Arthroplasty

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Arthroplasty is surgery performed to relieve pain and restore range of motion by realigning or reconstructing a dysfunctional joint.

Purpose

The goal of arthroplasty is to relieve pain and restore function in a stiffened joint. This surgery is usually performed when physical therapy or nonsurgical medical treatment have not improved function in the affected joint. There are two types of arthroplastic surgery: joint resection and interpositional reconstruction. Joint resection involves removing a portion of the bone from a stiffened joint. This increases the space between the bones forming the joint and improves the range of motion. Pain is relieved and motion is restored, but the joint is less stable. Scar tissue may eventually develop, filling the space and narrowing the gap between the bones.

Interpositional reconstruction is surgery to reshape the joint and add a prosthetic disk between the bones forming the joint. The prosthesis can be made of plastic, metal, ceramic material, or formed from body tissue such as skin, muscle, or fascia. When interpositional reconstruction fails, total joint replacement may be necessary. Joint replacement is also called total joint arthroplasty.

In recent years, total joint arthroplasty has become the operation of choice for most chronic knee and hip problems because of advances in the type and quality of prostheses (artificial joints). Elbow, shoulder, ankle, and finger joints are more likely to be treated with joint resection or interpositional reconstruction.

Arthroplasty is performed on people experiencing severe pain and disabling joint stiffness. Osteoarthritis (OA), a degenerative joint disease, is the most common condition causing joint destruction with pain and impaired movement. Other causes include rheumatoid arthritis (RA), hemophilia, synovitis, and rare bone diseases, all of which are known to destroy cartilage. Joint resection, rather than joint replacement, is more likely to be performed on people with rheumatoid arthritis, especially when the elbow joint is involved. Joint replacement is usually reserved for older patients, because of the limited life of the replacement joint. The younger the patient, the greater the reliance on non-surgical treatment.

KEY TERMS

Cartilage— The slippery tissue that covers the ends of joint bones.

Fascia— Thin connective tissue covering or separating the muscles and internal organs of the body.

Osteoarthritis— A degenerative “wear-and-tear” joint disease related to aging.

Prosthesis— An artificial joint, part of a joint, or limb.

Rheumatoid arthritis— A chronic autoimmune disease characterized by inflammation of multiple joints and crippling pain and stiffness.

Synovial fluid— A fluid that lubricates the joint and helps prevent wear on the bones.

Synovitis— Inflammation of the synovium, the thin membrane in the joint.

Thrombophlebitis— A condition in which blood clots form in veins near surgery site, causing swelling and pain; clots may travel via veins to the heart or lungs causing serious complications.

Demographics

The American Academy of Orthopaedic Surgeons reports that in 2004 in the United States about 478,000 were total knee replacement surgeries and 234,000 were hip replacement surgeries were performed. Additional sites for arthroplastic surgery include the ankle, shoulder, elbow, wrist, hand, and big toe. Surgery on smaller joints, such as the toe, have become more common in the 2000s as smaller artificial joints have improved in functionality and reliability.

Because the primary underlying condition in patients undergoing arthroplasty is osteoarthritis, a common cause for disability among older adults, the majority of patients who have arthroplastic surgery fit the demographic profile for osteoarthritis. Osteoarthritis is the most common disease of the elderly worldwide. In the United States in 2006, about 20 million people had diagnosed osteoarthritis. It is estimated that about half of all individuals over age 65 have osteoarthritis. Both men and women develop the disease; under age 45, men are more often affected, although more women than men are affected after age 45. Younger people can have the disease after a traumatic joint injury.

Arthroplasty is reserved for the most severely afflicted—approximately 3% of all patients with osteoarthritis. In addition, approximately 1% of the population worldwide has rheumatoid arthritis, which can strike people of all ages. Few of these people have arthroplastic surgery because this chronic crippling disease affects not only multiple joints but other parts of the body as well, including the immune system. Patients weakened by rheumatoid arthritis (RA) are more subject to infection and less likely to enjoy positive surgical results.

Description

Arthroplasty is performed under general anesthesia (affecting the entire body) or regional anesthesia (numbing a specific large area of the body) in a hospital by an orthopedic surgeon. Although many hospitals and medical centers perform common types of joint surgery, orthopedic hospitals that specialize in joint surgery tend to have higher success rates and fewer complications than less specialized centers.

In joint resection, the surgeon makes an incision at the joint, then carefully removes the minimum amount of bone necessary to allow free movement of the joint. The more bone that remains, the more stable the joint. Ligament attachments are preserved as much as possible. In interpositional reconstruction, both bones of the joint are reshaped, and a disk of material is placed between the bones to prevent their rubbing together. Length of hospital stay depends on the joint affected. In the absence of complications, a typical stay is brief. For total joint replacement, the entire joint is removed and replaced with an artificial joint. The hospital stay and rehabilitation period for total joint replacement tends to be longer than for joint resection or interpositional reconstruction.

Diagnosis/Preparation

Significant disabling pain, deformity, and reduced quality of life are the primary indications for arthroscopic procedures. Patients at this stage of discomfort and disability will most likely have already been diagnosed with a form of arthritis. Pain and stiffness on weight-bearing joints are the major symptoms that patients report; some experience night pain as well. Other symptoms may include stiffness, swelling, and locking of the joint. The joint may even give way, particularly when the knees or hips are affected.

To determine the extent of disabling, the referring physician and/or the surgeon will ask about walking distance, sporting ability, the need for walking aids, and the ability to perform self-care tasks such as dressing and bathing. Besides evaluation of the joint itself and level of mobility, the clinical examination will include evaluation of the patient’s general health, the condition of the ligaments and muscles around the affected joint, and an assessment of the patient’s mental outlook and social circumstances to help develop the most effective postoperative rehabilitation plan.

Diagnostic testing will typically include:

• X rays of the affected joint (and often other joints as well) to determine loss of joint space and to differentiate between OA and RA.
• Imaging studies, such as computed tomography (CT) scans, magnetic resonance (MRI), and bone densitometry to assess bone loss or bone infection.
• Cardiac tests, such as an electrocardiogram, to evaluate the heart and circulatory system.
• Blood tests to rule out infection and possibly to confirm arthritis.

Before arthroplastic surgery, standard preoperative blood and urine tests are performed to rule out such conditions as anemia and infection. If a patient has a history of bleeding, the surgeon will ask that clotting tests be performed. The patient will meet with the anesthesiologist to discuss any special conditions that may affect the administration of anesthesia. Surgery will not be performed if infection is present anywhere in the body or if the patient has certain heart or lung diseases. Smokers will be asked to stop smoking. Weight loss may also be recommended for overweight patients. If surgery involves deep tissue and muscle, such as total hip arthroplasty, the surgeon may order units of blood to be prepared in case transfusion is needed to replace blood lost during the surgery. Healthy patients may be asked to donate their own blood, which will be returned to them at the time of surgery (autologous transfusion). Certain pain medications may have to be discontinued in the weeks just prior to surgery.

Aftercare

Immediately after surgery, while still in the hospital, patients will be given pain medications for the recovery period and antibiotics to prevent infection. When patients are discharged after joint surgery, they must be careful not to overstress or destabilize the joint. Normally, this requires rest at home for a period of days to weeks. Physical therapy will begin almost immediately to improve strength and range of motion. Physical therapy is the most important aid to recovery and may continue for several months. Activity may be resumed gradually, using devices such as walkers or crutches, as recommended by the physical therapist. Lifestyle changes may include the use of special seating or sleeping surfaces and employing home care assistance for help with shopping, cooking, and household tasks.

WHO PERFORMS ARTHROSCOPY SURGERIES AND WHERE ARE THEY PERFORMED?

An orthopedic surgeon performs arthroplasty, including joint resection, interpositional reconstruction, and total joint arthroplasty (joint replacement). Orthopedic surgeons are board certified in their specialty and members of the American Academy of Orthopedic Surgeons (AAOS).

Orthopedic hospitals specialize in treating orthopedic conditions and performing orthopedic surgery. Although some orthopedic surgery may be performed in other hospitals and medical centers, better surgical results have been reported in the specialized centers.

Risks

Joint resection and interpositional reconstruction do not always produce successful results, especially in patients with rheumatoid arthritis, a chronic inflammatory disease that may continue to narrow the joint space and accelerate the formation of scar tissue. Repeat surgery or total joint replacement may be necessary. As with any major surgery, there are always risks of an allergic reaction to anesthesia, postoperative infection, or the formation of blood clots (thrombophlebitis) that may cause pain and swelling near the surgery site and travel through the veins to other parts of the body. A joint that has undergone surgery is less stable than a healthy joint, and dislocation or loosening of the resected joint may occur, especially with inappropriate physical activity.

Normal results

Most patients enjoy an improved range of motion in the joint and relief from pain. Younger people may be able to return to some form of low-impact sports activity. However, people who have degenerative or inflammatory diseases must understand that they will not suddenly have a normal joint, even while they will gain pain relief and improved function.

Morbidity and mortality rates

The number of deaths for all arthroplasty surgeries is less than 1%, with death more likely to occur among elderly patients and those with other serious medical conditions.

QUESTIONS TO ASK THE DOCTOR

• Is surgery my only option? What alternatives might work?
• How many surgeries like mine have you performed?
• What can I do after surgery to improve the result and avoid more surgery?
• Will joint replacement be inevitable in time even if I have resection or reconstruction?
• What changes can I make in my lifestyle to slow the progress of arthritis?

Alternatives

Pain management alone, particularly with the availability of more effective pain medicines that have fewer side effects, is the primary nonsurgical option when the underlying diagnosis is a form of arthritis. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for patients with arthritis. Those with RA are given drugs that suppress immune system activity, shown to be a factor in this type of arthritis. A range of nutritional supplements and vitamins are reported to offer health benefits to people with OA. Among them, glucosamine and chondroitin sulfate have been shown to offer some relief for pain and stiffness. Weight loss is often recommended as well.

Because immobility of the affected joint can increase pain and stiffness, patients with joint disease are usually encouraged to continue some type of physical activity. Keeping the muscles strong through modest exercise, such as stretching or swimming, is often recommended to help support the joint and maintain mobility. Various devices, such as braces or orthopedic shoes, may be recommended, as well as walking aids. Safety rails, special elevated toilet-seat extensions, and bath and shower seats can make the patient more comfortable in daily life. Movement therapy, such as yoga, Pilates, tai chi, and dance, may help maintain joint flexibility and slow chronic arthritis symptoms. Occupational therapy, massage therapy, and physiotherapy may help improve range of motion and overall comfort, as well as patient confidence.

Resources

BOOKS

Grelsamer, Ronald P. What Your Doctor May Not Tell You about Hip and Knee Replacement Surgery: Everything You Need to Know to Make The Right Decisions. New York: Warner Books, 2004.

ORGANIZATIONS

American Academy of Orthopaedic Surgeons(AAOS). 6300 North River Rd. Rosemont, Illinois 60018. (847) 823-7186. Fax: (847) 823-8125. http://www.aaos.org (accessed March 6, 2008).

Tish Davidson, AM

Lee Culvert

Tish Davidson, AM

Arthroplasty, shoulder seeShoulder resection arthroplasty

Arthroscopic knee surgery seeKnee arthroscopic surgery