Surgery:

Different surgical procedures are available as a final measure to relieve pain and increase function in patients with osteoarthritis. Certain surgical procedures can help relieve pain if medications fail. Even with these procedures, however, joint replacement may still be needed later on.

Arthroscopy and Debridement

Arthroscopy is performed to clean out bone and cartilage fragments (debridement) that, in theory at least, may cause pain and inflammation. It is also sometimes used to diagnose osteoarthritis. In this procedure, the surgeon makes a small incision and inserts the arthroscope, a pencil-sized instrument that contains a light and magnifying lens. The arthroscope is attached to a miniature television camera that allows the surgeon to see the inside of the joint.

Research and debate continues on whether arthroscopy provides true benefits for those with osteoarthritis and, if so, which patients may benefit the most from it. Arthroscopy is most likely to benefit people with mild-to-moderate osteoarthritis who have evidence of bone and cartilage fragments in the joint, or patients whose joints lock or catch with movement.

Joint Replacement (Arthroplasty)

When osteoarthritis becomes so severe that pain and immobility make normal functioning impossible, many people become candidates for artificial (prosthetic) joint implants using a procedure called arthroplasty. Hip replacement is the most established and successful replacement procedure, followed by knee replacement. Other joint surgeries (such as shoulders, elbows, wrists, and fingers) are less common, and some arthritic joints (in the spine, for instance) cannot yet be treated in this manner. When two joints, such as both knees, need to be replaced, having the operations done sequentially rather than at the same time may result in fewer complications.

Candidates. The primary indications for surgery are pain and significant limitations of movement, including walking, that cannot be treated by less invasive therapies.

Patients who may not be good candidates are those with the following conditions:

• Severe neurologic, emotional, or mental disorders
• Severe osteoporosis
• Other chronic medical conditions
• Obesity

Surgeons often prefer to delay prosthetic implantation in younger patients, because implants wear out and the patient will need at least one revision procedure later on. Newer, longer-lasting materials, however, may help reduce the rate of revision operations.

Elderly patients with poorly controlled osteoarthritis often do very well after joint replacement surgery. While full recovery may take older patients longer than younger people, the long-term outcome of the surgery is excellent, and leads to significant improvements in pain and quality of life.

Complications. Complications can occur, and, although uncommon, some can be life threatening. In addition to blood loss and infection, deep blood clots in the legs (deep venous thrombosis) are a serious potential complication. These clots can potentially travel to the lungs (pulmonary embolism) and pose a risk for death. Patients who are overweight are at higher than average risk for blood clots.

Recovery and Rehabilitation. Aside from the surgeon's skill and the patient's underlying condition, the success rate depends on the kind and degree of activity the joint receives following replacement surgery. Physical therapy takes about 6 weeks to rebuild adjoining muscle and strengthen surrounding ligaments. Patients typically experience considerable pain during this time.

While many patients find that joint replacement eventually provides pain relief and restores some mobility, they need time to adjust to the artificial joint.

Limitations after hip surgery include:

• Usually patients with new hips are able to walk several miles a day and climb stairs, but they cannot run.
• Prosthetic hips should not be flexed beyond 90 degrees, so patients must learn new ways to perform activities requiring bending down (like tying a shoe).

Limitations after knee surgery include:

• Walking distance improves in 80% of patients after knee replacement surgery, but patients still cannot run.
• Only slightly more than half of patients report improvement in stair climbing. (Artificial knee joints generally have a range of motion of just 110 degrees.)

Minimally Invasive Arthroplasty. Surgeons are exploring a variety of new techniques for a “minimally invasive” approach to knee and hip arthroplasty. They include using a shorter incision, and new types of smaller specialized instruments. The goal is to give the patient a shorter recovery time and less postoperative pain. However, minimally invasive arthroplasty is still in its early stages. At this time, there is no consensus on which minimally invasive technique works best, or if it actually achieves any additional benefits beyond the recovery period.

Unicompartmental Knee Arthroplasty. Unicompartmental knee arthroplasty (also called unicondylar knee arthroplasty) may be a useful procedure in cases of limited knee damage. It is recommended for relatively sedentary patients who are 60 years or older and not obese. It may relieve pain and delay the need for a total knee replacement. The procedure involves a small incision and insertion of small implants. It retains important knee ligaments, which preserve more movement than a total knee replacement.

Hip Resurfacing. Hip resurfacing is a surgical alternative to total hip replacement. It involves scraping the surfaces of the hip joint and femur and placing a metal cap over the bone. The procedure preserves much of the bone, so that a standard hip replacement can be done years later if needed. It may provide more stability, a faster recovery, and greater range of motion, making it a potentially good option for young, physically active patients.

Revision Arthroplasty. A repair procedure called arthroplasty revision may be used in cases where the original transplant fails. The specific procedure depends on whether the bone defects that occurred are contained or uncontained.

• Contained defects can be repaired with small bone grafts, the use of cement, or oversized cementless implants as required.
• Uncontained defects are more severe and may require a large bone graft or specially constructed implants to restore bone.

If a second arthroplasty is required, the potential for complications is magnified: more bone is cut, more blood is lost, and the operation takes longer. Patients are also generally older and more vulnerable to complications.

Realigning Bones (Osteotomy)

Osteotomy is a surgical procedure used to realign bone and cartilage and reposition the joint. If only a certain section (the medial compartment) of the knee is damaged and deformed by osteoarthritis, the surgeon may choose to perform an osteotomy:

• The surgeon opens the knee.
• The surgeon performs a debridement (removal of damaged tissue) in the joint to eliminate the loose or torn fragments that are causing pain and inflammation.
• The bone is then reshaped to remove the deformity.
• The procedure may ease symptoms and slow disease progression. It is best used in heavier adults who are under 60 years old.

Hemicallotasis. Hemicallotasis is a procedure for the knee that may be a less invasive alternative to osteotomy. The surgeon attaches the knee with pins to an external frame-like device that lengthens the deformed part of the knee over several weeks. The patient is mobile during this period. Infections at the pin site are the most common complications.

Fusing Bones (Arthrodesis)

If the affected joint cannot be replaced, surgeons can perform a procedure called arthrodesis that eliminates pain by fusing the bones together. The patient must understand, however, that fusing the bones makes movement of the joint impossible. Bone fusion is most often done in the spine and in the small joints of the hands and feet.