Joint replacement

Last updated
Joint replacement
Hip replacement Image 3684-PH.jpg
Hip joint replacement
ICD-10-PCS 0?R?0JZ
ICD-9-CM 81.5, 81.8
MeSH D019643

Replacement arthroplasty (from Greek arthron, joint, limb, articulate, + plassein, to form, mould, forge, feign, make an image of), or joint replacement surgery, is a procedure of orthopedic surgery in which an arthritic or dysfunctional joint surface is replaced with an orthopedic prosthesis. Joint replacement is considered as a treatment when severe joint pain or dysfunction is not alleviated by less-invasive therapies. It is a form of arthroplasty, and is often indicated from various joint diseases, including osteoarthritis and rheumatoid arthritis.[ citation needed ]

Contents

Joint replacement surgery has become more common, with knees and hips replaced most often. About 773,000 Americans had a hip or knee replaced in 2009. [1]

Uses

Shoulder

For shoulder replacement, there are a few major approaches to access the shoulder joint. The first is the deltopectoral approach, which saves the deltoid, but requires the supraspinatus to be cut. [2] The second is the transdeltoid approach, which provides a straight on approach at the glenoid. However, during this approach the deltoid is put at risk for potential damage. [2] Both techniques are used, depending on the surgeon's preferences.[ citation needed ]

The number of shoulder replacements carried out each year is increasing, but research looking into global records suggests that nine out of ten shoulder replacements last for at least a decade. [3] [4]

Hip

Hip replacement can be performed as a total replacement or a hemi (half) replacement. A total hip replacement consists of replacing both the acetabulum and the femoral head while hemiarthroplasty generally only replaces the femoral head. Hip replacement is currently the most common orthopaedic operation, though patient satisfaction short- and long-term varies widely.[ citation needed ]

It is unclear whether the use of assistive equipment would help in post-operative care. [5]

Knee

Knee replacement. Knee Replacement.png
Knee replacement.

Knee replacement involves exposure of the front of the knee, with detachment of part of the quadriceps muscle (vastus medialis) from the patella. The patella is displaced to one side of the joint, allowing exposure of the distal end of the femur and the proximal end of the tibia. The ends of these bones are then accurately cut to shape using cutting guides oriented to the long axis of the bones. The cartilages and the anterior cruciate ligament are removed; the posterior cruciate ligament may also be removed but the tibial and fibular collateral ligaments are preserved. [6] Metal components are then impacted onto the bone or fixed using polymethylmethacrylate (PMMA) cement. Alternative techniques exist that affix the implant without cement. These cement-less techniques may involve osseointegration, including porous metal prostheses.[ citation needed ]

The operation typically involves substantial postoperative pain, and includes vigorous physical rehabilitation. The recovery period may be 6 weeks or longer and may involve the use of mobility aids (e.g. walking frames, canes, crutches) to enable the person's return to preoperative mobility. [7]

Ankle

Ankle replacement has become a treatment of choice for people requiring arthroplasty, replacing the conventional use of arthrodesis, i.e. fusion of the bones. The restoration of range of motion is the key feature in favor of ankle replacement with respect to arthrodesis. However, clinical evidence of the superiority of the former has only been demonstrated for particular isolated implant designs. [8]

Finger

Finger joint replacement. Finger joint replacement prosthesis.png
Finger joint replacement.

Finger joint replacement is a relatively quick procedure of about 30 minutes, but requires several months of subsequent therapy. [9] Post-operative therapy may consist of wearing a hand splint or performing exercises to improve function and pain. [10]

Risks and complications

Medical risks

The stress of the operation may result in medical problems of varying incidence and severity.[ citation needed ]

Intra-operative risks

Immediate risks

Medium-term risks

Long-term risks

There are many controversies. Much of the research effort of the orthopedic-community is directed to studying and improving joint replacement. The main controversies are[ citation needed ]

Technique

Before major surgery is performed, a complete pre-anaesthetic work-up is required. In elderly people this usually would include ECG, urine tests, hematology and blood tests. Cross match of blood is routine also, as a high percentage of people receive a blood transfusion. Pre-operative planning requires accurate Xrays of the affected joint, implant design selecting and size-matching to the xray images (a process known as templating).[ citation needed ]

A few days' hospitalization is followed by several weeks of protected function, healing and rehabilitation. This may then be followed by several months of slow improvement in strength and endurance.

Early mobilisation of the person is thought to be the key to reducing the chances of complications [1] such as venous thromboembolism and Pneumonia. Modern practice is to mobilize people as soon as possible and ambulate with walking aids when tolerated. Depending on the joint involved and the pre-op status of the person, the time of hospitalization varies from 1 day to 2 weeks, with the average being 4–7 days in most regions.[ citation needed ]

Physiotherapy is used extensively to help people recover function after joint replacement surgery. A graded exercise programme is needed initially, as the person's muscles take time to heal after the surgery; exercises for range of motion of the joints and ambulation should not be strenuous. Later when the muscles have healed, the aim of exercise expands to include strengthening and recovery of function.

Materials

Some ceramic materials commonly used in joint replacement are alumina (Al2O3), zirconia (ZrO2), silica (SiO2), hydroxyapatite (Ca10(PO4)6(OH)2), titanium nitride (TiN), silicon nitride (Si3N4). A combination of titanium and titanium carbide is a very hard ceramic material often used in components of arthroplasties due to the impressive degree of strength and toughness it presents, as well as its compatibility with medical imaging.[ citation needed ]

Titanium carbide has proved to be possible to use combined with sintered polycrystalline diamond surface (PCD), a superhard ceramic which promises to provide an improved, strong, long-wearing material for artificial joints. PCD is formed from polycrystalline diamond compact (PDC) through a process involving high pressures and temperatures. When compared with other ceramic materials such as cubic boron nitride, silicon nitride, and aluminum oxide, PCD shows many better characteristics, including a high level of hardness and a relatively low coefficient of friction. For the application of artificial joints it will likely be combined with certain metals and metal alloys like cobalt, chrome, titanium, vanadium, stainless steel, aluminum, nickel, hafnium, silicon, cobalt-chrome, tungsten, zirconium, etc. [11] This means that people with nickel allergy or sensitivities to other metals are at risk for complications due to the chemicals in the device. [12]

In knee replacements there are two parts that are ceramic and they can be made of either the same ceramic or different ones. If they are made of the same ceramic, however, they have different weight ratios. These ceramic parts are configured so that should shards break off of the implant, the particles are benign and not sharp. They are also made so that if a shard were to break off of one of the two ceramic components, they would be noticeable through x-rays during a check-up or inspection of the implant. With implants such as hip implants, the ball of the implant could be made of ceramic, and between the ceramic layer and where it attaches to the rest of the implant, there is usually a membrane to help hold the ceramic. The membrane can help prevent cracks, but if cracks should occur at two points which create a separate piece, the membrane can hold the shard in place so that it doesn't leave the implant and cause further injury. Because these cracks and separations can occur, the material of the membrane is a bio-compatible polymer that has a high fracture toughness and a high shear toughness. [13]

Prosthesis replacement

The prosthesis may need to be replaced due to complications such as infection or prosthetic fracture. Replacement may be done in one single surgical session. Alternatively, an initial surgery may be performed to remove previous prosthetic material, and the new prosthesis is then inserted in a separate surgery at a later time. In such cases, especially when complicated by infection, a spacer may be used, which is a sturdy mass to provide some basic joint stability and mobility until a more permanent prosthesis is inserted. It can contain antibiotics to help treating any infection. [14]

History

Stephen S. Hudack, a surgeon based in New York City, began animal testing with artificial joints in 1939. [15] By 1948, he was at the New York Orthopedic Hospital (part of the Columbia Presbyterian Medical Center) and with funding from the Office of Naval Research, was replacing hip joints in humans. [15]

Two previously[ when? ] popular forms of arthroplasty were: (1) interpositional arthroplasty', with interposition of some other tissue like skin, muscle or tendon to keep inflammatory surfaces apart and (2) excisional arthroplasty in which the joint surface and bone were removed leaving scar tissue to fill in the gap. Other forms of arthroplasty include resection(al) arthroplasty, resurfacing arthroplasty, mold arthroplasty, cup arthroplasty, and silicone replacement arthroplasty. Osteotomy to restore or modify joint congruity is also a form of arthroplasty.[ citation needed ]

In recent decades, the most successful and common form of arthroplasty is the surgical replacement of a joint or joint surface with a prosthesis. For example, a hip joint that is affected by osteoarthritis may be replaced entirely (total hip arthroplasty) with a prosthetic hip. This procedure involves replacing both the acetabulum (hip socket) and the head and neck of the femur. The purpose of doing this surgery is to relieve pain, to restore range of motion and to improve walking ability, leading to the improvement of muscle strength.

See also

Related Research Articles

<span class="mw-page-title-main">Orthopedic surgery</span> Branch of surgery concerned with the musculoskeletal and bones system

Orthopedic surgery or orthopedics, is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal trauma, spine diseases, sports injuries, degenerative diseases, infections, tumors, and congenital disorders.

<span class="mw-page-title-main">Hip replacement</span> Surgery replacing hip joint with prosthetic implant

Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant, that is, a hip prosthesis. Hip replacement surgery can be performed as a total replacement or a hemi (half) replacement. Such joint replacement orthopaedic surgery is generally conducted to relieve arthritis pain or in some hip fractures. A total hip replacement consists of replacing both the acetabulum and the femoral head while hemiarthroplasty generally only replaces the femoral head. Hip replacement is one of the most common orthopaedic operations, though patient satisfaction varies widely. Approximately 58% of total hip replacements are estimated to last 25 years. The average cost of a total hip replacement in 2012 was $40,364 in the United States, and about $7,700 to $12,000 in most European countries.

Osseointegration is the direct structural and functional connection between living bone and the surface of a load-bearing artificial implant. A more recent definition defines osseointegration as "functional ankylosis ", where new bone is laid down directly on the implant surface and the implant exhibits mechanical stability. Osseointegration has enhanced the science of medical bone and joint replacement techniques as well as dental implants and improving prosthetics for amputees.

Arthroplasty is an orthopedic surgical procedure where the articular surface of a musculoskeletal joint is replaced, remodeled, or realigned by osteotomy or some other procedure. It is an elective procedure that is done to relieve pain and restore function to the joint after damage by arthritis or some other type of trauma.

<span class="mw-page-title-main">Implant (medicine)</span> Device surgically placed within the body for medical purposes

An implant is a medical device manufactured to replace a missing biological structure, support a damaged biological structure, or enhance an existing biological structure. Medical implants are man-made devices, in contrast to a transplant, which is a transplanted biomedical tissue. The surface of implants that contact the body might be made of a biomedical material such as titanium, silicone, or apatite depending on what is the most functional. In some cases implants contain electronics, e.g. artificial pacemaker and cochlear implants. Some implants are bioactive, such as subcutaneous drug delivery devices in the form of implantable pills or drug-eluting stents.

<span class="mw-page-title-main">Knee replacement</span> Surgical procedure

Knee replacement, also known as knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability, most commonly offered when joint pain is not diminished by conservative sources and also for other knee diseases such as rheumatoid arthritis and psoriatic arthritis. In patients with severe deformity from advanced rheumatoid arthritis, trauma, or long-standing osteoarthritis, the surgery may be more complicated and carry higher risk. Osteoporosis does not typically cause knee pain, deformity, or inflammation and is not a reason to perform knee replacement.

Oxinium is the brand name of a material used for replacement joints manufactured by the reconstructive orthopedic surgery division of medical devices company Smith & Nephew. It consists of a zirconium alloy metal substrate that transitions into a ceramic zirconium oxide outer surface.

Bone cements have been used very successfully to anchor artificial joints for more than half a century. Artificial joints are anchored with bone cement. The bone cement fills the free space between the prosthesis and the bone and plays the important role of an elastic zone. This is necessary because the human hip is acted on by approximately 10–12 times the body weight and therefore the bone cement must absorb the forces acting on the hips to ensure that the artificial implant remains in place over the long term.

<span class="mw-page-title-main">Hip resurfacing</span>

Hip resurfacing has been developed as a surgical alternative to total hip replacement (THR). The procedure consists of placing a cap, which is hollow and shaped like a mushroom, over the head of the femur while a matching metal cup is placed in the acetabulum, replacing the articulating surfaces of the person's hip joint and removing very little bone compared to a THR. When the person moves the hip, the movement of the joint induces synovial fluid to flow between the hard metal bearing surfaces lubricating them when the components are placed in the correct position. The surgeon's level of experience with hip resurfacing is most important; therefore, the selection of the right surgeon is crucial for a successful outcome. Health-related quality of life measures are markedly improved and the person's satisfaction is favorable after hip resurfacing arthroplasty.

<span class="mw-page-title-main">Shoulder replacement</span>

Shoulder replacement is a surgical procedure in which all or part of the glenohumeral joint is replaced by a prosthetic implant. Such joint replacement surgery generally is conducted to relieve arthritis pain or fix severe physical joint damage.

<span class="mw-page-title-main">Unicompartmental knee arthroplasty</span>

Unicompartmental knee arthroplasty (UKA) is a surgical procedure used to relieve arthritis in one of the knee compartments in which the damaged parts of the knee are replaced. UKA surgery may reduce post-operative pain and have a shorter recovery period than a total knee replacement procedure, particularly in people over 75 years of age. Moreover, UKAs may require a smaller incision, less tissue damage, and faster recovery times.

Ankle replacement, or ankle arthroplasty, is a surgical procedure to replace the damaged articular surfaces of the human ankle joint with prosthetic components. This procedure is becoming the treatment of choice for patients requiring arthroplasty, replacing the conventional use of arthrodesis, i.e. fusion of the bones. The restoration of range of motion is the key feature in favor of ankle replacement with respect to arthrodesis. However, clinical evidence of the superiority of the former has only been demonstrated for particular isolated implant designs.

"Professor" Derek McMinn is a British orthopaedic surgeon and inventor who practised in Birmingham, United Kingdom at the BMI Edgbaston Hospital. McMinn developed one of the successful modern metal-on-metal hip resurfacing and the instrumentation and surgical technique to implant it. Hip resurfacing is a bone-conserving, less invasive alternative to total hip replacement (THR) for young patients, markedly improves the health-related quality of life measures and currently makes up around a twentieth of all hip arthroplasty procedures performed in the United Kingdom. McMinn is also the inventor of several other prostheses for the hip and knee.

Metallosis is the medical condition involving deposition and build-up of metal debris in the soft tissues of the body.

Limb-sparing techniques, also known as limb-saving or limb-salvage techniques, are performed in order to preserve the look and function of limbs. Limb-sparing techniques are used to preserve limbs affected by trauma, arthritis, cancers such as high-grade bone sarcomas, and vascular conditions such as diabetic foot ulcers. As the techniques for chemotherapy, radiation, and diagnostic modalities improve, there has been a trend toward limb-sparing procedures to avoid amputation, which has been associated with a lower 5-year survival rate and cost-effectiveness compared to limb salvage in the long-run. There are many different types of limb-sparing techniques, including arthrodesis, arthroplasty, endoprosthetic reconstruction, various types of implants, rotationplasty, osseointegration limb replacement, fasciotomy, and revascularization.

<span class="mw-page-title-main">William H. Harris (orthopaedic surgeon)</span> American orthopaedic surgeon

William H. Harris, is an American orthopaedic surgeon, Founder and Director Emeritus of the Massachusetts General Hospital Harris Orthopaedics Laboratory, and creator of the Advances in Arthroplasty course held annually since 1970.

First Source - Orthopedic Surgery being a "choice."

<span class="mw-page-title-main">Index of trauma and orthopaedics articles</span>

Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.

<span class="mw-page-title-main">Reverse shoulder replacement</span>

Reverse shoulder replacement is a type of shoulder replacement in which the normal ball and socket relationship of glenohumeral joint is reversed, creating a more stable joint with a fixed fulcrum. This form of shoulder replacement is utilized in situations in which conventional shoulder replacement surgery would lead to poor outcomes and high failure rates.

References

  1. 1 2 Joint Replacement Surgery and You. (April, 2009) In Arthritis, Musculoskeletal and Skin Disease online. Retrieved from http://www.niams.nih.gov/#.
  2. 1 2 Nerot, C.; Ohl, X. (2014). "Primary shoulder reverse arthroplasty: Surgical technique". Orthopaedics & Traumatology: Surgery & Research. 100 (1): S181–S190. doi: 10.1016/j.otsr.2013.06.011 . PMID   24461235.
  3. ↑ "Most shoulder replacements last longer than a decade". NIHR Evidence. 2021-04-30. doi:10.3310/alert_46075. S2CID   242994004 . Retrieved 2022-07-06.
  4. ↑ Evans, Jonathan P; Evans, Jonathan T; Craig, Richard S; Mohammad, Hasan R; Sayers, Adrian; Blom, Ashley W; Whitehouse, Michael R; Rees, Jonathan L (September 2020). "How long does a shoulder replacement last? A systematic review and meta-analysis of case series and national registry reports with more than 10 years of follow-up". The Lancet Rheumatology. 2 (9): e539–e548. doi:10.1016/S2665-9913(20)30226-5. hdl: 10871/123324 . S2CID   225252643.
  5. ↑ Smith, Toby O; Jepson, Paul; Beswick, Andrew; Sands, Gina; Drummond, Avril; Davis, Edward T; Sackley, Catherine M (2016-07-04). "Assistive devices, hip precautions, environmental modifications and training to prevent dislocation and improve function after hip arthroplasty". Cochrane Database of Systematic Reviews. 2016 (7): CD010815. doi:10.1002/14651858.cd010815.pub2. ISSN   1465-1858. PMC   6458012 . PMID   27374001.
  6. ↑ Verra, Wiebe C.; van den Boom, Lennard G. H.; Jacobs, Wilco; Clement, Darren J.; Wymenga, Ate A. B.; Nelissen, Rob G. H. H. (2013-10-11). "Retention versus sacrifice of the posterior cruciate ligament in total knee arthroplasty for treating osteoarthritis". The Cochrane Database of Systematic Reviews. 2013 (10): CD004803. doi:10.1002/14651858.CD004803.pub3. ISSN   1469-493X. PMC   6599815 . PMID   24114343.
  7. ↑ Leopold SS (April 2009). "Minimally invasive total knee arthroplasty for osteoarthritis". N. Engl. J. Med. 360 (17): 1749–58. doi:10.1056/NEJMct0806027. PMID   19387017.
  8. ↑ Saltzman, C.L.; Mann, R.A.; Ahrens, J.E.; Amendola, A.; Anderson, R.B.; Berlet, G.C.; Brodky, J.W.; Chou, L.B.; Clanton, T.O.; Deland, J.T.; Deorio, J.K.; Horton, G.A.; Lee, T.H.; Mann, J.A.; Nunley, J.A.; Thordarson, D.B.; Walling, A.K.; Wapner, K.L.; Coughlin, M.J. (2009). "Prospective Controlled Trial of STAR Total Ankle Replacement Versus Ankle Fusion: Initial Results". Foot & Ankle International . 30 (7): 579–596. doi:10.3113/FAI.2009.0579. PMID   19589303. S2CID   787907.
  9. ↑ Page 50 in: Leslie Galliker (2014). Joint Replacements. ABDO. ISBN   9781617839030.
  10. ↑ Massy-Westropp, Nicola; Johnston, Renea V; Hill, Catherine L (2008-01-23). "Post-operative therapy for metacarpophalangeal arthroplasty". Cochrane Database of Systematic Reviews. 2009 (1): CD003522. doi:10.1002/14651858.cd003522.pub2. ISSN   1465-1858. PMC   8715905 . PMID   18254021.
  11. ↑ Pope, Bill et al. (2011) International Patent No. 127321A. Orem, UT: US http://worldwide.espacenet.com
  12. ↑ Thomas, Peter (2014-01-01). "Clinical and diagnostic challenges of metal implant allergy using the example of orthopaedic surgical implants: Part 15 of the Series Molecular Allergology". Allergo Journal International. 23 (6): 179–185. doi:10.1007/s40629-014-0023-3. ISSN   2197-0378. PMC   4479460 . PMID   26120529.
  13. ↑ Monaghan, Matthew, David Miller. (2013). US Patent No. 0282134A1. Warsaw, IN: US http://worldwide.espacenet.com/
  14. ↑ Mazzucchelli, Luca; Rosso, Federica; Marmotti, Antongiulio; Bonasia, Davide Edoardo; Bruzzone, Matteo; Rossi, Roberto (2015). "The use of spacers (static and mobile) in infection knee arthroplasty". Current Reviews in Musculoskeletal Medicine. 8 (4): 373–382. doi:10.1007/s12178-015-9293-8. ISSN   1935-973X. PMC   4630232 . PMID   26395472.
  15. 1 2 "Joints of Steel and Plastic". Life . April 12, 1948. pp. 127–130. ISSN   0024-3019 . Retrieved 2011-03-19.
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