Planning life with an artificial joint

"It is never too late to have arthroplasty of a damaged joint," says Vitolds Jurkevičs, the orthopaedic surgeon at the ORTO Clinic. "Solutions may be only technically complicated, but there are no irreparable situations." 

An artificial joint even of high quality, ideally replaced by an experienced and efficient doctor is and remains however a foreign substance in our body. That is why a responsible orthopaedic surgeon will not urge you to have arthroplasty without a good reason.

What is arthroplasty?

Joint arthroplasty is the removal of a joint – if its articular bone-forming part is damaged by illness or injury – and its replacement by an artificial joint. Joints in need of arthroplasty are most often knee and hip joints, seldom shoulder joints.

It is worth considering whether the time has come to take such a step if:

● you have been diagnosed with a disease which damages the joint;
● the joint is becoming deformed; 
● movements are becoming ever more agonizing and you are having aches and pains which are not alleviated by anti-inflammatory or analgesic drugs;

"These are arguments for planning the time of the operation," says Vitolds Jurkevičš.

Queueing for joint replacement

At State hospitals, diagnosed joint deformation and pains are reasons for a patient to be placed after the orthopaedic surgeon’s conclusion on the waiting list for planned State paid arthroplasty. According to the data published in the home page of the Traumatology and Orthopaedic Hospital, it has registered 6400 patients waiting for the replacement of the knee joint and 4000 patients waiting for the replacement of the hip joint. The waiting period lasts several years. However, the patient himself or herself has to pay for the operation only 31 euros plus 10 euros for each day spent at the hospital. Often money is the decisive factor to patiently wait for one’s turn.

Exceptions are made for those patients the development and progression of whose disease is more rapid and destructive than that of other patients. In the case of osteonecrosis, for example, the joint may fully disintegrate within half a year, but arthrosis wears out the bone surface very slowly (sometimes for decades). The decision about people whose treatment requires urgent surgery is taken by a medical commission. These patients are placed on a special waiting list. However, they may have to wait for their turn for a whole year or – if State funding is insufficient – even longer.

If the patient is able to cover half of the State-funded arthroplasty price, he may get a new joint within half a year. But the replacement surgery is performed out of turn if the patient covers the operation expenses himself or herself.

"The reasons for replacing a joint are various, that is why waiting for one’s turn on the waiting list which may last for years is not a good solution for the patient," says Vitolds Jurkevičš. "The joint has to be replaced when the right time has come and not when one’s turn has approached. Besides, not only the cases when the patient is afflicted with pain and is patiently waiting for his or her turn, but also the opposite situations when the patient’s turn has come but he or she does not feel so bad as to undergo an operation are illogical," says Vitolds Jurkevičs. He is of the opinion that an optimal situation is when the patient together with his or her orthopaedic surgeon considers the pros and cons and decides on the surgery which they plan for the nearest months. However, such an opportunity is ensured only by private clinics in Latvia.

We want to live longer!

As human life expectancy as well as several medical solutions which allow dealing with health problems are ever increasing in the world, the number of arthroplasty has also increased. According to the current estimates of the Polish scientists, about 800 000 joint replacements are performed every year. The scientists together with the leading prosthetic manufacturers and surgeons are also constantly searching for the best solutions to make the artificial joints last longer and to improve the quality of people’s life so that the patients could do normal everyday things including sports activities. 

The priority of a private hospital is to choose the highest world standards and follow them not only in each surgeon’s individual performance during surgery but at every stage connected both with the choice of top quality endoprosthesis and its installation technology. 

The priority of State hospitals is the possibility to offer State-paid arthroplasty and professional doctors’ performance while several essential stages are lacking – a person for whose surgery the State is paying cannot chose his or her artificial joint or its installation technology.

Endoprostheses of the leading world manufacturers and their counterfeits

There are several leading manufacturers of joint replacement materials in the world which are subject to very scrupulous checks already in the course of their development. Based on their wear and tear indicators, they are constantly being improved. These endoprostheses are entered into the Western and American State registers which mark the implantation date of each endoprosthesis and the date when the artificial endoprosthesis has undergone check-up procedures (replacement surgery). The data are reliable and objective and allow the doctors to assess the lifetime of different models and materials and choose the best of them. Each endoprosthesis of a leading manufacturer has a certificate which is given to the patient after surgery. Private hospitals in Latvia use only the materials of the world’s leading manufacturers of prostheses.

As it often happens with similar successful products, some endoprostheses produced in China, Pakistan or India are fakes. In their production, materials similar to those of the leading manufacturers are used. 

Fake endoprostheses are not included into international registers and there are no data about their lifetime. Due to that, there is a greater likelihood that the prosthesis would create problems to the patient – allergic reactions, inflammation of the soft tissues, the endoprosthesis may not grow in or it may loosen soon as a result of which the replacement of the endoprosthesis has to be performed not after 15 to 25 years which is the average lifetime of endoprostheses certified in the world, but much earlier.  Fake implants are a kind of a game of chance though the result may be sometimes good.

For the artificial joint to serve long without causing complications, it is essential not only to choose a certified endoprosthesis included into international registers but also to observe the highest standards in implanting it. However, compliance with these standards raises the price of surgery.  Each installation stage has been designed in such a way as to maximize the lifetime of the endoprosthesis and to minimize the risks of complications. Due to the high costs, this opportunity is being offered only by private clinics.

What is worth knowing about endoprostheses

The range of materials, the size and type of fixation of endoprostheses is so wide that it may confuse an uninformed person or give a wrong idea of what would be an appropriate implant. The leading manufacturers of endoprostheses in the world use three types of materials – metal alloys, ceramics and polyethylene. The choice of the material is determined by the way the endoprosthesis is affixed to the bone. This in its stead, is determined by the age of the patient, sometimes by the patient’s gender and lifestyle.

There are two ways to fasten (fix) the endoprosthesis to the bone – cementing it or without cementing it. Cement fixation when part of the bone is filled with this material is suitable for elderly patients whose bones are brittle. Well-laid cement without air bubbles makes the bone stronger and the artificial joint more stable. In order to fix the endoprosthesis to the bone, a long metal pin to which the joint implant adheres is anchored into the bone.

Cement-free fixing of the endoprosthesis is used for young people whose bones are strong. Cement is not filled into the bone but the endoprosthesis is fixed on a short metal pin. Taking into account the fact that young people usually wish to lead an active life after joint replacement, different material combinations are chosen for the surfaces of their endoprostheses than for those of elderly people whose joints have to be mainly safe and stable instead of being dynamic and mobile as those of young people. Cemented endoprostheses are usually more suitable for elderly people.

If arthroplasty has to be performed on tall and strong men under 55 years of age, it is often possible partly to retain the joint bones by filing off the damaged areas and covering the bone ends with artificial articular surfaces – like putting crowns on the teeth. 

Do you need morphine if you have pains?

The medical practice of treating joint diseases in our neighbouring Scandinavian countries and also several other countries is to extend the maximum period of time before surgery. In order to relieve the patient’s pain, doctors prescribe narcotic drugs already in the early stages of the disease. Narcotic drugs for alleviating joint pains are almost never used in Latvia. Narcotic drugs relieve pain but they do not prevent joint deformation or restriction of movements when the disease progresses. Besides, they are addictive.

Aches and pains which cannot be reduced by analgesic and anti-inflammatory drugs are a signal encouraging the patient to opt for surgery. "It is difficult to say what the best approach is. But in my opinion, man must live his life to the fullest. I have often operated on patients who have been refused surgery abroad and have been advised to wait. However, they have chosen to be operated on because they are aware of the restrictions their illness causes them," Vitolds Jurkevičs speaks of his experience.

The use of narcotic drugs may seem a boon for it relieves pain but in reality narcotic painkillers have bad consequences. "A person who has not used narcotic drugs feels relief after surgery. He or she does not have pain any more. The patient gradually regains vigour and joy of living. But a person who has used narcotic drugs feels a need to continue using analgesic drugs even though he or she has new joints," Vitolds Jurkevičs explains.

Life after arthroplasty – what should be reckoned with?

Having joint replacement surgery, the patient has to take into account the fact that an artificial joint has a limited lifetime since nothing artificial is as perfect as a natural thing. The lifetime of a joint endoprosthesis lasts 15 to 25 years. Depending on the material they have been made of, all endoprostheses accumulate products of degradation – microscopic chippings of the respective material. They gradually damage the bone, leading to scar tissue buildup. As a result, the endoprosthesis is dislocated and loosens.

Repeated joint arthroplasty or revision surgery is more complicated and longer than initial arthroplasty. However, after revision surgery the lifetime of the endoprosthesis is prolonged by 80% of its initial lifetime.

An essential stage follows after successful joint arthroplasty – learning to live with the new joint and using it to the fullest extent as if it were a healthy joint presented to the patient by Mother Nature.  Work with the physiotherapist should be started on the implantation day of the endoprosthesis. Properly moving and exercising the knee joint, a person may learn to walk without hobbling within two weeks after arthroplasty. He or she may learn to walk without hobbling after hip joint surgery within two to six weeks. "However, the patient must do regular exercises also after this period of time, if he or she wants the new joints to serve long and well," emphasizes Vitolds Jurkevičs.




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