This procedure attempts to eliminate inflammation at a joint by surgically removing as much of the synovium as possible. The procedure has been performed most commonly in patients with rheumatoid arthritis who, despite medical therapy, have a persistent pannus of inflamed synovium (usually around a wrist or a knee). Patients with degenerative diseases do not have marked synovial inflammation and are not candidates for this procedure.
Unfortunately, synovium can regrow. Even in patients with rheumatoid arthritis, the long-term benefits of synovectomy remain unproved.
Realigning arthritic joints (arthroplasty) generally does not work as well as complete joint replacement, but it can defer the need for joint replacement. The typical candidate is an adult under 50 years of age who has severe osteoarthritis of one compartment of the knee (typically the medial compartment). Excising a wedge of femur will realign the patient's knee so as to shift weight to the compartment with normal cartilage and thereby eliminate or reduce the patient's pain.
This is a fairly common complication in rheumatoid arthritis and requires immediate orthopedic referral. The most common sites are the finger flexors and extensors. Outside the context of rheumatoid arthritis, ruptures of the patellar tendon and the Achilles tendon are most common.
Arthrodesis (fusion) is being used less now than formerly, but a chronically infected, painful joint may be an indication for this surgical procedure.
In the last 3 decades, remarkable progress has been made in the replacement of severely damaged joints with prosthetic materials. Although many different joints can be replaced, the largest experience and greatest success have been with hip and knee replacement. Indication for total joint arthroplasty is severe pain (usually including pain at rest) accompanied by loss of function and severe destruction of the joint on radiograph. Age is also a consideration, as the durability of artificial joints beyond 10–15 years is limited with older surgical techniques and unproved with newer techniques. Thus, patients over 65 are less likely than younger ones to face the challenge of revision.
Whatever the patient's age, success of the replacement depends on the amount of physical stress to which the prosthetic components are subjected. Vigorous impact activity, even with the most advanced biomaterials and design, will result in failure of the prosthesis with time. Revision operations are technically more difficult, and the results may not be as good as with the primary procedure. The patient, therefore, must understand the limitations of joint replacement and the consequences of unrestrained joint usage.
A. Total Hip Arthroplasty
Hip replacement was originally designed for use in patients over 65 years of age with severe osteoarthritis. In these patients—usually less active physically—the prosthesis not only functioned well but outlasted ...