TOTAL KNEE REPLACEMENT

Transcription

1 TOTAL KNEE REPLACEMENT INFORMATION BOOKLET FOR PATIENTS St Vincent s Clinic, Department of Orthopaedic Surgery 438 Victoria Street, Darlinghurst NSW 2010 Sydney Australia Tel / Fax mjneil@hipandkneesurgery.net Michael J. Neil Pty Ltd ABN Provider No J PO Box 627, Coogee NSW 2034

2 Total Knee Replacement If your knee is severely damaged by arthritis or injury, it may be hard for you to perform simple activities such as walking or climbing stairs. You may even begin to feel pain while you re sitting or lying down. If medications, changing your activity level, and using walking supports are no longer helpful, you may want to consider total knee replacement surgery. By resurfacing your knee s damaged and worn surfaces, total knee replacement surgery can relieve your pain, correct your leg deformity and help you resume your normal activities. One of the most orthopaedic surgical advances of this century, knee replacement was first performed in Improvements in surgical materials and techniques since then have greatly increased its effectiveness. About 267,000 total knee replacements are performed each year in the United States. Whether you have just begun exploring treatment options or have already decided with your orthopaedic surgeon to have total knee replacement surgery, this booklet will help you understand more about this valuable procedure. HOW THE NORMAL KNEE WORKS The knee is the largest joint in the body. Nearly normal knee function is needed to perform routine everyday activities. The knee is made up of the lower end of the thigh bone (femur), which rotates on the upper end of the shin bone (tibia), and the knee cap (patella), which slides in a groove on the end of the femur. Large ligaments attach to the femur and tibia to provide stability. The long thigh muscles give the knee strength. The joint surfaces where these three bones touch are covered with articular cartilage, a smooth substance that cushions the bones and enables them to move easily. All remaining surfaces of the knee are covered by a thin, smooth tissue liner called the synovial membrane. This membrane releases a special fluid that lubricates the knee which reduces friction to nearly zero in a health knee. Normally, all of these components work in harmony. But disease or injury can disrupt this harmony, resulting in pain, muscle weakness, and less function.

3 COMMON CAUSES OF KNEE PAIN AND LOSS OF KNEE FUNCTION The most common cause of chronic knee pain and disability is arthritis. Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms. Osteoarthritis usually occurs after the age of 50 and often in an individual with a family history of arthritis. The cartilage that cushions the bones of the knee softens and wears away. The bones then rub against one another causing knee pain and stiffness. Rheumatoid Arthritis is a disease in which the synovial membrane becomes thickened and inflamed, producing too much synovial fluid which over-fills the joint space. This chronic inflammation can damage the cartilage and eventually cause cartilage loss, pain and stiffness. Post Traumatic Arthritis can follow a serious knee injury. A knee fracture or severe tears of the knee s ligaments may damage the articular cartilage over time, causing knee pain and limiting knee function. IS TOTAL KNEE REPLACEMENT FOR YOU? The decision whether to have total knee replacement surgery should be a cooperative one between you, your family physician, and your orthopaedic surgeon. You physician may refer you to an orthopaedic surgeon for a thorough evaluation to determine if you could benefit from this surgery. Reasons that you may benefit from total knee replacement commonly include: Severe knee pain that limits your everyday activities, including walking, going up and down stairs, and getting in and out of chairs. You may find it hard to walk more than a few blocks without significant pain and you may need to use a cane or walker. Moderate or severe knee pain while resting, either day or night. Chronic knee inflammation and swelling that doesn t improve with rest or medications. Knee deformity a bowing in or out of your knee. Failure to obtain pain relief from non-steroidal anti-inflammatory drugs. These medications, including aspirin and ibuprofen, often are most effective in the early stages of arthritis. Their effectiveness in controlling knee pain varies greatly from person to person. These drugs may become less effective for patients with severe arthritis. Inability to tolerate or complications from pain medications. Failure to substantially improve with other treatments such as cortisone injections, physical therapy, or other surgeries. Most patients who undergo total knee replacement are age 60 to 80, but orthopaedic surgeons evaluate patients individually. Recommendations for surgery are based on a patient s pain and disability, not age. Patients as young as age 16 and older than 90 have undergone successful total knee replacement.

4 THE ORTHOPAEDIC EVALUATION The orthopaedic evaluation consists of several components: The medical history, in which your orthopaedic surgeon gathers information about your general health and asks you about the extent of your knee pain and your ability to function. A physical examination to assess your knee motion, stability, and strength and overall leg alignment. X-rays to determine the extent of damage and deformity in your knee. Occasionally blood tests, an MRI (Magnetic Resonance Imaging) or a bone scan may be needed to determine the condition of the bone and soft tissues of your knee. Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether total knee replacement would be the best method to relieve your pain and improve your function. Other treatment options including medications, injections, physical therapy, or other types of surgery also will be discussed and considered. Your orthopaedic surgeon also will explain the potential risks and complications of total knee replacement, including those related to the surgery itself and those that can occur over time after your surgery. REALISTIC EXPECTATIONS ABOUT KNEE REPLACEMENT SURGERY An important factor in deciding whether to have total knee replacement surgery is understanding what the procedure can and can t do. More than 90 percent of individuals who undergo total knee replacement experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living. But total knee replacement won t make you a super-athlete or allow you to do more than you could before you developed arthritis. Following surgery, you will be advised to avoid some types of activity for the rest of your life, including jogging and some high impact sports. With normal use and activity, every knee replacement develops some wear in its plastic cushion. Excessive activity or weight may accelerate this normal wear and cause the knee replacement to loosen and become painful. With appropriate activity modification, knee replacements can last for many years.

5 PREPARING FOR SURGERY Medical Evaluation If you decide to have total knee replacement surgery, you may be asked to have a complete physical by your family physician several weeks before surgery to assess your health and to rule out any conditions that could interfere with your surgery. Tests Several tests, such as blood samples, a cardiogram, and a urine sample may be needed to help your orthopaedic surgeon plan your surgery. Preparing Your Skin and Leg Your knee and leg should not have any skin infections or irritation. Your lower leg should not have any chronic swelling. Contact your orthopaedic surgeon prior to surgery if either is present for a program to best prepare your skin for surgery. Medications Tell your orthopaedic surgeon about the medications your are taking. He or she will tell you which medications you should stop taking and which you should continue to take before surgery. Dental Evaluation Although the incidence of infection after knee replacement is very low, an infection can occur if bacteria enter your bloodstream. Treatment of significant dental disease (including tooth extractions and periodontal work) should be considered before your total knee replacement surgery. Urinary Evaluations A preoperative urological evaluation should be considered for individuals with a history of recent or frequent urinary infections. For older men with prostate disease, required treatment should be considered prior to knee replacement surgery. Social Planning Though you will be able to walk on crutches or a walker soon after surgery, you will need help for several weeks with such tasks as cooking, shopping, bathing, and doing laundry. If you live alone, your surgeon s office and a social worker or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at home. They also can help you arrange for a short stay in an extended care facility during your recovery, if this option works best for you. Home Planning Several suggestions can make your home easier to navigate during your recovery. Consider: Safety bars or a secure handrail in you shower or bath. Secure handrails along your stairways. A stable chair for your early recovery with a firm seat cushion (height of inches), a firm back, two arms, and a footstool for intermittent leg elevation. A toilet seat riser with arms, if you have a low toilet. A stable shower bench or chair for bathing. Removing all loose carpets and cords. A temporary living space on the same floor, because walking up or down stairs will be more difficult during your early recovery.

6 YOUR SURGERY You will most likely be admitted to the hospital on the day of your surgery. After admission, you will be evaluated by a member of the anaesthesia team. The most common types of anaesthesia are general anaesthesia, in which you are asleep throughout the procedure, and spinal or epidural anaesthesia, in which you are awake but your legs are anaesthetised. The anaesthesia team with your input will determine which type of anaesthesia will be best for you. The procedure itself takes about two hours. Your orthopaedic surgeon will remove the damaged cartilage and bone and then position the new metal and plastic joint surfaces to restore the alignment and function of your knee. Many different types of designs and materials are currently used in total knee replacement surgery. Nearly all of them consist of three components: the femoral component (made of a highly polished strong metal), the tibial component (made of a durable plastic often held in a metal tray), and the patellar component (also plastic). After surgery, you will be moved to the recovery room, where you will remain for one to two hours while your recovery from anaesthesia is monitored. After you awaken, you will be taken to your hospital room. YOUR STAY IN THE HOSPITAL You will most likely stay in the hospital for several days. After surgery, you will feel some pain, but medication will be given to you to make you feel as comfortable as possible. Walking and knee movements are important to your recovery and will begin immediately after your surgery. To avoid lung congestion after surgery, you should breathe deeply and cough frequently to clear your lungs. Your orthopaedic surgeon may prescribe one or more measures to prevent blood clots and decrease leg swelling, such as special support hose, inflatable leg coverings (compression boots), and blood thinners. To restore movement in your knee and leg, your surgeon may use a knee support that slowly moves your knee while you are in bed. The device, called a continuous passive motion (CPM) machine, decreases leg swelling by elevating your leg and improves your venous circulation by moving the muscles of your leg. Foot and ankle movement is encouraged immediately following surgery to also increase blood flow in your leg muscles to help prevent leg swelling and blood clots. Most patients begin exercising their knee the day after surgery. A physical therapist will teach you specific exercises to strengthen you leg and restore knee movement to allow walking and other normal daily activities soon after your surgery.

7 POSSIBLE COMPLICATIONS AFTER SURGERY The complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in less than 2 percent of patients. Major medical complications, such as heart attach or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur they can prolong or limit your full recovery. Blood clots in the leg veins are the most common complication of knee replacement surgery. Your orthopaedic surgeon will outline a prevention program, which may include periodic elevation of your legs, lower leg exercises to increase circulation, support stockings, and medication to thin your blood. Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery. YOUR RECOVERY AT HOME The success of your surgery also will depend on how well you follow your orthopaedic surgeon s instructions at home during the first few weeks after surgery. Wound Care you will have stitches or staples running along your wound or a suture beneath your skin on the front of you knee. The stitches or staples will be removed several weeks after surgery. A suture beneath your skin will not require removal. Avoid soaking the wound in water until the wound has thoroughly sealed and dried. A bandage may be placed over the wound to prevent irritation from clothing or support stockings. Diet Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to promote proper tissue healing and restore muscle strength. Activity Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal activities of daily living within three to six weeks following surgery. Some pain with activity and at night is common for several weeks after surgery. Your activity program should include: A graduated walking program to slowly increase your mobility, initially in your home and later outside. Resuming other normal household activities, such as sitting and standing and walking up and down stairs. Specific exercises several times a day to restore movement and strengthen your knee. You probably will be able to perform the exercises without help, but you may have a physical therapist help you at home or in a therapy centre the first few weeks after surgery. Driving usually beings when your knee bends sufficiently so you can enter and sit comfortably in your car and when your muscle control provides adequate reaction time for braking and acceleration. Most individuals resume driving about four to six weeks after surgery.

8 AVOIDING PROBLEMS AFTER SURGERY Blood Clot Prevention Follow your orthopaedic surgeon s instructions carefully to minimize the potential of blood clots that can occur during the first several weeks of your recovery. Warning signs of possible blood clots in your leg include Increasing pain in your calf. Tenderness or redness above or below your knee. Increasing swelling in your calf, ankle, and foot. Warning signs that a blood clot has travelled to your lung include: Sudden increased shortness of breath. Sudden onset of chest pain. Localised chest pain with coughing. Notify your doctor immediately if you develop any of these signs. 8. Preventing Infection the most common causes of infection following total knee replacement surgery are from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around your knee replacement and cause an infection. Following your surgery, you should take antibiotics prior to dental work or any surgical procedure that could allow bacteria to enter your bloodstream. Warning signs of a possible knee replacement infection are: Persistent fever (higher than 100 degrees orally). Shaking chills. Increasing redness, tenderness, or swelling of the knee wound. Drainage from the knee wound. Increasing knee pain with both activity and rest. Notify your doctor immediately if you develop any of these signs. Avoiding Falls A fall during the first few weeks after surgery can damage your new knee and may result in a need for further surgery. Stairs are a particular hazard until your knee is strong and mobile. You should use a cane, crutches, a walker, handrails, or someone to help you until you have improved your balance, flexibility, and strength. Your surgeon and physical therapist will help you decide what assistive aides will be required following surgery and when those aides can safely be discontinued. HOW YOUR NEW KNEE IS DIFFERENT You may feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending activities. Improvement of knee motion is a goal of total knee replacement, but restoration of full motion is uncommon. The motion of your knee replacement after surgery is predicted by the motion of your knee prior to surgery. Most patients can expect to nearly fully straighten the replaced knee and to bend the knee sufficiently to go up and down stairs and get in and out of a car. Kneeling is usually uncomfortable, but it is not harmful. Occasionally, you may feel some soft clicking of the metal and plastic with knee bending or walking. These differences often

9 diminish with time and most patients find these are minor, compared to the pain and limited function they experience prior to surgery. Your new knee may activate metal detectors required for security in airports and some buildings. Tell the security agent about your knee replacement if the alarm is activated. After surgery, make sure you also do the following: Participate in regular light exercise programs to maintain proper strength and mobility of your new knee. Take special precautions to avoid falls and injuries. Individuals who have undergone total knee replacement surgery and suffer a fracture may require more surgery. Notify your dentist that you had a knee replacement. You should be given antibiotics before all dental surgery for the rest of your life. See your orthopaedic surgeon periodically for a routine follow up examination and X-rays, usually once a year. Your orthopaedic surgeon is a medical doctor with extensive training in the diagnosis and non surgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles, and nerves. This brochure has been prepared by the American Academy of Orthopaedic Surgeons and is intended to contain current information on the subject from recognised authorities. However, it does not represent official policy of the Academy and its text should not be construed as excluding other acceptable viewpoints. Persons with questions about a medical condition should consult a physician who is informed about the condition and the various modes of treatment available. 35MO998 Product no

10 It is important that you contact my office directly after discharge if you have any concerns whatsoever about your operation and progress. I will always be available, even if not immediately, to answer any queries. My office contact is: Associated Professor Michael Neil Department of Orthopaedic Surgery St Vincent s Clinic Level 9, Room 901C 438 Victoria Street Darlinghurst SNW 2010 mjneil@hipandkneesurgery.net Telephone: (02) / (02) Fax: (02) SUCCESS RATE Following these protocols, the current success rate, measured by patient satisfaction rate, is approximately 95% for primary knee replacement surgery. This means that 95% of patients are very happy with their operation, have no regrets in having proceeded with surgery and would have the operation performed again, if required. PATIENT DISCLOSURE Associate Professor Michael Neil is actively involved in the design and evaluation of joint implants which are manufactured by a variety of orthopaedic companies. Professor Neil has consultancy arrangements with both DePuy Orthopaedics and Stryker Orthopaedics in relation to implant design, clinical research and ongoing orthopaedic education. THIS PROTOCOL IS NOT TO BE RELEASED TO, OR REPRODUCED BY A THIRD PARTY WITHOUT MY SPECIFIC PERMISSION

11 Arthroplasty Society of Australia Guidelines for Thromboembolic Prophylaxis after Total Joint Replacement Weighing Efficacy Against Risk A major focus of the Arthroplasty Society of Australia is to ensure that joint replacement surgery is made as safe as possible, particularly by putting in place measures to decrease the incidence of thromboembolic disease. After consideration of the current literature, this statement is a consensus opinion from this group of specialist joint replacement surgeons. When considering the varying effectiveness of the methods of prevention, the risks of thromboembolic disease that we wish to prevent need to be weighed against the risks of complications caused by preventative measures. Several effective measures to prevent thromboembolic disease have low complication rates. These include the institution of early mobilisation regimes, spinal anaesthetic, graduated compression stockings, foot pumps and sequential pneumatic compression boots. Use of one or more of these measures is strongly suggested. For some patients who have a higher risk of thromboembolic disease, additional measures by a pharmacological method may also be indicated. Pharmacological or chemical methods include the use of aspirin, Warfarin, heparin, low molecular weight heparins (i.e. Clexane, Fragmin, etc.), fondoparinux and the melagatran group. While chemical prophylaxis has been shown to reduce rates of deep venous thrombosis, it may not alter the more important incidence of pulmonary embolism or sudden death from embolic disease following surgery. All of these pharmacological methods have, however, significantly higher complication rates, which include limb swelling, haematoma, bleeding from the surgical site, wound breakdown, joint stiffness, increased infection rates, remote bleeding episodes, stroke and even death. The use of these additional means need to be carefully considered and thoroughly discussed with the patient in this context. Position Statement on Driving after Total Hip and Knee Replacement Surgery After consideration of the relevant literature, the Arthroplasty Society of Australia recommends that for a minimum period of six weeks following hip or knee replacement surgery that patients abstain from driving a motor vehicle. This is inclusive of manual and automatic cars, and independent of right or left side surgery. After this six week period, each individual s choice to resume driving should only be made when he or she feels confident to be able to control the vehicle safely.

12 Position Statement for Recommendations for Patients with Hip or Knee Joint Replacement who Require Dental Treatment Dental problem in the first 3 months following hip or knee joint replacement surgery Infection with abscess formation: Urgent and aggressive treatment of the abscess. Remove the cause (exondontic or endodontic) under antibiotic prophylaxis. Pain: Provide emergency dental treatment for pain. Antibiotics are indicated if a high or medium risk dental procedure performed. Non-infective dental problem without pain: Defer non-emergency dental treatment until 3 to 6 months after prosthesis replacement. Dental treatment after 3 months in a patient with a normally functioning artificial joint Routine dental treatment including extraction. No antibiotic prophylaxis required. Dental treatment for patients with significant risk factors for prosthetic joint infection Immunocompromised patients include: those with insulin-dependent diabetes those taking immunosuppressive treatment for organ transplants or malignancy those taking systemic rheumatoid arthritis those taking systemic steroids (e.g., patients with severe asthma, dermatological problems) Consultation with the patient s treating physician is recommended. Failing, particularly chronically inflamed, artificial joints: Consultation with the patient s treating orthopaedic surgeon is recommended. Defer non-essential dental treatment until orthopaedic problem has resolved. Previous history of infected artificial joints: Routine non-surgical dental treatment no prophylaxis indicated. Recommended antibiotic regimens where indicated 1. Dental clinic LA extractions or deep curettage Amoxycillin 2-3g orally 1 hour prior to procedure 2. Theatre procedures Amoxycillin 1g I/V at induction Followed by 500mg Amoxicillin I/V or orally 6 hours later. 3. Penicillin hypersensitivity, long term penicillin, recent penicillin/other B-lactam. Clindamycin 600mg 1 hour prior to procedure or Vancomycin 1g I/V 1 hour to finish 2 hours or Lincomycin 600mg just prior to the procedure 4. High risk case (i.e., Gross oral sepsis/severely immunocompromised/previous joint infection.) Gentamicin 2mg/kg I/V just before procedure (can be administered 3mg/kg provided there is no concomitant renal disease) PLUS Amoxycillin 1g I/V just before procedure followed by 500mg I/V or orally 6 hours later. If hypersensitive to penicillin replace Amoxicillin with Vancomycin 1mg I/V over 1 hour to finish just before procedure. Ref: Scott JF et al, Patients with artificial joints: do they need antibiotic cover for dental treatment? Aust Dent J 2005:50 Suppl 2S45-S53

13 Autologous Blood Donation Broadcast Monday 23 rd September 2002 With Norman Swan (ABC Science Health Matters All in the Mind, The Buzz Earthbeat, In Conversation, Ockhams Razor Science Show, The Lab Catalyst Quantum SUMMARY: People who are worried about receiving other people s blood when they need a blood transfusion during surgery often donate their own blood (autologous blood donation) before having surgery. TRANSCRIPT: Still to come, a spot of scatology, giving new meaning to turning the other cheek. Before that though, while we re talking about fainting at the sight of blood, the whole business of blood transfusion in the era of AIDS, Hepatitis C and Mad Cow Disease has become much more fraught. This in turn has driven a trend for people undergoing certain kinds of planned surgery, like a hip replacement, to donate two or three units of their own blood ahead of time. This means that if they need a transfusion, it can be autologous, from themselves. But findings from a Victorian study of the patterns of autologous blood donation has found that the process is not necessarily worth the money and effort. In fact you may need a transfusion simply because you ve donated so much blood! Dr Helen Savoia is a Consultant Haematologist at the Women s and Children s Hospitals, and this work was done when she was a transfusion consultant with the Red Cross in Melbourne. Helen Savoia: We asked the questions: what patients were presenting to have autologous blood collected, how many units were their doctors requesting, how many were actually collected and if the numbers weren t the same, why not? And how many of those units were actually transfused? And overall, we found that about 2,800 units were requested and just over 2,000 of those were actually collected. The main reason that patients didn t have the number of units collected that their surgeon wanted was there simply wasn t enough time to collect the number of units, and the second most common reason was that some patients would become too anaemic to have blood taken from them during the process of blood collection. Norman Swan: And how much of that was actually used? Helen Savoia: Nearly three-quarters of the units were actually transfused, and 27% were wasted or discarded. Norman Swan: Now you also compared that to the use of blood in operations in general, and I think you found that if you gave your own blood you were more likely to get it back again. Helen Savoia: That s right, yes. For most surgical procedures, people who donated their own blood had higher transfusion rates, and this was up to five times higher. Norman Swan: Were you able to tell whether or not those transfusions breached guidelines? I mean there are now guidelines as to when a blood transfusion is in fact warranted, does that mean that the surgeon thought, Well you ve got it, you re a little bit anaemic, I ll whack it in anyway, what s the risk?. Helen Savoia: That s a possibility. We were not able to assess that in this study. It has been suggested that that is one possible cause for transfusion rates being higher in this population, the attitude that, Well, you ve gone to all this trouble, we probably should use it. But also the actual process of donating autologous blood makes you anaemic and makes you more likely to need a transfusion during your surgery. Norman Swan: Ah, so the very process itself may say, Well we ve taken it out, we ll put it back, having depleted you?. Helen Savoia: That s right, yes. It s quite interesting. A study just published from some researchers in the United States has confirmed our findings. This was a small study in total hip replacement and

14 they compared 42 patients who donated 2 units of autologous blood each, and 54 patients who did not donate their own blood. And they were very strict about transfusion guidelines, so that all the patients in the group were transfused at the same transfusion trigger, same level of haemoglobin and 69% of patients in the autologous group received a transfusion and none of the non-donors received a transfusion. So these authors concluded that in hip replacement surgery, for non-anaemic patients, that autologous donation had no benefit at all, and increased the costs associated with surgery. Norman Swain: And that is your conclusion? Helen Savoia: Our study shows that autologous transfusion in 2002 has a significantly less role than it s believed to have had in the past. There may still be particular surgical procedures or particular patients where it may be applicable, but I think that what we really need to do to answer many of these transfusion questions is to do some well-designed studies. Norman Swan: And the cost involved, both personally and financially? Helen Savoia: In the Australian setting it s very difficult to actually attribute cots, but certainly costs involved would be for the patient, the time it takes. Each unit of blood would need an hour or two of patient time to actually make the blood donation and then there is a cost to the testing, since all blood does need to be tested for the various viral markers. Autologous collections are done both in public hospital settings, private pathology settings, and through Red Cross, and so there are various charges at different levels. I guess one of the things that are not been discussed is what s the actual risk of donating blood. Is there an adverse event rates with the actual process? Although adverse events associated with normal blood donation are very low, the majority of patients undergoing autologous donation are often more elderly and with more medical problems. Norman Swan: And giving more than one unit, which you don t do when you re donating autologously. Has any research been done into the effects on the person? I ve seen a few people who ve given their own blood for, say hip operations, and they look dreadful just before they go into theatre, I mean they look pale and weak, they look really sapped. Helen Savoia: Yes, the study I mentioned from the United States certainly said that the group of autologous donors had a significantly lower haemoglobin both on hospital admission and in the recovery room, compared with the non-donor group. Norman Swan: So here s the $64 question: If you re going in for a hip operation, you ve worked as a blood transfusion specialist, you know the risks: would you donate your own blood beforehand? Helen Savoia: The most important thing is that I would go to an experienced and meticulous surgeon and I think that currently anaesthetic and surgical techniques are probably more important in elective surgery and in actually minimising blood loss, and I probably wouldn t. Norman Swan: So is that a no? Helen Savoia: Yes. Norman Swan: And finally, did it prevent people getting a homologous blood transfusion, in other words did it realistically prevent people having somebody else s blood? Helen Savoia: Yes, I think it did. 90% of patients avoided having someone else s blood. What the real question is though is if they had not donated autologous blood, what would have happened. And since our study wasn t randomized, that s very difficult to know. But certainly the US study in total hip replacement suggests that figure may be quite low. Norman Swan: And by the way there have been studies in cardiac bypass surgery and hysterectomy which show that blood loss during those operations is so low these days that autologous blood donation is now worth doing. Dr Helen Savoia is a haematologist at the Women s and Children s Health, Royal Children s Hospital, Flemington Road, Parkville VIC savoiah@cryptic.reh.unimelb.edu.au Savoia H.F. et al. Utilization of Preoperative Autologous Blood Donation In Elective Surgery. ANZ Journal of Surgery 2002; 72:

15 RISKS AND COMPLICATIONS OF TOTAL KNEE REPLACEMENTS Although anything can theoretically happen to anyone undergoing major surgery, the following complications are the most usual ones seen in clinical practice. Complications Risk Treatment 1. DVT (Deep Vein Thrombosis) 15% Most are trivial picked up on routine scan day 5 Anticoagulants 2. P.E. (Pulmonary Embolus) 1% Can be major and cause of sudden death RX supportive intensive care anticoagulants 3. Wound haemorrhage 15% Associated with anticoagulants therapy Can cause knee stiffness May require re-operation with drainage 4. Knee stiffness 5% Physiotherapy Manipulation under anaesthesia Rarely re-operation 5. Infection 1% Early < 4 weeks Antibiotics Re-operation for drainage Late Removal of prosthesis Revision procedure or possible knee fusion