Knee pain, arthritis, cartilage damage - Dos & Donts in TKR / total knee replacement - Dr Mallinath

Knee pain Hi every one, I am Dr Mallinath, Sr Orthopedic Surgeon in Bangalore Expertise in joint replacement (knee and hip), key hole surgeries like arthroscopic surgeries, minimal invasive orthopedic surgeries And complex trauma management Idea is to take basic info/facts about TKR (total knee joint replacement) Which probably the most common replacement surgery being performed in Orthopaedics It is a replacement of the cartilage of the knee joint. It is also called as Knee arthroplasty It is a procedure similar to the capping done to caries tooth, where the damaged part of tooth is removed, drilled and capped. In TKR all surrounding structures like ligaments, bone are kept intact only the damaged cartilage is removed with special equipment and fitted with metal cap (implant) In this scenario selection of the patient is very important One need to have confirmed severe arthritis to consider him/her for TKR Second criteria is long standing severe pain due to knee arthritis (with damaged cartilage) and should have tried all other conservative modes of management of Knee arthritis before deciding to go for TKR Like life style modification, exercises and medication including injectable in the life style modification one has to avoid painful activities like squatting, climbing stairs.

One has to reduce weight & can take analgesic Before undergoing surgery, one can try injections(intra-articular), physiotherapy, supportive like knee cap, or walking stick Before undergoing surgery, one can try injections(intra-articular), physiotherapy, supportive like knee cap, or walking stick TKR to be considered only when one finds no relief (no improvement) from all these non-surgical modes of management Ideal age for TKR is more than 60 yrs. To 70yrs. Older the patient, better is for the patient but he/she should be fit both mentally and physically.

Older the patient, better is for the patient but he/she should be fit both mentally and physically. Fit enough to be able to walk after the surgery Diabetes and Hypertension are not contraindication for the TKR, Surgery can be done after controlling these medical conditions After surgery patients can walk on the same day or on the next day some patients walk after 4 to 5 hrs. Of surgery and some a day after depending on the on their ability to bear pain and fitness/strength They have to stay in hospital for 4 to 5 days & after that they can go home they have to come back after 10 days for suture removal & they have to do undergo regular physiotherapy Physiotherapy is not that painful.

Only for one or two weeks physiotherapy is required But patient has to do physiotherapy at his place (every day) for next one or two months To get the good range of movements. Otherwise the patient may develop stiffness which hampers the result of the TKR surgery Regular walking is recommended after TKR. They have to use walking stick or walker or cane for 1 or 11/2 months.

After that they can walk freely without support TKR implant usually lasts for almost 10 to 15 years. There are different types of implants Implants will not make all the difference, it makes some difference What is the difference between cemented and non-cemented implants? Where do we use it In the TKR it is only cemented replacement Is there anything like computer assisted TKR It's a controversial topic. If the surgeon is good results are good. It will not make much difference. Now a days lot of discussion is happening about robotic TKR But still they are research level and results are awaited Can we do both knee surgeries at single point of time some say it is ok to do and some say it is not ok... We can do both knee surgeries in a single stage if required Mild discomfort knee does not require knee replacement, only severe painful knee requires knee replacement There is one argument that if TKR is done on one side, other leg will become short and will worn out fast But that is not true, go for both side knee joint replacement only if it is required If patient needs both side knee replacement see the fitness of the patient to to go for simultaneous TKR (both sides in single sitting) Both side TKR in single sitting is not technically difficult, if the patient is fit both side TKR can be done in single sitting If patient is not fit to bear both side simultaneous TKR they he has to wait to wait till he is fit What the patient has to do at home after discharge? After surgery patient can walk any distance depending upon his ability/strength He/she can walk for 1 or 2 kms. Brisk walk is also ok But high impact activities like running. He can ride bicycle, two wheeler or drive car if the person is fit It is better to avoid sitting on the floor, squatting because strength is less in the older age group They will have difficulty is getting up, at that time they may fall and break their knee joint or other bone They must walk.

That is the main purpose of doing knee replacement At least they have to walk 1 or 2 kilo-meters, that reduces their weight and controls medical conditions like diabetes and hypertension Walking is required. Do you suggest any exercises after surgery at home Post surgery we teach them some bending exercises & thigh strengthenings, better to continue for life time, or they can walk daily If they walk for 1 or 2 kilo-meters that is enough for each day what happens to a person who undergoes TKR at younger age and the implant is worn out after 10 to15 years After that we have to do revision replacement. We have to remove the worn out implant and replace it with new revision implant It is not a very difficult surgery and can be done anywhere Is implant of revision surgery is different from regular implant It is little different.

It has got some extensions.. What do you say about cost of revision surgery? Cost of revision surgery is little more than the primary surgery Cost of revision surgery is little more than the primary surgery Is it because of higher implant cost or complexity of surgery? It is because of both factors, but more contribution from the cost of implant Patient will be relative fit during primary surgery, by the time he is for revision he will be 15 yrs. Older with more medical problems Its a common practice that people go on taking calcium hoping that their eroded cartilage may recover hoping that their eroded cartilage may recover Just to avoid surgery people do all kind of practices like over use of analgesics at later stage of arthritis Just to avoid surgery people do all kind of practices like over use of analgesics at later stage of arthritis Calcium tablet does not have role in arthritis treatment. It is required for bone health Only two factors work for knee joint health. One is optimal weight and the second is fitness In the initial stage patient may go for pain killers for short duration and less frequently If they over use painkillers, that may harm stomach and renals/kidneys.

So it is better to avoid taking long term painkillers one has to follow healthy life style, avoid painful activities, do regular exercises, reduce your wt. To avoid/delay replacement or one may use supportive like walking stick or knee stick Are there any recent trends that can help us to avoid TKR? Like intra articular injection of steroids or some joint lubricants Intra articular steroid injections are given to reduce inflammation and reduce pain. It is harmless if used judiciously one can take one or two injections in a year in a specialized centres only requirement is it has to be given under aseptic environment. It will reduce the pain. Some patients may get relief for 1 or 2 yrs. Only requirement is it has to be given under aseptic environment. It will reduce the pain. Some patients may get relief for 1 or 2 yrs.

There is no harm in trying artificial joint lubricating injections. It also may give some relief to the patient Cartilage transplantation and stem cell therapy are still in research phase and we don't know the long term results/effects Are there any alternatives to TKR There is one surgery called high tibial osteotomy or realignment surgery Knee arthritis especialy in younger age group is usually because of the bow legs. Bow legs means the legs are bent like bow at knee Because of bowed legs weight falls on only one side of the knee joint and one half portion of the knee joint is damaged This is the pathology in most of the patients In high tibial osteotomy realignment we have to straighten the bowed leg so that the weight is equally distributed and pain subsides We have seen patients walking after the surgery for almost 10 to 25 years without any problem they walk, sit on the floor, squat. They do all the activities comfortably.

Complications are also less. Scientifically there are only two thing which are proven to post pone TKR. One is weight reduction & the other is realignment procedure Other than subjective symptoms, are there any objective ways to certainly say that this patient is for TKR For TKR it is decided by orthopedician on clinical and radiological findings.