Knee replacement surgery for arthritis

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

When conservative management for arthritis fails, surgery is the next option. Total knee replacement (TKR) surgery, also called knee arthroplasty, is one of the most common elective surgeries done today.

Information from the American Academy of Orthopaedic Surgeons (AAOS)

The surgery replaces severely damaged cartilage tissue with a prosthesis made of metal and plastic that duplicates the function of the knee joint.

Since the 1970s, the technology and long term success of knee replacement surgery has improved, providing relief to people with chronic, debilitating knee pain. Knee replacement surgery — relieves pain and restores function in severely diseased knee joints.

A surgeon cuts away damaged bone and cartilage from the femur (thighbone), tibia (shinbone) and patella (kneecap), and replaces it with an artificial joint (prostheses) made of metal alloys, high-grade plastics and polymers.

In the 1950s, the first artificial knees were little more than hinges. Now that more than 600,000 knee replacement surgeries are performed each year, a wide variety of designs that take into account age, weight, activity level and overall health are available. They replicate the knee's natural ability to rotate and glide as it bends.

Total knee arthroplasty can improve knee problems associated with osteoarthritis, rheumatoid arthritis and other degenerative conditions such as osteonecrosis — a condition in which obstructed blood flow causes bone tissue to die.

The procedure may help if:

•A patient has pain that limits normal activities such as walking, climbing stairs and getting in and out of chairs, or they experience severe knee pain at rest.
•A patient has limited function or mobility, such as chronic knee stiffness and swelling that prevents them from bending and straightening the joint.
•A patient has tried other more conservative methods to improve symptoms.
•A patients has a significant knee deformity.
•A patient is age 55 or older. The procedure may be considered for younger adults as well. However, young, physically active people are more likely to wear out a new prosthetic knee prematurely. In situations like this, a doctor may recommend a nonsurgical treatment program or suggest an alternative surgery such as leg straightening (osteotomy), or a partial knee replacement which replaces fewer components than a total knee arthroplasty procedure.
•Good candidates for knee replacement are typically healthy, without conditions such as restricted blood flow, diabetes or infections that can complicate surgery and recovery. Obesity won't disqualify a patient from surgery, but it may slow healing and increase the risk of infection after surgery.

Today, most knee replacement programs prepare the patient for immediate postoperative rehabilitation and living arrangements.

Some tips for older individuals...

• Create a total living space on one floor since climbing stairs can be difficult
• Install safety bars or a secure handrail in the shower or bath
• Secure handrails along the stairways
• Obtain a stable chair with a firm seat cushion and back, and a footstool to elevate the leg
• Arrange for a toilet-seat riser with arms if a patient has a low toilet
• Try a stable bench or chair for the shower
• Remove all loose carpets and cords

Total knee replacement involves a 7-8” incision over the knee, a hospital stay of 1-3 days, and a recovery period (during which the patient walks with a walker or cane) lasting from one to three months. The large majority of patients report substantial or total relief of their arthritic symptoms once they have recovered from a total knee replacement.

Partial (unicompartmental) knee replacements offer excellent clinical results for the younger patient.

In the last few years, surgeons have become very enthusiastic about an exciting new approach. “Minimally-invasive” partial knee replacement (or "mini knee") is a surgical technique that allows a partial knee replacement to be inserted through a small (3-3.5”) incision, with minimal damage to the muscles and tendons around the knee.

The small size of the incision and the less-invasive nature of the surgical approach allow patients to recover from the “mini knee” operation much more quickly. Hospital stays are shorter--down to 1 or 2 days for most patients--and the recovery period is much faster. Patients lose less blood, experience substantially less pain than traditional knee replacement, and often walk unassisted (no cane or walker) within a week or two of the operation (see movie 1). Even many patients who have both knees done at once with this newer technique are able to walk without the assistance of a walker or cane fairly quickly.

Here are some recommendations if you decide to get your knee replaced...

If both knees bother you equally and there is X-ray evidence of severe arthritis in both joints, then bilateral knee replacement may be an option. The biggest benefit of having bilateral knee replacement done is that you will have one operation rather than two. Patients undergoing bilateral replacement usually spend a short time in a rehabilitation center after surgery before going home.

After surgery, you can expect to be in the hospital for one to three days for total knee replacement, four to six days following bilateral knee replacement and overnight for a partial knee replacement. In the hospital you'll have physical therapy so you can get used to your new knee. Following bilateral knee replacement surgery, you will go to a rehabilitation center for about one week before returning home.

The day after surgery, a physical therapist shows you how to exercise your new knee. To help regain movement, you may use a device called a continuous passive motion machine, which slowly moves your knee while you're in bed.

During the first few weeks after surgery, you're more likely to experience a good recovery if you follow all of your surgeon's instructions concerning wound care, diet and exercise. Your physical activity program needs to include:

• A graduated walking program — first indoors, then outdoors — to gradually increase your mobility
• Slowly resuming other normal household activities, including walking up and down stairs
• Knee-strengthening exercises you learned from the hospital physical therapist, performed several times a day

Once home, you'll continue doing the exercises you were shown in the hospital or the rehab center. You'll need to use crutches or a walker initially and then advance to a cane. Most patients will be able to put aside their walking aides about six weeks after surgery. Once recovery is complete and your physician approves, you can return to work and resume many activities including walking, golfing, dancing, swimming and bicycling. You will need to avoid high-impact activities.

About 90 percent of people who have a total knee replacement experience significant pain relief, improved mobility and a better overall quality of life.

Three to six weeks after the procedure, you generally can resume most normal daily activities such as shopping and light housekeeping. Driving is possible in four to six weeks if you can bend your knee far enough to sit in a car and you have enough muscle control to properly operate the brakes and accelerator.

After you've recovered, you can enjoy a variety of low-impact activities. For example:

• Recreational walking
• Swimming
• Golf
• Recreational biking
• Ballroom dancing

High-impact activities increase the risk of knee failure, however. Avoid such activities, including:

• Jogging or running
• Contact or jumping sports
• High-impact aerobics
• Vigorous walking or hiking
• Skiing
• Tennis
• Repetitive lifting of objects exceeding 50 pounds
• Repetitive aerobic stair climbing

As with any surgery, knee replacement surgery carries risk of potentially life-threatening infection, heart attack and stroke. Blood clots in the leg vein (thrombophlebitis) are a major concern, so blood thinners are commonly used to help prevent them.

Other risks include knee-joint infection, nerve damage, and the possibility that your new knee could break or become dislocated. Although the risk of such serious complications is less than 2 percent, infection is an ongoing concern. Even years after surgery, bacteria can travel through your bloodstream and infect the surgical site. Notify your doctor immediately if you notice such warning signs as a fever greater than 100 F, shaking chills, drainage from the surgical site, and increasing redness, tenderness, swelling and pain in the knee. If antibiotics fail to clear up the infection, you usually need one surgery to remove the infected joint and another surgery to install a new one. Your chances of a good-to-excellent outcome that reduces pain and improves function decline with each additional surgery.

Another risk of the procedure is prosthesis failure. Subjected to daily stress, even the strongest metal and plastic parts eventually wear out. Research shows that 1 percent of prosthetic knees fail each year, with 10 percent failing within 10 years and 20 percent within 20 years. Such failure risk is greater if you're a young, obese male or you have complicating conditions.

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