A. Hip replacements generally last 15 years, however with ceramic on ceramic or metal on metal prosthesis, we hope it will be more like 20 years plus.
Knee replacements last over 20 years in 90% of people implanted over age 70. As the age drops, so too does the survivorship of the prosthesis. In other words the younger the patient the more likely it is to wear out.
Partial knee replacements last 8-10 years but can be redone more easily than full knee replacements without the same complications.

A. The main restriction is repetitive impact. The implants are designed for normal activities but not running, jumping or heavy lifting. Kneeling is uncomfortable after knee replacements (partial or total) and is best avoided or minimised.

A. All sports that involve no running or impact. For example: walking, swimming, cycling, golf and tennis (social doubles), skiing ("blue" and groomed runs) and horse riding. Falls should be avoided and constitute a risk of damage to the bone surrounding the prosthesis.

A. To maximise the life of your new implant it is essential to avoid running and jumping, to keep as normal a weight as possible and to avoid any falls.
Regular exercise to strengthen the leg muscles and put the hip or knee through full normal movement, example swimming and cycling, is also beneficial.

A. Depends on each individual including home circumstances, family support, general health and type of joint replacement.

(a) Partial knee replacements
50% of patients go home the same day and are seen for follow-up at day 10. Others may need to stay for 2-3 days and sometimes go into rehabilitation for one week or more for hydrotherapy and physiotherapy.

(b) Total hip or knee replacements
Generally five days in hospital and then one to two weeks in rehabilitation for hydrotherapy and physiotherapy.

(c) Revision surgery
May be longer depending on the complexity of the operation.

A. For partial knee replacements, blood transfusion is never necessary.

For total hip or knee replacements, most patients will not need blood transfusion if their starting blood level is adequate [measured by the haemoglobin (Hb) = 13mmol/l]

Recent evidence suggests that giving blood prior to surgery (autologous transfusion) does not decrease the chance of requiring a blood transfusion from the blood bank. It has been shown that patients who give blood preoperatively tend to arrive for operation more anaemic than otherwise and therefore the blood is often used to top them up to a level that they would have started at anyway. Furthermore there are definite medical risks to donating blood (The Red Cross will not consider you over the age of 70 with any cardiac disease).

In knee replacements we use a "reinfusion drainage system". This system allows the blood drained from the knee itself to be reinfused within 6 hours of operation following filtration and collected and returned to the patient. With this system blood transfusion is virtually never required.

A. In all procedures, except some complex revision hip replacements where donated bone (allograft) is used, patients may fully weight bear as pain allows. You may need a walking frame or crutches initially to get on your feet, but then start walking with one stick only for two months.

A. After joint replacement surgery of all types, most recovery occurs by 3 months, but you will still continue to improve in terms of function and comfort for at least 12-18 months .

General milestones:

1. Driving - 6 weeks

2. Work - 2 months (earlier in partial knee replacement)

3. Golf, tennis, sports - 3 months

4. Sexual intercourse - 1 month (passive for 3 months)

5. Sleeping normally - 3 months

6. Travel/ air flight - 3 months

7. Further surgery/ anaesthesia - 2 months

Q. How often will I need to be seen for follow-up?

A. All joint replacement patients (within reason) should have long-term follow-up indefinitely.

General programme is:

   1. Postoperative visit 2 months

   (day 10 for partial knee replacement)

   2. 2nd post-op visit 1 year

   (3 months for partial knee replacement)

and thereafter every 4 years indefinitely with new x-rays.

- Patients from far away should send own x-rays with a short note of their progress at 4 yearly intervals if they are unable to attend personally.

- Fellows/ Research assistants may contact you from time to time if we are analyzing prostheses or procedures and reviewing such data for an audit or presentation and scientific publication.

A. When pain and/or disability has reached the stage of significant interference with quality of life and all conservative (non operative) measures have been exhausted.

Exception: Partial knee replacement surgery is best done before end-stage arthritis has set in so as "not to miss the boat". It is a "pre-knee replacement operation" done to improve quality of life and function for 8-10 years before the necessity of full knee replacement (hopefully avoiding it altogether). It is a bit like having a filling in a bad tooth early rather than risking loosing the tooth altogether and having it replaced.

A. Spinal (regional) anaesthesia is used a lot, often combined with nerve blocks, particularly for knee surgery.You may be asleep as well and will not hear or remember anything.General anaesthetic is sometimes necessary if a spinal block cannot or should not be performed (or if the patient prefers). The decision will be made with you and your anaesthetist who will see you the night before surgery.

Q. Who will be my anaesthetist?

A. Dr Neil works with four specialist anaesthetists routinely and all have been hand-selected. All are highly specialised, full fellows of the Royal Australasian College of Anaesthetists and are fully accredited to practice in all facilities on St Vincent's Campus, including St Vincent's General, St Vincent's Private Hospital and the Day Surgery Unit, St Vincent' s Clinic. All four anaesthetists have particular expertise and interest in orthopaedic surgery.

The anaesthetists are allocated to operating lists on certain days as follows:

1. Tuesday
   Day Surgery Unit Dr Simon Adamo

2. Wednesday PM Dr Michael Scarf
   St Vincent's Private Dr James Milross

3. Thursday Dr Colleen Kane
   St Vincent's Private Hospital Dr James Milross

4. Friday
   Day Surgery Unit Dr Colleen Kane
   St Vincent's Private Hospital Dr Simon Adamo

A pre-anaesthetic consultation can be arranged if necessary but generally your anaesthetist will assess you the night before operation or prior to surgery in the Day Surgery Unit.

A. There is a very active programme of DVT (deep venous thrombosis) prevention and detection at St Vincent's Private Hospital in collaboration with Dr Michael McGrath, Dr Peter Vale and Prof David Ma.

A recent study of over 550 patients demonstrated:
   1. There are certain genetic pre-dispositions to DVT after joint replacement surgery that can be detected by blood tests (Factor 5 Leiden)
   2. Active prophylaxis including calf compressors, low molecular weight Heparin, anti-thrombotic stockings, early mobilisation offers the best chance of avoiding this complication.

Every effort will be employed to prevent a clot. All patients have a surveillance doppler ultrasound scan at day 6 to detect any clots in the operated leg and treatment is planned accordingly.

The current incidence of deep venous thrombosis in total hip replacement is 5% - most of these are serious.

The current incidence of deep venous thrombosis in total knee replacements is 28% - most of these are trivial.

If the clot involves the knee or higher veins of the thigh, usually Warfarin orally will be instituted for three months.

Using this system of clot detection and prevention over the last 5 years, we have had no deaths from severe lung clots which are the most serious of all complications. Warfarin is usually continued for 3 months if instituted.

A. Joint replacement surgery is not severely painful, although knee replacements hurt more than hips.

Pain is relieved by a combination of nerve blocks, local anaesthetic infiltration intraoperatively and PCA ("patient controlled analgesia") self-administered narcotics postoperatively. The PCA has the disadvantage of sometimes producing nausea. We are currently looking at eliminating PCAs routinely following joint replacements and have starting using "painbusters" ( a local anaesthetic infiltration anaesthetic reservoir which delivers local anaesthetic to the joint and wound for three days). These have been used for two years and appear to make a significant reduction in the amount of narcotics required for postoperative pain relief.

Generally pain is more severe for 48 hours and then is well-controlled with oral tablets.

The arthritis pain is relieved IMMEDIATELY by replacement of the troubled joint and replaced by a surgical wound pain which is well-controlled and temporary.

We used CPM (continuous passive motion) machines after knee surgery some years ago to try and improve movement early. However we found:
   1. Patients had more pain (we re-christened the machines - "continuous pain machines"!).
   2. Wound problems were increased
   3. The results at one year were no different to those patients who did not have CPM.

Therefore CPM is used only in cases where the knee has been very stiff and requires manipulation (less than 10%).

A. Dr Neil has a scale of fees based on the personal circumstances of the patient, and fees will be discounted accordingly.

The fees set are those determined independently by Dr Neil based on his experience, expertise and the complexity of the operation.

The "GAP" is the out-of-pocket payment required above and beyond Medicare and the health-fund rebate and will vary from patients and operations. The office will happily supply a detailed estimate of all costs (including "The GAP") when surgery is booked. Any concerns can be directed to the office managers. Arrangements can be made for delayed or sequential payments of fees with notice.

Dr Neil has no contracts or agreements over fees with individual health insurers. However the cost of hospitalisation at St Vincent's Private Hospital is fully covered by health funds currently.

Estimated cost of surgery ( if no insurance or Medicare rebate - eg overseas patient)

   Primary Total Hip Replacement A$ 30,000

   Total Knee Replacement A$ 30,000

   Partial knee replacement A$ 15,000

   ACL reconstruction A$ 10,000

   Revision joint replacement surgery A$ 45,000 +

A. The length of the incision for hip and knee replacement is lessening with minimally invasive techniques, allowing a speedier recovery due to less tissue trauma.

Current incision:
   1. Primary hip replacement 15 cm
   2. Primary knee replacement 12 cm
   3. Partial knee replacement 7 cm
   4. Revision hip/knee replacement
   (entirely dependent on the previous scar and the surgery required. )
   5. ACL reconstruction 2 cm
   6. Cartilage repair 3 cm

The wounds usually heal with a pencil thin white scar, and sutures in the skin are invisible and dissolve. Some patients form "keloid" (large thick broad scars) because of their genetic make up and this is unavoidable in these individuals.

"Cica - care" wound dressing later can help reduce scarring and keloid formation in these patients.

Q. If I wait, will technology improve so I wont need a joint replacement?

A. Probably not.

Joint replacements are already an advanced technology and not likely to be superseded for generations if at all.

Improvements have been in 2 general areas in recent times:
    1. Bearing surfaces - to improve long-term wear
    2. Accuracy and reproducibility of implantation due to the skill and training of the surgeon and quality of the instrumentation.

Ceramic/ceramic and metal/metal are the "new" bearing surfaces over the last 5 years. It is hoped that these are 20 year + bearings (even over 30 years!) - who knows. Nothing new is likely to replace this technology soon.

Most research is now looking at cartilage repair and regeneration techniques, but it is not appropriate for bone on bone arthritis. Manipulation of genes which express OA by the cartilage producing cells (chondrocyte) is being actively studied but again will probably be a generation away for routine clinical application.

In summary, cementless porous coated modular implants coated with HA (bone mineral) are here in use now and offer great benefit to younger patients in terms of long-term survivorship and ease of revision of the prosthesis.