Knee replacement surgery and treatment information for patients including arthritis, Arthroscopic Surgery, Meniscus, Ligaments and Common knee Complaints

Patient Guides

This page provide information to guide patients in various conditions and procedures. Simply select from the title on the left to view the associated information.

Normal Knee Joint

Normal knee feels like a hinge joint with complex arc, which allows sideways and twisting movements. It consists of three bones namely Patella (Knee cap), Femur (Thigh bone) and Tibia (Shin bone). It is held together by ligaments (Bands) and is supported by muscles. The ends of bone are covered with very smooth Articular cartilage, which allows the bone ends to move easily over each other. In between the femur and tibia are two spacers like structures known as meniscus in medical terms and usually known as cartilage by non-medical person.

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Common Complaints affecting The Knee

Pain	Giving way (Knee feels unstable)
Swelling	Locking (Catching sensation inside the knee)
Deformity	Stiffness
Difficulty in walking

Following Examples are for guidance only,
You must consult your doctor for a Diagnosis These are the most common complaint affecting the knee joint. If you have one of the above complaint after the injury or the combination of complaints then it is possible that you have injured one or more than one structures affecting your knee.

Mild pain and stiffness (Improves and gets better in 3-4Weeks)
       Bruising of soft tissue around knee joint including minor sprain to the ligaments
       Minor flare up of osteoarthritic symptoms

Mild to moderate pain, swelling, stiffness and some difficulty in walking and locking
       Injury to meniscus (Tear)
       Injury to ligaments
       Injury to articular cartilage
       Bone bruise
       Flare up of Osteoartritic symptoms

Moderate to severe pain, swelling, great difficulty or unable to walk
       Tear of Anterior cruciate ligament
       Tear of Posterior cruciate ligaments
       Tear of Medial or lateral Collateral ligament
       Tear of meniscus
       Fractures (Broken Bone)

Knee keeps giving way
       Ligament Instability - Commonly due to Anterior cruciate ligament rupture

Knee is suddenly locked in one position
       Tear of the meniscus with torn piece trapped between the bone ends
       Loose piece of bone trapped inside

Deformity (Knee looks out of shape)
       Kneecap (Patella) out of position
       Fracture involving the knee joint

In the absence of injury

Pain, Stiffness, swelling mainly felt after activity
       Early features of Ostearthritis , Other type of arthritis and other uncommon conditions

Pain (Felt during rest and activity) , Stiffness , swelling and deformity
       Late features of Osteoarthritis or other types of arthritis

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Meniscus

Injury - Knee joint is one of the commonest joint to be injured. This can occur during sports (Football, Rugby & Skiing etc) , Fall , direct injury and vehicular accidents. Commonly injured structures are Meniscus, ligaments, Articular cartilage and bones.

Meniscus (Torn Cartilage) - These are half moon shaped tough elastic structures, which act like shock absorbers. Tear in meniscus is quite common in twisting injury. It can be associated with ligament injury and fractures involving knee joint. It can affect both young and older patients.

Normal Meniscus

Torn Meniscus

Common complaints - Pain, locking, clicking, giving way and feeling of something trapped inside the knee joint

Diagnosis & Investigation - Examination of the patient, MRI scan is quite sensitive but may be normal in 15% cases even if a tear is present.

Treatment - This often requires key hole surgery or in some cases repair.

Recovery - Very good results following surgery

Torn Meniscus

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Ligaments

Ligaments - Ligaments provide stability to the knee joints. The two collateral ( Medial & Lateral ) provide sideways stability and two cruciates ( Anterior & Posterior) provide stability in front and backward direction. Anterior cruciate and medial collateral ligaments are commonly injured.

Cruciate ligament injury - This ligament is usually torn in the middle and cannot be repaired. Rarely it is pulled out with a piece of bone at the end in which case it can be repaired.

Normal Anterior Cruciate ligament

Torn Anterior Cruciate

Common complaints - Marked swelling of the knee & moderate to severe pain shortly after injury. Knee usually starts to give way 4-6 weeks after injury.

Diagnosis & Investigation - Examination of the patient, X-Ray & MRI scan. Key hole surgery and examination of the knee under General anaesthesia may be required.

Treatment- Not all patients with cruciate ligament injury will require surgery. Reconstruction of the ligament is required if knee keeps giving way and is uncomfortable and swollen after activity. If untreated may lead to tear of the menisci. Reconstruction of the ligament is done by either using patellar tendon or hamstring tendon as a graft.
Recovery - Rehabilitation usually takes 6 weeks to three months and full recovery may take 6-9months.

Medial collateral ligament - Injury to Medial collateral ligament is usually associated with injury to other structures like meniscus, cruciate ligament and bone bruise. In majority of cases MCL heals without surgery. However surgery may be required especially when other structures are injured or high physical demand on the knee ( Sports Person ).

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Articular Cartilage Injury

Articular cartilage injury - The bone ends of the knee joint is covered by Articular cartilage, which allows the joint to move smoothly. It can be damaged due to injury or gradually degrades over time or due to disease process (Arthritis ). Once damaged it cannot be replaced. If it is left untreated the defect is filled by scar tissue.

Normal Articular cartilage

Injured Articular cartilage

Common complaint - Patients usually get pain, which may vary from dull ache to sharp in nature, swelling of the knee, catching sensation with noise felt inside the knee and occasional locking. These may slowly deteriorate over time.

Diagnosis & Investigation - May be difficult at times. X-Ray is usually normal and MRI may be normal unless the defect is large in size. Arthroscopic (Keyhole surgery) is usually required to evaluate the knee and plan further management.
    Treatment - A number of research is ongoing in order to improve the end result of treatment and outcome of surgery.
    Following Options area available
      Drilling & Micro fracture - of the defect in the cartilage to stimulate healing.

Osteochondral grafting - Taking surface cartilage with apiece of bone from a relatively less important area to fill the defect.
Cartilage cell implantation - This surgery is still classed as experimental and involves injection of cultured cartilage in to the defect.
Recovery - May vary between 3 months to 2-3 years.

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Arthritis

Arthritis - Arthritis simply means inflammation of the joint. This initially causes pain, swelling and stiffness of the joint which gradually deteriorates with time.. At a later stage it leads to deformity and destruction of the joint. There are various types of arthritis. Osteoarthritis is the commonest form of arthritis and is caused by gradual wear and tear of the joint. Diseases like Osteoarthritis and Rheumatoid arthritis damages the smooth Articular cartilage covering the ends of bone. As the cartilage starts to wear away, the bone ends are exposed and then rub against each other and in severe cases themselves become worn. This causes the knee to become painful, stiff, and deformed and affects all aspect of life including sleep. Osteoarthritis( degenerative arthritis ) commonly affects middle to late age patients. It can also affect patients of younger age if they had previous injury or operations involving the knee joint.

Osteoarthritic Changes
Treatment
- Different modes of treatment are available which can improve and control early symptoms of osteoarthritis.

- Painkillers, Anti-inflammatory tablets and local cream improve pain and swelling. Local injections and provides temporary pain relief.

- Arthroscopic surgery usually improves mechanical symptoms of osteoarthritis usually caused by meniscal tear and loose pieces of bone.

- Minor adjustment in lifestyle and sports activity

- Exercise regularly to improve muscle strength and movement of the knee joint

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Arthroscopic Knee surgery

What is Arthroscopic Knee Surgery ( Key Hole Surgery )?
It is a usually a day case surgical procedure in which inside of the knee is examined using a camera inserted through small cuts in the skin (usually one cut on each side of the knee cap). In majority of cases, performing the corrective surgery at the same time can solve the problem. In some cases further operation may be required.

Why should you have an arthroscopy? In majority of the cases surgery for torn meniscus, removal of loose piece of bone, biopsy and articular cartilage lesions can be done using special instruments. The advantage of arthroscopic surgery over conventional surgery is less pain and usually quicker recovery.

Investigation required before surgery
   - Magnetic scan (MRI) to know about the problem affecting the knee.
   - X-Ray of the knee joint may be required
   - In some cases simple blood test and ECG (tracing of heart) may be required.

Type of Anaesthesia

Various types of anaesthetic techniques are used. The consultant anaesthetist will recommend the best form of anaesthesia for you and will discuss the options with you before the surgery. You will not feel any pain during surgery.

What happens on the day of operation?
You will be admitted in a hospital 1 to 2 hours before surgery.
You will be seen both by the Consultant surgeon and the anaesthetist who will once again explain about the operation in detail. You can ask them any questions about surgery or aftercare.
You will be asked to sign a consent form and the surgeon will put and arrow mark on your leg, which requires surgery. A nurse who will ask certain questions about your health will also see you. A leaflet about the procedure and aftercare will be provided. Please make sure that you ask for this leaflet and read it while in hospital or at home.
The time taken during operation can vary from 20 minutes up to 90 minutes.
The surgeon will see you following surgery and explain about the findings and further care and a physiotherapist will advice you about your exercise

Aftercare following Arthroscopy

Your knee will have a support bandage, which should be removed after 48 hours.
You will receive a follow up appointment in two week when your stitches will be removed.
You should walk naturally as soon as possible and try not to limp.
Physiotherapist will give you a sheet of exercises. These are designed to strengthen your thigh muscles. It is important that you do them regularly.

Keep your wound and dressing clean and dry till the stitches are removed.
Keep your leg elevated on a footstool while sitting to avoid swelling.
Take the painkillers regularly as prescribed. Do not consume alcohol, drive or operate any machinery.
If you had a general anaesthetic then it is advisable to take rest and a responsible adult should stay with you overnight.
Take one - two weeks off work.
It is advisable not to drive for two weeks. Please check with your insurance company.
Your knee may have some swelling for 3-6 weeks depending upon the type of surgery.

What complications can occur?
1. Bleeding - It is not uncommon to see dry blood on the dressings after 48 hours .If you see fresh blood coming from the wound then you should contact the hospital.

2. Infection - The risk is extremely low( 1 in 1000 ). You will receive one dose of intravenous antibiotic during your operation. If you start to run temperature, if your knee becomes hot, painful, red and swollen then you should immediately contact the hospital.

3. Blood clots (Thrombosis)- The risk is 1-2%. If the calf muscles become swollen and painful then you should contact the hospital.

4. Numbness around the scar - This is rare and should recover with time.

How can you help?
1. If you are overweight, then try to loose weight. It reduces the risk of complications.

2. If you take warfarin then you should stop it at least three days before surgery. Make sure your surgeon knows that you take warfarin.

3. It is advisable to try to stop smoking at least 6 weeks before surgery. It reduces the risk of getting complications following general anaesthesia.

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Total Knee Replacement ( A New Knee Joint )

Knee Implant

X-ray of New Knee joints

Diseases like Osteoarthritis and Rheumatoid arthritis damages the smooth Articular cartilage covering the ends of bone. As the cartilage starts to wear away, the bone ends are exposed and then rub against each other and in severe cases themselves become worn. This causes the knee to become painful, stiff, and deformed.

When do you need a New Knee joint?
The decision is easy if you have one or all of the following:
1. Severe pain present both day and night which is not relieved by pain killers or other treatment.
2. If you can't walk far.
3. If you develop increasing deformity of the knee.
4. X- ray shows arthritis
Most patients are of age 60 years or over. In certain cases it can be done at a younger age. It is wise not to put off the operation because with time the muscles become weaker, stiffer and more deformed which reduces the chances of success following surgery.

Your New Knee Joint and how does it work.

Your new knee joint simply means replacing the worn surface of the bones with prosthesis. The thigh bone ( femur ) is resurfaced by a single piece of metal. The shin bone ( Tibia ) is replaced by a metal plate and a plastic is placed over the metal to act like a cartilage. This allows a smooth movement and marked improvement in pain, function and mobility.
Recent advances in knee replacement allow better range of movement and longer working life of the implant. In certain cases only part of the knee joint is replaced ( Unicondylar Knee ). The choice of implant depends on the condition of the knee joint, physical demand placed on the knee and the age of the patient.

What's new in knee joint replacement surgery?
New design in implants allows higher degree of flexion and better longevity of the implant.

What can you expect from a knee replacement?
The success following total knee replacement depends upon the surgeons experience, type of implant, condition of the knee before surgery, Patients expectation, motivation and cooperation during rehabilitation.
Contrary to the common belief the result of Total knee replacement is as good as Total hip replacement. About 95% of the knee replacement will last more than 10 years.
Pain - Majority of patient report 95% improvement in pain following surgery.

Flexion( Bend ) - 90% will achieve knee flexion of 100-110 degrees. New knee implant designs allow even better range of movements and tend to retain the normal range of movement, provided the patient has normal range of movement before surgery.

Walking Distance - Most people can walk 45 minutes or more with little or no discomfort. As the walking distance increases, it also helps the heart and lung and patient generally feel fitter with time.

Function - majority of patients find it much easier to do shopping, negotiating stairs, dressing & personal hygene and other house hold activity.

Leisure & Sports - Activities like swimming , general fitness exercise and golf are allowed after knee replacement.

Limitations - Kneeling, Heavy impact exercises & heavy manual work should be avoided.

Please remember a replaced knee joint will never act or behave like a normal knee.

What can you do to get a better result?
Try to loose weight if you are overweight.
Exercise your thigh muscles regularly before and after surgery. Miss a meal do not miss your exercise.
Maintain the movement of the knee joint
Be motivated and well informed
Try to stop smoking at least 6 weeks before surgery.

What happens before operation?
Your surgeon will explain to you in detail about Total knee replacement, Its advantage , disadvantage, limitation and complication in detail .You can ask him any question about the surgery or clear any doubts in your mind.

He will ask you question about you general health, medication and any allergies. If you are on warfarin then please make sure your surgeon knows about it.

Investigation like X-ray of the knee joint, chest x-ray, Heart tracing (ECG) , routine blood test and cross match are required before surgery. These investigations help us decide whether you are fit enough for the operation.
Most hospital now have pre-operative assessment clinic. A nurse who will take blood for investigation will see you and also do a heart tracing to check your heart.This gives you an opportunity to ask question about you hospital stay and any concern that you may have. If you have any source of infection in your body then it is very important that you tell the nurse or your surgeon about it.

Potential source of infection are:       Open wound or ulcers on the skin
      Mouth , teeth or gum
      Cough , cold or chest infection
      Bladder and groin area
      Skin space in between your toes

What happens on the day of admission ?
You will be admitted to hospital a day before surgery. The nurse, surgeon and the anaesthetist will see you. They will once again check you investigation, ask you questions about your general health and fitness for surgery. Your surgeon will explain once again about surgery and ask you to sign a consent form for surgery. You leg will be marked. You will have the opportunity to ask any question about surgery to your surgeon, about anaesthesia to your anaesthetists and nursing care to your nurse.
You will be asked to have a shower using an antiseptic soap on the day of admission and on the day of surgery before going to operating theatre.

Type of anaesthesia

Your anaesthetic will decide the most appropriate anaesthesia for you. Commonly a combination of general anaesthetic and nerve block is used. You will be asleep during the procedure. The nerve block will take away the pain in you leg after surgery. The effect of the block usually last 12-24 hours. In certain medical conditions a spinal or epidural anaesthesia may be used. This involves inserting a needle in your back to freeze the body from waist downwards.

After your operation

You will return back to ward after your short stay in recovery room. Your leg will have a bandage and a drain tube which helps reduce bleeding and collection of blood and will be removed in 24-48 hours.
Due to the nerve block ,you may not have much feeling in your leg. This also help reduce the pain after surgery.
You will have a drip in your arm, which may be used to give medications, fluid and blood if required. It is usually removed after 48 hours.
You will receive oxygen.
The nursing staff will check you pulse, blood pressure, temperature and your leg at regular intervals.
They will place ice packs ( Cryocuffs) over the knee joint to reduce bleeding.

Pain

Total knee replacement is a major surgery and some degree of discomfort after surgery is expected.. Following steps help to reduce pain.

1. Nerve block - The effect usually last 12-48 hours.
2. Patient controlled analgesia, pain killing injections is given through a pump controlled by a button.
3. Tablets to be taken while in hospital and to be taken home on discharge.
4. Majority of pain will settle 2-3 weeks, minor discomfort may persist up to 3 months.
5. Decreasing dose pain killers and antinflamatory agents may be required for 3 months.

Bleeding and Transfusion

Some bleeding is expected after major surgery. We will monitor it and take steps to minimise bleeding. In a small number of cases blood transfusion is required. It is wise to take it easy for first 6 weeks.

Swelling

Swelling following knee replacement is common. Majority of swelling will settle down in 6-weeks and minor swelling may be present up to 12 months. Swelling of the ankle may occur for 3 months. You can minimise it by moving your ankle and toes.

Movement

Most knee implants allows you to achieve a functional range of movement from 0 - 110 degrees. New implant design allows even better range of movement. There are many factors which are important.
1.  Range of movement of the knee before surgery
2.  Muscle strength
3.  Experience of the surgeon
4.  Type of implant
5.  Motivated and well informed patients

Warmth

The knee may feel slightly warm up to 12 months after surgery

Rehabilitation & Physiotherapy

Exercise is vital to you recovery. It will start on the day of operation and continue till you are back on your feet and achieve good knee function. Physiotherapist will visit you and help with the exercises on daily basis.

1.  They will help you to sit out next day and stand with support. Early mobilisation reduces the risk of blood clots and pressure sores.
2.   You will be shown the exercises for you knee . These help to strengthen your muscles and regain movement, balance and function. You must continue these exercises at home. It is important to do knee exercise for at least 10 minutes everyday throughout your life. Exercise to strengthen you quadriceps muscle is the key to success.
3.  Majority of patient are able to walk with one or two stick within 4-5 days.
4.  Do regular walks
5.  Most patients are allowed to return back to light work at around 6-8 weeks.
6.  Driving is usually allowed at 6- weeks.
7.  Try to avoid heavy lifting and twisting on your knee.
8.  You can go back to golf after 3 months.
9.  It is not advisable to go back to heavy manual work after knee replacement.

Discharge from Hospital ( Going Home )

This varies with age and medical conditions of the patients. Majority of patient go home safely between 5-10 days.

1.  You should be able to walk along the corridor without help
2.  Able to mange steps and stairs independently
3.  Able to easily bend your knee to about 90 degrees.
4.  You will go home when you, your surgeon, physiotherapist, and nurses are happy with your progress
5.  Part of your stitches will be removed just before discharge. The rest is dissolvable.

Review in clinic

You will be seen in outpatient department 2 weeks after surgery, 6 weeks and 3 months and 6 months after surgery. Further follow may be required in some cases.

Main risk of Knee replacement

Replacement surgery is a major operation. The risk and complications are very low. Precautions are taken at each and every step to avoid them.

Infection - It is accepted that in spite of best effort , infection can occur in 2% of cases. Deep infection is a rare but serious complication. This may require hospital admission, further surgery, antibiotics and in worse case removal of knee implant. In his hand the rate of infection is extremely low.

Steps taken to avoid Infection

Surgery performed in operating theatre with laminar airflow and use of body exhaust system.
      Shower with antiseptic soap
      Use of antibiotics
      Small wound and shorter surgery time
      Minimal wound handling after surgery

Thrombosis - Blood clot can occur either in hospital or at home after surgery. Patient complain of pain , swelling and slight discolouration of the calf or leg. It normally get better with treatment.

Steps taken to avoid Thrombosis

      Ted Stockings and foot pump to improve blood flow.
      Injection given at the time of surgery.
      Getting out of bed next day with early mobilisation.
      Aspirin for 6 weeks after surgery.

General complications - Complications like heart attack, stroke, clot in lung and even death are extremely rare and can occur in less than 1% .

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