Other Surgical Procedures
Hip Resurfacing
- Hip resurfacing is a modern surgical treatment for patients with hip arthritis.
- It differs from traditional hip replacement (THR) surgery in several ways:
- The removal of arthritic bone is limited to a few millimetres from the surface of the femoral head (ball) and acetabulum (socket) of the hip. Most of the bone of the femoral neck remains. This contrasts with the quite extensive bone resection required for THR in which the whole head and neck are removed and the marrow bone within the femur is prepared to receive a femoral stem.
- The resurfacing hip components are then secured to these surfaces, but as their name suggests they ‘resurface’ the joint rather than ‘replace’ the joint.
- How is this better? The hip has much improved stability (i.e. lower risk of dislocation). As a consequence this is often considered a good treatment option for young active patients who still want to pursue vigorous sporting activity. In addition, more bone is retained for future hip surgery, as all hip replacements including resurfaced hips eventually wear out. Conversion of a resurfaced hip to a conventional total hip replacement is usually more straightforward than revision of a THR
- The risks of surgery are similar to total hip replacement, but resurfacing hips carries a slightly higher likelihood of failure due to fracture, and rare allergic reactions to metal ions
- The durability of resurfacing hips is equivalent if not better than THRs in matched groups of patients. It is expected that nine out of ten resurfacing hips will still be working well in ten years time.
- Some hips are not suitable for resurfacing, the arthritis may have progressed to an advanced stage, there may be complex anatomy and pathology or soft, poor quality bone. In these cases it is always possible to perform a total hip replacement.
Hip Replacement
- Hip replacement remains the ‘Gold Standard’ operation for hip arthritis
- It remains one of the most successful orthopaedic operations performed in terms of quality of life improvements. While principally intended to relieve pain and improve mobility, modern surgeons aim to achieve ever higher functional levels.
- Many designs exist which have evolved over the last half century – some of the older designs work so well, they still are in use today.
- Most of the modern hip designs offer advantages over traditional designs as they can be tailored to fit virtually any hip anatomy (rather than one size fits all)
- The main variations in hip replacement surgery are:
- Surgical approach – front, side or back of hip
- How the implants are fixed to bone – cemented (instant bonding) or uncemented (an initial frictional fit and gradual bone growth and bonding)
- The bearing surface – a metal or ceramic on plastic, a ceramic on ceramic, or a metal on metal surface. Each has advantages and disadvantages
- There are many options available, the orthopaedic surgeon should explain the alternatives, types of implant, and rationale for use in each individual patient.
- The risks of surgery are low but significant in a small proportion of patients. Precautions are taken to minimise risks to each individual patient. Complications include infection, dislocation, deep venous thrombosis and pulmonary embolism, bleeding, nerve and muscle damage, fracture, and medical complications. Most complications are treatable, some require more surgery, rarely they are life threatening.
Knee Arthroscopy
- Knee arthroscopy uses fibre-optic technology and digital cameras to visualise the inside of the knee joint through a series of portals (keyholes). Specialised instruments are inserted into the joint and used to treat various conditions.
- Knee arthroscopy is good at dealing with mechanical joint problems. Symptoms suggestive of mechanical knee problems include pain, swelling, locking and giving way.
- There are many varieties of injuries and mechanical problems in the knee. Common conditions treated by arthroscopy include:
- Removal or repair of damaged gristle (cartilage/meniscus)
- Removal of loose fragments
- Smoothing of damaged articular cartilage
- Microfracture and repair of damaged articular cartilage
- Debridement and cleanout of articular cartilage debris
- Most arthroscopic knee surgery is performed as a daycase under a general anaesthetic. Crutches will be required for a few days. Rehabilitation under the guidance of a physiotherapist will aid recovery. Depending on the type of surgery undertaken recovery will take several days to weeks (repair work takes longer to heal).
- Risks of surgery are minimal, but infection, and clots are occasionally encountered. Treatment of arthritic lesions has less predictable results from arthroscopy. Ongoing pain and stiffness is not uncommon.
Knee Reconstruction
- Cruciate ligament injuries are frequently sustained during high intensity sport and trauma. Reconstruction of the anterior cruciate ligament is often required to restore stability in the injured knee.
- Not all cruciate ligament ruptures need surgery, a graded rehabilitation program may restore modest levels of function, particularly in low activity level individuals. Functional instability is the most significant ongoing symptom.
- Arthroscopic surgery to reconstruct the ACL uses the hamstring tendons or part of the patellar tendon to reconstruct this ligament.
- This operation is usually performed as an inpatient under a general anaesthetic, though it is also being carried out as a day case in some centres.
- Rehabilitation after surgery is an essential component of a successful outcome. A graded program of strengthening and stabilising exercises over a six to nine month period is usual, resumption of contact sports toward the end of this period is permitted.
- Risks of surgery include infection, deep venous thrombosis, stiffness and graft stretching and re-rupture.
Partial Knee Implant
- The knee contains three main joint compartments and arthritis can effect different individual parts of the knee joint. Partial knee replacements have been designed to treat these different areas.
- A unicompartmental knee replacement (UKR) is specifically designed to treat localised arthritis, leaving the unaffected ‘normal’ parts of the knee alone.
- Advantages of this technique as compared with a total knee replacement (TKR) are significant. These include a quicker hospital recovery, a more rapid return of function and a generally higher level of activity, with a better range of movement.
- Disadvantages are that the other parts of the knee may develop arthritis in the future (though far from definitely) and that these replacements will wear and eventually need to be replaced – usually by a TKR. UKA is a technically demanding procedure and may not be performed by every orthopaedic surgeon.
- Risks are similar to other joint replacement procedures. The risks of surgery are low but significant in a small proportion of patients. Precautions are taken to minimise risks to each individual patient. Complications include infection, dislocation, stiffness, deep venous thrombosis and pulmonary embolism, bleeding, nerve and muscle damage, fracture, and medical complications. Most complications are treatable, some require more surgery, rarely they are life threatening.
Total Knee Replacement
- Total knee replacement (TKR) is an effective surgical treatment for arthritis of the knee joint. It relieves pain and allows return to normal day to day function.
- Symptoms include pain in and around the knee, swelling, deformity and loss of function. Knee arthritis is confirmed on standard x-rays
- Surgery involves removing arthritic bone and implanting the new joint components. The surfaces of the knee have to have the arthritic bone skimmed off are are shaped to receive new joint surfaces. The components are either cemented into place or ‘press fit’ into place without cement. The new surfaces glide smoothly over one another on a dense plastic bearing interspaced between the joint surfaces.
- Surgery requires an inpatient stay of four to five days and recovery from surgery takes three months. Most modern knee replacements would be expected to last 12 to 15 years, but this is dependant on age activity level and weight.
- The risks of surgery are similar to other major joint surgery. The chances are low but significant in a small proportion of patients. Precautions are taken to minimise risks to each individual patient. Complications include infection, dislocation, stiffness, deep venous thrombosis and pulmonary embolism, bleeding, nerve and muscle damage, fracture, and medical complications. Most complications are treatable, some require more surgery, rarely they are life threatening.
