Total knee replacement (TKR) is a highly successful surgical procedure aimed at relieving pain and improving knee function, particularly in elderly patients suffering from advanced osteoarthritis. The procedure involves precise balancing of the knee joint, with methods including both cemented and cementless implants, and has been successfully performed at Neigrihms since 2010. Post-operative care involves rehabilitation strategies and physical therapy to ensure patients regain strength and mobility.

1. By:
Dr Bhaskar Borgohain
MBBS (AMC), MS Ortho (Delhi Univ.), DNB Ortho (NAMS),
AO Trauma Fellow, (Germany), Arthroplasty Fellow (Computer
Navigation)
Professor & HoD, Orthopaedics
NEIGRIHMS Shillong
www.neigrihms.gov.in

2.  TKR is a soft tissue operation
 Its all about the “Balancing”!
 It is deceptively simple looking
operation

3. Painless mobile and stable

4. Knee replacement is a deceptively simple looking surgery!

5.  Knee is that largest joint in the body
 Hyaline type cartilage ends
 Femur & tibia are joined by a complex ligaments,
muscle-tendon units
 Patella: serves as a bony fulcrum for to slide over
and amplify strength and torque
 Complex hinge joint: Knee can not only bend and
flex, it can twist and rotate

6.  Total knee replacement (TKR) is one of the
most successful surgeries of modern time in
Orthopaedics.
 The goals of the surgery are complete pain
relief and improve function of the affected
joint.
 Deformity correction, increase bending of the
knee joint due to improved range of motion,
besides pain relief is also possible.

7.  The NEIGRIHMS orthopaedic department
started performing Total hip replacements
since 2007 and Total knee replacements since
2010.
 Since then, these state of the art surgeries are
being performed successfully and with
negligible infection rates.

8.  We do both cemented (traditional) as well as
cemmentless (advanced) total hip replacement
and time tested fixed bearing total knee
replacements.
 These surgeries are first of its kind in the state
of Meghalaya and some of these are performed
even for the very first time in North-East India.

9.  Osteoarthritis causes pain, deformity and loss of
function.
 Usually done > 65 years so that single surgery serves
the lifetime of a person.
 TKR is indicated in advanced osteoarthritis of knee,
which can be primary or secondary to rheumatoid
arthritis, gout, post-traumatic degenerative arthritis
and rarely in painful but healed tubercular arthritis etc.
 TKR is indicated when the pain is severe enough to
affect the activities of daily living (ADL) significantly
requiring regular painkiller.

10. Osteoarthritis: Joint Damage & Deformity

11.  Replace with appropriate sized metallic components.
 The metallic implants are held secured to the bones
by using PMMA bone cement.
 The implants are metal alloys and a polyethylene
insert is inserted in-between the metals to reduce
friction during movements of walking.
 Tight ligaments are released to correct any deformity.
 Sometimes the undersurface of the patella also needs
replacement

13.  Metal implants made from nickel chrome alloys
 Though there is toughness in these systems, they tend
to roughen and scratch over time
Scorpio NRG
Knee Flexed ™
Triathlon PS
Knee System ™
Scorpio TS Revision
Implants Front View ™
ADVANCE STATURE®
Knee

14. Implants are commonly fixed with PMMA Bone cement

15. Flexion-extension gap for ligament balancing

16.  Current consensus among knee surgeons is.....
Flexion contractures should be corrected to the maximum extent
possible at the time of surgery.
 Aim: Balanced the “ flexion – extension gap”

17. Avoid anterior notching on femur by using
a manufacturer specific jig, e.g. Stryker

18. The basic bone cuts in TKR

21. Alignment and mechanical axis needs to be restored:
Centre of hip- centre of knee-centre of ankle should fall in one line

22. The electro-cautery wire can be used to check this during surgery

24. A 79 year old diabetic gentleman from Manipur with severe painful
OA of Both knee; Father of a pharmacist: both knee surgery done at
NEIGRIHMS
He could go back home walking with a single walking stick after stitch removal.

25.  The artificial components inserted into the knee are not
linked to each other
 Rely exclusively on the body’s muscles, ligaments, and
tendons to keep the kneecap in place.
 no stability built into the system.
 Most common type of replacement

26.  Many patients can walk a bit by second or third day
with support from the trained physiotherapist.
 Most patients have an uneventful post operative
period.
 But certain patients have a higher risk of post operative
wound complications like patients with diabetes
mellitus, rheumatoid arthritis, malnutrition and elderly
etc.

27. • Physical Therapy
• Gradually return to normal
activities
– Walking, climbing stairs
– No running, playing tennis
as it may wear the artificial
joints
• Doctors recommend a CPM
(Continuous Passive
Motion)
– It slowly and smoothly
bends and straightens your
knee
• Stationary Bicycle – regain
strength in knee and leg
muscles
• Swimming

28.  Early active quadriceps strengthening
 Aggressive full extension of knee
 3-4 sessions of stretching recommended/day as many of these
patients were accustomed to maintain the knee in a flexed
position prior to surgery.
 Discourage patient from putting pillow behind knee/ sitting in
reclined chairs
 Knee immobiliser/ night splints for those who lack extension,
obese patients and those who sleep in fetal position with knees
flexed
 Evaluation for ROM at 6 weeks, 3 months and 1 year – slow
progressers may require MUA
 Excellent post-op analgesia

29. • Used when the knee is highly unstable : the person's
ligaments unable to maintain stability
• Severely damaged knees
• The two metalic pieces are connected with a hinge-like
device that keeps the joint in-line & support proper
alignment for function.
– Though It doesn’t last as long as the other knee
replacements

30. COVENTIONAL TKR is possible and appropriate in:
MODERATE CASES with NORMAL LIGAMENTS
UKR- Unicondylar knee
Hinged
knee

31. • Used when the knee is highly unstable : the person's
ligaments unable to maintain stability
• Severely damaged knees
• The two metalic pieces are connected with a hinge-like
device that keeps the joint in-line & support proper
alignment for function.
– Though It doesn’t last as long as the other knee
replacements

32.  It is performed if the damage is limited to one
side of the joint only with the remaining part of
the knee joint being relatively spared
 The incision is only three inches compared to 8
inches for a total knee replacement
 Less invasive and more successful

33. Dislocation of knee after surgery can happen due to error:
Poor ligament balancing or incompetent ligaments
These are not our cases – but needs to be aware of this problem

34.  postoperative infection
 With more awareness among people about TKR
number of patients is bound to increase
 Overall high cost of the implants / accessories until
recent NPPA Guidelines, only limited the number of
beneficiaries.
 With increasing coverage under various health
schemes like RANS / Government sponsored health
insurances, more and more elderly with painful
arthritis are likely to get benefits of TKR in the future.

35.  All OT staff, Nursing personnel in successfully
conducting successful surgeries
 Anesthesia team for their support
 Physiotherapy unit
 NEIGRIHMS Admin
 Faculty colleagues
 All SRDs, orthopaedics