At the age of 73, Vincent Jacobs found himself in the unfamiliar surroundings of a hospital for the first time this past April, checking in to replace his right hip. Only a few weeks later -ten to be precise- he returned to the hospital to have his left hip replaced as well.
“Getting these replacements was incredibly frightening,” Jacobs confessed, but the debilitating pain he had been experiencing left him with no other option. “The pain I had been dealing with for years is completely gone now,” noted Jacob, calling it ’desperate’. Within two days of his first hip operation, he was discharged. The following day saw him take his first steps outside his Tallaght home, managing to walk the length of two semi-detached houses and back. Reflecting on his successful surgery at the Hermitage Clinic in west Dublin and his subsequent smooth recovery, Jacobs confessed he would’ve preferred to have the operation sooner.
This sentiment expressed by Jacobs is reiterated in the findings of a recent study involving patients who have undergone either knee or hip replacement surgery. Roughly 50% of these patients were discharged within two days, and a substantial 92% were in hospital for less than five days. Several respondents, almost half, urged others facing similar circumstances to opt for the procedure sooner rather than later. A surprising 42% were taken aback at the pace of their recovery post-surgery. Over half were back to their regular tasks and activities, such as work, exercise, and chores, within a month, and by the two-month mark, 78% had done the same.
This insightful study was commissioned by private hospital group Blackrock Health, conducted by Empathy Research in July. The study, which analysed responses from a national sample of 150 patients who had undergone either knee or hip replacement or both, built upon research from the previous year that revealed individuals often delay this surgery due to apprehensions about recovery time.
Orthopaedic surgeon Mr Niall McGoldrick, who consults at both Blackrock Health at the Hermitage and Tallaght University Hospital, acknowledges that it is rather usual for people to express a level of trepidation about undertaking surgery. In fact, he expresses concern if patients do not exhibit any anxiety at all. However, he reassures those with severe arthritic hips or knees, suffering from conspicuous symptoms, disturbed sleep, and loss of function, that their quality of life is expected to significantly improve post-surgery, provided there are no substantial complications during the operation. He conveys a particular confidence regarding hip replacements, characterising them as slightly more reliable than knee surgeries.
Mr McGoldrick calls it a great honour to perform hip and knee replacements that he believes are paramount in facilitating restoration of functionality and improvement in life quality. He reports a high success rate of around 95% for hip surgeries, with a slightly reduced rate for knee replacements. Like all surgical procedures, he warns there can be unforeseen complications, such as infections, fractures or dislocations, and nerve injuries, but he emphasises that these occur in approximately 1% of the cases or less. Another risk includes the possibility of clot formation in the calves.
Mr McGoldrick underlines that the current methods for managing joint replacement patients are tailored to reduce the risk of complications. Part of this risk-management approach includes a comprehensive prehab programme, wherein patients are recommended to visit their dentists to eliminate oral infection sources that could potentially contaminate the surgical site. Physical fitness is also given due consideration during this period.
According to Orlagh Murty, a physiotherapist at the Hermitage, the pre-surgery consultation with a physio entails a focus on activating and strengthening the core muscles directly linked to the surgical area. This is done to ensure that the post-surgery recovery process begins on a robust footing.
Typically, the process kickstarts approximately six to eight weeks ahead of the operation date. The individual will have two or three consultations at the healthcare centre and receive a personalised regimen for home, which aims to ensure optimal performance of the hip and facilitate a speedy recovery post-operation, as expressed by Murty. Following the operation, the treatment entails personal sessions and group classes.
In Murty’s perspective, part of the physiotherapist’s responsibility lies in teaching the patients that determined effort in the short-run will have long-term benefits. The goal is to help them realise that post-operation tasks such as rising from a chair, using the bathroom, walking and even activities like driving become much easier. A significant improvement in performing everyday tasks brings back their beloved hobbies and facilitates regaining control over their lives.
Delaying joint replacement further elongates the period of pain before the operation and might also extend recovery time. If the operation occurs after enduring extended pain, the patient might face severe mobility constraints and more significant muscle loss. However, those covered comprehensively or partially by private insurance for the estimated €15,000 expenditure for hip replacement could have the operation within months. In contrast, those without this privilege may have to wait years. The waiting period for an initial consultation with an orthopaedic specialist differs enormously among public hospitals, from 475 days at Galway University Hospital and 310 days at University Hospital Waterford, down to a mere eight days at Cork University Hospital, as per HSE.
Curtailing a patient’s enthusiasm for exercise might be necessary after the operation when the joint pain has subsided or disappeared, as per Murty’s observations. Although boosting their morale is important, it’s vital to make them realise that muscles require sufficient time to recuperate.
The main symptom indicating a patient may need joint replacement is pain. When a patient is suffering from hip arthritis, the pain is usually located in the groin area, outlines McGoldrick. However, it can also be felt in the outer hip or buttocks, and sometimes even down the thigh towards the knee. Persistent pain disrupting sleep is a significant indicator of severe discomfort.
When it comes to the knees, the pain is often experienced during activities that put weight on the joint. Patients usually describe pain in the joint itself, either on the inner or outer area, and occasionally behind the kneecap, particularly when climbing stairs.
The decision to recommend replacement is complex, comments McGoldrick. The patient’s overall health, co-existing conditions, and personal preference play roles along with the pain severity. While patient age does matter, it’s not the ultimate determining factor. If a patient experiences constant pain, especially during weight-bearing activities, sleeping disturbances and functional limitations, then they’re likely experiencing advanced arthritic changes, suggesting surgical intervention may be needed.
Such patients could range from their 50s to 80s. Today’s technology continues to improve, and we can anticipate artificial joints to last two decades or longer. Younger patients may put more stress on them, being in a typically more active stage of life.
A high body mass index (BMI) is a delicate factor to consider. Although BMI is a rudimentary measure, McGoldrick asserts that clinicians have a medical and moral obligation to ensure any planned surgery is as safe and efficient as possible for the patients.
It’s undeniable that a growing number of individuals are grappling with obesity. This increasing trend necessitates a delicate conversation within the orthopaedic and other surgical sectors regarding the risks involved, particularly around weight and the potential complications that can arise post-surgery such as infections, instability, and blood clots. Excess weight, defined by a Body Mass Index (BMI) greater than 40, noticeably amplifies these risks, but it’s not a deciding factor in refusing a joint replacement procedure outright.
The Irish National Orthopaedic Register, an initiative of the National Office of Clinical Audit, was established to track the safety of implants and understand patient outcomes. Their inaugural report in 2021 demonstrated data collected from seven elective public hospitals out of twelve. This report accounted for 3,723 hip and 2,871 knee replacements conducted over a period of almost five years. These figures encapsulate revision surgeries on previously operated joints, with hip and knee revisions recorded at 379 and 194 respectively.
In terms of hip replacement surgeries, the typical patient was 65 years old, had an even gender split and 41% of them had a BMI exceeding 30. On the other hand, for knee replacements the average age was 67 with a higher female count at 61% and 59% of the patients had a BMI more than 30.
One beneficiary of these surgeries, Jacobs, went from being an electrician to working in facilities management before retiring in his early sixties. Thanks to undergoing a double hip replacement, he could reclaim his ordinary life after four years of struggle. With only 2½ months since his last operation, the father and grandfather admits to being cautious. He carries a stick with him, even though he doesn’t rely on it, and is eagerly awaiting his return to swimming.
Jacobs credits his renewed vitality to his hip replacements, often vocalising his gratitude by singing Toby Keith’s “Don’t Let the Old Man In” to anyone within earshot. The song, penned by the country star who passed away from cancer this year, was inspired by a conversation with Clint Eastwood. The legendary actor, now 94, shared his plan to ring in his 88th birthday by taking on both acting and directing roles in a new film called “The Mule”. Keith, curious about Eastwood’s stamina, queried how he maintained his momentum. The actor’s response: “Everyday, I rise and refuse to let the old man in”.