What Is Total Knee Replacement

What Exercises Are Prescribed For Total Joint Replacement Of The Hip

The intensity of the exercise should be adjusted so that it is painless but still improves fitness. Running and jumping should be avoided, and shoes should be cushioned. Joints should not be placed at the extremes of motion.

A) Phase One : This is the post-operative phase, and the main goal would be to reduce swelling and control pain. The healing tissue is protected, and basic stretches are taught to restore a normal range of motion. Educating the patients regarding the prevention of dislocation of the operated joint. Walking using crutches or a walker is recommended.

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Reasons For Knee Replacement Surgery

The most common reason to undergo knee replacement surgery in Singapore and worldwide is to treat degeneration from osteoarthritis, rheumatoid arthritis, or post-traumatic arthritis caused by severe injury. Knee replacement surgeries are generally suitable for people who experience:

• Severe knee discomfort that causes difficulty in performing everyday tasks
• Chronic knee inflammation
• A knee deformity, where you may notice an arch on the inner or outer side of the knee
• Pain that impacts your quality of life, including your mental wellbeing.

If medication or physical therapy has not been effective in treating your knee stiffness and pain, your doctor may recommend total or partial knee replacement surgery as the best treatment option. Be sure to talk to your orthopaedic doctor to check if you are eligible for the procedure.

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Summary Of Operative Steps13

A 15cm vertical skin incision is made over the patella, in keeping with the medial parapatellar approach. A new blade is then used to dissect through the anterior border of the quadriceps, patella, and medial aspect of the patellar tendon.

Skin flaps are then retracted, the patella everted, and a medial arthrotomy is performed with a large blade. The knee is then extended in what is called the medial release, and the arthrotomy is completed. The knee is then returned to flexion. The infrapatellar fat pad and ACL are resected, and the tibia is externally rotated.

The articular surface and a small amount of subchondral bone from the tibia and the femur are then resected, it is up to the surgeon to choose whether to resect the tibia or the femur first. The primary aim is to remove adequate bone to replace it with metallic components and plastic whilst ensuring that the knee is stable throughout the range of movement.

The tibial cutting jig is now fixed in place, and alignment can be adjusted depending on how varus/valgus a patients knee is. Pins are used to fix the jig in place. A saw is then passed through a slot in the jig, and the diseased articular cartilage is resected.

A jig is placed onto the distal femur , and three cuts are made, resection of the distal femur, resection of anterior and posterior portions of the femur, and finally chamfer cuts.

Prosthetic femoral components are now trialled and are tapped on, ensuring the prosthetic is flush with the femur.

Figure 3

What Are The Goals Of Total Knee Replacement / Total Knee Arthroplasty

The following are the clinical goals of a Total Knee Replacement procedure

• To put the implants in a correct alignment and position
• To ensure that the remaining soft tissues are balanced
• To ensure that the implant is well fixed to the bone
• To ensure that the implant used is designed to offer high level of function & longevity

The above clinical goals translate to the following qualitative goals from a patient standpoint

• To relieve pain
• To last as long as possible

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How Is Management Of Rehabilitation Problems After Total Knee Arthroplasty Done

1) Difficulty in Full Extension of the Knee:

• Patients are asked to start walking backward.

• The therapist performs passive extension with the knee off the table, with and without weight placed across the ankle.

• The passive extension is also done by the therapist using a towel roll placed under the ankle, and the patient is asked to push downward with or without using a weight.

• Electrical stimulation is done for muscle re-education by passing electricity in the affected area through electrodes in a controlled manner.

2) Delayed Knee Flexion:

• The therapist passively stretches the knee into flexion.

• Wall slides for gravity assistance. This is done by asking the patient to lie down near a wall and place the affected knee parallel to the wall and the unaffected knee a little lower. The patient is asked to slide down the affected leg gently, and then it is slid upward using the unaffected leg.

• Stationary bicycling is recommended. This can be done first in the backward direction, and gradually if the range of motion is better and painless, it can be done in the forward direction.

Patient Preparation For Knee Surgery:

Consumables used in this step include bandage / drape for wrapping patients legs, leg positioning tools and anesthesia for the patient.

• Supine positioning on the OR table
• Pneumatic tourniquet is used to minimize blood loss during surgery
• Special table support may be used to allow the knee to be flexed and extended several times during the procedure
• Required levels of anesthesia are given to the patient

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Knee Replacement Recovery Exercises

Although you will be advised on specific exercises that you can do by your physical therapist, the exercises that you should focus on the most, particularly in the early recovery period, are exercises that work on range of motion, degree of bend in the knee as well as developing strength in the quadriceps muscles. As soon as you feel you are able to get onto a stationary or recumbent bike, you should do so. This is an excellent exercise as it is very low impact, but works on range of motion and strength, and the knee and can be aided by the contralateral side.

Working on range of motion and strength can be achieved by dangling your leg over the side of a chair or bed and extending the knee so that the leg is fully outstretched and holding it against gravity for several seconds before then allowing gravity to bend the knee again. This is a very simple exercise, but also very effective and can be done anywhere with relative ease and does not require any special equipment.

Possible Complications Of Surgery

The complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in fewer than 2% 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 full recovery.

Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.

Infection. Infection may occur in the wound or deep around the prosthesis. It may happen within days or weeks of your surgery. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.

Blood clots. Blood clots in the leg veins are one of the most common complications of knee replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. 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.

Blood clots may form in one of the deep veins of the body. While blood clots can occur in any deep vein, they most commonly form in the veins of the pelvis, calf, or thigh.

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How To Shower After Knee Surgery

If the surgeon used waterproof dressings, you can shower the day after surgery. If they used dressings that arent waterproof, youll have to wait for 57 days before showering and avoid soaking for 34 weeks to let the incision heal fully, according to the American Association of Hip and Knee Surgeons .

The PT may ask you to use a regular toilet rather than a bedpan and ask you to try to climb a few steps at a time. You may still need to use the CPM machine.

Work on achieving full knee extension at this stage. Increase knee flexion by at least 10 degrees if possible.

What can you do at this stage?

On day two, you can stand up, sit, and change locations. You can walk a little further and climb a few steps with help from your PT.

If you have waterproof dressings, you can shower the day after surgery. The PT may ask you to use a regular toilet in preparation for returning to your activities of daily living.

Alignment Of The Axes

In a normal knee, there are two axes:

• Mechanical axis: this is a straight line that connects the femoral head, passes through the knee and the center of the ankle joint.
• Anatomical axis: this is a straight line that passes through the bone shaft of the femur as well as the tibia

On the femoral side, there is 5-7 degrees of angular difference between the anatomical axis and the mechanical axis, whereas the axes are parallel on the tibial side.

In a deformed knee these angles deviate from the nominal values and hence bone cuts have to be made at specific angles in order to achieve appropriate alignments on the femoral as well as tibial side.

This is one of the critical goals of the Total Knee replacement procedure and hence several precision instruments are provided that produce artificial prostheses in order to enable the surgeons to measure the deviations and plan for appropriate cuts to achieve alignment between the axes and the components.

Overview of femoral and tibial cuts in Total Knee Replacement-The surgeon goes through the following bone cuts on the distal femoral end and proximal tibial side once the appropriate plan is made based on the axes alignments.

• Transverse distal femoral cut
• Anterior and posterior femoral chamfer cuts
• Transverse proximal tibial cut

Note: All surgeons do not follow the exact sequence of cuts listed above. They differ based on their preferences and surgical training.

There are 2 surgical techniques which the surgeons follow

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Tibia Resurfacing & Implant

The tibia is next to be resurfaced. The surgeon trims away damaged cartilage and bone, then carefully smooths and shapes the bone to fit cleanly with the tibia components. These are usually made of both plastic and metal. The metal section, or tibia tray, is attached to the tibia using bone cement. A rigid plastic insert is snapped onto the tray to provide a smooth, cushioned space between the tibia and femoral implants. This buffers the joint when you flex your knee and provides shock absorption when walking or running.

What Is A Total Knee Replacement

Total knee replacement is a type of surgery to replace a damaged knee joint. A minimally invasive surgery uses a smaller cut than a traditional total knee replacement. This type of surgery typically requires special tools so that the surgery team can see and do the procedure through the smaller incision.

The knee has several parts: the lower end of the thigh bone , the upper end of the shin bone , and the kneecap . A smooth substance called cartilage caps the ends of these bones and keeps the bones from grinding together. When there is damage to the knee joint, these bones may scrape together abnormally and cause pain.

During minimally invasive total knee replacement, your surgeon makes an incision to access your shinbone and thigh bone. Next, he or she removes a portion of the bones that make up the knee joint. Your surgeon replaces these bone parts with metal components that recreate the joint surface. A layer of plastic is placed between the metal components for smooth gliding.

Minimally invasive total knee replacement often takes place under general or spinal anesthesia.

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What Is A Knee Replacement Surgery

Knee replacement, also called knee arthroplasty or total knee replacement, is a surgical procedure toresurface a knee damaged by arthritis. Metal and plastic parts are used tocap 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 asevere knee injury.

Various types of arthritis may affect the knee joint. Osteoarthritis, adegenerative joint disease that affects mostly middle-aged and olderadults, may cause the breakdown of joint cartilage and adjacent bone in theknees. Rheumatoid arthritis, which causes inflammation of the synovialmembrane and results in excessive synovial fluid, can lead to pain andstiffness. Traumatic arthritis, arthritis due to injury, may cause damageto the cartilage of the knee.

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

What Type Of Pain Medication Will I Take After My Total Knee Replacement

Most patients require some form of narcotic analgesic in the early postoperative period after their surgery. Each patient is different in how they respond to this type of pain medication and while others may have been prescribed one medication, this may not work the same for you as it did for them. As such, the first line medication may be different to a family member or friend to whom you have spoken who has already had their knee replaced. We usually use medications such as hydromorphone and oxycodone in conjunction with medications such as Tylenol.

You are able to take these two medications together as their mechanism of action is different. It is important to remember that these medications do have side effects and experiencing nausea, constipation or drowsiness are all recognized side effects of narcotic analgesics. It is important to stick to the dosing schedule that your physician has indicated to you and that your pharmacist will reiterate to you at the time of filling your prescription.

Taking too many narcotic analgesics can result in worsening side effects without the benefit of improved pain relief and can even depress your respiratory drive causing you to breathe slower or stop breathing altogether. As such, it is essential that you do not exceed the maximum indicated dose on your prescription or medication container.

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What Happens After Knee Replacement Surgery

Some people go home the same day they have surgery. Other people will stay in the hospital a few days. To help prevent blood clots, you’ll most likely take blood thinners and wear special socks or coverings on your legs for a short time after surgery.

The success of your surgery depends a lot on what you do at home to help yourself recover. A physical therapist will teach you exercises to make your knee stronger and help it bend. It is important to do these exercises regularly. You may need to use a cane or walker for several weeks after the surgery. It will probably also be several weeks before you can drive. Your doctor will tell you when you can start driving again.

Most people who follow their recovery instructions can get back to nearly all of their normal daily activities within 3 to 6 weeks after surgery.

How Do I Get Ready For Total Knee Replacement

Ask your provider how you should plan to get ready for your surgery.

Tell your provider about any medicines you are taking, including:

• All prescription medicines

• Over-the-counter medicines such as aspirin or ibuprofen

• Herbs, vitamins, and other supplements

Ask if there are any medicines you should stop taking ahead of time, like blood thinners.

If you smoke, try to quit before your surgery.

If you are overweight, your provider may advise you to try to lose weight before your surgery.

Donât eat or drink after midnight the night before your procedure.

You may want to make some changes to your house, to make your recovery smoother. This includes things like adding a handrail in your shower.

In some cases, your provider might want additional tests before you have your surgery. These might include:

• X-rays, to get information about your hip

• MRI, to get more detailed information about your hip

• Electrocardiogram , to make sure your heart rhythm is normal

Follow any other instructions from your healthcare provider.

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