Replacement Parts in the 21st Century
by Susan D. Cole
No longer are we consigned to living the sunset of our lives as victims of crippling arthritis. The advent of joint replacement has vastly changed the outlook for people with arthritis and provided a plethora of new shoulders, knees and hips.
It was still dark when I arrived at the Orthopaedic Center of the Rockies surgical facility. I changed into starched dark blue scrubs and covered my hair with a filmy cap. Soon I was joined by seven other identically dressed figures; the team was assembled. For them it was business as usual. For me it was a rare opportunity to glimpse a medical miracle in the making. Today a patient would be released from a decade of constant pain. Today he would regain the full use of his arm. Today, his shoulder joint would be replaced.
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Arthritis isn’t picky; it affects people of all ages, from all walks of life. Sometimes it’s a result of trauma, like an auto accident, but more often it is just a part of aging. There are various types like degenerative joint disease (osteoarthritis) and disease-based rheumatoid arthritis. Often, in the business, arthritis is simply called the “wear and tear” disease. The advent of joint replacement has vastly changed the outlook for people with arthritis and provided a plethora of new shoulders, knees, and hips. Today, I would see the procedure used to insert an artificial shoulder joint.
The shoulder is a ball and socket joint that allows you to raise, twist, and bend your arm. It enables you to move your arm forward, to the side, and behind your body. Normal shoulders allow these movements smoothly. This is important because the shoulder must rotate through a greater range of motion than any other joint in the body. The rounded part of the upper arm is supposed to be covered with a layer of smooth cartilage. This layer protects the bone as it glides against a dish-like socket that forms the top part of the joint. But sometimes this process is interrupted.
Robert* had spent four decades working in the manual labor field. His left shoulder had borne the brunt of the heavy lifting and pounding of his daily job. Over time, the protective coating of cartilage over the bone started to wear thin and the bones began to rub against each other. The body tries to protect itself against the deterioration of the bones. “Spurs” often form around the edges of the ball socket and bits of cartilage and bone can break loose and become “floaters.” Combined with the friction of bone on bone this translates into pain. As we would soon discover, Robert’s shoulder joint ball was encircled with spiky bone spurs.
Like most of us, Robert had shied away from surgery. He tried medications to control the pain and, eventually, cortisone shots to reduce the inflammation in the joint. But the pain continued and the wearing in the joint began to reduce the function in his arm. If this process goes on too long, Robert would begin to experience numbness and loss of arm function. In extreme cases, the bones in the joint become so worn that there isn’t enough bone to work with and surgical replacement becomes impossible.
When I entered the surgical suite, covered from head to toe in blue and wearing a mask, I received one final warning from the surgical team: stay at least eighteen inches away from all instruments and blue covered tables. I pulled my arms close to my sides. Then I climbed up on the observation ladder overlooking Dr. Sean Grey’s shoulder.
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We were both positioned next to Robert’s left side. Robert was sleeping peacefully under anesthetic. He looked like he was lying in a lounge chair with his head and knees slightly elevated. His body was covered with a blanket and sterile drape and even his face was “tented.” His arm and shoulder had turned a burnt orange from Betadyne antibacterial wash and had been coated with a layer of “Saran Wrap.” The word “yes” had been written on the arm as final insurance that the correct one was being operated on.
After one last look at the CAT Scan and X-rays, Dr. Grey was ready to begin.
A diagonal incision was cut across the joint and the incision deepened with successive cuts. The tiny blood vessels were sealed off as they began to bleed by the physician’s assistant, Brian Hoffman. I was surprised at how little blood there was in the wound itself. Carefully the surgeon spread apart two of the major muscles, the peck major and the deltoid, to expose the joint itself. By avoiding actually cutting the muscles, the surgeon was able to minimize the recovery process for Robert.
Spreaders (retractors) held the muscles apart while the surgeon worked. Finally, the rounded head of the humerus was exposed. It was almost shiny, with virtually no cartilage at all, and jagged with bone spurs. Carefully the surgeon removed the diseased head of the humerus with a small scissor saw. Now a new head would be selected. The surgeon reached into a box filled with dome-shaped plastic patterns. They looked like mushrooms in colorful rows of orange, purple, and green. These would allow the surgeon to determine the exact size of implant Robert needed. At his word, the representative from the implant company (affectionately called the “box boy”) unwrapped the correct apparatus.
It had two major parts: a ball that looked like a golf ball on a tee, and a three-legged dish. The surgeon drilled out several inches of the arm bone, and inserted the “tee.” Robert’s jagged ball joint had been replaced with a shiny new sphere. Now it was time to replace the “dish.” Three holes were drilled in the top shoulder bone. Each hole was then dried with a blow dryer and a type of cement was inserted in each. Quickly the feet of the dish were inserted and held. The surgeon then had a nurse place a ball of cement into his other gloved hand and into mine.
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When the cement becomes hard the implant will be set. Bone cement is a special adhesive that looks like pale gray Play-doh. As I squeezed it, it began to get almost unbearably hot and then it hardened. “You have to be patient,” Dr. Grey explained. “The pressure on the dish must continue until the cement reaches just the right temperature and hardness.”
Finally, the procedure was complete and Robert had a new shoulder. Brian, the physician’s assistant, would sew up the incision and complete the remaining details. The surgeon would take a much needed break; there were seven more shoulder replacements today and the procedure required exertion. It took strength to wrestle the bones between the muscles during the operation. No wonder most orthopedic surgeons are men.
Robert would have several weeks of physical therapy and would have to be careful using his arm for the next year. It is important to ease back into regular activity so that the body can settle properly around the joint. But he was very happy. Yes, there are annoying aspects of having an artificial joint: special screenings and “pattings” at airports, a squiggly scar snaking across the shoulder, and a limit to clothing options (strapless gowns are probably no longer an option, although Robert wouldn’t be concerned about that). But the gains far outweigh the negatives.
As artificial joints become better and better, the surgeries increase in number. Most patients rave about the almost miraculous results and absence of pain. No longer are we consigned to living the sunset of our lives as victims of crippling arthritis. With high-tech, light weight stainless steel prostheses, we are actually worth less, dry weight, than the sum of our parts. But who’s counting? With knee replacements edging towards three-quarters of a million annually, hip replacements closing in on that number, and shoulder replacements at roughly 50,000 in the U.S., chances are that you are acquainted with someone who has a replacement part. +
*patient’s name has been changed to protect his privacy
Susan D. Cole is a college counselor and author of three books and numerous articles. She lives in Fort Collins.