Beyond Replacement: Exploring Minimally Invasive Knee Surgery Options in Singapore

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The most important recent development in knee replacement is the use of computer navigation. This is a tool used by the surgeon to provide information for more precise bone removal and to also ensure proper ligament balance. This, in turn, can increase the longevity of the knee replacement. Computer navigation is also available in Singapore and is offered by many of the orthopedic knee surgeons.

An option available to a minority of patients is a partial knee replacement. This is done when the damage to the knee is only limited to one part. The benefits include a smaller incision, less bone and cartilage being removed, and a faster recovery. This enables the patient to get back to a more active lifestyle and there is also evidence to suggest that the long-term patient satisfaction is higher than total knee replacement.

Today, “minimally invasive surgery” is a term often heard. In general, a minimally invasive knee replacement is one in which the surgeon uses a smaller incision which may lead to less pain and a faster recovery. It also attempts to cause less trauma to the surrounding tissues and ligaments. This is also now possible with advanced techniques and instrumentation available in Singapore.

Knee surgery is rarely a first option for patients with chronic pain and disability of the knee. Non-surgical methods such as rest, exercise, medication, and injections are usually attempted first. However, a decreased quality of life because of limitation in function and mobility of the knee is an indication to consider knee replacement. In Singapore, over 3000 knee replacements are performed yearly. This is due to a combination of an aging population, increased prevalence of knee arthritis, and an increased awareness and willingness of the population to seek medical treatment for this condition.

Overview of Knee Surgery

Knee surgery is a common medical procedure used to treat various conditions that cause knee pain. It involves making an incision over the knee area and using a camera and small tools to correct the problem. The type of surgery will vary depending on the extent of damage to the knee area. The two most common forms of knee surgery are arthroscopy and knee replacement surgery. Arthroscopy is a surgical procedure in which a small camera is inserted into the knee area allowing the surgeon to examine the knee in great detail. The benefit of this type of surgery is the minimal recovery time. Knee replacement surgery is exactly what the name suggests. The damaged knee is replaced with an artificial knee joint. This type of surgery is generally used to treat patients with severe osteoarthritis. Both surgeries are usually recommended with other treatments such as physical therapy and medications.

Benefits of Knee Surgery in Singapore

Singapore’s medical and surgical expertise. In Singapore, access to medical technology is widely available. Knee surgery procedures such as arthroplasty and arthroscopy are commonly carried out and are considered routine surgery for medial meniscus tear. Most orthopedic surgeons are skillful and highly experienced in their field of expertise. High success rates, both short and long term, can be expected with these surgeries. High success rates would also mean that there will be fewer complications and less chance that a revision surgery will be required in the future.

Nearly one-stop comprehensive hospital facilities. Patients are no longer required to hop from one place to another to get pre-operative assessments like blood tests, urine tests, and even to see their cardiologist. These can all be done in just a day at the hospital they are scheduled for surgery. The advantage of this is that there may be less waiting time to undergo the operation. Patients no longer have to wait for prolonged periods of time with an uncomfortable knee in need of surgery.

A health insurance feature which appeared in the Straits Times on 8th March 2008 discussed the benefits of having knee surgery Singapore. There are a few points that make knee surgery a viable option for knee problems. Although you might be frustrated with your knee problems, it is important that troubled knees and all treatment options have been thoroughly discussed with your orthopedic surgeon.

Types of Knee Surgery

Knee replacement surgery can be performed as a partial or a total knee replacement. In general, the surgery consists of replacing the damaged knee joint surfaces with metal and plastic components shaped to allow continued motion of the knee. The first recorded knee replacement surgery was performed in 1968 in England. Since then, improvements in materials and surgical techniques have greatly increased its effectiveness. Total knee replacement involves surgery on all three compartments of the knee. The surgery includes replacement of the femoral head, removal of the anterior cruciate ligament, and removal of damaged cartilage. At this time, total knee replacement is the most common and successful procedure treated on all three compartments. This surgery has produced excellent long-term results with the prosthetic joint lasting more than twenty years for 85-90% of patients. It is generally the treatment of choice for those with advanced osteoarthritis. However, there has been difficulty in defining patients who would benefit the most from a TKR. Some argue that the best candidates are those who have significant functional limitations and disabling pain. It should be noted that certain other health conditions could limit the benefits an individual might potentially gain from having a TKR. Such health conditions could include, but are not limited to: a history of sepsis in the joint, those with a marked loss of quadriceps muscle strength, those with a complex regional pain syndrome, and those with peripheral vascular disease. High weight has been considered a relative contraindication. This is because higher weight places higher loads across the knee, in which the artificial knee joint might have difficulty holding up over time. A person with a BMI of more than 25, or a person who is at least 6 pounds over their ideal weight, is at increased risk of needing a revision surgery on their knee. In this case, replacement of only one or two of the three knee compartments is more beneficial for the patient.

Total Knee Replacement

Knee replacement, or knee arthroplasty, is a common surgical procedure. Total knee replacement is a complex procedure that uses metal and polyethylene/ceramic plastic artificial knee joint to replace the full knee joint. It is generally necessary to perform a TKR operation once significant pain and difficulty walking is experienced due to arthritis. Total knee replacement is now a well-accepted treatment for severe arthritis of the knee. Over 6000 TKR operations are performed in Singapore yearly. The purpose of this essay is to outline the causes of arthritis, in detail the complex procedure of a total knee replacement, some complications which can occur, and finally the outcomes of such an operation. In knowing the outcomes and complications of the procedure, it will allow one to better understand whether they want to put themselves through such a drastic measure to help reduce their pain from arthritis.

Partial Knee Replacement

The rationale for a partial knee replacement is that the disease process in the knee is confined to a part of the joint. If the disease process in the knee is more advanced, then a total knee replacement may be more appropriate. A partial knee replacement is really a form of surgery which is resurfacing only the parts of the knee that have arthritis. The other compartments in the knee are left alone and this type of surgery is often referred to as a unicompartmental knee replacement. The advantage of a partial knee replacement over a total knee replacement is that it is a bone conserving procedure as the surgery does not involve replacement of the entire knee joint. This means that if further surgery is required in the future, the patient having undergone a partial knee replacement will have more bone stock available. Also, rehabilitation and the postoperative recovery period are generally more rapid for a partial knee replacement compared to a total knee replacement. Often the patient would be allowed to fully weight bear on the operated leg within a day or two and easily be off walking sticks or other walking aids by 2-6 weeks. Partial knee replacements generally also have a better range of motion than total knee replacements. This makes the surgery a good option for patients who have more minor knee arthritis but are limited by pain and loss of function. Younger patients with knee arthritis are a more common candidate for this type of surgery.

Arthroscopic Knee Surgery

The torn part of the meniscus is removed with a shaver. Meniscus repair is not usually possible for a tear that has occurred in someone with arthritis, as the meniscus is often too worn to be repairable. In these instances where meniscus repair is not possible, removal of the torn portion of the meniscus is still of benefit. A recent study has shown that even partial removal of the meniscus leaves the knee joint with more cushioning than if a total meniscectomy is performed. This will often lead to less pain and swelling in the knee and, more than likely, delay the onset of arthritis in the knee.

During arthroscopy, a small fiberoptic telescope a couple of millimeters in diameter is inserted into the knee joint through a small incision. This allows the surgeon to visualize the inside of the knee on a TV monitor and determine the extent of the injury to the meniscus. Other small incisions allow the surgeon to work inside the knee using pencil-sized instruments that are inserted through these small incisions.

Preparation for Knee Surgery

Preoperative assessment The surgeon will discuss your medical history and perform a thorough physical examination to assess your knee problem. X-rays, magnetic resonance imaging (MRI), and blood tests give the surgeon an overall view of your health and the affected knee. This will help to determine if your knee pain is emanating from the joint, as these tests can detect the damaged areas. If the pain is not coming from the knee joint, then knee replacement is unlikely to resolve your symptoms. If the tests reveal the pain is due to arthritis or a degenerative condition within the joint, then the MRI will allow the surgeon to determine both the extent of damage and if there is any other significant pathology that might preclude successful joint replacement. In severe cases of advanced arthritis, there may be an associated prepatellar bursitis or infection of the skin, underlying soft tissues (cellulitis), which may make it unsafe to perform joint replacement until these conditions have been treated and resolved. Joint replacement in the presence of an active infection will result in further complications, as the bacteria from the infection can travel through the bloodstream to the prosthesis, leading to a condition known as septic arthritis. This is a serious and difficult complication to treat, often requiring surgery to remove the prosthesis followed by a long course of antibiotics and a secondary joint replacement at a later date.

Preoperative Assessment

The role of medical consultation in preoperative assessment is undefined. A medical review is often required to manage conditions highlighted by blood tests or to optimize chronic medical conditions. A more controversial issue is the thoroughness of cardiac assessment required before TKA. This is considered in view of the fact that many patients with end-stage knee osteoarthritis have severe cardiac comorbidities that are managed palliatively. While numerous case reports have described significant cardiovascular complications following TKA, the cost-effectiveness of preoperative cardiac evaluation and perioperative cardiac intervention in reducing adverse events is uncertain. Use of risk indices may help clarify this in the future.

Preoperative assessment of the patient is an essential component of successful surgical management of knee osteoarthritis. In addition to history taking and physical examination, several adjuncts to the assessment are available to the surgeon. Simple tests such as full blood count, ESR, CRP, and coagulation studies can provide invaluable information on the overall health of the patient. Urine analysis and an ECG are recommended for older patients, particularly those with comorbid illness. While the predictive value of these tests for adverse events following surgery is low, they may highlight previously undiagnosed medical conditions. Identification of these conditions allows appropriate management, reducing the chance of an adverse event around the time of surgery.

Rehabilitation and Physical Therapy

Rehabilitation begins on the day of surgery. The patient is allowed and encouraged to put weight on the knee as tolerated. Pain and swelling is addressed with rest, ice, compression, and elevation (R.I.C.E.). Physical therapy is begun within the first two weeks of surgery. The first phase of therapy is aimed at reducing pain and swelling while protecting the repair. This is accomplished by elevating the leg, icing the knee, and doing small, easy exercises. In the second phase of rehabilitation (usually 3-6 weeks after surgery), the range of motion of the knee is increased to normal. This involves continuous passive motion (CPM) and physical therapy. If at any time the patient has an increase in pain and swelling, they should back off the exercises and consult their doctor. In the third phase (beginning 6 weeks post-operatively), strength is rebuilt, endurance is increased, and functional activities are emphasized. Treatment will shift from rehabilitation back to injury prevention. At this point in the rehabilitation process, patients who have had patellar tendon autografts often have pain and inflammation in the patellar tendon. This is due to the harvesting of the middle third of the tendon and will resolve with a decrease in the amount of quadriceps exercises. Simulation sports-specific rehabilitation is very important in order to have success in returning to sport. This should be done in conjunction with a physical therapist and/or athletic trainer as they will be able to provide feedback and progression of an exercise program. Heading back into the athlete-specific drills and skills too early increases the risk of re-injuring the knee or injuring the other knee. A good program of simulated activities will increase the patient’s knee function and decrease their risk of re-tearing their ACL.

Managing Expectations and Risks

Patients are often anxious to know what to expect from surgery and knee replacement is no exception. They are interested in how much it will hurt, how long the recovery will be, and whether they will be able to return to their previous level of activity. The answers to these questions are variable. It is difficult to predict how much a particular individual will be affected by pain or how long it will persist. Similarly, each patient’s recovery time will depend on how severely disabled the knee was before surgery. Generally speaking, if the patient’s knee function was quite poor, the recovery time will be shorter. However, if the patient is eager to return to a high level of activity, he or she should be prepared for a longer recovery time. High level activity usually requires pivoting and stress to the prosthesis, which is to be avoided, particularly during the first year after surgery. A frank discussion about the risks and variables that affect the outcome of knee replacement is important to align patient and surgeon expectations. It is at this time that the patient’s decision-making process is most critical. Although the decision for surgery is the patient’s in most cases, it should be an informed decision. Patients successful about knee replacement are most often those who understand its benefits and limitations and have realistic expectations about their outcome. It is not helpful to have the surgery if the patient is pessimistic about its chance of success. Finally, all surgical procedures have risks. While for knee replacement, the probability of a successful outcome that greatly relieves pain and restores mobility is quite high, there are potential complications that can have serious adverse effects on a patient’s life. A patient must carefully weigh these potential adverse effects against the expected benefits from surgery. In rare circumstances where the patient and surgeon feel that the risks of a poor outcome are too great, it might be advisable to delay the surgery.

Recovery and Aftercare

For the first several days following knee surgery, the patient may require a walker. Dressings are usually removed after 2 days and sutures after 7-14 days. Unless otherwise specified by the surgeon, knee motion is started early and the patient is encouraged to bend and straighten the knee. Icing and elevation of the leg can be helpful, especially after long periods of standing or sitting. Any severe increase in pain or swelling after the first few days should be reported to the surgeon. Most patients are walking without a limp 2-4 weeks after surgery, but may still need some type of support, such as a cane. Full recovery usually takes 6-8 weeks, at which time most patients can resume their normal activities. Evidence of improvement continues to be seen for at least a year, with the knee getting stronger and more stable. Your doctor will monitor your progress with periodic office visits and advise you when it is safe to engage in more demanding activities.

Postoperative Care

So that there is much focus on the recovery of function, exercises will be designed to enable a return to working, daily activity, sports, or recreational activity. Thus, patients are being aided back to full recovery.

An efficient range of motion rehabilitation program is likely to be prescribed which utilizes exercises and a continuous passive motion (CPM) machine. A specific exercise program similar to the following may be advised, depending on the individual and type of surgery: – Stationary cycling to improve strength and function – Leg lifts to improve quadriceps strength – Hamstring sets to improve strength and decrease anterior knee pain – Inner range quadriceps exercises

The aim of post-operative care is to aid the process of healing, to reduce the risk of infection, and to maximize the success of the operation. While in hospital post-surgery, a physiotherapist will visit and commence exercises, as well as beginning the process of independent exercises if successful. Patients are instructed on how to climb stairs with crutches, and an ascending technique is normally advised as it is less painful than descending. During the first two post-operative weeks, the patient should aim to be as active throughout the day as tolerated, to prevent joint stiffness. Patients recover faster and have less discomfort and swelling if they are mobile. Regular walks using crutches are advisable.

Rehabilitation Exercises

Rehabilitation is a slow process. You will need regular guidance and intense physiotherapy. The aim of the first few weeks is to get the wounds to heal and regain full knee extension. Start with static quadriceps exercises. Lie or sit with the legs straight, then push the back of the knees downwards into the bed or floor. This exercises the quadriceps without stressing the patella or repair. Transcutaneous electrical nerve stimulation (TENS) can be used to help regain quadriceps control. Place the pads just above and below the knee and use the machine twice a day for 20 minutes. This can start in the first week. Gentle patella mobilisations can start once the wound has healed. These are a progression of the quadriceps exercises. Sit with the legs out straight and the quadriceps tensed. Place a finger each side of the patella and then attempt to make the patella move upwards towards the hip by contracting the VMO part of the quadriceps. This exercise should not stress the patella and repair and is useful for regaining VMO control.

Long-term Follow-up

Usually, a patient will be reviewed at 6 to 8 weeks after the operation, then every 3 months for the first year, then every 6 months for the second year, then every year or as and when required. The following will take place during every patient’s visit. The dressings will be checked and a wound review will be performed to check for any signs of infection. The patient will be assessed to see whether the knee is swollen and a range of movements will be carried out by the surgeon to determine the extent of knee mobility. A check to see whether the patient is walking with a limp will be evident and the patient may be asked to walk. This assessment will help determine whether any of the muscles are weak, or whether support from a walking aid is required. A stick may be used to determine weight bearing on the knee. This is very important as patients may not even realize that they are walking in such a way and can place undue stress on the knee joint. An uneven gait (depending on which leg surgery was performed) can lead to increased stress on the other normal knee joint. The patient may be reviewed by a physiotherapist or occupational therapist to determine if they have any specific problems with regards to mobility and lifestyle. This is especially useful for patients who have had an arthroplasty and certain movements, for example sitting and getting up from a low chair, or getting in and out of a bath may need to be practiced. Finally, an x-ray of the knee joint may be performed to see how much progress has been made and review the status of the osteotomy. These assessments will determine whether the desired result has been achieved by the surgery or whether there are any underlying problems. Any discoveries at this stage may require further treatment, whether it is a change in the rehabilitation program, an administration of a steroid injection or in extreme cases a further operation.

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