Shoulder Joint Replacement

Total shoulder replacement is a highly successful procedure to reduce pain and restore
mobility in patients with end-stage shoulder arthritis and, in some cases, after a
severe shoulder fracture. Shoulder replacement surgery relieves pain and helps restore
motion, strength and function of the shoulder.

Although shoulder joint replacement is less common than knee or hip replacement, it is
just as successful in relieving joint pain.

Shoulder replacement surgery was first performed in the United States in the 1950s to
treat severe shoulder fractures. Over the years, shoulder joint replacement has come to be
used for many other painful conditions of the shoulder, such as different forms of
arthritis.

Today, about 53,000 people in the U.S. have shoulder replacement surgery each year,
according to the Agency for Healthcare Research and Quality. This compares to more
than 900,000 Americans a year who have knee and hip replacement surgery.

If nonsurgical treatments like medications and activity changes are no longer helpful for
relieving pain, you may want to consider shoulder joint replacement surgery. Joint
replacement surgery is a safe and effective procedure to relieve pain and help you
resume everyday activities.

Anatomy
Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder
blade (scapula), and your collarbone (clavicle). The shoulder is a ball-and-socket joint:
The ball, or head, of your upper arm bone fits into a shallow socket in your shoulder
blade. This socket is called the glenoid.

The surfaces of the bones where they touch are covered with articular cartilage, a smooth
substance that protects the bones and enables them to move easily. A thin, smooth tissue
called synovial membrane covers all remaining surfaces inside the shoulder joint. In a
healthy shoulder, this membrane makes a small amount of fluid that lubricates the
cartilage and eliminates almost any friction in your shoulder.

The muscles and tendons that surround the shoulder provide stability and support.

All of these structures allow the shoulder to rotate through a greater range of motion than
any other joint in the body

What is shoulder replacement surgery?

Total shoulder replacement, also known as total shoulder arthroplasty, is the removal of
portions of the shoulder joint, which are replaced with artificial implants to reduce pain and
restore range of rotation and mobility. It is very successful for treating the severe pain and
stiffness caused by end-stage arthritis.

Shoulder arthritis is a condition in which the smooth cartilage that covers of the bones of the
shoulder degenerate or disintegrate. In a healthy shoulder, these cartilage surfaces permit the
bones to comfortably glide against one another. When these cartilage surfaces disappear, the
bones come into direct contact, increasing friction and causing them to roughen and damage
each other. Bone-on bone movement can be quite painful and difficult. Surgically implanted
artificial replacement surfaces restore pain-free movement, strength and function.

How is shoulder replacement done?

In traditional shoulder replacement surgery, the damaged humeral head (the ball of the joint)
is replaced with a metal ball, and the glenoid cavity (the joint socket) is replaced with a
smooth plastic cup. (The humeral head is at the top of the humerus – the upper arm bone, and
the glenoid is located in the scapula – the shoulder blade.)

This metal-on-plastic implant system (rather than metal-on-metal) is used in virtually all
shoulder replacement. In some patients, such as those with severe shoulder fractures of the
humeral head, a partial shoulder replacement (called hemireplacement) may be
recommended. This technique replaces the ball component only.

Surgical steps of a traditional shoulder replacement

A traditional (anatomic) shoulder replacement surgery is composed of the following six basic
steps:

1. The surgeon separates the deltoid and pectoral muscles to access the shoulder in a
largely nerve-free area (to minimize nerve damage).
 2. The shoulder is opened by cutting one of the front muscles of the rotator cuff,
which covers the shoulder. This “opens the door” to allow the surgeon to view and
manipulate the arthritic parts of the shoulder ball and socket.
3. The arthritic sections of the joint are removed.
4. The implant socket, ball and stem components are inserted. The metal ball
component is attached to the stem, which extends down inside the patient’s
humerus.
5. The incision of the rotator cuff muscle is closed and stitched.
6. The external (skin-level) incision is cleaned and stitched, and a bandage applied as
a temporary covering.

Types of shoulder replacement implants

All shoulder replacement systems share the same basic components: a metal ball that rests
against a plastic (polyethylene) socket. But their designs vary.

What are the risks and complications of a shoulder

replacement?
Complications are rare in total shoulder replacement, but can include:

 instability (the ball slipping out of the socket)

 infection
 nerve damage
 glenoid loosening
 stiffness*

*An arthritic shoulder is often very tight prior to surgery. If, however, stiffness is still a
problem in a shoulder in after motion was restored during surgery, this is usually the result of
incomplete rehabilitation. Continuous physical therapy efforts are usually effective in
restoring shoulder motion and strength
Wrist Joint Replacement (Wrist Arthroplasty)

Wrist replacement, also referred to as wrist arthroplasty is a surgical procedure in which

the diseased or damaged joint is replaced with an artificial joint- a prosthesis. It aims to
create a stable, pain-free joint with a functional range of movement when conservative
treatments have failed.

Total wrist replacements are non-weight bearing joints; heavy household or occupational
activity, use of a walking aid or repetitive movements e.g. hammering will increase the
speed and incidence of loosening of the implants stems and the ultimate failure of the
implant. The ideal patient for a TWA should have a low demand lifestyle, should not
need the upper extremity for regular ambulation and transfers. Young active patients and
individuals with high physical demands are not considered good candidates for TWA.

Anatomy

The wrist is a more complicated joint than the hip or the knee. On the hand side of the
wrist, there are two rows of bones at the base of the hand. There are four bones in each
row. The bones in these rows are called the carpals. The long thin bones of the hand
radiate out from one row of carpals and form the basis of the fingers and thumb.

The radius and the ulna are the two bones of the forearm that form a joint with the first
row of carpals.

The ends of the bones are covered with an elastic tissue, called cartilage. Cartilage
creates a slick surface that enables the bones to move smoothly when they move against
each other.
The wrist/radiocarpal joint is a ellipsoid type of synovial joint. The wrist consists of two
rows of carpal bones which forms the proximal segment of the hand and articulates
proximally with the forearm via the wrist joint and distally with the five metacarpals.
The ends of the bones are covered with articular cartilage. Cartilage is an elastic
connective tissue whose purpose is to allow for a smooth, gliding motion between joints.
[1]
 Movements occurring in the wrist include flexion, extension adduction and abduction.
Diseases such as osteoarthritis and rheumatoid arthritis, injury and infection can damage
or wear out the articular cartilage. This may cause the wrist bones to rub against each
other producing pain, stiffness and swelling of the wrist

(Left) Articular cartilage protects the ends of bones where joints

meet. (Right) In this x-ray of a wrist with osteoarthritis, the cartilage is
destroyed and the healthy space between bones is narrowed (arrow).

If the cartilage is worn away or damaged by injury, infection, or disease, the bones
themselves will rub against each other, wearing out the ends of the bones. This causes a
painful, arthritic condition.
Osteoarthritis, the most common form of arthritis, results from a gradual wearing away
of the cartilage covering on bones.

Rheumatoid arthritis is a chronic inflammatory disease of the joints that results in pain,
stiffness and swelling. Rheumatoid arthritis usually affects several joints on both the
right and left sides of the body.

Both forms of arthritis may affect the strength of the fingers and hand, making it difficult
to grip or pinch.

The typical candidate for wrist replacement surgery has severe arthritis but does not need
to use the wrist to meet heavy demands in daily use. The primary reasons for wrist
replacement surgery are to relieve pain and to maintain function in the wrist and hand.

Surgery

Wrist replacement surgery may help retain or recover wrist movements. It may also
improve the ability to perform daily living activities, especially if there is arthritis in the
elbow and shoulder. During any total joint replacement, the worn-out ends of the bones
are removed and replaced by an artificial joint (prosthesis).

In some cases, fusing the bones of the wrist together will reduce or eliminate pain and
improve grip strength. However, if the bones are fused together, the wrist will not be
able to bend.

Implants
There are several different types of implants. Most have two components, one for each side
of the joint. These components are made of metal. A high-quality plastic, called polyethylene,
is used as a spacer between the two metal components. Newer implant designs try to replicate
the anatomy of the wrist.

One component is inserted into the radius of the forearm. The portion of this component that
faces into the wrist joint has a curve that fits a second component placed on the wrist side.
The component that inserts into the hand bone (the carpal component) has a flat surface that
faces the first component. It inserts into a carpal bone through one long stem and one or two
shorter stems. A plastic spacer fits between the components in the joint area. Spacers come in
different sizes so they can match the hand. A spacer is normally flat on one side and rounded
on the other. This design enables it to fit into the carpal component while it rocks on the
radial component, creating a more natural wrist motion.

The Artificial Wrist

Earlier designs of wrist implants had high complications and failure rates, however,
advances in prosthetic design have contributed to improved clinical outcomes and greater
implant longevity. The implant is made from metal and plastic and has 2 components-
radial and distal component.

The radial component: is the part that fits against the end of the radius bone. It is made
up of two pieces- a flat metal piece with a stem that attaches down into the canal of the
bone and a plastic cup that fits onto the metal piece, forming a socket for the artificial
wrist joint.

The distal component: is the part that replaces the small wrist bones. This piece is made
completely of metal. It is globe shaped to fit into the plastic socket on the end of the
radius. It is attached by two metal stems that fit into the hollow bone marrow cavities of
the carpal and metacarpal bones of the hand. The ellipsoidal head simulates the curvature
of the natural wrist and allows for a functional range of movement.

The prosthesis typically is stable and should demonstrate approximately 35 0 of flexion
and 350 of extension with modest tightness at full extensions.
Surgery

A longitudinal incision is made over the back of the wrist in line with the third
metacarpal. The tendons are moved away to expose the wrist joint. Care is taken while
moving the nerves to prevent any nerve damage. The damaged joint surfaces of the arm
bones are removed with a surgical saw. The first row of carpal bones may also be
removed. The radius bone is hollowed out and a radial component of the prosthesis is
fixed inside it with bone cement. Depending upon the design of the prosthesis, the carpal
component is placed in the remaining row of carpal bones or into the third metacarpal
bone of the hand. The carpal bones may also be linked or fused together to better fix the
carpal component. A plastic spacer is then fit between the metal components. With the
new prosthesis in place the wrist joint is tested through its range of motion, and is
irrigated with a sterile saline solution. The joint capsule is then sutured together. The
muscles and tendons are repaired, and put back in place. The incision is closed and the
wrist is bandaged with a sterile dressing. A cast is then applied.

Total Elbow Replacement

Although elbow joint replacement is much less common than knee or hip replacement, it
is just as successful in relieving joint pain and returning people to activities they enjoy.

Anatomy

The elbow is a hinge joint which is made up of three bones:

 The humerus (upper arm bone)

 The ulna (forearm bone on the pinky finger side)
 The radius (forearm bone on the thumb side)
The surfaces of the bones where they meet to form the elbow joint are covered with
articular cartilage, a smooth substance that protects the bones and enables them to move
easily. A thin, smooth tissue called synovial membrane covers all remaining surfaces
inside the elbow joint. In a healthy elbow, this membrane makes a small amount of fluid
that lubricates the cartilage and eliminates almost any friction as you bend and rotate
your arm.

Muscles, ligaments, and tendons hold the elbow joint together.

In total elbow replacement surgery, the damaged parts of the humerus and ulna are
replaced with artificial components. The artificial elbow joint is made up of a metal and
plastic hinge with two metal stems. The stems fit inside the hollow part of the bone
called the canal.

There are different types of elbow replacements, and components come in different sizes.
There are also partial elbow replacements, which may be used in very specific situations.
A discussion with your doctor will help to determine what type of elbow replacement is
best for you.
Cause

Several conditions can cause elbow pain and disability, and lead patients and their
doctors to consider elbow joint replacement surgery.
Rheumatoid Arthritis
This is a disease in which the synovial membrane that surrounds the joint becomes
inflamed and thickened. This chronic inflammation can damage the cartilage and
eventually cause cartilage loss, pain, and stiffness.
Rheumatoid arthritis is the most common form of a group of disorders termed
"inflammatory arthritis."

Osteoarthritis (Degenerative Joint Disease)

Osteoarthritis is an age-related, "wear and tear" type of arthritis. It usually occurs in
people 50 years of age and older, but may occur in younger people, too. The cartilage
that cushions the bones of the elbow softens and wears away. The bones then rub against
one another. Over time, the elbow joint becomes stiff and painful.
Surgery

To reach the elbow joint, your surgeon will make an incision (cut), usually at the back of
the elbow. After making the incision, your surgeon will gently move muscles aside to get
access to the bone. After removing scar tissue and spurs around the joint, your surgeon
will prepare the humerus to fit the metallic piece that will replace that side of the joint.
The same preparation is done for the ulna.

The replacement stems are placed into the humerus and ulna bones, and kept in place
with a bone cement. The two stems are connected by a hinge pin. After the wound is
closed, a padded dressing is then placed to protect the incision while it heals.

Some surgeons will place a temporary tube in the joint to drain the surgical fluid. This
tube can be easily removed in your hospital room within the first few days after surgery.

Implants
The metal replacement parts are made of chrome-cobalt alloy or titanium and there is a
liner made of polyethylene (plastic). The bone cement is made of
polymethylmethacrylate (acrylic, a type of plastic).

Ankle joint Replacement

Arthritis is inflammation of one or more of your joints. It can cause pain and stiffness in
any joint in the body and is common in the small joints of the foot and ankle.

There are more than 100 forms of arthritis, many of which affect the foot and ankle. All
types can make it difficult to walk and perform activities you enjoy.

Although there is no cure for arthritis, there are many treatment options available to slow
the progress of the disease and relieve symptoms. With proper treatment, many people
with arthritis are able to manage their pain, remain active, and lead fulfilling lives.
Anatomy
During standing, walking, and running, the foot and ankle provide support, shock
absorption, balance, and several other functions that are essential for motion. Three
bones make up the ankle joint, primarily enabling up and down movement. There are 28
bones in the foot, and more than 30 joints that allow for a wide range of movement.

In many of these joints the ends of the bones are covered with articular cartilage—a
slippery substance that helps the bones glide smoothly over each other during movement.
Joints are surrounded by a thin lining called the synovium. The synovium produces a
fluid that lubricates the cartilage and reduces friction.

Tough bands of tissue, called ligaments, connect the bones and keep the joints in place.
Muscles and tendons also support the joints and provide the strength to make them move.
The symptoms of arthritis vary depending on which joint is affected. In many cases, an
arthritic joint will be painful and inflamed. Generally, the pain develops gradually over
time, although sudden onset is also possible. There can be other symptoms, as well,
including:
 Pain with motion
 Pain that flares up with vigorous activity
 Tenderness when pressure is applied to the joint
 Joint swelling, warmth, and redness
 Increased pain and swelling in the morning, or after sitting or resting
 Difficulty in walking due to any of the above symptoms

Total ankle replacement (arthroplasty). In total ankle replacement, your doctor removes
the damaged cartilage and bone, and then positions new metal or plastic joint surfaces to
restore the function of the joint.

Although total ankle replacement is not as common as total hip or total knee
replacement, advances in implant design have made it a viable option for many people.

Ankle replacement is most often recommended for patients who have:

 Advanced arthritis of the ankle
 Arthritis that has destroyed the ankle joint surfaces
 Ankle pain that interferes with daily activities
Ankle replacement relieves the pain of arthritis and offers patients more mobility and
movement than fusion. In addition, being able to move the formerly arthritic joint means
that less stress is transferred to the adjacent joints. This lessens the chance of developing
adjacent joint arthritis.

As in any type of joint replacement, an ankle implant may loosen or fail over the years.
If the implant failure is severe, the replaced joint can be exchanged for a new implant —
this procedure is called a revision surgery.

Another option is to remove the implant and fuse the joint. This type of fusion is more
difficult than when fusion is done as the initial procedure. When the implant is removed,
there is space in the bone that must be filled with bone graft to maintain the length of the
leg. Because the new bone may not be as strong, the risk of nonunion is greater.