The State of Knee and Hip Replacement: More Surgeries, Younger Patients, Higher Costs

by Chris Centeno, MD /

knee replacement in young patients

You can’t drive a mile or two in the city where I live without seeing a bus bedecked with pictures of someone climbing mountains and hawking their new knee replacement. Now a new report confirms what I see, the number of these joint replacements is exploding. Is that a good or a bad thing? Let’s explore.

What’s Changed in the Last Decade?

Twenty years ago, the average knee or hip replacement recipient was elderly. All this patient population wanted to do was to walk the mall with less pain. However, that market is only so big, so device manufacturers began focusing on younger and younger patients. This has dramatically changed the risk matrix involved in these procedures. Why? Because these patients will need a second or third knee or hip replacement in their lifetimes. Given that taking an implanted device out and putting a new one in is a much more invasive procedure, the risk of complications for these patients goes way up.

Revealing BCBS Report on the State of Knee and Hip Replacement

A new report recently published by Blue Cross Blue Shield (BCBS) states that in the year 2017 alone, there were 242,000 BCBS members under the age of 65 who had elective hip or knee replacement. Between 2010 and 2017, the cost of elective orthopedic procedures through BCBS increased  by 44%. In addition, the number of procedures also increased with, for example, knee replacements being up by 17% and hip replacements being up by 33%.

The report states the increase in numbers is in all age groups, but the younger age groups—now even dipping into the Generation X population, whose oldest members are now reaching their mid-50s—are having the biggest impact. Elective knee replacements between 2010 and 2017 increased by 17% for the 45–54 age group and 18% for the 55–64 age group. Elective hip replacements during the same time period increased by 25% for the 45–54 age group and 42% for the 55–64 age group (for hip replacements, even the 35–44 age group showed a 14% increase).

Another key point addressed in the BCBS article is cost. The national average for a traditional inpatient hip or knee replacement is around $30,000. However, the cost for knee or hip replacement can vary drastically from state to state, ranging from around $19,000 in Des Moines, Iowa, to well over $60,000 in New York City. Even within the same city, the cost can vary. San Antonio, Texas, is one such city the article discusses, in which you can find knee replacements, for example, costing anywhere from around $22,000 to over $88,000.

The High-Cost Solution Presented: Outpatient Knee and Hip Replacements?

The BCBS article steers toward outpatient hip and knee replacements as a more cost-effective solution, coming in at a national average of still a whopping $19,000 (knee) to $22,000 (hip). This means the patient comes in that morning, has a knee or hip amputated, has an artificial joint installed, and then goes home later that same day!

The report cites lower complication rates in patients who have outpatient hip or knee replacement when compared to inpatient; however, they aren’t comparing apples to apples here as, currently, outpatient knee and hip replacements are fairly new and aren’t very common (11% and 8% respectively in 2017), so only those who are very healthy are candidates for same-day knee and hip replacement. In other words, the case mix severity would be much higher for inpatients and, therefore, complications would be more likely in this population.

So the BCBS cost-savings solution, presented in the article, for these aggressive and highly invasive orthopedic surgeries seems to be the standard traditional-insurance response: work toward getting more patients home asap—preferably the day of the knee or hip replacement.

The Aggressive Marketing by Knee and Hip Device Manufacturers Is Working

What does all of this mean? It means that all of the aggressive marketing by prosthetic hip and knee device manufacturers to younger and younger populations appears to be having its intended effect—younger and younger patients are getting knee and hip replacements, and it’s creating significant increases in the numbers of these highly invasive orthopedic surgeries. And as marketing increases demand, costs for hip and knee replacements are rising at drastic rates, and, naturally, insurance companies are responding with their own solutions to the problem.

Keep in mind, these numbers just account for one insurance organization (albeit the largest commercial health insurer), so this isn’t providing a full picture of the overall hip and knee replacement numbers we’re dealing with as an orthopedic industry as a whole.

All this being said, are these surgeries at least doing the job? Are patients’ expectations being met, and are there, as the article suggests, fewer and fewer complications associated with these surgeries? Are the exorbitant costs and lengthy recovery times worth it? Research in many cases seems to suggest the answer is no on all fronts. Let’s review.

Knee and Hip Replacements: What Recent Research Shows

Not only are the demographics trending toward younger and younger patients undergoing knee or hip replacement, but complications abound in these younger patients. Despite having less-severe arthritis, likely due to higher activity levels, younger patients generally seem to have poorer results, including pain and higher revision rates as well as higher use of painkillers, following knee replacement than their older counterparts.

Regarding function, one high-level study found that 5–6 knee replacements had to be performed to get one patient who could report they could do 15% more than they could prior to surgery, and side effects reported in the knee replacement group in the study included serious infections, scarring that led to revision surgery, deep blood clots, fractures, and so on. If you want more detail on this surgery, watch my video below:

It’s also important to note that one reason pain may be an ongoing issue following knee replacement is that it’s highly possible that knee pain wasn’t due to a problem in the knee but due to a problem in the low back. If this is the case, clearly, amputating and replacing the joint with an artificial one isn’t going to address the primary problem and eliminate the pain.

Employer-Funded Health Plans Addressing the Unfortunate State of Orthopedic Surgery by Providing Interventional Orthopedics Solutions

Many large corporations, such as Pulse Health Solutions, Access HealthNet, Connect Healthcare Collaboration, are addressing the high cost and low returns of so many elective orthopedic surgeries by providing employer-funded health plans with nonsurgical interventional orthopedics solutions to their employees. And they’re doing it at a fraction of the cost of orthopedic spend under the traditional insurance structure. Employees with Meredith Corporation are not only choosing interventional orthopedics procedures over invasive surgeries nearly 100% of the time, but they are experiencing on average an 80% improvement at six months, while Meredith Corporation is experiencing an 80% reduction in their orthopedic spend. Learn a lot more about this by watching our video with Steve Lacy, CEO at Meredith Corporation, above.

The upshot? We need to bend the knee and hip replacement curve down. Why? Not only is this incredibly expensive and not financially sustainable, but we’re also dramatically increasing the risk of complications for younger and younger patients. The companies selling these devices and the surgeons installing them will never push the pause or reverse buttons. Hence, we need more and more reliable alternatives so that patients choose less invasive options.

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Chris Centeno, MD

Regenexx Founder

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications.
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