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Robert Afra MD, Orthopedic Surgeon, Total Knee Replacement Surgery, San Diego, CA

TOTAL KNEE REPLACEMENT

Orthopedic Surgery San Diego is a well-established orthopedic clinic in San Diego, CA delivering comprehensive orthopedic care to our patients in San Diego and surrounding areas. Our Total knee replacement service in San Diego is provided by expert surgeons, physiotherapists, and nurses. They’ll tailor a treatment and care plan to meet your needs and help you to get the most from your operation.

What is Total Knee Replacement?

Total knee replacement, also known as total knee arthroplasty, is a surgical procedure in which a damaged or worn-out knee joint is replaced with an artificial joint or prosthesis. This procedure is commonly performed to relieve pain and restore function in individuals with severe arthritis or other conditions that affect the knee joint.TKA aims to improve the quality of life of individuals with end-stage osteoarthritis by reducing pain and increasing function and was found to improve patients’ sports and physical activity. The number of TKA surgeries has increased in developed countries, with younger patients receiving TKA.

Preoperative Optimization for Total Knee Replacement

Introduction

Adequate preoperative preparation and optimization is crucial for safe Total Knee Replacement or total knee arthroplasty (TKA) and good postoperative outcomes. Key elements include medical management, physical conditioning, patient education, and social support planning. Addressing modifiable risks preoperatively can reduce complications after Total Knee Replacement surgery.

Medical Risk Factor Optimization

Comorbid conditions like obesity, diabetes, hypertension, smoking, and anemia should be medically optimized. Losing weight, improving glycemic control, regulating blood pressure, smoking cessation, and iron supplementation all help reduce perioperative risks. Anticoagulation management is planned.

Nutritional Optimization

Protein intake and vitamin levels are screened and treated to help wound healing. Albumin levels predict outcomes. Malnutrition risks are addressed via diet, supplements, or referrals. Preoperative carbohydrate loading prepares metabolism for surgery and may reduce insulin resistance.

Total Knee Replacement San Diego

Physical Conditioning

Improving flexibility, muscle strength and endurance preoperatively enhances functional recovery. Aquatic therapy, home exercises, neuromuscular training, and gait aids expedite mobility gains after surgery. Stopping high-impact activities preoperatively also protects the joint.

Medication Management

Anti-inflammatory medications are typically held 1-2 weeks before surgery to reduce bleeding risks. Aspirin may be continued for cardiac patients. Reviewing supplements for their potential interactions is prudent. Pain medications are weaned appropriately.

Patient Education

Providing information on preoperative care, the procedure, rehabilitation stages, and expectations helps reduce anxiety while promoting participation in recovery. Clarifying restrictions, precautions, and follow-up needs ensures readiness.

Social Support Planning

Identifying family members or friends who can provide transportation to appointments, assistance at home, and emotional encouragement optimizes the support system. Preparing the post-discharge home environment also facilitates rehabilitation.

In summary, preoperative Total Knee Replacement surgery preparation encompasses medical, physical, educational, and social dimensions. Addressing modifiable risks and enlisting social support improves patient outcomes during the surgical episode of care. Thorough preoperative optimization is invaluable.

Surgical Steps for Total Knee Replacement

Introduction

Total Knee Replacement or Total knee arthroplasty (TKA) aims to resurface damaged articulations and recreate stable, pain-free motion in end-stage knee osteoarthritis. Precise surgical technique and execution are vital for clinical outcomes and implant longevity. The basic steps include exposure, bony resection, component placement, fixation, and closure.

Exposure

A midline skin incision and medial parapatellar arthrotomy allow exposure of the joint. The patella is retracted but not everted. Lateral releases balance the soft tissues. Visualization of the diseased surfaces and axes guides resection.

Femoral Preparation

Distal femoral cuts are made first based on flexion/extension gaps. An intramedullary guide aligns the distal femoral resection perpendicular to the mechanical axis in the coronal and sagittal planes. The posterior femoral condyles are then resected, creating a rectangular flexion space.

Tibial Preparation

Extramedullary tibial guides help achieve a 90 degree resection perpendicular to the tibial axis. The tibial slope matches the natural posterior inclination. Resection depth leaves a uniform rim of bone for cement fixation. The tibia is sized and prepared for the implant.

Patellar Resurfacing

The native patellar thickness determines the amount resected to avoid overstuffing. Diseased cartilage is removed, leaving subchondral bone. Smooth cuts avoid fractures. Insetting the component avoids patellar maltracking. Resurfacing reduces anterior knee pain.

Trialing and Final Components

Trial inserts establish balanced flexion and extension spaces. A trial reduction tests motion and alignment. Measurements guide any adjustments needed before final component implantation. Permanent components are cemented or press-fit based on fixation choice.

Closure

The arthrotomy is closed, followed by deep dermal and skin closure. Local anesthetics are injected around the joint. Sterile dressings and compressive bandages are applied to complete the procedure.

In summary, precise bone cuts, soft tissue balancing, and methodical trialing allow accurate placement of TKA components in proper alignment for pain relief and restoration of function. Attention to each step optimizes clinical outcomes.

Robotic vs Traditional Total Knee Replacement

Introduction

Robotic systems have been introduced in Total Knee Replacement or total knee arthroplasty (TKA) to improve component position and surgical precision. Multiple randomized trials now allow the comparison of robotic-assisted Total Knee Replacement to conventional techniques.

Component Alignment

Robotic Total Knee Replacement results in fewer knee alignment outliers compared to traditional methods based on postoperative imaging. Robotic assistance reduces variance from desired alignment goals, with fewer knees falling outside the targeted coronal plane range. This could enhance implant survival.

Soft Tissue Balancing

Some robotic platforms quantify ligament tensions and gaps to help balance flexor and extensor mechanisms. This could optimize contact stresses and patellar tracking compared to traditional manual balancing. However, effects on functional outcomes are unclear.

Surgical Invasiveness

Existing robotic Total Knee Replacement systems require larger incisions for bone referencing and robot arm positioning. Increased surgical dissection could raise risks of pain and complications compared to minimally invasive surgery. Comparative injury rates are not yet well studied.

Functional Outcomes

Early data shows robotic Total Knee Replacement provides similar functional improvement and pain relief by 6-12 months postoperatively compared to conventional TKA.5 Range of motion and gait parameters are also comparable between techniques. Long-term monitoring is still needed.

Revision Rates

The impact of robotic TKA on implant survivorship and revision rates is not yet known, given its relatively recent development. Theoretically, improved position and balancing could reduce wear and failure. However, no long-term revision comparisons exist to date.

Cost-Effectiveness

Robotic systems involve high capital, disposable, and service costs. The charges add thousands of dollars per case compared to traditional Total Knee Replacement methods. It is unclear if the clinical benefits of robotics justify the added expense for hospitals and payers.

In summary, robotic guidance improves component positioning in Total Knee Replacement but long-term superiority over conventional techniques remains unproven. Comparative functional outcomes, complications, revision rates, and cost-effectiveness require further study to justify routine adoption of robotic platforms.

Postoperative Physical Therapy After Total Knee Replacement

Introduction

Physical therapy is crucial after Total Knee Replacement or total knee arthroplasty (TKA) to help patients maximize function and outcomes. Evidence-based rehabilitation protocols progress through phases focused on protection, mobility, strength, and conditioning. Compliance with physical therapy is associated with better recovery.

Early Postoperative Phase (0-2 weeks)

Early emphasis is on reducing swelling and pain while restoring range of motion. Use of cold therapy, compression, elevation, and ambulation help limit edema. Passive range of motion exercise is initiated, focusing first on knee extension. Muscle activation and re-education begin with quadriceps sets and straight leg raises. Weightbearing is restricted initially.

Intermediate Phase (2-6 weeks)

As pain and swelling subside, active range of motion exercises and muscle strengthening progress. Closed chain exercises like mini-squats are introduced. Resistive exercises increase lower extremity strength and power in a functional position. Crutches are weaned and normal gait patterns retrained. Cryotherapy continues for pain and effusion.

Advanced Phase (6-12 weeks)

Advanced strengthening and conditioning prepare patients for higher level activities. Eccentric step-downs, lunges, and balance drills improve stability and proprioception. Light sports-specific actions rehearse pivoting, cutting, and jumping. Criteria for discharge include pain control, strength and motion recovery, and independence with activities.

Long-Term Considerations

Continued adherence to hip and core strengthening, cardiovascular exercise, and neuromuscular training helps maintain outcomes from Total Knee Replacement over years. Weight management optimizes joint loading. Preventing other joint problems promotes lifelong activity. Periodic follow-up helps track function. Most patients see benefits for 15-20 years postoperatively.

In summary, rehabilitation progresses through phases focused on mobility, strength, conditioning, and skills training. Patient participation is key for optimizing outcomes after Total Knee Replacement surgery. Physical therapy facilitates lasting functional gains.

Long-Term Infection Prevention After Total Knee Replacement

Introduction

Periprosthetic joint infection (PJI) is a devastating complication after Total Knee Replacement. Strategies for preventing late hematogenous infections are important for maintaining implant longevity. Basic principles include maintaining immunity, monitoring for infection, treating comorbidities, and appropriate antibiotic use.

Routine Health Maintenance

Annual influenza vaccination and staying current on other immunizations is crucial to avoid infectious illnesses. Good nutrition and physical activity support the immune system. Regular healthcare can detect and treat conditions early. Ongoing medical management of comorbid diseases also helps prevent infections.

Dental Care

Routine dental cleanings and procedures help maintain gingival health and avoid bacteria entering the bloodstream. Informing dentists about the Total Knee Replacement can guide antibiotic selection if needed. Some guidelines call for antibiotic prophylaxis prior to dental work within the first 2 years after Total Knee Replacement.

Prompt Infection Evaluation

Any signs or symptoms of infection warrant prompt investigation, including persistent fever, swelling, wound drainage, or joint pain. Bloodwork, joint aspiration, and imaging can diagnose an infection early when it is most treatable. Close follow-up ensures infections are not missed.

Prudent Antibiotic Use

Antibiotics should be used judiciously after Total Knee Replacement only for proven infections to avoid resistance. Empiric antibiotic courses without a definitive diagnosis can miss the optimal therapeutic window. Culture-directed antibiotic selection is preferred.

Skin Care

Careful cleansing and protection of open wounds, skin ulcers, or infections remote from the Total Knee Replacement prevent seeding deep infections. Small cuts should be monitored for signs of infection and treated promptly. Good hygiene is important.

In summary, maintaining wellness and immunity coupled with early infection detection optimizes prevention of late TKA infections. Patient education on precautions and prompt reporting of symptoms is key for successful long-term arthroplasty results.

Patient-Specific vs Kinematic Alignment in TKA

Introduction

Two techniques aim to improve alignment in total knee arthroplasty (TKA): patient-specific instrumentation and kinematic alignment. Each uses different principles to better replicate native anatomy and knee function. Prospective studies allow comparison of their relative merits.

Patient-Specific Instrumentation

Preoperative MRI and long-leg films generate cutting guides customized to the individual’s anatomy. Theoretically this provides more accurate, reproducible alignment versus standard instruments. However, outliers still occur due to technique errors. Costs and surgical time are increased with little proven benefit.

Kinematic Alignment

The goal is aligning components to restore native joint lines and ligament tension. More physiologic tibiofemoral rotation and patellofemoral tracking are achieved. Early functional results are improved, though impact on implant survival is unknown. It remains a challenging technique.

Surgical Duration

Both techniques prolong the surgical procedure. Kinematic TKA requires extensive soft tissue releases and measurements. Patient-specific guides still require intraoperative confirmation and adjustments as needed. The learning curve extends operative time.

Alignment Outcomes

Kinematic alignment shows promising reductions in variance from normal axes compared to mechanical alignment TKA. Patient-specific guides yield high early variability in studies as surgeons gain experience. Kinematic principles may yield more consistent results.

Clinical Function

Kinematic alignment aims to improve function, though effects on gait and strength have been variable. Some trials show earlier recovery versus mechanical TKA. Comparisons to patient-specific instrumentation have not shown differences in functional scores or range of motion.

Conversion Rates

Kinematic alignment has a high rate of intraoperative crossover to conventional alignment when ligament releases fail to adequately balance the knee. Patient-specific guides function as cutting blocks so do not have conversion issues, but alignment may still be suboptimal.

In summary, both new techniques aim for more anatomically aligned TKA. Kinematic principles show early promise to improve function but remain challenging. Patient-specific guides have not proven superior despite higher costs. Long-term implant survival data is needed.

Functional Outcome After Total Knee Arthroplasty

Introduction

The primary goal of total knee arthroplasty (TKA) is restoring function to improve mobility and allow participation in activities. Prospective studies consistently show significant functional gains after TKA for knee osteoarthritis. However, the magnitude of improvement varies based on multiple factors.

Baseline Function

Patients with poorer preoperative function and higher disability demonstrate the greatest improvements in outcome scores after surgery. Those with very advanced disease due to severe pain and stiffness have more room for functional gain. Milder preoperative disability correlates with smaller gains.

Comorbidities

Comorbidities like heart and lung disease, diabetes, and obesity negatively impact functional outcomes from TKA. Systemic health challenges make rehabilitation more difficult. Addressing comorbidities preoperatively helps optimize functional recovery.

Preoperative Expectations

Patients with higher preoperative expectations and more positive psychological outlooks toward TKA experience better function postoperatively. Motivation strongly influences effort invested in recovery. Unrealistic expectations beyond average results can also lead to disappointment.

Postoperative Complications

Surgical complications like arthrofibrosis markedly reduce postoperative TKA function. Other complications such as persistent pain, instability, infection, and venous thromboembolism also negatively impact functional outcomes. Avoiding adverse events is key.

Rehabilitation Compliance

Patients who actively participate in and adhere to postoperative rehabilitation have substantially higher functional gains from 6 weeks to 2 years after surgery. Compliance with exercise and mobility activity maximizes results.

In summary, patients with worse baseline function and fewer comorbidities tend to experience the greatest functional improvements from TKA. However, controlling expectations, avoiding complications, and commitment to rehabilitation play pivotal roles in optimizing individual outcomes.

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© 2023 Dr. Robert Afra – San Diego Orthopedic Surgery Shoulder – Knee – Elbow

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