By Matthew Craig, bounceREHAB Principal Physiotherapist & Special Guest Author, A/Professor Nigel Hope, Hip/Knee orthopedic surgeon
N.B: This blog has images and videos of live surgery which are amazingly educational, however, some readers may find them distressing.
‘BOUNCE PHYSIO’s Matthew Craig and Paul Dardagan were treated to something very special for what they thought was just another Thursday morning. They were personally invited by Professor Nigel Hope to gain valuable insight into the delicate (and sometimes, not so delicate:) observation of a total knee replacement (TKR). TKR are pretty common practice these days, everybody knows of someone in their lives that has struggled with a TKR. The bounceREHAB team see lots of people pre-post TKR (and THR) for rehabilitation. What strikes us these days however is the immense difference in the quality of patient experiences when presenting to physio post operatively.
In particular, Paul and I have wondered how has Prof. Nigel Hope consistently had our patients coming back looking great with comparison to his respected orthopaedic peers. Seriously at week 1 post op without a bruise!
Today was an amazing experience. I observed the following key points that sets Prof Hope’s surgical outcomes apart from other TKR’s that we rehabilitate:He performs all of his operations tourniquet-free – this allows the blood to flow freely through the patient’s affected limb area during surgery resulting in no bruising, less pain and a faster recovery time for the patient.
Today, the patient undergoing the TKR that we observed only lost approx 250ml of blood. This procedure takes extra time, many orthopaedic surgeons want to rush 2 operations into the same time that it would otherwise take a tourniquet-free routine. There is massive post operative advantages to be tourniquet-free. There is no “gush” of blood or pressure pain on the thigh causing immense pain in or around the knee joint. There is less likelihood of losing foot ‘pulse’ and blood flow because if you have a tourniquet there is no known way of knowing for sure if the popliteal artery has accidentally been cut in the operation.
He uses state of the art technology “My Knee” to perform ‘made to measure’ knee replacements. ‘MyKnee’ knee replacements are bio-engineering technology from Switzerland, which use computer generated 3D models of patient’s knee joints to design custom made joint replacements specific to the individual. Traditional knee replacements use standard industry prototypes for all patients irrespective of age, weight or size. The closest size match for the patient is used which results in a less than perfect fit. The difference between using ‘MyKnee’ and standard industry equipment is akin to buying a suit off the rack compared to a tailored made suit of the finest material. It takes most of the human error out of the procedure. ‘MyKnee’ achieves perfect limb alignment and ligament balance as well as superior comfort, mobility and longevity of the knee joint for the patient. Made to measure knee operations are also much less invasive than traditional knee replacements. Firstly, the custom made fit allows the surgeon to cut less muscle and tissue in the patient’s knee joint resulting in less pain and a smaller incision.
He uses a post-operative drain to drain in the 24 hours recovery and also places the patient in a longer crape bandage compression dressing. Dr Hope has the same expert team of 20 years that partakes in the assistance of surgery and sutures the operative wound “lightly” instead of “too tightly” in order to lessen the risk of keloid scarring. An ice pack with a compression pump is also in-situ on leaving the operating theatre. All these careful measures are taken to limit blood loss, knee swelling, bruising, pain for the patient. This approach reduces the likelihood of pain medication dependency in the first 4-6 weeks post-operatively.
Wow! What a sterling performance
The Knee and Osteoarthritis
The knee joint is comprised of three bones: the thigh bone (femur), the shin bone (tibia) and the kneecap (patella). When you flex or straighten your leg, the thigh bone turns on the shin bone, while the kneecap runs along the end of the thigh bone. The leg movement is driven by the thigh muscles, the biggest one being the quadriceps, located in the front of the thigh.
The thigh and shin bones are connected by ligaments, which give stability to the knee joint. The surface of the kneecap, thigh bone and shin bone, where the bones come in contact, is coated with a smooth tissue called articular cartilage. The cartilage, together with a substance called synovial fluid, prevents the bones from rubbing against each other and causing damage.
Osteoarthritis of the Knee
In case of osteoarthritis, the cartilage deteriorates and the bones start rubbing directly against each other. The result is joint pain, which worsens day by day, and limits motion. Knee replacement is a common treatment for severe osteoarthritis.
Successful knee replacement can result in dramatic pain relief and improvement in the knee joint function.
Total Knee Replacement
Total knee replacement surgery aims at substituting the bone and cartilage of the joint damaged by arthritis with plastic and metallic components. The surfaces of the thigh and shin bones are replaced with high-resistant metallic components, called the femoral component and tibial baseplate.
Between the femoral component and the tibial baseplate, a plastic insert is implanted. It replaces the cartilage function allowing the thigh and shin bone to slide on each other. All materials used in a total knee replacement are highly bio-compatible.
Why total knee replacement
With almost 50 years of history, total knee replacement surgery is a very common and safe procedure for the treatment of severe arthritis. Approximately 1,000,000 knee replacements are performed annually worldwide.
The main benefits of a successful total knee replacement are:
1. REDUCTION IN KNEE PAIN
The pain may be rapidly and dramatically reduced, usually eliminated.
2. RECOVERY OF MOBILITY
With less effort, you may regain close to the original mobility of your knee.
3. IMPROVEMENT IN QUALITY OF LIFE
Your everyday activities and your social life may no longer be limited by pain and reduced mobility!
When surgery is recommended?
There are several reasons why your doctor may recommend knee replacement surgery. People who benefit from total knee replacement often have:
A knee that has become bowed as a result of severe arthritis.
- Severe knee pain or stiffness that limits your everyday activities, including walking, climbing stairs, and getting in and out of chairs. You may find it hard to walk more than a few blocks without significant pain and you may need to use a cane or walker
- Moderate or severe knee pain while resting, either day or night
- Chronic knee inflammation and swelling that does not improve with rest or medications
- Knee deformity — a bowing in or out of your knee
- Failure to substantially improve with other treatments such as anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy, or other surgeries
Candidates for surgery
There are no absolute age or weight restrictions for total knee replacement surgery.
Recommendations for surgery are based on a patient’s pain and disability, not age. Most patients who undergo total knee replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total knee replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.
Deciding to have knee replacement surgery
Realistic Expectations: An important factor in deciding whether to have total knee replacement surgery is understanding what the procedure can and cannot do.
More than 90% of people who have total knee replacement surgery experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living; but total knee replacement will not allow you to do more than you could before you developed arthritis.
With normal use and activity, every knee replacement implant begins to wear in its plastic spacer. Excessive activity or weight may speed up this normal wear and may cause the knee replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports for the rest of your life after surgery.
Realistic activities following total knee replacement include unlimited walking, swimming, golf, driving, light hiking, biking, ballroom dancing, and other low-impact sports. With appropriate activity modification, knee replacements can last for many years.
Possible complications of surgery
The complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in fewer than 2% of patients. Major medical complications such as heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur, they can prolong or limit full recovery. Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.
Infection. Infection may occur in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.
Blood clots. Blood clots in the leg veins are one of the most common complications of knee replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program, which may include periodic elevation of your legs, lower leg exercises to increase circulation, support stockings, and medication to thin your blood.
Implant problems. Although implant designs and materials, as well as surgical techniques, continue to advance, implant surfaces may wear down and the components may loosen. Additionally, although an average of 115° of motion is generally anticipated after surgery, scarring of the knee can occasionally occur, and motion may be more limited, particularly in patients with limited motion before surgery.
Continued pain. A small number of patients continue to have pain after a knee replacement. This complication is rare, however, and the vast majority of patients experience excellent pain relief following knee replacement.
Neurovascular injury. While rare, injury to the nerves or blood vessels around the knee can occur during surgery.
Extending the Life of Your Knee Implant
Currently, more than 90% of modern total knee replacements are still functioning well 15 years after the surgery. Following your orthopaedic surgeon’s instructions after surgery and taking care to protect your knee replacement and your general health are important ways you can contribute to the final success of your surgery.
How Your New Knee Is Different
Improvement of knee motion is a goal of total knee replacement, but restoration of full motion is uncommon. The motion of your knee replacement after surgery can be predicted by the range of motion you have in your knee before surgery. Most patients can expect to be able to almost fully straighten the replaced knee and to bend the knee sufficiently to climb stairs and get in and out of a car. Kneeling is sometimes uncomfortable, but it is not harmful.
Most people feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending activities.
Most people also feel or hear some clicking of the metal and plastic with knee bending or walking. This is a normal. These differences often diminish with time and most patients find them to be tolerable when compared with the pain and limited function they experienced prior to surgery.
Your new knee may activate metal detectors required for security in airports and some buildings. Tell the security agent about your knee replacement if the alarm is activated.
Protecting Your Knee Replacement
After surgery, make sure you also do the following:
• Participate in regular light exercise programs to maintain proper strength and mobility of your new knee.
• Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery.
• Make sure your dentist knows that you have a knee replacement. Talk with your orthopaedic surgeon about whether you need to take antibiotics prior to dental procedures.
• See your orthopaedic surgeon periodically for a routine follow-up examination and x-rays, usually once a year.
Rehabilitation and other Physiotherapy Links
To ensure a smooth and successful recovery from total knee replacement surgery, it helps to understand the rehabilitation process and commit to a plan. Setting goals and working with a physiotherapist to achieve, and hopefully exceed, those goals will get you back to doing the activities you enjoy as soon as possible.
PRINCIPAL PHYSIOTHERAPIST @ bounceREHAB