Also called as Knee arthroplasty or Knee resurfacing, Knee replacement surgery, is done to provide pain relief and improved mobility to people who:
In most such cases, the knee joint is eroded, uneven, worn or damaged as the cartilage is worn away, and the knee joint is unable to bear the weight of the body. This condition results in pain, stiffness and a change in body alignment as well. People may not be in a position to move around freely, may give up on walking totally, or may have falls.
When this surgery is done, it restores the knee joint back to such a state that it can bear the weight, and thus, reduce the pain and provide improved movement and flexibility. The surgery involves the reconstruction and/or replacement of the degenerated joints using artificial parts or prosthetics as is seen fit.
Both TKR and PKR are aimed at improving the quality of life and mobility of the patient. When the damaged knee is replaced either partially or fully, people are able to independently move around, while it is possible that there could still be some minor issues. The hospital stay and recuperation depend on the TKR or the PKR
There are mainly two kinds of Knee replacements namely, Total Knee Replacement (TKR) and Partial Knee Replacement (PKR). [1]. The doctor is the best judge for deciding which kind of knee replacement a person needs.
Total Knee Replacement Surgery: This is the more common of the procedures, and it involves a replacement of both sides of the knee - the entire knee joint is replaced. In this, the damaged bone areas are removed and implants or prosthetics are fixed over the ends of the bone; this allows them to glide smoothly against one another, providing better mobility. This surgery usually takes about three hours and the patient may have less or no pain in the knee later on.
The implants are made of plastic and metal, and also customized according to each individual for maximum compatibility.
2. Partial Knee Replacement Surgery (PKR)
Partial Knee Replacement Surgery : In this case, only a part of or one side of the knee joint is replaced, making it a minimally invasive surgery, with shorter hospital stay than the TKR. Less bone is removed to replace it with the prosthetics, and this can only be done to such patients for whom only part of the knee is damaged. The restored free movement may also be slightly more than the TKR in this case.n symptoms. Can quickly turn fatal if the epiglottis swells up and restricts breathing.
In the United States, over 966,000 knee replacements were performed in 2017, and PKRs were were lesser than the TKRs. According to a report released by iData Research, a leading international medical market research and consulting firm, the increase in the knee replacement surgeries are actually driven by young people.
These people lead an active life and thus end up putting more pressure on the knee. This results in wear and tear, leading to issues. As a result of this, the life of the implants being used is also increasing, as younger patients will expect it to last longer. [2]
India is expected to see one million (10 Lacks) knee replacements every year by 2022 and has more than 3 crore people suffering from Arthritis. This is because knee arthritis incidence is 15 times more in India than the Western Countries. [3]
A range of symptoms like knee pain, immobility in the area, swelling, stiffness, inability to bear the weight, walk properly or climb stairs, etc. are seen commonly in people who end up with a surgeon, who will then conduct some tests to determine if the person needs a knee replacement surgery. [1]
The doctor will conduct a few tests to decide if you are indeed a candidate needing knee replacement. [5] They are:
Please note that in most cases, an X-Ray is more than enough for the orthopedic surgeon to decide on the extent of damage to the knee joint. Especially, if the patient has already been under treatment which yielded no results, surgery is the last option. Also, diagnostic tests 3 to 5 may be suggested on a need basis to ascertain damage to the bones and soft tissue structures around the knee such as ligaments, tendons, cartilage and muscles.
Once it is confirmed that a person needs to undergo knee replacement surgery, there will be a few tests and counselling sessions conducted in order to ensure that the patient is fully aware of the procedure and the outcome. The preoperative procedures may include consultations, and diagnostic tests like blood test to determine blood count and blood clotting, and may also involve electrocardiogram (ECG) and urine test. [1]
This surgery is performed under general, spinal, or an epidural anaesthetic, depending on the need and the medical record of the patient. Again, depending on whether it is a total or partial knee replacement, the duration of the operation may change.
The total knee replacement surgery lasts for about 3 to 4 hours. The hospitalization lasts for about 3 days or slightly more if any specific issue is there that needs to be monitored.
For patients choosing knee replacement surgery, it helps immensely to undergo weight management and a strengthening regimen prior to the operation. This helps you recover faster from surgery and prepares your musculature to support you as your knee joints recover.
Pre-Op: All supplements to be stopped except for calcium, iron and vitamin D around two weeks prior to surgery. The day prior to the surgery, you can follow your normal diet except for eating any solids late at night, especially after midnight. All prescribed medications also need to be taken, unless told otherwise.
Be sure to specifically check with your doctors/Hospital about -
On the day of surgery: Clear fluids can be taken up to three hours before surgery or till arrival at the hospital. These include water, broth, Black tea or coffee. However, if you have been specifically asked to avoid any foods, follow those instructions.
Non-citrus fruit juices like apple, cranberry and grape are also allowed. Milk and dairy products and pulpy or citrus juices are to be avoided. Once you get admitted for surgery, the doctors may conduct a few pre-surgery tests to ensure things are in order.
The total knee replacement surgery lasts for about 3 to 4 hours. Once the surgery is over, the patient will be moved to the Post-op recovery ward or High dependency ward to monitor the condition before moved to the regular ward within 2-3 hours
Though there could be some pain and discomfort (at times could be high as well, and in individual dependent), patients would need to start walking with the help of a walker, if required. The pain will decrease gradually as the joint becomes adjusted and flexible, and the muscles start strengthening. The surgeon gives specific discharge instructions which need to be followed to the T.
Physiotherapy is part of the rehabilitation process as well. There could be some medicines and supplements prescribed for a while, as also follow-up guidelines. People may also be instructed not to lift weights, or watch out for symptoms of infections, blood clotting or pulmonary embolism, in which case the doctor should be consulted immediately.
The importance of a strict adherence to the rehabilitation process in such cases cannot be highlighted enough, as that is what ensures your recovery and improves your quality of life. The suggested rehab process helps with:
The rehab starts from day one of the surgery and the patients are encouraged to stand up and start walking with assistance, within 24 hours of surgery. You may be assisted to sit up on the bed, and take a few steps by the bedside. The walking will be more on the second day and so on. You may be on antibiotics and anti-inflammatory drugs to control the pain, inflammation and any infections. The pain is expected to be high during the first one week and it will be bearable in the second week. As such the physiotherapist will concentrate on motion of the joint with minimal pain and the medicines will help with the pain as well
By this time, you are back home and the pain is definitely bearable and you are able to walk around more freely than in the first two weeks. You may also be able to do so without a full fledged walker and with the help of just a crutch or a walking stick. This basically means that you are indulging in weight bearing walking with neuromuscular control. Physiotherapy and exercises, as suggested is a must at any cost to keep this improvement going. There could still be some medicines for the pain, inflammation and infection.
If you have strictly followed the rehab process and physiotherapy, marked improvement is expected by this period, and you should slowly be able to walk without any assistance. There should be improved flexibility and strength in the knee joint and the physiotherapist will slowly test it as required. Do not try anything that is not suggested, just because you feel confident at this point. Basic routine activities may be started at this point, once you have had a follow-up consultation and the surgeon gives a go ahead.
A person is expected to have recovered to a great extent and be independently doing most basic everyday chores by this time. The rehab exercises at this stage will include stuff like toe and heel raises, partial knee bends, hip abductions, leg balances, step-ups, and bicycling on a stationary bike. All these are to be done under the supervision of the physiotherapist, unless advised otherwise. This happens to the MOST CRUCIAL period for long term recovery.
A range of motion is expected to be gained by the knee joint and people can even do swimming and bicycling by Week 11. This will further improve with continued physiotherapy to include activities like dancing, aerobics, playing football, etc. by Week 12. By this time, almost zero or no pain is expected.
Doctor should be contacted immediately if:
Nutrition
Nutrition and a healthy, balanced diet is also a big part of the process before as well as after a knee replacement surgery:[9]
Anti-inflammatory foods: Since swelling causes osteoarthritis and vice versa as well, people with this problem should eat anti-inflammatory foods. This can help reduce the inflammation and resulting pain to a great extent. Fish rich in Omega 3 fatty acids help reduce the levels of two proteins namely the C-reactive protein (CRP) and interleukin-6, which cause the inflammation. These are also helpful in stopping the inflammation from damaging the joints, which is what ultimately leads to the knee replacement surgery. Besides, fish oil supplements are said to prevent cartilage damage. You may try to include Salmon, Tuna, Mackerel and Sardines in the diet.
For vegetarians, plant based anti-inflammatory foods like olives, turmeric, green leafy vegetables like broccoli, spinach, avocados, etc. can be taken. Fruits and vegetables with Vitamin C like oranges, peppers, leafy vegetables, grapes, etc. also help in the anti-inflammatory part. Dairy products like low-fat milk, cheese, and yogurt, help provide essential Vitamin D and Calcium to the body, that are helpful for bone growth and strengthening.
Antioxidants: Food rich in antioxidants are known to protect our body from many diseases including cancer. They reduce the free radicals in the body and prevent inflammation and also boost the immunity. Hence, foods like berries, grapes, soy products, etc. should be included in the diet.
Unless advised by the doctor to to avoid certain foods, you may plan a balanced diet with all the elements mentioned above.
Depending on the hospital, the knee replacement cost in India will be between 2 to 3.5 lakhs for a single knee. This is drastically less as compared to the Western countries and recently the Government has capped the Maximum Retail Price for the knee implants being used, bringing this down even further. For bilateral knee replacement, you may have to shell out anywhere between 4.5 to 6.5 lakhs.
Chromium knee implants will now be costing Rs.54,720 plus GST and titanium and oxidized zirconium implants are priced at Rs.76,600 plus GST. [13]
The overall costs may vary depending on hospital accommodation, any other tests and complications, the specialists’ costs, etc.
The quality of life improves drastically for most patients after the knee replacement surgery and they will be able to independently move around and do most jobs that earlier they were not able to do due to their immobile knee. However, it is important to also keep some realistic views about the amount of mobility gained, so that disappointments are avoided. This probably would have been covered during the pre-surgery counselling session.
The artificial knee will not be equivalent to your good old knee before when the issues started. In other words, while it is a good replacement providing you mobility to a great extent, it won’t bend as much as the original knee. Also many activities like kneeling, running, jumping, and any heavy labor like lifting etc. are better avoided. High-impact activities like skiing, running or any other sport can have an effect on the knee implant and its lifespan. [16]
Most knee implants of today last at least 20 years and considering that people usually get operated late, especially in India, this should be good enough for a lifetime. Studies have indicated that only 2% of patients have needed a second knee replacement surgery in their lives. However there are factors like age, activities of the patient, body weight, and certain medical conditions that can affect the longevity of the implants. [17]
The risk factors of the knee replacement surgery can be as below and need to be discussed with the doctor before you go in for the surgery. [4]
Infection: Any surgery has an infection risk and since knee replacement also involves opening of the skin, there is always a chance of infection. Precautions are taken by the surgeons but one should look out for any soreness, swelling or discharge or even fevers and chills.
Bleeding: Again, bleeding after surgery is common, and is usually attended to as required by the doctors. However, in the case of any excessive bleeding, the matter needs to be addressed immediately.
Blood clots: One of the more common and significant risks of surgery are blood clots. Blood clots may form if a blood vessel is damaged during the surgery causing Deep Vein Thrombosis (DVT). This clot can break free and travel to the lungs, causing life threatening pulmonary embolism.
Allergic reaction: Since some foreign implants are put in the body, there is always a chance that the body shows some allergic reactions to it. This can manifest in the form of swelling, blisters, rashes, etc. It may in some rare cases cause headache, weakness, diarrhea, etc. or even a loss of mobility in the area.
Implant failure: Medical technology has improved by leaps and bounds and it is rare that you may find that an implant fails. But there is a minimal chance of that happening, if the implant wears out unexpectedly.
While the risks of a revision surgery within 90 days is seen at a 0.2%, the rate is approximately 3.7% within 18 months. The revision surgery could be due to any of the cases mentioned above. As long term risk beyond this, it is mostly only the wear and tear of the knee implant due to the patient activities that causes a revision surgery. This data stands at 6% for five years and 12% for 10 years
Weight Loss: This happens to be one of the best possible options to avoid knee replacement surgery for the future. The knee is the joint in the body that keeps taking the whole body weight constantly and hence is subject to wear and tear. This will be more, if you are obese, putting more stress on the joints. This causes cartilage to break down more quicker, and it is good idea to maintain ideal body weight, if required by losing weight.
Regular exercise: The knee joint also needs regular exercise/physiotherapy or Yoga to help strengthen the muscles and cartilages, provide lubrication and flexibility to the joint, and keep it loosened. Walking, swimming and stationary biking may be inculcated into the exercise regime, after consulting with the doctor.
Early detection: As mentioned above, early detection of the issue can help a lot in preventing the knee replacement surgery. The alternates like injections and physiotherapy can be tried, along with a balanced nutritious diet to try and contain the damage. At times, the doctor may also suggest using knee braces to avoid the weight on the knee. Certain medications and supplements may also be prescribed.
Apart from above, since osteoarthritis happens to be one of the prime causes leading to knee replacement, a diet that helps reduce cholesterol with intakes meeting recommended nutrition like Vitamin K and Omega 3 is helpful. Calcium intake, if required as a supplement after a certain age is also helpful. However, as yet the role of Vitamin D has not yet been corroborated through studies.[19]
All the above points can be useful in trying to avoid the knee replacement surgery.[10]
A medical professional is the best person to assess your specific condition and recommend the course of action. If they have proposed surgery, it means that the potential benefits of surgery far outweigh the potential complications. You may choose to go in for a second opinion, and it is always beneficial to evaluate your situation thoroughly before making a choice.
Conventional Treatments
+Anti-inflammatory medications (NSAIDs) are quite effective in reducing the pain, swelling and stiffness usually seen with knee arthritis. There are also some supplements recommended by the doctor namely glucosamine sulfate and hyaluronic acid. A combination of NSAIDs and the supplements can help improve the condition to a great extent, under the watchful eye of a medical specialist. Alongside, physiotherapy is a must.
+The next step if the above fails is to try corticosteroid injections, which help in reducing the inflammation, pain and swelling drastically. Further to cortisone injections, hyaluronic acid injections may also be suggested, if relief is not seen. They are meant to lubricate the knee so that you have improved mobility and reduced pain.
Acupuncture Treatment
A study conducted on the topic, has published findings saying that Acupuncture can indeed relieve knee pain due to osteoarthritis. This also becomes a low cost alternative to the replacement surgery. [7]
In this study around 90 patients with an average age of 71, and having severe symptoms and would have been advised surgery, opted for Acupuncture treatment. Marked improvement was seen in many of the patients as 41 of them were continuing after a year, and at the end of two years, 31 were still going for the treatment.
Ayurvedic Treatment
Perhaps there are few diseases and medical conditions for which the ancient Indian system of Ayurveda does not have some remedy or the other. Ayudevda offers herbal treatments, meditation and yoga to cure the knee pain caused due to osteoarthritis and avoid the knee replacement surgery.[8]
As we all know, Ayurveda, follows a holistic approach to treatment, and will not just treat the symptoms, but also the underlying causes, and also adopts preventive medications and practices to help cure the issue. There are many herbs like boswellia, turmeric, ashwagandha, ginger, triphala, guggulu, and shatavari that have been proven to be highly effective as anti-inflammatory agents and these are used for the knee treatment.
Curing the mind, is also a big part of curing the body and as such, meditation along with the conventional treatment helps a lot, as has been proven through a study. It helps allay fears and anxiety by calming the mind, and controlling the pain. Meditation also helps relieve stress to a great extent and that keeps the body healthier.
This can also be combined with Yoga, as a very effective tool to counter the pain and bring in some flexibility in the muscles and joints. There are certain Yoga poses that help strengthen the muscles, improve your flexibility and body balance, and also relieves stress from the joints. It also helps reduce the stiffness and the pain, and also brings with is an emotional wellbeing that also helps.
The article is intended to provide you with the best possible overview and is not a medical advice. Please consult your medical practitioner before implementing any of the suggestions
1.Knee replacement surgery: What you need to know, Christian Nordqvist. Medical News Today
2. Total Knee Replacement Statistics 2017: Younger Patients Driving Growth, iData Research, article dated 18/07/2018.
3. India facing knee arthritis epidemic: Dr. Vikram Shah, United News of India, dated 24 Nov 2018.
4. What are the risks of knee replacement surgery? Stephanie Watson, 10 January 2019.
5. Knee Pain, Mayo Clinic
6. Troubled by knee arthritis but not ready for knee replacement? Here are 5 alternatives, Mayo Clinic Health System, dated Mar 28, 2018.
7. Acupuncture offers low-cost alternative to knee surgery for osteoarthritis, research finds, ScienceDaily, dated Aug 2012, based on British Medical Journal, quoting references (A. White, M. Richardson, P. Richmond, J. Freedman, M. Bevis. Group acupuncture for knee pain: evaluation of a cost-saving initiative in the health service. Acupuncture in Medicine, 2012; DOI: 10.1136/acupmed-2012-010151
A. Asprey, C. Paterson, A. White. 'All in the same boat': a qualitative study of patients' attitudes and experiences in group acupuncture clinics. Acupuncture in Medicine, 2012; DOI: 10.1136/acupmed-2012-010150)
8. An Ayurvedic Approach to Osteoarthritis Treatment, Sheila Patel, MD, Medical Director of Chopra Center, Integrative Practitioner, dated 25th Sep 2012.
9. Diet tips for osteoarthritis knee pain, Brian Wu, 10 October 2018, Medical News Today.
10. 5 Tips to Help Your Patients Avoid Joint Replacement Surgery, Winifred D. Bragg, The Wellness Network, dated June 22nd, 2016.
11. Your Diet and Preparing for Surgery: HSS (Hospital For Special Surgery)
12. Recovery - Knee replacement, NHS, UK
13. Knee Replacement in India: Clinicspots
14. Why Physical Rehab Is So Important, WedMD
15. Recovery Timeline for TKR: Rehabilitation Stages and Physical Therapy : Healthline
16. Realistic Expectations After Total Knee Replacement: Healthline
17. How Long Do Knee Replacements Last?: verywell health
18. Risks and Complications of Total Knee Replacement Surgery: Healthline
19. What is the evidence for a role for diet and nutrition in osteoarthritis?: NCBI, Rheumatology ( Oxford, England)
