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INTRODUCTION

ELECTIVE JOINT RECONSTRUCTION HAS BECOME increasingly common for those with painful, advanced joint disease. Over a million total knee arthroplasty (TKA) and total hip arthroplasty (THA) surgeries were performed in 2010 alone, and this number continues to increase exponentially.1 It is predicted that by the year 2030, there will be approximately 3.5 million primary total knee arthroplasties (TKA) and almost 600,000 primary total hip arthroplasties (THA) performed each year in the United States.2 Improvements in implant design and manufacturing, surgeon experience, and changes in surgical, anesthetic, and rehabilitative protocols have allowed these procedures to be successfully performed on a much wider range of patients—including old and young, healthy and frail.

In the United States, the most common reason for arthroplasty surgery is primary generalized osteoarthritis.3,4 “Secondary” osteoarthritis is defined as that which stems from other conditions, such as instability or malalignment, trauma, inflammation (e.g., pigmented vilonodular synovitis), bone disorders, and remote infection of the joint or iatrogenic interruptions of the articular cartilage (e.g., multiple arthroscopies).

The radiographic hallmarks of osteoarthritis are joint space narrowing, osteophyte formation, subchondral cysts, and sclerosis; in advanced cases, there may also be large erosions and/or bony fusion (Fig. 91–1A and B).

Figure 91–1

Osteoarthritis of the (A) hip (B) knee. (Reproduced with permission from McElroy K, Innerfield C, Cuccurullo S, Rossi RP. Joint Replacement. In: Maitin IB, Cruz E, eds. CURRENT Diagnosis & Treatment: Physical Medicine & Rehabilitation, New York, NY: McGraw-Hill; 2014.)

Worldwide, avascular necrosis is one of the leading indicators for hip replacement, stemming most commonly from femoral neck fracture, steroids, excessive alcohol use, sickle cell disease, systemic lupus erythematosus, amyloidosis, developmental hip dysplasia, Legg-Calve-Perthes disease, and HIV disease. Additionally, inflammatory joint disease commonly leads to arthroplasty; underlying causes include autoimmune diseases (e.g., rheumatoid arthritis, spondyloarthropathies), crystalline arthropathies (e.g., gout, chondrocalcinosis), metabolic conditions (e.g., hemochromatosis), and hemophilic arthropathy.

Careful patient selection improves the odds of a successful surgery and a favorable patient outcome. Some patients are ineligible because of medical comorbidities—hip and knee replacements are considered high risk, major surgeries. Contraindications to hip or knee replacement surgery include the patient's inability to provide consent and/or follow through with instructions and recommendations (e.g., significant dementia), the presence of an active infection or a history of recurrent bone or joint infections, profound osteoporosis, marked joint or soft tissue laxity (e.g., Ehlers–Danlos Syndrome), insufficient cardiovascular capacity (functionally unable to withstand 4 METs of activity), or other medical comorbid condition that is deemed to heighten the risk of surgical complications to an extent that it overshadows the benefit.

THE IMPORTANCE OF NONSURGICAL, PREOPERATIVE CARE FOR ADVANCED ARTHRITIS

End-stage joint disease can result from a variety of inflammatory, pathologic, or metabolic conditions that lead to ...

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