Hip
During the procedure the surgeon replaces diseased and damaged bone and cartilage in the natural hip joint with an artificial joint. As with the natural joint, the artificial joint is in two parts – the 'femoral prosthesis' which forms the ball of the ball and socket joint (called the 'femoral head') and the 'acetabular prosthesis' which replaces the socket ('acetabulum').
The operation takes around 90 minutes, during which the patient is put under either spinal or general anaesthesia and receives a femoral nerve block to relieve pain during and after the surgery.
Total Hip Replacement can be performed through any of the three approaches – posterior, direct lateral and direct lateral. All of them have their pros and cons. We offer direct anterior approach THR in suitable patients and will discuss the options with you at the time of consultation. This would enable you to make an informed decision and work towards the best possible outcome.
- Posterior approach: Approaching the joint from the back of the hip. Worldwide this is the approach most used by Orthopaedic Surgeons. It is an excellent and reproducible approach but involves detaching the posterior capsule and some muscles and tendons that are repaired later. There is increased incidence of hip dislocation compared to other approaches, some of which require reoperation.
- Direct lateral approach: Requires detachment and later reattachment of the hip abductor tendon. Limp and gait abnormalities are more common with this approach which usually resolves with time.
- Direct anterior approach (DAA): Though this is not a new approach, its benefits in THR have been more widely realised in the recent few years. A summary of this approach, merits and challenges are discussed further below.
All of the above approaches have a long history and can be safely used to perform THR. The recently popularised DAA - THR has been in use for over 20 years, especially in Europe. Introduction of efficient instrumentation, use of proprietary surgical tables by some surgeons and better surgeon training have allowed its increasing use in hip replacement surgery.
In most cases, where the patient is younger than about 75 years, no form of bone cement is usually needed, as the implants are coated with a special material to allow the prosthesis to integrate naturally with the bone, creating a bond that lasts a long time. This approach is called 'uncemented THR'. Where patients are elderly or suffering from osteoporosis a 'hybrid THR' is performed where surgical cement is used to bond the bone and the femoral implant.
To learn more about postoperative recovery and rehabilitation, see the following guide on Total Hip Replacement Rehabilitation Protocol.
As with all surgical procedures there are some risks associated with total hip replacement. These are:
- Infection (0.6% risk)
- Bleeding
- Nerve injury causing numbness or weakness in affected leg
- Blood clot (DVT or embolism).
Risks specific to this procedure include:
- Joint dislocation
- Leg length discrepancy
- Fracture of thigh bone during or after procedure
- Loosening of artificial joint components (where bonding fails or there is wearing of the polyethylene component, or osteolysis).
Rehabilitation following total hip replacement tends to be less intense compared to total knee replacement. A home exercise regimen can accomplish most of the goals with periodic physiotherapist supervision and input.
- Observe hip precautions for 12 weeks (for posterior approach THR).
- Control pain and swelling.
- Regain normal gait and muscle control/strength.
- Restore proprioception, balance and coordination.
Day 1
- Sit at edge of bed and out in chair.
- Begin transfers and short walks with walker for 5-10 minutes twice during the day.
- In bed static quadriceps, ankle pumps, hip abduction and gentle SLR as able.
Day 2 to 3
- Progress with mobility. Aim for 50m walk with walker by day 3.
- Progress with exercises in bed and in chair as advised by therapist.
- Sit out in chair most of the day by day 3. Aim for a single sitting session of 45-60 minutes. All meals sitting in a chair.
- Use toilet or bathroom with assistance for all toileting needs.
Days 3 to 14: After discharge home or rehabilitation centre
- Continue exercises as advised by therapist.
- Progress with walking distance with walker. Aim for 100m.
- Sit out in chair for all meals and most of the day.
- Independent transfers into and out of bed.
- Perform HEP with assistance.
- Negotiate 4-6 stairs with assistance.
Weeks 2 to 6
- Continue home exercises. These aim to improve lower limb strength, proprioception and balance.
- Progress with walking distance
- Can start hydrotherapy if available
- Transition to straight cane or walking stick indoors as able.
Week 6 onwards
- Wean off stick indoors. Gradually progress to unaided ambulation as able and if safe.
- Progress with functional tasks within home environment and then in external environments.
Knee
Total Knee Replacement (TKR) or Total Knee Arthroplasty is indicated in end stage arthritis. The most common cause of this is osteoarthritis, which is in turn caused by the wearing away of the cartilage tissue in the knee joint. Other possible knee problems requiring TKR include:
- Rheumatoid arthritis
- Haemophilia
- Gout (leading to arthritis due to excess uric acid in the bloodstream)
- Osteonecrosis (avascular necrosis) – death of bone tissue caused by lack of blood supply
- Bone growth disorders such as bone 'dysplasia'
- Sequelae of infection
TKR is one of the most successful surgeries in orthopaedics, after Total hip replacements to improve mobility, function and quality of life. 85-90% of patients who undergo total knee replacement are happy with the results of surgery, with a considerable reduction in pain and a significant improvement in quality of life.
The goals of knee replacement surgery are restoration of limb alignment, appropriate ligament balance and a well tracking extensor mechanism (patella and its tendon attachments). New technologies are increasingly being used to achieve these goals. Computer assisted surgery (CAS) in Total knee arthroplasty, abbreviated to CAS-TKA and Robotic-Assisted TKA are some of such technologies. Download our guide on Total Knee Replacement procedure and rehabilitation below.
A total knee replacement procedure, as the name implies, involves the replacement of the entire knee joint with an artificial joint, or 'prosthesis'. It takes around 90 minutes and is conducted under general anaesthetic or an epidural (spinal) anaesthetic.
The procedure itself involves an incision to the front of the knee joint and the removal of damaged cartilage and bone from the thigh bone ('distal femur') and shin bone ('proximal tibia'). The artificial joint components are then inserted and fixated to the bones using bone cement or uncemented press-fit techniques.
We have special interest in multi-modality pain management and blood loss minimisation strategies in TKR surgery and utilise these for all patients.
After a total knee replacement most patients need to stay in hospital for a few days (most are out of hospital within three days). The evening of surgery (or the following morning) you will be encouraged to get up and do simple physiotherapy exercises and/or walk around a little.
Discharge home is criterion based and depends on your recovery and independence in toileting, leg control and mobilisation.
To learn more about postoperative recovery and rehabilitation, see the following guide on Total Knee Replacement Rehabilitation Protocol.
As with all surgical procedures there are some risks associated with total knee replacement. These are:
- Infection (about 1% risk)
- Bleeding
- Nerve injury causing numbness or weakness in affected leg
- Blood clots (DVT or embolism).
Risks specific to this procedure include:
- Post-operative stiffness in the knee
- Wearing or loosening of artificial joint - many artificial joints last a lifetime, however over time wearing and/or loosening may occur, in which case a revision procedure may be required.
In most cases of symptomatic advanced arthritis of the knee, the benefits of undergoing the procedure significantly outweigh the potential risks. Your surgeon will run through the details of the benefits as well as the potential risks and complications related to the procedure at your first consultation.
The following is a brief guide to rehabilitation after a total knee replacement procedure.
- These rehabilitation timelines are approximate, and actual progression depends on individual recovery.
- Patients can weight bear as tolerated from day one. Please use a walker or crutches until good pain control, quadriceps strength and walking mechanics are achieved.
- Avoid pillow under knees and focus on knee extension and quadriceps exercises from day one. Limb elevation with pillow under ankles or calves when lying is recommended.
First 2 weeks
- Apply icepacks 3-5 times daily for 10 minutes each time.
- Quadriceps and gluteal sets, proprioception and balance exercises (e.g. heel-to-toe walking).
- Straight leg raises.
- Active and passive Range of Movement (ROM) exercises.
- Gait training.
- Upper body conditioning.
- Please remember to apply ice packs three times daily for 10 min; take pain medication as advised and follow the advice of your therapist.
2 to 6 weeks
- Continue with the home exercise program.
- Progress to walking outside.
- Progress with quadriceps, ROM and proprioception or balance exercises.
- Start core strengthening exercises.
- Hydrotherapy or pool work-outs once incisions have healed.
- Aerobic exercises after 4 weeks as tolerated (e.g. static exercise bike).
6 to 12 weeks
- Add lateral steps and step-ups.
- Single leg stance (eccentric exercises initially).
- Progress with all functional activities including household chores, gardening, gentle sporting activities.
- Low impact activities only until 3 months.
- No twisting, pivoting until 3 months.
- Wean into a home or gym program.
Shoulder
A total shoulder replacement procedure is carried out under general anaesthesia (in addition a regional anaesthetic and/or nerve block may also be used) and generally takes around 90 minutes. It is normally conducted using conventional open surgical techniques.
During the procedure, the surgeon replaces the natural ball joint (which is located on the head of the humerus bone) and the natural socket (the 'glenoid') with artificial components. After the components are put in place, the wound is closed with absorbable sutures.
A technique called 'patient specific technology' allows an accurate 3D model of the natural joint and patient-specific 'jigs' (used to help correct positioning of the artificial joint) to be made using a CT or MRI scan. This then allows the surgeon to make very precise cuts to the bone and accurate location of the socket ('glenoid'). Accurate positioning of the artificial joints (to mimic as closely as possible the form of the natural joint components) may contribute to a better outcome for the patient.
Most total shoulder replacement procedures require a hospital stay of 2-3 days. The day after surgery your surgeon and your physiotherapist will run through the sorts of exercises you will need to complete once you are home in order to speed your recovery. They will also explain what you should do and what you should avoid doing during recuperation.
You will be advised on the most suitable pain medication. For the first 14 days after surgery you should also apply an ice pack for 10 minutes five times every day. You should continue to wear your sling for at least a month after surgery, removing it only for your daily exercise regime (3x 15-20min exercise sessions every day) or when taking a shower. The wound dressings are waterproof and when you are showering it is advisable to keep the affected arm at your side.
To learn more about postoperative recovery and rehabilitation, see the following guide on Total Shoulder Replacement Rehabilitation Protocol.
As with all surgical procedures there are some risks associated with total shoulder replacement. These are:
- Infection
- Bleeding
- Nerve injury causing numbness or weakness in the shoulder area
- Blood clot (DVT or embolism).
Risks specific to this procedure include:
- Loosening of the artificial joint
- Dislocation of the artificial joint
- 'Frozen shoulder' - a condition where the shoulder becomes stiff and painful.
The following is a brief guide to rehabilitation after a total shoulder replacement procedure.
- These rehabilitation timelines are approximate, and actual progression depends on individual recovery. Total recover can take 10-12 months, but significant functional gains can be expected by 12 weeks.
- You will need to wear a sling for 4 weeks, including at night. Please remove the sling for shower and for exercises 3-5 times daily for 15-20 minutes each time.
- Please follow the advice and exercises demonstrated by your surgeon and your physiotherapist to give yourself the best possible chance of recovery and a good outcome.
- Your therapist will incorporate these exercises into your daily home exercise regimen.
- We encourage hydrotherapy commencing 2-3 weeks after surgery. The warm water and buoyancy allow for comfort and less pain during exercises and muscle relaxation.
- Do not perform forceful exercises. Perform exercises within the limits of pain and allow for a gradual return of movements over time.
- For the first 2 weeks – Apply icepacks 3-5 times daily for 10 minutes each time.
- Remember to take pain medication as advised assisting with exercises and keeping you comfortable.
First 6 weeks
- Five times daily exercises out of sling.
- Self-stretching shoulder exercises as per protocol.
- Passive and gentle active-assisted forward elevation and rotations to neutral position only from the mainstay.
- The physiotherapist will see you in the hospital before discharge. Please follow their advice and the self-stretching exercises in the sheet will be incorporated in your home exercise regimen.
- Pendulum, stick-assisted and pulley exercises as tolerated.
- Start scapular retraction and shoulder shrugging as soon as able.
- Elbow, wrist and hand exercises.
- Can start ADLs (activities of daily living like eating, writing, typing, etc.) after 2 weeks with above limitations in movement.
- Maximum weight you can lift is a cup of tea.
6 to 12 weeks
- Gradually progress with ADLs.
- Progress with Active-assisted exercises. Can start active ROM exercises. No restrictions to range.
- Start gentle isometric rotation and isometric deltoid exercises (only 25-30% strength).
- Also start core strengthening and scapular stabiliser strengthening as able.
After 12 weeks
- Start rotator cuff and deltoid strengthening exercises.
- Progress with ROM.
- No restrictions to activities.
- Please remember – No forceful stretching. Allow movements and strength to return gradually.