Knee replacement surgery

Knee replacement surgery in Turkey is the standard and successful treatment of knee osteoarthritis to achieve effective pain relief, restore normal knee motion and improve function.

Introduction to the process of replacing the artificial knee joint

The need for Total Knee Replacement is increasing as a result of several reasons including arthritis and traumatic injuries. Arthritis is one of the biggest orthopedic problems in the world and has two main forms: degenerative arthritis (Osteoarthritis) and rheumatoid arthritis.⁽¹⁾

Patients with both forms can benefit from knee replacement. Traumatic injuries in accidents may also lead to the need for knee replacement depending on the type of fracture and the amount of bone loss in the joint during the accident. ⁽¹⁾

Knee replacement surgery has been shown to be very effective in improving health-related quality of life, with a somewhat social exception.⁽²⁾

It should be taken into account that the patients who are least satisfied with knee replacement surgery are those who have mild complaints before the joint replacement, so all conservative treatment methods must be exhausted before proceeding towards surgical treatment.⁽²⁾

What happens in the degenerative form is that the cartilage becomes stiff, so its flexibility decreases and increases its chances of being damaged, as the articular cartilage plays a shock absorbing role, which gradually erodes in the knee joint, and thus the damaged cartilage and ligaments become taut, which causes pain and eventually leads to the bones touching the knee joint to each other. Which causes severe pain, and this is usually observed in the elderly.⁽¹⁾

Rheumatoid arthritis is common in women in the age group of 40-60 years, in which the synovial membrane is affected, causing swelling and pain in the knee joint, and failure to undergo treatment will lead to deformation of the affected knee joint.⁽¹⁾

Reasons for the replacement of the artificial knee joint

End-stage degenerative knee arthritis is the most common underlying cause of knee replacement, with about 94-97% knee replacement procedures being performed due to primary or post-traumatic degenerative arthritis, and these patients are required to have accompanying degenerative changes Pain and limitation of knee joint function unresponsive to conservative (non-surgical) measures.⁽³⁾

Other common reasons for knee replacement surgery include:⁽²⁾

• Inflammatory arthritis
• Osteochondromatosis
• Villonodular synovitis
• Metabolic arthritis
• Osteonecrosis
• gout and pseudogout
• Post-traumatic arthritis
• fractures inside the joint

Contraindications of total keen replacement

Contraindications must be well known and considered before the surgery decision. Absolute contraindications for total knee arthroplasty include:⁽²⁾

• knee sepsis
• Chronic infection
• extensor mechanism dysfunction
• Severe vascular disease
• recurvatum deformity secondary to muscular weakness
• The presence of a functionally good knee arthrodesis.

Cases in which contraindication is relative and debatable include: medical conditions that impair safe anesthesia, insufficient soft tissue coverage, morbid obesity, neuropathy, a history of osteomyelitis around the knee joint, and physical and psychological conditions that prevent adequate rehabilitation of the patient. .⁽²⁾

The age of the person is not a contraindication to the surgery, and there is no age limit so patients of all ages can be suitable candidates for knee replacement surgery.⁽⁴⁾

Preoperative care of total knee replacement

Clinical evaluation before surgery is very important in assessing the condition medically and determining the relative risks that the patient may be exposed to. Pre-operative planning begins with selecting a suitable candidate for knee replacement surgery.⁽²⁾

Patient expectations and general risk factors play an important role in making the decision to perform surgery. Asking about the complaint, quality of life, evaluating the condition, and conducting a detailed clinical examination are among the basics of the pre-joint replacement clinical evaluation.⁽²⁾

The patient should be asked about the medical history of the patient, and sources of infections such as dental infections or skin, urinary and respiratory infections should be excluded. Each patient undergoes laboratory tests, an electrocardiogram, and a chest x-ray.⁽²⁾

Patients must have great cardiopulmonary capacity, as most of them are elderly, to withstand anesthesia and to withstand a blood loss of 1000-1500 mL over the perioperative period. (5)

A simple radiograph is usually sufficient for the initial radiological assessment and confirmation of the diagnosis or assessment of the severity of the disease. In exceptional cases, recourse to magnetic resonance imaging or computed tomography may be necessary, such as congenital dislocation of the patella, post-traumatic deformities, severe deformities, tumors and congenital anomalies.⁽²⁾

Underlying or predisposing orthopaedic diseases, which may interact the outcome of TKR should be reviewed previously. Examples of such conditions are as follows:⁽²⁾

• Adjacent joint degenerative arthritis
• adjacent degenerative arthritis
• Presence of any inflammatory arthritis, which may flare after surgery
• Any musculoskletal disability affecting postoperative mobility
• Having a history of thromboembolism or predisposing factors.

Examination should include the physical condition of the joint, range of motion, condition of the ligaments surrounding it, blood circulation and evaluation of the skin condition. Moreover, alignment of the lower extremities, patellar instability and gait analysis should be evaluated.⁽²⁾

The correct selection of an artificial joint of the appropriate size is one of the important stages in preoperative planning, and the expectations of the patient and the surgeon must be taken into account to improve results and increase satisfaction after the operation, and planning for the method of osteotomy may simplify the joint replacement procedure.⁽²⁾

During the planning of the surgery, the surgeon aims to obtain the optimal installation of the artificial joint and the optimal alignment of the limbs, which is possible by thinking in a three-dimensional way, and advance prediction of the course of the surgery should help improve the accuracy of the operation and shorten its duration in addition to reducing the rate of complications.⁽²⁾

How to perform an artificial knee replacement surgery

The replacement of the damaged part of the bone and cartilage is performed during the process of replacing the knee joint with an artificial one that contains metal and plastic surfaces to restore the movement and function of the knee, and the components of the artificial joint are fixed in most of the operations that are currently taking place with an adhesive fixing material (cement).⁽⁶⁾

Femoral (thigh bone) component- metal, replaces the weight bearing surface of the thigh bone, has a groove for the patella (knee cap) to move along.⁽⁶⁾

1. The metal part of the femur, it replaces the weight-bearing surface of the femur and has a groove for the patella to move along.
2. Patella (knee cap) – a plastic button is attached to the back of the knee cap to allow better movement along the femoral component.
3. The metal part of the tibia (shin bone), which includes a plastic component (polyethylene) that forms a smooth surface that helps the femoral part move during the movement of the knee joint.

During the process of installing an artificial knee joint, a tourniquet (a narrow band) is used around the upper thigh to prevent bleeding, and a surgical incision is made at the front of the knee that allows exposing the ends of the thigh and leg bones, and then the damaged parts are removed from the surface of the thigh and leg bones, allowing a suitable space to allow Implantation of the metal and plastic components of the replacement joint.⁽⁶⁾

Balancing the knee ligaments in order to straighten any deformity in the joint is an important part of the surgery. After that, the components of the replacement joint are placed in the knee and tested in terms of movement and stability, and then the surgical incision is closed. The process of replacing the knee joint usually takes about 1-2 hours. ⁽⁶⁾

Recovery and rehabilitation after the replacement of the artificial knee joint

Patients after total knee replacement surgery usually need to stay one night in the hospital depending on many factors, but in some cases they may go home the same day if they are eligible for the recovery and rehabilitation program.⁽⁷⁾

It is a very busy day for the patient and his family, as there are a lot of physiotherapy instructions and nursing care that are provided to them in a very short period of time, and recommendations and instructions will be given to the patient before discharge from the hospital to the home.⁽⁷⁾

When is the patient discharged to home? If you are discharged to home, you should be:⁽⁷⁾

• Independent in a home exercise program.
• Independent with ambulation with the correct use of a walker, crutches, or a cane.
• Able to get in and out of bed independently.
• Independent in bathing and dressing.
• Climbing and descending stairs safely and correctly if necessary.
• Following weight bearing precautions as ordered by your surgeon.
• Getting in and out of a car correctly and safely.
• Able to identify medications, name the side effects, and know when to take them.
• You or a family member is able to take care of your incision and dressing after surgery.
• Provide the necessary household equipment and the ability to use it effectively.

Early mobilization after total knee replacement

Early movement is an essential component of the recovery program after knee replacement surgery. Prolonged bed rest has adverse physiological effects such as increased insulin resistance, myopathy, decreased lung function, impaired tissue oxygenation and an increased risk of blood clots. Safe and effective analgesia is a prerequisite. To encourage the patient to move early after surgery.⁽⁸⁾

There is good evidence that early mobility facilitates recovery after knee replacement surgery. Recent meta-analyses show a significant reduction in hospital stay (by 1.8 days) when patients move within 24 hours of knee replacement surgery. It also helps to improve functional recovery. and reduce the incidence of deep vein thrombosis.⁽⁸⁾

Prevention and treatment of nausea and vomiting after knee replacement surgery

Postoperative nausea and vomiting can be more bothersome than pain, and its occurrence is related to risk factors such as women, non-smoking history, and history of motion sickness. These patients should receive dexamethasone at the beginning of the operation and a serotonin receptor antagonist at the end.⁽⁸⁾

Pain after an artificial knee joint replacement

It is normal to feel pain, swelling, and even some bruising after surgery, and the intensity and amount of pain will begin to decrease with time, and it may take up to 6 months for the pain and swelling to disappear completely. ⁽⁸⁾

A prescription for a group of painkillers will be given before leaving the hospital to help control pain after knee replacement surgery. The patient may be advised to take the following:

• A pain medication to be taken regularly for 4 days and then on an as needed basis
• A stronger pain medication that you can take every 2 hours as needed
• A non-steroidal anti-inflammatory drug (such as ibuprofen) is taken regularly for 4 days.⁽⁸⁾

Painkillers can be taken in advance 30-45 minutes before physical therapy sessions, as some treatments and exercises cause mild to moderate pain for a period of time, and if the pain persists, physical therapy can be stopped.⁽⁷⁾

Physical therapy after knee joint replacement in the hospital (physical therapy)

The physiotherapist often works on knee mobility and gait exercises, and begins working with the patient on the day of surgery. The therapist will teach the patient all the necessary precautions to allow proper healing and improve function of the new joint by walking with a walker or crutches after the operation.⁽⁷⁾

The patient will be taught exercises to move the knee, mobility techniques (getting in and out of bed), walking on a treadmill or crutches, walking up stairs, and activities of daily living (eg dressing and bathing).⁽⁷⁾

The physiotherapist will instruct the patient as to how much weight their body should place on their leg when getting up. Most can bear full body weight immediately after knee replacement surgery. Patient’s weight-bearing capacity is usually determined by surgeons during knee replacement surgery and remains the same for a period of time. 6 weeks.⁽⁷⁾

Physical therapy at home after total knee replacement

Some patients may choose to attend special physiotherapy sessions after discharge from the hospital to the home, while most of them can implement the exercise regimen independently, and the basic home exercise program begins after direct knee replacement surgery, as it aims to restore range of motion and strength in the knee joint, these must be practiced Preoperative exercises to familiarize yourself with them.⁽⁶⁾

Diet after knee replacement surgery

A healthy diet helps prepare the body for surgery, and the body needs good nutrition to heal and heal bones, muscles, and skin after knee replacement surgery. Well-nourished people are less likely to develop infections after knee replacement surgery.⁽⁶⁾

The goal of a healthy diet is to have a source of protein, vegetables or fruits, and whole grains in every meal. Protein can be especially important after knee replacement surgery as protein needs will increase because it can help the healing process.⁽⁶⁾

Complications of artificial knee joint replacement

In a 1990-2004 study of 4 million knee replacement patients after discharge from hospital, the overall incidence of complications related to the procedures performed in the hospital was 8.4%. Most complications were systemic (related to the patient's body) and not caused by the replacement itself.⁽⁹⁾

In another group study on a group of patients during a period of 90 days after knee replacement surgery, it was found that 6.7% of them had new heart problems such as myocardial infarction, heart failure, or arrhythmia, while 4.9% had thromboembolic problems, such as deep vein thrombosis or embolism. pulmonary.⁽⁹⁾

The most common reasons for readmission to hospital after knee replacement surgery were: limitation of knee motion 18.2%, incisional complications 14%, infection of the joint surgery site 9.9%, hemorrhage 9.9%, and venous thromboembolism 3.3%.⁽⁹⁾

Failure of the knee joint replacement surgery and re-operation

Up to 20% knee replacement surgery patients may be dissatisfied with the results, however joint surgery is not repeated unless the cause of failure is understood, and the 10-15 year survival rate of successful knee replacements is usually over 90% . ⁽⁹⁾

Periprosthetic Infection

The percentage of infections of the artificial joint after knee replacement surgery is about 0.4-2%, and severe infections occur within a period of up to two months after joint surgery, while moderate infections often occur within two months to two years after knee joint replacement surgery, while infections occur arrears after more than two years. ⁽⁹⁾

nerve damage

There are major nerves that pass through all the major joints, so there is a small chance that one of these nerves will be damaged during or after joint surgery. If this happens after knee replacements, it will lead to weakness or numbness in the lower leg and foot.⁽⁷⁾

Polyethylene Wear

A frequent late complication after knee replacement surgery, it results from the mechanical process of surface wear where the metal femoral part grinds against the polyethylene part.⁽⁹⁾

Osteolysis

It is one of the main reasons for the delay in re-performing the knee joint, and it occurs in joint operations with a percentage of up to 16% in which bone fixing material is used, and in a percentage ranging between 6-30% in joint replacement operations in which these materials are not used.⁽⁹⁾

Instability and Dislocation

It results from abnormal and excessive displacement of the parts of the artificial knee joint and is one of the most common causes of early failure in knee replacement surgery, and usually requires re-surgery within 4 years after joint replacement surgery.⁽⁹⁾

Expectations and outcomes after knee replacement surgery

The average life expectancy of the new knee joint is affected after operations Knee joint replacement With the amount of stress placed on it, controlling body weight and adhering to activity recommendations will increase the life of the knee joint, and often the artificial knee joint should last at least 15 years in 90% cases.⁽⁶⁾

The majority of patients showed a significant improvement in the condition of the joint after knee replacement operations compared to their condition before, while the percentage of 20%-10 of them showed a certain degree of functional weakness or dissatisfaction despite the absence of technical surgical deficiencies or complications..⁽⁴⁾

It has been noted that there are a number of patient-related factors that may contribute to poor surgical outcomes after knee replacement surgeries, including but not limited to obesity, comorbidities, and unrealistic expectations.⁽⁴⁾

obesity

Recent studies have found that obesity negatively affects the results of knee replacement surgery, the rate of complications, the duration of the artificial knee joint, and the cost of the knee joint replacement. Obesity can increase the risk of superficial and deep surgical incision infections (which is one of the most important complications that can appear and affect on the success of replacement surgery) and may contribute to increased hospital stay and direct medical costs after surgery Knee replacement.⁽⁴⁾

comorbidities

The incidence of diseases increases with age, which can negatively affect the outcome of knee replacement, and these diseases lead to: an increase in the length of stay and the cost of hospitalization, poor results Artificial knee joint replacement, and low patient satisfaction after knee replacement surgery, and mental health problems such as anxiety and depression must be taken into account before replacing the artificial knee joint, as it has been proven that they are among the factors that contribute to dissatisfaction and poor results after knee joint replacement.⁽⁴⁾

Patient expectations for post-artificial knee joint replacement

Patient expectations can significantly contribute to satisfaction after knee replacement surgeries. It has been shown that unrealistic or achievable expectations can lead to dissatisfaction regardless of objective criteria for assessing knee function. To ensure appropriate expectations, it is important to discuss the general framework in joint replacement surgery. Knee Patients will inevitably be disappointed with the outcome of replacement surgeries if they expect a 100% to be free of pain after a joint replacement, return to a high level of athletic performance, or be able to squat and kneel without hindrance.⁽⁴⁾

The cost of an artificial knee replacement surgery in Türkiye

The cost of knee joint replacement in Turkey varies according to the type of joint used, the competence of the surgeon, and the quality of the hospital in which the operation will be performed.

The cost of installing the best type of single knee joint in Turkey starts with quality ZIMMER This includes performing the operation under the supervision of a professor specializing in joint surgery in Turkey and with modern techniques that require only a simple incision that does not cause muscle rupture.

The price of the operation may vary depending on the patient's condition, the technique used, and the quality of the artificial joint. Note that the procedure of replacing both knee joints for the patient is about 9 thousand US dollars.

Tips after knee replacement surgery

Use crutches or a walking cane at first

Try walking unaided after about 6 weeks if you feel ready.

Get up and walk for 5 minutes every hour to prevent blood clots

Wait at least 6 weeks to drive again if you have had a total knee replacement or 3 weeks if you have had a partial knee replacement.

Avoid twisting your knee and bending down too low

Follow the exercises recommended by your physical therapist

Keep your leg elevated as much as possible to reduce swelling

Return to work when you feel ready - generally after about 6 to 12 weeks but it depends on the type of work you do

Don't sit with your legs crossed for the first six weeks

Do not sleep with a pillow under your knee (there is no need to sleep in a special position after the operation)

Don't kneel on your new knee until your doctor tells you you can

Do not stand for long periods, as this may be the cause of leg swelling after knee replacement surgery

Don't do household chores that involve lifting or moving anything heavy during the first trimester

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Sources:

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