Vincent Jacobs (73) had never been in a hospital bed until April this year, when he went in to have his right hip replaced.
Ten weeks later, he was back to have the left hip done.
“I was afraid of my life getting these done,” he admits. But he had got to the point of so much pain, that he didn’t care what it entailed. “I have no pain whatsoever now, and I had it for years. Pain is desperate.”
He was discharged within 48 hours of the first hip replacement and the next day he was out the door of his home in Tallaght to walk the length of two semi-detached houses and back. Both the surgery at the Hermitage Clinic in west Dublin and his recovery went so well, he wished he had gone for it sooner.
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Jacobs’s experience is echoed in newly-released research among patients who have had a hip or knee replacement. One in two of them was discharged within 48 hours, with 92 per cent of those surveyed spending fewer than five days in hospital.
The top advice from nearly half the respondents for others in a similar position was: “the sooner you do it, the better”. Almost half, 42 per cent, were surprised at how quickly they started to progress after surgery. More than half reported being back to normal activities, such as work, exercise and household tasks, within one month and 78 per cent had reached that stage by two months.
The Empathy research was commissioned by the private hospital group Blackrock Health and carried out in July on a nationally representative sample size of 150 patients who had undergone a hip or knee replacement, or both. It was a follow-up to research the previous year that found people tended to put off hip/knee surgery due to fears about how long it would take them to recover.
It is very normal for people to have some degree of anxiety about this surgery, says consultant and orthopaedic surgeon Mr Niall McGoldrick, who works in both the private and public health services, with Blackrock Health at the Hermitage and at Tallaght University Hospital. “In fact, I would be almost more worried if patients didn’t think about it and didn’t have some anxiety.
“But someone who is quite debilitated with a very profoundly arthritic hip or knee, where they’ve got significant symptoms and sleep disturbance and functional loss, once they get through the operation safely and there’s no major issues, you just know that they are going to ultimately do quite well and that they’ll be very satisfied with the outcome. I would say hip replacements are probably a little bit more predictable than knee replacements.”
McGoldrick considers it a “real privilege” to be performing hip/knee replacements, which he describes as “one of the greatest operations that we have surgically in terms of restoring function and quality of life”.
Success is in the order of 95 per cent or better for hips, marginally less for knees. “As with any kind of surgery, there can be unplanned complications that can and do arise. Most of them are in the order of about 1 per cent or less. Things like, unfortunately, wound infections, fractures or dislocations, injury to the nerves in the area.”
Clots can also develop in the calves.
But the way joint replacement patients are managed now is all geared towards minimising the chance of any such complications, he stresses. As part of a thorough prehab programme, Jacobs says he was advised to see his dentist. This can eliminate a source of infection, such as tooth decay or gum disease, which could enter the bloodstream and infect the surgical area. Physical fitness is also addressed.
[ ‘How long will my artificial knee last?’Opens in new window ]
“The main purpose of coming to see a physio before surgery is to allow us to really engage in that core muscle group that we need to get working,” says Orlagh Murty, a physiotherapist at the Hermitage. “If it’s a hip we need to get the hip muscles working, the lower limb, leg muscles working. You need to give as much power pre-surgery so that when their journey after surgery has happened, they’re on a good baseline.”
Typically, this will start six to eight weeks before the surgery date. Patients attend two or three sessions at the clinic and will also be given an individualised home programme “to get that hip working as best as they can, so that when they have the surgery the journey is a lot quicker on the other side”, says Murty. Post-surgery therapy includes one-on-one sessions and group classes.
She sees part of the physio role as educating patients that short-term hard work and graft will pay off. “You want them then to know that they can get out of the chairs easier, they can get off the toilet – functional activities become easier once they have this hip operation. The walking gets easier. The stairs get easier. The driving gets easier. The hobbies come back. So there’s a huge amount on the other side that allows them to get their life back.”
Undue delay in getting a joint replacement not only prolongs the pre-surgery period of pain but it may mean a longer recovery time. If the surgery is being done after a long period of pain, the patient will probably have very reduced mobility and there will be more muscle wastage.
However, while those with private insurance to cover most or all of the approximate €15,000 cost of a hip replacement may be able to get surgery done within a few months, most others will likely have to wait years. Waiting times just for a first appointment with an orthopaedic specialist vary hugely among the public hospitals, ranging from 475 days at Galway University Hospital and 310 days at University Hospital Waterford, to just eight days at Cork University Hospital, according to the HSE.
After surgery, when the joint pain has hugely diminished or gone, the problem may be reining in the patient’s enthusiasm for exercise, says Murty, to make sure they don’t overdo it and hinder their recovery. You want them to feel great, she says, but they have to understand that muscles need time to build up again.
Pain is the predominant symptom indicating that a patient might benefit from a joint replacement. If it is hip arthritis, the pain will typically be in the groin, explains McGoldrick, but it can also be in the outer aspect of their hips or in the buttocks. Occasionally they will feel it down their thigh towards their knee. “Night pain or sleep disturbance is one of the things that we’re looking for as well. That kind of pain suggests that it’s pretty bad pain.
“If it’s the knees, again it’s usually pain on weight-bearing activity. So when they’re walking, they’ll typically describe pain within the joint itself, either on the medial or lateral side, or occasionally they’ll report it kind of behind their kneecap, particularly when they’re managing stairs.”
[ Hip replacement: ‘I went home the same day and since then I’ve been flying’Opens in new window ]
At what point a replacement should be recommended “is a million dollar question”, says McGoldrick. In addition to the severity of symptoms, there are also considerations such as overall patient health, co-existing conditions and, of course, patient preference.
“Age is a consideration, but it’s not the be-all and end-all. Usually, I think if patients are presenting with fairly constant pain, particularly with all forms of weight-bearing activity and they’re describing sleep disturbance and functional restriction, then really they’re kind of towards the end stage of arthritic change in their joint and you will be offering them surgical intervention.”
Such patients could be aged from 50s to 80s. Technology is improving all the time and artificial joints can be expected to last up to 20 years or longer, although younger patients will make more demands on them, he points out, being typically in a more active phase of life.
A high body mass index (BMI) is another, sensitive, factor that also has to be taken into account. In reality, BMI is a crude measure, says McGoldrick, but clinicians have an ethical and medical responsibility to make sure scheduled surgery is as safe as possible for patients.
“We have to counsel them about risk and that includes, obviously, a conversation, delicate as it sometimes can be, about the role that weight loss can play. We know that for every incremental jump beyond, say, a BMI of 40, that the risk starts to increase that patients will have a complication, whether it be infection or an instability episode, or a venous thromboembolism [blood clot] or something like that.”
There is no denying that the number of patients living with obesity is increasing and it is something that the orthopaedic and other surgical services will have to grapple with, he adds. “I wouldn’t necessarily deny a patient a joint replacement per se solely based around BMI but I think it would be subject to conversation and making sure that it wasn’t excessive.”
The National Office of Clinical Audit (noca.ie) set up the Irish National Orthopaedic Register to monitor the safety of implants and patient outcomes. Its first report, published in 2021, recorded 3,723 hip replacement surgeries and 2,871 knee replacement surgeries over nearly five years. This was data from seven out of 12 elective public hospitals that perform non-emergency joint replacements. (Those figures include revision operations on previously implanted joints, at 379 for hips and 194 for knees.)
For the primary hip replacement surgeries, the average age of patients was 65; the gender split was 50/50 and 41 per cent involved patients with a BMI greater than 30. The corresponding figures for knee replacements were: average age 67; 61 per cent female and 59 per cent of patients had a BMI over 30.
Jacobs, a former electrician who went into facilities management before retiring in his early 60s, says, thanks to the double hip replacement, he has “a completely normal life now, which I hadn’t for four years. I am able to do all my walks”.
Although, just 2½ months since the second surgery, the father of two and grandfather of four says he is still watching himself and always takes a stick with him “but I don’t use it”. He is looking forward to going back swimming.
New hips “gave me my life back”, adds Jacobs, who sings the Toby Keith song “Don’t Let the Old Man In” to anybody who will listen. Country singer Keith, who died of cancer earlier this year, wrote it after Clint Eastwood told him he was going to celebrate his 88th birthday with a new film that he was both starring in and directing, The Mule.
“How do you keep going?” the singer asked.
Eastwood, who is now aged 94, replied: “I get up every morning and I don’t let the old man in.”
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