Total Hip and Knee Replacement

The UVA Guide to Total Hip Replacement for Patients and Family Members

The UVA Guide to Total Knee Replacement for Patients and Family Members

Individuals considering hip and knee replacement surgery will usually be experiencing considerable pain in the affected joint and will have x-rays demonstrating arthritic damage. In addition the potential patient may be experiencing limitation of motion and interference with certain activities. For example, individuals with hip disease may have difficulty putting on their shoes and socks or arising from a soft chair. People with arthritic knees find going up and down stairs to be difficult.

Patients begin to seriously consider surgery when nonoperative treatment no longer provides pain relief. Typically patients will have tried different anti-inflammatory drugs such as (Motrin or Aspirin), perhaps cortisone injections and sometimes a can or crutches for weight relief. Most surgeons believe that joint replacement is indicated when pain and limitation of function is sufficiently severe to prevent either employment or full enjoyment of the retirement years.

Total hip and total knee replacements have much in common. The decision to proceed with either operation is usually made during an office visit with an orthopaedic surgeon. A preoperative visit is then planned at the hospital one-week or so prior to the scheduled surgery date. At this time routine laboratory studies are obtained and the patient has an opportunity to discuss the rehabilitation program with the physical and occupational therapist that will be working with them in the hospital. If a patient has been seen recently by their family physician for a physical examination, laboratory results obtained at the time of that visit can be substituted for the studies ordinarily ordered at the hospital.

The Operation
On the day of the operation the patient will be asked to arrive at the hospital quite early and generally without taking any food or drink after midnight. The anesthesiologist will talk to the patient about the type of anesthesia. The options are ordinarily either general anesthesia or an epidural block. Both of these types of anesthesia are equally safe and it is largely a matter of patient and anesthesiologist preference. If a patient chooses an epidural block (has their hips and legs numbed), they do not need to be wide-awake in the Operating Room as sedation is always administered. One advantage of epidural anesthesia is that long acting pain relieving medication can be added through the epidural catheter offering the patient substantial pain relief for the first two to three days after the operation.

The surgery takes approximately two hours. Patients will spend another hour or two in the recovery room before being returned to the orthopaedic floor in the hospital. Most individuals will feel like having some supper the night of the operation. With modern pain relief techniques most do not experience a great deal of discomfort.

Post-Surgery Care
The physical therapist will see you the morning after the operation and begin a walking and exercise program. Depending upon the type of prosthesis utilized you will be asked to bear only partial weight or be allowed to bear full weight with the assistance of a walker. Over the course of four to five days following surgery most individuals will become independent in their walking and are prepared to either return home or to enter a skilled nursing facility.

The individuals needs and resources determine the choice of where one goes following their hospitalization. If someone has achieved a high degree of independence in the hospital and has strong family support then returning home with the aid of a visiting physical therapist and nurse may be the optimal choice. Alternatively if someone lives alone or has a spouse who does not enjoy robust health then Medicare will make available without charge twenty days in a skilled nursing facility. At the skilled nursing facility the patient receives daily physical therapy and appropriate nursing care. Often the patient finds that the full 3 weeks in the skilled nursing facility is not necessary to obtain the degree of independence necessary for returning home.

Recovery Process
The recovery process for hip and knee surgery varies depending on the joint operated on and the type of implant that is utilized. For example, knee replacement components are generally cemented and the average patient utilizes a walker or crutches for 3 weeks or so following the operation and then makes the transition to a cane. Most patients find that by six to eight weeks post-operative they are able to walk without any assistive device at all. The emphasis after knee replacement is less on the ability to walk, which returns quickly, but concentrates more on regaining strength and range of motion.

Following hip replacement the patient may remain on crutches or a walker somewhat longer before they make the transition to a cane. Hip range of motion returns rapidly following replacement surgery, but in general the ability to walk independently is somewhat more prolonged than after knee replacement. The average patient following hip replacement is walking with a cane 6 - 7 weeks following the operation and generally is free of any assistive devices within 2 - 3 months post-operative.

The goal of hip and knee replacement surgery is to relieve pain, improve range of motion and give the patient the ability to perform those activities of daily living which were difficult prior to the operation. These goals are generally met in at least 90% of all our patients undergoing this type of surgery. Even those individuals who experience results that are less than optimum generally feel that they are better than they are prior to the operation.

Risk of Complications
There are complications with hip and knee surgery that can compromise the outcome. Historically infection has been the most serious complication. Serious infections occur approximately 1% of the time following these operations. When this happens, the patient will need to undergo an extensive course of antibiotic treatment and may require additional surgery.

Individuals undergoing hip and knee surgery are at risk for developing blood clots in their legs. This problem is usually just troublesome, but if the clot migrates to the lungs it can be quite serious. Significant pulmonary embolism as with infection is an unusual complication, but always requires re-hospitalization and a period of treatment with different medications.

Orthopaedic surgeons take a number of measures around the time of the operation and during the hospitalization to prevent these complications from occurring.

Implant Life
Many patients ask how long a hip and knee replacement will last. Surprisingly there is very little actual wear of the artificial components that are used in replacement surgery. The normal articulation is that of metal against polyethylene with the plastic component being the one most likely to wear. Sufficient thickness of polyethylene is used in modern surgery to generally provide a lifetime of use before damaging wear occurs.

There are other component problems, principally loosening, which can lead to late failure in hip and knee replacement surgery. For example, in centers like the University of Virginia which do a high volume of this kind of surgery for every 100 patients who undergo replacement for the first time there may be 5 or 10 patients having prosthetic joints replaced again. Most of this revision surgery is performed on patients who had their initial replacement done 10 - 15 years ago when the techniques were not optimal. Most orthopaedists believe that with modern techniques and implants the long-term revision rate will be much lower than that seen at the present time.

Individuals will often ask whether they should have their prosthesis cemented or should they have one of the implants into which their own bone will grow. Your orthopaedic surgeon will advise you of his or her preference. Most orthopaedic surgeons will use the bony ingrowth type of component on the socket side of every hip replacement. The choice of implant on the thigh bone or femur side of the joint is generally made on the basis of the patients expected activity level. Cemented components have the advantage of allowing immediate full weight bearing and a predictable outcome. Certain individuals, however, can be expected to place greater stresses on their hip (generally younger or heavier patients) and may be candidates for the bony ingrowth type of prosthesis. If firm union does occur between prosthesis and the patient's bone we anticipate that this bond will last for many years. This disadvantage of the non cemented femoral component is increased cost, the need to be partial weight bearing for a prolonged period of time and to some extent uncertainty as to whether biologic union between bone and implant will occur.

In total knee replacement most surgeons will cement all components. Occasionally in younger individuals the femoral component will be the biologic ingrowth design, but almost always the tibia and patellar components will be cemented.

The UVA Guide to Total Hip Replacement for Patients and Family Members has been put online so you can receive more information about this procedure.

Surgeons performing Hip Replacements at UVA

The UVA Guide to Total Knee Replacement for Patients and Family Members has been put online so you can receive more information about this procedure.

Surgeons performing Knee Replacements at UVA