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Total Joint Replacement

One of the major technological advancements developed by orthopaedists over the last quarter century has been the total joint replacement. Pioneering work by orthopaedists in England and later the United States led to the development of total hip and knee replacements. At one time only performed in a few specialized centers, these surgical procedures are now provided on a regular basis at nearly all community hospitals. The surgery has the potential to eliminate or significantly decrease pain associated with degenerative arthritis, rheumatoid arthritis, or joint disease secondary to congenital anomalies. An interesting parallel development reveals similar advances with these types of protheses to treat hip disease in the canine population. Veterinary advances have occurred alongside those in the orthopedic community.

In the past, the hip replacement or knee replacement procedures were limited to older individuals whose activities of daily living were severely compromised, secondary to their arthritic condition. These patients already had trials of arthritic medications without success. Commonly, they already relied on the use of cane or walker for household or community ambulation. The initial rule of thumb was that the patient needed to be more then sixty-five years old, in acceptable medical health, with a painful arthritic condition that severely limited activities of daily living. The patients that met these criteria were evaluated by the orthopaedist and the risks and benefits of the proposed surgery were discussed.

Despite the occasional complication, the initial results of total joint replacements were excellent. This led to a more broad definition of the indications. Over the years, the age for total joint replacement has steadily decreased. It is not uncommon for individuals in their fifties with moderately severe arthritis to undergo these procedures. Occasional special cases occur with joint replacements being performed in forty-, thirty-, and even twenty-year-olds for a specific hip or knee disease. One of the more well-known cases is that of former professional athlete, Bo Jackson. His hip was replaced for treatment of avascular necrosis which developed after a hip injury damaged the blood supply to the upper femur bone.

Total joint replacement surgery is not a benign procedure, and significant risks are evident. Any major orthopedic procedure has with it the risk of blood loss requiring transfusions. Blood clots can also form in the legs postoperatively. These clots can fragment and travel through the veins to the heart or lungs. Such blood clots in the lungs are known as pulmonary emboli and may be life threatening. Treatment of this potential problem utilizes anticoagulation prophylaxis. By this, the blood is thinned out with various medications, making blood clots less likely. Proper care must be taken to prevent blood from thinning too much and allowing excessive bleeding during and after surgery.

Another major problem with joint replacements is the ever-present risk of infection. Although this incidence is low, when it does occur, a significant problem is encountered. Prolong antibiotics and repeat surgery are often necessary. Additional problems may occur resulting in unequal leg lengths postoperatively or loss of joint motion.

Unfortunately, when hip or knee replacements are performed in younger individuals, they are far more likely to eventually loosen. Complication rates in the younger individuals are more than triple those of the older population. Loosening of the prothesis, associated with actual mechanical failure and breakage of the implants, leads to revision surgery. The results of revision surgery are never as good as those obtained with the initial procedure. With this in mind, great caution should be exercised when evaluating individuals for this surgery. It should always be kept in mind that the purpose of the surgery is to allow for a return to activities of daily living and not recreational sports.