The knee is made up of the lower end of the thigh bone (femur), which rotates on the upper end of the shin bone (tibia), and the knee cap (patella), which slides in a groove on the lower end of the femur. Large ligaments attach to the femur and tibia to provide stability. The long thigh muscles (quadriceps) give strength to the knee.

The joint surfaces where these three bones touch each other are covered with articular cartilage, a smooth substance that cushions the bones and enables them to move easily.

Normal Knee Joint

All remaining surfaces of the knee are covered by a thin, smooth tissue liner called the synovial membrane. This membrane releases a special fluid that lubricates the knee, reducing friction to nearly zero in a healthy knee.
Normally, all of these components work in harmony. But disease or injury can disrupt this harmony, resulting in pain, muscle weakness and less function

Total knee replacement is one of the most commonly performed surgeries for knee osteoarthritis, or degenerative joint disease with an excellent result.

In knee replacement damaged cartilage or surfaces of the joint is replaced by high grade metal and plastic material. Knee replacement completely relieves pain, improve quality of life and allow the patient to perform all routine normal activities.

Arthritic Knee	Knee Replacement
X-ray before TKR	X-ray after TKR

The decision whether to have total knee replacement surgery should be a co-operative one between you, your family, and me. Following criteria would help to decide about this:

1. Severe knee pain that limits everyday activities.
2. Moderate or severe knee pain while resting, either day or night.
3. Failure to obtain pain relief from non-steroidal anti-inflammatory drugs.
4. Inability to tolerate or complications from pain medications.
5. Failure to substantially improve with other treatments such as cortisone     injections, physical therapy, or other surgeries.
6. Knee stiffness--inability to bend and straighten your knee.
7. Deformity – a bowing in or out of the knee.
8. Chronic knee inflammation and swelling that doesn't improve with rest or     medications.

Most patients who undergo total knee replacement are aged between 60 to 90 years, but I evaluate patients individually. Recommendations for surgery are based on a patient's pain and disability, not age. Total knee replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.

Many different types of designs and materials are currently used in total knee replacement surgery. Nearly all of them consist of three components: the femoral component (made of a highly polished strong metal – cobalt chrome molybdenum), the tibial component (made of a durable plastic often held in a metal tray), and the patellar component (also plastic)

Knee Implant

Medications - Inform me about the medications you are taking. I will tell you which medications you should stop taking and which you should continue to take before surgery. Any blood thinning medications to be stopped 7 days prior to the surgery.

Dental Evaluation - Treatment of significant dental diseases (including tooth extractions and periodontal work) should be considered before total knee replacement surgery.

Urinary Evaluation - A preoperative urological evaluation should be considered for individuals with a history of recent or frequent urinary infections. For older men with prostate disease, required treatment should be considered prior to knee replacement surgery.

Preparation of Skin and Leg - Knee and leg should not have any skin infections or irritation and lower leg should not have any chronic swelling.

Social Planning - Though you will be able to walk on crutches or a walker soon after surgery, you will need help for several weeks with such tasks as cooking, shopping, bathing and doing laundry.

Home Planning - Several suggestions can make your home easier to navigate during your recovery. Consider:

1.Safety bars or a secure handrail in your shower or bath.
2.Secure handrails along your stairways.
3.A stable chair for your early recovery with a firm seat cushion    (height of 18-20 inches), a firm back, two arms, and a footstool    for intermittent leg elevation.
4.A toilet seat riser with arms, if you have a low toilet.
5.A stable shower bench or chair for bathing.
6.Removing all loose carpets and cords.
7.A temporary living space on the same floor, because walking up    or down stairs will be more difficult during early recovery.

You will be admitted to the hospital one the day prior to your surgery. After admission, you will be interacting with nurses in the ward.

Several tests - such as blood samples, a cardiogram, 2 D or dobutamine stress echo, x-rays of chest and affected joints and a urine sample examination will be carried out.

Medical and Pre Anesthetic Evaluation - Complete physical examination will be performed by physician, cardiologist and anesthetists before surgery to assess your health and to rule out any conditions that could interfere with your surgery.

The most common types of anesthesia are spinal or epidural anesthesia, in which you are awake but your legs are anesthetized and general anesthesia, in which you are asleep throughout the procedure. The anesthetist team will determine which type of anesthesia will be best for you with your input.

Time Required for Surgery - The procedure itself takes about one and half hours.

Post surgery recovery - After surgery, you will be moved to the recovery room, where you will remain for one to two hours while your recovery from anesthesia is monitored. After you awaken, you will be taken to your hospital room. Patients having medical problems or high risk patients are observed in ICU (Intensive Care Unit) for 24 hours.

Post-operative pain management - A very special technique patient control analgesia (PCA)  is used where a catheter is kept in epidural space and through PCA pump pain relieving medicines are delivered in controlled fashion. If patient need more dose a bolus can be injected by patient by themselves through hand press button given to them in post-operative period for 2 to 5 days.

There is no post-operative pain; hence this is painless joint replacement surgery.Other pain relieving medications are also given as injections or oral tablets to control pain.

Physiotherapy and recovery - In general physiotherapy program is not strenuous and not painful. Foot and ankle movements are encouraged immediately following surgery to increase blood flow in leg muscles to prevent leg swelling and blood clots. A physical therapist will teach specific exercises to strengthen leg muscles and restore knee movement to allow walking and other normal daily activities soon after surgery.

To restore movement in your knee and leg, you may use a knee support that slowly moves your knee while you are in bed. The device, called a continuous passive motion (CPM) machine, decreases leg swelling by elevating leg and improves venous circulation by moving the muscles of leg.

Sitting at the edge of the bed and standing usually stated next day from surgery.

Patients have been also taught proper gait training with the use of walker and crutches or canes and have been explained   when to take off these walking aids.

To avoid lung congestion after surgery, deep breathing exercises are also taught.

You may be prescribed one or more measures to prevent blood clots and decrease leg swelling, DVT pump inflatable leg coverings (compression stockings) and blood thinners if required.

Hospital Stay - Likely stay in the hospital is for five days after surgery.

The complication rate following total knee replacement is low.

Infection: This is avoided by performing surgery in special joint replacement operation theatre having laminar air flow, use of body exhaust gown and appropriate antibiotics.

Risk of clot formation:  Blood clots in the leg veins are the most common complication of knee replacement surgery. You will be outline with a prevention program, which may include periodic elevation of legs, lower leg exercises to increase circulation, support stockings and blood thinning medication.

Loosening and Dislocation: Although implant designs and materials as well as surgical techniques have been optimized, wear of the bearing surfaces or loosening of the components may occur on long term. If this happens then re-operation / revision surgery can be done.

You may feel some numbness in the skin around your incision.

You also may feel some stiffness, particularly with excessive bending activities. Improvement of knee motion is a goal of total knee replacement. Most patients can expect to nearly fully straighten the replaced knee and to bend the knee sufficiently to go up and down stairs and get in and out of a car. Kneeling is usually possible.

Occasionally, one may feel some soft clicking of the metal and plastic with knee bending or walking.

These differences often diminish with time and most patients find these are minor, compared to the pain and limited function they have experienced prior to surgery.

The success of surgery also will depend on how well you follow instructions at home during the first few weeks after surgery.

Activity - Exercise/physiotherapy is a critical component of home care, particularly during the first six weeks after surgery. Physiotherapy plays an important role and should be continued with help of physiotherapist for 6 weeks and there after by own.

You should be able to resume most normal activities of daily living within three to six weeks following surgery. Your activity program should include:

1. A graduated walking program to slowly increase your mobility,     initially in home and later outside.
2. Resuming other normal household activities, such as sitting and     standing and walking up and down stairs.
3. Specific exercises several times a day to restore movement     and strength of the knee.
4. Driving usually begins when your knee bends sufficiently so     you can enter and sit comfortably in your car and when your     muscle control provides adequate reaction time for braking     and acceleration. Most individuals resume driving about four to     six weeks after surgery.

Blood Clot Prevention - Follow my instructions carefully to minimize the potential of blood clots that can occur during the first several weeks of your recovery.

Warning signs of possible blood clots in leg include:
1. Increasing pain in your calf.
2. Tenderness or redness above or below knee.
3. Increasing swelling in calf, ankle and foot.

Notify me immediately if develop any of these signs.

Preventing Infection - The most common causes of infection following total knee replacement surgery are from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around knee replacement and cause an infection.

Warning signs of a possible knee replacement infection are:
1. Persistent fever (higher than 100 degrees orally).
2. Shaking chills.
3. Increasing redness, tenderness or swelling of the knee wound.
4. Drainage from the knee wound.
5. Increasing knee pain with both activity and rest.

Notify me immediately if you develop any of these signs.