JOINT REPLACEMENT

Joint arthroplasty is defined as the replacement of worn out arthritic joints in the body with artificial implants/prosthesis for pain relief, increased mobility and movements. Weight bearing joints in the body normally get worn out with increasing age. The common joints involved are the knees and hips. The other joints which rarely do get worn out are the shoulders and elbows. When this happens, the worn out bones are replaced by artificial prosthesis. These artificial prostheses mimic the original joints in term of design and function. Sometimes replacement surgeries are also indicated in young individuals because of secondary conditions leading to joint destruction and deformity such as trauma and diseases like rheumatoid arthritis.

KNEE REPLACEMENT

Knee is considered to be one of the most important joint in the body as it plays a leading role in bearing the body weight. Knee is the most common joint that gets worn out with age. Patients with diseases such as osteoarthritis, hemophilia, gout, rheumatoid arthritis etc. may also require knee replacement. When the knee joints get damaged, it is necessary to be replaced. The prosthesis used in joint replacements varies depending on patient factors and cost. The replaced knee can last for uptotwenty five years depending on the activity level of the patient.

Indications :
  1. Severe knee pain restricting day to day activities like walking, climbing stairs, using the commode etc.
  2. Night pains disturbing your sleep.
  3. Deformity in knees.
  4. Restricted knee bending and stiffness.
  5. Failure of other treatments modalities like physiotherapy and medications.

Advantages :

The realistic results that the patient can hope to achieve following a replacement surgery are

  1. Significant pain relief
  2. Improved ambulatory status
  3. Straighter knee free from deformity
  4. Bending upto 100 degrees (Can go upto 130degrees)
  5. Active lifestyle


HIP REPLACEMENT

Hip is one of the largest weight bearing joints in the human body. It plays a vital role in mobility and stability. A variety of causes may lead to destruction of this joint, the most common being Osteoarthirtis, trauma to the joint, rheumatoid arthritis, congenital causes (Hip dysplasias) and avascular necrosis. When this happens, replacement of the damaged portion is essential for alleviating pain and improving the quality of life.

Causes:

Though a variety of factors may lead to hip damage, the common causes are listed below

  1. Osteoarthritis: it is caused due to the degradation of cartilage inside the associated hip joint. As a result, the bones get rugged against each other and cause wear and tear. Hip fracture: an intense hip damage caused by an accident will requires replacement surgery.
  2. Rheumatoid arthritis: Misdirected action of immune system on the joint lining causes rheumatoid arthritis. It can lead to hip damage. Hip dysplasia: It is the abnormal growth of hip bones. Hip replacement will be necessary to correct hip dysplasia. Mostly, younger individuals are affected with these kinds of disorders.
  3. Avascular Necrosis: It is the deformity in the joint caused by reduced blood supply of the head of femur bone leading to its collapse. It is common in smokers, steroid use and deep sea divers. Young individuals are commonly affected.

Symptoms & Indications :

The common symptoms that patients face are

  1. Continuous pain.
  2. Difficulty in walking
  3. Shortening of the leg
  4. Inability to squat
  5. Reduced hip movements

Advantages :

The realistic results that the patient can hope to achieve following a hip replacement surgery are

  1. Significant pain relief
  2. Improved ambulatory status
  3. Increased hip movements
  4. Correction of shortening
  5. Active lifestyle

Limitations:

The limitations of the surgery are

  1. Patients cannot squat on the floor or sit use Indian commodes
  2. Patient cannot be involved in high energy activities and sports
  3. Implants get worn out over a period of time requiring revision surgery

Types of joint replacement

They are broadly categorized into two types.

  1. Partial hip replacement (Surface replacement): As the name indicates, only a part of the hip which is worn out is replaced. Hip joint is made of 2 bones – the cup of the pelvic bone and the head of thigh bone(femur). When only the head is involved, then this surgery is the ideal choice.
  2. Total hip replacement: Total joint arthroplasty is indicated when both the cup and the ball gets worn out. This is the most commonly done surgery and has good results in terms of pain and activity level.

These surgeries may be cemented (where the artificial prosthesis are fixed to the bone with bone cement) or uncemented.

Patient selection:

Patients with the above mentioned indications are ideal candidates for joint replacement. Age is not a criterion for joint replacement but symptoms are. Patients with associated co-morbidities like diabetes, hypertension, heart conditions, lung and urinary tract infections, dental caries etc. need a complete pre operative evaluation before deciding on surgery.

Implant selection:

A variety of implants are available in the market for joint replacement surgeries. They are available in stainless steel, cobalt chromium alloys, titanium alloys, tantalum alloys, zirconium alloys and the new oxinium implants. Different prosthetic designs are available to increase the longevity of the prosthesis. They may be cemented or uncemented. Implant selection is primarily dependent on patient factors and expectations. The cost also plays an important role in our society.

The surgery

The normal inpatient time in the hospital varies from 7 to 10days. The stages involved in preparing for the surgery are

  1. Pre operative
  2. Intra operative
  3. Post operative
  4. Home care

Pre operative work up:

Pre operative work up starts with a Consultation with the OrthopaedicSurgeon which lasts for about 45minutes. It includes a detailed history, general physical examination, hip joint examination, x rays, blood investigations, ECG, Echo and patient counseling. Patient will additionally have to meet a Physician, a Cardiologist, an Anaesthetist and sometimes a Gynecologist for pre operative assessment of their general condition. Blood may be required in the pre, intra or post operative period in patients with low blood levels. Pre operative work up can be done as inpatient or outpatient. Once the patient is fit for surgery, he or she is admitted for undergoing the procedure.

Patient counseling: It involves a detailed discussion about the hospital stay and surgery, the realistic expectations that the surgery can achieve, the limitations of the surgery, the choice of prosthesis, the post operative rehabilitation protocol, social and home planning and finally the complications that may occur during or after the procedure.

Intra operative period:

After admission, the patient is kept on empty stomach for a minimum period of six hours prior to surgery. The knee joint is prepared an hour before surgery and the patient is shifted to the operation theater half hour before the scheduled time. The surgery last for a period of about 2 hours. The anesthesia routinely administered is spinal or epidural anesthesia where the patient is awake during the procedure but both the legs numb below waist level. The other type is the general anesthesia where the patient is put to sleep. After giving anesthesia, an incision of suitable size is made on the hip. These incisions can be of different types such as posterior, lateral, anterior, and antero-lateral depending on the Surgeon’s choice. The original hip joint is removed and immediately replaced with an artificial one through this incision. Most of the hip prosthesis are created using alloy of different metals and stainless steel. An adequate support will be provided by a polyethylene ace tabular cup and a ceramic head. The surgery will last for about 60-90 minutes. Metal components may be fitted onto the bone using an appropriate cementing material. The wound is closed with stitches. After the surgery patient is shifted to the post operative recovery room. Blood may be given in the operation theater or in the post operative ward.

Post operative period:
  1. Day 1: The patient is usually made to sit and stand on the 1st post operative day. Diet is normalized. Antibiotics and thromboprophylaxis are continued. If they are comfortable, they are even made to walk a few steps. Blood may or may not be given depending on the blood loss. Pain is controlled by epidural catheters which are retained for 2 days.
  2. Day 2: Wound is inspected and dressing is changed on 2nd day. Blood drain is removed. The patient is made to walk further more with support of a walker. They are given commode training and exercises. Recovery is generally quick and one can perform his/her daily activities but with some care. Injectable medications are converted to tablets.
  3. Day 3 to Day 5: It involves aggressive physiotherapy and exercises. Stairs climbing is usually delayed. Patient is discharged once mobilization is satisfactory.

Home care:

Home care involves wound care and home physiotherapy. The success of a replacement surgery depends a lot on home physiotherapy. Physiotherapists visit patients at home to assist them in rehabilitation till they are satisfied that can train by themselves. They normal provide home physio for a week to 10 days. The dressing should not be disturbed and should be water free. Dressing is changed after 5 days and sutures are removed after 10 to 12 days.

Complications:

Surgical and post operative complications do occur in a small percentage of patients who undergo joint replacement. They include infection, dislocation, deep vein thrombosis (blood clots forming in the legs), pulmonary embolism, neurovascular injuries and implant failure.

The possible risks and complications caused by the surgery include:

  1. Dislocation
  2. Loosening
  3. impingement
  4. infection
  5. osteolysis
  6. metal sensitivity
  7. nerve palsy
  8. blood clot

After the surgery, you will have to continue frequent check-ups as prescribed by the doctor.


SHOULDER REPLACEMENT

The medical procedure of replacing a part or the whole of glenohumeral joint by an artificial implant is referred to as shoulder replacement. Although shoulder joint replacement is less common than knee or hip replacement, it is just as successful in relieving joint pain. Patients who have most of the symptoms and signs of the disease can go for the diagnosis and have the treatment according to the suggestions of the doctor.

Anatomy:

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The shoulder is a ball-and-socket joint: The ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade. This socket is called the glenoid.

The surfaces of the bones where they touch are covered with articular cartilage, a smooth substance that protects the bones and enables them to move easily. A thin, smooth tissue called synovial membrane covers all remaining surfaces inside the shoulder joint. In a healthy shoulder, this membrane makes a small amount of fluid that lubricates the cartilage and eliminates almost any friction in your shoulder.

The muscles and tendons that surround the shoulder provide stability and support.

All of these structures allow the shoulder to rotate through a greater range of motion than any other joint in the body.

The replacement of either the head of the humerus bone (ball) or both the ball and the glenoid (socket) is performed. The surgery is performed because of intense shoulder pain.

This pain can be attributed to several factors:

  1. Degenerative joint disease (osteoarthritis): The cartilage in the shoulder that cushions the bone movement wears away. This results in a painful and stiff shoulder.
  2. Avascular necrosis: As blood supply to bone joints decrease, bone cells die. This leads to shoulder joint destruction and arthritis results.
  3. Rotator Cuff Tear Arthropathy: Arthropathy is the degeneration of the weight bearing portion of the joint. When a large tear occurs in the rotator cuff (associated tendons and muscles that make up the shoulder joint), arthropathy may happen. This arthropathy can lead to cartilage destruction.
  4. Severe fractures: A sudden shattering of the upper portion of the bone can lead a severe fracture. Putting the broken pieces back into the right place becomes a herculean task. Under this condition, shoulder replacement may be the only option left. Older individuals having osteoporosis are prone to such fractures.
  5. Shoulder replacement techniques can have many options. Some of the types of this replacement are stemmed hemiarthroplasty, resurfacing hemiarthroplasty, reverse total shoulder replacement etc.

Surgery :

For the replacement of shoulder joint, the surgeon will first make a cut over the shoulder joint. This cut is made in order to make an open up the area. Then, the surgeon will remove the top of the humerus (upper arm bone). The next procedure is to cement the new material head and stem into place. It will be followed by smoothening of the surface of the old socket and then cement the new one in place. After this, the cut or incision will be closed with sutures or staples. In order to protect the wound from infections, the doctor may place a bandage or dressing over the wound. This surgery may take one to three hours.

Post-surgery

For the surgery, the patient may have to stay in the hospital for one to three days after the surgery. During this period, the patient may receive physical therapy in order to the adjacent muscles from getting stiff. Patient’s arm will be in sling for 2-6 weeks. During this period, the patient is not supposed to do active movements. It may take four to six months for the recovery. The new shoulder joint can last up to 10 years, if it is used properly.

Possible risks & complications

Application of anesthesia can cause certain problems such as

  1. Allergic reactions and
  2. Breathing problems

Any surgery can have the common risks and complications such as infection, blood clotting and bleeding. Other risks and complications of shoulder replacement surgery are:

  1. Damage to blood vessels while surgery
  2. Bone break while surgery
  3. Nerve damage while surgery
  4. Allergic reactions to the new joint
  5. Dislocation of the new joint and
  6. Implant may loosen over time