Arthroplasty

(literally "re-forming of
joint")
Arthroplasty
(latin arthroplastica)

It is an orthopedic surgical procedure

where

the

articular

surface

of

musculoskeletal joint is
replaced,
remodeled, or
realigned
by

osteotomy

procedure.

or

by

some

other

It is an elective procedure,
It is done to:
-relieve pain and
-restore function of the joint after
damage by arthritis or some other type
of trauma.

Arthroplasty

with

endoprosthesis

is

reconstructive procedure whose purpose is

to restore the damaged joint by creating a
substitute joint which has actions similar
to that of the physiological joint.

The term arthroplasty is used

interchangeably with total joint
replacement or alloplasty .

The

first

totally

replacement

in

successful

human

joint

subject

was

performed in 1959.
The

hip

was

the

successfully replaced.

first

joint

to

be

Joint Replacement Classification

1) Full Joint Replacement or Total
Arthroplasty :
In this both sides of the joint is replaced;
e.g. in case of hip joint both the
acetabulum and the head of the femur is
replaced.

2) Partial Joint Replacement or Hemiarthroplasty :

In this only the part of the joint that is
damaged is restored.
e.g. commonest surface to be replaced are
the head of the femur,
the femoral or tibial compartment in the
medial compartment of the knee.

All partial replacements

may be revised to a full
replacement if indicated.

3) Resurfacing Arthroplasty
In this the diseased bone and cartilage
from the joint surfaces are removed and
the joint surfaces are fitted with the
prosthesis.

e.g. The procedure involves removing

diseased bone and cartilage from the
surface of the femoral head and the
acetabulum;
fitting the femoral head with a shortstemmed cap;
Or
replacing the acetabular component with
a prosthesis.

4) Interpositional Arthroplasty:
in this the joint is interposed or filled
with some other tissue like skin, muscle
or tendon to keep inflammatory surfaces
a part .
e.g. interposition arthroplasty with bonetendon allograft for the treatment of
unstable sternoclavicular joint.

5) Excision Arthroplasty:
In excisional arthroplasty

the joint

surface and bone is removed leaving

scar tissue to fill in the gap.

6) Revision Arthroplasty
If repeated complications arise
(e.g. dislocation, infection)
or
the prosthesis reaches the end of its
natural life and begins to loosen,
a revision arthroplasty is done.

Excision

arthrodesis

(Girdlestone's

procedure)
It involves removing part of the ball or
head of the thigh bone (femur), thereby
allowing it to fuse with the socket of the hip
(acetabulum) in the straight leg position.

Excision arthrodesis now a days is

less common because of advances in
revision surgery.

Another classification of joint

replacement is by the degree of
control offered by the joint
1. Constrained
2. Semi-constrained and
3. unconstrained

1. Constrained joints:
. in this there is a link between the two
components and
. all

anatomical

movements

of

the

artificial joints are restricted to a

greater or lesser extent.

2. Semi-constrained joint:
. although
constrained

restricted
joint

the

semi-

allows

some

movements in all planes.

3.Unconstrained joint:
.it permits free movement in all
anatomical planes.

Fixatio
n

Fixation of prosthesis can be achieved by

two ways:
1. Cemented Fixation
2. Non-cemented Fixation

All joint replacement were inserted

initially with a bond of polymethylemethacrylate (PMMA) cement.
Acrylic
cement
can
sustain
compressive stress well but they can
not control shear or torsional stress.

Hence repeated rotational movement

across the bone-cement interface results
in a splitting of the cement and release
of cement particles.

These particles may then cause bone

destruction and with damage to the
cement, loosening of the prosthetic
component will occur.
Biomechanically loosening is inevitable
at some stage because cement is stiffer
than bone.

The more obese or active the patient is

the

greater

loosening.

the

load

and

risk

of

A greater surface area of cement will

create more problem, particularly for longstem implants.

2. Non-cemented fixation:
Alternative way of fixation relies on the
natural

growth

of

bone

around

through the prosthetic implant.

or

In this attachment is achieved by new

bone

growth

at

the

bone-prosthesis

interface and no cement is used.

Bone growth is enhanced by the tightness

of the press fit of the component and the
resulting trauma and compression to the
bone stimulates new growth (Rothman &
Hozack 1988).

In addition to it a coating of hydroxy

apatite on the prosthetic component is
used to stimulate bone growth.

The surface of the prosthetic component

may

also

grooves

be
or

contoured
holes

to

attachment of the new bone.

with

bumps,

allow

easier

Joint replacement using non-cement

technique requires a period of nonweight

bearing

or

partial

weight

bearing to allow stabilization of the

component.

Non-cemented hip should not have

weight borne on them for 6 weeks.
Cemented

can

bear

immediately after surgery.

weight

The length of time of reduced weight

bearing depends on the type of joint being replaced
expectation of the patient and
the rate of bone growth

Cement-less technique is often the

preferred choice of fixation in young
patient

(<65

arthroplasty

years)

undergoing

Hybride Design:
When only one component of a total
joint replacement is cemented then its
called as hybrid design.
If loosening occurs un-cemented joint
can be revised to a cemented joint.

Replacement prosthetic parts are

made out of inert metals such as:
-stainless steel
-chrome-cobalt moybdeum
alloys
-high density polyethene

Silicon elastomer with polypropylene

reinforcement is used only for finger
joints.

The survival of the replacement:

it is the length of time the patient may
expect the joint to last for given normal
use.

The

artificial

coefficient

joints

has

approximately

a
six

friction
times

higher than a natural joint and thus

loosening is inevitable.

The

successful

survival

of

joint

replacement relies on all members of

the

team

lying :

understanding

the

under

1. biomechanics

principles

of

the

normal joint and

its replacement,
2. the limitations of the materials used
and
3. the surgical procedure.

The

patient

should

be

made

to

understand why these are issues so

that the rehabilitation programme can
be modified to protect the joint.

Complication:
1. Loosening,
2. Deep infection,
3. Fracture and
4. Dislocation
are the main complications of joint
replacement surgery (Rothman &
Hozack 1988)

Indications for Joint Replacement

1. Pain and loss of function:
National Aduit Office 2000)

Major weight bearing joints (like hip and

knee) are the most common joints to be
replaced.

The repetitive high loads and torsional

stress

taken

predispose

across

them

(osteoarthrosis).

to

these
wear

and

joints
tear

Osteoarthrosis and
Rheumatoid arthritis
are

the

commonest

pathologies

associated with joint replacement.

Post-traumatic joint stiffness or

avascular necrosis
would also predispose the patient to
pain and loss of function at specific
joints.

Joint replacement may be indicated even in

the younger patient if the joint destruction
is irreversible.
A younger person with a single joint
pathology should be counseled before the
surgery takes place about the potential
problem of overuse and loosening.

Assessment
Full clinical examination is not necessary
for pre-operative assessment of a total
joint replacement because
joint stability,
range of motion,
muscle power,
proprioception
will all change post operatively.

Therefore the therapist should

concentrate on:
1. Respiratory function
2. Specific range of motion
3. Muscle power and
4. General functional ability

General functional ability : e.g.

walking(distanced travelled and aid used)
sitting to standing
stair climbing
bending forward
dressing task
upper limb function etc.

Analysis and recording the altered

patterns used preoperatively to perform
or compensate for normal function;
will help the physiotherapist to build a
postoperative rehabilitation programme to
the specific needs of the patient.

e.g. if a patient has been overusing

the lumbar spine to gain sufficient
forward flexion to put on shoes or
socks then back pain may be a
problem.

Hence

specific

programme

for

the

strengthening
hip

flexors

and

extensors to achieve the hip motion

required to reduce the compensatory
spinal movements;
otherwise the patient will continue
using their learned pattern.

Patients

are

different

and

how

they

compensate for loss of motion/strength/

propioception will be individual although the over all loss of function may
be the same.

Leg length discrepancies may also

be seen

prior to

replacement

lower limb

particularly

the

joint
hip

because of bone erosion and pathology.

Measurement of leg length discrepancy

preoperatively will help physiotherapy
to evaluate the change in biomechanics
as these will still remain a problem postsurgery, despite surgical correction.

Noting

the

preoperative

use

of

walking aid requirements especially if

the patient has upper limb problems.

Scales

can

be

used

to

assess

movement, function and stability.

Postoperative Assessment
After the surgery the assessment will
concentrate on achievement of
functional goals,
muscle strength and
range of active movement.

The objective assessment is to evaluate

the stability of the joint and the general
functional ability and balance of the
patient.

If a lower limb joint is replaced the joint

proprioception will be lost as a result of
capsule and ligament damage and the
excess swelling or bruising in the early
stages.

Hip

Even with the advances in design and

surgical technique, the number of hip
replacements needing revision through
reaching the end
of their natural life is immense (Mallory
1992).

Following a revision arthroplasty a period

of bed rest may ensue.
If this is the case then the role of the
physiotherapist is to maintain the motion
and muscle strength of the lower limbs,
maintain circulation and respiratory
function and prevent the complications
of bed rest.

Postoperative
excision

management

arthroplasty

of

requires

an
the

patient to have good muscle control

around the hip.

A considerable shoe raise (>7.5cm) is

necessary to accommodate the leg length
discrepancy, which will increase as the
end of the femur telescopes into the
acetabulum on weight bearing.
It is possible for the patient to mobilize
with a frame or crutches but the outcome
is not wonderful.

Specific treatment for the affected joint

will depend on whether an excision
arthroplasty has taken place;
Then the therapist must maintain
isometric muscle power around the joint
and some active joint motion.

The joints above and below the excised

joints should be exercised as much as
possible, allowing for the fact that the
patient has very little control of the
excised joint in the early stages.

HRA is sometimes referred to as a

metal-on-metal procedure.
This should not
conventional

be

confused

with

THR performed with a hard-on-hard hip

prosthesis.