What is arthroplasty?

Arthroplasty: Definition and Clinical Applications

Arthroplasty is a surgical procedure that involves the reconstruction or replacement of a damaged joint to relieve pain, restore mobility, and improve quality of life in patients with degenerative joint disease. 1

Definition and Purpose

• Arthroplasty is defined in the broadest sense as a reconstructive procedure that alters the structure or function of a joint, encompassing various surgical techniques from joint resurfacing to complete replacement 1
• Total joint arthroplasty represents the most valuable, established surgical option for severe, end-stage osteoarthritis, providing considerable pain relief, functional restoration, and improved quality of life 2
• The primary goal of arthroplasty is to address joint pain and dysfunction caused by conditions such as degenerative osteoarthritis, inflammatory arthropathy, avascular necrosis, and complicated fractures 3

Types of Arthroplasty

Conservative Arthroplasty

• Conservative treatments leave the damaged cartilage in place while attempting to decrease joint load or improve the articular surface 4
• Examples include osteotomies (such as tibial valgus osteotomy) which realign the joint to redistribute weight-bearing forces 4
• These procedures are typically offered to younger patients to delay or potentially avoid the need for total joint replacement 4

Radical Arthroplasty (Total Joint Replacement)

• Involves replacing the damaged cartilage with an artificial endoprosthesis 4
• Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are the most common and successful joint replacement procedures 2
• These procedures are primarily indicated for patients with moderate-to-severe osteoarthritis or osteonecrosis who have failed appropriate nonoperative therapies 5

Arthrodesis

• A surgical intervention that sacrifices joint function by fusing the bones 4
• Typically performed on smaller osteoarthritic joints such as wrists and ankles 4

Common Arthroplasty Procedures by Joint

Hip and Knee Arthroplasty

• Total hip and knee arthroplasties are considered among the most successful procedures in medicine, with high satisfaction rates (75-89% for TKA) 5
• These procedures are primarily performed for patients with symptomatic advanced knee or hip osteoarthritis 5
• The 2023 American College of Rheumatology guidelines conditionally recommend proceeding to TJA without delay over delaying for physical therapy or NSAID trials in patients with moderate-to-severe osteoarthritis who have failed nonoperative therapy 5

Shoulder Arthroplasty

• Shoulder arthroplasty has demonstrated encouraging outcomes but the data is not yet as robust as for hip and knee replacements 6
• Types include humeral head resurfacing, hemiarthroplasty, total shoulder arthroplasty, and reverse total shoulder arthroplasty 5
• Most shoulder arthroplasties are performed for degenerative conditions, with total shoulder arthroplasty now being more common than hemiarthroplasty 5

Other Joint Arthroplasties

• Elbow arthroplasty provides good pain relief but functional outcomes are not as favorable as other major joints 6
• Ankle arthroplasty has not demonstrated outcomes as positive as other major joints, with ankle fusion (arthrodesis) remaining the criterion standard treatment 6

Perioperative Management

Pain Management for Arthroplasty

• For TKA, a multimodal approach is recommended, combining general anesthesia with femoral nerve block or spinal anesthesia with local anesthetic plus spinal morphine 5, 7
• This primary technique should be supplemented with paracetamol, NSAIDs/COX-2 inhibitors, cooling and compression techniques, and appropriate opioids based on pain intensity 5, 7
• For extended analgesia, continuous peripheral nerve block catheter techniques may be considered rather than single-shot injections 7

Complications and Considerations

• Major contraindications for any joint arthroplasty include systemic and joint infection and neuropathic joints 3
• Common complications of TKA include loosening (39.9%), infection (27.4%), instability (7.5%), periprosthetic fracture (4.7%), and arthrofibrosis (4.5%) 5
• For shoulder arthroplasties, complications can include prosthetic loosening, glenohumeral instability, polyethylene wear, osteolysis, periprosthetic fracture, impingement, rotator cuff tears, infection, and nerve injury 5
• Identifying the cause of pain after arthroplasty is critical, as reoperation for unexplained pain is often associated with suboptimal results 5

Clinical Decision-Making

• The decision for arthroplasty should be made after patients have completed trials of at least one appropriate nonoperative therapy 5
• Patients with moderate-to-severe pain or loss of function who have radiographically confirmed moderate-to-severe osteoarthritis or osteonecrosis are candidates for arthroplasty 5
• While physical therapy may provide benefit in knee and hip OA, delaying surgery for physical therapy may cause increased pain due to disease severity in patients already indicated for arthroplasty 5