Approximately, 500,000 Americans undergo either total hip or total knee replacement surgery annually. The underlying reason is usually end-stage arthritis- when the cartilage which cushions the joint has worn away.
Technology has improved to such a point that these replacements which consist of metal, plastic or ceramic materials and mimic the function of a normal joint, are usually very effective.
Most patients can return to activities they enjoyed before their joint became diseased. But after 10 to 20 years these replacement joints may also wear out, requiring a second or even third replacement surgery. This procedure is called a revision joint replacement. As one might imagine, these subsequent replacements can be much more complicated than the earlier surgery.
There can be several reasons why a revision could be required. Sometimes the hip begins to dislocate. This can happen either many years later from overuse of the joint, or shortly after the first surgery if there were technical problems or errors in getting the prosthetic joint in place.
Patients don’t always heed instructions so that they may exert too much stress on a fresh prosthesis before they should. This can cause the replacement to fail.
A dreaded complication of joint replacement is infection occurring shortly after surgery. The appliance needs to be removed and the patient will require long term intravenous antibiotics. After the infection is totally cleared up, the patient will require a revision operation.
The most common cause for revision surgery is progressive wear and tear of the initial prosthesis. Over time, these prostheses can loosen or wear away. A patient can experience symptoms such as pain, and reduced range of motion of the joint.
There are a number of reasons why a revision surgery is so difficult. Firstly, the original implant has to be taken out. Over the years, soft tissue structures around the joint can change. There is the development of scar tissue, alteration of bone structure, loosening of ligaments and so on. These changes make a revision surgery very different and much more difficult from a first surgery where the anatomy is not distorted.
Prior to surgery, different imaging procedures such as x-rays with multiple views, CAT scanning and MRI are required to give the surgeons a road map.
Sometimes, the bone around the joint has eroded and grafting of new bone is required.
While most patients require total implant replacement, sometimes only a portion of the prosthesis needs to be replaced, rather than the whole thing. This presents another problem since the orthopedist must find a correct-sized mate for the remaining implant section. This can be a complicated process since the part may need to be sculpted to fit just right.
Surgery can take anywhere from an hour for a partial replacement to five or six hours for a completely new hip or knee joint.
Age does not appear to be a limiting factor and people of any age are eligible for revision surgery. The primary factor that determines whether a patient will be suitable is their overall health. If they are in good health, then revision is a good option.
Another factor is quality of life. If a patient cannot function without a revision, then surgery is probably indicated.
The rehabilitation following revision surgery is much harder and takes much longer than a first time replacement. While patients can bear weight almost immediately after a first joint replacement, revision patients must wait six weeks or longer. The rehabilitation also is much more gradual than for first timers. So how can a person prevent the need for having a revision?
Joint replacements nowadays generally last 20 years compared with 10 to 15 years for older models. There are things people who have undergone revision can do to prolong the lifespan of their replaced joint and lower the odds of eventually needing a revision surgery.
Patients must realize that though they no longer have pain, this does not mean they can return to their previous activity level, particularly if that activity level was extreme.
While regular exercise and recreational activities are recommended, it’s important for a patient to use moderation.
Some examples… an elliptical trainer is better than a treadmill. Cycling is more advisable than running. If a patient is a tennis player, they should play on soft courts rather than hard. And so on…
Maintaining ideal weight is critical.
Regular visits to the joint replacement surgeon are advisable since they can sometimes spot problems before they occur.
It’s also important to remember that patient should go to a hospital that specializes in joint replacements, especially revision replacements, if they need a revision.
These operations require extensive training and a well-coordinated team of experts to get the best results. Surgical errors by inexperienced doctors can lead to complications and the need for additional operations.
The best place to go is an orthopedic specialty hospital or a teaching hospital.
About the Author: Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info: Arthritis Treatment
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