Dr. Hemant Sharma
FRCS (England) MRCS (England) DNB
Specialist in Revision Lower Limb ArthroPlasty
Complex Hip, Knee and Sports Injury
To improve the patient satisfaction rate from 88%. Nowadays we have a concept of personalised alignment or functional alignment.
This is a technique of performing a knee replacement operation where we try to restore the pre-arthritic alignment of the patient. In simple words it means we try to restore the same alignment which the patient had before they developed an arthritis.
This can be done using some robotic system.
To give an example Mako, referred by Stryker, USA has the ability to perform functional alignment.
Patients who have serious medical illness like uncontrolled diabetes, those who have glycosylated haemoglobin levels of more than 8.5.
Patients who have severe osteoporosis, which means weakness of the bones which can break while performing the surgery.
Patients who have untreated infection in the urine, chest or any other parts of the body which has a chance of causing infection to the artificial joint.
Even in growing infected toenails are less factor for infection.
We need x-rays of both knees standing AP and the lateral view. We also require x-rays of the lumbosacral spine AP and lateral view, x-rays of the chest PA view is often required by the anaesthetic risks to see the fitness.
The doctors will often ask for tests which are important to check the status of the heart. These tests include simple ECG, 2D echocardiography. It is better to get a dobutamine stress echocardiogram because it is higher chances to pick up the problems in the heart.
Complete blood count, kidney and liver function test, blood group, viral marker, glycosylated haemoglobin if you are a diabetic, thyroid function test if someone is taking medicines for thyroid disease.
: Complete blood count, kidney and liver function test, blood group, viral marker, glycosylated haemoglobin if you are a diabetic, thyroid function test if someone is taking medicines for thyroid disease.
Surgeon factors This includes experience of the surgeon, his training, the volume and last but not the least good communication skills, empathetic attitude towards the patient. It is extremely important for a surgeon to understand the needs of the patient and be a good listener.
Hospital factors: The hospital should be clean, it should tailor the care according to the needs of the patient. Generally, these hospitals are opaque and have a complete set up of other specialities. It is essential to her blood bank, cardiology backup and the medical team. Physiotherapists and a good department is a must.
The food should be clean and hygienic. There should be a good facility for the attendance where they can park and rest. The hospital should be transparent in the billing procedure and should not compromise on the quality and safety of the patient.
Patient factors: The patient should be motivated enough to undergo the operation. They should clearly understand the risks and benefits of the operation. They should clarify everything from the doctor and the hospital regarding the operation and the finances involved.
Remember we as doctors are in the business of feeling people. We would want our patients to recover fast and go out of the hospital completely satisfied. Surgery is just one aspect of the treatment. There are multiple factors which I always label as X factors which make the patient happy.
Doctor would want the patient to fully understand the surgery before they commit. They are also advised to exercise. We encourage them to sit and walk almost immediately after the operation when the pain allows. They should drink plenty of water because it decreases the risk of clot in the legs and the lungs. During the initial days we elevate the leg and the pillows and the advice to the patient is to move the ankle and the toes to decrease the swelling. There is no role of bed rest.
Complete healing generally takes 3-5 months’ time. When the temperature of the knee that has been operated becomes normal, I generally tell the patient that healing is complete. Healing continues up to 18 months.
It is generally 10-15 cm.
The movement after the knee replacement operation entirely depends upon the movement before the operation. Some patients have very severe deformity and have less movement. It is recommended that patients will get 10-15° more or sometimes less than the moment they have come to the doctor?
The muscle which is in the front of the knee joint called the quadriceps, muscles behind the thigh called hamstrings, leg muscles or calf muscles and gluteal muscles commonly referred as buttock, extremely important for a faster and better recovery.
Generally, varies from 3-5 days. I am working with newer techniques and technology is for the patient at discharge same day after the operation. Unfortunately, in India, the insurance companies do not allow that.
Generally anaesthetic state and the surgeons prefer to give regional anaesthesia in which only lower limbs will have numbness. This is advantageous because patients can be pain free after the operation and also eat and drink soon after the surgery is over.
Some patients where this type of anesthesia cannot be given to undergo a general anaesthesia. To ensure that this patient does not have pain, doctors would give pain blocks.
The surgical time from incision to the closure can vary from 45 minutes to one hour 15 minutes depending upon the complexity of the operation and surgeon to surgeon.
Having said that, there is a time which anaesthetics needs. This is generally 30-40 minutes.
In addition, there is a time for cleaning of the part and draping which can take 15-20 minutes.
A patient who has complete relief in the pain and can go back to the life which he was having before the operation. Ideally, we want the implants to last lifelong but everything in the nature has shelf life.
It is very common to see in the Indian population and significant, severe deformity with bones which are smaller in size and weaker. This is because patient is generally presented late to the doctors.
Periprosthetic Joint Infection (PJI) is an infection surrounding a prosthetic joint implant, such as in knee or hip replacements. Derived from “peri-” meaning surrounding, “prosthetic” for the artificial joint, and “joint” indicating the intersection of bones, PJI signifies the invasion of bacteria or other microorganisms around this artificial joint.
Common symptoms include joint pain, swelling, warmth around the surgical area, fever, drainage from the wound, and limited mobility.
Its treatment often needs both surgical interventions, like joint cleaning called as debridement or Implant removal and putting an antibiotic coated spacer placement, with prolonged antibiotic therapy.
The importance of early detection and swift intervention is crucial.
It occurs mainly due to intraoperative contamination during surgery. This can happen despite strict clean surgical environment. Other sources include Blood(hematogenous) spread, where an infection from another part of the body reaches the joint via the bloodstream.
The list is long, those with poor immunity, malnutrition, obesity, autoimmune diseases, disease of the arteries, uncontrolled diabetes and smoking.
The ability of some bacteria to create biofilms on artificial joint makes the antibiotics impossible to reach the bacteria and treat the infection.
– Clinical examination where the patient’s history and symptoms, such as pain, swelling, and wound discharge.
Aspiration of the fluid from the joint and sending it for examination of bacteria and sensitivity to the antibiotics is also recommended.
Laboratory investigations: blood tests can detect elevated inflammation markers like CRP and ESR. In addition, culture from the blood and urine can also help us in finding out the source of infection.
A radiological investigation such as ultrasound scan, x-ray, MRI scan, bone scan can also help us in detecting infection because it causes some changes in the soft tissues and the bone.
Starting broad-spectrum antibiotics till we do not have the appropriate results of the culture is often done. Specific antibiotics are started if we know the bacteria and the sensitivity of the bacteria.
If the infection is detected before 4 weeks, the surgeon will clean the joint in the operation theatre and sometimes change the plastic liner in the knee replacement as well as a head of the femur in case of a hip replacement.
If the infection is chronic or old, the doctor will remove the implant and put antibiotic spacer for minimum of 3 months duration.
Generally, it is use for 3 months. Once the blood tests become normal and the patient’s clinical symptoms have improved, a second operation is required where this antibiotic spacer is removed, and a new implant will be inserted.
Before the surgery it is essential to manage the potential risk factors such as controlling the blood sugar levels, checking the urine for any infection, ensuring that there is no other source of infection in the body.
Smokers have higher chances of getting joint infection.
Sometimes dental infection can be a potential cause.
Use of antibiotics before and after the operation.
Clean-air operation theatre.
Maintaining and hygiene protocol after the operation. Avoiding unnecessarily visitors in the hospital.