Download PCP Guide To Joint Replacement Surgery

PCP Guide To Joint
Replacement Surgery
PCP Guide To Joint Replacement Surgery
Introduction
This document is intended to provide members of the primary care community with background and
important perspectives on the surgical treatment of chronic joint pain. Chronic joint pain can be a complex
and challenging treatment process. This document will provide background and clinical insights regarding
surgical treatment options and direction on the stage of disease progression and discomfort at which referral
to a surgical specialist should be considered.
Treatment Options For Chronic Joint Pain
In your everyday practice you undoubtedly treat a number of patients who are experiencing chronic joint
pain as a result of arthritis and utilize the following conservative treatments depending on the patient’s
current condition.
• Rehabilitation, diet and exercise, such as aquatic therapy, walking and biking
• Hot and cold treatments
• Assistive devices, including orthotics
• Medications, including topical creams
Once the conservative treatments detailed above fail to provide pain relief, you may decide to administer
either a corticosteroid or hyaluronic acid injection directly into the joint or refer the patient on to an orthopedic
specialist for this procedure. Studies have shown that when used in the appropriate patients, relief using
hyaluronic acid injections may last for 6 –12 months.1, 2
However, we know that for many patients conservative treatments cannot permanently delay the onset of
increasing joint damage and eventual osteoarthritis. When the conservative treatments fail to minimize the
joint pain and the patient’s quality of life is negatively impacted, surgical treatment options should be
considered and the patient should be referred on to an orthopedic surgeon in your area.
Depending on the severity of damage to the joint, patients can expect to undergo one of the
following procedures:
Minimally Invasive Arthroscopic Surgery
Hip arthroscopy is pursued as a less invasive surgical option for the treatment of several intra-articular hip
disorders and has an increasing role in the treatment of pre-arthritic and early arthritic disease. It is contraindicated in cases of advanced degenerative joint disease and disease states in which arthroscopic access to
the joint may be limited.3
Knee arthroscopy has been increasingly used as an option to delay major reconstructive surgery. Like hip
arthroscopy, this procedure is contraindicated in patients with advanced knee arthritis.4
PCP Guide To Joint Replacement Surgery
Joint Replacement
Knee and hip replacements are the most common joint replacement surgeries, accounting for more than one
million surgeries per year. Women are more likely to have joint replacement surgery accounting for more than
60% of the surgeries in 2006.5
In people with limited joint arthritis, a partial joint replacement may be considered. In these cases, it is
possible to replace only the damaged area with a metal and plastic implant. This procedure can usually
be done through a smaller incision than a total joint replacement and may be associated with shorter
recovery times.
For people who qualify for the procedure, partial joint replacement offers the following benefits: 6
• May alleviate pain and may delay, or eliminate, the need for a total joint replacement
• More natural motion and function because the procedure preserves more of the healthy part of the joint
• Less blood loss during surgery when compared to total joint replacement
Total joint replacement may be recommended if a patient has significant arthritis and other non-operative
treatments have not adequately relieved pain and restored joint function. The definition of an “appropriate”
candidate for total joint replacement surgery changes continuously. In general, there is no set upper age limit
for joint replacement candidates; however, the decision for surgery should be based on a person’s general
medical condition, fitness for surgery, and how much the arthritis affects the person’s quality of life.
Recovery from joint replacement surgery varies by person, but on average, patients return to normal daily
activities within three to six weeks after surgery as pain decreases over time.7 Newer, less invasive surgical
procedures allow rehabilitation and walking to begin the day of or day after surgery.
Results of total joint replacement have been shown to be excellent in the majority of patients. Outcomes
will vary depending on the quality of the surrounding tissue, the severity of the arthritis at the time of surgery,
activity level, a patient’s dedication to recovery, and adherence to recommended instructions.
Patients may expect to reduce or eliminate pain, see enhanced movement and mobility and improve the quality
of their lives through returning to most normal activities and participating in low-impact sports.
However, it is important to communicate to patients that joint replacement surgery may not bring them back
physically to doing everything they did prior to the advanced stage of arthritis. Certain activities that are hard on
joints are not recommended post-surgery, including running, skiing, tennis, or contact sports.8
Patients should also be aware of potential complications. Some of the potential complications associated with
joint replacement surgery are similar to those that exist with any major surgery (e.g. infection, risk of bleeding).
Others specific to joint replacements include:
• Malalignment
• Implant breakage
• Premature wear
PCP Guide To Joint Replacement Surgery
Joint Replacement Options
Due to remarkable advances in technology, there are many joints that can be replaced, including the knee,
hip, shoulder, elbow, finger, and ankle. Below are more details on different joint replacement options.
Hip
Total hip replacement replaces the arthritic ball of the upper femur, as well as the damaged cartilage from
the hip socket. Hip replacement implants are typically made from a metal alloy and polyethylene (plastic),
metal, or ceramic.
During surgery, the arthritic ball is replaced with a metal ball that is solidly fixed to a metal stem inside the
femur. The socket is replaced with a plastic or metal liner fixed in a metal shell. The implants are designed to
create a new, smoothly functioning joint that prevents painful bone-on-bone contact in an effort to maximize
comfort and functionality.
Hip replacement patients normally stay in the hospital two to three days. Therapy that begins in the hospital
will usually continue after discharge for approximately two to six weeks.
Knee
Total knee replacement resurfaces the end of the femur, the top of the tibia and sometimes the back of the
patella. Traditional total knee replacements require an incision between six and eight inches long. Minimally
invasive total knee replacement is designed to shorten the traditional incision, lessen trauma to soft tissues,
and reduce recovery time.
Knee replacement patients usually stay in the hospital for two to three days. Therapy that begins in the
hospital will normally continue after discharge for at least two to six weeks.
Shoulder
There are several different types of shoulder replacements. The most common form of total shoulder
replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to
a stem, and a plastic socket.9 During shoulder replacement, the ball end of the humeral head is replaced
with a metal ball. The glenoid may or may not be resurfaced with polyethylene.
Most shoulder replacement patients stay in the hospital for only one to two days. Therapy usually continues
for three months or more after discharge.
PCP Guide To Joint Replacement Surgery
Managing patient expectations on joint replacement
Prior to their first appointment with an orthopedic surgeon, you may be asked several questions about
the potential treatment they will receive and the expected outcomes. It is important to adequately manage
their expectations while reiterating that the surgeon will discuss the procedure and potential outcomes
more in-depth.
A patient assessment tool can be beneficial in this conversation. This can be a starting point to discuss what
the patient can expect during an appointment with an orthopedic surgeon, the general criteria that may qualify
them for surgery and the importance of seeing a specialist.
Similarly, a discussion about non-surgical options can be held where you can detail the expected results of the
treatment, including longevity of response, review the potential side effects of lifestyle impact, and schedule a
follow-up appointment to monitor the treatment progress.
What to expect post-surgery
• Hospital stay between two to three days
• Assisted walking within 24 hours of surgery
• Pain medication
• Physical therapy
• Prescribed by physician
• Supervised physical therapy for two to four weeks
• Home exercise program as directed by physician
Resuming normal activities
• Routine activities in 1-2 weeks
• Low impact activities in 1-2 months
• Restriction on high impact activities like running, jumping and impact sports
Referring to specialist recommended guidelines
Considerations/Assessments prior to referral10
Preoperative Medical Assessment
Pre-operative medical assessment is an important contributing factor to success of joint replacement
surgery. The goals of such assessment include:
• Assessing the risk of potential perioperative morbidity and mortality
• Determining whether the patient’s condition can be optimized prior to surgery
PCP Guide To Joint Replacement Surgery
While the patient’s ultimate “readiness” for surgery will be determined by the anesthesiologist on the day of
surgery, other steps can be taken prior to this time to gauge the appropriateness of a given patient for joint
replacement surgery. Specifically, the assessment should evaluate:
• Risks for intraoperative and acute postoperative outcomes
• Preexisting conditions, both related to and unrelated to the scheduled surgical procedure
The preoperative evaluation should include a thorough history and physical examination using a systemsbased approach to include all body systems. This history and exam should seek to identify undiagnosed,
poorly managed or other conditions that can place the patient at higher perioperative risk for morbidity
and mortality.
Key Risk Assessments
Cardiac Risk
Assessment of patients for cardiac risk should seek to identify patients with new or unstable cardiopulmonary
symptoms for additional preoperative testing. Additionally, this evaluation should determine the need and
appropriateness of beginning preventative therapies. Preoperative ECG should be ordered for all patients
with a history of coronary artery disease, vascular disease or cerebrovascular disease.
Pulmonary Risk
Pulmonary complications (e.g. pneumonia, respiratory failure) are likely more common than cardiac
complications. Physical examination, especially assessment of functional status, is likely more predictive
of pulmonary risk that preoperative tests . Chest radiographs should be ordered for patients with signs/
symptoms of pulmonary disease
Diabetes
Blood glucose levels in orthopedic surgical patients should be maintained in the 110-150 mg/dL range
throughout the perioperative period
Weight11
Obesity is a known risk factor for venous thromboembolism, greater operative blood loss, delayed wound
healing, and deep joint infection following both hip and knee replacement surgery. These patients, especially
those with body mass indexes greater than 35 require longer hospitalizations and more intensive rehabilitation
and have increased incidence of postoperative complications following knee arthroplasty.
Where possible, recommend referrals to physical therapists to assist in development of exercise and activity
programs to strengthen muscles while avoiding stress on the affected joints. Additionally, obtain the service
of a nutritionist to help support the obese patient in a program of weight reduction.12
Depression
Patients undergoing joint replacement must be mentally and physically healthy enough to tolerate surgery and
sufficiently motivated to carry out the exercise program needed to ensure full rehabilitation. Identification and
treatment of underlying depression helps to improve pain control, functional status, and overall quality of life.13
PCP Guide To Joint Replacement Surgery
Skin Condition
Prior to joint replacement, surgeons need to be aware of the presence of chronic skin conditions, such as
chronic ulcers, around the joint as this can predispose infection.14
References
1 Altman, R.D.; Moskowitz, R.; Hyalgan® Study Group: “Intra-articular
sodium hyaluronate (Hyalgan®) in the treatment of patients with
osteoarthritis of the knee: a randomized clinical trial.” J Rheumatol,
25: 2203–2212, 1998.
2American College of Rheumatology Subcommittee on Osteoarthritis
Guidelines: “Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update.” Arthritis Rheum, 43:
1905–1915, 2000.
9American Academy of Orthopaedic Surgeons. Shoulder Joint
Replacement. Available at http://orthoinfo.aaos.org/topic.
cfm?topic=A00094. Accessed on February 22, 2011.
10AAOS Comprehensive Orthopedic Review, J. Lieberman, p. 143-145
11Surgical Management of Obesity. H. Buchwald, GSM Cowan, WJ
Pories. 2007. p. 385.
3AAOS Comprehensive Orthopedic Review, J. Lieberman, p. 1005
12Primary care medicine: office evaluation and management of the
adult patient. AH Goroll, AG Mulley. 2009. pp 1099-1100.
4AAOS Comprehensive Orthopedic Review, J. Lieberman, p. 1001
13ibid
5Hospitalizations - National Hospital Discharge Survey 1998-2006.
Data obtained from: U.S. Department of Health and Human Services;
Centers for Disease Control and Prevention; National Center for
Health Statistics. Available at http://www.aaos.org/research/stats/
Joint_Replacements_all.pdf. Accessed on October 16, 2009.
14Fundamentals of Surgical Practice. AN Kingsnorth, AA Majid. 2006.
p. 456
6American Academy of Orthopaedic Surgeons. Osteotomy and
Unicompartmental Knee Arthroplasty. Available at http://orthoinfo.
aaos.org/topic.cfm?topic=A00354. Accessed on August 31, 2009.
7 American Academy of Orthopaedic Surgeons. Total Knee Replacement.
Available at http://orthoinfo.aaos.org/topic.cfm?topic=A00389.
Accessed on February 22, 2011.
8ibid
Biomet is a manufacturer of orthopedic implants and does not practice medicine. Only an orthopedic surgeon can determine what treatment is appropriate.
Individual results of total joint replacement may vary. The life of any implant
will depend on your weight, age, activity level, and other factors. For more
information on risks, warnings, and possible adverse effects, see the Patient
Risk Information section found within Biomet.com. Always ask your doctor
if you have any questions regarding your particular condition or treatment options.
©2011 Biomet • www.biomet.com
Form No. HCI0345.0 • REV071511