A total joint replacement surgery (also called an arthroplasty) is a procedure performed on joints that are damaged, arthritic, or worn down to a degree that makes them chronically painful or unusable. During the procedure the joint or joint surface is removed from the body and replaced with a more durable prosthetic. These prosthetics can be made from a variety of safe and resilient materials including plastics, metals and ceramics. Total joint replacements can be done on many joints throughout the body but the three most common are knee, hip, and shoulder replacement surgeries.
The goal of a total joint replacement is to reestablish comfortable and fluid movement in a joint that has not responded to other forms of therapy. There are various ailments and injuries that could lead to you needing a total joint replacement. Some causes of damage and degeneration that could lead to this are:
- Injury (fracture/dislocation)
- Worn down cartilage
There are potential risks involved with an arthroplasty just as there are with all surgical procedures, but it is documented that 90% of patients 55 or older who receive a total joint replacement still retain good function 20 years later.
Typically, there are no restrictions based on age or weight that would prevent you from being able to receive a total joint replacement. In most cases you will be brought in for a preliminary assessment where the doctor will ask you a few questions regarding your history of injury, your current level of pain/mobility, and what other rehab and therapy options you might have tried. Depending on what the doctor finds they will likely decide to schedule an x-ray or an MRI to get a better look at the damage inside the joint and progress from there.
There are multiple approaches that a surgeon can take to perform an arthroplasty. A total replacement involves removal of the joint in its entirety so that all working parts can be replaced with more durable prosthetics. The benefit of a total joint replacement is that it helps ensure that all the damaged bone, cartilage and tissue is replaced. This reduces the risk of future problems in the trouble area. Another option is partial joint replacement. The joints in the body all consist of multiple working parts, and in some cases only a specific section of the joint will require replacement. The benefit of this is that it is generally a much quicker procedure, and the recovery time of the patient is expedited since less work has been done. The downside of a partial replacement is that the healthy parts of the joint that were left untouched could start causing pain on their own, leading the patient to need a second surgery in the future. Partial joint replacements are typically performed on younger patients who have a lot of healthy tissue and cartilage still left in the problem area.
As the science of joint replacement improves doctors are coming up with safer and more efficient ways to perform these procedures. A traditional arthroplasty requires a single incision large enough for the doctor to access the entire joint. This gives the surgeon more space to work with and better access to all parts of the joint, but it also causes more pain for the patient post op and leads to a longer recovery time. Some doctors decide to perform what is referred to as a minimally invasive arthroplasty, where a much smaller incision is made next to the joint and the doctor uses advanced technology and careful techniques to perform the surgery while cutting down on unnecessary damage and recovery time.
The angle of approach for the surgery is something else that your doctor will address with you. Depending on your specific injury and body shape your doctor will have to decide whether to address the joint from the front of the body, the back of the body, or in the case of the hip and the knee from the side.
Prosthetic parts can be made from a variety of materials, and it is up to the surgeon to decide what types of prosthetics will be used where. The main pieces of the prosthetics that replace the bone will typically be ceramic, metal, or plastic, and the spacers they place between these parts to allow for fluid movement will be plastic as well.
After your physical assessment and x-ray appointment if your doctor decides that an arthroplasty is right for you, you will be given a list of preparatory instructions regarding what you should or should not do the morning of your procedure. It is very important that you listen carefully and make sure to ask any questions that come up when receiving these instructions. Your doctor will then want to run a few more tests to ensure that you are safe to go into surgery. These will likely include a dental check, urine and blood test, and an assessment of any medications that you are currently taking.
It is most common to use general anesthesia during an arthroplasty, which is when the doctor administers the anesthesia through an IV in the arm. This will put the patient to sleep and prevent them from waking during the procedure. Some patients also receive a nerve block either in place of or in tandem with the general anesthesia. A nerve block is an injection that disrupts nerve activity and prevents pain signals from being sent to the brain. This can help prevent the patient from experiencing too much pain upon waking up from surgery. Lastly in the case of a total hip arthroplasty the doctor may choose to use an epidural which is an injection administered in the epidural space around the spine that causes the body to go numb between the belly button and the upper legs.
The three most common joints to replace in the body are the hips, knees, and shoulders, and there are multiple ways to go about replacing each of these body parts.
With a total shoulder replacement your doctor will typically pick from one of the following options depending on the specifics of your case:
- Anatomic total shoulder replacement, where both the ball and socket parts of the shoulder are replaced
- Reverse total shoulder replacement, where both the ball and socket parts of the shoulder are removed but the ball part of the implant is attached to the shoulder blade and the socket to the arm, opposite of the body’s natural anatomy
- Partial shoulder replacement, where only the ball part of the joint on the upper arm is replaced
With hip replacement surgeries you also have total and partial replacements, with the partial typically only requiring the removal of the ball part of the joint. From there the doctor will decide whether they want to take an anterior approach (from the front), posterior approach (from the back) or a lateral approach (from the side). There are also traditional and minimally invasive approaches to a hip replacement, just as there are with other joint replacement surgeries, and the specific route your surgeon chooses to take will depend on a variety of factors including:
- The shape of your bones and musculature
- The type of implant being used
- The method of attachment being used
- The health of your bones
- Activity level
With a knee arthroplasty you again have the traditional approach where a large incision is made on the front of the joint (usually 8-12 inches), the quadriceps tendon is cut so that the knee cap can be flipped over to expose the joint, then the damaged areas are removed and replaced. The minimally invasive approach involves a smaller 3–4-inch incision through which the knee cap is pushed to the side rather than being detached and flipped. This means less damage needs to be done to the quadriceps tendon, allowing the patient to recover much more quickly. There is also a quadriceps sparing technique, which like the minimally invasive approach uses a smaller incision and specialized tools to help perform removal and replacement without causing unnecessary damage. The difference here is that the quadriceps tendon is left completely intact, and the entire procedure is performed underneath the muscles. This approach takes longer than a traditional approach and requires some specialized equipment to perform but it is easier on the body and allows for a much quicker recovery.
There are cutting edge computer and robotic-assisted procedures being done at advanced centers like SCIC where a patient’s joint is scanned, and the data is registered into a computer where a 3D model is created. This gives the surgeon a detailed and in depth look into the unique makeup of the patient’s joint, allowing for more accurate incisions and a more natural placement of the prosthetics. This increased accuracy helps reduce the amount of pain for the patient, lowers the risk of implant dislocation, and helps preserve the healthy tissue and bone surrounding the surgery site.
A typical joint replacement surgery can take anywhere from 1-4 hours depending on the extent of the work being done and method the surgeon chooses to use. Prosthetics generally fall into one of two categories, cemented or uncemented. Also referred to as a press-fit prosthesis, uncemented prosthetics have a rough and porous surface that encourages the existing bone to naturally grow around the implanted material and hold it in place. Cemented prosthetics use a layer of adhesive like an acrylic polymer to connect the implant to the bone.
Once the prosthetic is successfully attached the surgeon will do a mobility test on the joint to make sure everything fits properly and that there are no impediments to movement. When it is confirmed that the prosthetic is secure and positioned properly the surgeon will close the wound using dissolvable stitches on the flesh beneath the skin, and glue on the skin’s outer layer.
After the procedure is complete you will be moved to a recovery room where you will be monitored for a few hours until the anesthesia wears off. You may be placed in a continuous passive movement device (CPM) at this point which bends and moves the joint around in a controlled way to help restore range of motion. Your after care instructions will vary depending on the specifics of your procedure so be sure to listen to your doctor and ask any questions that might come up. As with all surgeries there are a variety of problems that can arise post-op and you should make sure to contact your doctor immediately if you notice any unusual changes in your wound or condition. Some things to look out for are:
- Excessive bleeding
- Continued or increased joint pain
- A loose feeling in the joint around the prosthetic
Do not hesitate to ask your doctor for more details regarding these post-op issues, they will be happy to address all of your concerns and explain what should be done to prevent such occurrences.
Physical therapy can be started just hours after the procedure and the exercises you are given for rehabilitation should be done every day. It is not uncommon to notice numbness or slight pain around the incision site, and you may even hear a metallic clicking as you move the joint around. This is all normal and should begin to fade away with time. You will likely remain at the hospital for a few days after your procedure until you are declared fit to return home. From there your recovery will be monitored with routine checkups and consistent physical therapy. Recovery times vary but it is usually recommended to continue physical therapy for at least twelve weeks after your procedure.
Here at SCIC, we use cutting edge technology and the most advanced surgical techniques to ensure that you receive the highest quality of care. It is our goal to help relieve your pain and restore your body to a proper and painless condition. If you have questions regarding an injury of your own or if you would like to consult a doctor to discuss a total joint replacement surgery for you, please feel free to contact us