Older, heavier Americans fuel a $4 billion knee replacement market

People who have joint replacements before age 60 are more likely to be obese and to have other health problems like diabetes or heart and pulmonary conditions, says David Ayers, chair of orthopedics and physical rehabilitation at the University of Massachusetts Medical School. "It's not that these are young, healthy, fit people," says Ayers, who has analyzed data on 35,000 joint surgery patients in a federally funded database.

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The force on the knee when going up stairs can be three to five times body weight, says David Teuscher, president of the American Academy of Orthopaedic Surgeons. Not everyone who suffers from obesity gets knee pain, but the extra weight can aggravate arthritic knees. The relationship may run both ways, as joint pain deters people from work or exercise. "We counsel our patients for weight reduction, but more and more we're realizing that they're never going to be able to lose the weight unless we replace the knee and put them into an exercise program," Teuscher says.

Richard Rothman, founder of the Rothman Institute, a Philadelphia orthopedic center, says he once deterred younger patients from joint replacements if possible. Improvements in the implants and surgery have changed that calculation. In 1970, recovery typically meant three weeks in the hospital. Now, Rothman says, many patients are discharged the next day, or even the same day. Doctors have developed better methods of managing pain during and after the operation, and the artificial joint materials have become more durable, reducing the likelihood that younger patients will need to replace implants.

Some patients who get knee replacements don't get the benefits—particularly if their pain or impairment was mild to begin with. "The actual eligibility criteria for [total knee replacement] is by definition vague," says Daniel Riddle, a physical therapist and professor at Virginia Commonwealth University. He led an analysis of 205 knee replacements that judged almost one-third of them to be inappropriate. After two years, that group showed little improvement. The results, from four study sites, aren't generalizable to the U.S.

Riddle says people with depression or conditions that make them more susceptible to pain may have a harder time recovering. Patients considering the procedure need to weigh the severity of their symptoms with their expectations for recovery. A new artificial knee won't mean a sidelined tennis enthusiast will be able to return to the court. "If a patient's expectations are so high that they're unrealistic, those patients are going to be dissatisfied," Riddle says.