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Joint Replacement Surgery


What is it?

Joint replacement surgery has revolutionised the treatment of arthritis of the hip and knee particularly in the older person. Almost all patients receive major benefits from total hip arrthroplasty. These benefits are apparent within three months of surgery and usually include relief of pain with consequent improvement in physical function, social interaction and overall health.

The success of joint replacement has not only caused a greatly increased use of the technique but also provoked great interest in the ways to avoid or solve the very real problems that still occur in some patients. The vast majority of patients proceed through this surgery without complication. It is ideally suited for the older individual but in some circumstances it is appropriate for younger patients and good long-term results can be expected.

Who needs a joint replacement?

The main indication or reason for a joint replacement of any sort is significant pain in that joint. Joint replacement may secondarily ease stiffness and deformity but in the absence of significant pain would rarely be done. In general older people benefit most with excellent relief of pain and a long-lasting joint.

Painful joints are usually the result of arthritis. There are many types of arthritis but osteoarthritis and rheumatoid arthritis are the most common. There is usually no outside cause for osteoarthritis. That is the joints do no wear out because of overuse. The fact is that some people's hip or knee joints may wear abnormally for reasons that are not clear. Rarely a major injury in the past may be a cause. Falls and strains do not usually cause the problem, although previous knee cartilage or ligament injury may be a factor.

Rheumatoid arthritis is an inflammatory arthritis. In this type of arthritis the body in some way sets up a damaging inflammation within the joints. Again it is not exactly certain why this should occur in one person and not another, but the result is stiff and painful joints. Gout is another type of inflammatory arthritis but it rarely damages the major joints.

The end result of the various forms of arthritis is the loss of the normal smoothness to the joint bearing surfaces. The joints then become painful and stiff. In joint replacement surgery the damaged bearing surfaces are replaced with man-made materials.

Considerations before a joint replacement is undertaken

Your doctor and your specialist will take a history and examine you. This is because the doctor must be certain that your pain is coming from the joint in question. This is not always clear cut - for example pain in the groin is usually coming from the hip joint but pain in the buttock often is radiating from the back. Pain in the front of the thigh or knee may be radiating from the hip, or may be coming locally from the knee.

Once your doctor has made a diagnosis of the type of arthritis then he or she will advise on treatment. The best initial treatment is almost always tablets which take away pain and settle inflammation. Many people do not like to take tablets but in general the benefits of the tablets outweigh the risks and they may let the person avoid surgery or delay it for a long period. Delaying surgery until a person is older is reasonable as, like all man-made things, artificial joints do wear out.

Modification of activities can also be useful. A walking stick can be very helpful and may relieve pain and minimise a limp. Generally keeping fit and strong is very useful. This can be done in ways which minimise loading the joint - for example using an exercycle, swimming or waterwalking. Maintaining body weight as close as possible to the ideal will also minimise symptoms.

There may be operations other than joint replacement to help painful joints. These operations may be useful in younger patients particularly. This is because all artificial joints eventually loosen or wear out and an operation which can delay or eliminate the need for joint replacement may be the best option. These operations include re-aligning joints so that less damaged regions take up the load. Stiffening a joint so that it does not move can also eliminate pain.

Preparing for the operation

Your specialist will take a history and complete a physical examination. The specialist will discuss the reasons for the surgery, its benefits and risks. This is the time to ask questions. You will have to complete a consent form. There will also be hospital forms to complete which ask details about your past history, medications and previous operations. It also asks for insurance and billing information.

The ideal patient for joint replacement is older, with arthritis affecting one or more joints, who is otherwise fit and well. Medical problems e.g. blood pressure or heart conditions do not prevent joint replacement surgery but do need to be treated first. Infection within a joint or abscesses on the skin of the leg or about the toes would mean that surgery should not be done, at least until the problem is cured. Also abscesses or infections elsewhere, for example in the mouth or bladder, must be treated.

You will have screening blood and urine tests. Your doctor may advise you to see the anaesthetist in advance of the surgery but usually you would meet the anaesthetist in the hospital on the day of the surgery.

You will be admitted to hospital on the day of the surgery or the night before and an identity bracelet placed on your wrist. A cardiogram is usually taken. You will usually be asked to wash or shower with an antiseptic solution. You may be asked to have an enema. Your surgeon will see you before operating and will mark the area to be operated. There are a number of other checks to be sure that the correct joint is being replaced. The nursing staff will usually check the consent form that you have signed and see that it agrees with what is on their list. They will usually ask you to confirm the consent. The surgeon will generally check the x-ray again just before starting to be sure that this correlates with what is planned. You will be seen by the anaesthetist; your anaesthetic will be discussed and you may be given a pre-med. This is medication to prepare you for your anaesthetic.

Your anaesthetist will discuss this with you in the hospital before the surgery. Commonly you will have a spinal or epidural anaesthetic in combination with a general anaesthetic or heavy sedation. This means that local anaesthetic is injected around the nerves in the spine. This makes the legs go to sleep for about three hours and takes away any pain. The general aneasthetic or sedation helps you sleep while the operation is being done. Minor complications such as nausea and vomiting are quite common but are usually easily controlled and settle within 1-2 days. The details of your anaesthetic can be discussed with your anaesthetist.

Blood transfusion

Almost all patients undergoing hip and knee joint replacement require a blood transfusion. Most people accept blood from a blood bank. There is the option of collecting your own blood. It may then be given back to you if needed.

Donated blood

In this circumstance you accept blood donated by another individual. In New Zealand this is very safe. Donated blood is screened for many infections such as HIV/AIDS, Hepatitis A, B, C, and syphilis. The risk of catching HIV/AIDS from New Zealand blood is extremely small - probably close to 1 in a million. The risk of catching hepatitis is not known but may be 1 in 5000 to 1 in 25,000. In fact, most problems relate to clerical errors and overall catastrophic complications are very unusual.

Self donated or autologous blood

In this circumstance you attend the blood bank and donate 1 or 2 units of blood. This is stored and is given back to you during or after the operation if required. You can rapidly manufacture more blood to replace the donated blood and on occasion you may not need to have the blood given back. When you donate blood you need iron tablets to assist your body to replace the blood.

The blood bank makes a charge if you donate your own blood. If you use blood donated by someone else there is no charge. There is no facility for directed donation i.e. you cannot arrange for a family member or friend to donate blood for you.


Conclusion

Joint replacement surgery has transformed the lives of hundreds of thousands of people world wide. Ninety five percent of patients will proceed through surgery without trouble and can expect a long lasting and comfortable joint.

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