Mr Madhur Shrivastava, MB BS, MChOrth, Consultant Orthopaedic Surgeon with special interests in primary and revision hip surgery, resurfacing hip arthroplasty, primary and revision knee arthroplasty, navigated minimally invasive hip and knee arthroplasty, resurfacing and total shoulder arthroplasty and sports injuries
The last 50 years have given us tremendous advances in the care of orthopaedic patients. These
include improved anaesthetic techniques, auto-transfusion of blood, medical management of comorbid conditions, information technology and specialty specific technological advances. New orthopaedic devices, computer aided techniques, medical imaging and minimally invasive techniques have greatly improved patient care.
Consumerism and media advertising have guided many of the new technologies. At the Spire
Parkway Hospital, we embrace new technology and techniques with great caution and only on the
basis of medical evidence and positive patient outcome.
Total hip and total knee arthroplasty continues to be an evolving science. Numerous debates exist with respect to technique and implants used. There is continued controversy regarding issues of cementless versus cemented fixation, surface finish for cemented implants, and ideal bearing surface. There is increasing focus on less invasive surgical procedures to facilitate rapid return of function.
The primary appeal of hip resurfacing is the absence of invasion of the femoral canal and
maintenance of femoral bone stock. However femoral neck fracture, avascular necrosis and
synovitis secondary to metal ions can result in a cumulative revision rate of 7.2%. The procedure is technically more demanding than conventional total hip replacement. We therefore undertake hip resurfacing for a select group of patients who aspire to follow physically demanding occupations and recreational pursuits. Implants with proven track records are used to reduce implant related problems.
Cemented hip arthroplasty is undertaken for elderly patients with not so physically demanding
lifestyles. Cement is the commonest method used to fix femoral components in the UK. Polished
collarless tapered stems are most widely used. Compared with cementless fixations, cement is very forgiving. Correct leg lengths can be easily achieved. Thigh pain does not occur and intraoperative fractures are very rare. Antibiotics can be added to the cement to decrease incidence of infection.
There has been, however, an exponential increase in the usage of un-cemented hip implants for
relatively young and active patients. Ceramic-on-ceramic bearings for total hip arthroplasty have
4,000 times lower wear than metal-on-conventional polyethylene. The bearings can however lead
to a squeaking noise in 6% of the patients. Most surgeons use ceramic-on-ceramic bearings in a
select subgroup of very young patients for whom the potential benefits outweigh the occasional
problem of squeaking and the rare chance of ceramic fracture.
Patient and gender specific knee replacements have been recently introduced to provide for optimal fixation and function. Proprietary software program is used to prepare a 3D model of the arthritic knee from scans. These ShapeMatch implants / instruments give the best possible fit and patient outcome following knee replacements. A High-Flex total knee replacement design can also be used in patients who wish to kneel or pray or acquire an increased knee bend posture.
The perioperative care of patients with total hip and knee replacements has undergone a significant evolution. We use the concept of a rapid recovery protocol with the distinct intention to speedy recovery to reduce morbidity and complications. The protocol comprises of comprehensive preoperative education and medical evaluation, and physiotherapy to enhance postoperative rehabilitation.
Multiple studies have noted the adverse effects of cigarette utilisation on the perioperative period
and therefore we discourage smoking and encourage nutritional supplements to improve
postoperative wound healing. Serum albumin and transferrin levels are routinely checked to
decrease postoperative morbidity.
Multi-modal pain management techniques are used to reduce perioperative pain to improve early
mobilisation and functional outcome. The management of pain involves pre-emptive analgesia and intra-operative infiltration of the joint with long acting local anaesthetics and platelet rich plasma. Postoperative pain is controlled by non-steroidal anti-inflammatory medication. Concomitant with effective pain management is aggressive physiotherapy and rehabilitation. Dedicated physiotherapists mobilise the patient within three to four hours after hip or knee replacement to reduce postoperative stiffness, deep vein thrombosis, chest infections, urinary retention and gastric stasis.
Intra-operative blood loss is reduced by the use of tranexamic acid, local haemostatic PRP injections and careful haemostasis. Patient’s own blood can be aseptically collected and re-transfused, reducing the perioperative blood loss, postoperative pain and swelling, and also the risk of blood borne diseases.
The establishment of specific protocols for the care and treatment of patients undergoing total hip
and knee arthroplasty can thus provide efficient and effective service. The clinical pathways are
standardised and therefore the patients experience reduced and uncomplicated hospital stays. By adopting rapid recovery protocol at Spire Parkway Hospital, our patients are able to achieve postoperative milestones at significantly earlier times.