Indications: Osteoarthritis, Rheumatoid Arthritis, Trauma etc.
Patients are seen in this specific clinic approximately 2-3 weeks prior to surgery. Here they under a thorough assessment by both medical and nursing staff. This includes simple blood and urine tests as well as the taking of swabs which identify patients carrying certain bacteria including MRSA. Mr Hartwright sees patients at this point in order to explain the nature of the surgery and possible risks, identify any possible problems, obtain the patient’s consent to surgery and, of course, to answer any outstanding questions the patient may have.
Xray’s are taken of the affected hip and these are uploaded to the hospital’s computerised viewing system (Picture ArChiving System – PACS). Once on this system, Mr Hartwright and his team use specific templating software which allows them to decide on the correct implants to use.
Patients normally receive either a spinal (a needle into the spinal area causing numbness below the waist), or general anaesthetic. On the whole, spinal anaesthesia is preferred as it causes fewer possible cardiorespiratory problems. There are potential risks with either technique and patients are encouraged to discuss any issues they may have with the Anaesthetist pre-operatively.
If a patient is thought to have any anaesthetic risk factors which may cause problems during, or after surgery, they are seen in pre-assessment clinic or given an appointment to see an Anaesthetist well before the day of surgery.
Mr Hartwright performs the operation through a small incision on the outside of the hip/thigh (where possible he uses a mini-incision i.e. surgical incision <10cm). He uses what is called an anterolateral approach which is thought to decrease the rate of hip dislocation.
He most commonly uses uncemented implants (i.e. not requiring cement to hold them in situ) but varies the implants depending upon what he feels is best for the patient. Similarly, he uses a number of different bearing surfaces (the ball and socket part of the joint) including ceramic, metal and polyethylene.
The average hospital stay is approximately one week. However, when a patient fulfills certain criteria, Mr Hartwright uses an Enhanced Recovery Programme. This is tends to decrease the length of stay to approximately 3-4 days.
Mr Hartwright encourages patients to start mobilising as soon as comfort allows. This is done under the supervision of either the physiotherapists or nursing staff. Most patients start to walk on the day following surgery. Prior to discharge, patients are taught how to walk safely with crutches and climb a small flight of stairs.
Patients are provided with instructions as to the exercises that they should perform once discharged. It is vital that they do these exercises in order to optimise the results of surgery.
There are certain movements that patients should not perform post-operatively so as to prevent the risk of dislocation. These include bending the hip beyond 90° (a right angle) and twisting the hip. Patients are instructed by the physiotherapists in how to use techniques to avoid these movements.
Mr Hartwright uses clips to close the skin. These are removed at 10-14 days post-operatively. This is normally performed by the patient’s district or practice nurse.
Patients are discharged with compression stockings which are worn in order to prevent blood clots (Deep Vein Thromboses – DVT). They are instructed to wear these for 6 weeks.
Patients are allowed to drive at 6 weeks post-operatively so long as they feel safe to drive (and are able to perform emergency manoeuvres).
Pre-operatively, the Hb is checked and where necessary treated to bring it up to an acceptable level before surgery is considered.
During the operation, techniques (including careful haemostasis) are used to limit blood loss and a drain is inserted into the operative site which salvages any blood lost.
Post-operatively, blood collected in the drain is given back to the patient and the Hb is checked again. If the Hb level falls below a certain level (which is patient/symptom dependent) a blood transfusion may be deemed necessary. There are risks involved with receiving blood transfusions (please refer to blood transfusion on www.blood.co.uk).
Pre-operatively: Patients are pre-assessed so as to identify patients who are at greater risk of infection and measures are taken to decrease these risks e.g. Identifying and treating those patients who are MRSA carriers or who have urinary tract or other infections.
Patients are advised to take care of their skin pre-operatively; any cuts or scratches may allow bacteria to enter a patient’s system and consequently increase the risk of infection.
All instruments are sterilised to strict guidelines.
Joint replacement surgery is performed in specially designed theatres (with air filters and laminar flow) so as to decrease the risk of airborne infection.
The surgical site is prepared using antibacterial solution with the aim of preventing the entry of bacteria from the patient’s own skin.
All theatre staff directly involved in the procedure thoroughly wash their hands and wear sterile gowns and gloves such that no unsterile object comes into contact with the patient.
The surgical site is covered with a dressing so as to avoid infection from direct contact.
The rate of infection in patients undergoing joint replacement surgery is generally quoted as 1%. Link to RHCH infection rates.
Mr Hartwright’s rate of infection for joint replacement surgery is under 0.3%
Patients are encouraged to inform either the nursing and medical staff if they are experiencing pain. There are many analgesic agents at our disposal and there is no longer any need for patients to suffer in discomfort.
The rate of dislocation varies but is generally quoted as occurring in 1-4% of patients undergoing joint replacement surgery.
None of Mr Hartwright’s patients have suffered with a dislocation of their hip replacement.
Usually, any difference in leg length is not noticed by the patient but if it is noticeable (normally a discrepancy of ?2cm) then a heal raise can be placed in the other shoe to offset this inequality.
There are many other potential risks but the above probably represent the most important and certainly most asked about.