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Complications:
• Compartment
Syndrome-a very rare complication where the fluid that
is used to irrigate the knee joint goes into the muscular compartments
of the calf. Increased pressure in the calf can compromise the blood
supply of the lower leg and also the nerve and may require emergency
surgery to decompress the at risk leg.
• Deep
Venous Thrombosis (DVT)-occurs when blood clots form in
the deep veins of the leg and can happen after any operation but
is more probably after surgery with knees, pelvis and hips. It may
cause the leg to swell, become warm to the touch, and become painful.
If the blood clot breaks off-it travels to the lungs-this is called
Pulmonary Embolus. Pulmonary Embolus is rare but a very life threatening
complication and the patient can die from it. Treatment is anticoagulation
for 3-6 months for both DVT and Pulmonary Embolus. Preventative
measure for DVT also include encouragement of movement of leg to
reduce the chances of clot formation and pressure stockings on legs
that keep blood in the legs moving.
• Graft
Problems:
-Graft
Impingement-if the drill holes in the bone are placed incorrectly,
the new graft may rub against the bone as the knee bends and straightens
and thus impede the movement of the knee. Usually, it becomes impossible
to full straighten the knee. This problem may be resolved with physical
therapy but usually another arthroscopic surgery is required to
shave away the obstructing part of the bone to allow more room for
the graft. However, this may not solve the problem and thus further
surgery may be necessary and required to drill new tunnels in order
to place the graft in the correct position in the joint.
-Graft Fixation Screws-local irritation can arise from the screws
that are used to secure the graft and provide tension. If necessary,
the screws are removed.
-Graft Failure-Bone-Patellar Tendon-Bone graft reconstructions have
great stability and fixation initially. In the long run, the graft
relies on revascularization to allow and encourage bone growth that
would be permanent and formation of new ligament. This process takes
around six months but is possible that it will continue for up to
two years post-surgery. Failure to revascularize can cause the weakening
of the graft and lead to recurrent symptoms of instability.
• Haemarthrosis-any
surgical procedure is complicated by bleeding around and within
the knee joint. Haemarthrosis can be treated with ice, rest, and
physiotherapy but can also lead to delayed recovery and stiffness
of the joint in question.
•
Infection-chances are very law but precautions are taken
before, during, and after the procedure to prevent this complication
from forming. Antibiotics are given intravenously both pre and post
surgery. Proper care of the surgical items and careful work by the
surgeon are also other factors in preventing infection. Yet despite
sterile conditions, infection can still happen. Two different types
are superficial and deep. Superficial infections are wounds only
and usually settle with antibiotics. Deep infections involve the
joint. These require further surgery to washout the joints with
intravenous antibiotics. However, this may lead to stiffness and
early degeneration of the joint.
• Meniscus-more
easily torn in reconstructed knee-60% of meniscus tear occur with
an ACL tear but the tear is sometimes missed and seen only if the
surgery is unsuccessful and there is a reoperation. If a reoperation
does not occur and the athlete continues on with a meniscus tear,
this could develop into osteoarthritis as the femur, without the
meniscus, rubs against the cartilage and wears it down so it connects
and impacts against the tibia. One third of patients have a torn
meniscus when reconstruction is finished and five years later only
one patient is lucky enough to have both meniscus intact. This can
be dealt with arthroscopic surgery.
• Nerve injury-small areas of numbness
can occur around the incision area. Usually such numbness is not
permanent. Sometimes wounds can become painfully sensitive but normally
settles with time. Nerve complications are very rare and account
for 0.01% to 0.06% compared to other complications. Further neurovascular
risks are reduced with proper position of the patient on the operating
table, padding on the leg holders to reduce pressure, and careful
use of the infusion pump system so as not to cause compartment syndrome
from extravasation of fluid.
• Patellar
Complications:
-Patellar
Fracture-Use of the bone-patellar tendon-bone graft may result in
fraction of the patella and can occur either at the time of harvest
or during rehabilitation. Such fracture may require operative reduction
and fixation and also can result in chronic patello-femoral pain.
-Patellar Tendon Rupture-if surgery is done improperly, the patellar
tendon can rupture-this would lead to another surgery with the probably
use of an allograft instead or use of a hamstring graft.
-Patellar tendonitis & calcification-patellar tendonitis can
occur during the rehabilitation time. Symptoms are treated with
rest, anti-inflammatory drugs, and physiotherapy. Local calcification
may occur in the patellar tendon from the location of graft harvest
and produce local irritation.
• Reflex
Sympathetic Dystrophy-a condition that is not understood
very well and can complicate any operation. It consists of swelling,
sweating, regional pain, and stiffness due to overactivity of the
sympathetic nerves in the area that were accidentally triggered
by the surgery.
• Stiffness-loss of motion in the joint-even
though it is rare, if there is excessive scarring within the knee
joint after ligament surgery, this can lead to an increasingly stiff
knee. What is most important and needed immediately after surgery
are range-of-motion exercises to prevent knee stiffness. Physical
therapy thus beings sooner rather than later. Stiffness can occur
if the surgery is done too prematurely-too soon after the injury
when the knee is not strengthened enough to bend through its normal
proper range of motion. A surgeon should not construct a torn ACL
unless the knee can move well. Other causes of stiffness include
prolonged immobilization, infection, reflex sympathetic dystrophy,
and pain. Also problems that are related to the technicality of
graft placement may lead to loss of flexion or extension. Contracture
of the anterior soft tissue of the knee after taking the BPTB-Bone-Patellar
Tendon-Bone graft can limit the range of motion. Extra fibrous/scar
tissue formation or new bone formation around the graft can also
produce stiffness by acting as a mechanical block to extension.
Sources:
http://www.yourmedicalsource.com/library/acltears/ACL_have.html
http://www.kneeclinic.com.au/papers/ACLcomp.htm
American Journal of Sports Medicine. July-August
2002 by Tae Kyun Kim & associates
DIFFERENT TYPES OF ARTHRITIS
overall arthritis: 41 million women, 28.9 million men in U.S.
alone
• Ankylosing
spondylitis-type of arthritis that affects the spine and the
separate bones of the spine grow together as a result of inflammation
• Fibromyalgia-affects mostly women-widespread
pain hits and affects the muscles and also attachments to the bone
• Gout-result of a defect in the chemistry of the
body. This condition is very painful and attacks small joints, usually
the big toe. However, gout can almost always be controlled with
medication and changes in food intake/diet
• Juvenile arthritis-general term for any and all
types of arthritis that occur in kids. Children may develop different
types, such as juvenile rheumatoid arthritis or childhood forms
of lupus, ankylosing spondylitis or other types of arthritis
• Rheumatoid Arthritis-autoimmune disease where
the joint lining becomes part of the immune system activity of the
body. The synovial membrane thus becomes thickened and inflamed
and produces too much fluid that overfills the joint space. It is
one of the most serious and disabling types, affecting mostly women
• Scleroderma-disease of the body's connective
tissue that causes the skin to thicken and harden
• Septic arthritis-also known as infectious arthritis-it
is a joint infection that is a very severe problem and requires
immediate medical and surgical attention. If it is not treated quickly,
knee infections can cause rapid destruction of the joint and can
become life threatening
• Systemic lupus erythematosus- a.k.a. lupus-a
serious disorder that can damage and inflame connective tissues
and joints in the body
http://www.arthritis.org/resources/gettingstarted/default.asp
http://www.orthop.washington.edu/faculty/Leopold/totalknee/02
OSTEOARTHRITIS:
• Osteoarthritis-a
degenerative joint disease in which the cartilage in the ends of
the bones in joint softens and degenerates away and thus the bones
rub hard against each other and cause pain and movement loss. It
is the most common form of arthritis and affects mostly the over-50
population but there are some under the age of 50 and even as young
as 30. Osteoarthritis is a generally progressive loss of articular
cartilage and sclerosis of subchondral bone and even formation of
the bone cysts and osteophytes. Osteophytes are bone overgrowth
that causes joints to look huge and are the anomalies that doctors
see on x-ray showing arthritis in the joints.
http://www.arthritis.org/resources/gettingstarted/default.asp
http://www.orthoinfo.aaos.org/booklet/thr_report.cfm?thread_id=9&topcategory=knee
Types
of osteoarthritis:
•Primary Osteoarthritis-usually associated with ageing
•Secondary osteoarthritis-consequence of another disease or
condition. This condition could be abnormal congenital joint structures,
surgery on the joint, or repeated trauma on the joint.
http://www.gehf.com.au/content/showpagenum.asp?Page=6197
Details
about osteoarthritis:
•WARNING TO ALL ATHLETES!! Sports of high impact are at
high risk for osteoarthritis!!
Sports
at high risk for osteoarthritis are the ones that are at risk also
for ACL and other ligament tears:
•Baseball
•Softball
•Basketball
•Volleyball
•Football
•Soccer
•Skiing
•Rugby
•Handball
•Squash
•and other sports with high torsional loading
In
one study, more than 30% of football players with a history of knee
injury had evidence of osteoarthritis 10 or more years later. Of
soccer players with injured knees, 63% showed signs of arthritis.
Scandinavian
Journal of Medicine & Science in Sports. 1999. 9:285-289
Who else gets osteoarthritis: Risk factors
“If you try to exercise through pain, you can break
cartilage that can never heal.”
•Surgery to remove broken cartilage increases probability of
that person to get total knee replacement in the future
•Repeated cortisone-type injections weaken cartilage and increase
further damage
•Nonsteroidal pain medications cannot stop nor prevent later
damage
•Weak thigh muscles increase the probability for knee damage
in the future
•Previous Injury or Surgery on the Joint
Others:
(Average Joes)
•Lack of exercise
•Being overweight or obese
•Strain from work (standing all day) or repetitive physical
activity
•Poor Posture
•Genetic Joint Defect or Pre-disposition for the disease
http://www.gehf.com.au/content/showpagenum.asp?Page=6197
http://www.drmirkin.com/joints/7770.html
What surgeries may be considered to treat osteoarthritis
Surgery is reserved only for those patients that have such
severe osteoarthritis that they do not get pain relief from medication,
home treatment, or other methods and who are immobile due to the
lacking cartilage in the joint.
• Arthrodesis-surgery
that joins and fuses two bones in a diseased joint. The effect is
that the joint can no longer move. It is rarely used in the knee
but is sometimes used in cases of severe osteoarthritis in a young
person that is not eligible for total knee replacement surgery
• Arthroscopy-provides relief of symptoms of osteoarthritis
and may be used to fix a joint if it becomes “locked” or stuck due
to loose bone fragments and cartilage
• Osteotomy-used mostly in people with mild osteoarthritis
with abnormality or deformity of the legs
http://my.webmd.com/hw/arthritis/uh1514.asp
Knee
Replacement: Yes or No
Yes:
• Your symptoms of pain and stiffness have become so severe
that you are unable to complete reasonable daily activities.
• Other methods of treatment, such as education, exercise,
and pain medication, do not relieve your symptoms.
• You want to be able to do low-impact activities, such
as swimming and golf, as well as chores and housework.
• And other reasons that are personal.
No:
•Surgery may not improve your range of motion, and the artificial
knee will not be as functional as a normal healthy knee.
•Risks of knee replacement surgery, though not common, include:
-Infection in the surgical wound or joint
-Blood clots, more common in people who are overweight
-Nerve injury around the surgical site
-Difficult wound healing, more common for people with immune system
diseases, such as diabetes.
•Knee replacements generally last 10 to 20 years so you may
need to have another surgery later in life if the joint wears out
or loosens.
•And other personal reasons.
http://my.webmd.com/hw/arthritis/uh1514.asp
FAQS: Knee Replacement Surgery
• How
does Total Knee Replacement look like? Link to the
video of Total Knee Replacement
http://www.arthritis.org/conditions/surgerycenter/surgerycenterflash/totalknee.html
• Other Alternative to Total Knee Replacement
http://www.arthritis.org/conditions/surgerycenter/surgerycenterflash/uni.html
Who
gets Knee replacement Surgery: Statistics
•Around ~270,000 knee replacements are done annually
and the numbers are growing each year as baby boomers reach the
golden years.
•Most of the patients are over 65 years old but now there's
a trend where patient population is getting younger and younger.
Some are just 50 years old.
•Ninety to ninety five percent of patients that undergo total
knee replacement surgery express satisfaction and overall better
quality of life for it reduces pain and disability.
http://www.mayoclinic.org/kneereplacement-jax/
What
are Complications of Total Knee Replacement?
Almost similar to Ligament Complications
•Thrombophlebitis-Deep
Venous Thrombosis-can occur after any operation and happens when
a blood clot forms in the veins of the leg . If the blood clot breaks
apart from the vein, they can swiftly travel to the lung through
the circulatory system and get lodged in the capillaries of the
lung, effectively cutting off the supply of blood to that area of
the lung. This is called Pulmonary Embolism.
•Infection-an infection can spread from other infected areas
into the artificial joint. Antibiotics have to be taken when patient
is having dental work, surgical procedures on the bladder or colon
to reduce the risk of spreading bacteria to the joint.
•Stiffness-there are cases where the ability to bend the knee
does not return to normal even after the surgery. Many surgeons
now utilize a machine called CPM-Constant Passive Motion-after surgery
to increase the range of motion while other doctors go with physical
therapy to regain motion. The increase in scarring after surgery
can lead to increasingly stiff knee and the physician would perform
another operation to break up the scar tissue to increase the motion
of the joint.
•Loosening-is the major reason for the failure of the artificial
joints. The artificial joints loosen where the metal and cement
contacts the bone. Most joints last 10-12 years and in some cases,
will loosen earlier or later than that. Most joints will eventually
loosen and require another surgery for revision. Hence Total Knee
Replacement is recommended usually for the older population of 65
and over and younger patients are told to wait and take medications
and follow other treatments to ease the pain. A revision surgery
is harder to do than the first surgery because the probability of
complications increase and the legs and muscles are already weakened
from the previous surgery
Sources
http://www.healthpages.org/AHP/LIBRARY/HLTHTOP/TKR/
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