Knee Replacement Surgery is one of the most common types of joint replacement procedures performed nowadays. Ideal candidates for knee replacement surgery are people whose legs have become painful & stiff or in case their knees have developed angular deformities like genu valgus (knock knee deformity) & genu varus (bowlegged deformity). People whose knees are preventing them from engaging in activities which are important & when other operative or non-operative treatments have failed to bring positive results may also benefit from knee replacement surgeries. Bone & cartilage at the top of shin bone (tibia) & at the end of thigh bone (femur) are normally removed during knee replacement surgery. Precise instruments are thereby utilized in order to create surfaces which will perfectly accommodate the joint implants. Robotic technology & computer navigation have wonderfully contributed so as to improve precision & allow doctors to make predictable results. Metal implants which are shaped like natural femur are placed on femur during surgery. Plastic inserts & a metallic tray are also implanted on top of tibia. The surface underneath patella or kneecap is removed & replaced with a plastic button. Now, when this newly organized knee moves, it is only the specialized plastic which is moving against the newly attached femoral component which eventually eludes pain.
Read : Affordable Revision Total Knee Replacement Surgery in India
Total Knee Replacement Surgery (TKR)
Also known as Total Knee Arthroplasty, Total Knee Replacement Surgery is a surgical intervention which replaces arthritic knee joints with another artificial plastic or metal replacement components called ‘prostheses’. Normally recommended for older patients who are suffering from pain & loss of function due to arthritis & have failed to yield results from conservative methods of therapy, total knee replacement surgery effectively replaces ends of thigh bone & shin bone with plastic prosthesis.
Reasons for Total Knee Replacement Surgery
- Infection in Knee Joint
- Increased Stress like Overweight & Overuse
- Trauma including Fracture
- Connective Tissue Disorders
- Inflammation like in Rheumatoid Arthritis
- Inactive Lifestyle causing Obesity (additional weight puts extra force on joints which can also lead to arthritis over a period of time
Read: Knee Replacement Surgery In India
Conditions Caused by an Arthritic Knee
- Cartilage lining gets thinner than normal or is completely absent. Degree of inflammation & cartilage damage however varies with stage & type of arthritis.
- Capsule of an arthritic knee is swollen.
- Knee joint space is irregular & narrowed in outline. This can easily be seen in a X-ray image.
- Excessive bone or bone spurs can also develop around edges of joints.
- Either singly or a combination of these factors eventually cause stiffness in arthritic knees & drastically limit activities due to fatigue or pain.
Diagnosing Osteoarthritis
Diagnosing of osteoarthritis is generally based on the patient’s history, X-rays & a physical examination. There are no blood tests which can diagnose osteoarthritis.
Benefits of Total Knee Replacement Surgery
Decision to proceed with TKR procedure is a cooperative effort between the patient, the surgeon, family & the local doctor. Benefits following TKR surgery include relief from symptoms of arthritis including some of the following.
- Severe pain which limits everyday activities like walking, getting in & out of chair, visiting friends, shopping, gardening & others.
- Pain which wakes up patients at night.
- Bowleg or Knock Knee deformities.
- Stiffness in joints.
Patients generally try a variety of conservative treatments like anti-inflammatory medications, weight loss therapies, simple analgesics, canes, modification of activities and/or physical therapies prior to TKR surgery. Only after these have failed is the right time to consider total knee replacement surgery. Moreover, most patients undergoing TKR surgery are between 60 – 80 years of age. However, each patient is individually assessed & even people as young as 20 years or as old as 90 years are occasionally operated upon for TKR & with good results.
Read: Knee Joint Replacement Surgery Cost In India
Preparing for Total Knee Replacement Surgery
- Surgeons will send TKR patients for routine blood tests & other investigations which are normally required prior to undergoing surgery.
- Patients will also be asked to undertake a general overall health check with a physician.
- Patients are expected not to have undergone any treatment for dental, medical or surgical problems in recent past.
- Patients are expected & advised to make arrangements for post-operative domestic help prior to surgery.
- Patients should stop taking aspirin or other anti-inflammatory medications at least 10 days prior to date of surgery as they can cause excessive bleeding.
- Patients should also cease to take any herbal or naturopathic medications at least 10 days prior to undergoing TKR surgery.
- Patients will also need to stop smoking or consuming tobacco at least 6 weeks prior to undergoing TKR surgery.
Total Knee Replacement Surgery Procedure
- On the day of TKR Surgery
- Patients will be admitted to hospital, most probably on the day of TKR surgery.
- They may have to undergo further medical tests on admission.
- Patients will meet nurses & answer some questions which are necessary for medical records.
- They will subsequently meet the anesthetist, who will also ask them a few questions.
- Patients are provided hospital clothing & asked to change into them after having a shower prior to surgery.
- TKR operation site will be cleaned & shaved approximately 30 minutes prior to surgery.
- Patients are subsequently transferred to the operation theater.
TKR Surgical Procedure
Every knee is individual & knee replacement surgeries take this into account by providing different sizes for knee replacement. In cases where patients have more than the usual amount of bone loss, extra pieces of bone or metal are also sometimes added. Surgery is typically performed under sterile conditions in an operation theater under the influence of spinal or general anesthesia. Patients will lie on their back & a tourniquet will be applied to upper thigh so as to reduce blood loss. Total knee replacement surgery will take about two hours of time to complete. Surgeons will then cut down to the bone in order to expose bones of knee joint as the next step of surgery. Damaged portions of tibia & femur are cut at appropriate angles with the help of specialized jigs. Trial components are subsequently inserted so as to check accuracy of cuts & to determine if thickness of plastic which is required to be placed in between these two components. Patella or knee cap may now be placed depending upon a number of factors & on the surgeon’s choice. Real components will then be inserted with or without cement & the knee will be checked again so as to make sure that everything is properly functioning. Knee is then carefully closed & drains inserted. The operated knee is finally dressed & bandaged as required.
Surgical Approach for Total Knee Replacement
Total knee replacement surgery is performed through an incision made in front of the knee. There are quite a few different ways to handle extensor mechanism & soft tissue of the knee which are separately discussed below. However, each approach is having its advantages & disadvantages.
Medial Parapatellar Approach – Incision in medial parapatellar approach involves cutting quadriceps tendon above the knee cap & around the inside of knee cap. This tendon is subsequently repaired at the end of the total knee replacement procedure. Idea behind cutting the tendon is that this might heal better than when muscle belly of VMO is cut. Patella is also typically flipped during this approach & which allows surgeons to gain access to the knee joint. Moreover, this may or may not affect knee rehab within the short term.
Mid-Vastus Approach – This approach cuts into the VMO muscle belly & around inside of knee cap instead of cutting the quadriceps tendon. The idea behind leaving large portion of VMO attached to quadriceps is that VMO muscle may be able to help knee extension strength & patellar tracking. Muscle belly is eventually repaired at the end of total knee replacement procedure. Moreover, patella may or may not be flipped during the mid-vastus approach.
Sub-Vastus Approach – This approach basically elevates the VMO muscle instead of cutting through it. Patella is also typically not flipped in this approach. Sub-vastus approach is however difficult in muscular patients having large VMO muscles & which generally makes this operation a little bit harder. Moreover, quadriceps muscle strength & patella tracking may temporarily improve with this approach in short term, but will show no long term differences after a few months.
Quad-Sparing Approach – This approach cuts just inside the knee cap. Quad-sparing approach however requires specially designed side cutting instruments. Moreover, there is a steep learning curve regarding use of these instruments & many surgeons worry about the accuracy of bone cuts & limb alignment while using these side cutting instruments. Although quad-sparing approach has received some press coverage, it has not yet caught on among orthopedic surgeons.
Lateral Parapatellar Approach – This is an uncommon approach where incision extends around the outside (lateral) of knee cap. Quite a few orthopedic surgeons would use lateral parapatellar approach for severe valgus deformities.
Good results following total knee replacement surgery can be achieved with any of the above mentioned approaches. Patients should however make it a point to allow surgeons to perform the procedure through whichever approach they are most comfortable with.
Total Knee Replacement Surgery Aftercare
When patients wake up after total knee replacement surgery, they will be in recovery room with intravenous drip in arm, a catheter in bladder along with a number of monitors checking on vital observation. They are usually provided with a button to press for pain medication provided through a Patient Controlled Analgesia (PCA) machine. Patients will subsequently be shifted to a ward when they are stable. Postoperative protocol is largely surgeon dependent but drain in general will be removed after 24 hours. Patients will sit out of bed & start moving knee & walk around within a day or two following total knee replacement surgery. Dressing will also now be reduced on the 2nd post operative day in order to make movement easier for the patient. Rehab & mobilization will however be supervised by physical therapists. It is important for patients to breathe deeply & cough up phlegm in case they have. Orthopedic surgeons will selectively use stockings, inflatable leg coverings & injections into abdomen to thin DVT’s or blood clots in legs. Long term results of total knee replacement surgery will depend upon how much care patients take following the operation. Patients will normally remain in hospital for about 5 – 7 days time after which depending upon their needs they may either return home or join a rehabilitation facility. Patients will however invariably need to undergo physical therapy on knee following total knee replacement surgery.
Recovery at Home Following Total Knee Replacement Surgery
Patients will be discharged from hospital either on crutches or a walker & will usually progress to a cane within 6 weeks. Sutures are at times dissolvable, but in case they are not, they will need to be removed around the 10th day following total knee replacement surgery. Bending the knee will vary from one patient to another, but by 6 weeks of time, they should normally bend to 90 degrees at least. However, the goal is to obtain a 110 115 degrees movement. Patients may also shower once the incision site is healed & drive about 6 weeks after TKR surgery as they regain control of leg. Patients should overall be comfortably walking by the end of 6 weeks. Other strenuous physical activities like sports may take about 3 months of time to be comfortably possible. Patients will also need to take special precautions around home so as to make it safe. They may need to add rails in bathrooms or may be required to modify sleeping arrangements, especially when they are upstairs. TKR surgery patients usually have a check up with the surgeon at the end of 6 weeks & who will evaluate their progress. Patients should also continue to see surgeons for the rest of their life in order to check their knees & take X-rays as required. This is extremely important as at times knee may feel excellent but can have problems which can only be recognized through X-rays. Moreover, TKR patients are always at risk of infections especially when bacterial germs can get into the bloodstream & find their way to the knee while undergoing dental treatments or some other surgical procedures.
Risks & Complications Associated with Total Knee Replacement Surgery
It is quite important that patients are informed about risks & complications associated with total knee replacement surgery prior to undergoing the procedure. Like with all major surgeries, TKR surgery also involves potential risks. However, decision to proceed with this procedure is made largely because advantages outweigh potential disadvantages. Complications arising out of TKR surgery can either be medical (general) or local which are specific to the knee.
Medical Complications of TKR Surgery
Medical or general complications largely include those of anesthesia & overall well being. Almost any medical condition can occur following TKR surgery of which some are listed below.
- Allergic reactions to anesthesia & medications.
- Blood loss which may require blood transfusion with low risk of disease transmission.
- Bladder Infections, Pneumonia, Kidney Failure, Strokes & Heart Attack.
- Complications from nerve blocks like infection or damage to nerves.
- Serious medical problems leading to ongoing health concerns requiring prolonged hospitalization or death in rare cases.
Local Complications of TKR Surgery
Infection – Infection at incision site can occur with any type of surgery. This can be superficial or deep in knee with TKR surgery. However, infection rates vary & when they occur they can be effectively treated with antibiotics & may also require further surgery in some cases. The new knee may rarely be needed to remove in order to eradicate infection.
Deep Venous Thrombosis (Blood Clots) – These may originally form in calf muscles & subsequently travel to lungs so as to cause pulmonary embolism. This can occasionally be a serious problem & even life threatening in some cases. TKR surgery patients must therefore notify the surgeon in case they experience pain in calf or shortness of breath at any stage.
Stiffness in Knee – The new knee should ideally bend beyond 100 degrees, but occasionally it may not be able to bend as expected. Manipulations are therefore required sometimes, which means the TKR surgery patient will have to go back to the operating room where the knee is bent for the patient under the influence of anesthesia.
Wear & Tear – Plastic liner inside the new joint may eventually wear out over time, which is usually between 10 – 15 years, & may then require to be changed.
Wound Irritation or Breakdown – TKR operation will cut & disturb some skin nerves. Patients will therefore inevitably experience some numbness around the wound. This will however not affect the functioning of the new joint. Patients can also feel some aching around the scar. Massaging & vitamin E cream can effectively help reduce this condition. Occasionally, patients also experience reactions to sutures or wound breakdown which may require a course of antibiotics or in rare cases further surgery.
Cosmetic Appearance – Sometimes the knee may look different than it was earlier. This is because it is now put into the correct alignment in order to allow proper functioning.
Inequality in Leg Length – This limb length discrepancy following TKR surgery is due to the fact that the corrected knee is straight now than before, & this change is unavoidable.
Dislocation – This is an extremely rare condition where ends of knee joint lose contact with each other. Plastic inserts can also sometimes lose contact with tibia or the femur.
Patella Problems – Knee cap or patella can also dislocate sometimes; which means that it has moved out of place & can therefore loosen or break.
Ligament Injuries – There are a number of ligaments which surround the knee which be torn, stretch or break during TKR surgery or at any other time afterwards. Another surgery may however be required so as to correct this problem.
Damage to Blood Vessels & Nerves – It is very rare that blood vessels & nerves get damaged during TKR surgery. In such a possibility, a second operation may be required for repairing. Nerve damage can cause loss of movement or feeling below the knee & which can also be permanent.
Fractures or Breaks in Bone – This can occur during TKR surgery or afterwards due to a fall. It may effectively be repaired but may require surgery to do so. Therefore, it is advisable that patients thoroughly discuss their concern with orthopedic surgeons prior to undergoing TKR surgery.
Total Knee Replacement Surgery Outcomes
Surgery as such is not a pleasant prospect for any person. But for some people suffering from severe arthritis it could be the difference between leading normal lives, or, having to put up with debilitating conditions. TKR surgery therefore can be regarded as a part of treatment plan which may help restore function to damaged joints while relieving pain. TKR surgery is one of the most successful operations performed nowadays. This is an excellent surgical intervention which is designed to improve the patient’s quality of life which takes away pain & improves function. Depending upon the age & activity level of the patient, almost 90 – 95 percent of total knee replacement surgeries generally survive for over 15 years. Moreover, TKR surgery is offered only when non-operative treatments for severe knee arthritis have failed. Therefore, this is an important decision which is to be made & ultimately is based on an informed decision between the patient & his surgeon along with the family & general practitioner. Though most people are extremely happy with their new knee from TKR surgery, complications can also occur & patients must be well aware of these prior to taking a decision. It is therefore best for patients to wait who are undecided, until they are sure of undergoing TKR surgery for their arthritis problems.
Cost of Total Knee Replacement Surgery in India
Total knee replacement or TKR surgery is a complex procedure which requires an orthopedic surgeon make precise measurements & skillfully remove diseased portions of bone so as to shape the remaining structure of bone to accommodate knee implants. Healthcare infrastructure & surgical quality of orthopedic treatments in India are excellent & at par with the best in the world. Moreover, India has fast emerged as a leading medical tourism destination in the new world providing a wide spectrum of affordable healthcare solutions to international tourists seeking low cost medical procedures away from their homeland. HealthYatra.com is a globally reputed online healthcare tourism platform offering a variety of low cost medical procedures including orthopedic treatments like total knee replacement surgery for international patients without any waiting period. Consultants associated with HealthYatra.com would also be glad to combine an exotic vacation at reasonable costs so as to make your healthcare journey to India a memorable experience.