Total Joint Arthroplasty

most afflicted with arthritis

knee

OA

–Repetitive trauma causes cartilage to breakdown

–Synovial fluid increases

–Result is inflammation and mechanical failure

–Genetic predisposition

inflammatory arthritis

•Rheumatoid Arthritis: autoimmune d/o, symmetrical and polyarticular

•Psoriatic Arthritis

•Systemic Erythematous Lupus

•Ankylosing Spondylitis

inflammatory arthritis results in …

synovitis, joint effusion, warmth and painful erythema

Ankylosing Spondylitis

inflammatory autoimmune d/o effecting primarily the spine and SI jts, but also the limbs. 

Can cause eventual fusion of the spine

xray findings of arthritis

–Narrowing of the joint space

–Subchondral sclerosis

–Osteophyte bone spurs

–Bone cysts

–Eburnation of bone

eburnation

 ivory like appearance of bone in areas of cartilage erosion

RA lab findings

+ Rfactor and elevated ESR

psoriatic arthritis lab findings

Elevated ESR and HLAB27

AS lab findings

HLA B27

gouty arthritis lab findings

+ uric acid

joint aspirate should appear

clear and yellow

aspirate indic of lymes dz

yellow + PCR

cloudy pus aspirate

septic joint

joint aspirate look at

crystal

uric acid

color

Non-surgical Treatment Options arthritis

•Acetaminophen

•Non-steroidal anti-inflammatories (NSAIDS)

•Corticosteroids → Injections or pills

•Viscosupplements → Synvisc, Euflexa, Orthovisc, Hyalgan…

•Glucosamine/Chondroitin

Total Knee Replacement

•End surface of femur is replaced with metal

•End surface of tibia is replaced with metal

•Plastic liner is inserted between femur and tibia

•Patella is resurfaced with plastic

What is MIS?

•Minimally Invasive Surgery (MIS) is intended to reduce disruption and damage to the muscles and soft tissues.

•MIS techniques facilitate optimal healing and faster, easier rehabilitation in comparison to the standard total joint replacement.

incision in MIS TKR

•Shorter incision → 3-4 inch scar

anesthesia used for MIS TKR

Spinal anesthesia relaxes the muscles more consistently than general, thereby allowing easier exposure and decreased risk of tearing the muscle

benefit of MIS TKR

Quadriceps sparring → small snip in VMO only

how does pt benefit from MIS TKR

•Reduced blood loss

•Faster, easier rehab and return to function

•Faster return of quadriceps strength

•Permanently retains terminal quad strength better than standard TKR

•Better ROM post-op

•Shorter hospital stay

•Same day surgery for healthy pts

Unicompartmental Resurfacing indications

–Medial or lateral compartment disease

–No inflammatory disease

–Intact ACL

knee pain may be a problem of …

lumbar spine or referred pain from hip joint

Causes of Hip Arthritis

• AVN

• Trauma

• Congenital hip dysplasia

• Perthes Disease

• SCFE

• genetics

AVN common in pt with hx of..

corticosteroid, ETOH, trauma

congenital hip dysplasia

Abnormal femoral shaft/head angle, shallow acetabulum (ages 0-5)

Perthes disease

Blood flow to head temporarily stops, causing AVN (ages 5-10)

SCFE

Displaced epiphysis causes collapse of femoral head from AVN (ages 10-15)

Total Hip Replacement

•Femoral head and neck are removed

•Acetabulum is reamed out and metalic cup is fit into the healthy bone

•Plastic liner is fit into the cup

•Metal stem is fit into the femoral canal

•New ball is placed on the femoral stem

•Joint is reduced: head put into the acetabular cup

Traditional Approaches total hip

posterior or lateral

incision of MIS THR

3-4” incision about 1/3 the size of the standard 8-12” incision

Direct Anterior Approach incision

3-4 inch incision

direct anterior approach hip surgery

•Muscles and tendons not detached from femur or pelvis

•No need for ‘THR Precautions’ or Restrictions of movement

Traditional THR Implant

•Metal cup is press fit into the acetabulum

•Plastic liner is locked into the metal cup 

•Stem is press fit into the femoral canal

•Metal head is placed on top of the stem

Metal on Metal THR Implants

Cobalt-chrome surfaces

*Larger head=better mobility & less dislocations

Metallosis: wear leads to damage to bone/tissue & increased metal ions in the blood??

Ceramic on Ceramic Implants

Less debris and wear than metal

* Last longer

* Improved fluid properties

Rare but annoying squeaking

Hip Resurfacing

Head of pts OWN femur is capped with metal ball

*Cap is press fit into acetabulum

*More natural mobility

benefit of hip resurfacing

• More natural mobility

• Faster recovery

• Good for younger patients

mcc of Ankle Arthritis

–OA, RA

–Post-traumatic

disadvantage of fusion for Ankle Arthritis

ALL motion is restricted

3 axis of motion of ankle

inversion/eversion

plantar and dorsiflexion

rotation

Total Ankle Replacement

allows relief of pain while maintaining motion

shoulder arthritis causes

–OA: h/o high intensity overhead activities

–RA

–Post-traumatic

–AVN

–Rotator Cuff Arthropathy

is shoulder arthritis common?

Not common bc it is a non-weightbearing  joint

xray findings in shoulder arthritis

•Decreased joint space (loss of cartilage)

•Flattening and irregularity of bone

•Bone spurs

•Loose pieces of bone in the joint

Shoulder Hemiarthroplasty

Stemmed Hemiarthroplasty

Copeland Procedure

Total Shoulder Replacement

•Humeral head is removed

•Stem is press-fit or cemented into humeral shaft

•Polyethylene plastic is cemented to the glenoid

•Metal head is put on stem

•Joint is reduced

General Anesthesia

Controlled, reversible state of unconsciousness

4 meds General Anesthesia

amnesia, analgesia, muscle paralysis, and sedation

risk of general anesthesia

N/V, HA, Sore throat, delayed return to normal mental function

malignant hyperthermia

hereditary hypermetabolic d/o of skeletal muscle

hallmark signs malignant hyperthermia

masseter ms spasm, increased temp, rigidity and acidosis

Spinal/Epidural Anesthesia benefit

–Less blood loss

–Better pain control post-op

–Faster OOB & mental recovery

–Avoid risks of GA

Spinal/Epidural Anesthesia risk

–HOTN

–HA, seizure

–LBP, Nerve damage

–Infection

TJR Post-Op Complications

•Deep Vein Thrombosis (DVT)

•Pulmonary Embolus (PE)

•Nerve Injury

•Ileus

•Infection

•Delayed wound healing

•Joint instability

•Peri-prosthetic fracture

•Heterotopic ossification

Deep Vein Thrombosis sx

–Edema, pain, erythema and/or warmth in the limb

–Limb fatigue

–Low grade fever, diaphoresis

–Tachycardia

•May be asymptomatic!

which surgery increased risk of DVT

THR > TKR

test to dx DVT

Doppler US, Venography, MRI

DVT Prophylaxis

•Pneumatic Foot Pumps

•Early mobility

•meds

meds used for DVT prophylaxis - ASA

Inhibit Platelets and COX 1

immediate onset, no monitoring needed

meds used for DVT prophylaxis - warfarin

inhibit vit K

therapeutic 48-72 hours, requires monitoring blood PT/INR

meds used for DVT prophylaxis - Dabigatran (Pradaxa) and LMWH

inhibit thrombin

–Dabigatran (Pradaxa) – oral

–LMW Heparin (Fragmin) (Lovenox) – SQ , immediate onset

meds used for DVT prophylaxis - X inhibitor

Fixed dose, no blood monitoring

–Rivaroxaban (Xarelto) - oral

–Apixaban (Eliquis) - oral

–Edoxaban (Savaysa) - oral

–Fondaparinux (Arixtra) - SQ

PE sx

–Dyspnea, tachypnea, hypoxia

–Pleuritic chest pain

–Tachycardia

–Change of mental status

PE test

–Venthilation/Perfusion (VQ) Scan

–Helical CT

–Pulmonary Angiogram: gives definitive diagnosis

gold standard dx of PE

angiogram

Nerve Injury/Palsy

•Trauma from retractors or saw

•Traction injury from excessive tension or position of limb

Thermal injury from cement

common nerve injury with THR

sciatic nerve

common nerve injury with TKF

peroneal nerve

common nerve injury with TSR

axillary and radial nerve

Ileus sx

–Abdominal distention

–Nausea/vomiting

–Hypoactive/absent bowel sounds

tx ileus

–NPO, NG tube

–Usually self-limiting

mcc of Ileus

•Due to a combination of narcotics, immobility and anesthesia

ileus

functional obstruction of the intestine due to inactivity and/or paralysis of the intestinal muscles

Rf for Infection &Delayed Wound Healing

–DM, RA, immunosuppressed, steroids

–h/o prior sx or h/o prior infection

prevention of infection

pre & post-op Abx

If Infection suspected post surgery…

aspirate and get culture BEFORE Abx are given

synovial fluid anaylsis

–Cell count with diff

–Aerobic/anaerobic cultures

–Gram Stain

–Fungal & AFB

Peri-prosthetic Fractures

•Can occur early, after a fall, or decades late

•Pain with weight bearing activities during the post-op period is NOT normal! 

Order an x-ray!

Heterotopic Ossification

formation of lamellar bone inside soft tissue where it shouldn’t exist

•STIFF Post-Op PATIENTS DESPITE THERAPY, MEDS, and WORK!!!

RF for Heterotopic Ossification

co-morbidities such as Ankylosing Spondylolitis, RA, Diffuse idiopathic Sketetal hyperostosis (DISH),  Pagets, Quadraplegia or Paraplegia, or TBI.

mc joint affected by Heterotopic Ossification

hip