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Ballarat Orthopaedics & Sports Medicine

Joint Replacements

At Ballarat Orthopaedics & Sports Medicine, we have experience in a breadth of joint replacement. A joint is where two or more bones come together, like the knee, hip, and shoulder.  When severe pain or joint damage limits your daily activities, a joint replacement may be your best option. Having a surgeon able to discuss the other options – be it non operative treatments, realignment surgery,  partial or total knee replacement is best.

Joint replacement is a surgical procedure in which parts of an arthritic or damaged joint are removed and replaced with a metal, plastic or ceramic device called a prosthesis. The prosthesis is designed to replicate the movement of a normal, healthy joint. We have strict criteria, and the patient needs to take some care to avoid injury or infection of the joint replacement.

Hip

Non operative treatments of hip arthritis

Before a patient undergoes a hip replacement it is important to be sure the benefit exceeds the risk. Non-operative treatments such as medications (analgesics and anti-inflammatories) or an injection into the joint have a useful role for some patients. Especially where the patient is relatively young, or the joint not grossly arthritic, it may be possible to resume almost full activity with these treatments.

Cycling for instance – where the joint moves through a repeated safe range, may be possibly despite arthritis. In general – patients who are “Slim, Supple, and Strong” will tolerate an arthritic joint much longer than their less fit colleagues. A hiking pole or walking stick will reduce the force on the joint and increase your walking distance.

Conventional Hip Replacement

The hip is a ball and socket joint. Since Sir John Charnley came up with a reliable method of fixing a new ball and socket in 1958, and then from 1962 using polyethylene, hip replacement has progressively become mainstream surgery. The current techniques allow rapid recovery – the majority of patients will walk on the day of surgery and be ready to go home the day after. Some elderly frail patients may need to spend some time in rehabilitation, but this group is only 2% or so of our patients, and we will identify those patients at a preadmission appointment.

Patients usually go home using a single elbow crutch, and are advised to walk every 1-2 hours during daylight hours. There is no reason to be “housebound” assuming the ground outside is relatively safe. It is better if there is someone at home – not to nurse you – but provide company.

Birmingham Hip resurfacing

Hip resurfacing surgery is a great operation in terms of relieving pain, stiffness, and disability caused by hip arthritis especially in the younger male patient. The Birmingham prosthesis has been in clinical use since 1993, and reserves the neck of the femur, putting a new surface on it, rather than replacing the whole ball. It is a metal on metal design, and not suitable for those with metal allergies, osteoporosis, or a relatively small hip joint.

Anterior approach hip replacement

The most common approach in Australia – the “posterior approach” – is being challenged with a new approach – the “anterior approach”. The Australian Arthroplasty Society has a statement that surgical approach does not influence results. The risk – benefit equation is critical.

Anterior approach theoretically may reduce the dislocation rate, and may speed up recovery. The question is whether it increases the risk of what were rare complications – fracture, or possibly infection. A thin, ligamentously lax patient has the most to benefit from an anterior approach. Different incisions can be used, this “Bikini” incision heals beautifully in thin people as it is parallel to “Langers lines” and avoids getting to close to the boney prominence. A similar scar starting at the same site but angling towards the outer kneecap can be used in heavier patients.

Our surgeons can talk to you about both approaches.

hip-replacement2
Knee

Non operative treatment of arthritis

Before a patient undergoes a knee replacement it is important to be sure the benefit exceeds the risk. Non-operative treatments such as medications (analgesics and anti-inflammatories) or an injection into the joint have a useful role for some patients. Weight reduction reduces the forces on the knee, and reduces pain. Especially where the patient is relatively young, or the joint not grossly arthritic, it may be possible to resume almost full activity with these treatments.

Cycling – where the joint moves through a repeated safe range, may be possibly despite arthritis. In general – patients who are “Slim, Supple, and Strong” will tolerate an arthritic joint much longer than their less fit colleagues. A hiking pole or walking stick will reduce the force on the joint and increase your walking distance.

Knee Replacement

The knee is a complex hinge joint. Since Insall & Bernstein introduced their total condylar knee replacement in 1974, knee replacement has progressively become mainstream surgery. The current techniques allow rapid recovery – the majority of patients will walk on the day of surgery and be ready to go home the day after. Some elderly frail patients may need to spend some time in rehabilitation, but this group is only 2% or so of our patients, and we will identify those patients at a preadmission appointment.

Patients usually go home using a single elbow crutch, and are advised to walk every 1-2 hours during daylight hours. There is no reason to be “housebound” assuming the ground outside is relatively safe. It is better if there is someone at home – not to nurse you – but provide company.

Partial Knee Replacement

Some patients have arthritis isolated to a single area of the knee. The pain may be more variable – some days might be OK, others terrible. The range of movement of the knee is well maintained. These patients don’t always do well with a Total Knee Replacement as they may loose some range of movement. The partial knee replacement allows better movement and function, and a faster recovery to normal function.

Shoulder

Shoulder – Non Operative Treatment

Non-operative treatments can include paracetamol, anti-inflammatory medications and activity modification. Modifications include moving objects from overhead cupboards into easily accessible ones, and the use of clothes dryer & clotheshorse.

Before seriously considering shoulder replacement, it is important that these simple non operative treatments have been undertaken which clearly have less risk than surgery.

Shoulder Replacement

Shoulder arthritis alone is less common surgery than hip or knee replacement. None the less, good designs are available, and the success of them in the Australian Joint Replacement Registry seems to be reasonably good, 93.6% continuing to function well at 7 years from surgery.

Shoulder replacement replaces the surface of the shoulder blade (glenoid) with a curved polyethylene surface, and a new ball replacing the surface of the upper arm (humerus). A titanium or metal stem within the upper humerus secures it to bone. Shoulder replacement relies on the surrounding tendons to balance the “ball and socket”.

Reverse Shoulder Replacement

With an ageing population, it is apparent that long standing torn tendons in the shoulder can lead to arthritis. Pain and weakness are the most common reasons for a referral to an orthopaedic surgeon for treatment. The inability to usefully move the arm is called “pseudo paralysis”.

A reverse shoulder replacement is an interesting engineering feat. By swapping the ball to the glenoid side of the shoulder joint, the deltoid muscle is able to function without the underlying rotator cuff tendons. The deltoid muscle is the main muscle required to lift one’s arm overhead – so the pseudo paralysis is treated.

Reverse shoulder replacements are doing well in the Australian Joint Replacement Registry, which in 2016 was tracking the progress of 12362 patients across the country. At 7 years from surgery, only 4.7% have come to further surgery. One of the factors in this is probably that reverse shoulder replacements are often done in older patients, more than 50% of the operations are done in patients over 50 years of age.

Ankle

Ankle – Non Operative Treatment

Non-operative treatments can include paracetamol, anti-inflammatory medications and activity modification. An ankle brace to support it during activity, or lace up boots may diminish the pain.

Weight reduction may be necessary for some patients. Before seriously considering any of the reconstruction operations, it is important that these simple non operative treatments have been undertaken which clearly have less risk than surgery.

Ankle replacement

Ankle replacement is a rarely performed operation, the results are not as good as hip or knee replacement, and the solutions for failed ankle replacement are all drastic. For this reason, most patients are better to have ankle ankle fusion.

Ankle replacement might be considered in an elderly patient with good bone quality, and a reason that ankle replacement may not be so good such as arthritis of the joint below the ankle as well.

ankle-replacement_orig2

Ankle fusion

A more robust operation with a higher success rate for ankle arthritis is ankle fusion. A fusion operation is where the arthritic joint surfaces are removed, and the underlying “cancellous” bone surfaces compressed together with screws.

The operation is usually done arthroscopically, with a single night in hospital. A plaster cast is required to protect the fusion, and then a cam boot or “moon boot” until the fusion is solid at three months. Some “up-down” movement of the foot is still possible after the surgery as the next series of joint contribute some movement in that direction.

ankle-fusion_orig

Triple arthrodesis

Almost as common as ankle arthritis is arthritis of the next series of joints below the ankle the do the “in-out” movement that allows one to walk across a slope. The three joints move together, so when arthritic, often all three are involved.

Like other fusion operations, the joint surfaces are removed, and the cancellous bone surfaces are compressed together. Bone graft may be required especially if there is a significant deformity. Like ankle fusion, a plaster cast is used initially, then a cam boot until about three months from surgery.

ankle-triple-arthrodesis

Subtalar arthrodesis

Occasionally only a single joint is involved, the joint between the talus and the calcaneum (the so-called sub-talar joint) is the most commonly involved. This can be fused with either open or arthroscopic surgery.

ankle-subtalar-arthrodesis-
Elbow

Elbow Replacements

more information coming soon

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