Joint replacement is the surgical replacement of a joint with an artificial prosthesis.
Great advances have been made in joint replacement since the first hip replacement was performed in the United States in 1969. Improvements have been made in the endurance and compatibility of materials used and the surgical techniques to install artificial joints. Custom joints can be made using a mold of the original joint that duplicate the original with a very high degree of accuracy.
The most common joints to be replaced are hips and knees. There is ongoing work on elbow and shoulder replacement, but some joint problems are still treated with joint resection (the surgical removal of the joint in question) or interpositional reconstruction (the reassembly of the joint from constituent parts).
Seventy percent of joint replacements are performed because arthritis has caused the joint to stiffen and become painful to the point where normal daily activities are no longer possible. If the joint does not respond to conservative treatment such medication, weight loss, activity restriction, and use of walking aids such as a cane, joint replacement is considered appropriate.
Patients with rheumatoid arthritis or other connective tissue diseases may also be candidates for joint replacement, but the results are usually less satisfactory in those patients. Elderly people who fall and break their hip often undergo hip replacement when the probability of successful bone healing is low.
More than 170,000 hip replacements are performed in the United States each year. Since the lifetime of the artificial joint is limited, the best candidates for joint replacement are over age 60.
Joint replacements are performed successfully on an older-than-average group of patients. People with diseases that interfere with blood clotting are not good candidates for joint replacement. Joint replacement surgery should not be done on patients with infection, or any heart, kidney or lung problems that would make it risky to undergo general anesthesia.
Joint replacements are performed under general or regional anesthesia in a hospital by an orthopedic surgeon. Some medical centers specialize in joint replacement, and these centers generally have a higher success rate than less specialized facilities. The specific techniques of joint replacement vary depending on the joint involved.
The surgeon makes an incision along the top of the thigh bone (femur) and pulls the thigh bone away from the socket of the hip bone (the acetabulum). An artificial socket made of metal coated with polyethylene (plastic) to reduce friction is inserted in the hip. The top of the thigh bone is cut, and a piece of artificial thigh made of metal is fitted into the lower thigh bone on one end and the new socket on the other.
The artificial hip can either be held in place by a synthetic cement or by natural bone in-growth. The cement is an acrylic polymer. It assures good locking of the prosthesis to the remaining bone. However, bubbles left in the cement after it cures may act as weak spots, causing the development of cracks. This promotes loosening of the prosthesis later in life. If additional surgery is needed, all the cement must be removed before surgery can be performed.
An artificial hip fixed by natural bone in-growth requires more precise surgical techniques to assure maximum contact between the remaining natural bone and the prosthesis. The prosthesis is made so that it contains small pores that encourage the natural bone to grow into it. Growth begins 6 to 12 weeks after surgery. The short term outcome with non-cemented hips is less satisfactory, with patients reporting more thigh pain, but the long term outlook is better, with fewer cases of hip loosening in non-cemented hips. The trend is to use the non-cemented technique. Hospital stays last from four to eight days.
The doctor puts a tourniquet above the knee, then makes a cut to expose the knee joint. The ligaments surrounding the knee are loosened, then the shin bone and thigh bone are cut and the knee removed. The artificial knee is then cemented into place on the remaining stubs of those bones. The excess cement is removed, and the knee is closed. Hospital stays range from three to six days.
In both types of surgery, preventing infection is very important. Antibiotics are given intravenously and continued in pill form after the surgery. Fluid and blood loss can be great, and sometimes blood transfusions are needed.
Many patients choose to donate their own blood for transfusion during the surgery. This prevents any blood incompatibility problems or the transmission of bloodbourne diseases.
Prior to surgery, all the standard preoperative blood and urine tests are performed, and the patient meets with the anesthesiologist to discuss any special conditions that affect the administration of anesthesia. Patients receiving general anesthesia should not eat or drink for ten hours prior to the operation.
Immediately after the operation the patient will be catheterized so that he or she will not have to get out of bed to urinate. The patient will be monitored for infection. Antibiotics are continued and pain medication is prescribed. Physical therapy begins (first passive exercises, then active ones) as soon as possible using a walker, cane, or crutches for additional support. Long term care of the artificial joint involves refraining from heavy activity and heavy lifting, and learning how to sit, walk, how to get out of beds, chairs, and cars so as not to dislocate the joint.
The immediate risks during and after surgery include the development of blood clots that may come loose and block the arteries, excessive loss of blood, and infection. Blood thinning medication is usually given to reduce the risk of clots forming. Some elderly people experience short term confusion and disorientation from the anesthesia.
Although joint replacement surgery is highly successful, there is an increased risk of nerve injury. Dislocation or fracture of the hip joint is also a possibility. Infection caused by the operation can occur as long as a year later and can be difficult to treat. Some doctors add antibiotics directly to the cement used to fix the replacement joint in place. Loosening of the joint is the most common cause of failure in hip joints that are not infected. This may require another joint replacement surgery in about 12% of patients within a 15-year period following the first procedure.
More than 90% of patients receiving hip replacements achieve complete relief from pain and significant improvement in joint function. The success rate is slightly lower in knee replacements, and drops still more for other joint replacement operations.
Catheterization— Inserting a tube into the bladder so that a patient can urinate without leaving the bed.
Prosthesis— A synthetic replacement for a missing part of the body, such as a knee or a hip.
Rheumatoid arthritis— A joint disease of unknown origins that may begin at an early age causing deformity and loss of function in the joints.
Siopack, Jorge, and Harry Jergensen. "Total Hip Arthroplasty." In Western Journal of Medicine March 1995: 43-50.