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Orthopedic Surgery

Innovations in knee replacement

Dr. Aharon Menachem
Deputy Manager of the Orthopedic Department, Tel Aviv Medical Center, Joint replacement specialist

About 85% of the population over 60 years old suffers from attrition of various joints, about 60% will suffer from pain in one or more joints.



Atrophic joint disease (osteoarthritis or osteoarthrosis) is a process of attrition of the joint cartilage, which causes the bone that is usually underneath the cartilage to be exposed into the joint with consequential narrowing of the normal joint space.
These changes, together with the creation of bony spurs (osteophytes), cause a modification in the shape of the affected joint, especially in the knees (“zero shaped leg”) and the small joints of the palms.
In a majority of cases the reason for the development of osteoarthritis is unknown; in some other cases the reason is a trauma as in fractures involving the joints, or birth deformities like developmental dysplasia of the hip. There are also a large number of inflammatory joint diseases, such as rheumatoid arthritis, lupus, psoriasis, etc., which cause the destruction of the joints.
The conservative treatment against pain caused by these conditions includes analgesics, anti-inflammatory medications, physiotherapy and injections of steroids (cortisone) into the patient’s affected joint. In recent years a new treatment has been added: an injection into the joints (especially the knees) of a substance (hyaluronic acid) intended to cover the joint and to relieve the pain for a few months.
Food supplements like chondroitin and glucosamine, which are supposed to improve the cartilage, also took a significant place as part of the conservative treatment, in spite divergences of opinion concerning their efficacy.
When pain causes significant suffering, limiting the patient’s normal daily function and diminishing his or her quality of life, surgery should be considered.
Knee joint. The common surgery for elderly life quality improvement as a result of a process of attrition of the joint cartilage is total knee replacement. During the surgery, damaged cartilage remains are removed, the bone is prepared according to the implant shape and after that the implant is attached with material named cement.
There are patellar component, which is attached to the hip bone and tibial component, which is attached to the shin bone; the patellar component is made of hard metal – cobalt chrome alloy, the tibial component is made of titanium or cobalt chrome alloy, it’s depends of implant type. There is a plastic component between metal components, which is made of polyethylene and substitutes the cartilage function.
This surgery with total hip joint replacement operation are defined as a huge success of the modern medicine, cause of above 90% of successful cases and full function returning along with significant life quality improvement. In long-term patients follow-up there is approximately 96% of success after 15 and more years.
Before making a decision for this type surgery is advisable to deliberate the bound risks, including bacterial infection (till 1%), non-clarified pain and early implant weakening, which cause to pain and repeated operations.
In recent years a significant development occurs in the medical equipment production and along with computerization, which includes navigation appliances, it’s allow to make more accurate surgery with better long-term results.
In recent years knee implants were under upgrading process, it’s was acceptable till now that a plastic component is attached to the tibial component; this implant structure makes available straightening and bending movement and disables a circular movement (approximately 5 degrees to each side). This circular movement, as much as it’s small, is liable to cause to increased process of plastic attrition.
Today most of leading companies in the implant production field manufactures implants with plastic components, which enable a circular movement in addition to straightening and bending movement (mobile bearing).
Indeed there is no important difference between implant types in function checking, which includes pain, movement range and implant long-term life; but in the light of the increase of life expectancy, diminution of average patients age and raising expectations from surgery results, it’s possible to let that implants with this type plastic component will prolong life above 15-20 acceptable today years.
Hip joint. In recent years an important development occurs in total hip replacement surgeries.
It was acceptable in the past to attach implants to the bone with cement and this is acceptable today in knee surgeries. Hip joint surgeries technique is much more difficult with worst results, but in recent years affixing is biological - implants are made of titanium, noble metal with flexibility characteristics that are similar to the bone ones.
Some implant areas are textured with perforated surfaces creation, which contact with bone. During the post-surgery therapy process the contacting with implant bone invading holes and fixing tightly the implant. This method is approved by itself and is most acceptable.
Hip implants imitate the original joint anatomy, in other words, made of hard metal rounded head on hemisphere of hard polyethylene. During the years attrition process of polyethylene causes to local reaction of tissues with implant weakening and repeated operations necessity. These surgeries are more complicated and cause significant damage to the bone with worst results.
Today there are two types of almost non-attritional movement surfaces, local reaction is much easier and therefore the implant life will be prolonged. The first type is ceramic surfaces with imperceptible attrition. Another and most common type is metal-on-metal type; today this type is liable to give best long-term results.
Additionally, today’s technology enables production of mega heads, this fact also donates to the attrition process minimizing.
The necessity of “bone preserving” implants appeared as a result of damage that is liable to be caused to the bone tissue in repeated operations. Bone preserving implant was acceptable in the past and failed due to obsolete production technique, but it’s returning now and it is used for young people with good bone quality. In this surgery the hip head bone is preserved without necessity of invasion into the hip bone itself. This surgery is more complicated than regular operation and at this stage its long-term results are not clear.
Another bone preserving implant with easier usage and much smaller than acceptable implants. The implant was invented at Mayo Clinic in the USA, and it was remaining in use till recent years at some centers in the world with excellent results during follow-up within 20 years.
This implant invades to the hip bone, but with its close associated component and easiest damage to the hip bone, enabling thereby immediate stability and allowing more or less easy removal without a huge damage to the hip bone if necessity in repeated operations occurs.
The combination of small implant and hard movement surfaces like ceramic-on-ceramic or metal-on-metal seems to be promising and, perhaps, it leads to important breakthrough with significant prolonging of implants life.
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