Knee Replacement Surgery

There are a number of conditions which can cause knee pain. The most common cause of knee pain is arthritis. “Arthritis” means inflammation of a joint, but in general it describes any condition which causes damage to the cartilage.

What is Cartilage ?

The bone ends of a joint are covered with a smooth material called cartilage. The cartilage cushions the bone and allows the joint to move easily without pain. Without it, bones would grind together.

What are the causes of knee pain?

Osteoarthritis is the most common cause of knee pain in patients over 40 years of age. It is seen in many people as they age, although it may begin when they are younger as a result of injury or overuse. Although any joint may be involved, osteoarthritis is more common in weight-bearing joints such as the knee, hip, and spine than in the wrist, elbow, and shoulder joints. The cartilage covering the bone ends gradually wears away. Bone growths called "spurs" develop in osteoarthritic joints. The joint inflammation causes pain & swelling. Continued use of the inflamed joint produces pain.

This is the most common cause knee pain in patients below 40 years. Tracking of patella or knee cap is abnormal in these patients and they experience pain while going up or downstairs & while squatting.

Knee pain is usually associated with pain and swelling in other joints. There may be constitutional symptoms like fever, body-ache, morning stiffness, etc. Examples of this type of arthritis are Rheumatoid Arthritis, soriatic Arthritis, Ankylosing Spondylitis, Acute Rheumatic Fever, etc.

Examples of this type of arthritis are Septic and Tubercular Arthritis. Septic Arthritis is the most dangerous type which needs urgent diagnosis and treatment. Otherwise it could lead to septicaemia and a permanently damaged joint.

Knee pain may be due to injuries to the knee which can lead to Meniscal Tears, Cruciate Ligament Tears, Chondral Cartilage Tears or Fractures. Meniscal tears usually result from a twisting injury and the knee becomes painful and swollen. Patient gives history of clicking sensation. It may need Trimming of meniscus or meniscectomy which can be done with the help of key-hole surgery or Arthroscopy.

Cruciate Ligament Tears result in unstable knees and patient has difficulty in running or taking sudden turns. Many of them will improve with quadriceps strengthening exercises but if disability persists or in athletes Anterior Cruciate Ligament Reconstruction will be needed.

Tumors may be the cause of knee pain in any age group but are rare. Benign tumors are more common in young patients whereas malignant tumors are more common in middle age and older age groups. In malignant tumors there may be constitutional symptoms like fever, night sweats, body-aches etc.

How common is osteoarthritis of the knee?

40% of people over 70 years suffer from Knee Osteoarthritis (OA). 80% of patients with Knee OA have some degree of limitation of movement, and 25% cannot perform their daily activities. Patients with Knee OA experience decrease in quality of life.

What are the symptoms of knee osteoarthritis ?

Initially patients complaint of pain and stiffness of the joint especially after a period of inactivity or while climbing stairs or getting up from squatting position. The pain may be felt in the front, the back or the sides of the knee. Later on, the mobility of the patient reduces and pain is felt even at rest and sleep gets disturbed. There may be other symptoms such as swelling, painful limp, giving way, locking or reduced walking distance. The leg gradually becomes deformed and may be either bow-legged or knock-kneed.

Treatment of osteoarthritis

Aims of treatment are

  • Reduction of pain
  • Improvement of function
  • Stop/ retard progression of the disease
  • Correction of deformity

Nonsurgical treatment of knee arthritis

  • Behavioural and Environmental Changes
  • It may be easier for you to cycle than to walk
  • Exercise in water may be much easier than on dry land
  • Doing little & often is better than overdoing too much at a time
  • Toilet seats, low chairs and bed can be raised
  • It is better to take showers than baths
  • Use of a walking aid can make a big difference in walking
  • Loose weight if you are overweight
  • Physical and Mechanical Interventions
  • Heat application before exercise and cold applications after exercise will reduce inflammation
  • Walking aids will reduce the loading on the knee while walking
  • Knee braces and wedged shoes have been shown to be helpful in some cases
  • Physiotherapy - Physiotherapy aims to restore function to the maximum degree possible through exercises increasing the range of movement in the joint and improving muscle strength.
  • Pharmacological Management - Simple pain-killers like paracetamol may be helpful in relieving pain initially, but if you have to take pain killer daily for a long period, it is best to consult your doctor to avoid the side effects of the pain-killer.
  • Topical analgesic creams may occasionally help relieving the pain temporarily.
  • Intra-articular injections of steroid and Sodium Hyaluronate may improve symptoms in mild and moderate degrees of arthritis.

Pharmacological approaches provide symptomatic relief from pain but can not cure or arrest the progression of the disease.

Caution

  • Do not stand for more than 10 minutes; instead use a high stool or take frequent rests.
  • Limit stair climbing; take the elevator, escalator, or ramp.
  • Avoid bending and squatting; keep items at waist level
  • Avoid low beds, chairs, and toilets; elevate them when possible

What you can do?

  • Exercise - the right kind of exercise can slow down the disease, very important in keeping the cartilage from breaking down and causing more stiffness and pain.
  • It is better to exercise for a short time frequently than for a long time only once in a while.
  • Protect your joints from injury and stress.
  • Use heat on joints before exercise for 15-20 minutes.
  • Use ice on joints after exercise for 15-20 minutes.

What are the indications of surgery?

  • Progressive limitation in activities
  • Failed medical therapy
  • Gross deformities and laxities of joints
  • Gross symptoms

What are the surgical options?

  • Arthroscopy - In cases of mild to moderate osteoarthritis when there is normal alignment, arthroscopic washout and debridement may be helpful in relieving the symptoms. It helps therapeutically if there is a degenerative meniscal tear which can be trimmed and any loose bodies may be removed or the washout may be palliative in relieving pain by diluting the inflammatory material. Arthroscopy usually relieves symptoms temporarily for somewhere between 6 months to 2 years.
  • Osteotomy - Osteotomy is done to correct deformity by removing or adding triangular wedges of bone. It is useful in preventing deterioration of joints in early osteoarthritis due to a pre-existing deformity such as a bowleg. This procedure will reduce pain but will not eliminate it altogether.
  • Total Knee Replacement - Treatment of Choice for end stage arthritis whether it is due to osteoarthritis, rheumatoid arthritis or post-injury.
  • Gross symptoms

Joint Replacement Surgery

WHAT ARE THE BENEFITS OF TOTAL KNEE REPLACEMENT?

  • TKR can relieve pain that doesn't respond to other treatment options
  • Pain reduction in 90 to 95% of the patients
  • Reduced stiffness and improved joint movement
  • Increased walking ability
  • Improved alignment of deformed joints

WHY SHOULDN’T YOU WAIT TOO LONG FOR A KNEE REPLACEMENT?

If you do not respond to medical therapy and continue to have severe pain and disability, you may as well get the operation done sooner so that you can enjoy the pain-free life sooner. It is worth noting here that more than 96% patients undergoing knee replacements have no major complications. If your arthritis has reduced your walking, the sedentary lifestyle will soften your bone and your muscles will become weak. After the operation, you will need a longer time to rehabilitate. The more you wait, the more your knees will become deformed which means that to straighten your knees, your surgeon has to do more soft tissue release that may increase your post-operative pain.

Pharmacological approaches provide symptomatic relief from pain but can not cure or arrest the progression of the disease.

COMMON POST-OPERATIVE (TKR) COURSE

  • 1. Day 1 : Standing, bending and sitting out in a chair / May take a few steps with help
  • 2. Day 2 : Walking (with aids)
  • 3.Day 4/5 : Stair climbing
  • 4. Day 5-7 : Home (with 2 walking sticks)
  • 5. Week 6 : Walking unaided (or 1 stick) / Driving
  • 6. Week 10-12: Full recovery

CLINICAL OUTCOMES OF TOTAL KNEE REPLACEMENT

  • 1. At 1 year post-op, range of movement 0-120 deg
  • 2. 95-100% survival rate at 10 years
  • 3. 85-95% survival rate at 15 years
  • 4. 80-85% survival rate at 20 years

WHAT ARE THE RECENT ADVANCES IN KNEE REPLACEMENT SURGERY?

  • 1. Objective refinements in surgical techniques e.g. Computer Assisted Surgery or Navigation System
  • 2. Improvement in implant design such as High Flex Knees
  • 3. Post operative pain control – Epidural Analgesia

COMPUTER ASSISTED SURGERY

The small percentage of failure in knee replacement surgery was attributed to:

  • 1. Difficulty in pinpointing anatomical landmarks
  • 2. Appreciating minor variations of angles with naked eye
  • 3. Inability to judge equal soft tissue tension

The introduction of computer assisted navigation techniques improved accuracy and precision of joint replacements.

The navigation unit is a sophisticated surgical tool which consists of –

  • Camera
  • Touch-screen
  • Computer base unit and
  • Increased walking ability
  • Sensors placed on patient

The computer guides the surgeon on a dynamic basis to :

  • Correct deformity
  • Equal soft tissue tension
  • Precise placement of the artificial joint

What is ahigh flexion knee?

High flexion in total knee replacement is any flexion beyond 125 degrees. Many Asian patients refuse knee replacement as they can’t squat. With high flexion implants which have a rotating platform, patients are able to kneel and pray.

Trauma Surgery

Trauma is the branch of surgical medicine that deals with treating injuries caused by an impact. Many trauma patients are the victims of car crashes, stabbings and gun shot wounds. Trauma can also be caused by falls at home in the toilet, bathroom, is in bed or fall from the bed or any small injuries after can involve certain bones & certain joints. Most common fractures that we treat in this institution are, Fracture neck of the Femur & other fracture around the shaft of the femur, distal end of the femur proximal knee joint involving knee joint, proximal tibia shaft distal tibia, Proximal Humerus that means shoulder or elbow, wrist all are very common fractures due to minor injuries from fall or low impact. In the case of severe trauma, such as a catastrophic car crash, the trauma surgeon may be one part of a surgical team that includes vascular surgeons (to repair damage to blood vessels), orthopedic surgeons (to repair broken bones) and other surgeons as needed.

WHAT ARE THE BENEFITS OF TOTAL KNEE REPLACEMENT?

  • DHS
  • AFN
  • PFN
  • LC LCPS
  • Locking Platform
  • Locking nails
  • Pelvic Fracture Surgery
  • Poly Traumas

Pelvic and Acetabular Fracture Surgery

ABOUT THE ACETABULUM

Two parts comprise the hip joint: a ball on the upper end of the thigh bone, called the head of the femur; and a socket in the pelvis known as the acetabulum. The hip joint, like other joints, is made up of specialized structural elements that serve as precisely fitting, moving parts. The head of the femur rotates freely within the smooth, concentric surfaces of the acetabulum. An extremely low friction tissue, hyaline cartilage, lines this joint as well as others in the human body. The friction between two hyaline cartilage surfaces is much less than the best man-made bearing. Acetabulum fractures often result from automobile or motorcycle accidents, falls from great heights and industrial accidents, when a accidental strong force drives the head of the femur through the acetabulum.

ABOUT ACETABULUM FRACTURES

Fractures of the acetabulum disrupt the smooth surface and precise fit of the hip joint. If the bone is allowed to heal with large gaps and irregularities, severe abrasion to and the ultimate destruction of the cartilage will result. In some cases, the bone itself will show wear. The consequence: severe hip arthritis. Patients who develop arthritis have pain when walking, loss of hip motion, and limited functional capabilities. Fractures of the acetabulum cause internal bleeding from the broken bone and the surrounding injured soft tissues. Major blood vessels may be torn, causing severe bleeding. There can be damage to internal organs, such as the bowel or bladder. The nerves that provide sensation and muscle function to the leg or that control bowel, bladder and sexual function may also be impaired.

Non-Operative Treatment

This is the traditional treatment technique and may involve traction to the leg. Recent medical studies however indicate non-operative treatment is best reserved for a minority of fractures (about 11%). Traction can prevent further displacement of the femur into the acetabulum but does not accurately reduce (reposition) acetabulum fractures and can lead to muscle atrophy and joint stiffness as well as a high incidence of arthritis.

Acetabulum Fracture Surgery

Surgery is required to obtain the best possible results for the majority of patients. Acetabulum fracture surgery preserves the hip joint by accurate reconstruction of the fractured bone. This reconstruction restores the smooth surface of the acetabulum and its accurate fit to the femoral head. In the majority of cases, arthritis is prevented and there is close to normal hip function.

Pre-Operative Treatment

Prior to surgery, patients undergo a comprehensive series of tests to obtain baseline data essential to the surgeon, medical specialists, anesthesiologist and other members of the health care team. These include an electrocardiogram, blood and urine tests, and a history and physical examination to determine any past or existing medical problems. X-rays are also obtained, including 5 standard pelvis views and CT (computed tomography) scans. Sophisticated computer software allows the technologist to make cross-sectional CT scans into three-dimensional images. These x-rays enable the surgeon to determine the fracture pattern and precise degree of displacement and to plan the surgical approach. (Figures 3 & 4).

Intra-Operative Procedure

For best results, surgery should take place within seven days of injury. The potential for difficulties and complications increases after three weeks.

Depending on the fracture pattern, one of three surgical approaches will be chosen which will give the best access for reconstruction of the acetabulum. These include the Kocher-Langenbeck approach (posterior approach), the Ilioinguinal approach (simultaneous access to both anterior & posterior portions of the pelvic ring), and the Extended iliofemoral approach (lateral approach). The patient is placed on a special operating table that applies traction to the leg during surgery and assists in reducing the fracture.

Surgery to repair acetabulum fractures is called open reduction and internal fixation. Open refers to making an incision that exposes the broken bone fragments to view. Reduction refers to the process by which the surgeon uses specially designed instruments to grasp the bone fragments and manipulate them into their normal position. Internal fixation occurs when metal screws and plates are used to hold fractured bone fragments to the unbroken portions of the pelvis.

Screws and plates (thin strips of metal with holes to accommodate screws) fix fractured bone fragments together. Typically made of stainless steel, these implants do not react with body fluids or cause an allergic response. Implants made of vitallium or titanium are also safe and effective. .

The operation itself takes between two and five hours, with a blood loss ranging from 100 to 2,000 cc’s. A blood transfusion may be necessary but only as a last resort after using the cell saver. The cell saver collects lost blood, washes the blood cells and returns them to the patient’s circulation. During surgery, drains will be placed in the surgical site, which will be removed two to three days post-operatively. The dressing covering the incision will be checked on a regular basis and changed or removed two to three days after surgery. Patients wear compression boots and anti-embolus stockings to prevent blood clots from forming in the large veins or veins traveling to the lungs.

After several months, the solidly healed bone will once again support normal function. The cartilage will also heal, filling in the now reduced fracture lines. And though the metal plates and screws implanted during surgery will become superfluous, they are also harmless. Typically, they will be left in place to avoid unnecessary surgical removal.

Total Hip Replacement

ABOUT THE ACETABULUM

Joint Replacement is not a very recent concept. Arthroplasty or Joint Replacement had its inception in the mid-nineteenth century when surgeons when surgeons attempted to produce extra-articular pseudarthrosis by simple resection of ankylosed joints but failed as these joints were not stable. Several investigators tried Interpositional Arthroplasty with muscle, fat, fascia, Bakelite, Glass, etc.which led to early failures. In 1940, Smith-Petersen developed the Vitallium mould Interpositional Arthroplasty which produced comparatively good results.

The modern era of Total Hip Replacement began in the 1960s when Sir John Charnley developed the principles of low-friction Arthroplasty for Total Hip Replacement. Now this is a fairly routine operation and the chances that you’ll be completely happy with the outcome of Total Hip Replacement are about 98%.

The conventional Total Hip Prosthesis consists of a stemmed stainless steel component for the femoral head articulating with a high density polyethylene acetabular component and both being securely fixed to the supporting bone with polymethylmethacrylate cement.

Recent Developments in Total Hip Replacement

Fractures of the acetabulum disrupt the smooth surface and precise fit of the hip joint. If the bone is allowed to heal with large gaps and irregularities, severe abrasion to and the ultimate destruction of the cartilage will result. In some cases, the bone itself will show wear. The consequence: severe hip arthritis. Patients who develop arthritis have pain when walking, loss of hip motion, and limited functional capabilities. Fractures of the acetabulum cause internal bleeding from the broken bone and the surrounding injured soft tissues. Major blood vessels may be torn, causing severe bleeding. There can be damage to internal organs, such as the bowel or bladder. The nerves that provide sensation and muscle function to the leg or that control bowel, bladder and sexual function may also be impaired.

The plastic socket made of Ultra High Molecular Weight Polyethylene is the implant’s weakest point as the plastic wears away at a rate of about one mm per year against a metal ball giving the artificial joint a life expectancy of about 15 years.

Recently developed Cross-Linked Polyethylene wear at a slower rate in the lab and are expected to increase the life expectancy of the implants. Microscopic plastic debris produced by daily wear may migrate between the implant and the bone. The body reacts to these foreign particles by producing osteolytic enzymes that erodes the bone leading to loosening of the implants.

The metal parts of the implants are made up of Cobalt-chrome or Titanium which are extremely well tolerated by the body.Recently developed Metal-on-Metal Hips where both ball and socket are made up of Cobalt-chromehave very low wear rates and allow greater range of movements in the hips compared to plastic sockets. However, there is a growing concern about the long-term frictional release of cobalt or chrome ions from the joint which may lead to Metallosis.

Most recent development is Ceramic-on-Ceramic hips where the ball and socket are made of ceramic, usually Aluminium Oxide. Rate of wear is even less than with metal-on-metal surfaces, and there are no metallic ions to worry about. There is a small risk of ceramic component fracturing (1 in 25,000) which may require re-operation. The ceramic-on-ceramic total hip is the best modern implant for all patients, especially for the young and the active. The drawback is that they are comparatively much more expensive than the conventional implants.

Revision Joint Replacement

The replaced joints may fail after 10 to 15 years or occasionally earlier. The parts may wear out or become loose or they may break. The porous surfaces of cementless implants may not properly bond to the bones leading to loosening. In these cases, an operation will be required to replace the damaged part or even the entire implant. Another common reason for revision surgery especially in India is infected joint replacement where the infected artificial joint needs to be removed followed by a waiting period for elimination of infection and later re-implantation

Revision Joint Replacement is a much more complex and technically difficult operation that requires a long operating time. These technically demanding operations should be performed by a surgeon skilled in both first-time joint replacement as well as revision surgery.

The magnitude of revision surgery depends on the difficulty of implant removal and the quantity and quality of bone remaining after removal of implants. The revision operations may require special kinds of prostheses and bone grafts form your pelvis or bone banks to take care of the residual bone defects.

In cases of revision hip replacements, the bone may need to be cut to remove the implants which may then require wires to hold the bones together till healing. There is a chance that you may have a shorter or longer leg than it was before the operation. There is a high risk of hip dislocation for about 3 months after revision surgery and you must follow the restrictions strictly to prevent any dislocation. The range of movement may be significantly less compared to a first-time joint replacement.

The cost of revision surgery may be significantly higher than a first-time joint replacement as you may require special implants along with increased operative time, increased length of hospital stay and the need for longer duration of antibiotics