- Urinary problems and the need for urinary catheters.
- Chest infections
- Ileus (intestines cease to function for a few days)
- Constipation
- Stomach/duodenal ulcers
- Confusion and even psychosis
- Nausea and vomiting
- Inadequate pain relief
- Delayed wound healing
Major but rare complications of Joint Replacement Surgery:
- Deep venous thrombosis and Pulmonary embolus (blood clots on the leg and lung).
- Heart Attacks/strokes
- Infection in the joint following surgery
- Nerve damage and blood vessel damage.
- Fracture (break) of bones
- Failure to cure symptoms or even worsening of knee pain.
Who needs a knee replacement?
In 2000, joint replacement procedures numbered more than 1.6 million worldwide, most performed as a result of arthritis. An estimated 500 million people (one in six ) throughout the world suffer from arthritis. (Dorland’s Biomedical, The Worldwide Orthopaedic Market, 2001)
The surgeon will want to know whether you can be helped by surgery. Key questions for the surgeon will be;
- How severe is the pain?
- Does it keep you awake at night?
- How far can you walk?
- What are you expecting to gain from the surgery?
- Are you fit enough to survive the anaesthetic or conversely are you too young to have a knee replacement?
- Have you tried simpler forms of treatment to help with your symptoms?
If your knee pain is mild, you live a full and active life unimpeded by your knee or you have had not tried simpler measures such as pain killers, braces, injections or even an arthroscopy (key-hole surgery to wash out the knee) then you should not be considered for surgery.
What other treatments are available for arthritis of the knee?
Physiotherapy certainly can help symptoms and the effect has been shown to last for up to 1 year. Taping and strapping has not been shown to be of any benefit.
Braces
Braces range from elastic bandaging to several hundred pounds worth of high-tech knee braces. No brace has been shown to alter the actual mechanics or disease progress in arthritis . However some patients have been helped by braces.
Anti-inflammatories and pain killers
- These medications can be taken as tablets, gels, suppositories and even injections but all have side effects such as stomach ulcers.
- Analgesia or pain killers tablets help with the symptoms. Chondroitin sulphate (shark cartilage tablets) are widely available from chemists and newspaper adverts and are safe and probably as effective as anti-inflammatory tablets.
Knee Injections
- Joint Injections. Injections of steroids into joints can alleviate symptoms of arthritis. There are risks associated with this treatment, such as the risk of introducing infection into joints with the needle (1 in 50,000) and there are theoretical risks of causing cataracts, bone death and bone loss with these injections.
- Newer materials can now be injected into joints and it is claimed alleviate symptoms of arthritis. Drugs such as Hyaluronic Acid (Hyalgan or Synvisc) have all been around for years but are relatively new in Europe. The jury is still out as to whether they are any better than anti-inflammatory tablets.
Operations for Arthritis of the Knee
Knee Arthroscopy
What is knee arthroscopy?
Knee arthroscopy involves the insertion of a tiny computerized camera and often special instruments into the knee joint through two or three little nicks in the skin. The camera allows the surgeon to see clearly inside the joint to confirm a diagnosis, the degree of damage, and in many cases treat the problem – all during the same procedure.
Because no major incisions are made, knee arthroscopy does not involve a lengthy hospital stay (most patients go home the same day) and recovery time is usually reduced when compared with traditional “open” surgery. Depending on the condition treated, many patients have normal use of their knee within a few days after treatment.
What type of anesthesia is typically used?
While both general and local anesthesia may be used for knee arthroscopy, in most cases, local anesthesia is selected because it reduces the risk of complications and generally allows the patient to return home sooner. Local anesthesia may be administered in small amounts all around the skin and knee tissues, or injected into the spinal or femoral (thigh) area to “block” sensation below the main trunk of the body.
What conditions can be treated by knee arthroscopy?
Common knee conditions that can be corrected through arthroscopy include torn cartilage, torn ligaments, knee cap problems, and loose fragments of cartilage.
- Torn cartilage: A set of C-shaped pads called the meniscus act as shock absorbers for the knees and reduce friction during movement. A torn meniscus is the most common knee injury and is a cause of catching, swelling, and pain when the knee is rotated. Depending on the size and location of the tear, the cartilage may be either trimmed, sutured, or removed. If left untreated, a cartilage tear can lead to arthritis.
- Torn ligament: A major cause of a wobbly knee is injury to the anterior cruciate ligament; a severe injury can result in a partial or complete tear. A torn ligament causes swelling, pain, looseness, and a feeling that the knee will “give out.” Ideally, a badly torn ligament should be reconstructed soon after injury, before repeated injuries tear cartilage or loosen other ligaments.
- Knee cap problems: Normally, the underside of the knee cap is lined with smooth cartilage which can roughen as a result of injury or prolonged wear and tear. The result is pain swelling, and a grinding noise. Surgeons may correct this condition by shaving the irregular, roughened surface of the knee cap. Occasionally in more severe cases, a Patellofemoral Knee Replacement may be required.
- Incorrect alignment of the knee cap with the groove of the thighbone can also cause pain and swelling. This can often be remedied by releasing bands of dense connective tissue that pull the knee cap off center.
- Loose bodies: Fragments of cartilage that have broken off the knee joint’s bony surfaces and are floating in the joint are known as “loose bodies.” Using special arthroscopic instruments, the loose bodies are located and then removed.
Where is knee arthroscopy performed?
Knee arthroscopies maybe performed in a hospital or a surgery center. Your doctor will discuss this with you. The time from check-in to discharge can be as little as three or four hours. Many people return to their normal activities within four or five days, but this of course depends on the specific procedure performed. People with physically demanding jobs can usually return to work in two or three weeks. Ask your doctor for your specific recommendations.
Cartilage transplantation
Cartilage transplantation means transferring undamaged pieces of cartilage from unaffected areas of the knee joint to where it is needed, or alternatively transplanting cartilage from donors (dead people). It offers possibilities for the treatment of arthritis but is still experimental and as yet unproven.
Osteotomy about the knee
Sometimes, if the knee is bow-legged (varus) or knock-kneed (valgus), this puts huge abnormal forces through the knee, resulting in arthritis. An operation called an Osteotomy to-reset the leg bones so that the knee is straight may be offered. Again, controversial, but hugely popular in Europe where results of 80% + success are claimed at up to 15 years even in young patients. Unpopular in the UK, partly because the complications of surgery such as nerve damage and failure of the bones to mend or mending in the wrong position. Arguably, subsequent Total Knee Replacement surgery is more difficult if the operation fails.
However, as is discussed below, this may be a very good operation for younger patients as it may at least buy some time before a TKR is needed.
Should the above measures fail to control the pain of an arthritic knee and the patient‘s quality of life is affected then they may be offered a knee replacement
Knee replacements
With modern materials and improvements in techniques and antibiotic therapy, total knee replacement (TKR) is the best treatment currently available for end stage osteoarthritis and rheumatoid? and is an increasingly common operation. There is still reluctance to offer TKR to young patients (< 60 years) as the results of surgery beyond 10 to 15 years, are unknown with many patients complaining of pain and poor function.
Although there have been numerous survival studies of the better known implants, confirming the procedure does have successful long-term survivals in older age groups, pain and function is often not assessed.
Which knee replacement ?
There are large numbers of different designs of knee replacements from which your surgeon may choose.
The early designs of knee replacement were simple hinges. However the natural knee rotates as well as bends so these early designs tended to fail. The majority of current designs just replace the surface of the joint and are not hinged. They rely on your own existing knee ligaments to keep the knee stable. In situations where knee ligaments are damaged, there is the option with some designs to use stabilised components that reproduce some of the functions of the ligaments.
With knee replacements there is a worry that the plastic surface of the joint replacement may wear out; in order to minimise this risk and retain full movement, some knee replacements use mobile bearings(mobile bearing knee replacements)
Most of the designs introduced 10 years ago or more have been superseded by new and supposedly better knee replacements. There are therefore very few that have ten year results. We will therefore have to wait a few years to see how well they will do.
Cement
The components of the knee replacement can be either cemented to the bone ends or be attached to the bones without cement (uncemented); most surgeons prefer to use cement for both parts of the replacement as it does not appear to cause any problems and studies have shown that cementing the tibial component definitely gives better results. Some will use cement for one half and not the other while others will not use cement for either.
Kneecap
It is possible to replace the back of the kneecap. Some surgeons do this for virtually every case, some hardly ever do it and some do it if the kneecap is badly worn. It is generally believed that there is less likely to be pain if the surface of the kneecap is replaced. However there are risks with doing this. For example it increases the risk of your kneecap breaking after surgery and the plastic in your kneecap may fail. Again there are only a few studies to show whether or not your kneecap should be replaced or not and there is no obvious overall better outcome with either option. Having the kneecap resurfaced lowers the risk of knee pain after surgery but increases the need for revision (redo) surgery for failure; not having the kneecap resurfaced increases the need of redo surgery for knee pain that persists after surgery.
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