Computer assisted knee replacement

Now that your doctor has advised you knee replacement, it means, he has considered all the other options and he is convinced that your knee is damaged to a point where knee replacement is the best option.

We understand that it is not easy to accept surgery as an option. Patients have apprehensions related to success of the operation and the process of undergoing surgery. This is the reason why patients often come for surgery when it is too late, and by then the results of surgery become inferior. It is in this background that we decided to educate our patients and help them in making an informed decision. We truly believe that knee replacement is a lifechanging operation.

There are three main reasons why patients do not get knee replacement done:

1. They think that they will be able to manage with damaged knee for ‘whatever life left’. We have seen patients who have spent years of their active life suffering, hoping that they will be able to avoid operation. But, what ultimately happens is that their problem continues to increase, and they start compromising their life-style-stop going for walks, social events, etc. They get homebound or even wheelchair bound, and then and only then, they agree to undergo operation. They do regret though, when they come for operation, that they should have got it done earlier. They all have a wish that somebody should have explained to them what this operation is all about.
2. The thought that the ‘surgery may not be successful’ and ‘they may become bed-ridden after surgery’ scares patients. They may have heard or seen some such patients, and this fear becomes stuck in their mind.
3. They cannot afford the cost of surgery. This is an unfortunate but a real reason, as the operation happens to be expensive.

Know about your knee joint

Knee joint is made of three bones – the thigh bone (femur), the leg bone (tibia), and the knee cap (patella). All these bones are covered with smooth-like-marble soft caps, called cartilage (Fig-1a).

When a joint moves, it is the cartilage caps which make it frictionless. With age or due to old injury these caps wear out and the bone ends become raw. Movement now causes friction between the bones, which causes pain and stiffness. This is called arthritis, and leads to deformity, crackling sound and limitation in knee movements (Fig-1b). Over time, the patient develops weakness, unsteadiness of gait and they may actually fall.

What actually is knee replacement?

Most people think that knee replacement means the original knee will be taken out and replaced with some sort of a metallic joint (Fig-2a). It is but natural that such a thought will create anxiety in anyone. The name ‘total knee replacement’ is a misnomer as there is no operation in which the whole knee is replaced.

 

 

 

 


What is replaced is only the cartilage caps which normally cover bone ends (Fig-2b). These artificial caps are made up of high quality steel, and are fixed to the end of the bones with a special glue called bone cement. The glue is so strong that within minutes, the artificial parts is glued on to the bone. It will, therefore, be more appropriate to call it a knee resurfacing operation.

 

How does your doctor come to know that you need knee replacement?

The decision that you need knee replacement is based on two factors:

  1. (a) X‐ray should confirm that the knee is permanently damaged and your legs deformed. For this special xrays are required (Fig-3a,b).
  2. The damaged joint should be affecting patient’s quality of life. This means, he/she should be feeling disabled due to knee problem in activities of day-today life. Sometimes, patients themselves find it difficult to comprehend whether their day-to-day life is disturbed because of the knee. For this, we have devised a scoring system by which the patient tests himself/herself, and thus comes to know of his disability.

What will happen if I do not undergo operation?

Once the arthritis has reached a stage that there is no other treatment except surgery, avoiding operation is not without price. With time, your ability to move around becomes compromised, you gain weight, your muscles become flabby, your ligaments stretch out and make the knee unstable and your bones become weak. A number of patients, trying to manage with bad arthritic knees, find it difficult to move around. Some eventually cannot walk even few steps, and get wheelchair bound (Fig-4).

Due to weak knees and loss of control on the knees, some patients eventually fall, break their bones and land up in emergency. As you would understand, this acts as ‘last straw on the camel’s back’, and puts the patient to bed permanently.

What should I do if I wish to postpone surgery?

If you would like to wait, this is what you should do:

(a) Weight control by modifying eating habits

(b) Regular exercises to strengthen knee muscles

(c) Restrict activities such as long walks or standing for long

(d) Use knee support or a stick

(e) Take safe pain-relieving medicines

(f) Use pain‐relieving oils or creams

(g) See your doctor at regular interval to monitor deterioration of knee condition

What is the success rate of this operation?

This is one of the very successful knee operations. This is truly a ‘life-changing’ operation. Nearly 95% do well for 20 years plus, and their quality of life improves remarkably. Operation gives near complete relief in pain. The legs become normal shaped (Fig-5), and you can walk perfectly well. On an average, patient can walk up to 3-4 km, and can climb two floors easily. You can enjoy your social activities.

It is common misconception amongst some that they may not be able to take the operation at their age. The fact is that this operation is done mostly in the elderly, usually after 65 years. It is natural that people at that age will have some or the other medical problems such as high blood pressure, heart disease, diabetes, etc. Despite all these diseases, this operation has been found quite safe in the elderly at any age, even as late at 90.

Nevertheless, a thorough check up is done before surgery, and all care is taken, keeping in mind pre-exisiting health problems. The operation is usually not done under general anaesthesia, but is done under spinal anaesthesia (injection in the back, which makes the legs numb). You will be awake all through the operation, with no sensation in the legs. You will not come to know anything as you will be put to sleep by medicines. Most patients have a pleasant experience of the operation, and say that they did not come to know when the operation started and finished.

Is the operation painful?

The thought of operation brings the thought of pain. Though every operation is associated with some pain & discomfort, with the use of modern pain control techniques, it has been possible to make this operation, reasonably pain-free (Fig-6). Some of these techniques are the same used for relief in labour pain (painless labour). One can imagine if the labour pain – one of the worst pain, can be controlled with these techniques, pain of knee surgery is nothing. We are particularly sensitive to ensuring a painfree surgery, and do everything to make your operation so.

What is the life of replaced knees?

The replaced knee lasts for 20 years in upto 95% of cases. In those in which it does not last that long, for whatever reason, a second operation may sometime be done to fix the problem.

How long does it take to recover?

You will be in the hospital for 5‐7 days. You will be admitted one day prior to surgery for fine tuning of your medical check up, and will be operated the next morning. You will be in post-op recovery area for 24 hours, and then shifted to your room. Gentle physiotherapy is started from the day after surgery. A typical recovery schedule for those who get both knees replaced is as shown in Fig.-7.

You are made to stand on day 3 or 4 after operation. At the time of discharge from the hospital, you will be able to take a few steps and walk to the toilet using a walker. Once at home, physiotherapy is continued for a period of 4 to 6 weeks. Most patients are able to walk for 2-3 km within 12 weeks of surgery. Those with single side knee replacement take half this time.

Can both the knees be operated at the same time?

Yes, it is very much possible, and is our routine practice for last 20 years. There is enough evidence to support that in selected cases, the success rate of doing both knees together is no different from doing them separately. In some cases it is desirable to operate one knee at a time.

This depends upon the following:

1) Health status of the patient

2) Obesity

3) When one knee is not too bad

4) When one knee is too badly damaged & needs solo attention

How much does this operation cost?

Cost may vary depending upon the technique and the implant used. You may discuss this in detail when you come for scheduling the surgery. We have packages for different categories of patients.

Which implant do we use?

We use the best quality, imported implants which have a long track record. There are a lot of new implants coming in the market all the time. We keep ourselves updated with all the new developments, and carefully choose the one best for our patients.

What is the procedure of getting operated?

Once you decide to get operated, our team will take over and explain the whole procedure to you. This consists of the following:

(a) Finalizing the date for surgery, and backward planning.

(b) General health check to assess whether you have any health issues which need attention. This will involve a visit to the anaesthetist who will certify your fitness for surgery.

(c) Physiotherapy

(d) Dietary advice

(e) Home visit by a physiotherapist to assess whether modification in your setup is required to suit your
needs after discharge.

(f) Health insurance related or payment related issues.

What is the procedure after admission?

Knee replacement is usually the first case in the morning. This means that you will be taken to the OT around 8 am (Fig-8). It takes nearly an hour to give anaesthesia and prepare for surgery. The actual operation takes only about 1 hour for one knee.

After the operation you will be kept in a post-op room for close monitoring. Once you recover fully, you will be shifted back to the room. You rest for a day, and feel better, and then gentle physiotherapy is begun. Most patients will sit by the side of the bed, with legs hanging on day 2 of surgery. Most will stand on day 4 and walk a few steps. From here on, patients are encouraged to walk under supervision of trained physiotherapists. They are advised to take precautions while moving out of bed, going to the toilet etc. Most patients feel fit and confident to go home after 7 days.

What is the post-operative requirement?

Once you are discharged from the hospital, approximately 1 week after the surgery, our home care team will take over under guidance of our chief physiotherapist. This is done considering the difficulty faced by patients in visiting the hospital repeatedly. They will organise of physiotherapy at home, stitch removal, etc. Your stitches will be removed at home 20 days after surgery.

What complications can occur?

Knee replacement is a fairly successful operation but as in any surgery, complications can occur. Though we take all precautions and follow international norms, complications can occur. We can only assure you that we take all care to keep complications to the minimum, and in case they do occur, we take immediate action to diagnose and treat them. With this aggressive approach, we have been able to keep our complication rate to the bare minimum.

The following is an account of possible complications. It is our duty to let you know about these, more to inform you and not to alarm you. It is not a complete list by any means,
but covers the most common ones.

Early:

a) Anaesthesia‐related complications can occur in any operation, anywhere.
b) Age-related complications, can occur as per patient’s medical status.
c) Clot formation in the leg (DVT) occurs one in thousands but sometimes can even be life threatening. We do take all precautions to safeguard you.

Delayed:

a) Infection
b) Unstable feeling while walking happens because of stretching of the ligaments. This happens usually in obese people, and in those who unduly postponed their operation and had compromised ligaments to start with.

Late:

a) Loosening: The artificial parts may loosen. This happens either due to overweight, weak bones or misuse.

Post-op instructions

You must work on your new knees so that you get the best result. Some of the following things have to be kept in mind:

a) Once the stitches are removed, take regular bath and wet the affected knee same as the other one. There is absolutely no risk.
b) Do regular physiotherapy, which is mainly in the form of exercises. Some patients can do it themselves and they just need to learn from physios, others need more regular sessions by a personal physio. It takes sometime, but all improve eventually. You can take normal pain-killers, if exercise sessions are painful.
c) Sit on high chair and on high commode which will make it easy for you to get up from these. It is sitting on and getting up from a chair or bed, which is the last to recover.
d) Some swelling in the knees is normal and takes up to 6 months to subside. It is body’s response to new material in your body.
e) Some patients need painkillers for a period of 2‐3 months, but it’s not needed after that.

Long term care of your new knee:

  1. Do regular exercises: The strength and extent of your recovery depends upon the muscles. Regular knee exercises will keep your knees strong.
  2. Do not sit on the floor or sit cross-legged: Sitting in these positions causes a lot of load on the knees. This can result in early wearing away of the knees.
  3. Consult us if you notice any of the following:a. Pain not settling for 2 weeksb. Swelling not settling for two weeksc. Clicking sounds which were not there earlier.Although most of these problems are inconsequential, a check is worthwhile.
  4. Go for check up once in 6 months. Keep your old x‐rays etc.
  5. If you develop infection in any part of your body such as tooth, urine, throat etc. do consult a doctor early. You should inform your doctor about the operation, as it is
    desirable to cover such patients with antibiotics early.

How we have perfected the technique of knee replacement?

  • We use the best quality imported implant from world’s leading brands in this field. These implants have a ‘track record’ of over 25 yrs.
  • We use computer navigation (Fig-9) to ensure good fitting of the prosthesis.
  • We have the international standard OT protocols.
  • Our anaesthetists are trained in getting such operations done routinely, and make it an operation with minimum pain.
  • We have a well-designed post operative rehab protocol.
  • We have a coordinated home care team – including physio, and assistants to remove stitches at home.
  • Our team member, including senior doctor is easily approachable to the patient’s 24×7.
  • Needless to say, the senior surgeon does all operations himself.

Our philosophy: Most important, we have a philosophy of treatment. We take every patient as a human being with different requirements – physical and psychological. We customize our treatment to patient’s need. Our aim is to give our patient the experience of having gone through the treatment, what we would expect for our own relative. For us, by choosing us their doctor, the patient is giving us a great honour, and we value it. To showcase that we care, all our operated patients have direct access to cellphones of our team, including that of the chief surgeon.