New Techniques in Knee Surgery
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: 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. There is little evidence to suggest that knee arthritis can be prevented or caused by exercises or activities, unless the knee was injured or was otherwise abnormal before the exercise program began.
There is no evidence that once arthritis is present in a knee joint any exercises will alter its course. However, exercise and general physical fitness have numerous other health benefits. Regular range of motion exercises and weight bearing activity are important in maintaining muscle strength and overall aerobic heart and lung capacity. Exercise will also help prevent the development of osteoporosis which can complicate later treatment.
Certainly people who are physically fit are more resilient and, in general, more able to overcome the problems associated with arthritis. Physically fit people also tend to recover more quickly from surgery, should that eventually be necessary to treat the knee arthritis. 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: 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.
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. It is usually reasonable to try a number of non-operative interventions before considering knee replacement surgery of any type. Prior to surgery an orthopedic surgeon may offer medications either non-steroidal anti-inflammatory medications or analgesics like acetaminophen which is sold under the name Tylenol knee injections or exercises.
A surgeon may talk to patients about activity modification weight loss or use of a cane. The decision to undergo the total knee replacement is a "quality of life" choice. Patients typically have the procedure when they find themselves avoiding activities that they used to enjoy because of knee pain.
When basic activities of daily life--like walking shopping or reasonable recreational pastimes--are inhibited or prevented by the knee pain it may be reasonable to consider the surgery. Arthritis is often progressive and symptoms typically get worse over time. 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.
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.
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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. It removes all motion from the knee resulting in a stiff-legged gait.
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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.
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. 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.
Not all surgical cases are the same, this is only an example to be used for patient education. It is most suitable for middle-aged and older people who have arthritis in more than one compartment of the knee and who do not intend to return to high-impact athletics or heavy labor. In the video below, orthopedic surgeon Dr. Seth Leopold demonstrates minimally invasive knee replacement surgery and discusses the benefits to patients.
This University of Washington program follows a patient through the whole process, from pre-op to post-op. Current evidence suggests that when total knee replacements are done well in properly selected patients success is achieved in the large majority of patients and the implant serves the patient well for many years. Many studies show that percent of total knee replacements are still functioning well 10 years after surgery. Most patients walk without a cane, most can do stairs and arise from chairs normally, and most resume their desired level of recreational activity.
In the event that a total knee replacement requires re-operation sometime in the future, it almost always can be revised re-done successfully. However, results of revision knee replacement are typically not as good as first-time knee replacements.
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There is good evidence that the experience of the surgeon correlates with outcome in total knee replacement surgery. It is therefore important that the surgeon performing the technique be not just a good orthopedic surgeon, but a specialist in knee replacement surgery. Total knee replacement is elective surgery. With few exceptions it does not need to be done urgently and can be scheduled around important life-events.
Like any major surgical procedure total knee replacement is associated with certain medical risks. Although major complications are uncommon they may occur. Possible complications include blood clots, bleeding, and anesthesia-related or medical risks such as cardiac risks, stroke, and in rare instances, large studies have calculated the risk to be less than 1 in death. Risks specific to knee replacement include infection which may result in the need for more surgery , nerve injury, the possibility that the knee may become either too stiff or too unstable to enjoy it, a chance that pain might persist or new pains might arise , and the chance that the joint replacement might not last the patient's lifetime or might require further surgery.
However, while the list of complications is long and intimidating, the overall frequency of major complications following total knee replacement is low, usually less than 5 percent one in Obviously the overall risk of surgery is dependent both on the complexity of the knee problem but also on the patient's overall medical health. Many of the major problems that can occur following a total knee replacement can be treated.
The best treatment though is prevention. An orthopedic surgeon will use antibiotics before, during, and after surgery to minimize the likelihood of infection. Your physician will take steps to decrease the likelihood of blood clots with early patient mobilization and use of blood-thinning medications in some patients. Good surgical technique can help minimize the knee-specific risks.
So, choosing a fellowship-trained and experienced knee replacement surgeon is important. Again the overall likelihood of a severe complication is typically less than 5 percent when such steps are taken. Patients undergoing total knee replacement surgery usually will undergo a pre-operative surgical risk assessment. When necessary, further evaluation will be performed by an internal medicine physician who specializes in pre-operative evaluation and risk-factor modification. Some patients will also be evaluated by an anesthesiologist in advance of the surgery. Routine blood tests are performed on all pre-operative patients.
Chest X-rays and electrocardiograms are obtained in patients who meet certain age and health criteria as well. Surgeons will often spend time with the patient in advance of the surgery, making certain that all the patient's questions and concerns, as well as those of the family, are answered. The total knee requires an experienced orthopedic surgeon and the resources of a large medical center. Some patients have complex medical needs and around surgery often require immediate access to multiple medical and surgical specialties and in-house medical, physical therapy, and social support services.
There is good evidence that the experience of the surgeon performing partial knee replacement affects the outcome. It is important that the surgeon be an experienced--and preferably fellowship-trained--knee replacement surgeon. A large hospital usually with academic affiliation and equipped with state-of-the-art radiologic imaging equipment and medical intensive care unit is clearly preferable in the care of patients with knee arthritis.
Total knee replacement surgery begins by performing a sterile preparation of the skin over the knee to prevent infection.
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This is followed by inflation of a tourniquet to prevent blood loss during the operation. Next, specialized alignment rods and cutting jigs are used to remove enough bone from the end of the femur thigh bone , the top of the tibia shin bone , and the underside of the patella kneecap to allow placement of the joint replacement implants.
Proper sizing and alignment of the implants, as well as balancing of the knee ligaments, all are critical for normal post-operative function and good pain relief. Again, these steps are complex and considerable experience in total knee replacement is required in order to make sure they are done reliably, case after case. Provisional trial implant components are placed without bone cement to make sure they fit well against the bones and are well aligned.
At this time, good function--including full flexion bend , extension straightening , and ligament balance--is verified. Finally, the bone is cleaned using saline solution and the joint replacement components are cemented into place using polymethylmethacrylate bone cement. The surgical incision is closed using stitches and staples. Total knee replacement may be performed under epidural, spinal, or general anesthesia. We usually prefer epidural anesthesia since a good epidural can provide up to 48 hours of post-operative pain relief and allow faster more comfortable progress in physical therapy.
No two knee replacements are alike and there is some variability in operative times. A typical total knee replacement takes about 80 minutes to perform. Whenever possible we use an epidural catheter a very thin flexible tube placed into the lower back at the time of surgery to manage post-operative discomfort.
This device is similar to the one that is used to help women deliver babies more comfortably.
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As long as the epidural is providing good pain control we leave it in place for two days after surgery. After the epidural is removed pain pills usually provide satisfactory pain control. Patients with a good epidural can expect to walk with crutches or a walker and to take the knee through a near-full range of motion starting on the day after surgery.
Following discharge from the hospital most patients will take oral pain medications--usually Percocet Vicoden or Tylenol for one to three weeks after the procedure mainly to help with physical therapy and home exercises for the knee. Aggressive rehabilitation is desirable following this procedure and a high level of patient motivation is important in order to get the best possible result. Oral pain medications help this process in the weeks following the surgery. Most patients take some narcotic pain medication for between 2 and 6 weeks after surgery.
Surgeons drill tiny holes into the bone to let blood bleed into the defect and form scar tissue. The results are OK, but people are always looking to possibly improve on it. ACI has been proven to provide long-lasting pain relief and to help patients regain knee function. Most of our work is with microfracture. MACI was not yet available in the U. We received FDA approval for it in December and launched it in early Once you have those injuries, the cartilage is not going to repair itself.
In some cases, osteochondral allografts, or OCAs, are performed. These are bone and cartilage grafts sourced from cadavers instead of the patient. But the supply of grafts is limited and the procedure is highly invasive. In addition, controlled clinical trials have not been run, since tissue bank products are subject to a lower level of regulation. Some physicians believe the procedure has a higher risk of failure.
The only option to regrow your own cartilage is ACI. Once the doctor is satisfied with the fit, the MACI membrane is glued into place. The cells migrate onto the bone, adhere to it, start to replicate, and initiate cartilage production to fill in the defect. The FDA has approved MACI for first-line treatment of any cartilage defects of the knee, but not for the meniscus the thin fibrous cartilage between the surfaces of the knee , Michel said.
One California team physician who uses MACI has achieved gratifying results with some of his patients, who include college and professional athletes. Patients can expect to return to pain-free simple activities of daily living within four to six months. The European experience over the past decade has demonstrated successful results with this procedure compared with other available cartilage repair techniques, he said. Jones was the first UCLA surgeon to adopt the technique. He has performed nearly 50 MACI surgeries in his high-volume cartilage surgery practice.
He follows all his patients that undergo the MACI procedure and administers routine patient-reported outcome questionnaires to monitor their outcomes, he said. Favorable MACI outcomes have been demonstrated in several significant studies. The improvements that were noted in patients that underwent MACI were sustained at two and five years, demonstrating promising durability of the cartilage repair tissue that we obtain with the MACI technique.
Jones said MACI should be used for any patient with a symptomatic cartilage defect of the knee that has failed a trial of nonoperative management, including NSAIDs and supervised physical therapy. Michel said he hopes MACI will have more widespread use, and Vericel is evaluating improved versions of the product for development in the coming years.