Tiny Cut Means Less Pain, Quicker Recovery

trend to minimally invasive total hip surgery

Much the same way arthroscopy has dramatically improved knee surgery, minimally invasive hip surgery has revolutionised hip surgery. A smaller incision means less tissue trauma. Less tissue trauma means less pain. Less pain means a quicker recovery for the patient.

Much more than a smaller incision

However, this treatment program is much more than a smaller incision. Keeping in mind that osteoarthritis patients are well, ideally, with a painful joint fixed, the patient should be back at their normal activities the same day. That has been our aim over the last six years.

During this development period and in our personal experience with over 600 patients, we have been able to achieve for a significant number a level of comfort and function not previously available. With a combination of adequate patient education, careful anaesthesia and minimally invasive surgery, patient mobility is compromised as little as possible.

Return to mobility within hours

This allows a return to weight-bearing and mobility within hours of the operation, minimising other secondary effects of surgery, such as prolonged recumbency, venous stasis, deep venous thrombosis, pneumonia, urinary tract infections, gastrointestinal disturbances, etc.

70% of hip resurfacing leave in 24 hours

Of the hip resurfacing patients, over 70 per cent left hospital within 24 hours. Of the total hip replacements, a patient age group which is older and more infirm, over 70 per cent were able to be discharged home within three days.

Similar results have been obtained for knee replacement surgery.

The effect of this treatment process is not only to improve patient quality of life, but as a result there has been a dramatic and statistically significant decrease in post-operative complications.

In order to achieve our goal, the following are required:

• Minimally invasive surgery. With this approach, soft tissue trauma is minimised
• Stable implant. The implant needs to be of a type that can be used immediately. Accordingly, stability is paramount.
• Minimal blood loss. Often blood loss and transfusion can make patients feel unwell and cause a delay in mobility.
• Pain management. The main inhibitor to patient mobility is often pain. With a combination of medications and local anaesthetic infiltration pain can be minimised and often suppressed to the extent that patients can mobilise, fully weight-bearing, within several hours after surgery.
• Early mobilisation. It is with early mobilisation that function is maximised, muscle atrophy and stiffness minimised, and other complications such as thrombo-embolic disease minimised.

Letter from Dr Kohan

Natural Therapies

In this issue we include a table of health food supplements and natural therapies, and how they interact with standard medications. There has been a lot written in recent press articles about natural medications. The problems in relation to the Pan Pharmaceutical manufacturing plant have been highlighted. Quality of manufacture is only one problem. With many of the “natural therapies” there is an enormous variation in the content and strength of the ingredients.

If a natural therapy is going to be effective, then by necessity, it must have some active ingredients. These active ingredients, if not clearly identified, pose a significant risk, because of potential cross-reactions with other treatments that may be necessary during the course of any health care plan. Sometimes these cross-reactions can be dangerous. It is important, therefore, to bring to the notice of the doctor the fact that non-prescribed therapies are being taken.

By doing so, the risk of a cross-reaction is minimised. Sometimes these medications can be toxic and require other tests, which may not be done routinely, to be performed.

Many patients think that these “natural therapies” are not medications, and do not think it important enough to inform the doctor. However this is not the case, and it is always better to let your doctor know too much information, rather than not enough.

Lawrence Kohan

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Dr Kohan answers your questions

Pregnancy after Total hip Replacement

As total hip replacement is increasingly performed in younger patients, the question of the efficacy of pregnancy post hip replacement is asked quite often.

In the past, total hip replacement was reserved for the older less active patient 60 or more. Today thanks to new improvements in prosthetic design and advances in the surgical techniques, total hip replacement is a viable option for the younger, active patient.

The number of women of child bearing years who are having hip replacements have been increasing. The concern in the past has been a high incidence of revision in women with hip replacements and pregnancy. A study conducted By Rafael Sierra at the Mayo Clinic in America between 1975-1995 and presented at the latest American Academy of Orthopaedic Surgeons in March 2003 looked at 228 women aged 18-45 years. From this group, there were 627 pregnancies.Dr Sierra found the majority of these women could deliver vaginally.

A small number of these patients experienced mild pain during the pregnancy. No patient had a complication and no patient required a revision hip replacement as a result of the pregnancy. This study shows pregnancy and childbirth can occur successfully in patients with a total hip replacement.

Successful pregnancy in the presence of total hip components does not appear to present a risk to the patient, the pregnancy or the implants. Because most of the younger patients who undergo total hip replacement often have significant medical problems, medical clearance should be recommended.

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Update on Glucosamine

Information provided by The Joint Health Advisory, The Stone Foundation for Sports Medicine and Arthritis Research.

Glucosamine is indicated for slow onset but durable pain relief and functional improvement in Osteoarthritis. Four keys points are the mechanism for its effects.

• Glucosamine is negatively charged and absorbs excess water. This will increase the hydration of the joint and tissues.
• Glucosamine can stimulate the production of hyaluronic acid. This acid will increase the lubrication to the joint.
• Glucosamine acts as a natural anti-inflammatory, which will decrease pain and swelling.
• An increase in glucosamine levels will improve repair to tissue damage in the joint.

Frequently asked questions.

1. What exactly is glucosamine?
   Glucosamine is a charged sugar molecule that is an essential component of the extra cellular matrix of cartilage (the cement between cartilage cells). It absorbs and releases water with each step, thereby acting as a shock absorber for the joint. With more glucosamine there is more joint protection. It also contributes to the repair process when cartilage is injured. Glucosamine is also an anti-inflammatory but has no known side effects. Glucosamine supplements are made from shells of shellfish.
2. What kind of benefits will I notice from taking glucosamine?
   Research indicates that 75 to 80 percent of all people who try glucosamine for arthritis report improvements in both pain relief and mobility. However, as with any supplements, glucosamine may not work for everybody.
3. Why is better, stronger, healthier cartilage important?
   Cartilage, a smooth, firm material made of a few cells with an amorphous matrix of charged sugar and collagen, covers the bone ends in the joint. Damage to this cartilage produces pain and a grinding in the joints. Osteoarthritis and post-traumatic arthritis are types of diseases in which the cartilage is damaged. Osteoarthritis, which effects at least 40 million people in United States, results from a change in the quality of cartilage due to injury, disease, genetics, overuse or ageing. As the cartilage begins to lose its fluidity and cushioning effects, damage to the underlying bone occurs, often resulting in stiffness and pain.

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Dietary supplements

Dietary supplements are widely used, particularly among athletes, the elderly and the chronically ill. But the consumer may not anticipate the effects these supplements may have on the body. Clinical problems have evolved from the relatively loose regulation of dietary supplements. Dangerous interactions with prescription medications may result in serious side effects, including excessive leading following surgery, cardiac events, and even death.
Below is a table outlining supplements’ interactions with prescribed medications. This information has been provided by the 2003 AAOS Complementary and Alternative Care Committee.

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FOCUS ON...
Dr Dennis Kerr
MBBS,MHA,FANZCA,FFICANZCA, Dip ABA, FHKCA,FHKAM

Dr Kerr has over 20 years experience in anaesthesia and intensive care, and his involvement with Dr Kohan has been for the last 10 years. He believes in meticulous pain management for the entire postoperative period. Dr Kerr is involved in preoperative education, preoperative planning and postoperative care.
Dr Kerr’s vision: “ allaying the patient’s fears, setting their expectations, educating the patient about the process and assuring the patient that you will be there for them whenever they might need assistance is a powerful analgesic in its own right”

Dr Dennis Kerr
MBBS,MHA,FANZCA,FFICANZCA, Dip ABA, FHKCA,FHKAM

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Antibiotic prophylaxis for dental patients with total joint replacement

An advisory statement from the American Dental Association and the American Academy of Orthopaedic Surgeons.

An expert panel of dentists, orthopaedic surgeons and infectious disease specialists, convened by the American Dental Association and the American Academy of Orthopaedic Surgeons performed a thorough review of all available data to determine the need for antibiotic prophylaxis to prevent hematogenous prosthetic joint infections in dental patients who have undergone total joint arthroplasties.

The result is a report which has been adopted by both organisations as an advisory statement. The panel’s conclusion: antibiotic prophylaxis is not indicated for dental patients with plates and screws, nor is it routinely indicated for most dental patients with total joint replacement. However, it is advisable to consider premedication in a small number of patients who may be at potential increased risk of total joint infection.

Patients who are about to have a total joint arthroplasty should be in good dental health prior to surgery and should be encouraged to seek professional dental care if necessary. Patients who already have a total joint arthroplasties should perform effective daily oral hygiene to establish and maintain good oral health.

Presently, no scientific evidence supports the position that antibiotic prophylaxis to prevent infections is required before dental treatment in patients with total joint prosthesis. The risk benefit and cost effectiveness ratios failed to justify the administration of routine antibiotic prophylaxis. It is likely that bacteria associated with acute infection in the oral cavity, skin, respiratory,

astrointestinal and urogenital systems and for other sites can cause late implant infection. Patients with a total joint prosthesis with acute oral facial infection should be vigorously treated with elimination of the source of infection and appropriate therapeutic antibiotics. Practitioners should maintain a high index of suspicion for any unusual signs and symptoms in patients with total joint prosthesis.

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