Factfinder

Questions to ask your doctor

Orthopaedics

If you suffer from painful and damaged joints, there are a number of different people who may be involved in your treatment including nurses, physiotherapists and orthopaedic surgeons. If the problem is caused by arthritis you may see a rheumatologist. If you suffer from back pain you, anaesthetists and others who specialise in pain management may also be involved in your treatment.

For many problems, surgery can be effective, but it is important to see a surgeon with the right skills and experience. Statistics show there is a link between the number of operations carried out by an orthopaedic surgeon and the likelihood of a successful outcome. Large scale US studies of hip and knee patients have found that hospital volume has significant associations with key outcomes such as mortality infection, dislocation and hospital readmission. For example, quality of outcome following a total knee replacement was found to be better at hospitals doing more than 200 operations a year compared with those doing fewer than 25 procedures a year.

Below are some of the key questions to ask the doctors treating you.

Knee problems

The orthopaedic surgeon's dream is to inject new cartilage cells into worn and painful knee joints in order to rejuvenate them. The techniques for doing this are still in their infancy but some early results are promising. The techniques are not available everywhere and should still be regarded as experimental. Keyhole surgery for soft tissue knee injury and joint replacement are still the most up-to-date and effective treatments for knee problems.

Keyhole or arthroscopic surgery is highly beneficial to patients because it involves a minimally invasive technique, is usually done as a day case and is conducive to a relatively rapid recovery.

The arthroscope is one of the most valuable and informative diagnostic tools available to the orthopaedic surgeon. It consists of a fibreoptic telescope attached to a miniature camera which can be inserted into the joint through a small incision (less than 1cm in length). This allows the surgeon to see and assess damage to the joint through images projected on a TV monitor.

Operations on the knee are relatively common. Over 125,000 arthroscopies and 65,000 knee replacements were carried out last year. Knee injuries are the result of damage to the bone, the surfaces of the bone in the joint (the articular cartilage) or the soft tissue (cartilage, ligament, muscle and tendons). A doctor's examination will show if the bones are tender or displaced and whether the ligaments are intact. X-rays can reveal a fracture but they do not reliably reveal joint surface or soft tissue injury. It may be necessary to carry out blood tests, a magnetic resonance (MRI) scan and a bone scan to diagnose a knee problem.

The majority of routine operations on the knee, even complex procedures like cruciate ligament reconstruction, can now be carried out arthroscopically (using keyhole techniques). The arthroscopic surgeon uses a variety of small, specialised instruments that are passed in and out of small incisions. Compared to conventional open surgery, arthroscopic surgery produces less scarring, less trauma and less pain. Most people return to normal activity after a few days. Complications are rare but may include swelling or infection in a small proportion of cases.

Not all knee conditions can be treated by arthroscopy. Some, such as knee replacement, still need an open operation.

Knee ligament surgery

A ligament injury can range from a sprain to a complete tear. A sprain or a partial tear may heal by itself. A complete tear may require surgery. The ligament most commonly injured is the anterior cruciate ligament (ACL), which stabilises the knee and aligns the leg bones.

Operative treatment for an ACL injury should only be considered when the knee keeps giving way, usually when twisting or turning). Such instability causes a general lack of confidence in the knee, and sport or other outdoor activities may be impossible. ACL reconstruction may also lessen the risk of further injury to the knee such as torn cartilage.

A torn ACL cannot be simply stitched together. Instead, surgery involves the torn ligament being replaced by a graft. The graft can be made from two of the patient's own hamstring tendons or a strip of kneecap tendon. It is inserted into the knee joint in exactly the same position as the original ACL, often using keyhole techniques that leave small scars and minimise postoperative pain.

ACL reconstruction is successful in more than 90% of cases. Patients should be able to return to full sporting activity after six months.

Key questions

Does the ACL reconstruction surgeon have adequate skills?
ACL reconstruction is specialised and surgeons need considerable experience to carry it out. You should ideally see a surgeon who performs this operation regularly (at least once a month). Some hospitals perform more than 200 operations a year while others do fewer than 10 per year.

How long will I have to wait for surgery?
On average the wait for ligament surgery is over 200 days and in the areas with the longest waits it can be almost a year. This is partly because many patients needing this operation are less urgent than other patients. However, there are hospitals that usually provide treatment much more quickly - within a matter or weeks.

What happens after surgery?
The rehabilitation period is a very important part of the overall treatment programme and you should make sure it is conducted under the supervision of an experienced physiotherapist. Initially the emphasis is on straightening the knee properly. An aggressive approach can be adopted with supervised workouts in the gym, cycling, and swimming.

Knee replacement surgery

Advanced osteoarthritis of the knee can only be treated effectively by replacing the knee joint. The knee is divided into two "compartments" - sometimes just one compartment is diseased and needs replacement (unicompartmental replacement), and sometimes a total knee replacement (TKR) is required. It is also possible to just replace the kneecap (patella) if the arthritis is limited to that area.

Patients undergoing total knee replacement spend about seven days in hospital, during which time they have intensive physiotherapy. They should be able to cope independently when they return home. Walking will continue to improve over the next few weeks and driving a car should be possible within six weeks of the operation.

Approximately 30,000 total knee replacements are performed in the UK each year, and the success rate is more than 90%. If the operation is not successful, knee replacements can loosen and then have to be replaced - but the revision rate is less than 10% at ten years.

Key questions

Does the surgeon have adequate experience?
The surgeon who performs the operation should perform the operation regularly, say, at least once every month Our data shows that over a third of revision knee replacement operations take place in hospitals doing fewer than one operation a month, while larger centres do at least 30 operations a year. For revision surgery, which is more complex than replacement, it may be necessary to travel to a specialist centre to find a suitably skilled surgeon.

What is the hospital's post-operative infection rate?
The most worrying complication of joint replacement is infection, which occurs in less than 3% of cases. The risk of infection is increased in diabetics, patients on steroids and patients who are on immunosuppressive treatment. In a survey by Dr Foster, rates for deep infections - where the artificial joint becomes infected - varied from none to 3 per cent between different hospitals. Hospitals should be able to tell you their postoperative infection rate. Another measure of post-operative problems is the percentage of patients readmitted within 28 days of leaving hospital. Nationally, 5 per cent of patients have to be readmitted in this time, but in some hospitals it is double this.

Are there intensive care facilities in the hospital where I am having my knee replacement operation?
This is a major operation and the hospital should have good postoperative recovery facilities and experienced support staff.

Back problems

Up to 80% of the population has back pain at some point in their lives, and for about a quarter it will recur from time to time. A history and examination should detect any serious problems such as cancer, infection, and pressure on spinal nerves or the spinal cord. But most people have what has been termed "simple" back pain, and for 85% of these it is often impossible to give a precise diagnosis.

Most episodes of back pain get better on their own. In the first four weeks of an acute painful episode it is important to take regular painkillers and keep mobile. Rest will do more harm than good. After four to 12 weeks of back pain, physiotherapy, chiropractic or osteopathic treatments may be helpful.

Although surgery helps some people with long-term back problems, for many it's a matter of looking to cope with the pain. Many hospitals offer chronic pain management services. These should combine use of pain-killing medicines with psychological therapies and physiotherapy to help patients cope as best they can. A useful website is backpain.org.uk

Back surgery

Surgery for back pain is usually only considered after six months or more of severe back pain and only after other treatments have been used extensively. If your doctor refers you to a spinal surgeon, bear in mind that only 5% of patients end up having surgery.

Surgical interventions include removing a disc, or removing the disc tissue squashing a nerve (decompression), disc fusion and disc replacement. Fusion surgery and disc replacement are designed to help preserve people's mobility, but they do not help everybody - the success rate is 60-70%. Success rates for discectomy (disc removal) and decompression are higher at 75% to 85% but this is usually carried out for leg pain.

Surgery is probably the most reliable way of dealing with sciatica pain that has not settled on its own after eight to 12 weeks of painkillers. If surgery is being considered, specialist imaging such as an MRI scan is required.

While there are no sources of clear-cut criteria for comparing spine surgeons, you can ask some key questions about the surgeon your doctor is proposing to refer you to.

Key questions

Is the surgeon adequately trained in treating back problems?
Specialist spine surgeons usually belong to one of the specialist societies, such as the British Scoliosis Society (BSS), The British Association of Spine Surgeons (BASS), The Society for Back Pain Research (SBPR) or the British Cervical Spine Society (BCSS).

Different skills are required for different procedures. Simpler procedures such as spinal decompressions and dealing with disc prolapses are undertaken by most spinal surgeons. More complex procedures such as those for spinal deformity and tumours require high levels of specialist training and experience. Surgeons doing this type of work are usually in the larger NHS teaching hospitals or work in specialised teams.

Ask whether spinal surgery makes up a large part of the surgeon's workload, or whether he/she is more of a general orthopaedic surgeon or neurosurgeon? A specialist who focuses on spinal surgery is more likely to be adept and up-to-date in terms of best surgical techniques.

What is the surgeon's success rate?
Most responsible spine surgeons keep a database of their results, outcomes and complications. They should be able to tell you how often they carry out a specific operation and what their results for it are. They should also be able to tell you what proportion of their work is spinal surgery.

Wrist and hand problems

Hand injuries constitute a quarter of all accidents. They should be assessed as quickly as possible. Complicated cases need to be referred to specialist centres, usually in regional plastic surgery or major orthopaedic units.

Pain in your hands and wrists can be caused by a range of conditions including arthritis and osteoarthritis as well as conditions linked to repetitive strain injuries such as carpal tunnel syndrome and tendonitis.

Treatment generally starts with medication including painkillers and anti-inflammatory tablets. Medications include gold, steroids, sulphasalazine and methotrexate.

If these bring no results, surgery is considered. Removal of the lining of joints (synovectomy), for example, can slow down the progress of some deformities. Removal of large synovial cysts, which often form at the back of hands, is also possible and is a relatively small operation. This also reduces the risk of tendon rupture.

Wrist joint problems can be very painful and disabling. Total wrist replacement is now a very successful operation with good long-term results. Other options are partial or total wrist fusion - particularly suitable for those with physically demanding work.

If hand surgery is required, it cannot be conducted in isolation, and requires input from physiotherapists and occupational therapists who will provide rehabilitation after the operation.

Key questions

How quickly will I be seen by a specialist?
Hand injuries constitute a quarter of all accidents. Currently, a hand surgery service is linked to every accident and emergency department. The assessment of severity of all injuries must take place promptly. Secondary referral centres are needed for more complicated cases which are not emergencies and these are mostly situated in regional plastic surgery or major orthopaedic units. These specialist centres allow concentration of knowledge and experience in rare conditions such as complex congenital anomalies, severe problems related to arthritis, and major disorders of nerves and muscles, and research opportunities are facilitated in this environment. As in all surgical specialties, hand surgery cannot be conducted in isolation, requiring input from the rehabilitation services of physiotherapy and occupational therapy.

Has my surgeon had specialist training?
In order to support the practice of hand surgery, a proper structure of learning and training has been established. It begins with the basic surgical training and advances through the separate disciplines of orthopaedic or plastic surgery. Over and above this, there is specialised training in advanced techniques of hand surgery. The Royal College of Surgeons has promoted this, and the British Society for Surgery of the Hand works in conjunction with the College in providing the necessary advanced training. The final period of hand training often allows complementary experience in a plastic surgery unit for an orthopaedic trainee, and vice versa.

How many operations on hand and wrist conditions have you carried out?
The volume and importance of hand surgery is often not appreciated. Although currently in Britain only about 10 surgeons confine their work to hand and upper limb surgery, there were only two a decade ago, and at least 150 surgeons now have a major interest in hand surgery, while still spending some of their working week in orthopaedic or plastic surgical practice. A study carried out at the Pulvertaft Hand Centre in Derby concluded that a population of 500,000 generated enough work for two consultants - one hand surgeon and one orthopaedic or plastic surgeon with a 70% interest in hand surgery. Most hospitals carry out hand surgery frequently. However more complex operations, such as some reconstruction operations are performed much more rarely and a specialist surgeon should be sought. Most hospitals with a large orthopaedic department and most regional plastic surgery centres will have one or more surgeons who specialise in hand surgery.

Rheumatoid arthritis is a common condition affecting the hand and wrists. How will this be diagnosed?
There is no single test which clearly diagnoses early rheumatoid arthritis. When you first develop joint pains, it may be difficult for a doctor to say that you definitely have rheumatoid arthritis as there are many other causes of joint pains. Blood tests can detect inflammation and characteristic antibodies, but these do not prove that you have rheumatoid arthritis.

So, you may have a time of uncertainty when early symptoms 'could be' rheumatoid arthritis. In time, X-rays of joints may begin to show typical erosions (early damage) and other features of rheumatoid arthritis which makes the diagnosis more certain.

Someone with rheumatoid arthritis is likely to go to their doctor with other symptoms first; hand problems usually develop later.

Is surgery the first option?
Usually not. Treatment generally starts with medication including painkillers and anti-inflammatory tablets. Other medications include gold injections, steroids, sulphasalazine and methotrexate. Some control is usually achieved in most cases.

Operations can be useful in the early stages of the condition when the symptoms are not being brought under control by medications. Removal of the lining of joints, called synovectomy, can help the pain and also slow down the progress of any deformities. Removal of large synovial cysts, which often form at the back of hands, is also possible. This also reduces the risk of tendon rupture.

I have to have a total wrist replacement. What is my surgeon's success rate?
Wrist joint involvement can be disabling because of pain and restricted motion. Operations are commonly performed to improve function and help pain but surgeons will not advise total wrist replacement in most cases. Other procedures are partial or total wrist fusion. The latter is suitable for those who are involved in physically demanding work. The operation can be very successful in relieving pain and improving strength and function. The forearm and finger movements are retained in this operation and therefore the loss of movement at the wrist joint is not such a disadvantage. Partial wrist fusion may retain some wrist movement while relieving pain but can hold the problem only temporarily and total wrist fusion can be necessary at a later date.

What is your attitude to complementary therapies for rheumatoid arthritis?
Many people try complementary treatments such as special diets, bracelets and therapies but the value of such treatments has not been proved. For advice on the value of any treatment it is best to consult a doctor or a national support group.

Foot and ankle problems

Understanding and management of foot and ankle damage has progressed significantly in the last few years. Minimally invasive arthroscopic (keyhole) surgery is used to both explore and treat the ankle, and replacements of ankle joints and small joints in the foot are now being performed regularly.

Podiatrists, technicians, and specialists in diabetes, arthritis, circulation, plastic surgery and orthopaedics all work closely together to solve complex foot and ankle problems.

If the ankle has become stiff and painful because of arthritis or cartilage wear, treatments include steroid injections and physiotherapy, but if this brings no relief ankle fusion or ankle replacement are options.

If the ankle bone is badly broken, and a simple plaster cast is not sufficient, special screws and plates are used to hold the bones in place while they heal. Sometimes surgery is required to reinforce the ankle bones, or repair other internal damage.

Key questions

What does the surgeon specialise in?
You should be treated by a surgeon who specialises in foot and ankle surgery. Foot and ankle specialists may have a number of sub-specialties such as arthritis, diabetes, sports injuries, fractures, heel pain, bunions and so on. Not all of them cover all of these areas. Check that the surgeon you are seeing specialises in the problem for which you are seeking treatment.

What is the surgeon's success rate?
Foot and ankle surgery is generally as successful as other forms of orthopaedic surgery, such as hip and knee replacement. It is a rapidly growing specialty with a number of developments in terms of treatment. If you are recommended surgery ask the surgeon how often they have performed that particular procedure and what their success rate is.

Hip problems

What is revision surgery?
Revision surgery is needed when significant problems develop with a hip replacement. It is forming an increasing proportion of the workload of orthopaedic surgeons. The operations are more complex than the initial hip replacement and take longer (three hours on average). The equipment is more wide-ranging and expensive and complications are more frequent. Components have often been cemented in place, or patients' bone has grown into them, which makes extraction very difficult.

Advanced techniques are increasingly used in revision surgery, such as the transfemoral approach, where the thigh bone is split to provide access to the implant and cement. This approach may be appropriate for some patients.

Key questions

Statistics show that age is important, as the risk of complications developing is higher for older people. There are a range of complications, which can occur during the operation, in the first few weeks after the operation or in the long term.

These can include dislocation, infection, leg length inequality and, more rarely, fracture, nerve damage and vascular damage but there are many more complications that can happen as a result of a hip replacement operation.

Do you specialise in hip replacements?

Make sure you see someone with a specialism and strong track record in hip replacement.

Which joint replacement do you use?
There is a bewildering array of artificial hip joints (prostheses) for the surgeon to choose from. The National Institute for Health and Clinical Excellence (NICE)recommends that surgeons only use hips which have demonstrated a lifespan of at least 10 years in 90% of cases, but some hospitals also use prostheses that are not on the recommended list. You should discuss with your surgeon the prosthesis he or she intends to use and check with them that it is one that meets the NICE criteria.

Will you carry out a preoperative assessment and what will it involve?
Preoperative assessments by a nurse are increasingly used to see if people are fit enough to undergo major hip surgery. You should also be assessed by the surgeon and the anaesthetist before being admitted to hospital for your operation, to avoid you having to be sent home if you are not up to the operation.

What is your complication rate?
Hip replacement operations have a high success rate. Complications are fairly infrequent, but they do occur. For example, in a survey by Dr Foster, post operative deep infection rates after hip surgery varied from none to 3 per cent. Your hospital should be able to tell you their complication and infection rates.

How many of your hip operations fail?
All hip operations eventually fail, no matter how well the operation was done initially or what components were used. If a hip operation has functioned well and without pain for the expected length of time it is considered to be a success. You should expect a new hip to last at least 10 years and up to 20 years.

You should be asked if you would like to be put on the National Joint Registry. This is a record of hip replacement operations performed in the UK. If problems emerge with the type of prosthesis that you have had fitted, you will be notified.

Who is your anaesthetist and what is their experience?
Doctors having operations worry as much about the anaesthetist as the surgeon. Your life is literally in the anaesthetist's hands, even in what is otherwise a routine surgical procedure. Find out your anaesthetist's experience for this kind of surgery. If possible, it is good to meet the anaesthetist before the operation to check you are fit for anaesthetic.

Are there intensive care facilities?
If things go wrong, you need high dependency or good intensive care facilities, so it is important to know whether there is a facility on site or where the nearest one is.

Specific questions if you have a shoulder or elbow problem

How long will I have to wait for treatment?
Waiting times for shoulder surgery vary considerably and will depend on the type of surgery you need. Before surgery, you will be seen in the orthopaedic clinic for pre-operative x-rays, and a full assessment of your needs.

How experienced are you? Do you have the necessary skills to treat my condition?
The most common elbow problem treated by orthopaedic surgeons is lateral epicondylitis, which is also known as tennis elbow. It may be caused by a sudden injury or repetitive use of the arm. Some doctors feel that the pain is caused by small tears in the tendon called the extensor carpi radialis brevis. The pain is usually worse with strong gripping with the elbow in an extended position, as in a tennis backhand stroke.

Another problem often seen by orthopaedic surgeons is golfer's elbow (medial epicondylitis). This often begins as microscopic tears in the tissue lead to an inflammatory or hypervascular process. Surgery should be a last resort and involves cleaning up the tendon from diseased tissue.

Another common condition is cubital tunnel syndrome, which is a pinched nerve at the elbow commonly known as the funny bone.

What procedures do you carry out for shoulder problems?
There are four common procedures performed on shoulders. These are:

  • Arthroscopy, which allows the surgeon to look inside the shoulder joint using small incisions and identify the problems and creating space for the tendons to slide by removing bone spurs and the damaged soft tissue
  • Bankart procedure, which is an operation that tightens ligaments and repairs torn capsular detachments, restoring shoulder stability
  • Rotator cuff repair, which is performed to repair the tear, relieving the pain and improving the function of the muscles and tendons that move the joint
  • Prosthetic shoulder replacement, which is a procedure involving replacement of the head of the humerus, or 'ball' (hemiarthroplasty) or in some cases the resurfacing of the 'socket' or glenoid as well (total shoulder replacement).

What are the latest developments in treating shoulder problems?
Researchers are developing fixation techniques in shoulder replacement operations, which are carried out increasingly in patients with rheumatoid and osteoarthritis. Shoulder replacement operations are less common than hip and knee replacement operations, but the aim is to create an effective shoulder replacement that will last for many years.

What are the latest developments in treating elbow problems?
There have recently been developments in arthroscopic and other procedures involving the joint. The most common condition is usually treated by non-operative methods. A trial of at least six months is usually considered before surgery. This could consist of a brace for the forearm and modified activity with the elbow, or a splint (at night) in the case of cubital tunnel syndrome. There is no conclusive evidence to say that anti-inflammatory medicine or physical therapy is of benefit. Cortisone injections can be beneficial, but no more than three injections are recommended in one location over a year.

How many operations have you carried out for elbow problems?
The most common procedure (for the most common problem, tennis elbow) is a simple excision of diseased tissue from within the tendon and re-attaching the tendon.

Will I have to stay in hospital?
Many treatments for elbow problems (including the above) can be carried out on an outpatient basis, with a regional anaesthetic - where only the arm goes to sleep. A relatively small incision, of about three inches, is made.

How long will it be before I can return to normal activities?
Eighty five to 90% of patients with this technique are usually able to carry on everything as before without pain after a recuperation period of between two and three months. Around 10% of patients have improvement but with some pain during vigorous activities and only around 3% of patients have no improvement at all.

Sports injuries

More people than ever now take part in sporting activities, and sports injuries have escalated as a consequence. About 5% of patients in hospital accident and emergency departments have a sports injury, though most people with sports injuries do not see a doctor. Contact sports such as rugby and football often cause sudden twisting and the result can be knee ligament tears and ankle sprains. Professional footballers (who can run 11km in a game) and runners also suffer overuse injuries such as knee pain or stress fractures. Sports such as swimming and cycling have their own peculiar set of problems such as swimmer's shoulder - an inflammation of muscles and tendons in the shoulder.

There are simple points to remember if you want to avoid sports injuries:

  • get fit to play sport, don't use sport to get fit
  • most injuries happen when you are tired
  • use proper running shoes for training
  • switching between different pairs of shoes reduces the risk of injury
  • take proper care of equipment

Most injuries settle with time; if yours does not recover in a few weeks, then seek further help. General practitioners are rarely experts in sports medicine unless they have a personal interest. If you want to see a practitioner in sports medicine, it may be best to ask your doctor if there is a specialist you can see on the NHS - a physiotherapist or an orthopaedic surgeon who specialises in sports injuries, for example. If not, you may have to seek help from a private practitioner or a private clinic.

Most problems can be diagnosed just performing an examination of the injured area, but this requires a detailed knowledge of anatomy. If there is a need for further investigation, then X-rays are used to assess whether bone has been damaged. Soft tissue injuries to muscle tendon or ligament are better seen with an ultrasound scan (which is quick) or an MRI scan (where you will have to join a long waiting list on the NHS). With overuse injuries, you may need a biomechanical assessment to pinpoint exactly what you are doing that is causing a problem.

Simple measure such as rest, massage, stretching and exercises are the answer for most injuries. Physiotherapists use manipulation and mobilisation. Electrotherapy techniques such as ultrasound interferential therapy, laser therapy and pulsed short wave diathermy therapy, are often used but there is little evidence that they do any good. Sometimes anti-inflammatory medicines such as brufen or voltarol are prescribed or need to be bought over the counter either as tablets or gels. These should not be used long term. For overuse injuries, the answer may be as simple as corrective insoles in shoes or changing saddle height on a bicycle.

Key questions

What is the person treating you qualified in?
Many private clinics advertise treatment of sports injuries without any special training or expertise. There are now plenty of qualifications in sports medicine available and so you should seek someone who has taken the trouble to gain such a diploma. Physiotherapists are well-qualified, and probably deal with more sports injuries than any other group. Some injuries such as a sudden swelling of the knee following a tackle, or a knee that won't straighten after a twist or a dislocated shoulder need immediate care from an orthopaedic surgeon who may be a sports-injury specialist.

What rehabilitation services are available?
Rehabilitation is a vital part of treatment - as part of your recovery it is important that you regain muscle power and a sense of joint position. So whether you are seeking NHS or private treatment, it's worth asking who will provide rehabilitation, what it will consist of, and what equipment is available. Isokinetic machines may be available to measure power. Core stability exercises are designed to retrain muscles responsible for posture and support of the spine and pelvis. These are a major advance in preventing and treating sports injuries, as the source of many injuries can be traced back to poor posture and control. Many clubs use these as part of general training.

Useful links

« Back to main menu