Many people with arthritis who undergo surgery find it reduces the pain and increases mobility. It is one of a range of treatments available.
In the year April 2012 to March 2013 there were 185,433 joint replacements in England, 10,860 in Wales and 110 in Northern Ireland.
The following topics are on this page:
There is also this Surgery and Arthritis booklet for more information.
Preparing for surgery
There are a number of thing you can do to prepare for an operation.
Stopping smoking more than eight weeks before an operation can reduce risks at the time of surgery. This could include chest infections, heart and circulation problems as well as poor healing of wounds.
If you are overweight or obese this increases the probability of developing high blood pressure, heart disease and diabetes.
By eating a balanced diet and, perhaps, being prescribed statins you might lower the cholesterol in your blood.
General tips include:
- eat five daily portions of fruit and vegetables
- take in fibre daily
- reduce consumption of sugary foods
- reduce consumption of dairy products
If possible, introduce daily exercise into your routine. Ideally, adults should exercise for 30 minutes five times a week and it should increase your heart rate.
If you drink heavily (more than the recommended three units daily for men and two for women), you are more at risk of experiencing problems under anaesthetic or just after your operation. Problems could include alcohol withdrawal, heart problems or infection. If you drink the night before surgery it may cause anaesthetic complications and a slower recovery.
Letting people know
This allows friends and family to make arrangements to take time off work for example so that they can provide support for you. Let them know when they can visit you.
You will be invited to attend a pre-operartive assessment at the hosiptal and asked to fill in a questionnaire about your medical history, health and home circumstances. You will be given advice about where to report to in the hospital and screened for MRSA (methicillin-resistant staphylococcus aureus). You will be told whether to fast (not eat) before the operation and given information about medication.
What to do before you come into hospital
Here are some things you can do to get yourself ready for an operation.
- If you smoke, try to cut down or give up. You could be referred to a smoking cessation clinic
- If you are overweight the risks of having an anaesthetic increase. Your doctor or nurse should be able to give you advice
- If you have loose teeth or insecure crowns you may want to visit your dentist prior to an operation
- If you have a long-term condition, ask your doctor if you need a check-up
Contact the pre-operative assessment clinic if you:
- have the flu, a cold or diarrhoea – the operation can be postponed
- have been in contact with someone with MRSA since your pre-operative assessment.
- change your mind
This is the principle that a competent adult gives consent to receive any type of medical intervention. Consent can be given verbally or in writing. Consent must be informed, voluntary and the person must have capacity. Informed means being made aware of the benefits and risks of any treatment and what is involved. Also, what alternatives there are as well as what could happen if treatment is not undertaken. All adults are presumed to have capacity to decide on their medical treatments unless there is significant evidence to suggest that this is not the case.
Anaesthesia means loss of sensation. Anaesthetics are used during operations and other treatments to prevent pain and/or discomfort. There are various types.
Local anaesthesia – which involves giving an injection which numbs part of the body and you remain conscious. These anaesthetics block the nerve signal from that part of the body to the brain and wear off after a few hours.
Regional anaesthesia – including an epidural, prevents you from feeling pain without losing consciousness. Spinal anaesthesia is similar to epidural anaesthesia. This involves local anaesthetic being injected directly into the cerebral spinal fluid in your lower back.
General anaesthesia – occurs when gas or the anaesthetic is given through a cannula (a small tube inserted in to the body, often a blood vessel to give or collect fluids) and induces unconsciousness by interrupting the flow of nerve signals. It is ordinarily used for long and/or painful forms of surgery and is the most common type of anaesthesia for surgery.
- Nausea (up to 1 in 30)
- Feeling cold (1 in 4)
- Temporary memory loss/confusion
- Bladder problems could occur if an epidural is used
- Sore throat (2 in five)
- Damage to lips or teeth (1 in 4,500)
These are possible side effects and some are very rare. Your anaesthetist will meet you before the operation and will ask about your health, types of anaesthetics, risks and benefits.
Venous thromboembolism refers to blood clots which form in deep veins, frequently in the legs or groin. These clots are referred to as deep vein thrombosis. If part of the clot detaches it can travel through the blood vessels and lodge in and block the arteries of the lung. This is called pulmonary embolism. It is a major cause of death in hospital patients. Your risk of pulmonary embolism will be assessed in the pre-operative assessment. Preventative measures include wearing anti-embolism stockings, medication and recommendations for exercise.
MRSA and C-difficile
MRSA (methicillin resistant staphylococcus aureus) is a type of bacteria which cannot be treated with the antibiotic methicillin as well as some others. Hence, MRSA must be treated with other antibiotics to which the bacteria are not yet resistant.
MRSA is usually passed through physical contact but sometimes it travels through the air in sputum.
If you are going into hospital, you will be screened for MRSA, often at the pre-operative assessment. A nurse may take a swab from your nose, armpit or groin. If you carry MRSA, you will be informed by your GP, surgery or hospital and they will let you know what to do next. The MRSA will be treated before your operation.
How the infection is treated depends on the type of infection, the site of infection and the symptoms you have.
Clostridium difficile is a bacterial infection and can often affect the digestive system if you have taken antibiotics. Older or frail people are more at risk and a new strain has emerged recently which causes a more severe infection.
In 2013, the NHS performed just over 66,000 hip procedures in England and Wales.
Joints occur where bones meet and most are mobile allowing movement. The hips are ball and socket joints which allow movement in a number of directions. The acetabulum is the socket which houses the ball or head of the femur (thigh bone). The hip joint differs from other joints because it has significantly more bony contact and stability.
A hip joint consists of the following:
- acetabulum – the socket or cup in the pelvis that holds the femoral head
- bursa – a small fluid-filled sac located at joints which has a cushioning effect
- cartilage – a type of connective tissue that covers the surface of bones at a joint acting as a lubricant
- femur – thigh bone
- ligament – a type of strong elastic connective tissue that attaches bones together at joints whilst allowing movement
- synovial membrane – a dense fibrous connective tissue that lines the joint and seals the joint into the synovial capsule. The synovial membrane secretes synovial fluid (a viscous fluid) around the joint to lubricate it
- tendon – a type of tough connective tissue that connects muscle to bone, keeps the joint stable and controls movement
The need for surgery
A hip replacement is needed if you have persistent pain or reduced movement affecting daily life. This could result from damage caused by osteoarthritis, rheumatoid arthritis or a fracture. The alternatives to surgery include resurfacing, analgesics (painkillers) or corticosteroid injections. Hip replacements are suitable for most people except those with serious conditions which could impact on surgery or the ability to recover.
As a general rule the operation will follow the process below.
- The surgeon will make an incision in the hip area – 20-30cm in conventional surgery
- The surgeon will remove the head of the femur and hollow out the acetabulum or socket in the pelvis. The ball fits into the stem of the femur and a cup is inserted into the hollowed out socket. The two most frequently used types of hip prostheses are cemented and uncemented. A cemented artificial hip joint is attached to the bone with surgical cement. An uncemented artificial hip is attached to the bone with a porous surface on which new bone grows, forming a bond. Sometimes both these types are used
- The incision will be closed with stitches or surgical staples
- A drain may be left in to remove fluid from the site
In the recovery room you may have an intravenous drip and the drain mentioned above. Once stable you will return to the ward, lying on your back with a pillow between your knees to keep them apart.
You will be helped to walk as soon as possible after the operation. A physiotherapist may give you exercises and help you walk with crutches if you need them. An occupational therapist may assess your physical ability, your home circumstances and may provide/loan equipment to assist such as a raised toilet seat. Most people leave hospital between four and eight days after the operation.
You will be asked to return to hospital 6-12 weeks after the operation to check that there are no problems.
You may not be able to and/or you may be advised not to bend your hip more than 90 degrees towards your stomach as there is a chance of dislocation. You will be advised to sleep on your back with a pillow between your legs for the first 6-12 weeks.
You may expect to drive after six weeks if you can do so safely. Check with your insurance company that you are covered during your recovery. You may be able to return to work from 6-12 weeks after the operation depending on how much activity your job requires.
For general risks associated with surgery see above.
An artificial hip can dislocate. This is most likely to happen after surgery before it has fully healed and, if this happens, it needs to be corrected under anaesthetic. Dislocation occurs in 3% of cases.
Loosening of the joint – this is the most common problem. It occurs when the shaft which supports the ball and goes down into the femur becomes loose, often due to bone thinning. Although it can happen at any time it usually does so 10-15 years after the operation. Then revision surgery might be needed.
Wear and tear – can occur in artificial joints when particles break off and become absorbed into surrounding tissues. The wear and tear can loosen the joint. This can be assessed by periodic X-rays and if severe can be rectified by surgery.
Stiffening of the joint – soft tissue can harden around the artificial joint. It can be treated with radiation or drugs.
Infection – it is possible that a deep infection can occur. The new joint needs to be removed to treat the infection. New hip implants can then be substituted 6-12 weeks later.Metal implants – recent data suggests that large head metal-on-metal hip implants (those 36mm diameter or greater) wear more quickly than other types of implants. Friction between the moving parts of the joint can cause small particles (debris) to break off and enter surrounding tissue.
Sometimes these particles can cause discomfort and over time this can cause damage. Which, in turn, causes the artificial joint to become loose which may be painful. This means that further surgery is required.
Please read our Hip Surgery factsheet for further information.
Knee replacement surgery
90,842 knee replacement procedures were recorded by the National Joint Registry in 2012.
The knee is composed of four bones: the femur, fibula, patella and tibia. The distal end (lowest end) widens and articulates (moves) with the tibia and patella (kneecap). The fibula does not articulate with the femur or patella and is not involved in supporting weight.
The need for surgery
There are two types of knee replacement, total knee replacement and partial or half replacement where only one side is replaced.
The most common reason for knee replacement surgery is osteoarthritis. This surgery can also help if you have rheumatoid arthritis, gout or injury. Some people may not be able to have a knee replacement, for example, those with very weak quadriceps or those with open sores just below the knee.
- An incision is made over the front of the knee exposing the kneecap. The kneecap can then be moved to the side allowing access to the joint
- The damaged end of your thigh bone (femur) and shin bone (tibia) are removed. A prosthesis is made and fitted following precise measurement of the ends of the bones
- A curved piece of metal replaces the end of the femur and the end of the tibia is replaced by a flat metal plate held in place by cement. The bone is treated to encourage it to fuse with the artificial implants. A plastic spacer is used as cartilage between the two metal components
- The back of your kneecap may also be replaced
- The wound is closed with either stitches or staples and a dressing is applied to the wound
There are surgical alternatives to knee replacement surgery but the outcome may not be as good.
Arthroscopic washout and debridement
An arthroscope (tiny telescope) is inserted through small incisions through the skin and tissue in the knee. The knee joint is washed out with saline and any debris removed. It is not recommended if you have severe arthritis.
This is a keyhole operation where small holes are made in the surface layer of bone with a sharp tool. Growth of cartilage is then stimulated from bone marrow. It is a useful technique if there is a small area of damage. The results are not as good as for knee replacement surgery and the technique is not well proven by data.
Osteotomy is an open operation in which the surgeon cuts the tibia (shin bone) and adds or removes a wedge. This means that weight is no longer focused on the damaged part of the knee. It is sometimes used for younger people with limited arthritis or where they are too young for knee replacements, at least for time being.
Autologous chondrocyte implantation (ACI)
Your own cells are used to grow new cartilage and then introduced to the damaged area. This technique is rarely used for arthritis and, to date, only as part of clinical trials.
Mosaicplasty (cartilage replacement)
This is a keyhole operation which involves using cartilage and bone from other parts of the knee to repair the damaged surface.
After the operation, you will spend some time in the recovery room where you may receive fluids and painkillers through a cannula into the arm. In some cases the painkillers can be controlled by the you and, in others, administered by a nurse. You may also be given oxygen through tubes that go into the nose. Occasionally, a blood transfusion may be required. These will be removed after the first day or so.
There will be a dressing on your knee to protect it and various drains from the knee to prevent the collection of blood inside the wound.
The staff will help you to walk about as soon as possible, often within 24 hours of surgery. Walking may begin with a frame or crutches and many people walk independently with a frame or walking sticks after a week or so. There may be some discomfort which is common.
You may be given exercises by a physiotherapist to strengthen the muscles around the knee, which can begin the day after the operation. They will also give advice on avoiding complications and dislocations.
A passive motion machine may be used to re-establish movement in the knee joint reducing stiffness, helping with circulation.
When can I go home?
Usually within three to five days of the operation depending on the type of knee replacement and the recovery you have made.
Initially you may feel tired. Follow the advice that was given to you in hospital and if you have any worries or concerns, contact your GP.
Continue with the exercises recommended to you by the physiotherapists in hospital and, depending on arrangements, monitored by a physiotherapist.
You should be able to stop using crutches and resume normal leisure activities around six weeks after the operation. It may take a few months for the pain and swelling to subside and up to a year for the swelling to completely disappear. Recovery from this type of surgery can take up to two years. Even when you have fully recovered it is best to avoid extreme movements or sports especially where there is a risk of falling.
During the first three months, limit yourself to light activities, do not stand for long periods and avoid bending down or stretching for the first six weeks.
Driving can begin when you can bend your knee sufficiently to get in and out of the car and control it safely. This is usually around four to six weeks after surgery. You may want to check with your doctor or physiotherapist before doing so.
Returning to work
This depends on your individual circumstances and the work you do, but usually it’s 6-12 weeks after the operation.
Will it affect my sex life?
Your surgeon should be able to give advice. As a rule, it should be alright to have sex 6-8 weeks after the operation avoiding kneeling positions.
An appointment will be made for you at the outpatients department usually 6-12 weeks after an operation. The consultation may include an X-ray and a check that the wound is healing satisfactorily. The surgeon will then see you again a year later and then every five years to check whether the joint is beginning to loosen. A knee can be replaced as often as needed although each time, it is less effective.
General risks associated with operations and anaesthesia are covered in the risks/complications section.
- Fracturing of the bone around the implant can occur and treatment will depend on the nature of the fracture
- Excess bone may form around the artificial joint, restricting movement. This may be removed by subsequent surgery
- Excess scar tissue may also form and restrict movement and again this may be rectified by surgery
- The kneecap can become dislocated, which will require surgery to replace
- Ligament, arterial or nerve damage near the knee
- Persistent pain in the knee
A total of 2,225 shoulder replacement procedures were recorded by the National Joint Registry in 2012.
The shoulder joint
The main shoulder joint is a ball and socket joint where the head of the humerus (the ball) fits into the glenoid (socket) in the scapula or shoulder blade. It is encapsulated by a fibrous sheath called the capsule which holds it and provides support. Within this is the synovium, which produces synovial fluid and this lubricates the joint. The movement is controlled by four muscles and tendons called the rotator cuff.
In addition, the shoulder includes a smaller joint (the acromioclavicular joint) where the scapula or shoulder blade meets the clavicle or collarbone, above the main joint.
The need for surgery
A shoulder replacement may be considered if your pain cannot be relieved by drugs or exercise. Lack of movement can be caused by friction between the joint surfaces or by contraction of surrounding ligaments and/or tendons. Often, only the humeral side of the shoulder is replaced.
In most cases after surgery, the pain diminishes and the range of movement increases, but it will remain reduced when compared to a natural healthy joint.
- The incision is made from the front (deltopectoral), or from the side (deltoid split)
- The choice of implants depends on the degree of degradation and on the structure and functionality of the rotator cuff
- The head of the humerus is removed. If it is resurfaced, the head of the humerus capped
- The component that replaces the head of the humerus is made of an alloy based on cobalt and chromium
- The part of the implant which replaces the glenoid depression or socket is made of very high-density polyethylene
- The humeral head only is replaced in a hemiarthroplasty, or both the humeral head and the glenoid are replaced in a total shoulder replacement
- The glenoid implant is held in place by either acrylic bone cement (cemented) or bone ingrowth (cement-less) where the bone ‘knits’ with the implant
Most people will have tried several alternatives before considering surgery. These include:
- drug treatments including analgesics (painkillers) and non-steroid inflammatory drugs
- disease modifying drugs (DMARDs) for those with rheumatoid arthritis
- local anaesthetics
- other forms of surgery may be helpful such as cleaning out a joint (debridement)
- removal of the synovia
Physiotherapy should begin as soon after surgery as possible, beginning with range of movement exercises. The safe extent will depend on the type of surgical approach used.
The time spent in hospital is contingent on co-morbidities (other conditions you may have) and usually varies between 2-5 days.
The advice given prior to discharge usually includes:
- wearing a sling every night at least for the first month
- not using your arm to raise yourself from a sitting or lying position
- following any programme of exercises that may be given to you
- increasing the amount of exercise over time – balance rest and exercise
- not lifting anything heavier than a cup of liquid for the first six weeks after surgery
- no heavy lifting or contact sports for at least six months
Complications after shoulder replacement surgery are much less than in other joint replacements such as the hip or knee.
See information about anesthetics and side effects
- Damage to nerve and blood vessels
- Fracture of the humerus bone
- Tears in the rotator cuff
- Post-operative fractures of the humerus
- Instability of the shoulder
- Loosening of the glenoid component in the socket
- Wound infection
For a description of the hip joint see hip replacement surgery
The need for surgery
The need for a hip replacement may arise when:
- your hip pain is persistent and other treatments have not helped
- daily activities become difficult to undertake because the movement in your hip or hips has been so reduced
- your quality of life is adversely affected by the pain
The surface of the head of the femur is removed as well as the surface of the acetabulum (the socket or cup in the pelvis that holds the femoral head). These surfaces are then covered with metal. The technique requires you to have relatively strong bones and is suitable for younger adults but may not be suitable for older adults. In addition, it may not be suitable for post-menopausal women because the bones are often weakened and become brittle.
In June 2012 the Medical Healthcare Products Regulatory Agency (MRHA) released an alert which said that metal on metal artificial hip implants and hip resurfacing may wear more quickly than when other materials are used. It also suggested that there may be soft tissue damage from debris rubbing off the surfaces. Hip resurfacing always has metal implants and the surfaces of these implants move over each other. Hip replacements are made from a variety of material alternatives such as plastic or ceramics. It also advised that people who have had metal on metal hip replacements or resurfacing should be monitored annually and measurement of ions in the blood taken to decide whether to replace the hip again.
Carpal tunnel decompression
What is it?
Carpal tunnel syndrome is a condition in which the median nerve is compressed as it passes through the wrist and becomes less effective. The muscles of the thumb are controlled by the motor median nerve and sensations are relayed to the brain through the sensory nerve.
Carpal tunnel syndrome causes pain in one or both hands. It starts gradually and the pain is often felt in the fingers and thumb.
Surgery is usually undertaken in outpatients departments and recovery is completed within a month. Often surgery is performed when other treatments have failed. The procedure is performed under local anaesthetic and it releases pressure on the nerve.
You may need surgery if there’s severe compression of the median nerve or if the numbness and pain doesn’t improve with other treatments. Carpal tunnel release surgery relieves pain by reducing the pressure on the median nerve. The carpal tunnel ligament is cut which reduces the pressure on the nerve.
Surgery usually takes place as a day case and you can expect to recover in less than a month. The operation is normally carried out under a local anaesthetic and usually leaves only a small scar. If you’ve had carpal tunnel syndrome for a long time – especially if you have muscle-wasting or loss of sensation – the operation may not bring a complete recovery, but the pain should be greatly reduced. For most people the surgery is very successful but, as with all surgical treatments, some people will have complications.
For keyhole, surgery one or two short incisions are made, one to two centimetres long. One is made on the inside of your wrist and the second, if there is one, is in the palm. An endoscope, or small camera on a tube, will pass through an incision and allow the ligament to be seen. The instruments to complete the operation will be inserted through the same or the other incision.
After surgery, your hand will be bandaged and you might use a sling. The hand should be kept raised for 24 hours to reduce swelling and stiffness. To further reduce swelling and stiffness, exercise your fingers gently.
It might take several weeks to recover completely so in the meantime only use your hand for light activities and those that do not cause excessive pain or discomfort.
Recovery time for keyhole surgery is slightly less than for open release surgery. There is some evidence to suggest that there is less pain during the first three months after surgery with keyhole compared to open surgery.
Usually alternatives to surgery are tried first and only when they have not been effective is surgery tried. If the symptoms are mild or carpal tunnel syndrome occurs during the late stages of pregnancy, you may be advised to have other treatments.
- Steroid injections. Carpal tunnel syndrome responds well to steroid injections if the symptoms are mild to moderate. The steroids or corticosteroids reduce inflammation
- Wearing wrist splints at night can help reduce pressure on the median nerve
- Physiotherapy or exercises for the hand as well as improving your posture particularly, for example, sitting at a desk
Risks and complications
Usually this surgery provides a complete cure except if you have had carpal tunnel syndrome for a long time. Possible complications include:
- inability to separate the roof of the carpal tunnel which usually means persistent carpal tunnel syndrome symptoms
- persistent wrist pain
- nerve injury
- scar tissue
- complex regional pain syndrome – a rare condition which results in a burning pain in one of the limbs
The decision to have surgery performed by the NHS or undertaken privately can be influenced by long waiting times in the NHS. However, paying for an operation in a private hospital is expensive and not an option for everyone. For example, a hip replacement costs between approximately £7,000 and £10,000. Some think the immediate improvement to the quality of their life is worth the money.
There are advantages to having an operation in a private hospital.
- You may have your own room with an en-suite bathroom
- There may be more choice about when you have meals and choice of menu or when drugs are taken
There may also be disadvantages.
- Being isolated from other patients
- Most private hospitals do not have intensive care units if things go wrong
- It may not be clear what is included in the cost of your operation and any additional costs can mount up. Some private hospitals have fixed packages which include provision for treatment if there are complications. Injections, drugs and occupational therapy may or may not be included so it is a good idea to check.