Total joint replacement is the mainstay of treatment for end-stage arthritis of the hip or knee, a stage characterized by intolerable levels of pain and physical impairment despite appropriate medical management [1]. Although arthritis has typically been associated with older age, an increasing number of young patients are undergoing total joint replacements, suggesting that people are meeting the requirements for corrective surgery earlier in life [1].

International data from the Global Burden of Disease show that the prevalence of knee arthritis peaks around the age of 50 years, while hip arthritis prevalence increases steadily with age [2]. This data has also identified steady growth in disease burden due to arthritis since 1990 among people aged 15 to 49 years, with women in this group carrying the greatest burden [2]. The most recent data published in 2013 reflects that, in this younger age group, arthritis accounted for 2.4 million years lived with disability worldwide [2]. Years lived with disability due to high body mass index has also increased significantly for those 15 to 49 years since 1990, emphasizing the role rising obesity levels play in the increasing prevalence of arthritis in younger populations [2]. By 2030, the prevalence of arthritis in the United States is projected to reach 67 million, reflecting an increase of 40% over 25 years [1].

A recent 2021 study performed a nationwide analysis of total hip replacement utilization in the <21-year-old population [4]. Hospital admissions in patients under 21 from approximately 4,200 hospitals in 46 states were analyzed [4]. Researchers found that the frequency of total joint replacement in the United States has increased over the past two decades, similar to the conclusions of previous studies within the field [4]. The most common underlying conditions leading to total joint replacement in the <21-year-old population were osteonecrosis, osteoarthritis, and inflammatory arthritis [4].

There are several possible explanations for the increased rate of total joint replacement in younger patients in the United States [1]. The increase in the number of younger patients diagnosed with end-stage arthritis may be linked to the sharp increase in the prevalence of obesity [1]. Additionally, the increased willingness of surgeons to perform total joint replacement on younger patients as the preferred treatment option in individuals with advanced arthritis may be a factor [1]. Technical advances in joint replacement surgery have led to lower rates of complications and improved patient-reported outcomes [1].

The use of total joint replacements has proven to be a highly effective procedure for relieving discomfort & restoring function to those with arthritis [3]. Pain is a major concern for patients undergoing total joint replacement, especially for those undergoing the procedure at a younger age [3]. Poorly controlled pain can significantly limit rehabilitation and recovery [3]. It may also lead to chronic and neuropathic pain [3]. Chronic pain has been reported in 12.7% of subjects at 6 months postoperatively after poorly controlled initial postoperative pain [3].

Traditionally, pain management after total joint replacement was treated predominantly with oral and intravenous opioid medication through bolus or patient-controlled analgesia [3]. However, the multitude of adverse side effects of unilateral opioid therapy, as well as the growing concern about the risks of opioid dependence on a societal level, has resulted in alternative approaches to pain management [3]. Currently, multimodal analgesia (including NSAIDs, acetaminophen, gabapentinoids, opioids, and nonopioids) represents the most used approach to pain management for total joint replacements [3].

References

1. Ravi, B., Croxford, R., Reichmann, W. et al. (2012). The changing demographics of total joint arthroplasty recipients in the United States and Ontario from 2001 to 2007. Best Practice & Research Clinical Rheumatology, 26(5), 637-647. doi:1016/j.berh.2012.07.014
2. Ackerman, I., Kemp, J., Crossley, K. et al. (2017). Hip and knee osteoarthritis affects younger people, too. doi:2519/jospt.2017.7286
3. Golladay, G., Balch, K., Dalury, D. et al. (2017). Oral multimodal analgesia for total joint arthroplasty. The Journal of Arthroplasty, 32(9), S69-S73. doi:1016/j.arth.2017.05.002
4. Kahlenberg, C., Gibbons, J., Jannat-Khah, D. et al. (2021). Use of Total Hip Arthroplasty in Patients Under 21 Years Old: A US Population Analysis. The Journal of Arthroplasty, 36(12), 3928-3933. doi:1016/j.arth.2021.08.004