Basics of Surgery for Arthritis

Possible Benefits of Surgery

Arthritis is usually a chronic condition and sometimes can lead to disability. However, there are many ways you and your doctor can lessen these problems. One of the ways may be surgery. Joint surgery can offer several benefits: Relief of pain is the most important benefit of joint surgery. Many people with arthritis have constant pain. Some of this pain can be relieved by rest, heat and cold treatments, exercise, splints, and medication. When these therapies don't lessen the pain, surgery may be considered. Improved movement and use of a joint are also important benefits of joint surgery. Continuous inflammation and the wearing away of bone and cartilage can cause joints, tendons, and ligaments to become damaged or pulled out of place. Losing the use of a joint, such as a hip, knee, hand, elbow or shoulder, can seriously hamper a person's activities. When this happens, surgery to replace or stabilize the joint may be suggested. An improvement in the appearance of deformed joints, especially in the hand, can be expected with some types of surgery.

Learn about the surgery

The decision to have surgery is a major one. It is not a decision to be made quickly or without good reasons. Before you decide to have surgery, be sure to learn what operation is being suggested, what are the alternatives, what are the risks and what is involved in the recovery process. Don't be shy about asking lots of questions of your surgeon, including information on his or her success record with the particular procedure. As you consider whether or not to have surgery, keep in mind that every person's needs are different. Your doctor may inform you that surgery won't give you the results you want. If your doctor thinks that surgery can help you, there are still many things you need to know.

Questions to ask

Preparing mentally and physically for surgery is an important step toward a successful result. People who understand and are knowledgeable about the process have swifter recoveries and fewer problems. Sometimes it may be hard to remember what you want to ask the doctor unless you write down your questions. Here are some questions you may want to ask.

About the surgery

• What other kinds of treatment may I have other than surgery?
• How successful will these treatments be?
• Can you explain the operation?
• Do you have written materials or videotapes on this surgery that I can review?
• How long will the surgery take?
• Can surgery be performed as an outpatient?
• What risks are involved in the surgery? How likely are they?
• Are blood transfusions necessary, and if so, can I donate my own blood?
• What type of anesthesia will I have? What are the risks?
• How much improvement can I expect from the surgery?
• Will more surgery be necessary?
• If surgery is chosen, will you contact my family doctor? Will he or she be involved in my hospital stay? In what way?
• Are you Board Certified, and do you have a special interest in arthritis surgery?
• What is your experience doing this type of surgery?
• Would you give me the name of another person who has undergone this surgery who would talk to me about it?
• Is an exercise program recommended before and after the operation?
• Must I stop any of my medications before surgery?
• What happens if I delay surgery?
• What are the risks if I don't have the surgery?

After the surgery

• How long will I stay in the hospital?
• How much pain will there be? Will I receive medication for it? What kind of pain is normal to expect? How long will this pain last?
• How long do I have to stay in bed?
• When do I start physical therapy? Will I need home or outpatient therapy?
• May I review written materials or videotapes concerning this phase of my care?
• Are physical therapy, occupational therapy, and home health care covered by insurance? (You may need to address this question to your insurance company.)
• Will I need to arrange for special help at home? If so, for how long? Is it covered by my insurance?
• What medications will I need at home, and how long will I need to take them?
• What limits will there be on my activities-driving, using the toilet, climbing stairs, bending, eating, sex?
• How often will I have follow-up visits with you? Are they covered by insurance? Are they included in the cost of the surgery?

Preparing for Surgery

If you have serious problems with your lungs or heart disease, the strain of some types of surgery may be too much for you. Before any kind of surgery, it's important to have other health problems under control. In addition, any type of bacterial infection must be cleared up before surgery. One possible problem after joint surgery is infection, which can spread from one part of the body to another through the bloodstream. If you smoke, you should stop prior to surgery if you can. Diet is an important factor in general health and becomes especially important in times of stress, such as around the time of surgery. It is best to eat foods that are rich in nutrients prior to surgery and during the entire first year after surgery. Vitamin C is especially important because it enhances the healing process. Do not take aspirin or aspirin-like medications for three days before surgery. These medications interfere with blood clotting. If you take cortisone, prednisone, or any steroid medication, you must tell your surgeon before the operation. These medications should not be stopped before or after surgery. Occasionally people develop blood clots in their legs or arms after surgery. The risk of this may be decreased by using blood-thinning drugs. Discuss this and other potential problems with your surgeon. Being overweight may put extra stress on the heart and lungs. Also, if the surgery is on a weight-bearing joint (like a hip or knee), recovery of the joint may be slower. Excess weight puts added strain on the joint and makes it harder to do the exercises needed to make the joint stronger after surgery.

Recovery

Before you decide on surgery, you must be aware that you have to follow a strict treatment plan after the operation. It's important to realize that the operation is only the first step toward restoring joint function. The amount of work you put into the recovery process often makes the difference between success and failure. Your doctor's orders regarding medication, joint protection, rest, exercise, physical therapy, and the possible use of splints must be followed very carefully. If you don't believe you can follow through on all your prescribed care, then surgery may not be the best treatment for you.

After the Surgery

Depending on the type of surgery, your doctor will usually prescribe a period of rest, physical therapy, and limited activity. Before you decide on surgery, make sure your household can be arranged so that your full recovery is possible. You may need days or weeks of rest. In addition, you may need to use splints, a cane, a walker, a wheelchair, or crutches before you are able to perform your usual tasks. Talk with your doctor about any short-term limitations and what you can expect during the recovery period. You may also be referred to an occupational therapist for advice on how to do your daily activities in ways that are safe for your joints. If your surgery involved your hand(s) or arm(s), you will most likely be able to get up the first day after the operation. If it involved one or both legs, how soon you are allowed out of bed will depend on the surgery. Often, you will be able to get up the first day after surgery, but it may be longer. Once your doctor has given permission for you to get up, you will begin to feel better the more you move around.

Physical Therapy

As soon as you're able and depending on the type of surgery you've had, you will begin physical therapy consisting of various exercises. You must dedicate yourself to this program and be prepared to work hard. If you don't, your repaired joint may be less useful than it could be. Some pain is common during the early stages of physical therapy. This pain usually comes from the muscles, not the joint. Some of your muscles have not been used much or may have been working in abnormal ways to protect a sore joint. Some muscles may have been cut and stitched during surgery. It is important to realize that muscles strengthen in response to exercise. An exercise that hurts today may hurt a little less tomorrow. You will see improvements in range of motion, along with decreased pain, as time goes on. You will have to work hard for the first few weeks after surgery to achieve range of motion, and a little less so for several months after that to regain strength. As time goes on, keeping up with your physical therapy requires dedication. You may find that you're bored with the exercises, and you may be tempted to slack off. Don't! Remember that it takes time, but the rewards can be great. You should start to see some encouraging results, such as the ability to perform a task that was too painful to do before surgery. The combined efforts of your doctors, nurses, therapists--and most important--yourself are essential to success.

Costs and Insurance

Costs will vary depending on the surgeon, anesthesiologist, admitting physician, hospital, type of surgery performed, medication, physical therapy requirements, types of implants used, and any other special tests or treatments. Check with your doctor, insurance company, and if you qualify, Medicaid or Medicare to find out what your coverage includes. Do this before the surgery so you won't have any unpleasant surprises. A hospital stay is expensive. If you've already spent time in the hospital during the year, you should check your insurance policy for benefits coverage during the remainder of the year. You will probably want to check on the managed care requirements of your policy, which may include second surgical opinions and assigned length-of-stay designations.

The Decision is Yours

Joint surgery is not for everybody. Even if your doctor and surgeon determine your condition would be improved by surgery, the decision to have the operation is up to you. You need to weigh your options and understand what the surgery will involve--before, during, and after surgery, and over the months of physical therapy. It will require patience and the willingness to follow through with physical therapy. Your commitment is the key ingredient in the success of joint surgery. If you're not sure about having surgery, ask for a second opinion from another doctor. Ask your doctor to suggest a surgeon with arthritis experience. Sign a release form and ask that your medical records and X-rays be sen to the consulting physician. Consider the advice of all your doctors carefully. Doctors, nurses, physical and occupational therapists, and social workers are part of the team that will work to make the surgery a success. Your family and friends are also members of the team. Look to them for emotional support and for assistance during your recovery. But the most important team member is you.

Joint Structure

Understanding what surgery can do for you will be easier if you have a good idea of the structure of joints. A joint is a place in the body where two bones come together. Ligaments are fibrous cords that attach bones to bones. Tendons are like ligaments except they connect muscles to bones. A bursa is a fluid-filled sac that acts as a cushion between muscles and bone or tendons. The tissue lining the joints is called the synovium. In conditions like rheumatoid arthritis, the synovium becomes inflamed. This inflammation releases chemicals that, over months or years, will thicken the synovium and damage the cartilage and bone of the affected joints. Inflammation of the synovium causes pain and swelling. The ends of the bones are covered with cartilage. In osteoarthritis, the cartilage becomes cracked and pitted and no longer allows smooth movement of the joint. When cartilage wears away in a weight-bearing joint such as the hip or knee, it can produce severe pain, deformity, and loss of mobility.

Synovectomy

Synovectomy is the removal of diseased synovium. This reduces the pain and swelling of rheumatoid arthritis and prevents or slows down the destruction of joints. However, the synovium often grows back several years after surgery and the problem can happen again. Osteotomy Osteotomy is the correction of bone deformity by cutting and repositioning the bone, then resetting it in a better position. Osteotomy of the tibia (shinbone) is occasionally performed to correct curvature and weight-bearing position of the lower leg in people with osteoarthritis of the knee. Resection Resection is the removal of part or all of a bone. This is often done when diseased joints in the foot make walking very painful and difficult. Resection is also done to remove painful bunions. Resection on parts of the wrist, thumb, or elbow can help improve function and relieve pain. Arthrodesis Arthrodesis, or bone fusion, is done to relieve pain, usually in the ankles, wrists, fingers, and thumbs. The two bones forming a joint are joined together so that the resulting fused joint loses flexibility. However, a fused joint can bear weight better, is more stable, and is no longer painful. Arthroplasty Arthroplasty is the rebuilding of joints. This can be done by resurfacing or relining the ends of bones where cartilage has worn away and bone has been destroyed. Arthroplasty also refers to total joint replacement, where all or part of an arthritic joint is removed and replaced with metal, ceramic, and plastic parts. Total joint replacement has been widely used for many years, and the results are usually excellent, especially in hips and knees. Other joints, such as the shoulders, elbows, ankles, and knuckles, may also be replaced. With new materials, improved surgical methods, and a better understanding of replacement joint function, this procedure has enabled many people who were severely disabled to become more active again.

Arthroscopy

Arthroscopy is a process that allows a doctor to see directly into the joint through an instrument called an arthroscope. This is a very thin tube with a light at the end. The arthroscope is connected to closed-circuit television. Arthroscopic surgery can be used to find out what kind of arthritis exists and how much damage is present. Also, the surgeon can perform many other procedures such as biopsy, cutting away a loose piece of tissue that is causing pain, repairing a torn cartilage, or smoothing a joint where the surface has become rough. Extensive surgery, such as synovectomy or reconstruction of ligaments, is also performed through an arthroscope. The advantage of arthroscopic surgery is that it does not require as much anesthesia or as much cutting as a standard operation. A person can recover from it much more quickly and start walking sooner. The procedure is most often done on the knee or shoulder, but is being used more often on other joints such as the elbow, wrist, and ankle.

Surgery is One Option

The loss of hand function is a serious matter, especially when the hands are also painful. When other therapy has not helped enough to allow you to do necessary tasks, such as holding a fork or zipping clothing, surgery may be the answer. In addition, some people with arthritis are concerned about deformity in their hands. While surgery may improve the look of the hands, remember that the main purposes of surgery are to decrease severe pain and to restore function.

Surgical Options for the Hand and Wrist

There are several types of operations that are performed on the hands and wrists: tendon repair, synovectomy, joint replacement, and arthrodesis. People with hands that are severely affected by rheumatoid arthritis may develop dorsal tenosynovitis. This condition involves the long tendons on the back of the hand ("dorsal"-back; "teno"-tendon; "synovitis"-inflammation of the synovial membrane). This problem produces a soft lump that is painless. The affected tendon, however, sometimes tears so that a finger cannot be moved. The surgery to repair the tendon is usually successful. Recovery is made within a few weeks. The surgery--which is often done before the tendon ruptures--is a very important part of the treatment for some people with rheumatoid arthritis. Sometimes surgery is done to tighten tendons that are too loose or to loosen tendons that are too tight. This type of surgery improves the function of the hands and fingers. Often a deep ligament may need loosening to correct carpal tunnel syndrome. Excess synovial tissue can be removed from the wrists and fingers. Synovectomy helps relieve pain and prevent deformity. It is done mainly in the early stages when deformity is not too great. Deformity itself doesn't always hinder the function of the hand as much as you might think. However, when hand and finger deformity is very painful and has not been helped by rest, injections, medication, exercise, and splinting, replacement of the finger joints can be done. When there is pain in the wrist, several procedures may be considered. Arthrodesis limits movement, but it produces excellent relief of pain and more stability for some hand joints. Resection of one of the wrist bones may improve motion, reduce pain, and prevent future tendon ruptures. Wrist joint replacement, a relatively new procedure, may be effective in reducing pain while improving movement.

High Success Rate

Severe arthritis of the hips can cause constant pain and make it very difficult to sit or walk. Improvements in surgery have enabled many people to function with less pain and better mobility. The success rate for hip replacement surgery is 95 percent for the first five to 10 years in osteoarthritis and almost as high in rheumatoid arthritis.

Hip Replacement Components

There are two types of components used for joint replacement: one is held in place by cementing the component to bone, and the other has a porous metal or chemical coating that does not require cement. The condition of the bones and the age of the person are both considered to be very important when deciding which type of component will be the best. The cementless porous metal replacement parts have a "bumpy" appearance. After the replacement parts have been implanted, new bone grows between and around the "bumps." This locks the new hip in place and does away with the need for cement. Because these replacement parts are fairly new, they have not been tested long enough to tell if they are better than the cemented type. Cementless porous-coated total joint replacement cannot be used in some instances. Most components that are held in place with cement begin to loosen at some time, usually after 10 years or so. This occurs because tissue grows in between the cement and the bone, causing the replacement to loosen. Surgery can be repeated for people who need their first replacement removed.

Shoulder Surgery

Please consult the shoulder section for articles and movies about shoulders and shoulder surgery.

Elbow Surgery

Elbow joint replacements are highly technical procedures which can relieve pain and help restore function. These procedures are performed less often than knee and hip replacements, thus it may be necessary to search for surgeon who has considerable experience with them. See the Elbow Replacement Surgery for Arthritis article for more information. Surgical options for the foot and ankle Ankles and feet have to bear all of the body's weight. Pain and loss of function can be severely disabling. Because there are many bones in the foot and ankle, careful evaluation by an orthopedic surgeon is necessary before deciding upon surgery. One of the most common types of surgery is bone fusion of the ankle. Sometimes synovectomy, tendon surgery, or replacement of the ankle is done. Fusion of selected joints in the foot is also done when joints become so painful or deformed that the person is unable to walk. Toe deformities can be corrected by a number of procedures, including fusion of the big toe, resection of the base of the toes, and rarely, replacement of toe joints. Fusion of bones in the foot can be done for severely collapsed arches.

Surgical Options for the Knee

The knee supports a lot of weight and is subject to lifelong demands. It is prone to injury because of its exposed position and the stress it must bear. For a painful knee that has not improved through therapy, the orthopedic surgeon can offer a number of surgical procedures. They include arthroscopy, synovectomy, osteotomy, and total joint replacement. All of these offer relief from pain, and joint replacement can improve both stability and mobility. Both cemented and non-cemented components are now available.

Credits

Some of this material may also be available in an Arthritis Foundation brochure. 
Adapted from the pamphlet originally prepared for the Arthritis Foundation by John Lavorgna, MD, Jeffrey T. Nugent, MD, G. James Sammarco, MD, and Leo Whiteside, MD. This material is protected by copyright.