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Our Location
East Shore Medical Centre
Suite 03-05A,
319 Joo Chiat Place,
Singapore 427989
Tel: (65) 6348 2605
Fax: (65) 6348 2606
Mount Elizabeth Medical Centre
Suite 12-10,
3 Mount Elizabeth Road,
Singapore 228510
Tel: (65) 6738 2628
Fax: (65) 6738 2629
Gleneagles Medical Centre
Suite 05-13,
6 Napier Road,
Singapore 258499
Tel: (65) 6474 0600
Fax: (65) 6474 0700
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Surgery
When do I need surgery? And what kinds of surgery are there?
If non-surgical measures have not been successful in relieving pain, surgery may be considered. In
the more severe cases of OA, where the joint is unstable or progressively deformed, surgical measures
may be a better option. Your surgeon will discuss with you the options and will recommend the best
reatment plan for you.
There are 2 types of surgery
- Arthroscopic Washout
- Total knee Replacement
Arthroscopic Washout:
What is an arthroscopic washout?
The aim of this operation is to trim or remove damaged cartilage fragments and loose debris
from the joint so as to reduce pain experienced during movement. The bones may be drilled to
stimulate new cartilage growth. It is usually performed on patients who are relatively young
and are suffering from moderate OA.
What should I expect? Will I have to be admitted
You will be put under anaesthesia, after which small incisions will be made in the knee joint,
for the insertion of the arthroscope and other instruments. The arthroscope, a small rod-like
instrument, acts like a camera that transmits magnified images of the knee joint onto the
video monitor and guides the surgeon through the procedure.
After surgery, only few patients require pain medication. The procedure can be carried out as a
day surgery (with patient going home the same day if fit) or requiring a one to two day hospital
stay. Upon discharge, you will be given instructions on what activities you should avoid and which
exercises you should do to aid your recovery. You may require crutches to reduce the weight on your
operated leg and limit discomfort.
Total knee Replacement
What if my OA is way too advanced for an arthroscopic washout
Your doctor will discuss with you the best procedure for you. The most advanced degenerative problems
will finally require replacement of the painful knee with an artificial knee replacement. The decision
to proceed with surgery should be made jointly by you and your doctor only after you feel that you
understand as much about the procedure as possible.
What is a total knee replacement (TKR)? What does it entail?
Picture of destroyed cartilage
Picture of healthy cartilage
The above pictures depict a knee with normal cartilage and one with destroyed cartilage.
Picture of worn out knee
Picture of knee prosthesis
A TKR is basically resurfacing the worn out ends of the knee with metal components. These are
made of high-density alloy of cobalt chrome.
Each prosthesis is made up of four parts
The tibial component (bottom portion) replaces the top of the lower bone, the tibia. The femoral
component (top portion) replaces the two protusions of the upper bone, the femur where the patella
(knee cap) runs. The patellar component (kneecap portion) replaces the joint surface on the bottom
of the patella that rubs against the femur in the femoral groove.
The femoral component is made of metal. The tibial component is usually made up of two parts - a
metal tray that is attached directly to the bone and a plastic spacer that provides the bearing surface.
The plastic used is very tough and very slick - (so slick and tough that you can ice skate on a sheet
of the plastic without much damage to the material). A cemented prosthesis is one that is held in place
by a type of epoxy cement that attaches the metal to the bone.
What are the results of a total knee replacement?
Results of a Total Knee Replacement
Results of a Total Knee Replacement
How do you hold the components in place? Won't it fall off after period of time?
The components are held by very strong epoxy cement known as PMMA. This fits the components solidly
to your bone.
What do I have to do before surgery?
Once the decision to proceed with surgery is made, there are several things that may need to be done. Your
orthopedic surgeon may suggest a complete physical examination by your medical or family doctor. This is to
ensure that you are in the best possible condition to undergo the operation. One purpose of the preoperative
visit is to record a baseline of information. This includes measurements of your current pain level, functional
abilities, the presence of swelling, and the available movement and strength of each knee.
Who is a candidate for a total replacement?
Total knee replacements are usually performed on people suffering from severe arthritic conditions.
Most patients who have artificial knees are over the age of 55, but the procedure is also performed in
younger people.
The circumstances vary, but generally you would be considered for a total knee replacement if:
- You have pain everyday.
- Your pain is severe enough to restrict not only work and recreation but also the ordinary activities of daily living.
- You have significant stiffness of your knee.
- You have significant instability (constant giving way) of your knee.
- You have significant deformity (lock-knees or bowlegs).
What can I expect from an artificial knee?
An artificial knee is not a normal knee, nor is it as good as a normal knee. Latest publications
have shown that the knee joint can last for around anywhere between 15-25 years". Most patients do
not require revision surgery and many will outlive their artificial joint.
If the replacement provides you with pain relief and if you do not have other health problems, you
should be able to carry out many normal activities of daily living. The artificial knee may allow you
to return to active sports or heavy labour under your physician's instructions. Activities that overload
the artificial knee must be avoided. About 90 percent of patients with stiff knees before surgery will
have better movement after a total knee replacement.
What are the risks of a total knee replacement?
A total knee replacement is a major operation. The result of most complications is that you must stay in
the hospital longer.
The most common complications are not directly related to the knee and usually do not affect the result
of the operation.
These complications include:
- Blood clots in a leg (thrombophlebitis)
- Blood clots in a lung
- Heart attack
- Strokes or even death.
- Urinary tract infections
Though these are common complications and may occur, they are relatively uncommon. A pre-operative
assessment and post-operative care are always carried out to minimize the chances of such complications
from occurring.
Complications affecting the knee itself are less common. In these cases, the operation may not be as
successful. These complications include:
- Persistent knee pain
- Loosening of the prosthesis
- Stiffness
- Infection in the knee
A few complications such as infection, loosening of prosthesis, and stiffness may require reoperation.
Infected artificial knees sometimes have to be removed.
Are blood clots in the legs or lungs dangerous?
Thrombophlebitis, sometimes called Deep Venous Thrombosis(DVT), can occur after any operation, but
is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in
the large veins of the leg forms blood clots within the veins. This may cause the leg to swell and
become warm to the touch and painful. If the blood clots in the veins break apart, they can travel
to the lung, where they get stuck in the capillaries of the lung and cut off blood supply to that
portion of the lung. This is called a pulmonary embolism. (Pulmonary = lung, embolism = fragment of
something travelling through the vascular system). Most surgeons take preventing DVT very seriously.
There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving
as soon as possible!
Some of the commonly used preventive measures include:
- Pressure stockings to keep the blood in the legs moving
- Medications that thin the blood and prevent blood clots from forming. (Fraxiparine)
What about knee infections? Are they bad?
Infection can be a very serious complication following an artificial joint replacement. The
chance of getting an infection following artificial knee replacement is probably somewhere
around 1%. Some infections may show up very early - before you leave the hospital. Others may
not become obvious for months, or even years, after the operation. Infection can spread into
the artificial joint from other infected areas. Your surgeon may want to make sure that you take
antibiotics when you need dental treatment, or surgical procedures on your bladder and colon to
reduce the risk of spreading germs to the joint.
What about stiffness after total knee replacement? What can I do to avoid it?
In some cases, the ability to bend the knee does not return to normal after an artificial knee replacement.
Many orthopaedic surgeons are now using a machine known as a CPM machine (Constant Passive Motion)
immediately after surgery to try and increase the range of motion following artificial knee replacement.
Other orthopaedic surgeons rely on physical therapy beginning immediately after the surgery to regain the
motion. It is not clear which is the best approach. Both approaches have benefits and risks, and the choice
is usually made by the surgeon based on his experience and preferences.
To be able to use the leg effectively to rise from a chair, the knee must bend at least to 90 degrees. A
desirable range of motion should be greater than 110 degrees. Balancing of the ligaments and soft tissues
(during surgery) is the most important determining factor in regaining an adequate range of motion following
knee replacement, but sometimes an increase of scarring after surgery can lead to an increasingly stiff knee.
If this occurs, your surgeon may recommend taking you back to the operating room, placing you under anesthesia
once again, and forcefully manipulating the knee to regain motion. Basically, this allows the surgeon to breakup
and stretch the scar tissue without you feeling it. The goal is to increase the motion in the knee without
injuring the joint.
How long do artificial knees last?
About 85 to 90 percent of total knee replacements are successful up to ten years. The major long-term problem is
loosening. This occurs because either the cement crumbles (as old mortar in a brick building) or the bone melts
away (resorbs) from the cement. By ten years, 25 percent of total knee replacements may look loose on x-ray, and
about 10 percent will be painful and require reoperation. By ten years, possibly 20 percent may require reoperation.
Loosening is in part related to your weight and activity. For that reason, total knee replacements are usually not
performed on very obese or young patients. A loose, painful artificial knee can usually, but not always, be replaced.
The results of a second operation are not as good as the first, and the risks of complications are higher.
What happens immediately after surgery?
Although circumstances vary from patient to patient, you are likely to have some or all of the following after
surgery:
- You will find that a large dressing has been applied to the surgical area to maintain cleanliness and absorb
any fluid. This dressing is usually changed 2 to 4 days after surgery by the surgeon.
- A hemovac suction container with tubes leading directly into the surgical area enables the nursing staff to
measure and record the amount of drainage being lost from the wound following surgery. The hemovac is usually
removed by your doctor two to three days after surgery.
- An intravenous (IV) line started before the surgery, will continue until you are taking adequate amounts of
fluid by mouth. When you are taking fluids well, the IV may be changed to a Heparin-lock, a small sterile tube,
which will keep a vein accessible for antibiotics and allow for easier movement. Antibiotics are frequently given
every eight hours, for two to three days, to reduce the risk of infection.
- One side effect of anesthesia is often a difficulty in urinating after surgery. For this reason, a sterile
tube called a catheter may be inserted into your bladder to ensure a passageway for urine. This may remain in
place for one to two days.
- Elastic stockings, or TED hose as it is commonly known, helps to increase blood flow and decrease the chances
of blood clots. You will also be given medications and exercise instructions (moving your ankles up and down),
which also helps to prevent clots.
- Post-operatively you may have temporary nausea and vomiting due to the anesthesia or medications given to you.
Anti-nausea medication may be given to minimize the nausea and vomiting.
- You will be allowed to progress in your diet as your condition permits; starting with ice chips and clear
liquids to a normal diet as tolerated.
- A knee immobilizer will be worn as directed by your physician.
- To help prevent complications, such as congestion or pneumonia, deep breathing and coughing exercises are
important. Breathe in deeply through your nose; then slowly breather out through your mouth. Repeat this three
times and then cough two times. You will be encouraged to use your incentive spirometer.
- In order to speed up your rehabilitation, you may be using a continuous passive motion (CPM) machine. It
is a device that is fitted to your leg and is placed in bed with you. It slowly and smoothly bends and straightens
your knee. You will use the machine periodically during the day, and it will be adjusted to increase the bend
in your knee.
- You will be assisted to sit on a chair the first day after surgery provided there are no complications.
Physical therapy is started 1-2 days after surgery. It is very important for you to have pain medication 30
minutes before going to physical therapy to help you fully participate in exercises
How long will a total knee operation take?
The operation normally takes about 2 hours. However, including transfers and a short stay in the recovery area,
the total time may take up to 6 hours.
Will I receive a general anaesthetic?
The type of anaesthesia which you will receive may either be a general anaesthetic (GA) or a regional anaesthetic
(RA). A GA will let you go to sleep. An RA, involves an injection into your spine which will numb your legs but
you will be awake. The type of anaesthesia given will depend on your anaesthetist after discussion with you.
What about pain control after surgery?
You will be given what is called PCA: patient controlled anaesthesia. This is given as a continuous infusion of
morphine as well as intermittent doses, which will be controlled by yourself. Your anaesthetist will discuss this
further with you.
How long can I expect to stay in hospital before being discharged?
Most patients stay in hospital for about 7 to 10 days. Sometimes a short period of recuperation and physiotherapy
may be required at Ang Mo Kio Community Hospital. Your doctor will discuss that option with you if required.
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