What is arthritis:

Osteoarthritis is a joint disease that affects Cartilage which covers the ends of bones in a joint.. It helps absorb shock of movement.

In osteoarthritis, the top layer of cartilage breaks down and wears away. This allows bones under the cartilage to rub together. The rubbing causes pain, swelling, and loss of motion of the joint

Diagnosis: 1. x rays of the joint is all that is required

There are mainly three types of arthritis:

1) Osteoarthritis or age related arthritis
2) Inflammatory arthritis Like Rheumatoid arthritis , or rarely psoriatic arthritis.
3) Post traumatic arthritis :

• In general, arthritis occurs more frequently in women than in men
• Before age 45, OA occurs more frequently in men;
• After age 45, OA is more common in women.

Alternatives to knee replacement Surgery. 
Knee replacement is a major Surgery and should only be performed when absolutely necessary.

FACTS;  Non Surgical options for Osteoarthritis Knee pain.

1. Weight loss and exercises. Losing pounds may help you lose pain. Being just 10 pounds overweight adds up to 60 pounds of force on your knee with each step. Exercise can help you achieve your weight loss goal while strengthening your muscles and reducing pain.
2. Physical Therapy; The physical therapist may apply ice and heat or transcutaneous electrical nerve stimulation ( TENS) or Ultrasound imaging. These and other therapy can increase your cutaneous blood flow.
3. Walking with a Cane in the hand on opposite side as the painful knee may help in reducing pain.
4. Knee injections. Hyaluronic acid or Steroid injection. .Result of cortisone injection is more predictable and much cheaper than Hyaluronic acid ( Synvisc , Hyalgan ).
Cortisone injection usually works to relieve pain within a few days and lasts several weeks.
5. Stem cells; and stromal Vascular fraction: this experimental treatment uses bone marrow stem cells from the hip and fat cells from abdomen to help regenerate cartilage tissue in the knee. This is cutting-edge Stem Cells Therapy as an alternative to Total Knee Replacement .The Stem cells Therapy after Arthroscopic surgery helps in reducing pain and repair the knee cartilage.

Surgical Options :

1.. Arthroscopic surgery: to remove bone and cartilage fragments inside the knee. (The Knee can be cleaned or flushed to remove loose bone or cartilage pieces that may be causing pain.) Patient goes home the same day after the operation.
You are able to walk without crutches and resume your daily activities and drive after a week.
2. Biological joint preserving procedures; in early stages of arthritis are helpful. There are several types of procedures and are done through a key hole arthroscopically.
3. Knee osteotomy. Patients with knee deformity or damage to only one side of their knee may benefit from an Osteotomy. This procedure is usually used for younger patients with limited knee damage. Advantage: patient’s own knee joint is retained.

What happens without surgery? Arthritis is often progressive and symptoms typically get worse over time. Knee arthritis does not usually improve on its own.
Medication (Tablets) may temporarily improve the pain while on tablets, but does not alter the course of arthritis. It is not advisable to take tablets on a long term basis in order to avoid complications like kidneys failure , Heart attack and Stroke. And most importantly reduced life span (age).

Decision to have Surgery.

In advanced stage of the Arthritis, with pain on movements, disturbed sleep, stiffness, swelling and deformity. Pt experiences a grating or grinding sensation ( crepitus) while moving the joint.  Pt usually needs walking stick and not relieved by other non surgical means than T K R is the best option.

Considerations when choosing an Orthopaedic Surgeon scheduling your Joint replacement operation.
1. Experience; How long the Surgeon been practicing, and how many knee replacement he has performed.
2. Education: review the Surgeons qualifications, degrees, training in joint replacement surgery.

More Surgical training & experience is associated with fewer complications.

“Amateurs practice until they get it right. Professionals practice until they can not get it wrong.”

Total knee replacement not only improves quality of life but quantity of life as well. It increases the age or life span of the patient. This is now among the safest and most effective of all standard Orthopaedic surgeries.

Osteoarthritis is associated with increased mortality secondary to cardiovascular disease.

Osteoarthritis is the most common arthritis affecting 20 % of adult population. In a study involving 2200 adults with Osteoarthritis of Knees and hips, it was found that those patients who underwent total knee replacement were less likely to experience a serious cardiovascular event during 7 years follow up . Total joint replacement of knees and hips therefore have cardioprotective ( beneficial effect on heart) benefit consequently it increases life span by approximately 7 years.

Risks of delaying the knee replacement operation:
1. Risk of deformity developing inside or outside the joint.
2. Risk of muscles, ligaments and other structures becoming weak and loosing function.
3. Increased pain/ inability to manage pain.
4. Increased disability/ lack of mobility.
5. Difficulty with normal activities of daily living.
There are also other risks that arise with regards to the surgical procedure, for example, the risk of deformities due to postponement tends to make knee replacement surgery a more complicated and complex. The surgery may than take longer and require a longer amount of time under anesthesia. In addition postponement may require different and more expensive prosthesis, therefore more expensive operation than the standard routine total knee replacement.

Of all possible surgical interventions, total knee replacement offers the greatest quality of life improvement and increased longevity

Complications :

Early failures: Although most studies show that 90% of total knee will last 20 years or more, early failures may occur due to variety of reasons. These include: infection, fracture of bone around the implant (Prosthesis), loosening of implant , instability and pain in the replaced knee .

Infection. Infection may occur in the wound or deep around the prosthesis. It may happen while in the hospital or after you have gone 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 like Wound wash out with a camera ( Arthroscope), exchange of plastic insert or even revision knee replacement operation. Very rarely removal of the prosthesis may be required.

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: implant surfaces may wear down and the components may loosen.

Continued pain. A small number of patients continue to have pain after a knee replacement.

Neurovascular injury ( Injury to nerve or artery). While extremely rare, injury to the nerves or blood vessels around the knee can occur during surgery.

Avoiding problems after Surgery.:

Blood Clot Prevention

You should continue taking the blood thinning medication you started in the hospital.

Warning signs of blood clots.

Increasing pain in the calf
• Tenderness or redness above or below your knee
• New or increasing swelling in your calf, ankle, and foot

Warning signs of pulmonary embolism. The warning signs that a blood clot has travelled to your lung include:

• Sudden shortness of breath
• Sudden onset of chest pain
• Localized chest pain with coughing

Common Sequels after Total knee replacement: Most people 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.

Physiotherapy exercises after the operation.

You will be shown a few exercises to begin moving and strengthening your knee

Stairs; Always go one step at a time.

Going up: First take a step up with your healthy leg first. While coming down take a step down with your affected leg first.

Sticks may be needed for up to 6 weeks and older patients may have to continue the use of a walking aid a bit longer.

Not all patients require out-patient physiotherapy after having a knee replaced. If you have a good knee bend and good muscle control; outpatient physiotherapy is not necessary. You should however, continue doing exercises at home for at least 3 months.

Dr Ram Soni.
M.S. Ortho.
LRCP &S Edinburgh . UK.
M Ch. Ortho & trauma. University of Liverpool. UK.
Consultant Orthopaedic and Joint replacement and Arthroscopic Surgeon . J.K. Hospital. Bhopal . M.P.
www.ramsoniorthosurgeon.com ramkesoni@yahoo.co.uk
ph 7898301750

Author has worked in National Health Service in UK for over 30 years. 

A Patient guide to knee Replacement and its alternatives.