Some joints may benefit from splinting e.g. rheumatoid hands, thumb CMC OA
Steriod injections may provide temporary relief
Surgery - fusion, replacement, excision
Arthroplasty
Involves either replacement of part of the joint (hemiarthroplasty) or the whole joint (total joint replacement)
Choice of materials
Joint replacements can be made of stainless steel, cobalt chrome, titanium alloy, polyethylene and ceramic
Components may or may not be cemented (bone cement - PMMA) - advantages and disadvantages of both
The surfaces can consist of a metal‐polyethylene, ceramic‐polyethylene, ceramic–ceramic or metal‐metal bearing couple
There is no single ideal material or combination of materials for a joint replacement
Ultimately the joint replacement will fail due to loosening (caused by wear particles producing an inflammatory response or high stresses) or breakage of the joint replacement components
Metal particles can cause an inflammatory granuloma (known as a pseudotumour) which can cause muscle and bone necrosis
Polyethylene particles can cause an inflammatory response in bone with subsequent bone resorption (osteolysis) resulting in loosening
Ceramics can shatter with fatigue due to their brittleness
Indications for a Total Knee Replacement
Only for older, medically fit appropriate patient with end stage arthritis and severe pain refractory to chronic management
Constant severe pain, sleep disturbance, pain limiting function/walking distance, frequent bad 'flare-ups'
Those with milder OA and severe pain tend not to do well - increased chance of developing chronic pain
Older patient where replacement will last for good - 60+ as a guide
Expect TKR to last 15-20 years in older, low demand patients if put in well
Indications for a Total Hip Replacement
Pain
90% of cases wil be pain free after recovery
Vast majority of cases will have large functional improvement
In a low demand older patient the estimated lifespan of a THA is around 15 years
Complications
Early local complications: infection, dislocation, instability, leg length discrepancy, nerve injury, arterial bleeding/ischaemia, bleeding, DVT
Early general complications: hypovolaemia, shock, acute renal failure, MI, ARDS, PE, chest infection, urine infection
Late local complications: infection (haematogenous spread), loosening, fracture, implant breakage, pseudotumour formation
Revision joint replacements
Revision joint replacements are a bigger procedure than the primary procedure with often substancial blood loss, increased the complication rates and often poorer functional outcome
Revision joint replacements tend not to last as long as primary joint replacement
Once a revision fails - risk of fusion or amputation
Other considerations
Younger patients more likely to need revision surgery due to having increased demands on the replacement, and 'outliving' their replacement
20% of patients who have a TKR have unexplained moderate-severe pain
May be due to the complexity of and reliance upon the tension of the soft tissues around the knee
Predictors - young, obesity, psychological distress, preexisting chronic pain, less severe OA
Alternatives to a total knee replacement
Unicompartmental knee replacement
Only the worn area of the knee is replaced
Less invasive, no ligaments removed or lengthened
Knee may feel more natural
Fairly easy to revise
Many cases not suitable
Reoperation rate significantly higher than TKR
Major concern is progression of OA in unreplaced knee - might regret not doing TKR
Osteotomy
Surgical realignment of a bone which can be used for deformity correction or to redistribute load across an arthritic joint and shift load onto an undiseased part
Can be used for early arthritis in the knee and hip
Doesn't remove the damaged joint, controversial
Only for very active patients who would damage or loosen a joint replacement
Cartilage regeneration surgery
Cartilage regeneration surgery may be beneficial in a case of small localised area of articular cartilage damage with persistent pain
Results unpredictable
Does not work for more general/widespread changes of OA or multiple defects
Keyhole surgery - 'clean out'
Performed histortically to try to alleviate symptoms and prevent knee replacement
Usually ineffective, any benefit tends to be short lived
Should not be offered on NHS
Surgical joint options for smaller joints
Excision or resetion arthroplasty
Involves the removal of bone and cartilage of one or both sides of the joint
Quite disabling for larger joints but can be an effective procedure for smaller joints (e.g. 1st CMC joint in foot for hallux valgus)
Occasionally utilized after failure of hip or shoulder replacement
Arthrodesis
Surgical stiffening or fusion of a joint in a position of function
The remaining hyaline cartilage of the joint and subchondral bone is removed and the joint is stabilized, resulting in bony union and fusion
Alleviates pain but function may be limited, particularly in large joints, and may increase pressure in surrounding joints leading to arthritic change
Used in end stage ankle arthritis, wrist arthritis and hallux rigidus
Upper limb arthritis surgery
Rheumatoid hand problems
Synovectomy
Tendon realignemnt
Tendon replacement
Fusion
Elbow
Arthritic change at the radio‐capitellar joint which has failed non-operative management can be treated with surgical excision of the radial head - good pain relief with minimal functional limitation
An elbow severely affected by RA or OA at the humero‐ulnar joint which isn't satisfactorily treated with conservative management can be treated surgically with a Total Elbow Replacement - lifting limited to 2.5kg posteriorly following replacement
Elbow replacements have a limited life span and so are not good for young/active patients
Shoulder
Anatomic replacement
Reverse polarity shoulder replacement for OA secondary to rotator cuff tear
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