Squatting after Unicondylar Knee Replacement

Knee Replacement is a revolutionary surgery. It gives patients a miraculous cure from severe knee pain and deformity. Patients achieve a lasting and complete relief from pain. It is a boon for patients handicapped by knee arthritis. It is one of the most successful surgeries in all of medicine.
In an effort to continuously improve, science makes breakthroughs all the time. The knee is made of 3 compartments. Arthritis damages these compartments but often not uniformly.  When we as surgeons are doing total knee replacement, we often find that one compartment is badly damaged whereas the other compartments are well preserved. In total knee replacement, we replace all the compartments irrespective of the damage. The knee also has two important ligaments called the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). These ligaments are removed in a total knee replacement. Replacing all compartments leads to much bone loss and bleeding. In order to do a good knee replacement, we need to take a big incision (cut) in the skin and the muscle. Big cuts result in more pain and slower recovery. Patients need supervised physiotherapy to regain knee function. After total knee replacement patients can walk freely and comfortably, however the absence of ligaments doesn't allow them to sit on the floor or squat easily.
Scientific research has led to the evolution of Unicondylar Knee Replacement (UKA) to solve these issues. The principle of UKA is to replace only the damaged compartment. Only one of the three knee compartments is replaced. There is minimum cutting of bone and less blood loss. Patients feel much less pain and recover quickly. No painful physiotherapy is required after surgery. My UKA patients are walking comfortably just a few hours after surgery. They hardly feel postoperative pain. The surgery is done through a small cut in the skin using special instruments with a minimally invasive technique. Both ACL and PCL are preserved. After UKA patients are able to easily squat in a toilet and sit on the floor. UKA feels like a natural knee. The long term results of UKA are comparable to total knee replacement. UKA is just as durable and will give a patient many years of pain-free knees.
Not all patients are eligible for UKA. It cannot be done in very advanced arthritis where all compartments are damaged. It also cannot be done in patients who have damaged ACL or PCL ligaments. Even so a large number of arthritis  patients can benefit from this modern surgery. Your doctor is the best judge of whether you are eligible for UKA.
UKA is a bone, muscle and ligament preserving surgery done through a minimally invasive technique with advantages of fast recovery, less pain and better function. It is a spectacular gift of modern scientific research.

​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!!

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!