Obviously, preventive measures require many more joint replacement candidates to address their weight issues as well as their arthritis pain and function. That brings us to a 55-year-old man with severe knee OA who tells me that he needs to make a living tiling floors and he needs to fix his knee pain so he can return to racquetball a few years back.
Everyone wants to know, can you improve the quality of life? Historically, rheumatologists who specialize in the medical management of arthritis have reluctantly echoed the orthopedic surgeon’s advice for their end-stage arthritis patients to lose weight and engage in low-impact exercise. But the surgeons’ suggestions were usually accompanied by a sense of resignation that the patient’s primary care physician and rheumatologist would eventually hear as a firm decision to proceed with knee replacement.
Knee replacement surgery is a process of removing damaged bone and resurfacing the knee joint. Plastic and metal pieces are used to cap the ends of the bones that form the knee. Usually, arthritic damage affects one side of the knee. Partial knee replacement involves just replacing the affected side of the joint. Among today’s arthritis patients, who might dispose of 30 years or more knee replacement by sending men and to a lesser degree women back to physically demanding work and recreational activities. So while patients over 65 increasingly seek knee replacement, the operation is no longer exclusive to them.
What is Knee Replacement Surgery?
Knee replacement surgery, also known as knee arthroplasty, can help relieve pain and restore function in severely diseased knee joints. The procedure involves cutting away damaged bone and cartilage from your thighbone, shinbone, and kneecap and replacing it with an artificial joint (prosthesis) made of metal alloys, high-grade plastics, and polymers. The prosthesis mimics the function of a normal knee. The goal of knee replacement surgery is to resurface the parts of the knee joint that have been damaged and to relieve knee pain that cannot be controlled by other treatments. It is not suitable for everyone, and an orthopedic surgeon can explain whether or not the procedure is recommended in individual cases. The decision to have knee replacement surgery should be a cooperative one between you, your family, your GP, and your orthopedic surgeon. This procedure is usually offered to patients who are over the age of 55 and have severe osteoarthritis. In recent years, minimally invasive knee replacement surgery has been developed, designed to cause less damage to the soft tissues around the knee. The surgeon makes a shorter incision during the procedure. It is believed the advantages of this approach are less pain after surgery, a shorter hospital stay, and a quicker recovery. However, it is not suitable for everyone, and only the orthopedic surgeon can determine whether or not the procedure is appropriate for an individual. This type of knee replacement is discussed in more detail later in the document.
Benefits of Knee Replacement Surgery
Knee replacement surgery can help patients return to a more active lifestyle. Most patients have a dramatic reduction in pain and as a result, they are able to increase their function. Studies have shown that total knee replacements can effectively increase a patient’s ability to be more active. One study showed that 2 years after the surgery, patients were significantly more active and performed a greater number of different activities compared to their activity level before the surgery. With more dependable components and surgical techniques, the new joints are lasting longer, well into the patient’s old age. This is an important benefit for younger patients, as the artificial joints may wear out after 15-20 years, requiring a second surgery and possibly a third. The second replacement is generally not as successful as the first, so it is desirable to put it off as long as possible.
Preparing for Knee Replacement Surgery
It is important for you to understand and be informed about the knee replacement surgery prior to the procedure, as it will help you to actively participate in the process and make informed decisions. Preparing for the surgery involves understanding what to expect during the hospital stay and planning for your recovery once you return home. Although individual treatment plans may vary, this section will help you in learning some of the basic elements of preparation. One of the first prospects for you to consider is some of the potential needs you may have when you return home from the hospital after surgery. This will depend upon your physical layout of the living quarters and the amount of support you will have at home. Completing some home safety modifications and enlisting support persons may help in a smoother transition through this period. Some dictions include removal of obstacles and safety hazards such as loose carpet or electrical cords. Consider preparing and freezing some meals for the first few weeks, setting up a first floor recovery station if you normally sleep upstairs and obtaining some adaptive equipment to help you through daily activities. Items such as a shower chair, raised toilet seat and an assistive device like a cane or single crutch will provide safety and assist with independence. They will likely not be necessary long-term purchases and community resources may also provide a means for obtaining such items. You will need someone to drive you home from the hospital and it is helpful to have at least a part-time caregiver for the first two weeks. You should plan to have help with shopping and transportation to any physical therapy sessions. Making a plan now will decrease stress later. Consider enlisting family and friends and be specific about what you may need help with. They will appreciate knowing that they are providing valuable support. If these are some of the things that we will need to prepare for in the future after knee replacement surgery, what will occur during the actual hospital stay? He can give us sort of a day in the life when you are in the hospital for knee replacement. This can aid in further preparation and planning.
The Procedure
The actual surgical procedure generally takes only 1-2 hours, but the preparation and rest time add a few hours, and perhaps a day, to this time. To begin the operation, the skin over the knee is cleaned with an antiseptic liquid and then isolated with sterile drapes. Usually, the knee is approached through a vertical or longitudinal incision along the middle of the joint. This exposes the front of the knee cap and the lower end of the thigh bone. The damaged cartilage and bone is then removed from the knee joint, after which the surfaces are shaped to hold the new artificial joint. This shaping is generally confined to the edges of the joint. The next step is to make a decision as to whether to resurface the joint with a new joint (either cemented or uncemented) or to insert a prosthesis. Resurfacing is the simpler operation. If it is decided to resurface the joint, then the damaged bone and cartilage is replaced with metallic components and high density polyethylene. If it is decided to use a prosthesis, then a small amount of bone is sacrificed to hold the prosthesis in place. This is called a total knee replacement. A prosthesis is more frequently used in elderly patients with weak bones. After the joint has been replaced or resurfaced, the wound is closed with stitches. A tube drain may be left in the joint to drain any excess blood. This is held in place with a stitch and removed the morning after the operation. Finally the leg is dressed with a crepe bandage.
Surgical Techniques for Knee Replacement
The major advances in knee replacement over the years are the minimally invasive surgical techniques. In the past, the surgical dissection in knee replacement surgery was extensive. This was particularly damaging to the quadriceps muscle and tendon as they are necessary to be cut to allow good exposure to the knee joint. Failure to adequately repair the quadriceps tissues can lead to a permanent weakness and therefore a poor function after knee replacement surgery. Minimally invasive surgery has changed this and enhances the recovery after surgery. There are a number of techniques and the degree of invasiveness may vary. In general, the aim is to replace the knee joint without major disturbance to the tissues around it. This enhanced recovery technique usually also requires a change in the type of artificial knee being implanted as this design will need to have been proven to function well despite less stability from the ligament and surrounding tissues. Note these techniques are only suitable for certain patients depending on the severity of arthritis and the knee deformity, sometimes a more traditional technique is required. Whether the operation is suitable for you will depend on your arthritis and knee deformity. Measures of angular deformity need to be taken, this involves X-rays of your knee and is an angle given in degrees. The angle is measured between the femur and tibia. The angle allows us to assess the severity of the knock knee or bow leg. Treatment may improve this angle but it cannot restore your knee to age 20. The function of the quadriceps muscle is important for good mobility after surgery and there are several studies to suggest that muscle strength is linked to good functional outcomes. The functional outcome is a measure of how well you are able to walk and do other activities of daily living. High-quality X-rays or an MRI will also be necessary to assess the severity of cartilage loss and the severity of malalignment of your leg.
Anesthesia Options for Knee Replacement Surgery
Regional anesthesia has become very popular for knee replacement and is now used in over 70% of surgeries in the US.
A combination of initial spinal or epidural anesthesia and later general anesthesia can be an excellent option for some patients. It is well established that patients having total joint replacement with regional (spinal or epidural) anesthesia have fewer complications, such as heart attack or deep vein thrombosis, than those having general anesthesia. The reasons for this are not entirely clear, and it may be related to the overall health of patients who choose regional anesthesia, or it may be due to effects of the anesthetics on the body’s stress response to surgery.
In general anesthesia, you are unconscious and have no awareness or other sensations. Spinal or epidural anesthesia involves an injection in the back that will numb the legs. Below the waist will be numb and the patient will remain awake, which avoids the risks and effects of general anesthesia. The numbness may be sufficient to avoid using general anesthesia, or it can be supplemented with sedation or light general anesthesia. These issues should be discussed between the patient, the surgeon, and the anesthesiologist.
Anesthesia is used to control pain during a total knee replacement. Decisions about anesthesia are made after considering a patient’s physical condition, the type of surgery, and the surgeon’s training. The anesthesia used can affect how comfortable the patient is after the surgery and how quickly the patient recovers. The most common types of anesthesia are general, regional, and spinal.
Length of the Knee Replacement Surgery
The length of the surgery varies. Most surgeons can complete the procedure in one to two hours. Factors that can influence the length of the surgery include the need for complex surgical techniques, implanting multiple components, and if excessive bone damage or other complicating factors are present. Occasionally, a surgery will be stopped and rescheduled for another time if it is determined that the benefits of the surgery do not outweigh the risks at that time. This is specifically done to avoid the risk of infection in those with multiple medical problems. Length of the hospital stay is usually 3-5 days. This too can be influenced by many factors. A recent paper presented at the American Association of Hip and Knee Surgeons meeting demonstrated that Medicaid patients and those with multiple medical problems stay significantly longer after joint replacement. This comes as no surprise as the body of evidence clearly demonstrates that hospital length of stay is a measure of disease burden and is not specifically related to the surgery itself. High quality implant surgery in a patient with few medical problems may even be safely performed in an ambulatory surgery center with discharge home a few hours after the procedure. Length of hospital stay is also influenced by insurance approval issues and sometimes home care or rehabilitation placement problems. With the worldwide movement to reduce health care costs, shorten hospital stays, and perform more surgeries in an outpatient setting, length of hospital stay after joint replacement will probably continue to decrease in the future.
Recovery and Rehabilitation
Immediately following knee replacement surgery, a patient will undergo a recovery process. In the hospital, the patient will be given a patient-controlled analgesia (PCA) pump, which allows the patient to self-administer small doses of pain medication by pressing a button. By receiving small doses of pain medication, the patient is able to better control his or her pain. PCA is only used in the hospital. Your health care team will teach you how to prevent blood clots, proper positioning, and alignment of your new joint, and safety tips to use at home. You will continue to take antibiotics to prevent infection and drugs to prevent blood clots. You may need to be on a blood thinner for some time after surgery. During your hospital stay, you will work with a physical therapist and/or an occupational therapist. Soon after surgery, you will begin standing and walking with the help of a walking aid, and learn how to perform your daily activities in a way that is safe and does not damage your joint. Over time, you will become less dependent on the walking aid and will learn the proper methods for sitting, standing, and walking so that you do not dislocate your new joint. These therapists will also recommend special equipment make changes in your home to facilitate an easier recovery. This may include raised toilet seats, a bath seat, a shower grab bar, or a handrail. Discharge from the hospital is usually 2-5 days after surgery. When you are discharged, you will be able to sit in a chair for extended lengths of time, do light household activities, and will be able to walk short distances. Outpatient physical therapy will then be set up for you, the first six to eight weeks will be focused on regaining knee motion and muscle strength. Full recovery from the surgery will take 3 to 4 months. This is because of the extent of the surgery and since muscle strength and knee motion may continue to improve for up to a year after surgery. While variable, here is a typical recovery process for a knee replacement: 2-6 weeks: Using a walking aid, you will gradually increase the distance you can walk. 2-3 months: You will decrease the use of the walking aid and will begin to increase the strength and endurance of your leg muscles. 3-4 months: You will work on gradually increasing the time you can spend walking and will look to return to recreational activities such as golf, cycling, or swimming. 6-12 months: You will work on returning to normal leg function. This includes work and recreational activities that require prolonged standing and knee stress. At this point it will be determined if you can return to activities such as doubles tennis or golf.
Postoperative Care and Pain Management
On returning to the nursing unit/wards, the patient will be on pain medications and will still have an anesthetic effect for some hours. We like the patient to be awake and secure before any food or fluid is offered. We monitor the patient’s pulse and blood pressure during this time and are vigilant for any signs of postoperative complications. The postoperative wound can be closed in a number of ways, so the advice on wound management will vary among individuals. There is a preference to use a water-resistant dressing which will stay in place for the first 10 to 14 days after surgery, allowing the patient to shower the day following surgery. This allows reassurance to the patient that the wound will remain dry and reduces the frequency of dressing changes. All stitches and staples are usually removed at 14 days post-surgery. A gauze dressing will be applied if a waterproof dressing is not suitable, and occasionally a backslab and bandages if the knee is particularly swollen. No matter what the dressing, every patient should have the dressing checked at three to five days and then between ten to 14 days following surgery.
Physical Therapy and Rehabilitation Exercises
It is common to feel some uneasiness as you exercise and you may notice mild to moderate swelling afterwards. In most cases, applying ice to the knee and taking a short rest will reduce any uneasiness and swelling, allowing for a smooth and constant progression in exercise. Your progress in therapy will depend on the type of surgery you had and your general fitness level. Remember that therapy will need to continue for at least two months for total knee patients and possibly longer for partial knee patients. Regular activity, particularly walking, is not a substitute for therapeutic exercise programs and underdoing exercises to stimulate a greater activity level can impede your progress.
Physical therapy after knee replacement surgery has two crucial parts. Firstly, your therapist will teach you exercises to restore movement to your knee and leg. A part of the flexibility instruction may involve the therapist moving your knee throughout its ranges of action, passive exercise. You can also do passive exercise on your own by bending the other leg to move the replaced knee. The second part of therapy is the strengthening exercise to build up the muscles around the knee. These generally begin with isometric exercises and progress to weight-bearing exercises. The objective of building muscle strength is to alleviate force from the affected joint and stop wearing of the new joint.
Returning to Normal Activities after Knee Replacement Surgery
Returning to normal activities over both the short and long term is a crucial factor to evaluate the success rate and ultimate satisfaction from knee replacement surgery. It is possible to do all your normal activities like walking, exercising, household work, gardening, etc. However, it needs to be first understood how the artificial knee functions and how much punishment it can take. The first point to understand is that the artificial knee is not a normal knee and there are certain restrictions. Once the acute postoperative recovery phase is over, usually around 6 weeks, the patient can begin to increase the level of activity in a progressive way. Swimming is perhaps the best activity as it gives exercise to nearly all the muscle groups and is not too stressful on the knees. Low-stress walking, cycling, and playing golf are also acceptable. By around 3 months, providing the knee has a good range of movement, many patients are able to increase the activity to include things like gentle hill walking. At approximately 6 months, if the knees are both functioning well, it is usually possible to return to most sports and activities, with certain modifications and restrictions. For example, it is usually best to avoid impact loading sports, as the knee replacement may not be able to tolerate this. If the sports involve a lot of twisting or turning, there may be increased stress on the knee and implant, and this may increase the likelihood of future complications. An example of this is football or racket sports; whilst there are no definite reasons why these activities should not be undertaken, there is an increased risk of future complications for the knee. For that reason, many surgeons advise that these sports are not restarted after knee replacement. Ultimately, everything is individual and the patient should heed the advice of their own surgeon.
Knee Replacement Surgery in Singapore
The vast majority of knee replacement surgeries are done in Singapore using the latest and most advanced techniques. This may or may not be a good thing. Always ask your surgeon what technique he will be using and what the expected outcome is. Techniques involving computer navigation and minimally invasive surgery, while theoretically appealing, often lack a proven track record when it comes to patient outcomes. Be sure to separate the marketing hype from the facts. Your surgeon should be candid about what he hopes to achieve and whether or not surgery is likely to be of significant benefit to you.
When it comes to cost, knee replacement surgery in Singapore doesn’t come cheap. However, for those who can afford it, the standard of care is top rate and hassle-free. Medical insurance plans will often cover a portion of the cost. It is advisable to discuss this with your insurer directly. As a gauge, inclusive of hospital stay, the total cost of surgery might run from $15,000 to $30,000. This is significantly less than what it is likely to cost in many European or North American hospitals.
Singapore is an ideal location to have knee replacement surgery. The country has an excellent healthcare infrastructure and boasts many world-class hospitals and orthopaedic surgeons. If you are contemplating knee replacement surgery, the first step is to discuss the issue with your local orthopaedic surgeon, who will be able to refer you to an orthopaedic surgeon in Singapore if it is deemed to be the best course of action.
Leading Hospitals and Surgeons in Singapore
The Orthopaedic and Arthroplasty Department at National University Hospital is also among the best in the region. It is a comprehensive orthopaedic service that provides subspecialized treatment in Orthopaedic Surgery, Sports Medicine, and Rheumatology. It aims to provide cutting-edge treatment for musculoskeletal conditions through education, research, and service to the general public. The department is one of the most active areas in the region for medical education and research and is dedicated to advancing the field of orthopaedic surgery and medicine. The department provides comprehensive treatment for arthritis, from medicinal and rehabilitation services to the most advanced surgical techniques. It also has an excellent service for cartilage and ligament preservation and transplantation. The department is also a regional centre for training in total joint replacement and has also provided training to some of the top knee surgeons in the region today.
The Institute of Orthopaedic and Sports Medicine at Gleneagles Hospital is a one-stop centre for orthopaedic, sports injuries, and rehabilitation services. It has the best and most comprehensive diagnostic and therapeutic facilities for orthopaedic and sports injuries in the region. They offer a comprehensive service for the treatment of knee arthritis, from medication and physiotherapy to the most advanced surgical techniques. The hospital has the latest technology for minimally invasive partial and total knee replacements, as well as a comprehensive arthroplasty service. They also provide the latest techniques in cartilage and ligament preservation and transplantation.
Cost and Insurance Coverage for Knee Replacement Surgery
As for Singapore Permanent Residents and foreigners, the cash outlay is much higher. Not forgetting the private sector patients, who will incur higher costs due to the better quality of service, shorter waiting times, and more comfort. Private integrated shield plans now cover treatments up to the cost of B2 or A class (in restructured hospitals), and therefore cash outlay can still be partially salvaged. Ultimately, whether the cost is bearable or detrimental to the patient is subjective to the patient and his family.
For Singapore citizens, the total out-of-pocket cost can be heavily subsidized by the use of Medisave. Medisave has withdrawal limits ranging from $300 to $600 per year and can be used for payment for the patient himself, his spouse, parents, and children. Knee replacement is also a part of the fixed prearranged operations which will allow claiming from MediShield.
Medical costs in Singapore have been gradually increasing and are currently one of the highest both in Asia and around the world. Unlike dental extraction or cardiac surgery, there is no fixed fee for knee replacement. In the public sector, total payments can vary greatly anywhere from $10,000 to $30,000, including pre-surgery consultation and tests, surgery, in-hospital stay, and medication.
Patient Experiences and Testimonials in Singapore
Over the years, Singapore has developed a solid reputation for knee replacement surgery with successful patient outcomes. Patients are also taking a keen interest in the feedback and reviews from other patients about their surgical experiences. Often, the experiences shared by other patients become the decision point or make patients more confident of the choices they make about the surgeries. These days, healthcare consumerism has led to increasing demand for information about other patients’ experiences. This can be looked up on hospital forums, discussion groups or various online sources of information. The aim of this article is to provide an insight into the experiences of a few patients who underwent knee replacement surgery in Singapore. Terry’s knee replacement surgery at Gleneagles Hospital Singapore. The surgery, post-op and recovery note: Terry had emailed to ask if he could contribute his experience and it was felt his record of all phases of his knee replacement was a comprehensive look at knee replacement recovery and surgery. Due to his record of all phases of surgery, his experience is quite detailed.
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