Arthrodesis of the knee joint with a nail
In the long run, it eliminates pain and improves weight bearing capacity and stability at the expense of certain limitation of function, e.g. when walking up and down stairs, driving a car or sitting in a restricted space. Arthrodesis of the knee is not recommended in patients with limited mobility, who spend most of the day sitting, and the limb fixed in extension is uncomfortable.
Arthrodesis in flexion can be used to stabilize a “floating” severely damaged elbow. However it is technically highly difficult, and therefore preference is given in older patients to custom-made braces.
Priority in the hip and shoulder is given to mobility rather than stability. Arthrodesis of these joints is almost never performed in older patients. Preference is given to arthroplasty and, in extreme cases, mainly in the hip joint, to resection arthroplasty (Fig. 32.2). The same applies to the conditions after removal of the hip joint replacement, where the patient’s local or general condition does not allow reimplantation. After several weeks, there occurs robust scarring in the region of the joint. Rigid fibrous scar tissue then allows walking over short distance and preserves the joint motion necessary for comfortable sitting. The toll is the decreased weight bearing capacity and limb shortening of varying extent, requiring the use of axillary crutches and orthotic shoes.
Girdlestone resection arthroplasty of the hip joint
This is the most commonly used reconstructive surgery in the elderly. Technically it is applicable for all large joints of limbs. An appropriately indicated and implanted joint replacement eliminates pain and preserves the function of the joint or even restores it, if already lost. Currently, there is no age limit for it. Its main contraindication is any infection in the organism leading to loosening or failure of the implant, neurological or muscles disorder affecting the postoperative function of the total replacement and severe internal conditions limiting the possibilities of anaesthesia.
The hip joint is still the most common of the joints indicated for total arthroplasty as the damage to the joint by inflammation is often combined in this region with secondary osteoarthritic changes progressing even at sites where inflammation resolved a long time ago.
Hip disorders include a combination of rheumatic destruction with proximal femur fractures, less frequently a combination of rheumatic destruction with developmental dysplasia of the hip, and aseptic necrosis of the femoral head resulting from a long-term corticotherapy. All the above-mentioned pathological conditions of the hip are further complicated, mainly in women, by severe osteoporosis caused by several factors (menopause, corticotherapy, inactivity, damage to connective tissue).
These complicated conditions of the hip are most commonly treated by total joint replacements (including both the acetabular and femoral components) fixed by bone cement. There are several reasons for their use.
First, osteoporotic bone is difficult to prepare, and only under favourable circumstances a precise and stable bed can be created for primary fixation of cementless implant components. Secondly, blood loss is lower with the use of cemented implants, as the bone cement closes the exposed cancellous bone of the pelvis and femoral canal. Thirdly and most importantly, cemented joint replacements allow full weight bearing from the first postoperative days. This considerably facilitates and accelerates the necessary early mobilization of the patients also in case of movement coordination disorders or a frequent polyarticular involvement.
Sometimes highly painful and dysfunctional hip must be treated in patients with a poor general health status. This happens mainly in situations when the joint damaged by rheumatism was further affected by a femoral neck fracture or when the underlying disease was followed by rapidly progressing necrosis of the femoral head associated with its resorption. These patients suffer from intensive pain, are almost immobilized and are difficult to treat even in bed. These cases are often a vital indication for surgery.
The patient is usually operated on under spinal anaesthesia, and the operative time should be reduced to minimum. For this purpose, hemiarthroplasty is used, i.e. cemented implants consisting of the femoral component only. A range of available sizes of the implant allow choosing a component that fits the patient’s native acetabulum which remains in place. This solution considerably reduces the operative time and the burden put on the patient, eliminating the most demanding part of the operation on the pelvis. The disadvantage is a shorter life expectancy of these implants, and therefore the procedure should be reserved as an emergency solution for biologically old patients with limited mobility.
Knee total arthroplasty is the second most common joint replacement. Its indication is not limited by age. Life expectancy of an appropriately indicated and properly implanted knee joint replacement may exceed twenty years . Indication for knee replacement is rather relative. Perception of problems is highly subjective. Isolated knee joint replacement in the presence of untreated involvement of the neighbouring joints will only minimally improve the patient’s mobility, treatability and self-care capacity.
Indication for the operation requires a careful assessment of the patient’s general ability to cooperate in the postoperative period as the knee joint is considerably more demanding in terms of intensity and duration of active postoperative rehabilitation than the hip joint. For the above given reasons, it is necessary to respect in older patients more than ever their attitude to potential operation and not to press them. An exception is the presence of a severe valgus deformity with a simultaneous good function of the adjacent joints. This type of deformity tends to accelerating progression depending on the degree of deformity and may cause full loss of walking ability in a relatively short time. In addition, late correction of severe valgus deformities is associated with a number of technical and surgical compromises often leading to a reduced life expectancy of the implant.
Implants are cemented. The burden put on the patient is lower than in hip surgery. Blood loss is markedly lower thanks to the use of pneumatic tourniquet. Due to superficial placement of the implant, any disorder of surgical wound healing is burdened with a higher risk of development of implant infection. Knee replacements may be seriously endangered also by small contaminated skin defects, e.g. trophic ulcers, or in patients with rheumatoid disease, by relatively often infected plantar pressure sores. A very serious and underestimated risk is posed by untreated interdigital mycoses, quite frequently seen in older patients, that are an entry point for highly dangerous streptococcal infections. Erysipelas on the limb with implanted endoprosthesis leads almost in 100 % of cases to its failure, and also its reimplantation is burdened by a high rate of failures. Successful treatment and healing of all the mentioned foci are basic prerequisites for indication for knee replacement .
The number of implanted shoulder replacements is currently rapidly growing, although they still lag far behind the number of joint replacements implanted in lower limbs. As shoulder is not a weight bearing joint, even relatively progressive destructions may be associated with only insignificant subjective complaints. The range of motion gets insidiously limited, and mainly older patients relatively well adapt to this limitation. Therefore in purely rheumatology indications, shoulder replacement is performed mainly in younger patients with the aim to manage pain but mainly to maintain maximum mobility in the joint and self-care capacity and ideally also capability for work. A fully functional shoulder replacement requires early indication and a highly demanding and relatively intensive long-term rehabilitation. The situation is different in older patients. The shoulder disorder as a rule develops over a long time, and they get used to it. As they usually have a number of other more serious health problems, they usually reject the operation. They may change their attitude at the moment when this condition is further complicated by a concomitant trauma, commonly by a proximal humerus fracture after a fall or necrosis of humeral head and its resorption. These conditions are associated with a severe functional limitation and significant pain.
Endoprosthesis of a suitable type is then indicated also in cases when the type of damage and the patient’s health do not provide a guarantee of full recovery of the range of motion in the joint. Indication for operation in this context aims at elimination of pain and long-term maintenance of the best possible functional outcome. Shoulder replacements of all types are not associated with a high surgical burden, and blood loss is minimal. The surgical burden can be further minimized by the use of cemented proximal humerus hemiarthroplasty where the artificial joint articulates with the original glenoid (Fig. 32.3). The extent of recovery of the range of motion is usually limited by the patient’s ability to rehabilitate and mainly by the condition of the rotator cuff, which is largely responsible for the functional outcome and is difficult to reconstruct if damaged. In patients with a good general health status and sufficient prerequisites for the following rehabilitation, the functional outcome may be further improved by a reverse shoulder endoprosthesis (Fig. 32.4), compensating the rotator cuff defect . Its implantation, however, requires adequate bone quality in the region of the glenoid and scapular neck allowing a stable fixation of the respective component. Unfortunately, these prerequisites are only exceptionally met in older patients. Contraindications of shoulder replacement are similar to those in other joint replacements. A special contraindication for all types of shoulder replacements, including the reverse ones, is axillary nerve palsy, because without its function it is impossible to achieve the required stability of the implanted endoprosthesis. Rheumatologists should be aware of the fact that a healed shoulder replacement of any type is not a contraindication for axillary crutches.