1. Knee Arthritis and Knee Joint Replacement

2. ACL Reconstruction

What are the non-surgical treatments for Knee Arthritis?

Weight Loss
Probably one of the most important, yet least commonly performed treatments. The less weight the joint has to carry, the less painful activities will be. Roughly loosing 1 kg means 3 kg less burden on the joint. Being obese can make surgery difficult.

Activity modification
Patients need to learn to avoid activities that induce pain like squatting on floor, sitting cross-legged, kneeling, or using stairs. Some minor modifications will help them do routine activities without pain.

Walking Aids
Use of a walking stick or a single crutch should be used on the same side of the painful knee. It will help decrease the demand placed on the arthritic joint , reduce pain and improve mobility

Physiotherapy
Strengthening of the muscles around the knee joint helps in maintaining the range of motion as well as function of the knee joint. Doing regular exercises will not worsen the arthritis. In active patients the recovery after surgery is also rapid.

Anti-inflammatory & Pain-killer Medication.
These are helpful to treat pain and inflammation. Medications also improve mobility. Different types are available and are prescribed taking into consideration patient’s safety and pain levels. Medications should be taken as per doctor’s instructions only.

Chondroprotective agents
Glucosamine and chondroitin sulphate are considered as ‘chondroprotective agents’ or ‘neutraceuticals’. They may slow down the process of arthritis and have some pain relieving effect. For best results both these medications should be taken together in appropriate dosage. I do prescribe it for my patients and many have found them useful.

Corico-steroid injections
help in reducing inflammation, swelling and pain in knees with rheumatoid arthritis and osteo-arthritis. Multiple injections must not be taken to avoid infection in the knee joint.

Visco-supplementation
These injections are clear liquids which increase the viscosity of joint fluid and also the elasticity of the joint cartilage. They improve the lubrication and reduce friction between raw end of arthritic joint surface. They may cause healing of small cartilage defects. Their pain relieving effect may last for 6 to 12 months. They are most useful for mild to moderate arthritis. These injections are available as a single shot (Synvisc) or multi- injections (Hyalgan).

When is Knee Joint Replacement recommended?

Knee Replacement is indicated when there is:
Moderate or severe knee pain that limits one’s everyday normal activities of daily living e.g. walking, climbing stairs, and getting in and out of chairs.
No improvement in pain after taking regular pain killers.
Harmful side-effects from pain-killer medications
No improvement in pain even after modification / restriction of activities or use of a walking stick.
No improvement with physiotherapy, weight loss, cortisone or hyaluronic acid injections.
Severe pain that causes restriction of social life with sense of being house bound and dependent on others to lead a normal life.
Confirmation of advanced arthritis on x-rays.

What are the benefits of Knee replacement surgery?

Having a total knee replacement surgery will:

alleviate or remove knee pain
improve mobility and function
correct angular deformity, if any
improve quality of life and help the patient to return to normal daily activities
make the patient independent again without need to rely on family members or nursing care.

Can both knees be replaced at the same time?

Yes both knees can be replaced at the same time in a medically fit patient who does not have extremely severe or complex knee deformities.

Bilateral knee replacements have the following advantages:
Saves cost.
Avoids need for a separate second hospitalisation
Rehabilitation time is same as in a single knee replacement
Overall return to normal life is faster.

How can I prepare for my hospital stay?

Get informed. Find out about your standard of room in the hospital, whether a relative can stay with you overnight,what kind of anaesthesia ( general or spinal) will be given to you and any other information relevant to your surgery.
Arrange home help. Line up a relative or a nurse or an attendant to help you at home for some weeks after coming home from hospital.
Arrange for transport. Arrange for someone to take you to and from the hospital in a comfortable vehicle.
Prepare your home. Prepare your bed and chair where you would be spending most of your time after the surgery. In case you are using Indian style toilet, please arrange for a raised seat.
Clean up. Before going into hospital have a good long bath or shower, cut and clean your nails. Put on freshly washed clothes. This helps prevent unwanted bacteria going with you to hospital and complicating your care.

How long does a total knee replacement surgery take?

The actual surgical procedure usually takes about 1-2 hours. However, pre-operative preparations as well as wake-up time may make your operating room and recovery room stay longer.

What type of anesthesia is used?

This is decided by the anesthetist after your health status has been checked. The anesthesia can be general, epidural or spinal. The anesthetist will discuss these matters and choose the best option for you.
Generally knee replacement surgery is done under epidural anesthesia. The area below the waist is made numb for the operation. After the epidural anesthesia is given, patient can choose to remain fully awake or have a sedative injection.
Epidural anesthesia is continued (via a tiny catheter tube and a syringe pump) for next 2-3 days for pain control. It helps in starting exercises in bed without pain and improves patient confidence about physiotherapy.

What does the surgeon do in a Knee Replacement Surgery?

The Joint Replacement surgeon will remove the damaged cartilage and bone from the lower end of femur (thigh bone) and the top of shin bone (Tibia) by precision cutting devices. If necessary, the inside of knee cap (patella) is also shaved off.
The knee joint is then reconstructed using artificial implants to give correct alignment, stability and range of motion. This artificial knee joint will now function like a normal knee.

In a typical knee replacement:
The femoral component is made of highly polished strong metal.
The tibial component is either made of titanium. A highly durable plastic tray is locked onto the tibial base-plate. Femoral component will be moving on this plastic tray during knee motion.

The patellar component is made of highly durable plastic button.
The femoral, tibial and patellar components are fixed into place by using a special glue – Bone Cement (methyl methcrylate).
Newer designs keep coming in the market enabling better function.
Dr. Jadhav will select the best option for you.

Front and side views of right total knee replacement

How soon will I be up and about?
The physiotherapist will help you to get up and walk about as quickly as possible. 1-2 days after your surgery you may be able to sit on the edge of the bed, stand, and even walk with the help.You have to use a walker initially and then move onto crutches if your progress is satisfactory.You will also be taught to use stairs with help of crutches.

It is normal to experience discomfort while walking and exercising. Your legs and feet may be swollen. A physiotherapist will teach you exercises to help strengthen the knee and explain precautions to be taken.

How long will I need crutches or a walker?
Most patients will need to use crutches or a walker for about 4-6 weeks or until instructed otherwise by their physiotherapist.

How soon will the pain go away?
The joint pain that you had before the surgery will go away immediately, but there will be a different type of pain due to the operation. This post-operative pain will be temporary and is well controlled with pain-killer medications either in the form of injections or tablets.

When can I go home?
Your hospital stay will be around 5 to 7 days depending on your fitness and progress following the operation. A complete discharge summary along with the instructions for medications, follow-up visits and physiotherapy guidelines will be given to you on discharge.

Will I need to change anything at home because of my knee replacement surgery?
To ensure a comfortable and trouble free recovery, we recommend a list of modifications at your home prior to discharge
Handrail in your bathroom. Bathroom must be kept dry and non-slippery. A stable chair for shower.
Stairways must have hand rails
A stable chair with a firm seat cushion, a firm back, two arms, and a footstool for intermittent leg elevation
A toilet seat riser with arms. If you have an Indian toilet, Toilet seats to be arranged.
All loose carpets and cords must be removed from home
Living, bedroom and bathroom to be on the same floor preferably, because walking up or down stairs will be difficult during early recovery

Should I do exercises at home?
Your physiotherapist will instruct you about simple home exercises and also the frequency of doing these. These exercises help in developing strength of thigh muscles and increasing range of knee joint movement. Regular walks are also necessary. The knee should have Ice-packs for 20 minutes thrice a day after exercises. The joint should be kept elevated while at rest.
Patients should follow these instructions to avoid over-exercises which can cause more pain or swelling.

When are the stitches removed?
Sutures or skin staples are removed 14 days after surgery. Your wound will be checked and the dressing changed prior to discharge. This new dressing can be left undisturbed till the time of suture removal.

When can I have a bath / shower?
You can have a bath or shower generally 2 weeks after the operation when wounds have been checked for healing and all sutures or skin staples have been removed.Until then we advise sponging without getting the operative wound wet.

How long will it be before I feel normal?
You should be able to get rid of the crutches by 4 to 6 weeks and feel more or less normal by three months. Normal daily activities of living become easier. Always take advice from your surgeon and physiotherpaist before beginning any new activity.

When can I drive again?
It depends on your progress, but usually after about 4-6 weeks. You need to have pain-free knee joint, sufficient muscle strength and good knee joint motion prior to driving. Please consult Dr. Jadhav for further advice.

When can I go back to work?
It depends on the type of your job and recovery from surgery. Most office-type workers can resume work in 4-6 weeks.

When will I have to go back to the hospital for follow-up visits?
Usually 6 weeks after your knee replacement, you need to meet Dr.Jadhav for a check-up. He will examine your operation site, your walking, your balance and muscle strength.

Dr. Jadhav will then see you at 6 months and 1 year following your surgery. X-rays will be done during these visits to check that all is well. Subsequent follow-ups are advised after 5 and 10 years with new x-rays of your knee replacement to see for any signs of loosening.

How will I feel after Knee Replacement Surgery?
After a total knee replacement patients experience a remarkable reduction of knee pain. There is improvement in the ability to perform activities of daily living without the need of help from others. They feel confident and have an improved social life.

You can bend the operated knee upto 90-100 degrees easily in 2-3 weeks time. This amount of knee bending can allow you to get in and out of a chair or use stairs. The amount of knee bend after surgery depends upon how much mobility you had prior to your surgery. Certain modern implants can give you additional bend but you will not get full knee bending as in a normal knee.

It is common for some patients to have a sense of stiffness for initial few weeks after knee replacement.

Some swelling can persist on the operated leg for 6-9 months. A small area of numbness around knee is also common but this sensation does not bother patients.

It can take 2- 3 months before you feel near normal again. You should be prepared to continue home exercise for 4-6 months.

You need to understand that total knee replacement will not allow you to do more than what you were able to do before you developed arthritis. You must avoid certain activities like jogging and high-impact sports for the rest of your life.

With normal use and activity, every knee replacement develops some wear in its plastic cushion. Excessive activities or increased body weight may accelerate this normal wear. This may cause the knee replacement to loosen and become painful. With appropriate activity modification, knee replacements can last up to 15 years.

Is there anything I should look out for or worry about?
After knee replacement surgery you should contact Dr. Jadhav if you notice any fever or chills ( 38° C or 100.4° F), persistent warmth or redness around the knee, discharge (leakage) from wound, persistent or increased pain in the knee or calf muscle pain and shortness of breath.

What are the risks of Knee Replacement surgery?

Possible risks during Knee Replacement surgery are:
Risks for any anesthesia are:
Allergic reactions to medicines
Breathing problems

Risks for any surgery are:
Blood clots in the legs (DVT- deep vein thrombosis) that may travel to the lungs (PE- pulmonary embolism)
Infection, including in the lungs, urinary tract, and chest
Bleeding

Some risks of this surgery are:
Infection of the knee joint
Wear of the artifical joint
Loosening of the artificial joint over time
Knee stiffness
Allergic reaction to the artificial joint
Injury to nerves - Some area of numbness develop over the outer apsect of knee. This numbness reduces in 4-6 months with return of normal sensations. Often a very small patch of numbness (the size on thumb nail) remains but this does not bother patients.
Injury to blood vessels

People who have a prosthesis, such as an artificial joint, need to carefully protect themselves against infection. You should carry a medical identification card in your wallet that says you have a prosthesis. You may need to take antibiotics before any dental work or invasive medical procedures.