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A Joint Decision

When is the right time for joint replacement

By Steve Calechman

When he was four years old, Courtney Gilman picked up one of his dad’s tennis racquets and started hitting balls against a fence. He never stopped. Until 4 years ago, that is, when at the age of 51 the pain in his hip was too much to ignore. Not only was he unable to play competitively anymore, his livelihood as a tennis instructor was in jeopardy. He had his right hip replaced in May of 2018.

Whit Griswold, a writer and editor on Martha’s Vineyard, reached his breaking point at 71 when a lifetime of running, hunting, fishing and boating had given him so much pain in his shoulders and knees that virtually every move he made had to be a calculated decision. Now 74, he meets each day with one new shoulder, two new knees and an entirely different attitude.

For Amy Macdonald, now 60, it was a different story. When she was 23, she received a cortisone injection that was accidentally dosed too high. The blood supply to her hips was cut off and the balls became brittle, but that wasn’t immediately evident until an X-ray a year later revealed the deterioration.

After that, she had holes drilled into her socket in an attempt to promote blood flow, and, at 25, she spent the year on crutches in the hopes that taking weight off would allow her hips to self-repair. It didn’t work, and she had the left hip replaced when she was 26, the right one when she was 39.

Gilman, Griswold and Macdonald are three of the millions of people who decided to have a joint replaced. While they all made similar decisions, they all got there a different way. As popular as joint replacement surgery has become, sometimes the decision to go ahead with the surgery can be as torturous as the pain itself.

For Macdonald, a resident of Cambridge, Massachusetts, it was a no-brainer.

“Waiting wasn’t an option. I wanted to live a more normal life.”

“Waiting wasn’t an option. I wanted to live a more normal life. I wanted to be a young woman,” she says. But for Gilman and Griswold, it wasn’t so black and white. Both had pain that prevented them from doing ordinary activities, and, for Gilman, being able to fully work. While Griswold had concerns that come with any operation, both their decisions involved a certain math. As Griswold says, “It was not being sure of how long the replacements will last and how long I’ll last. I don’t want to do this again.”

So when is enough enough? How do you know when it’s time to sign that consent form? And when to hold off? That depends. On one hand, there’s never been a better time to get joint replacement surgery. Incisions have become smaller. Anesthesia is regional, and most surgeries are done within hours, the patient home that day. With knees, there are more sizes of kneecaps available, so parts can be better customized, says Trevor Murray, M.D., an orthopedic surgeon at the Cleveland Clinic.

With shoulders, the reverse replacement technique that came to the United States from Europe a decade ago can treat osteoarthritis stemming from rotator cuff tears, a common issue that conventional replacements hadn’t been able to address.

But some have found that the barriers to getting joint replacement is not technological, but psychological. “For some, the resistance is the prideful, “‘That’s not me. That’s other people,’” says Robyn Landow, Ph.D., a psychologist in New York City. “Even if ego wasn’t involved, people will live with the pain until the surgery couldn’t possibly be any worse, and then, finally, they take action.”

Age plays a role because replacement joints don’t last forever – 20-25 years is realistic

So the question remains of how to decide when the time is right. Age plays a role because replacement joints don’t last forever – 20-25 years is realistic, says Vijay Dayarnani, PT, a physical therapist at Spaulding Outpatient Center in the Boston area. A 2017 Lancet study found that revision surgery for those getting replacements over the age of 70 was 5 percent. The risk was 35 percent for men in their early 50’s, and 20 percent for women of the same age.

Use also factors in, as Murray likens joints to new tires on a car. “If it’s parked in the garage, they’ll last forever, but you’ll have no fun,” he says. “If you drag race, you’ll have fun, but they’ll wear out.”

Gilman saw his first doctor in early 2015 who recommended he wait for the necessary hip replacement because he was only 51. In the meantime, he says that he spent thousands of dollars a year on an array of bodywork, medications, and supplements to stay on the court. He kept playing up until five months before his surgery, but he’d balance on one leg and use his racquet to push himself back into position. He could only feed balls, so he had to pass on doing higher intensity private lessons.

During matches, Gilman’s focus on the ball would temporarily occupy his mind, but the energy expenditure was exhausting and eventually undoable. And off the court, he couldn’t walk, move or get out of his car. “It was pretty torturous,” he says. He went to a different doctor in February of 2018, who saw X-rays with bone-on-bone, and asked, “Why weren’t you here sooner?” Gilman says that in hindsight, he should have originally gotten a second opinion. All told, it was three years of managing the pain, or, as he says, “a wasted three years.”

Griswold says his active lifestyle had been unforgiving on his back and knees and was causing his joints to make party trick sounds. The pain wasn’t debilitating, but it would wake up this “good sleeper”. More than that, it tempered every calculation. He’d still go fishing, just not as long. The simplest tasks weren’t so simple. “Maybe I’ll get a glass of water, maybe I won’t,” he says.

Gilman says he was walking down the hospital hallway after surgery without any kind of assistance. Within three days, he was feeding balls; within a week, he was teaching. The only initial issue was feeling like there was a rod in his leg, but after one week and while doing tai chi, the problem cleared. “It felt pure and smooth. I felt like I was 20 again,” he says.

A month later, in June of 2018, he played a friendly doubles match, where he didn’t have to hop, and two weeks later, he and his wife won a doubles tournament in New Hampshire. “It was great, because it felt like I was back,” he says.

Even with advancements, if a procedure is going to be successful, rehab is unavoidable. “People think they’re fixed surgically and they’re good to go,” Dayarnani says. Surgery addresses the damaged joint, but there’s been a breakdown in the body and that brings with it muscle atrophy and a change in the joint’s structure. Therapy involves exercises to regain strength and soft tissue work to open up the muscle fibers and have the joint move freely. The timeline hasn’t changed much over the years, Dayarnani says, but it’s reachable – 6-12 months to return to something close to full range of motion with minimal to no pain.

But before that, there can be discomfort. Macdonald says that she didn’t have a hard rehab – hips aren’t that way – but not so with knees. Griswold says that the first day post-surgery was fine, but when the pain medication wore off, the second 24 hours “sucked,” he says. Add to that, “PT is a pain in the ass,” he says. “It hurts doing what they ask you to do, but if you pay attention and do what you’re told, it’ll work.”

Even with the discomfort, Griswold doesn’t hedge. “It’s worth doing all of it, completely,” he says. He’s actually planning to have his other shoulder done within the year. Like Macdonald, Gilman says his rehab was easy. He was surprised by how much he improved. And the changes weren’t just physical. “Your attitude becomes better. Your outlook becomes better. You smile more because you’re not fighting pain constantly,” he says.

Without the right mindset, recovery becomes harder. “The key is no expectations,” Dayarnani says. There can be setbacks, like sleeplessness, throbbing, numbness. It also takes patience, because while it might be possible to run 6 miles, the body might be saying something else on a given day, and it pays to listen, he says.

“Wow. I haven’t done that in forever. I could be who I am.”

Gilman’s concession has been to not play singles for the first year. But that doesn’t mean he hasn’t been able to appreciate his new joint. In his first post-surgery match he was able to run around his backhand, creating an unreturnable angle from the forehand side. “It’s a fun shot, but you have to be able to move,” Gilman says, and it had been probably 10 years since he had that footwork. But he did it, and when the ball didn’t come back, it was, “Wow. I haven’t done that in forever. I could be who I am.”

About the Writer

Steve Calechman (Bucket Age: 35) lives just north of Boston. He thankfully has all his original joints and hopes to keep it that way, although his two young sons might have other plans. His work has appeared in Men’s Health, The Boston Globe Magazine, Fatherly, and The Old Farmer’s Almanac.

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