KNEE CLINIC

Dr Mallinath G

MBBS, MS Orthopedics [AIIMS] Fellowship in Joint Replacement [AIIMS]

CONSULTANT KNEE SURGEON

Dr Mallinath G is a consultant in the Department of Orthopaedic Surgery BGS Global hospital Banglore. He did his MBBS from Mysore medial college Mysore. He was topper at AIIMS, PGI, GIPMER and all India PG entrance examination in first attempt. He did his post graduation at prestigious All India Institute of Medial Science [AIIMS] New Delhi. After obtaining his degree of Master of Surgery in Orthopedics, he was selected for joint replacement fellowship in AIIMS. He then joined senior residency at AIIMS. He has made numerous paper presentations at national and international conferences. On returning to Banglore he joined the Hosmat Hospital, as a Consultant Orthopaedic Surgeon. He has a particular interest in ligament reconstruction of the knee, knee carilage transplantaion, arthroscopic surgery, knee deformity correction, treatment of knee fractures and knee replacement. He is also interested in pediatric knee and foot deformity correction.

Consultation: Amrutha Orthopaedic Care AGS layout Banglore-61

BGS Global Hospital,Kengeri Banglore-60

Phno-9945104397

Procedures

commonly performed are Total knee replacement (TKR), High flex TKR, Minimally invasive TKR, Hip resurfacing, THR, Proxima hip, arthroscopic ACL reconstruction, lateral-release. Tibial tubercle transfer, meniscal surgery, high tibial osteotomy are other procedures. Young individuals suffering from articular cartilage injuries and chondromalacia patella are offered arthroscopy and a reconstructive cartilage procedure. These are abrasion chondroplasty & micro fracture.He is also interested paediatric knee and foot deformity correction.

Osteoarthritis of knee

It is generally disease of advancing years. It is also called degenerative joint disease. In early stages affects mostly the cartilage.

Causes

• Advancing age

• Obesity makes it worse

Obesity ® increased stresses across the joint ® increased frequency of OA

• Damage to joint cartilage

• Genetic predisposition

• Metabolic

Suspect OA of Knee if…

• Stiff, swollen, painful joint

• Difficulty In walking & on stairs, getting out of chair and bed

• Need support while walking – holding railings, wall, stick, etc.

• Intermittent course of symptoms with remissions or good periods

• Loss of movement and deformity at the joint indicates advanced stage of disease

X-ray

• Show the extent of cartilage damage

Treatment of Osteoarthritis

• Exercise

• Weight control

• Rest and joint care

• Pain relief techniques

• Medicines

• Alternative therapies

• Surgery

Exercise

• Improves muscle strength to control joint position and protects ligaments

• Decreases pain

• Increases flexibility

• Maintain weight

• Improve mood and outlook

• Promote general physical fitness

“Inexpensive and has no side effects”

Rest and Joint care

• Regularly scheduled rest

• Learn to recognize body signals and know when to stop or slow down

• Prevent pain of over exertion

• Relaxation techniques and stress reduction

• Canes and splints to protect joints and take pressure off them

• Use splints only for limited period ® need to exercise to keep muscle strength

Rest and Joint Care

• Avoid movement that is lost like squatting

• Avoid low beds, chairs, and toilets, elevate them when possible

• Wear properly fitted shoes with well-cushioned soles.

• Avoid continuous standing, walking and stair climbing for longer period. You can do everything just few minutes less.

• Use ramps or elevators. If you must use stairs, take them one at a time, stopping occasionally to rest.

Non Drug Pain Relief

• Warm towel

• Hot packs

• Warm bath or shower

• Cold packs in some cases

(Acute exacerbation)

• Water therapy in a heated pool or whirlpool

Medicines

Paracetamol

Primarily a pain reliever
Less long term side effects
Should be used cautiously with liver disorders and heavy alcoholics

Other drugs

Ibuprofen, Diclofenac, Nimesulide

Intra articular steroid injection

- Temporary measure

- Not more than once a year

Hyaluronic acid injection – effective in some persons

Total Knee Replacement

It is a surgical procedure in which parts of the knee joint, that have been damaged, usually by a form of arthritis, are replaced with artificial parts. It is usually considered when other, non-surgical methods of treatment (i.e., activity modification, weight loss, medications and injections) have failed to relieve arthritis-associated knee pain.

Resuming Normal Activities

• Will be able to walk on 2^nd day with support.

• Avoid driving for 6-8 weeks

• Can sleep comfortably on your back, either side or face down

• Can return to work in 8-10 weeks depending on the type of work

Discuss treatment options with your doctor.

Total knee replacement

Pre operative evaluation: we will systematically evaluate patients before operation and it includes.

History-discuss symptoms, other medical problems, any medications taken, allergies.

Physical examination-includes observation of the knee area, assessment of gait, palpation and other manual tests of the knee.
Imaging studies-X-rays of the knee from multiple angles
Laboratory studies-May includes blood count, electrocardiogram, chest x-ray, and urine culture.

THE PROCEDURE — the procedure is performed in an operating room after the patient receives general, spinal, or epidural anesthesia. The patient is given antibiotics to reduce the risk of developing an infection. An incision is made to expose the inside of the knee joint. The bone and cartilage on the lower end of the femur (thigh bone) and upper end of the tibia (shin bone) are removed. The replacement (prosthetic) joint, usually made of metal and plastic, is then implanted.

AFTER SURGERY

Pain management:

Postoperative management includes controlling pain with intravenous or oral medication. Many joint replacement patients are given "patient-controlled analgesia". This gives pain medication through an intravenous line (IV) in the hand or arm. Patients are able to control, within preset limits, when a dose is given.

A blood-thinning medication such as low molecular weight heparin will be given to help prevent blood clots in the legs.

Rehabilitation:

Most patients spend seven to ten days in the hospital, during which they work with a physical therapist to develop an exercise and rehabilitation program. Most patients will be able to walk on 2^nd day with support.

Potential complications:

Joint replacement surgery has a high success rate. However, like any operation, joint replacement surgery is not without risk.

Thromboembolism

Inflammation, swelling, and lack of movement of the legs increase the risk of a blood clot forming in a vein (thrombosis).

Infection

Infection following knee replacement is a relatively uncommon but serious complication.

Others: loosening, dislocation, fracture and Nerve injury and sensory loss

Anterior cruciate ligament (ACL) injuries

Anterior cruciate ligament is sited in the centre of the knee and runs from the back of the femur to the front of the tibia and acts to prevent excessive forward movement of the leg. Its main role is to keep the knee stable during rotational movements like twisting, turning or side-stepping activities.

Injuries:

Injuries to the ACL typically occur during a non-contact twisting. Contact injuries like road traffic accidents can also injure the ligament. Immediate swelling often occurs due to bleeding into the knee. Other injuries to the knee can occur at the same time. If the ACL is torn the knee is likely to give way with twisting activities

Symptoms

The symptoms of patients with an injury to the ACL include a feeling of instability or giving way. It may be associated with swelling and pain.

Diagnosis

A ruptured ACL can normally be diagnosed from the history and examination. The diagnosis can be difficult in some cases. In these cases the diagnosis can usually be confirmed by MRI scan. A torn ACL cannot be seen on x-ray.

Treatment

Non-operative treatment: involves a supervised physiotherapy programme

Anterior Cruciate Ligament (ACL) Surgery:

Following an ACL rupture your surgeon may decide, after discussion with you, that reconstruction is required.

It is usually performed using arthroscopic (keyhole) surgery

The ACL reconstruction procedure involves removing the remains of the damaged ACL and replacing it with another form of soft tissue, called a graft. A number of grafts are available for use to replace the ACL. We commonly use hamstring tendons. Graft will be fixed with bio absorbable screws

Admission:

Patient will be admitted one day before surgery for evaluation.

Recovery

Recovery following a routine Anterior Cruciate Ligament (ACL) reconstruction takes approximately four to six months. Hard work begins after operation. It requires dedication and patience for good result.

Meniscal Tear

Each knee has two menisci. There is one on the medial (inner) side of the knee and one on the lateral (outer) side of the knee. They are C or crescent shaped. They are made up of a tough gristly material called fibrocartilage. They improve the congruity of the joint and act as shock absorbers of the knee.

Symptoms: The symptoms from a torn meniscus include pain, clicking and catching sensations, and locking of the knee.

Diagnosis: The diagnosis of a meniscal tear is often made on the history of injury. Sometimes cartilage tears are associated with other injuries such as ligament ruptures. An x-ray will usually be undertaken even though a cartilage will not show up. This is because it is a simple investigation which can exclude other problems such as arthritis. Sometimes an MRI scan will be performed to confirm a cartilage tear if there are any doubts.

Treatment:

Once the diagnosis of a torn meniscus is made you may well require surgery to treat it, as it is uncommon for these tears to heal. This is because in order for something to heal, it requires a blood supply and the meniscus itself has a poor blood supply.
Arthroscopy: Surgery will be nearly always keyhole procedure. A small proportion of meniscal tears are suitable for repair. More commonly the torn part has to be removed, a partial meniscectomy. The amount of cartilage removed depends on the size of the tear.

Cysts: Cysts on the outer (lateral) side of the knee are more common than those on the inner (medial) aspect of the knee. Sometimes cysts are associated with meniscus tears. Usually these cysts can be drained into the knee at the time of meniscectomy. Rarely, they may require removal with a bigger cut through the skin directly over the swelling.