JENNIFER BOULDEN

The first Arkansan to have a radical new knee replacement procedure offering hope to adults of all ages was a 71-year-old who could no longer manage his daily three-mile run.

Raymond Foltz retired from his job as chief of maintenance for O’Hare International Airport in Chicago 10 years ago, and since then, he and his wife have made a comfortable, active retirement in Cabot. Foltz has had arthritis pain in his knee for over sixteen years but was able to run three miles every day until about five years ago when his knee abruptly stopped working well enough to allow him to run one morning. Wanting to stay active, he switched his routine to a rigorous daily cardio workout at the gym. In mid-July, his knee once again started causing him pain. Instead of discontinuing his routine, he kept it up at a lower level — only 45 minutes on the stationary bike, the weight off his knees. But he knew it was time to get something done about his knee, and he was sure he would need a total knee replacement.

A referral landed him in the UAMS office of Richard Evans, MD, chief of Adult Reconstruction, director of the Center for Hip and Knee Surgery and associate professor in the UAMS Department of Orthopedic Surgery. Evans concurred that Foltz needed surgery but told him he had a choice: the standard total knee replacement or a bicompartmental knee resurfacing surgery approved by the FDA less than a month before. The new procedure, called the “deuce” because it removes two of the three compartments of the knee instead of the one- or three-compartment surgeries commonly available. Foltz opted for the deuce, and Evans performed the 90-minute operation on Aug. 22.

Evans is one of fewer than 200 surgeons in the United States who are certified in the new procedure. The majority of those certified are joint specialists at academic institutions. Evans said that while more than a million traditional joint surgeries will be performed in the United States this year, the vast majority of those don’t require inordinate technical proficiency beyond what is acquired in residency. The deuce and a similar, but independently developed, new hip resurfacing procedure he began performing in March are different.

“They’re just more difficult. They take longer to do,” Evans said. He likens them to a wide variety of other minimally invasive orthopedic procedures that are now available for patients but that have been slow to take off in the industry despite their vastly improved outcomes. “They are so hard to perform that many physicians find them more trouble than they are worth. The benefits to the patient are enormous, but if you can’t do it well, you don’t want to do it anyway. The guys who are going to try this are the guys who do total joints almost exclusively.”

The benefits are impressive, though. Because the parts used in total knee and hip replacements wear out relatively quickly and subsequent replacements have a diminishing efficacy, patients with arthritis or joint injuries must usually wait until they are over 65 get a new knee or hip. Not so with the deuce or hip resurfacing. “With the resurfacing, we don’t cut anything out,” Evans explained. “We just resurface the joint itself. It’s a lot less metal, a lot less bone loss.”

Besides being less invasive, the resurfacing gives the patient another 10 to 20 years of activity. This makes the new procedures optimal for anyone not old enough or bad off enough to need a total joint replacement. Foltz said that he thinks the vast majority of arthritis sufferers like himself could benefit from the surgery. “Before, we had to either live with the pain or get rid of the pain by having the total knee done. This is a godsend.”

The surgeries can get middle-aged or younger people into their retirement before they wear out the surface replacement and need their first total hip or knee replacement. Evans said many patients as young as in their 20s have already had the hip resurfacing.

“The last thing we want to do is put a new hip in them at that age,” he said, “but the resurfacing makes them new people. A lot of these folks can go back to work, back to their lives.” He said it’s one thing to “fix Grandma so she can chase the grandkids around the house,” but another to give a young or middle-aged patient a chance to earn a living wage free from crippling disability. “From my perspective, it’s a lot more satisfying.”

Another benefit to the deuce surgery is that for the first time, patients can retain their ligaments. This was a big factor for Foltz, because he’d read that total knee replacements are sometimes uncomfortable; without those outer ligaments, the knee doesn’t feel as secure. Plus, retaining those ligaments allows the lateral movements necessary for sports and all kinds of daily activities. “I don’t play soccer,” Foltz said, “but I can go out on the golf course every day without fear of my knee buckling if I step in a hole in the grass.”

Because the ligaments remain intact and the procedures are available for adults of all ages, Evans said the surgery is likely to become enormously popular with athletes and anyone with an active lifestyle. “You can get back to that level of performance, although we try to counsel people who are triathletes or competitive or very hard skiers, runners, whatever, on what not to do,” he said. “It is that successful.”

Another interesting aspect to the deuce surgery is that this is one of the first areas of orthopedics where sports medicine and adult joint reconstruction are merging. “The technologies are marrying each other,” Evans said. “For people who have old high school or college football injuries, for instance, and they’re in their 30s and 40s with an unstable knee that’s worn out, we can go in and do a ligament reconstruction and at the same time do a resurfacing with the deuce and give them a new knee from a sports and a joint-resurfacing standpoint at the same time. With a total knee, we don’t have that option.”

Like so much of medicine, orthopedics is becoming extremely high-tech.
“We’ve got a computer-assisted robotic surgery we’re using, plus the minimally invasive surgeries and this new resurfacing technology that’s coming out,” Evans said, “and there’s even more in the pipeline. It’s a pretty fertile time in orthopedics right now.”

That’s a very good thing, because the baby boomers are coming on strong. Soon, orthopedists will have more joints to fix than they can imagine, Evans predicts. “They’re going to be much more active than our parents were, and they’re still going to be weekend warriors,” he said. “But at least we’ve got some new good options for them. All this technology coming out at the same time couldn’t have been timed better.”

Two weeks after his surgery, Foltz reported that he’d spent most of that time walking almost normally, using a cane only rarely. What’s more, while he’s not planning on resuming his daily runs, he’s already back in the gym. “So far, I’m managing 30 minutes on the bike at a pretty high level each day,” he said, “but once I get these staples out next week and the swelling goes all the way down, then I’ll really be able to get back into it 100 percent.”



October 2007