Advances in Hip & Knee Replacement -- December 13, 2010 -- Dr. C - NewsChannel5.com | Nashville News, Weather & Sports

Advances in Hip & Knee Replacement -- December 13, 2010 -- Dr. Craig Morrison & Dr. Jeff Hodrick

Posted:

Monday, December 13, 2010
TOPIC: Advances in Hip & Knee Replacement
Craig Morrison, MD: orthopaedic surgeon
Jeff Hodrick, MD: orthopaedic surgeon
Saint Thomas Hospital

News notes via webmd.com

Hip replacement surgery

Total joint replacement involves surgery to replace the ends of both bones in a damaged joint to create new joint surfaces.

Total hip replacement surgery replaces the upper end of the thighbone (femur) with a metal ball and resurfaces the hip socket in the pelvic bone with a metal shell and plastic liner.

Total hip replacement surgery replaces damaged cartilage with new joint material in a step-by-step process.

Doctors may attach replacement joints to the bones with or without cement.

  • Cemented joints are attached to the existing bone with cement, which acts as a glue and attaches the artificial joint to the bone.
  • Uncemented joints are attached using a porous coating that is designed to allow the bone to adhere to the artificial joint. Over time, new bone grows and fills up the openings in the porous coating, attaching the joint to the bone.

Doctors often use general anesthesia for joint replacement surgeries, which means you'll be unconscious during surgery. But sometimes they use regional anesthesia, which means you can't feel the area of the surgery and you are sleepy, but you are awake. The choice depends on your doctor, on your overall health, and, to some degree, on what you prefer.

Your doctor may recommend that you take antibiotics before and after the surgery to reduce the risk of infection. If you need any major dental work, your doctor may recommend that you have it done before the surgery. Infections can spread from other parts of the body, such as the mouth, to the artificial joint and cause a serious problem.

Some doctors are doing hip replacement surgery through smaller incisions. This is called minimally invasive surgery. It may mean less blood loss and a smaller scar. But it can also mean a longer time in surgery because the surgery is harder to do. And if the new hip cannot be fitted properly through the smaller incision, the doctor may have to make a larger opening anyway. Minimally invasive surgery is not done often for hip replacement. If you are interested in this type of surgery, talk to your doctor. Whether the procedure is a good idea for you depends on your doctor's opinion and also on his or her training and practice.

What To Expect After Surgery

Right after surgery

You will have intravenous (IV) antibiotics for about a day after surgery. You will also receive medicines to control pain and perhaps medicines to prevent blood clots (anticoagulants). It is not unusual to have an upset stomach or feel constipated after surgery. Talk with your doctor or nurse if you feel ill.

When you wake up from surgery, you may have a catheter, which is a small tube connected to your bladder, so you don't have to get out of bed to urinate. You may also have a compression pump or compression stocking on your leg, which squeezes your leg to keep the blood circulating and to help prevent blood clots. And you may have a cushion between your legs to keep your new hip in the correct position.

Your doctor may teach you to do simple breathing exercises to help prevent congestion in your lungs while your activity level is decreased. You may also learn to move your feet up and down to flex your muscles and keep your blood circulating. And you may begin to learn about how to keep your hip in the correct positions while you move in bed and get out of bed.

The first few days

You will probably still be taking some medicine. You will gradually take less and less pain medicine. You may continue anticoagulant medicines for several weeks after surgery.

Rehabilitation (rehab) after hip replacement surgery may vary depending on whether the surgeon used cement or cementless methods to attach the joint replacement surfaces. Whether your surgeon used cement also determines how much weight you can put on your leg. Your surgeon will let you and your rehab team know what limitations you have. Usually, you cannot put any weight on an uncemented hip for about 6 weeks. With a cemented or hybrid (one piece cemented and one piece uncemented) hip, you can usually put some weight on your leg right away. But you'll still need a walker, a cane, or crutches for several weeks.

In general, most people get out of bed with help on the day after surgery. Over the next few days, you will learn how to walk with a walker or crutches. Your physical therapist and sometimes an occupational therapist will teach you how to exercise, walk, and do activities such as dressing and cooking while you allow your hip to heal. Depending on the type of surgery you had and your doctor's instructions, you may learn the following precautions to keep your hip from dislocating:

  • Avoid combinations of movement with your new hip. For example, do not sit with your legs crossed because in that position you both bend your hip and bring your hip across your body.
  • Your doctor may not want your hip to bend more than 90 degrees. If so, your therapist may suggest these ideas:
  • Do not sit on low chairs, beds, or toilets. You may want to get a special raiser for your toilet seat temporarily.
  • Do not raise your knee higher than your hip.
  • Do not lean forward while you are sitting down, or as you sit down or stand up.
  • Do not bend over more than 90 degrees. This means you can't bend down to tie your shoes for a while.
  • For about 8 weeks, your doctor may not want your leg to cross the center of your body toward the other leg. If so, your therapist may suggest these ideas:
  • Do not cross your legs.
  • Be careful as you get in or out of bed or a car, so your leg does not cross that imaginary line in the middle of your body.
  • Your doctor may not want your leg to rotate in or too far out. If so, your therapist may suggest that you keep your toes pointing forward or slightly out.

Most people go home within a few days to a week after surgery. Some people who need more extensive rehab or those who don't have someone who can help at home go to a specialized rehab center for more treatment.

Continued recovery

After you go home, monitor the surgery site and your general health. If you notice any redness or drainage from your wound, notify your surgeon. You may also be advised to take your temperature twice each day and to let your surgeon know if you have a fever over 100.5F.

For a while, you may need to sit only in high chairs (not on low seats that flex your hip more than 90 degrees), use a toilet seat raiser, and sleep on your back.

You may need to use a walker or crutches for several weeks after surgery until you can bear your full weight, have less pain, and can safely move around without falling. How long you need to use crutches or a walker depends on the condition of your bones and what type of procedure your doctor used as well as his or her experience working with other people who had similar surgery.

Physical therapy generally continues after you go home from the hospital until you are able to function more independently. Total rehabilitation after surgery will take at least 6 months.

You will have an exercise program to follow when you go home, even if you are still having physical therapy. You should also take a short walk several times each day. If you notice any soreness, try a cold pack on your hip and perhaps decrease your activity a bit, but don't stop completely. Staying with your walking and exercise program will help speed your recovery.

For most people it is safe to have sex about 4 to 6 weeks after a hip replacement. Talk to your doctor about how and when it is safe. And ask your physical therapist or occupational therapist about positions that will not put your new hip joint at risk.

Living with a hip replacement

Your doctor will probably want to see you at least once every year to monitor your hip replacement. Gradually, you will return to most of your presurgery activities. If you drive a car, your doctor will probably allow you to start driving an automatic shift car in 6 to 8 weeks, as long as the seat is not too low and you are no longer taking pain medicine.

Because of the way the hip is structured, every added pound of body weight adds 3 pounds of stress to the hip. Controlling your weight will help your new hip joint last longer. For suggestions, see the topic Weight Management.

Stay active to help maintain strength, flexibility, and endurance. Your activities might include walking, swimming (after your wound is completely healed), dancing, golf (don't wear shoes with spikes, and do use a golf cart), and bicycling on a stationary bike or on level surfaces. More strenuous activities, such as jogging or tennis, are not advised after a hip replacement.

Your doctor may want you to take antibiotics before dental work or any invasive medical procedure for at least 2 years after your surgery. This is to help prevent infection around your hip replacement. After 2 years, your doctor and dentist will decide whether you still need to take antibiotics. Your general health and the state of your other health conditions will help them decide.

Why It Is Done

Doctors recommend joint replacement surgery when hip pain and loss of function become severe, and medicines and other treatments no longer relieve pain. Your doctor will use X-rays to look at the bones and cartilage in your hip to see whether they are damaged and to make sure that the pain isn't coming from somewhere else.

Total hip replacement may not be recommended for people who:

  • Have poor general health and may not tolerate anesthetic and surgery well.
  • Have an active infection or are at high risk for infection.
  • Have osteoporosis (significant thinning of the bones).
  • Are involved in heavy manual labor or physically demanding sports.
  • Are severely overweight (replacement joints may be more likely to fail in people who are very overweight).

But doctors evaluate each person individually.

How Well It Works

People who have hip replacement surgery have much less pain than before the surgery and are usually able to resume daily activities. You will probably be able to do your daily activities more easily because the joint moves better.

  • It probably will be easier for you to do things such as climb stairs, get in and out of a car, walk without tiring, walk without a limp or with less of a limp, and take care of your feet.
  • You probably will be able to resume activities, such as golfing, biking, swimming, or dancing, that you did before surgery.
  • Your doctor may discourage you from running, playing tennis, and doing other things that put a lot of stress on the joint.

Most artificial hip joints will last for 10 to 20 years or longer without loosening, depending on such factors as:

  • Your lifestyle and how much stress you put on a joint.
  • How much you weigh (being very overweight puts extra stress on the joint).
  • How well your new joint and bones mend.

The younger you are when you have the surgery and the more stress you put on the joint, the more likely it is that you will eventually need a second surgery to replace the first artificial joint. Over time, the components wear down or may loosen and need to be replaced.

Your artificial joint should last longer if you are not overweight and if you do not do hard physical work or play sports that stress the joint. If you are older than 60 when you have joint replacement surgery, the artificial joint probably will last the rest of your life.

Doctors continue to discover new ways to improve the life span of artificial hip joints. What we know today about the long-term outcomes of hip replacement surgery comes from studies of joints that were replaced 10 to 20 years ago or longer. People who have hip replacement surgery today may expect the artificial joint to last longer than joints replaced 10 to 20 years ago.

Risks

The risks of hip replacement surgery can be divided into two groups:

  • Risks of the surgery and recovery period
  • Long-term risks that may occur months to years after the surgery

The risks of each complication depend in part on your other health problems and on the surgeon.

What To Think About

Continued exercise (such as swimming and walking) is important for your general well-being and muscle strength. Discuss with your doctor what type of exercise is best for you.

You may donate your own blood to use during surgery if needed. This is called autologous blood donation. If you choose to do this, start the donation several weeks before the surgery so that you have time to donate enough blood and rebuild your blood volume before surgery.

If you need more than one joint replacement surgery, such as a knee and a hip, there are some general guidelines that may help you and your doctor decide in which order to do the surgeries.

Knee replacement surgery

Joint replacement involves surgery to replace the ends of bones in a damaged joint. This surgery creates new joint surfaces.

In knee replacement surgery, the ends of the damaged thigh and lower leg (shin) bones and usually the kneecap are capped with artificial surfaces lined with metal and plastic. Usually, doctors replace the entire surface at the ends of the thigh and lower leg bones. But it is increasingly popular to replace just the inner knee surfaces or the outer knee surfaces, depending on the location of damage. This is called partial replacement, or unicompartmental replacement. Doctors usually secure knee joint components to the bones with cement.

In knee replacement surgery, doctors remove the damaged cartilage and replace it with new joint surfaces in a step-by-step process.

Joint changes caused by osteoarthritis may also stretch and damage the ligaments that connect the thighbone to the lower leg bone. After surgery, the artificial joint itself and the remaining ligaments around the joint usually provide enough stability so that the damaged ligaments are not a problem.

Doctors often use general anesthesia for joint replacement surgeries, which means you'll be unconscious during surgery. But sometimes they use regional anesthesia, which means you can't feel the area of the surgery and you are sleepy, but you are awake. The choice of anesthesia depends on your doctor, on your overall health, and, to some degree, on what you prefer.

Your doctor may recommend that you take antibiotics before and after the surgery to reduce the risk of infection. If you need any major dental work, your doctor may recommend that you have it done before the surgery. Infections can spread from other parts of the body, such as the mouth, to the artificial joint and cause a serious problem.

What To Expect After Surgery

Right after surgery

You will have intravenous (IV) antibiotics for about a day after surgery. You will also receive medicines to control pain, and perhaps medicines to prevent blood clots (anticoagulants). It is not unusual to have an upset stomach or feel constipated after surgery. Talk with your doctor or nurse if you don't feel well.

When you wake up from surgery, you will have a bandage on your knee and probably a drain to collect fluid and keep it from building up around your joint. You may have a catheter, which is a small tube connected to your bladder, so you don't have to get out of bed to urinate. You may also have a compression pump or compression stocking on your leg, which squeezes your leg to keep the blood circulating and to help prevent blood clots. Some surgeons recommend that you spend time in a continuous passive motion machine (CPM) to help keep your knee flexible. The machine has a cradle for your leg and is fitted to your leg length and joint position. The amount it bends your knee is adjustable. You may already have a CPM slowly bending and straightening your knee when you wake up after surgery.

Your doctor may teach you to do simple breathing exercises to help prevent congestion in your lungs while your activity level is decreased. You may also learn to move your feet up and down to flex your muscles and keep your blood circulating.

The first few days

You will probably still be taking some medicine. You will gradually take less and less pain medicine. You may continue anticoagulant medicines for several weeks after surgery.

Most people who have knee replacement surgery start to walk with a walker or crutches the day after surgery and can bear weight on the knee if it is comfortable.

A physical therapist will help you gently bend and straighten your knee. Your therapist will also begin some simple exercises to help strengthen your leg muscles.

Rehabilitation (rehab) after a knee replacement is intensive. The main goal of rehab is to allow you to bend your knee at least 90 degrees-enough to do daily activities, such as walking, climbing stairs, sitting in and getting up from chairs, and getting in and out of a car. Most people can get considerably more bending than 90 degrees after surgery. But one of the factors that affects how much bend you get after surgery is how much bend you had before surgery. To get the most benefit from your surgery, it is very important that you take part in physical therapy both while you are in the hospital and after you go home from the hospital.

Most people go home within a few days to a week after surgery. Some people who need more extensive rehab or those who don't have someone who can help at home go to a specialized rehab center for more treatment.

Continued recovery

After you go home, monitor the surgery site and your general health. If you notice any redness or drainage from your wound, notify your surgeon. You may also be advised to take your temperature twice each day and to let your surgeon know if you have a fever over 100.5F.

b generally continues after you go home from the hospital until you are able to function more independently and you have recovered as much strength and range of motion in your knee as you can. You will continue to work on increasing the amount you can bend your knee and on building strength and endurance. Total rehab after surgery will take several months.

You will have an exercise program to follow when you go home, even if you are still having physical therapy. You should also take a short walk several times each day. If you notice any soreness, try a cold pack on your knee and perhaps decrease your activity a bit, but don't stop completely. Staying on your walking and exercise program will help speed your recovery.

Your doctor may recommend that you ride a stationary bicycle to strengthen your leg muscles and improve your knee bending. Swimming is also a good exercise after knee surgery, after your stitches or staples are removed and you are able to go in the water.

Living with a knee replacement

Your doctor may want to see you periodically for several months or more to monitor your knee replacement. Gradually, you will return to most of your presurgery activities.

Controlling your weight will help your new knee joint last longer. For suggestions, see the topic Weight Management.

Stay active to help keep your strength, flexibility, and endurance. Your activities might include walking, swimming (after your wound is completely healed), dancing, golf (don't wear shoes with spikes, and use a golf cart), and bicycling on a stationary bike or on level surfaces.

For at least 2 years after your surgery, your doctor may want you to take antibiotics before dental work or any invasive medical procedure. This is to help prevent infection around your knee replacement. After 2 years, your doctor and dentist will decide whether you still need to take antibiotics. Your general health and the state of your other health conditions will help them decide.

Why It Is Done

Doctors recommend joint replacement surgery when knee pain and loss of function become severe, and medicines and other treatments no longer relieve pain. Your doctor will use X-rays to look at the bones and cartilage in your knee to see whether they are damaged and to make sure that the pain isn't coming from somewhere else.

Doctors may not recommend knee replacement for people who:

  • Have poor general health and may not tolerate anesthesia and surgery well.
  • Have an active infection or are at risk for infection.
  • Have osteoporosis (significant thinning of the bones).
  • Have severe weakness of the quadriceps muscles at the front of the thigh.
  • Have a knee that appears to bend backward when the knee is fully extended (genu recurvatum), if this condition is due to muscle weakness or paralysis.
  • Are severely overweight (replacement joints may be more likely to fail in people who are very overweight).

Some doctors will recommend other types of surgery if possible for younger people and especially for those who do strenuous work. A younger or more active person is more likely than an older or less active person to have an artificial knee joint wear out. People who are very overweight are also more likely to have an artificial knee joint wear out from the extra stress on the joint.

Doctors usually don't recommend knee replacement surgery for people who have very high expectations for how much they will be able to do with the artificial joint (for example, people who expect to be able to run, ski, or do other activities that stress the knee joint). The artificial knee allows a person to do ordinary daily activities with less pain. It does not restore the same level of function that the person had before the damage to the knee joint began.

How Well It Works

Most people have much less pain after knee replacement surgery and are able to do many of their daily activities more easily.

  • The knee will not bend as far as it did before you developed knee problems, but the surgery will allow you to stand and walk for longer periods without pain.
  • After surgery, you may be allowed to resume activities such as golfing, riding a bike, swimming, walking for exercise, dancing, or cross-country skiing (if you did these activities before surgery).
  • Your doctor may discourage you from running, playing tennis, squatting, and doing other things that put a lot of stress on the joint.

The younger you are when you have the surgery and the more stress you put on the joint, the more likely it is that you will eventually need a second surgery to replace the first artificial joint. Over time, the components wear down or may loosen and need to be replaced.

Your artificial joint should last longer if you are not overweight and you do not do hard physical work or play sports that stress the joint. If you are older than 60 when you have joint replacement surgery, the artificial joint will probably last the rest of your life.

People who have a partial knee replacement may have less pain. But in one study they were not as satisfied as people who had a total knee replacement.1

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