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Orthopaedic Surgery – General Rules for a Successful Outcome

Posted Nov 28 2009 10:02pm

Will the operation work?

by Professor Justin Cobb, the Chair of Orthopaedics at Imperial College, London.

Every patient’s biggest fear in orthopaedics (after MRSA) is that the operation won’t work out. While many people do get back to full function, the significant group who do not achieve full function following knee replacement means that it is just under half as effective as hip replacement.

There are two reasons for this: total knee replacement is often too much of an operation for individual patients, and unfortunately often is not done accurately enough.

What are the rules here?

Rule No. 1 is: keep away from surgeons.

Rule No. 2 is: keep away from surgeons. If you are enjoying age appropriate activity, and only taking the occasional pain killer then do not consider surgery. Most painful joints are only wearing out slowly, and there are risks to any operation.

Rule No. 3: given the choice between a big operation and a small operation, always take the small one. When a knee hurts enough to interfere with life, you know it is going to hurt, so you start avoiding things you used to enjoy doing, which makes you a bit depressed and short tempered. In these circumstances it is okay to talk about having something done. But the medical machinery may take advantage of you, and by the time you are finished, you have been scanned, told how bad things are, had a small procedure that didn’t work, followed by a big one that you are told is a great success. But you still can’t do the things you wanted to, so you are even more depressed because you now know that you really are growing old. Nevertheless, you smile nicely at the surgeon who tells you how well you have done and through your clenched teeth you smile and say thank you but vow never to have another operation as long as you live.

Rule 4: only have a small operation if you are as sure as you can be that it will work.

“You have widespread degenerative changes” – The high spend high cost way of treating sore knees:

An MRI scan, costing rather more than you spent on your first car tells you helpfully that you have widespread degenerative changes. The surgeon who commissioned it reads you the reports, shaking his head (or sucking his teeth) and offers to see what he can do. At arthroscopy, he takes photographs to show just how bad things are, and does his best, by taking out worn bits, to make you better again – an operation that has been shown to be no better than placebo. Often you are better for a bit, but then the pains come back, and the next stop is a total knee replacement. Done well, this operation is a satisfactory one, but the functional level you aspire to – to get back to normal life- often isn’t reachable.

In Professor Cobb’s full article Knee Replacement in London he explains the Imperial College philosophy to orthopaedic surgery. However, anyone seeking minimal surgical options would also be advised to read the latest expert orthopaedic surgery article by Samantha Tross on the main Web site to this blog, or the article on total knee replacement by Mr Jonathon Lavelle.

The point is that this is too serious an operation to leave entirely to trust. Every (potential) patient should seek appropriate non-surgical approaches in the first instance and may want to seek advice from pain specialists such as Nigel Kellow as well as the GP. However, by getting involved and asking a few questions there will be a far higher chance of a better outcome.

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