Understanding arthritis
Cartilage is the cushion, which covers the knee joint surfaces like the rubber on your car tyre. Movement in the absence of cartilage leads to a grinding of bone on bone and production of debris, which causes swelling, pain and destruction. This is what happens in knee arthritis.

“This grinding process in the knee joint continues in spite of medications, which only reduce swelling and pain but do not restore the lost cartilage.” This process can be slowed down by weight reduction, activity modification, muscle strengthening exercises with judicious use of anti-inflammatory medication. The time to consider surgical intervention comes when the patient is functionally incapacitated or in danger due to severe bone destruction.

About Conventional Total Knee Replacement
Total knee replacement surgery is one of the most cost effective ways of treating severe knee arthritis. This surgery simply involves removing the damaged bone surfaces and replacing them with metal and plastic.

Total knee replacement is a good established operation for end stage knee arthritis.

Knee Replacement surgery has advanced significantly with the use of high bending implants, gender specific implants (special implants for women) and computer assisted surgery, but, the operation continues to be done through a midline muscle and tendon cutting approach as shown in the diagram below on the right. The red line depicts the conventional approach to expose the knee joint.

Less attention has been given to preserving soft tissues during this operation. The bone work is done satisfactorily but the soft tissue damage that occurs during the operation is often not given due importance. The conventional technique damages the quadriceps muscle and other normal tissues. It causes more bleeding and post operative pain. The damage to the muscle is slow to recover and in a lot of cases the muscle may never come back to full potential. This leads to slower rehab in spite of very intensive physiotherapy. Knee bending is slower and often incomplete.

We have to appreciate the fact that the purpose of knee replacement is to replace the damaged articular surface. This has to be done with minimum damage to other normal tissues for best results. TISSUE PRESERVING TOTAL KNEE REPLACEMENT (TPTKR) is a step in this direction.

Tissue Preserving Total Knee Replacement (TPTKR)

TPTKR is an attempt to make a good surgery better. It goes beyond the general scope of conventional knee replacement surgery. The quadriceps muscle is one of the most important muscles around the knee. One cannot stand without a functioning and strong quadriceps. The stronger this muscle the better is the functioning and survival of the knee replacement. A successful knee replacement cannot be done in patients who have a very weak quadriceps muscle. This muscle is weaker in old patients and also affected by the arthritis. It therefore does not make good sense to damage this quadriceps muscle any more than it already is. This is even more important in older patients whose tissue reserve is already low. About 60-70% of patients who present with severe end stage arthritis for total knee replacement surgery are older than 60 years. These patients have a lower functional reserve than younger patients, their muscles are weaker and they often have other co-morbid conditions. TPTKR addresses this by causing less soft tissue damage.

Tissue preserving total knee replacement surgery is appreciating the fact that the purpose of the operation is to purely replace the unhealthy surfaces with new materials, and at the same time correcting deformity and achieving stability. The technique allows you to achieve this objective with minimum collateral damage. This method combines three important steps

a) Muscle preserving exposure
b) Computer navigation techniques
c) Appropriate implant choice

Let us understand each step:
a) THE MUSCLE SPARING EXPOSURE
The muscle sparing technique does not cut the QUADRICEPS muscle and damage it. It allows entry into the joint along the side of the muscle by simply flipping it to the side and not cutting through it. It gives satisfactory exposure with standard instruments. It is minimally invasive in the true sense and allows easy access even in obese patients. The joint exposure is ample and allows satisfactory bone preparation and cuts with implantation for a durable result. Specialised dissection and joint positioning pushes it beyond the standard subvastus exposure.

THE QUADRICEPS MUSCLE AND TENDON

b) Navigation technology increases the accuracy of bone cuts and alignment. There is less need for ligament releases and minimal bone resection is carried out. The exposure of the joint is ample enough to insert the computer arrays in the bone through the incision itself without further damage

c) Great importance is given to the use of established implants most appropriate for the patient’s condition and anatomy. For example, in case of female patients we can combine the muscle sparing technique with gender specific knee replacement design which is less metal in the knee for the same size and less constraining on the tissues.
This method achieves the following –
• Good surgical exposure
• Less soft tissue damage
• No blood transfusion
• Less bone damage
• Good surgical implantation

Advantages of tissue preserving surgery

• Less post surgery pain
• Less bleeding (we rarely transfuse blood including patients who undergo both knee replacements in one sitting)
• Faster return of knee function – muscle strength and control comes back more quickly – allows faster rehabilitation. Patients can walk on day of surgery in most cases
• Shorter hospital stay
• Less soft tissue damage and a better result
• Early return of knee motion
• Recovery time is less than one third of that with conventional technique.

In the tissue preserving technique the skin incision size depends on the size of the patient. Incision size has little bearing on the postoperative result. A good knee replacement happens when we remember that not only do we have to execute the bone work properly but at the same time preserve the tissues that are going to stabilize and move these bones.

Since the age of 24, when I was first diagnosed with rheumatoid arthritis, I thought I had no hopes but to live with the pain and compromised gait, till I consulted Dr. Kaushal Malhan who gave me the hope of a new beginning with specialized tissue preserving knee and hip surgery. He understood the needs of a young person like me and with advanced surgery truly gave a new meaning to my life” said Ketan Mhatre – a young 33 year old IT professional who has undergone a hip resurfacing and bilateral knee replacement with tissue preserving technique at Fortis Hospitals Mulund.Dr. Kaushal Malhan, Consultant Knee and Hip Surgeon, Fortis Hospitals Mulund along with his team performed the hip resurfacing and knee replacement surgery on Ketan with specialised tissue preserving methods to treat his worn out joints. Ketan Mhatre who lives with his wife and parents in Thane was suffering from severe pain in his joints. His hip and knee joints were damaged to the extent that they made a cracking sound while walking. He was unable to stand and walk due to excruciating pain. Medicines of all sorts were not helping him as his joints were totally damaged by the arthritis. With endstage secondary arthritis in almost all his weight bearing joints, Ketan’s life and career was crippled. This disease had completely compromised his physical and social life and posed a threat to his career.

Dr. Kaushal Malhan, Consultant Knee and Hip Surgeon Fortis Hospitals explains “Ketan’s problems began with the onset of inflammatory type of joint arthritis which started to damage a number of joints in his body especially those of the lower limbs. In spite of good medical treatment the disease progressed unabatedly and caused severe damage to the right hip and both knees. He was unable to stand straight and walk. Since the joints were completely destroyed there was no option but to consider replacement surgery. In view of his young age I decided to replace his joints with techniques that would preserve as much as possible. I did a bone conserving hip resurfacing surgery and bilateral tissue preserving total knee replacement. Both knees had to be done in one sitting because of the extreme deformity. Doing one at a time would not allow proper rehabilitation and Ketan was in no condition to allow a long drawn wait and rehabilitation.

A recent pan-India health survey reveals that osteoarthritis has emerged as the numero uno ailment in India, even trouncing traditional heavyweights like AIDS, diabetes, cancer and hypertension. The survey – titled ‘TNS Arogya 2006-07 The Health Monitor’ – conducted by TNS, an ISO-accredited market research agency in Delhi, in October 2007, was carried out across a swathe of 15 cities – Delhi, Lucknow, Ludhiana, Jaipur, Varanasi, Chennai, Bangalore, Hyderabad, Cochin, Kolkata, Patna, Mumbai, Ahmedabad, Nagpur and Indore. According to the study, in the age band of 25 to 35 years, osteoarthritis is the second most prevalent disease in India after diabetes. The study showed that despite this, awareness amongst Indians about the bone ailment is almost nil as compared to high profile diseases like cancer, AIDS and diabetes. The prevalence of doctor-diagnosed arthritis is projected to increase to nearly 25 percent of the adult population by the year 2030. Almost one-third of all cases will be in working-age adults, those 45 to 64 years old. This large increase poses a major challenge to the health care and public health systems. The World Health Organization (WHO) estimates that 70 million Indians are victims of arthritis. According to the US-based Arthritis Foundation, 80 per cent of the 50-plus people in the world will experience arthritis in one of its many hundred forms.

A study published in the Journal of Community Medicine Vol. 1, No.1, January 2007 showed significant difference in the prevalence of osteoarthritis in elderly of rural & urban areas. The low prevalence of osteoarthritis in rural elderly could be due to differences in their life style. Rheumatoid Arthritis has a prevalence of 0.75%. Projected to the whole population, this would give a total of about seven million patients in India.
“Statistics have shown that over the past several years, the age of onset of osteoarthritis has been steadily decreasing. Also secondary arthritis is being commonly seen in younger people. The number of young patients with endstage joint disease seeking a satisfactory remedy is going up day by day. These patients are beyond the scope of medicines and need surgical treatment. These are high demand patients who need high performance surgery. Conventional joint replacement surgery is therefore less appropriate. The innovative tissue and bone sparing techniques we have been doing at our centre are very appropriate for this group of patients” added. Dr. Kaushal Malhan.

“A common myth around joint replacements is that it is a surgery for the old arthritic patients and a number of misconceptions prevail when it comes to the young joint replacement patient. Today a number of young patients have end stage arthritis where the joint is completely destroyed. These patients can benefit significantly from joint replacement surgery. Specialised tissue and bone conserving techniques which have been very successful in the older patients are especially advantageous in the younger group of patients. They allow faster recovery and return to work with less postoperative pain. The blood loss and hospital stay is lesser and healing is faster.

Revision surgeries if ever needed will be an easier undertaking when bone conserving operations are to be revised. The concept of tissue preserving joint reconstructive surgery has been nurtured by us over the last many years with good success. We find that these techniques are useful for all groups of patients but hold special advantages for the younger high demand group” he added.

“I was reluctant in the beginning to undergo a surgery and had the fear of losing the limited gait I had, but I had limited choice. After learning the benefits I opted for the surgery. After surgery my pain had gone, and when that happened, it seems the world opened up for me and I thrived to get back to normal again. My confidence started building gradually and I looked at life with a more positive outlook. I followed a stringent post op physiotherapy and rehabilitative programme. From the day when taking even a step was unimaginable for me, today I comfortably climb two floors without anybody’s help. I look forward to my professional life and lead a very active social life and love going out with my friends and family. And this is only possible because of the surgery that I have undergone” said Ketan Mhatre. “Today, technology and medical science have advanced so much that one need not compromise their quality of life and career” he added.