Arthroplasty of the knee, is a commonly performed operation done to relieve the pain and disability from rheumatoid arthritis or more often osteoarthritis of the knee.[Arthroplasty (literally "formation of joint") is an operative procedure of orthopaedic surgery performed for replacing the arthritic or dysfunctional joint surface with something better or remodeling or realigning the joint by osteotomy or some other procedures]
This operation is undertaken by orthopaedic surgeons and consists of replacing the diseased and painful joint surfaces of the knee with metal and plastic components shaped to allow continued motion of the knee.
How Knee replacement is done?
The standard technique involves exposure of the front of the knee by a long incision which detaches part of the quadriceps muscle (in fact the vastus medialis) from the kneecap. This is a key factor in the lengthy recovery from the operation. The muscle has to heal. The kneecap is displaced to one side of the joint allowing exposure of the distal end of the thighbone (femur) and the proximal end of the shinbone (tibia). The ends of these bones are then accurately cut to shape using cutting guides oriented to the long axis of the bones. The cartilages and the anterior cruciate ligament are removed; the posterior cruciate ligament may also be removed but the collateral ligaments are preserved. Metal components are then impacted onto the bone or fixed using poly methyl methacrylate (PMMA) cement. A round ended implant is used for the femur, mimicking the natural shape of the bone. On the tibia the component is flat, although it often has a stem which goes down inside the bone for further stability. A flattened or slightly dished high density polyethylene surface is then inserted onto the tibial component so that the weight is transferred metal to plastic not metal to metal. During the operation attention must be paid to correcting any deformities and balancing the ligaments so that the knee moves through a good range of movement and is stable. In some cases the joint surface of the kneecap is also removed and replaced by a polyethylene button cemented to the kneecap. At the end of the surgery the muscle is repaired to the kneecap and the wound is closed. It is common practice to leave a drain in the knee to reduce post-operative swelling from bleeding into the knee. Blood transfusion to replace intra-operative and post-operative losses are commonly required.
Types of knee replacement.
There are many different implant manufacturers and all require slightly different instrumentation and technique. No consensus has emerged over which design of knee replacement is the best. All manufacturers in the U.S. offer fixed-bearing knee design options, but only one in the U.S. offers a mobile-bearing option, which is thought to reduce the level of wear on the implant. This might also reduce the chance of revision surgery. The first surgery a patient goes through for a knee replacement is called a primary surgery; any subsequent surgeries (usually to fix or replace the first implant) are called revisions.
Clinical studies are very difficult to perform requiring large numbers of cases followed over many years. The most significant variations are between cemented and uncemented components, between operations which spare or sacrifice the posterior cruciate ligament and between resurfacing the patella or not. Some also study patient satisfaction data associated with pain.
Techniques of Minimally Invasive Surgery are being developed in Total Knee Replacement but have not yet found complete acceptance. The driving force here is to spare the patient the large cut in the quadriceps muscle which could increase post-operative pain or lengthen disability.
Unicompartmental arthroplasty is a different operation with different indications. The joint surfaces of either the inner or the outer sides of the knee are replaced.
Any dental work after this surgery requires an antibiotic before the dental work can be done.
Risk involved in knee replacement.
According to the American Academy of Orthopaedic Surgeons (AAOS), "blood clots in the leg veins are the most common complication of knee replacement surgery. Your orthopaedic surgeon will outline a prevention program, which may include periodic elevation of your legs, lower leg exercises to increase circulation, support stockings and medication to thin your blood."
Periprosthetic fractures are becoming more frequent with the aging patient population and can occur intraoperatively or postoperatively.
Also according to AAOS, "the complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in less than 2 percent of patients. Major medical complications such as heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur, they can prolong or limit your full recovery."
The knee at times may not recover its normal range of motion (0 - 135 degrees usually) after total knee replacement. Much of this is dependent on pre-operative function. Most patients can achieve 0 - 110 degrees, but stiffness of the joint can occur. In some situations, manipulation of the knee under anaesthetic is used to improve post operative stiffness. There are also many implants from manufacturers that are designed to be "high-flex" knees, offering a greater range of motion. High-flex knees typically function at their best when paired with a mobile-bearing knee.
In some patients, the kneecap is unstable post-surgery and dislocates to the outer side of the knee. This is painful and usually needs to be treated by surgery to realign the kneecap. This is very rare, but possible.
In the past, there was a considerable risk of the implant components loosening over time as a result of wear. As advancements in medical technology have improved though, this risk has fallen considerably. One implant manufacturer claims to have reduced this risk of wear by 79% in fixed-bearing knees. Another implant manufacturer claims to have reduced the risk of wear by 94% in mobile-bearing knees, just in the past five years. Knee replacement implants can last up to 20 years in many patients; whether or not they actually survive that long depends largely in part upon how active the patient is after surgery.
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For simplicity, the knee is considered a hinge joint because of its ability to bend and straighten like a hinged door. In reality, the knee is much more complex because the surfaces actually roll and glide as the knee bends. The first implant designs used the hinge concept and literally included a connecting hinge between the components. Newer implant designs, recognizing the complexity of the joint, attempt to replicate the more complicated motions and to take advantage of the posterior cruciate ligament (PCL) and collateral ligaments for support.
Up to three bone surfaces may be replaced during a TKA: the lower ends (condyles) of the thighbone, the top surface of the shinbone and the back surface of the kneecap. Components are designed so that metal always articulates against plastic, which provides smooth movement and results in minimal wear.
1. Femoral component: The metal femoral component curves around the end of the thighbone and has an interior groove so the kneecap can move up and down smoothly against the bone as the knee bends and straightens. Usually, one large piece is used to resurface the end of the bone. If only one side of the thighbone is damaged, a smaller piece may be used (unicompartmental knee replacement) to resurface just that part of the bone. Some designs (posterior stabilized designs) have an internal post with a circular-shaped device (cam) that works with a corresponding tibial component to help prevent the thighbone from sliding forward too far on the shinbone when you bend the knee.
2. Tibial component: The tibial component is a flat metal platform with a polyethylene cushion. The cushion may be part of the platform (fixed) or separate (mobile) with either a flat surface (PCL-retaining) or a raised, sloping surface (PCL-substituting).
3. Patellar component: The patellar component is a dome-shaped piece of polyethylene that duplicates the shape of the kneecap anchored to a flat metal plate.
There are more than 150 knee replacement designs on the market today. Several manufacturers make knee implants. The brand and design used by your doctor or hospital depends on many factors, including your needs (based on your age, weight, activity level and health), the doctor's experience and familiarity with the device, and the cost and performance record of the implant. You may wish to discuss these issues with your doctor.
The metal parts of the implant are made of titanium- or cobalt/chromium-based alloys. The plastic parts are made of ultrahigh-density polyethylene. All together, the components weigh between 15 and 20 ounces, depending on the size selected. The construction materials used must meet several criteria:
* They must be biocompatible; that is, they can function in the body without creating either a local or a systemic rejection response.
* Their mechanical properties must be able to duplicate the structures they are intended to replace; for example, they are strong enough to take weightbearing loads, flexible enough to bear stress without breaking and able to move smoothly against each other as required.
* They must be able to retain their strength and shape for a long time. The chance of a knee replacement lasting 15 to 20 years is about 95 percent.
To date, man-made joints have not solved the problem of wear. Every time bone rubs against bone, or metal rubs against plastic, the friction creates microscopic particulate debris. Just as wear in the natural joint contributed to the need for a replacement joint, wear in the prostheses may eventually require a second (revision) surgery.
During a TKA, the knee is in a bent position so that all the surfaces to be replaced can be exposed. The usual approach is lengthwise through the front of the knee, just to the inside of the kneecap, although some surgeons will approach the joint from the outer side, just above the kneecap. The incision is 6" to 12" long. The large quadriceps muscle and the kneecap are moved to the side to reveal the bone surfaces.
After taking several measurements to ensure that the new implant will fit properly, the surgeon begins to smooth the rough edges of the bones. Depending on the type of implant used, the surgeon may begin with either the thighbone or the shinbone.
Special jigs are used to accurately trim the damaged surfaces at the end of the thighbone. The devices shape the end of the thighbone so it configures to the inside of the prosthesis. The shinbone is cut flat across the bone and a portion of the bone's center is drilled out. The surgeon removes just enough of the bone so that when the prosthesis is inserted, it recreates the joint line at the same level as prior to surgery. If any ligaments around the knee have contracted due to pain and deformity before the surgery, the surgeon carefully releases them so that they function as close to the normal state as possible.
The prostheses are inserted, tested and balanced. The surgeon wants to be sure that the joint line is in the right place and the kneecap is accurately aligned for proper joint movement. If it is necessary to resurface the kneecap, the surgeon will apply a shaped piece of polyethylene that maintains the original width of the kneecap.
The knee replacement may be "cemented," "cementless" or "hybrid," depending on the type of fixation used to hold the implant in place. Although there are certain general guidelines, each case is individual and your surgeon will evaluate your situation carefully before making any decisions. Do not hesitate to ask what type of fixation will be used in your situation and why that choice is appropriate for you.