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Family Health Magazine - FAMILY MEDICINE

Joint Replacement Surgery
Giving joints a new lease on life

Orthopedic surgeons have been replacing hips and knees for about 40 years now. In that time, surgical techniques and designs for artificial joints have greatly improved. Today, hip and knee replacement surgery is one of the best ways to relieve severe joint pain and restore mobility.

Making the decision

Since hip and knee replacement surgery is voluntary, you should have no doubt that surgery is the right treatment option for you. Here is a list of basic questions to consider before going ahead with surgery.

  • Can I continue to bear the pain that I am experiencing now?
  • Have I given up activities I enjoy because of pain and stiffness?
  • How much does pain limit my movement and my ability to get around?
  • Has pain and stiffness gotten worse over the past several months to a year?
  • Are drugs, exercise and other therapies failing to provide enough relief?
  • Am I prepared for the demands of recovery after surgery, including exercises and physical therapy?
  • Will my health insurance fully cover joint surgery and recovery costs? Are there out-of-pocket expenses? Can I afford these?
  • Will I be able to take the necessary time to recover from surgery? Will family or friends be able to help me?
  • What realistic level of improvement can I expect after hip or knee replacement surgery?

Even so, the decision to have surgery requires serious thought. Even if it is right for you, the road back to health involves many steps. Your active involvement is necessary. First, you will need to prepare for the physical demands of surgery and educate yourself on what the surgeon will do. Then you must commit to doing rehabilitation exercises after surgery. As with any treatment, you should be aware of the benefits as well as the risks. It is a bit involved, so let us start with a quick anatomy lesson.

Anatomy of the hips and knees

Hips and knees are both weight-bearing joints. They carry the body and allow the limb to move. The hip joint is shaped like a ball and socket. The rounded top of the thigh bone fits into a cup on the pelvis. This makes a normal hip very flexible.

The knee joint acts more like a hinge. The bottom of the thigh bone glides smoothly over the top of the shin bone. Muscles and tendons keep the knee joint in line.

Both of these joints have thick pads of cartilage, smooth gliding surfaces which make movement easy. Cartilage also protects against the shocks of everyday living — walking, climbing, jumping and so on.

However, joints can stop working properly. Most often, joint damage is caused by advanced osteoarthritis. Rheumatoid arthritis or a sports injury are two other leading causes. Whatever the reason, the end result is pretty much the same. Joint cartilage becomes brittle and crumbles away from the surfaces it is meant to protect. Often, joints reach the stage where bone is rubbing against bone, making movement very painful and very difficult.

Constant joint pain can affect your quality of life. It often means you can no longer take part in family activities or favourite hobbies. If so, your family doctor may recommend talking to an orthopedic surgeon.

The journey through the care path is basically the same for all patients. Procedures may vary slightly from one hospital or surgeon to another but the following route is typical.

First visit

During a first office visit, the surgeon will look at your X-rays and do a physical examination of your knee or hip. Next, you will be asked about your medical history to give a sense of your heart health and general fitness. Expect to discuss how you have been dealing with joint problems until now. Bring a list of any non-surgical treatments you have tried, such as drugs, cortisone shots, physiotherapy, braces or canes, and notes on how they worked. Your age, weight and lifestyle will be considered, since they influence the eventual outcome. Positive attitude and determination also count.

If there is no obvious reason not to go ahead, you will be asked to sign a legal consent form. This allows the surgeon to operate and act in your best interest during surgery.

Pre-operative clinic

Next, you will visit the pre-operative (before surgery) clinic. Ideally this happens four to six weeks before the actual surgery. One of the clinic’s internal medicine and/or anesthesia doctors will do a second physical exam. You will fill out a detailed questionnaire. The idea is to identify and improve any health issues that may affect your ability to have anesthesia and surgery.

You will have blood tests to determine your blood type and to find any possible infections that need to be cleared up before surgery. Your urine may also be tested to check for infections. If there are any problems, enough time is allowed to clear them up before surgery. X-rays give your surgeon an up-to-date picture of what to expect during the operation.

Apart from checking you over, the pre-operative clinic serves to teach you about the surgery. In some provinces, patient education is done all on one day. In others, you may attend weekly sessions for about a month. Usually a physiotherapist oversees your instruction. You may also have sessions with an anesthesiologist, nurse, occupational therapist and social worker. Together, they will answer questions and try to give as complete a picture as possible of what lies ahead. If for some reason you have not already signed a consent form, you will get another chance during this clinic visit.

SurgeryHip/Knee X-rays

On the day of surgery, it is wise to bring a buddy (family or friend) to help you through a stressful experience. You will check in at the hospital an hour or two before the scheduled operation.
As your time for surgery approaches, things become busy. Your blood pressure, pulse and breathing rate are checked. An intravenous tube is inserted into a vein in your wrist, so you can receive fluids via this route. The surgeon will visit you to ensure you are the right patient and to confirm the correct joint is being replaced, often by initialling it with felt marker.

Once in the operating room, the anesthesiologist freezes you from the waist down and sedates you. Although you will be conscious, you will feel nothing in your lower limbs. The sedation also makes you unconcerned about the activity around you.

In hip replacement surgery, the top of the thigh bone is removed. Part of the thigh bone is hollowed out to make room for the stem of the hip implant. The top of the implant has a rounded metal-alloy ball that looks very much like the top of the thigh bone. A metal cup lined with high density plastic is implanted in the pelvis. This fits perfectly over the metal ball on the thigh implant.

In knee replacement surgery, the bottom of the thigh bone and the top of the shin bone are removed. They are joined together again using an artificial knee joint made of metal-alloy and plastic, using epoxy-like glue. First-time hip surgery takes one-and-a-half to two hours; knee surgery usually takes a bit longer.

Risks

The main risks associated with these operations are infections and blood clots. Usually, to lower the risk of infection, you receive intravenous antibiotics before and after surgery. Still, about one in 100 patients develop an infection afterward. Most are mild and can be treated with more antibiotics. Others require minor surgery to drain the wound.

Need help?

If you are considering knee surgery, you don’t have to make the decision alone. Ortho Connect is a free, telephone-based peer support program. It helps you understand more about your surgery by talking to someone who has been through the same experience. The program works by connecting patients – often living in severe pain and with restricted mobility – with trained volunteers who were once patients themselves.

This national support program, developed by the Canadian Orthopaedic Foundation, is available for those considering or undergoing any type of bone and joint surgery. Some patients find it an easier way to ask questions, including personal ones that are difficult to discuss with a surgeon. You learn in advance what to expect and how critical your own efforts will be.

You can access Ortho Connect via the Foundation’s website at www.orthoconnect.org or by calling the Foundation at 1-800-461-3639. Next, you will complete a form, listing the type of surgery, language spoken, age, gender, and other information that helps link you to a volunteer. After receiving a request for services, the Foundation usually provides a volunteer match within 48 hours.

The worst kind of infection (and the least common) develops around where the implant attaches to bone. Usually, the implant has to be surgically removed and the infected space filled with an antibiotic pack. Intravenous antibiotics are also used to kill the infection. Once the infection is gone, a new implant is put in.

During the time when a patient’s legs are frozen, lack of movement raises a risk of blood clots forming in the veins of the legs. Such a clot could break loose and be carried by the blood flow to the lungs. Here, it could cause a fatal blockage, called a pulmonary embolism.

To reduce this risk, patients are given blood thinners for two to four weeks following surgery.
Your surgeon does not mention these risks to scare you. Before surgery you must clearly understand the risks, no matter how remote, and weigh them against the benefits. This is the only way to make a fully informed decision that the surgery is right for you.

Recovery

Hospital stays for joint replacement usually last less than a week. A physiotherapist will teach you exercises to strengthen the muscles around your new implant. You must do your exercises at least twice a day, preferably three to four times. Once you leave the hospital, more physiotherapy is necessary. In some centres, the physiotherapist comes to your home. In others, you will need a ride to get to the physiotherapy clinic.

During the first few weeks, you must take care in walking and doing everyday tasks as your body heals and adapts to the new implant. After two weeks, the staples in the skin incision can be removed. It takes about six weeks for the wound to heal completely. During this time, the pain from the operation gradually eases.

Life will get back to normal. The pain you knew before the operation will be gone, and you should become able to do many regular activities you’d been forced to abandon.

As a surgeon, I can tell you nothing pleases me more than running into one of my patients out enjoying life again.

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FAMILY HEALTH is written
with the assistance of
College of Family Physicans of Canada
Alberta College of Family Physicians
FAMILY HEALTH is written
with the assistance of
The College of Family Physicans of Canada
Alberta College of Family Physicians
While effort is made to reflect accepted medical knowledge and practice, articles in Family Health Online should not be relied upon for the treatment or management of any specified medical problem or concern and Family Health accepts no liability for reliance on the articles. For proper diagnosis and care, you should always consult your family physician promptly. © Copyright 2012, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 2S6    [FM_FHc09]
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