1. Total Knee Replacement (TKR) – A Current Treatment Modality For Knee Pain.

What is TKR?
It is the replacement of normal knee joint by artificial joint made up of stainless steel alloy called cobalt chrome alloy and plastic called ultra high molecular weight high density polyethylene. Steel part covers the bone ends of joint and polyethylene insert remains in between the two steel ends.

When it is necessary?
Most common indication of TKR is pain which is not relieved with non operative methods like medicine, intra- articular injections, braces, physiotherapy etc

At what age can joint replacement be done? Can it be done for children?
Joint replacement is commonly done for patients above the age of 60 years. It may be done between ages of 40 and 60. It is occasionally done between ages of 20 and 40. It is never done in children.

What is that condition which leads to TKR?
Most common is age related degeneration of knee joint i.e. osteoarthritis, rheumatoid arthritis, tumor related joint disease etc

How these diseases affect the joint?
Every disease has its own way to destroy the joint by destroying the cartilage i.e. tissue layer which smoothens the bone ends to make joint frictionless , decreasing the joint lubrication by decreasing the synovial fluid, decrease in joint space, inflammation & swelling, extra bone formation, muscle weakness, decrease in range of motion, deformity of knee, and leading to painful gait, limp, life confined to bed.

How one can avoid destruction of joint?
Age related degeneration comes with growing age as other diseases like cataract, graying of hair, tooth decaying etc. but one can keep the joint healthy by doing regular exercises for knee, avoiding squatting and overweight.
Other conditions with specific pathology should be treated accordingly by doctors.

Is there any alternative to TKR?
Yes, before going for the TKR one can try medicines like analgesics to decrease pain, chondroprotective drugs for regeneration of cartilage which is the important tissue of joint, steroid intra- articular injections to reduce inflammation, injections to increase lubrication of joint, braces etc. All these measures can delay the TKR, but ultimately TKR is the choice.

Is there any operation which can replace the TKR?
No, there is no alternative operation to TKR till date but there is a variant of this known as unicondylar knee replacement i.e. half knee replacement, is being done in some selected conditions.
One procedure is there known as high tibial osteotomy, which is advised in early stages of osteoarthritis to correct the alignment of knee. With this operation knee load distribution becomes equal and leads to pain free knee movement. This is recommended in selected cases, but ultimately lands with TKR.

What is the average time taken for joint replacement surgery?
The average time taken for joint replacement surgery is 1-1.1/2 hrs.

How much is the hospital stay after TKR?
It varies with the condition of the patient, normally it is 7-14 days.

What is the role of physiotherapy and exercises after joint replacement?
Physiotherapy exercises called CPM - Continuous Passive Motion machine start within 1-2 days after joint replacement, while walking is started 2-3 days after joint replacement with full weight bearing, as tolerated.

How many days patient takes to get out of bed and walk?
Usually after 3 days patient starts walking with walker but it depends on the condition of patient./

For how many years it works?
About 20 years is the life of TKR.

Can a person with diabetes, high blood pressure, or heart trouble undergo joint replacement?
Even a person with diabetes, high blood pressure, cardiac disorders can undergo joint replacement surgery under medical supervision. The diabetes or BP must be under control.

Is there any risk to life during this operation?
TKR is like other operation so no added risk is involved in this operation. But generally this is done in elderly age group those are having other diseases like diabetes, heart disease, hypertension, asthma etc. so one should be confident that his hospital is fully equipped to tackle these added risks.

After the knee replacement will the patient be able to squat?
It is difficulty to do the traditional squatting. However, one can sit cross legged for a special occasions and can also sit in the sideways sitting position of the ground avoiding full bending at knee using support below knee.

What are the precautions to be used after joint replacement?
It is advisable to use a bedside commode for 3 to 4 weeks and a English toilet after that, Avoid sitting on floor, jogging, running and fast sports after joint replacement surgery. Moderate speed walking, climbing stairs and swimming are permitted

Does one need plaster of Paris cast after surgery?
No, your knee is free, a brace is used for few days for comfort and support and, usually hinged knee cap is used for walking for a few weeks

How far can one walk after a Joint Replacement?
One can walk as many kilometers as general health will allow. Some patients can walk even 8 K.M at one stretch. But generally one can walk for 2-5 K.M without any problem
So go for new treatment modalities and live with pain free knee.
For further queries contact ORTHOMAX, bone & joint center.

2. INFECTED, NEGLECTED AND COMPLICATED ORTHOPAEDIC TRAUMA: A REAL CHALLENGE

The incidence of orthopaedic trauma is rising due to increase in road side accidents. High energy impact produces highly complex form of orthopaedic injuries like open fractures, multiple fractures, and open joint injuries. Often these are associated with other complications like loss of soft tissue cover, bone loss and neurovascular injuries. As compared to domestic orthopaedic injuries, operating these complicated injuries demands high level of expertise, including a team work comprising of orthopaedic, plastic and vascular surgeons.

Many of these injuries if not treated properly will end up in infection and nonunion of bony fractures, thus further complicating the existing injuries. One can encounter many such cases which have already been operated upon but still require second or redo surgeries for one or the other complication cited above. To operate on infected orthopaedic cases and one with failed or broken plates or nails require meticulous preoperative planning , case discussion among team members to find best possible treatment, a good counseling and motivation of patient and his family to know the course of treatment to be carried out.

There are many treatment options available to deal with these cases like removal of infected nail/plate, removal of infected bone and tissues, reinsertion of antibiotic laden nails, suppression of infection with antibiotics and application of illizarov Russian technique. Every case is different so treatment has to be individualized as per the case.
Those cases which are highly infected and associated with loss of bone require to be treated by lastly mentioned illizarov technique .This technique is not being done at many centers because of its technical complexities but has produced satisfying results in expert hands for selected cases. In this procedure multiple circular rings are applied along the limb along with tensioned wires. Bone loss up to 20 cm can be reconstituted successfully over a period of time. Many limbs necessitating amputation have been successfully saved and functionally restored.

By ORTHOMAX, BONE AND JOINT HOSPITAL

3. COSMETIC LEG LENGTHENING

(OPERATIVE HEIGHT INCREASE)
Leg Lengthening is a complex process that has traditionally been performed in children to correct limb length discrepancy (LLD). LLD is the difference between the length of two legs, caused by previous fractures, bone infections, and neurological conditions during childhood such as cerebral palsy and polio. Today, society places considerable value on physical beauty and presentation, and these prejudices extend to short stature, which may cause psychosocial disturbance in early adolescence. Recently, this technique has been applied to individuals with short stature who wish to be taller. This new application is called COSMETIC LEG LENGTHENING or symmetric extended limb lengthening. Now this surgery is being used, with some controversy, to radically change height of people born with dwarfism and people who suffer from psychological condition called "Height Neurosis".

Patients who wish to undergo cosmetic limb lengthening must first submit to an intense psychological evaluation to determine whether in fact they suffer from “SHORT STATURE DYSPHORIA” - meaning that they are consistently unhappy with their heights while being well adjusted & happy in other aspects of their life. It has to be determined to what extent the person’s quality of life has been affected by his perceived lack of height and if performing the surgery will make a difference. This requires in depth doctor – patient discussions.

In lengthening procedure, the surgeon attaches a frame (illizarov) to bone with metal pins. Bone is cracked through a small incision and frame is distracted at rate of 1mm per day. The gap thus created gradually fills up with new bone. The surrounding muscles, nerves, blood vessels and skin also grow. Children under the age of 12yrs are not accepted for this procedure because it is essential that the patient, rather than parents, make up his/ her mind as to whether or not this procedure will be worthwhile. Upper age limit for this surgery is 18-20 yrs as tissues become too stiff to be stretched after that age. Women less than 5 ft and males less than 5’-5” are eligible candidates. Maximum height increase varies from 5 to 8 cms.

Limb lengthening procedure has generated wide spread interest and controversy. It is not without complications such as intense pain throughout the procedure, infection, unnecessary operation on normal limb and long recovery period (8 to 10 months). Patients should carefully weigh the risks and benefits of surgery. Patients who really need to undergo this procedure are those who are in severe psychological distress over their short stature. Cosmetic leg lengthening is a complex procedure – “It is not as simple as doing a nose job “. Still, for some – it is all worth it.