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driving after knee replacement australia
May 27, 2020

Driving After Total Knee Replacement

Knee Procedures, Orthopaedic Post a Comment

When can patients safely drive after a total knee replacement?

Patients usually want to get back to their normal activities as soon as and as safely as they possibly can after undergoing total knee replacement surgery. Driving is an integral aspect of activity resumption to re-establish social and recreational independence.

Due to increased longevity of the population and an associated increase in age-related degenerative conditions like arthritis, the number of total knee replacements around the world will increase rapidly.

3-D printed patient-specific instrumented (PSI) guides/blocks that are custom made for the patient involve a smaller incision with minimal soft tissue disruption and improved accuracy in Knee replacement (reference below). This also promotes enhanced recovery after knee replacement surgery where patients mobilise early. Rapid recovery is achieved, as well as increased post-operative comfort and motion.

Studies have demonstrated that if patients are unable to drive it presents a significant obstacle, and in the older population the inability to drive may be associated with reduced mobility, loneliness and increased incidence of depression. Recent studies have demonstrated the importance of returning to work as soon as possible following a joint replacement, for both social and economic reasons.

Dr Nizam has done one of the largest studies where 160 PSI total knee replacements were evaluated on patients with a mean age of 68 (45-90 years).

The results indicated that 73% of patients had already resumed driving within the first 3 weeks after total knee replacement surgery – 10% resumed driving within the first post-operative week, 52 (35%) in the second week and 41 (28%) in the third week. Working patients returned to work within 5 to 120 days (mean 26 days) after total knee replacement surgery.

There was no significant difference in the time taken to resume driving between the operative side (left vs right-sided) surgery, especially after the first week.

80.92% of patients informed that they were more comfortable driving after undergoing total knee replacement surgery than before surgery, as their pain and stiffness were now eliminated. This also made it easier for them to enter and exit the vehicle.

After total knee replacement surgery with our technique, patients can safely resume driving within 2 weeks after PSI total knee replacement, and can return to work within 3 weeks after surgery if they are deemed medically fit.

Reference: https://jisakos.bmj.com/content/jisakos/4/2/88.full.pdf

Disclaimer – Individual results can vary – patients are asked to discuss their specific restrictions with their surgeon after surgery.

how to reduce swelling after knee replacement surgery
May 27, 2020

Is Robotic Knee Replacement Surgery Better?

Knee Procedures, Orthopaedic Post a Comment

 

Total Knee Replacement has been shown to be both durable and reliable in relieving pain and improving function in patients with end stage knee arthrosis, allowing the patients to return to normal activities with improved quality of life. The number of knee replacements are increasing rapidly as the population lives longer.

The survival of a knee replacement depends on many factors:

Patient Factors:

Patients who are overweight or obese and have multiple medical problems may have reduced longevity of the knee replacement, and increased complications.

Prosthesis Factors: This depends on the design of the prosthesis. The more modern ones are more conforming to native kinetics and kinematics than older prostheses. The market includes standard knee replacement prostheses, medial pivot knee replacements, and many other designs.

Surgeon/Technique: Surgical techniques can vary from surgeon to surgeon. It is important the patient asks the surgeon for details of the surgery.

What does the robot really do in a knee replacement?

It positions the re-usable robotic arm over the knee so that the bone resections can be made appropriately, depending on the plans. In some instances, the robotic arm only positions the cutting guide into position, and the rest of the surgery is done manually by the surgeon.

Is the prosthesis different in robotic knee replacements?

The prostheses are not different, they are the same prostheses that have been used in standard knee replacements.

Does robotic-assisted knee replacement result in a better outcome or longer-term survivor-ship than conventional knee replacement?

Robotic-assisted knee replacement was introduced to enhance the precision of bone preparation and component positioning, with the goal of improving the clinical results and longevity of knee replacements.

Although numerous reports suggest that bone preparation and knee component alignment may be improved using robotic assistance, no long-term randomised trials of robotic-assisted knee replacements have shown whether they result in improved clinical function or survivorship of the knee replacement.

Almost 700+ robotic-assisted knee replacements and almost 700+ standard conventional/traditional knee replacements performed by one surgeon were compared. The patients were followed up for at least 10 years.

The study found there was no difference between robotic-assisted knee replacement and conventional knee replacement in terms of functional outcome scores, aseptic loosening, overall survivorship, and complications.

Considering the additional time and expense associated with robotic-assisted knee replacement, the study did not recommend its widespread use.

There is more marketing capital in the robotic joint replacement industry than there is scientific evidence of any advantages.

Does robotic joint replacement increase infection risk?

The robotic arm of the machine is usually re-used for all patients, however there are plastic sterile disposable drapes over the arm and console and they are usually sealed.

However the surgeon has to touch the console while operating many times in most cases during the surgery. This is a necessary prerequisite to getting the planning right to determine bone resections, alignment and component sizes as these are not planned before the actual procedure itself.

This means – in lay terms – the surgeon has touched other surfaces besides the patient.

It is a statistic that the higher the frequency of touching other surfaces the higher the risk of infection.  This is a result of robotic-assisted joint surgery and could apply to any similar surgery, but if is the case it would need to be proven in a clinical trial.

What about pin track infections in robotic-assisted knee replacement?

In robotic-assisted joint replacements, 2 pins are usually inserted in the femur (thigh bone) and 2 pins in the upper tibia (above the shin). Some surgeons place these pins within the surgical wound but others don’t and have to make separate stab incisions to place them for attachment of trackers/sensors during the operation.
One of the disadvantages of these pins in robotic-assisted knee replacements is that there could be an increased risk of infection from pin tracking sites.

Could there be fractures associated with robotic-assisted knee replacements?

The other disadvantage of the pins used in robotic-assisted knee replacements (on the distal femur and proximal tibia a total of 4 pins) is that if the bone is soft, it acts as a stress riser increasing the risk of fracture in the femur or tibia after the knee replacement. Most surgeons usually try to avoid this, but it still remains a risk.

 

Disclaimer – Individual results can vary – patients are asked to discuss their specific restrictions with their surgeon after surgery.

meniscus tear treatment
May 27, 2020

Everything You Need to Know About Driving After a Hip Replacement

Hip Procedures, Orthopaedic Post a Comment

Understandably, patients who have undergone hip replacement surgery have a strong desire to return to normal activities — especially considering it may have been some time since they were able to perform them comfortably.

Driving is one vital activity that, prior to hip replacement surgery, may have been difficult or impossible. Medical and legal guidelines regarding when it is safe to drive following a hip replacement are currently somewhat unclear, and are difficult  to legislate as everyone experiences a different healing process.

Medical recommendations for driving after a hip replacement

The most recent medical advice for driving post-surgery is a minimum of 6-8 weeks after the procedure. The issue with this recommendation is the fact that it is based on outdated studies which used a traditional posterior hip replacement. They are also only based on soft tissue recovery.

More recently, anterior hip replacements have shown much faster recovery times. One study stated that brake reaction times resumed around 2 days after micro-invasive surgery. Dr. Nizam has run one of the most extensive studies in regards to safe driving after anterior bikini hip replacement surgery. As this procedure does not involve the cutting of any muscles or tendons, the muscle around the hip joint remains intact. This leads to a faster recovery with less restriction, pain, swelling, and muscle weakness.

Recovery results from Dr. Nizam

Over a 14-month period, Dr. Nizam found the following post-surgery results from the 212 anterior hip replacement procedure:

  • 14% driving within the first week
  • 39% driving within two weeks
  • 76% driving within three weeks
  • Over 98% reported they were confident driving for the first time.

There was no significant difference in these figures when comparing the operative sides of surgery. One main variation, however, was patients with right-sided anterior hip replacements resumed driving sooner and experienced less pain as they got in and out of the car.

The study also found no significant correlation between recovery time and transmission of vehicle (automatic/manual gear). 49.5% of Dr. Nizam’s patients were able to move around without the use of walking aids before the resumption of driving.

Further information on the study

The study also looked at the position of the hip, knee, and ankle of  the drivers to determine possible causes of any discomfort. The majority of movements while accelerating or braking involve the ankle joint, with the knee also predominantly engaged while braking (0-5° knee extension).

During emergency braking there can be a rise in downward ankle flexion to 30° when maximum force is applied to brake completely. Hip adduction and internal rotation of up to 5-10° was also noted when the right lower extremity was engaged to move from the accelerator to the brake, a minimal movement in automatic vehicles.

The study also revealed that patients were able to return to work within 1 to 79 days (on average, 24 days).

Disclaimer – Individual results can vary – patients are asked to discuss their specific restrictions with their surgeon after surgery.

knee surgury
May 27, 2020

Knee Joint Replacement Infections

Knee Procedures, Orthopaedic Post a Comment

This is called a periprosthetic joint infection and can be a devastating complication of joint replacement surgery.

These joint infections can be associated with significant morbidity, reduced mortality and increased health care costs. They also present a big burden to the patient due to prolonged hospitalisation and multiple surgical procedures over long periods. The periprosthetic joint infection rate for primary joint replacement can be up to 1-2% despite taking every precaution to prevent it.

There are multiple risk factors for periprosthetic joint infections, including:

Patient factors:

A high BMI (body mass index) over 40 increases the risk of joint infections by 3.3 times, and if the BMI is over 50, the patient is 21 times more likely to get an infection.

Other risk factors for periprosthetic joint infections are malnutrition, diabetes, smoking, ischaemic heart diseases, rheumatoid arthritis with immunosuppressive medication or steroids, anaemia, alcohol abuse, chronic diseases like kidney failure, and socio-economic status.

Other surgical factors which can influence infection rates can include the length of the operation, post-operative bleeding or haematoma, the complexity of surgery, and tissue handling. However, after many months or years after joint replacements, blood-borne infections from other parts of the body, e.g. a tooth abscess, could also result in joint infection.

How Do Patients Present with Periprosthetic Joint Infections?

There are many ways patients can present when they have a deep-seated joint infection.
Most patients present with warmth and swelling around the joint itself and with pain and difficulty moving. This can be weeks or months after surgery. Other symptoms include fevers, a wound drainage or wound breakdown, and help should be sought immediately.

What Investigations are done in the Case of Joint Infections?

Once a full patient history and examination is carried out, blood tests are performed, including blood cultures. Other investigations include x-rays, ultrasound scans where appropriate, or bone or white cell scans (if relevant).

In some cases, the surgeon has to go back into the joint to take samples. This can be done arthroscopically in the case of knee replacements or with needle aspirates for both knee and hip infections. These samples are sent off for bacterial culture and sensitivity.

What Happens After a Joint Infection is Established?

Treatments can vary depending on the complexity and timing of initial surgery – whether the infection occurs early after surgery (less than 3 months), 12-24 months after or 2 years after.

Most early infections can be treated with thorough washout and a liner change and multiple debridement and washouts, in addition to 6 weeks to 3 months course of antibiotics. This is called DAIR – debridement, antibiotics and implant retention. Patients who have a long history of symptoms or have sinus infections are less likely to benefit from this treatment method.

The treatment success of DAIR can range from 31 to 82%. One of the most common organisms causing joint infections is Staph Aureus (Methicillin sensitive Staph A – MSSA). There are other organisms causing joint infections, including streptococcus species, coagulase negative staph, anaerobic organisms and MRSA (resistant staph).

What is One-Stage Exchange Arthroplasty in Joint Infection?

Some patients can have One-Stage Exchange Arthroplasty, where the patient can have one operation to remove the implants and the wound debrided and cleaned before implantation of a new prosthesis. In this case, the patient has to be healthy, have a known organism grown that is susceptible to antibiotics, and have good bone quality and soft tissue envelope.

Patients who have many organisms, poor tissue envelope, are immunocompromised or have multiple medical comorbidities are not candidates for this procedure, especially if the infection has been long-standing or chronic.

What is 2 Stage Exchange Arthroplasty in Joint Infection?

A two-stage revision or exchange arthroplasty involves removal of the joint replacement prosthesis, temporary cement spacer (antibiotic impregnated) implantation, administration of local and systemic antibiotics for up to 3 months or more, followed by reimplantation of the prosthesis after eradicating the joint infection. Success rates of over 90% are reported in some literature.

How Can I Prevent Joint Infections?

It is important to reduce and control the risk factors of joint infections such as obesity, smoking, diabetes, heart diseases or other chronic health problems, and optimise these before surgery with a perioperative physician.

It is also imperative for patients to ask their surgeon what precautions they should take before, during and after surgery that can reduce the risk of infection.

If the skin over the joint is not prepared well, the surgical approach involves a lot of tissue dissection with bleeding and swelling, and also results in operations that last much longer than the average surgical time  with post-operative bleeding, haematoma or drainage – and these factors  increase the risks of joint infections.

Disclaimer – Individual results can vary – patients are asked to discuss their specific restrictions with their surgeon after surgery.

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