Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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