Debi Irons lived to dance.

But last fall, days after her 50th birthday, she could barely walk. Excruciating pain radiated down her legs whenever she tried. Doctors diagnosed severe, degenerative arthritis. With her cartilage completely gone, Irons’ situation was not going to get better on its own.

“My feet didn’t touch the ground. I was swinging from the crutches,” said Irons, who owns the Art Moves Dance Studio in Norway.

After some deliberation, she underwent surgery to replace both hips in May.

By mid-August she was dancing again. She calls her experience “amazing.”

Twenty years ago, Irons would have been considered an anomaly in the joint replacement world. Doctors back then advised patients in their 50s to wait as long as possible — sometimes 10 years or more — before getting a knee or hip replaced. Recovery was harder. The joints themselves were good but not great. And a second joint replacement — likely for those younger patients — was problematic. 

Not a lot of people went back to dancing. 

Today Irons is one of thousands of Mainers every year who undergo joint replacement, and at increasingly younger ages.  

Hospitals like the surgery  — all six of Maine’s largest hospitals now have joint replacement centers — because it’s both lucrative and popular. Patients like it because it can, in its best form, cut their pain, get them moving and allow them to take up activities they once had to abandon.

Joint replacement isn’t perfect. There can be medical complications, including infection. Artificial joints may need to be replaced if they’ve been in a long time, especially if the person has been very active. Depending on insurance, the surgery can be expensive. And not everyone is happy with the end result. 

But despite the potential pitfalls, nearly twice as many Americans got a total or partial knee or hip replacement in 2009 as they did in 1999, from just over 602,000 discharges to about 1.1 million, according to federal statistics.

And that number is expected to grow even more.

Irons, for one, can see why.  

“Gosh, the things they can do now,” she said. “Now that it’s over, I can’t believe I even questioned it.”

Then and now

Joint replacement has been around for decades. Early on, doctors used artificial joints often made from Teflon or metal and cemented them in place. The joints themselves were all about the same size, whether the patient was petite or very large. Patients were strongly encouraged to wait as long as possible before undergoing surgery, both because the artificial joints were not as functional as natural joints and because artificial joints wore out after about 20 years, forcing a now-elderly patient to undergo a second, more complex joint replacement surgery with a likely tougher recovery.

“Like any other medical technology there’s a learning curve,” said Stephen Walsh, medical director for Eastern Maine Medical Center’s joint replacement center in Bangor. “The initial joint replacements in the ’70s were reserved for people who, if they come in with a cane, they’re not ready until they got two canes and a wheelchair.”

It was, he said, “a salvage procedure.”

Joints now come in an array of sizes and materials, including titanium and other metals, ceramic, and plastic, and combinations thereof. Some joints are cemented into place while others aren’t. Minimally invasive surgery is increasingly common, requiring still a sizable incision, but sparing more of the patient’s muscle than in past versions of the surgery.

Of all the joint replacements available, including knee, hip, shoulder, ankle, elbow and finger, knee replacements are the most popular, followed by hip. The knee surgery calls for doctors to trim off the end of the bones with the bad cartilage, then cap the bones with the artificial joint, much like a dentist caps a tooth. The hip surgery requires doctors to pop the hip ball out of its socket, saw off the ball, machine the socket, then replace it all with an implanted joint.

Over the decades, recovery periods and expectations for patients have also changed. 

Roger Furbish’s joints began disintegrating when he was a teenager. Now 86, the Lisbon man has undergone seven joint replacements in 60 years: both hips, both shoulders, both knees, and the re-replacement of one of his hips. In 1952 Furbish had his first surgery, a left hip replacement that was a cutting-edge procedure at the time. He spent eight weeks in the hospital, over four of those weeks in traction.

“The leg that was up there was sort of frozen. It was terrible,” he said.

In 1993, when Furbish had that replacement hip replaced, he stayed in the hospital for eight days, but no traction.

By the time he had his last joint replacement in 2000, a knee, doctors had him up and out in a few days.

“Now they hardly let you lie down,” Furbish said.

It’s not much of an exaggeration.

Hospitals now want joint replacement patients walking within a day, ideally within hours. Patients are still well-medicated against the pain, walking reduces the odds of bed sores, blood clots and pneumonia, and recovery is easier when patients start working with those new joints right away. They want patients out of the hospital and back home or in temporary residential rehab in less than a week, preferably within one to three days, because patients are happier out of the hospital, there’s a lower chance of contracting a hospital-based infection or illness and shorter stays cost less. Nationally, the length of hospital stays were cut in half between 1993 and 2009, from an average 8.9 days to 4.3 days for hips and 6.3 days to 3.4 days for knees, according to the Agency for Healthcare Research and Quality, which is part of the U.S. Department of Health and Human Services. 

In recent years, hospitals have brought together all the changes in techniques, technology, materials and recovery into a single, overarching invention: the joint replacement center.

Each of Maine’s six largest hospitals — Eastern Maine Medical Center, Maine Medical Center in Portland, MaineGeneral Medical Center in Augusta and Waterville, Central Maine Medical Center in Lewiston, Mercy Hospital in Portland and St. Mary’s Regional Medical Center in Lewiston — have opened joint centers in the past four years.

Although there are some differences in the details — St. Mary’s, for example, has a room specially designed for obese patients — the six large-hospital centers are very similar. Located on a floor within each of the hospitals, the centers bring together doctors, nurses and rehab specialists experienced in dealing with joint replacement patients. Rooms are almost universally private and decorated to feel more like a calming hotel suite than a hospital room. Physical therapy rooms are usually located nearby, if not on the same floor as the joint replacement patients. One- to two-hour educational sessions to advise potential patients about the procedure are common. 

Hospitals say the centers help them standardize joint replacement, making it more efficient and improving patient care. But centers are also money makers.

A popular center brings in hundreds of patients a year for a surgery that can easily cost tens of thousands of dollars. The race to create a joint center, then the competition to keep it favored by patients, can be fierce.

“Orthopedics is what hospitals want to be known for — some hospitals, if they choose — because it’s a good revenue stream. It’s just sustainable,” said Heather Skolfield, director of the Orthopaedic Institute at Mercy Hospital, whose joint center did nearly 680 joint replacement surgeries last year. “When you look out into the market 10 years from now, orthopedics is the service line that’s going to be growing because of the baby boomers. The need for orthopedic surgery is going to be significant. More than it is today. It’s not just money; it’s if you want to be in business.”

The numbers back her up. EMMC, for example, saw 339 joint replacement patients in 2007, shortly before it opened its joint center. In 2010, that number jumped about 70 percent to 586. CMMC saw 199 patients for just hip and knee replacements in 2008, before it opened its center. That number also jumped about 70 percent, to 337, in 2010.

Those are big increases, but they still have a ways to go to approach Maine Medical Center, which has the most popular joint center of Maine’s six biggest hospitals. Last year MMC saw 1,860 joint replacement patients.

In May, Irons, the dance instructor, became one of MMC’s newest joint patients.

‘Pretty amazing, really’

Irons was a child when she fell in love with the physicality, creativity and expression of dance.

“I knew when I was 10 I wanted to be a dancer,” she said.

She danced, taught dance and choreographed dance all over the world. Nearly 30 years ago she opened her own dance studio, Art Moves, in Norway. Despite all the stress on her joints, Irons lived and worked pain free. In the past few years her leg gave out a few times and once she found it difficult to take a ballet class during a dance festival, but she didn’t think much about it. 

“I just figured it was some injury or something that would just go away,” she said.

Then, last November, just days after her 50th birthday, Irons felt pain in her legs so terrible she could barely walk. Because she had a high health insurance deductible, she consented only to basic blood tests, just enough to confirm she didn’t have a serious illness. She went forward with a planned vacation to Spain, certain her legs would get better with rest. 

They didn’t.

Finally the pain got so bad she saw a specialist in Spain. The cartilage in her right hip was gone, he told her. She needed a hip replacement. Back in Maine, her regular doctor suggested a surgeon at MMC. He told her the cartilage in her left hip was gone, too. 

Irons made an appointment for surgery. But she didn’t take the prospect of a double hip replacement lightly.

“I did have a spell of what I would call sheer terror,” she said. “I thought ‘Here I am Miss Natural, I even have my gray hair, and someone’s going to cut into me, take a piece of my bone out and put a piece of metal in.'”

But like with many people considering joint replacement, Irons’ hip was moving bone on bone, with nothing in between to cushion it. She couldn’t even walk, let alone dance. 

“I would have been in a wheelchair,” she said. “I would have had to have a different career. There’s just no way.”

Irons underwent the surgery on May 11. She spent two nights in the hospital, then went home with the help of home health care. She worked on rehab for months. Then, in August, she took to the stage, dancing during a benefit show friends threw to help with her medical bills.

Irons calls the whole joint replacement experience “pretty amazing, really.”

Recovery wasn’t easy. She had to work hard in physical therapy, strengthening her muscles and learning how to move with her new hips. It’s work that’s still ongoing.

“It’s going great. I mean, it’s never fast enough for me, but that’s just the way I am anyway,” she said.

Irons plans to be back at Art Moves on Sept. 8.  

“I’m looking forward to just getting back to doing what I do and having this just kind of fade into the background as a nice story to tell,” she said.

But joint replacement isn’t always a nice story.

“It takes time to heal.”

Raymond Anctil, of Greene, had pain in his knees for years. Walking his dog, hunting, riding his ATV, snowmobiling — it all hurt. And it was getting worse. 

Like Irons and so many others, a doctor told him his joints were rubbing bone-on-bone. A surgeon recommended knee replacement — the left knee would be first — and Anctil agreed. It wasn’t a hard decision for him.

“I was glad that finally, I figured, it would be fixed,” said Anctil, 74.

The surgery went fine. His recovery didn’t.

Despite months of rehab, Anctil’s knee wasn’t getting any better. He’d been there when his wife had undergone her own knee replacement earlier, and his experience didn’t seem anything like hers.

“She recovered so well,” he said. “In two-and-a-half month she was in no pain and walking normal.”  

Even several months after surgery, Anctil dragged his foot when he walked. He felt worse than it had been before the replacement, in pain, disabled and doomed to stay that way.

And the surgeon wasn’t much help.  

“I felt the pain was not decreasing, it was increasing,” Anctil said. “He (the surgeon) kept saying to me ‘Well, it takes time to heal.’ That was the quotation he’d said to me every time I’d go visit him, ‘It takes time to heal.’ And after a year I said I need to go see this doctor and say, ‘Please, help me.’ And again he said ‘It takes time to heal.’ Those were his famous words.”

Finally on Anctil’s last visit, as his hand was on the door to leave, the doctor suggested a scan. The scan revealed inflammation, which indicated some kind of problem. Unhappy with his original surgeon, Anctil sought a second opinion. It didn’t take long for that second doctor to figure out exactly what was wrong.

“He took my leg on his knee and he flexed my knee back and forth and he said, ‘Whoa. This knee was all afloat,'” Anctil said. 

On May 31, Anctil’s replacement knee was replaced. This recovery went like the first one should have.

“I’m back to doing my own lawn and I’m back to walking my dog every day, twice a day,” he said. “And I go ATV riding every day with this dog.”

The precise number of botched joint replacement surgeries is not readily available, though the National Institute of Arthritis and Musculoskeletal and Skin Diseases says more than 90 percent of joint replacements are a success.

While he’s happy with his newest knee, Anctil can’t forget everything he went through with the first knee replacement. Doctors have told him he needs his right knee done now. He’s not so sure that’s a good idea.

“I don’t think I’m going to chance it,” he said.

Risk and reward

Experts say joint replacement isn’t perfect and prospective patients should carefully consider their options before scheduling surgery. Doctors advise those with joint pain to try over-the-counter medication and rehab exercises first. If that doesn’t work, they suggest shots of cortisone or other medications, such as Synvisc, which helps lubricate the knee. When all else fails, they say patients can consider surgery, but they should be aware of some things: 

* There are risks with surgery, including blood loss and infection. 

* Although not common, there can be complications with the artificial joint after surgery, such as in Anctil’s case.   

* The FDA has received an increased number of complaints in recent months regarding metal-on-metal artificial hips, including that the implants deteriorated within a few years and that the metallic pieces that wore off the implant caused people to get sick.    

* No matter how advanced current artificial joints are, they are not as good as natural joints. Although every situation is different, it’s possible the new joint may have a smaller range of motion or may require the patient to stop certain activities, such as jogging.

* Rehab exercises are strongly recommended after surgery since patients who don’t do the exercises often don’t reach their new joint’s full potential. Many doctors also recommend patients do strengthening exercises in the weeks or months leading up to surgery.

* It can take several months — up to a year — to fully recover.

Celeste Philippon knows those caveats from both sides of the hospital bed. As care coordinator at St. Mary’s joint center, she runs the center’s educational sessions for people considering joint replacement and checks in with patients after surgery. She’s also had a hip replacement herself.

“I was nervous, and I tell patients that all the time. I was scared,” said Philippon, 52.

There were some parts of her experience she wasn’t wholly happy with: she had trouble getting clearance from hospital staff to walk on her own after surgery, and her follow-up medication instructions were confusing, even though she’d been a nurse for 30 years. But overall Philippon’s glad she had the hip replaced. Walking was so painful before the surgery that her gait became an embarrassing sway. Today she is sway-free.

She tells potential patients that. She also tells them how hard she had to work to walk again. And she reminds them that joint replacement is a significant surgery and they shouldn’t consider it lightly.

Three times potential patients decided not to go through with surgery after taking her class. She’s OK with that.

“Even if they walk away thinking ‘I’m not going to doing this,’ they learn something and they have a better understanding,” she said. “And when their friends and family say ‘I’m having my hip done’ or ‘I’m having my knee done,’ they absolutely understand what that person is about to go through.”

Most often, people take the class and decide to go through with joint replacement. Although surgery can be a scary prospect, they’ve done their research and weighed their options. The pain is just too much.  

“For a lot of patients, taking the class and going to see the doctor gels it for them,” she said. 

Experts believe more and more patients will opt for joint replacement surgery in the coming years. The American Academy of Orthopaedic Surgeons predicts an exponential increase in joint replacement by 2030.

They’re also getting the surgery at younger ages. While the percentage of those getting surgery between the ages of 65 and 84 — the traditional age for joint replacement — dropped between 1999 and 2009, according to the Agency for Healthcare Research and Quality, surgery among those 45 to 64 grew.

Doctors say that’s because, in part, obesity is leading to increasing joint problems and baby boomers want to maintain an active lifestyle up to and past retirement, and they aren’t willing to let joint pain sideline them.

Local joint centers expect their numbers to only increase. 

Irons has advice for those considering it. 

“Just go for it,” she said.

ltice@sunjournal.com

Number of joint replacements done by Maine’s six largest hospitals in 2010:

Maine Medical Center, Portland: 1,860

Mercy Hospital, Portland: 679

Eastern Maine Medical Center, Bangor: 586

Maine General Medical Center, Augusta/Waterville: 474

St. Mary’s Regional Medical Center, Lewiston: over 400

Central Maine Medical Center, Lewiston: 357

Advice from local joint replacement veterans:

Debi Irons, 50, double hip replacement: “Just go for it.”

Roger Park, 61, knee replacement: “Make sure it’s time, one. And No. 2, take the pre-surgery period very seriously in terms of maintaining weight, being extremely active and fit.”

Raymond Anctil, 74, knee replacement: “Surgery is a rewarding thing if it’s successful, and most of them are. I would say go to a doctor who has done the most.”

Deborah Blanchard, 61, knee replacement: “Push through it. If you do not do the therapy, you will not be back to what you want to do.”

Geraldine Richards, 75, knee replacement: “Don’t hesitate to do it. It’s not worth the wait.”

Mac Cook, 60, knee replacement: “Make sure you do the rehab, the therapy. You need to bend that knee like you bend the other knee, and if you don’t get (rehab), you never will.”

Joan Gauthier, 63, knee replacement: “I wouldn’t have it done unless you really, really, really need to have it done, unless you can’t stand the pain anymore.”

Laurie Henderson, 49, knee replacement: “You know when you’re ready. You know when you can’t take it anymore. If you’re unable to do normal things like go up and down stairs or walk animals, it’s time to get your life back.”

Expert advice for those looking for a joint-replacement surgeon:

 * Get a recommendation from a trusted doctor, such as your primary care doctor.

 * Consider the recommendations of friends or family who have had the same surgery, though don’t base your decision entirely on this. Even poor surgeons will have some happy patients.

 * Verify your surgeon’s credentials, for example, through the American Academy of Orthopaedic Surgeons or the state of Maine’s free docfinder site, www.docboard.org/me/df/mesearch.htm.

* Ask your surgeon questions, including information about the surgeon’s infection and complication rates, why the surgeon chose the specific prosthesis to be used, what the expected outcome of your joint replacement should be and how pain will be managed after surgery.

* Consider how many times your doctor performs your type of surgery every year. The more, the better.

* Go to the Maine Health Management Coalition Foundation’s website at www.mhmc.info/search-doctors or the U.S. Department of Health and Human Services’ website at www.hospitalcompare.hhs.gov to learn more about the health and safety ratings of the hospital you’re considering.

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