What is a knee replacement?
One of the most widely performed surgeries nowadays is knee replacement surgery. Knee replacement surgeries are done for more than 700,000 people in the United States every year, and most of them experience a noticeable improvement in the durability of the joint and its capability of flexing and extending. Knee replacement, which is also called arthroplasty, is a well-known surgical procedure and is done all over the world nowadays. Knee replacement results in pain-relief and retaining the joint’s ability of smooth movement by replacing the most affected and weight-bearing part of the joint by an inert and safe material.
The first knee endoscopy was done by a physician from Denmark called Dr. Severin Nordentof in 1912, while the first recorded knee arthroscopy was done forty-three years later by a Japanese surgeon called Masaki Watanabe He removed a solitary giant cell tumor from a knee joint during the procedure. Two years later, Dr. Watanabe shared his knowledge and experience and published The Atlas of Arthroscopy which is still considered the basis of modern minimally invasive knee arthroscopy.
Many studies were published to sum up the causes that may lead to knee replacement. However, we are going to cover the most frequent roots. Osteoarthritis is the most common cause of knee replacement. It is a chronic condition in which bones or cartilages of the joint are inflamed for some reason. Many studies say that symptomatic knee osteoarthritis (confirmed by a radiologist) especially in its late-stage affects nearly 3.8% of the population all over the world. This inflammation may potentially cause serious impairments. Pain and stiffness generally progress and get worse, so in the early stages, alternative non-invasive methods of treatment are available in most cases and can resolve osteoarthritis in most cases.
Symptoms of osteoarthritis include limited motion, joint pain with activity, redness, and swelling of the knee. Making effort such as carrying heavy weights, climbing stairs, bending, or squatting becomes much harder and exacerbate the pain. The damaged tissues in tendons, ligaments, and bone mostly give the patient no choice except a total knee replacement. Severe deformity from trauma or late-stage arthritis may lead to knee replacement surgery. Autoimmune diseases such as rheumatoid arthritis may damage the articular parts of the knee joint which will eventually lead to a knee replacement surgery to restore the joint smoothness. Osteoporosis isn’t considered by many orthopedics as a potential cause so it does not typically cause deformity or inflammation and is not a reason to perform knee replacement. Other minor causes are cartilage defect and ligamental tear which are less frequently reported than the previously mentioned causes.
⇒ Now, let’s discuss knee replacement alternatives.
Knee replacement alternatives
Medical guidelines include all methods of treatment and recommends nonsurgical intervention in most cases with mild to moderate pain. Thus, surgical procedures like knee replacement are not considered the first line of treatment. Many patients neglect the alternative non-invasive pathways of treatment. Orthopedics always have to take into consideration that knee replacement is the last resort for almost all patients, and that they should not choose that option unless nonsurgical methods of treatment no longer make noticeable progress, so if you complain from knee pain you should consider all your options.
› We are going to cover the top five alternative and approved methods of treatment with the most considerable efficacy.
1. Medications
Medications are the most common option patients and physicians tend to choose. Although doctors typically try to limit the number of medications prescribed to avoid interaction and side effects, there are different medications for knee arthritis that have proven their efficacy and potent action. Over-the-counter anti-inflammatory medications (NSAIDs) are said to be the first line of treatment especially in arthritis cases regardless of its cause, and they can be quite effective in relieving the pain, swelling, and stiffness associated with knee arthritis. Although all NSAIDs are available in most pharmacies, physicians tend to prescribe diclofenac for its reported effectiveness in reducing knee pain. NSAIDs are well-tolerated by most patients and are rarely found to cause hypersensitivity.
In addition to NSAIDs, steroids are well reputed for their potent analgesic action but unfortunately, some patients are contraindicated to take steroids, so you should ask the doctor before taking them. Glucosamine sulfate and hyaluronic acid are considered a minor class and an adjuvant medication but somehow they have been successful in reducing knee arthritis symptoms.
2. Physical therapy
Physical therapy is not less important than any other alternative method of treatment. It could make a tremendous improvement. A physical therapist can make out a plan to strengthen the quadriceps (thigh muscle that has a major role in extending your knees and keeping your standing position). Physical therapists always encourage the patient to practice a sport especially those who suffer from obesity and they can also supervise you to make sure you’re doing the exercises correctly. Recent studies estimate that every extra 10 pounds increase the chance of developing knee osteoarthritis by 36 percent. On the other hand, losing 10 pounds means you are 3 times less likely to develop osteoarthritis.
Physical therapy nearly has no risks, so feel free to start your course anytime and it does not involve exerting effort but on the contrary it is all about applying ice and heat to reduce inflammation and pain, stretching muscles attached to the knee joint, and neuromuscular training. Physical therapy may also include some activities walking, cycling, and strengthening exercises to prevent muscle atrophy (damage) and to restore joint smooth movement.
3. Plasma-rich protein injections (PRP):
Some doctors consider PRP injections an experimental treatment as it involves injecting an osteoarthritic knee with plasma-rich protein (PRP) in three steps. Firstly, some blood (usually one to two ounces) is drawn from the patient by a healthcare provider. Then, the blood is centrifuged in the lab to separate blood cells from the platelets that contain growth factors. This process takes from 30 to 45 minutes. Finally, they inject those platelets into the joint.
Current guidelines advise people not to use this therapy, as there are doubts about its safety and effectiveness, on the other hand, there is growing evidence that it is totally safe to use for patients regardless of their age.
4. Acupuncture
Acupuncture is an ancient Chinese technique that may help reduce inflammation and pain. It includes using sharp, thin needles to stimulate the muscles and change the flow of energy within the body. It is believed that acupuncture acts by triggering certain points on the nerve that transmits pain sensation to the brain and block it. Acupuncture has not only proved its efficacy as a powerful method of analgesia and painkilling, but also the number of professional acupuncturists is growing so it has become much easier to get treated with it. If you suffer from knee pain and afraid of medications’ side effects, acupuncture might be your ideal solution as the risks of acupuncture are too low, so acupuncture could be worth trying.
Although researches show that acupuncture can help relieve knee pain within a short period, it is still considered a symptomatic treatment with no direct effect on the cause of pain.
5. Stem cell treatment
Stem cells are located in long bones and are responsible for regenerating the damaged and worn out tissues. This experimental treatment involves using bone marrow stem cells extracted from the hip bone to help regenerate cartilage tissue in the knee after injecting these cells into it. Recent reports have shown that stem cell treatment is efficient in regenerating the damaged cartilage and has great results in bone growth and restoring the joint functions.
Stem cell therapy is certified all over the world and has become a part of medical practice. Surgeons usually do not recommend stem cell injections in osteoarthritis (OA) cases, because there is no standardized treatment method yet.
Knee replacement surgery
In case of failure of the previously mentioned alternative treatments to show any more progress and noticeable benefits, knee replacement surgery is the last resort. Your medical status should be evaluated carefully by your orthopedic surgeon before making such a procedure.
Who is supposed to get KR surgery?
We will cover the most frequent candidates for it. An orthopedic evaluation done by an orthopedic surgeon determines whether you are a good candidate for a knee replacement or not. If your osteoarthritis has been diagnosed as late-staged and nonsurgical therapies are no longer relieving your symptoms, your orthopedic surgeon will recommend knee replacement surgery. If you complain of chronic pain from your entire knee or under your kneecap, you are more likely to have a total knee replacement. In case of mild to moderate joint damage especially if it is limited to one compartment of the knee, partial (unicompartmental) knee replacement will be more suitable for you than a TKR as modern unicompartmental knee replacements have demonstrated excellent long-term results in both young and old patients.
Medical history has a major role in the process of proper patient selection. Your orthopedic surgeon will ask you several questions including whether had surgical intervention in it or not, the degree of pain, and your general health. The doctor may also ask you to get some imaging tests such as X-rays or magnetic resonance imaging (MRI) scans. These images help your doctor determine the extent of damage and deformity in the bone of your knee joint. Several x-ray images from different positions will be taken to inspect bones forming the joint closely while MRI scans better show soft tissues like cartilage and ligaments to be evaluated better. You will notice that your physician is concerned more about the location of the pain to determine what kind of knee surgeries you are eligible to have. Physical examination is as important as every previous step as your knee will have to be examined carefully so that your doctor can test its range of motion, the ability of function, durability, and response to the stimulus.
Knee replacements are considered to be one of the most successful procedures in all of medicine, so if you are about to have your knee implant, no need to feel worried about it. Knee replacement surgery has four main types which are:
- Total knee replacement.
- Partial (unicompartmental) knee replacement.
- Kneecap replacement (patellofemoral arthroplasty)
- Complex or revision knee replacement.
» To know more about them and which will fit your needs, you might need to read the following paragraph carefully.
Total knee replacement
According to statistics, total knee replacement is the most commonly performed surgery among the four types. It is estimated that 700,000 knee replacements are performed every year in the US. Total knee joint replacement surgery has been performed for more than 40 years. Over those years, great improvements in materials and designs have raised the expectations of its results. TKR surgery duration ranges from one hour to three hours according to the surgeon’s experience and used techniques.
TKR is a complex procedure and a major surgery, so you have to make sure you are in a need for it and to have that discussion with your doctor. Knee implants are not identical to prosthetic implants since the latter are made to fit the patient’s knee and to compensate for the damaged parts, and therefore these implants vary greatly by design, size, and materials. In total knee replacement surgery, the whole joint is replaced with an inert and safe prosthetic implant.
We can roughly sum up TKR surgery into five steps:
- The anesthesiologist will apply mostly general anesthesia to the patient and monitor his heart rate and vital activities.
- The orthopedic surgeon makes a 10-inch incision and removes the damaged tissue from the femur (thigh) and tibia (shin)bones as well as the torn parts of the surrounding muscles and cartilage.
- Then, he attaches the metal components to the lower end of the thigh bone and upper part of the tibia to form the articular shape of the joint, he also adds bone cement to fix them into place.
- To complete the implantation, the surgeon flattens the surface of the patella (knee cap) before returning it to fit perfectly with the other implants and underlying bone. He may also readjust the parts or add cement to ensure its proper positioning.
- The surgeon closes the incision with stitches or staples and applies bandages to prevent secondary infections. Finally, you leave the operating room to start your rehabilitation. Continuous passive motion (CPM) machine will have an important role in your first phase of rehabilitation as it will gently bend and flex your new knee for you to maintain knee full range of motion while you are lying down.
Partial knee replacement
Partial knee replacement is the second most frequently operated surgery after TKR for patients suffering from knee pain. It is believed that trauma, osteoarthritis, and old age are the most reported causes of limited knee joint damage leading to partial knee replacement. Thus, if your pain is located almost entirely on either the medial or lateral portions of your knee, you may be a candidate for a partial knee replacement. In the past, partial knee replacement was done to patients older than 55 years who were sedentary, while nowadays doctors consider potential candidates of partial knee replacement who usually complain of stiff knee and limited articulation as if their ligaments in their knee feel weak or torn.
In comparison to TKR, partial knee replacement is done in a less invasive way and outpatient settings. The major steps of partial knee replacement surgery are generally similar to those of total knee implants. Although doctors often recommend partial knee replacement for patients whose ligaments are intact and strong, they tend to perform total knee replacement for those who suffer from rheumatoid arthritis. The duration of -partial knee replacement surgery is shorter than that of total knee replacement. The healing process is faster after partial knee replacement and the patient feels more like a normal knee than total knee replacement.
How long does a knee replacement last?
Orthopedic surgeons always state that prosthetic implants do not last forever and, like any material, wear out by time. It could last you the rest of your life or it may wear out before its expected date. Itis all up to your lifestyle and the activities you do regularly. Some vigorous activities are not appropriate for people with prosthetic implants. Unfortunately, no one can be sure that knee replacement will be the last operation needed on that joint. However, recent studies estimated that modern implants can last decades, as 80-90% of patients who had knee replacement did not need to repeat the operation and change the implanted part for over 20 years. Recently, the FDA has approved a replacement that claims a 30-year lifetime of use.
Despite the current development in the material of the implant and surgical techniques that aim to make implants last longer, patients should take into consideration the factors that affect the longevity of knee replacement implants. We will cover the most three reported reasons for wearing out the prosthetic implant:
- The patient’s activities as exposing the implanted part (regardless of its material) to intense pressure while doing vigorous activities could make it wear out much earlier than its expected date.
- Patient’s weight is always advised to be kept within the normal range as an overweight patient places much stress on the implanted joint. It is estimated that each additional 20 pounds of weight a person carries puts more than 100 pounds of stress on the knees. Doctors recommend exercising or practicing a sport as it is critically important to keep healthy and to decrease the applied pressure on the knee joint for it to last longer.
- The patient’s age should be taken into consideration to estimate how long the implanted knee joint will last. The younger the patient is, the more he is likely to repeat the operation to change the worn-out implant. Besides, younger individuals tend to be more active so, they may get a second operation in their fifties or earlier.
What does knee replacement surgery cost?
If your doctor decided that you cannot put off knee replacement surgery anymore, you should know the expenses of this procedure. Hospitals in the United States mostly costs about 40,000$ – 45,000$ for partial knee replacement surgery, while the average cost of total knee implanting is 55,000$. The cost of both types of knee replacement surgery is affected by different factors. Thus, it fluctuates by thousands of dollars.
What are the factors affecting knee replacement costs?
To assume the range of fluctuation you should consider the following factors:
- Where you are going to have the surgery as hospitals of some states cost more than others.
- The reputation of the surgeon as experienced orthopedic surgeons often cost more.
- Type of the applied anesthesia.
- How long you will stay in the hospital because patients are charged for how many days they spend in the hospital.
- Physical therapy (PT) services which are essential to rehabilitation, contribute to a great extend in the overall cost.
Knee replacement recovery
After total and partial knee surgeries, patients will have to be rehabilitated to restore their ability to resume their daily activities normally. Rehabilitation (rehab) is a crucial stage in which you’ll get back on your feet and start doing certain exercises under the supervision of a physical therapist. During this stage, an occupational nurse or family member will help you do tasks such as changing the bandage, bathing, and dressing. Your physical therapist will gradually modify your exercises as your knee gets improved.
How long to recover from a knee replacement?
Rehab may take from 4 months up to one year to fully return to your lifestyle. Physical therapists usually divide rehabilitation into three stages:
- From surgery to week 3, patients will need to use a CPM (continuous passive motion) machine. They will have to get used to walking using assistive devices like walkers, and canes.
- From week 4 to week 9, patients usually can walk on their own without assistance. Rehab during this stage includes strengthening their upper leg muscles and improving the patient’s balance by standing on one foot for as long as possible.
- The last stage from week 10 to the end of rehab. This stage is just restoring your daily routine with time to time visits to your physical therapist. Keep in mind to avoid pushing yourself too far to keep your implanted joint as long as possible.