OPTIONS FOR SURGICAL TREATMENT OF ARTHRITIS

Hips and knees represent synovial joints. This means that where the bones come together, there is a thin layer of cartilage covering the end of the bone. The cartilage is for cushioning the stress of walking and provides for smooth movement. This cartilage is surrounded by a capsule of strong ligaments. The capsule contains fluid (synovial fluid) which lubricates the joint.

NORMAL HIP JOINT    NORMAL KNEE JOINT

The presence of arthritis implies that all or part of a joint is irregular and has lost its smooth cartilage covering. Bone is rubbing on bone. This results in inflammation in the joint and causes pain for the patient.

ARTHRITIC HIP JOINT    ARTHRITIC KNEE JOINT

The initial intervention in the treatment of arthritis is usually the prescription of medication which reduces inflammation and thereby decreases the pain which the patient is experiencing. This includes such medicines as: aspirin, Mortin, Naproxen, Clinoril, and Feldene. Additionally, measures to decrease the stress which the joint is forced to resist are instituted. This would include weight reduction, a decreased activity level and crutches or a cane. It is important to consider all of these non‑operative treatments before making the decision for surgery.

Basically three options are available for surgical treatment. The first is arthrodesis or fusion. The joint surfaces and arthritis are completely removed, and the bones comprising the joint are held together by internal fixation (screws, pins or rod). Fusion of a joint eliminates any movement of that joint, and thereby no pain comes from the irregularity and inflammation which previously existed. This method of treatment is extremely durable and can be subjected to activity without fear of failure of the fusion. Arthrodesis also has some disadvantages. Because motion is eliminated, function can be significantly compromised. The activities of daily living which require movement and agility are more difficult. Additionally, because movement is lost at the joint which is fused, adjacent joints are subjected to increased motion and stress. This can, over many years, lead to the deterioration of these joints. If this occurs, the fusion can often be converted to a joint replacement with relief of the symptoms from the adjacent joints. In spite of the disadvantages, fusion is an excellent option for young, active or overweight individuals.

HIP FUSION

The second surgical option is osteotomy. An osteotomy is when the bone above or below a joint is cut and the joint is aligned or directed differently. This allows a portion of the joint which is spared from arthritis to bear the load. If a joint is totally destroyed with arthritis, an osteotomy will not be successful. Therefore, to consider osteotomy as a surgical option, part of the joint must be free of arthritis.

NORMAL KNEE JOINT    ARTHRITIC KNEE JOINT

Osteotomy is an excellent treatment option for younger patients with less extensive joint destruction. It allows the maintenance of joint motion, relieves the symptoms of arthritis, and at the same time circumvents the restrictions of joint replacement. After osteotomy, patients are able to participate in any and all activities they would like. If an osteotomy is successful for many years prior to the recurrence of any symptoms, all of the surgical options remain available for further treatment. Specifically, joint replacement, arthrodesis, or repeat osteotomy could be selected for the next surgical procedure. No bridges will be burned. The main disadvantage of osteotomy is that only certain types of arthritis in certain patients are good candidates for the procedure. It has also been slightly less predictable in its results compared to joint replacement.

OSTEOTOMY    HEALED OSTEOTOMY

Total joint replacement, or arthroplasty, has become the most popular method of treating arthritis surgically. This procedure removes the arthritis completely and provides a new metal‑on‑plastic joint which predictably relieves pain and maintains motion.

 The recovery period from joint replacement is relatively short and usually uncomplicated making it ideal for elderly patients. Replaced joints normally function well for many years.

HIP ARTHROPLASTY

The most common "failure" is when the prosthesis (the artificial metal and plastic pieces) loosens from the bone. This is similar to a filling in a tooth loosening after a cavity has been repaired by a dentist. If this happens, it may be the result of excessive stress. This is most commonly seen in young patients or in overweight individuals. It is for this reason that patients who have their joints replaced are limited in some of the more physical activities in which they can participate.

FAILED HIP ARTHROPLASTY

If a joint replacement loosens and becomes painful, the operation must be redone. In this situation, the bone loss resulting from the loosening and surgery is a challenge to overcome, and often the results from repeat or revision operations are not as good as first‑time operations. 

Operations usually go without any problem. However, if a complication does occur, it can be difficult to treat. For example, infection rarely occurs, but if it does, it may be very difficult to control.

 Most patients who have had joints replaced enjoy many years of painless, unlimited activity without problems. Indeed one of the most frequent comments is, "Why did I wait so long to have the operation?" Good and excellent results are experience in well over 90 percent of patients. These initial good results have the potential for lasting many years ‑ indeed the entire lifetime of most patients.

 Other surgical procedures have appropriate use in selected patients. This would include: arthroscopy with debridement (removal of arthritic spurs and irregularities), patellectomy (removal of the kneecap), and partial joint replacement. These procedures are used less frequently, but in the correct patient, the results are very good.

LIFE WITH AN ARTIFICIAL JOINT

Hip and knee replacements are intended to relieve the pain and suffering of arthritis and markedly improve your quality of life. Unfortunately they do not provide you with a "normal" joint that is as good as one which has never had disease or surgery. Nevertheless, even with the limitations and restrictions which exist after surgery, you will experience a significant resolution of pain and an increased activity level. This should last many years. Indeed, in most patients, this painfree period will last throughout the remaining life of the individual. These good and excellent results are present in over 90 percent of the people who have hip and knee replacements. The quality of the result and its duration seem to be related to how technically well the operation was performed. This emphasizes the importance of the surgeon's experience and good surgical technique.

Part of the new joint's life expectancy is determined by the patient. If a patient puts excessive stress on the joint, it cannot be expected to last very long. Excessive stress is caused by obesity, over activity and participation in activities which overload the joint. It is, therefore, recommended that after surgery, the patient keep his weight near the ideal body weight. Heavy lifting should also be avoided. It is recommended not to lift over twenty-five pounds repeatedly and up to fifty pounds only occasionally. Running, jumping sports, tennis, skiing, horseback riding and other similar sports should be avoided. Walking, swimming, golf, bicycling, bowling and dancing are all encouraged.

One extremely uncommon potential complication of having an artificial joint is the occurrence of an infection in the joint. This is very rare, but may occur if bacteria settles into the joint from the blood stream. Bacteria can get into the blood if there is an infection elsewhere in the body. An example of this would include bladder infection, pneumonia, an infected tooth or toenail or other localized infectious process. If you should have an infection develop anywhere, it is important that it be treated quickly and thoroughly. To accomplish this, contact your personal physician immediately. If he is not available, please call Dr. Bertin. There is also concern over major dental and gastrointestinal surgery. In these instances, it would be advisable to take antibiotics prior to the procedure to kill any bacteria which may be shed into the circulation. This is particularly true if you are taking prednisone or other steroid preparations. Penicillin, sulfa, or other antibiotics can be given. Ask the doctor or dentist to assist with these precautionary measures. They are the same as the recommendations for people with artificial heart valves.

Revision Total Joint Replacement

If your artificial joint fails and has to be reoperated, the situation can often be dramatically improved. Pain, limited activity and decreased movement can usually be treated. This improvement may not be as dramatic as that experienced after your first operation. Indeed, the results of revision total joint replacement are overall not as good as first operations. This is one of the reasons we try to get the best result possible with the first surgery and maintain it with appropriate precautions. As our experience with revision surgery increases, we are able to improve the quality of our results. The future is thus more optimistic than the past.

Systematic Follow-up

Routine checkups including physical examination and X-rays are extremely important for three reasons:

1. Any change in the condition of the joint can be discovered early and extensive problems hopefully eliminated. This often shows first on X-rays and may cause absolutely no symptoms. This is infrequent. However, if it occurs, regular periodic examinations can reveal a minor problem before it becomes severe.

2. Dr. Bertin keeps track of all joint replacements as part of prospective clinical research. This research helps establish which procedure is best for each particular problem. You, as an individual patient, are very important even when you have a good result. If all patients are not kept tract of, it is difficult to draw firm conclusions. When disproportionate percentages of good and bad results return for follow-up, the data is not accurate. This clinical research leads to improved health care for future patients and possibly even you if further treatment becomes necessary.

3. The final benefit from periodic evaluation is continued education of you, the patient. Each exchange between health care professionals and a patient increases his understanding of the disease and its treatment. This will hopefully assist you in coping with the disease more successfully.

These benefits accrue to you and others. The schedule for examinations is six weeks, three months, six months, and one year after surgery and then annually for the first five years. Thereafter, the visits are scheduled for every two years. The fee for these services is usually covered by your insurance company. When these visits are routine, the examination may well be performed by Dr. Bertin's physician assistant, Scott Frischknecht, and the X-rays reviewed by the doctor.