Knee Replacement

Overview

When the smooth cartilage that covers the ends of the bones in your knee wears away, bone starts to rub against bone. The joint becomes painful, stiff and sometimes bent out of line. A knee replacement removes the damaged surfaces and covers the ends of the thigh bone (femur) and shin bone (tibia) with metal parts, with a tough plastic insert between them so the joint can glide again. The back of the kneecap is sometimes resurfaced as well.

The aim is less pain and a knee you can rely on for walking, stairs and daily life. It is a big operation with weeks of hard rehabilitation work afterwards, and the knee will not feel exactly like a natural one. Most people describe it as a new knee they have to get used to.

Joint replacement is a common reason people travel to India, Thailand and Malaysia, and hospitals in Turkey and Mexico do it too. The choice of country is yours.

Who needs it

Surgeons usually consider knee replacement when:

• X-rays show advanced arthritis, most often osteoarthritis (wear and tear), or rheumatoid arthritis, or damage after an old injury.
• Pain limits your walking, wakes you at night or stops you from working.
• Other treatment has been tried and no longer helps. That includes weight loss, physiotherapy, painkillers, walking aids and joint injections.

There is no fixed age. What matters more is how much the knee limits your life and how fit you are for surgery.

A surgeon may ask you to wait or to prepare first if you have an infection anywhere in the body (including teeth, skin or urine), poorly controlled diabetes, or significant heart or lung problems. Very high body weight raises the risk of complications, and surgeons may suggest losing some weight first.

Reports the surgeon will want

• Standing X-rays of both knees, from the front and the side, and ideally a view of the kneecap. Standing films show how much joint space is left under your body weight.
• Any MRI, though X-rays are usually enough for arthritis.
• Blood tests, an ECG (a tracing of the heart's electrical activity), and an echocardiogram (ultrasound scan of the heart) if you have heart disease.
• Your HbA1c (a blood test showing average blood sugar over about three months) if you have diabetes, and a full list of your medicines, especially blood thinners.

How it is done

The operation usually takes one to two hours. Many hospitals use spinal anaesthesia (an injection in the back that numbs you from the waist down) with sedation, often combined with a nerve block to ease pain afterwards. Some patients have a general anaesthetic instead.

Total or partial

In a total knee replacement, the surgeon replaces all the worn surfaces. This is the standard operation for arthritis that affects the whole joint.

A partial knee replacement, also called unicompartmental, replaces only one part of the knee, most often the inner side. It suits people whose arthritis is limited to that area and whose ligaments are healthy. The cut is smaller and recovery can be quicker, but not everyone is suitable, and some partial knees are later converted to a total.

How the parts go in

The surgeon makes a cut down the front of the knee, removes thin slices of worn bone and cartilage with precise guides, and fixes the new parts in place, usually with bone cement. Getting the alignment and the balance of the ligaments right matters for how the knee feels and how long it lasts.

Robotic-assisted surgery

Some hospitals offer robotic-assisted knee replacement. The surgeon plans the position of the parts using a CT scan or measurements taken during the operation, and a robotic arm helps keep the bone cuts within that plan. The surgeon still performs the operation. Studies show more accurate alignment, while evidence of better long-term results compared with the standard method is still being gathered. Ask each surgeon how they work and why.

Recovery and how long you stay

You will usually stand and take your first steps with a walking frame on the day of surgery or the next morning. Physiotherapy is the heart of recovery. Each day the physiotherapist works on bending and straightening the knee, walking, and climbing stairs. Some days are uncomfortable. The work you put in during the first six weeks shapes how well the knee moves later.

Preventing blood clots

Any leg operation raises the risk of a deep vein thrombosis (DVT), a blood clot in the deep veins of the leg that can travel to the lungs. Hospitals reduce this risk with early walking, compression stockings or foot pumps, and blood-thinning medicine as injections or tablets, often for a few weeks. Surgeons usually ask you to finish the full course, including doses after discharge.

How long you stay

Expect 3 to 5 days in hospital. Most patients stay in the country for about two to three weeks in total. That covers tests before surgery, the hospital stay, daily physiotherapy afterwards, and removal of stitches or clips at around two weeks. MediCurage looks for a room near the hospital with a lift and a raised toilet seat, and your coordinator arranges the trips to outpatient physiotherapy.

Flying home

Published advice on long flights after joint replacement varies, and your surgeon sets the date for your case. Patients who travel for surgery usually fly once their surgeon is satisfied with the wound and their walking, and often while still taking blood-thinning medicine. On the plane, surgeons usually advise an aisle seat, compression stockings, regular walks and plenty of water.

At home, keep going with the exercises and arrange physiotherapy locally. Most people walk without aids within a few weeks to two months, and the knee keeps improving for a year or more.

Questions to ask your surgeon

1. Do I need a total or a partial knee replacement, and why?
2. Which implant will you use, and can surgeons in my country service it if needed later?
3. Will you use robotic assistance or navigation, and what difference does it make in your hands?
4. Would you replace both knees at once in my case?
5. Which anaesthetic do you recommend for me?
6. Which blood thinner will I take, and for how long?
7. When can I fly, and what should I do on the flight?
8. How much bend should I aim for before I leave?
9. Which signs of infection or a clot mean I should call you straight away?

If two surgeons give you different answers to the same question, ask each of them to explain their reasoning. That conversation often tells you more than the answer itself.