Complicated Joint Replacement

Overview

Arthroplasty is the surgical replacement of a joint. Your healthcare practitioner will remove a damaged joint and replace it with an artificial joint during the surgery. Metal, ceramic, or heavy-duty plastic can be used to make the prosthetic joint (prosthesis). The replacement joint appears and moves similarly to the natural joint.

A ''complicated'' joint replacement, as opposed to a''standard'' joint replacement, is defined as the existence of any of a number of concerns in a patient that may create complications in the conventional treatment and must be prepared for in advance to assure the patient's success.

Surgeons can replace joints in any part of your body, but the most common types of arthroplasty are hip replacement and knee replacement.

Orthopedics seeks to treat patients who have advanced arthritis in their hip or knee joints, as well as failing joint replacement. This includes the following:

• Patients who require complicated joint replacement owing to anatomic variance, past trauma, infection, or the patient's advanced age.
• Patients with complicated medical issues who may require further assistance from our tertiary medical experts.
• Patients with painful or failing joint replacements, as well as those suspected of having infected joint replacements.

These patients will benefit from a multidisciplinary team approach that will allow to give the best therapy for each individual.

 

Who May Need Complicated Joint Replacement?

Your surgeon may recommend arthroplasty if you have:

• Nonsurgical therapies such as physical therapy (PT), medications, bracing, injections, walking assistance devices, and rest have not relieved joint pain.
• Joint stiffness and reduced mobility make it difficult or impossible to carry out daily tasks.
• Inflammation (swelling) that does not improve with drugs or lifestyle modifications.

These symptoms can result from several conditions, including:

• Arthritis, specifically osteoarthritis.
• Rheumatoid arthritis.
• Fractures, including a hip fracture.
• Joint abnormalities, such as hip dysplasia.
• Avascular necrosis (lack of blood supply to the bone).

 

What Makes Joint Replacement Complicated?

Limiting soft tissue trauma entails not only creating a tiny incision, but also making it large enough to prevent stretching the skin, maintaining the muscles, and exposing the bones so that replacement components may be properly positioned.

Because of these considerations, a surgical method that can be expanded should be chosen.

 

Weight

Obese individuals are at a higher risk of the following problems: surgical mortality, infection, thromboembolic complications, and dislocation.

THA is challenging in these patients from the beginning of the preoperative consultation because the patient must be advised of the elevated risks.

The patient's installation is also difficult, and the depth of the soft tissues occasionally necessitates the employment of a particular retractor. However, even when so-called minimally invasive procedures are utilized, the surgical strategy does not appear to alter the risks.

Despite having a lower cortical index, obese people do not have an increased risk of fracture. In some people, however, the surgery will take longer and there will be more blood.

A traditional surgical technique is advised, with special emphasis paid to hemostasis. The risk of instability should be assessed during the preoperative evaluation, and particular devices or procedures to stretch out the gluteal muscles should be offered if necessary.

 

Cutaneous complications

If there has been previous surgery on the hip, there are generally few problems: internal fixation, osteotomy. Although it is preferable to use an established surgical technique, the incision can be created elsewhere with little risk. In irradiated hips, the surgical approach may potentially be an issue, with the likelihood of healing complications. There is also the possibility of stiffness owing to profound fibrosis. Plastic surgery may be required if there is severe skin retraction.

 

Neurological diseases

There are two types of neurological diseases: those that lower muscular tone (polio, myelomeningocele) and those that enhance it (spastic hemiplegia, Parkinson's).

When these disorders are present since childhood, they cause dysplasia and possibly hip dislocation due to an increase in forces that tend to dislocate the femoral head out of the acetabulum.

A neurological condition, of any kind, increases the chance of dislocation owing to a lack or excess of muscular tone. Typically, an implant that reduces the risk of dislocation is recommended.

This justifies a preoperative neurological evaluation, including an electromyogram (EMG), to verify that muscle tone is kept to a minimum and that spasticity may be managed with appropriate procedures. Tenotomies, particularly of the adductor muscles, can be used during surgery to treat spasticity and muscular retraction.

 

Morphological bone deformity

Some people have distinct bone formations from birth. Hip dysplasia, in which the socket is slightly shallower than the ball, increases the likelihood of hip dislocations and hence impairs hip replacement surgery. Another hip condition that can be congenital (inherited) or induced by a prior bone fracture is coxa vara ad, which occurs when the femoral head (the ball at the top end of the thigh bone) emerges from the femur at an unusual angle. It frequently results in the afflicted limb being somewhat shorter than the other.

Other issues that must be taken into account ahead of a hip replacement fracture include:

• Muscular issues (especially strength of gluteal muscles).
• Skin conditions.
• Bone conditions.
• Neurological conditions.
• Previous fractures.
• Avascular necrosis (bone tissue death due to lack of blood supply).

All of these factors must be taken into account before proceeding with a hip replacement. Some conditions (or combination of conditions) may rule out a hip replacement or create an unacceptable level of risk to the patient. In other cases, these complexities can be planned for and of course make the procedure more difficult but ultimately feasible. 

What Happens Before Complicated Joint Replacement?

Your healthcare practitioner will assist you in preparing for the surgery. In the weeks leading up to surgery, they may advise you to take part in physical therapy, exercise, or a nutrition plan. These programs help guarantee that you are fit for the procedure.

Several tests, including blood testing, an electrocardiogram, and a chest X-ray, may be required before to arthroplasty to examine your overall health. You may need to see your primary care physician or another expert for pre-operative examination, depending on your medical history. For surgical planning, certain procedures need a CT scan or an MRI.

Inform your provider about your medical history and any drugs you are taking. Certain drugs (such as blood thinners) may need to be discontinued prior to surgery. The night before your treatment, your provider will inform you what time you should cease eating and drinking.

 

What Happens During Complicated Joint Replacement?

Your procedure might take place in an outpatient facility or a hospital. The procedure used by your surgeon differs based on the type of surgery and the joint that has to be replaced. You will be sedated shortly before your procedure. This assures that you will not experience pain during the arthroplasty procedure.

Incisions (cuts) are made by your surgeon, and the injured joint is removed. The joint is then replaced with an artificial joint. They close the wounds with stitches, staples, or surgical glue. Your provider applies a bandage on the joint. A brace or sling may also be required.

Surgeons can do some joint replacement procedures using minimally invasive techniques. These techniques use fewer incisions and special tools. The recovery time for minimally invasive procedures can be less than it is for traditional procedures. Your surgeon will recommend the most appropriate procedure for you.

 

What Happens After Complicated Joint Replacement?

Depending on the operation, you may be able to go home the same day, or you may need to stay in the hospital for a day or two. Discuss rehabilitation plans with your physician. You will need to arrange for someone to drive you home. You may also require assistance walking about or conducting duties like as washing or showering.

After surgery, you will feel some pain. The first few days after your procedure, you should:

• Avoid physical activity. Take time to rest as you recover from surgery. Your provider may recommend placing ice or a cold compress on the new joint for about 20 minutes at a time.
• Perform your physical therapy and home exercise program as prescribed. It is important to follow your provider’s instructions. They will not only help in your recovery to restore function but also help to protect the new joint.
• Elevate. Depending on the joint you had replaced, your provider may recommend keeping the joint elevated while you rest. For example, if you had a knee replacement, rest with your foot on a stool or chair instead of the floor.
• Keep your incisions clean and covered. Follow your provider’s incision care instructions carefully. Ask your provider when you can remove the dressing, take a shower or bathe after your procedure.
• Take pain medication. Your provider may recommend over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) or prescription pain medication. Be sure to follow your provider’s instructions when taking pain medication. You may also need drugs to reduce swelling or prevent blood clots.

 

Risks & Complications

1. Blood Clots: After any operation on the lower extremities, blood clots in the leg veins are possible. Blood thinners, foot pumps, and early mobilization can all help to reduce the occurrence of blood clots. The biggest risk of blood clots is that they will detach and migrate to your lungs' veins. This is known as a pulmonary embolus, and it can cause breathing difficulties, chest discomfort, and even death.

Blood clots can form anywhere in either leg and may or may not cause pain or edema (DVT). If you experience unexplained leg discomfort or swelling, notify your doctor, who may arrange a duplex ultrasound to detect for a blood clot. The risk of these clots causing mortality has been lowered to less than 0.1%. Additional blood thinners and, on occasion, a filter in your veins are used to treat a confirmed blood clot.

    2. Dislocation: The artificial hip joint's ball may become dislodged from the socket, which is generally painful. The chance of this happening can be reduced by using optimal component positioning, certain surgical methods, and larger femoral head sizes. If your complete hip dislocates, a surgeon will manipulate your leg while you are sedated or anesthetized to replace the ball in the socket. In certain cases, unstable hip replacements must be changed to correct this issue if it persists.

    3. Infection: Antibiotics are administered before and after surgery to reduce the risk of infection, although infections can still arise promptly or years later. It is generally treated with further operation to remove contaminated tissue and, in some cases, the prosthetic as well. If the components are removed, a revision hip prosthesis can occasionally be implanted months later if the infection clears, but the patient is sometimes left without a hip joint. Although joint infections are seldom fatal, they constitute a terrible consequence.

    4. Unequal Leg Lengths: The length of your legs usually is within 1 centimeter after surgery, but it may be necessary to lengthen your leg during the hip surgery to help prevent dislocation of your hip. Sometimes, during a revision surgery, the leg length will be off by more than 1 centimeter. If the unequal lengths are bothersome, a lift can be built or inserted into the shoe of your shorter leg

    5. Component Loosening: Occasional the bone will not grow into the implanted components. The components may loosen and change position. The motion of the loose component may cause pain and require another surgery to revise the components

    6. Nerve Injury: Although extremely rare, the procedure can injure nerves in your legs and feet, as well as the nerve in your thigh. These nerves may or may not heal on their own. If they do not, you may need to walk with an ankle or knee brace, and your walking abilities may be reduced.

    7. Bleeding: In rare cases, the operation damages the blood arteries around the hip, resulting in severe bleeding that requires surgery or other techniques under X-ray control to repair. Blood may collect in the incision even if no major blood vessels are injured, necessitating further surgery (or monitoring) to cure the condition.

    8. Limp: The limp that most people have before the surgery usually persists until the muscles become stronger after surgery. It sometimes never goes away, and sometimes the surgery creates a new limp. Most people, however, note that the way they walk is greatly improved by the surgery

    9. Fracture: The femur or pelvis can crack when preparing the bone for insertion of the components, actually inserting the components, or even years after the surgery. Fractures usually are treated with metal cables or a plate, and usually heal

    10. Bearing surface: Each bearing surface carries its own set of risks. Polyethylene bearings have the potential to wear and cause osteolysis. Ceramic bearings have the potential to squeal and break. Metal-bearing surfaces can trigger an allergic hypersensitivity reaction and discharge metal ions into the blood and surrounding tissue.

     11. Need for Additional Surgery: Though uncommon, hip replacements might fail sooner than predicted. Other complications that may necessitate further surgery include: bone formation where it should not, bone shattering around the prosthesis (during or after surgery), and irritation of the soft tissues by wire or sutures.

     12. Other Problems: This list is meant to cover only the major problems most frequently encountered. Just as everyone is unique, so are many problems It is important to remind patients that though numerous complications have been reported in the literature, most are minor and rare. 

 

When Can I Go Back to My Usual Activities?

Everyone recovers differently from joint replacement. Ask your provider when you can get back to the activities you enjoy after your arthroplasty. It’s a good idea to have this conversation before surgery so you know what activities are appropriate following a full recovery.

Your recovery time will depend on several factors, including:

• Activity level and lifestyle.
• Age.
• Joint that was replaced.
• Other health conditions or orthopedic problems.
• Whether you had a total joint replacement or a partial joint replacement.

For most people, a physical therapy program can speed recovery time. Physical therapy strengthens the muscles around the replaced joint. This helps them better support the joint. These exercises also increase flexibility and help you move.

 

Conclusion

Hip and knee joints are complicated joints that support our weight and allow us to move. They enable us to work, play, and be physically active. To give function, they are comprised of articulating bones that are supported by ligaments, tendons, muscles, and cartilage. Multiple structural components of these joints are affected by congenital abnormalities, complicated fractures, and complex traumas. As a result, their treatment necessitates a personalized strategy that involves correct diagnosis and each treatment plan tailored to the specific condition, which may entail more than one form of treatment and surgery. These reconstructive procedures are known as complicated hip and knee operations.

They attempt to reconstruct the hip or knee joint in order to alleviate discomfort and offer the greatest possible stability and function. They also include surgery to repair hip and knee bones after removing a portion of the bone to treat bone cancer.