Hips :: Knees :: Shoulder :: Elbow :: Back & Spine
Foot & Ankle :: Paediatric Orthopaedics ::Sports Medicine
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Additional Information on Hip and Knee Surgery
This website and the general handout I provide in the office will outline all the general principles of hip and knee replacement surgery, the realistic outcomes and things you need to be aware of. This handout provides extra information that you may find useful.
Before surgery you will need to attend a pre-admission clinic at the hospital where you will meet a clinical nurse who will go over the basic admission process and post operative course. In addition there are routine pre-operative blood tests and an ECG that are performed. Occasionally a chest X-ray is needed.
If any significant abnormality is detected in your pre-operative visit, the appropriate action/referral will occur to investigate and treat any issue needing attention.
If you see a cardiologist routinely and are on a regular blood thinner, please advise your cardiologist you are having a joint replacement and that you need to stop blood thinners such as warfarin, plavix/clopidigrol and aspirin. I am happy to perform the replacement under low dose aspirin (100mg) if your cardiologist insists.
MEDICATION YOU NEED TO STOP
Please stop all anti-inflamatories (mobic, celebrex, nurofen, voltaren etc ) 1 week before surgery.
Herbal medication (fish oils, garlic, echinacea, kava, glucosamine etc ) need to be stopped 1 week before surgery as they can cause excessive bleeding.
If you are diabetic it is important that your diabetes is under proper control. Your GP will usually see to this.
Dental issues. If you have any major dental issues requiring attention please get this done before your joint replacement.
If you have any prostate issues (Males), please inform me as every patient needs a urinary catheter for 24-48 hrs and prostate problems can result in a difficult catheterisation therefore it is best to have a urologist consult if need be.
ANTISEPTIC SHOWER SOAP
You will be given an antiseptic soap at the pre-admission clinic that you need to shower with for the 2 days prior to surgery. This will reduce the risk of a skin infection after surgery.
Please DO NOT shave hair around the hip or knee before surgery. The hospital nursing staff will shave the area if needed using special clippers that do not cut the skin.
The surgery is usually carried out under a combined spinal anaesthetic and light general / sedation. Spinal anaesthesia is safe and has been shown to assist in reducing complications during joint replacement surgery. It provides excellent post operative pain relief. The Anaesthetist will discuss this with you in detail.
A urinary catheter is used in all cases. Patients with a spinal as well as those who don't have a spinal but get morphine for pain relief, will invariably have difficulty passing urine for 12-18 hrs and hence the need for a catheter. It is much easier to pass a urinary catheter when you are sedated just before surgery than to pass a catheter when you are awake on the ward with a full bladder.
Removing a catheter is a very easy process done by the ward nurses and is not painful at all.
Antibiotics are given intravenously for 24-36 hrs and your IV cannula will remain in your arm for this period. The cannula is also often attached to a PCA machine which allows you to administer pain killers when needed. I do not use a PCA in all patients as often (such as in the minimally invasive hip approach) the local anaesthetic and oral pain tablets are sufficient.
You will be given the appropriate pain relief regime that the anaesthetist will order. This regime is tailored to each individual's needs.
The key to preventing thrombosis is mobilisation and exercise . Every patient is fitted with a calf compressor after surgery. This machine compresses the calf intermittently which promotes venous blood flow back to the heart and prevents clots. The compressors are used whilst in bed for the first 48 hrs. The sooner you get out of bed and walk the less the risk of a thrombosis.
In addition to early mobilisation and calf compressors you will either be given oral aspirin or clexane injections to assist in reducing the incidence of thrombosis.
I encourage 2 walks a day whilst in hospital. The more you can manage the better but don't overdo things.
Whilst the risk of a thrombosis is low despite all preventative measures they can still occur and are treated accordingly. I do not perform a routine Doppler scan to check for thrombosis as all studies have shown that routine scanning is a waist of time.
ANTIBIOTIC POLICY FOR PROCEDURES FOLLOWING JOINT REPLACEMENT
The risk of getting an infection in your replaced joint is extremely rare following routine procedures such as dental work and colonoscopies.
For routine dental cleaning after joint replacement surgery there is no need to take antibiotic prophylaxis. For major dental work after a joint replacement ( such as root canal etc) I recommend a single dose of 2gm amoxicillin 1 hour before provided you are not allergic to amoxil.
COLONOSCOPY, Prostate, Bladder or Gynaecological procedures after joint replacement :
Routine colonoscopy without any major biopsies or risk of bleeding do not require prophylactic antibiotic cover.
Surgery to the bladder, bowel, gynaecological and prostate surgery require a single intravenous antibiotic dose that is administered by the surgeon at the time of the procedure. Please advise them that you have a joint replacement.
Some other things about replacements:
All knee replacements have some numbness on the outer side of the wound. This is unavoidable as there is a skin nerve that goes directly across the skin incision and hence is purposefully cut in order to open up the knee joint. It is a minor nerve and the numbness will tend to lighten up over time but is never completely eliminated.
All knee replacements click. This is normal. It is simply the metal and polyethylene parts touching each other and is no cause for alarm. It is how the joint functions. The clicking noise will tend to get quieter over time.
Hip Replacements can occasionally click at the extreme of motion. No cause for alarm. Some ceramic on ceramic hip bearings can squeak (rare) again no cause for alarm.
Intraoperative stability is important in hip replacements. Rarely one may need to tension the hip which can lead to a leg length discrepancy. Various techniques are used to minimise this possibility.
The key to a successful recovery is motivation to mobilise and to do the exercises the physiotherapist will show you. Hip and Knee replacement surgeries have excellent outcomes provided the patients assist in a motivated recovery.
Click on the topics below
Normal Anatomy :: Hip Arthroscopy :: Anterior Hip Replacement
Femoroacetabular Impingement :: Total Hip Replacement THR
Hip Resurfacing :: Revision Hip Replacement
Complex Hip Surgery :: Periacetabular Osteotomy :: Prevent Osteoarthritis :: Hip Fracture
Normal Anatomy of the Hip joint
How does the Hip joint work?
Find out more in this web based movie.
Total Hip Replacement (THR)
Total Hip Replacement (THR) procedure replaces all or part of the hip joint with an artificial device (prosthesis) to eliminate pain and restore joint movement.
Find out more about Total Hip Replacement (THR) with the following links.
Anterior Hip Replacement
Direct Anterior Hip Replacement is a technique in which hip replacement surgery is performed through an alternative approach compared to conventional hip replacement surgery. Historically, hip replacement surgery was performed utilizing traditional posterior or lateral approaches. This necessitates that certain muscles or tendons are cut in order to access the hip joint and perform the surgery.
Find out more about Anterior Hip Replacement with the following links.
Hip Arthroscopy is a relatively new surgical technique that can be effectively employed to treat a variety of Hip conditions.
Find out more about Hip Arthroscopy with the following link
Femoro Acetabular Impingement FAI
Femoroacetabular Impingement FAI is a condition resulting from abnormal pressure and friction between the ball and socket of the Hip joint resulting in pain and progressive Hip dysfunction. This when left untreated leads to the development of secondary osteoarthritis of the hip.
Hip Resurfacing or bone conserving procedure replaces the acetabulum (hip socket) and resurfaces the femoral head. This means the femoral head has some or very little bone removed and replaced with the metal component. This spares the femoral canal. Find out more about Hip Resurfacing from the following options.
Find out more about Hip Resurfacing with the following links.
Revision Hip Replacement
This maybe because part or all of your previous hip replacement needs to be revised. This operation varies from very minor adjustments to massive operations replacing significant amounts of bone and hence is difficult to describe in full.
Find out more about Revision Hip Replacement with the following links.
Complex Hip Surgery
Find out more about Complex Hip Surgery with the following links.
Periacetabular osteotomy is the surgical procedure indicated in hip dysplasia and it involves cutting the bone around the acetabulum so as to fit the head of the femur bone into acetabular socket. This method was developed and performed by Professor Reinhold Ganz and therefore it is also called as Ganz osteotomy.
THE PERIACETABULAR OSTEOTOMY
Periacetabular Osteotomy is a hip preserving procedure performed to correct a congenital deficiency of the acetabulum:
Acetabular dysplasia is a condition defined by inadequate development of an individual's acetabulum. The resulting acetabulum is shallow and "dish shaped" rather than "cup shaped". The upper portion (roof of the acetabulum is obliquely inclined outward rather than having the normal horizontal orientation.
Because of these abnormalities, the superior and usually anterior femoral head are incompletely covered by this dysplastic acetabulum. Individuals with acetabular dysplasia usually develop through childhood and adolescence without symptoms or knowledge of their abnormality.
By the age of 30 however the patient typically experiences pain from their hip and they often seek medical evaluation and an X-ray discloses the abnormality (acetabular dysplasia). Other patients may have been treated for hip problems as an infant or child.
Acetabular dysplasia is often also associated with abnormalities in the shape of the upper femur which may contribute to the patient's hip symptoms.
Acetabular dysplasia is associated with an abnormally high stress on the outer edge (rim) of the acetabulum which leads to degeneration of the articular cartilage (arthritis). It is also possible for breakdown of the acetabular labrum (rim cartilage of the acetabulum) or a fatigue fracture of the rim of the acetabulum to occur as a result of this rim overload. Any one or a combination of these conditions can cause hip pain sufficient for the patient to seek medical evaluation and treatment.
When the diagnosis of acetabular dysplasia is made, the X-ray also usually shows a sign of arthritis which is most commonly an acetabular cyst though increased bone density, a femoral head cyst, osteophytes (bone spurs), and/or cartilage thinning may also be present. If the dysplasia is left uncorrected worsening of the arthritis is predictable and often progresses to a severe status within a few years and sometimes even a few months. For the patient, this means increasing hip pain, progressive loss of hip motion, and worsening
Periacetabular Osteotomy (PAO) is a surgical treatment for acetabular dysplasia that preserves and enhances the patient's own hip joint rather than replacing it with an artificial part. The goal is to alleviate the patient's pain, restore function, and maximize the functional life of their dysplastic hip.
PAO is a procedure that was developed and first performed in 1984 in Bern, Switzerland by Professor Reinhold Ganz.
Two parts comprise the hip joint: a ball on the upper end of the thigh bone (femur), called the head of the femur, and a socket in the pelvis known as the acetabulum. The hip joint, like other joints, is made up of specialized structural elements that serve as precisely fitting moving parts. The head of the femur rotates freely within the smooth, concentric surface of the acetabulum. An extremely low friction tissue, hyaline cartilage, lines this joint as well as others in the human body. The friction between two hyaline cartilage surfaces is much less than the best man-made bearing.
A normal acetabulum "covers" the upper (superior) portion of the head of the femur as well as a partial portion of the front (anterior) and back (posterior) of the femoral head "Periacetabular" means around the acetabulum. "Osteotomy" means to cut bone. Simply put, the PAO cuts the bone around the acetabulum that joins the acetabulum to the pelvis. Once the acetabulum is detached from the rest of the pelvis by a series of carefully controlled cuts, it is rotated to a position of ideal coverage as dictated by the specific acetabulum's unique anatomy. PAO thereby re-orientates the acetabulum by changing its rotational position. The dysplastic roof that incompletely covers the femoral head is brought over the head to give the head a normal coverage and also brings the roof from an oblique to a horizontal position.
Other subtle changes typically also occur. Anterior coverage may increase. Also the shortening of the extremity and lateralization of the joint which are often a part of acetabular dysplasia can also be improved. Individual cases of dysplasia however present with their own unique deficiencies and the PAO must often be tailored to solve these unique problems. X-rays take during surgery confirm the correct position of the acetabulum and screws (typically 3) are inserted into the bone to maintain the acetabulum's new corrected position during bone healing.
A proximal femoral osteotomy (cutting and repositioning the bone of the upper femur) is also advisable in about one out of 20 patients who undergo PAO surgery in order to correct abnormalities related to the femur. The indication for this is not always known until during the PAO operation. The femoral osteotomy is then completed during the same surgery though a second incision is necessary.
As with any other major hip surgery, there is some risk of complications. Surgical wound infection and injury to major nerves or arteries is possible. Non-union (lack of healing) of the bone following the osteotomy is also possible.
Studies have shown PAO to be a relatively safe operation with the chance for any one of these complications to be less than one percent.
The Natural History of an untreated shallow hip is to develop osteoarthritis in the patients 30’s or 40’s
The periacetabular osteotomy is designed to delay the onset and progression of hip arthritis. There is still a possibility that despite the surgery hip arthritis will continue to progress and very rarely may develop sooner if a complication arises
The Operation and Aftercare:
A cell saver is used in the operation to reduce the degree of blood loss.
An Epidural Anaesthetic as well as a General Anaesthetic is used during the surgery. The Epidural is for pain relief and is usually kept in for 3 days. A urinary catheter is placed in your bladder for 3 to 4 days. It is common for the vaginal or scrotal skin to swell for about 1 week post operatively. The swelling will always resolve. Patients spend the two hours following surgery in the recovery room where nurses closely monitor them.
The same team of medical specialists and nursing staff cares for each patient pre- and post-operatively. Included among the team's post-surgical priorities are pain management, preventing infection, and the prevention of deep vein thrombosis (blood clots in large veins), and pulmonary emboli (blood clots traveling through veins to the lungs).
Patients begin physical therapy as soon as possible to improve hip motion and muscle function and to learn to use appropriate assistive devices such as crutches or a walker. During the first eight weeks following surgery, the operated hip should bear no more than a limited weight of 5Kg’s. Placing full weight on the operated side prior healing may lead to screw breakage and for the osteotomy to lose its position. Too vigorous exercise such as resistive exercise against weights can also cause failure. If failure occurs, re-operation may be necessary and the chance of developing arthritis is greatly increased.
The usual hospital stay is 5 to 7 days and depends on how rapidly pain subsides and progress in physical therapy. At discharge pain medication is prescribed as well as an anticoagulant to prevent blood clots. Some degree of pain after discharge is natural which may increase or decrease on different days but the general trend should be toward decreasing pain. Some patients may sense an occasional "click" or "pop" in or around the hip. Numbness and a tingling sensation is common around the incision area. It is usual to feel numb on the outer aspect of the thigh due to bruising of a small skin nerve. This usually resolves but if not it does not cause any functional problems in the future.
After discharge if you experience severe or consistent pain or have redness, swelling and/or wound drainage please contact the hospital
Follow-up outpatient visits are necessary to monitor progress by X-ray and physical examination. The first follow-up visit is usually scheduled about 6 weeks after surgery and the second at 12 weeks.
At 8 weeks after the surgery the patient is allowed to progress to full weight bearing and work toward discontinuing use of the crutches. Muscle strengthening exercises often with the help of a physical therapist are also started. Progress in walking depends on return of muscle strength. The majority of patients are walking without support by 3 months after the surgery Subsequent follow-up visits are at 6 months, I year and 2 years after surgery and then at 2 year intervals. Screws are usually removed after 6 to 8 months as a small day only procedure with minimal discomfort.
Osteotomy should not be thought of as an inferior second choice to total hip replacement that the young patient with early arthritis must undergo because he or she is too young for total hip replacement. The results after PAO, which preserves the patient's own hip, justify its use and the long term results can be better than what the patient could have obtained from a hip replacement. The patient's own hip is a living tissue with self-maintenance capabilities, whereas deterioration with time is inevitable for an artificial part.
It is improtant to understand that a pelvic ostetomy (PAO) is not going to make your joint "normal" again. The surgery is indicated to releave pain from a dysplastic (shallow) joint and to try and delay the progression of osteoarthritis. Osteoarthritis will always develop if one has a shallow hip. A well done PAO will delay (or possibly even prevent) the development of end stage arthritis of the shallow hip. After recovering from a PAO you should not participate in high impact running sports or competetive impact sports. You are able to walk, hike, play tennis, swim, cycle, excersise sensibly in the gym and snow ski. One always looses a little hip flexibility after a PAO.
Appropriately selected patients have an 85% chance of a successful operation and pain free hip 20 years after the surgery.
Results of periacetabular ostetomies show the majority of patients with poor results did not have an immediate poor result but were benefited by the PAO for a variable period (6-12 years) before requiring further surgery.
For patients who develop a poor result some time after their PAO surgery the cause is typically advancing hip arthritis. These patients are almost always best treated by total hip replacement surgery. For these patients the previous PAO has typically enhanced the acetabular bone with the increased femoral head coverage. Enhancement of a dysplastic acetabulum contributes to the success of a later total hip replacement by making the stability of the prosthetic acetabulum more reliable.
I trust the information provided in this handout will give you a better understanding about your hip problem and the surgical treatment available. Please do not hesitate to ask any questions.
Find out more about Prevent Osteoarthritis with the following links.
Hip fracture is a break in the upper end of the thigh bone forms the hip joint. It usually occurs in elderly people aged over 65 years either due to a fall or a direct blow to the hip. Certain medical conditions such as osteoporosis, cancer and stress injuries weaken the bone and increase the risk of hip fractures in elderly people. Often, hip fractures require surgical correction and the surgery depends on the part of the upper femur bone affected.
Find out more about Hip Fracture with the following links.