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Choosing a Surgeon And a Prosthesis

Discussion in 'Pre-Surgery Information' started by Josephine, Feb 28, 2009.

  1. Josephine

    Josephine NURSE DIRECTOR, BONESMART Administrator
    Thread Starter

    Member Since:
    Jun 8, 2007
    The North
    United Kingdom United Kingdom

    When faced with the need to choose a surgeon for your joint replacement, it can be overwhelming. How do you choose? How do you know?

    Well, for a start you can make a note of the questions below and then interview some surgeons to make sure you get a good one. I know friends will say to you 'Mr. X is highly/well respected in our area' or 'Mr X is the 'top' surgeon'. You might ask around and be told that those who had Mr. X do their hip or knee were delighted and found him ‘such a nice man’. Such recommendations are good but they're not everything. ALL surgeons are 'well respected' and have 'fans'. It comes with the job. But it means little if your hip is botched up and then you find others with problems popping out of the woodwork.

    Another phrase often heard is that Mr X is the 'top surgeon in his field'. What field? His locality? His hospital? His state/county? In whose opinion is he top? The general public? Patients who have had good outcomes? His professional peers?

    Personally, only the opinion of his professional peers would count with me as to whether a surgeon is top in his field or not since they would be the only ones capable of making such a judgement.

    It's also easy to get overwhelmed by the mountain of information about different prostheses. Again, how do you choose? How do you know?

    Just be aware where you are getting your information from! Manufacturers have websites to promote their own products and are therefore naturally going to emphasise the positives in their own wares and compare them with the negatives of others. Examples: "We advocate the use of ceramic because it is known that wear particles from plastic liners causes tissue reactions" or "Metal on metal creates ions." Be sure and find the fine print in any website or any article you read to see exactly WHO is presenting the information. Many times it will be someone who has a financial stake in what is written, meaning you should consider that when you evaluate the information.

    US: 225,900 primary hip replacements and 431,485 primary knee replacements were carried out in 2004 according to data from the Nationwide Inpatient Sample
    UK: 27,814 primary hip replacements and 75,629 primary knee replacements were recorded in the National Joint Registry in 2008

    Of these, a very tiny number have problems, statistics show less than 1% overall.

    Metal on plastic has been the bench mark combination of materials since way back to the early sixties. Otherwise there is metal on metal, ceramic on plastic and ceramic on ceramic. Each have their own positive and negative aspects but suffice it to say that, in my opinion, choosing requires knowledge and skill and is a matter for the surgeon. All have been tried and tested over the years.
    Warning: on no account accept a metal on metal hip

    As for the longevity of the prostheses, the official line is 10-15 years, professionals reckon it to be 15-20. Statistics show it to be approaching 20-25 and maybe even more. There are many, many people walking around now, living good, productive and happy lives who had their replacements done in the 60s and 70s! There is a news report in the hip forum about a lady who had hers done in 1966! See these

    Longevity of implants
    Hips that have lasted 32, 40, 41 and 45 years
    67½ year old - the THRs, not the patient!

    When will I be "ready" to have my joint replaced?
    First of all, read around the older threads here on BoneSmart and you'll see that a lot of other members have asked that very same question! Many continue to prevaricate even though they have cut back dramatically on the things that make their lives worthwhile. But ask yourself this: "Just how much more disabled do I want to be before I get that hip/knee fixed?" No one knows what's around the corner. Anything could happen. So if you wait another 5 or 10 years - you'll never get those years back.

    The simple fact about joint replacement - the primary objective of the procedure - is to give you back your life, to give you back your vitality and to give you back you! You won't discover that so much as REdiscover it!

    The upshot is that all hip and knee implants are pretty much tried and tested. Most have been around for years and although they have been 'redesigned' and refashioned from time to time, they are basically the same prosthesis. They have stood the test of time. What makes one operation a success and causes another to fail is mostly down to surgical skill and experience.

    My advice is this:
    Choose your surgeon carefully and ask him these questions
    (print these off and take them with you)

    1. How long have you used your current prosthesis and what are your reasons for having selected it?
    2. How many (knee/hip) surgeries do you do each year? (Anything over 200 is good; 300+ is better)
    3. What is your infection rate? (0.5% or less is good)
    4. What is your incidence of short term complications? (dislocations, wound infections)
    5. What is your incidence of long term complications? (infections, loosenings, breakages of prosthesis, clicking, clunking, unidentifiable pains, need for manipulations)

    Any surgeon worth his salt will not only be ready and willing to discuss these questions, but will have the figures ready to provide to you. Any hint of reluctance, offense or waffle - go find yourself another surgeon!

    UK members can use the National Joint Registry
    US members can use the "Find a Clinic" tool on this forum

    Once you have found a surgeon whose responses you feel comfortable with, accept whatever prosthesis he uses as you can trust that it has a better than average track record. Though to be honest, most do anyway.

    All the best in your journey to a new joint!
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  2. Josephine

    Josephine NURSE DIRECTOR, BONESMART Administrator
    Thread Starter

    Member Since:
    Jun 8, 2007
    The North
    United Kingdom United Kingdom
    Here are some additional questions you may want answered.

    About the surgeon:
    How long have you been specializing in knee and hip surgery?
    Approximately how many knee replacements do you do in a year?
    How many replacements have you done in your career?
    What brand of prosthesis do you use? Why do you use it?
    In your experience, how long do the replacements last?
    Do you perform both TKR and PKR (for knees only)?
    What is your criteria for PKR (for knees only)?
    Do you perform Minimally Invasive Surgery (MIS)? If so, please define what that means, the benefits, and how it is done. How does it affect the quadriceps muscle, tendons, ligaments (knees only)?
    How many revisions have you had to do for the replacements you have done?
    Why did they have to be revised?
    What is your rate of short-term and long-term infection for this surgery?
    Who will I see from the surgeon's office when I'm in the hospital? It may be the surgeon every day, but if its the weekend there may be a partner who sees you. If your surgery is done at an academic center, residents (OS in training) may be seeing you. The OS may have a PA (physician assistant) that makes rounds. Find our their names so you fee comfortable when they come by to see you.

    Questions about the hospital:
    What hospital will you use for this surgery? WHY THIS PARTICULAR HOSPITAL? Do they have special experience with orthopaedic surgery?

    You can also check on US clinics and hospitals star rating here

    Surgery and After:
    What kind of pre-op tests do I need to do and in what time frame before surgery?
    What kind of anaesthetic do you recommend and why?
    What method do you use for closing sutures?
    What should I expect to experience during the surgery and shortly after?
    Will I be on a CPM machine in the hospital (knees only)?
    How long will I be in the hospital?
    Can someone that I designate stay with me in my room after the operation? Can (s)he stay the night?
    Is an automatic ice machine part of the recovery (knees only)? If you don't prescribe one, will you help me purchase one as I understand they are very effective? Can your staff arrange that purchase for me?
    How can I obtain a walker, and/or crutches for use as a walking aid once I leave the hospital? Can your staff order these things for me and help me with insurance assistance in getting them?

    Pain management and after care:
    How do you manage patient pain in the hospital, especially right after the operation?
    (relate stories of people who woke up to find either blocks or anesthesia not working, and experienced lag time in managing the pain)
    What pain meds do you find are most effective?
    Will you prescribe refills of pain meds and for how long?
    Will you provide me with adequate pain meds to take home with me?
    How will I manage the pain level once I have to leave this area and return home?

    Miscellaneous questions:
    What will be my mobility limitations following the surgery?
    What kind of blood thinners will I take and for how long? How will I take them - injection or orally?
    What surgery complications should I be prepared for, and how would we deal with them?
    Will I need to take an antibiotic after surgery? If so, what kind and for how long?
    How many follow-up visits should I plan for - both right after surgery and the coming months thereafter?
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  3. Josephine

    Josephine NURSE DIRECTOR, BONESMART Administrator
    Thread Starter

    Member Since:
    Jun 8, 2007
    The North
    United Kingdom United Kingdom
    • Like Like x 12
  4. Brad

    Brad Junior Member

    Member Since:
    Feb 10, 2011
    Connecticut, United States
    Re: Should I wait for an Anterior Approach doctor

    It certainly cannot hurt to talk to more than one surgeon if your insurance allows it. I was so worried about the whole thing (hip replacement), I talked with 5 doctors and 2 of them did the direct anterior approach (talk about "over kill"). In the end I had a posterior or lateral approach, I don't know which, but I have a 13 cm (5 inch) scar on the side of my right hip. I chose my surgeon based on "feel," confidence, willingness to answer all my questions, experience (i.e. 300+ surgeries a year), location (convenience to my home) and hospital. While I had those "criteria" in mind, I chose the surgeon that gave me the most confidence and made me feel the most comfortable, regardless of surgical approach.

    I literally had pages of questions I took with me to each Dr appointment. One of the anterior Drs, upon seeing my questions, said to me, "Don't ask any questions and don't write anything down, just listen." Needless to say, that Dr did not get the job, but since I paid the co-pay I let him talk and took up his time anyway. :LOLL:
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