Total Knee Replacement

Total knee replacement is also known as arthroplasty. It is carried out by relining of the knee joint (bone end surfaces) with artificial parts called prostheses. When pain, stiffness, knee swelling and limitation of motion in the knees deter one from one's daily activities, one may need total knee replacement. There are three components used in the artificial knee. The first component, femoral (thigh) component, is made of metal and covers the lower end of the femur.

The second, tibia (shin bone) component, made of metal and polyethylene (medical-grade plastic), covers the top end of the tibia. The base of this component is metallic, usually Titanium. At the top of the metal is polyethylene which acts as a cushion and form a smooth gliding surface between the metal of the femoral and tibia components.

The third component, the patella or knee cap, is made up of polyethylene. The surgeon decides at the time of operation if it should be replaced in a particular situation or not.

Generally, these components are cemented to their respective bones.

Total knee replacement is conducted through an incision that runs three or four inches above the knee down along the inside of the kneecap to several inches below the knee. The new components are stabilized by your ligaments and muscles, just as your natural knee was earlier.

Patients with severe arthritis of both knees can be offered replacements of both knees together, after a thorough medical evaluation.

Unicondylar Knee Replacement

As the name suggests, in certain situations only one side of the knee is replaced. This is termed as Unicondylar Knee Replacement. It has very definite indications, which only a surgeon can judge and advise.

Unicondylar Knee Replacement is comparatively economical and since the operation is less extensive, the post-operative recovery is shorter.

Preparation for surgery

A detailed medical check up is carried out to ensure safity of the patient about one to two weeks prior to surgery. In case of requisite parameters like blood sugar or blood pressure beyond permissable limits, corrective action can be carried out before the operation.

Usual pre-surgery investigations carried out are listed below. However, at times additional investigations may be required :

Investigations

Blood transfusion may be required during the surgery, depending upon your preoperative Hemoglobin levels. One may donate one's own blood a few days before the operation, which is then transfused back to him on the day of the operation, if required.

The patient is admitted to the hospital a day before the surgery date. He/she will be advised not to eat or drink anything after midnight on the day of surgery. A night prior to that, an injection of blood thinning agent (anti-coagulant) may be administered to minimize the chances of blood clotting in the legs. Usually antibiotics are started in the morning of the operation. However, with patients having greater risk of infection, antibiotics may be started a night before.

Usually, operation is carried out under epidural / spinal anesthesia where the legs are anesthetized and a fine tube is put in the back through which anesthetic agent keeps dripping in. This also helps greatly in controlling the pain in post-operative period. The anesthesiologist will speak to you before surgery and discuss the type of anesthesia to be used.

Recovery

After the surgery (operation) is over, the patient is taken to the post-operative recovery room. There will be a drain tube coming out of the bandage on your knee. This is only to removes any blood collected in the knee and minimizes the chances of infection. At the same time, an intravenous line will be transfusing blood or fluids into the patients arm. This will be used to give antibiotics over the next few days. In some instances a urinary catheter may be used to help elderly patients or those who have urinary difficulty.

Some instrument leads will also be attached to your body to continuously monitor your vital parameters like ECG, blood pressure, pulse rate, breathing rate, etc. The patient is retained in the recovery room for a few hours and once the anesthetists are satisfied that the patient is comfortable, he will be shifted to his room. Rarely, even in patients with medical problems does one need to stay in ICU or High Dependency Unit for more than a day or two.

Today, more than 500,000 people in the developed world undergo Total Knee Replacement surgery every year as a means of diminishing pain and stiffness and restoring mobility.

Post-Operative Management & Physiotherapy

The patient will be advised to start in-bed Chest and Knee exercises on the evening of the operation itself. After 24 - 48 hours the drain from the knee is removed and the dressing reduced in size. One will be made to sit on bedside with legs supported.

4 - 6 days after the operation you will be encouraged to stand and walk using a walker and a day or two later, you should be able to visit the toilet with assistance.

You are usually discharged from the hospital one week after the surgery with instructions regarding medicines and physiotherapy.

Stitches are removed 2 weeks after your operation.

2- 3weeks after the operation, patients are encouraged to walk with a walking stick.

6 - 8 weeks after the surgery, patients are trained to start climbing stairs.

12 weeks post operative, one can usually begin driving vehicle with due precautions.

YOU ARE ADVISED NOT TO SQUAT OR SIT CROSS-LEGGED AFTER THE OPERATION.

Follow-up

The patient is re-examined periodically, say after six weeks, then three months and after that after another twelve months of the surgery. The patient is normally requested to see his/her surgeon once a year after the first year.

Any infection must be promptly treated with proper antibiotics because infection can spread from one area of the body to another through the blood stream. Every effort must be made to prevent infection in the artificial joint.

Increasing chances of success

Total Knee Replacement is the most successful operation for severe arthritis and to increase the chances of success, ensure the following:

• Choose a Joint Replacement specialist surgion.
• Choose a well-equipped and reputed hospital having facilities appropriate for Joint Replacement surgery.
• Discuss with the surgeon and ensure that good quality implants are used.
• Meet and talk to other patients who have been operated by the Surgeon performing your surgery.
• Follow the instructions given by your Surgeon.

Revision Joint Replacement

The usual life span of a successful Total Knee Replacement is about 10-15 years. It may however vary in individual circumstances. Once a joint is worn out or fails, a Revision Joint Replacement can be done, though it is a more extensive procedure. The success of the Revision Surgery varies in individuals depending on the preoperative status of their 'Primary Replacement Joint'.

The Hip Joint

The hip joint is the strongest weight-bearing joint of the body.

It is a ball-and-socket joint that connects the pelvis to the thigh bones. The hip socket is called the acetabulum. It forms a deep cup that surrounds the ball of the upper thigh bone, the femoral head. The surface of the femoral head and the inside of the acetabulum are covered with a smooth shiny cartilage that cushions, protects and at the same time allows almost frictionless movement. This cartilage contains no nerve endings or blood supply and receives nutrients from a moisturizing lubricant (synovial fluid) produced by the synovial lining surrounding the hip joint. If damaged, the cartilage is not capable of repairing itself.

fibres (Ligaments) connect the bones of the hip joint and provide necessary stability to the joint and elasticity for its movement. Muscles and tendons also play an important role in keeping the hip joint stable and mobile.

Total Hip Replacement

There are two major types of Total Hip Replacements: a cemented prosthesis and an un cemented prosthesis. Both are widely used. The surgeon makes the choice based on the patient's age and lifestyle.

Each prosthesis is made up of two parts:

• The ace tabular component, made of high-density polyethylene. At times, it has a metal shell backing. The ace tabular component is placed inside the socket.
• The femoral component made of metal. The femoral head that attaches to the stem may be a separate part. It is made either of metal or ceramic. The femoral stem extends into a canal in the thigh bone.
• When the ace tabular component is un cemented and femoral component is cemented. It is called Hybrid Total Hip Replacement

Today, almost one million people in the developed world that undergo total hip replacement surgery every year as a means of diminishing pain and restoring mobility.

Treatment

Once the joint cartilage has been damaged to an extent that any attempt to use it becomes extremely painful and X-Rays confirm the severe destruction, surgical options need to be considered. Surgery should be advised after a thorough general check up of the patient keeping in mind the need for post-operative physiotherapy as well as the stress of anesthesia and the surgery itself. Often medically unfit patients are well advised to live on palliative procedures like drugs and injections into the painful joint.

Various surgical interventions are available depending on the severity of patient's condition and the doctor's judgment. These include:

• Femoral Hemiarthroplasty (Replacement of half a hip)
• Total Hip Replacement (THR)
• Cemented prosthesis
• Un-cemented prosthesis
• Hybrid Total Hip Replacement

Benefits of the surgery

After the surgery, once the artificial hip joint has healed, the patient normally benefits by having:

• Alleviation of joint pain
• Increased movement and mobility
• Correction of deformity
• Increased leg strength
• Improved quality of life due to the ability to return to normal activities and pastimes.
• Leglength equality.

Femoral Hemiarthroplasty

Femoral Hemiarthroplasty is carried out instead of a Total Hip Replacement, when the socket cartilage is normal. In such case, the socket is not replaced. It is an operation similar to that of a total hip replacement, but its ball, the femoral head is large and fills the normal socket, bearing directly against the cartilage. Though this is a less expensive procedure, it also lasts for less time than a Total Hip Replacement.

Preparation for surgery

As for knee replacement

List of investigation

As for knee replacemen

Recovery

After the surgery the patient is shifted to the post operative recovery room. A bandage is tied over the hip with a drain tube coming out of the bandage to remove any blood collected in the hip joint. This minimizes the chances of infection. The legs of the patient are kept apart by a pillow in between them.

An intravenous line will be transfusing blood or fluids into the patient's arm. This will later be used to administer antibiotics over the next few days. In some instances a urinary catheter may be used to help elderly patients or those who have urinary difficulty.

Like in most other such operations, some instrument leads will be attached to the body to continuously monitor patient's vital parameters like EGG, blood pressure, pulse rate, breathing rate, etc. The patients remain in the recovery room for a few hours and are shifted to their own room once the anesthetists are satisfied in all respects.

It is rare even with patients having medical problems, that there is a need to stay in ICU or High Dependency Unit for a day or two.

Post-operative management and physiotherapy

• Patient is encouraged to start in-bed exercises within 24 hours of the operation.
• The drain from the hip joint is removed after 24 - 48 hours. Patient is made to sit on bedside with legs supported.
• 02 to 03 days after the operation (cemented hip), patient is encouraged to stand and walk using a walker and a day or two later, one is able to visit the toilet with assistance using a high seat.
• 03 to 04 weeks after the operation, patients are encouraged to walk with a walking stick.
• In case of Hybrid or Un cemented Hip Replacement, the patient is usually advised non weight bearing exercises with a walker for 02 weeks, then partial weight bearing for 04 weeks. Full weight bearing is advised at 08-12 weeks after the operation.
• The patient is usually discharged from the hospital one week after the surgery with instructions regarding medicines and physiotherapy.
• Stitches are removed 02 weeks after the operation. (Cemented Total Hip Replacement)
• 06 - 08 weeks after the surgery, patients are encouraged and trained to start climbing stairs.
• 12weeks post operative, one can usually begin driving vehicle with due precautions.

Precautions after the surgery

First eight weeks:

• Always use your walker, crutches or cane.
• Walk. It is your most vital physical therapy.
• Gradually increase the distance.
• Do not sleep on your side until instructed by physician.
• Do not cross your legs at the knees or ankles.
• Do not bend the hip beyond a 90 angle - avoid low chairs and Indian style toilet.
• Do not pivot or twist on the operated leg.
• Do not bend over to pick up anything from the floor.
• If in doubt about any activity, consult your Surgeon before performing it.

Follow up

The patient will be advised to consult your surgeon periodically, say after six weeks, then three months and again after twelve months after the surgery. You are normally advised to see your surgeon regularily once a year after the first year, even if things look normal.

Any infection must be promptly treated with proper antibiotics because infection can spread from one area of the body to another through the blood stream. Every effort must be made to prevent infection in your artificial joint.

Increasing chances of success

Total Hip Replacement is one of the most successful operations for severe and painful arthritis and to increase your chances of success ensure the same as for total knee operations, or generally in case of any major operation.

Revision joint replacement

The usual life span of a successful Total Hip Replacement is about 10-15 years. It may however vary in individual circumstances. Once a joint is worn out or fails, a Revision Joint Replacement can be done, though it is a more extensive procedure. The success of the Revision Surgery varies in individuals depending on the pre-operative status of their 'Primary Replacement Joint'.

Understanding the risk

It must be understood that all major operations include an element of risk and though these should not be over emphasized, the patient should be aware of these, particularly the elderly who are at a greater risk than the younger age group. Major complications include infection, dislocation of the ball from socket, blood clots in veins of legs and lungs. These can occur in any centre in the world.

Problems and aspirations of each individual patient differ and these must be discussed with the surgeon at length before the patient accepts the Total Hip Replacement operation. Patient must know all that can go wrong and what can be done to save the situation.

Shoulder Replacement

Shoulder replacement surgery is an option for treatment of severe arthritis of the shoulder joint. Arthritis is a condition that affects the cartilage of the joints. As the cartilage lining wears away, the protective lining between the bones is lost--when this happens, painful bone-on-bone arthritis develops. Severe shoulder arthritis is quite painful, and can cause restriction of motion. While this may be tolerated with some medications and lifestyle adjustments, there may come a time when surgical treatment is necessary.

Symptoms of severe arthritis of the shoulder

• Pain with activities
• Limited range of motion
• Stiffness of the shoulder
• Swelling of the joint
• Tenderness around the joint

Treatments available

Alternate and simplar treatments for shoulder arthritis should be tried before considering shoulder replacement surgery. As the shoulder is not a weight-bearing joint (like the knees and hips), many patients can tolerate shoulder arthritis with some basic treatments and modifications of their activities. Only as a last resort should the operation be carried out to reduce the exposure to risk to the patient undergoing such operation.

Total shoulder replacement

Total shoulder replacement surgery alleviates pain by replacing the damaged bone and cartilage with a metal and plastic implant. The shoulder joint is also a ball-and-socket joint, much like the hip joint. The ball is the top of the arm bone (the humerus), and the socket is within the shoulder blade (scapula). This joint allows people an enormous range of motion at the shoulder.

When shoulder replacement surgery is performed, the ball is removed from the top of the humerus and replaced with a metal implant. This is shaped like a half-moon and attached to a stem inserted down the center of the arm bone. The socket portion of the joint is shaved clean and replaced with a plastic socket that is cemented into the scapula.

To assess the need and preparedness for shoulder replacement surgery

Patients who have tried the usual treatments for shoulder arthritis, but have not been able to find adequate relief, may be the right candidate for shoulder replacement surgery. Patients considering the procedure should understand the potential risks of surgery, and understand that the goal of joint replacement is to alleviate pain. Patients generally find improved motion after surgery, but these improvements are not as consistent as the pain relief following shoulder replacement surgery.

Elbow replacement:

Elbow replacement involves surgically replacing bones that make up the elbow joint with artificial elbow joint parts (prosthetic components). The artificial joint consists of two stems made of high-quality metal. They are joined together with a metal and plastic hinge that allows the artificial elbow joint to bend. The artificial joints come in different sizes to fit the patient.

Alternative Names:

Total elbow arthroplasty; Endoprosthetic elbow replacement

Treatment Procedure

The patient may receive general anesthesia (unconscious, no pain) or regional anesthesia that prevents the arm from feeling pain. Patients receiving regional anesthesia are also given medicine to help them relax during the operation.

The orthopedic surgeon makes an incision, usually in the back of the upper and lower arm, to expose the elbow joint. He then removes the lower end of the bone in the upper arm (humerus) and the upper end of the large bone in the lower arm (ulna), along with any damaged tissue.

The orthopedic surgeon then drills out a portion of the center of the humerus and ulna and inserts one stem of the prosthesis into each bone. Usually, bone cement is used to hold the stems in place.

The surgeon then attaches the two stems together with the hinge system. The orthopedic surgeon closes the wound with stitches, applies a bandage, and might place the arm in a splint for stability.

Indications:

Elbow replacement surgery can be performed when the patient’s joint has been severely damaged. Causes of damage include:

• Osteoarthritis
• Rheumatoid arthritis
• Severely broken bone  in the upper or lower arm near the elbow
• Severely damaged or torn tissues in the elbow
• Tumor in or around the elbow

Expectations after surgery:

The patient will stay in the hospital for about three or four days. A splint may be used after surgery to help stabilize the elbow.  Elbow replacement surgery relieves pain for most patients.

Convalescence:

Physical therapy, starting with gentle flexing exercises, will be prescribed. Patients who have a splint typically start therapy a few weeks later than those who do not.

The patient will need help with everyday activities, such as driving, shopping, bathing, meal preparation, and household chores, for up to six weeks.

Some patients may begin to regain function of the elbow as soon as 12 weeks after surgery, although additional recovery can take up to a year.

The patient should not lift more than five pounds with the operated arm, even when fully recovered.

Complex Trauma Management

Complex joint trauma is a term reserved for specific and severe injuries that include two or more structural elements of the joint. These structural elements are the articulating bones, the major ligaments of the joint, the local soft tissue envelope and the neurovascular structures. Complex joint trauma has a high risk for complications and requires a special treatment algorithm. A staged surgical protocol with initial soft tissue debridement, closed joint reduction and external fixation of the extremity followed by secondary reconstructive surgery after soft tissue recovery is suggested.

Paediatric Orthopedics

Paediatric Orthopedics is the study and treatment of growing bones, joints and muscles. Pediatric orthopedists use any techniques, including observation of growth, physical therapy, braces and splints, and occasionally surgery to treat various conditions such as congenital deformities, injuries, neurological disorders, and scoliosis. These conditions are discussed in general below, with links being added to more specific information as time goes by.

Variations of Normal Anatomy & Congenital Deformities

Frequently, young children and adolescents have conditions that are variations of normal anatomy. These include children who toe-in or toe-out excessively, children with "bad posture" such as round-back or sway-back, and children who are delayed in learning to walk or have unusual patterns of walking such as "toe walking". Often these problems are variations of normal developmental patterns and do not represent an underlying disease.

In such cases, the child's growth and patterns of walking, posture, and muscular development need to be observed over time in order to establish whether the child's growth pattern will return to normal spontaneously.

A small percentage of children have birth defects. These include spinal problems such as spina bifida, limb deformities such as clubfoot, or other congenital defects such as extra fingers or toes. Pediatric Orthopedists frequently follow these children through years of growth and into adult life.

Childhood Injuries

Children often break bones. With these fractures there is often a potential injury to the growth centers of the skeleton. Pediatric Orthopedists evaluate the child for potential growth problems that may happen after the injury heals and treat growth disturbance if it occurs. Appropriate treatment of fractures, sprains and dislocations can ensure minimal disturbance of function and a quick return to normal childhood growth and activity.

Paediatric Sports Injuries

Pediatric Sports Medicine is an important part of health care. Children who engage in activities like soccer, karate, and skateboarding may have acute injuries such as broken bones, sprains, and dislocations. Many times chronic stress injuries occur, such as fractures, tendinitis, and apophysitis. Examples are "Little Leaguer's Elbow", Osgood-Schlatter's disease of the knee, and Sever's Disease of the foot. Treatment of these injuries is usually simple and seldom requires surgery.

Neurological Disease

Many patients seen by Pediatric Orthopedists have neurological disorders such as cerebral palsy, spina bifida, or the family of diseases known as dystrophies. Most of these disorders result in muscle imbalance and deformity in the areas involved, such as drop foot, scoliosis, or paralytic clubfoot.

Children with cerebral palsy or spina bifida frequently require bracing or surgery to improve their ability to function to their greatest potential.

Scoliosis and Kyphosis

These conditions are deformities of the spinal column and may occur at any time before or after birth, but are more frequent during the adolescent growth spurt. Scoliosis is curvature of the spine seen in about 5% of teenage girls. Kyphosis is an excessive round-back deformity common in teenagers.

ARTHRITIS

Arthritis is a generic, non-specific term often loosely used to describe symptoms like aches, pains and stiffness in joints, mostly associated with older generations. Similarily, rheumatism is alsp a term used for aches and pains in muscles, joints or other parts of the body.an

Arthritis can be of many types. The commonest include Osteoarthritis, Rheumatoid arthritis, Infective arthritis and Traumatic arthritis. Most of these involve progressive deterioration of joint cartilage.

And what is cartilage ? As explained earlier, cartilage is a smooth, shiny, glistening material, which covers the ends of bones that articulate to form a joint. When cartilage is healthy, the joint moves smoothly like a well oiled machine. When cartilage is worn out or diseased, it becomes rough, irregular, cracked and swollen. This leads to stiffness, and pain when an attempt is made to move the joint.

Osteoarthritis:

This is the most common form of arthiritis, where cartilage simply wears out due to over use or old age, much like a car tyre. Damaged cartilage is unable to replenish or repair itself, so it withers out, becomes less flexible and is more prone to injury and damage. Over a period of time, the cartilage can wear away completely, causing the bones of the joint to rub directly against each other causing severe pain.

Rheumatoid Arthritis:

It is an auto-immune disease where body's immune system, which is designed to fight infections and help healing wounds, goes haywire and attacks its own tissues, especially joints. The joints, usually fingers, swell and become painful. It often involves all other major joints of the body. With passage of time the joints get destroyed and produce deformities. Drugs often control the pain and inflammation but once the joint is destroyed, replacement remains the main treatment.

Infective Arthritis

A common occurrence in India following either usual bacterial infection or tuberculosis. These often lead to severe signs of infection followed by rapid course of joint damage.

Traumatic Arthritis:

Injuries to the joints damage the lining cartilage. The cartilage develops cracks, which do not heal with original quality tissue. This becomes a weak spot, which gradually wears and follows a course akin to osteoarthritis.

There are well over a hundred type of other arthritis. However the above-mentioned account for over ninety five percent of the patients.

A vascular Necrosis (Osteonecrosis) It is not "Arthritis" but a condition in which part of the femoral head dies due to lack of blood supply and becomes irregular in shape. The joint then becomes very painful.

The most common causes of Osteonecrosis are excessive alcohol intake, excessive use of cortisone-containing medications, injury to the hip joint or following some surgery around the hip joint.