Joint Replacement

When pain and stiffness in your hip or knees keep you away from your daily activities, it is the time for total knee or hip replacements. Basically the cartilage of hip or knee joints wears off due to many reasons. Which causes decrease in joint space and osteophyte formation.

Common causes are
• Osteoarthritis
• Rheumatoid arthritis
• Post traumatic
• AVN of Hip(a vascular neurosis of hip) due to alcohol, steroid enduced or sickle cell disease or idiopathic(common) without any disease
When all the conservative treatment fails to give adequate relief to the patients and X-Ray or their investigation shows joint space reduction, Joint Replacement is indicated

The knee is the largest joint in the body. It is commonly referred to as a “hinge” joint because it allows the knee to flex and extend. While hinges can only bend and straighten, the knee has the additional ability to rotate (turn) and translate (glide).

The knee joint is formed by the shin bone (tibia), the thigh bone (femur) and the kneecap (patella). The end of each bone is covered with a layer of slick cartilage, which cushions and protects the bone while allowing smooth movement. If damaged, the cartilage cannot repair itself.

Tough fibers, called ligaments, connect the bones of the knee joint and hold them in place, adding stability and elasticity for movement. Muscles and tendons also play an important role in keeping the knee joint stable and mobile.





A joint is a junction where two or more bones meet. The hip joint forms where the top of the femur (thigh bone) meets the acetabulum (the socket of the pelvic bone). The top of the femur is ball-shaped and fits snugly in the socket formed by the acetabulum. The bones of the hip joint are covered by a layer of smooth, shiny cartilage that cushions and protects the bones while allowing easy motion. Surrounding the hip joint is the synovial lining, which produces a moisturizing lubricant. Tough fibers, called ligaments, connect the bones of the joint and hold them in place, while adding strength and elasticity for movement. Muscles and tendons also play an important role in keeping the joint stable.

Total Hip Replacement:

Total hip replacement or “arthroplasty” is the replacement of the ball and socket of the hip joint with artificial parts called prostheses. There are two main components used in total hip replacement. The femoral component is made of metal and replaces the ball. The acetabular component replaces the socket and may be made entirely of a very hard medical-grade plastic called polyethylene. It may also be made of a metal and polyethylene combination in which the polyethylene cup is placed inside a metal shell. The acetabular component is then secured inside the natural pelvic socket.

The natural ball portion of the femur (thigh bone) is removed during surgery and the inside of the femur (the canal) is drilled and enlarged to fit the femoral component of the hip prosthesis. The socket portion of the pelvis is also enlarged with a special surgical instrument to make room for the new artificial socket component. The femoral component is inserted down the enlarged shaft of the thigh bone. The acetabular component is inserted into the enlarged socket. The ball and socket are then fitted together and stabilized with the surrounding ligaments and muscles, just as your original hip had been.

Joint Replacement now is a very successful operation with newer techniques and implants with very long term good results for at least 15-20 years.

There are many injection therapy also for knee joints pain like,
- Platelets concentrate injections: Platelets harvested from patients own blood is injected in joint to enhance cartilage formation.
- Hyaluronidase enzyme injection: to increase the viscosity of synovial fluid and help in cartilage regeneration.
- Local steroid injections for pain relief.

Fore Surgery: You may be asked to see your family physician or an internal medicine doctor for a more thorough medical evaluation. To prepare yourself for surgery, you may be asked to do a number of things. You may be asked to lose weight if you are overweight. If you smoke, it is important for you to stop two weeks prior to surgery. If you are taking aspirin or certain arthritis medications, inform your surgeon; you may need to stop taking these two weeks before surgery. If you are taking aspirin under the direction of a physician for vascular or cardiacreasons, your doctor may advise you to continue taking it as directed. Your doctor may want you to donate your own blood ahead of time for a possible transfusion during surgery.

Your Surgery: You will probably be admitted to the hospital the morning of surgery. You cannot eat or drink anything after midnight the day of surgery. The day of your surgery, you will be taken to the operating room about a half hour early. In order to receive medications and blood transfusions during surgery, an intravenous (IV) line will be started. The anesthesiologist will speak to you before surgery, and discuss the type of anesthetic to be used.

The Recovery Room: You will awaken after your surgery in the Post-Anesthesia Recovery Room. You will remain there until you have recovered from the anesthesia, are breathing well, and your blood pressure and pulse are stable. You may feel as though you only left your room for a few minutes. If you experience pain, medication will be available.

What to expect after surgery: You may have a tube or drain coming through the surgical dressing that is attached to a drainage apparatus. This system provides gentle, continuous suction to remove any blood that may accumulate in the surgical area. The drain will probably be removed several days after surgery. Your dressing will be changed and a smaller one applied. You may move the leg that was not operated on as soon as you awaken. As you lie on your back, flexing the unoperated hip will reduce aching in your lower back. The nurse will help you find comfortable positions. You may turn with a pillow between your legs. The nurse will encourage you to do ankle pumping exercises every hour to protect against blood clots An IV may remain in your arm for several days to administer antibiotics or other medications you may need. This helps prevent infection and gives you proper nourishment until you are eating and drinking comfortably. You will begin regular fluid and food intake under the direction and advice of your surgeon. To prevent problems in your lungs, you may receive an incentive spirometer after surgery to encourage you to cough and breathe deeply. This is used every hour while you are awake. It is normal to feel discomfort after surgery. Inform the nurse of your pain, and medication will be ordered.

HIGH TIBIAL OSTEOTOMY (HTO)

Joint preservation surgery to repair damage to articular cartilage inflicted by osteoarthritis and malalignment. With each step, forces equal to three to eight times your body weight travel between the thigh bone (femur) and shin bone (tibia) in your knee. These forces are dampened by a meniscus on the inner and outer portion of the knee, and the ends of the bones are protected by articular cartilage. Patients with a condition known as osteoarthritis, or degenerative arthritis, experience a successive wearing on the menisci and articular cartilage, which may develop tears. These degenerative processes limit the ability of the knee to glide smoothly and can result in popping, catching, locking, clicking and pain. In a condition called malalignment, unbalanced forces cause excessive pressure on either in the inner (medial) or outer (lateral) portion of the knee. Degenerative arthritis and malalignment can cause the knee’s protective tissues to wear on one side more than the other in a repetitive cycle of damage. A partial or total knee replacement can correct this condition when joint damage is beyond repair. In certain cases, however, a technique known as an osteotomy can realign the knee, taking pressure off the damaged side. A procedure known as a high tibial osteotomy wedges open the upper shin bone (tibia) to reconfigure the knee joint. The weight-bearing part of the knee is shifted from degenerative or worn tissue onto healthier tissue. A high tibial osteotomy is generally considered a method of prolonging the time before a knee replacement is necessary because the benefits typically fade after eight to ten years. This procedure is typically reserved for younger patients with pain resulting from instability and malalignment. An osteotomy may also be performed in conjunction with other joint preservation procedures in order to allow for cartilage repair tissue to grow without being subjected to excessive pressure

Description:
Osteoarthritis can develop when the bones of your knee and leg do not line up properly. This can put extra stress on on either the inner (medial) or outer (lateral) side of your knee. Over time, this extra pressure can wear away the smooth cartilage that protects the bones, causing pain and stiffness in your knee.

Advantages and Disadvantages:
Knee osteotomy has three goals:
• To transfer weight from the arthritic part of the knee to a healthier area
• To correct poor knee alignment
• To prolong the life span of the knee joint

By preserving your own knee anatomy, a successful osteotomy may delay the need for a joint replacement for several years. Another advantage is that there are no restrictions on physical activities after an osteotomy - you will be able to comfortably participate in your favorite activities, even high impact exercise. Osteotomy does have disadvantages. For example, pain relief is not as predictable after osteotomy compared with a partial or total knee replacement. Because you cannot put your weight on your leg after osteotomy, it takes longer to recover from an osteotomy procedure than a partial knee replacement. In some cases, having had an osteotomy can make later knee replacement surgery more challenging.
The recovery is typically more difficult than a partial knee replacement because of pain and not being able to put weight on the leg. Because results from total knee replacement and partial knee replacement have been so successful, knee osteotomy has become less common. Nevertheless, it remains an option for many patients.

Procedure:
Most osteotomies for knee arthritis are done on the tibia (shinbone) to correct a bowlegged alignment that is putting too much stress on the inside of the knee.


(Left) This x-ray of a healthy knee shows the normal joint space between the tibia and femur. (Right) In this x-ray, osteoarthritis has damaged the inside portion of the knee. The tibia and femur are rubbing against each other, causing pain (blue arrow).
During this procedure, a wedge of bone is removed from the outside of the tibia, under the healthy side of the knee. When the surgeon closes the wedge, it straightens the leg. This brings the bones on the healthy side of the knee closer together and creates more space between the bones on the damaged, arthritic side. As a result, the knee can carry weight more evenly, easing pressure on the painful side.



In a tibial osteotomy, a wedge of bone is removed to straighten out the leg. Tibial osteotomy was first performed in Europe in the late 1950s and brought to the United States in the 1960s. This procedure is sometimes called a "high tibial osteotomy." Osteotomies of the thighbone (femur) are done using the same technique. They are usually done to correct a knock-kneed alignment.

Candidates for Knee Osteotomy:
Knee osteotomy is most effective for thin, active patients who are 40 to 60 years old. Good candidates have pain on only one side of the knee, and no pain under the kneecap. Knee pain should be brought on mostly by activity, as well as standing for a long period of time. Candidates should be able to fully straighten the knee and bend it at least 90 degrees. Patients with rheumatoid arthritis are not good candidates for osteotomy. Your orthopaedic surgeon will help you determine whether a knee osteotomy is suited for you.

Before Surgery:
You will likely be admitted to the hospital on the day of surgery. Before your procedure, a doctor from the anesthesia department will evaluate you. He or she will review your medical history and discuss anesthesia choices with you. Anesthesia can be either general (you are put to sleep) or spinal (you are awake but your body is numb from the waist down). Your surgeon will also see you before surgery and sign your knee to verify the surgical site.

Surgical Procedure:
A knee osteotomy operation typically lasts between 1 and 2 hours. Your surgeon will make an incision at the front of your knee, starting below your kneecap. He or she will plan out the correct size of the wedge using guide wires. With an oscillating saw, your surgeon will cut along the guide wires, and then remove the wedge of bone. He or she will "close" or bring together the bones in order to fill the space created by removing the wedge. Your surgeon will insert a plate and screws to hold the bones in place until the osteotomy heals. This is the most commonly used osteotomy procedure, and is called a closing wedge osteotomy.


After the wedge of bone is removed, the tibia may be held in place with a plate and screws. In some cases, rather than "closing" the bones, the wedge of bone is "opened" and a bone graft is added to fill the space and help the osteotomy heal. This procedure is called an opening wedge osteotomy. After the surgery, you will be taken to the recovery room where you will be closely monitored as you recover from the anesthesia. You will then be taken to your hospital room.

After Surgery:
In most cases, patients stay at the hospital for 2 to 4 days after an osteotomy. During this time, you will be monitored and given pain medication. After the operation, your surgeon may put your knee in a brace or cast for protection while the bone heals. You will most likely need to use crutches for several weeks. About 6 weeks after the operation, you will see your surgeon for a follow-up visit. X-rays will be taken so that your surgeon can check how well the osteotomy has healed. After the follow-up, your surgeon will tell you when it is safe to put weight on your leg, and when you can start rehabilitation. During rehabilitation, a physical therapist will give you exercises to help maintain your range of motion and restore your strength.