JOINT REPLACEMENT FACTS

Why does a joint need to be replaced?
When there is a bleed into a joint the synovium (lining of the joint) becomes inflamed (swollen). The synovium eventually looks like a ragged piece of liver with fibrils which can then become nipped within the joint causing further bleeding.

The iron pigments within the blood eventually destroy the cartilage covering of the end of the bones leaving raw rough areas. These changes ultimately lead to joint destruction, pain and decreased range of movement.

Joints which may be replaced are:-

Common	Less Common
Hips	Shoulder
Knees	Elbow

Surgical procedures to correct joint damage are:-

• Ankles
  • Synovectomy - removal of damaged joint lining - can be carried out by open surgery or arthroscopically (i.e. using a small camera inserted in the ankle. This means that the incision will be much smaller -also known as 'keyhole' surgery)
  • Cheilectomy - removal of small bony growths around the joint margins
  • Arthrodesis - fusing the joint surface to leave a painless but immobile joint; However, the patient will still be able to walk
  • Joint replacement - uncommon due to the complexity of the joint
• Elbow
  • Synovectomy (open and closed) is very successful
  • Removal of radial head - can improve forearm rotation, which will help with carrying out daily living tasks
  • Joint debridement - clearing of the joint surfaces and removing loose fragments etc.
  • Joint replacement - rare and not very successful due to the complexity of the joint
• Hip
  • Total hip replacement - involves replacing the joint completely with a metal ball and a plastic cup
  • Girdlestones Procedure-I a rare operation, which involves the removal of the ball part of the hip joint and allowing a fibrous union to occur. This procedure is sometimes used following a failed total hip replacement i.e. repeated dislocation or deep infection
  • Femural Osteotomy - as for knee
    
• Knee
  • Total knee replacement involves removing the damaged surfaces of the femur and the tibia with metal components
  • Synovectomy - as with the elbow joint this can be performed as an open procedure or arthroscopically and is often used before considering total knee replacement
  • Osteotomy -This involves realigning the limb by removing a wedge of bone from either the femur or the tibia,often relieving the pain
    

When should I consider joint replacement?
When pain and bleeding into joints becomes constant and interferes with everyday life and all other treatment e.g. physiotherapy and painkillers do not control the pain.

How do I find the best surgeon/doctor to do my joint replacement?
If you are going to have this major surgery you need to be sure that whoever is doing it has the skills/experience and a good success rate. In the case of PWH you need to be sure the surgeon/doctor has previous experience of joint replacement with patients with bleeding disorders and has good clinical backup from a haematology department dealing with haemophilia.

What does each operation involve?
This may vary according to the type of operation, the individual surgeon's choice, joint damage, physiotherapy and patient compliance. Rough guidelines only can be given in a general fact sheet. However you should receive a full explanation before the operation as to what to expect and more importantly what will be expected of you. This should include diagrams of anatomy, demonstration joint components if available and physiotherapy programme.

• ·Replacement factor -Factor levels must be monitored very carefully before, during and after surgery. Clotting levels have to be raised as high as possible before surgery. Blood samples are often taken 10 minutes, 30 minutes and 60 minutes after administration of factor. If the haematologist is satisfied with the factor level the operation will take place. After the operation factor levels will be monitored daily and appropriate levels of factor given.
• Adequate pain relief is vital throughout rehabilitation period and this should be closely monitored by the multi-disciplinary team for all operations

Total Hip Replacement (THR)

• First post op day - generally bed rest with legs abducted to prevent dislocation but mobilisation out of bed depends on the Surgeon and may start on Day 1.
• Bed exercises - quadriceps contraction and ankle exercises.
• Routine chest physiotherapy.
• Day 2 onwards - following check X-ray you will normally start walking with the aid of crutches/zimmer frame.
• Mobility normally progresses quite quickly and you may be discharged 7-14 days after operation - sometimes earlier.
  

Due to the nature of the THR there are certain activities that you MUST NOT do for the first eight weeks:

1. Sit on low chairs/toilet
2. Cross legs
3. Bend down to pick up items off floor
4. Lie on the un-operated side
5. Drive

You will be seen by an occupational therapist who will provide the necessary equipment such as raised toilet seats, helping hands, high chair etc. Out-patient physiotherapy is not often required following THR.

Total knee replacement (TKR):
Intensive pre and post operative physiotherapy is required and willingness to work hard in order to obtain best results is essential.

• First day Post-op - Ankle movements and quadriceps exercises are performed.
• Routine chest physiotherapy as for hip.
• Day 2 - Providing factor levels are adequate knee flexion (bending) exercises are started either actively or using a continuous passive motion machine (CPM).
• You will usually be mobilised with or without a splint on your knee. Once you can lift your leg straight off the bed the knee splint can be discarded. This should be aimed for as soon as possible.

Once you have good quadriceps control and reasonable knee flexion you can be discharged with regular out-patient physiotherapy until the maximum range of motion has been achieved.

It must be noted that an increase in joint range of motion is not often achieved following TKR in haemophilia. However, most people are left with a functional and pain free joint.

Shoulder Joint Replacement:
This is a less common procedure with a complex rehabilitation programme -the shoulder joint is capable of a wide arc of motion and due to the shallow joint surface, unlike the hip, the shoulder joint replacement can dislocate.

• First day post-op - Shoulder is kept in a shoulder immobiliser for up to six weeks only being removed regularly for exercises
• Active finger, wrist and elbow movements
• Chest physiotherapy
• Day 2-14 - passive exercises only performed by the physiotherapist allowing only forward flexion and abduction taking the arm sideways from the body and no lateral rotation). These exercises need to be performed 4-6 times per day. The strict regime is necessary to allow the soft tissue structures of the joint to heal.
  
  The rehabilitation period can last up to three months of intensive physiotherapy.

Your physiotherapist will carefully guide you through the stages of the rehabilitation programme usually in conjunction with a written guide to each stage.

For best results it is essential that you follow the programme of exercises prescribed by your physiotherapist.

Elbow Surgery
Post operative regimes are dependent upon surgery performed. Early joint mobilisation is normally advocated under strict supervision by the physiotherapist. Active resistance free exercises on a shiny surface are also performed in the first few days post surgery.

The joint may or may not be immobilised in a back-slab in the initial stages of rehabilitation only being removed for exercises.

Gradual increasing activities avoiding weight-bearing exercises can be introduced, such as pulleys to assist movement. Outpatient physiotherapy will be necessary to increase muscle strength and range of motion.

Ice therapy or pulsed short wave diathermy (heat treatment) may be used as an adjunct to other physiotherapy techniques in order to reduce swelling and enhance pain relief.

What are the risks involved in having a joint replaced?
As with all surgery there are risks attached. However, it is necessary to weigh up the advantages and disadvantages before undergoing surgery. You will need to make careful preparation, seek advice and have all potential risks explained in order to make an informed choice.

Main complications

• Early post-operative bleeding should be controlled with good factor replacement and gradual physiotherapy by an experienced physiotherapist specialising in haemophilia care
• It is not uncommon to have joint bleeds following surgery
• Dislocation of prosthesis - especially hip and shoulder
• Acute infection
• Nerve damage - particularly an inability to raise your foot or wrist
• Chest infection

Late complications:

• Deep infection - possible in those who are immuno suppressed
• Loosening of components
• Decreased range of motion
• Many complications are treatable but if a joint fails then there is a possibility for the surgeon to perform a revision of the joint or carry out some salvage surgery.

How long will I spend in hospital?
Normally between 7-14 days but this is dependent upon the type of operation, surgeon, haemophilia doctor, and physiotherapist..

What different types of artificial joints are available?
How will I know which type is best?
These are very important questions and the Government is setting up a national registry of hip & knee replacement techniques to allow comparisons of the various types. However, they are outside the scope of this fact sheet. Technology has changed greatly in the last 10-15 years and there are a variety of materials and designs of joints now available. Ask your orthopaedic surgeon for up-to-date information.

What kind of aftercare is needed?
Close liaison with your physiotherapist and centre staff is important. Following lower limb surgery you will not be discharged from hospital until you are safe with crutches. You should be able to transfer independently from bed to chair, chair to toilet and negotiate stairs safely and have the necessary support at home:

• i.e. equipment fitted and in place.
• Social Service support if necessary.
• Outpatient physiotherapy/surgeon follow-up appointment.

Most comprehensive care centres have a dedicated physiotherapist experienced in haemophilia management and you will most likely know him/her. Pre-op assessment clinics are vital to inform patients of the necessary rehabilitation programmes.

How long will the recovery period last?
Times will vary depending on the individual and on the joint which has been replaced, but as a general rule the best progress is made with the first two/three weeks following surgery. Further improvement in strength and general wellbeing can continue for up to six months.

Pain management
Post operation analgesia will be given as required. To gain maximum benefit from surgery pain needs to be controlled especially during exercises. Initially you may be attached to a patient controlled analgesia machine (PCA) which allows you to be in control of your analgesia requirements. You cannot overdose yourself with these machines. Intravenous analgesia is gradually withdrawn and replaced with oral tablets. You will need good pain control throughout the rehabilitation phase and this should be carefully monitored.

While you are in hospital your physiotherapist will see you once or twice per day and take measurements of your joint range of motion using a goniometer (an instrument used to measure the amount of movement in a joint. This is measured in degrees). He/she will keep you informed of your improvements and provide sport encouragement throughout.

How long will my joint replacement last?
Hip and knee replacements should last 12 - 15 years. There may be problems with shoulder and elbow replacements for those using crutches.

• Acknowledgements:
  Ø Brenda Buzzard, Superintendent Physiotherapist at the Royal Victoria Infirmary, provided the information for this fact sheet.
  Ø Thanks are also due to Mr. P. Hirst, Orthopaedic Surgeon at the Manchester Royal Infirmary for his advice and assistance.
  Ø Lincoln and District Group, a local group of the Haemophilia Society, have sponsored this and other fact sheets. We would like to acknowledge their vital contribution to the work of the Haemophilia Society.

This fact sheet can only give basic general information drawing on medical opinion and evidence available at the time of writing. Different people may give you different advice on certain points; and there may be some variations in the way care is managed in different hospitals or areas. It is important that you contact your own doctor(s) and nurse(s) for further information and advice on your own individual circumstances.

Published June 2001
Amended June 2003