Arthroplasty: Definition, Indications, and Contraindications

Arthroplasty: Definition, Indications, and Contraindications

Prepared by Dr. Abdulkadir POLAT

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Overview

Arthroplasty is a reconstructive surgical procedure performed to relieve pain, restore function, and improve quality of life in patients with end-stage joint disease or irreparable joint damage. Understanding core definitions, key indications, ideal patient features, and contraindications is essential for appropriate patient selection and risk reduction.

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Definitions

Arthroplasty

Surgical removal of damaged joint surfaces followed by reconstruction or replacement using artificial materials (implants/prostheses).

Total Arthroplasty

Replacement of all articular surfaces of a joint.

Partial Arthroplasty / Hemiarthroplasty

Replacement of only part of the articular surfaces (e.g., femoral head replacement in the hip).

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Most Commonly Performed Joints

• Hip (THA / hemiarthroplasty)
• Knee (TKA)
• Less common: shoulder, elbow, ankle, MTP joints, small joints

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Major Indications

1) Advanced Symptomatic Osteoarthritis

Most common indication for hip and knee arthroplasty.

Arthroplasty is typically considered when the patient has:

• Severe pain (often including night pain)
• Significant limitation in daily activities
• Failure of conservative treatments (NSAIDs, physical therapy, injections, weight loss)

Note: Indication is primarily based on symptoms and function and may apply regardless of radiographic stage when disability is substantial.

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2) Femoral Neck Fractures

Typically in elderly patients with osteoporosis, especially with displaced fractures.

Key considerations:

• High risk of avascular necrosis and nonunion
• Hemiarthroplasty or THA is often preferred in displaced fractures depending on patient factors.

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3) Avascular Necrosis (AVN)

• Joint-preserving procedures may be appropriate in early disease
• THA is indicated in advanced collapse or secondary arthritis.

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4) Rheumatoid Arthritis and Other Inflammatory Arthropathies

Indicated when there is:

• Joint destruction or deformity
• Disabling pain and functional impairment
• Failure of medical treatment with persistent limitation.

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5) Post-Traumatic Arthritis

Secondary osteoarthritis due to:

• Intra-articular fractures
• Malunion
• Malalignment

Arthroplasty may be required when symptomatic degeneration becomes advanced and function is significantly impaired.

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6) Tumor / Tumor Resection

• Reconstruction after periarticular tumor resection
• Often requires modular tumor prostheses, especially when wide resection leads to major bone and soft tissue loss.

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Ideal Patient Profile (Clinical Selection)

Patients who most commonly benefit from arthroplasty include those with:

• Severe chronic joint pain (often with night pain)
• Markedly reduced walking distance
• Difficulty with basic activities of daily living (stairs, sitting, rising)
• Failure of adequate conservative treatment
• Supportive radiographic findings such as:
  • Joint space narrowing
  • Osteophytes
  • Subchondral sclerosis
  • Deformity

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Contraindications for Arthroplasty

Absolute Contraindications

• Active joint infection
• Systemic sepsis
• Severe neurologic/neuromuscular disorder compromising ambulation
• Medical condition prohibiting anesthesia

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Relative Contraindications

• Very young, highly active patient (risk of early revision)
• Morbid obesity
• Severe peripheral vascular disease
• Poorly controlled diabetes or active inflammatory disease
• Osteoporosis (increased risk of loosening, particularly in revision settings)

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Key Clinical Pearls (OrthoRico Style)

• Arthroplasty decisions are primarily symptom- and function-driven, not solely radiograph-driven.
• Infection is an absolute contraindication and must be excluded.
• Patient optimization (glycemic control, weight management, vascular status) directly impacts outcomes.
• Tumor and post-traumatic cases often require specialized implants and advanced planning.

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Take-Home Message

Arthroplasty is a definitive surgical solution for end-stage joint pathology when pain and disability persist despite conservative management. Appropriate patient selection requires clear understanding of indications, ideal clinical profile, and contraindications to minimize complications and maximize long-term outcomes.

Preoperative Optimisation Checklist (Arthroplasty)

1) Infection Risk & Screening

• Any active infection? (skin, urinary, dental, respiratory, etc.)
• If suspicious: CRP/ESR, clinical exam, and targeted consultation if needed
• Skin check: intertrigo, ulcers, cellulitis, active dermatitis/psoriasis flare
• Prior joint surgery or history of PJI → perform risk stratification

2) Medical Optimisation

• Diabetes: HbA1c target (per institutional policy) + perioperative glucose plan
• Cardiac risk: consider cardiology evaluation when indicated; plan antiplatelet/anticoagulant management
• Pulmonary: optimise COPD/OSA; support smoking cessation
• Renal/hepatic disease: medication dose adjustments and perioperative fluid/electrolyte strategy
• Anaesthesia fitness: ASA assessment and required pre-op workup

3) VTE (DVT/PE) Risk Plan

• Assess VTE history, malignancy, obesity, immobility, thrombophilia
• Prophylaxis plan: mechanical + pharmacological (per local protocol)
• Early mobilisation strategy

4) Haemoglobin & Blood Management

• Screen for anaemia (Hb, ferritin ± B12/folate as appropriate)
• Correct iron deficiency preoperatively when present
• Bleeding risk assessment / TXA plan (if appropriate)

5) Nutrition & Weight

• Morbid obesity: higher risk (infection, wound complications, medical events)
• If malnutrition suspected: albumin/total protein and dietitian support
• Set practical, patient-specific weight and nutrition goals

6) Bone Health

• Osteoporosis risk: age, fragility fracture history, chronic steroid use
• Consider DXA and initiate treatment when indicated
• Note implications for fixation choice (cemented vs cementless) and fracture risk

7) Rheumatology / Immunosuppression Plan (if applicable)

• Perioperative management of DMARDs/biologics (aligned with local / EULAR–ACR practice)
• Stress-dose steroid considerations if on chronic steroids
• Infection risk assessment and optimisation

8) Patient Preparation

• Set expectations: pain control, rehab timeline, walking goals
• Home setup and support needs (stairs, caregiver availability)
• Prehabilitation: quadriceps, hip abductors, gait training

Hip vs Knee Arthroplasty: Practical Differences in Indications (Quick Table)

Topic	Hip Arthroplasty (THA / Hemiarthroplasty)	Knee Arthroplasty (TKA / UKA)
Most common indication	Advanced symptomatic hip OA	Advanced symptomatic knee OA
Fracture-related indications	Displaced femoral neck fractures in elderly: hemi/THA common	Primary TKA for fractures is uncommon; more often post-traumatic OA later
AVN	AVN with collapse/secondary arthritis is a key indication for THA	AVN less common; TKA indication more selective
Inflammatory arthropathy	RA/inflammatory arthritis with hip destruction/deformity	RA/inflammatory arthritis with knee destruction/deformity
Post-traumatic arthritis	After acetabular or femoral head/neck injuries	Common after tibial plateau or distal femur fractures
Deformity/alignment focus	Limb length, offset, rotation, COR restoration	Varus/valgus deformity, flexion contracture, instability, balancing
Partial replacement	Hemiarthroplasty (especially fractures)	UKA in selected unicompartmental disease
Primary planning goal	Pain relief + restoration of hip biomechanics (COR/offset)	Pain relief + stability + alignment + balanced gaps

References

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5. Ritter MA, Meding JB. Total knee arthroplasty: Indications, techniques, and results. Instr Course Lect. 2004;53:267–275.
6. Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995;77(3):459–474.