| Joint Replacement
The replacement of natural joints with artificial ones is
a constantly improving form of treatment for severe arthritis
(primarily osteoarthritis and rheumatoid arthritis). No longer
does severe damage to joints mean lifelong pain, dependence
on crutches, or confinement to a wheelchair. Over the past
three decades, reconstructive surgery has restored mobility
and relieved pain for thousands who suffer from degenerative
conditions. In the United States alone, more than 150,000
total joint replacements are performed each year by orthopedists.
How Is It Done?
A total joint replacement is a surgical procedure. The patient
is given an anesthetic, and the surgeon replaces the damaged
parts of the joint with artificial materials. For example,
in the knee joint the damaged ends of the bones that meet
at the knee are replaced, along with the underside of the
kneecap. In the hip joint, the damaged ball is replaced by
a metal ball with a stem that fits down into the femur. A
new, plastic socket is implanted into the pelvis to replace
the old damaged socket. Total joint replacement can be performed
on other joints as well, including the ankle, shoulder, hip,
fingers, and elbow. Most often, hips and knees are the joints
needing replacement.
The materials used in a total joint replacement are designed
to enable the joint to move in the same way as the normal
joint. The artificial components are generally composed of
a metal piece that fits closely into a matching sturdy plastic
element. The metals are varied and include stainless steel,
or alloys of cobalt, chrome, and titanium. The plastic material
is a polyethylene that is extremely durable and wear-resistant.
Also, a bone cement is often used to anchor the bone to the
new, artificial component. 'Cementless' joint replacements
have also been developed. In these replacements, the prosthesis
and the bone are made to fit together directly.
Recovery Period
The recovery period following surgery will vary depending
on the patient and on the joint that has been replaced. In
general, the orthopedist will encourage the patient to use
the joint shortly after the operation. In the case of a total
hip or knee replacement, the patient will be standing and
beginning to walk within several days. A physical therapist
will instruct the patient in the use of crutches or cane.
If the shoulder, elbow, or wrist joint has been replaced,
use of the new joint can begin very soon after surgery. The
patient will learn to do appropriate exercises to move and
strengthen the joint.
Risks and Complications
There are risks with any surgical procedure. The person considering
total joint replacement should tell the orthopedic surgeon
about any additional medical conditions that might complicate
the surgery. The patient's regular physician should be told
of the proposed surgery. Before the operation, the patient
should discuss with the anesthesiologist the anesthesia type
and possible risks involved.
The much-feared but uncommon complication of total joint
replacement is infection. Less than 1% of all total hip replacements
can be expected to become infected. Infection may occur just
in the area of the wound or deep around the prosthesis. It
may occur during the hospital stay or after the patient goes
home. It may even occur years after the operation. Infections
in the wound area are generally treated with antibiotics.
Deep infections may require further surgery and removal of
the prosthesis.
Spread of infection from another part of the body to a joint
replacement has been known to occur. To prevent such infection,
persons with total joint replacements generally are given
antibiotics before dental cleaning and more extensive dental
procedures, as well as before other types of surgery. If an
infection occurs, it must be treated with antibiotics.
Other complications that are directly related to the implanted
prosthesis can be grouped into several categories:
Loosening. Loosening of the prosthesis is the most
common mechanical problem occurring after total joint replacement.
Loosening causes pain, and if loosening is significant a second
total joint replacement may need to be performed. New methods
of fixing the prosthesis to bone may minimize or eliminate
this problem.
Dislocation. This complication sometimes occurs after
total hip replacement, generally right after the operation.
In most cases, the orthopedic surgeon can relocate the dislocated
hip manually. Rarely is another operation necessary. A brace
may be worn for a period of time after dislocation occurs.
Wear. Although some wear can be measured in artificial
joints, it occurs slowly. Wear may contribute to looseness,
but it is rarely necessary to do corrective surgery because
of wear alone.
Breakage. Breakage of an implanted joint is rare.
A second operation is necessary if this occurs.
Impaired Nerve Function. Rarely, nerves in the vicinity
of the total joint replacement are damaged during the operation.
This generally occurs when the orthopedic surgeon must correct
considerable joint deformity in order to implant the prosthesis.
With time, these nerves usually begin to function normally
again.
Benefits
The main benefit to the patient after total joint replacement
is pain relief, which often is quite dramatic. Although there
may be some soreness in the replaced joint after surgery,
this will eventually disappear and muscle power will return
with exercise.
Motion of the joint will generally improve. The extent of
improvement will depend on how stiff the joint was before
the operation. An extremely stiff joint will continue to be
stiff for some time after total joint replacement.
Most older persons can expect their total joint replacement
to last a lifetime. It will give years of pain-free living
that would not have been possible otherwise. Some younger
persons with a total joint replacement who are quite active
may have to have a second total joint replacement. Materials
and surgical techniques are improving rapidly, however, because
of the efforts of orthopedists working with engineers and
other scientists.
Conclusion
In the management of arthritis, health professionals must
consider the whole person. They must treat not only the pain
and stiffness in patients' joints, but the anxieties in their
minds, taking fully into account patients' personalities,
backgrounds, and personal problems.
No factor is more important in the treatment and rehabilitation
of the arthritis patient than maintenance of psychological
balance under the stressful conditions imposed by the disease.
Complex emotional and vocational problems resulting from chronic
disability often require the attention of psychologists, social
workers, and vocational specialists. In the overall management
of arthritis, these specialists must work in close cooperation
with each other and with the doctors, therapists, relatives
of the patient and others involved, if best results are to
be achieved.
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