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SYNOVECTOMY

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 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.

ARTHRODESIS

Arthrodesis (fusion) is being used less now than formerly, but a chronically infected or painful joint may be an indication for this surgical procedure, which permanently reduces range of motion. The sole indication for arthrodesis is pain control.

TOTAL JOINT ARTHROPLASTY

In the last three 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 cause 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 the patients. Severe arthritis that fails to respond to conservative measures remains the principal indication for hip arthroplasty. Hip arthroplasty may also be indicated in younger patients severely disabled by painful hip disease (eg, rheumatoid arthritis congenital conditions or avascular necrosis). Contraindications to the operation include active infection and neurotrophic joint disease. Obesity is a relative contraindication. Serious complications may occur in about 1% of patients and include thrombophlebitis, pulmonary embolization, infection, and dislocation of the joint. Extensive experience has now been accumulated, and the short-term results are highly successful in properly selected patients. The long-term success has been limited by loosening of the prosthesis, a complication seen in 30–50% of patients 10 years after replacement with "first generation" ...

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