Exercise and Longevity

As I mentioned in my previous posts here and here, exercise can be beneficial to older adults for a number of reasons. Exercise is perhaps one of the most important weapons in the fight against aging because of its myriad of positive effects on the body. This paper summarizes the results from a number of studies and concludes that regular aerobic exercise an increase mood, energy levels, strength, balance, and coordination. This sounds remarkably like the effects of HGH supplementation. In addition to these immediate effects, regular exercisers also had lower overall death rates than their sedentary counterparts. In fact, the individuals in any given age group (accounting for gender) with the lowest death rates were also the most active. In addition to even this is the increased independence for older adults who exercise regularly. Being physically fit can decrease the chances of a fall, and reduce the effects of one on the body. Stronger bones are more resistant to fracture, after all. The National Acadamie's Institute of Medicine suggests that all Americans aim for 60 minutes of physical activity each day.

Capromorelin - New Drug to Prevent Frailty in Old Age?

The American pharmaceutical giant Pfizer has recently released a new drug that holds promise to reduce the effects of aging. Capromorelin has been shown to increase levels of human growth hormone in elderly patients. The effects of this increase in HGH include lean muscle gain, improved balance, and improved coordination. Human growth hormone levels typically peak from late childhood to around puberty, when growth is most rapid. From then on, levels decline steadily and then drop off quickly after about age sixty. This decrease is associated with a lack of energy, less powerful immune system, and more rapid 'wear and tear' on the body. Theoretically, bringing HGH levels back up to near-puberty levels could bring back some youthful vigor to an otherwise frail individual. While this may be the case, it is also possible to raise HGH levels naturally through exercise, proper diet, and adequate sleep. For the time being, these may be safer options for healthy people considering a drug to increase their growth hormone production.

Osteoporsis - Preventative Measures

One of the leading causes of debilitation of women over the age of 50 in the United States is osteoporosis. Bones are constantly being broken down and rebuilt by osteoclasts and osteoblasts, respectively. This process is known as bone remodeling. Osteoporosis is condition in which bones are destroyed at a rate faster than they are rebuilt and therefore become weaker over time. Since an increase in osteoclast activity can lead to a reduction in bone mass, it has been proposed that estrogen (which stimulates osteoblast activity) could be used to combat the effects of osteoporosis. This theory also explains why osteoporosis affects primarily post-menopausal women (women who are producing less estrogen than they previously were).

Preventing osteoporosis is a worthy goal, and there are several ways to go about it. First and most importantly is calcium intake. Calcium in the bloodstream is necessary for both slowing bone breakdown and promoting bone formation. Increasing dietary calcium can lead to this desired effect. Secondly, vitamin D is needed to promote absorption of calcium. Vitamin D can be absorbed through the skin from sunlight, and can also be ingested. Vitamin D fortified milk is an excellent source of both calcium and vitamin D.

Finally, exercise is a great way to slow osteoporosis. Bones respond to stress by building more bone. Running, for example, will help strengthen the bones of the lower body and help prevent the onset of frailty. It is important to note that impact exercies should be undertaken gradually in order to reduce the risk of developing stress fractures in individuals who already are experiencing some early form of osteoporosis.

Assistive Technology for Older Americans

While this may not be directly related to orthopedic surgery, I feel that I should discuss the current situation of assistive technologies for older adults. This is because older adults are a large (and growing) population that is prone to conditions that sometimes warrant surgery and other times require technological assistance, such as a mobile scooter or a walker. These kinds of technologies can be crucial in maintaining a senior citizen's mobility and independence, but they are not cheap. It can be difficult for an individual to afford these items, or other more expensive technologies like modified bathrooms, and there is limited funding available to help support these cases. According to the Executive Director of the American Society on Aging, Gloria Cavanaugh, the major hurdle is often proving that these devices or home modifications are 'medically necessary.' Healthcare providers are often hesitant to approve funding for assistive technologies, since they claim that they are essentially frivolous. The fact of the matter though, is that these assistive technologies can dramatically improve the quality of life for an older individual by preserving independence and eliminating the need for a personal caretaker. This is a great reason to approve funding, in my opinion. One of the most difficult aspects of aging in America is the dependence that is associated with it. Prolonging the independence of a senior citizen should always be a priority.

Increasing population age = more joint replacements

There's another thing that I should have mentioned in my previous post. According to WebMD, hip replacements are expected to rise 174% in the next 20 years, and knee replacements are expected to rise by as much as 673%. That is an astronomical increase in joint replacement surgeries! This relates back to my previous post, when I talked about the increasingly active lifestyle that today's older generations are living. The knee replacement rates are particularly indicative of this. A total knee replacement is frequently performed on an individual who has been active for a lifetime, and consequently has done damage to the knees. This is unavoidable for many active people. Eventually joints wear out, but luckily we have great replacement technology. Total knee replacements can be expected to last for upwards of twenty years without any significant degradation. Of course, it is always possible for an extremely active and young individual who gets a knee replacement to have a revision later without much hassle.

Changing Population Demographics

One of the most interesting pressures that physicians face today is the issue of an aging population. I decided to look into this phenomenon and I found an interesting site called longevity-science.org that talked about this very issue. According to some scholarly predictions, the world's elderly population is expected to rise from 6.9% of the total population today up to 19% by 2050. That is a striking increase, and one that will surely be felt by the medical profession. Orthopedic surgeons will be seeing more joint replacement patients in the years to come since there will be a greater number of elderly individuals leading increasingly active lifestyles. It almost seems improper to refer to today's elderly population as "elderly," considering how physically capable and full of life many of them are. I think it will be great to watch the progression that will take place in the next fifty years. Eventually it will be commonplace to run into centegenarians jogging in the park or lifting weights in the gym. Maybe I'll be lucky enough to be one of them.

Back in the Game

Well, after taking almost a year off from working on the site, I've decided to get back into it all and try to get the Bone Breaker bigger than ever. Look for new posts and research coming soon.

Interactivity and Web 2.0: Getting in touch with other bloggers

This week I again went through the blogosphere in search of quality orthopedic blogs. Thanks to Google Directory, I was able to find two such excellent blogs. The first, Doctor Tarlow on Knees, is maintained by Dr. Stephan Tarlow, an orthopedic surgeon from Scottsdale, Arizona. One of the more recent posts on this blog talked about a new computer program that might be able to help surgeons align replacement knees with greater accuracy. I had a few clarification questions to ask Dr. Tarlow, and the full text of my comment is available below.

The second blog that I found myself reading is actually About.com’s section on orthopedics. I read an interesting post about minimally invasive procedures, and decided to share my opinion with the author, Dr. Jonathan Cluett. Again, the full text of my comment can be found below.

“Otis Med: Shape Matching Custom Fit Total Knee Replacement”
Comment:

Dr. Tarlow,

Very interesting post. I just recently stumbled upon your blog, so let me begin by saying that I am very grateful to read the thoughts of a surgeon who clearly cares very much about providing the best, and sometimes newest treatments for his patients. I am currently an undergrad at the University of Southern California and I am very interested in pursuing a career in surgery, particularly orthopedics.

So as for your post, I have a few questions regarding knee replacement surgery. You mentioned in your post that in a traditional replacement, the knee is aligned with its axis perpendicular to a line running from hip to ankle. Is a normal knee not always aligned like this? As far as I understood, this is the driving concept behind the Otis Med system, but it seems to me that most knees ought to be pretty close to this ideal that is used in the traditional replacement. In other words, is “customization” really worth the two or three degrees that a patient’s knee may be off by? As you said, the majority of traditional knee replacements can be expected to last several decades.

Additionally, why is it that the Otis Med system looks at the degenerated knee and tries to reconstruct it to pick a replacement? Wouldn't it be easier to look at the healthy knee and assume symmetry? That way, no computer reconstruction would be necessary.

Forgive me if my comments seem uninformed or off-base. This is all very interesting to me, so I'm just trying to understand as much as I can.

Thanks,

JDM

“Are surgeries done through small incisions better?”
Comment:

Dr. Cluett,

This is a topic that has interested me for quite some time now. It seems to me that surgeons are constantly on the look out for ways to do less and less invasive surgery. In fact, I have even read about natural-orifice surgeries being performed on patients who really don't want scars. But what intrigues me the most is that often times these minimally invasive surgeries (particularly orthopedic ones, it seems) are very difficult for surgeons to perform, and thus increase the risk of surgical error. Do you think that this is indeed the case? Take, for example, a mini-hip replacement. I have read that there is concern about the ultimate alignment of the prosthesis with this technique.

Other minimally invasive surgeries, though, I feel are done because of a greater understanding of human anatomy. The Quad-sparing knee replacement provides an excellent. This procedure works around the quadriceps instead of through it so that the new joint can be better stabilized post-op. I think that it should be reasons like this, not cosmetic ones, that lead surgeons to create new surgical techniques. Thoughts?

Quad-Sparing Knee Replacement Surgery: The New Gold Standard

All aspects of surgery are being affected by a new minimally invasive trend. No matter what procedure is being performed, if there is a way to do it with less negative impact on the body, today’s surgeons are working on ways to make it happen. A few weeks ago I wrote a post about the mini hip replacement that has developed recently. This week I will write a similar post about a relatively new procedure known as a quadriceps-sparing total knee replacement. It has the same end result as a traditional total knee replacement, or TKR, but it does so with considerably less damage to the surrounding tissue in the operating room. I believe that this new procedure, unlike the total hip replacement, is a great improvement on the traditional surgery. While it is a more difficult operation when compared to the traditional TKR, its advantages are more than just cosmetic and I believe it is a superior choice for all people looking for a knee replacement.

During a traditional knee replacement surgery, a vertical incision is made along the top of the knee that exposes the quadriceps muscle. A secondary incision is then made through the quadriceps to expose the knee joint. At this stage, many tendons and much muscle tissue has been cut, resulting in unavoidable blood loss and a need for major anesthesia. The knee prosthesis is then inserted by a method similar to the total hip replacement. A plastic cup is placed on one end of the joint and a metal ball is attached to the other, as can be seen in the x-ray at left. The new joint is then assembled and aligned and tested for mobility. Once the surgeon is satisfied with the functionality of the prosthesis the soft tissue is sutured and the incisions are closed. Traditional knee replacement patients will typically stay in the hospital for three to four days, and then have up to eight weeks of physical therapy to recover completely.

This is the area in which the quad-sparing procedure becomes most attractive. Patients who undergo this surgery can expect to leave the hospital in less than one day, and the reasons are multi-fold. First of all, the incision is much smaller. In the traditional surgery, the incision is approximately eight to twelve inches in length. With the new technique it can be as small as three inches, with most being about four (see image below right). The incision is made on the side of the knee, which allows the joint to be exposed without severing any tendons or disturbing much muscle tissue. Because of this, there is less blood loss compared to the traditional TKR and less anesthesia is needed. Less anesthesia is almost always preferred by surgeons since surgery itself is a very traumatic experience for the body and heavy sedation only complicates the recovery process.

After the surgery is complete, the patient can usually be walking around as soon as he/she wakes up. Since there is no major structural trauma caused by the surgery, the road to recovery is a very quick one. The success rate is astounding. Take this study done by Rush University Medical Center, for example. In their trial run of fifty patients, ninety-six percent were able to go home the same day as their surgery. Granted, each patient was the first one treated that day (allowing maximum same-day recovery time), but it is still quite impressive. Additionally, all patients were required to pass an inspection before discharge. A patient was deemed fit to go home if he/she could get out of bed unassisted, stand up from a sitting position, walk 100 feet, and ascend and descend a full flight of stairs. When one considers the fact that these patients were able to perform these basic actions on the very day that they had a total knee replacement surgery, it is really quite remarkable.

As for the long-term reliability of this procedure, only time will tell. It has still been less than five years since the first one was performed, so longevity has not yet come into play. There is the obvious concern that the prosthesis may not be properly aligned in the quad-sparing method due to a lack of direct visual confirmation during surgery. However, unlike in the mini hip replacement, I feel that there are enough alignment tools available to the surgeon to confirm a good placement without the need for a direct line of sight. While the alignment process may take longer with the quad-sparing method due to a need for x-rays in the operating room, the whole procedure takes the same time. Both techniques take about two hours to complete, although prep time may be longer for the quad-sparing method.

As I said earlier, I think that the quad-sparing method is going to become the new standard for knee replacement. Since the quadriceps is the dominant muscle responsible for stabilizing the knee, it makes perfect sense that it should be preserved rather than aggravated during surgery. As surgical imaging advances in the future, it will only become easier for this surgery to be performed with the same kind of accuracy associated with the traditional method. I look at this as great news for the millions of Americans who are aging and becoming candidates for knee replacement surgery. Knowing that the recovery will be so quick will surely make it a less stressful experience.

Back to the Linkroll: Further Efforts to Increase the Value of my Blog

A few weeks ago, I decided to update my linkroll by trolling through the web in search of high quality sites to link to. I am continuing this charge with my newest post because I want my blog to become more than just a dead-end sink for my own writing. I want to provide links to other quality sites so that my readers will be able to use my blog as a multi-dimensional source of information. As with my previous post, I relied on the Webby Awards and the IMSA criteria to determine what sites were of a quality high enough to link to from my blog.

I started by choosing medical journals with a focus on orthopedics. The Journal of Bone and Joint Surgery, the Stone Clinic, and the Journal of Pediatric Orthopaedics are three such organizations, and their web sites are easy to use. The main flaw with all of these sites is that they are written for orthopedic specialists, so some of the articles are hard to understand. Edheads, on the other hand, is an interactive site with flash animations of hip and knee replacement surgeries. It is directed more toward the layman than the specialist, which makes it easy to follow but also gives it a childish air. Orthoseek.com and Swarm Interactive strike a nice balance between these two extremes. Orthoseek.com contains medical definitions in an easy to use format but does not overwhelm the reader with medical jargon. Swarm Interactive is a wonderful site with animated descriptions of many surgical procedures. It is designed for patient education, so the videos are simple enough to be easy to understand but detailed enough to provide a valuable learning experience. YourSurgery.com is another site that aims to educate patients getting ready to have surgery. Unlike Swarm Interactive, Yoursurgery.com is not a free service. To watch one video costs five dollars, and a year-long membership costs one hundred dollars. I am nevertheless including it on my linkroll because it looks like it could be an invaluable resource to any of my readers who do not mind paying for high-quality information. Last but not least is World Ortho (provider of the image above), a site whose navigation system alone won it high marks in my opinion. Possibly the most interesting piece of information on this site is a series of lecture notes from an Orthopedics class. It was very enriching for me to read them, and I hope my readers will find them equally stimulating.