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Questions and answers about joint replacement

Are there special centres for joint replacement surgery or can I go to any hospital?

Nobody is an expert at everything. This is also true in medicine. Which is why there are special centres for joint replacement. Furthermore not every hospital performs joint replacement surgery every day. Since it is a very specialized operation, only extensive experience and a thorough knowledge of the field can produce an optimal result. You should therefore find out in good time whether the hospital you are considering carries out this type of operation frequently and thus with the requisite know-how.

A further means of finding a specialized centre in Germany is to look for hospitals that have been awarded the “endoCert-Certificate”. If a centre has this certification you can be sure that it will perform joint replacement procedures in the best possible quality.

Should I have my operation early or wait as long as I can? When is the best time for surgery?

When x-rays prove joint damage, two factors are crucial for deciding on the right time for surgery: quality of life and degree of suffering. Regardless of age one should contemplate an operation if medication to stop pain no longer helps or if it is leading to pronounced side effects. One should also take into account the damage caused to other joints and structures such as the spine by limping or poor posture. An operation postponed for too long can result in permanent injury to the spine, even after surgery.

What are the risks of a hip or knee replacement operation?

Joint replacement surgery of the hip or knee is among the most successful orthopaedic operations with a vast body of experience: in Germany alone some 210,000 hips and 165,000 knees are replaced every year. As with every other surgical intervention there are certain risks. On the one hand these are the general risks that can arise from any operation, on the other the special risks relating to the specific operation.

General risks include:
• Deep vein thrombosis in the legs with risk of a pulmonary embolism
• Infection of the wound
• Injury to the nerves
• Blood loss and the necessity for blood transfusions

Special risks include:
• Joint instability with possible dislocation
• Lengthening of the leg
• Ossifikation around the hip joint and/or scarring around the knee that impair joint motion
• Joint infection

To safeguard against these risks we can implement a number of measures:
• You will receive blood thinning medication (Heparin) regularly to guard against thrombosis
• The operating time is short
• The surgical team is very experienced and specially trained
• The operating theatres are free of bacteria, so the risk of infection is greatly reduced
• Precise planning before the operation, partly augmented by computers, minimizes the danger of dislocating the joint or unwanted leg lengthening
• Short-term medication and/or radiation therapy also virtually eliminate any possible ossification where there is a tendency for this to happen in the area of the joint. As you can see, surgery is not completely risk free, but risks remain very small if the right measures are implemented.

What ist MIS (minimally invasive surgery)?

The less tissue is damaged by surgery the better. So called "minimally invasive" surgical interventions allow skin, muscle and bone to be spared by special techniques. Optimized surgical approaches, specially designed surgical instruments, new patient positioning methods and bone sparing implants are combined to enable you to quickly return to your activities of daily living and regain your quality of life after surgery. It also is an important prerequisite for a possible revision operation after many years of painfree use. A well-trained, experienced and coordinated surgical team is essential for these demanding techniques.

Which prosthesis is right for me? Which material is better: Metal, ceramics or plastic?

This question can only be answered in a discussion between you and your surgeon. However the final decision has to be made during surgery.
In principle younger people's bone reacts faster and more pronouncedly to an implant. Therefore implants can be used that are are stabilized by direct contact with the surrounding bone (cementless implant).
For bones altered by osteoporosis or rheumatic diseases a fixation of the implant with a so-called bone cement (a two-component epoxy glue) can make sense. This ensures high stability. A combination of the two techniques is also possible and is often used.

In a knee joint replacement one can also choose between a partial or full knee replacement depending on the extent of the cartilage damage. Both types of prostheses have a comparable durability and the decision to implement one ort he other is usually made during surgery.

In cemented prostheses chrome-cobalt alloys are mostly used today, in uncemented prostheses titanium alloys are favored. Equally important are the bearing materials.

Knee: Metal and Polyethylene

Hip: Usually Ceramic/Polyethylene, in certain cases Ceramic/Ceramic and Metal/Polyethylene

Even these specially selected, very durable materials though will wear. This wear limits the durability of the implants. Which bearing material is preferrable is determined individually according to the patients need.

Will my legs be of equal length after surgery?

One of the goals of joint replacement surgery is to ensure that the legs will be of the same length. Experience and careful pre-operative planning ensure that this goal is reached in most cases. Under special circumstances however it might be necessary to lengthen the operated leg in order to gain the necessary stability for optimal function and to prevent dislocation. Under these circumstances this might result in a difference in length. Either the spine takes care of this difference or a shoe raise provides help. As a rule however both legs are of equal leg length after the operation.

How ist he normal course of recuperation?

The course of recuperation is quite individual. In contrast to the hip the knee is a highly complex joint. Only the perfect coordination between the different muscles, ligaments and the joint guarantee a good joint function. Alignment of the joint (straightening of the bent leg) will alter the recuperation process because the body has to adapt to the new posture. This can take up to a year after surgery.

Will I need a blood transfusion?

Since joint replacement surgery is not an emergency, it can be planned well in advance. You can therefore donate your own blood for the operation. Furthermore the blood you lose during surgery can be collected, cleaned and given back to you (mechanical auto transfusion). In rare cases blood transfusions cannot be avoided but careful screening of blood donors and strict controls over blood products has led to a major reduction in the risk of disease transfer through blood transfusion.

How long do I have to stay in the hospital after surgery and when can I go back to work?

You should reckon on being in hospital for 7 to 10 days after a joint replacement operation, followed by 21 days in a recuperation centre. After joint replacement surgery, dependent on the type of operation, we would normally certify you as unfit to return to work for between six weeks and four months

How soon after surgery can I walk without crutches?

You will usually get up out of bed for the first time on the day after surgery and will learn to walk with the aid of crutches under the guidance of a physiotherapist. Depending on the type of surgery it will normally be three weeks before you can walk without crutches. 

How important are check-ups after surgery?

About one year after surgery you will return to our hospital for an out-patient check-up. Further appointments should be planned every 5 years thereafter. The continuing regular check-ups by your surgeon will ensure the longest possible trouble-free functioning of your joint since he can see possible changes at an early stage and if necessary can treat them. Even if you feel well you should schedule a check-up every two years. The reason: some changes begin without any pain and can only be felt relatively late. You can therefore help prevent major damage to your joint by regular visits for a check-up.

What impact will the artificial joint have on my life?

Once you have an artificial joint your lifestyle will not actually change very much. The real difference will be the major improvement in your quality of life, since the pain and discomfort coming from your hip or knee will either no longer be there or be hardly noticeable. Changes in the neighbouring joints and other structures such as the spine of course do not vanish immediately after surgery but can improve during the following months. In general you should avoid overtaxing yourself physically, not pushing your body beyond its limits of fatigue and planning your activities accordingly.

Heavy lifting and continuous, substantial bodily exertion are not recommended. When choosing the type of sport you should consider low impact activities like swimming, cycling, hiking and cross-country skiing. Other suitable sports are golf and - with restrictions - alpine skiing and tennis.
Sports unsuitable after joint replacement include squash, martial arts and team sports like football, basketball or volleyball. In general only sports you have mastered before surgery should be taken up again afterwards. In your job you should also avoid heavy manual work wherever possible, if necessary considering a change in the type of job you do.

With the fixtures and furniture in your house or apartment you can also implement changes to protect your joint, especially for the time immediately after your operation: raised toilet seats, higher beds or sofas, the removal of dangers like cables running across the floor. Handles in the bath, next to the toilet or in the shower are also helpful.

How long can I expect my artificial joint to last?

An artificial joint will last on average for 15 to 20 years - a long time if you take into account the enormous stresses it is continuously subjected to. The main reason for possible problems is the loosening of implants due to the wear of the bearing materials involved. But other factors like height, body weight, activity level and quality of bone substance also play an important role in the longevity of the implant.

Newly developments in materials give cause for high hopes that the implants used today will last much longer than the ones used in the past. This is confirmed by laboratory tests which show excellent results. These developments are however in part only a few years old. Therefore clinical proof is restricted to a limited period but so far fully confirms our predictions.
If, after many years of unhampered use, the implant needs to be replaced (the experts call this "revision surgery"), special implants are available for this purpose. Thanks to new and improved techniques, revision surgery today is much less invasive and no longer restricted to one or two operations. It can, if necessary, be repeated several times.

Dental work after joint replacement surgery

When should I take antibiotics for dental work as a joint replacement patient?
Healthy teeth are important. For people with artificial joints visiting a dentist can have an additional meaning: Bacteria one can find around teeth and gums can spread in rare cases via the blood stream to the joint and cause a joint infection. This then can lead to much worse problems than the toothache itself. In accordance with the directives of the American Dental Association and the American Orthopaedic Association the following guidelines have been established for bearers of an artificial joint having to undergo dental work. Since there are relatively few scientific studies on the subject these guidelines are quite general and should be individualized by your dentist and surgeon.

When do you need prophylactic antibiotics?
In most cases of dental work you do not need antibiotics. Since you have an artificial joint the chance for a joint infection are greater than for people without joint replacement. If large amounts of bacteria come into play antibiotics are recommended for the following situations:

• If you have an inflammatory joint disease like rheumatoid arthritis or systemic lupus
• If your immune system has been impaired by disease, prescription drugs or irradiation
• If you are an insulin dependent diabetic (type 1)
• If your artificial joint has been implanted in the last two years
• If you have previously had a joint infection
• If you are undernourished
• If you suffer from hemophilia

Which dental interventions need antibiotics?
You should take an antibiotic for the following dental interventions:

• Tooth extraction
• Periodontics
• Tooth implantations or the replantation of teeth
• Root canal work
• Injections of a local anesthetic into the gums
• Removal of dental calculus when bleeding is expected

Which antibiotics are recommended?
The following antibiotics are recommended:
• If you can take oral antibiotics and are not allergic to penicillin, 2 grams pf amoxicillin, Cefalexin or Cefadroxil one hour before the dental treatment

• If you can not take oral medication and are not allergic to penicillin 2 grams of ampicillin or 1 gram of Cefazolin as an injection one hour before dental treatment

• If you are allergic to penicillin 600 milligrams of Clindamycin orally or as an injection one hour before dental treament.

These recommendsations should help your dentist to decide which treatment is best for you. Since it is impossible to account for all situations this is not a directive but a general guideline that is no substitute fort he clinical evaluation of your doctor or dentist. The use of antibiotics is always decided by your trating physician based upon their personal experience and evaluation.

Sex after joint replacement surgery

After a knee replacement you can take up sexual activities as soon as the wound has healed and you feel up to it. There are no restrictions if you consider stopping an activity as soon as you feel discomfort or pain.

After hip replacement surgery sexual activities will usually be more pleasant and less restricted by the improved range of motion. As soon as wound and soft tissue healing is completed, which is usually the case after 4 to 6 weeks, it is mostly possible to begin sexual activities.

Please note that extensive bending of the operated hip, especially paired with rotation, should be avoided.

In the beginning a more passive role, maybe lying supine, with slightly spread and bent legs is advised. The legs should be supported and brought into a comfortable position by cushions of possible. When the hip continues to heal more active roles and positions can usually be implemented without risk. If you experience pain or discomfort just refrain from the respective movement or position for a while.

Please inform your partner before having sex about the surgery and the recommendations stated above.

If you adhere to the points made above, sex after joint replacement will in all likelyhood be more fulfilling and enjoyable than before your surgery. 
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