Total Knee Replacement

Arthritis results in painful joints. Joint replacement is a procedure which makes the arthritic joints pain free so that one can get back to pain free mobility and carry on normal day to day life.

What is a total knee replacement?

A total knee replacement is a surgical procedure whereby the diseased knee joint is replaced with artificial material. The knee is a hinge joint which provides motion at the point where thigh meets the lower leg. The thighbone (or femur) abuts the large bone of the lower leg (tibia) at knee joint. During a total knee replacement cartilage, the end of the femur bone is removed and replaced with a metal shell.

The end of the lower leg bone (tibia) is also removed and replaced with a channeled plastic piece with a metal stem. Depending on the condition of the kneecap portion of the knee joint, a plastic “button” may also be added under the kneecap surface. The artificial components of a total knee replacement are referred to as prosthesis.

The posterior cruciate ligament is a tissue that normally stabilizes each side of the knee joint so that the lower leg cannot slide backward in relation to the thighbone. In total knee replacement surgery, this ligament is retained, sacrificed, or substituted by a polyethylene post. Each of these various designs of total knee replacement has its own particular benefits and risks.

Which patients should consider a total knee replacement?

Total knee replacement surgery is considered for patients whose knee joints have been damaged by progressive arthritis, trauma, or other rare destructive diseases of the joint. The most common reason for knee replacement in India is severe osteoarthritis of the knees.

Regardless of cause of damage to the joint, the resulting progressively increasing pain and stiffness and decreasing daily function lead the patient to consider total knee replacement. Decisions regarding whether or when to undergo knee replacement surgery are not easy. Patients should understand the risks as well as the benefits before making these decisions.

Are there any risk / complications associated with the TKR operation?

Despite the best possible care, every surgery has its share of risk & complications despite taking all possible precautions to prevent any untoward incident, the risk is approximately 1% (complications e.g. infection, dislocation, DVT/PE, fractures, anesthetic risk etc.)

What is involved with the preoperative evaluation for total knee replacement?

Before surgery, the joints adjacent to the diseased knee (hip and ankle) are carefully evaluated. This is important to ensure optimal outcome and recovery from the surgery. Replacing a knee joint that is adjacent to a severely damaged joint may not yield significant improvement in function as the nearby joint may become more painful if it is abnormal. Furthermore, all medications that the patient is taking are reviewed. Blood-thinning medications such as clopid and anti-inflammatory medications such as aspirin may have to be adjusted or discontinued prior to surgery.

Routine blood tests of liver and kidney function and urine tests are evaluated for signs of anemia, infection, or abnormal metabolism. Chest X-ray and EKG are performed to exclude significant heart and lung disease that may preclude surgery or anesthesia.

What happens in the postoperative period? What is involved in recovery from surgery?

  • A total knee replacement generally requires between one and a half to three hours of operative time. After surgery, patients are taken to a recovery room, where vital organs are frequently monitored. When stabilized, patients are returned to their hospital room.
  • Passage of urine can be difficult in the immediate postoperative period, and this condition can be aggravated by pain medications. A catheter inserted into the urethra (a Foley catheter) allows free passage of urine until the patient becomes more mobile.
  • Patients can begin physical therapy 24 hours after surgery. Some degree of pain, discomfort, and stiffness can be expected during the early days of physical therapy.
  • A unique device that can help speed recovery is continuous passive motion (CPM) machine. The CPM machine is first attached to the operated leg. The machine then constantly moves the knee through various degrees of range of motion for hours while the patient relaxes. This can help to improve circulation and minimize the risk of scarring and contracture of tissues around the knee.
  • Patients will start walking using a walker and crutches. Eventually, patients will learn to walk up and down stairs. A number of home exercises are given to strengthen thigh and calf muscles.

How does the patient continue to improve as an outpatient after discharge from the hospital? What are recommended exercises?

  • For an optimal outcome after total knee replacement surgery, it is important for patients to continue in an outpatient physical-therapy program along with home exercises during the healing process. Patients will be asked to continue exercising the muscles around the replaced joint to prevent scarring (and contracture) and maintain muscle strength for purposes of joint stability. These exercises after surgery can reduce recovery time and lead to optimal strength and stability. Use of Ice packs and pain killer will be required for early mobilization and good results.
  • The wound will be monitored by surgeon and his staff for healing. Patients also should watch for warning signs of infection, including abnormal redness, increasing warmth, swelling, or unusual pain. It is important to report any injury to joint to the doctor immediately.
  • Future activities are generally limited to those that do not risk injuring the replaced joint. Sports that involve running or contact are avoided, in favor of leisure sports, such as golf, and swimming. Swimming is the ideal form of exercise, since the sport improves muscle strength and endurance without exerting any pressure or stress on the replaced joint.
  • Patients with joint replacements should alert their doctors and dentists that they have an artificial joint. These joints are at risk for infection by bacteria introduced by any invasive procedures such as surgery, dental or gum procedures, urological and endoscopic procedures, as well as from infections elsewhere in the body.
  • The treating physician will typically prescribe antibiotics before, during, and immediately after any elective procedures in order to prevent infection of the replaced joint.
  • Rarely about 1% of patients with total knee replacements can require a second operation years later. The second operation can be necessary because of loosening, fracture, or other complications of the replaced joint. Reoperations are generally not as successful as original operations and carry higher risks of complications. Future replacement devices and techniques will improve patient outcomes and lead to fewer complications.

FAQ:

Q: Will I benefit from the TKR Surgery?

A: You will benefit from the surgery only if

  • You have significant pain despite painkillers
  • You have limitation in walking despite using a stick
  • You have disturbed sleep at night
  • You have restriction in your day to day activities

Q: How soon do I have to undergo this surgery?

A: Most TKR surgeries are elective rather than emergency operations (Your surgeon will inform you, if you need emergency operation)

Q: What does TKR mean and is it safe?

A: TKR means putting in an artificial joint in place of your arthritic painful joint. The plastic and metal used in the imported artificial joints are tested to be safe and approved by the FDA after stringent testing in US, as well as in India.

Q: How long will this artificial Knee last?

A: Almost 85% of these artificial Knees have a life span of approximately 20 years.

Q: How long do I stay in hospital and when will I walk again after surgery?

A: Each individual is different and thus, exact timing cannot be guaranteed but most patients, all being well, are discharged from the hospital in approximately 5 days, and are made to stand and walk next day of surgery with support.

Q: I have trouble in both my knees, can they be operated at the same time?

A: Yes, most patients can undergo bilateral knee replacement in the same sitting (exception high risk for anesthesia etc), the discharge from hospital and mobilization gets a bit delayed.

Q: What are advances in knee replacement which are available in Sarvodaya Hospital?

A: Orthopedic Surgeons at Sarvodaya Centre for Orthopedics & Joint Replacement are performing the knee replacement surgery with special techniques to offer greater benefits to patients. These are:

  • Hospital has got international norms specification operation theatre which ensures minimal chances of infection.
  • We are using International brand of prosthesis which are FDA approved, long lasting and high flex knee with which one can sit crossed leg on ground.
  • LIGAMENT SPARING TKR (CR):- We use ligament sparing techniques to have optimal function of knee after TKR. Cruciate retaining (CR) knee give better function of knee. Both cruciate lig sparing (XR) Knee are future knee which when imported in India will be giving almost normal knee function.
  • MINIMAL PAIN FOLLOWING TKR: – To minimise pain following surgery, we use patient controlled analgesia (PCA) using Baxter Epidural pump, Buvalor skin patches and physiotheraphy to minimise the requirement of narcotics. Use of muscle sparing surgery (Subvastus approach) ensures minimal pain and fast recovery from surgery.
  • COMPUTER NAVIGATION:- Sarvodaya is equipped with painless latest navigation machine to have accuracy in implant alignment.
  • KINEMATIC ALLINGNMENT:- With new techniques of kinematic alignment bone cuts are minimized and ligament are preserved.
  • MUSCLE SPARING: In this technique muscles in front of knee are not cut & knee is exposed keeping muscle fully intact by taking it to one side. It is technically demanding but result of TKR are encouraging. Patient requirement for physiotherapy is minimized and muscle functions are restored early.
  • HIGH FLEX KNEE: – Majority of patient undergoing TKR at Sarvodaya are implanted high flex knee which can help the patient in sitting crossed-legged and squatting. Elderly can worship in Mandir, Gurudwara in normal way.
  • NO SUTURE REMOVAL:- After knee replacement self-dissolving suture are applied and patient not come for suture & staple removal. Also cosmetically knee looks better.

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