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GERIATRIC TIMES | FALL 2009 Joint Replacement Surgery Common in the Geriatric Population Wael K. Barsoum, MD; Karim Elsharkawy, MD; Alison Klika, MS, Orthopaedic & Rheumatologic Institute The geriatric population is rapidly growing in the United States, currently representing approximately 20 percent of the population. This amounts to nearly 35 million elderly people today and an expected 70 million by 2030. Eight out of 10 senior citizens have musculoskeletal problems, with knee and hip osteoarthritis (OA) accounting for approximately half of these conditions. These �gures have tremendous potential to affect the future of orthopaedics, as well as the general healthcare system. Osteoarthritis, while it can result secondary to injury, is generally a pathology that is linked to the aging process. Clinical and radiological assessments are the diagnostic tools of OA. Managing the problem is challenging, as it has both physical and psychological consequences as evidenced by low SF-36 scores and a high prevalence of anxiety and depression. Treatment modalities can be grouped into two main categories; non-operative and operative. The non-operative approach consists of a combination of medications such as acetaminophen, NSAIDs, COX2 inhibitors; physical therapy; patient education; and weight loss. Once all non-operative options have been exhausted, a patient may choose to consider surgery. The operative approach has gone through a great deal of evolution, resulting in modern day joint replacement surgery. These procedures were initially introduced in the United Kingdom in the late 1960s. Over the last 50 years, several improvements have been made in terms of implant design, bearing surfaces combinations, surgical approaches and intraoperative navigation technology. The key to successful joint replacement surgery is multifactorial, with preoperative, operative and postoperative management playing equally important roles in a patient’s outcome. A thorough preoperative evaluation, with risk assessment and optimization of medical comorbidities has been shown to minimize postoperative complications and improve functional outcomes. Infection after a total joint arthroplasty is a devastating complication, and so preventive measures in the form of a laminar airflow system, thorough prepping and draping of the operative site, instrument sterilization and adherence to the operating room etiquette are strictly implemented. Antibiotics administered within one hour of the incision and for 24 hours postoperatively have proven to reduce the incidence of infection to about one to four percent for both total hip (THA) and total knee arthroplasty (TKA). 16 In THA, the surgical approach, commonly posterior or anterolateral, is surgeon dependent. I utilize the posterior approach with careful repair of the posterior capsule at the end of the procedure. Controversy remains regarding cemented versus cementless fixation, each with its own advantages and disadvantages. At Cleveland Clinic, cementless fixation for primary THA is the rule and has yielded excellent results (Fig 1). The key to successful joint replacement surgery is multifactorial, with preoperative, operative and postoperative management playing equally important roles in a patient’s outcome. The choice of bearing surface combination is another important factor and should be individualized and discussed with every patient. Metal-on-polyethylene is the most commonly used combination. One disadvantage of this combination is a relatively high wear rate, which has led to substantial efforts made by both orthopaedic surgeons and device companies to improve wear resistance. One of the latest improvements is sequentially crosslinked polyethylene, which has shown reduced wear. Vitamin E doped polyethylene is another recently developed option with favorable in vitro results. Metal-on-metal is used in patients with a more active lifestyle, but is contraindicated in patients with chronic renal failure and females in their reproductive years, due to the unpredictable consequences of metallic ions dissemination. First introduced in 1970, ceramics have had three decades of evolution and improved manufacturing techniques. Currently, ceramics are used for high functional demand patients and patients with metal sensitivity.
Fig 1: Anteroposterior view (AP) of a total hip arthroplasty Fig 2: Anteroposterior view (AP) of a bilateral total knee arthroplasty In TKA, the common surgical approach is the medial parapatellar approach. The main controversy in TKA is whether to retain or sacrifice the posterior cruciate ligament (PCL). Most Cleveland Clinic surgeons retain the PCL unless otherwise indicated (Fig 2 & 3). Other options, useful to have in the armamentarium of the joint replacement surgeon, are the unicompartment knee arthroplasty (UKA) and the patellofemoral arthroplasty. These procedures are beneficial in patients with isolated compartment arthritis, provided that the indications are strictly respected. Otherwise, high failure rates will ensue. Over the past few years, there has been a trend towards minimally invasive surgery (MIS) with smaller incisions, a subvastus approach, and as much preservation as possible of the extensor mechanism. The goals of MIS are shorter hospital stay, better pain scores and quicker recovery period. Despite showing promising results, long term outcomes are needed to assess its effectiveness. Another area that has been heavily investigated is computer assisted navigation to improve the accuracy of clevelandclinic.org/geriatrics Fig 3: Lateral view of a total knee arthroplasty implantation and knee kinematics. I use navigation in cases of extra-articular deformities and retained hardware. After four decades of continuous evolution and improvement, total joint arthroplasty has proven to be one of the most successful elective surgeries. It has excellent potential for increasing the quality of life of the patient, and is second only to cataract surgery in this respect. ■ Dr. Barsoum is Vice Chairman of Cleveland Clinic’s Department of Orthopaedic Surgery. Physicians may contact him at 216.444.7515, or by email to barsouw@ccf.org 17
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