Knee Replacement Surgery: Relief from Chronic Knee Pain

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There are 3 main types of knee replacement operations: total knee joint replacement, knee joint resurfacing, and a replacement of just the femoral or patella. The last one of these is not often recommended and there is less evidence in the literature to show that it provides good results in pain relief and increase in mobility compared to the other two.

The operation consists of shaping the ends of your thighbone and shinbone. An artificial piece is attached to the thighbone, which is usually made of metal, and finally a polyethylene plastic, and also a metal plate that holds the plastic or a plastic cup is attached to the shinbone and its end. In some cases, there is only knee joint resurfacing on one side of the knee and this is sometimes treated with what is known as a half replacement where only one side of the knee is resurfaced. In conclusion, there can be a total knee joint replacement where both sides of the knee are resurfaced. This is usually a safer operation than the partial replacement as the rate of complications is lower and there is better success for reduction of pain and improvement in mobility that results in increased quality of life.

A knee replacement (also called knee arthroplasty) may be a cure for those with terminal knee osteoarthritis. Your surgeon removes injured fragments of bone from your shinbone and thighbone. This is usually a final resort treatment when all other strategies have been exhausted. Often people do not opt for knee replacement until the pain has disabled their mobility and they are performing poorly in jobs and other treatments to minimize pain.

Overview of knee replacement surgery

Knee replacement is a surgical procedure to resurface a knee damaged by arthritis. Metal and plastic parts are used to cap the ends of the bones that form the knee joint, along with the kneecap. This surgery may be considered for someone who has severe arthritis or a severe knee injury. The main benefit of total knee replacement is the reduction of pain. This is the most common reason people have the surgery. At the same time, people want to keep or regain movement in their knee. Finally, for some people the way the knee looks or feels is reason enough. The idea of a knee replacement operation can be frightening. Many people have the idea of orthopedic surgery based on the experience of their parents’ generation. Knee replacement has become more and more refined in recent years. This means fewer and fewer people can remember seeing a relative go through a long recovery with a significant scar and irregular mechanical function of the artificial knee. Satisfaction is generally very high. Candidates for substantially advanced knee arthritis are quite predictable. The diagnosis is normally made on the basis of symptoms alone and confirmed by x-rays. There are possible considerations of age and weight in deciding the best timing for surgery. Written by: Jonathan Cluett, MD, a private practice orthopedic surgeon specializing in hip and knee replacement in Jacksonville, Florida. Please note: Cluett’s professional information has been updated to reflect his current status as of April 2013.

Causes of knee pain at night

Osgood-Schlatter is self-limiting and will resolve on its own without any treatment once the child stops growing and the growth plate closes. However, a great non-surgical treatment for pain relief is, of course, the use of ice and anti-inflammatories, and the knee can be supported with a knee brace, especially overnight, to prevent involuntary stretching of the knee and exacerbation of the symptoms.

Another cause of knee pain at night is a condition called Osgood-Schlatter disease. This generally only affects children, especially those who participate in sports. It is caused by the constant pulling of the patellar tendon on the growth plate of the shin bone. What happens is the body, in turn, tries to heal this injury during sleep when a lot of general healing occurs, and thus the area becomes inflamed and painful.

There are several potential causes that can lead to knee pain at night. It may be something as simple as sleeping in a position that is not conducive to knee health, which can be prevented by using a pillow to support the knee. This can help with a number of conditions, and if the knee is simply sore from an injury, it may prevent vivid dreams involving the knee to alleviate the pain during the day.

Knee Replacement Surgery

Preparing for knee replacement surgery In the time leading up to surgery, there are several things you can do to prepare your home and help plan for your recovery after the operation. This can help ensure a smooth transition, making the process of rehabilitation and overall recovery as easy as possible. Simple things such as rearranging furniture to create more room, purchasing necessary groceries, and arranging for someone to help you during the initial days of discharge can help greatly. This will decrease the likelihood of accidents and help to make your experience more comfortable. Getting into the habit of using a cane or walker prior to surgery will also help to increase your mobility and decrease the risk of falls after your operation. It is also important to address any major dental problems and/or infections in order to decrease the risk of infection after joint surgery. This is important, as there is a direct correlation between infections in the teeth and gums and knee infections after surgery. Finally, finding ways to modify work life or home responsibilities is important to consider. Many individuals find it helpful to take a leave of absence from work in order to have adequate time to recover.

Knee replacement surgery can help improve the quality of life of the individual who undergoes the procedure. It is recommended for individuals who suffer from chronic knee pain that affects daily living and does not respond to conservative treatments or medication. Pain at rest or at night, severe pain that limits everyday activities, a deformity, and knee stiffness are some of the reasons an individual may consider knee replacement surgery. To decide whether or not to have knee replacement surgery, the individual and the orthopedic surgeon must take into account the activity level, age, and overall health status. Duration and severity of the pain as well as the extent of the damage to the knee joint are also important factors to consider.

Preparing for knee replacement surgery

When a patient and their doctor have decided that surgery is the best option, there are several steps that the patient can take to prepare. First and foremost, the patient may be asked to have a complete physical by their primary care doctor before the surgery. The results of their physical examination, blood tests, and electrocardiogram will be sent to the orthopedist to make sure that the patient is healthy enough to undergo surgery. The orthopedist may also suggest that the patient donate some blood that will be given back to them during the surgery. This will be used if the patient needs a blood transfusion during the surgery or after it. The doctor may also have the patient see a medical physician before surgery to obtain medical clearance for surgery. The orthopedist may also request an evaluation and treatment by a physical therapist. This will help determine the patient’s physical status before surgery so that therapy can be continued after surgery. The therapist may be able to teach the patient some exercises that can be done before surgery to help strengthen the knee, which will help with recovery after surgery. The patient can also meet with the physical therapist after surgery to learn how to properly use an assistive device and to learn proper ways to go up and down stairs and to get in and out of a chair.

The procedure of knee replacement surgery

This can be done under either general anaesthetic (where you are put to sleep) or by an injection in your spine, known as an epidural. The operation usually takes 1 to 2 hours. The surgeon will make a cut down the front of the knee, exposing the kneecap. This is then moved to the side so that the end of the thigh bone is visible. The end of the thigh bone is then cut flat and the same is done to the top of the shin bone, removing the arthritic bone and any uneven or excessive bone so that the new artificial knee joint can be fitted accurately. This is usually carried out using a power tool. The surgeon then has to decide whether to use fixed or mobile bearings. A bearing is the part of the knee joint that provides a smooth surface over which the other artificial joint parts can glide. Fixed bearings are attached to the end of the thigh bone or top of the shin bone, whilst the mobile bearing sits inside a shallow plastic socket. This plastic socket is usually fixed into the bone with bone cement. Both varieties can provide good results. The thigh and shin bone are then prepared to receive the artificial joint. In the case of fixed bearings, this usually involves making a box-shaped hole. The artificial joint is made from metal alloys, ceramic material, or strong plastic. Fixed bearings may be attached using bone cement or press fit. Mobile bearings are attached using press fit only. The type of joint used will depend on patient factors and surgeon preference. The lower part of the artificial joint is usually very strong plastic and this acts as a shock absorber, so that the joint is not rigid and functions well when walking.

Recovery and rehabilitation after knee replacement surgery

Dedication to regain your ability to walk is critical to a successful recovery. The full benefits of your surgery will only be realized if you are willing to push yourself during physical therapy and make sacrifices to protect your new knee. During your hospital stay, physical therapists will give you exercises to improve strength and mobility in your new knee. Measures to prevent blood clots and infection will continue. You will start self-administered blood thinner and be given antibiotics. X-rays may be taken to ensure the knee is in the correct position. Once your knee is healed enough to the point where it is safe to bend, and the swelling is starting to decrease, you will be able to leave the hospital and continue your rehabilitation at home.

Now let’s look at what happens after the knee replacement surgery. Depending on the condition of your knee and your overall health, your hospital stay will be 2-3 days. The anesthetic will have worn off by the time you wake up, and you will likely feel a good amount of pain for which the hospital staff can give you medication. Your new knee will be bandaged, and there may be a tube near the wound to drain blood. Physical therapy will begin right away to help in getting you to move around. You will be helped out of bed and into a chair on the day of your surgery and will be walking with a walker or crutches the next day.

Treatment for Knee Pain at Night

Options for knee pain at night treatment will depend on the underlying cause. Help is available, whatever the reason. If the pain is due to overuse or a recent injury, often the best treatment is to apply ice to the knee and to take an anti-inflammatory medication, such as ibuprofen. The R.I.C.E. formula – rest, ice, compression, and elevation – can help alleviate the pain relatively quickly if the pain is due to a minor injury. Resting the knee may be necessary for a couple of days to avoid making the injury worse. In more severe injuries, or those that do not resolve with the R.I.C.E. formula, a knee brace or other supportive device and physical therapy may be indicated. If the problem is chronic, the treatment will often involve controlling the arthritis. This can be done with the R.I.C.E. formula and an anti-inflammatory medication. Sometimes injections of cortisone or of a viscous supplement to the joint can be helpful. Several viscosupplementation products are currently available; these include Synvisc, Hyalgan, and Supartz. All are delivered as a series of injections to help provide pain relief for osteoarthritis of the knee. If non-operative measures fail to alleviate the pain, your orthopaedic surgeon may recommend a total knee replacement.

Non-surgical options for treating knee pain at night

R.I.C.E usually is the right thing to do after aggravating a painful knee. Doing R.I.C.E towards the evening and before bed can have good effects. Do this at least 30 minutes before bed so inflammation, if increased during, can subside before sleep. Rest the knee and try not to stand up too much and put too much pressure on it. The knee should also be well supported as to not stress the knee and cause further pain. This may be done with a compression bandage or sleeve. If the knee has joint swelling, rest is more important than movement and applying the ice packs for 10-15 minutes several times is advised. Compression helps prevent fluid build-up and decreases swelling. ACE wraps should be applied starting from below the painful area and working upward. They should not be looped above the knee as this can impede circulation and cause swelling below the knee instead. Ice is generally advised to be applied for 20 minute periods, but given the knee’s size, the time may need to be extended. Be aware that numbness, tingling or changes in skin color should not occur, as this indicates the ice is too cold and/or the knee is having adverse reactions to the cold. If the knee is sensitive to cold, an ideal is to ice 20 minutes on and 40 off. Finally, elevation helps prevent swelling and should be done while ice is not in use. The knee should be above the level of the heart and extra pillow support can be used to ensure that the leg does not roll off the support and cause discomfort. Remember that delaying the extra pillow and having the leg below the heart can cause more swelling as the blood and fluid will pool in the joint.

Using a pillow between the knees is not unlike sleeping with a bolster for support, but it helps with minimal or no joint compression. Select a relatively firm pillow to ensure its support under pressure. A thicker pillow offers more cushion and can spread the legs farther, making it a better choice for those who don’t have any problems moving and separating their legs. Side sleepers can also tuck a small pillow between the box spring and the mattress. This pillow can prevent twisting and sinking of the lower leg and knee. Placing a pillow under or around the painful area relieves pressure and decreases pain. The pillow should be big enough that the painful area is partially sitting on the pillow, thus taking some weight and pressure off the joint. Wrapping plastic bags filled with water and ice in a towel or cloth warms to room temperature by morning and can be used to ice the knee. These makeshift ice packs will conform to the knee, offering better comfort and better coverage than traditional ice packs. Keep extra cloth or a towel underneath the knee so no moisture condensation forms on the skin, which can make the area feel cold, wet and uncomfortable.

Medications for relieving knee pain at night

Unfortunately, knee pain tends to be most severe at night, preventing many from sleeping well. This leads to fatigue and increased pain the following day as individuals lack the rejuvenation that sleep provides. However, there are several methods for managing knee pain at night, starting with medications. Medications can be divided into those that provide pain relief, such as NSAIDs or analgesics, and those that help to control inflammation. Over-the-counter NSAIDs (non-steroidal anti-inflammatory drugs) include ibuprofen (Advil, Motrin) and naproxen (Aleve); these medications can be very effective in relieving both pain and inflammation and are generally safe. Chronic use of NSAIDs can irritate the stomach and affect kidney function so anyone with significant medical problems should check with their doctor before using these medications. Acetaminophen (Tylenol) is an analgesic and can help with mild pain but is not effective in reducing inflammation. It is safe and a reasonable option for those with mild knee pain. Step two in oral pain medications is the use of prescription NSAIDs or COX-2 inhibitors, many of which have recently been removed from the market. COX-2 inhibitors have been shown to be as effective as over the counter NSAIDs and are less likely to irritate the stomach. However, one study comparing Celebrex to ibuprofen found no significant difference in GI problems between the two drugs. All NSAIDs carry a black box warning about increased risk for heart attacks and strokes. So, while they are effective in relieving pain, it is important to use them in moderation. This is especially true for those with cardiovascular risk factors, such as high blood pressure, high cholesterol, diabetes and smoking. If use of these medications is needed for moderate to severe pain, it is reasonable to consult with a physician and monitor overall health while taking them. For those with severe pain unrelieved by other medications, short-term use of narcotics can be effective. However, narcotics can affect mood, are habit forming, and carry several side effects, so they are not a first line treatment for knee pain at night.

Physical therapy exercises for managing knee pain at night

Straight leg raise: Increase the strength in your quadriceps muscles by continuing to sit with your good leg bent and the leg with knee pain out straight. Tighten the muscles on the top of your thigh and lift your leg 6 inches off the ground. Hold for 5 seconds and slowly lower. Repeat this 10 times.

Quadriceps setting: Sit with your leg out straight and the back of your knee resting on a towel roll. Push the back of your knee down into the towel, tightening the muscles at the front of the thigh. Hold for 5 seconds and repeat 10 times.

Physical therapy exercises are an effective way to help manage knee pain at night. It is important to ensure the muscles around the knee are strong, and at the same time the range of motion is appropriate and not too excessive. A physiotherapist is able to provide a specific program that has been tailored to the needs of the individual. The following exercises are a general guide only and should not be attempted without professional advice.

Lifestyle changes to alleviate knee pain at night

The final adjunct to treating knee pain at night is alleviating the pain enough to sleep. Deep, uninterrupted sleep is when tissue healing and repair occurs. If pain causes frequent awakenings or difficulty falling asleep, the following tips may help: Adjust the times when you are taking your NSAIDs (anti-inflammatory medications). If you are taking them just once a day, try switching to twice a day, but be sure this is under the guidance of your physician. Some patients find taking them an hour before bedtime helps calm the pain enough to sleep. Ice the knee for 10-20 minutes prior to retiring for the night. This may help calm heightened pain and inflammation from the day’s activities. Finally, if your sleep is frequently disrupted or non restorative due to pain, see your physician to further evaluate the underlying cause of the pain. Be assured of one thing, with the right steps, the vast majority of patients are able to overcome the frustration of knee pain at night. By taking a systematic approach to the cause of the pain and through targeted remedies, it is reasonable to expect improved sleep and a more pain-free existence during the overnight hours.

It can be safely stated that, with the emergence of modern surgical procedures and improved post-operative care, patients undergoing total knee replacement can expect a good quality of life and pain relief. A significant amount of research has emerged suggesting that a patient’s quality of life can be predicted at 5 years after surgery and long-term success can be achieved through the usage of joint-specific measures as well as general health measures. However, the pre-operative patient who experiences pain at night appears to have a poorer quality of life after surgery. This is of concern, with night pain being an independent predictor of a poor quality of life 2 to 5 years after TKR. This indicates that the nature of nocturnal pain is different from daytime pain. Future research into understanding night pain and its provision of pain relief has the ability to improve the quality of life of patients who undergo TKR. To date, research has not extensively investigated the use of pharmacological treatment on pain at night in patients with osteoarthritis of the knee. Studies into the effectiveness and safety of these methods of pain relief would be of benefit to patients. Management of nocturnal pain needs to be incorporated into the overall treatment program for knee osteoarthritis and specifically pre-operative patients who are considering TKR. By improving our understanding of the nature of nocturnal pain and provision of effective treatment, we can improve the quality of life of patients suffering from arthritis of the knee. This will have beneficial effects on patients who are or those who are considering total knee replacement.

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