Introduction

There is no ‘typical’ patient who is appropriate for a joint arthroplasty. As with all modern medicine, a decision has to be made which balances the risks of surgery against the potential improvements. Patient age per se is no longer an acceptable clinical decision-making tool (Brander et al. 1997). Generally, the surgical team promote conservative treatments and optimisation of health until pain or disability is severe enough to cause a significant impact on the person’s quality of life, where surgery would make things significantly better or prevent a major deterioration.

Thus, successful modern joint replacements are based on appropriate patient selection, selection of the appropriate implant, specific surgical technique and expertise, and multi-disciplinary patient preparation and rehabilitation. Nonetheless an artificial joint is not as efficient as its organic counterpart: it does not repair itself and does not absorb the stresses and strains of daily life as an organic joint can.

Upper limb arthroplasty

There are prostheses available for every joint in the upper limb. Elbow, wrist and finger arthroplasties are performed mainly for patients with rheumatoid arthritis, although metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints are now being developed for patients with osteoarthritis (OA) and following trauma. The carpometacarpal joint of the thumb is the most common joint replacement for OA. There are also prostheses available to replace the ulnar head and the radial head; these are normally used for reconstruction following difficult forearm and elbow fractures.

Shoulder arthroplasty

Initially developed for the reconstruction of severe proximal humerus fractures, proximal humeral arthroplasty was also used for people suffering from OA, with surprisingly good results. In 1973, Neer redesigned the humeral component and added a glenoid to make the first unconstrained total shoulder arthroplasty. The basis of the design was to produce as near to an anatomical replacement as possible – the principle followed in most modern prostheses (Neer et al. 1982).

There are many factors influencing the outcome of shoulder arthroplasty (Iannotti and Williams 1998; see Table 23.1) that physiotherapists need to know about so that realistic rehabilitation goals can be set. Therefore, good communication with the surgical team is very important.

Primary OA is the indication for total shoulder arthroplasty from which the best results can be expected. The result is dependent on the severity of the degenerative changes that have taken place prior to surgery. For patients who have primary OA without gross soft-tissue damage or loss of bone, a near-normal range of movement and strength can be expected: patients who start off with rotator cuff disease or glenoid erosion should have less high expectations.

For total shoulder arthroplasty, the most common surgical approach is known as the ‘deltopectoral approach’. The incision passes between the deltoid and pectoralis major, and access to the shoulder joint is via the subscapularis muscle and the anterior part of the capsule. Thus, the subscapularis muscle is the only active structure which will need to be protected in the early postoperative period.

Table 23.2 shows a typical postoperative protocol; however, these will vary depending upon the surgeon’s preference, any intra-operative changes to the procedure, patient factors and their response. As always, the postoperative regimen must be agreed between the surgeon and the physiotherapy team.

People with rheumatoid arthritis (RA) who undergo shoulder arthroplasty are likely to have a number of the adverse pathological factors (Table 23.1). The expected results will depend on how many, and how severe, they are, so the results are generally not as good as in OA patients. The surgical approach and basic postoperative management are the same.

In advanced disease (either OA or RA type) it is not always possible to insert a glenoid component – it is not possible to attach the glenoid component securely enough if there is gross bone loss around the glenoid fossa. Also, if there is a lack of rotator cuff function, the humeral head will ‘rock’ the glenoid component, causing loosening. The problem of glenoid fixation is one of the ongoing dilemmas in shoulder arthroplasty (Figure 23.1 and Figure 23.2).

Following a complex fracture it is normally a hemi-arthroplasty that is performed, as the glenoid is usually intact. The operation can be performed either as the primary treatment for the fracture or later as a secondary procedure (the results are better if it is performed in the acute phase). Frequently, the tuberosities are disrupted giving the surgeon the additional challenge of restoring normal anatomical alignment and cuff attachment with secure fixation, thus allowing early rehabilitation. The physiotherapy programme should be individualised, taking into account any soft tissue trauma that will have occurred at the time of injury.

Total elbow arthroplasty

Elbow joint replacement is a more recent and much less common operation. Although the number performed remains small, it is regarded as a well-established surgical procedure. It is performed usually within specialist orthopaedic centres for patients with marked degenerative changes predominantly from RA, but also from OA or trauma. Usually, all conservative management strategies have failed leaving the patient with significant pain, disability and a poor quality of life.

The joint consists of two metal stems cemented into the humerus and ulna, joined by a metal and plastic hinge. The postoperative regime depends on the surgeon’s preference; some patients are splinted for a few weeks prior to mobilisation. Normal function usually starts to resume after 12 weeks. There will always be a carrying-weight restriction on people with a total elbow arthroplasty.

The hand

RA can affect any joint in the body, but it is particularly devastating to the complex collection of joints and intricate soft tissues that make up the hand (Figure 23.3). Note in Figure 23.3 the ulnar deviation of the fingers and the more functionally debilitating deformity of the volar subluxation of the metacarpal heads that robs the flexor tendons of a proportion of their power, thus weakening grip. The multi-disciplinary team (MDT) within specialist hand units assess, surgically treat and rehabilitate patients to regain hand function.

The most common surgical procedure is the replacement of the MCP joint by a silastic flexible hinge (Figure 23.4), developed by Swanson. A flexible implant arthroplasty is different in principle from other joint arthroplasties in that the implant acts as an inert flexible spacer, which is quickly surrounded by a layer of synovial tissue. The new tissue remains in contact with the implant and surrounding this a stronger capsule develops.

As well as excising the destroyed joint surfaces and inserting the flexible hinge, the surgeon must release and rebalance the soft tissues crossing the joint if function is to be restored.

Postoperatively, the short-term aims are:

These aims are achieved by early controlled movement, which stimulates the formation of a strong, but flexible, capsule around the implant. The most common way of controlling the movement is by the use of a dynamic extension splint (DES), often referred to as an ‘outrigger’ (Figure 23.5), although in recent years static splinting regimes have also been developed (Figure 23.6).

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