 55 or younger and 1,900 (2,171 total hip replacement; 77%) older than 55.
The researchers follow-up was 5 years for both groups. There were more male patients in the younger (55%) than older (41%) group. Body mass index (BMI) was higher in younger patients independent of gender. Kaplan-Meier survival to endpoint of all cause revision was similar between groups at 12 years with 97.5% for younger versus 97.1% for older patients. Most frequent reason for revision overall was periprosthetic femoral fracture univariate analysis revealed risk factors were female gender and age being more than 65 years old.
The researchers concluded that “Use of modern polyethylene, such as vitamin E-stabilized highly cross-linked, liners during total hip replacement may improve survivorship in younger patients undergoing total hip replacement.”
What factors could increase the longevity of a total hip replacement?
A July 2022 study (3) looked to see what factors could increase the longevity of a total hip replacement. The researchers focused on highly cross-linked polyethylene (a polyethylene designed in the 1990’s to offset wear and tear of the hardware components). They note that since its introduction, studies on the longevity of this polyethylene are lacking.
The researchers evaluated patients who underwent total hip arthroplasty with highly cross-linked polyethylene at an average 10-year follow-up for (1) linear and volumetric wear rates, (2) patient and implant characteristics, (3) implant survivorships, and (4) functional scores. The general findings were:
- Younger age patients had higher volumetric wear of the polyethylene.
- Increasing body mass index trended toward higher total and yearly linear and volumetric wear.
- Ten (of the total 110) patients (in the study) required revisions
- Younger age and higher body mass index at the time of surgery may be important patient characteristics influencing long-term wear.
Return to sports prompts younger patients to get hip replacement
A March 2021 study (4) examined the impact of total hip replacements in patient under the age of 50. The authors note that “an increasing number of younger (less than 50 years old) and active patients will receive surgical interventions, and expectations for an active lifestyle will accordingly increase. In addition, surgeons now have a growing array of techniques and implant materials to choose from. Despite these developments, evidence to provide the best standard-of-care to patients with high expectations for return to sports (RTS) is scarce and urgently needed.”
The researchers of this study offered findings based what recommendations arthroplasty surgeons currently make to patients with high return to sports expectations, what factors may influence their recommendations and what surgical techniques and implant specifications are considered favorable in the treatment of patients with a more active lifestyle?
- “The majority of surgeons (81.9%) were in favor of return to sports after total hip replacements. Risks associated with sports after total hip replacements were considered minimal (1%), with periprosthetic fractures ranking highest, followed by hip dislocation and polyethylene wear. Some surgical decision-making was influenced by high-return to sports expectations in regard to implant fixation, stem type, femoral head diameter, and bearing-surface tribology. We observed an increasingly liberal counseling of patients for high-impact sports.”
Hip resurfacing or hip replacement?
An August 2022 paper (5) studied the long-term results of total hip replacement in young and active patients. Hip resurfacing replacement is an alternative in such patients and gaining popularity. This review was done, according to the research team, to compare complications and outcomes between Hip resurfacing replacement and total hip replacement by assessing the latest studies over the past ten years. The results? “Despite similar function and revision rates, Hip resurfacing replacement was seen to have lesser associated complications and ionic levels (the amount of ionized debris from the plastic of the hip replacement) may not be a detrimental issue. Hip resurfacing provides relative ease during revisions, especially in younger patients and it may be an alternative to total hip replacement in the younger population.”
Options to hip replacement
When a patient comes into our office, the realistic expectation of effectiveness of treatment is confirmed by a physical examination and a patient history. Following the consultation we sit down with the patient and present our recommendations for their hip pain treatments.
Hip injections using Bone marrow stem cells
Over the years we have seen our fair share of people with a diagnosis of a bone-on-bone hips. The people we usually see have a lot of hip pain and instability which causes walking difficulties, balance difficulties and prevents these people from feeling stable on their feet. Some people come in with a diagnosis of avascular necrosis. Some of these people have been told that the only way they will ever get pain relief is from a hip replacement. But most people I see with avascular necrosis of the hip or shoulder don’t need a surgery. Sometimes they only need a little education to help them understand what is happening in their hip and that they can avoid the hip replacement.
References
1 Ayers DC, Yousef M, Zheng H, Yang W, Franklin PD. Do patient outcomes vary by patient age following primary total hip arthroplasty?. The Journal of Arthroplasty. 2022 Mar 12.
2 Lombardi Jr AV, Byrd ZO, Berend KR, Morris MJ, Adams JB, Crawford DA. Mid-term survival of total hip arthroplasty in patients younger than 55-year-old. The Journal of Arthroplasty. 2022 Feb 28.
3 Sax OC, Douglas SJ, Chen Z, Mont MA, Nace J, Delanois RE. Low wear at 10-year follow-up of a second-generation highly cross-linked polyethylene in total hip arthroplasty. The Journal of Arthroplasty. 2022 Feb 22.
4 Vu-Han T, Hardt S, Ascherl R, Gwinner C, Perka C. RECOMMENDATIONS FOR RETURN TO SPORTS AFTER TOTAL HIP ARTHROPLASTY ARE BECOMING LESS RESTRICTIVE AS IMPLANTS IMPROVE. Archives of orthopaedic and trauma surgery. 2021 Mar;141(3):497-507.
5 Kumar P, Ksheersagar V, Aggarwal S, Jindal K, Dadra A, Kumar V, Patel S. Complications and mid to long term outcomes for hip resurfacing versus total hip replacement: a systematic review and meta-analysis. Eur J Orthop Surg Traumatol. 2022 Aug 25. doi: 10.1007/s00590-022-03361-5. Epub ahead of print. PMID: 36006506.
6 Zaballa E, Dennison E, Walker-Bone K. Function and employment after total hip replacement in older adults: A narrative review. Maturitas. 2022 Sep 14.