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Orthopedic Advances: Repairing and Replacing the Original Equipment

Issue: May 2009

By: Teo Nissen, M.D. and Mark P. Harris, M.D.

Orthopedic procedures are changing how physicians and patients approach several common orthopedic challenges.

As close to the “original” as possible

The human body is truly amazing: incredibly complex, delicate, durable and simply magnificent all at once. That’s why physicians know there’s nothing better than the original equipment. However, the natural process of aging or the stresses of sports injuries can lead the patient to a point of pain and dysfunction and the need to repair the original equipment. That’s when it’s time to consider arthroplasty.

The three primary areas of arthroplasty are hip, knee and shoulder, and new innovations in joint replacement and repair now come in many flavors.

Newer surface interfaces that have better wear characteristics are being designed. These come in the form of metals (aluminum, ceramics); articulations (including metal-on-metal or ceramic-on-ceramic); and plastic inserts and spacers using more durable polyethylene technology. There are also new innovations in the design of the prosthesis to recreate the normal anatomy of the joint that is being replaced.

Hip, knee and shoulder arthroplasty

For the hip, there is a new innovative surgical resurfacing procedure called Birmingham Hip Resurfacing arthroplasty (BHR). This is different from a regular total hip replacement in that it is a “bone sparring” procedure, preserving the normal bone of the upper femur and allowing normal mechanics and weight-bearing loads across the area. BHR is now an option for some younger and more active patients.

Total knee replacements have newer anatomic designs with better metal-plastic articulations that are expected to increase the longevity of the knee replacement and make it more durable. This gives the younger, more active patient with arthritis of the knee the potential for a total knee replacement.

For the shoulder, there is new technology in both resurfacing procedures and procedures such as the “reverse total shoulder,” which may be utilized in patients with arthritis and concomitant rotator cuff deficiency.

As boomers age, while at the same time desire to remain very active, medical advances in arthroplasty have given us many more treatment options. Arthroplasty, however, must still be approached deliberately and with full understanding of the implications of such procedures. As an orthopedic surgeon, I am keenly aware that when you replace someone’s joint, it wears out – often much quicker than the original. The components we use for joint replacements are still not nearly as durable as what we’re born with.

Sports injuries

Over the last decade, there has been a refinement of arthroscopic procedures for many surgical issues that have been historically performed with an open incision. These refinements now allow us to use multiple 0.5 mm incisions along with a fiber optic camera to treat pathology that in the past would require large, open incisions of 5 to 7 cm. This results in less trauma to the patient with significantly less dissection and blood loss, quicker postoperative recovery and less pain associated with these procedures. Some of the problems that can be addressed in this manner are those involving the cartilage and meniscus, ligament pathology (such as ACL tears), problems with the rotator cuff in the shoulder, and problems with instability or dislocations of the shoulder. There are also newer “biologic” techniques for addressing focal cartilaginous problems in young, active patients as well as tendinopathies, including conditions such as Achilles tendonitis, patellar tendonitis, and golfers and tennis elbow.

Trauma

Primary innovations in treating traumatic injuries include minimally invasive surgical techniques for decreasing surgical dissection during reconstruction of limbs. There have been innovations in metal alloy orthopedic plates, including a thinner profile and pre-contoured shape, which allow for more stable fixation of complex periarticular fractures. The improved plate fabrication reduces dissection and allows quicker postoperative mobilization to minimize the complications associated with these types of fractures. There has also been refinement for minimally invasive techniques for the fixation of long bones, including computer-assisted techniques, which allow the orthopedic surgeon to precisely match the anatomy of the injured extremity to that of the uninjured limb. For patients who experience bone loss or fracture-healing difficulty, there have been significant advancements in bone augments, substitutes and bone stimulators.

Pain management

Good pain management is a significant concern of the orthopedic surgeon. It can lead to quicker rehabilitation, better mobility, improved patient satisfaction and shortened hospital stays.

In acute postoperative pain management, there is an evolving clinical concept called preemptive analgesia. The goal of preemptive analgesia is to prevent sensitization of the nervous system to the subsequent stimuli caused by the surgical intervention before the onset of noxious stimuli occurs. If utilized properly, this strategy can decrease the intensity of postoperative pain, decrease the amount of opioid medication used and contribute to decreased number of days in the hospital.

Interoperative pain management is currently achieved by utilizing regional blocks, spinal anesthesia and epidural anesthesia. Long-acting anesthetics (such as marcaine) can be infiltrated into the wound site to help immediately post-op in the recovery room and continue providing benefit until the patient reaches the hospital bed on the nursing floor.

Improved pain control postoperatively has been achieved through innovations such as patient controlled analgesia (PCA) at bedside. It requires an IV pump and specific orders for a basal rate, a time interval before the next dose be given and 24 hour dose maximum.

Although we have not even come close to matching the durability and versatility of our original equipment, great advances have been made in arthroplasty, and it is now a well-accepted treatment modality for restoring mobility and relieving pain in patients with hip, knee and shoulder injury, overuse and osteoarthritis. Gains in technology have now allowed patients in their 40s and 50s to be eligible for joint repair or total joint replacement, offering millions the prospect of maintaining an active lifestyle with excellent mobility and advanced pain management.

Dr. Teo Nissen is affiliated with Sutter Solano Medical Center in Vallejo and practices at Bay Area Orthopedic Surgery and Sport Medicine. Special thanks to Dr. Mark P. Harris who contributed to the Pain Management portion of this article.

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