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Operations


ANATOMY OF THE NORMAL HIP JOINT

 

The hip joint is located where the thigh bone (femur) meets the pelvic bone. It is a “ball and socket” joint. The upper end of the femur is formed into a round ball (the “head” of the femur). A cavity in the pelvic bone forms the socket (acetabulum). The ball is normally held in the socket by very powerful ligaments that form a complete sleeve around the joint (the joint capsule). The capsule has a delicate lining (the synovium). The head of the femur is covered with a layer of smooth cartilage that is a fairly soft, white substance about 3-4mm thick. The socket is also lined with cartilage (also about 3-4 thick). The cartilage cushions the joint, and allows the bones to move on each other with very little friction. An x-ray of the hip joint usually shows a “space” between the ball and the socket because the cartilage does not show up on x-rays. In the normal hip this “joint space” is approximately 6-7mm wide and fairly even in outline.


 

DISEASES OF THE HIP JOINT


The term “arthritis” literally means inflammation of a joint, but is generally used to describe any condition in which there is damage to the cartilage. Inflammation, if present, is in the synovium. The proportion of cartilage damage and synovial inflammation varies with the type and stage of arthritis. Usually the pain early on is due to inflammation. In the later stages, when the cartilage is worn away, most of the pain comes from the mechanical friction of raw bones rubbing on each other.


There are two broad categories of arthritis:


Osteoarthritis mainly damages the joint cartilage, but there is often some inflammation as well. It usually affects only one or two major joints (usually in the legs). It does not affect the internal organs. The cause of hip osteoarthritis is not known. It is thought to be simply a process of “wear and tear” in most cases. Some conditions may predispose the hip to osteoarthritis, for example, a previous fracture that involved the joint. Growth abnormalities of the hip (such as a shallow socket) may lead to premature arthritis. Some childhood hip problems later cause hip arthritis (for example, a type of childhood hip fracture known as a Slipped Epiphysis; also Perthe’s Disease). In osteoarthritis of the hip the cartilage cushion is either thinner than normal (leaving bare spots on the bone), or completely absent. Bare bone on the head of the femur grinding against the bone of the pelvic socket causes mechanical pain. Fragments of cartilage floating in the joint may cause inflammation in the joint lining, and this is a second source of pain. X-rays show the “joint space” to be narrowed and irregular in outline. There is no blood test for osteoarthritis.


Rheumatoid Arthritis (R.A.) starts in the synovium and is mainly “inflammatory”. The cause is not known. It eventually destroys the joint cartilage. R.A. affects multiple joints simultaneously.


 

SYMPTOMS OF HIP DISEASE


The most prominent symptom of hip arthritis is pain. Most patients think that their hip is in the region of the buttocks and are surprised to learn that hip pain is most commonly experienced in the groin. The pain can radiate down the front of the thigh for a few inches as well. Occasionally it goes all the way down the thigh to the knee (“referred pain”). This is because the hip and knee have an overlapping nerve supply. In fact, in some patients with hip disease, knee pain may be the only symptom!


Most patients with significant hip disease have a limp and one leg may feel shorter than the other. Bone on bone contact occasionally causes the patient to feel or hear the hip creaking during walking. 


As the disease progresses, the hip becomes stiff and less movement is possible. This may make it difficult for you to clip your toenails or to tie your shoelaces, and may also limit your ability to spread your legs. Quite often the first step or two after prolonged sitting may be especially painful. Eventually you may have to “take a break” to ease the pain after walking only short distances. The distance you can walk will gradually decrease until you can only take one or two steps at a time.


 

WHEN SHOULD YOU HAVE HIP REPLACEMENT SURGERY?


If your symptoms are mainly from an arthritic hip, and you are physically fit enough to undergo surgery, when should you consider having your hip replaced? Hip arthritis is not a life-threatening condition: the procedure is “elective”. There are possible complications associated with hip replacement surgery. The decision to have the operation is a highly personal matter, and only you can make that decision. If you are confined to a wheelchair and in constant pain, it is a decision that will be quite easy for you to make, even though the operation (any operation) involves taking a certain amount of risk. If your disability is great enough, the potential benefits are worth the risk. If your arthritis is responding to conservative measures, and you can still walk long distances without a cane, you don’t need a hip replacement.


If you are in doubt about whether or not you should have the surgery then a second opinion may give you the reassurance you need. You may also discuss your hip problem with your family doctor or a rheumatologist, and other people who have had hip replacements. The nice thing to know is that you need never be crippled because of your hip arthritis, because of the option of hip replacement available to you.


Here are some facts to help you make your decision:


1. Once you have hip arthritis it will never get better. It won’t even stay the same. It will generally progress as time goes by. There are no exercises, diets, vitamins, or minerals (including calcium), which will make any difference. 


2. The rate of further deterioration varies greatly from person to person. The pain may become unbearable within six months for one person yet drag on at a tolerable level for several years in another person who has the same degree of arthritis.


3. You will never need a hip replacement if you are willing to live with the pain.


4. You may believe that it is better to delay having the operation in hope that the technology of hip replacement will improve with time. However, the rate of progress in this area is extremely slow, so this is something to consider only if you are very young, or your arthritis is mild and you can easily live with your symptoms.


5. More than 98% of patients who have a hip replacement operation have no major complications.


 

TOTAL HIP REPLACEMENT SURGERY


You will be advised of the time to arrive at the hospital, and you should have had nothing to eat or drink for 6 hours prior to the operation. Both the anaesthetist and myself will visit you before the operation. I will mark your leg so that the correct side will be operated on.


Please take your other medications up to the day of your operation but not on the morning of surgery until this is discussed with the anaesthetist. If you are on blood thinners (warfarin) please contact me to confirm when you should stop.


The anaesthetist will also discuss the advantages of general anaesthesia (in which you


are unconscious) and spinal anaesthesia in which the lower half of your body is completely numb (and pain-free) and you will sleep lightly but not be unconscious.


 

IN THE OPERATING ROOM


First-time hip replacements take about 1-2 hours of operating time. You will be in the operating room for about another hour (for anaesthetic induction and other necessary procedures before and after the operation). Revision operations can take up to 4 hours of operating time (or even more). When the operation is over I will ring your family to report your progress.


At the time of the operation the arthritic femoral head is removed. It is replaced with a metal ball, which is attached to a metal stem. The stem is either cemented into the hollow marrow space of the femur, or just impacted in and the bone allowed to grow into the surface. The worn out hip socket is lined with a socket, which is held into a metal shell that the bone grows into. The painful parts of the arthritic hip are completely replaced with metal and plastic surfaces.


In the very young I have been inserting both the stem and socket without cement and using a metal on metal joint that hopefully will last longer, but this is experimental and not recommended for everyone as we don’t know how it will do over 20 years.



WHAT TO EXPECT AFTER LEAVING THE OPERATING ROOM


You will wake up in the recovery room. You will be comfortable and usually surprisingly free of pain. You cannot be visited in the recovery room, but can be visited as soon as you get to your room. You will be in the recovery room for about 2 hours. 


 

PAIN CONTROL


A major breakthrough in pain-management has been the development of a device known as the PCA Unit (Patient Controlled Analgesia). This is a computerized device, which attaches to your intravenous line. You are able to self-administer small doses of narcotic by pressing a button at the end of an electric cable. The machine is pre-programmed so that it is not possible for you to give yourself more narcotic than is safe. It has a number of advantages. Firstly, you do not need to call a nurse to administer pain injections. Secondly, because only small doses are given at a time, you will not be as drowsy as you might otherwise be, if you were given big-dose injections every 3 hours. 


Most patients are surprised at how little pain they have after the operation.


You must ask for sleeping pills, pain pills or pain injections because the nurses will not automatically give them. Do not restrict yourself from using the PCA machine or asking for pain medications. We do not want you to be in pain. You need not fear that you will become addicted to the pain medication.


  

PHYSICAL THERAPY


The physio will get you up on the first day after surgery, and will teach you the right amount of weight to put on your operated leg. Essentially unless I tell you otherwise you can put as much weight on your leg as is comfortable. You will also be taught all the necessary restrictions to prevent your hip from dislocating.


During waking hours you should “pedal” your feet up and down every five minutes or so, the entire time you are in the hospital, to help prevent blood clots from forming.


By the second or third day after surgery most patients no longer have an IV, and are feeling quite well. Many patients complain that the operated leg feels “too long” for the first few weeks after surgery, even when the legs are absolutely equal in length. It can take several months for this false sensation to disappear.


GOING HOME


You can go home when your temperature is normal, your wound looks okay and you are able to get in and out of bed by yourself, and go to the bathroom by yourself. Some patients reach this goal within 3 days; others take as long as 7 days.


 

EQUIPMENT YOU WILL NEED AT HOME


While you are in the hospital, the physio will help you decide what equipment you will need when you get home. You will need crutches or a walker to help with walking for about 3 to 4 weeks after surgery. A toilet seat extension will be needed so that you do not sit too low on the toilet. 


 

WHAT TO EXPECT AFTER YOU GET HOME


You will be able to go home in a regular sized car. It is better if someone can be at home with you for at least portions of each day to assist you with shopping, meal preparation, etc. Constant nursing care is rarely needed at home. 


Your first follow-up appointment will be made and there will be a card with the time and date in your admission folder. This visit is usually four weeks after your surgery. If any problem develops you will need to come in sooner. Until then continue all the restrictions which you were taught in the hospital. If any problem develops you will need to come in sooner. 


It is not uncommon to develop some swelling of the knee, foot and ankle in the weeks after surgery. If this occurs, you should elevate your leg on pillows when you are not up and about.


Wound sutures are internal and do not need to be removed. You can shower once the wound is dry. It is best to shower rather than get into a bath. We recommend avoiding a bath for at least two months after surgery. A shower stool is helpful so as to avoid slipping while taking a shower.


Once you get home you are not expected to stay in bed. You should be up and about on your walker or crutches most of the time, but rest as much as you need to. You may lie on the operated side when it is comfortable. However, when you lie on either side for at least the first 4 weeks after surgery, you should put one or two fluffy pillows between your knees. This is to make you more comfortable and also to prevent dislocation of the hip joint. You should not try to cross your legs for the first 4 weeks after surgery. You should not bend your thighs up to a greater than 80 degree angle. It will therefore be difficult for you to pick up objects from the floor, and also for you to put on your shoes and socks. You should strictly avoid low chairs, low stools, low toilet seats, since they may cause the hip to dislocate.


Please use your stockings until you are walking well without crutches.


 

DRIVING AFTER HIP REPLACEMENT SURGERY.


Driving is best avoided until about 4-6 weeks after the surgery, but generally you will be safe once you can walk well off the crutches.



RETURNING TO WORK AFTER HIP REPLACEMENT SURGERY


You will probably not return to work for 4-6 weeks after the operation. Quite a few patients do return earlier, depending on the nature of their work, and depending on how important it is for them to be back at work.


 

PROBLEMS YOU MAY ENCOUNTER AT HOME


1. Excessive swelling of your leg and foot: It is not uncommon to develop some swelling in the first few weeks after surgery. If this occurs, you should elevate your leg whenever you are not up to walking. However, excessive swelling of the foot and lower leg can be due to thrombosis (blood clots) in the veins in the leg. I should be notified if swelling is associated with pain or tenderness in the calf muscles, or if the swelling just seems over-excessive, and doesn’t respond to elevation.


2. Chest pain, a cough or shortness of breath may be signs of embolism. Please do not ignore these symptoms. Call me right away.


3. Drainage from the wound, or increasing redness around the wound, could signify impending infection. Our office should be notified, and in most instances you will need to come in and let me take a look at it.


4. High fever could also be a sign of impending infection. 


5. Increasing hip pain. Pain should be decreasing from day to day. If it seems to be steadily increasing, let me know.


6. Dislocation of the hip. If your hip dislocates, you will immediately recognise what has happened. You will have severe hip pain, your foot will “point the wrong way” and you will not be able to walk.


7. The operated leg feels too long. After hip replacement most patients complain that the operated leg feels too long. This is usually a false sensation and goes away after a month or two. It is somewhat akin to the feeling one gets that the filling is too prominent after the dentist fills a tooth. A week or so later the filled tooth feels normal! A great deal of effort is put into trying to get the leg lengths correct. But accurate measurement is very difficult during surgery. It is common to be off by 5mm or so. Most people easily adjust to a difference of 5mm, and are hardly aware of it. Many people without hip or leg problems have up to 10mm in difference. Sometimes, however, the patient may feel that the leg is 10-15mm or more too long when, in fact, the leg lengths are absolutely equal. 


Very occasionally during surgery a major leg length difference is caused due to occasional technical problems, mainly when operating on the thigh bone during the operation. If this occurs then I will discuss this with you in detail after the operation and a shoe raise may well be required. It is always my intention to make your legs the same length.


8. Thigh Pain. Patients with hip replacements without cement may have thigh pain for 18 to 24 months after surgery until the implant is securely locked in place by bone ingrowth. This pain can be expected to be minimal and can be ignored.



IN GENERAL, THE LEG SHOULD BE GETTING BETTER EACH DAY. IF YOU THINK YOU ARE GETTING WORSE IN ANY WAY, PLEASE GIVE ME A CALL.



TOTAL HIP PRECAUTIONS FOR THE FIRST 6 WEEKS AFTER SURGERY


1. Don't bend your operated hip beyond 80°


- Don't raise your knee higher than your hip.


- Don't sit on sofas or low chairs. Put cushions down first.


- Use an elevated toilet seat.


- Don't lean forward while sitting. 


-Get assistance for lower extremity dressing.


2. Don't allow your legs to slouch or cross.


 

COMPLICATIONS OF HIP REPLACEMENT SURGERY


Unfortunately, even the most minor of surgical operations carries some risk of complications occurring. Hip replacement surgery is very successful, and complications are relatively uncommon, considering the complexity of the procedure. It is fair to say that you have about a 96% chance that you will go through the operation without any significant complication occurring. The most common complication is blood clots in the legs. The most serious complication is infection. The most important long-term complication is loosening.


1). Blood clots in the veins of the legs are the most common complication of hip replacement surgery. As long as the clots remain in the legs they are a relatively minor problem. Occasionally, they dislodge and travel through the heart to the lungs (pulmonary embolism). This is a potentially serious problem, since (very rarely) death can result from embolism. The chances of this are one in about 5000. They are usually not dangerous if appropriately treated, but may delay your discharge from the hospital for two or three days. If you are not already taking aspirin I will give you some to take for 6 weeks after surgery.


2). Infection. The risk of an infection in first-time hip replacement is currently reported as being about 0.5%. Antibiotics given to you before, during and after the operation further help to lower the rate of infection. The risk of infection in the weeks after the operation is increased if you have rheumatoid arthritis or diabetes, if you have been taking cortisone for prolonged periods of time, if the affected joint has had previous infection, or if you have infection anywhere else in your body (teeth, bladder, etc) at the time of surgery. The artificial joint can become infected many years after the operation. The bacteria travel through the blood stream from a source elsewhere in the body, such as from an infected wound, or a gall-bladder infection. Even regular dental work can release bacteria into the blood. Infections of the bladder, teeth, prostate, kidneys, etc. should be cleared up by appropriate treatment well before the day of surgery. Patients who have had joint replacements probably should take antibiotics by mouth before and after any dental work (although the risk is very small) and must have all infections vigorously treated.


3). Loosening of the prosthesis from the bone is the most important long-term problem. How long the bond will last depends on a number of factors.


4). Wear of the Plastic Polyethylene Socket starts from the day of surgery. The plastic socket is the weakest link in the hip implants in current use worldwide. Metal-on-metal bearings were only recently introduced. Although the rate of wear is very small, it may take ten to twelve years of use to prove that they are without problems of their own. 


5. Dislocation of the hip replacement occurs in a small percentage of patients (about 1 in 100). Dislocation means that the metal ball slips out of the plastic socket. In the first six weeks after the surgery, the ball is only held in the socket by muscle tension. During this time, before scar forms around the ball, and before muscle strength returns, the hip is more likely to dislocate. Therefore, for the first six weeks certain positions have to be avoided to prevent dislocation.


The physiotherapist will teach you what positions to avoid, and how to safely use your hip replacement during this early phase of your recovery. If the hip does dislocate, it is usually a simple matter for the doctor to pull on the leg and “pop” the hip back into place. Revision hip replacements, replacements in people who are grossly overweight and replacements in people with poor muscles are more likely to dislocate. Occasionally patients develop repetitive dislocations, requiring a brace to be worn for several months to prevent further dislocation. Sometimes further corrective surgery is needed to solve the problem.


6). Fracture of the femur rarely occurs during hip replacement. It is more common during revision hip surgery. Occasionally the femur may be accidentally perforated during first time or revision hip surgery. It can also fracture later from any trauma such as falling down stairs. If your femur is accidentally cracked during surgery, you may have to remain on crutches for up to 2 months to allow healing to occur. 


7). Residual pain and stiffness can occur. In virtually all cases the surgery will make a significant improvement in your pain and mobility. In most cases, you will have no pain at all, and the hip will feel “normal”. The completeness of the pain relief, and the degree of mobility is partially determined by your hip problem before surgery. Rarely, patients have pain after surgery, which cannot be explained.


8). The length of the leg may be changed by the surgery. Getting leg lengths exactly right can be very difficult. Some leg length difference may be unavoidable. Sometimes the leg will be deliberately lengthened in order to stabilize the hip or to improve muscle function. Shoe lifts may be necessary if the difference is more than 2.0 cm. In the first weeks after surgery, most patients complain that the operated leg feels “too long” even when the legs are perfectly equal in length. This is an artificial sensation, which will resolve itself after a few weeks to a few months.


9). Injury to the arteries of the leg is an exceedingly rare but possible complication. The major arteries of the leg lie close to the front of the hip joint. The damaged vessel can usually be repaired by a vascular surgeon if recognised in time. If the nerves of the leg are injured, they usually recover; but it may take six months or more. Occasionally, they don’t recover at all.


10). Anaesthetic complications can occur, and very rarely even death can occur from the anaesthesia. Your anaesthetist will see you before surgery and explain the risks involved.




ANATOMY OF THE NORMAL KNEE JOINT


The knee is a "hinge type" joint, which is formed by two bones held together by flexible ligaments; the bones are the femur (thigh bone) and the tibia (shin bone). The kneecap (patella) also forms part of the knee joint. It glides over the end of the femur as the knee bends. The moving parts of a normal knee are covered with a layer of articular cartilage, which is a white smooth substance about 6-8mm on the patella and 3-4mm thick on the femur and tibia. An x-ray of the knee normally shows space (the "joint space") between the femur and the tibia as well as between the femur and the patella. This is not empty space but represents the cartilage (which does not show up on x-rays). The smooth, cartilage-covered surfaces of the knee move on each other with very little friction in the normal joint. In the normal knee the "joint space" is approximately 6-8mm wide and fairly even in outline.



DISEASES OF THE KNEE JOINT


There are a number of conditions that can cause arthritis of the knee. The term “arthritis” literally means inflammation of a joint, but is generally used to describe any condition in which there is damage to the cartilage. Usually the pain early on is due to inflammation. In the later stages, when the cartilage is worn away, most of the pain comes from the mechanical friction of raw bones rubbing on each other. 


There are two broad categories of arthritis.


Osteoarthritis mainly damages the joint cartilage, but there is often some inflammation as well. It usually affects only one or two major joints (usually in the legs). It does not affect the internal organs. The cause of knee osteoarthritis is not known. It is thought to be simply a process of “wear and tear” in most cases. Some conditions may predispose the knee to osteoarthritis, for example, a previous fracture that involved the joint. In osteo- arthritis of the knee the cartilage cushion is either thinner than normal (leaving bare spots on the bone), or completely absent. X-rays show the “joint space” to be narrowed and irregular in outline. There is no blood test for osteoarthritis.


Rheumatoid Arthritis (RA) starts in the joint lining and is mainly “inflammatory”. The cause is not known. It eventually destroys the joint cartilage. Bone next to the cartilage is also damaged and it becomes very soft. R.A. affects multiple joints simultaneously. It can also affect internal organs. 



SYMPTOMS OF KNEE DISORDERS


Arthritis pain coming from the knee joint may be felt in the front, the back, or the sides of the knee. Not all "knee pain" necessarily comes from the knee joint itself. Hip pain frequently radiates down the thigh to the knee. Sometimes knee pain is so prominent in patients with hip disease that the patient (and sometimes even the physician) can be fooled into thinking that the problem is in the knee when in fact the problem is in the hip. Other knee symptoms include catching, giving way (buckling), locking, swelling, a painful limp, creaking and a decreased distance the patient can walk because of pain. The movement that is possible in the knee joint will gradually become less: the knee may not straighten out all the way or may not bend fully, or both. The leg may become increasingly "bow-legged" or "knock-kneed" with time. At night the knee pain may wake the patient when he or she turns over while sleeping.


 

TREATING KNEE ARTHRITIS WITHOUT SURGERY


1. Should you limit your activities? - If you have knee arthritis, the more you walk the more the knee will hurt. In time, running, tennis, golf and eventually even walking may become impossible. You can minimize the pain by simply cutting back on activities that seem to aggravate the knee. Whenever possible, use an elevator (or an escalator) instead of stairs, and avoid long walks that leave you in pain. However, “saving the joint” by becoming totally sedentary will not slow down the arthritis. Therefore it is recommended that you remain as active as your pain will comfortably allow.


2. Weight loss will probably decrease your pain if you are greatly overweight. But weight reduction alone is unlikely to completely relieve the pain. Obesity also makes the knee operation more difficult, and complications occur more frequently in overweight people.


3. Cortisone injection. The symptoms of mild and moderate degrees of arthritis frequently improve with the injection of cortisone into the joint. This is not recommended more than once every two to three months or so if it works. The amount needed is very small and side effects are rare or minor. The more advanced the arthritic damage the less likely is Cortisone to be beneficial.


4. Knee braces generally have not been found to be very helpful for knee arthritis, but recently special braces and wedged shoes have been shown to be helpful in some cases. An ace bandage may help to control swelling of the joint and gives some psychological benefit as well.


5. Non-Steroidal Anti-Inflammatory Drugs (NSAID) are a group of drugs that decrease the inflammation (pain and swelling) in arthritic joints. The pain relief can be quite amazing. Although they are commonly referred to as “arthritis pills”, none of them will in any way influence the outcome of the arthritis. There are many available, and newer ones are constantly being brought onto the market. The “newest” one is not necessarily the most effective. Most people respond better to one NSAID than to another, and you may have to try several before the “right” one can be found for you. They all have potentially serious side effects and should only be taken under medical supervision. Most can only be obtained by prescription and are expensive. Aspirin is cheap, and is often just as effective as any of the other anti-inflammatories. It should therefore be tried first. 


 

WHEN SHOULD YOU HAVE KNEE REPLACEMENT SURGERY?


 If your symptoms are mainly from an arthritic knee, and you are physically fit enough to undergo surgery, when should you consider having your knee replaced? Knee arthritis is not a life-threatening condition: the procedure is “elective”. The decision to have the operation is a highly personal matter, and only you can make that decision. If you are confined to a wheelchair and in constant pain, it is a decision that will be quite easy for you to make, even though the operation (any operation) involves taking a certain amount of risk. If your disability is great enough, the potential benefits are worth the risk. If your arthritis is responding to conservative measures, and you can still walk long distances without a cane, you don’t need a knee replacement. 


Here are some facts to help you make your decision:


1. Once you have knee arthritis it will never get better. It won’t even stay the same. It will generally progress as time goes by. There are no exercises, diets, vitamins, or minerals (including calcium), which will make any difference.


2. The rate of further deterioration varies greatly from person to person. The pain may become unbearable within six months for one person yet drag on at a tolerable level for several years in another person who has the same degree of arthritis.


3. You will never need a knee replacement if you are willing to live with the pain.


4. You may believe that it is better to delay having the operation in hope that the technology of knee replacement will improve with time. However, the rate of progress in this area is extremely slow, so this is something to consider only if you are very young, or your arthritis is mild and you can easily live with your symptoms.


5. More than 96% of patients who have a knee replacement operation have no major complications.


6. The main arguments against waiting too long are:


a). The longer your arthritis forces you to “sit around” the softer your bones become, and the weaker your muscles. 


b). If your pain and disability are not responding to conservative measures, and you realize that you are going to have to have the operation sooner or later anyhow, you may reasonably conclude that there is no point in waiting. Why put it off for another year or two when you could have spent that time enjoying your life free of pain!


If you are in doubt about whether or not you should have the surgery then a second opinion may give you the reassurance you need. You may also discuss your knee problem with your family doctor or a rheumatologist, and other people who have had knee replacements. The nice thing to know is that you need never be crippled because of your knee arthritis, because of the option of knee replacement available to you.


 

TOTAL KNEE REPLACEMENT SURGERY


You will be advised of the time to arrive at the hospital, and you should have had nothing to eat or drink for 6 hours prior to the operation. Both the anaesthetist and myself will visit you before the operation. I will mark your leg so that the correct side will be operated on.


Please take your other medications up to the day of your operation but not on the morning of surgery until this is discussed with the anaesthetist. If you take blood thinners (warfarin) then please discuss with me when you should stop the tablets. 


The anaesthetist will also discuss the advantages of general anaesthesia (in which you are unconscious) and spinal anaesthesia in which the lower half of your body is completely numb (and pain-free) and you will sleep lightly but not be unconscious.


 

IN THE OPERATING ROOM


First-time knee replacements take 1 to 2 hours of operating time. You will be in the operating room for about another hour (for anaesthetic induction and other necessary procedures before and after the operation). Revision operations can take up to 4 hours of operating time (or even more). When the operation is over I will ring your family to report your progress.


The term “knee replacement” sounds like a more radical procedure than it actually is. Most patients imagine that 3 inches of bone is removed from each of the knee bones and that a large metal and plastic device is installed in its place. In actual fact, the procedure is more akin to dentistry and a better term would be Knee Resurfacing. A thin layer of bone is removed from the damaged surface of the femur (thigh bone) using special instruments that remove the correct thickness of bone. The removed bone is then replaced by a thin layer of metal, approximately the same thickness as the bone that was removed. In a similar fashion the upper end of the tibia (shin bone) is removed and is replaced with a wafer of plastic. The back part of the kneecap (patella) may also be resurfaced with a piece of plastic. The three parts are attached to the bone by means of “bone cement”. After the knee has been replaced, the metal “cap” covering the end of the femur rubs against the plastic covering on the end of the tibia, preventing bone from rubbing on bone and giving relief from pain. 


Knee disease can be treated by other surgical methods besides total knee replacement.


1. Unicompartmental Knee Replacement - Each knee actually has two “compartments” - an inner and an outer compartment. Not infrequently one compartment will be severely affected by arthritis while the other may be almost normal. In these circumstances you may best be served by having only the “bad” compartment replaced (called a “uni-compartmental knee replacement”). The advantages of this include a better range of motion, and quicker recovery. The main disadvantage is that the non-replaced compartment may continue to deteriorate and later need to be resurfaced anyway. 


2. Osteotomy - This is another procedure by which knee arthritis can be treated. This is an operation in which either the tibia or the femur bone is cut and the alignment of the leg is changed. Most patients, as they develop arthritis in the knee, either become increasingly bow-legged or knock-kneed. This deformity of the leg actually accentuates and accelerates the arthritis in the knee. If the leg can be straightened by “osteotomy” then the symptoms of knee arthritis will usually be improved. Osteotomy of the knee is usually reserved for younger patients who have mild disease and bow legs, and who can still straighten their knee completely. Osteotomy under the right circumstances can give excellent pain relief but the results are not as predictable as knee replacement surgery. Even those patients who have an excellent result can expect to have a knee replacement at some time in the future.


3. Knee Fusion - This is a procedure in which the femur bone is made to fuse to the tibial bone. This results in a permanent and complete stiffness of the knee joint. The procedure is rarely performed today because most patients will not accept a totally stiff knee. Occasionally it is recommended for a young person whose work involves heavy labour. However, it is very inconvenient to have a stiff knee. It makes getting in and out of tight spaces very difficult. A stiff knee is also very inconvenient when sitting in a movie theater or on an airplane and it also makes driving more difficult.


 

WHAT TO EXPECT AFTER LEAVING THE OPERATING ROOM


You will wake up in the recovery room. You will be comfortable and usually surprisingly free of pain. You cannot be visited in the recovery room, but can be visited as soon as you get to your room. You will be in the recovery room for about 2 hours. 


 

PAIN CONTROL


A major breakthrough in pain-management has been the development of a device known as the PCA Unit (Patient Controlled Analgesia). This is a computerized device, which attaches to your intravenous line. You are able to self-administer small doses of narcotic by pressing a button at the end of an electric cable. The machine is pre-programmed so that it is not possible for you to give yourself more narcotic than is safe. It has a number of advantages. Firstly, you do not need to call a nurse to administer pain injections. Secondly, because only small doses are given at a time, you will not be as drowsy as you might otherwise be, if you were given big-dose injections every 3 hours.


You should ask for sleeping pills, pain pills or pain injections because the nurses will not automatically give them. Do not restrict yourself from using the PCA machine or asking for pain medications. We do not want you to be in pain. You need not fear that you will become addicted to the pain medication.


 

PHYSIOTHERAPY


The physiotherapist will get you up on the first day after surgery, and will teach you the right amount of weight to put on your operated leg. Essentially unless I tell you otherwise you can put as much weight on your leg as is comfortable. 


During waking hours you should “pedal” your feet up and down every five minutes or so, the entire time you are in the hospital, to help prevent blood clots from forming.


Most people have no problem getting the knee to bend but the physio will show you exercises to help regain your bend. The big problem I see after knee replacements is difficulty getting the knee out straight. I like my patients to spend 1-2 hours per day sitting with the foot on a stool and the knee unsupported to encourage full straightening.



GOING HOME


You can go home when your temperature is normal, your wound looks okay and you are able to get in and out of bed, and go to the bathroom by yourself. Some patients reach this goal within 3 days; others take as long as 7 days.



EQUIPMENT YOU WILL NEED AT HOME


While you are in the hospital, the physio will help you decide what equipment you will need when you get home. You will need crutches or a walker to help with walking for about 3 to 4 weeks after surgery. 


 

WHAT TO EXPECT AFTER YOU GET HOME


You will be able to go home in a regular sized car. It is better if someone can be at home with you for at least portions of each day to assist you with shopping, meal preparation, etc. Constant nursing care is rarely needed at home. 


Your first follow-up appointment will be made and there will be a card with the time and date in your admission folder. This visit is usually four weeks after your surgery. If any problem develops you will need to come in sooner. 


It is not uncommon to develop some swelling of the knee, foot and ankle in the weeks after surgery. If this occurs, you should elevate your leg on pillows when you are not up and about.


Wound sutures or staples are usually removed on the 8th or 9th day after surgery. We will ask the nurse at your GP’s rooms to remove your stitches. You can shower once the wound is dry, even before the staples are removed. It is best to shower rather than get into a bath. We recommend avoiding a bath for at least two months after surgery. A shower stool is helpful so as to avoid slipping while taking a shower.


Once you get home you are not expected to stay in bed. You should be up and about on your walker or crutches most of the time, but rest as much as you need to. 


Please use your stockings until you are walking well without crutches.


 

DRIVING AFTER KNEE REPLACEMENT SURGERY.


Driving is best avoided until about 6 weeks after the surgery, but generally you will be safe once you can walk well off the crutches.


 

RETURNING TO WORK AFTER KNEE REPLACEMENT SURGERY


You will probably not return to work for 6 to 8 weeks after the operation. Quite a few patients do return earlier, depending on the nature of their work, and depending on how important it is for them to be back at work.


 

PROBLEMS YOU MAY ENCOUNTER AT HOME


1. Excessive swelling of your leg and foot: It is not uncommon to develop some swelling in the first few weeks after surgery. If this occurs, you should elevate your leg whenever you are not up to walking. However, excessive swelling of the foot and lower leg can be due to thrombosis (blood clots) in the veins in the leg. I should be notified if swelling is associated with pain or tenderness in the calf muscles, or if the swelling just seems over-excessive, and does not respond to elevation.


2. Chest pain, a cough or shortness of breath may be signs of embolism. Please do not ignore these symptoms. Call me right away.


3. Drainage from the wound, or increasing redness around the wound, could signify impending infection. Our office should be notified, and in most instances you will need to come in and let me take a look at it.


4. High fever could also be a sign of impending infection. 


5. Increasing knee pain. Pain should be decreasing from day to day. If it seems to be steadily increasing, let me know.


 

IN GENERAL, THE LEG SHOULD BE GETTING BETTER EACH DAY. IF YOU THINK YOU ARE GETTING WORSE IN ANY WAY, PLEASE GIVE ME A CALL.


 

COMPLICATIONS OF KNEE REPLACEMENT SURGERY


Unfortunately, even the most minor of surgical operations carries some risk of complications occurring. Knee replacement surgery is very successful, and complications are relatively uncommon, considering the complexity of the procedure. It is fair to say that you have about a 96% chance that you will go through the operation without any significant complication occurring. The most common complication is blood clots in the legs. The most serious complication is infection. The most important long-term complication is loosening.


1). Blood clots in the veins of the legs are the most common complication of knee replacement surgery. As long as the clots remain in the legs they are a relatively minor problem. Occasionally, they dislodge and travel through the heart to the lungs (pulmonary embolism). This is a potentially serious problem, since (very rarely) death can result from embolism. The chances of this are one out of about 5000. They are usually not dangerous if appropriately treated, but may delay your discharge from the hospital for two or three days. I will give you a prescription for aspirin to take for 6 weeks after surgery if you are not already on it.


2). Infection. The risk of an infection in first-time hip replacement is currently reported as being about 0.5%. Antibiotics given to you before, during and after the operation further help to lower the rate of infection. The risk of infection in the weeks after the operation is increased if you have rheumatoid arthritis or diabetes, if you have been taking cortisone for prolonged periods of time, if the affected joint has had previous infection, or if you have infection anywhere else in your body (teeth, bladder, etc) at the time of surgery. The artificial joint can become infected many years after the operation. The bacteria travel through the blood stream from a source elsewhere in the body, such as from an infected wound, or a gall-bladder infection. Even regular dental work can release bacteria into the blood. Infections of the bladder, teeth, prostate, kidneys, etc. should be cleared up by appropriate treatment well before the day of surgery. Patients who have had joint replacements probably should take antibiotics by mouth before and after any dental work (although the risk is very small) and must have all infections vigorously treated.


3). Loosening of the prosthesis from the bone is the most important long-term problem. How long the bond will last depends on a number of factors.


4). Wear of the Plastic Polyethylene liner starts from the day of surgery. The plastic liner is the weakest link in the knee implants in current use worldwide.


5). Residual pain and stiffness can occur. In virtually all cases the surgery will make a significant improvement in your pain and mobility. Rarely, patients have pain after surgery, which cannot be explained. The knee will often click quite a lot but this is nothing to worry about.


6). Wound healing can occasionally be a problem after knee replacement. The skin wound over the knee sometimes does not heal completely. 


7). Nerve damage can (rarely) occur with knee replacement. The most common nerve damaged is the nerve to the muscles, which bring the foot up toward the face (the peroneal nerve). The odds of this occurring are probably one in many hundreds. If it does occur, the affected nerve usually recovers after 6 to 12 months. Quite commonly the skin around the knee feels "numb" because of small skin nerves that get cut at surgery. Sensation usually returns to normal within a few months.


8). Patellar complications can occur. Occasionally the kneecap does not track properly causing it to "jump" as the knee bends. The chance of this occurring is less than 1%. 


6). Injury to the arteries of the leg is an exceedingly rare but possible complication. The major arteries of the leg lie close to the back of the knee joint. The damaged vessel can usually be repaired by a vascular surgeon if recognised in time.  


10). Anaesthetic complications can occur, and very rarely even death can occur from the anaesthesia. Your anaesthetist will see you before surgery and explain the risks involved.




What is the carpal tunnel?


There are eight small bones called carpal bones in the wrist. A ligament (also called retinaculum) lies across the front of the wrist. Between this ligament and the carpal bones is a space called the carpal tunnel. The tendons that attach the forearm muscles to the fingers pass through the carpal tunnel. A main nerve to the hand (median nerve) also goes through this tunnel before dividing into smaller branches in the palm.


The median nerve gives feeling to the thumb, index and middle fingers, and half of the ring finger. It also controls the movement to the small muscles at the base of the thumb.



What is carpal tunnel syndrome?


This syndrome is a set of symptoms caused by compression (squashing) of the median nerve in the carpal tunnel. About 1 in 1000 people develop this syndrome each year. Most cases occur in people in their 40's and 50's, but it can occur at any age. It is also common during pregnancy. Women are affected 2-3 times more often than men.



What are the symptoms of carpal tunnel syndrome?


• 'Pins and needles'. This is tingling or burning in part or all of the shaded area shown above. The index and middle fingers are usually first to be affected.


• Pain or aching in the same fingers may then develop. The pain may travel up the forearm.


• Numbness of the same finger(s), or in part of the palm, may develop if the condition becomes worse.


• Weakness of some muscles in the fingers and/or thumb occurs in severe cases. This may cause poor grip and eventually lead to wasting of the muscles at the base of the thumb.


Symptoms vary from mild to severe depending on how 'squashed' the median nerve becomes. One or both hands may be affected. Symptoms tend to come and go at first, often after you use the hand. Typically, symptoms are worse at night and may wake you up. The symptoms may be eased for a while by raising the hand up or hanging it down. 'Flicking' the wrist may also give relief. Symptoms persist all the time if the condition becomes severe.


 

What causes carpal tunnel syndrome?


• Unknown. In most cases it is not clear why it occurs. It is thought that some inflammation develops in a tendon going through the carpal tunnel which causes swelling. There is little space to expand in the narrow carpal tunnel, and this may lead to pressure on the nearby median nerve. Tendon inflammation can occur if you over-use your hand. Carpal tunnel syndrome is more common in manual workers, especially if you have a job where you use a lot of wrist movement such as scrubbing or wringing.


• Bone or arthritic conditions of the wrist such as rheumatoid arthritis or wrist fractures may lead to carpal tunnel syndrome.


• Various other conditions are associated with carpal tunnel syndrome. For example: pregnancy, obesity, an underactive thyroid, diabetes, the menopause, other rare medical illnesses, and a side-effect of some drugs. Some of these conditions cause water retention (oedema) which may affect the wrist and cause carpal tunnel syndrome.


• Rare causes include cysts, growths, and swellings coming from the tendons or blood vessels passing through the carpal tunnel.



Do I need any tests?


A test to measure the speed of the nerve impulse through the carpal tunnel is sometimes advised (nerve conduction test). A slow speed of impulse down the median nerve confirms the diagnosis. Sometimes the symptoms are so typical that no tests are needed to confirm the diagnosis.



What are the treatments for carpal tunnel syndrome?


Non-surgical options


• Not treating is an option, particularly if symptoms are mild. In some cases symptoms go over time without treatment. In up to 1 in 3 cases the symptoms go without treatment within six months. (In about 2 in 3 cases that develop during pregnancy the symptoms go after the baby is born.) The situation can be reviewed if symptoms get worse.


• One or two steroid injections into, or near to, the carpal tunnel is an option. Steroids reduce inflammation. The steroid is combined with a local anaesthetic to make the injection painless. One study found that a single injection eased symptoms in about 3 in 4 cases. Symptoms returned in some people but about half of the treated people were free of symptoms a year later. Another study found that two steroid injections given 14 days apart was as good as surgery (in cases where there was no wasting of the muscles when surgery is usually needed.) Other studies report variable success rates with steroid injections.


• A splint to keep the wrist in a fixed position and 'rested' may cure the problem. It is worn for a few weeks (especially at night).

                

Surgery


Open release for CTS is occasionally done using a general anesthetic (one that puts you to sleep). More often, it is done using a local anesthetic.


Once you have anesthesia, your surgeon will make sure the skin of your palm is free of infection by cleaning the skin with a germ-killing solution. A tourniquet is usually used above the elbow to make it easier to see the nerve, it is on for about 5 minutes but can be quite tight.


A small incision is made in the palm of the hand, usually about one inch long. In some severe cases, a slightly longer incision is extended into the forearm. The nerve is then released. This operation usually only takes about 10 minutes


After the skin is stitched together, your hand will be wrapped in a bulky dressing. You can usually go home about an hour after the operation. The sutures are removed about 10 days after the operation and you can resume normal activities as symptoms allow.



Complications


What might go wrong?


As with all major surgical procedures, complications can occur. This document doesn't provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following open carpal tunnel release are listed below:


Anaesthesia


As this is almost always done under local anaesthesia the risks are very small. The injections can be a bit uncomfortable.


Infection


Infection is a possible complication after surgery, especially infection of the incision. If you have signs of infection or other complications, call your surgeon right away.


Incision Pain


Some patients continue to have pain along their incision. The area often stays sensitive long after the surgery. However, symptoms of incision sensitivity tend to get better within four to six months after surgery.


Nerve Symptoms


Sometimes people still feel some numbness and tingling after surgery, especially if they had severe pressure on the median nerve prior to surgery. When the thenar muscles (mentioned earlier) are notably shrunken (atrophied) from prolonged pressure on the median nerve, full strength and normal sensation may not fully return even after having the surgery.


Hand Weakness


Muscles that are used to squeeze and grip may seem weak after surgery. During normal gripping, the tendons of the wrist press outward against the carpal ligament. This allows the carpal ligament to work like a pulley to improve grip strength. The weakness is usually gone by 3-4 months.




The arthroscope is a fibre-optic telescope that can be inserted into a joint (commonly the knee, shoulder and ankle) to evaluate and treat a number of conditions .A camera is attached to the arthroscope and the picture is visualized on a TV monitor. Most arthroscopic surgery is performed as a Day-Only procedure and is usually done under general anaesthesia. Knee arthroscopy is a common procedure and over 100 000 arthroscopies are performed in Australia each year. 


Arthroscopy is useful in evaluating and treating the following conditions:


1. Torn floating cartilage (meniscus): The cartilage is trimmed to a stable rim or occasionally repaired 


2. Torn surface (articular) cartilage 


3. Removal of loose bodies (cartilage or bone that has broken off) and cysts. 


4. Reconstruction of the Anterior Cruciate ligament 


5. General diagnostic purposes (rare) 



Basic Knee Anatomy 


The knee is the largest joint in the body. The knee joint is made up of the femur, tibia and patella (knee cap). All these bones are lined with articular (surface cartilage). This articular cartilage acts like a shock absorber and allows a smooth low friction surface for the knee to move on. Between the tibia and femur lie two floating cartilages called menisci. The medial (inner) meniscus and the lateral (outer) meniscus rest on the tibial surface cartilage and are mobile. The menisci also act as shock absorbers and stabilizers. The knee is stabilized by ligaments that are both in and outside the joint. The medial and lateral collateral ligaments support the knee from excessive side-to-side movement. The (internal) anterior and posterior cruciate ligaments support the knee from buckling and giving way. The knee joint is surrounded by a capsule (envelope) that produces a small amount of synovial (lubrication) fluid to help with smooth motion. Thigh muscles are important secondary knee stabilizers. 


 

Meniscal Cartilage Tears


Following a twisting type of injury the medial (or lateral) meniscus can tear. This results either from a sporting injury or may occur from a simple twisting injury when getting out of a chair or standing from a squatting position. Our cartilages become a little brittle as we get older and therefore can tear a little easier. The symptoms of a torn cartilage include:


• Pain over the torn area i.e. inner or outer side of the knee 


• Knee swelling 


• Reduced motion 


• Locking if the cartilage gets caught between the femur a tibia 


Once a meniscal cartilage has torn it will not heal unless it is a very small tear which is near the capsule of the joint. Once the cartilage has torn it predisposes the knee to develop osteoarthritis (wear and tear) in 15 to 20 years. It is better to remove torn pieces from the knee if the knee is symptomatic. 


Torn cartilages in general continue to cause symptoms of discomfort, pain and swelling until the loose, ragged pieces are removed. Only the torn section is removed and the knee should recover and become symptom free. If the entire meniscus is removed, the knee will develop osteoarthritis in 15 to 20 years. Now-days only the torn section is removed and it is hoped that this will delay the onset of long-term wear and tear osteoarthritis. Occasionally, provided the knee is stable and the tear is a certain type of tear in a young patient (peripheral bucket handle tear), the meniscus may be suitable for repair. If repaired one has to avoid sports for a min of three months. 


 

Articular Cartilage (Surface) injury


If the surface cartilage is torn, this is most significant as a major shock-absorbing function is compromised. Large pieces of articular cartilage can float in the knee (sometimes with bone attached) and this causes locking of the joint and can cause further deterioration due to the loose body floating around the knee causing further wear and tear. Most surface cartilage wear will ultimately lead to osteoarthritis. Mechanical symptoms of pain and swelling due to cartilage peeling off can be helped with arthroscopic surgery. The surgery smoothes the edges of the surface cartilage and removes loose bodies. 



Bakers' cysts


Bakers cysts or popliteal cysts are often found on clinical examination and ultrasound / MRI scan. The cyst is a fluid filled cavity behind the knee and in adults arises from a torn meniscus or worn articular cartilage in the knee. These cysts usually do not require removal as treating the cause (torn knee cartilage) will in most cases reduce the size of the cyst. Occasionally the cysts rupture and can cause calf pain. The cysts are not dangerous and do not require treatment if the knee is asymptomatic. 


 

Day of surgery 


Please take all your normal pain and other drugs up to the day of surgery. 


You will be admitted on the day of surgery and need to remain fasted for 6 hours prior to the procedure. 


The limb undergoing the procedure will be marked and identified prior to the anaesthetic 


Once you are under anaesthetic, the knee is prepared in a sterile fashion. A tourniquet is placed around the thigh to allow a ‘blood – free' procedure. 


The Arthroscope is introduced through a small (size of a pen) incision on the outer side of the knee. A second incision on the inner side of the knee is made to introduce the instruments that allow examination of the joint and treatment of the problem. 


 

Post-operative recovery 


You will wake up in the recovery room and then be transferred back to the ward 


A bandage will be around the operated knee. 


Once you are recovered your drip will be removed and. Your Surgeon will see you prior to discharge and explain the findings of the operation and what was done during surgery. 


Pain medication will be provided and should be taken as directed 


You can remove the bandage in 48 hours. 


It is NORMAL for the knee to swell after the surgery. Elevating the leg when you are seated and placing Ice-Packs on the knee will help to reduce swelling. (Ice packs on for 20 min 3-4 times a day until swelling has reduced) 


You are able to drive and return to work when comfortable unless otherwise instructed 


Please make an appointment 21 or so days after surgery to monitor your progress.


 

Risks of Arthroscopy


General Anaesthetic risks are extremely rare in Australia. Occasionally patients have some discomfort in the throat as a result of the tube that supplies oxygen and other gasses. Please discuss with the Specialist Anaesthetist if you have any specific concerns 


Risks related to Arthroscopic knee surgery include: 


• Postoperative bleeding 


• Deep Vein Thrombosis 


• Infection 


• Stiffness 


• Numbness to part of the skin near the incisions 


• Injury to vessels, nerves and a chronic pain syndrome 


• Progression of the disease process 


The risks and complications of arthroscopic knee surgery are extremely small. One must however bear in mind that occasionally there is more damage in the knee than was initially thought and that this may affect the recovery time. In addition if the cartilage in the knee is partly worn out then arthroscopic surgery has about a 65% chance of improving symptoms in the short to medium term but more definitive surgery may be required in the future. In general arthroscopic surgery does not improve knees that have well established Osteoarthritis.


 

Frequently asked questions


How long am I in Hospital? 


A: Approx 4 hours 


Do I need crutches? 


A: Usually not required  


When can I get the knee wet? 


A: After 48 hrs remove the bandage and it is usually OK to get wet 


When can I drive? 


A: After 24 hrs if the knee is comfortable 


When can I return to work? 


A: When the knee feels reasonably comfortable 


When can I swim? 


A: After removal of the stitches 


How long will my knee take to recover? 


A: Depending on the findings and surgery usually 4 to 6 weeks following the surgery. Badly torn cartilages in people over 25 years can take 3-4 months to fully recover


When Can I return to Sports? 


A: When the knee feels comfortable enough.



Contact us

25 Pembroke St
Hamilton, 3204
New Zealand

Phone: +6478393659
Fax: +6478381575
Email: office@hardyortho.co.nz