Dear Dr. Roach: I am an 80-year-old semi-retired vet with knee pain that has been managed with injections for years. The right knee is bone-on-bone, and last year, I had to get what my doctor referred to as a booster, three months after my usual six-month shot in my right knee. The left knee is stable with six-month shots.
Since then, I’ve been doing quite well and just managing with Tylenol and the occasional Voltaren. My doctor and I were considering replacement on the right knee this year, but then I started to improve. I’m relatively healthy now with controlled hypertension and benign prostatic hyperplasia (BPH). I’m told by other friends and relatives, including my daughter-in-law who is a rheumatologist, that I may regret waiting on the surgery, as I may not be as healthy in a few years.
On the other hand, I’m quite active now, and I know that it’s a tough recovery. There is an old saying that “it’s minor surgery if it’s on you, but major if it’s on me.”
If you were in my shoes, would you wait for more disability or go for the surgery now?
C.A., D.V.M.
It sounds like you most likely have osteoarthritis, the most common reason to consider joint replacement surgery. The main reason to consider joint replacement in general is when the symptoms, especially pain or an inability to exercise, can’t be managed by other treatments — like the occasional injection, Tylenol and the diclofenac (Voltaren) you are taking now.
A total knee replacement isn’t a minor surgery at all. It is common, even routine, but there is always the possibility of a bad outcome, including infection, reaction to the prosthesis, blood clots, nerve damage and bleeding. People over 80 are at highest risk for complications, but even so, complications only happen in a few percent of people. Still, you need to be aware of the risks to make an informed decision.
I often advise my own patients not to wait too long, but it sounds like you aren’t having too much pain nor disability. So, I would not urge you to rush to surgery. It is true that you may not be in as good physical shape as you are now in a few years, but I have had patients in their late 80s do well with joint replacement surgery.
Dear Dr. Roach: My wife was recently diagnosed with spinal osteoporosis, and her doctor suggested a yearly shot of zoledronic acid. Her insurance already approved it. She is checking the side effects, which showed a risk of fractures. Our question is, why does she need to get an injection?
A.V.
The evidence is strong that in people at high risk for fractures — such as those with osteoporosis, a history of fractures, and a high calculated risk by the FRAX score — medication like zoledronic acid (Reclast) reduces the risk of a fracture. It does not eliminate the risk, since no medicine is perfect.
If used carelessly, medicines like Reclast, alendronate (Fosamax) and others do increase the risk of an unusual fracture, called an atypical femur fracture. The risk of this is low if these medicines are used for a time period (usually three to five years), and then the person’s risk is reevaluated. Atypical femur fractures usually happen when a person is kept on the medicine for many years, after it has already done what it can to reduce risk. I recommend consultation with an expert, such as an endocrinologist, who has experience in treating osteoporosis.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
