NEW JOINTS, NEW LIFE
Total joint replacement is an option of last resort for those with unmanageable osteoarthritis
By Jin Paul de Guzman
"Hip replacement patients may start walking
two days after surgery."
-Dr. Gustilo |
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The declaration of 2000-2010 as the International Bone and Joint Decade aims to highlight the largely ignored impact of musculoskeletal disorders on society. Although poliomyelitis is on its way to total eradication, other diseases of the bones and the joints still pose considerable challenge: cases of trauma and complete disability resulting from vehicular accidents remain numerous, particularly in developing countries; osteoporosis continues to plague elder women; arthritis persists in being one of the leading causes of near-immobility and pain. Given the global rise in ageing populations, the impact of musculoskeletal disorders that infirm them is likely to become a heavier burden-at present, joint diseases comprise half of all the chronic conditions of people older than 65.
One of the most prevalent musculoskeletal diseases is osteoarthritis. Worldwide there are 355 million people suffering from it. In the country 16 percent of the population are believed to be dealing with osteoarthritis-many of them believing that living with it is an ineluctable part of growing old.
But as Dr. Arnel Malaya, president of the Philippine Academy of Rehabilitation Medicine, says, "You don't have to live with [arthritis]. You can do something about it, and you should not be disabled just because of arthritis." Or as writer/orthopedic surgeon Jose Pujalte Jr. said in his book, Doctor on Call: A Medical Anthology: "Life is movement. Stiffness and stasis lead to death."
Joint Suffering
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SLICE: MEDICAL OBSERVER lensman Boaner Medina captures every step of his
replacement surgery on film at the Asian Hospital and Medical Center. Clockwise
from top left: Dr. Gustillo primes his patient, a middle-aged woman with chronic
osteoarthritis accessing the jointl removing the femoral head; the femoral head
removes; femoral component of the prosthesis is cemented into place;. incision
is closed |
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While the degeneration of the bones and joints may be seen as a natural part of growing old, it does not solely determine people's likelihood of coming down with osteoarthritis. As they age there may be more marked changes in their bones and joints-for instance, cells become less dense and the collagen network deteriorates. With the body's capacity to regenerate worn and torn tissues no longer so efficient as in youth, changes in bone and joint structure develop. Trauma and overuse may increase their chance of developing the condition. Obesity is also considered a risk factor.
Damage sets gradually in, and as it reaches more critical levels, what is previously felt as stiffness and discomfort may easily graduate to howling pain.
Perhaps matters concerning patients' quality of life are of utmost importance in the management of any disease. Rheumatologist Sandra Navarra highlights this need in preparing a management strategy for osteoarthritis patients, together with the following: maximize functional independence, minimize joint damage, optimize treatment of pain and inflammation, and provide access to care at reasonable cost. These, of course, are adjusted to the patients' condition and needs. And depending on their needs, patients are provided varying pharmacologic and nonpharmacologic ways of dealing with the disease. In some cases, surgery may be considered.
To most patients, the use of pain medication may be enough pharmacologic intervention. Aside from relieving pain, painkillers relieve the swelling that occasionally comes with the condition. Traditionally nonsteroidal antiinflammatory drugs (NSAIDs) are prescribed. But because a number of studies have shown the connection between long-term NSAID use and the development of gastropathy, and occasional renal and hepatic side effects, some doctors recommend lower doses, or switch their patients to pain medication with lower risks for gastropathy, such as cyclooxygenase-2 inhibitors.
An important nonpharmacologic way to manage OA is through muscle-strengthening exercise. While movement in itself may prove be painful challenge to most patients, remaining immobile will only compound the problem: if patients remain sedentary, the muscles surrounding their joints weaken, and the possibility of gaining excess weight rises. The joints then receive more pressure when used, which leads to more pain. If they engage in moderate physical activity and exercise, patients will be able to protect their joints from further degeneration, and at the same time, they will be able to engage in-and enjoy-activities of daily living.
Hips Are Hip
But there are patients to whom these pharmacologic and nonpharmacologic management strategies are not enough. When conventional management strategies fail-especially if there is already considerable joint damage and intractable pain-surgical intervention may be necessary.
One of the more common surgical procedures for OA is total joint arthroplasty. Over the years the procedure has undergone significant improvements, leading to its becoming safer and its yielding more favorable results. It is also recommended to non-OA patients, such as those with congenital abnormalities or those who experienced hip trauma.
Earlier this year MEDICAL OBSERVER witnessed renowned orthopedic surgeon Ramon Gustilo perform total hip arthroplasty on a patient with severe OA. Gustilo, who presently chairs the orthopedics department of the University of Minnesota and is a visiting consultant to a number of hospitals in the country, performed the procedure at the Asian Hospital and Medical Center.
While such procedures as arthrodesis (hip fusion) and osteotomy are also performed on patients with severe OA, the functional limits resulting from the former and the varying success rates of the latter make them a little less favorable to patients.
The prosthesis that shall replace the damaged joint is composed of a femoral stem and an acetabular cup. Gustilo, who has been performing THRs since the 1960s, explained that the prosthesis is often made of chrome-cobalt and titanium, and plastic (polyethylene), which is slick and tough enough to survive over a long period. The prosthesis may either be cemented or uncemented.
There are a number of ways to gain access to the hip joint, all of which depend on the surgeon's preference or training. Once the joint is exposed, the femoral head and part of the neck are resected. The acetabulum is reamed. Once finished the acetabular component is put in place-this may be done by using bone cement, or by screwing the shell in place. To accommodate the femoral component of the prosthesis a canal is made in the femur by tamping, reaming, and rasping. The femoral component is sometimes cemented into place. In other instances, the femoral canal is drilled so carefully as to ensure a snug fit between the implant and the bone. The entire procedure, which takes an hour and a half to two hours for each joint, requires precision to ensure that one side is a practical mirror image of the other. Often surgeons perform trial fittings of components and trial reductions, to avoid problems.
Some problems may prohibit patients from undergoing THR. Orthopedic surgeon Peter Bernardo, in a lecture he delivered to the Philippine Hip and Knee Society (which Gustilo founded in 1991), described some conditions to which THR is contraindicated: active infection in knee or elsewhere; incompetent muscular mechanism; compromised vascularity to the extremity; and local neurologic disruption affecting musculature
There are also possible complications. One of the most common is deep venous thrombosis. To reduce the risk of blood clotting in the leg and pelvis, patients are prescribed anticoagulants, are made to wear pressure stockings to ensure proper blood circulation. Also, patients are encouraged to move around early; Gustilo said that patients may start walking two days after surgery.
Other possible complications include infections and dislocation. Most implants remain effective and durable for more than 10 years-some even go up to 20 years. Also Gustilo said that in about 10 percent of patients, the procedure may have to be repeated.
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