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  • Arthritis & Knee Replacement

    General Information

    General Information

    When people talk about knee arthritis they are usually referring to osteoarthritis or “wear and tear” damage to the knee. It is important to remember that arthritis of the knee is also a term used for some inflammatory diseases of the joint which can also cause knee pain and a similar end result. One example of this type of arthritis is rheumatoid arthritis.

    The underlying process in knee osteoarthritis, which may eventually cause severe pain, is of damage and complete wearing out of the articular cartilage (joint surface) in any part of the knee joint.
    This results in bone grinding on bone in the knee, which is a painful and disabling condition.
    Any of the three main parts of the knee (the medial compartment, the lateral compartment, and the patello-femoral joint – ‘knee cap’) can be affected by knee osteoarthritis. One or more parts of the knee may be affected at any one time, but the commonest site for knee arthritis affecting a single compartment is in the medial (inner) compartment.

    Knee Osteoarthritis may arise when there has been no previous story of injury or damage to the knee. Sometimes it gradually comes on after an initial injury to the articular cartilage of the knee, and it is well known that having a torn cartilage does increase the risk of developing knee osteoarthritis later in life.

    Symptoms of knee osteoarthritis

    The predominant symptom of knee osteoarthritis pain of varying degree. This can be felt as a relatively mild background ache in the knee which might interfere, for example, with sporting activities or a long walk, right up to constant severe disabling pain which makes walking very difficult or impossible. Knee osteoarthritis may also be so severe that sleep can be disturbed and there is pain at rest. The normal activities of daily living may become difficult to perform because of arthritis of the knee.

    Sometimes, because of the roughening of the knee joint surface, there may be catching, clicking, clunking or similar symptoms as well as pain. In more severe cases of knee osteoarthritis these are less significant than the underlying pain.

    Swelling of the knee joint is often seen.

    A tear of a so called ‘degenerate cartilage’ can often be found in the knee with osteoarthritis.

    Diagnosis of knee osteoarthritis

    The diagnosis of osteoarthritis of the knee can be made from the typical symptoms of this condition along with examination.

    Anybody who has suspected knee osteoarthritis will usually have an x-ray of the knee taken which will confirm the diagnosis.

    Arthritis of the Knee

    Treatment of knee osteoarthritis

    If you have osteoarthritis of the knee you may well have undertaken some form of treatment before coming to see a knee surgeon. These non-surgical means of knee osteoarthritis treatment include simple pain killers, anti-inflammatory tablets, injections of cortisone or other substances, advice about weight loss, modification of activities and physiotherapy. Physiotherapy may include a whole range of associated treatments and might also result in advice about using a walking stick etc.

    If the suspicion is of an early degree of knee arthritis and/or you are relatively young, it may be appropriate to have an arthroscopy of the knee. This will improve some of the mechanical symptoms arising from the knee, give some temporary relief by washing out the irritating debris within the knee, and define the exact problem with a view to later major surgery. However, knee arthroscopy treatment cannot reverse the damage or cure knee osteoarthritis itself.

    Eventually the decision might be made between yourself and your surgeon, that the pain has reached the point where the only option is knee arthroplasty. Knee arthroplasty is a general term for knee replacement. Knee replacement may take the form of a total knee replacement or a partial (unicompartmental) knee replacement.

    Total Knee Replacement

    Total Knee Replacement

    Total knee replacement surgery involves the resurfacing of the worn out parts of the knee using a metal component on the end of the femur and the top of the tibia, with a plastic bearing in between. Some surgeons also put a plastic component on the back of the kneecap. The way in which replacement knee surgery relieves pain is simply by removing the source of the pain which is the bone grinding on bone; the knee lining is effectively resurfaced.

    A total knee replacement operation usually takes place under a general or spinal anaesthetic. The final decision about this is down to the anaesthetist.

    There will be an incision down the front of the knee. Total knee replacement surgery itself takes approximately one hour.

    When you wake up you will find that there is a firm bandage around the knee and sometimes a light splint will be applied for comfort.

    Depending upon the anaesthetist, you may have had injections into the nerves which supply feeling to the lower leg. This is called a regional nerve block and the aim is to achieve some post operative pain relief.

    There may also be one or two small tubes coming out through the skin in the thigh. These are called drains. The aim of a drain is to remove some of the blood which unavoidably collects within the knee after surgery. During total knee replacement surgery there is little or no bleeding because most operations for knee replacement are done with a tourniquet applied to the upper thigh.

    Rehabilitation and physiotherapy will usually commence the day after total knee replacement surgery.

    CLICK HERE TO LINK TO PHYSIOTHERAPY

    For a total knee replacement, the average length of stay in hospital is approximately 3-4 days. If you have had removable stitches or metal skin clips put into the skin these will be removed approximately 10 and 12 days after total knee replacement surgery. If you have had dissolving stitches put in the skin these do not require removal.

    Physiotherapy after total knee replacement will often continue on an outpatient basis until you have made an appropriate recovery and your surgeon will give you a check up appointment 6 to 8 weeks from total knee replacement surgery.

    One of the things to remember about total knee replacement is that, although the most rapid recovery takes place over the first weeks, it takes up to six months for recovery to fully occur.

    Click below to watch the case study video

    Mobile bearing knee replacement

    In total knee replacement or unicompartmental knee replacement, the plastic bearing which sits between the two metal components may be fixed (a fixed bearing knee replacement) or mobile. A mobile bearing total knee replacement means that the plastic is not fixed rigidly to the tibial component, and can move around in a number of planes. Depending on the actual implant used this movement may take place backwards and forwards, sideways, rotation or a combination.

    The benefits of these types of implants are still theoretical and laboratory based, but the idea is that there may be a reduction in the wear of the plastic and therefore the long term loosening. There are also some claims that function and range of movement of the knee may be improved. There is no solid evidence for this yet.

    Minimally invasive knee replacement (MIS)

    Minimally invasive surgery has evolved rapidly over the last few years with some excellent advances and some problems globally. The most extreme MIS techniques (involving very small incisions with modified surgical instruments and implants) have not been performed by YKC surgeons and have largely been discontinued due to complications.

    Surgeons from the Yorkshire Knee Clinic have been involved in the assessment of more rational MIS knee replacement surgery and a randomised controlled trial of MIS vs. Standard knee replacement surgery performed in Harrogate has recently been published (‘The Knee’, May 2012) demonstrating the potential for a reduced length of stay in the MIS patients with no evidence of increased problems.

    Our surgeons use the smallest incision which allows safe and satisfactory implantation of the knee replacement. The combination of this approach, rapid mobilisation and improved pain control has led to excellent patient outcomes following both partial and total knee replacement.

    Benefits and risks of knee replacement

    Severe pain is the main reason for having a knee replacement. Associated problems such as deformity of the knee because of the arthritis (e.g. bow legs) and reduction in function, will improve following knee replacement but in themselves are not a reason for having the operation.

    There is no operation that does not carry some risks.

    The main risks of knee replacement are:

    Infection

    The chances of a serious deep infection affecting a knee replacement are approximately 1%. This is a major complication which can require further surgery to clear the infection. Up to 2-3% may develop a simple wound infection.

    Please note – all knee replacements can be warm and swollen for up to three months following surgery – this does not necessarily indicate infection.

    Deep Vein Thrombosis

    (DVT, blood clots) affecting the lower leg can occur but precautions are taken to reduce the chance of this either in the form of blood thinning tablets /or injections, or special calf pumps to keep the blood flowing. Pulmonary embolism (PE) is a rare but serious complication arising when a blood clot obstructs some of the veins in the lungs. NICE (National Institute for Health and Clinical Excellence) issues guidelines for hospitals to reduce the risks of thromboembolism (blood clots) – www.nice.org.uk

    Nerve Damage

    Nerve damage can occur, but this is usually seen in the form of a numb patch of skin to one side of the scar (in most patients). It is extremely rare to have nerve damage from a knee replacement causing weakness in the leg or foot.

    Stiffness

    Sometimes despite having a technically successful operation, the knee can be stiffer than hoped for which can result in aching and general dissatisfaction. It is not always possible to work out a reason for this.

    The above are some of the major and more commonly occurring early risks from total knee replacement but your surgeon or physiotherapist will discuss and answer any more specific questions with you.

    On average, you have approximately a 90% chance of achieving an excellent result from a knee replacement, giving you pain relief for at least 10-15 years. A further 6-8% are much improved compared to previous symptoms. Eventually knee replacements can fail by wearing out or loosening amongst other things, and this can occasionally occur in the first few years.

    Partial knee replacement

    Partial Knee Replacement

    If your knee arthritis affects only one of the three major compartments of the knee you may be suitable for a unicompartmental, sometimes called a half knee replacement. The most usual site for this is the medial (inner) compartment of the knee.

    Approximately 25% of patients with established knee arthritis may be suitable for a medial unicompartmental replacement. There are some theoretical and actual benefits of this procedure: the incision is smaller, the length of stay in hospital is usually shorter and the speed of rehabilitation is quicker with lower overall risks of complications like infection. Patients who have had a medial unicompartmental knee replacement often report their knee feels more ‘normal’ than those with total knee replacements.

    There is some evidence that the long-term survival of a unicompartmental knee replacement is slightly shorter than that of a total knee replacement, however the potential benefits can outweigh this risk. A Yorkshire Knee Clinic study of patient-reported outcomes (assessing the functional results of knee surgery) has demonstrated better function in patients with unicompartmental knee replacements.

    Benefits and risks of knee replacement

    Younger or more active patients with arthritis affecting only one side of the knee may be suitable for ‘offloading’ treatment options including bracing, osteotomy (re-alignment) or the new offloading device (KineSpring). Associated problems such as deformity of the knee because of the arthritis (e.g. bow legs) and reduction in function, will improve following knee replacement but in themselves are not a reason for having the operation.

    CLICK HERE TO WATCH THE CASE STUDY VIDEO

    There is no operation that does not carry some risks.

    The main risks of knee replacement are:

    Infection

    The chances of a serious deep infection affecting a knee replacement are approximately 1%. This is a major complication which can require further surgery to clear the infection. Up to 2-3% may develop a simple wound infection.

    Please note – all knee replacements can be warm and swollen for up to three months following surgery – this does not necessarily indicate infection.

    Deep Vein Thrombosis

    (DVT, blood clots) affecting the lower leg can occur but precautions are taken to reduce the chance of this either in the form of blood thinning tablets /or injections, or special calf pumps to keep the blood flowing. Pulmonary embolism (PE) is a rare but serious complication arising when a blood clot obstructs some of the veins in the lungs. NICE (National Institute for Health and Clinical Excellence) issues guidelines for hospitals to reduce the risks of thromboembolism (blood clots) – www.nice.org.uk

    Nerve Damage

    Nerve damage can occur, but this is usually seen in the form of a numb patch of skin to one side of the scar (in most patients). It is extremely rare to have nerve damage from a knee replacement causing weakness in the leg or foot.

    Stiffness

    Sometimes despite having a technically successful operation, the knee can be stiffer than hoped for which can result in aching and general dissatisfaction. It is not always possible to work out a reason for this.

    The above are some of the major and more commonly occurring early risks from total knee replacement but your surgeon or physiotherapist will discuss and answer any more specific questions with you.

    On average, you have approximately a 90% chance of achieving an excellent result from a knee replacement, giving you pain relief for at least 10-15 years. A further 6-8% are much improved compared to previous symptoms. Eventually knee replacements can fail by wearing out or loosening amongst other things, and this can occasionally occur in the first few years.

    Patello-femoral resurfacing

    Patello-femoral Resurfacing

    Arthritis affecting only the joint between the knee cap and femur (the patello-femoral joint) may be suitable for patello-femoral resurfacing. In patello-femoral resurfacing a plastic component is put on the back of the knee cap and a metal component on the front of the femur leaving the main knee joint between the tibia and the femur alone. Patello-femoral resurfacing is a relatively new technique compared to total knee replacement, but is successful in patients who have a certain type of osteoarthritis and your surgeon may discuss this with you.

    Benefits and risks of knee replacement

    Younger or more active patients with arthritis affecting only one side of the knee may be suitable for ‘offloading’ treatment options including bracing, osteotomy (re-alignment) or the new offloading device (KineSpring). Associated problems such as deformity of the knee because of the arthritis (e.g. bow legs) and reduction in function, will improve following knee replacement but in themselves are not a reason for having the operation.

    CLICK HERE TO WATCH THE CASE STUDY VIDEO

    There is no operation that does not carry some risks.

    The main risks of knee replacement are:

    Infection

    The chances of a serious deep infection affecting a knee replacement are approximately 1%. This is a major complication which can require further surgery to clear the infection. Up to 2-3% may develop a simple wound infection.

    Please note – all knee replacements can be warm and swollen for up to three months following surgery – this does not necessarily indicate infection.

    Deep Vein Thrombosis

    (DVT, blood clots) affecting the lower leg can occur but precautions are taken to reduce the chance of this either in the form of blood thinning tablets /or injections, or special calf pumps to keep the blood flowing. Pulmonary embolism (PE) is a rare but serious complication arising when a blood clot obstructs some of the veins in the lungs. NICE (National Institute for Health and Clinical Excellence) issues guidelines for hospitals to reduce the risks of thromboembolism (blood clots) – www.nice.org.uk

    Nerve Damage

    Nerve damage can occur, but this is usually seen in the form of a numb patch of skin to one side of the scar (in most patients). It is extremely rare to have nerve damage from a knee replacement causing weakness in the leg or foot.

    Stiffness

    Sometimes despite having a technically successful operation, the knee can be stiffer than hoped for which can result in aching and general dissatisfaction. It is not always possible to work out a reason for this.

    The above are some of the major and more commonly occurring early risks from total knee replacement but your surgeon or physiotherapist will discuss and answer any more specific questions with you.

    On average, you have approximately a 90% chance of achieving an excellent result from a knee replacement, giving you pain relief for at least 10-15 years. A further 6-8% are much improved compared to previous symptoms. Eventually knee replacements can fail by wearing out or loosening amongst other things, and this can occasionally occur in the first few years.

    patello-femoral-resurfacing-0001

    Customised Knee Replacement Surgery

    Customised Knee Replacement Surgery

    Patient Specific Instrumentation, Computer Navigation and Robot-assisted surgery.

    The potential benefits of new techniques designed to assist the surgeon to more accurately position the components of knee replacements are constantly being evaluated by the Yorkshire Knee Clinic surgeons. Computer-navigated (assisted) surgery has been used for complex cases for some years but its value in routine cases is less proven.

    Special instruments personalised to the individual patient (based on MRI or CT scans) are now available. The potential benefits of these are to improve the accuracy of bony cuts (required for positioning the implants) in an attempt to improve the alignment and rotational position of knee replacements. Long-term benefits could be seen in terms of both function and life expectancy of the knee replacements but there is no firm evidence for this.

    These customised instruments (which take 4-5 weeks to manufacture) are now routinely available to assist knee replacement surgery. Similar personalised instruments have now been created to assist unicompartmental knee replacement with encouraging early results.

    Advances in robot-assisted surgery and custom-made implants continue to be monitored by the Yorkshire Knee Clinic but so far their clinical- and cost-effectiveness remain uncertain.

    customised-knee-replacement-surgery-0001

    Joint Offloading Treatments

    Joint Offloading Treatments

    Younger or more active patients with arthritis affecting only one side of the knee may be suitable for ‘offloading’ treatment options.

    Load absorption has been used as a moderately successful treatment for many years with simple knee ‘offloader’ braces designed to take the load of one worn side of a knee and transfer it to the other side. Unfortunately these braces (whilst often effective) are not well tolerated in the long term with many being abandoned or only used occasionally. High tibial osteotomy offers a more permanent offloading treatment although it also permanently alters the anatomy of the leg potentially affecting the outcome of future treatment options especially knee replacement.

    High tibial osteotomy

    High Tibial Osteotomy

    High tibial osteotomy (HTO) involves the cutting of the tibia just below the knee joint to realign it. In cases of medial compartment osteoarthritis that is not too severe, and affecting relatively young active patients, it may be considered by your surgeon.

    In such patients the benefits of HTO are that if successful and once a full recovery is achieved, there are no components to loosen or wear out and therefore you may recommence whatever activities you wish as long as you understand that the arthritic part of the knee can still deteriorate. The surgery works by taking the weight off the worn out side of the knee and transferring it to the healthy side of the knee.

    Only a small proportion of patients with knee arthritis are suitable for this treatment especially as the success of partial knee replacement has increased. The pain relief is not as reliable as with a knee replacement. In appropriately selected patients there may be a 75% chance of a good result (i.e. the pain being better than it was before surgery) at 10 years from surgery.

    HTO does, however, have an important role in the treatment of some patients with knee instability following complex ligament injuries.

    KineSpring Load Absorber

    KineSpring Load Absorber

    In an attempt to deliver the effectiveness of bracing and high tibial osteotomy without some of the disadvantages a new device (KineSpring, Moximed) has been developed and tested in clinical trials over the last few years. Initial encouraging results in Australia have been followed by clinical trials in a few specialist centres in Europe. Nick London is one of the surgeons who have been evaluating the device as part of the European COAST trial and subsequently offering the surgery to private and NHS patients. Patients with wear on the inner side (medial) of the knee that have continuing symptoms affecting their activities may be considered. The aims of this device are to:

    • 1. Reduce pain/discomfort with activities
    • 2. Increase activity levels
    • 3. Delay knee replacement surgery

    It is important to know that although early results are encouraging in the majority of patients, this new technology is still under evaluation and not all patients are suitable.

    Further information is available from http://www.moximed.com

    (Nick London holds a consultancy agreement with Moximed for development and surgeon-training.)