Which Type Of Joint?
You may have hoped this would be easy-you just order up a new knee or hip, and in it goes. But it’s not quite that simple. You and your doctor need to consider if you will have a cemented or uncemented joint and what type of knee prosthesis to use.
Cemented. Cemented is just like it sounds. Remember that tube of cement you used as a child to glue model airplanes together? It’s not the same glue, of course, but the idea is the same: The new joint is actually glued to the bone. Your joint heals quickly, but about half the time, it will loosen or become unglued in 10 to 20 years. When this happens, you may need more surgery to reglue the joint, a procedure called a revision. Revisions are more complicated than the original surgery, as more bone must be cut away and the surgery takes longer.
Generally, the cemented joints are recommended for people over 65. One reason is that bones have grown thinner in many older people, and for these people a cemented joint may work better. But this is hardly a fIxed rule. If you’re a healthy, active 70-year-old, for instance, you probably have stronger bones than a sedentary person 20 years younger who already has osteoporosis, or thinning of the bones. (Osteoporosis is linked to a lack of calcium and vitamin D. lt can be hereditary and is most common in postmenopausal women who do not take supplemental estrogen, although some men suffer osteoporosis as well.)
Uncemented. With uncemented joints, your existing bone actually grows right into the bumpy, sandpapery material of your new joint. It produces a tighter bond, but because it isn’t initially fastened as tightly as cemented joints,
it takes longer to heal. You should be prepared to spend more recovery time, perhaps three or more months on crutches, and postpone dancing that jig at your nephew’s wedding.
Full or partial. Knees are complicated apparatuses, so surgeons have developed two options for knee replacements. Your knee has two compartments, inside and outside. A total (bicondylar) knee prosthesis replaces both compartments. It has two parts: the femoral part, a metal unit that fits on top of your femur bone, and a tibial part, a metal “tray” on a stem that’s fastened to your tibia. After this procedure, you’ll walk freely but be able to bend your new knee only 90 to 110 degrees, less than the 140 degrees of a natural knee.
A unicompartmental (unicondylar) knee prosthesis replaces only one compartment of the knee, either the inside or the outside one. An obvious benefit is that it’s less extensive surgery and allows more knee flexibility than a total replacement. Doctors may recommend this for young, active people who will be more likely to wear out their prosthesis, thus minimizing the amount of later surgery they may need.
A Look At Other Procedures
Here’s a rundown of other procedures your doctor may recommend.
Osteotomy. In Greek, this means bone cutting, and that’s exactly what it is. Bone near a damaged joint, often the knee, is cut away and the rest of the bones are realigned, sometimes by removing or adding wedges of bone. Osteotomy particularly helps people with osteoarthritis whose cartilage has eroded unevenly, resulting in joints that don’t line up right. This procedure can straighten out slight abnormalities that may have caused you to be a bit bow-legged or knock-kneed, for example. Good candidates are people with mild arthritis in just one compartment of the knee and those who are too young or otherwise not ready for joint replacement. Some researchers recommend an osteotomy for people who want to continue sports that involve running or jumping or a job that requires bending or lifting. In about six weeks, you’ll be 80 percent recovered, and after six months, fully recovered. Of 34 men aged 60 and under who had osteotomies, 28 of them were happy with the surgery, and most could continue their previous activities, such as skiing and bicycling. After an average of seven years, 8 of the 34 required a second operation, mosdy joint replacement.
Resection. This is a fancy word for removal of all or part of a bone, generally in the hands, wrists, elbows, ankles or toes. It can relieve pain in the feet, for example, when body weight is distributed unevenly and dislocated parts of the bones bear the brunt of the burden with each step. Usually people with rheumatoid arthritis can benefit from resection; recovery can take several weeks.
Arthrodesis. In this procedure, two bones are fused, or fastened together, permanently. This is used for unstable, painful joints that can’t usually be replaced, such as in the wrists, feet, ankles, and thumbs, and occasionally for joints in the back or neck. In the knee, for example, the femur and tibia would be joined so that they basically become one bone. After arthrodesis, the joint cannot be moved, but it’s more stable and you’ll no longer feel pain. For several months after surgery, you’ll have to wear a brace. That can place additional strain on adjoining joints, and once in a while joints become unfused. Arthrodesis is seldom chosen unless a joint replacement is impossible.
The Nitty Gritty Of Surgery
You and your doctor have determined that surgery is the best option for you. Now you need to find answers to some specific questions.
Who does it? The person who operates on you will generally be an orthopedic surgeon. Or sometimes you may need a hand surgeon who has also been trained in either orthopedic or plastic surgery. As with most things in life, practice makes perfect, so feel free to ask how often the doctor has done this operation. Often, a surgeon at a teaching hospital or joint center will have more procedures under his belt. And while your surgeon’s skill is important, it’s also crucial that you feel comfortable asking questions.
Select the hospital. Your options may be limited by where your chosen orthopedic surgeon operates, where you live, or where your health plan will allow you to go. If you have the luxury, however, you’ll want to choose a hospital with a good general reputation that’s also known for orthopedics.
What to expect afterward. Ask your doctor specifically what you’ll be able to do after your successful surgery. It’s crucial to tell the doctor exactly what activities you most enjoy or what your work involves, because the surgeon may use different techniques, depending on your goals. Whether or not you consider your procedure a success will partly depend on the expectations you carry into surgery. So if you want to be able to polevault after surgery, and it leaves you only able to walk and swim free of pain, you may be disappointed. But if you know ahead of time that pole-vaulting isn’t realistic, you’re more likely to be happy with the activities you can do.
Consider a second opinion. Your insurance mayor may not pay for your visit to another doctor, but many people feel that it’s a wise investment before you undertake a costly medical procedure. You need to make sure you’re making the choice that’s right for you.
Get the specifics. Take a notepad with a list of questions for your doctor. You’ll want to know:
Are there any alternatives to this type of surgery?
What’s involved in this operation? How long will it take? . How long will I stay in the hospital?
How much time is required for rehabilitation? Will I need physical therapy? In the hospital or at home?
Will I need crutches or a walker while I recover?
How much time will I have to take off from work?
How many times have you done this procedure?
What is the cost? (You’ll have to ask your health insurance representative how much is covered by your insurance. )
Is a blood transfusion necessary? Can I donate my own blood in advance?
What after-surgery care will I need? Will I need home nursing, a physical therapist, an occupational therapist, or a nutritionist?
Things To Do Before You Leave Home
You’ve weighed your options, discussed the procedure with your doctor, and your surgery date is reserved. Ready to go, right?
A little forethought can make things a whole lot easier during your hospital stay and when you come home. And sometimes it can help prevent some unpleasant surprises. Here’s a checklist.
Catch up on paperwork. This includes arranging for deposits of income and paying bills that will become due during your hospital stay and your first few weeks of recovery. And, not to borrow trouble, but if you’re like most of us, you’ll go into any operation with an easier mind if you’ve asked your lawyer to draw up a power of attorney and update your will if necessary.
Visit your dentist. You should have any necessary dental work done well before the operation. Bacteria from even a minor infection elsewhere in the body, like the mouth, can get into your bloodstream and travel to the joint. One thing you don’t want is to have your new joint get infected, and this can happen if unfriendly bacteria start swimming around in your bloodstream. (If you need dental work after your joint replacement, your doctor may prescribe preventive antibiotics in advance for safety’s sake. Be sure to check with your doctor before any dental work.)
Assess your surroundings. Look around at your home or office as though you’re seeing it during your recovery period. If you’ll be using crutches or a walker, how easy will it be to get around? Tidy up and move obstacles out of the way. If your bedroom is upstairs, consider lining up some helpers to set up a temporary downstairs bedroom and make it cheerful. Your friends will be just as happy to hold your hand in the living room.
Go shopping. Stock up on grocery staples and house-hold items now. Prepare and freeze meals ahead of time. Now’s the time to indulge in that novel you’ve been wanting to read or borrow stacks of videos from your neighbor. Your local library, besides lending books, probably also lends videos; update your library card and check things out ahead of time. If you have a computer and modem, often you can search the library catalogs and request titles you want and even renew items over the modem.
Pack with care. Be choosy about what to take with you to the hospital. Pack comfy pajamas and robe but not your favorites (there’s a chance they’ll get stained), nonslip slippers, an inexpensive watch or clock, magazines, and phone numbers of friends and relatives. Leave your valuables at home, but don’t forget a favorite photo. A small inexpensive tape player with headphones can fill your mind with music.