Many of the patients walking into orthopedic and spine clinics today look different than they did 10 years ago — not just older, but more active, more informed and more demanding of a return to activity rather than simply a return to function. That shift is reshaping everything from implant selection to preoperative screening to how surgeons think about age itself as a clinical variable.
Six surgeons connected with Becker’s to share how the aging population has changed their practice over the last decade.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: If you had to describe how the aging population has changed your practice in the last decade, what would you say?
Ilyas Aleem, MD. Associate Professor in the Spine Division of the Department of Orthopedic Surgery and Department of Neurosurgery at University of Michigan (Ann Arbor): The aging population has changed my practice with more revision surgeries and more awareness of bone health — osteopenia and osteoporosis — and its impact on spinal fusion outcomes.
Nathan Cafferky, MD. Adult Reconstruction, Total Joint Surgery and Trauma Surgery, The Steadman Clinic; U.S. Ski Team Physician (Vail, Colo.):
Roughly 70% of my practice is now Medicare age, and the defining change over the last decade is what those patients expect from us. Historically, total joint replacement was an operation to help people walk again — to get them out of pain and back to the grocery store. That’s no longer the ask. My patients want to play pickleball, golf, ski and mountain bike. They come in with a list of activities they intend to return to, not a list of things they’ve given up.
That’s reshaped the practice in a few concrete ways. The conversation has shifted from pain relief to performance, with preoperative counseling now centered on activity goals and realistic return-to-sport timelines rather than walking distance and stairs. Implant selection, bearing surfaces and alignment strategy get more attention, because these patients will load the joint harder and longer than the patients this operation was designed for a generation ago. Age alone is also a much weaker screening criterion than it used to be — a physiologically fit 78-year-old skier is a better candidate than a sedentary 62-year-old with multiple comorbidities. Volume and expectations have risen together, which puts real pressure on perioperative efficiency and how we define a successful outcome.
The whole total joint delivery program has shifted to meet these demands: more robust preoperative medical screening, real emphasis on prehabilitation and nutrition, and technologies like navigation and robotics that have improved reproducibility and outcomes. We now offer outpatient total joint surgery, rapid recovery protocols and return-to-sport-specific rehab built around what the patient actually wants to get back to.
The one thing that hasn’t improved alongside all of this is reimbursement. Every part of the program has gotten better — screening, technology, recovery, rehab, outcomes — and over that same decade Medicare has continued to cut physician payment for the operations delivering those results. CMS’ CY 2027 Physician Fee Schedule proposed rule, released July 14, makes the point: Effective Jan. 1, 2027, the conversion factor would fall to $33.17 for qualifying APM participants (down 1.19%) and $32.84 for everyone else (down 1.68%), driven largely by the expiration of the temporary 2.5% increase Congress provided for 2026. CMS has also proposed paying only 50% for a separately identifiable office visit furnished on the same day as a procedure with a global period, which hits surgical practices directly.
Whatever the arithmetic behind it, the practical effect is limiting access to care. More surgeons will be forced to opt out, and it will be Medicare patients who absorb that — longer waits, fewer options and, in some markets, no local surgeon willing to take the case. This older population sees these surgeries as a new lease on life, not a last resort. That’s a genuinely different job than the one this operation was built for, and I think it’s the most underappreciated story in joint replacement right now.
Eric Cohen, MD. Orthopedic Surgeon, University Orthopedics (East Providence, R.I.):
As an orthopedic total joints surgeon, the aging population has shifted my practice over the last decade from treating isolated mechanical wear-and-tear to managing complex geriatric longevity. Age is no longer a barrier — biological fitness, rigorous medical optimization and enhanced recovery pathways allow us to successfully perform replacements on active older adults well into their 80s and 90s. Today, success is measured by more than an X-ray. We also value preserving independence, preventing falls and utilizing durable implants to ensure patients can maintain mobility and quality of life for decades to come.
S. Ali Ghasemi, MD. Clinical Assistant Professor of Orthopedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University; Jefferson Einstein Philadelphia Hospital (Philadelphia):
One of the biggest changes I’ve seen is that we’re not simply treating an aging population — we’re treating an aging but increasingly active population. Patients in their 50s, 60s and beyond increasingly want to continue running, cycling, skiing, playing recreational sports and maintaining the lifestyle they’ve enjoyed for decades. Their expectation isn’t simply pain relief; they want to preserve function and, whenever possible, preserve their natural joint.
That’s elevated the importance of joint preservation in orthopedic practice. Traditionally, a patient with advanced degenerative changes might have been directed relatively quickly toward joint replacement. Today, in appropriately selected patients, we increasingly ask whether we can address the underlying mechanical and biologic problems, preserve the native joint, maintain activity and potentially delay arthroplasty. That’s particularly relevant in knee osteoarthritis — joint replacement remains an excellent and necessary operation for many patients, but it shouldn’t necessarily be the first destination for every active patient with significant radiographic arthritis. I believe demand for joint preservation will grow substantially over the next decade as the population ages while remaining active longer.
Farzin Kabaei, MD. Orthopedic Surgeon, Robotic Hip and Knee Replacement LA (Los Angeles):
Ten years ago I would not have said this out loud: I replace hips and knees in people in their 80s and I expect them back on the court. Not walking to the mailbox — the court. That change didn’t come from surgeons. It came from patients. The 82-year-old sitting in my office now is not the 82-year-old I trained on. She plays pickleball four mornings a week. She golfs. She has a trainer. By the time she sees me, she isn’t asking whether she’ll walk again — she wants to know how long until she’s back in her doubles league.
That’s changed how I decide who gets an operation. Age used to be a rough screen; it tells me almost nothing now. What I want to know is what the heart and lungs look like, what the bone looks like, whether this person has been moving or sitting for the last five years, and what they actually plan to do afterward. I’ll take a fit, optimized 84-year-old with a specific goal over a sedentary 60-year-old who hasn’t exercised in 20 years.
Patients also show up having done their homework — asking about anterior versus posterior approaches, robotics, implant choice, longevity. Ten years ago I explained those things; now I’m frequently the one being interviewed. That’s more pressure, and it should be. If a patient intends to play tennis at 85, the alignment has to be right, the balance has to be right, and the reconstruction has to outlast what we used to plan for. There’s much less room to be approximately correct.
Sananthan Sivakanthan, MD. Assistant Professor of Neurosurgery and Orthopedics, Banner University Medical Center Tucson (Ariz.): The aging population has significantly impacted both the clinical delivery of care and the business side. Clinically, there’s been an increase not only in case volume but in case complexity, particularly around medical comorbidities. That has pushed the field toward less invasive techniques — not as a lifestyle preference, but as a necessity. The old open paradigm of spine surgery can be highly morbid for this patient population, so we’ve developed better minimally invasive approaches, shifted to staged surgeries and built out stronger preoperative and postoperative optimization protocols. That shift requires careful thought, though, because for elderly patients with complicated medical histories, time under anesthesia becomes critical.
The business side hasn’t kept pace. Reimbursement and site-of-service policy are optimized for simpler cases on healthy patients in outpatient settings, yet the sickest and most complex older patients still need the resources of a hospital-based practice. The payment models don’t fully reflect that gap.
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