Total knee replacement surgery was first performed in 1968, and has evolved over the years into a reliable and effective way to relieve disabling pain and allow patients to resume their active lives. Improvements in surgical techniques and implant design and construction have helped make this one of the most successful orthopaedic procedures today. As the population has become older and remained more active, the need for total knee replacement continues to increase. Today, approximately 270,000 total knee replacements are done every year in the United States.
Many of the advancements in knee replacement surgery have taken place at the SPARSH Hospital. Improvements in the surgical technique and the design of new implants are a few of the contributions the surgeons of the Hip and Knee service have made.
Arthritis of the knee is a condition in which there is loss of the articular cartilage of the femur, tibia, or patella. This can be seen on x-ray as a loss of the space between the two ends of bone.
Because of the loss of the gliding surfaces of the bone, people with arthritis may feel as though their knee is stiff and their motion is limited. Sometimes people actually feel a catching or clicking within the knee. Generally, loading the knee joint with activities such as walking long distances, standing for long periods of time, or climbing stairs makes arthritis pain worse. When the arthritis has gotten to be severe, the pain may occur even when sitting or lying down. The pain is usually felt in the inside part of the knee, but also may be felt in the front or back of the knee. As the cartilage is worn away preferentially on one side of the knee joint, people may find their knee will become more knock-kneed or bow-legged.
Arthritis of the knee usually occurs in people as they enter their 60′s-70′s, but this is variable depending upon factors such as weight, activity level, and knee anatomy. Arthritis may be caused by a variety of factors, including simple wear and tear, inflammatory disorders such as lupus or rheumatoid arthritis, infections, and post-traumatic. People who have had prior injury to their knee, damaging the meniscus or cruciate ligament may also develop arthritis. The end result of all these processes is a loss of the cartilage of the knee joint, leading to bone rubbing against bone.
If the non-operative methods have failed to make your condition bearable, surgery may be the best option to treat knee arthritis. The exact type of surgery depends upon your age, anatomy, and underlying condition. Some examples of surgical options to treat arthritis include an osteotomy, which consists of cutting the bone to realign the joint; and knee replacement surgery.
An osteotomy is a good alternative if the patient is young and the arthritis is limited to one area of the knee joint. It allows the surgeon to realign the knee to unload the arthritic area and place weightbearing on relatively uninvolved portions of the knee joint. For example, a patient who has begun to become more bow-legged might be realigned to be more knock-kneed in order to redistribute the load across the joint. The advantage of this type of surgery is that the patient’s own knee joint is retained and could potentially provide many years of pain relief without the disadvantages of a prosthetic knee. The disadvantages include a longer rehabilitation course and the possibility that arthritis could develop in the newly aligned knee.
Knee replacement surgery involves cutting away the arthritic bone and inserting a prosthetic joint. All of the arthritic surfaces are replaced, including the femur, tibia, and patella. The arthritic surfaces are removed, and the ends of the bone are replaced with the prosthesis, like capping a tooth. The prosthetic component is generally made of metal and plastic surfaces which are designed to glide smoothly against one another.
The total knee replacement is performed in an operating room with a special laminar airflow system, which helps reduce the chance of infection. Your surgeon will be wearing a “spacesuit”, also designed to reduce the chance of infection. The entire surgical team will consist of your surgeon, two to three assistants, and a scrub nurse.
The anesthesia for a total knee replacement is given through an epidural catheter, which is a small tube inserted into the back. This is the same type of anesthesia given to women in labor. You will be made numb from the waist down so that you will not feel anything. The catheter stays in for 1-2 days after the surgery to help with your post-operative pain control. During the course of the operation, you can be as awake or as sleepy as you want to be.
After the epidural block is administered, a tourniquet, or cuff, will be placed around your thigh. The tourniquet will be inflated during surgery to help reduce the loss of blood. The incision for a total knee replacement is made along the front of your knee. The incision will measure anywhere from 4 to 10 inches depending upon your anatomy.
The arthritic surfaces of the femur, tibia, and patella are exposed and removed with power instruments. In so doing, deformities of the knee are corrected, and the knee will appear straighter after surgery. The bone is prepared to receive the artificial knee joint, and then the prosthesis is inserted. During the closure, two drains are inserted around the operated area to assist with evacuation of blood. Staples are used to close the skin.
The entire operation will take from 1 to 2 hours. Afterwards, you will be brought to the recovery room, where your blood work and vital signs will be checked. . Most patients can be brought to a regular room within a few hours; others will need to stay overnight in the recovery room, as determined by your surgeon and anesthesiologist. Patients generally stay in the hospital for 3-4 days following total knee replacement surgery.
Your return to activity will be guided by your surgeon and therapists. Generally, patients are able to walk as much as they want by 6 weeks post-operatively. Patients are able to resume driving at 6 weeks. At 8 weeks, patients are able to resume playing golf and swimming; at 12 weeks, they may play tennis. Your surgeon will help you decide what activities you may resume.
Most patients will be asked to donate 1 to 2 pints of their own blood in the weeks preceding knee replacement surgery. This helps reduce the need for a blood transfusion from our blood bank. Almost all of the patients will receive the donated blood as a transfusion after surgery. Rarely, an additional transfusion is necessary from our blood bank. The blood from the blood bank is carefully screened to the best of our ability to detect any infectious diseases.
You will be asked to see a medical doctor at SPARSH prior to your surgery. This is a precaution to make certain that you are healthy enough to undergo knee replacement surgery. In the course of this workup, you may be asked to have additional testing to examine your heart and lung function. After your surgery, this medical doctor will see you in the hospital.
Immediately after total knee replacement surgery, you will be in the recovery room. Most patients are able to go to a regular room after a few hours, when the sensation returns in your legs. You will be given a pain pump connected to your epidural catheter which will allow you to control when you are given pain medicine. Most people are quite comfortable with the pain pump in place.
On the day of surgery, you may do some of the exercises as instructed by your physical therapist, including quadriceps contractions and moving the feet up and down. Depending on your surgeon’s preference, you may begin bending your new knee right after surgery, or on the first day after surgery. You will be allowed to take some ice chips after surgery to wet your mouth, but drinking liquids or eating may cause you to become nauseated. You will have a catheter in your bladder so that you do not have to worry about urinating. Once you regain the movement in your feet, you may be allowed to sit up, stand, and take a few steps with the assistance of a walker and a therapist.
The first day after surgery will be an active one, designed to help you get more mobile. You will meet our physical therapists, who will instruct you in more exercises to perform while in bed. In the next few days, you will find it easier and easier to move about. You will be freed up from the pain and urinary catheters. Pain medication will be given in the form of tablets. Eventually you will progress to walking with a cane or crutches. On the second day after surgery, if your bowels have shown evidence of recovery, you will be allowed to eat regular food.
Some of the risks of the surgical procedure include the loss of blood, formation of a clot in your leg, and the chance of infection. The overall incidence of these risks is very small. They should be discussed with your surgeon prior to proceeding with the operation.
Some of the risks of having a prosthetic knee include the chance that the parts may loosen or wear out over time, or the prosthesis may become infected. Again, these issues will be discussed with you by your surgeon.
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