KNEE REPLACEMENT
Category: Orthopedic Surgery
Abstract : Knee replacement Definition Knee replacement is a procedure in which the surgeon removes damaged or diseased parts of the patient’s knee joint and replaces them with new artificial parts. The operation itself is called knee arthroplasty. Arthroplasty comes from two Greek words, arthros or joint and plassein, to form or shape. The artificial joint itself is called a prosthesis. Most k
Knee replacement
Definition
Knee replacement is a procedure in which the surgeon removes damaged or diseased parts of the patient’s knee joint and replaces them with new artificial parts. The operation itself is called knee arthroplasty. Arthroplasty comes from two Greek words, arthros or joint and plassein, to form or shape. The artificial joint itself is called a prosthesis.
Most knee prostheses have four components or parts, and are made of a combination of metal and plastic, or metal and ceramic in some newer models.
Purpose
Knee arthroplasty has two primary purposes: pain relief and improved functioning of the knee joint. Because of the importance of the knee to a person’s ability to stand upright, improved joint functioning includes greater stability in the knee.
Pain relief
Total knee replacement, or TKR, is considered major surgery. Therefore, it is usually not considered a treatment option until the patient’s pain cannot be managed any longer by more conservative treatment. Alternatives to surgery are described below.
Pain in the knee may be either a sudden or gradual development, depending on the cause of the pain. Knee pain resulting from osteoarthritis and other degenerative disorders may develop gradually over a period of years. On the other hand, pain resulting from an athletic injury or other traumatic damage to the knee, or from such conditions as infectious arthritis or gout, may come on suddenly. Because the structure of the knee is complex and many different disorders or conditions can cause knee pain, the cause of the pain must be diagnosed before joint replacement surgery can be discussed as an option.
Joint function
Restoration of joint function and stability is the other major purpose of knee replacement surgery. It is helpful to have a brief outline of the major structures in the knee joint in order to understand the types of disorders and injuries that can make joint replacement necessary as well as to understand the operation itself.
The knee is the largest joint in the human body, as well as one of the most vulnerable. Unlike the hip joint, which is partly protected by the bony structures of the pelvis, the knee joint is not shielded by any other parts of the skeleton. In addition, the knee joint must bear the weight of the upper body as well as the stresses and shocks carried upward through the feet when a person walks or runs. Moreover, the knee is essentially a hinge joint, designed to move primarily backwards and forwards; it is not a ball-and-socket joint like the hip, which can swivel and rotate in a variety of directions. Many knee injuries result from stresses caused by twisting or turning movements, particularly when the foot remains in one position while the upper body changes direction rapidly, as in basketball, tennis, or skiing.
The normal knee joint consists of a bone, the patella or kneecap, and a set of tendons, ligaments, and cartilage disks that connect the femur, or thighbone, to the lower leg. There are two bones in the lower leg, the tibia, which is sometimes called the shinbone; and the fibula, a smaller bone on the outside of the lower leg. There are two collateral ligaments on the outside of the knee joint that connect the femur to the tibia and fibula respectively. These ligaments help to control the stresses of side - to - side movements on the knee. The patella - a triangular bone at the front of the knee - is attached by tendons to the quadriceps muscles of the thigh.
This tendon allows a person to straighten the knee. Two additional tendons inside the knee stretch between the femur and the tibia to prevent the tibia from moving out of alignment with the femur. Cartilage, which is a whitish elastic tissue that allows bones to glide smoothly against each other, covers the ends of the femur, tibia, and fibula as well as the surfaces of the patella. In addition to the cartilage that covers the bones, the knee joint also contains two crescentshaped disks of cartilage known as menisci (singular, meniscus), which lie between the lower end of the femur and the upper end of the tibia and act as shock absorbers or cushions. The entire joint is surrounded by a thick layer of protective tissue known as the joint capsule.
Disorders and conditions that may lead to knee replacement surgery include:
• Osteoarthritis (OA).
Osteoarthritis is a disorder in which the cartilage in the knee joint gradually breaks down, allowing the surfaces of the bones to rub directly against each other. The patient experiences swelling, pain, inflammation, and increasing loss of mobility. OA most often affects adults over age 45, and is thought to result from a combination of wear and tear on the joint, lifestyle, and genetic factors. As of 2003, OA is the most common cause of joint damage requiring knee replacement.
• Rheumatoid arthritis (RA).
Rheumatoid arthritis is a disease that begins earlier in life than OA and affects the whole body. Women are three times as likely as men to develop RA. Its symptoms are caused by the immune system’s attacks on the body’s own cells and tissues. Patients with RA often suffer intense pain even when they are not putting weight on the affected joints.
• Trauma.
Damage to the knee from a fall, automobile accident, or workplace or athletic injury may trigger the process of cartilage breakdown inside the joint. Trauma is a common cause of damage to the knee joint. Some traumatic injuries are caused by repetitive motion or overuse of the knee joint; these types of injury include bursitis, or housemaid’s knee, and so-called runner’s knee. Other traumatic injuries are caused by sudden twisting of the knee, a direct blow to a bent knee, or being tackled from the side in football. There are several factors that increase a person’s risk of eventually requiring knee replacement surgery.
While some of these factors cannot be avoided, others can be corrected through lifestyle changes:
• Genetic.
Both OA and RA tend to run in families. One study done in France reported that the genetic factors affecting osteoarthritis in the knee can be traced back almost 8,000 years. Both OA and RA, however, are polygenic disorders, which means that more than one gene is involved in transmitting susceptibility to these forms of arthritis.
• Age.
Knee cartilage becomes thinner and weaker with age, even in people who have no family history of arthritis.
• Sex.
Women athletes have three times as many knee injuries as men. At present, orthopedic specialists are conducting studies to determine the cause(s) of this difference. Some doctors think it is related to the fact that most women have wider hips than most men, which results in a different pattern of stresses on the knee joint. Others think that the ligaments in women's knees tend to loosen more easily.
• Biomechanical.
Biomechanics refers to the study of body structures in terms of the laws of mechanics, such as measuring the forces that affect the operation of a joint. Biomechanical studies have shown that people with certain types of leg or foot deformities, such as bowlegs or difference in leg length, are at increased risk of knee disorders because the stresses on the knee joint are not distributed normally.
• Gait-related factors.
Gait refers to a person’s pattern of motion when walking or running. Some people walk with their feet turned noticeably outward or inward; others tend to favor either the heel or the toe when they walk, which makes their gait irregular. Any of these factors can increase strain on the knee joint.
• Shoes.
Poorly fitted or worn-out shoes contribute to knee strain by increasing the force transmitted upward to the knee when the foot strikes the sidewalk or other hard surface. They also introduce or increase irregularities in gait. Women’s high-heeled shoes are particularly harmful to the knee joint because they do not cushion the foot; and they cause prolonged tightening and fatigue of the leg muscles.
• Work or other activities that involve jumping, jogging, or squatting.
Jogging tends to loosen the ligaments that hold the parts of the knee joint in alignment, while jumping increases the shock on the knee joint and the risk of twisting or tearing the knee joint when the person lands. Squatting can increase the forces on the knee joint as much as eight times body weight.
Demographics
According to the American Academy of Orthopaedic Surgeons (AAOS), there are about 270,000 knee replacement operations performed each year in the United States. Although about 70% of these operations are performed in people over the age of 65, a growing number of knee replacements are being done in younger patients. A Canadian survey released in January 2003 stated that the number of knee replacements performed in patients younger than 55 rose 90% between 1994 and 2001. Most surgeons expect to see the proportion of knee arthroplasties performed in younger patients continue to rise.
One reason for this trend is improvements in surgical technique, as well as the design and construction of knee prostheses since the first knee replacement was performed in 1968. Although most knee prostheses are still cemented in place as of 2003, cementless prostheses were introduced in the 1980s. A second reason is people’s changing attitudes toward aging and their expectations of an active life after retirement. Fewer are willing to endure years of discomfort or resign themselves to a restricted level of activity.
In terms of gender and racial differences, women are slightly more likely to seek knee replacement surgery than men, and Caucasians in the United States are more likely to have the operation than African Americans. Researchers have suggested that one reason for the racial difference is a difference in social networks. People in general are influenced in their health care decisions by the experiences and opinions of friends or family members, and Caucasians are more likely than African Americans to know someone who has had knee replacement surgery.
Description
The length and complexity of a total knee replacement operation depend in part on whether both knee joints are replaced during the operation or only one. Such disorders as osteoarthritis usually affect both knees, and some patients would rather not undergo surgery twice. Replacement of both knees is known as bilateral TKR, or bilateral knee arthroplasty. Bilateral knee replacement seems to work best for patients whose knees are equally weak or damaged. Otherwise most surgeons recommend operating on the more painful knee first so that the patient will have one strong leg to help him or her through the recovery period following surgery on the second knee. The disadvantages of bilateral knee replacement include a longer period of time under anesthesia; a longer hospital stay and recovery period at home; and a greater risk of severe blood loss and other complications during surgery.
If the operation is on only one knee, it will take two to four hours. The patient may be given a choice of general, spinal, or epidural anesthesia. An epidural anesthetic, which is injected into the space around the spinal cord to block sensation in the lower body, causes less blood loss and also lowers the risk of blood clots or breathing problems after surgery. After the patient is anesthetized, the surgeon will make an incision in the skin over the knee and cut through the joint capsule.
He or she must be careful in working around the tendons and ligaments inside the joint. Knee replacement is a more complicated operation than hip replacement because the hip joint does not depend as much on ligaments for stability. The next step is cutting away the damaged cartilage and bone at the ends of the femur and tibia. The surgeon reshapes the end of the femur to receive the femoral component, or shell, which is usually made of metal and attached with bone cement.
After the femoral part of the prosthesis has been attached, the surgeon inserts a metal component into the upper end of the tibia. This part is sometimes pressed rather than cemented in place. If it is a cementless prosthesis, the metal will be coated or textured so that new bone will grow around the prosthesis and hold it in place. A plastic plate called a spacer is then attached to the metal component in the tibia. The plastic allows the femur and tibia to move smoothly against each other.
Lastly, another plastic component is glued to the rear of the patella, or kneecap. This second piece of plastic prevents friction between the kneecap and the other parts of the prosthesis. After all the parts of the prosthesis have been implanted, the surgeon will check them for proper positioning, make certain that the tendons and ligaments have not been damaged, wash out the incision with sterile saline solution, and close the incision.
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