Rheumatoid arthritis can lead to crippling deformities in joints and unlike osteoarthritis which is seen in elderly population, it can affect us at any age. Rheumatoid arthritis is the second commonest type of arthritis due to which patients require a knee replacement surgery world wide.
Despite many advances in the medical treatment if this disease, severe joint damage can happen in-spite of medications and often such patients have to undergo replacement surgery of multiple joints for pain relief and to regain normal functional life.
We would like to share a story of thirty seven year old courageous school teacher suffering from crippling rheumatoid arthritis, that affected her at the age of seventeen.
The disease was aggressive and inspite of regular medications, she developed painful and stiff joints. She braved her condition with steely determination and a smile on her face. The disease progressed relentlessly, affecting both the knees. Gradually, the knees developed deformities, became very stiff and remained painful even at rest. Both the knees lost all the movement and were fixed in a bent position. She had started walking laboriously with a marked limp. This was affecting her physically as well as emotionally and she had started losing the mental battle against the crippling disease. In her quest to remain mobile, she tried rigorous physiotherapy and even took injections in the knee joints, all without any improvement in her condition. She visited us at Gurgaon Knee and Shoulder Clinic to consult Dr Jayant Arora, where the option of knee replacement surgery was discussed with her as a last resort to restore movements, relieve pain and improve walking. She was explained, that unlike most knee replacements, her surgery was not going to be straightforward and there were several issues that needed to be addressed. Since, she was nearly half the age as compared to a typical patient under going knee replacement, knee replacement made from a special material (Oxynium) was used instead of a standard metal implant. Oxynium implants are preferred in young patients undergoing knee replacement as that are stronger than metal implants and are expected to last longer. Our vastly experienced Surgeon performed the replacement of both knees at Columbia Asia Hospital using a modified surgical technique to account for stiff and tight muscles,deformed and weak bones. The rehabilitation was carefully planned and done under regular supervision, leading to a very quick recovery. Her colleagues were left amazed when she resumed working three months after surgery, able to walk normally, climb stairs and drive, as if there was never anything wrong in her knees. The only thing that didn't change was her infectious smile!
RECENT ADVANCES IN KNEE SURGERY-TECHNIQUES AND
TECHNOLOGY
Total knee replacement
surgery has been a safe and effective surgery for treatment of advanced stages
of knee arthritis. It has been in use for many decades and over the years many
advances in technology, surgical techniques and material have enabled this
surgery to become even more precise with better and longer lasting results and allow quick recovery. I have
attempted to explain some of these advances in simple words
Advancement in Technology--Computer Navigated
Knee Surgery
Computer navigation in
total knee replacement has been in clinical use for last 10 years in US and UK
and it attempts to correct some of the problems faced in traditional total knee
replacement. Accurate placement of a knee replacement is one of the most
important predictors of longevity of knee replacement. Minor misalignment can
lead to early loosening, early polyethylene wear and poor function. Computer
navigation allows the surgeon to accurately check and adjust, if necessary,
each step along the way, whilst performing the knee replacement, which still
allows the surgeon to exercise his skill and judgement for optimal positioning
of the implant.
The computer
navigation system works by combining computers, infrared cameras and
instruments that reflect infrared light back to the camera. This permits the
surgeon to finely adjust the position of the new knee with certainty, so that
he or she can orientate the replacement joint to function optimally. The
surgeon is always in control of the operation and only uses the computer to
provide information on where to place the new knee.
When using the
computer navigation system, pins are required, to be temporarily inserted into
the bone; they are then removed once the new knee is inserted. This requires
two very small (half a cm long) additional incisions to be made on the skin
over the shin bone in addition to the standard scar used to insert the new
knee, which is over the front of the knee.
Numerous studies have
shown that the information from the computer navigation provides patients with
a more precise operation to those performed with the standard instruments. It
was thought to be a breakthrough technological advance, however one of the main
reasons why this technology is not more widespread is that it can take longer
to perform the surgery using the computer navigation system, additional costly equipments
are needed and it needs two small additional incisions. Some of the drawbacks
of this technology are now addressed by Patient matched instruments which is
described below.
Advancement in
Technology--Custom made Instruments/Patient matched Instruments
One of the most recent recent
advancement is the development is Patient Matched Instrumentation. These
patient-specific surgical instruments are custom made for the precise alignment
of patient’s knee, potentially increasing implant longevity.
This techniques requires
MRI (Magnetic Resonance Images) and X-Ray images of patient’s affected leg into
an advanced web-based software program, which will generate virtual images of
the knee. Surgical instruments and guides are then designed and built, mapping
out specific bone cuts to accurately align the implant to the knee. These knee
instruments are specifically made as per the size and shape of the patient’s knee bones and take 6 weeks to get ready.
There are several
distinct advantages of this technology. It removes multiple steps from the
traditional surgical technique and shortens surgical time as most of the
planning about size and placement of implants takes place preoperatively using
computer software programme. This may
lead to less blood loss and a lower risk of infection.
Patient Matched instruments allow surgeon to
achieve precise alignment of the knee implants, potentially reducing wear – a
leading cause of early implant failure.Customized instruments enable a less
invasive surgical procedure which can reduce soft tissue and muscle damage
which may speed the recovery time.
A knee implant
accurately aligned may not only feel more natural, but may also last longer
than traditional knee replacements.
Advancement in technique-Minimally Invasive Knee (MIS) surgery
I don’t think minimally invasive surgery is
the kind of “disruptive technology” that is going to revolutionize total knee
replacement, which is already a safe, effective, time tested operation. The
gains, if any, are likely to be marginal, and I think these other approaches to
postoperative care can probably match them. So my advice to the patients is to
not to focus on the length of the incision because it will be irrelevant within
2-3 months of surgery! What would really matter in the long term would be the
position of their implants !!!Advances
in technology like computer navigatedsurgeryand patient matched
instruments are helpful for the surgeon to achieve this goal.
Advancement in materials—Highly crosslinked Polyethylene and
Ceramic implants
The plastic insert
(polyethylene) that is used as a substitute of the cartilage in the artificial
knee gradually wears out with time.There has been a major advancement in the quality of these plastic
inserts and by producing crosslinking in its structure, the durability if these
inserts have increased manifolds in experimental studies. These Highly
cross-linked plastic inserts and now available in both knee and hip replacement
implants and should be offered to all patient and must always be used in young
patients. Similarly using ceramic
implants instead of Metallic implants have shown to reduce the wear of this
plastic insert further and should be offered to young patients who need knee
replacement surgery. Ceramic implants have been used routinely in
hipreplacement surgery for many years.
