Patient Profile: Fred Brown

Knee replacement surgery can be defined as an operation that involves the replacement of a worn out, damaged or diseased knee with a joint that is artificial. Knee replacement surgery was performed first in the 1960s, and since then there have been great improvements in the effectiveness of the surgical materials and techniques. Total knee replacement has been considered the most successful of all procedures in all of the medicine. Total knee replacement has been exercised for about 50 years, but its complexities only started to be recognized thirty-five years ago. The initial artificial implants were done in 1941 as the process where molds were applied to the femoral condyles that followed the same designs in the hip. The debate as to whether knee ligaments can be sacrificed or preserved continues to this era. Cemented total knee replacements will continue being the official criteria for total knee arthroplasty (TKA), but promising midterm results are being shown by the use of uncemented designs with bioactive surfaces. (Cankaya, & Della Valle, 2016)

The main indication for TKA is the relief of pain induced by severe arthritis. This means that the pain should be notable and disabling. If the dysfunction of the knee causes reduction of the quality of life for the client, it should be brought into account. Repair of a deformity is also an important indication for surgery. The replacement exhibits a predictable survival that is negatively influenced by the level of activity. It is meant for aged patients with moderate activities. Rarely does severe patellofemoral arthritis justify the arthroplasty because the outcome expected is superior to that of patellectomy. Deformity can also be a primary sign for the replacement in clients with mild arthritis especially in flexing contracture, or when valgus laxity is present. (Dunbar, & Richardson, 2012)

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Absolute contraindications for TKA include sepsis of the knee, severe vascular disorder, an ongoing reservoir of infection, extensor mechanism dysfunction and knee arthrodesis. Some of the relative contraindications include medical illnesses that hinder anesthesia that is safe and also the needs for rehabilitation and surgery. Other contraindications involve skin diseases occurring within the field of surgery, neuropathic joint, obesity and a history of osteomyelitis around the knee region. (Hanna Eskander, 2016)

In the anatomy, the mobility of the knee joint has been classified as possessing six levels of freedom, which comprise of three flexible translations and three rotations. The movements are defined by the shape and state of the articulating covering and surfaces of the femur and tibia hence the bearing of the four main ligaments of the knee joint. This means the posterior and anterior cruciate ligaments which together with the medial and lateral collateral ligaments primarily serve as a four based bar linkage system. The principal function of the medial collateral ligaments involves restraining the valgus rotation and turning of the knee joint with the second role being to regulate the external rotation. The anterior cruciate ligament resists the anterior and utmost displacement of the distal tibia on the femur during the period the knee tends to be flexed hence controlling the screw home layout mechanism of the tibia in the terminal extension of the knee.

What Is Knee Replacement Surgery?

In the procedural planning, some operative and effective procedures are considered in clients with degenerative disorder of the knee. Arthroscopic comprehensive debridement is indicated sometimes in a mild joint disease that is degenerative which presents with mechanical manifestations and recurring, steadfast effusions. Proximal tibial valgus osteotomy is normally kept for clients with medial tibiofemoral compartment syndrome and also a correctable varus deformity in the knee joint area. Similarly, patients with lateral tibiofemoral compartment disease can be considered for a distal femoral varus osteotomy. (Hanssen, & Scott, 2012)

A comprehensive preoperative medical evaluation of clients undergoing TKA is vital in the prevention of potential complications in the perioperative period. It is important to complete the evaluation in a preadmission clinic before the day of surgery. Clients undergoing the surgery must have a good functional cardiopulmonary system to handle anesthesia and the blood loss which occurs over the perioperative period. Patients should have a full informed, and well-read consent for the surgery hence fully understanding the risks and potential complications which may occur during the procedure.

Preoperative laboratory evaluation includes the renal function studies, full blood count, erythrocyte sedimentation rate (ESR), urine investigation and culture, serum electrolytes, and the prothrombin time. Urinalysis is done to exclude occult infection of the urinary system. Some of the imaging studies include radiographic views such as the patellofemoral view, standing and upright anteroposterior view, long leg radiographs and standing X-rays/ radiographs where the knee is extended or flexed in a 45-degree position. (Kane, 2013)

Other preoperative tests include ECG which is performed in clients with a history of cardiac issues and elderly patients. More imaging modalities of occasional benefit in the assessment of significant loss of bone or infection include the computed tomography, indium white blood cell (WBC) scanner, bone densitometry and the magnetic resonance imaging technique. (Laskin, 2012)

Different types of TKA prostheses comprise medial pivots, rotating platforms, fixed bearers, posterior cruciate ligament (PCL) retaining and the substituting PCL. The procedure may be performed while the subject is under general or regional anesthesia. The decision of the selection of the type of anesthesia is made following the discussion of the patient and the anesthetists with some preoperative information from the surgical crew. The patient is placed up on the operating table while in a supine manner that follows a preoperative scrubbing and cleaning of the leg. (Lee, 2017)

This follows up depends on the client, the surgeon, and the healthcare system. An example would be a medical and surgical follow-up appointment after four weeks, four months, eight months, and subsequent years and after that, as would seem appropriate. This modification for each patient can be according to age, the presence of complications or the degree of activity. A significant knee function is normally restored following TKA, and numerous patients can return to low contact sporting activity. Various studies indicate a functional score and a 90-95% survival rate of the prosthetics at 13-16 years of close follow-up. There exists no difference between PCL retaining and substituting designs.  A 95& prosthesis survival rate is observed for cementless designs at 11-13 years and does not have the same length of follow-up. (Mostofi, & Shetty, 2012)

Indications For Total Knee Replacement

Total knee arthroplasty is conducted in a laminar flow operating surgical theater where meticulous regard to detail is done to inhibit the contamination of the site of operation. Antibiotics and antithrombotic prophylactic medications are administered nearly 30-40 minutes before the surgical incision is done. The access to the knee joint is usually anterior towards the medial parapatellar approach, but some surgeons use the subvastus or lateral approach. Osteophytes are then cleared together with the intra-articular soft tissues. Sufficient bone is removed so as to recreate the level and plane of the joint position by the use of the prosthesis. Because of the preoperative deformity, there is some contraction of some ligaments about and around the knee. Total Knee Replacement: Procedure Indications And Complications Example Paper  These are carefully released in a balanced stepwise fashion around the knee hence allowing efficient knee kinematics. (Parvizi, & Klatt, 2011)

After the procedure, the client undergoes recovery and is normally observed for 24 hours in a suitable high dependency ward. Adequate pain relief by analgesia and optimum hydration is essential in the presumed time of high physical stress. Analgesia may also be provided via a continued intraoperative epidural, oral analgesia or a patient controlled intravenous analgesia. The patient is encouraged to performed continuous passive range of motion activities under the supervision of physiotherapists. Drains are removed, and the individual is instructed to ambulate on postoperative day two. Discharge is recommended only when the wound heals satisfactorily, and the knee flexion of about 85-90 degrees has been accomplished. (Shakespeare, & Kinzel, 2015) The patient should also be considered supported and safe in the home setting environment, and little or complications are present. Thromboembolism prophylactic therapy should be continued and maintained at home for a period. The initial review as an outpatient is generally in five weeks to four months while approximately one of every thirty patients will require critical care services after the TKA surgery. (Rand, 2013)

Studies have indicated that the overall mortality rate with TKA is little than 2%, but the figure may rise with increased age, male gender, and multiple preexisting pathological conditions. Optimization and identifying such diseases in the preoperative period is vital for the reduction of perioperative complications. The complications of TKA include infections, neurovascular and patellofemoral complications, aseptic loosening and thromboembolism. Arthrofibrosis which is a condition of excessive scar tissue is also considered a complication that may occur after the surgery. (Schwarzkopf, Chin, Kim, Murphy, & Chen, 2017)

Conclusion

The current empirical studies do not provide a concrete basis for making clinical recommendations regarding the outcomes of the TKA. More pressure is mounting for more discriminations for the identification of subjects for elective surgery hence the need for more information. Currently, the ideal research designs for answering questions concerning the indications of the surgeries, remain as randomized trials in which individuals with advanced arthritis are normally assigned randomly to a certain medical management or joint replacement. Therefore, more research into the effectiveness of the TKA and the client characteristics that are associated with better outcomes need to be carried out with observational studies that will help answer and address many issues that are yet to be addressed.

References

Cankaya, D., & Della Valle, C. (2016). Blood Loss and Transfusion Rates in the Revision of Unicompartmental Knee Arthroplasty to Total Knee Arthroplasty Are Similar to Those of Primary Total Knee Arthroplasty But Are Lower Compared With the Revision Total Knee Arthroplasty. The Journal Of Arthroplasty, 31(1), 339-341.doi.org/10.1016/j.arth.2015.08.002

Dunbar, M., & Richardson, G. (2012). Cemented Femoral Fixation: Back to the Future. Seminars In Arthroplasty, 23(3), 155-158.doi.org/10.1053/j.sart.2012.06.002

Hanna Eskander, H. (2016). Knee Surgery: Total Knee Replacement or Partial Knee Replacement. Orthopedics And Rheumatology Open Access Journal, 3(4).doi.org/10.19080/oroaj.2016.03.555619

Hanssen, A., & Scott, W. (2012). Total knee replacement (1st ed.). Philadelphia, Pa.: Saunders.

Kane, R. (2013). Total knee replacement (1st ed.). Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality.  Total Knee Replacement: Procedure Indications And Complications Example Paper