Dr Romesh Gaur
MBBS, MBBS, DNB(ORTHO),
Arthroscopy is a surgical procedure orthopedic surgeons use to visualize, diagnose, and treat problems inside a joint.
The word arthroscopy comes from two Greek words, “arthro” (joint) and “skopein” (to look). The term literally means “to look within the joint.”
In an arthroscopic examination, an orthopaedic surgeon makes a small incision in the patient’s skin and then inserts pencil-sized instruments that contain a small lens and lighting system to magnify and illuminate the structures inside the joint. Light is transmitted through fiber optics to the end of the arthroscope that is inserted into the joint.
Here are parts of the shoulder joint as seen trhough an arthroscope: the rotator cuff (RC), the head fo the humerus (HH), and the biceps tendon (B).
By attaching the arthroscope to a miniature television camera, the surgeon is able to see the interior of the joint through this very small incision rather than a large incision needed for surgery.
The television camera attached to the arthroscope displays the image of the joint on a television screen, allowing the surgeon to look, for example, throughout the knee. This lets the surgeon see the cartilage, ligaments, and under the kneecap. The surgeon can determine the amount or type of injury and then repair or correct the problem, if it is necessary.
Why is arthroscopy necessary?
Diagnosing joint injuries and disease begins with a thorough medical history, physical examination, and usually X-rays. Additional tests such as magnetic resonance imaging (MRI) or computed tomography (CT) also scan may be needed.
Through the arthroscope, a final diagnosis is made, which may be more accurate than through “open” surgery or from X-ray studies.
Disease and injuries can damage bones, cartilage, ligaments, muscles, and tendons. Some of the most frequent conditions found during arthroscopic examinations of joints are:
For example, synovitis is an inflammation of the lining in the knee, shoulder, elbow, wrist, or ankle.
Acute or Chronic Injury
• Shoulder: Rotator cuff tendon tears, impingement syndrome, and recurrent dislocations
• Knee: Meniscal (cartilage) tears, chondromalacia (wearing or injury of cartilage cushion), and anterior cruciate ligament tears with instability
• Wrist: Carpal tunnel syndrome
• Loose bodies of bone and/or cartilage: for example, knee, shoulder, elbow, ankle, or wrist
Some problems associated with arthritis also can be treated. Several procedures may combine arthroscopic and standard surgery.
• Rotator cuff surgery
• Repair or resection of torn cartilage (meniscus) from knee or shoulder
• Reconstruction of anterior cruciate ligament in knee
• Removal of inflamed lining (synovium) in knee, shoulder, elbow, wrist, ankle
• Release of carpal tunnel
• Repair of torn ligaments
• Removal of loose bone or cartilage in knee, shoulder, elbow, ankle, wrist.
Although the inside of nearly all joints can be viewed with an arthroscope, six joints are most frequently examined with this instrument. These include the knee, shoulder, elbow, ankle, hip, and wrist. As advances are made in fiberoptic technology and new techniques are developed by orthopaedic surgeons, other joints may be treated more frequently in the future.
How is arthroscopy performed?
Arthroscopic surgery, although much easier in terms of recovery than “open” surgery, still requires the use of anesthetics and the special equipment in a hospital operating room or outpatient surgical suite. You will be given a general, spinal, or a local anesthetic, depending on the joint or suspected problem.
A small incision (about the size of a buttonhole) will be made to insert the arthroscope. Several other incisions may be made to see other parts of the joint or insert other instruments.
When indicated, corrective surgery is performed with specially designed instruments that are inserted into the joint through accessory incisions. Initially, arthroscopy was simply a diagnostic tool for planning standard open surgery. With development of better instrumentation and surgical techniques, many conditions can be treated arthroscopically.
The surgeon inserts miniature scissors to trim a torn meniscus.
For instance, most meniscal tears in the knee can be treated successfully with arthroscopic surgery.
After arthroscopic surgery, the small incisions will be covered with a dressing. You will be moved from the operating room to a recovery room. Many patients need little or no pain medications.
Before being discharged, you will be given instructions about care for your incisions, what activities you should avoid, and which exercises you should do to aid your recovery. During the follow-up visit, the surgeon will inspect your incisions; remove sutures, if present; and discuss your rehabilitation program.
The amount of surgery required and recovery time will depend on the complexity of your problem. Occasionally, during arthroscopy, the surgeon may discover that the injury or disease cannot be treated adequately with arthroscopy alone. The extensive “open” surgery may be performed while you are still anesthetized, or at a later date after you have discussed the findings with your surgeon.
What are the possible complications?
Although uncommon, complications do occur occasionally during or following arthroscopy. Infection, phlebitis (blood clots of a vein), excessive swelling or bleeding, damage to blood vessels or nerves, and instrument breakage are the most common complications, but occur in far less than 1 percent of all arthroscopic procedures.
What are the advantages?
Although arthroscopic surgery has received a lot of public attention because it is used to treat well-known athletes, it is an extremely valuable tool for all orthopaedic patients and is generally easier on the patient than “open” surgery. Most patients have their arthroscopic surgery as outpatients and are home several hours after the surgery.
What is recovery like after arthroscopy?
The small puncture wounds take several days to heal. The operative dressing can usually be removed the morning after surgery and adhesive strips can be applied to cover the small healing incisions.
Although the puncture wounds are small and pain in the joint that underwent arthroscopy is minimal, it takes several weeks for the joint to maximally recover. A specific activity and rehabilitation program may be suggested to speed your recover and protect future joint function.
It is not unusual for patients to go back to work or school or resume daily activities within a few days. Athletes and others who are in good physical condition may in some cases return to athletic activities within a few weeks. Remember, though, that people who have arthroscopy can have many different diagnoses and preexisting conditions, so each patient’s arthroscopic surgery is unique to that person. Recovery time will reflect that individuality.
Soft Tissue Repair
The effective use of therapeutic exercise in the management of musculoskeletal disorders depends on sound clinical reasoning based on the best evidence available that supports the selection of the treatment interventions. Examination of the involved region is an important prerequisite for the structural and functional impairments that are limiting or may be preventing full participation in desired activities. It is also important during the examination process to determine whether the tissues involved are in the acute, subacute, or chronic stage of recovery so that the type and intensity of exercises do not interfere with recovery but can most effectively facilitate healing for maximum return of function and prevention of further problems. This chapter and subsequent chapters in this book have been written with the assumption that the reader has a foundation of knowledge and skills in examination, evaluation, and program planning for orthopedically related problems in order to make effective choices of exercises that will meet the goals.
Utilizing the principles presented in this chapter, the reader should be able to design therapeutic exercise programs and choose techniques for intervention that are at an appropriate intensity for the stage of healing of connective tissue disorders. Specific joint, soft tissue, boney, and nerve lesions as well as common surgical interventions are presented in the remaining chapters.
Soft Tissue Lesions
Examples of Soft Tissue Lesions: Musculoskeletal Disorders
• Strain: Overstretching, overexertion, overuse of soft tissue: tends to be less severe than a sprain, occurs from slight trauma or unaccustomed repeated trauma of a minor degree.6 This term is frequently used to refer specifically to some degree of disruption of the musculotendinous unit.14
• Sprain: Severe stress, stretch, or tear of soft tissues, such as joint capsule, ligament, tendon, or muscle. This term is frequently used to refer specifically to injury of a ligament and is graded as first- (mild), second- (moderate), or third-(severe) degree sprain.14
• Dislocation: Displacement of a part, usually the boney partners in a joint, resulting in loss of the anatomical relationship and leading to soft tissue damage, inflammation, pain, and muscle spasm.
• Subluxation: An incomplete or partial dislocation of the boney partners in a joint that often involves secondary trauma to surrounding soft tissue.
• Muscle/tendon rupture or tear: If a rupture or tear is partial, pain is experienced in the region of the breach when the muscle is stretched or when it contracts against resistance. If a rupture or tear is complete, the muscle does not pull against the injury, so stretching or contraction of the muscle does not cause pain.8
• Tendinopathy/tendinous lesions: Tendinopathy is the general term that refers to chronic tendon pathology.23 Tenosynovitisis inflammation of the synovial membrane covering a tendon. Tendinitis is inflammation of a tendon; there may be resulting scarring or calcium deposits. Tenovaginitis is inflammation with thickening of a tendon sheath. Tendinosis is degeneration of the tendon …
What Is Joint Replacement Surgery?
Joint replacement surgery is removing a damaged joint and putting in a new one. A joint is where two or more bones come together, like the knee, hip, and shoulder. The surgery is usually done by a doctor called an orthopaedic (or-tho-PEE-dik) surgeon. Sometimes, the surgeon will not remove the whole joint, but will only replace or fix the damaged parts.
The doctor may suggest a joint replacement to improve how you live. Replacing a joint can relieve pain and help you move and feel better. Hips and knees are replaced most often. Other joints that can be replaced include the shoulders, fingers, ankles, and elbows.
What Can Happen to My Joints?
Joints can be damaged by arthritis and other diseases, injuries, or other causes. Arthritis or simply years of use may cause the joint to wear away. This can cause pain, stiffness, and swelling. Diseases and damage inside a joint can limit blood flow, causing problems in the bones, which needs blood to be healthy, grow, and repair themselves.
What Is a New Joint Like?
A new joint, called a prosthesis (praas-THEE-sis), can be made of plastic, metal, or ceramic parts. It may be cemented into place or not cemented, so that your bone will grow into it. Both methods may be combined to keep the new joint in place.
A cemented joint is used more often in older people who do not move around as much and in people with “weak” bones. The cement holds the new joint to the bone. An uncemented joint is often recommended for younger, more active people and those with good bone quality. It may take longer to heal, because it takes longer for bone to grow and attach to it.
New joints generally last at least 10 to 15 years. Therefore, younger patients may need to have the same damaged joint replaced more than once.
Do Many People Have Joints Replaced?
Joint replacement is becoming more common. More than 1 million Americans have a hip or knee replaced each year. Research has shown that even if you are older, joint replacement can help you move around and feel better.
Any surgery has risks. Risks of joint surgery will depend on your health of your joints before surgery and the type of surgery done. Many hospitals and doctors have been replacing joints for several decades, and this experience results in better patient outcomes. For answers to their questions, some people talk with their doctor or someone who has had the surgery. A doctor specializing in joints will probably work with you before, during, and after surgery to make sure you heal quickly and recover successfully.
Do I Need to Have My Joint Replaced?
Only a doctor can tell if you need a joint replaced. He or she will look at your joint with an x-ray machine or another machine. The doctor may put a small, lighted tube (arthroscope) into your joint to look for damage. A small sample of your tissue could also be tested.
After looking at your joint, the doctor may say that you should consider exercise, walking aids such as braces or canes, physical therapy, or medicines and vitamin supplements. Medicines for arthritis include drugs that reduce inflammation. Depending on the type of arthritis, the doctor may prescribe corticosteroids or other drugs.
However, all drugs may cause side effects, including bone loss.
If these treatments do not work, the doctor may suggest an operation called an osteotomy (aas-tee-AAHT-oh-me), where the surgeon “aligns” the joint. Here, the surgeon cuts the bone or bones around the joint to improve alignment. This may be simpler than replacing a joint, but it may take longer to recover. However, this operation has become less common.
Joint replacement is often the answer if you have constant pain and can’t move the joint well—for example, if you have trouble with things such as walking, climbing stairs, and taking a bath.
What Happens During Surgery?
First, the surgical team will give you medicine so you won’t feel pain (anesthesia). The medicine may block the pain only in one part of the body (regional), or it may put your whole body to sleep (general). The team will then replace the damaged joint with a new man-made joint.
Each surgery is different. How long it takes depends on how badly the joint is damaged and how the surgery is done. To replace a knee or a hip takes about 2 hours or less, unless there are complicating factors. After surgery, you will be moved to a recovery room for 1 to 2 hours until you are fully awake or the numbness goes away.
What Happens After Surgery?
With knee or hip surgery, you will probably need to stay in the hospital for a few days. If you are elderly or have additional disabilities, you may then need to spend several weeks in an intermediate-care facility before going home. You and your team of doctors will determine how long you stay in the hospital.
After hip or knee replacement, you will often stand or begin walking the day of surgery. At first, you will walk with a walker or crutches. You may have some temporary pain in the new joint because your muscles are weak from not being used. Also, your body is healing. The pain can be helped with medicines and should end in a few weeks or months.
Physical therapy can begin the day after surgery to help strengthen the muscles around the new joint and help you regain motion in the joint. If you have your shoulder joint replaced, you can usually begin exercising the same day of your surgery! A physical therapist will help you with gentle, range-of-motion exercises. Before you leave the hospital, your therapist will show you how to use a pulley device to help bend and extend your arm.
Will My Surgery Be Successful?
The success of your surgery depends a lot on what you do when you go home. Follow your doctor’s advice about what to eat, what medicines to take, and how to exercise. Talk with your doctor about any pain or trouble moving.
Joint replacement is usually a success in most people who have it. When problems do occur, most are treatable. Possible problems include:
• Infection. Areas in the wound or around the new joint may get infected. It may happen while you’re still in the hospital or after you go home. It may even occur years later. Minor infections in the wound are usually treated with drugs. Deep infections may need a second operation to treat the infection or replace the joint.
• Blood clots. If your blood moves too slowly, it may begin to form lumps of blood parts called clots. If pain and swelling develop in your legs after hip or knee surgery, blood clots may be the cause. The doctor may suggest drugs to make your blood thin or special stockings, exercises, or boots to help your blood move faster. If swelling, redness, or pain occurs in your leg after you leave the hospital, contact your doctor right away.
• Loosening. The new joint may loosen, causing pain. If the loosening is bad, you may need another operation to reattach the joint to the bone.
• Dislocation. Sometimes after hip or other joint replacement, the ball of the prosthesis can come out of its socket. In most cases, the hip can be corrected without surgery. A brace may be worn for a while if a dislocation occurs.
• Wear. Some wear can be found in all joint replacements. Too much wear may help cause loosening. The doctor may need to operate again if the prosthesis comes loose. Sometimes, the plastic can wear thin, and the doctor may just replace the plastic and not the whole joint.
• Nerve and blood vessel injury. Nerves near the replaced joint may be damaged during surgery, but this does not happen often. Over time, the damage often improves and may disappear. Blood vessels may also be injured.
As you move your new joint and let your muscles grow strong again, pain will lessen, flexibility will increase, and movement will improve.
What Research Is Being Done?
Studies of the various forms of arthritis, the most common reason for joint replacement surgery, are helping doctors better understand these diseases and develop treatments to stop or slow their progression and damage to joints.
Scientists are studying replacement joints to find out which are best to improve movement and flexibility. They are also looking at new joint materials and other ways to improve surgery. For example, researchers are looking for ways to reduce the body’s inflammatory response to the artificial joint components, and are trying to learn why some types of prostheses are more successful than others.
Other scientists are also trying to find out why some people who need surgery don’t choose it. They want to know what things make a difference in choosing treatment, in recovery, and in well-being.
Revision Joint Surgery
Joint replacement surgeries for hips and knees affected by arthritis are almost always successful, restoring joint function and easing pain for nearly all patients who have them.
But as more and more people undergo a joint replacement—including younger patients—it brings an interesting dilemma: More patients now need a second joint replacement, called a joint revision surgery, as they outlive their original joint implant.
In general, statistics show that knee and hip replacements will last 10 to 20 years for 90% of patients. The likelihood of needing a revision grows as time passes. One survey examining patient registries of hip and knee replacement patients found an average revision rate of 6% after 5 years and 12% after 10 years.1
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Here are the main problems that can occur after a joint replacement to trigger a need for revision surgery:
• Loosening of the implant.
This is the most common problem from a joint replacement. When a joint is replaced, the new joint components are cemented or fitted into place. But over time, friction can cause tiny particles to break away and loosen the bonds between bone and implant. This can cause pain in the joint, as well as instability.
• Dislocation of the joint.
Sometimes, the new joint will become unaligned and “pop” out. This is a more common complication with hip replacement. It can be caused by scar tissue interfering with the joint, weak joint-supporting muscles, or patients not following treatment guidelines after their joint replacement.
If an infection takes hold at the site of the joint replacement, it can cause enough pain and swelling that a revision is needed. With current hospital standards and available antibiotics, the risk for an infection that would trigger joint revision is very small. Doctors may do a blood test or joint aspiration to detect an infection.
• Joint problems that will only get worse.
If wear, loosening, or any other disorder of the replaced joint is threatening to cause a bone fracture or deterioration past the point of correction, a revision may be needed. This may be revealed as the result of an X-ray of the joint.
Revision surgeries are more complex and have higher rates of post-surgery complications than first-time joint replacements. It’s important that revision surgeries are done by surgeons with skill and experience in that type of surgery.
Bone Fracture Repair
What is bone fracture repair?
When you experience a bone break (also known as a fracture), it’s important that the bone can heal properly in its original position. There are several treatments for a broken bone, and the one a doctor recommends is based upon several factors. These include how severe the break is and where it is. While some bones can heal by wearing a cast, others may require more invasive treatments, such as bone fracture repair.
Bone fracture repair is a surgery to fix a broken bone using metal screws, pins, rods, or plates to hold the bone in place. It’s also known as open reduction and internal fixation (ORIF) surgery.
Why is bone fracture repair done?
Bone fracture repair is used when a broken bone does not or would not heal properly with casting or splinting alone. Improper healing that requires ORIF surgery can occur in cases when the bone is sticking through the skin (compound fractures) and fractures that involve joints, such as wrists and ankles. If bones that are surrounding the joints could not be repaired, a person’s functional mobility could be severely impacted.
How to prepare for bone fracture repair
Tell your doctor about your medical history, including any chronic conditions or prior surgeries. Also tell your doctor about any medications you are taking or are allergic to, including over-the-counter medicines and supplements.
Your doctor will also ask for imaging tests to view exactly where the bone has broken. Examples could include X-rays, CT scans, and MRI.
The day before your procedure, your doctor will likely recommend that you do not eat anything after midnight. You should have someone drive you to the hospital or surgery center and be prepared to take you home after your procedure.
The risks of bone fracture repair
Complications from this surgery are very rare. These complications may include:
• an allergic reaction to anesthesia
• blood clots
You can minimize your risk for complications by disclosing all medical conditions and medications you’re taking as well as following your doctor’s post-procedure orders carefully. This can include instructions on keeping your dressing clean and dry.
How bone fracture repair is performed
Bone fracture repair surgery can take several hours. You may be given general anesthesia to put you to sleep during your surgery or local anesthesia to numb only the broken limb.
The surgeon may make an incision over the fracture site if a plate and screws are to be utilized. He may make an incision at the end of a long bone and place a rod down the inner aspect of the bone to stabilize and repair a fracture.
The fractured bone is then set into place. Your surgeon may use metal screws, pins, rods, or plates to secure the bone in place. These can be either temporary or permanent.
Your doctor might recommend a bone graft if your bone shattered into fragments during your original injury. This procedure uses bone from a different part of your body or from a donor to replace the portions of bone that were lost.
Blood vessels that were damaged during your injury will be repaired during surgery.
When the broken bone has been set properly, your surgeon will close the incision wound with stitches or staples and wrap it in a clean dressing. Your injured limb will most likely be put in a cast after the procedure is complete.
After bone fracture repair
Your doctor will tell you the expected recovery time for healing your fracture. According to the Cleveland Clinic, this process will typically take six to eight weeks. However, this time frame can vary based on the fracture type and location.
Immediately after the procedure, you will be taken to a recovery room. Here, hospital staff will monitor your blood pressure, breathing, heart rate, and temperature. Depending on the extent of your injury and surgery, you may need to stay in the hospital overnight or longer, depending on your progress after surgery.
There will be some pain and swelling after the surgery. Icing, elevating, and resting the broken limb can help to reduce inflammation. Your doctor will also prescribe painkillers to ease your discomfort. However, if your pain starts to worsen after a few days instead of getting better, call your physician.
Your doctor will give you instructions about how to care for your stitches or staples. As a general rule, you will want to keep the surgical site clean and dry. Your doctor will often place a surgical bandage over the site that they will remove at a follow-up visit. You can expect some numbness at the incision site, but call your doctor if you begin to experience:
• foul-smelling drainage
Your doctor will also likely recommend physical therapy to help you strengthen and stretch the muscles around the injured bone. This will aid in healing as well as ideally help to prevent further injury.
While it’s easy to think of your bones as a solid piece of material, they actually have many blood vessels that can promote healing. With time, your body will start to grow new threads of blood cells that will ultimately grow back together, helping to heal the bone. Just remember that even though the fracture has been repaired, it can happen again. Practice caution whenever possible to prevent re-injury. This can include eating a diet rich in bone-boosting foods, such as those that contain calcium and vitamin D. Wearing protective gear, such as pads, braces, or a helmet can all help you prevent a future fracture.
Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthytissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy.
• In oral hygiene and dentistry, debridement refers to the removal of plaque and calculus(tartar) that have accumulated on the teeth. Debridement in this case may be performed using ultrasonic instruments, which fracture the calculus, thereby facilitating its removal, as well as hand tools, including periodontal scaler and curettes, or through the use of chemicals such as hydrogen peroxide.
• In podiatry practitioners such as chiropodists, podiatrists and foot health practitioners remove conditions such as calluses and verrucas.
• Debridement is an important part of the healing process for burns and other serious wounds; it is also used for treating some kinds of snake and spider bites.
• Sometimes the boundaries of the problem tissue may not be clearly defined. For example, when excising a tumor, there may be micrometastases along the edges of the tumor that are too small to be detected, and if not removed, could cause a relapse. In such circumstances, a surgeon may opt to debride a portion of the surrounding healthy tissue — as little as possible — to ensure that the tumor is completely removed
Surgical or “sharp” debridement and laser debridement under anesthesia are the fastest methods of debridement. They are very selective, meaning that the person performing the debridement has complete control over which tissue is removed and which is left behind. Surgical debridement can be performed in the operating room or bedside, depending on the extent of the necrotic material and a patient’s ability to tolerate the procedure. The surgeon will typically debride tissue back to viability, as determined by tissue appearance and the presence of blood flow in healthy tissue
Autolysis uses the body’s own enzymes and moisture to re-hydrate, soften and finally liquefy hard eschar and slough. Autolytic debridement is selective; only necrotic tissue is liquefied. It is also virtually painless for the patient. Autolytic debridement can be achieved with the use of occlusive or semi-occlusive dressings which maintain wound fluid in contact with the necrotic tissue. Autolytic debridement can be achieved with hydrocolloids, hydrogels and transparent films. It is suitable for wounds where the amount of dead tissue is not extensive and where there is no infection.
Chemical enzymes are fast acting products that slough off necrotic tissue. These enzymes are derived from micro-organisms including clostridium and histolyticum; or from plants, examples include collagenase, varidase, papain, and bromelain. Some of these enzymatic debriders are selective, while some are not. This method works well on wounds (especially burns) with a large amount of necrotic debris or with eschar formation. However, the results are mixed and the effectiveness is variable. Therefore this type of debridement is used sparingly and is not considered a standard of care for burn treatments
When removal of tissue is necessary for the treatment of wounds, hydrotherapy which performs selective mechanical debridement can be used. Examples of this include directed wound irrigation and therapeutic irrigation with suction. Baths with whirlpool water flow should not be used to manage wounds because a whirlpool will not selectively target the tissue to be removed and can damage all tissue. Whirlpools also create an unwanted risk of bacterial infection, can damage fragile body tissue, and in the case of treating arms and legs, bring risk of complications from edema
Allowing a dressing to proceed from moist to dry, then manually removing the dressing causes a form of non-selective debridement. This method works best on wounds with moderate amounts of necrotic debris (e.g. “dead tissue”)
In maggot therapy, a number of small maggots are introduced to a wound in order to consume necrotic tissue, and do so far more precisely than is possible in a normal surgical operation. Larvae of the green bottle fly are used, which primarily feed on the necrotic (dead) tissue of the living host without attacking living tissue. Maggots can debride a wound in a day or two. The maggots derive nutrients through a process known as “extracorporeal digestion” by secreting a broad spectrum of proteolytic enzymes that liquefy necrotic tissue, and absorb the semi-liquid result within a few days. In an optimum wound environment maggots molt twice, increasing in length from 1–2 mm to 8–10 mm, and in girth, within a period of 3–4 days by ingesting necrotic tissue, leaving a clean wound free of necrotic tissue when they are removed. When they stay longer or too many are used, healthy tissue can be damaged as well.
Fusion of Bones
What is Joint Fusion Surgery?
If you have severe arthritis pain, your doctor may suggest that you have joint fusion surgery (also called “arthrodesis”). This procedure fuses, or “welds,” together the two bones that make up your aching joint.
It causes the bones to become one solid bone, and it can lessen your pain. It can also make your joint more stable and help you bear more weight on it.
Do I Need It?
Over time, arthritis can cause severe damage to your joints. If other treatments haven’t helped, joint fusion surgery may be the next step. This procedure can also relieve symptoms of back problems like degenerative disk disease and scoliosis.
Joint fusion surgery can be done on many different joints, such as your:
It can take a while to heal — sometimes many months — from joint fusion surgery. Because of this, your doctor will want to know that you can cope with a long recovery.
What Happens During Surgery?
You’ll go into the hospital or have outpatient surgery (go home the same day), depending on the type of joint fusion surgery you need.
Your doctor may choose to give you general anesthesia, which will allow you to sleep through the procedure. In other cases, you may have local anesthesia. This means you’ll stay awake, but the area of the joint will be fully numbed.
Once you’ve had anesthesia, your doctor will make an incision (cut) in your skin. Then, she’ll scrape away all the damaged cartilage (tissue) from your joint. This will allow your bones to fuse.
Sometimes, your surgeon will place a small piece of bone between the two ends of your joint. She’ll carefully take this bone from your pelvic bone, heel, or just below your knee. Or, it could come from a bone bank, which stores donated bones for use in surgeries like this. Your doctor might also choose to use a special manmade substance in place of an actual bone.
Next, she’ll use metal plates, screws, or wires to close the space within your joint. This hardware is often permanent and will stay in even after your joint heals.
After she’s finished, your surgeon will close your incisions with sutures or staples.
Spinal fusion can be used to treat a variety of conditions affecting any level of the spine – lumbar, cervical and thoracic. In general, spinal fusion is performed to decompress and stabilize the spine. The most common cause of pressure on the spinal cord/nerves is degenerative disc disease. Other common causes include disc herniation, spinal stenosis, trauma, and spinal tumors. Spinal stenosis results from bony growths (osteophytes) or thickened ligaments that cause narrowing of the spinal canal over time. This causes leg pain with increased activity, a condition called neurogenic claudication. Pressure on the nerves as they exit the spinal cord (radiculopathy) causes pain in the area where the nerves originated (leg for lumbar pathology, arm for cervical pathology). In severe cases, this pressure can cause neurologic deficits, like numbness, tingling, bowel/bladder dysfunction, and paralysis.
Lumbar and cervical spinal fusions are more commonly performed than thoracic fusions.Degeneration happens more frequently at these levels due to increased motion and stress.The thoracic spine is more immobile, so most fusions are performed due to trauma or deformities like scoliosis and kyphosis.
Conditions where spinal fusion may be considered include the following:
• Degenerative disc disease
• Spinal disc herniation
• Discogenic pain
• Spinal tumor
• Vertebral fracture
• Kyphosis Spondylolisthesis
• Posterior rami syndrome
• Other degenerative spinal conditions
• Any condition that causes instability of the spine
Bone morphogenetic protein (rhBMP) should not be routinely used in any type of anterior cervical spine fusion, such as with anterior cervical discectomy and fusion. There are reports of this therapy causing soft tissue swelling, which in turn can cause life-threatening complications due to difficulty swallowing and pressure on the respiratory tract.
According to a report by the Agency for Healthcare Research and Quality (AHRQ), approximately 488,000 spinal fusions were performed during U.S. hospital stays in 2011 (a rate of 15.7 stays per 10,000 population), which accounted for 3.1% of all operating room procedures This was a 70 percent growth in procedures from 2001. Lumbar fusions are the most common type of fusion performed ~ 210,000 per year. 24,000 thoracic fusions and 157,000 cervical fusions are performed each year.
A 2008 analysis of spinal fusions in the United States reported the following characteristics:
• Average age for someone undergoing a spinal fusion was 54.2 years – 53.3 years for primary cervical fusions, 42.7 years for primary thoracic fusions, and 56.3 years for primary lumbar fusions
• 45.5% of all spinal fusions were on men
• 83.8% were white, 7.5% black, 5.1% Hispanic, 1.6% Asian or Pacific Islander, 0.4% Native American
• Average length of hospital stay was 3.7 days – 2.7 days for primary cervical fusion, 8.5 days for primary thoracic fusion, and 3.9 days for primary lumbar fusion
• In-hospital mortality was 0.25%
There are many types of spinal fusion techniques. Each technique varies depending on the level of the spine and the location of the compressed spinal cord/nerves. After the spine is decompressed, bone graft or artificial bone substitute is packed between the vertebrae to help them heal together. In general, fusions are done either on the anterior (stomach), posterior (back), or both sides of the spine. Today, most fusions are supplemented with hardware (screws, plates, rods) because they have been shown to have higher union rates than non-instrumented fusions. Minimally invasive techniques are also becoming more popular.These techniques use advanced image guidance systems to insert rods/screws into the spine through smaller incisions, allowing for less muscle damage, blood loss, infections, pain, and length of stay in the hospital. The following list gives examples of common types of fusion techniques performed at each level of the spine:
• Anterior cervical discectomy and fusion (ACDF)
• Anterior cervical corpectomy and fusion
• Posterior cervical decompression and fusion
• Anterior decompression and fusion
• Posterior instrumentation and fusion – many different types of hardware can be used to help fuse the thoracic spine including sublaminar wiring, pedicle and transverse process hooks, pedicle screw-rod systems, vertebral body plate systems.
• Posterolateral Fusion – bone graft is placed between the transverse processes in the back of the spine. These vertebrae are then fixed in place with screws and/or wire through the pedicles of each vertebra attaching to a metal rod on each side of the vertebrae.
• Interbody Fusion – the entire intervertebral disc between vertebrae is removed and bone graft is placed in the space between the vertebra. A plastic or titanium device may be placed between the vertebra to maintain spine alignment and disc height. The types of interbody fusion are:
1. Anterior lumbar interbody fusion (ALIF) – the disc is accessed from an anterior abdominal incision.
2. Posterior lumbar interbody fusion (PLIF) – the disc is accessed from a posterior incision.
3. Transforaminal lumbar interbody fusion (TLIF) – the disc is accessed from a posterior incision on one side of the spine.
4. Transpsoas interbody fusion (DLIF or XLIF) – the disc is accessed from an incision through the psoas muscle on one side of the spine.
5. Oblique lateral lumbar interbody fusion (OLLIF) – the disc is accessed from an incision through the psoas muscle obliquely
An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is also used to correct a coxa vara, genu valgum, and genu varum. The operation is done under a general anaesthetic.
Osteotomy is one method to relieve pain of arthritis, especially of the hip and knee. It is being replaced by joint replacement in the older patient.
Due to the serious nature of this procedure, recovery may be extensive. Careful consultation with a physician is important in order to ensure proper planning during a recovery phase. Tools exist to assist recovering patients who may have non weight bearing requirements and include bedpans, dressing sticks, long-handled shoe-horns, grabbers/reachers and specialized walkers and wheelchairs.
Two main types of osteotomies are used in the correction of hip dysplasias and deformities to improve alignment/interaction of acetabulum – (socket) – and femoral head (femur head) – (ball), innominate osteotomies and femoral osteotomies. The bones are cut, reshaped or partially removed to realign the load-bearing surfaces of the joint.
Osteotomy of the knee
Knee osteotomy is commonly used to realign arthritic damage on one side of the knee. The goal is to shift the patient’s body weight off the damaged area to the other side of the knee, where the cartilage is still healthy. Surgeons remove a wedge of the tibia from underneath the healthy side of the knee, which allows the tibia and femur to bend away from the damaged cartilage.
A model for this is the hinges on a door. When the door is shut, the hinges are flush against the wall. As the door swings open, one side of the door remains pressed against the wall as space opens up on the other side. Removing just a small wedge of bone can “swing” the knee open, pressing the healthy tissue together as space opens up between the femur and tibia on the damaged side so that the arthritic surfaces do not rub against each other.
Osteotomy is also used as an alternative treatment to total knee replacement in younger and active patients. Because prosthetic knees may wear out over time, an osteotomy procedure can enable younger, active osteoarthritis patients to continue using the healthy portion of their knee. The procedure can delay the need for a total knee replacement for up to ten years.
The location of the removed wedge of bone depends on where osteoarthritis has damaged the knee cartilage. The most common type of osteotomy performed on arthritic knees is a high tibial osteotomy, which addresses cartilage damage on the inside (medial) portion of the knee. The procedure usually takes 60 to 90 minutes to perform.
During a high tibial osteotomy, surgeons remove a wedge of bone from the outside of the knee, which causes the leg to bend slightly inward. This resembles the realigning of a bowlegged knee to a knock-kneed position. The patient’s weight is transferred to the outside (lateral) portion of the knee, where the cartilage is still healthy.
After regional or general anesthesia is administered, the surgical team sterilizes the leg with antibacterial solution. Surgeons map out the exact size of the bone wedge they will remove, using an X-ray, CT scan, or 3D computer modeling. A four- to five-inch incision is made down the front and outside of the knee, starting below the kneecap and extending below the top of the shinbone.
Guide wires are drilled into the top of the shinbone (tibia plateau) from the outside (lateral side) of the knee. The wires usually outline a triangle form in the shinbone.
A standard oscillating saw is run along the guide wires, removing most of the bone wedge from underneath the outside of the knee, below the healthy cartilage. The cartilage surface on the top of the outside (lateral side) of the shinbone is left intact. The top of the shinbone is then lowered on the outside and attached with surgical staples or screws, depending on the size of the wedge that was removed. The layers of tissue in the knee are stitched together, usually with absorbable sutures.
Rehabilitation and Prevention
A fall or torque to the leg during the first two months after surgery may jeopardize healing. Patients must exercise extreme caution during all activities, including walking, until healing is complete.
After rehabilitation, preventing osteoarthritis involves slowing the progression and spread of the disease. Maintaining aerobic cardiovascular fitness has been an effective method for preventing the progression of osteoarthritis. Light, daily exercise is much better for an arthritic knee than occasional, heavy exercise.
It is especially important to avoid any serious knee injuries, such as torn ligaments or fractured bones, because arthritis can complicate knee injury treatment. High-impact or repetitive stress sports, like football and distance running, should be avoided.
Because osteoarthritis has multiple causes and may be related to genetic factors, no universal prevention tactic exists.
General recommendations include:
• Keeping a slight bend in the knees will take the pressure off during standing.
• Avoid activities that causes pain which lasts over an hour.
• Perform controlled range of motion activities that do not overload the joint.
• Avoid heavy impact on the knees during everyday and athletic activities.
• Gently strengthen thigh and lower leg muscles to help protect the bones and cartilage in the knee.
• Non-contact activities keep joints and bones healthy and maintain fitness over time. Exercise also helps promote weight loss, which can take stress off knees.