Overview

Did You Know?
According to the latest News and Numbers from the Agency for Healthcare Research and Quality, orthopedic procedures have increased in the U.S. by nearly 25 percent between 1997 and 2005, climbing from 822,000 to 1.3 million [1] . These procedures include knee reconstruction or replacement (knee arthroplasty), total and partial hip replacement, and spinal fusion. If you need an orthopedic procedure, you are clearly not alone.

The data from the report indicate that that between 1997 and 2005 in the U.S.:

• The number of knee surgeries climbed by 69 percent from 328,800 to 555,800.
• Hip replacements rose 32 percent from 290,700 to 383,500.
• Spinal fusion operations increased 73 percent from 202,100 to 349,400.
• Women were 60 percent more likely than men to have hip replacements and 70 percent more likely to have knee surgeries. Spinal fusions were equally likely in both men and women.
• Hospital stays for orthopedic procedures totaled $31.5 billion (11 percent of all hospital patient care costs).
• Medicare paid the largest share of hospital costs for knee surgeries and hip replacements (covering nearly 60 percent of all knee surgeries and 64 percent of all hip replacements). On the other hand, private insurance was billed for over half (52 percent) of spinal fusions.

What Types of Orthopedic Procedures are People Having Abroad?
In addition to knee and hip replacements, BridgeHealth has assisted in coordinating total disc replacement, ACL reconstruction, shoulder surgery to repair a weakened or torn rotator cuff, and many knee arthroscopies for repair of meniscus tears. Please refer to the Surgical Procedures section for a more detailed list of procedures we offer.

But Why Travel for Orthopedic Surgery?
As with many other goods and services, the global marketplace has given rise to competition in orthopedic surgery. Within the healthcare universe the result has been the creation of three distinct benefits for consumers when traveling internationally for medical services: a rise in higher quality care, an opportunity for dramatic cost savings, and a level of superior service and patient experience.

Of course, the primary reason to travel for orthopedic surgery is the affordable pricing of procedures. Also, the extraordinary care and recovery assistance at our provider destinations is of paramount importance – especially for those needing affordable postoperative physical therapy and nursing care.

Definition

Orthopedic surgery attempts to correct disorders or injuries of the musculoskeletal system including arthritis, trauma, and congenital deformities.

How Do You Know It's Time for Orthopedic Surgery?

The Arthritis Foundation recommends that you speak to your rheumatologist or orthopedic surgeon about the possibility of joint replacement if you are experiencing any of the following discomforts:

• You are unable to sleep at night because of the pain.
• You've tried a series of different medications that don't help alleviate the pain; or the medication you have been on is no longer effective.
• You feel that the pain from your arthritis is keeping you from regular outings, such as visiting friends, going shopping, or taking a vacation.
• Your pain causes you to have trouble getting out of a chair, going up stairs, getting off the toilet, or getting up from the floor [2].

Surgical Procedures

BridgeHealth’s World-Class Provider Network™ offers the following orthopedic procedures. If you do not see your particular need listed here, please contact a Travel Care Coordinator to discuss further options.

ACL Reconstruction
An Anterior Cruciate Ligament (ACL) tear is one of the most common knee injuries. The ACL is one of four ligaments that work to stabilize the knee. When the ACL is torn, reconstructive surgery is not performed right away; allowing any swelling to decrease and inflammation to subside improves the ability of the joint to function after surgery.

ACL reconstructive surgery is not a “repair” of the ligament per se, but rather is a reconstruction as the name implies. In the surgery, a part of a healthy ligament – usually the patellar ligament that connects the kneecap to the tibia – is used to replace the torn ACL.

Arthroscopy of the Knee, Ankle or Shoulder
Arthroscopic surgery is a method of viewing or performing surgery on a joint by use of an arthroscope, which consists of a tube, a lens, and a light source utilizing fiber optics to visualize the surgical area. Arthroscopic surgery is used to look inside of an ailing joint to understand the cause of the existing symptoms.

Bankart Lesion Repair
A Bankhart lesion injury is a specific type of shoulder ligament tear that usually occurs during a shoulder dislocation. When the shoulder pops out of joint, it tears a ligament on the labrum, a cuff of cartilage at the end of the arm bone. This tear results in a general sense of instability and contributes to repeated dislocations and achiness in the shoulder area.

Surgery to repair a Bankart lesion involves reattaching the torn labrum to the shoulder socket. This repair can be achieved arthroscopically or through a standard incision. About 90 percent of Bankhart lesion repair patients return to normal activities without further shoulder dislocations.

Hand Surgery
Surgery is a common option to treat many hand conditions. For details on the types of hand surgeries BridgeHealth offers, please contact a BridgeHealth Travel Care Coordinator today.

Hip Resurfacing
The ReCap® Femoral Resurfacing Head is a metal (cobalt chromium) cap that resurfaces the head of the femur. This conservative procedure makes the technique less invasive than traditional hip replacement surgery. The ReCap® Head may require a smaller incision and less bone removal, which can allow you to recover more quickly and with less pain.

Oxford Knee Replacement
An Oxford® Partial Knee implant is designed to repair only one side of the knee, making it much smaller than a total knee implant. This partial replacement can be performed in a minimally invasive manner. Advantages to a partial replacement are less bone cartilage removed from the knee, shorter recovery time, and greater natural motion after recovery. Not all patients are candidates for an Oxford? Partial Knee replacement. Please discuss your specific situation with your doctor to decide if this type of replacement is right for you.

Post Trauma Reconstruction
The types and severity of trauma sustained to joints varies widely as do the surgical treatments. Please contact a Travel Care Coordinator to discuss your specific needs regarding reconstructive surgery.

Shoulder Impingement Repair (open or closed)
Patients who have ruled out a rotator cuff tear as the source of their shoulder pain are often diagnosed with shoulder impingement syndrome (also called shoulder bursitis or rotator cuff tendonitis). When non-surgical treatments have been exhausted, a shoulder impingement repair may be necessary. This surgery is performed arthroscopically using a small video camera and a shaver inserted through small incisions. The surgeon uses the shaver to remove the inflamed bursa. Recovery time is short and patients can begin gentle movements immediately after surgery.

Shoulder Replacement
Shoulder joint replacement surgery is performed to replace a shoulder joint with artificial components (prostheses) when the joint is severely damaged by such degenerative joint diseases as arthritis, or in complex cases of upper arm bone fracture.

Torn Rotator Cuff Repair
Rotator cuff repairs can be performed in a variety of ways which vary in their invasiveness. An open repair requires a six to 10 centimeter incision where the tendon is exposed and repaired. A mini-open repair uses a smaller incision (three to four centimeters) to access the tendon and an arthroscope to look at the area. The final technique is exclusively arthroscopic. Small incisions are made to insert a camera and repair instruments and the surgeon can watch the repair on a monitor. The less invasive the technique, the shorter the recovery period. Not all methods are suitable for all patients, so please consult with your doctor before deciding on a particular type of procedure.

Total Hip Replacement
Total hip replacement involves replacing the damaged parts of the hip joint with artificial joint parts (prosthetic components) made of high-quality metal and plastic. The parts are typically held in place by bone cement. The artificial joints come in different sizes to fit the patient.

Hip replacement surgery usually takes two to three hours, during which time you'll be under general or regional anesthesia. During the operation, the surgeon separates your thighbone from the socket. Working between the large hip muscles, the surgeon removes the diseased or damaged bone and tissue, leaving healthy bone and tissue intact. The artificial socket is pressed into place. The top end of the thighbone is hollowed out to allow insertion of the metal stem with the attached ball. The ball and the socket join to form the new hip joint.

Symptoms that might lead you to consider hip replacement include:

• Pain that keeps you awake at night
• Little or no relief from pain medications
• Difficulty walking up or down stairs
• Trouble standing from a seated position
• Having to stop activities you enjoy, such as walking, because you're in too much pain

Total Knee Replacement
Knee replacement surgery is recommended for the three types of arthritis that can affect the knee. If non-surgical treatments for the knee pain and immobility have failed and lifestyle and activities are being limited, knee replacement surgery should be considered. Surgical options include knee arthroscopy (although this is rarely used just for arthritis), partial knee replacement, and total knee replacement.

The goal of knee replacement is to provide a pain-free knee that can withstand relatively normal activities and lasts for a long time. To achieve this goal, it is important that the knee implants be inserted with proper positioning. The bones and ligaments are prepared very carefully to allow the knee to be functional and durable. According to the American Academy of Orthopedic Surgeons, 90 to 95 percent of knee replacements last 15 years or longer if proper, current techniques are used.

New Advances

Minimally Invasive Joint Replacement Surgery
Minimal incision hip replacement uses the same prosthesis to replace the hip joint, but the surgery is performed in a way that requires only a three to five inch incision — a departure from the current 10 to12 inch incision. Some studies have shown that people who undergo minimally invasive hip replacement have an easier and less painful recovery, spend less time in the hospital, and have fewer complications. However, not all studies have reached this conclusion. More studies and longer follow-up are needed to evaluate minimally invasive techniques [2].

Birmingham Hip Resurfacing (BHR)
Hip resurfacing first emerged as an alternative to hip replacement in the 1960s but fell out of favor because of problems with the polyethylene parts used at the time. A new generation of cobalt chrome caps and socket linings led to its re-emergence in the 1990s.

Although hip resurfacing has been used in Europe for many years, it is relatively new to the United States. The first hip resurfacing system was approved by the Food and Drug Administration in 2006.

Gender-Specific Knee Implant
A gender-specific total knee replacement implant is a prosthesis that is specifically designed either for a male or a female. The size of the implant is slightly different to accommodate for the slightly different size of the bones between genders [3]. Currently, there is no data to suggest that creating a gender-specific implant design will help achieve the goals of better function or improved durability. Most orthopedic surgeons will tell you that implants already come in a variety of sizes that will accommodate almost any patient's anatomy.

Support and Aftercare

Medical Aftercare
Many procedures performed overseas will require follow-up care once you return home. BridgeHealth has over 80 offices in all states that are available to our clients for both pre and post-operative care.
We can help arrange a wide variety of aftercare needs including post-procedure checkups, prescription services, and even higher levels of care if necessary. We Your Travel Care Coordinator will review your aftercare concerns, discuss your options with you and arrange care if necessary.

Additional Considerations

What to Ask the Surgeon
The Arthritis Foundation recommends asking your surgeon the following questions before having joint replacement surgery:

• What makes someone a good candidate for joint surgery?
• What are the risks involved in joint surgery?
• Would there be any other non-surgical treatments I haven't yet tried that would ease my pain and help me move more easily?
• How would surgery help my particular problem?
• What would not change after the operation?
• How long is the recovery process?
• What is involved in the recovery process?
• What type of procedure would you recommend for me?
• How often in the past year have you performed this operation?
• Can you tell me what the outcome (decreased pain, improved function) has been for most of these patients?
• Can you provide the names of several people I could contact to discuss their experiences with surgery?

Risks of Orthopedic Surgery
With any surgery, complications can occur. Although some complications are serious, most can be treated successfully. In rare circumstances, complications can include:

• Blood clots. These clots in the leg veins can form as a result of decreased movement of your leg after surgery, as well as from injury to the veins during surgery. You will likely receive blood-thinning medications after your surgery to try to prevent clots from forming. Compression devices, such as elastic stockings, and exercise to increase blood flow through the veins in your legs also can reduce your risk. Intermittent compression is used during the procedure to further decrease your risk of blood clot formation.
• Infection. Infections can occur at the site of your incision and in the deeper tissue near your new hip. Most infections are treated with antibiotics, but a major infection near your prosthesis may require surgery to remove and replace the prosthesis.
• Dislocation of a hip joint implant. Certain positions can cause the ball of your new joint to become dislodged. To avoid this, don't bend more than 90 degrees at the hip and don't let your leg cross the midline of your body. Surgery usually isn't necessary to relocate your hip joint.
• Loosening or a joint implant. Over time your new joint may loosen, causing pain in your hip. Surgery might be needed to fix the problem.
• Breakage of prosthesis. Though rare, your artificial hip can break several years after surgery. The prosthesis is FDA approved and the studies on the wear and tear sustained by a joint prosthesis are available. Another surgery would be required to replace the broken joint.
• Change in leg length for hip or knee replacement. Your surgeon takes steps to avoid the problem, but occasionally your new hip may make your leg longer or shorter than the other one. Sometimes this is caused by weakness in the muscles surrounding your hip. In this case, strengthening those muscles using the techniques given to you by the overseas physical therapist can resolve the issue.
• Joint stiffening. Sometimes the soft tissues around your joint harden, making it difficult to move your hip — a process called ossification. This usually isn't painful. If you're at risk of ossification, your doctor may recommend medications or radiation therapy to prevent it from happening.

Be sure to write down your concerns and questions and review them with your surgeon at the time of your consult. They will freely discuss these issues with you.

Destinations

The following countries feature members of our World-Class Provider Network™ who perform orthopedic procedures. Not all procedures are available in all of the countries listed, so please contact a Travel Care Coordinator for more details.

Costa Rica - With its white sand beaches, generous hospitality, affordable luxuries, and medical expertise this geographically desirable Central American nation is an ideal destination for many procedures.

India - Home to the Taj Mahal, this Asian country is not only a popular tourist destination, but also features highly skilled doctors, a modern medical infrastructure and the latest medical technology.

Mexico - Long a favored vacation getaway, Mexico is home to a friendly culture, comforting pace and the opportunity for many high quality procedures, all at a comfortable distance from home.

Panama - Featuring numerous nature-oriented sight-seeing opportunities, Panama’s capital of Panama City is the safest and most modern metropolitan area in Central America. Panama boasts a high percentage of US-trained doctors and is a relatively short flight from many major US airports.

Turkey - Situated between Europe and Asia, Turkey is home to Istanbul, one of the most significant cities in ancient and modern history. Today, Turkey’s medical industry features state-of-the–art facilities and many Western-trained physicians.

How BridgeHealth Works

As the premier provider of medical travel services, BridgeHealth International, Inc. (BridgeHealth) is dedicated to empowering you with all of the information you need to make your trip successful.

BridgeHealth understands that the prospect of traveling abroad for medical procedures can be an overwhelming experience. Because we place such a premium on the continuity of communication and care, we provide you with your own experienced Travel Care Coordinator who can help you in a way that is tailored to your exact wants and needs. Your Travel Care Coordinator is your personal contact through every step of the process and can assist you by:

• Helping you complete our Short Form Inquiry, and arranging for a BridgeHealth Nurse to talk with your international surgeon
• Planning your dates of travel including arranging for the lowest airfare possible with complimentary airport pick up, ground transport and airport drop off and ground transport to and from your consultation when you discuss the risks of surgery, your trip to the hospital for surgery and post-procedure visits with the doctor.
• Scheduling your appointments in your destination country
• Helping with passports, visas and immunizations
• Providing you with your pre- and post-procedure instructions and being available if you have questions about them.
• Answering all your questions about costs, length of stay, cultural issues abroad, what to pack, and what kinds of incidental costs you may have to plan for (ex: taxis, shopping or sightseeing tours)
• Arranging for ongoing updates on your condition with your family and friends while you are away
• Coordinating follow-up medical services for your return home

In addition to your Travel Care Coordinator, you can also speak with a BridgeHealth Registered Nurse who can answer your questions about specific medical procedures or conditions. Your nurse will also be involved in coordinating your care with your surgeon(s).

To get started, please see the Get Started: Build Your Bridge Today section.

Pricing

Rest assured that BridgeHealth has negotiated the best prices available. There are no added fees for using our Travel Care Coordinators. We are here to help reduce your stress and assist you with making the best, most informed choice possible.

The cost for your procedure depends upon the particulars of the procedure itself, the destination, and your specific medical condition. The information you provide on your Short Form Inquiry can help us give you the most accurate price range for your procedure. Generally, prices for a hip or knee replacement range from approximately US$6,500 to $13,500.

Get Started: Build Your Bridge Today

Your journey into international healthcare starts by providing us with the information we need to best assist you. Please begin by filling out our Short Form Inquiry. If you are unsure about how to answer any questions on the form, a BridgeHealth Travel Care Coordinator will be happy to assist you with any questions or concerns.

After your Short Form Inquiry is complete, a Travel Care Coordinator or BridgeHealth Nurse will review your information with international surgeons and contact you within 24-48 hours. This allows us to give you the most precise pricing estimate, tailored to your exact wants and needs.

If you prefer to speak with someone immediately, or need assistance completing your Short Form Inquiry, you can reach us by phone toll free from the US and Canada at 800.680.1366 or +1.303.457.5759 from other countries. Our on call coordinators and nurses are available 24 hours a day, 7 days a week for emergencies and to assist clients abroad. All non-emergency inquiries are assigned to a coordinator immediately and calls are returned the same day received.

References

1. The News and Numbers is based on data from the report Hospital Stays Involving Musculoskeletal Procedures, 1997 - 2005 <http://www.hcup-us.ahrq.gov/reports/statbriefs/sb34.pdf>. The report uses data from the Nationwide Inpatient Sample, a database of hospital inpatient stays that is nationally representative of all short-term, non-federal hospitals. The data are drawn from hospitals that comprise 90 percent of all discharges in the United States and include patients from all insurance providers as well as the uninsured http://www.ahrq.hhs.gov.

2. From "All You Need to Know About Joint Surgery," © 2002, Arthritis Foundation

3. Barrett, WP, “The Need for Gender-Specific Prostheses in TKA.” Orthopedics, Sept. 29, 2006

Helpful Links

Center for Disease Control

American Orthopedic Association

Comprehensive hip implant website

Slide show on hip replacement (must have Adobe Acrobat Reader to access)

Illustrated hip replacement

Comprehensive list of things to help after hip surgery

Diet, home safety tips to avoid hip injury

Type in any orthopedics procedure or condition and get a detailed explanation

Glossary

There are three basic types of arthritis that may affect the knee joint:

Osteoarthritis (OA) is the most common form of knee arthritis. OA is usually a slowly-progressing degenerative disease in which the joint cartilage gradually wears away. It most often affects middle-aged and older people.

Rheumatoid Arthritis (RA) is an inflammatory type of arthritis that can destroy the joint cartilage. RA can occur at any age. RA generally affects both knees.

Post-traumatic arthritis can develop after an injury to the knee. This type of arthritis is similar to osteoarthritis and may develop years after a fracture, ligament injury, or meniscal tear.

There are a number of surgical treatment options for knee pain and immobility, including the following:

Arthroscopic surgery uses fiber optic technology to enable the surgeon to see inside the joint and clean it of debris or repair torn cartilage.

An osteotomy cuts the shinbone (tibia) or the thighbone (femur) to improve the alignment of the knee joint.

A total or partial knee arthroplasty replaces the severely damaged knee joint cartilage with metal and plastic.

Cartilage grafting is possible for some knees with limited or contained cartilage loss from trauma or arthritis.

There are also a number of non-surgical treatments for knee pain and immobility:

Lifestyle modifications include losing weight, switching from running or jumping exercises to swimming or cycling, and minimizing activities that aggravate the condition, such as climbing stairs. Many, but not all, people with osteoarthritis of the knee are overweight. Simple weight loss can reduce stress on weight bearing joints, and can result in reduced pain and increased mobility.

Physical therapy and exercise can be effective in reducing pain and improving mobility. An individualized plan can be developed by your physician or a physical therapist. Supportive devices such as a cane, energy-absorbing shoes or inserts, a brace, or knee sleeve can be helpful. A brace can assist with stability and function.

Anti-inflammatory medications can include aspirin, acetaminophen or ibuprofen to help reduce swelling in the joint. Simple pain relievers such as Tylenol are available without a prescription. A more potent type of pain reliever is a nonsteroidal anti-inflammatory drug or NSAID. These drugs, which include brands such as Motrin, Advil and Aleve, are available in both over-the-counter and prescription forms. COX-2 inhibitor is a special type of NSAID that is often prescribed if knee pain is moderate to severe. Common brand names of COX-2 inhibitors include Celebrex and Vioxx. It should be noted that Vioxx was recently withdrawn from the market by its manufacturer.

Glucosamine and chondroitin (kon-dro'-i-tin) sulfate are oral supplements that may relieve the pain of osteoarthritis. These are two large molecules that are found in the cartilage of our joints. Supplements sold over-the-counter are usually made from synthetic or animal products.

Corticosteroids are powerful anti-inflammatory agents that can be injected into the joint.

Viscosupplementation is a method of adding fluid to lubricate the joint and make it easier to move. This fluid is a concentrate of hyaluronic acid, or hyaluronate (hi-a-lou'-ron-ate), a molecule that is found in the joints of the body. Therapy consists of a series of injections designed to change the character of the joint fluid. There is less fluid in a knee with osteoarthritis than in a healthy knee. Three to five weekly shots are needed to reduce the pain, but the pain relief is not permanent. Injections are given for moderate to severe pain. They can be very useful if there is significant swelling, but are not very helpful if the arthritis affects the joint mechanics.

Special medical treatments for rheumatoid arthritis include gold salt injections and other disease-modifying drugs.

Alternative therapies include the use of acupuncture and magnetic pulse therapy. Many forms of therapy are unproven, but reasonable to try, provided you find a qualified practitioner and keep your physician informed of your decisions.

Acupuncture uses fine needles to stimulate specific body areas to relieve pain or temporarily numb an area. Although it is used in many parts of the world and evidence suggests that it can help ease the pain of arthritis, there are few scientific studies of its effectiveness. Be sure your acupuncturist is certified, and do not hesitate to ask about his or her sterilization practices.

Magnetic pulse therapy is painless and works by applying a pulsed signal to the knee, which is placed in an electromagnetic field. Like many alternative therapies, magnetic pulse therapy has yet to be scientifically proven.

Other measures may include applications of heat or ice, water exercises, liniments, or elastic bandages.

Birmingham Hip Resurfacing
When is Birmingham Hip Resurfacing NOT appropriate? The BHR System should not be used in a patient who:

• Has an infection of the body or blood.
• Has bones that are not yet fully grown.
• Has any blood vessel-related disease, muscle-related disease, or nerve-and-muscle-related disease that will prevent the artificial hip joint system from remaining stable, or that may prevent following instructions during the recovery period.
• Has insufficient bone health or strength due to:
• Severe bone loss (osteoporosis) or a family history of severe bone loss.
• Bone loss, such as avascular necrosis, affecting more than half of the femoral head.
• Multiple fluid-filled cavities (cysts) greater than one centimeter in the femoral head.
• Note: a test, such as DEXA scan, may be needed to determine the level of bone loss.
• Is female and of child-bearing age. It is unknown whether metal ions released by the device could harm an unborn child.
• Has a kidney with significantly impaired function. The patient will need testing (creatinine, GFR, BUN) before and/or after surgery to test the kidneys.
• Has had reactions to wearing metal jewelry (metal sensitivity).
• Has a suppressed immune system due to diseases such as AIDS, or is receiving high doses of corticosteroids.
• Is severely overweight.

Your doctor will need complete information about your overall health to determine whether the BHR system is right for you. You should tell your doctor about any health problems, even if they are not related to the hip, because some medicines and diseases (such as diabetes) can affect kidney or bone strength [1].

More long-term research is needed to evaluate the potential risks and benefits of hip resurfacing. Some studies have raised concerns about a higher failure rate with resurfacing, which requires additional surgery. Although hip resurfacing may be attractive because it preserves more bone, this potential advantage must be weighed against the potential risks of additional surgeries. Your x-rays, MRI, and other images provided will be reviewed on a case-by-case basis. Your Travel Care Coordinator will provide you with the surgeon’s recommendations and you may always discuss the reasons for the recommendation with the surgeon or a BridgeHealth nurse.

Disclaimer

The information provided here is presented for your education and is not intended to replace a consultation with a licensed physician. It is not to be construed as medical advice nor is it to be used for any emergency health need you may be experiencing. Surgery always carries with it risks of infection and bleeding and anesthesia always carries numerous risks including death. Any country, including the United States, can have an outbreak of illness at anytime. These illnesses are listed at the Centers for Disease Control (CDC) website www.CDC.gov. © BridgeHealth International, Inc. 2008. For more details, see Terms of Use.