Osteoarthritis

Osteoarthritis [OA] denotes wear and tear of a joint. It commonly affects the knees since they bear the weight of the body. Osteoarthritis affects the cartilage that covers the joint surfaces. The cartilage begins to degenerate and the fluid between the joint decreases. Gradually, the cartilage thins and cracks. Over time, it gets wears out, exposing bone surfaces. The exposed bones rub against each other, causing pain while moving.

Osteoarthritis usually affects the weight bearing sections of the knee, which include the junction of the lower leg bone (tibia) with the upper leg bone (femur), and beneath the kneecap (patella). The disease may affect only one section of the knee, leaving the two other sections relatively healthy. While anti-inflammatory drugs, cortisone injections, and physical therapy are short-term solutions to managing the pain, many people eventually require knee replacement surgery.

Types of arthritis

While the Arthritis Foundation supports interventions for all types of arthritis and related conditions with information and other assistance, the organization concentrates on three forms of the disease:

• Osteoarthritis (OA), a degenerative joint disease characterized by the breakdown of joint cartilage. It’s the most common form of arthritis, affecting 27 million Americans, most over the age of 45.

• Rheumatoid arthritis (RA), a systemic autoimmune disease that affects the entire body and is characterized by the inflammation of the membrane lining the joint, causing stiffness, warmth, redness and swelling. An estimated 1.5 million Americans have RA, which attacks twice as many women as men.
• Juvenile arthritis (JA), which affects 294,000 American children and can cause joint swelling and pain, eye inflammation, activity limitations and growth problems.

The Arthritis Foundation also provides helpful information and tips about other types of arthritis, including (but not limited to):

• Lupus, a chronic inflammatory disease that can affect various parts of the body, especially the skin, joints, blood and kidneys. It affects at least 239,000 Americans, eight to 10 times more women than men.
• Gout, which affects an estimated 3 million Americans, causing sudden, severe attacks of pain, redness, warmth and swelling in some joints, often the big toe, and affecting more men than women.
• Fibromyalgia, an arthritis-related condition characterized by general muscular pain and fatigue that affects about 5 million Americans, more often women than men.
• Psoriatic arthritis, a type of chronic inflammatory arthritis associated with the skin condition psoriasis, affecting 2 percent of the U.S. population.

Signs and symptoms

Regardless of the type of arthritis, the common symptoms for all arthritis disorders include varied levels of pain, swelling, joint stiffness, and sometimes a constant ache around the joint(s). Arthritic disorders like lupus and rheumatoid can also affect other organs in the body with a variety of symptoms.

How is OA treated?

Not everyone with OA needs surgery.

In the early stages, lifestyle changes, correct footwear and physiotherapy to stretch and strengthen the thigh muscles bring relief to the degenerating knees. Losing weight helps as it reduces the pressure on the joints. Lifestyle changes like following a good posture, avoiding taking the stairs and staying hydrated are beneficial too. Pain relief measures such as anti-inflammatory medications and local applications help, but the relief is temporary.

Keyhole surgery like arthroscopy has shown its worth in early cases of knee wear.

However, if the degeneration is not controlled by these measures, total knee replacement is suggested.

What is Total Knee Replacement?

In total knee replacement or TKR surgery, the degenerated parts are shaved off and substituted with smooth surfaces made of artificial material. Contrary to popular belief, the whole knee is not replaced, only the affected surfaces are.

The newly-constructed knee almost behaves and moves like a normal joint. A metal cap covers the thigh bone, a plastic trough forms the upper end of the leg bone and a plastic disc is implanted on the lower surface of the kneecap.

Am I eligible for a TKR?

If  one has arthritis of the knee and have run out of conservative options for treatment, and are otherwise medically fit, he could have a knee replacement. If one find walking or performing simple everyday activities such as getting up from a chair difficult, it may be time to consider knee replacement surgery.

Who cannot opt for a TKR?

• A person with active infection in the arthritic joint, elsewhere in the body or in the skin near the troubled knee, should refrain from or defer TKR.
• Persons with compromised cardiac function, severe uncontrolled diabetes and hypertension should also be cautious.

How is TKR actually done?

The surgery is performed under anaesthesia(Epidural anaesthesia). The anaesthesia is such that it provides up to 48 hours of post-operative pain relief, and allows for faster, more comfortable progress in physical therapy.

The skin over the knee is sterilised. Next, a tourniquet is applied at the thigh to temporarily stop blood supply to the knee ,to preventing blood loss during the operation. A cut is made through the skin and the muscles to expose the knee joint. The joint is then cleaned by removing extra bone growths and damaged tissue. The tight soft tissues are released to adequately expose the surfaces of the bones. All this is done using specialised devices. Then, trial implants are positioned on the exposed bones. Placing of the trial implants ensures that the alignment of the knee is correct. The trial implants are taken through the range of full movement and other intricacies such as ligament balance.

Finally, the trial implants are removed and final implants are pressed onto the bone ends with a layer of cement between the implants and the bones. The components are held in place till the cement hardens. A drainage tube is placed and the cut is closed using stitches and staples. A dressing is given on the stitches.

How long does the surgery last?

No two TKR procedures are similar. Hence, the time taken to perform varies. However, a typical total knee replacement operation lasts between 60 and 90 minutes.

What tests are needed before surgery?

Patients undergoing TKR surgery usually will have to undergo a pre-operative surgical risk assessment. The routine tests include, full blood count, blood group, blood sugar, HIV, HCV [a hepatitis test] and Australia antigen status, ECG and chest X-ray.

If required, further evaluation and tests are performed by physician.

An anaesthesiologist also evaluates the patient before surgery.

How much does TKR cost?

The costs vary according to the grade of the hospital, the class of the room and the choice of implant.

What are the complications?

Like any surgical procedure, TKR too is associated with certain risks.

major complications are uncommon.

• possibilities of blood clots in the veins of the leg.
• There is a chance of excessive bleeding .
• anaesthesia-related cardiac complications or stroke.
• Studies have shown rare instances of death.

Risks specific to knee replacement include

• Infection
• Nerve or blood vessel injury.
• The knee may become either too stiff or unstable.
• Sometimes, the joint replacement might not last the patient’s lifetime and might require revision surgery.

However, while the list of minor complications is long and intimidating, the frequency of major complications following a TKR is low. The overall risk of surgery is dependent on the surgeon’s skill, complexity of the knee problem and the patient’s medical profile.

How are the surgery-related risks managed?

The best way to manage potential complications is by preventing them. Early patient mobilisation and use of blood-thinning medications in some patients can prevent blood clots in the veins. Good surgical technique can help minimise post-operative infection and bleeding. With sound precautions and attention to detail, the overall likelihood of complications can be greatly reduced.

What can I do to avoid infections?

If you have an infection in your body, even a tooth infection, have it treated well before surgery. There is growing evidence that a calm mind can aid wound healing and keep away infection. Deep breathing techniques, relaxation music and meditation can be helpful in keeping surgical stress at bay.

How soon can I expect to become mobile?

If there are no complications, you can start moving within a couple of days after surgery. Initially, you’ll need a walker and gradually you will be encouraged to put full weight on the operated leg. At the time of discharge, many patients are able to walk with the help of a cane. Those who come for surgery with a lighter body and stronger muscles, start walking without support sooner.

Is there need for physiotherapy after TKR?

Physiotherapy is a must for early rehabilitation and longevity of your implants. Strong thigh muscles are necessary for optimum function after TKR.

Physiotherapist will teach you movements to keep the joint flexible and to maintain good posture after surgery. But you have to avoid sitting on furniture that is low in height.

How long will the new knee serve me well?

If performed by an experienced surgeon, the best implants can last about 15 years. You need to follow the advice regarding weight management and change of lifestyle for better and longer results.

What activities can I do after surgery?

The goal of TKR is to return patients to a good level of functioning without knee pain. To minimise long-term complications and extend the life of the artificial joint, certain broad guidelines help.

Recommended activities include:

• Swimming
• Water aerobics
• Cycling on stationary bike
• Level ground walking
• Golf
• Weight training exercises
• Yoga without extreme knee bending
• Table tennis
• Ball room dance.

Activities that are not recommended include:

• Jogging or running
• Impact exercises
• Full squats and sitting cross-legged
• Sports that require knee twisting [aggressive tennis, basketball, badminton]
• Contact sports
• Heavy labour.

Can I avoid knee replacement?

Knee replacement can be avoided in many cases if one takes proper care in the initial stages of OA. I recommend the 3S goal of being Supple, Strong and Slim. How long should a patient remain in hospital after a knee replacement?

After a single total knee replacement, 4-5 days of hospitalization is sufficient. This is to provide pain relief and mobilization. For sequential bilateral  knee replacement you will get ten days in hospital. For simultaneous bilateral surgeries under one anesthesia, you will get 6 days in hospital.

 When can the patient stand up after a knee replacement?

You can do so within 24 – 48 hrs after the operation.

If both knees can be operated simultaneously?

If you are young & fit, then both knees can be done in one sitting (Bilateral simultaneous TKR). An approximat cut off age for bilateral simultaneous knee replacements is 75 years. Older patients and those with co morbidities  a few days or months between the two knee operations is preferable.

For how long will I have to use a walker?

You may need a walker for about 15 days and a cane or crutches for another fortnight. Then you can walk without any aids.

What prosthesis are used?

We use only standard prosthesis made in the US. These are all imported to India by the same international companies. The costs of the prosthesis are cheaper in India.

These are

• NexGen prosthesis from Zimmer LPS  flex fixed  & mobile bearing
• Genesis metal & Oxinium, Journey metal & Oxinium ( Smith & Nephew )
• PFC from Depuy( Johnson & Johnson)
• Scorpio NRG knee (Stryker)

 When will the patient be pain free after surgery?

Post-operative pain is controlled to tolerable levels by excellent multi modal anesthesia with an epidural block and analgesics. Two to three weeks of pain medication are required for most people.

 What anesthesia will I receive?

You can have the operation done under general anesthesia (fully unconscious) or a regional anesthesia( spinal or epidural) in which you will be sedated but not knocked out. Regional anesthesia is a safe mode for diabetics and elderly people. Both are often supplemented by regional nerve blocks.

 I am diabetic. Can I have the operation?

Many patients in our practice are diabetic. The diabetologist will try to bring your sugar levels to within normal levels.  Wound healing is good in well controlled diabetes.

How long will I be on pain medication after total knee replacement surgery?

You will likely require some form of pain medication after your hospital stay. Initially, you will be on a strong oral pain medication (such as a narcotic). Most people are able to wean off of their strong pain medication after 1 month and are able to switch to an over-the-counter pain medication (such as Tylenol or ibuprofen). If you are on Coumadin (warfarin), Plavix, or other blood thinner, avoid taking any NSAIDs.

What is the recovery time for total knee replacement surgery?

Everyone heals from total knee replacement surgery at a different pace. In most cases, however, you will likely use a walker or crutches for 2 to 4 weeks after your operation. You will then advance to a cane and wean to no assistive device at all. You will gradually return to normal function without any assistive devices. In general, most patients are close to full recovery after 3 months.

How long will I be in the hospital after total knee replacement surgery?

The length of time spent in the hospital varies from patient to patient. Average length of stay for a total knee replacement is 3 to 4 days.

How long will I be on a “blood thinner” after total knee replacement surgery?

Typically, you will be on a blood thinner up to 1 month. The exact type and duration will be determined by your physician based on your specific medical history and risk. Of note, if you are on Coumadin (warfarin), it is extremely important to have your blood thinner level checked regularly and your Coumadin dose adjusted accordingly.

Do I need antibiotics when I get ill after total knee replacement surgery?

Typically, you do not need antibiotics for illnesses such as a cold or flu. These are caused by viruses. However, if you have a bacterial infection (such as strep throat), you should be placed on an antibiotic by your primary physician. This helps prevent infection from traveling to your joint replacement.

Do I need antibiotics before dental work or an invasive procedure after total knee replacement surgery?

Yes. Please refer to the antibiotic prophylaxis recommendation sheet given to you. Avoid any dental cleaning or non-urgent procedures for 6 weeks post-operatively

How much range of motion (ROM) do I need after total knee replacement surgery?

Most people require 70° of flexion (bending the knee) to walk on level ground, 90° to ascend stairs, 100° to descend stairs, and 105° to get out of a low chair. Your knee should also come to within 10° of being fully straight to function well.

Can I go up and down stairs after total knee replacement surgery?

Yes. Initially, you will lead with your non-operated leg when going up stairs and lead with your operated leg when going down stairs. You can use the phrase, “Up with the good, down with bad” to help you remember. As your leg gets stronger (after about 1 month), you will be able to perform on stairs in a more regular pattern.

What are good positions for my knee? What positions should I avoid?

You should spend some time each day working on straightening your knee (extension) as well as bending your knee (flexion). A good way to work on extension is to place a towel roll underneath your ankle when you are lying down. A good way to work on flexion is to sit on a chair or stationary bicycle and bend your knee. Avoid using a pillow or towel roll behind the knee for any length of time.

Can I use weights after total knee replacement surgery?

Generally, you should not use weights for the first 2 months after total knee replacement surgery. However, as everyone’s strength varies, consult with your physical therapist before using weights. Use light weights to begin with (1 to 5 lbs.) and gradually progress. No squats, lunges, or leg presses. Avoid exercises that cause significant discomfort or pain.

Should I take iron supplements after total knee replacement surgery?

Iron supplements help your body replenish its iron stores and blood count, which may be depleted post-operatively. You may take an over-the-counter iron supplement or a multivitamin with iron for this purpose. Please note that iron may contribute to constipation and also darken the stool.

What should I expect for my range of motion (ROM) after total knee replacement surgery?

Everyone’s range of motion (ROM) varies and depends on individual factors. Your potential will be determined at the time of your surgery. In most cases, you will have at least 90°  of flexion by 4 to 6 weeks. Typically, ROM continues to improve with continued physical therapy. If your ROM is poor (less than 70° of flexion as you approach 4 weeks post-op), please call to notify your surgeon.

I feel depressed after total knee replacement surgery. Is this normal?

It is not uncommon to have feelings of depression after your knee replacement.  This may be due to a variety of factors, such as limited mobility, discomfort, increased dependency on others, and/or medication side effects. Feelings of depression will typically fade as you begin to return to your regular activities. If your feelings of depression persist, consult your physician.

When can I travel after total knee replacement surgery?

You may travel as soon as you feel comfortable. It is recommended that you get up to stretch or walk at least once an hour when taking long trips. This is important to help prevent blood clots. Long flights or car rides may increase the risk of a blood clot. Use of a blood thinner such as aspirin may be indicated.

Will I set off the machines at airport security after total knee replacement surgery? Do I need a doctor’s note about my surgery?

You may set off the machines at airport security, depending on the type of hip implant you have and the sensitivity of the security checkpoint equipment. A wallet card or letter is not helpful or required to travel.

Can I drink alcohol after total knee replacement surgery?

If you are on Coumadin, avoid alcohol intake. Otherwise, use in moderation at your own discretion. You should also avoid alcohol if you are taking narcotics or other medications.

When can I drive after total knee replacement surgery?

If you had surgery on your right knee, you should not drive for at least 1 month. After 1 month, you may return to driving as you feel comfortable. If you had surgery on your left knee, you may return to driving when you feel comfortable as long as you have an automatic transmission. DO NOT DRIVE IF TAKING NARCOTICS. Most important, do not take chances, and only resume driving if you are confident in yourself. It is recommended that you test your driving ability prior to driving in traffic.

Can I have sex after total knee replacement surgery?

You may resume sexual activity when you feel comfortable.