Surgery – IndicationsRx

Orthopedic surgical procedures can dramatically improve the quality of life for patients with various types of arthritis.  In the past century, advances in surgical interventions have been among the most impactful innovation in the care of patients with musculoskeletal conditions.

Types of Surgery: Commonly employed orthopedic procedures include:

1. synovectomy or tenosynovectomy (i.e., removing synovial tissue from joints or tendons),
2. ligament or tendon reconstruction (e.g., repair of torn or fraying tendons),
3. osteotomy (cutting of bone to optimize mechanics),
4. arthrodesis (intentional fusion of joints), and
5. arthroplasty (joint replacement surgery).

According to the Center for Disease Control and Prevention there were 719,000 total knee replacement and 332,000 total hip replacement surgeries in the United states in 2010.  Joint replacement surgery has been an increasingly useful procedure for severe arthritis or damage of the hip, knee or glenohumeral joints. Under optimal conditions, most orthopedists state that a joint replacement should yield successful results for 10 to 20 years; however newer materials suggest that a replaced knee (for instance) may last up to 30 years. Hence, joint replacement (hips or knees) is a reasonable option for both the middle aged and elderly patients. However, revison arthroplasties of the same joint are successively more difficult and less successful than the first procedure. Other joints that may be considered for joint replacement include the metacarpophalangeal and first carpometacarpal joints. Osteotomy is a more limited procedure than joint replacement. It may be useful in some instances (e.g., unilateral knee or hip osteonecrosis or osteoarthritis) in which realignment may optimize joint mechanics and thereby improve pain and function. Arthrodesis is considered for joints for which the results of joint replacement have not been so promising (e.g., wrists, tarsus). Tenosynovectomy and tendon or ligament repairs are generally less extensive surgical procedures designed to improve joint mechanics, repair tendon rupture or impending rupture or debulk severe, localized synovitis.

Indications: The main indications for joint surgery include:

1. intractable/refractory pain or
2. significant functional limitation, and
3. objective evidence of progressive damage (by examination or imaging).

When referring patients to an orthopedic surgeon, it should be evident that pain or functional impairment are directly related to damage or destruction of the affected joint or appendage. For example, a person with advanced degenerative changes on x-ray who experiences severe pain both with activity and at rest should be considered a potential candidate for surgical intervention. On the other hand, if a patient has severe pain, but no or minimal evidence of joint damage, other etiologies for the pain should be considered (e.g., neuropathic pain, fibromyalgia, periarticular disorders).  In addition, before undertaking surgery, there are often other interventions should be considered. This may include simple analgesics are the first step pain management, assistive devices and splinting can help optimize functional status and physical therapy may provide suffient relief or improve the patients strength and function prior to eventual therapy (Pre-hab).

Contraindications: Contraindications to joint surgery include active infection or uncontrolled bleeding diathesis. Because postoperative rehabilitation is crucial to a good outcome after joint replacement, many of the relative contraindications to this surgery include conditions that could interfere with rehabilitation potential (e.g., decreased mobility unrelated to the involved joint, morbid obesity, lack of motivation, severe comorbid diseases).  Younger age is also a relative contraindication to joint replacement surgery because (1) those who are extremely physically active after joint replacement may experience prosthetic failure sooner than those with normal or sedentary activity and (2) repeat procedures are often associated with a poorer outcome. Nonetheless, children with severe polyarticular or systemic juvenile idiopathic arthritis may require joint arthroplasty as young adults.  A recent study showed the 10 year arthroplasty success to be 92% and the 20 year arthroplasty survival to be 75%.

Complications: The risk of an infected prosthesis after joint replacement is 1-2%.  Hence of the 1 million hip and knee replacement done this year, up to 20,000 will be complicated by perioperative infection. Prosthetic infection may be difficult to diagnose. Hence a high index of suspicion is necessary to know who should undergo nuclear bone scanning or other diagnostic procedures. Prosthetic joint infection should be suspected if there is: 1) persistent wound drainage following joint replacement; 2) sudden onset of a painful prosthesis, ongoing or increasing pain in the weeks to months after arthoplasty (when pain should be declining); 3) when there is persistent elevation of the ESR and CRP; 4)  in patients with a history of prior wound healing problems or prosthetic infections. Diabetics are not at greater risk of post-operative infections when compared to non-diabetics. However, obese patients are at higher risk of post-operative complications and infections.   Lastly, it appears that the use preoperative intraarticular hip steroid injections does not increase the risk of subsequent infection after hip arthroplasty.  For those diagnosed with prosthetic infection, 4-6 weeks of intravenous antibiotic therapy will be necessary.

Other complications of arthroplasty may include of wound infection, pulmonary complications, deep vein thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI) and other complications following orthopaedic surgery

Cost: The cost of a single total joint arthroplasty (hip or knee) averages around $55,000, but ranges from $20,000 to $180,000.

BIBLIOGRAPHY

Osmon DR, Berbari EF, Berendt AR, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013; 56: e1-e25.  PMID: 23223583