As you consider a hip or knee replacement, you may be concerned about being sidelined for weeks from your job, golf game or grandkids. Not to worry. Thanks to new surgical techniques and pre-operation planning, today’s joint replacement patients are back on their feet faster than ever.
“You want to get back to work as quickly as possible,” says orthopedic surgeon Dr. Daniel R. Cavazos of Hampton Roads Orthopaedics and Sports Medicine, which has offices in Newport News, Williamsburg and Yorktown. “You want to be with family, return to work within a week or so, get back to your life.”
Advances in techniques and equipment involve less bone removal and less cutting of muscle, says Dr. Wilford K. Gibson of Atlantic Orthopaedic Specialties, which has offices in Chesapeake, Norfolk and Virginia Beach.
For hip replacements, Cavazos and Gibson access the hip through the front—called the direct anterior approach—as opposed to the alternate (posterior) technique through the patient’s buttocks. During surgery, the surgeon uses a special table called a Hana table that allows the medical team to position the leg and expose the hip, Gibson says. The Hana table also helps ensure that the length of the patients’ legs matches as closely as possible, Cavazos says.
“With the traditional approach, it was very common for patients to be in the hospital for three to five days,” Gibson says. “Then they went either to an assisted living facility or a rehab hospital for 20 to 30 days. It could take six to eight weeks before they were able to go to outpatient therapy. It could take up to three months before they were able to go back to work.”
Six months after surgery, patients’ recovery is the same regardless of which approach was used, the surgeons say. But with the anterior approach, fewer muscles are cut and the patient is in less pain immediately after the operation.
“They’re generally up the same day of surgery,” Gibson says.
Patients quickly transition from a walker to a cane in days, he says. The initial recovery is much faster.
“With the anterior approach, the recovery the first two months is dramatically different,” Cavazos says. “Most of these patients go home the same day or the next day. They’re off narcotics within three or four days, driving within a week and back to work in seven to 10 days.”
Patients, especially those who had their first hip replaced with the posterior approach, rave about the anterior approach, Gibson says.
“Some say it’s like night and day,” he says. “There was less pain. They were able to get up and walk the day of surgery because the muscles still worked.”
Knee replacements also have advanced since your parents or even your older brother had their knees replaced.
“The total knee replacement is nothing like it was five years ago,” Cavazos says.
For a successful knee replacement, what you do before surgery can make a huge difference in your recovery, Cavazos says. For about a year, Cavazos has prescribed physical therapy before surgery for his knee replacement patients. In prehab, patients start doing the physical therapy exercises they’ll do after surgery, Cavazos says.
Part of prehab includes teaching and helping patients to completely straighten out their knee, he says. “That strengthens muscles and you are ready to move your knee and walk on day one,” he says.
Cavazos wasn’t convinced of the benefits of prehab until he tried it.
“Until I did it, I thought it was a bunch of hogwash,” Cavazos says frankly. “But you have to experience it. When these prehab patients come in for surgery, they’re excited about getting their knee done. The fear factor goes down dramatically. They’re not afraid of the work they need to do. When they start rehab after surgery, they know what they have to do and they understand the absolute necessity. Rehab is like a race and prehab is like training for that race. You don’t train for a race on the day of the race. You want to train before the race.”
Some patients, especially those in their 30s and 40s with end-stage arthritis, are good candidates for a custom knee replacement, called a patient-specific knee, Gibson says. In a traditional knee replacement, the surgeon and assistants take measurements after the procedure has begun, he says.
With a patient-specific knee, a CT scan measures the shape and size of the bone before surgery and a replacement knee is made to create as close to normal alignment, rotation, flexion and extension of the knee, Gibson says. During surgery, less bone needs to be cut, he says.
Although this procedure has yet to be proven in long-range studies to be superior, it’s a good option for younger patients because it preserves more bone in case the patient’s knee replacement wears out in the future, Gibson says.
“If the knee has to be revised 20 or 30 years down the road, we want to have enough bone left to place another well-functioning knee,” he says.
Knee replacements using robots offer similar advantages because a CT scan prior to surgery means less bone needs to be removed, Gibson says. This procedure is a good option for patients who, because of a previous surgery such as for a broken bone, already have screws, plates or other hardware in their legs, he says.
Other advances include replacing staples with skin glue, which results in less pain and a less drastic scar, Cavazos says. Blood transfusions also are no longer required because new surgical techniques result in less bleeding, he says.
Pain management also has improved in the last two to three years, Gibson says.
“Most patients are very happy when they wake up in the recovery room and they don’t have any pain,” Gibson says. “They see their leg straight. They feel their foot working. They don’t have to take as much narcotics.”
These advances all translate to a faster return home and overall recovery, Cavazos says.
“Ninety-five to 98 percent of our patients walk on the same day, do stairs on the second day and go home the morning of the third day,” he says.
As with hips, patients who had their first knee replacement 10 or even five years ago are pleased at today’s advances, Gibson says.
“They are amazed that current technology allows them to get their knee replaced and go home in one to two days,” he says. “Some patients who are younger can even be done as outpatients.”