Sunday September 23, 2012
Replacing worn joints
Story and photos by PAUL YEO
Getting your knees replaced is not as big a deal as many people think.
FOR the past five to six years, Cheong Ah Lan, 51, had been coping with right knee pain that somewhat restricted her movements.
Then a year later, her left knee was also affected.
She bravely soldiered on despite the pain. The housewife, a mother of four, tended to her responsibilities with nary a complaint, though she couldn’t jog anymore because of the pain.
Two years ago, the pain worsened, and this severely restricted her mobility.
She went through all the non-surgical options, and delayed seeing an orthopaedic surgeon because of her fear of going under the knife.
Because of that, Cheong had to live with the pain and swelling of both her knees. She says: “It’s not only the pain I have to cope with. Quite often, while walking, I can feel a grinding sensation in both my knees. It’s as if the bones are grinding against each other. On occasion, I could also feel my knee ‘lock up’, and I couldn’t move because of that.”
When she couldn’t stand the pain anymore, she consulted consultant orthopaedic surgeon Dr Ko Chung Yee. Investigations showed that her knees were severely affected by osteoarthritis, and it was recommended that she undergo bilateral total knee replacement surgery (TKR), a procedure that would help alleviate her symptoms and help her regain her mobility.
When do you need a TKR?
At what stage should you consider TKR? Ask yourself these questions:
·Do you have severe knee pain or stiffness that limits daily activities?
·Do you suffer severe knee deformity – bowing in or out of the knees?
·Do you experience swelling of the knee that does not improve with rest or medications?
If you answer yes to any of the above, then you should consider the procedure to rid you of such problems.
According to Dr Ko, too many patients adopt a wait-and-see attitude, despite the pain in their knees severely affecting their mobility.
“Don’t be afraid of such surgery,” he advises. “I know of someone who had been living with the pain and immobility for 20 years. She was 70 years old then. Despite advice to get her knees fixed up, she refused, saying she was ‘too old’. By the time she reached 86 years of age, she was wheel-chairbound, and still didn’t want surgery, citing the ‘too old’ excuse.
“Not long after that, she fell while she was in the toilet, and fractured her hip in the process. If she had her knees done 20 years ago, she probably wouldn’t be facing such a predicament.”
When knees fail
The knees are integral to daily living, and any injury or disease affecting the knees will not only cause pain, but also affect the ability to perform even the simplest of activities, such as walking or climbing up the stairs.
When medications and other palliative methods are no longer helpful, than TKR is a suitable option.
Knee replacement surgery was first performed nearly 50 years ago. Subsequent improvements in surgical techniques, as well as materials, have made it one of the most successful procedures in medicine.
Basically, the procedure involves “resurfacing” of the worn and diseased parts of the knees, and in effect, only the surface of the bones is actually replaced.
Different types of knee implants are used to meet each patient’s individual needs. However, according to Dr Ko, “Though there are many different types of knee implants, they are all pretty similar in quality, and in good hands, all give good results.”
To better understand TKR, you need a working knowledge of what the knee is.
Essentially, the knee is made up of the lower end of the thigh bone (femur), the upper end of the shinbone (tibia), and the kneecap (patella). The ends of these three bones (where they meet) are covered with cartilage, a smooth substance that protects the bones and facilitates movement.
The menisci are located between the femur and tibia. These “C-shaped” wedges act as “shock absorbers” that cushion the joint.
The knee is anchored by ligaments that hold the femur and tibia together and provide stability.
All these components of the knee are essential for functioning, and when disease or injury affects any of these components, problems arise.
Hence, TKR involves replacing these worn and diseased parts.
In general, knee replacement surgery consists of three steps:
Step 1: Removing the damaged cartilage at the ends of the femur and tibia (as well as a small amount of bone).
Step 2: Metal implants are inserted to recreate the surface of the joint.
Step 3: A spacer is inserted between the metal components to create a smooth gliding surface.
More than 90% of people who have total knee replacement surgery experience a reduction of knee pain, and a significant improvement in the ability to perform daily activities.
Most can expect to be able to almost fully straighten the replaced knee. Kneeling is sometimes uncomfortable, but it is not harmful.
Some people feel numbness in the skin around the surgical incision. Others may also feel some stiffness, particularly with excessive bending activities.
Many people can feel or hear some clicking of the metal and plastic parts in the knee when walking. This is not unexpected, and most will get used to the sensation after some time.
However, with the activities of daily living, the knee replacement implant can wear out. This wear-and-tear can be accelerated with excessive activity or weight. Therefore, patients are advised against high-impact activities, such as running, jogging, or other high-impact sports after surgery.
Realistic activities following total knee replacement include walking, swimming, golf, and other low-impact sports.
With appropriate activity modification, knee replacements can last for many years. Currently, more than 90% of modern total knee replacements are still functioning well 15 years after the surgery.
What wrecks the knees
There are many causes of knee problems, but the most common is arthritis, whether it is osteoarthritis, rheumatoid arthritis or post-traumatic arthritis.
Osteoarthritis is essentially the “wear-and-tear” type of arthritis that usually occurs in those above 50 years of age, though it may occur in younger people. Here, the cartilage that cushions the bones wears away, leading to the bones grating against each other, causing knee pain and stiffness.
Rheumatoid arthritis is basically chronic inflammation that damages the cartilage, and eventually causes pain and stiffness.
According to Dr Ko, he has carried out TKR on a 20-something-year-old man who is suffering from rheumatoid arthritis.
Post-traumatic arthritis can be a consequence of serious knee injury that may damage cartilage over time.
Timing is everything
The timing of surgery is based on how much pain and disability a person is suffering. Those who need TKR usually:
·Have severe knee pain or stiffness that limits everyday activities, and do not improve with other treatments such as medications, injections, or physical therapy.
·Suffer severe knee deformity – bowing in or out of the knee.
·Experience chronic inflammation and swelling that does not improve with rest or medications.
Before surgery, the orthopaedic surgeon will assess general medical fitness for surgery. In addition, the orthopaedic surgeon will explain the potential risks and complications of total knee replacement, including those related to the surgery itself and those that can occur over time after your surgery.
In general, the procedure has been performed successfully at all ages, from the young teenager with juvenile arthritis, to the elderly patient with degenerative arthritis.
According to Dr Ko, the procedure usually takes about one to two hours, with the total length of hospital stay varying from one to three days, depending on whether one or both knees are done.
Dr Ko says that the patient is encouraged to move around as soon as possible after surgery.
“Early mobility is encouraged to help with faster recovery. It is also expedient to get the patient moving around to prevent the complication of blood clots in the legs, which can have serious consequences,” he explains.
Cheong underwent TKR a few weeks ago. The day after her surgery, a therapist worked on her, encouraging her to do some knee exercises to strengthen her legs and help restore knee movement.
She was discharged the day after, with a set of instructions, and a list of exercises to carry out daily while at home, as well as instructions on wound care.
A team of physiotherapists visited her home a week later to assess her progress.
When met, she said that she had been walking for the past two days. “I carry out my daily exercise, and I’m slowly regaining my mobility,” she notes. “Thus far, there have been no problems, though there’s still some discomfort, especially in my left knee.”
The whole process is aimed at getting the patient back to their normal activities as soon as possible.
In general, a person who has undergone TKR will most likely be able to resume driving approximately four to six weeks after surgery.
Although you will be able to walk on crutches or a walker soon after surgery, you will need help for several weeks with such tasks as cooking, shopping, bathing, and doing laundry.
In general, the timeline for full recovery is 30% after a week, 60 to 70% after a month, and full recovery after a year.
n For more information on total knee replacment, you can visit quillorthopaedic.com.