Hip Replacement
	Total Knee Replacement
	Arthroscopy

Hip Replacement

What is a hip replacement?

Hip replacement, or arthroplasty, is a surgical procedure in which the diseased parts of the hip joint are removed and replaced with new, artificial parts. These artificial parts are called the prosthesis. The goals of hip replacement surgery include increasing mobility, improving the function of the hip joint, and relieving pain.

Who should have hip replacement surgery?

People with hip joint damage that causes pain and interferes with daily activitiesdespite treatment may be candidates for hip replacement surgery.Osteoarthritis is the most common cause of this type of damage. However, other conditions, such as rheumatoid arthritis (a chronic inflammatory disease that causes joint pain, stiffness, and swelling), osteonecrosis (or a vascular necrosis, which is the death of bone caused by insufficient blood supply), injury, and bone tumors also may lead to breakdown of the hip joint and the need for hip replacement surgery.

In the past, doctors reserved hip replacement surgery primarily for people over 60 years of age. The thinking was that older people typically are less active and put less stress on the artificial hip than do younger people. In more recent years, however, doctors have found that hip replacement surgery can be very successful in younger people as well. New technology has improved the artificial parts, allowing them to withstand more stress and strain and last longer.

Today, a person’s overall health and activity level are more important than age in predicting a hip replacement’s success. Hip replacement may be problematic for people with some health problems, regardless of their age. For example, people who have chronic disorders such as Parkinson’s disease, or conditions that result in severe muscle weakness, are more likely than people without chronic diseases to damage or dislocate an artificial hip. People who are at high risk for infections or in poor health are less likely to recover successfully. Therefore they may not be good candidates for this surgery. Recent studies also suggest that people who elect to have surgery before advanced joint deterioration occur tend to recover more easily and have better outcomes. 

Why do people have hip replacement surgery?

For the majority of people who have hip replacement surgery, the procedure results in:

• A decrease in pain
• Increased mobility
• Improvements in activities of daily living
• Improved quality of life.

 What does hip replacement surgery involve?

The hip joint is located where the upper end of the femur, or thigh bone, meets the pelvis, or hip bone. A ball at the end of the femur, called the femoral head, fits in a socket (the acetabulum) in the pelvis to allow a wide range of motion.

During a traditional hip replacement, which lasts from 1 to 2 hours, the surgeon makes a 6- to 8-inch incision over the side of the hip through the muscles and removes the diseased bone tissue and cartilage from the hip joint, while leaving the healthy parts of the joint intact. Then the surgeon replaces the head of the femur and acetabulum with new, artificial parts. The new hip is made of materials that allow a natural gliding motion of the joint.

In recent years, some surgeons have begun performing what is called a minimally invasive, or mini-incision, hip replacement, which requires smaller incisions and a shorter recovery time than traditional hip replacement. Candidates for this type of surgery are usually age 50 or younger, of normal weight based on body mass index and healthier than candidates for traditional surgery. Joint resurfacing is also being used.

Regardless of whether you have traditional or minimally invasive surgery, the parts used to replace the joint are the same and come in two general varieties: cemented and uncemented.

Cemented parts are fastened to existing, healthy bone with a special glue or cement. Hip replacement using these parts is referred to as a “cemented” procedure. Uncemented parts rely on a process called biologic fixation, which holds them in place. This means that the parts are made with a porous surface that allows your own bone to grow into the pores and hold the new parts in place. Sometimes a doctor will use a cemented femur part and uncemented acetabular part. This combination is referred to as a hybrid replacement.

Is a cemented or uncemented prosthesis better?

The answer to this question is different for different people. Because each person’s condition is unique, the doctor and you must weigh the advantages and disadvantages.
Cemented replacements are more frequently used for older, less active people and people with weak bones, such as those who have osteoporosis, while uncemented replacements are more frequently used for younger, more active people.

Studies show that cemented and uncemented prostheses have comparable rates of success. Studies also indicate that if you need an additional hip replacement, or revision, the rates of success for cemented and uncemented prosthesis are comparable.

However, more long-term data are available in the United States for hip replacements with cemented prostheses, because doctors have been using them here since the late 1960s, whereas uncemented prostheses were not introduced until the late 1970s.

The primary disadvantage of an uncemented prosthesis is the extended recovery period. Because it takes a long time for the natural bone to grow and attach to the prosthesis, a person with uncemented replacements must limit activities for up to 3 months to protect the hip joint. Also, it is more common for someone with an uncemented prosthesis to experience thigh pain in the months following the surgery, while the bone is growing into the prosthesis.

How to prepare for surgery and recovery?

People can do many things before and after they have surgery to make everyday tasks easier and help speed their recovery.

Before surgery

• Learn what to expect.
• Arrange for someone to help you around the house for a week or two after coming home from the hospital.
• Arrange for transportation to and from the hospital.
• Set up a “recovery station” at home. Place the television remote control, radio, telephone, medicine, tissues, wastebasket, and pitcher and glass next to the spot where you will spend the most time while you recover.
• Place items you use every day at arm level to avoid reaching up or bending down.
• Stock up on kitchen supplies and prepare food in advance, such as frozen casseroles or soups that can be reheated and served easily.

After surgery

• Follow the doctor’s instructions.
• Work with a physical therapist or other health care professional to rehabilitate your hip.
• Wear an apron for carrying things around the house. This leaves hands and arms free for balance or to use crutches.
• Use a long-handled “reacher” to turn on lights or grab things that are beyond arm’s length. Hospital personnel may provide one of these or suggest where to buy one.

What can be expected immediately after surgery?

You will be allowed only limited movement immediately after hip replacement surgery. When you are in bed, pillows or a special device are usually used to brace the hip in the correct position. You may receive fluids through an intravenous tube to replace fluids lost during surgery. There also may be a tube located near the incision to drain fluid, and a type of tube called a catheter may be used to drain urine until you are able to use the bathroom. The doctor will prescribe medicine for pain or discomfort.

On the day after surgery or sometimes on the day of surgery, therapists will teach you exercises to improve recovery. A respiratory therapist may ask you to breathe deeply, cough, or blow into a simple device that measures lung capacity. These exercises reduce the collection of fluid in the lungs after surgery.

As early as 1 to 2 days after surgery, you may be able to sit on the edge of the bed, stand, and even walk with assistance.

While you are still in the hospital, a physical therapist may teach you exercise such as contracting and relaxing certain muscles, which can strengthen the hip. Because the new, artificial hip has a more limited range of movement than a natural, healthy hip, the physical therapist also will teach you the proper techniques for simple activities of daily living, such as bending and sitting, to prevent injury to your new hip.

How long are recovery and rehabilitation?

Usually, people do not spend more than 3 to 5 days in the hospital after hip replacement surgery. Full recovery from the surgery takes about 3 to 6 months, depending on the type of surgery, your overall health, and the success of your rehabilitation.

What are possible complications of hip replacement surgery?

According to the American Academy of Orthopedic Surgeons, more than 193,000 total hip replacements are performed each year in the United States and more than 90 percent of these do not require revision.

New technology and advances in surgical techniques have greatly reduced the risks involved with hip replacements.

The most common problem that may arise soon after hip replacement surgery is hip dislocation. Because the artificial ball and socket are smaller than the normal ones, the ball can become dislodged from the socket if the hip is placed in certain positions. The most dangerous position usually is pulling the knees up to the chest.

The most common later complication of hip replacement surgery is an inflammatory reaction to tiny particles that gradually wear off of the artificial joint surfaces and are absorbed by the surrounding tissues. The inflammation may trigger the action of special cells that eat away some of the bone, causing the implant to loosen. To treat this complication, the doctor may use anti-inflammatory medications or recommend revision surgery (replacement of an artificial joint). Medical scientists are experimenting with new materials that last longer and cause less inflammation. Less common complications of hip replacement surgery include infection, blood clots, and heterotopic bone formation (bone growth beyond the normal edges of bone). Studies are also looking at the use of bisphosphonates, ciprofloxacin, pentoxifylline, and other medications to prevent this bone resorption around the implants.

When is revision surgery necessary?

Hip replacement is one of the most successful orthopedic surgeries performed. Studies have shown that more than 90 percent of people who have hip replacement surgery will never need to replace an artificial joint.

Total Knee Replacement

Joint replacement is becoming more common, and hips and knees are the most commonly replaced joints.

The new joint, called a prosthesis, can be made of plastic, metal, or both. It may be cemented into place or uncemented. An uncemented prosthesis is designed so that bones will grow into it.

First made available in the late 1950’s, early total knee replacements did a poor job of mimicking the natural motion of the knee. For that reason, these procedures resulted in high failure and complication rates. Advances in total knee replacement technology in the past 10 to 15 years have enhanced the design and fit of knee implants.

Total knee replacement is often the answer for people when X rays and other tests show joint damage; when moderate-to-severe, persistent pain does not improve adequately with non-surgical treatment; and when the limited range of motion in their knee joint diminishes their quality of life.

In the past, patients between 60 and 75 years of age were considered to be the best candidates for total knee replacement. Over the past two decades, however, the age range has been broadened to include more patients older than 75, who are likely to have other health issues, and patients younger than 60, who are generally more physically active and whose implants will probably be exposed to greater mechanical stress.

About 90 percent of patients appear to experience rapid and substantial reduction in pain, feel better in general, and enjoy improved joint function. While most total knee replacement surgeries are successful, failure does occur and revision is sometimes necessary. Risk factors include being younger than 55 years old; being male; being obese; and having osteoarthritis or other illnesses.

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Arthroscopy

What is arthroscopy?

Arthroscopy is a surgical procedure orthopedic surgeons use to visualize, diagnose and treat problems inside a joint.

The word arthroscopy comes from two Greek words, "arthro" (joint) and "skopein" (to look). The term literally means "to look within the joint." In an arthroscopic examination, an orthopedic surgeon makes a small incision in the patient's skin and then inserts pencil-sized instruments that contain a small lens and lighting system to magnify and illuminate the structures inside the joint. Light is transmitted through fiber optics to the end of the arthroscope that is inserted into the joint. By attaching the arthroscope to a miniature television camera, the surgeon is able to see the interior of the joint through this very small incision rather than a large incision needed for surgery.

The television camera attached to the arthroscope displays the image of the joint on a television screen, allowing the surgeon to look, for example, throughout the knee-at cartilage and ligaments, and under the kneecap. The surgeon can determine the amount or type of injury, and then repair or correct the problem, if it is necessary.

Why is arthroscopy necessary?

Diagnosing joint injuries and disease begins with a thorough medical history, physical examination, and usually X-rays. Additional tests such as an MRI, or CT also scan may be needed. Through the arthroscope, a final diagnosis is made which may be more accurate than through "open" surgery or from X-ray studies.

Disease and injuries can damage bones, cartilage, ligaments, muscles, and tendons. Some of the most frequent conditions found during arthroscopic examinations of joints are:

• Inflammation
• Synovitis - inflamed lining (synovium) in knee, shoulder, elbow, wrist, or ankle.
• Injury - acute and chronic
• Shoulder - rotator cuff tendon tears, impingement syndrome, and recurrent dislocations
• Knee - meniscal (cartilage) tears, chondromalacia (wearing or injury of cartilage cushion), and anterior cruciate ligament tears with instability
• Wrist - carpal tunnel syndrome

Loose bodies of bone and/or cartilage - knee, shoulder, elbow, ankle or wrist.

Although the inside of nearly all joints can be viewed with an arthroscope, six joints are most frequently examined with this instrument. These include the knee, shoulder, elbow, ankle, hip, and wrist. As advances are made by engineers in electronic technology and new techniques are developed by orthopedic surgeons, other joints may be treated more frequently in the future.

How is arthroscopy performed?

Arthroscopic surgery, although much easier in terms of recovery than "open" surgery, still requires the use of anesthetics and the special equipment in a hospital operating room or outpatient surgical suite. You will be given a general, spinal or a local anesthetic, depending on the joint or suspected problem.

A small incision (about the size of a buttonhole) will be made to insert the arthroscope.

Rotator cuff procedure

Repair or resection of torn cartilage (meniscus) from knee or shoulder

• Reconstruction of anterior cruciate ligament in knee
• Removal of inflamed lining (synovium) in knee, shoulder, elbow, wrist, ankle
• Release of carpal tunnel
• Repair of torn ligaments
• Removal of loose bone or cartilage in knee, shoulder, elbow, ankle, wrist

After arthroscopic surgery, the small incisions will be covered with a dressing. You will be moved from the operating room to a recovery room. Many patients need little or no pain medications.

Before being discharged, you will be given instructions about care for your incisions, what activities you should avoid, and which exercises you should do to aid your recovery. During the follow-up visit, the surgeon will inspect your incisions; remove sutures, if present; and discuss your rehabilitation program.

The amount of surgery required and recovery time will depend on the complexity of your problem. Occasionally, during arthroscopy, the surgeon may discover that the injury or disease cannot be treated adequately with arthroscopy alone. The extensive "open" surgery may be performed while you are still anesthetized, or at a later date after you have discussed the findings with your surgeon.

What are the possible complications?

Although uncommon, complications do occur occasionally during or following arthroscopy. Infection, phlebitis (blood clots of a vein), excessive swelling or bleeding, damage to blood vessels or nerves, and instrument breakage are the most common complications, but occur in far less than 1 percent of all arthroscopic procedures.

What are the advantages?

Although arthroscopic surgery has received a lot of public attention because it is used to treat well-known athletes, it is an extremely valuable tool for all orthopedic patients and is generally easier on the patient than "open" surgery. Most patients have their arthroscopic surgery as outpatients and are home several hours after the surgery.

Recovery after arthroscopy

The small puncture wounds take several days to heal. The operative dressing can usually be removed the morning after surgery and adhesive strips can be applied to cover the small healing incisions.

Although the puncture wounds are small and pain in the joint that underwent arthroscopy is minimal, it takes several weeks for the joint to maximally recover. A specific activity and rehabilitation program may be suggested to speed your recover and protect future joint function.

It is not unusual for patients to go back to work or school or resume daily activities within a few days. Athletes and others who are in good physical condition may in some cases return to athletic activities within a few weeks. Remember, though, that people who have arthroscopy can have many different diagnoses and preexisting conditions, so each patient's arthroscopic surgery is unique to that person. Recovery time will reflect that individuality.

Your orthopedist is a medical doctor with extensive training in the diagnosis and non-surgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves.