Dr. Thomas Boerger, MD FRCSI (Tr&Orth) Consultant Trauma & Orthopaedic Surgeon with specialist expertise in Hip and Knee Replacement shares his insights into the management trends that optimise treatment and expedite recovery.
The growing percentage of aging people in most populations in Europe and North America, together with a desire of the older generation to remain active, mobile, and pain-free for longer, are driving the increasing demand for joint replacement surgery.
People over 55 experience joint pain caused by osteo-arthritis, typically affecting large weightbearing joints and the spine. Old sports injuries and weight gain in later years also hasten the development of degenerative arthritis of hip and knee.
Quick recovery from surgery consequent to less time spent in comprehensive rehabilitation and coupled with a rapid return to an active life with pain-free mobility, are the ultimate goals of definitive orthopaedic intervention.
Bearing this in mind, it is clear that modern orthopaedic practice must simultaneously place the emphasis on an accurate diagnosis and the offer of a patient-specific treatment plan.
I am Dr Thomas Boerger, Consultant Trauma & Orthopaedic Surgeon. I have a busy public practice in Gibraltar and a thriving private practice in Southern Spain, and I fully champion this modern management approach.
Joint Replacement has evolved in both diagnostic and treatment fronts, based on modern Orthopaedic management principles.
Management principles
Today, general Orthopaedic management is mainly focused on delaying joint replacement surgery, whenever possible, by employing injectable biologics, cartilage transfer and reproduction, offloading knee joint bracing and joint preserving surgery, e.g., acetabular, and corrective limb alignment osteotomies, as appropriate.
With the passing of time, definitive joint replacement surgery becomes inevitable when the degenerative arthritic condition significantly worsens. Advances in joint replacement are firmly based on the need to improve on durability of implants through extensive research and design of enhanced bearing surfaces.
Advances in Diagnostics
Calibrated X-ray, CT and 3-Tesla MRI imaging are readily available during, or immediately after, the initial private consultation with me at HC International Hospital (Marbella) where I offer a one-stop diagnostic clinic experience.
National Joint Registries
National Joint Registries of different countries have been invaluable to consolidate joint replacement implant datasets, improve knowledge-base of implant performance and enable direct and valid implant comparison when personalizing surgical treatment plan for individual patients. It has also the added benefit of allowing identification of poor-performing implants and surgical techniques. Consequently, only top-performing implants that are relevant to my patients’ needs are chosen and recommended, based on evidence-based knowledge and thorough consideration, in my international and up-to-date Joint Replacement practice.
Advances in Joint Replacement Surgical Techniques
I use pre-operative computer-based templating to ensure that the correct choice of implant shape and size to exactly recreate the original joint geometry for my patient is possible.
Other new surgical techniques, such as patient-specific instruments, patient-specific printed joint prosthesis, image-guided navigation, and robotic support during surgery etc., are also currently offered by some surgical units. However, it has been difficult to conclude with any certainty that they confer better outcomes in either patient experience or in implant longevity. Some expert critics even proclaim that many of these ‘new surgical advances’ are merely industry-driven patient-directed marketing tools.
Bilateral knee replacement in one operative session is now possible, even, at times, desirable. This allows for simultaneous and effective management when both knees are significantly diseased and severely painful. Bilateral surgery minimises risks as these patients would have one hospital admission, one anaesthetic load and one surgery episode, instead of two over a length of time. While these patients are typically able to walk on the day of surgery, most patients, quite rightly, make use of the excellent inpatient facilities at HC International Hospital to recover without hurry, benefitting from in-patient pain relief, nursing support and physiotherapy engagement. I have a special interest in performing bilateral partial knee replacement surgery with my average operating time is under 2 hours.
Advances in Approach to Rehabilitation
Other management advances include the use of multimodal anaesthetics, tissue-sparing surgery, and physical therapy, which together allow for low opioid use in the early postoperative hours and days.
Same day mobilisation and, in selected patients, also same day discharge to a hospital-at-home setting with district nurse support are increasingly important and relevant, particularly in the public sector, to lower the exorbitant costs of a Joint Replacement episode.
A successful joint replacement experience necessitates meticulous preoperative assessment, full optimisation of patient factors, ready availability of a well-performing operative team affording precise, swift surgery, followed by tight scheduled reviews to address any rehabilitation needs arising.
Preparation for Surgery
- Apart from the usual pre-operative screening blood tests and ECG, we further invest necessary time and effort in microbiological work-up for MRSA and MSSA and offer associated eradication and re-testing.
- Frequently, diabetic patients require optimisation of their long-term glucose management.
- In conjunction with our in-house interventional cardiologists, any potential cardiac disease is assessed with relevant stress tests + ECHO and optimised with medication, cardioversion and at times coronary stenting.
- Other critical items include absolute smoking cessation, alcohol intake moderation, urinary symptom / prostate management and dental review aiming at the treatment of potentially infected gums and roots (we follow the recommendations of the international consensus group on the prevention of Prosthetic Joint Infection).
Aftercare & Online Communication
In addition to scheduled follow-up with me for consultant specialist post-joint replacement reviews, typically at 2 weeks, 6 weeks, 6 months and 1 year post procedure, my patients also have access to my practice nurse through video-call consultations and WhatsApp communication. The nurse will also visit you at home if necessary.
My PA is available by phone and email to provide you with any relevant information and administrative/clerical support.
Choosing Your Specialist Surgeon
I have written before on “How best to make the most out of your Orthopaedic Surgeon Consultation and Treatment”. (You can read the article here).
You are right to choose an experienced, professional, and caring specialist surgeon over any ‘new’ or ‘advanced’ treatment offered to you ever so readily elsewhere.
You should be able to speak freely to your consultant specialist, ask questions and raise concerns. Your consultant specialist should explore with you all valid clinical options specific to your condition needs, based on established evidence base and international standards.
Without a doubt, you are at the heart of it all, from the first clinical contact to the last post-operative review, even beyond, with Dr Thomas Boerger and team.
Any Questions?
Feel free to contact me on WhatsApp, phone, or email. Details are on my website:
This article has been written by Dr Thomas O. Boerger, MD FRCSI (Tr&Orth) Consultant Orthopaedic Surgeon, who obtained his primary medical qualification from Berlin, Germany, and who is fully post-graduate Surgical and Orthopaedic sub-specialty trained and qualified in London, UK. Dr Boerger completed and published, Orthopaedic research projects with the Department of Biomechanical Engineering, Imperial College, London and University of Leeds, UK. He has also specific Arthroplasty (Hips and Knees) and Soft tissue/Ligamentous reconstruction fellowship experiences in Florence (Italy), Canberra (Australia), and Sydney (Australia). Dr Boerger is currently operating in St Bernard’s Hospital, Gibraltar, and High Care International Hospital, Marbella, Costa del Sol, Spain.