Twelve years ago, my motorcycle (750 pounds of sheer chrome and metal) fell on my right knee when my front wheel got stuck in a pothole while I was navigating a construction site. Construction sites are not a good place to be with a motorcycle but being a novice rider then, I didn’t know how to ride safely. The injury had been hugely painful until my knee healed a couple of months later (or so I thought)…
Unfortunately, serious injuries that involve ligaments and muscles, affect the joint’s cartilage as well as the joint. Even when the pain seems to have passed, the cartilage damage continues and it becomes increasingly frail. Four good years passed with no symptoms at all, but one day during my martial arts class my knee suddenly locked and I had to undergo emergency surgery to clean chips of bone and cartilage. After that I got a 3 years of respite that allowed me to keep active doing martial arts, going to the gym and riding my motorcycle. Gradually, the symptoms and pain increased to such an extent that I required an injection of cortisone in my knee joint every year, but the injection seemed to make a remarkable difference. For two years in a row, the effect of my yearly injection lasted almost a year, but the third time it only improved my symptoms for three months and the last injection I received this summer only helped me for two weeks. Long story short, I am now scheduled for a “total knee replacement” by the end of the year.
And so it goes, my personal story gives me the opportunity to discuss total joint replacement. Joint replacement becomes more common as we get older, due to the wear and tear processes, or “post traumatic osteoarthritis” after a serious joint injury, like in my case.
In knees or hips that need replacing (both are now very common procedures), the orthopedic surgeon will remove the painful joint and replace it with an artificial joint made from metal and plastic components. The surgeries are done when all other treatment options have failed to control pain and stiffness. The information I am conveying to you comes from a very reputable medical website (www.webmed.com). The surgeries can be minimally invasive (with a much smaller incision) or traditional. During minimally invasive joint replacement the cut is 2 to 5” long instead of the traditional 8-10” cut to expose the hip or knee joint. In the end, the procedure is the same regardless of the size of the incision.
The small incision is thought to reduce blood loss during the surgery, speed up healing, decrease recovery time and shorten the hospital stay. However, it is performed by a very small number of surgeons, and unless the doctor is experienced, the outcomes may be worse than the standard approach.
During surgery, the patient is given a general anesthetic and goes into deep sleep (more often than not in hip replacements) or a spinal anesthetic at which time the patient remains awake but does not feel pain as she/he is numb below the waist (this is what my surgeon prefers for my knee surgery).
The doctor will gain entry into the damaged joint from the side of the hip or the front of the knee, depending on what joint is being replaced. The damaged part of the joint is removed, and the surfaces of the bones are shaped to fit the artificial components of the new joint, which now are held together with a special type of “glue”. Blood loss is usually minimal but occasionally a transfusion is required.
In traditional joint replacement surgeries, the patient stays in the hospital for 3-6 days following surgery. Physiotherapy to mobilize the joint starts starts on the second day. Within a couple of days the patients walk with a walking device (walker, crutches or a cane) until the hip or knee is able to support the person’s body weight. Most people go directly home (and continue physiotherapy in a local facility), but others may be admitted to an inpatient rehabilitation facility depending on their medical condition.
Standard instructions after joint replacement surgery are as follows: stair climbing should be kept at a minimum for a few weeks; recliners should be avoided while your chair should have a firm straight back; all rugs should be removed to avoid falls; in case of hip replacement an elevated toilet seat is recommended; and “enthusiastic pets should be kept away until healing is completed”. The last piece of advice made me laugh as I was reading it, but it is very true, particularly if you are like me and you have two big agile dogs who gleefully jump on you to show you their affection! Therapy continues for weeks to a couple of months. Again this depends on the person and his/her physical condition. Pivoting, twisting or squatting should be avoided for several weeks.
My surgeon spent time with me to warn me about potential risks. During and after surgery I have a risk of a blood clot traveling from my leg to my lungs; nerves in the site of surgery may swell or get damaged and cause some long term problems; and finally the replacement parts may become loose or break. All these potential risks are small and remote, but they are risks and we should know them in advance.
I also wanted to know how long my new joint was going to last, as my knee replacement came unexpectedly early and I was terribly worried about the “life expectancy” of the prosthetic joint. He explained to me that while in the early 70s these artificial joints were expected to last 10 years or less, today 85% of these joints or more last a good 20 years, due to an improvement in surgical techniques and artificial joint materials. This was most welcome news to me!
My final question was: What can I expect after my knee replacement with regards to my activities? My surgeon told me that in the early years of hip and knee replacements, the expectation for the patient was to “just walk about and perform a few basic activities in the house or take a few short walks outside”. Today, most of his patients walk very long distances, play golf or even hike! However, he warned me that my martial arts and heavy impact activities such as running were “out”, while returning to my elliptical training, ballroom dancing, and weight lifting, was feasible and advisable.
How do I feel about my surgery? While I do not like hospitals, doctors and surgeries (I do not know anyone who does!), I am looking forward to being able to climb steps with a reciprocal gait, get out of the car without holding on the doors, walk distances as I used to do (up until a few months ago), and more than anything, return back to my beloved gym.
For more information you can check www.webMD.com and search for knee or hip replacement.
Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)
Director, Comprehensive Pain Program,
Senior Investigator, Krembil Neuroscience Centre
Toronto Western Hospital,
Chair ACTION Ontario www.actionontario.ca