What is arthroplasty?
An arthroplasty is the surgical reconstruction or replacement of a joint. During this procedure, the surgeon and their team will remove the joint surfaces that need replacing, and in their place attach stainless steel, ceramics, or plastic components that replicate a healthy joint. During this procedure, the surgeon can ensure that the joints are positioned in the best possible alignment, and can compensate for previously developed changes to the bones.
Who needs joint replacements?
When to have a joint replacement is always a complicated discussion. When patient reports pain that is inhibiting daily activity, and after conservative management including physical or occupational therapy and injections have failed, a surgeon may recommend surgery. This would be further supported by imaging showing significant changes to the joint cartilage.
Some medical conditions may precede a replacement. A chronic history of osteoarthritis or rheumatoid arthritis may negatively impact the joint health, leading to further pain. If a patient has a major fracture near a joint, that may result in increased pain best managed with a replacement as well.
What joints do orthopedic surgeons replace?
Many joints can be replaced at this point by an orthopedic surgeon. These include:
Shoulder (glenohumeral) joint
Shoulder joint replacements involve replacing the ball and socket parts of the shoulder joint. If there is a history of rotator cuff issues, the surgeon may choose to switch the ball to the shoulder blade and the socket to the arm bone to add stability to the joint. Often, patients will be in a sling for 6-8 weeks following surgery, after which their rehabilitation team will start initiating gentle range of motion exercises and stretches, gradually progressing to strength and endurance training. Most patients will complete rehabilitation at 4 to 6 months post op.
Elbow (humeral-ulnar) joint
Elbow joint replacement involves replacing part of both your upper and lower arm bones. Within the first week, patients are allowed to start gently moving their arm with assistance, with elbow straightening being the motion the slowest to be progressed to protect the surgical site. Once normal motion is restored, slow progressions of strength training can begin. Most patients will complete rehabilitation at 4 months post op.
Wrist (radiocarpal) joint
Wrist joint replacement involves replacing the part of the forearm that connects to the wrist bones. This surgery requires casting for around 4 weeks post op to allow for bone healing and ensure the joint replacement heals. Following the removal of the cast, the rehabilitation team will help guide a patient through range of motion exercises, while also working on improving the scar from the surgery. Once range of motion improves, slow progressive strength training will help return the wrist to its normal function. Most patients will complete rehabilitation at 12 weeks post op.
Hip joint replacements involve replacing the ball and socket parts of the hip joint. Most patients are able to stand and start walking with a walker the day of their surgery, and will either start home health or outpatient physical therapy the week of their surgery. The first few weeks will focus on improving the flexibility of the hip muscles and decreasing post-surgical pain, followed by improving strength, endurance, and balance to return to normal walking. Most patients will complete rehabilitation at 12 weeks post op.
Knee (tibiofemoral) Joint
Knee joint replacements include replacing both surfaces of the knee, as well as potentially adding a new surface to the back of the knee cap. Most patients are able to stand and start walking with a walker the day of their surgery, and will either start home health or outpatient physical therapy the week of their surgery. The first few weeks will focus on improving the flexibility of the knee joint to full bend and straighten, and decreasing post-surgical pain. Once motion is normal, physical therapy will focus on strength, endurance, and balance to return to normal walking. Most patients will complete rehabilitation at 12 weeks post op.
Ankle (talocrural) Joint
Ankle joint replacements include replacing the bottom of the shin bone and its connection to the ankle bone. Patients will not be allowed to put weight into the foot for between 2-6 weeks depending on the surgical protocol. During this period, it’s important to keep all other joints moving and strong. Once a patient is allowed to weight bear, rehabilitation with be split between working on motion and strength, and with practicing walking mechanics and balance. Both will gradually progress until the patient no longer needs an assistive device. Most patients will complete rehabilitation at 4-5 months post op.
Arthroplasty: The Process
What happens before joint replacements?
Prior to a joint replacement, the surgeon will make sure that you are cleared for surgery. This will involve a check of all your medications, as well as clearance from your other physicians. Once your medial team has approved your surgery, your surgeon will likely refer you to physical or occupational therapy to help you prepare for the surgery. This can include stretching and strengthening which will help you recover faster post-operatively. Therapy is also when you will be introduced to using assistive devices or braces you many need post-operatively, and your therapist can teach you how to remain safe around your home while you recover.
What happens during arthroplasty?
Depending on your surgeon’s preferences, your procedure can happen in either an outpatient surgical center or in a hospital. This will depend on if your surgeon thinks you will need to stay overnight following the procedure. During the surgery, you will be put under general anesthesia. The surgeon will make the smallest possible incisions needed to successfully perform the replacement, in an attempt to disrupt the least amount of muscles and nerves. After, the surgical team will care for you until you recover from the general anesthesia.
What happens after joint replacements?
Most patients are able to stand and walk as soon as their general anesthesia wears off. Depending on where you live, and how heavily impacted you are from the surgery, you may be released to your home the day of surgery, or you may stay 2-4 days in the hospital.
During your early recovery, your surgeon will have a specific protocol for you to follow. Each surgery requires a different protocol, so it’s important for you to discuss with your surgeon what your limitations are. While some replacements, like the hip, require minimal limitations, other joints like the shoulder require immobilization for up to 6 weeks.
Your medical and rehabilitation team will help teach you how to compensate during your early recovery to make life easier while you are limited. Make sure to take your medication as prescribed by your surgeon, and if you have negative side effects, discuss them with your surgeon to see if a change in medication is possible. Keep your incision areas clean and dry to help them heal, and use elevation to help with any joint swelling.
After your early recovery, your rehabilitation team will help you manage your pain, rebuild your motion, strength, and endurance, which will translate to better function and use of your new joint. Swelling and discomfort are expected for anywhere between 6 months to a year post-operatively, but some recover faster.
Advantages of joint replacements
The main advantage of the joint replacement is removing the limited joint and replacing it with components that will move like normal, without generating pain. By removing the joint surfaces, the pain generator in the joint has been removed, which will help with pain. For some, as arthritis worse, their joints may also become difficult to move. A replacement will help restore some of the normal alignment and mobility of the joint.
Risks of joint replacements
There are a few risks with joint replacements. The two initial concerns are blood clots and infections. Blood clots can occur at any time, but particularly after a major surgery, the body will form clots to help with the healing process. To protect against blood clots forming and creating a problem, regular gentle movements and exercise can reduce the risk of a clot breaking loose. After any type of incision, infection is always a concern. The incision site should be kept clean and dry, and closely monitored. If there is ever a sudden change in redness, swelling, or if the incision starts to produce fluid that is green or yellow and has an order, the surgical team should be contacted immediately.
During rehabilitation, the two major concerns are dislocation and falls. With contemporary advancements of surgical procedures, joint replacement dislocations have dramatically declined. However, its important to follow your surgeons protocol during your early recovery to minimize the risk of the joint dislocating. Falls are also a risk after lower extremity joint replacements. Your rehabilitation team will help teach you how to safely use your assistive devices to minimize fall risk.
When can I get back to normal activities?
Returning to normal activity will vary based on several factors. Age, health status, and adherence to treatment will all potentially impact the speed of recovery. Most patients will experience some amount of swelling for up to 6 months, and most patients will feel “normal” after 1 year. However, by the 6 month marker, most patients are nearing full function, with minimal restrictions or limitations.
How long do joint replacements last?
While some replacement used to be labeled as lasting 10 years, patients are now finding their joint replacements are lasting longer and longer. Many patients will never need another surgery following their joint replacement, but a small minority of patients will need some type of revision to replace some of the joint components.