The surest guide to determine the need for
total knee replacement is the severity of the pain in your knee joint. Although you
suffer severe pain, you may still be unable to describe the pain, not even pinpoint its
location.
Most patients with knee joint disease
feel pain in the knee joint.,
You must, however, be aware
that not all pain that you feel in your knee joint area is provoked by a knee joint
disease.
The pain in this area may be caused by
encroachment of some of the nerves around the
hip or knee joint, or even from encroachment of spinal nerves
inflammation in tendons and bursa ( sacs with
fluid lying between tendons and bone) around the knee joint
pain in the knee joint area, especially on
inside of the knee joint may be a projection of pain generated by a hip joint disease
Patients operated on for minor knee problems are more
often dissatisfied with the results of their total knee operation
Total knee replacement is major surgery and entails certain
risks. Thus, it should not be undertaken unless there are compelling reasons for it.
Will the operation be more
difficult if you wait?
It depends.
Usually the operation will not be more difficult if you are
suffering from slowly progressing idiopathic osteoarthritis of the knee joint
(wearing out disease of the knee joint).
On one condition, however: you must exploit the
"waiting time" to improve your general physical condition and improve the
strength of the muscles around both of your knees.
Just as well, if you observe increasing contracture in your
knee, increasing instability, or wasting of the musculature around the knee,
then you should not wait.
Remember also that as you wait too long the function
in your knee and your general health are likely to decline. The operation results in
patients waiting too long are worse. (Fortin 1999)
There are certain diseases that may destroy the knee joint
too much if you will be waiting too long (rheumatoid arthritis, e.g.).
So ask always your surgeon whether the
operation will be more difficult if you postpone it.
How important are X-ray pictures?
How much importance should you put on the X-ray pictures
for your decision to be operated on?
This depends on the character of your knee joint disease.
Remember that a X-ray picture is a meager shadow of reality. The X-ray picture cannot tell
how much pain and other discomfort you really have. In some very painful knee joint
diseases (avascular necrosis, e.g.), the conventional X-ray picture cannot even
discover any disease in the knee joint initially.
In general, however, the patients with more advanced X-ray
changes have also more pain in their knee joints.
Should you wait for development of
better artificial knee joints?
It is true that new models of total knee joints are
generally better than the old ones but the rate of progress in this area is uncertain.
If your pain and disability are severe, than there is no
point in waiting for progress of the technique.
Should you wait for bio-engineered
knees?
The bio - engineering science makes certainly a very good
progress in preparing living cartilage tissues - at least as heralded in the media. Should
you wait until these bio-engineered cartilage cells be available to be implanted into your
worn out knee joint?
You should know two facts.
First, as yet the bio -engineered cartilage cells failed to
heal badly worn joint cartilage in osteoartitic knees. This method is as yet most
successful only for small cartilage defects in femur condyles, not for typical
osteoarthritis changes. (www.carticel.com).
Second, only about 20 % of all results in this field
have been published. Much of the development in this field is financed by private
for-profit companies and they decide which results should be published. Bad results
usually do not improve the price of stock shares.
Can osteoarthritis of your knee
improve without operation?
In contrast to the osteoarthritis of the hip joints,
osteoarthritis of the knee is less forgiving and deteriorates more often with time.
The pain and stiffness in your knee may improve without
treatment, but the progress of osteoarthritis is not predictable, it varies greatly
from person to person. The pain may become unbearable within six months for one person,
yet drag on at a tolerable level for several years in another person who has the same
degree of arthritis on X-ray pictures.
What about stiffness,
deformity, or instability of your knee.
All these symptoms may be
cured by the total knee operation, although not always completely. If you suffer from
these symptoms, then you have more reasons to contemplate a total knee operation.
It is also important to know
that
very severe instability of the
knee joint and
very severe weakness of the
muscles (mainly the quadriceps muscle) around the knee joint
usually exclude good function
of the total knee joint and many surgeons would be against total knee replacement of such
knee joints
Are your expectations
realistic?
The total knee joint will
relieve your pain and restore a great deal of function in your destructed knee, but it
will never be as good as a natural healthy knee joint.
So you are not a good
candidate for a total knee replacement if you have unrealistic goals such as
unlimited walking possibility
complete disappearance of
all pain
normal range of motion in the
knee joint
ability to return to sports
such as soccer on competitive level
Who is an ideal
patient for a Total knee replacement
According to enquiry among
surgeons, the patient with best chances to succeed with Total knee replacement should
have severe pain in the knee
joint
have the diagnosis of
osteoarthritis
the knee joint should be
stable or only slightly unstable
the musculature around the
knee should be reasonably strong
the skeleton should be
reasonably strong
the patient should weight less
than 100 kg
the patient should not have
other serious diseases
the patient should be > 60
years old
the patient should be well
motivated and informed about the possibilities and risks of the surgery
Knee pain after
fused hip joint
Fusion of the hip joint has been a wonderfull operation,
used often in the past to reliefe pain in the destructed hip joint. Unfortunately, these
patients developed often severe osteorthosis and pain in the spine and in the knee.
Patients with severe osteoarthrosis and pain in the knee
after fused hip joint often contemplate a total knee operation to relieve knee pain. The
results of such operation are not good, the pain often continues and the total knee fails.
To relieve the severe knee pain, the surgeon should first
take down the fused hip joint and replace it with a total hip. This is a big operation
with risk for postoperative complications.
Then the surgeon may perform a total knee replacement. The
results of this operation are usually good. (Rittermeister 2000)
WHO CANNOT HAVE A TOTAL KNEE SURGERY
- Patients with recent (
arbitrary < 9 months) heart infarct and stroke
- Patients with uncontrolled diabetes, lung, kidney, or other
systemic disease
- Patients with ongoing or recent infection in the knee joint
area
- Patients with severe paralysis of muscles around the knee
- Patients with severe circulation problems (painful
claudicatio) in the extremity.
- Patients with severe skin damage in the front of the knee
joint
- Patients with open wounds in the lower leg.
Other reasons why surgeons may
abstain from operation
Many surgeons will hesitate to carry out total knee
replacement in
- badly motivated patients
- patients seeking financial or other gain from total knee
surgery
- overweight patients ( > 100 kg)
- persons with alcohol abuse
- people with dementia
(Mancuso
1996)
OTHER IMPORTANT FACTORS
There are other very important factors that
decide whether you should have total knee replacement and whether you will be satisfied
with the operation.
These factors include your age - you are
never too old but you may be too young (in the eyes of your surgeon) for a TKR surgery
For more information about this factor, please
visit the sections below:
Are
you too young to have a TKR?
References:
Fortin P et al.: Arthritis Rheum 1999;42:
1722-8
Lane et al.: Clin Orthop 1997;345:106-12
Mancuso et al : J Arthroplasty, 1997; 11: 34 - 46.
Parvizi et al.: J Bone Joint Surg-Am, 2001; 83-A:
1157 -60)
Ritter et al.: Clin Orthop 1997;345:99-105)
Rittermeister M et al.: Clin Orthop 2000, 371: 136-45
Sulek et al Anesthesiology.: 1999;3:672-6)
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