Joint Replacement
What Is Arthritis
Arthritis literally means "inflammation of a joint." In some forms of arthritis, such as osteoarthritis, the inflammation arises because the smooth covering (articular cartilage) on the ends of bones become damaged or worn. Osteoarthritis is usually found in one, usually weightbearing, joint.
In other forms of arthritis, such as rheumatoid arthritis, the joint lining becomes inflamed as part of a disease process that affects the entire body. Some other types of arthritis are: seronegative spondyloarthropathies, crytalline deposition diseases, and septic arthritis.
Arthritis is a major cause of lost work time and serious disability for many people. Although arthritis is mainly a disease of adults, children may also have it.
Anatomy
Arthritis is a disease of the joint. A joint is where the ends of two or more bones meet. The knee joint, for example, is formed between the bones of the lower leg (the tibia and the fibula) and the thighbone (the femur). The hip joint is where the top of the thighbone (femoral head) meets a concave portion of the pelvis (the acetabulum).
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A smooth tissue of cartilage covers the ends of bones in a joint. Cartilage cushions the bone and allows the joint to move easily without the friction that would come with bone-on-bone contact. A joint is enclosed by a fibrous envelope, called the synovium, which produces a fluid that also helps to reduce friction and wear in a joint. Ligaments connect the bones and keep the joint stable. Muscles and tendons power the joint and enable it to move.
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Cause
There are two major categories of arthritis.
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The first type is caused by wear and tear on the articular cartilage (osteoarthritis) through the natural aging process, through constant use, or through trauma (post-traumatic arthritis).
The second type is caused by one of a number of inflammatory processes.
Regardless of whether the cause is from injury, normal wear and tear, or disease, the joint becomes inflamed, causing swelling, pain and stiffness. This is usually temporary. Inflammation is one of the body's normal reactions to injury or disease. In arthritic joints, however, inflammation may cause long-lasting or permanent disability.
Natural History
Osteoarthritis
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This drawing of an arthritic hip shows how the cartilage covering the leg bone (femur) and the acetabulum of the hip become damaged over time.
The most common type of arthritis is osteoarthritis. It results from overuse, trauma, or the degeneration of the joint cartilage that takes place with age. Osteoarthritis is often more painful in joints that bear weight, such as the knee, hip, and spine, rather than in the wrist, elbow, and shoulder joints. However, joints that are used extensively in work or sports or joints that have been damaged from fractures or other injuries may show signs of osteoarthritis. Other disorders that injure or overload the articular cartilage may lead to osteoarthritis.
In osteoarthritis, the cartilage covering the bone ends gradually wears away. In many cases, bone growths called "spurs" develop at the edges of osteoarthritic joints. The bone can become hard and firm (sclerosis). The joint becomes inflamed, causing pain and swelling. Continued use of the joint is painful.
Rheumatoid Arthritis
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Rheumatoid arthritis is a long-lasting disease. It is estimated that 1% of the population throughout the world have rheumatoid arthritis. Women are three times more likely than men to have rheumatoid arthritis. The development of rheumatoid arthritis slows with age.
Rheumatoid arthritis affects many parts of the body, but mainly the joints. The body's immune system, which normally protects the body, begins to produce substances that attack the body. In rheumatoid arthritis, the joint lining swells, invading surrounding tissues. Chemical substances are produced that attack and destroy the joint surface.
Rheumatoid arthritis may affect both large and small joints in the body and also the spine. Swelling, pain, and stiffness usually develop, even when the joint is not used. In some circumstances, juvenile arthritis may cause similar symptoms in children.
Diagnosis
Arthritis is diagnosed through a careful evaluation of symptoms and a physical examination. X-rays are important to show the extent of any damage to the joint. Blood tests and other laboratory tests may help to determine the type of arthritis. Some of the findings of arthritis include:
- Weakness (atrophy) in the muscles
- Tenderness to touch
- Limited ability to move the joint passively (with assistance) and actively (without assistance).
- Signs that other joints are painful or swollen (an indication of rheumatoid arthritis)
- A grating feeling or sound (crepitus) with movement
- Pain when pressure is placed on the joint or the joint is moved
Medications
Over-the-counter medications can be used to control pain and inflammation in the joints. These medications, called anti-inflammatory drugs, include aspirin, ibuprofen, and naproxen. Acetaminophen can be effective in controlling pain.
Prescription medications also are available. A physician will choose a medication by taking into account the type of arthritis, its severity, and the patient's general physical health. Patients with ulcers, asthma, kidney, or liver disease, for example, may not be able to safely take anti-inflammatory medications.
Injections of cortisone into the joint may temporarily help to relieve pain and swelling. It is important to know that repeated, frequent injections into the same joint can damage it, causing undesirable side effects.
Viscosupplementation or injection of hyaluronic acid preparations can also be helpful in lubricating the joint. This is typically perfomed in the knee.
Exercise and Therapy
Canes, crutches, walkers, or splints may help relieve the stress and strain on arthritic joints. Learning methods of performing daily activities that are the less stressful to painful joints also may be helpful.
Certain exercises and physical therapy may be used to decrease stiffness and to strengthen the weakened muscles around the joint.
Surgery
In general, Surgery is performed for arthritis when other methods of non surgical treatment have failed to relieve pain and other symptoms. When deciding on the type of surgery, we will take into account the type of arthritis, its severity, and the patient's physical condition.
There are a number of surgical procedures. These include :
- Removing the diseased or damaged joint lining ( Arthroscopic Debridement & joint lavage )
- Realignment of the joints
- Fusing the ends of the bones in the joint together, to prevent joint motion and relieve joint pain
- Replacing the entire joint ( Total Joint Replacement)
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Long-Term Management
In most cases, persons with arthritis can continue to perform normal activities of daily living. Exercise programs, anti-inflammatory drugs, and weight reduction for obese persons are common measures to reduce pain, stiffness, and improve function.
In persons with severe cases of arthritis, orthopaedic surgery can often provide dramatic pain relief and restore lost joint function.
Some types of arthritis, such as rheumatoid arthritis, are often treated by a team of health care professionals. These professionals may include rheumatologists, physical and occupational therapists, social workers, rehabilitation specialists, and orthopaedic surgeons.
Research
At present, most types of arthritis cannot be cured. Researchers continue to make progress in finding the underlying causes for the major types of arthritis. In the meantime, orthopaedic surgeons, working with other physicians and scientists, have developed many effective treatments for arthritis.
Hip Replacement
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If your hip has been damaged by arthritis, a fracture or other conditions,common activities such as walking or getting in and out of a chair may be painful and difficult. Your hip may be stiff and it may be hard to put on your shoes and socks. You may even feel uncomfortable while resting.
If medications, changes in your everyday activities, and the use of walking aids such as a cane are not helpful, you may want to consider hip replacement surgery. By replacing your diseased hip joint with an artificial joint, hip replacement surgery can relieve your pain, increase motion, and help you get back to enjoying normal, everyday activities.
First performed in 1960, hip replacement surgery is one of the most important surgical advances of the last century. Since 1960, improvements in joint replacement surgical techniques and technology have greatly increased the effectiveness of total hip replacement.
Anatomy
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The hip is one of the body's largest weight-bearing joints. It consists of two main parts: a ball (femoral head) at the top of your thighbone (femur) that fits into a rounded socket (acetabulum) in your pelvis. Bands of tissue called ligaments (hip capsule) connect the ball to the socket and provide stability to the joint.
The bone surfaces of the ball and socket have a smooth durable cover of articular cartilage that cushions the ends of the bones and enables them to move easily.
A thin, smooth tissue called synovial membrane covers all remaining surfaces of the hip joint. In a healthy hip, this membrane makes a small amount of fluid that lubricates and almost eliminates friction in your hip joint.
Normally, all of these parts of your hip work in harmony, allowing you to move easily and without pain.
Common Causes of Hip Pain and Loss of Hip Mobility
The most common cause of chronic hip pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease.
- Osteoarthritis usually occurs in people 50 years of age and older and often individuals with a family history of arthritis. It may be caused or accelerated by subtle irregularities in how the hip developed. In this form of the disease, the articular cartilage cushioning the bones of the hip wears away. The bones then rub against each other, causing hip pain and stiffness.
- Rheumatoid arthritis is an autoimmune disease in which the synovial membrane becomes inflamed, produces too much synovial fluid, and damages the articular cartilage, leading to pain and stiffness.
- Traumatic arthritis can follow a serious hip injury or fracture. A hip fracture can cause a condition known as osteonecrosis. The articular cartilage becomes damaged and, over time, causes hip pain and stiffness.
Is Hip Replacement Surgery for You?
Whether to have hip replacement surgery should be a cooperative decision made by you, your family, your primary care doctor, and the orthopaedic surgeon. The process of making this decision typically begins with a referral to us for an initial evaluation.
Although many patients who undergo hip replacement surgery are 60 to 80 years of age, we evaluate patients individually. Recommendations for surgery are based on the extent of your pain, disability, and general health status-not solely on age.
You may benefit from hip replacement surgery if:
- Hip pain limits your everyday activities such as walking or bending.
- Hip pain continues while resting, either day or night.
- Stiffness in a hip limits your ability to move or lift your leg.
- You have little pain relief from anti-inflammatory drugs or glucosamine sulfate.
- You have harmful or unpleasant side effects from your hip medications.
- Other treatments such as physical therapy or the use of a gait aid such as a cane do not relieve hip pain.
The Orthopaedic Evaluation
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We will review the results of your evaluation with you and discuss whether hip replacement surgery is the best method to relieve your pain and improve your mobility. Other treatment options such as medications, physical therapy, or other types of surgery also may be considered . The orthopaedic evaluation will typically include:
- A medical history, in which we gather information about your general health and ask questions about the extent of your hip pain and how it affects your ability to perform every day activities.
- A physical examination to assess hip mobility, strength, and alignment.
- X-rays (radiographs) to determine the extent of damage or deformity in your hip.
- Occasionally, blood tests or other tests such as MRI (magnetic resonance imaging or bone scanning may be needed to determine the condition of the bone and soft tissues of your hip.
What to Expect From Hip Replacement Surgery
An important factor in deciding whether to have hip replacement surgery is understanding what the procedure can and cannot do.
Most people who undergo hip replacement surgery experience a dramatic reduction of hip pain and a significant improvement in their ability to perform the common activities of daily living. However, hip replacement surgery will not enable you to do more than you could before your hip problem developed.
Following surgery, you will be advised to avoid certain activities, including jogging and high-impact sports, for the rest of your life. You may be asked to avoid specific positions of the joint that could lead to dislocation.
Even with normal use and activities, an artificial joint (prosthesis) develops some wear over time. If you participate in high-impact activities or are overweight, this wear may accelerate and cause the prosthesis to loosen and become painful.
Preparing for Surgery
Medical Evaluation
If you decide to have hip replacement surgery, you will be asked to have a complete medical examination before your surgical procedure. This is needed to assess your health and identify conditions that can interfere with your surgery or recovery.
Tests
Several tests may be needed to help plan your surgery: blood and urine samples may be tested and a cardiogram and chest x-rays (radiographs) may be obtained.
Preparing Your Skin
Your skin should not have any infections or irritations before surgery. If either is present, contact us for a program to improve your skin before surgery.
Blood Donations
You will need to arrange for blood donors. Blood arranged will be stored as you will need blood after surgery.
Medications
Tell us about the medications you are taking. We will advise you which medications you should stop or can continue taking before surgery.
Weight Loss
If you are overweight, you may be asked to lose some weight before surgery to minimize the stress on your new hip and possibly decrease the risks of surgery
Dental Evaluation
Although infections after hip replacement are not common, an infection can occur if bacteria enter your bloodstream. Because bacteria can enter the bloodstream during dental procedures, you should consider getting treatment for significant dental diseases (including tooth extractions and periodontal work) before your hip replacement surgery. Routine cleaning of your teeth should be delayed for several weeks after surgery.
Urinary Evaluation
Individuals with a history of recent or frequent urinary infections and older men with prostate disease should consider a urological evaluation before surgery.
Social Planning
Although you will be able to walk with crutches or a walker soon after surgery, you will need some help for several weeks with such tasks as cooking, shopping, bathing, and laundry. You may have to make arrangements for home help and for personal needs at your home .
Home Planning
The following is a list of home modifications that will make your return home easier during your recovery:
- Securely fastened safety bars or handrails in your shower or bath
- Secure handrails along all stairways
- A stable chair for your early recovery with a firm seat cushion (that allows your knees to remain lower than your hips), a firm back, and two arms
- A raised toilet seat
- A stable shower bench or chair for bathing
- A long-handled sponge and shower hose
- A dressing stick, a sock aid, and a long-handled shoe horn for putting on and taking off shoes and socks without excessively bending your new hip
- A reacher that will allow you to grab objects without excessive bending of your hips
- Firm pillows for your chairs, sofas, and car that enable you to sit with your knees lower than your hips
- Removal of all loose carpets and electrical cords from the areas where you walk in your home
Your Surgery
You will most likely be admitted to the hospital a day prior to your surgery. Prior to admission, a member of the anesthesia team will evaluate you. The most common types of anesthesia for hip replacement surgery are general anesthesia (which puts you to sleep throughout the procedure and uses a machine to help you breath) or spinal epidural anesthesia (which allows you to breath on your own but anesthetizes your body from the waist down). The anesthesia team will discuss these choices with you and help you decide which type of anesthesia is best for you.
Many different types of designs and materials are currently used in artificial hip joints. All of them consist of two basic components: the ball component (made of a highly polished strong metal or ceramic material) and the socket component (a durable cup made of plastic, ceramic or metal, which may have an outer metal shell).
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Special surgical cement may be used to fill the gap between the prosthesis and remaining natural bone to secure the artificial joint.
A non cemented prosthesis has also been developed and is used most often in younger, more active patients with strong bone. The prosthesis may be coated with textured metal or a special bone-like substance, which allows bone to grow into the prosthesis.
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The surgical procedure involves removing the damaged cartilage and bone and then position new metal, plastic, or ceramic joint surfaces to restore the alignment and function of your hip.
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Hybrid Total Hip Replacement
A hybrid total hip replacement has one component, usually the acetabular socket, inserted without cement, and the other component, usually the femoral stem, inserted with cement. This technique was introduced in the early 1980s . A hybrid hip takes advantage of the excellent track records of cementless hip sockets and cemented stems.
Partial Hip Replacements
If only one part of the joint is damaged or diseased, a partial hip replacement may be recommended. In most instances, the acetabulum is left intact and the head of the femur is replaced, using components similar to those used in a total hip replacement. The most common form of partial hip replacement is called a bipolar prosthesis.
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Hip Resurfacing
A newer technique for hip replacement that has recently emerged is called hip resurfacing. In this procedure, the socket is replaced similar to a total hip replacement. The femur, however, is covered or "resurfaced" with a hemispherical component. This fits over the head of the femur and spares the bone of the femoral head and the femoral neck. It is fixed to the femur with cement around the femoral head and has a short stem that passes into the femoral neck.
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Hip resurfacing is an emerging procedure, most commonly performed in younger patients.T he most important reason to do a hip resurfacing rather than a traditional artificial hip replacement, is to remove as little bone around the hip as possible. This is especially important when you may need a second, or revision, hip replacement as you grow older .
After surgery, you will be moved to the recovery room where you will remain for 1 to 2 hours while your recovery from anesthesia is monitored. After you awaken fully, you will be taken to your hospital room.
Minimally Invasive Total Hip Replacement
Over the past several years, we have developed new minimally invasive surgical techniques for inserting total hip replacement implants through smaller incisions.
This allows for quicker, less painful recovery and more rapid return to normal activities. Minimally invasive and small incision total hip replacement surgery is a rapidly evolving area. Although certain techniques have proven to be safe, others may be associated with an increased risk of complications, such as nerve and artery injuries, wound healing problems, infection, fracture of the femur, and malposition of the implants, which can contribute to premature wear, dislocation, and loosening of your hip replacement.
Patients who have marked deformity of the joint, those who are heavy or muscular, and those who have other health problems that can contribute to wound healing problems are not candidates for this technique .
Your Stay in the Hospital
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You will usually stay in the hospital for 3-5 days. After surgery, you will feel pain in your hip. Pain medication will be given to make you as comfortable as possible.
To avoid lung congestion after surgery, you will be asked to breathe deeply and cough frequently.
To protect your hip during early recovery, a positioning splint, such as a V-shaped pillow placed between your legs, may be used.
Walking and light activity are important to your recovery and will begin the day of or the day after your surgery. Most patients who undergo total hip replacement begin standing and walking with the help of a walking support and a physical therapist the day after surgery. The physical therapist will teach you specific exercises to strengthen your hip and restore movement for walking and other normal daily activities.
Complications
The complication rate following Hip replacement surgery is low. Serious complications, such as joint infection, occur in fewer than 1% of patients. Major medical complications, such as heart attack or stroke, occur even less frequently.
Blood clots in the leg veins or pelvis are the most common complication of hip replacement surgery. For this you are made to start ankle pump exercises , put pressure stockings & take blood thinners .
Other complications such as dislocation, nerve and blood vessel injury, bleeding, fracture, and stiffness are very rare .
Over years, the hip prosthesis may wear out or loosen. This problem is less common with our newer materials and techniques. An average Total hip replacement lasts for 20 years .
Recovery
The success of your surgery will depend in large measure on how well you follow our instructions regarding home care during the first few weeks after surgery.
Wound Care
You will have stitches or staples running along your wound or a suture beneath your skin. The stitches or staples will be removed approximately 2 weeks after surgery.
Avoid getting the wound wet until it has thoroughly sealed and dried. A bandage may be placed over the wound to prevent irritation from clothing or support stockings.
Diet
Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength. Be sure to drink plenty of fluids.
Activity
Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal light activities of daily living within 3 to 6 weeks following surgery. Some discomfort with activity and at night is common for several weeks.
Your activity program should include :
- A graduated walking program, initially in your home and later outside
- A walking program to slowly increase your mobility and endurance
- Resuming other normal household activities
- Resuming sitting, standing, and walking up and down stairs
- Specific exercises several times a day to restore movement
- Specific exercises several times a day to strengthen your hip joint
- You may wish to have a physical therapist help you at home
Avoiding Problems After Surgery
Blood Clot Prevention
Follow our instructions carefully to minimize the potential risk of blood clots, which can occur during the first several weeks of your recovery.
Warning Signs
Warning signs of possible blood clots include:- Pain in your calf and leg that is unrelated to your incision
- Tenderness or redness of your calf
- Swelling of your thigh, calf, ankle, or foot
Warning signs that a blood clot has traveled to your lung include:
- Shortness of breath
- Chest pain, particularly with breathing
Notify us immediately if you develop any of these signs.
Preventing Infection
The most common causes of infection following hip replacement surgery are from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around your prosthesis.
Following your surgery, you may need to take antibiotics prior to dental work, including dental cleanings, or any surgical procedure that could allow bacteria to enter your bloodstream.
Warning signs of a possible hip replacement infection are:
- Persistent fever (higher than 100°F orally)
- Shaking chills
- Increasing redness, tenderness, or swelling of the hip wound
- Drainage from the hip wound
- Increasing hip pain with both activity and rest
Avoiding Falls
A fall during the first few weeks after surgery can damage your new hip and may result in a need for more surgery. Stairs are a particular hazard until your hip is strong and mobile. You should use a cane, crutches, a walker, or handrails or have someone help you until you improve your balance, flexibility, and strength.
Your physical therapist will help you decide which assistive aides will be required following surgery, and when those aides can safely be discontinued.
Other Precautions
To assure proper recovery and prevent dislocation of the prosthesis, you must take special precautions:
- Do not cross your legs.
- Do not bend your hips more than a right angle (90°).
- Do not turn your feet excessively inward or outward.
- Use a pillow between your legs at night when sleeping until you are advised by us that you can remove it.
We will give you more instructions prior to your discharge from the hospital.
How Your New Hip Is Different
You may feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending. These differences often diminish with time, and most patients find these are minor compared with the pain and limited function they experienced prior to surgery.
Your new hip may activate metal detectors required for security in airports and some buildings. Tell the security agent about your hip replacement if the alarm is activated. You may ask us for a card confirming that you have an artificial hip.
After surgery, make sure you also do the following:
- Participate in a regular light exercise program to maintain proper strength and mobility of your new hip.
- Take special precautions to avoid falls and injuries. Individuals who have undergone hip replacement surgery and experience a fracture may require more surgery.
- Notify your dentist that you have had a hip replacement. You will need to take antibiotics before any dental procedure for a minimum of 2 years after your surgery and possibly longer, depending on your past health history.
- You need to be seen periodically for routine follow-up examinations and x-rays (radiographs), even if your hip replacement seems to be doing fine.
Shoulder Replacement
Many people know someone with an artificial knee or hip joint. Shoulder replacement is less common. But it is just as successful in relieving joint pain. Shoulder replacement surgery started in the 1950s. It was used as a treatment for severe shoulder fractures. Over the years, this surgery has come to be used for many other painful conditions of the shoulder. These include:
- Osteoarthritis (degenerative joint disease)
- Rheumatoid arthritis
- Post-traumatic arthritis
- Rotator cuff tear arthropathy (a combination of severe arthritis and a massive non-reparable rotator cuff tendon tear)
- Avascular necrosis (osteonecrosis)
- Failed previous shoulder replacement surgery
- Severe fractures
The shoulder is a ball-and-socket joint that enables you to raise, twist and bend your arm. It also lets you move your arm forward, to the side and behind you. In a normal shoulder, the rounded end of the upper arm bone (head of the humerus) glides against the small dish-like socket (glenoid) in the shoulder blade (scapula). These joint surfaces are normally covered with smooth cartilage. They allow the shoulder to rotate through a greater range of motion than any other joint in the body.
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The surrounding muscles and tendons provide stability and support. Unfortunately, conditions like those listed above can lead to loss of the cartilage and mechanical deterioration of the shoulder joint. The result can be pain. You can have a stiff shoulder that grinds or clunks. This can lead to a loss of strength, decreased range of motion in the shoulder and impaired function. X-rays of the shoulder would show:
- Loss of the normal cartilage joint space
- Flattening or irregularity in the shape of the bone
- Bone spurs
- Loose pieces of bone and cartilage floating inside the joint
In severe cases, bone-on-bone arthritis may lead to erosion--wearing away of the bone.
Risk Factors
Osteoarthritis is a common reason people have shoulder replacement surgery. Osteoarthritis is sometimes called "wear-and-tear" arthritis. It affects mainly older individuals in all walks of life. Over time, the shoulder joint slowly becomes stiff and painful. Unfortunately there is no way to prevent the development of osteoarthritis.
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A severe fracture of the shoulder is another common reason people have shoulder replacements. When the shoulder is injured by a hard fall or car accident, it may be very difficult for a doctor to put the pieces back together. When the head of the upper arm bone is shattered, the blood supply to the bone pieces is interrupted. In this case, a Shoulder replacement is recommended . Older patients with osteoporosis are most at risk for a severe shoulder fracture.
Patients with a massive long-standing rotator cuff tear may develop cuff tear arthropathy. In this injury, the changes in the shoulder joint due to the rotator cuff tear may lead to arthritis and destruction of the joint cartilage.
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Avascular necrosis is a condition in which the bone of the humeral head dies due to lack of blood supply. Chronic steroid use, deep sea diving, severe fracture of the shoulder, sickle cell disease and heavy alcohol use are risk factors for avascular necrosis.
Symptoms
Patients with arthritis typically describe a deep ache within the shoulder joint. Initially, the pain feels worse with movement and activity, and eases with rest. As the arthritis progresses, the pain may occur even when you rest. By the time a patient sees a physician for the shoulder pain, he or she often has pain at night. This pain may be severe enough to prevent a good night's sleep. The patient's shoulder may make grinding or grating noises when moved. Or the shoulder may catch, grab, clunk or lock up. Over time, the patient may notice loss of motion and/or weakness in the affected shoulder. Simple daily activities like reaching into a cupboard, dressing, toileting and washing the opposite armpit may become increasingly difficult.
Treatment Options
Nonsurgical Treatment
Treatment of an arthritic shoulder starts with rest, exercise and taking arthritis medications. Resting the shoulder and applying moist heat can ease mild pain. After strenuous activity, an ice pack may be more effective at decreasing pain and swelling.
Physical therapy may be helpful when arthritis is in early stages. It helps maintain joint motion and strengthen the shoulder muscles. Physical therapy is less effective when the arthritis has advanced to the point that bone rubs on bone. When this is the case, physical therapy may make the shoulder hurt more.
Arthritis medications, called nonsteroidal anti-inflammatories (NSAIDs), can control arthritis pain. Periodic cortisone injections into the shoulder joint can provide temporary pain relief. Excessive cortisone shots can have adverse effects, however.
Surgical Treatment
Shoulder joint replacement.
If nonoperative treatments fail, shoulder replacement surgery may be needed. Shoulder replacements are usually done to relieve pain.
There are several different types of shoulder replacements. The usual total shoulder replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem, and a plastic socket.
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The components come in various sizes. If the bone is of good quality, we will choose to use a non-cemented or press-fit humeral component. If the bone is soft, the humeral component may be implanted with bone cement. In most cases, an all-plastic glenoid component is implanted with bone cement. Implantation of a glenoid component is not advised if:
- The glenoid has good cartilage.
- The glenoid bone is severely deficient.
- The rotator cuff tendons are irreparably torn.
Patients with bone-on-bone osteoarthritis and intact rotator cuff tendons are generally good candidates for conventional total shoulder replacement.
Depending on the condition of the shoulder, we may replace only the ball. Sometimes, this decision is made in the operating room at the time of the surgery.
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Reverse total shoulder replacement components
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Another type of shoulder replacement is called reverse total shoulder replacement. Reverse total shoulder replacement is used for people who have:
- Completely torn rotator cuffs and
- The effects of severe arthritis (cuff tear arthropathy) or
- Had a previous shoulder replacement that failed
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X-Rays before and after reverse total shoulder replacement for cuff tear arthropathy
For these individuals, a conventional total shoulder replacement can still leave them with pain. They may also be unable to lift their arm up past a 90-degree angle. Not being unable to lift one's arm away from the side can be severely debilitating. In reverse total shoulder replacement, the socket and metal ball are switched. That means a metal ball is attached to the shoulder bone and a plastic socket is attached to the upper arm bone. This allows the patient to use the deltoid muscle instead of the torn rotator cuff to lift the arm.
Shoulder replacement surgery is highly technical. It should be performed by a surgical team with experience in this procedure. Each case is individual. We will evaluate your situation carefully before making any decisions. Do not hesitate to ask what type of implant will be used in your situation. Ask why that choice is right for you.
Before surgery, patients see their internist or family practice physician for a preoperative medical evaluation. Cardiac patients should see their cardiologist as well. Two weeks before surgery, you should stop taking the following medications that thin the blood and can lead to excessive bleeding during surgery:
- Nonsteroidal anti-inflammatory medications (aspirin and ibuprofen such as Motrin and Advil)
- Most arthritis medications
The surgery is performed on an inpatient basis. Most patients are discharged from the hospital on the second or third day after the operation.
Rehabilitation
A careful, well-planned rehabilitation program is critical to the success of a shoulder replacement. You usually start gentle physical therapy on the first day after the operation. You wear an arm sling during the day for the first several weeks after surgery. You wear the sling at night for 4 to 6 weeks. Most patients are able to perform simple activities such as eating, dressing and grooming within 2 weeks after surgery. Driving a car is not allowed for 6 weeks after surgery.
Here are some "do's and don'ts" for when you return home :
- Don't use the arm to push yourself up in bed or from a chair because this requires forceful contraction of muscles.
- Do follow the program of home exercises prescribed for you. You may need to do the exercises 4 to 5 times a day for a month or more.
- Don't overdo it! If your shoulder pain was severe before the surgery, the experience of pain-free motion may lull you into thinking that you can do more than is prescribed. Early overuse of the shoulder may result in severe limitations in motion.
- Don't lift anything heavier than a glass of water for the first 6 weeks after surgery.
- Do ask for assistance. Your physician may be able to recommend an agency or facility if you do not have home support.
- Don't participate in contact sports or do any repetitive heavy lifting after your shoulder replacement.
- Do avoid placing your arm in any extreme position, such as straight out to the side or behind your body for the first 6 weeks after surgery.
Many thousands of patients have experienced an improved quality of life after shoulder joint replacement surgery. They experience less pain, improved motion and strength, and better function.
Knee Replacement
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If your knee is severely damaged by arthritis or injury, it may be hard for you to perform simple activities such as walking or climbing stairs. You may even begin to feel pain while you are sitting or lying down. If medications, changing your activity level, and using walking supports are not longer helpful, it is time to consider total knee replacement. By resurfacing your knee's damaged and worn surfaces, total knee replacement can relieve your pain, correct your leg deformity, and help you resume your normal activities.
Common Causes of Knee Pain and Loss of Knee Function
The knee is the largest joint of the body. Nearly normal knee function is needed to perform routine everyday activities. The most common cause of chronic knee pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms.
Osteoarthritis usually occurs after the age of 50 and often in an individual with a family history of arthritis. The cartilage that cushions the bones of the knee softens and wears away. The bones then rub against one another causing knee pain and stiffness
Rheumatoid Arthritis is a disease in which the inner lining of the knee becomes thickened and inflamed, producing too much fluid which over-fills the joint space. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain and stiffness.
Post Traumatic Arthritis can follow as serious knee injury. A knee fracture or severe tears of the knee's ligaments may damage the particular cartilage over time, causing knee pain and limiting knee function.
Is total knee replacement for you?
The decision whether to have total knee replacement is a cooperative one between you, your family, your family physician, and your orthopaedic surgeon.
Reasons that you may benefit from total knee replacement commonly include :
- Severe knee pain that limits your everyday activities, including walking, going up and down stairs, and getting in and out of chairs. You may find it hard to walk more than a few blocks without significant pain and you may need to use a cane or walker.
- Moderate or severe knee pain while resting, either day or night.
- Chronic knee inflammation and swelling that doesn't improve with rest or medication.• Knee deformity-a bowing in or out of your knee.
- Failure to obtain pain relief from non-steroidal anti-inflammatory drugs. These medications are most effective in the early stages of arthritis
- Inability to tolerate or complications from pain medications.
- Failure to substantially improve with other treatments such as cortisone injection, physical therapy, or other surgeries.
Most patients who undergo total knee replacement are age 55 to 80, but each patient is evaluated individually. Recommendations for surgery are based on a patient's pain and disability, not age. Patients as young as age 16 and older than 90 have undergone successful total knee replacement.
Realistic Expectations About Knee Replacement Surgery
An important factor in deciding whether to have total knee replacement is understanding what the procedure can and can't do. More than 90 percent of individuals who undergo total knee replacement experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living. But total knee replacement won't make you a super-athlete or allow you to do more than you could before you developed arthritis.
Following surgery, you are advised to avoid some types of activity for the rest of your life, including jogging and high impact sports.
Preparing for surgery
Medical evaluation : if you decide to have total knee replacement, you are asked to have a complete physical by your family physician several weeks before surgery to assess your health and to rule out any conditions that could interfere with your surgery.
Tests : Several tests, such as blood samples, a cardiogram, and a urine sample are done.
Physical therapy : You will begin to practice some of the exercises you'll use after surgery. You'll also be trained in the use of either a walker or crutches.
Preparing Your Skin and Leg : Your knee and leg should not have any skin infections or irritation. Contact your orthopaedic surgeon prior to surgery if either is present for a program to best prepare your skin for surgery.
Blood Donation : You may be advised to arrange for 3-4 units of blood prior to surgery.
Medications : Tell your orthopaedic surgeon about the medications you are taking. He will tell you which medications you should stop taking and which you should continue to take before surgery.
Dental Evaluation : Although the incidence of infection after knee replacement is very low, an infection can occur if bacteria enter your bloodstream. Treatment of significant dental diseases should be considered before your total knee replacement surgery.
Urinary Evaluations : A preoperative urological evaluation should be considered for individuals with a history of recent or frequent urinary infections. For older men with prostate disease, required treatment should be considered prior to knee replacement surgery.
Home Planning Several suggestions can make your home easier to navigate during your recovery. Consider :
- Safety bars or a secure handrail in your bath
- Secure handrails along your stairways
- A stable chair for your early recovery with a firm seat cushion (height of 18-20 inches), a firm back, two arms, and a footstool for intermittent leg evaluation.
- A toilet seat riser with arms, if you have a low toilet.
- A stable chair for bathing.
- Removing all loose carpets and cords.
- A temporary living space on the same floor, because walking up or down stairs will be more difficult during your early recovery.
Your Surgery
You are normally admitted to the hospital a day before the surgery. After admission, you are evaluated by a member of the anesthesia team. The most common types of anesthesia are general anesthesia, in which you are asleep throughout the procedure, and spinal or epidural anesthesia, in which you are awake but your legs are anesthetized. The anesthesia team with your input will determine which type of anesthesia will be best for you.
You can have one or both knees replaced at the same sitting. The usual norm is to replace both knees in the same sitting if both are severely involved and there is no medical contraindication. The damaged cartilage and bone is removed and then new metal and plastic joint surfaces are positioned to restore the alignment and function of the knee. Many different types of designs and materials are currently used in total knee replacement.
After surgery, you are moved to the recovery room, where you will remain for one day while your recovery from anesthesia is monitored. Your hospital room is fumigated and next day you are taken to your room.
Your Stay in the Hospital
You will most likely stay in the hospital for 8-9 days. After surgery, you will feel some pain, but medication will be given to you to make you feel as comfortable as possible. Walking and knee movement are important to your recovery and will begin immediately after your surgery.
Foot and ankle movement is encouraged immediately following surgery to also increase blood flow in your leg muscles to help prevent leg swelling and blood clots. Most patients begin exercising their knee the day after surgery. A physical therapist will teach you specific exercises to strengthen your leg and restore knee movement to allow walking and other normal daily activities soon after your surgery.
Your Recovery at Home
The success of your surgery also will depend on how well you follow your orthopaedic surgeon's instructions at home during the first few weeks after surgery.
Wound Care You will have staples running along your wound on the front of your knee. The staples will be removed 2 weeks after surgery. Avoid soaking the wound in water until the wound has thoroughly sealed and dried. A bandage may be placed over the wound to prevent irritation from clothing. Diet Some loss of common appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength.
Activity Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal activities of daily living within three to six weeks following surgery. Some pain with activity and at night is common for several weeks after surgery. Your activity program should include :
- A graduated walking program to slowly increase your mobility, initially in your home and later outside.
- Resuming other normal household activities, such as sitting and standing and walking up and down stairs.
- Specific exercises several times a day to restore movement and strengthen your knee. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home or in a therapy center the first few weeks after surgery.
Driving usually begins when your knee bends sufficiently so you can enter and sit comfortably in your car and when your muscle control provides adequate reaction time for braking and acceleration. Most individuals resume driving about four to six weeks after surgery.
How Your New Knee is Different
You may feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending activities. Improvement of knee motion is a goal of total knee replacement, but restoration of full motion is uncommon. The motion of your knee replacement after surgery is predicted by the motion of your knee prior to surgery. Most patients can expect to nearly fully straighten the replaced knee and to bend the knee sufficiently to go up and down stairs and get in and out of a car. Kneeling is usually uncomfortable, but it is not harmful. Occasionally, you may feel some soft clicking of the metal and plastic with knee bending or walking. These differences often diminish with the time and most patients find these are minor, compared to the pain and limited function they experienced prior to surgery.
Your new knee may activate metal detectors required for security in airports and some buildings. Tell the security agent about your knee replacement if the alarm is activated.
After surgery, make sure you also do the following :
- Participate in regular light exercise programs to maintain proper strength and mobility of your new knee.
- Take special precautions to avoid falls and injuries. Individuals who have undergone total knee replacement surgery and suffer a fracture may require more surgery.
- Notify your dentist that you had a knee replacement. You should be given antibiotics before all dental surgery for the rest of your life.
- See your orthopaedic surgeon periodically for a routine follow-up examination and X-rays, usually once a year.
Is total knee replacement permanent?
Most older persons can expect their total knee replacement to last 15 years or more. It will give years of pain-free living that would not have been possible otherwise. Younger knee replacement patients may need a second total knee replacement. Materials and surgical techniques are improving through the efforts of orthopaedists working with engineers and other scientists. The future is bright for those who choose to have a total knee replacement to achieve an improved quality of life through greater independence and healthier pain-free activity.
