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Total Knee Arthroplasty / Replacement (TKA/TKR)

Total knee replacement, also called arthroplasty, is a surgical procedure to resurface a knee damaged by arthritis. Metal and plastic parts are used to cap the ends of the bones that form the knee joint, along with the kneecap. This surgery may be considered for someone who has severe arthritis or a severe knee injury.

Various types of arthritis may affect the knee joint. Osteoarthritis, a degenerative joint disease that affects mostly middle-aged and older adults, may cause the breakdown of joint cartilage and adjacent bone in the knees. Rheumatoid arthritis, which causes inflammation of the synovial membrane and results in excessive synovial fluid, can lead to pain and stiffness. Traumatic arthritis, arthritis due to injury, may cause damage to the cartilage of the knee.

The goal of knee replacement surgery is to resurface the parts of the knee joint that have been damaged and to relieve knee pain that cannot be controlled by other treatments.

Hospital Stay: Hospital Stay: 7 days
Duration: Duration: 2 hrs
Cost Estimate: Cost Estimate: 5000 USD - 13800 USD These are indicative prices in Indian Hospitals

Anatomy of the Knee

Joints are the areas where 2 or more bones meet. Most joints are mobile, allowing the bones to move. Basically, the knee is 2 long leg bones held together by muscles, ligaments, and tendons. Each bone end is covered with a layer of cartilage that absorbs shock and protects the knee.
There are 2 groups of muscles involved in the knee, including the quadriceps muscles (located on the front of the thighs), which straighten the legs, and the hamstring muscles (located on the back of the thighs), which bend the leg at the knee.
Tendons are tough cords of connective tissue that connect muscles to bones. Ligaments are elastic bands of tissue that connect bone to bone. Some ligaments of the knee provide stability and protection of the joints, while other ligaments limit forward and backward movement of the tibia (shin bone).
The knee consists of the following:

  • Tibia – This is the shin bone or larger bone of the lower leg.
  • Femur – This is the thighbone or upper leg bone.
  • Patella – This is the kneecap.
  • Cartilage – A type of tissue that covers the surface of a bone at a joint. Cartilage helps reduce the friction of movement within a joint.
  • Synovial membrane – A tissue that lines the joint and seals it into a joint capsule. The synovial membrane secretes synovial fluid (a clear, sticky fluid) around the joint to lubricate it.
  • Ligament – A type of tough, elastic connective tissue that surrounds the joint to give support and limits the joint’s movement.
  • Tendon – A type of tough connective tissue that connects muscles to bones and helps to control movement of the joint.
  • Meniscus – A curved part of cartilage in the knees and other joints that acts as a shock absorber, increases contact area, and deepens the knee joint.

Reasons for Total Knee Arthroplasty

Knee replacement surgery is a treatment for pain and disability in the knee. The most common condition that results in the need for knee replacement surgery is osteoarthritis. Osteoarthritis is characterized by the breakdown of joint cartilage. Damage to the cartilage and bones limits movement and may cause pain. People with severe degenerative joint disease may be unable to do normal activities that involve bending at the knee, such as walking or climbing stairs, because they are painful. The knee may swell or “give-way” because the joint is not stable. Other forms of arthritis, such as rheumatoid arthritis and arthritis that results from a knee injury, may also lead to degeneration of the knee joint. In addition, fractures, torn cartilage, and/or torn ligaments may lead to irreversible damage to the knee joint.

If medical treatments are not satisfactory, knee replacement surgery may be an effective treatment. Some medical treatments for degenerative joint disease may include, but are not limited to, the following:

  • Anti-inflammatory medications
  • Glucosamine and Chondroitin Sulfate
  • Pain medications
  • Limiting painful activities
  • Assistive devices for walking (such as a cane)
  • Physical therapy
  • Cortisone injections into the knee joint
  • Viscosupplementation injections (to add lubrication into the joint to make joint movement less painful)
  • Weight loss (for obese persons)

Before the Surgery

  • In addition to taking a complete medical history, the doctor may perform a complete physical examination to ensure that the patient is in good health before undergoing the procedure. The patient may undergo blood tests or other diagnostic tests.
  • Notify the doctor if the patient is sensitive to or are allergic to any medications, latex, tape, and anaesthetic agents (local and general).
  • Inform the doctor of all medications (prescribed and over-the-counter) and herbal supplements that the patient is taking.
  • Notify the doctor if the patient has a history of bleeding disorders or if he/she is taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for to stop these medications prior to the procedure.
  • If the patient is pregnant or suspect that she is pregnant, the doctor should be notified.
  • The patient will be asked to fast for eight hours before the procedure, generally after midnight.
  • A sedative is usually given prior to the procedure to help the patient relax.
  • A physical therapist may meet the patient prior to surgery to discuss rehabilitation.

During the Surgery

Knee replacement requires a few days’ stay in the hospital. Knee replacement surgery is most often performed under general anaesthesia. The anaesthesiologist will discuss this with the patient in advance. Generally, knee replacement surgery follows this process:

  • The patient will be asked to remove clothing and will be given a gown to wear.
  • An intravenous (IV) line may be started in the arm or hand.
  • The patient will be positioned on the operating table.
  • A urinary catheter may be inserted.
  • If there is excessive hair at the surgical site, it may be clipped off.
  • The anaesthesiologist will continuously monitor heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
  • The skin over the surgical site will be cleansed with an antiseptic solution.
  • The doctor will make an incision in the knee area.
  • The doctor will remove the damaged surfaces of the knee joint and resurface the knee joint with the prosthesis. The knee prosthesis is made up of metal and plastic. The most common type of artificial knee prosthesis is a cemented prosthesis. Uncemented prostheses are not commonly used anymore. A cemented prosthesis attaches to the bone with surgical cement. An uncemented prosthesis attaches to the bone with a porous surface onto which the bone grows to attach to the prosthesis. Sometimes, a combination of the 2 types is used to replace a knee. The prosthesis is generally comprised of 3 components: the tibial component (to resurface the top of the tibia, or shin bone); the femoral [thigh bone] component (to resurface the end of the thighbone; and the patellar component (to resurface the bottom of the kneecap that rubs against the thighbone).
  • The incision will be closed with stitches or surgical staples.
  • A drain may be placed in the incision site to remove fluid.
  • A sterile bandage or dressing will be applied.

After the Surgery

After the surgery the patient will be taken to the recovery room for observation. Once the patient’s blood pressure, pulse, and breathing are stable and he/she is alert, the patient will be taken to the hospital room. Knee replacement surgery usually requires an in-hospital stay of several days.

It is important to begin moving the new joint after surgery. A physical therapist will meet the patient soon after surgery and plan an exercise program. A continuous passive motion (CPM) machine may be used to begin the physical therapy. This machine moves the new knee joint through its range of motion while the patient is resting in bed. Pain will be controlled with medication so that the patient can participate in the exercise. An exercise plan will be given to be followed both in the hospital and after discharge.

The patient will then be discharged home. Physical therapy will continue until the patient regains muscle strength and good range of motion.

Rehabilitation

Once the patient is home, it is important to keep the surgical area clean and dry. Specific bathing instructions will be given. The stitches or surgical staples will be removed during a follow-up visit. To help reduce swelling, the patient may be asked to elevate the leg or apply ice to the knee.

Pain relievers can be taken for soreness as recommended by the doctor. Aspirin or certain other pain medications may increase the chance of bleeding. Hence it is important to take only recommended medications.

The doctor should be notified if any of the following occur:

  • Fever
  • Redness, swelling, bleeding, or other drainage from the incision site
  • Increased pain around the incision site

Normal diet can be resumed unless the doctor advises differently. The patient should not drive until the doctor allows it. Other activity restrictions may apply. Full recovery from the surgery may take several months.

It is important that the avoid falls after knee replacement surgery, because a fall can result in damage to the new joint. The physical therapist may recommend an assistive device (cane or walker) to help the patient walk until his/her strength and balance improve.
Making certain modifications at home may help during the recovery. These modifications include, but are not limited to, the following:

  • Proper handrails along all stairs
  • Safety handrails in the shower or bath
  • Shower bench or chair
  • Raised toilet seat
  • Long-handled sponge and shower hose
  • Dressing stick
  • Sock aid
  • Long-handled shoe horn
  • Reaching stick to grab objects
  • Removing loose carpets and electrical cords that may cause the patient to trip
  • Avoiding stair-climbing until recommended by the doctor

Complications

As with any surgical procedure, complications can occur. Some possible complications may include, but are not limited to, the following:

  • Bleeding
  • Infection
  • Blood clots in the legs or lungs
  • Loosening or wearing out of the prosthesis
  • Fracture
  • Continued pain or stiffness

The replacement knee joint may become loose, be dislodged, or may not work the way it was intended. The joint may have to be replaced again in the future.
Nerves or blood vessels in the area of surgery may be injured, resulting in weakness or numbness. The joint pain may not be relieved by surgery. There may be other risks depending on the patient’s specific medical condition.

Outlook

With proper care and rehabilitation, a total knee arthroplasty (TKA) may last 20 years or longer. More than 85%-90% of replaced knee joints continue to work 10 years after surgery.

There’s no precise formula for determining when you should have a knee replacement. But if you’re having trouble getting up to answer the phone or walk to your car, you may be a candidate. A thorough examination by an orthopaedic surgeon should yield a recommendation. It might also be beneficial to receive a second opinion.

For some, lifestyle modifications, physical therapy, medication, or alternative treatment methods can help manage knee problems. Also, you may want to speak to your surgeon about other procedures that are commonly recommended before resorting to knee replacement surgery, including steroid or hyaluronic acid injections and arthroscopic surgery that addresses the damaged cartilage.
However, delaying or declining a necessary knee replacement could result in a less favourable outcome. Ask yourself: Have I tried everything? Is my knee holding me back from doing the things I enjoy?

The surgeon will make an incision on the top of your knee in order to expose the damaged area of your joint. The standard incision size can be as long as 10 inches, but a minimally invasive procedure can result in incisions as short as 4 inches. During the operation, the surgeon moves your kneecap aside and cuts away damaged bone and cartilage, which are then replaced with new metal and plastic components. The components combine to form a synthetic (but biologically compatible) joint that mimics the movement of your natural knee. Most knee replacement procedures take 1.5 to 2 hours to complete.

Implants are comprised of metal and medical-grade plastic. To seal these components to your bone, two methods are used: bone cement, which typically takes about 15 minutes to set; and a cement-less approach that uses components with a porous coating that grows into tissue or attaches to bone. In some cases, a surgeon may use both techniques in the same surgery.

Any surgery with anaesthesia has risks. However, complication rates and mortality for general anaesthesia are extremely low. An anaesthesia team will determine whether general anaesthesia or spinal, epidural, or regional nerve block anaesthesia is best.

Although you will experience some pain after surgery, it should diminish quickly—within four or five days max. Your doctor will most likely prescribe medication to help you manage the pain, which will be administered intravenously (IV) immediately after surgery. After you are released from the hospital, you will switch to painkillers taken in a pill or tablet form. After you have recovered from surgery, you should experience significantly less pain in your knee but there’s no way to predict exact results—some patients have knee pain for a full year after the surgery. Your willingness to engage in physical therapy and make lifestyle modifications can have a significant impact on your post-surgery level of pain and adjustment to the implant.

You will wake up with a bandage over your knee and, in most cases, a drain to remove fluid from the joint. It is likely that you will wake up with your knee elevated and cradled in a continuous passive motion (CPM) machine that gently extends and flexes your leg while you are lying down. A doctor might also insert a catheter so you don’t have to get out of bed to get to a toilet. In addition, you may wear a compression bandage or sock around your leg to improve blood circulation and reduce the odds of a clot. Your doctor will administer antibiotics intravenously and you may receive anticoagulants (blood thinners) to reduce the odds of a clot. Many patients experience an upset stomach during the immediate post-surgery period—this is normal, and your doctor or nurse can help provide medication to ease stomach pain.

Most patients are up and walking within a day or two—with the aid of a walker or crutches. A physical therapist will help you bend and straighten your knee a few hours after your surgery.
After you return home, physical therapy will continue regularly for weeks and you will be asked to engage in specific exercises designed to improve the functionality of the knee. If your condition is more severe, or if you don’t have the needed support at home, the doctor may recommend you first stay at rehabilitation or nursing facility, though this is rare. During the weeks after surgery, your doctor will wean you from pain medication.

If you live in a multiple story house, prepare a bed and space on the ground floor so that you can avoid the stairs when you first return. Make sure the house is free of obstructions and hazards including power cords, area rugs, clutter, and furniture. Focus specially on pathways, hallways, and other places where you are likely to have to walk through. It’s wise to make sure that handrails are secure and a grab bar is available in the tub or shower you plan to use. You may want to add a bath/shower seat.

Your doctor will likely recommend that you use a CPM machine at home, while lying on a flat surface or bed. You may be sent home from the hospital with this device, but if you aren’t, your doctor or therapist can arrange that one be delivered to you. A CPM machine helps to increase your knee motion during the first few weeks after surgery, and is usually prescribed to slow the development of scar tissue and to help you achieve the maximum range of motion from your implanted knee. It is crucial to use the device as prescribed by your doctor or PT.
Additionally, your doctor will prescribe mobility equipment that you need, like a walker, crutch, etc.

You should be able to resume normal daily activities—such as walking and bathing—within several days. Low impact exercise should also be doable after your rehabilitation period, typically six to 12 weeks. Consult with your physical therapist about introducing new activities during this rehabilitation period. You should avoid running, jumping, bicycling up and down hills and other high impact activities.

Studies show that upwards of 85 percent of patients still have a functioning artificial joint 20 years after receiving it. However, wear and tear on the joint can adversely affect its performance and lifespan. Younger patients are more likely to have the joint wear out and require a revision during their lifetime. Consult with a doctor about what’s right for you.

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