If this is a medical emergency, call 10177 (ambulance) or go to your nearest emergency room immediately.
Hip and knee replacement are planned procedures, but urgent situations do arise — both before surgery (falls, fractures, infection) and after surgery (complications). This article covers those scenarios.
Pre-Surgical Emergency: Hip Fracture
If a patient waiting for planned hip replacement sustains a hip fracture (fall, trauma) before the elective procedure:
Hip fracture is a PMB surgical emergency — entirely separate from the planned elective replacement. Emergency surgery (hemiarthroplasty, dynamic hip screw, or total hip replacement depending on fracture type) is PMB-funded as an emergency.
Go to the ER immediately. Call 10177. This is treated as an acute trauma event — pre-authorisation is not required for the emergency.
Post-Surgical Complications — Act Immediately
Prosthetic Joint Infection (PJI)
The most feared complication of joint replacement. Symptoms: increasing joint pain, redness, warmth, swelling, fever, wound discharge days to months or years after surgery.
Action: Go to the ER immediately. PJI requires emergency treatment — IV antibiotics, aspiration, or revision surgery. This is a PMB emergency — scheme must fund.
Why urgent: Delayed treatment of PJI dramatically worsens outcomes. Do not wait for a scheduled appointment if PJI is suspected.
Pulmonary Embolism (PE) Post-Surgery
Joint replacement surgery carries elevated PE risk. If you develop sudden breathlessness, chest pain, or unexplained rapid heart rate in the weeks following joint replacement — call 10177 immediately. PE is life-threatening and a PMB emergency.
DVT (Deep Vein Thrombosis)
Swollen, painful, red calf after joint replacement — go to the ER or urgent GP same day. DVT is a PMB condition; anticoagulation treatment is funded.
Wound Complications
Minor wound ooze in the first days is normal. If you develop: - Increasing redness tracking away from the wound - Wound opening or dehiscence - Significant new swelling of the limb - Fever
Contact your surgeon immediately. If you cannot reach them, go to the ER.
Implant Failure / Dislocation
Hip dislocation (sudden severe pain + inability to bear weight after THR) is an emergency. Call 10177 or go to the ER. Closed reduction under sedation or open surgical reduction are required — PMB-covered.
Knee stiffness / manipulation under anaesthesia (MUA): If knee range of motion does not progress adequately, MUA may be required. This is an in-hospital day procedure — pre-authorise with your scheme. Covered under surgical benefit.
Emergency Coverage Summary
| Post-surgical situation | PMB Status | Action |
|---|---|---|
| Hip fracture (pre-surgery, trauma) | Yes — emergency PMB | ER/10177 immediately |
| Prosthetic joint infection (PJI) | Yes — emergency PMB | ER immediately |
| PE after joint replacement | Yes — PMB (PE DTP) | Call 10177 immediately |
| DVT post joint replacement | Yes — PMB (DVT DTP) | ER/urgent GP same day |
| Hip dislocation (post-THR) | Yes — emergency PMB | Call 10177/ER |
If Your Pre-Authorisation Is Declined
If your scheme declines pre-authorisation for a clinically indicated joint replacement:
- Request written reasons.
- The most common grounds for decline: insufficient conservative treatment documentation, inadequate X-ray evidence of severity, or missing clinical motivation from the orthopaedic surgeon.
- Ask your surgeon to submit a more detailed clinical motivation with X-ray images, full conservative treatment record, and functional impairment assessment.
- Internal appeal — submitted in writing with supplementary clinical evidence.
- If the appeal fails: Council for Medical Schemes: 0861 123 267 | www.medicalschemes.co.za. Hip and knee replacement are PMB procedures — a scheme declining them for a clearly qualifying patient is declining a PMB.
The Unexpected Bill After Surgery
If you receive a bill after surgery that is significantly higher than expected:
- Ask for an itemised account from the surgeon, anaesthesiologist, and hospital separately.
- Confirm what your scheme paid on each bill — call your scheme and ask for the Explanation of Benefits (EOB) statement.
- Check your gap cover claim — has the gap cover provider received and paid the claim? Most gap cover claims are processed automatically, but some require submission.
- Challenge any billing for premium implants you did not consent to in advance. A surgeon may not upgrade an implant without informed financial consent.
- If the bill relates to a balance billing dispute: The Council for Medical Schemes has jurisdiction over scheme-related billing disputes. File a complaint.
Resources and Helplines
Emergency services: 10177 (ambulance) | 10111 (police) ER24: 084 124 | Netcare 911: 082 911 South African Orthopaedic Association (SAOA): saoa.org.za Council for Medical Schemes: 0861 123 267 | www.medicalschemes.co.za Talk to Eldon →