1. Knee Arthritis and Knee Joint Replacement

2. ACL Reconstruction

What are the causes of Knee Arthritis?

What are the symptoms of Knee arthritis?

How does a doctor diagnose knee arthritis?

What are the non-surgical treatments for Knee Arthritis?

When is Knee Joint Replacement recommended?

What are the benefits of Knee replacement surgery?

Can both knees be replaced at the same time?

How can I prepare for my hospital stay?

How long does a total knee replacement surgery take?

What type of anesthesia is used?

What does the surgeon do in a Knee Replacement Surgery?

What are the risks of Knee Replacement surgery?

 

What are the causes of Knee Arthritis?

The common causes of knee arthritis are:

Osteoarthritis

Usually occurs in people after 50 years of age
Sometimes occurs in individuals with a family history of arthritis
The articular cartilages that cushion the lower end of thigh bone (femur), the top of shin bone (tibia) and inside of knee cap (patella) become soft and wear away.
The individual suffers from severe, chronic joint pain and stiffness.

Rheumatoid arthritis

Auto-immune disorder attacking the joint cartilage.
The synovial membrane becomes thickened and inflamed.
Excess synovial fluid is produced that overfills the joint space.
There is chronic inflammation, pain and stiffness with damage to the joint cartilage and eventually cartilage loss.

Traumatic arthritis

A fracture around the knee involving the joint surfaces.
Tears of the knee ligaments and subsequent knee instability causes damage to the articular cartilage over time.

What are the symptoms of Knee arthritis?

Patients with knee arthritis will have:

Deep aching chronic joint pain, during movement and at rest
Swelling and heat around the joint
Stiffness in a joint, particularly in the morning.
Difficulty with walking, sitting, crossing legs or using stairs
Difficulty with sitting on floor or using Indian toilets.
A crunching or grinding sound during the movement of the joint
Knee that may lock /catch /give way
Deformity of knee
Disturbed sleep

How does a doctor diagnose knee arthritis?

The typical symptoms of knee arthritis, clinical examination and X-rays of the knee help in diagnosing arthritis of the knee.
MRI and CT have limited role in diagnosis of arthritis. MRI can, however, help in diagnosis of meniscal tears in early stages of arthritis.

 

 

 
 
 

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For all appointments please call :
+91 787 552 6272

 

Dr Anand Jadhav is Sr. Consultant for Joint Replacement and Arthroscopic Surgeries in the following hospitals.

London Joints Clinic
Office number S5, Second Floor, Sacred World, Opp Sacred Heart Town, Near Mc Donald's, Jagtap Chowk, Wanowrie, Pune 411 040.
Mon, Thurs, Sat: 5pm to 7pm

Jupiter Hospital, near Babasaheb Ambedkar Bridge, Baner Road, Baner, Pune.

Ruby Hall Clinic, Wanowrie, Pune.

What are the non-surgical treatments for Knee Arthritis?

Weight Loss
Probably one of the most important, yet least commonly performed treatments. The less weight the joint has to carry, the less painful activities will be. Roughly loosing 1 kg means 3 kg less burden on the joint. Being obese can make surgery difficult.

Activity modification
Patients need to learn to avoid activities that induce pain like squatting on floor, sitting cross-legged, kneeling, or using stairs. Some minor modifications will help them do routine activities without pain.

Walking Aids
Use of a walking stick or a single crutch should be used on the same side of the painful knee. It will help decrease the demand placed on the arthritic joint , reduce pain and improve mobility

Physiotherapy
Strengthening of the muscles around the knee joint helps in maintaining the range of motion as well as function of the knee joint. Doing regular exercises will not worsen the arthritis. In active patients the recovery after surgery is also rapid.

Anti-inflammatory & Pain-killer Medication.
These are helpful to treat pain and inflammation. Medications also improve mobility. Different types are available and are prescribed taking into consideration patient’s safety and pain levels. Medications should be taken as per doctor’s instructions only.

Chondroprotective agents
Glucosamine and chondroitin sulphate are considered as ‘chondroprotective agents’ or ‘neutraceuticals’. They may slow down the process of arthritis and have some pain relieving effect. For best results both these medications should be taken together in appropriate dosage. I do prescribe it for my patients and many have found them useful.

Corico-steroid injections
help in reducing inflammation, swelling and pain in knees with rheumatoid arthritis and osteo-arthritis. Multiple injections must not be taken to avoid infection in the knee joint.

Visco-supplementation
These injections are clear liquids which increase the viscosity of joint fluid and also the elasticity of the joint cartilage. They improve the lubrication and reduce friction between raw end of arthritic joint surface. They may cause healing of small cartilage defects. Their pain relieving effect may last for 6 to 12 months. They are most useful for mild to moderate arthritis. These injections are available as a single shot (Synvisc) or multi- injections (Hyalgan).

When is Knee Joint Replacement recommended?

Knee Replacement is indicated when there is:
Moderate or severe knee pain that limits one’s everyday normal activities of daily living e.g. walking, climbing stairs, and getting in and out of chairs.
No improvement in pain after taking regular pain killers.
Harmful side-effects from pain-killer medications
No improvement in pain even after modification / restriction of activities or use of a walking stick.
No improvement with physiotherapy, weight loss, cortisone or hyaluronic acid injections.
Severe pain that causes restriction of social life with sense of being house bound and dependent on others to lead a normal life.
Confirmation of advanced arthritis on x-rays.

What are the benefits of Knee replacement surgery?

Having a total knee replacement surgery will:

alleviate or remove knee pain
improve mobility and function
correct angular deformity, if any
improve quality of life and help the patient to return to normal daily activities
make the patient independent again without need to rely on family members or nursing care.

Can both knees be replaced at the same time?

Yes both knees can be replaced at the same time in a medically fit patient who does not have extremely severe or complex knee deformities.

Bilateral knee replacements have the following advantages:
Saves cost.
Avoids need for a separate second hospitalisation
Rehabilitation time is same as in a single knee replacement
Overall return to normal life is faster.

How can I prepare for my hospital stay?

Get informed. Find out about your standard of room in the hospital, whether a relative can stay with you overnight,what kind of anaesthesia ( general or spinal) will be given to you and any other information relevant to your surgery.
Arrange home help. Line up a relative or a nurse or an attendant to help you at home for some weeks after coming home from hospital.
Arrange for transport. Arrange for someone to take you to and from the hospital in a comfortable vehicle.
Prepare your home. Prepare your bed and chair where you would be spending most of your time after the surgery. In case you are using Indian style toilet, please arrange for a raised seat.
Clean up. Before going into hospital have a good long bath or shower, cut and clean your nails. Put on freshly washed clothes. This helps prevent unwanted bacteria going with you to hospital and complicating your care.

How long does a total knee replacement surgery take?

The actual surgical procedure usually takes about 1-2 hours. However, pre-operative preparations as well as wake-up time may make your operating room and recovery room stay longer.

What type of anesthesia is used?

This is decided by the anesthetist after your health status has been checked. The anesthesia can be general, epidural or spinal. The anesthetist will discuss these matters and choose the best option for you.
Generally knee replacement surgery is done under epidural anesthesia. The area below the waist is made numb for the operation. After the epidural anesthesia is given, patient can choose to remain fully awake or have a sedative injection.
Epidural anesthesia is continued (via a tiny catheter tube and a syringe pump) for next 2-3 days for pain control. It helps in starting exercises in bed without pain and improves patient confidence about physiotherapy.

What does the surgeon do in a Knee Replacement Surgery?

The Joint Replacement surgeon will remove the damaged cartilage and bone from the lower end of femur (thigh bone) and the top of shin bone (Tibia) by precision cutting devices. If necessary, the inside of knee cap (patella) is also shaved off.
The knee joint is then reconstructed using artificial implants to give correct alignment, stability and range of motion. This artificial knee joint will now function like a normal knee.

In a typical knee replacement:
The femoral component is made of highly polished strong metal.
The tibial component is either made of titanium. A highly durable plastic tray is locked onto the tibial base-plate. Femoral component will be moving on this plastic tray during knee motion.

The patellar component is made of highly durable plastic button.
The femoral, tibial and patellar components are fixed into place by using a special glue – Bone Cement (methyl methcrylate).
Newer designs keep coming in the market enabling better function.
Dr. Jadhav will select the best option for you.

Front and side views of right total knee replacement

How soon will I be up and about?
The physiotherapist will help you to get up and walk about as quickly as possible. 1-2 days after your surgery you may be able to sit on the edge of the bed, stand, and even walk with the help.You have to use a walker initially and then move onto crutches if your progress is satisfactory.You will also be taught to use stairs with help of crutches.

It is normal to experience discomfort while walking and exercising. Your legs and feet may be swollen. A physiotherapist will teach you exercises to help strengthen the knee and explain precautions to be taken.

How long will I need crutches or a walker?
Most patients will need to use crutches or a walker for about 4-6 weeks or until instructed otherwise by their physiotherapist.

How soon will the pain go away?
The joint pain that you had before the surgery will go away immediately, but there will be a different type of pain due to the operation. This post-operative pain will be temporary and is well controlled with pain-killer medications either in the form of injections or tablets.

When can I go home?
Your hospital stay will be around 5 to 7 days depending on your fitness and progress following the operation. A complete discharge summary along with the instructions for medications, follow-up visits and physiotherapy guidelines will be given to you on discharge.

Will I need to change anything at home because of my knee replacement surgery?
To ensure a comfortable and trouble free recovery, we recommend a list of modifications at your home prior to discharge
Handrail in your bathroom. Bathroom must be kept dry and non-slippery. A stable chair for shower.
Stairways must have hand rails
A stable chair with a firm seat cushion, a firm back, two arms, and a footstool for intermittent leg elevation
A toilet seat riser with arms. If you have an Indian toilet, Toilet seats to be arranged.
All loose carpets and cords must be removed from home
Living, bedroom and bathroom to be on the same floor preferably, because walking up or down stairs will be difficult during early recovery

Should I do exercises at home?
Your physiotherapist will instruct you about simple home exercises and also the frequency of doing these. These exercises help in developing strength of thigh muscles and increasing range of knee joint movement. Regular walks are also necessary. The knee should have Ice-packs for 20 minutes thrice a day after exercises. The joint should be kept elevated while at rest.
Patients should follow these instructions to avoid over-exercises which can cause more pain or swelling.

When are the stitches removed?
Sutures or skin staples are removed 14 days after surgery. Your wound will be checked and the dressing changed prior to discharge. This new dressing can be left undisturbed till the time of suture removal.

When can I have a bath / shower?
You can have a bath or shower generally 2 weeks after the operation when wounds have been checked for healing and all sutures or skin staples have been removed.Until then we advise sponging without getting the operative wound wet.

How long will it be before I feel normal?
You should be able to get rid of the crutches by 4 to 6 weeks and feel more or less normal by three months. Normal daily activities of living become easier. Always take advice from your surgeon and physiotherpaist before beginning any new activity.

When can I drive again?
It depends on your progress, but usually after about 4-6 weeks. You need to have pain-free knee joint, sufficient muscle strength and good knee joint motion prior to driving. Please consult Dr. Jadhav for further advice.

When can I go back to work?
It depends on the type of your job and recovery from surgery. Most office-type workers can resume work in 4-6 weeks.

When will I have to go back to the hospital for follow-up visits?
Usually 6 weeks after your knee replacement, you need to meet Dr.Jadhav for a check-up. He will examine your operation site, your walking, your balance and muscle strength.

Dr. Jadhav will then see you at 6 months and 1 year following your surgery. X-rays will be done during these visits to check that all is well. Subsequent follow-ups are advised after 5 and 10 years with new x-rays of your knee replacement to see for any signs of loosening.

How will I feel after Knee Replacement Surgery?
After a total knee replacement patients experience a remarkable reduction of knee pain. There is improvement in the ability to perform activities of daily living without the need of help from others. They feel confident and have an improved social life.

You can bend the operated knee upto 90-100 degrees easily in 2-3 weeks time. This amount of knee bending can allow you to get in and out of a chair or use stairs. The amount of knee bend after surgery depends upon how much mobility you had prior to your surgery. Certain modern implants can give you additional bend but you will not get full knee bending as in a normal knee.

It is common for some patients to have a sense of stiffness for initial few weeks after knee replacement.

Some swelling can persist on the operated leg for 6-9 months. A small area of numbness around knee is also common but this sensation does not bother patients.

It can take 2- 3 months before you feel near normal again. You should be prepared to continue home exercise for 4-6 months.

You need to understand that total knee replacement will not allow you to do more than what you were able to do before you developed arthritis. You must avoid certain activities like jogging and high-impact sports for the rest of your life.

With normal use and activity, every knee replacement develops some wear in its plastic cushion. Excessive activities or increased body weight may accelerate this normal wear. This may cause the knee replacement to loosen and become painful. With appropriate activity modification, knee replacements can last up to 15 years.

Is there anything I should look out for or worry about?
After knee replacement surgery you should contact Dr. Jadhav if you notice any fever or chills ( 38° C or 100.4° F), persistent warmth or redness around the knee, discharge (leakage) from wound, persistent or increased pain in the knee or calf muscle pain and shortness of breath.

What are the risks of Knee Replacement surgery?

Possible risks during Knee Replacement surgery are:
Risks for any anesthesia are:
Allergic reactions to medicines
Breathing problems

Risks for any surgery are:
Blood clots in the legs (DVT- deep vein thrombosis) that may travel to the lungs (PE- pulmonary embolism)
Infection, including in the lungs, urinary tract, and chest
Bleeding

Some risks of this surgery are:
Infection of the knee joint
Wear of the artifical joint
Loosening of the artificial joint over time
Knee stiffness
Allergic reaction to the artificial joint
Injury to nerves - Some area of numbness develop over the outer apsect of knee. This numbness reduces in 4-6 months with return of normal sensations. Often a very small patch of numbness (the size on thumb nail) remains but this does not bother patients.
Injury to blood vessels

People who have a prosthesis, such as an artificial joint, need to carefully protect themselves against infection. You should carry a medical identification card in your wallet that says you have a prosthesis. You may need to take antibiotics before any dental work or invasive medical procedures.

What is the role of Anterior Cruciate Ligament (ACL) in Knee?

How is ACL Injured?

What are the symptoms of ACL Injury?

What other structures around can be injured along with the ACL?

How is Anterior Cruciate Ligament (ACL) injury Diagnosed?

Do all patients with ACL injury need surgery?

How is ACL injury treated non-operatively?

When is surgery recommended in ACL injury?

Why is ACL surgery recommended?

What is ACL reconstruction?

What are the benefits of ACL surgery?

What is done during ACL reconstruction?

Are there any risks associated with ACL Reconstruction Surgery?

What is the role of Anterior Cruciate Ligament (ACL) in Knee?

The anterior cruciate ligament (ACL) is one of the main restraining ligaments of the knee. The ACL is situated in the centre of the knee and runs from the back of the femur to the front of the tibia.

The ACL acts to prevent excessive forward movement of the tibia. It keeps the knee stable during rotational movements like twisting, turning or side-stepping activities.

Another important function of the ACL is to provide important neurological feedback about orientation of the one’s limbs in space. This perception is important for normal joint function in daily activities, occupational tasks and sports.

How is ACL Injured?

ACL is frequently injured in contact sports like football and pivoting sports like skiing. Non-contact twisting movement like side stepping, pivoting, landing from a jump can cause an ACL tear. ACL can also be injured in motorbike or car accidents due to sudden twisting of knee.

 

 

 

What are the symptoms of ACL Injury?

In acute stages:
A popping sensation can be felt or heard during injury to ACL
Swelling of the knee
Pain in the knee
Difficulty in weight bearing or walking
Difficulty in bending the knee

In chronic stages:
Sense of giving way & instability with twisting movements.
Pain
Swelling

What other structures around can be injured along with the ACL?

Meniscal Injuries: either the outer (lateral) meniscus or inner (medial) meniscus or both can be injured.
Cartilage Injuries: The cartilage lining the femur, tibia or patella could be damaged. These cartilage lesions could be from minor flaps to major defects.
Ligament injuries: Medial collateral (MCL), lateral collateral (LCL) or Posterior cruciate ligament (PCL) injuries may also occur.
Fractures: could involve the tibia or femur.

How is Anterior Cruciate Ligament (ACL) injury Diagnosed?

ACL injury is diagnosed based on patient’s history of injury, symptoms and clinical examination. Special tests for ACL confirm excessive forward movement and also pivoting of tibia.

In acute cases, clinical examination is not possible due to pain and swelling. In such cases MRI is done to confirm the diagnosis.

A torn ACL is not seen on x-rays. But an x-ray may show any fractures around the knee joint.

MRI scan of a normal ACL

MRI scan of a torn ACL

Do all patients with ACL injury need surgery?

Not all patients with ACL injury need surgery. You may choose not to have surgery if you:
Have a minor tear in your ACL (a tear that can heal with rest and rehabilitation).
Are not very active in sports and your work does not require a stable knee.
Are willing to stop doing activities that require a stable knee or stop doing them at the same level of intensity. You may choose to
    substitute other activities that don't require a stable knee, such as cycling or swimming.
Can complete a rehabilitation program that stabilizes your knee and strengthens your leg muscles to reduce the chances that you will
     injure your knee again and are willing to live with a small amount of knee instability.
Do not feel motivated to complete the long and rigorous rehabilitation program necessary after surgery.

How is ACL injury treated non-operatively?

Conservative treatment of an ACL injury involves:
Rest - from sports or heavy work
Ice pack - to reduce swelling and pain
Anti-inflammatory medications – reduce pain and inflammation. Allow patients to tolerate physiotherapy
Strength – all muscles around the knee must be strengthened especially the hamstrings. These muscles can then take over some of
     the ACL’s role in knee stability.
Balance and proprioception - as the ACL has an important role in providing information to the muscles and brain about the position of
     the knee joint, specific re-training of other nerves is performed to help compensate.
Functional Knee Braces are may also be prescribed to help patients with damaged ACL’s. Their benefits are not fully understood
    although they may help with proprioception. They are expensive and may not provide much in the way of support to knee stability.

When is surgery recommended in ACL injury?

ACL reconstruction is recommended when you:
Have completely torn your ACL or have a partial tear and your knee is very unstable.
Have gone through a rehabilitation program and your knee is still unstable.
Are very active in sports or have a job that requires knee strength and stability (such as construction work), and you want your knee to
    be as strong and stable as it was before your injury.
Are willing to complete a long and rigorous rehabilitation program.
Have chronic ACL deficiency that is affecting your quality of life.
Have injured other parts of your knee, such as the cartilage or meniscus, or other knee ligaments or tendons

Why is ACL surgery recommended?

A knee with torn ACL has abnormal mobility of the tibia during normal activities and sports. This causes secondary damage to the joint cartilage and the meniscal tissues. Damage to the joint cartilage leads to knee arthritis at a younger age.

The goal of ACL surgery is to:
restore normal or almost normal stability in the knee
return you to the level of function you had before the knee injury
limit loss of function in your knee
prevent injury or degeneration to other knee structures.

What is ACL reconstruction?

ACL reconstruction is the commonest ligament reconstruction performed around the knee. ACL reconstruction is a surgical attempt to replace the stabilizing function of the anterior cruciate ligament. It involves removing the remains of the damaged ACL and replacing it with another form of soft tissue, called a graft.

A number of grafts are available for use to replace the ACL. The two commonest graft techniques are to use two “hamstring tendons” – the semitendinosus and gracilis muscle tendons – or a so called BTB (bone tendon bone, or patella tendon graft).

This surgery can be done by open technique or by arthroscopically (through key holes) using telescope, camera and specialized instruments.

Dr. Anand Jadhav performs all ACL surgeries arthroscopically because it offers:
Excellent visualization of structures in the knee joint
Tiny scars offer better cosmetic results
Minimal tissue damage and bleeding
Less pain
Early rehabilitation
Shorter hospital stay

What are the benefits of ACL surgery?

There is a 90 to 95% chance of a good result in patients who are having the operation for appropriate reasons and who comply with rehabilitation (6-9 months), These patients have good muscle strength , knee stability and a painless range of motion. Patients can return to their pre-injury occupation or sports.

What is done during ACL reconstruction?

This operation is done under general, spinal or epidural anesthesia. A tourniquet is applied on the upper thigh in order to provide bloodless operating field.

Diagnostic arthroscopy is performed through two tiny key-holes on either sides of lower portion of knee cap.

Any meniscal or cartilage injuries are dealt with.

The remnants of the torn ACL (stumps) are cleared with shavers from the femur and tibia.

Sites for inserting new ACL at tibial and femoral ends are clearly identified and marked.

Hamstring tendon grafts (semi-tendinosis and gracilis) are harvested through a small incision on upper part of leg.

The quadruple configuration graft is prepared and its diameter and length noted.

Tibial and femoral bone tunnels of matching diameters and desired lengths are drilled with help of special guides.

The hamstring graft in now pulled into the knee joint through the tibial tunnel and then further upwards through the femoral tunnel.

The femur side graft fixation is done either with an endo-button (a suspension device) or a metallic or absorbable screw. The graft is then tensioned with a special device to remove any slack during graft preparation.

The tibial side fixation is done with either a metallic or absorbable screw.

Arthroscopic view of complete ACL tear

Graft replacing ACL

The new ACL is now checked for its position, tension, fixation strength and any signs of impingement against any bony part in the knee.

The wounds are closed and pressure pads are applied.

A hinged knee brace is applied.

When can I start walking or moving the knee?
Patients can start walking or moving the knee on the same day of the operation or the next day. They usually need the help of elbow crutches or a walker initially to help in mobilization. You will be given instructions about the type of exercises to be done for the next 3 months. These exercises will be monitored weekly by our physiotherapist. My team will guide you through your recovery period.

How long will I need to use crutches?
2- 4 weeks depending on your progress.

How Long I need to stay in hospital?
Your hospital stay will be 1-2 days

How long do I need to use the brace?
You need to use the knee brace for 4-6 weeks depending on your progress

When are the sutures removed?
The sutures are removed 10-12 days after the surgery.

When can I go back to work?
For office-type jobs you can return to work after 2 weeks and for other heavy intensity jobs after 3 months, provided the progress is satisfactory.

When can I drive a car or ride a motor-bike?
You can drive a car after 4-6 weeks and ride a motor-bike after 6-8 weeks. Your knee should be pain-free with good range of motion, strength and stability.

How long do I have to continue physiotherapy and why?
I recommend that you continue physiotherapy for a minimum of 3 months to regain normal range of knee motion, good muscle strength and sense of stability (proprioception) in the knee joint. Patient are then encouraged to continue their rehabilitation further for 6-9 months in a step-wise manner to gain maximum benefits from the ACL reconstruction.

Patients who comply with rehabilitation have a very high chance of a good result. Stability is restored and the patient can undertake most of the normal activities, including sports.

When can I resume normal sporting activities e.g. play football?
Generally any sort of sporting activities are restricted for 6-9 months. Full intensity sports are allowed after 9 months of rehabilitation.

Are there any risks associated with ACL Reconstruction Surgery?

Like any other surgical procedure ACL Reconstruction has following risks:

The risks of any anesthesia are:

Allergic reactions to medicines
Breathing problems

The risks of any surgery are:

Bleeding
Infection

Additional risks of this surgery are:

Stiffness of the knee
Failure of the ligament to heal
Failure of graft fixation devices
Pain in the knee
Weakness of the knee
Blood clot in the leg
Injury to a nearby blood vessel, nerves or tendon
Numb area on outer side of knee
Difficulty with kneeling
Fracture of patella if patellar tendon graft is used.
Rupture of new ligament if knee is injured again.

 

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