Unicondylar Knee replacemnt - 2

As we have seen in the previous article, unicondylar knee replacement is a natural evolution of total knee replacement. It has advantages. It is done using a minimally invasive technique. There is less cutting of skin and tissue. Muscles are not cut. This results in a faster recovery and little postoperative pain and swelling. The amount of bone removal and blood loss is less. The surgery is safer than traditional knee replacement.
The incision for unicondylar knee is half the length of a total knee replacement. The surgery is done using special instruments designed for minimally invasive surgery (MIS). The quadriceps (thigh muscle) is spared. The muscle strength remains intact after surgery. Patients can walk comfortably without a walker. As against this, the quadriceps is cut in total knee replacement, which results in weakness post-surgery. After traditional knee replacement, all patients need a walker to help them walk surgery for as long as 3-4 weeks. 
Safety has been a long standing concern of total knee replacement, especially because the surgery is performed in elderly patients. The cutting of muscle, removal of bone and blood loss puts a stress on the body. This stress becomes significant in those who have preexisting compromises like a weak heart, lung or kidney. Surgeons are worried for infection with diabetic patients. With Unicondylar surgery the stress is reduced. More patients are now eligible for knee replacement with much less risk! 
To be able to sit on the floor is important for our religious customs and traditions. This vital function was snatched away from patients after traditional knee replacement! It is the primary reason for dissatisfaction. Do we finally have an answer?
Ligaments play an important role in knee function. They give the knee stability and allow people to do high demand activities like running, squatting and sitting on the floor. In a traditional knee replacement, the ligaments (anterior cruciate ligament & posterior cruciate ligament) are cut. This I strongly believe is a loss. It is the absence of ligaments after traditional knee replacement, which does not allow patients to squat in an Indian toilet comfortably or sit on the floor. In unicondylar knee replacement, both ligaments are preserved (ACL and PCL). Preserving the ligaments has advantages. After surgery the knee feels like the natural knee. It remains stable and strong. Unicondylar surgery gives the patient the confidence to perform all daily activities in a normal fashion just like they used to when they were younger! It is a cure in the true sense. After this surgery, patients are allowed to sit on the floor, sit cross legged and even squat in an Indian toilet!
So can all arthritis patients benefit from this surgery? Ligaments are not only preserved in this surgery, they are also crucial for the success of this surgery. Unfortunately, in the arthritis process, sometimes ligaments are also damaged along with the cartilage. In patients with damaged ligaments, Unicondylar surgery does not work. For them traditional knee replacement remains the only way out. Your doctor will be the best judge to decide if you can benefit from Unicondylar surgery.       

Unicondylar Knee Replacement

Total knee replacement is an excellent surgery. It has evolved over the decades to become one of the most successful procedures in all of medicine. Patients are cured of pain and disability. They regain their ability to walk normally, without a limp or support. They can resume living normal lives again. Without surgery, they are stuck in a rut of suffering and handicap with a lifelong dependency on kidney destroying medicines.

However, total knee replacement comes with a bag of its own problems. It is not without reason that patients fear the surgery. The foremost fear is that the surgery is a major surgical adventure.

Major surgery means more risk! The risk of an adverse event in the peri-operative period is always lurking round the corner.

Major surgery means more pain! Post operative pain is dreaded! Only recently have we truly succeeded in pain control with the use of ultrasound and nerve locator guided nerve blocks and LIA (local infiltration analgesia). 

Major surgery means more weakness! Patients routinely require a walker to walk for a week or two after surgery. 

Major surgery means a longer recovery! Patients take up to 3 months to return to normalcy and actually start experiencing the benefits of the surgery. 

What is a half knee (or partial knee) replacement? The knee is made of 3 different compartments. Two compartments are between the thigh and leg bone and the third compartment is between the knee cap and the thigh bone. In total knee replacement, we replace all three compartments and sacrifice two ligaments (out of 4) and both menisci (natural shock absorbers found in the knee). However, arthritis does not damage all compartments equally. Most of the times, it is only the medial or inner compartment that suffers the brunt of the destruction. In partial knee replacement, only this compartment is replaced with sacrifice of a single meniscus. Two compartments, all 4 ligaments and one meniscus is preserved. Many studies have shown this procedure to be as effective in relieving pain as total knee replacement. The survival of partial knee prosthesis is also as good as total knee prosthesis. 

By doing this selective procedure we gain many advantages. This surgery is done by a minimally invasive technique. It involves less cutting of skin, muscle, tissue and bone. Most of the knee is left untouched as it is healthy. Hence this is not a major surgery.

Risk of an adverse event is less!

Pain is very less! Lesser volume of trauma coupled with modern pain management makes post op pain negligible.  

Less muscle cutting means minimal weakness! Patients can stand and walk without a walker on the same day, a few hours after surgery. All this translates into a faster recovery. No longer do patients have to wait for 3 months to get back to normal.  

Partial knee replacement or unicondylar knee replacement is a natural evolution of a total knee replacement. It retains all the effectiveness of a total knee and brings with it significant advantages! I have pointed out the advantage of less risk and quicker pain-free recovery in this article.....but it doesn't stop here! Stay tuned for the next article. 

PAINLESS - Total Knee Replacement

Total knee replacement is a highly successful surgery. Patients disabled with knee pain who can barely walk on their deformed legs undergone a dramatic transformation after the surgery. They experience complete relief from pain and complete correction of deformity. After surgery they don't need pain killers. They can walk normally without a stick or walker and at a normal pace. 

However the surgery is a major procedure involving cutting of muscle and bone. This leads to a slow and painful recovery. Post surgery pain after knee replacement can be unbearable and remains as a major deterrent to someone who wants to undergo the operation. Traditional methods of pain control include intravenous or intramuscular analgesic injections and epidural pumps. Intravenous medicines have safety issues and are not effective. Epidural pumps involve placing an epidural catheter (a very thin tube) in the epidural space near the spinal cord. Through this tube medicine is administered which numbs the spinal nerves and relieves pain. A well functioning epidural pump is very effective but has certain problems. Firstly, placing an epidural catheter is a blind procedure and many times the catheter is not in an ideal position. As a result it fails to reduce pain. Secondly, epidural pumps may cause a drop in blood pressure in some patients which requires constant monitoring. Lastly, epidural medicines may cause temporary sensory loss and motor weakness in the legs which makes walking after surgery difficult. 

In recent years, technological advancements in the science of anaesthesia and pain management have made painless knee replacement possible. Patients are standing and walking by evening on the day of surgery! Nerve blocks are a known technique of analgesia (pain relief). Two technologies have become available to the anaesthetist in the operation theatre which have revolutionized the efficacy of nerve blocks. First is a nerve locator. As its name suggests it helps in precisely locating a peripheral nerve which then can be blocked by administrating medicine. Second is portable ultrasound. Combining these technologies increases the accuracy of locating a nerve to 95%. This allows the anaesthetist to confidently block peripheral nerves (nerves outside the spinal cord) with predictable success. In the case of knee replacement, a femoral block and an adductor canal block is used to numb the pain. These blocks are effective and safe. There is no drop in blood pressure and no motor weakness. As a result we have successfully eliminated the need for epidural pumps. 

Another advance that we routinely use is called LIA - Local Infiltration Analgesia. This involves injecting a combination of medicines in the local tissues around the knee joint at the end of the surgery. With modern drugs and optimal doses, this technique alone numbs the knee for 12 to 24 hours. Again the technique is safe and effective. it does not require monitoring of blood pressure and does not cause any weakness. 

The last addition is that of pain patches. Newer opioid analgesics (artificial morphine substitutes) are available as pain patches. A single patch can work for a week. The action is not only long lasting but fast as the medicine is directly absorbed in the blood from the skin (bypassing the stomach). 

Not only is total knee replacement a highly successful surgery, it is now a comfortable and pleasant experience as well. Today’s analgesia is safe and effective. All patients are able to walk on the day after surgery and many manage to walk on the same day. Nerve blocks, LIA and Pain Patches are so effective that they have made painless knee replacement a reality today.

​Life After Knee Replacement​

Lots of patients are advised knee replacement! But do you really need it? How to really know if you require a surgery? Knee Replacement is a major surgery which should not be taken lightly. It's a great success for those who actually need it and can be a disaster for a  patient who doesn't. The doctor is naturally the best person to make the decision. Sadly many doctors are doing unnecessary surgery for monetary gain. The time has come for patients to become smart! It is my wish that patients become aware enough to decide for themselves. Patients should be able to choose a good decision from a bad one. Enlightening patients has always been my sincere endeavour! 

 

Knee replacement is the final option for a patient with arthritis. It is chosen when all else fails. The patient should have tried all possible treatment methods before considering surgery. Surgery is done for a patient who has constant and severe pain. Pain on getting up from the floor or when going up and down stairs, is common and doesn't usually warrant a knee replacement. However pain during walking is far more serious. Patients who need surgery can barely walk a few hundred feet. Every step is painful. They limp and walk very slowly. Many need a walking stick for support.  Activities of daily living are affected. Such patients tend to remain at home. They will avoid social commitments that require them to leave the house. Getting up at night and going to the bathroom is a huge and painful effort. Painkiller medications are required to get through the day. If you are so disabled and have tried many types of treatments without much benefit, get a knee replacement done.It is a beautifully successful surgery after which you will become normal again. But if you are not so bad, then think again! Knee replacement may not be the best option for you. It may be wiser to wait a while and consider other options. 

 

What has been the experience of patients who have undergone this surgery? Is it really successful? Does it give long term relief? Is the surgery painful? Before surgery, the patients are screened for infection and assessed for fitness. This involves investigations like blood tests, chest X-ray, etc. A physician checks the patient and certifies him or her fit for surgery. The patient is admitted one day prior to surgery. The surgery is done most often under spinal anaesthesia. A small injection is given with a thin needle in the lower back of the patient which makes the legs numb. The actual surgery lasts for 60 to 90 minutes. When the anaesthesia wares off, the patient experiences postoperative pain. The pain is severe for the first 2 to 4 days. Doctors usually have pain management protocols in place to manage the pain like epidural injections, blocks etc. After that the patient gets pain while exercising the knee (lifting the leg, bending the knee) and during walking.  As time passes the pain reduces and completely disappears by 8 to 10 weeks. The patient starts walking on the second or third day after surgery.  Post surgery the patient's leg becomes weak (due to cutting of muscle during surgery). Initially the patient needs a walker to walk. As time passes the leg becomes stronger and the patient can walk independently. Surgery also leads to swelling of the leg and the knee. This is a normal reaction to surgical trauma. The swelling automatically subsides in 12 to 16 weeks. After this period of recovery is complete, the patient truly experiences the benefits of surgery. The Person stops being a patient and becomes normal. He/she has complete relief from pain. He/she can walk normally (and fast) without a limp or stick. He/she does not need pain killers.

 

Even though knee replacement is a major surgery and has a long recovery time, it is a truly gratifying surgery which gives a person spectacular and lasting results.         

...ANYTHING BUT SURGERY!! (PART 2)

In the last article, I discussed treatments for knee arthritis that have poor results but are aggressively marketed to make quick profits! These treatments are experimental or commercial, many are non scientific and most result in a huge waste of money for the patient.

So if these treatments do not work, which ones do? What does authentic scientific research say? Why is this scientific research so important? If a particular medicine works for one person without side effects, can it be recommended for all? You may think why not? We do it all the time! Most of us have seen some medicine or treatment work very well in our friends or relatives. Then we start recommending that treatment to everybody! What’s wrong with that?

The problem is that a treatment that works for one person may not work for another. A treatment that is safe for one person may not be safe for another. That’s where scientific trials and statistics come in! If there are hundred patients, scientific evidence tells us if a treatment works for all 100 or it works for 75 out of 100, or 50 out of 100 or for only 10 out of 100.

Now let’s consider the treatment that worked for our friend. What if that treatment worked only in 10 out of 100 and caused side effects in 80 out of 100? Our friend was lucky, wasn’t he? With this information, will you start recommending this treatment to everybody? I’m guessing – NO!

There are multiple scientific review committees all over the world who have formed recommendations for knee arthritis by looking at research, evidence and statistics. The effectiveness and safety of these recommendations has been solidly proven. So what are these recommendations? These recommendations are for osteoarthritis of the knee. They are not for arthritis affecting other joints or for rheumatoid arthritis which is different type of arthritis.

Recommendation – patient education. Education by the doctor, physiotherapist or counsellor or patient self education from books or internet tremendously helps patients with arthritis. One may wonder how? Most fear and anxiety is out of ignorance!  Patients who learn about the problem, how and why it has happened to them, what will make it worse, what will make it better etc are less anxious. And as anxiety goes down, so does pain. Patients with knowledge look after themselves better, are more likely to follow advice and treatment recommendations and stay away from quack therapies.

Recommendation – weight loss. Weight loss is strongly proven by multiple studies in different countries to help decrease pain in patients with knee arthritis. I have written about weight loss in a previous article. It’s not easy to lose weight! But it’s not impossible like most of my patients think. It is a full time job. It requires huge efforts and 100% commitment. A conscious effort to adopt a healthy diet, reasonably restrict quantity of food consumed and daily exercises will result in weight loss in 9 out of 10 people. The problem is that we are lazy. We don’t want to put in any effort. We want some magic medicine or some belt or some therapy to melt the fat away. Unfortunately none of these work!

Recommendation – exercise. Exercise is a recommendation that I give all the time. I have written extensively on exercise in the past. I have dedicated multiple articles on the subject. This recommendation is backed by solid scientific research! Exercise is the magic pill you are looking for. It’s cheap and has no side effects! And it works. And it will work in all patients. But a lot of my patients tell me ‘exercise didn’t work for me!’  Exercise does not work in 2 situations. First is when arthritis is very advanced. And the second and most common reason is that patients don’t do exercise properly. Exercise is something which is taken very lightly. People will go to driving school for a month to learn to drive their car but will refuse to go to a physiotherapist for 10 days to learn the right way to do exercise. People will research the internet thoroughly to find a good doctor but will not research to find the different types of exercise that will benefit them. Exercise is a gold mine, my friends. The physiotherapist and the doctor will only show you the way... they will only show you the tip of the iceberg. It’s up to you to dig deeper after that. 10 minutes of doing a few repetitions when you wake up in the morning doesn’t help. You have to spend effort and time to achieve results.

Recommendation – braces and footwear modification. There is no strong evidence in scientific literature for or against braces (knee caps and belts) and footwear modifications. There is no harm in trying braces! Patients who find benefit in braces should continue to use them.

Recommendation – assistive devices for walking. Again... a very effective recommendation. Using a walking stick decreases pain and increases the distance that the patient can walk. It would also decrease the requirement for medication, buy time and postpone surgery. But most patients refuse to use a stick because of some misplaced sense of shame! As a patient, I would give little importance to what other people think especially because I am suffering and others are not!

Recommendation – medication. So which medications are recommended for arthritis? Is there a medicine that will cure the problem? The answer unfortunately is NO. No medication, whether it is allopathy, ayurveda, homeopathy or Chinese has been conclusively proven to cure knee arthritis. Lot of them ‘claim’ to cure arthritis but there is no concrete scientific evidence. That means that the chances that a particular medicine will work for you are as good as the chances that drinking a glass of water will work! Another common misconception is to take calcium supplements for arthritis pain. Osteoporosis or weak bones is a problem that accompanies arthritis or joint inflammation. Calcium supplements are used to treat osteoporosis. They have no role in the management of arthritis.

Medications are however recommended to control the pain of knee arthritis. The main medication is Acetaminophen (Crocin). Acetaminophen is a mild analgesic with a very good safety profile. It does not cause acidity in majority of people and does not affect the kidney even with long term use. It has been scientifically proven to be safe even if used for a long period of time. Other analgesics (pain killers) can be used as short term treatment to control attacks of severe pain. Topical analgesics (pain killer ointments) are also strongly recommended and useful. They are also safe for long term use. What about Glucosamine? There have been extensive studies carried out on the effects of glucosamine. The results say that all it does is give relief of pain in some patients. It does not cure the problem or cause cartilage to grow back. It is safe. The recommendation is to use it (if you can afford it) only if it gives relief from pain.  

 To conclude, I recommend my readers to develop a scientific outlook while assessing treatments especially new miraculous cures promoted by aggressive marketing. Here Science, Statistics and Evidence all become your friends as they protect you from being cheated of your time, energy and hard earned money!

Recommendations from

•        AAOS 2008 (American Association of Orthopaedic Surgeons)

•       OARSI 2007 (Osteoarthritis Research Society International)

•       NICE 2009 (NHS, UK)

•       RACGP 2009 (Royal Australian college of General Practitioners)

•       NGC 2007 (Singapore)

•       EULAR 2003 (European League Against Rheumatism)

...ANYTHING BUT SURGERY!!

Fear to do undergo surgery is common and well justified. Any normal person would not want to undergo knee replacement by choice and would look for ways and means to avoid surgery. While this is a sensible approach, I see many patients taking it too far. They will avoid surgery at all costs, no matter how much pain they have to suffer. Fear instilled by friends and family adds to the problem.

Many crooks are trying to make a quick buck at the expense of this fear. Newspapers, pamphlets, TV, Internet etc are flooded with advertisements of products promising a miraculous cure for arthritis. I see patients getting duped and cheated by these thugs on a regular basis. My readers call me often to enquire about the authenticity of these products!

Stem cells, oils, lasers, Cytotron, rope therapy, expensive knee injections etc are just some examples of alternative treatments being promoted. While some of these are in an experimental phase, others are plain ridiculous! None of these treatments have been proven to work.
Oils for massage, as a remedy for pain, have been around for centuries. Oils work! There is a strong scientific rationale for their use in arthritis pain. But they do not cure arthritis! At best they give some hours of relief from pain. They work better in early stages and their effect decreases as arthritis advances. I myself recommend patients to use oils. But when an oil is advertised as a cure and it is expensive to buy, then I have a problem with that oil! If you are buying a bottle of oil that is costing thousands of rupees, you are surely being cheated. Please don’t get carried away with tall claims made in advertisements. It is a big scam!

The next famous treatment is lasers! Lasers work beautifully in eye and kidney stone surgery, but have little effect on arthritis. Cartilage is a tissue that has poor capacity to regenerate and repair itself. Many people have tried a number of different ways to repair cartilage and most of them have failed. Lasers too have little effect if any on cartilage growth and repair. Besides in advanced stages of arthritis, the leg becomes deformed. Logically, till the deformity is corrected, arthritis pain can never completely go. Lasers do not correct deformity. Again an expensive treatment that doesn’t work!!

Cytotron is based on Rotational Field Quantum Magnetic Resonance – RFQMR – technology. The promoters claim that “The beams are precisely controlled and focused onto tissues ...which in turn stimulates cartilage growth in case of diseases such as Osteoarthritis or stops the tumor's growth in Cancer.” Again claims of a miraculous cure from a new, expensive and experimental treatment. There is a contradiction in their statement! How can the same therapy promote one cell type to grow (cartilage) and cause another cell type to die (cancer cells)? Whenever some therapy claims a cure and is expensive, we all should ask ourselves one question. Why has this therapy not been accepted by the international community at large? If it really worked then arthritis patients would have stopped getting knee replacements by now and cancer patients would have had nothing to fear!

Another treatment is rope therapy. Here an attempt is made to correct the deformed or crooked legs by literally pulling them straight with ropes. This has been attempted by orthopaedic surgeons in the past and is called ‘traction’ in medical terms. Traction fails to correct legs deformed by osteoarthritis. Small corrections are achieved sometimes but are lost quickly after therapy is discontinued. While on this therapy some patients experience pain relief but again this is temporary.

Stem cells have become the miracle cure for every illness nowadays! Stem cell therapy has a definite role in arthritis treatment. The procedure is known as ACI (autologous chondrocyte implantation). This procedure works very well in early stages in which the knee has a small area of cartilage loss. A small amount of cartilage is taken from the patient’s knee and it is grown in the laboratory by stem cell technology. The grown cartilage is then implanted in the defect. This therapy has shown promising results. But it only works in patients who have a defect and that too, a small one. It cannot work in advanced stages where the knee is excessively damaged and the legs have become deformed. Stem cells have limitations!              

Medicines are now available that can to be injected into the knee as treatment. Injections have a definite role and can give tremendous relief to the patient when used correctly and judiciously. But injections are unpredictable. Some patients are hugely benefitted while in others, there is no effect. Because of the unpredictable results, I would be hesitant in using very expensive injections. As a patient, one will feel the pinch if an expensive injection doesn’t work!

To conclude, arthritis of the knee is a difficult problem to solve. Fear of surgery has led patients to look for alternative cures. Many crooks have taken advantage of this situation and are selling quack treatments. These treatments do not work and are very expensive. Many patients are being cheated of their hard earned money. So I plead with my readers to be careful when looking for alternative treatments. Beware! 

  

RECENT UPDATES IN KNEE REPLACEMENT

Knee replacement is one of the most successful surgeries in all of medicine. Pioneering work in knee replacement was done in the early 70's by prominent scientists and surgeons in the US and UK. Since then knee replacement has come a long way. 

Surgeon experience has grown. Surgery is faster, more precise and with minimum errors. Anaesthesia is better. Pain management is better. All this has resulted in faster recuperation for the patient. The patient walks independently on the second day after surgery. The patient is discharged in 5 or 6 days. Replacing both the knees in one sitting is now possible and the advantages are obvious. The knee replacement prosthesis’ have undergone a tremendous evolution as well. Better prosthesis translates into better function and a longer life for the joint. Most patients enjoy a near normal knee function postoperatively with the knee bending completely. In fact for patients needing knee replacement, things have never looked as promising as they are now! 

Fear to do undergo surgery is common and well justified. Any normal person would not want to undergo knee replacement by choice and would look for ways and means to avoid surgery. While this is a sensible approach, I see many patients taking it too far. They will avoid surgery at all costs, no matter how much pain they have to suffer. Fear instilled by friends and family adds to the problem. If feel this kind of attitude is unwarranted. 

Unqualified people classically will see a result as black or white. This person selling fruit is good, that petrol pump is bad, this school is terrible, etc. There may be some truth in the statement but it can never be a whole truth. This is because life is never black or white, but many shades of grey! Let me try and explain with an example. If a surgeon did one thousand knee replacements in a year, and one surgery went wrong, he would have a success rate of 99.9%, right? Sounds good? Now let's consider the surgery that went bad. What would that patient’s relative say? He would obviously tell you that knee replacement is a bad surgery and no one should get it done (black or white response) Is he justified in making such a statement? May be. But is he saying the truth? No! 

Are we as doctors justified in denying 999 people an excellent result because of the possibility of one case going wrong? No! 

I urge everyone to take any decision rationally and sensibly. It is unwise to base your decision on one particular example. There are too many variables. Some hospitals have better infrastructure than others, some joint replacement prosthesis are better than others, some surgeons are better than others and some patients are more suitable for this surgery than others!! Do your homework well and you will be rewarded with an excellent result. 

Progress in any field is welcome and inevitable. Even though knee replacement has progressed tremendously, more progress continues. 

Computer assisted surgery (CAS) is one such recent advance. Computers have brought accuracy in all fields. May it be computerised matching of colours or computerised cut out of designs. Humans cannot match computers in accuracy. CAS improves the accuracy of knee replacement. This results in better restoration of alignment of the leg and better fitting of the components. 

Another advance is custom knee replacement or knee replacement using custom made instruments and implants. Knee replacement is about fitting components of the right size into patients. Just as a custom made suit fits far better than a readymade one… similarly custom made instruments increase the accuracy of knee replacement. For this an MRI of the patients knee is done before surgery and sent to the company (mostly abroad) The company then manufactures instruments tailor made to that knee based on MRI and ships them to us. We then use these instruments to do knee replacement with perfect accuracy and therefore better results. 

The knee has three compartments and all are involved in a typical case of advanced osteoarthritis. However in a few patients, only one or two compartments are involved. Nowadays it is possible to do partial knee replacement in these patients (uni-condylar knee replacement and bi-condylar knee replacement). These surgeries are more bone and ligament saving. Because we remove less, patients feel the knee is more natural after surgery. Also revising these implants to a total knee replacement is easier later. 

And lastly I'll just mention Robotic Surgery. Yes robots have arrived in the field of knee replacement. In knee replacement we have to cut the bone accurately to allow accurate replacement with implants. In robotic knee replacement, the bone is cut by a robotic arm. This ensures extreme accuracy and therefore superior results. Robotic surgery is still in its infancy in India. 

To conclude, knee replacement is a fantastic surgery. It is getting better every day. With recent advances, success is almost guaranteed. But every surgeon cannot do it and every hospital is not equipped for it and every patient is not ideal for it! Do your homework! 

WHEN NOTHING ELSE WORKS...

Most patients with advanced knee arthritis are still looking for that elusive cure. They are unable to accept that they need surgery. They strongly believe that something or someone somewhere can solve the problem with some magic medicine. They will keep trying fancy treatments like acupressure, rope therapy, braces, etc. The list goes on and on.

In all joints like the knee, the bone ends are covered by a smooth lining called cartilage. Cartilage ensures smooth, painless knee movements. Damage to the cartilage marks the beginning of arthritis. In advanced cases the cartilage lining is completely eroded. The bone below the cartilage gets exposed and bone starts rubbing on bone. This leads to severe pain. The real problem here is that cartilage does not regenerate or grow back. No matter what you try or which medicine you take, the original cartilage doesn’t come back. As the disease progresses and more and more cartilage is lost, the leg starts getting deformed at the knee. This makes matters worse. A crooked leg condemns the patient to more pain and disability. This pain can never go till the cartilage comes back and the leg becomes straight. Both these goals are impossible with non operative treatment!

So why does knee replacement work when everything else is failing? To understand this we need to understand the history of knee replacement. Researchers, scientists and doctors worldwide were struggling to solve the issue of arthritis since centuries. Initially they tried to replace the cartilage with other substances from the patient’s body like fat, fascia etc. But none of the structures they used had the qualities of cartilage and they would breakdown very fast and the procedure would fail. Then in the 60’s a genius called Sir John Charnley made a few landmark discoveries. He invented an extremely strong plastic called high molecular weight polyethylene. This plastic resembled cartilage very closely. The friction between this plastic and metal was as low as between two bones lined by natural cartilage. In addition to its fantastic friction properties, this plastic was also extremely strong. The other landmark discovery was of bone cement. This cement anchored the artificial joint to natural bone so strongly that the union lasted many years. These two discoveries changed the face of replacement surgery. Sir John Charnley designed an artificial hip joint which lasted 10 to 15 years. This was the first successful replacement. Using these landmark discoveries scientists started working on knee replacement. Finally after many attempts they achieved success and durable artificial knee joints were designed.   

Knee replacement works because it achieves both the desired goals. Cartilage is replaced by a strong and durable ‘cartilage like’ plastic. Furthermore the deformity is completely corrected after the surgery. As the damaged cartilage is replaced, the patient gets complete relief of pain. And as the leg becomes straight, this relief lasts many, many years. 

So does knee replacement work? Yes! It is one of the most successful surgeries of modern medicine. But it is a complicated surgery. To work it has to be done properly. The surgeon has to learn the technique and spend an adequate time in training. A well trained, experienced surgeon will do a good job almost every time. Infection is a constant threat to any surgery. In replacement surgery, infection can ruin everything. So in addition to a good surgeon, you need a good operation theatre.

These two factors are the reason, this surgery fails. An inadequately trained surgeon in a poor operation theatre is a recipe for disaster. Because of these issues, this wonderful surgery has earned a bad name.

 Instead of avoiding surgery because of fear which stems from a lack of awareness, I encourage patients to educate themselves regarding the pros and cons of this surgery and gain benefits.

What you KNEEd to know...

What is knee replacement?

Knee replacement is a surgery in which around 1cm of diseased bone and cartilage is removed and replaced by artificial metallic caps. The new joint surface restores normal joint movements and eliminates pain.

When is a patient ready for knee replacement?

1.       When pain is unbearable and constant

2.       When walking even short distances takes a lot of time and effort

3.       When the patient needs a walker or stick support to walk

4.       When the patient stops going out of the house for recreation, work or to attend social functions in fear of pain

5.       When deformity or limp becomes very severe

What are the advantages of this surgery?

1.       Complete relief of pain

2.       Complete correction of deformity

3.       Patient walks independently without help of a stick

4.       Patient can walk as much distance as he/she desires

5.       Patient can climb stairs

How long will a knee replacement last?

Knee replacement typically lasts for 15 to 20 years after which it may become loose and need a revision surgery.

How long will a patient have to be in bed after a knee replacement?

A patient usually walks within a couple of days after the surgery. The patient is able to go to the toilet on his/her own whilst in the hospital itself.

Is this surgery painful?

Most patients experience postoperative surgical pain. This pain can nowadays be well controlled with modern pain management techniques.

How long is the recovery?

Most patients need 1 – 2 months to recover completely and experience a pain free joint

What are the complications of this surgery?

Infection is the most feared complication. With modern theatre setup and discipline, infection rate is less than 0.6%. All other complications are rare.

Armed with this knowledge, the arthritic patient need not suffer anymore!