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.
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 vertical incision over the middle of the knee (midline incision). He uses what is called a medial parapatellar approach which divides the deep tissues around the inside of the knee next to the knee cap.
He uses cemented implants (i.e. requiring cement to hold them in situ) but varies the actual implants depending upon what he feels is best for the patient. The usual implants are made of Cobalt chrome, Titanium and Ultra High Molecular Weight Polyethylene (UHMWPE). Occasionally Mr Hartwright uses OxiniumTM (oxidized zirconium) which is thought to improve the longevity of the TKR.
The average hospital stay is approximately 5 days but this depends upon how quickly the patient recovers and rehabilitates.
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. They are normally expected to achieve knee flexion of at least 90° (a right angle) before they are discharged.
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.
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).
In general complications are more common with Revision Hip Surgery compared with primary (first time) replacements.
Mortality PE Wound Inf Readmission Dislocation
Primary THA 1% 0.9% 0.2% 4.6% 3.1%
Revision THA 2.6% 0.8% 0.95% 10% 8.4%
Rates of complications occurring within ninety days after surgery (Rates and Outcomes of Primary and Revision Total Hip Replacement in the United States Medicare Population. JBJS (Am) 85:27-32 (2003))
There are many other potential risks but the above probably represent the most important and certainly most asked about.