NOTE: This Message was originally addressed to Tom Mckeever
      from Dempt@eskimo.com and was forwarded to you by Tom Mckeever
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> TOTAL JOINT REPLACEMENT IN POST- POLIO
>
> by Marny Eulberg, M.D.
>
> educational meeting, September, 1992, Mercy Medical Center
> Colorado Post-Polio Connections
>
>     
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>
> My qualifications are that first I am a physician, a family practice
> physician not an orthopedic surgeon so I'll give you the generalities
> of the surgery not the nitty-gritty of how many parts there are or
> where the screws go. Secondly I am a polio survivor and had a total
> joint replacement done in March of this year (1992).
>
> The primary reason fro a total joint replacement, in fact pretty much
> the only reason is severe arthritis of the affected joint.
> Occasionally the same procedure is used for a severe fracture that
> cannot be fixed any other way. Several joints can be replaced the most
> common are hip, knee and finger. There are some physicians woh are
> doing replacements of wrists, shoulders and ankles. The technology for
> the last three is stillbeing developed so physicians have not had as
> much experience but it is a possibility.
>
> There are limitations about total joint replacement in folks who've
> had polio; when a joint is removed, part of the bones and ligaments
> holding the bones together are removed and replaced with plastic or
> metal parts. It now depends on your muscles to hold the joint in place
> and keep it from dislocating. So it is not generally appropriate nor
> will it be as useful and work for you if you have a joint replacement
> in a polio affected extremity, unless you have fairly decent muscles
> around that joint. If you have a very weak leg and ;you have arthritis
> in that knee or hip a total joint replacement may not be a good
> choice.
>
> Fortunately joints that have not carried much weight do not get
> arthritis nearly as often, patriculary the wear and tear of
> degenerative arthritis. Total joint replacement can be useful for
> folks who had polio if it is in their good leg, a joint that's wearing
> out from doing work for two legs all these years. It's not the total
> answer, it's not without problems and risks. We don't know how long
> the parts last. They have beendoing total hips for 25 years, total
> knees for 15-20 years before they wear out. We're not exactly sure how
> many times it can be redone...each time some bone is removed so
> there's probably some limit as to how many times a joint can be
> replaced. In general orthopedic surgeons are going to want you to wait
> as long as possible, be as old as possible and still be in good health
> in order to survive the surgery and recover from it well. Surgeons are
> reluctant to do surgery on anyone less than 40 or 50 because we don't
> know how long the parts will last.
>
> After the surgery intensive physical therapy is required to learn how
> to use the joint and to strengthen the muscles around the joint to get
> the range of motion back.
>
> There are risks as it is a big surgery: 1) 50% chance of getting blood
> clots, so anticoagulants are used to thin the blood; 2) there is a
> chance of infection and if we get infection where we have replacement
> hardware it is difficult to git rid of and sometimes to get rid of the
> infection we have to take all the parts out then wait six months to a
> year before another total joint replacement can be done. Surgeons do
> use antibiotics before and after surgery, they wear all kinds of fancy
> headgear, the air is recirculated through special filters in the room.
> 3) Joint replacement surgery is a bloody surgery so surgeons have
> their patients donate two or three pints of their own blood before
> surgery. 4) Also parts can loosen, they are put in with glue but over
> time normal bones around the glue tend to loosen so over the years
> there is a 10-15% chance of parts loosening.
>
> It's not all bad. Obviously if you're hurting a lot, getting so you
> can't do the things you want to do, have restriction of motion so you
> can't bend downto get things anymore or sit comfortably anymore, or
> get in and out of the car comfortably anymore. If the surgery is
> successful, which it is 90 to 99% of the time, you lose the pain and
> gain more mobility. But you lose the ligaments that were there for
> stability so it's not quite the same. It's going to feel and be a
> little more wobbly, it's more likely it may give out in extreme
> positions. You also lose proprioception whis is in a joint and also
> the muscles where you have nerves that tell you where you are in
> spacel; tell you whether that joint is straight or bent or partially
> bent. You can relearn to use some of the other sensors in your muscles
> but you'll probably feel a little more unsteady on that leg. That can
> be a problem if that's been your good leg, the one you've always
> depended on.
>
> Unlike some of you who had orthopedic surgery when you were children
> or younger, 30 or 40 years ago you were put in a cast for six weeks to
> six months to heal; now orthopedic surgeons are aware of how important
> motion is and how joints get stiff. Now, shortly after surgery, thaer
> are machines called CPM's continuous passive motion, that will start
> bending your knee up and down continuously for several hours a day;
> there also are CPM machines for shoulders and other kinds of joints.
>
> Some of the parts of joint replacement are put in with cement, some
> are cementless. There are advantages and disadvantages of both;
> cemented, the joint is weight bearing much more quickly because it's
> pretty solid within a few days after surgery. Cementless, the bone has
> to grow into the metal parts and takes the same amount of time to
> weight on it as a bad break - three to six months before it's full
> weight bearing.
>
> As smart as we think we are, we are not as good at doing anything as
> the Creator was when he made the parts in the first place. None of the
> things we do work as well. We try to duplicate a joint, we try to get
> close, but the original parts were designed best.
>
> QUESTION: Why don't they do as many wrist replacements?
>
> ANSWER: A wrist is not a weight bearing joint so if it is affected
> with arthritis it's usually rheumatoid which can affect the whole
> hand. A wrist is a more complicated joint unlike the hip, which is a
> ball and socket joint. A knee is actually a lot harder than the hip
> because a knee is not just bending and straightening when you step on
> it each time you also turn it in a little bit and out a little bit so
> it's been hard to duplicate that internal and external rotation. With
> a wrist you go up and down, sideways and all sorts of combinations of
> those movements. In the forearm there are two bones; in your wrist
> there are six so to dulplicate that has been a difficulty.
>
> QUESTION: Is anyone doing any joint replacements in the spine?
>
> ANSWER: No, not that I know of.
>
> QUESTION: What are some of the consequences of knee joint replacement
> surgery?
>
> ANSWER: The major consequences despite weakened muscles, is the knee
> may be a little more likely to dislocate, may pop apart and not line
> up right. But, in three to six months after the surgery you're going
> to know that. You'll probably do okay unless you get into a real
> extreme situation where you start falling and putting unusual forces
> around your knee that might dislocate somebody's normal knee too.
>
> QUESTION: Will total joint replacement eliminate all the pain in the
> joint?
>
> ANSWER: In a joint replacement you'll lose the bone and nerve fibers
> in the bone, but you still have nerve fibers in the skin and muscle
> around that joint. So you may not get total pain relief. One of the
> signs if the joint is loosening up is pain.
>
> QUESTION: Sometimes surgeons use ground bone graft in re-replacement
> of the joint. Why don't they use ground bone instead of cement in the
> first place?
>
> ANSWER: It takes longer to heal. The cement hardens fast, within a day
> or two and allows the joint to be weight bearing quicker. The ground
> bone has to heal just like a broken bone so it takes longer before it
> can bear weight. If you had polio you're llgoing to have to be hopping
> on your weak leg or trying to walk with crutches or a walker, so you
> need to have that leg fairly functional as soon as possible.
>
> QUESTION: What are antibiotic marbles?
>
> ANSWER: Antibiotic marbles are just another way of getting the
> antibiotic right into the joint rather than trying to give it in the
> vein where it has to go all through the body and hope it gets the
> right concentration into the right joint. Antibiotic marbles are a way
> of slowly releasing the antibiotic over a period of time.
>
> QUESTION: How soon can you expect relief from pain after surgery?
>
> ANSWER: In hip surgery it's usually much faster than knee surgery.
> Sometimes after hip relplacement the pain is gone immediately. In knee
> replacement it will probably take three to six months before you can
> say, "Ahh, yes, that's better. I'm glad I did it."
>
>     
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>
>
> Source: Colorado Post-Polio Connection, Winter 1992
>
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