Before you need total knee replacement surgery abroad with Saint James Hospital you are likely to have tried other treatments, such as pain relief medication and aids to help you walk.  If these options have failed to deal with the severe pain you’re experiencing in your knee joint or improve your lack of mobility, then total knee replacement surgery may be the option to take. 

Total Knee Replacement surgery, or knee arthroplasty, resurfaces the damaged and diseased parts of the knee joint and replaces them with prosthetics.   Partial or unicompartimental knee replacement is far less common and is carried out when only one part of your knee joint is damaged or diseased. 

People undergoing total knee replacements are generally between 60 – 80 years of age and have severe knee pain as a result of arthritis – osteo-, rheumatoid or traumatic (following injury) arthritis.  Younger people are treated (though not children), but it is possible that their prosthetic knee may need revisionary surgery later in life.  Generally, you can expect a good 15 years service from your knee replacement prosthetics. 

The surgery is a major operation lasting around two hours.  It has been performed routinely, safely and widely since its inception in the late 1960s.  The choice and durability of the prosthetics is constantly improving and today, a range of joint parts are available, made from non-corrosive metals and metal alloys as well as high-grade plastics and polymers. 

The success of your knee replacement surgery depends on your following guidelines and exercises advised by your physiotherapist.  Total Knee Replacement surgery will enable you to perform the regular activities you enjoyed before your pain and lack of mobility set in, but it won’t enable you to take up certain strenuous activities or sports.    Be realistic about the new lease of life it will give you. 

Your surgical team will talk to you about the after care required, both in Malta and on your return home.  You are likely to require not only our immediate nursing team, but also physiotherapists and occupational therapists.  Once home, you may need the assistance of any social services too if you feel you may benefit from special household or mobility aids. The range of services you may require needs to be thought through before your operation.  

If all goes according to plan, you can expect to need to stay in hospital for around 5 days, and in your chosen accommodation for 2 weeks, before you will be signed off as fit to travel home. 

Total Knee Replacement is most commonly called for when a person has osteo-, rheumatoid or traumatic arthritis in the knee joint.  It is also used to correct a knee joint assist damaged by other medical conditions such as bone tumor or bone loss resulting from a lack of blood supply (avascular necrosis). 

Total Knee Replacement is a major operation with a relatively long convalescence period so it is usually advised only when you have tried non-invasive treatment to relieve your pain and increase your mobility.  The surgery is more commonly carried out on people over 50 years, with the largest age group of candidates between 60 to 80 years old.  However, younger people who have premature arthritis or have had an injury may be recommended for a total knee replacement. 

Rest assured that your surgeon’s recommendation for the operation is based not on age only, but also on your general health and the extent of your disability and pain.  If you have a total knee replacement while young, you should be aware that the prostheses used may last fewer years and you may need revisionary  surgery later on in life. 

You are good candidate for total knee replacement if you:

• Have debilitating knee pain so severe that you have difficulty with routine activities such as walking, climbing stairs, getting in and out or bed and rising from chairs, driving and so on.
• Find your pain and stiffness prevents you moving, lifting or crossing your legs comfortably
• Still have pain and inflammation when resting or at in bed at night
• Have knee joint deformity – bowed in or out for instance
• Have taken a course of cortisone injections, had anti-inflammatory medication, or had ongoing physiotherapy all to no avail
• Have unpleasant side effects from your medication to relieve pain    
• Find that walking aids (canes, sticks etc) are proving useless in giving you greater mobility or reduction in pain and stiffness
• Are in general good health apart from the knee pain and lack of mobility
• Are over 50 and preferably between 60-80 years of age
• Are not obese (obesity won’t preclude you from knee replacement surgery but it will hinder your recovery and you may find it reduces the effectiveness of the prosthetic).

What Total Knee Replacement surgery will & won’t do

A total knee replacement allows you to go about your daily routine free from the intense original pain and stiffness you experienced before.  You need to be realistic about your life style following surgery though as you may not be able to do more than before your pain set in.  Don’t expect to return to or take up high-impact sports for instance. 

It is important you follow advice about how you should move, what sports and exercise you can do safely with your new joint, and how to exercise to assist your recovery.  If you previously had a routine or job involving lengthy periods of standing, weight bearing, lifting, climbing, or other physical demands, you may find you won’t be able to return to that kind of lifestyle without the possibility of undermining your knee joint replacement surgery – there are risks, albeit rare, of knee dislocation and fracture or undue stress and strain prematurely wearing out the prosthesis.   

At Saint James Hospital, we guarantee you will be fitted with prosthetics from leading, international brand-name suppliers.  In the case of knee replacement, our surgical partners in Malta use prosthetics from Johnson & Johnson. 

When the very first total knee replacements were carried out in the late 1960s, the prosthetic joint was really not much more than a hinge mechanism.  Today’s knee replacement prosthetics are sophisticated, durable and high performance and provide near frictionless movement.

Quality prosthetic materials are biocompatible, which means that they are designed to be accepted by your body.  They are also designed to be as impervious to corrosion and wear as possible.  You find prosthetics made from stainless steel and various metal alloys, as well as durable plastics and polymers.  The prosthetic is composed of a femoral part (thigh bone end) made of highly polished strong metal; the tibial part, made of durable plastic, which can be cupped in a metal tray; and the knee cap or patellar part which is also made of plastic.

Any or all the parts of our knee joint may require prosthetic replacement. Your surgeon will advise which materials are best for your needs and discuss also whether you need only have unicompartimental knee replacement, which refashions just one of the three structures that make up the knee joint

Composition of the knee joint

The knee joint is the largest joint in the body, and is composed of three, interlinking, moving parts: the lower end of the thighbone (femur), which rotates on top of the upper end of the shin bone (tibia), in front of which ‘floats’ the knee-cap (patella, fixed in a groove at the end of the femur). Ligaments hold the parts and provide stability.  Thigh and calf muscles are also attached at the knee joint.  Where the various parts meet, we have a ‘cushion’ of cartilage and a membrane which produces synovial fluid to lubricate the joint and prevent friction and stiffness. 

The consultation is the most important part of your decision to undergo surgery abroad with Saint James Hospital.  Total knee replacement is a major operation of around two hours and it entails not only a fairly lengthy convalescence period but also considerable forethought and preparation. 

You will, for instance, need to be thoroughly examined, and your medical history gone over in great detail.  You may need blood taken to be used in the operation itself, and this may require you to have medication levels altered or to undergo any other medical, even dental or periodontal treatment you need well before your intended date for knee replacement surgery.  This is because there is a risk of infection from other invasive procedures, even up to two years post surgery.

All this and more needs to be covered at the consultation stage, so that you are prepared and can get the greatest benefit from your knee replacement surgery abroad.  Below, are some of the procedures you may need to undergo during the consultation stage plus things to think about and prepare for.  It is not an exhaustive list, but will give you an idea of the planning required.

Pre-operative assessment

You may be required to have:

A complete physical examination

This can be done by your regular doctor back home. It will, among other things, check your general health and look for any other medical issues that need to be treated prior to knee replacement surgery.  Your physician will look, for example, for diabetes or high blood pressure, skin infections or excessive swelling beyond what is reasonably expected in knee arthritis. The examination will also assess you physical ability – your strength, the mobility of your knee and other related joints and so on.

X-Rays and MRI Scans

These will assist your surgeon in understanding the extent of your knee damage, bone density and so on.

Blood tests and/or blood taken

Blood tests are drawn one or two days before surgery to examine your general health state, to determine if any signs of infection are present or to determine how a specific organ is functioning.

Urological examination

If you are prone to urinary tract infections or have a history of prostate problems or cancer, you may need urinary tests.

Dental treatment done prior to surgery

Bacteria can enter the bloodstream during invasive dental work, so many surgeons advise you to have any major dental treatment completed up to two months before surgery, and to delay any for up to two years post surgery.  This decreases the likelihood of infection around the new knee joint during or following surgery. 

Other health issues

You are likely also to have your weight and strength assessed.  Since the knee is the body’s largest joint, it will have greater stress if you are over weight or obese.  Your surgeon and physicians in your home country may advise you to lose weight and adopt a healthy eating programme in the months before surgery. 

Similarly, smoking can slow down the healing process as well as increase surgical risk, so you are advised to quit permanently if you can, or at least temporarily. 

What to expect from the surgeon

Below, is a general list of topics that apply to most surgical procedures.  You should be prepared to supply information on and/or discuss with your surgeon:

• Your expectations of the surgery
• The likely results of your particular operation
• Any medical conditions, drug allergies and medical treatments
• Use of current medications, vitamins, herbal supplements, alcohol, tobacco and drugs
• Any previous surgery
• Any family history that may be relevant such as instances of arthritis, bone cancer and so on 
• Assess your general health
• Discuss the value of and any complications of knee replacement surgery for your age and lifestyle
• Talk about the type of anesthetic used, its effects etc

You may be asked in preparation for surgery to:

• Take or stop certain medications or adjust your current medications
• Have certain lab tests or further medical evaluation
• Refrain from smoking in advance of surgery
• Adopt a healthy eating (possibly weight loss) programme
• Avoid taking aspirin, anti-inflammatory drugs and herbal supplements as they can increase bleeding

Questions you should ask your surgeon

It is important that you are fully informed of the after care, any possible complications and the likely results of your surgery.  You will also need to know how the procedure is carried out, which type of prosthetic will be used, and how you will need to care for your new knee joint.  Below is a checklist of some key questions to ask:

• How will the surgery be performed?
• Do I need full knee replacement or partial knee replacement?
• Which type of prosthetic is best for me?
• How do I best prepare for the operation?
• Do I need assistance in post-operative care – occupational therapists, physiotherapists, help at my accommodation and on my return home?
• What results can I expect?
• What risks and complications may occur? 
• What discomfort will I have? 
• What is my prognosis in the short term (first months to a year) and longer term?
• How long can I expect my new knee joint to serve me?
• Are there any activities or environments I should avoid while I recover?
• Following the operation, what exercise can I take and when can I start? 
• What other activities can I expect to resume and when? 
• Will I need any revisionary surgery?
• What instructions should I follow after the operation?

Anesthetics & Pre-op

Surgery is performed mostly under general anesthetic, but can be carried out with a spinal epidural which numbs you from the waist downwards although you will be conscious during the operation.

In general anesthesia, you will have an intravenous tube inserted in your arm to administer the medication and fluids required during surgery. Compression stockings will be placed on both legs to help avoid the risk of deep vein thrombosis.

The Surgery

The operation itself takes around two hours during which time your surgeon removes the damaged cartilage and bone and prepares the surfaces of the femur and tibia (end of your thigh and shin bones), before positioning the new metal and plastic joints.  Sometimes you will also have the back of your knee cap resurfaced with plastic, or it can be replaced in full. 

To carry out the procedure, the surgeon makes an incision – usually between 15 and 20cm long – to expose your knee joint. The precise location and length of the incision depends on the visibility required and the extent of your replacement – full or part.  The surgeon then ensures the new joint is properly aligned and functioning before closing the incision with sutures or staples. The incision is dressed and drainage tubes inserted and left in place for up to two days to prevent fluid build up. 

Following surgery, you will have an x-ray of the new joint to help the surgeon compare the immediate results with the knee joint’s state in the future. 

Immediate post-op

In the recovery room, you will be attended by nursing staff who monitor your medication and fluid levels, blood pressure, pulse and other major indicators of your general well being following the operation.  They will also be looking for any signs of any deep vein thrombosis building up in your legs or moving to your lungs.

Once your anesthetic has worn off, you will receive pain-relief medication and be encouraged to cough to clear your lungs.  Later that day, when you are totally alert, you will be taken to your hospital room.  You may find that the surgeon has recommended you have a machine to help your blood circulation. This is called a continuous passive motion exercise machine (CPM) which will elevate your leg and move your leg muscles to assist blood circulation. 

The prognosis for success in total knee replacement surgery is good and around 90 per cent of people undergoing the surgery find they have a dramatic reduction in knee joint pain and are able to return to their routine enjoying a far greater quality of life.  If you have reasonable expectations about your new lease of life and follow the advice on the care of your new joint, you can expect the long-term gain to far outweigh the short-term discomfort of your operation and convalescence.

Immediate recovery

For knee replacement surgery to succeed in the early days, you will need to follow clear guidelines on post-operative care and then be prepared to learn how best to carry out daily functions such as getting out of bed, bathing and so on.

Even as early as the day of your operation you may be asked to start some gentle foot and knee movements.  This is to ensure better blood circulation and to help prevent the likelihood of a deep vein thrombosis. 

By day one and two following your operation, you will be asked to make some first, gentle, aided steps.  You may have the services of a physiotherapist in the early days following the operation.  The physiotherapist will help you improve you mobility by working with you to help you walk and do gentle exercises.  You will find you have discomfort during these first days, but try to persevere as it is important for your healing process that the hip is strengthened and that your circulation is improved. 

Your physiotherapist will also be using a variety of aids such as a stroller/walker and crutches.  You will have clear instructions about what to undertake and how much weight/load bearing your new knee joint can sustain, both short term and long term.  If you had a partial knee replacement, and especially if you are younger than 55, you will find that your recovery time is shorter.  But don’t be tempted to undermine the healing process by returning too early to certain activities.  You may be advised to permanently forgo some strenuous exercise, such as high-impact sports. 

Usually, after about three to five days in hospital, and if you have made sufficient progress, free from any complications such as infection or thromboses, you can return to your accommodation to continue the gradual rehabilitation.   

Long-term care

At your accommodation, you will be constantly in touch with and monitored by the after-care team, including nursing staff and a physiotherapist.  You will need assistance still to carry out these daily functions so it is important before you arrive in Malta to have discussed with both your surgeon, friends and family both your after-care needs in Malta and on your return home.

You can expect to return to your normal daily routine within around three to six weeks.  But long-term recovery rates are specific to you and you will need to work out a plan with your health care team based on your needs, lifestyle and work routine.  Your health care professionals will work out a gradual mobility and rehabilitation programme tailored to you.

However, there is general advice which applies to nearly all people who have had total knee replacement surgery.  Below are some of the common instructions given knee replacement patients:

• Continue with pain-relief medication as long as is recommended by your surgeon, or doctor back home.
• Continue to wear the compression stockings for the first weeks at home.  Since it is very tight, you will need assistance in changing it. 
• Continue the exercises advised by your physiotherapist.  These exercises are designed to build your stamina, encourage circulation and generally help aid your recovery and return to independent living. 

Avoid:

• Certain movements and positions in the first eight weeks following the surgery.   Check with your own physiotherapist for precise details.
• Driving for between four to six weeks (or more if advised by your physician)
• Long periods of standing
• Lifting weighty items – for around three months
• Crossing the operated leg over the other one
• Twisting your leg outwards or inwards (duck- or pigeon-toe positions)

There are numerous adjustments you may need to make to your individual lifestyle.  In general, you will be advised to refrain permanently from high-impact sports such as jogging, basketball and tennis.  You will need to take advice about what to avoid and how to tackle other activities such as cycling, golf and skiing.  Some sports have greater risk of causing a fall, even if they are not in themselves impact sports.  Before returning to or taking up any sport or more strenuous activity, seek advice from your physician.

Total knee replacements have a good safety record and have been performed as a common, routine operation since the late 1960s.  Most people undergoing knee replacements report significant gains in terms of pain reduction and greater mobility. The operation can bring a noticeable improvement in quality of life and even a ‘new lease of life’ for many people. 

However, it is difficult to gauge with total accuracy the results for each individual.  The outcome depends also on the expectations set beforehand about what the surgery can and can’t do to enhance a person’s life. 

It is wise to remember that you are being fitted with a prosthesis, which, while excellent in terms of its composition and functionality, can never replace the strength and durability of a natural, healthy knee joint.  Depending on the age you are at when you undergo the operation, the prosthetic joint may or may not last the rest of your life.  A prosthetic joint will probably give a good 15, even up to 20 years of service, but younger patients may find that they need revisionary surgery during their lifetime.  Second knee replacements or revisionary surgery is unlikely to be as successful an operation. 

You should discuss the risks and complications with your surgeon at the consultation stage.  Ideally, you should try to map out what your lifestyle and expectations are as your post-operative routine will have a bearing on the longevity of your prosthesis.