joint replacement

Are you one of the millions of silent sufferers living with chronic pain caused by arthritis or an injury to the hip or knee?

While conservative treatment options are the first line of treatment, some patients with severe disease may require hip or knee replacement surgery.

While we’re more used to human surgeons wielding the scalpel, nowadays, such surgery can be done with the help of robotic technology.

In Malaysia, over 300 patients have undergone robotic arm- assisted knee or hip replacement surgery since its introduction here in recent years.

Consultant orthopaedic, joint and arthroplasty surgeon Dr Chua Hwa Sen shares that the popularity of robotic arm-assisted knee and hip replacement surgeries is growing due to its ability to provide each patient with a surgical experience that is specifically tailored to the individual’s needs and anatomy.

With the new technology, he says surgeons are able to facilitate more accurate placement of implants, while being minimally invasive in cutting the patient.

This allows patients to experience less post-operative pain and recover faster.

He explains: “Treatment begins with CT-based 3D modelling to help surgeons view in detail each patient’s diseased anatomy prior to surgery to formulate a personalised surgical plan.

“Given that every joint is different – even more so for diseased joints, as the degree of severity varies greatly in different patients – the robot (along with pre-operative CT scans and 3D reconstruction) greatly helps surgeons plan accurately for each patient.

“The robot intraoperatively helps surgeons to seek the most ideal position and size of new joints for the patients, as well as accurately resect the bones and implant the new joints.”

Interest among the surgical community in this procedure is also increasing, with more and more surgeons showing interest in being trained for these procedures.

They merely assist

Dr Chua also assures that the robot is not doing the entire surgery and is merely assisting with the operation.

“People often think that surgeons sit back and relax when the surgery is being conducted by the robot.

“That is not true.

“The robot is a semi-active robot. Hence, the procedure is called robotic arm-assisted joint replacement.

“The surgeon is there every step of the way to expose the joints, release soft tissues, feed live movement of the joints to the robots intraoperatively to have wider combinations of data.”

He explains that the robot’s function during surgery is to enable surgeons to be precise in determining the best placement of implants within the joint.

The robot can accurately feed back data that is impossible to be detected with the naked eyes, he says, adding that it can adjust bone cuts and the degree of joint rotation as precisely as 0.1mm and 0.5 degrees respectively.

“Accuracy makes the surgery less invasive and enables us to sacrifice less healthy bone and tissues.

“‘The more we see, the more you keep’ is the key message of CT- based 3D modelling robotic arm-assisted joint replacement to our patients.”

Dr Chua notes that the robot’s accuracy reduces post-operative pain greatly, reduces the need for physical therapy, helps patients accept new joints with less effort, achieves a much better outcome, and potentially increases the longevity of the new implants.

Urging the public to be more open to technological advancements, he says the rise of robotics and artificial intelligence in healthcare is beneficial to society and should be embraced.

“Instead of being wary of it, let it assist us and improve our quality of life.”

Introduction

Although a substantial portion of the United States population has been infected with and recovered from Coronavirus Disease-19 (COVID-19), many patients may have persistent symptoms and complications from disease-driven respiratory disease, arrhythmias, and venous thromboembolism (VTE). With institutions resuming elective total joint arthroplasties (TJA), it is unclear whether a prior resolved diagnosis of COVID has any implications on postoperative outcomes.

Methods

All elective TJA performed in 2021 at our institution were retrospectively reviewed and a history of prior COVID+ result recorded. Baseline demographics, days from prior COVID+ result to surgery date, preoperative methicillin-resistant Staphylococcus aureus (MRSA) nares colonization, and laboratory markers were obtained to determine baseline characteristics. Postoperative estimated blood loss (EBL), length of stay (LOS), rate of revision surgery, and discharge destination were compared between groups. Perioperative and postoperative rates of VTE, urinary tract infection (UTI), pneumonia, postoperative oxygen supplementation, cardiac arrhythmia, renal disease, sepsis, and periprosthetic joint infections within six months of surgery were recorded.

Results

Of the 155 elective TJA performed in 2021, 24 patients had a prior COVID+ diagnosis with a mean of 253 days from positive result to surgery date. There were no significant differences in baseline demographics, comorbidities, and preoperative lab markers between groups. Surgeries on patients with a prior COVID+ had a significantly higher EBL (260 vs 175cc), but postoperative outcomes of VTE, UTI, pneumonia, oxygen supplementation requirement, nares MRSA+, cardiac disease, and infection rates between groups were similar. Bivariate logistic regression revealed increased days from COVID+ diagnosis (>6 months) to surgery date were associated with a shorter LOS.

Conclusion

Although a prior COVID+ diagnosis had increased intraoperative blood loss, there were no significant differences in respiratory, infectious, cardiac, and thromboembolic complications up to six months after elective TJA. This study suggests that asymptomatic C+ patients receiving elective TJA do not require more aggressive prophylactic anticoagulation or antibiotic regimens to prevent VTE or perioperative infections. As institutions around the nation resume pre-COVID rates of arthroplasty surgeries, a prior diagnosis of COVID appears to have no effects on postoperative complications.

Introduction

Materials & Methods

Results

Discussion

Conclusions

More than 1.25 million Americans will undergo knee or hip replacement surgery every year. And while most will report a dramatic improvement in their quality of life following recovery, some will experience a rougher road to recovery than others.

Joint replacement surgery can decrease pain and improve mobility. Patients can increase the success of the procedure by following expert advice during recovery.

If you or someone you care about is thinking about joint replacement surgery, experts say that there are steps you can take to make your recovery smoother and your procedure even more successful.

“The best thing for a good outcome after elective joint replacement surgery is to be informed and prepared,” says Dr. Elizabeth Desmond, orthopedic surgeon at Dignity Health Sierra Nevada Memorial Hospital. “It is important to have a good understanding and reasonable expectations of your operative and post-operative course.”

Dr. Desmond says the key is to ask questions early on in the process.

“You should ask how long you will be in the hospital (some joint replacements are done as an outpatient, others with a very short hospital stay),” she explains. “You should also have a discussion about pain management and you should have your home set up ahead of time for your needs, including having any needed assistive devices available.”

Dr. Desmond says patients should approach the pain management conversation with the goal of minimizing their use of opiate medications as much as possible. And regarding the home set up, she recommends minimizing stair use and planning ahead to ensure needed items are within each.

Recommended assistive devices may include a walker, a shower chair, a raised toilet seat, a bedside commode, or anything else your physician believes may be useful during your recovery.

Once your joint replacement surgery is complete and you’re back home, it’s important to remember that the work has only just begun. How you rehabilitate your joint will help to determine how your recovery goes and how successful your procedure ultimately is.

“The repeated goal at all stages is rehabilitation,” Dr. Desmond says. “The reason patients choose to have joint replacement is due to pain and a loss of function. The best way to ensure a good outcome is to participate in therapy/rehab and follow the specific activity restrictions and recommendations you have been given.”

While it may seem counterintuitive, Dr. Desmond says it is important to begin moving and walking as soon as possible after joint and hip replacement surgery.

“There will be some pain and discomfort, but delaying your rehab only makes recovery longer and more difficult,” she explains.

For the first couple days after surgery, Dr. Desmond says patients should focus on adequately controlling their pain (ideally a combination of non-narcotic and narcotic pain medications) and working with their physical therapist.

Then, one to two weeks following surgery, the focus should be on progressing with physical therapy rehabilitation.

“Do your assigned exercises as prescribed and wean off of narcotic pain medications,” Dr. Desmond says. “Ideally at this point you should stop taking narcotic pain medication if possible.”

One to two months out from surgery, the focus should continue to be strengthening the joint through rehabilitation with physical therapy.

“If you were given any specific activity or motion restrictions, these should be coming to an end at 6-8 weeks, which will make your rehab progress even better,” Dr. Desmond explains.

Throughout your recovery, you should keep an eye on your incision and the joint itself. Infections can happen and should be treated quickly.

The most common signs of infection are fevers, chills, night sweats, redness, increasing swelling, discharge or a foul smell around the wound.

Another complication that is infrequent but would need to be addressed quickly is a blood clot or pulmonary embolism, which may cause leg swelling, calf pain/cramping/soreness, shortness of breath, chest pain that worsens when you take a deep breath or cough, rapid breathing, or rapid pulse. Immediately contact your doctor if those symptoms are present.

In general, Dr. Desmond says patients should expect to be gradually improving following joint replacement surgery.

“There will be days that are worse than others, but the trajectory should be that of improvement,” she says. “Any changes that worsen and do not improve with rest or elevation should be reported and evaluated.”

If you are fortunate enough to have a spouse, family member of friend around to help you recover following joint surgery, they can help to increase the success of your procedure too.

“Having someone present is very important,” Dr. Desmond says. “The patient will need help with many basic tasks, from transportation, prescription pick up, changing dressings, food preparation, etc. The partner can help to ensure that the patient is taking all of the prescribed medications at the appropriate intervals and is aware of any signs of common complications.”

Finally, Dr. Desmond wants people to know that in general, joint replacement surgery is very successful in addressing issues of joint pain and decreased mobility.

“The important thing to remember is that the improvement will not happen all at once,” she says. “Most patients will take at least three months to return to their basic, daily, non-strenuous activities. Full recovery and strength can take up to six to 12 months. In the end, the vast majority of patients have a significant improvement in their quality of life.”

Tulsa Bone and Joint’s Union Pines Surgery Center is now the first ambulatory surgery center in Oklahoma to have the Mako SmartRobotics technology.

With the Mako SmartRobotics system, surgeons can better see how surgeries like a knee replacement will impact the entire body.

“What the Mako allows us to do, the way I explain it to my patients, is it allows us to know the consequences of the bony cuts we’re going to make, before we actually make them,” said Dr. Scott Reid, an Orthopedic Surgeon.

This data can help surgeons decide the best course of action for each patient, because everyone does not react the same way.

This is especially helpful in situations where the result can be hard to predict.

“The problem with soft tissue releases is that they’re not very predictable,” said Reid. “You may think when you’re in the operating room that you’ve balanced the knee really well, ultimately that may not actually be the case.”

Finding potential problems earlier, can change the recovery process, and the lives, of patients.

“One outlier, if we have one patient out of 100 that has a poor outcome because we didn’t get the implants in exactly the way they needed to be, that’s a big burden to that patient and we want to try to eliminate those as much as possible,” said Reid. “But there’s a big cost to the system.”

Reid says this technology has been in hospitals for nearly a decade, but using the Mako at Tulsa Bone and Joint’s surgery center can benefit more patients.

“Now, I think we’ve got every insurance contract that we have, to include Medicare and all the other subsidiaries of Medicare, we have the technology available to them now,” said Reid.

He’s excited about the future of this technology and the number of people it can help in the future.

“If we can use this technology to provide a more consistent outcome to our patients, ultimately that’s what we’re looking for,” said Reid.

The first two knee replacements using this surgery were performed successfully last Thursday.

Some 300,000 children ages 16 or younger have juvenile idiopathic arthritis (JIA), an umbrella term for various health conditions that can cause joint pain, swelling, stiffness, and loss of motion. Like other forms of arthritis, JIA starts when a child’s immune system becomes overactive, triggering an inflammatory response.

It’s not uncommon for JIA to be a long-term health condition, but there are many effective medications that can treat your child’s arthritis. Thanks to these drugs, inflammation is often brought under control before it reaches the point of causing joint damage. That means kids diagnosed with JIA today are much less likely to need surgery than in generations past.

Medication, along with active treatment tools like exercise and assistive devices such as splints, mean that your child’s joint pain can often be kept to a minimum.

Still, though considered a last resort, surgery may sometimes benefit some of the most severe cases of JIA. This could be either because medication is unable to stop the progression of joint damage, or your child was not diagnosed with JIA until after joint damage had already occurred. In these cases, surgery may offer pain relief with JIA and could also restore function to damaged joints.

Who Needs Surgery for JIA?

Step one, say experts, is to try and avoid invasive procedures for JIA kids. “We try to treat children aggressively with medication so we can preserve their joints and avoid surgery,” says Farzana Nuruzzaman, M.D., a pediatric rheumatologist at Stony Brook Children’s Hospital and clinical assistant professor at the Renaissance School of Medicine at Stony Brook University in Stony Brook, NY. “Unfortunately, in some cases the arthritis has caused so much damage that certain types of surgery are needed.” In those cases, if your child is not improving on medication and her quality of life is suffering, surgery may be an option.

If your child’s jaw is affected by arthritis pain, for instance, surgery might be recommended, says Beth Susan Gottlieb, M.D., chief of the division of pediatric rheumatology at Northwell Health in New Hyde Park, NY. “Arthritis in the jaw can slow down the growth of the lower jaw, which causes a smaller jaw,” Dr. Gottlieb explains. “Surgery can improve the appearance of the face and make the joint healthier.”

Types of JIA Surgery

If your child is a candidate for JIA surgery, it helps to know what to expect. The surgical procedures that may be recommended include:

Osteotomy

In an osteotomy, explains Dr. Nuruzzaman, a bone is cut and repositioned to fix a bone deformity. Then the bone is reset into a better position. An osteotomy could be performed on the foot, hip, knee, or the temporomandibular joint (TMJ) in the jaw. Jaw surgery can not only make eating and chewing easier but can improve a child’s facial structure and self-confidence. This procedure is considered low-risk and safer than a total knee or hip replacement, according to the American College of Rheumatology.

Joint Fusion (Arthrodesis)

In a joint fusion, “the surgeon removes the damaged cartilage from the ends of two bones that form a joint and then holds [the bones] in place with a pin or a rod,” Dr. Nuruzzaman explains. Over time, the two bones fuse to form a single unit, much as a broken bone fuses when it heals. While arthrodesis can stabilize a joint and help it bear weight better, the fusion of these bones will result in the loss of some mobility. It’s usually performed on joints in the foot and ankle, hand and wrist, or spine, per the Arthritis Foundation.

Synovectomy

The synovium is a thin membrane that lines the joint capsule, but when JIA causes chronic inflammation of this lining, it grows much thicker and can affect the structure and function of the joint. In this procedure, explains Dr. Nuruzzaman, the surgeon removes inflamed synovial lining that develops from chronic inflammation.A synovectomy alsocan be done arthroscopically, says Daniel Lovell, M.D., professor of pediatrics at the University of Cincinnati School of Medicine at the Cincinnati Children’s Hospital Medical Center. “The surgeon can go in using a scope and can also do an injection of steroids at the same time, which can reduce pain,” he says.

Epiphysiodesis

This procedure can help correct a difference in leg lengths, Dr. Nuruzzaman explains. (Leg-length discrepancy is a common symptom of JIA, per the American Academy of Orthopeadic Surgeons). Epiphysiodesis is usually is for children whose anticipated leg-length discrepancy is nearly an inch and who have a year or two of growth remaining. In a temporary epiphysiodesis, metal plates may be used to temporarily halt bone growth in the longer leg. With a permanent epiphysiodesis, part of the growth plate is removed.

“The growth plate of the longer leg is removed or replaced with a metal plate so the longer leg growth stops,” Dr. Nuruzzaman says. In addition, Dr. Lovell explains, if a leg has excessive angulation due to arthritis causing one side of the knee to grow faster, then a temporary epiphysiodesis may be used to straighten the leg by limiting the growth on the faster growing side of the knee joint.

Total Joint Replacement (Arthroplasty)

An arthroplasty “is when the damaged joint is removed and replaced with an artificial joint,” Dr. Nuruzzaman says. Considered a last-ditch option for children, it is usually reserved for a joint that is so damaged, painful, and stiff that it interferes with a child’s quality of life and ability to function. The hip is the joint that is most commonly replaced, followed by the knee. “Total joint replacement is usually done in later adolescence or young adulthood,” says Dr. Lovell.

The Pros and Cons of Surgery for JIA

All surgeries have a potential risk, and the surgeon should carefully explain both risks and benefits. And keep in mind: surgery is generally not a cure. “Surgeries do not protect against the progression of the underlying inflammatory disorder,” Dr. Nuruzzaman says.

Moreover, some surgeries may need to be repeated. For instance, performing TMJ surgery before facial growth is complete (15 years for girls and 17 to 18 years for boys) may mean that repeat operations may be necessary.

One con of joint fusion is that after the surgery, your child will not be able to bend the joint. And sometimes, the bone does not fuse, the wound may not properly heal, or arthritis develops in nearby joints due to stress from the fusion. It is important that you and your child understand both the benefits and risks of joint fusion.

Another consideration: Artificial joints cannot grow like natural joints so if the joint is replaced before growth is complete, then the growth in the area of the replaced joint will stop. In addition, an artificial joint does not last forever. For this reason, repeat surgeries are typically needed and can be more challenging to perform.

The main benefit of surgery for JIA is that for many children with juvenile arthritis, surgery can offer pain relief and improve their quality of life.

What You Can Expect After Surgery

Recuperation from surgery for JIA varies depending on the surgery, the joint, your child’s overall health, and more. Full recovery from a joint fusion may take months. After an epiphysiodesis, the recovery is brief and has few complications, per the Arthritis Foundation. One possible complication is that the metal plates could loosen, or a leg that is corrected temporarily could revert to its previous length.

Osteotomy procedures are generally low risk, but recovery can be rough: The Arthritis Foundation notes that for a few months after the procedure, kids have to wear elastic bands to support the jaw. They may also need to use a palatal splint and eat a soft diet.

After a synovectomy, symptoms like pain and swelling should get better. Usually, though, the synovium will grow back over time if there is not control of the inflammation in the joint with the medicines used to treat the arthritis, Dr. Lovell says. The synovectomy can be repeated if this happens.

Outlook for Children with JIA

The good news is that JIA is treatable, most children who have it can expect to live normal lives, and very few will need joint surgery, Dr. Lovell says. Some children will see their JIA go into remission.

And surgery can be a good option for some children with JIA. “We try to avoid surgery,” says Dr. Nuruzzaman. “But in some cases, it can improve a child’s quality of life.”