Practical Considerations When Having Your Joint Replacement Surgery
In response to your query regarding Total or Resurfacing Hip Replacement:
( In general this letter also applies to Total Knee Replacements)
All prospective total joint replacement patient’s need to be seen and examined carefully as well as reviewed together with their appropriated x-rays prior to surgery. This needs to be done at least two weeks before the prospective surgical date but waiting lists can be longer. On occasion, depending upon your general physical status, you may be required to see a physician before surgery, for more specialized tests in respect of the cardiovascular (Heart and blood vessels) and pulmonary (Lungs) systems and the ability to withstand anaesthesia and surgery. Failing this, you would be admitted on the night before surgery so that you may undergo these specialized tests for anaesthesia which include a chest x-ray, an echo-cardiogram (electrical assessment of heart function), and blood tests which will include a full blood count and renal (kidney) function screen.
Most people are admitted on the day of surgery. It is best to arrive early i.e. 7am at the hospital reception, where the paper work will be completed and then you will be taken up to the ward. After being settled in the ward you will be admitted by the nursing staff. The surgical site will be painted with antiseptic solution (containing Iodine) and covered with a sterile towel. I will see you in the ward and address any last minute questions and finalize consent if not already done. My anaesthetist will also see you and go over this aspect of the procedure.
You will then be transferred to the theatre suite receiving room prior to being prepared in the theatre for anaesthesia. The surgery itself takes approximately one to one and a half hours long after which you will be transferred to a recovery area for approximately half an hour or transferred directly to the high care unit. In most cases, patients are kept overnight in a high dependency unit for appropriate close monitoring of their vital signs. This is done under the auspices of a specialist physician, the anaesthetist and myself, thus very much a team approach to perioperative care.
As mentioned before the surgery can take up to 1hr 30min, but will seem like a few minute to you. The anesthesia varies between hip and knee replacement surgery and our techniques for pain control are based on recent advances and evidenced based studies. There is always a combination of local and general anaesthesia. The sutures are all under the skin and absorbable. The dressings are designed to keep tension off the wound and are water resistant enough to allow showering. My hip replacements are done with a posterior approach which allows patients to fully weight bear the day after surgery if their pain allows. In a thin patient the wound can be as short as 8 cm. Length of wounds are however dictated by the size of the patient and the dictates of the surgery. Cosmetic considerations are secondary and there is no effect on ability to mobilize. It’s what is done under the skin that counts. Knee replacement wounds are usually 10 to 15cm long and have the same dressings. Mobilization is also full weight bearing on day 1 as pain allows.
I will see you every day after surgery and your dressings will be changed as required. On Day 1 post op, physiotherapy rehabilitation is begun, with mobilization out of bed and into a chair and if you should feel so inclined, you may begin mobilization with a walking frame and/or crutches. Usually you will be transferred back to the ordinary ward within 24 hours if the physician has no concerns regarding your vital signs. The length of hospital stay varies from patient to patient but on average is approximately 4 – 5 days. Essentially I like to keep my patients in the ward until they are able to manage a pair of crutches and walk up and down a flight of stairs. I have had an 84 year old take 2 days and a 54 year old take 2 weeks, so pain perception varies and a lot depends on one’s mental attitude. Knee replacements are more painful and do take longer to recover from. The leg is placed in a continuous passive motion machine for early movement on the day of surgery.
The physiotherapist will discuss various do’s and don’ts in respect of mobilization after total hip or knee replacement surgery and provide various aids in terms of preventing one of the complications of hip replacement namely that of dislocation. This will include a raised toilet seat and a hand held grasper which will assist in lifting objects off the floor.
Once mobile and relatively independent my patients are discharged home. There will be a follow up visit at approximately the 12 day mark in order to assess the status of the wound and remove all the dressings. Thereafter there is at least a six week post-surgical visit with repeat x-rays and review. Longer term follow up includes a visit at the six month mark with a check x-ray and thereafter yearly for five years. Various outcome scores (Questionnaires) need to be completed in order to provide for an objective assessment of the final result.
In terms of costs, these are divided in to two broad categories, namely those of the professionals involved in providing the service and the cost of the implant and hospital stay. The hospital fees including the fee for the actual implant which is billed for through the hospital, as well as theatre time and time spent in the wards is by far the most expensive aspect of this whole procedure and can be as much as R150 000, 00 . This can be more depending on the length of stay especially if a longer period is required in a high dependency unit. Most, if not all of this fee is covered by the medical aid if you have a good policy. It is advisable to check with your medical aid regarding the prosthesis (implant) limit applicable to your contract with them. If there is a shortfall one can negotiate with the implant company directly for a discount. If you have GAP cover or a high level policy then all your costs should be covered.
Please remember that the fees charged for the services of the professionals involved in your care, are independent of the above. The Health Professionals Council of SA has stated that any payment arrangements that affect this independence, and thus the ability of the professional to provide unbiased clinical care, be deemed unethical. The professional service contract is with the patient, and the patient’s insurance contract is their own and separate.
All follow up visits from my side as the index surgeon are included in the surgical fee for the first 6 months, despite being legally able to bill for followup from 6 weeks. In most cases a booking for a total joint replacement can be accommodated within a four to six week period. One of the main contributors to the costs of having a total hip or knee replacement remains the cost of the implant. This is over and above the hospital theatre and ward costs. The usual quotes for implants range from between R30 00,00 to R60 000,00 and will be given to you. GAP cover at approximately R200 pm also covers these differences but check your policy.
I trust this letter will assist you in making an informed decision regarding your choice of having a total hip/knee replacement under my care. Please, do not hesitate to contact me or my staff should any further questions require answering.
Dr. T.W. Munting