The most common reason for the insertion of a joint replacement is osteoarthritis, i.e. joint wear that exceeds normal levels or is age-related . Various considerations regarding open or minimally invasive surgery, materials, etc. need to be taken into account for the use of joint endoprostheses. You can find out more in the text below.
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Due to an ageing society, joint replacement, i.e. the use of an artificial joint - a joint endoprosthesis - has become an integral part of operating theaters. Around 233,000 hip endoprostheses and around 187,000 knee endoprostheses are implanted in Germany every year(source).
Today, medical progress makes it possible to replace almost every joint in the human body. Thanks to improvements in material development, optimized surgical procedures and better durability, endoprostheses used today achieve very good long-term results.
As a result of an ageing society and the resulting increase in the rate of osteoarthritis (joint wear and tear), the demand for endoprostheses has risen enormously.
Although osteoarthritis is the most important reason, it is not the only reason why a joint replacement may be necessary. Younger patients also require joint replacements more frequently. The most important reasons are listed below:
Osteoarthritis refers to the wear and tear of a joint. Around 5 million people in Germany suffer from osteoarthritis. Osteoarthritis is the most common reason for an artificial joint.
Osteoarthritis can becaused by excessive strain on the joint, for example due to increased body weight, or congenital or traumatic misalignments of the extremities.
If osteoarthritis occurs as a result of another disease (e.g. arthritis = joint inflammation), it is referred to as secondary osteoarthritis. Basically, any joint can be affected by osteoarthritis, with the knee joint being particularly affected(gonarthrosis). The hip(coxarthrosis) and shoulder(osteoarthritis of the shoulder) are also often a reason for an endoprosthesis.
A joint replacement is considered if the osteoarthritis cannot be treated with medication or other treatment methods.
The video shows the destruction of the joint surfaces in osteoarthritis of the knee:
Arthritis is an inflammation of the joints on the basis of which osteoarthritis can develop. If this inflammatory disease occurs in many joints, it is referred to as polyarthritis.
Chronic polyarthritis, also known as rheumatoid arthritis, mainly affects the finger and toe joints, but also
are affected. In severe forms that do not respond to medical treatment, joint replacement may be necessary.
Malalignment of the extremities also leads to signs of wear and tear in the joints similar to osteoarthritis. For example
can be a reason for a hip joint replacement. Malpositions in the knee joint axis can result in a joint replacement of the knee joint.
Necrosis is the death of individual or several cells or tissue parts in the living organism.
Femoral head necrosis(necrosis of the femoral head), for example, is characterized by the death of part of the bony head of the femur as a result of reduced blood flow to the bone (e.g. in diabetes mellitus, alcoholism or injuries).
After fractures in the joint area, an endoprosthesis occasionally has to be inserted. A typical fracture of this type is the femoral neck fracture.
This fracture of the neck of the thigh bone in the immediate vicinity of the hip joint is usually the result of a fall onto the side. Falls or blows to the shoulder can also result in deformities of the shoulder that make joint replacement necessary.
If bone tumors and metastases (metastases) occur in the area of the bone near the joint, the bone can be damaged to such an extent that an endoprosthesis must be inserted.
For example, an artificial hip joint is used for proximal femoral metastases (metastases near the hip joint in the femur) or an artificial shoulder joint for tumors of the proximal humerus (metastases near the shoulder joint in the humerus).
Dislocations are dislocations, dislocations or dislocations of a joint. A dislocation of the hip joint, for example, results in a dislocation or dislocation of the hip joint. Foot dislocations and shoulder dislocations are also common diagnoses.
If these dislocations occur repeatedly and cannot be treated in any other way, implantation of an endoprosthesis may be necessary.
In the case of certain diseases or injuries in the joint area, the affected joint is stiffened, which is referred to as arthrodesis. The stiffening of the joint leads to increased wear of the joint (arthrosis). As a result, it may be necessary to implant a joint replacement.
Specialists for the implantation of an endoprosthesis are specialists in orthopaedics and trauma surgery who have specialized in the surgery of the corresponding joint and have extensive experience in their field.
An endoprosthesis must fulfill numerous conditions. For example, it must
as light as possible.
The materials used in joint replacements today are mostly metal alloys based on iron, cobalt and titanium as well as polyethylene, ceramics and bone cement.
As it has not yet been possible to create lubrication in joint replacements, depending on the materials and processing used, friction and movement can lead to abrasion and loosening of the endoprosthesis with bone formation, resulting in granulomatous tissue, metal or ceramic fractures and corrosion.
In order to achieve a joint replacement that is as durable and complication-free as possible, we are constantly working on
researched.
Doctors can fix a joint replacement to the remaining bone in different ways. The joint replacement is only firmly anchored in the body by newly formed bone substance.
In order to speed up this process and improve the accuracy of fit, the endoprosthesis is often anchored in the bone with bone cement; this is known as a cemented joint replacement.
Alternatively, a joint replacement can also be implanted without cement, in which case it is referred to as a cementless joint replacement.
However, there is also a combination of both procedures, i.e. one part of the artificial joint is cemented (e.g. the acetabular cup prosthesis) and the other part is implanted without cement (e.g. the stem of the hip joint prosthesis). This joint replacement is known as a hybrid endoprosthesis.
A joint replacement of the hip must occasionally be performed after severe pathological changes in the hip joint. Osteoarthritis is a common and probably the best-known cause of wear and tear. In addition to osteoarthritis, there are numerous other congenital and acquired diseases as well as the consequences of injury that lead to premature joint wear and thus to secondary osteoarthritis.
In a healthy hip joint that is not affected by osteoarthritis, the ends of the bones are covered by a layer of cartilage that forms a smooth surface.
The wear and tear caused by osteoarthritis can lead to deposits of uric acid crystals on the one hand and to a breakdown of the cartilage substance on the other. This makes even, smooth joint contact impossible.
Further changes occur in the acetabulum and femoral head, causing the cartilage layers of the femoral head and acetabulum to wear away more and more through movement. This results in pain during exertion (e.g. when walking even short distances) and ultimately also at rest.
Although there are also non-surgical treatment methods, if these no longer lead to freedom from pain and a restoration of mobility, a hip replacement should be considered to improve the quality of life.
A distinction is made between partial and total hip replacements (= hip TEP). While only the femoral neck and the femoral head are replaced in partial arthroplasty and the acetabulum remains intact, in total arthroplasty both the femoral neck, the femoral head and the acetabulum are replaced by the joint replacement.
In a cemented joint replacement, the stem and socket of the artificial joint are anchored to the bone with bone cement. In a cementless joint replacement, the artificial joint grows into the bone without the use of bone cement.
In addition to osteoarthritis, there are other disorders that can result in excessive wear of the joint cartilage and bone. These include incorrect loading due to deformation of the leg(bow leg or knock-knee) as well as old injuries or inflammation in the knee joint.
If the cartilage layers rub against each other, the cartilage is worn away over time. Exposure of the bone causes pain during movement. Severe pain is the result.
The damaged parts of the joint can be replaced with a joint replacement. There are three types of knee joint prosthesis, depending on the extent of the damage to the knee joint caused by osteoarthritis:
Complete, axis-guided joint replacement is always necessary if the entire knee joint, i.e. including the joint cartilage and ligaments, has been destroyed by the osteoarthritis or if there is a significant axis deviation between the femur and tibia.
Patients with an artificial joint should undergo regular clinical examinations (e.g. for redness or swelling of the skin, changes in function) and have an X-ray taken in order to detect complications or changes to the bone or the artificial joint at an early stage.
These changes include, for example
Complications can occur during the insertion of the artificial joint (intraoperative complications) or after the operation (postoperative complications) and can occur early or late. The most important complications include
Infections are among the most feared complications in arthroplasty. They must always be taken very seriously, as in the worst case they can lead to the removal of the prosthesis, as the infection usually causes the prosthesis to loosen.
If an early infection occurs, i.e. an infection within the first year, it usually originates in non-sterile operating theaters or infected surgical wounds.
If a late infection occurs, it is often the result of an infectious disease. External signs of an infection of the artificial joint are
Every operation is associated with general risks. When inserting an endoprosthesis, for example, these include
These complications can usually be avoided through careful surgery.
In addition to thromboses and embolisms as well as pressure ulcers and a reduced general condition, the following can occur after joint replacement surgery
may occur.
Fatigue fractures of joint replacements are now rare, as the materials and procedures used today virtually eliminate this risk.
In contrast, femoral shaft fractures are more likely to occur in joint replacements of the hip (hip TEP) or knee (knee TEP) in the area of the artificial joint or below the endoprosthesis. This is particularly due to osteoporosis in old age.
A relatively common problem is loosening of the joint replacement, which can occur after 10 to 15 years due to heavy loads. The joint replacement loses its anchorage and therefore its stability in the bone.
Joint replacement surgery is performed either under spinal anesthesia as a partial anesthetic or under general anesthesia. In both cases, the patient feels no pain.
Depending on which joint is to be replaced and which type of surgery is chosen, the operation takes between 45 and 120 minutes. Some joints can also be replaced using a minimally invasive procedure.
The muscles are pushed aside after the skin has been cut open. This exposes the hip joint.
After the neck of the femur has been cut and the destroyed femoral head removed, the diseased hip socket is milled out. The new, artificial hip socket can then be anchored in place.
The bone marrow space of the femur must be prepared so that the new, artificial stem fits exactly. The two parts of the joint replacement are joined together by placing and fitting the prosthesis head onto the prosthesis stem.
The muscles are then sutured and the wound is closed again.
The operation is usually performed from the front. If the kneecap is pushed to the side, all parts of the knee joint are clearly visible.
Depending on the extent of the joint destruction caused by the osteoarthritis, destroyed bone parts and cartilage remnants as well as the meniscus are removed.
Using previously made templates, the bone is prepared in such a way that the prosthesis parts to be inserted fit exactly. Once the correct fit and mobility of the artificial joint have been checked, the joint replacement is fixed to the bone.
The surgical opening is then sutured shut.
The success of the operation and the longevity of the artificial jointdepend on the patient's aftercare and behavior. A physiotherapist instructs the patient so that they can use the joint again and carry out daily activities independently.
In order to detect complications in good time, which may develop slowly and not initially manifest themselves through symptoms, the patient should attend regular follow-up examinations in the years following the operation.
The topic of "minimally invasive hip and/or knee arthroplasty" is currently the subject of much discussion in the media and has a high public profile.
Unfortunately, the focus is often on the short incision and the beautiful aesthetic results. Much more important, however, is the soft tissue protection of the muscles and muscle insertions during deep dissection with the advantages for support, mobility, sensation after the operation and, in particular, for the protection of the bone substance, which must be removed as little as possible.
There are certain differences in the assessment of minimally invasive hip arthroplasty and minimally invasive knee arthroplasty, which is why these should be discussed separately.
Minimally invasive hip arthroplasty is currently attracting a great deal of public interest, whereby the literature and scientific papers to be found here are in considerable contrast to the unscientific articles that can be found.
More than 2 million entries on this topic can be found in Google alone, whereas far fewer (only a few thousand) articles can be found in medical search engines, and only a small number of these meet the high scientific criteria.
Patients naturally notice the short skin incision, but the surgeon is only marginally interested in this. From a medical point of view, protection of the large hip muscles is of crucial importance. This has a very positive effect in the early postoperative phase.
The preservation of joint and muscle sensation is an important advantage that can allow much faster early rehabilitation and mobilization without limping. If the patient is allowed to put weight on the implants immediately with good pain therapy, he will be able to do this very quickly and well with this good musculature.
Some special instruments are required for minimally invasive hip surgery, and it is advantageous to use special implants such as short stems and bone-sparing titanium shells as cups.
There are various, quite comparable surgical approaches that allow gentle surgery. These include a more anterior, lateral or posterior approach, all of which can deliver good results in the hands of an experienced surgeon. It is crucial that the muscles of the hip joint, which are required for the insertion of the hip joint, are not damaged or even destroyed during the procedure.
The best results with minimally invasive hip and knee procedures are of course achieved through pre-operative patient training, excellent pain relief during and after the procedure and an experienced team of physiotherapists and aftercare professionals. They must encourage the patient to use the joint and muscles that can be loaded earlier as a result of the minimally invasive operation. The hip joint also offers advantages for early rehabilitation.
It remains to be seen whether the long-term results are as good or better than with conventional surgical procedures. This has not yet been definitively decided, although some surgeons believe they can show that less limping, less long-term muscle damage and less impairment of the hip-stabilizing muscles occur with these procedures, even over a longer period of time.
The disadvantages of minimally invasive surgery are, of course, the lack of long-term results that indicate how long a hip joint implanted using this type of surgery will last, although the early results do not suggest any differences.
The smaller step also requires an experienced surgeon who is very familiar with the method, as the view of the pelvic and femur bones is restricted. Sometimes even aids such as curved instruments and navigation have to be used in order to insert the implants correctly without affecting the muscle.
Gentle surgery on the hip joint appears to be advantageous for the patient in various approaches if the surgeon is really experienced and has also learned this difficult technique under the guidance of an experienced surgeon. The learning curve for the surgeon is long and difficult. The advantage for the patient is only given if a very experienced surgeon performs the procedure and has really mastered it.
In minimally invasive procedures, optimal implant positioning and precise leg length assessment for leg length compensation remain difficult.
Statistics show that blood loss and postoperative painkiller consumption appear to be lower than with standard approaches. The quality of implantation in the hip joint appears to be comparable.
Minimally invasive implantation of knee joint endoprostheses can theoretically offer similar advantages to conventionally installed prostheses as in the hip joint.
However, muscle protection in the knee joint is not only dependent on the gentle surgical technique and special approaches, but also on how long the tourniquet lasts and how long the leg is not supplied with blood due to a tourniquet, which presumably causes greater damage to the muscles than gentle surgery can make up for. This must be taken into account.
Most scientific studies on this topic show no differences between conventional access and minimally invasive access of any kind over a 6-month period.
The video shows the principle of total knee joint replacement:
In knee arthroplasty, however, it has been shown that the risk of misplacement of the prosthetic components due to poorer visibility with a smaller access route and smaller skin incision plays a much greater role than in hip arthroplasty. This must be weighed up precisely.
Of course, the surgeon's aim should always be to cause as little damage as possible to the patient's soft tissue, tendons and muscles during the operation. On the other hand, the surgeon must also install the knee joint with particular precision and perhaps even use customized prostheses that are only suitable for this patient. It may also be advisable to use special implantation instruments in order to achieve optimum positioning, which is particularly important for artificial knee joints.
The advantage of minimally invasive approaches does not appear to be as pronounced in the knee joint as in the hip joint. In most studies, there are also no differences to conventional surgical procedures in terms of blood loss and early mobilization.
Not every type of damage to the hip and knee joint can be operated on using minimally invasive techniques. In particular, if severe deformities with bone loss and significant axial deviation are present, the approach must be large enough to ensure that this can be adequately addressed, corrected and treated.
This can be small, gentle and muscle-sparing, but it can also be considerably larger in order to achieve the best possible surgical result.
It is always difficult when patients are very overweight or have congenital changes that need to be corrected and require additional bony measures. A beautiful and good early result is certainly desirable, but it must also be compatible with an excellent long-term result.
In all cases , however, the surgeon must perform a large number of minimally invasive procedures each year in order to guarantee the high training volume required.
In Germany alone, well over 350,000 artificial hip and knee joints are now implanted every year. Naturally, it is desirable that patients not only receive the best possible care, but also undergo rapid rehabilitation, which enables them to return to full resilience for their everyday lives at an early stage. Minimally invasive hip joint surgery can usually make this easier
Where possible, minimally invasive surgery should be used. This always applies to hip and knee joints. However, if this is associated with a risk to the patient, the patient will suffer more harm than good if the implant is positioned incorrectly and soft tissue is damaged by tugging and pulling just to hold the small incision.
The minimally invasive technique could become the new standard for the hip joint. The advantages for the knee joint have not yet been clearly identified.
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