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STRONG ARGUMENT

13 Jun 2010 | Brunch (HT)

Total Hip Replacement

How does your hip joint function?

The hip joint is perhaps the strongest weight-bearing joint of the body. Powered by large muscles, the hip joint is essential to many of the body's most basic movements.

The hip joint is a ball-and-socket joint that connects the pelvis and the thigh bones. The hip socket is called the acetabulum and actually forms a deep cup that surrounds the ball of the upper thigh bone or femoral head. The surface of the femoral head and the inside of the acetabulum are covered with a smooth shiny cartilage that cushions, protects and at the same time allows near frictionless movement.

Cartilage, which contains no nerve endings or blood supply, receives nutrients from a moisturizing lubricant (synovial fluid) produced by the synovial lining surrounding the hip joint. If damaged, the cartilage is not capable of repairing itself.

Strong fibres (ligaments) connect the bones of the hip joint and provide necessary stability to the joint and elasticity for its movement. Muscles and tendons also play an important role in keeping the hip joint stable and mobile.

What is Arthritis? What are the different types of Arthritis?


Arthritis is a non-specific term often loosely used to describe symptoms like aches, pains and stiffness in joints. Rheumatism is similarly used for aches and pains in muscles, joints or other parts of the body. Arthritis can be of many types. The commonest include osteoarthritis, Rheumatoid arthritis, Infective arthritis and Traumatic arthritis. Most of these involve progressive deterioration of joint cartilage. Cartilage is a smooth, shiny, glistening material, which covers the ends of bones that articulate to form a joint. When cartilage is healthy, the joint moves smoothly like a well oiled machine. When cartilage is worn out or diseased, it becomes rough, irregular, cracked and swollen. This leads to stiffness, swelling, redness and pain when an attempt is made to move the joint.
	Osteoarthritis: Arthritis where cartilage simply wears out due to over use or old age much like car tyre. Damaged cartilage is unable to replenish or repair itself, and it becomes frayed. It becomes less flexible and is more prone to injury and damage. Over a period of time, the cartilage can wear away completely, causing the bones of the joint to rub directly against each other causing severe pain.


	Rheumatoid Arthritis: It is an auto-immune disease where body's immune system which is designed to fight infections and help healing wounds, goes haywire and attacks its own tissues, especially joints. The joints, usually fingers, swell and cause pain. It often involves all other major joints of the body. With passage of time the joints get destroyed and produce deformities. Drugs often control the pain and inflammation but once the joint is destroyed, replacement remains the main treatment.
	Infective Arthritis: A common occurrence in India following either usual bacterial infection or tuberculosis. These often lead to severe signs of infection followed by rapid course of joint damage.
	Traumatic Arthritis: Injuries to the joints damage the lining cartilage. The cartilage develops cracks, which do not heal with original quality tissue. This becomes a weak spot, which gradually wears and follows a course akin to osteoarthritis.
There are over a hundred type of other arthritis. However the above-mentioned account for over ninety five percent of the patients. Avascular Necrosis (Osteonecrosis): It is not "Arthritis" but a condition in which part of the femoral head dies due to lack of blood supply and becomes irregular in shape. The joint then becomes very painful. The most common causes of Osteonecrosis are excessive alcohol intake, excessive use of cortisone-containing medications, injury to the hip joint or following some surgery around the hip joint.

What is the treatment for Hip Arthritis?


Once the joint cartilage has been damaged to an extent that any attempt to use it is very painful and X-Rays confirm the severe destruction, surgical options need to be considered. Surgery should be advised after a thorough general check up of the patient keeping in mind the need for post-operative physiotherapy as well as the stress of anaesthesia and the surgery itself.
Often medically unfit patients are well advised to live on palliative procedures like drugs and injections into the painful joint.
Various Surgical interventions are available depending on the severity of patient's condition and the doctor's judgement. These include:
	Femoral Hemiarthroplasty:
		Replacement of half a hip
	Total Hip Replacement (THR)
		Cemented prosthesis.
		Un-cemented prosthesis.
		Hybrid Total Hip Replacement

What are the benefits of joint replacement surgery?


After the surgery, once the artificial hip joint has healed, the patient normally benefits by having:
	Reduced joint pain.
	Increased movement and mobility.
	Correction of deformity.
	Increased leg strength.
	Improved quality of life due to the ability to return to normal activities and pastimes.

What is Total Hip Replacement?


There are two major types of Total Hip Replacements:
	a cemented prosthesis
	an uncemented prosthesis
Both are widely used. The surgeon makes the choice based on the patient's age and lifestyle.
Each prosthesis is made up of two parts:
	The acetabular component is made of high-density polyethylene. At times it has a metal shell backing. The acetabular component is placed inside the socket.
	The femoral component is made of metal. The femoral head that attaches to the stem may be a separate part. It is made either of metal or ceramic. The femoral stem extends into a canal in the thigh bone.
	When the acetabular component is uncemented and femoral component is cemented, it is called Hybrid Total Hip Replacement.
Today, almost one million people in the developed world undergo Total Hip Replacement surgery every year as a mean of diminishing pain and restoring mobility.

What is Femoral Hemiarthroplasty?

Femoral Hemiarthroplasty is done instead of a Total Hip Replacement, when the socket cartilage is normal. The socket is not replaced. The femur component is similar to that of a total hip replacement, but its ball is large and fills the normal socket, bearing directly against the cartilage. Though this is a smaller procedure, it lasts for less time than a Total Hip Replacement.

What is done for the preparation before surgery?


You undergo a detailed medical check up to make your surgery safe about one to two weeks prior to surgery. Any shortcoming in normal values like blood sugar or blood pressure can then be safely controlled before the operation. You may be asked to stop certain medicines that you are taking for any other ailment or some medicines may be added. Usual pre-surgery investigations are listed below, however at times additional investigations may be required in some cases.
List of Investigations
	Hb : Blood Sugar: F BT :
	TLC : PP CT :
	DLC : Urea : PT :
	Platelet Count : Creatinine : PTT :
	Blood group : Na+ : ECG :
	Urine R/M : K+ : HbsAg :
	Chest X-ray : HIV : Echocardiogram :
The patient needs blood transfusion during surgery depending upon the pre-operative haemoglobin levels. Some patients prefer to donate their own blood a few days before the operation, which is transfused back to them on day of the operation. The patient is admitted to the hospital a day before the surgery date and advised not to eat or drink anything after midnight on the day of surgery. An injection of blood thinning agent (anti-coagulant) is administered, a night before or the evening after the operation, to minimize chances of blood clotting in the legs. Usually antibiotics are started in the morning of the operation. In patients with greater risk of infection (such as diabetics), at times antibiotics may be started a night before. In order to receive medications and blood transfusions during surgery, an intravenous (IV) line will be started. The anaesthesiologist will speak to you before surgery and discuss the type of anaesthetic to be used. Most people are operated upon under epidural/ spinal anaesthesia where their legs are numbed and a fine tube is put in the back through which anaesthetic agent keeps dripping in. This also controls your pain in post-operative period.

How long does it take to recover from joint replacement surgery?

After the surgery the patient is shifted to the post-operative recovery room. A bandage is tied over the hip with a drain tube coming out of the bandage. This removes any blood collected in the hip joint and minimizes the chances of infection. The legs of the patient are kept apart by a pillow in between them.

An intravenous line will be transfusing blood or fluids into the patient's arm. This will later be used to give you antibiotics over the next few days. In some instances a urinary catheter may be used to help elderly patients or those who have urinary difficulty.

Some leads will be attached to your body to continuously monitor your ECG, blood pressure, pulse rate, breathing rate, etc. The patients remain in the recovery room for a few hours and are shifted to their own room once the anaesthetists are satisfied in all respects.

Rarely, patients with medical problems need to stay in ICU or High Dependency Unit for a day or two.

What is the Post-Operative Management process & the Physiotherapy applied after joint replacement surgery?

Patient is encouraged to start in-bed exercises within 24 hours of the operation. After 24-48 hours drain from the hip joint is removed and the dressing is reduced in size. Patient is made to sit on bedside with legs supported.

2-3 days after the operation (cemented hip) patient is encouraged to stand and walk using a walker and a day or two later, patient is able to visit the toilet with assistance using a high seat.

3-4 weeks after the operation, patients are encouraged to walk with a walking stick. In case of Hybrid or Uncemented Hip Replacement, the patient is usually advised non-weight bearing is advised at 8-12 weeks after the operation.

You are usually discharged from the hospital one week after the surgery with instructions regarding medicines and physiotherapy.

Stitches are removed 2-3 weeks after the operation

Cemented Total Hip Replacement
6-8 weeks after the surgery, patients are trained to start climbing stairs.
12 weeks post operative, one can usually begin driving vehicle with due precautions.

What are the precautions I should take after the surgery?

First eight weeks:


	Always use your walker, crutches or cane
	Walk. It is your most vital physical therapy. Gradually increase the distance.
	Do not sleep on your side until instructed by physician.
	Do not cross your legs at the knees or ankles.
	Do not bend the hip beyond a 90' angle - avoid low chairs and Indian style toilet.
	Do not pivot or twist on the operated leg.
	Do not bend over to pick up anything from the floor.
	If in doubt about any activity, consult your Surgeon before performing it.

How do I follow-up the precautions after the surgery?

You may be seen six weeks, three months and twelve months after your surgery. You are normally requested that you see your surgeon once a year after the first year, even if you are not having any problems.

Any infection must be promptly treated with proper antibiotics because infection can spread from one area of the body to another through the blood stream. Every effort must be made to prevent infection in your artificial joint.

How can I be sure about the success of the surgery?


Total Hip Replacement is one of the most successful operations for severe arthritis and to increase your chances of success ensure the following:
	Choose a Surgeon who is a specialist in Joint Replacement surgery and does them regularly.
	Choose a well-equipped hospital having an operation theatre and facilities appropriate for Joint Replacement surgery.
	Discuss with the Surgeon and ensure that good quality implants are used.
	Meet and talk to other patients who have been operated by the Surgeon performing your surgery.
	Follow the instructions given by your Surgeon.
Patients must give a detailed account of their medical history to the Surgeon as it may have a bearing on their operation and its result.

What is Revision Joint Replacement?


The usual life span of a successful Total Hip Replacement is about 10-15 years. It may however vary in individual circumstances. Once a joint is worn out or fails, a Revision Joint Replacement can be done, though it is a more extensive procedure. The success of the Revision Surgery varies in individuals depending on the pre-operative status of their 'Primary Replacement Joint'.

What are the risks factors during and after the surgery?

All major operations include an element of risk and though these should not be over emphasized, the patient should be aware of these, particularly the elderly who are at a greater risk than the younger age group. Major complications include infection, dislocation of the ball from socket, blood clots in veins of legs and lungs. These can occur in any centre in the world.
Problems and aspirations of each individual patient differ and these must be discussed with the Surgeon at length before the patient accepts the Total Hip Replacement operation. Patient must know all that can go wrong and what can be done to save the situation.

Do I need to sign a written consent for the surgery?

For any surgical procedure, you need to sign an 'Informed Consent Form'. You must understand the language of the form and clarify all doubts before signing it.

Total Knee Replacement

What is the Knee Joint and how does it function?

The knee is the largest joint in the body. It is commonly referred to as a "hinge" joint because it allows the knee to flex and extend (bend and straighten). While hinges can only bend and straighten, the knee has the additional ability to rotate (turn) and translate (glide). The knee joint is formed by the tibia (shin bone), the femur (thigh bone) and the patella (knee cap).

How does your healthy knee function?

Each bone end is covered with a layer of smooth shiny cartilage that cushions and protects while allowing near frictionless movement. Cartilage, which contains no nerve endings or blood supply, receives nutrients from the fluid contained within the joint. Surrounding the knee structures is the synovial lining, which produces this moisturizing lubricant. If damaged, the cartilage is not capable of repairing itself.

Strong fibres, called ligaments, link the bones of the knee joint and hold them in place, adding stability and elasticity for movement. Muscles and tendons also play an important role in keeping the knee joint stable and mobile.

What is Arthritis?


Arthritis is a non-specific term often loosely used to describe symptoms like aches, pains and stiffness in joints. Rheumatism is similarly used for aches and pains in muscles, joints or other parts of the body. A large majority of people, including some doctors, tend to use these words imprecisely.

What is an Arthritic Knee?


Arthritis can be of many types. The commonest includes osteoarthritis, Rheumatoid arthritis, Infective arthritis and Traumatic arthritis. Most of these involve progressive deterioration of joint cartilage. Cartilage is a smooth, shiny, glistening material, which covers the ends of bones that articulate to form a joint. When cartilage is healthy, the joint moves smoothly like a well oiled machine. When cartilage is worn out or diseased, it becomes rough, irregular, cracked and swollen. This leads to stiffness, swelling, redness and pain when an attempt is made to move the joint.
	Osteoarthritis: Perhaps the commonest types of arthritis where cartilage simply wears out due to over use or old age much like a car tyre. In India the knee joint suffers from this affliction most commonly leading to severe pain, difficulty in movements and often bending of the legs and knees producing a duck like waddling gait.
	Rheumatoid Arthritis: is an auto-immune disease where body's immune system which is designed to fight infections and help healing wounds, goes haywire and attacks its own tissues, especially joints. Usually young adults develop this type of joint involvement and the sufferer feels ill. The joints, usually fingers swell and become painful. It often involves all other major joints of the body. With passage of time the joints get destroyed and produce deformities. Drugs often control the pain and inflammation but once the joint is destroyed, replacement remains the main treatment.
	Infective Arthritis: A common occurrence in India following either usual bacterial infection or tuberculosis. Once again the joints are destroyed. These often lead to severe signs of infection like temperature and follow rapid course of joint damage.
	Traumatic Arthritis: Injuries to the joints damage the lining cartilage. The cartilage develops cracks, which do not heal with original quality tissue. This becomes a weak spot, which gradually wears and follows a course akin to osteoarthritis though at much younger age. This can often be seen in sports personalities like football and rugby players and cricketers.
There are over a hundred types of other arthritis. However the above-mentioned account for over ninety five percent of the patients.

What is the treatment for Knee Arthritis?


Anti-inflammatory drugs often suppress the pain and limit swelling, yet the problem is not cured. Once the joint cartilage has been damaged to an extent that any attempt to use it is very painful and X-rays confirm the severe destruction, surgical options need to be considered. Surgery should be advised after a thorough general check up of the patient keeping in mind the need for post-operative physiotherapy as well as the stress of anaesthesia and the surgery itself. Often medically unfit patients are well advised to live on palliative procedures like drugs and injections into the painful joint.
Various Surgical interventions are available depending on the severity of patient's condition and the doctor's judgement. These include:
	Arthroscopic debridement: A telescope is inserted into the knee and products of wear and tear are removed.
	High Tibial Osteotomy: The shin bone (tibia) is cut at the upper end and realigned to distribute the loads in a knee which is only partially arthritic.
	Total Knee Replacement
	Unicondylar Knee Replacement
Patients must give a detailed account of their medical history to the Surgeon as it may have a bearing on their operation and its result.

WHow is Total Knee Replacement performed?

How is Total Knee Replacement performed?


Total knee replacement or "Arthroplasty" is the relining of the joint (bone end surfaces) with artificial parts called prostheses. There are three components used in the artificial knee. The femoral (thigh) component is made of metal and covers the end of the thigh bone.
The tibial (shin bone) component, made of metal and polyethylene (medical-grade plastic), covers the top end of the tibia. The metal (usually Titanium) forms the base of this component. The polyethylene is attached to the top of the metal to serve as a cushion and form a smooth gliding surface between the metal of the femoral and tibial components.
Knee Replacement Component These components are usually cemented to their respective bones, though some uncemented models are also available.
The third component, the patella or knee cap, is made up of polyethylene. The surgeon decides at the time of Operation if it should be replaced in a particular situation or not.
The total knee replacement is conducted through an incision that runs three or four inches above the knee down along the inside of the kneecap to several inches below the knee. The new components and muscles function just as your natural knee did.
Patients with severe arthritis of both knees can be offered replacements of both knees together after a thorough medical evaluation.

What is Unicondylar Knee Replacement?


In some patients only one half of the knee joint is worn out. In these situations only one side of the knee is replaced. This is termed as Unicondylar Knee Replacement. It has very definite indications, which only your surgeon can judge and advice you.
Unicondylar Knee Replacement is comparatively economical and since the operation is less extensive, the post-operative recovery is sooner.

What is done for the preparation before surgery?


You undergo a detailed medical check up to make your surgery safe about one to two weeks prior to surgery. Any shortcoming in normal values like blood sugar or blood pressure can then be safely controlled before the operation.
You may be asked to stop certain medicines that you are taking for any other ailment or some medicines may be added.
Usual pre-surgery investigations are listed below, however at times additional investigations may be required in some cases.
list of investigations
	Hb : Blood Sugar: F BT :
	TLC : PP CT :
	DLC : Urea : PT :
	Platelet Count : Creatinine : PTT :
	Blood group : Na+ : ECG :
	Urine R/M : K+ : HbsAg :
	Chest X-ray : HIV : Echocardiogram :
You will need some blood transfusion during the surgery. This will depend upon your pre-operative Haemoglobin levels. Some patients prefer to donate their own blood a few days before the operation, which is then transfused back to them on day of the operation.
You will be admitted to the hospital a day before the surgery date. You are advised not to eat or drink anything after midnight on the day of surgery. You will be taken to the operating room about an hour in advance of the surgery.
A night before surgery, you may be given an injection of blood thinning agent (Anti-coagulant). This is used to minimize the chances of blood clotting in your legs.
Usually antibiotics are started in the morning of the operation. In patients with greater risk of infection, at times antibiotics may be started a night before.
In order to receive medications and blood transfusions during surgery, an intravenous (IV) line will be started. The anaesthesiologist will speak to you before surgery and discuss the type of anaesthetic to be used.
Most people are operated upon under epidural/ spinal anaesthesia where their legs are numbed and a fine tube is put in the back through which anaesthetic agent keeps dripping in. This also controls your pain in post-operative period.
When pain, stiffness, knee swelling and limitation of motion in your knees keep you from your daily activities, you may need Total Knee Replacement.

How long does it take to recover from Knee surgery?


After your surgery (operation) you will be taken to the post-operative recovery room. You will have a bandage over your knee and a drain tube coming out of the bandage. This removes any blood collected in your knee and minimizes the chances of infection.
An intravenous line will be transfusing blood or fluids into the patient's arm. This will later be used to give you antibiotics over the next few days. In some instances a urinary catheter may be used to help elderly patients or those who have urinary difficulty.
Some leads will be attached to your body to continuously monitor your ECG, blood pressure, pulse rate, breathing rate, etc. You will remain in recovery room for a few hours and once the anaesthetists are satisfied that you are comfortable, your will be sent to your room.
Rarely, patients with medical problems need to stay in ICU or High Dependency Unit for a day or two.
Today, more than 5000,000 people in the developed world undergo Total Knee Replacement surgery every year as a means of diminishing pain and stiffness and restoring mobility.

What is the Post-Operative Management process & Physiotherapy applied after the surgery?

You will be encouraged to start in-bed Chest and Knee exercises on the evening of the operation. After 24-48 hours the drain from your knee is removed and the dressing reduced in size. You will be made to sit on bedside with legs supported.
4-6 days after the operation you will be encouraged to stand and walk using a walker and a day or two later, you should be able to visit the toilet with assistance. You are usually discharged from the hospital one week after the surgery with instructions regarding medicines and physiotherapy.
Stitches are removed 2-3 weeks after your operation.
3-4 weeks after the operation, patients are encouraged to walk with a walking stick.
6-8 weeks after the surgery, patients are trained to start climbing stairs.
12 weeks post operation, one can usually begin driving vehicle with due precautions.

You are advised not to squat or sit cross-legged after the operation.

How do I follow-up precautions after the surgery?

You may be seen six weeks, three months and twelve months after your surgery. You are normally requested that you see your surgeon once a year after the first year, even if you are not having any problems.

Any infection must be promptly treated with proper antibiotics because infection can spread from one are of the body to another through the blood stream. Every effort must be made to prevent infection in your artificial joint.

How do I be sure about the success of the surgery?


Total Knee Replacement is the most successful operation for severe arthritis and to increase your chances of success ensure the following:
	Choose a Surgeon who is a specialist in Joint Replacement surgery and does them regularly.
	Choose a well-equipped hospital having an operation theatre and facilities appropriate for Joint Replacement surgery.
	Discuss with the Surgeon and ensure that good quality implants are used.
	Meet and talk to other patients who have been operated by the Surgeon performing your surgery.
	Follow the instructions given by your Surgeon.

What is Revision Joint Replacement?


The usual life span of a successful Total Knee Replacement is about 10-15 years. It may however vary in individual circumstances. Once a joint is worn out or fails, a Revision Joint Replacement can be done, though it is a more extensive procedure. The success of the Revision Surgery varies in individuals depending on the pre-operative status of their 'Primary Replacement Joint'.

What are the risks factors during and after the surgery?

All major operations include an element of risk and though these should not be over emphasized, the patient should be aware of these, particularly the elderly who are at greater risk than the younger age group. Major complications include infection, blood clots in veins of legs and lungs. These can occur in any centre in the world.
Problems and aspirations of each individual patient differ and these must be discussed with the Surgeon at length before the patient accepts the Total Knee Replacement operation. Patient must know all that can go wrong and what can be done to save the situation.

Do I need to sign a written consent for the surgery?


For any surgical procedure, you need to sign an 'Informed Consent Form'. You must understand the language of the form and clarify all doubts before signing it.

What is DEGENERATIVE SPINE problem?


Due to underlying disc degeneration and disc dehydration, nature tries to maintain stability and rigidity by thickening the ligamentum flavum and the factes. These changes occupy the space from where the nerves are passing leading to narrowing of the spinal canal, in the mobile zone of the spine called Lumbar or cervical canal stenosis. The nerve bundle passing through the tight canal is not able to meet increased blood flow, as well as the nerve conduction speed which has to increase while walking, so patient feels inability to walk more than a certain distance and has to stop for a while, before walking again. The symptoms increase so slowly that a person does not realise and only presents when symptoms are in advanced stage. Finally the spine can become deformed to one side developing scoliosis.
Decompression options available are:
	Laminotomy
	Laminectomy
	Anterior discectomy or corpectomy in cervical spine with fusion
Both the options can be accompanied by fixation with pedicle screw fixation and bone graft either in the intertransverse gutter or the space created by curetting the disc space.

What are SPINE DEFORMITIES?


Spine develops as multiple segments in the fetus in an intricate manner, failure to fuse (spina bifida), failure to segment (unsegmented bar), or failure to form one half (hemivertebra) are some of the anomalies which when loaded with vertical weight can lead to deformity of the spine. It is scoliosis if spine is curved on side, kyphosis when spine is curved in front, kyphoscoliosis when both the deformities co-exist. Deformity is mainly cosmetic; involvement of neurology warrants urgent investigations and remedy. Failure to form the pars interarticularis of L5 vertebra causes the whole spine to shift in front when loaded is called spondylolisthesis and spondyloptosis when the L5 falls in front of S1 stretching along with it the nerves in the inter-vertebral foramen.Options available for deformities are:
	Braces and keep under observation till the balance is maintained and the child is growing straight
	Surgical correction and fusion when the sagittal or coronal balance starts tilting

What are SPINE INFECTIONS?


Spinal infections are mostly tuberculosis in India, or post-operative, or bacteria after septicemia, Fungal or other bacteria are rarely found. With the advent of MRI it has become easy to find out the culprit area in patient who is clinically a suspect. Other tests to confirm the infection are tried to obtain a sample to help further management through a minimally invasive/ open route. Emergence of strains resistant to regular drugs for infection is a big challenge. Precious time is saved to treat these infections by aggressive diagnostic workup and where necessary, surgery viz:
	Resection of the diseased segment
	Reconstruction and fusion

What are SPINE TUMORS?


Most common spine tumors are depositions from already existing primary sites. These are growth of tissue outside the dural covering and relatively easy to get rid of. Tumors deposited inside the dural sheet but yet outside the nerve bundle are also salvageable, but tumors deposited inside the neural tissue are most difficult to get satisfactory results. Primary tumors of the spine like Chordoma are very difficult to resect, the tumor tissue is removed and local pressure effects are salvaged.
	Global resection
	Anterior reconstruction
	Fusion

What is REDO SPINE SURGERY?


Since spine surgery is now happening at places which are equipped with modern medical facility. The ortho-spine team has the expertise and experience to undertake failed back surgeries safely and with consistent good results. These complex surgeries are carried out after detailed multidisciplinary work up, risk assessment and realistic expectations.

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Max Institute of Orthopaedics provides state-of-the-art facilities for treatment of all bone and joint related ailments.

Joint Replacement Surgery - Knee Replacement Surgery - Birmingham Hip Replacement Surgery - Sports Injury Treatment - Foot and Ankle Surgery - Arthroscopic Knee Surgery - Spine Surgery India

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