Total knee replacement surgery (which is typically known as total knee arthroplasty).
Knee replacement may be a surgical procedure that decreases pain and improves the standard of life in several patients with severe arthritis of the knees. usually patients undergo this surgery once non-operative treatments have did not offer relief of arthritic symptoms. Non-operative treatments will include activity modification, anti-inflammatory medications, and knee joint injections.
Surgeons have performed knee replacements for over three decades usually with excellent results; most reports have ten-year success rates in more than 90 percent.
Total Knee Replacement
Traditional total knee replacement involves a 7-8” incision over the knee, a hospital stay of 3-5 days, and a recovery period (during which the patient walks with a walker or cane) typically lasting from one to three months. The large majority of patients report substantial or complete relief of their arthritic symptoms once they have recovered from a total knee replacement.
Pain is the most noticeable symptom of knee arthritis. In most patients the knee pain gradually gets worse over time but sometimes has more sudden “flares” where the symptoms get acutely severe. The pain is almost always worsened by weight-bearing and activity. In some patients the knee pain becomes severe enough to limit even routine daily activities.
Morning stiffness is present in certain types of arthritis. Patients with morning stiffness of the knee may notice some improvement in knee flexibility over the course of the day. Rheumatoid arthritis patients may experience more frequent morning stiffness than patients with osteoarthritis.
Swelling and warmth
Patients with arthritis sometimes will notice swelling and warmth of the knee. If the swelling and warmth are excessive and are associated with severe pain, inability to bend the knee, and difficulty with weight-bearing, those signs might represent an infection. Such severe symptoms require immediate medical attention. Joint infection of the knee is discussed below.
An orthopedic surgeon will begin the evaluation with a thorough history and physical exam. Based on the results of these steps your doctor may order plain X-rays.
If a patient has arthritis of the knee it will be evident on routine X-rays of the joint. X-rays taken with the patient standing up are more helpful than those taken lying down. X-rays with the patient standing allow your physician to view the way the knee joint functions under load (i.e. standing) which provides important treatment clues.
Also, plain X-rays will allow an orthopedic surgeon to determine whether the arthritis pattern would be suitable for total knee replacement or for a different operation such as minimally-invasive partial knee replacement (mini knee).
It is important to distinguish broadly between two types of arthritis: inflammatory arthritis (including rheumatoid arthritis, lupus and others) and non-inflammatory arthritis (such as osteoarthritis).
There is some level of inflammation present in all types of arthritis. Conditions that fall into the category of true inflammatory arthritis are often very well managed with a variety of medications and more treatments are coming out all the time. Individuals with rheumatoid arthritis and related conditions need to be evaluated and followed by a physician who specializes in those kinds of treatments called a rheumatologist. Excellent non-surgical treatments (including many new and effective drugs) are available for these patients; those treatments can delay (or avoid) the need for surgery and also help prevent the disease from affecting other joints.
So-called non-inflammatory conditions including osteoarthritis (sometimes called degenerative joint disease) also sometimes respond to oral medications (either painkillers like Tylenol or non-steroidal anti-inflammatory drugs like aspirin, ibuprofen, celebrex, or vioxx) but in many cases symptoms persist despite the use of these medications.
It is important to avoid using narcotics (such as Tylenol #3, vicoden, percocet, or oxycodone) to treat knee arthritis. Narcotics have many side effects, are habit-forming, and make it harder to achieve pain-control safely and effectively after surgery ,should that become necessary. Narcotics are designed for people with short-term pain (like after a car accident or surgery) or for people with chronic pain who are not surgical candidates. People who feel they need narcotics to achieve pain control should consider seeing a joint replacement surgeon (an orthopedic surgeon with experience in knee replacements) to see whether surgery is a better option.
Possible benefits of total knee replacement surgery
Regardless of whether a traditional total knee replacement or a minimally-invasive partial knee replacement (mini knee) is performed the goals and possible benefits are the same: relief of pain and restoration of function.
The large majority (more than 90 percent) of total knee replacement patients experience substantial or complete relief of pain once they have recovered from the procedure. The large majority walk without a limp and most don’t require a cane, even if they used one before the surgery. It is quite likely that you know someone with a knee replacement who walks so well that you don’t know (s)he even had surgery!
Frequently the stiffness from arthritis is also relieved by the surgery. Very often the distance one can walk will improve as well because of diminished pain and stiffness. The enjoyment of reasonable recreational activities such as golf, dancing, traveling, and swimming almost always improves following total knee replacement.
If a knee surgeon and a patient decide that non-operative treatments have failed to provide significant or lasting relief there are sometimes different operations to choose from.
If X-rays don’t show very much arthritis and the surgeon suspects (or has identified by MRI) a torn meniscus, knee arthroscopy may be a good choice. This is a relatively minor procedure that is usually done as an outpatient and the recovery is fairly quick in most patients.
However, if X-rays demonstrate a significant amount of arthritis, knee arthroscopy may not be a good choice. Knee arthroscopy for arthritis fails to relieve pain in about half of the patients who try it.
For younger patients (typically under age 40 but this age cutoff is flexible) who desire to return to a high level of athletic activity or physical work a procedure called osteotomy (which means “cutting the bone”) might be worth considering. This option is suitable only if the arthritis is limited to one compartment of the knee.
Osteotomy involves cutting and repositioning one of the bones around the knee joint. This is done to re-orient the loads that occur with normal walking and running so that these loads pass through a non-arthritic portion of the knee. That’s why it doesn’t work well if more than one compartment of the knee is involved–in those patients there is no “good” place through which the load can be redistributed.
Knee fusion also called “arthrodesis ” permanently links the femur (thigh bone) with the tibia (shin bone) creating one long bone from the hip to the ankle. It removes all motion from the knee resulting in a stiff-legged gait.
Because there are so many operations that preserve motion this older procedure is seldom performed as a first-line option for patients with knee arthritis. It is sometimes used for severe infections of the knee certain tumors and patients who are too young for joint replacement but are otherwise poor candidates for osteotomy.
Minimally-invasive partial knee replacement (mini knee)
Patients who are of appropriate age–certainly older than age 40 and older is better–and who have osteoarthritis limited to one compartment of the knee may be candidates for an exciting new surgical technique minimally-invasive partial knee replacement (mini knee). Partial knee replacements have been done for over 20 years and the “track record” on the devices used for this operation is excellent. The new surgical approach which uses a much smaller incision than traditional total knee replacement significantly decreases the amount of post-operative pain and shortens the rehabilitation period. The decision of whether this procedure is appropriate for a specific patient can only be made in consultation with a skillful orthopedic surgeon who is experienced in all techniques of knee replacement.
Minimally-invasive partial knee replacement (mini knee) is not for everyone. Only certain patterns of knee arthritis are appropriately treated with this device through the smaller approach.
Generally speaking patients with inflammatory arthritis (like rheumatoid arthritis or lupus) and patients with diffuse arthritis all throughout the knee should not receive partial knee replacements.
Patients who are considering knee replacements should ask their surgeon whether minimally-invasive partial knee replacement (mini knee) is right for them.
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