Joint-replacement surgery

Description
Through joint replacement, or arthroplasty, the diseased portions of a joint are surgically removed and replaced by prostheses, or artificial parts. The most common joint replacement procedures involve the hip and knee. Nearly any joint can be replaced, however, including the shoulder, elbow, ankle and fingers.

Purpose/indications
Joint replacement is done to relieve pain and improve joint function. The most common reason for joint replacement is osteoarthritis. Other conditions that may be improved by joint replacement include rheumatoid arthritis, avascular necrosis (a condition in which bone dies due to inadequate blood supply), bone tumors and injury.
Joint replacement was once generally reserved for adults older than 60. Thanks to new technology and procedures, people younger than 60 may now be candidates for joint replacement as well. A typical prosthesis lasts about 10 to 15 years -- possibly as long as 20 years -- at which time a revision may be needed.

Of course, joint replacement is not appropriate for everyone. People who have severe osteoporosis or muscle weakness, poor overall health or an active infection, or those at high risk for infection may not be good candidates for joint-replacement surgery.


Patient preparation
Before surgery, your doctor will document the details of your medical history and do a physical exam. You'll need various lab tests, such as a complete blood count, blood chemistry and urinalysis. X-rays of the joint to be replaced will be done. Depending on your age, a chest X-ray and electrocardiogram (a recording of the electrical activity of the heart) may also be done. Depending on your health history, other tests may be required as well. It's also a good idea to talk with your doctor about donating your own blood in advance should a blood transfusion become necessary during surgery.
Advance planning for your care after surgery will ease the transition home. Depending on the affected joint, consider the following suggestions:

Arrange for help at home for the first one to two weeks. Some people choose to stay at an extended care facility.

If you must take the stairs to reach your bedroom, arrange a temporary sleeping area on the main floor.

Remove tripping hazards from your home, such as throw rugs, electrical cords near walkways and extra clutter.

Install an elevated toilet seat, shower handrails and shower bench. You may also want to purchase a long-handled device to help pick up items on the floor or otherwise out of reach.

Make sure you have a stable chair with two arms and a firm seat and back.

Prepare and freeze meals in advance. You may also want to arrange to have others bring meals to your home for the first one to two weeks.

Arrange everyday items at arm level to avoid reaching up or down.

Set up the area where you will spend most of your recovery time. You may want a table to store handy items such as the TV remote control, phone, radio, reading materials and glasses, tissues, trash can, water pitcher and cup.
The night before surgery, you'll be asked not to eat or drink anything after midnight. To prevent infection, you'll receive a dose of antibiotics before and up to 24 hours after surgery.

The day of surgery or before the hospital admission, you'll meet with the anesthesiologist. Depending on factors such as the type of surgery, your health history and personal preference, and your doctor's preference, you might have general, epidural or spinal anesthesia. General anesthesia renders you temporarily unconscious. With epidural and spinal anesthesia, a local anesthetic is injected into a specific space in the spinal cord to numb certain parts of your body.


Procedure
Although every surgery has its own standard procedure, your individual health history could play a role in any variation to the procedure. Discuss these issues with your doctor.
During the procedure, the diseased portion of bone and cartilage is removed first. Then, the prosthesis is implanted. Each prosthesis has several components, usually a combination of metal (titanium, stainless steel, or cobalt and chrome alloys), ceramic and plastic (usually polyethylene) parts. Joint-replacement surgery usually takes one to three hours.

Joint-replacement surgery is often done using bone cement, but the procedure may also be done without cement or using a combination. See the benefits and risks of each option below.

Cemented
With a "cemented" prosthesis (the original type of prosthesis), a cement made of polymethyl methacrylate is used to glue the prosthesis to the bone.

Benefits

Cemented prostheses have immediate stability.
Cemented prostheses have a long history of reliability.
Risks

The cement particles may loosen from the bone and cause pain.
Uncemented or cementless
Uncemented prostheses were developed to prevent problems with cement particles breaking off. Uncemented prostheses are made of porous material, allowing bone to grow into the artificial part. They're not recommended for those who have very weak bones.

Benefits

Uncemented prostheses may last longer than the cemented variety.
Revision surgery may be easier than with cemented prostheses, which is an advantage for younger patients who are more likely to need revision surgery at some point.
Risks
It takes longer for bone to grow and stabilize the joint, which limits the patient's activities after surgery for up to three months.
With a hip replacement, bone growth may cause thigh pain after surgery.
Hybrid
A hybrid joint replacement can be used for some joints, such as the hip. It usually involves the combination of a cemented thigh bone component and an uncemented hip socket component.

Benefits

Uncemented hip cups or sockets tend to last longer than cemented versions.
With a hip replacement, a hybrid replacement reduces the risk of thigh pain after surgery.
There is a lower risk of joint loosening and related complications.
Risks

In the cemented part of the joint, the cement particles may break off if the prosthesis becomes loose and cause pain.
It takes longer for bone to grow and stabilize the joint in the uncemented portion of the joint, which limits the patient's activities after surgery for up to three months.

Postprocedure care
You'll have an IV after surgery for fluids, nourishment and possibly medication. If you have a hip or knee replacement, you might also have a drain from the incision and a catheter draining your urine. You'll also receive medication for pain and, generally, a blood thinner to prevent blood clots. If you have a hip replacement, you may need to hold a special pillow between your legs immediately after surgery to keep the hip in place, depending on the surgical approach used. Physical therapy for hip and knee replacement often begins the day after surgery. The average hospital stay is three to five days, although this will depend on the type of surgery you have, any complications and various other factors.
Physical rehabilitation is an essential part of successful joint replacement. Again, physical therapy for hip and knee replacement usually begins the first day after surgery. At first, you'll learn how to transfer from the bed to a chair. By second day, you may learn how to walk using crutches, a walker or a cane. For any type of joint replacement, you'll practice range of motion and strengthening exercises, as well as how to handle routine daily activities. Finally, you'll learn how to protect the affected joint and specific activities to avoid. It may take three to six months or longer to completely recover from joint-replacement surgery.


Benefits of joint replacement
The benefits of joint replacement often include:
improved quality of life
pain relief
improved range of motion and use of the affected joint
decreased deformity of the affected joint

Risks of joint replacement
The risks of joint replacement may include:
infection
nerve injury
loosening of joint
joint dislocation or bone fracture
prosthetic breakage
bleeding
anesthesia side effects
deep vein thrombosis (a blood clot deep inside a blood vessel in the arm or leg)
pulmonary embolism (a blood clot, air bubble, fat deposit or other foreign substance that travels through the bloodstream and lodges in an artery in the lung)
Rarely, severe complications may be fatal.


Considerations
To prevent infection in the affected joint after surgery, you'll need to take antibiotics before any dental work or invasive procedure.
As with any procedure, it's important to talk with your doctor about specific physical limitations after surgery. For example:

After knee- or hip-replacement surgery, your doctor may recommend avoiding vigorous, high-impact activities, such as jogging and tennis. Walking, stationary bicycling, cross-country skiing and swimming are generally recommended.

After shoulder-replacement surgery, swimming is generally discouraged.

After elbow-replacement surgery, you may be restricted to lifting small amounts of weight.

Pregnancy-specific information
Join-replacement surgery is not recommended during pregnancy.

Senior-specific information
Aging increases the risk of osteoarthritis, the most common indication for joint-replacement surgery. Most joint-replacement surgeries are done in adults older than 60.