Knee Replacement

Knee Replacement Surgery

Knee replacement surgery is generally considered to be a very successful operation. There are different types of knee replacement, including both partial and total knee replacement. Each one has their benefits and risks. Mr Costin-Brown performs both of these surgeries, and will discuss with you which would be best for you.

Also known as knee arthroplasty, knee replacement is a surgical procedure that involves replacing all or part of a damaged or diseased knee joint with an artificial joint, known as a prosthesis. The goal of the surgery is to alleviate pain, improve mobility, and enhance the overall function of the knee joint.

There are many reasons why a patient may require a knee replacement, including:

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End-stage osteoarthritis (most common). This occurs when the cartilage of the knee joint is worn away, resulting in pain, stiffness, and decreased mobility.

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Rheumatoid arthritis

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Avascular necrosis (disruption of blood supply to the knee)

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Previous injuries or fractures

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Trauma (e.g. hip fracture)

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When is the right time to have a knee replacement?

The timing for knee replacement surgery is a subjective decision that depends on individual circumstances. It is important to carefully consider the surgery as it is a significant procedure. While there is no definitive answer to determine the right time for knee replacement, several factors can guide the decision-making process.

Typically, knee replacement is recommended when non-operative measures have been exhausted (see non-operative measures), such as medication, physical therapy, and lifestyle modifications, and your symptoms significantly impact your daily activities and overall quality of life.

Involving your loved ones in the decision-making process is crucial, as they can provide valuable insights into how your knee symptoms affect your life (often you may not notice how your knee is affecting you when you have lived with it for so long). Their support during and after the surgery is also essential, making their involvement important.

Mr Costin-Brown will conduct a comprehensive assessment of your symptoms, perform a thorough examination, and engage in a detailed discussion with you. This process, known as “joint decision-making,” aims to involve both the patient and the surgeon in making an informed decision regarding the most appropriate course of action, considering the benefits and risks of surgery.

What is involved with a knee replacement?

Essentially, knee replacement involves removing all or part of the damaged joint and replacing it with an artificial joint (prosthesis).

A cut is made in the skin over the front of the knee and the tissues are incised to expose the joint. The damaged joint surfaces are removed by making a series of precise cuts of the bone using special jigs, which shapes the bone ends to accommodate the new prosthesis.

The artificial joint components, which consist of metal alloys and high-grade plastics, are secured to the reshaped bone surfaces using orthopaedic “cement”, which essentially glues the implants to the bone.

The new knee is tested to ensure that it is stable and moves well. Afterwards, the tissues are repaired and a dressing is applied to the wound.

Should I have a partial or a full knee replacement?

The decision between a partial or full knee replacement depends on various factors specific to your condition. Partial knee replacement is considered when arthritis is limited to one part of the joint without affecting other areas, and your symptoms reflect this. Successful partial knee replacement also relies on the normal function of your knee ligaments.

Both partial and total knee replacements come with their own benefits and risks. Partial knee replacements generally offer a quicker recovery and better function. However, there is a higher chance of requiring further surgery in the future if arthritis develops in the remaining parts of the knee, necessitating a full knee replacement.

During your consultation, Mr Costin-Brown will conduct a comprehensive assessment, including a thorough examination and X-rays. He will discuss your options with you and help you make an informed decision based on your specific circumstances.

What anaesthetic will I have for the surgery?

Whenever feasable, Mr Costin-Brown and his team recommend having your knee replacement performed under “spinal anaesthetic” (like an epidural). This has many benefits over a general anaesthetic (where you are fully asleep and require a breathing tube), including a quicker recovery, improved pain control and reduced risks.

Some patients may have concerns about being awake during surgery. However, it’s important to note that even with a spinal anaesthetic, you can receive additional sedation to help you feel more relaxed and sleepier during the procedure. Your anaesthetist will discuss this with you before your surgery to address any anxieties or preferences.

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What happens after surgery?

Following the operation, you will be taken to recovery for a period of time before being moved back to the ward. If all goes to plan, you will be encouraged to mobilise with the physiotherapist the same day (or following day if not possible) with the aid of crutches. The physiotherapists will teach you how to use the crutches and manage activities following your surgery.

You will undergo routine blood tests and a check XR of your knee to ensure that there are no issues. You will have your vital signs (blood pressure, heart rate, etc…) monitored regularly.

When all of the above is satisfactory, you will be discharged home. Usually this is day 1 following your operation. Some patients will be suitable for discharge the same day (if you are suitable for this service, arrangements will be made in advance). Some patients, however, take longer to recover or be safe on their crutches, and therefore stay longer. You will not be discharged before you are ready.

What exercises do I need to do after the operation?

One of the big risks of knee replacement surgery is stiffness. After knee replacement surgery, it is common to experience soreness, stiffness, and swelling in the knee. However, it is crucial to actively move and exercise the knee to prevent stiffness and promote healing. Although pain is expected during the recovery process, taking prescribed painkillers as directed will help manage discomfort and enable you to engage in movement and exercises.

Your physiotherapist will provide you with specific exercises to perform at home. It is recommended to perform these exercises four times a day, ensuring that you take your painkillers 30 minutes before each session. Following each set of exercises, it is important to rest, elevate, and apply ice to your knee. These measures help reduce swelling and support the healing process.

Consistency and regularity in performing exercises, along with face-to-face physiotherapy sessions, play a vital role in maximising the range of motion and functional recovery of your new knee. By actively participating in your rehabilitation program and following the guidance of your physiotherapist, you increase your chances of achieving a successful outcome and regaining optimal knee function.

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Is everyone happy following knee replacement surgery?

While the majority of patients who undergo knee replacement surgery experience significant improvements and are satisfied with the outcome, it is important to acknowledge that there is a proportion of patients who may be dissatisfied. There are various reasons why patients may not achieve the desired level of satisfaction following knee replacement.

Published rates of patient satisfaction and dissatisfaction can vary, but in general, the majority of patients (around 75%) report feeling much better after surgery. Approximately 15% report feeling slightly better, while around 4% feel their condition remains the same. Unfortunately, there is a small percentage (approximately 6%) of patients who report feeling worse or much worse following knee replacement. This means that about 1 in 10 patients may not experience the expected improvement or may even have a worsened condition after surgery.

It is important to note that individual outcomes can vary due to factors such as pre-existing health conditions, complications during surgery or recovery, the presence of other knee-related issues, or individual response to the procedure. Additionally, patient expectations and subjective experiences can also influence their perception of the surgical outcome.

What are the risks of surgery?

Every operation carries a risk. You need to be aware of the risks before proceeding with knee replacement.
Even though some risks are small, you need understand them and their implications. Risks include:

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Bleeding, and the potential requirement for a blood transfusion. If you have a reason that you would not wish to have a blood transfusion (e.g. Jehova’s witness), please make Mr Costin-Brown aware of this

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Scar. You will have a scar at the front of the knee. Some patients find this scar uncomfortable and tender, particularly for the first few months.

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Numbness. You will have a numb area of the outside of the scar following your surgery. This is due to the tiny nerves just under the skin that run from the inside to outside of the knee. Making the cut in the skin damages these nerves resulting in the numbness on the outside. Over time, the area reduces in size, but never totally goes away.

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Damage to surrounding structures, including nerves, blood vessels and tendons. If a nerve or blood vessel was to be damaged, this may result in weakness and numbness of your lower leg or loss of blood supply to the lower leg, respectively.

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Stiffness, where the knee does not go fully straight or bend well. It is important to do the exercises regularly and attend face to face physiotherapy after your operation.

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Leg length difference (i.e. your operated leg being longer or shorter than the other).

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Fracture. It is possible to break your bones when performing surgery, as the implants require a tight fit in order to be secured. If a fracture was to occur, this would be identified and dealt with, either at the time of surgery or soon afterwards.

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Further surgery. If you suffer a complication, you may require further surgery.

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Blood clots (deep vein thrombosis or pulmonary embolus). You can develop a blood clot in the leg following surgery. This can break off and travel to the lungs / heart / brain and can be life threatening. Around the time of surgery, you will be given blood thinners to thin the blood and minimise the risk of this occurring.

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Infection. Infection of a joint replacement is significant. If bugs get around the new joint, they cling onto the metalwork, and are nearly impossible to remove with antibiotics alone, and often require further surgery to remove the implants and put new ones in (either at a single surgery, or over two separate surgeries). Mr Costin-Brown does his utmost to minimise the risk of infection, including clean theatres, sterile implants, meticulous technique, antibiotics, etc… but despite these measures, the average risk is around 1%. Some patients have a higher risk of infection (including patients with diabetes, patients on immune suppressing drugs, patients with obesity, etc…) and Mr Costin-Brown will discuss this risk with you.

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Difficulty kneeling. Some patients will struggle to kneel down following knee replacement. This can be due to a combination of reasons. There is no reason that you should not kneel down after knee replacement, but you may find the scar too sensitive, or may struggle to bend the knee enough to get down/up afterwards. One of the biggest predictors or whether a patient will be able to kneel down following their operation is whether they could kneel down before surgery.

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Instability. Before surgery, the majority of patients will have a deformity of their knee (it will go inwards or outwards). During the operation, your knee will be made straighter. This can affect the balance of the ligaments on the inside or outside of the knee. This may feel strange to start off with, but should improve with time. Occasionally, the balance of the ligaments is not right and the can be unstable.

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Wear / loosening. Over time, the implants can wear down or work loose from the bone. Modern day implants have excellent survival, but if they do wear down or work loose, you may require revision surgery. On average, the chance of your new knee lasting you at least 10 years is around 95%. However, individual circumstances (age, sex, weight, activity level, etc…) affect how long your hip may last.

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Anaesthetic risks. There are risks associated with the anaesthetic, and your anaesthetist will discuss these with you prior to your operation.

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Death. Knee replacement surgery is by and large a safe procedure. However, there is a very small, but not insignificant risk of death (less than 1%).