Knee surgery has become a very popular course of action. With an aging population, a proclivity for sports, and a growing number of health-conscious people, the need for knee surgery has never been more pronounced. This course of action should never be taken lightly. It is paramount to understand the repercussions and implications of such invasive surgery. Often, people consider knee surgery when all other options have been exhausted. Physiotherapy, cortisone injections, weight loss, non-impact sports and exercises, pain medication, and glucosamine are all popular ways people try to avoid knee surgery. Others have knee surgery as a fresh means of solving a long-term knee problem. No matter what your reasons for considering knee surgery, it is important to have a strong understanding of what the surgery is about and what you can expect. This guide will provide you with a comprehensive understanding of knee surgery. From what knee surgery involves, to what procedures are done for which problems, through to what you can do to prepare yourself and what the recovery process will involve. This guide is designed for those about to have knee surgery, those in the process of recovery, those helping others through the process, or even those learning about knee surgery out of interest. So again, no matter what your reasons for wanting to learn about knee surgery, this guide will have the answers you are looking for.
What is Knee Surgery?
There are several types of knee surgery that may be recommended, depending on the specific injury. Arthroscopic surgery is a minimally invasive procedure utilizing an arthroscope with several small incisions. It is commonly called “surgery,” but does not involve an overnight stay in the hospital and is generally less involved than open surgery. High tibial osteotomy is a procedure used to correct alignment issues on one side of the knee. During this procedure, a wedge of bone is removed, and this can shift the weight-bearing axis to a less damaged part of the knee or leg. This surgery is generally indicated for younger patients with symptoms and injury isolated to one side of the knee. Open knee ligament repair is surgery used to repair a torn ligament. This is done by making a larger incision to access the damaged area and reattaching the ligament to bone or other ligaments. Finally, knee arthroplasty, often called a total knee replacement, involves resurfacing the damaged knee joint with metal and plastic components. This is commonly done to treat severe arthritis.
Knee surgery is a medical procedure to treat an injury to the knee. It may involve an incision to repair the injured area or a minimally invasive procedure with the use of an arthroscope or other tools to repair the damage. Knee injuries can be the result of trauma, such as a sports injury or car accident. They can also result from disease, such as an infection, gout, or arthritis. The indications for knee surgery will vary depending on the type and severity of the injury. For some, knee surgery may be indicated, whereas others may do well with conservative treatment.
Importance of Knee Surgery
Knee surgery is a medical procedure to repair, reconstruct, or replace a damaged knee joint. The importance of knee surgery is why an invasive procedure is undertaken at all. The decision to have a knee replacement is a very important one. It is a good idea to furthermore know about the operation and what to expect right from the start. The more you know, the better prepared you will be to get the best outcome. This booklet is to help you understand what is involved in knee replacement and to make an informed decision about whether this operation is right for you. The most common indicator for knee replacement is end-stage joint disease with a significant amount of pain and functional impairment. Knee replacement should be considered when you have arthritis and have severe pain that is affecting your quality of life. When you experience times of pain in your knee that restrict your daily activities, mild pain at night that interferes with your sleep, sustained pain or function limitations despite the use of medication, changes in the appearance of the knee, and when pain or stiffness is associated with inflammation. When considering pain, joint dysfunction, and joint failure, in the long run the outcomes of knee replacement are worth it in terms of what you have to gain. Knee replacement can restore your quality of life and allow you to return to the activities that you are unable to perform now. This improved quality of life can continue for 20 years or more.
Factors to Consider Before Knee Surgery
Before deciding to have knee surgery, several different factors should be taken into account. It is at the heart of this decision-making process that this guide has been written. It is designed to assist you, the patient, to better understand the full implications of an anterior cruciate ligament tear and to provide a clear understanding of the rationale behind choosing surgery or a conservative treatment approach. A complete understanding of the nature of the injury, treatment options and their limitations, potential for further damage, and the implications of activity level and long-term effects on the knee are essential to making an informed decision about the treatment of an ACL tear. This guide provides a higher level of detail and focuses primarily on an ACL injury, but it should be noted that a meniscus tear or injury to other ligaments often has a completely different set of implications, and if there are questions regarding these injuries, this guide covers those as well. This guide is also designed for those experiencing an ACL deficiency. This occurs when an individual opts against ACL reconstructive surgery, whether or not this is a well-informed decision, and attempts to rehabilitate the knee and use a brace to return to normal or high-level activity. The concept of conservative management will be addressed throughout this work, and if it is the primary interest of the reader, there is a section devoted to this treatment option.
Types of Knee Surgery
Arthroscopy is probably the most common procedure that comes to mind. It is a surgical technique that allows surgeons to view, diagnose, and treat problems inside the knee joint. The procedure is minimally invasive and utilizes a small camera (called an arthroscope) which is inserted through a small incision to magnify and transmit images inside the joint. The camera displays the images on a TV screen and the surgeon uses these images to guide miniature surgical instruments. Arthroscopy is used to treat a variety of knee problems, some of which are arthritis related, and also for the reconstruction of torn ligaments. It is often performed to remove the damaged tissue or debris in the knee. Due to only small incisions being required, arthroscopy usually results in less scarring and a quicker recovery time for the patient. Usually this type of surgery is performed in a day surgery setting and does not require hospitalization. Probably the most invasive form of knee surgery is a total knee replacement. This is major surgery from which it can take months to recover. The surgery involves resurfacing the damaged knee joint with artificial materials. Damage occurs when the surfaces of the knee joint become eroded and worn thin. This exposes the bone and results in pain and decreased movement of the joint. The damaged areas are resurfaced by positioning metal implants on the end of the thigh and shin bones and capping them with a smooth plastic button. This way, the damaged knee surfaces are removed and replaced, with the aim for no bone-on-bone contact between metal and plastic. Often a TKR is performed on patients with severe arthritic condition. After surgery, vigorous rehabilitation is very important to the recovery of knee movement and general mobility. It is usually a few months after surgery before the patient feels substantial relief. A partial knee replacement is significantly less invasive than a TKR and is an alternative to the surgery. It is indicated when damage to the knee is confined to only one of the three knee compartments: the medial (inside), lateral (outside), or the patellofemoral (front) compartments. The surgery is possible when the ligaments in the knee are healthy. Damage to the knee is usually characterized by pain localized to one of the compartments, and relief of that pain often indicates success of the surgery in solving the problem. A PKR involves resurfacing of the damaged compartment with a prosthesis similar to the one used in a TKR. Benefits of a PKR include quicker recovery and less pain because the surgery does not involve resurfacing of the entire knee joint. The surgery is, in effect, an alternative for patients who might undergo a total knee replacement but are unsuitable due to age or health restrictions.
Arthroscopy
– Inside the knee joint. This is often caused by a torn cartilage (known as a meniscal tear). It can cause the knee to ‘give way’ or ‘lock’. – Inflammation of the knee. This can be caused by a number of different conditions such as rheumatoid arthritis, gout, or by repeated bleeding into the knee joint. In a very small number of patients, an arthroscopy can help to diagnose the cause of unexplained but persistent knee pain. This is often referred to as a negative arthroscopy. – Knee pain with no obvious cause. In some patients with knee pain where the diagnosis is unclear, a knee arthroscopy may help to locate the problem. This is most likely to be performed in younger patients. This is sometimes referred to as an investigative arthroscopy. – Damage to the surface of the knee joint. This can be caused by repeated bleeding into the joint or in some cases is the result of a previous injury. In some cases, this can be treated during arthroscopy with techniques such as microfracture. (NB: Currently, arthroscopic microfracture is not routinely recommended for isolated patellar chondral defects).
What are the common indications for knee arthroscopy? There are many different reasons why knee arthroscopy may be suggested. Arthroscopy is often used to confirm a diagnosis made after a physical examination and other imaging tests such as MRI scans or x-rays. Common conditions where arthroscopy may be suggested include:
When is knee arthroscopy needed? Arthroscopy involves the use of a small telescope-like device to examine the inside of a joint. It is used to diagnose a variety of knee problems and is also used to guide the surgical procedure for repairing a knee problem. Arthroscopy can be performed under local, regional, or general anesthetic. The procedure usually takes between 30 minutes and over an hour. Usually, arthroscopy is a day-case procedure and does not require an overnight stay in the hospital.
Total Knee Replacement
Candidates for total knee replacement will most likely have severe knee pain or stiffness that interferes with their daily activities, including walking, climbing stairs, and getting in and out of chairs. It may be hard to walk more than a few blocks without significant pain and swelling in the joint. You may feel that the pain is too much and that the knee is the primary cause of limitation, or that it prevents you from doing your job satisfactorily. If you feel that you may want to consider knee replacement, X-rays can help your evaluation to determine whether the damage in your knee is suitable for this kind of surgery.
For severe knee problems that do not seem to be improving with other treatments, the evaluation may recommend total knee replacement. Knee replacement surgery is a treatment that can help you by relieving pain and disability, and may also allow you to be more active comfortably. During knee replacement, a surgeon cuts away damaged bone and cartilage from your thighbone, shinbone and kneecap and replaces it with an artificial joint made of metal alloys, high-grade plastics and polymers. Today, metal and plastic knee replacements with plastic spacers are the most commonly used.
Partial Knee Replacement
Ideal candidates are those who have arthritis that only affects one compartment in the knee. There are three compartments in the knee: the inside (medial), the outside (lateral), and the front (patellofemoral). If the arthritis only exists in the medial compartment, for example, a medial unicompartmental knee replacement would be ideal. Medical history, a physical examination, and x-rays will help determine if a patient is a good candidate for partial knee replacement. Early onset arthritis, intact ligaments, and an aligned knee are all factors that would favor a partial knee replacement over a total knee replacement. Although partial knee replacement is favorable for the patient, only about 10% of knee replacements are partial because of the strict criteria for being a candidate.
Partial knee replacement, also called unicompartmental knee replacement, is a surgery that is minimally invasive and used to create resurfacing in only the diseased portion of the knee. This allows patients to keep the healthy portion of their knee joint and only replace the area that is damaged. This procedure can result in a less painful and shorter recovery since the healthy portion of the knee is not removed. Patients are generally up and walking within hours after surgery. Because the incision is much smaller and less muscle is cut, patients typically have less pain and require less pain medications. Partial knee patients often are also able to achieve a better range of motion in the knee compared to total knee replacement patients.
Knee Ligament Reconstruction
For patients who have injuries to the cruciate ligaments, they have the option of having anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) reconstruction. Patients with ACL tears often have knees that give way during activities that involve cutting, pivoting, or twisting. Many have trouble playing sports, going up or down stairs, and some have ongoing knee problems and pain. The event of injury is usually with a pop in the knee and immediate swelling. The ACL is important for knee stability, and the goal of ACL reconstruction surgery is to prevent further injury to the meniscus or articular cartilage. The ACL normally stops the tibia from sliding too far forward on the femur, and when the ACL is torn, this can cause damage to occur to the other structures in the knee. This is a badwipe behaviour, and if left unchecked can cause further serious knee damage. ACL reconstruction is usually performed where the torn ligament is removed and replaced with a tendon graft. There are various sources for the graft including hamstring or patellar tendon which have specific advantages and disadvantages. The most appropriate graft will be decided in consultation with the surgeon and depending on the patient’s specific injury and knee. Rehabilitation after an ACL reconstruction is detailed in Chapter 6. The general aim is to provide a knee that does not give way and is free of the symptoms that were present before the injury. Most patients with desk type jobs will be able to return to work within one to two weeks. However, activity involving heavy lifting and stair climbing may require three to six weeks off. High impact recreational activities will need to be avoided for three to six months and return to pivoting and competitive sports is not recommended until at least six months. Physiotherapists are often involved to assist with a functional recovery program that will return strength and mobility to the knee. This is a slow process with a full recovery sometimes taking up to a year. Success rates are high with around 90% of people gaining pre-injury knee stability and about 85% of people being able to return to the sports they were participating in before the injury.
Cost of Knee Surgery in Singapore
Another factor will be the hospital cash deposit for foreign patients. This anomaly in pricing means that foreigners will more likely pay a much higher amount for the same surgery compared to a PR or a citizen. Citizens and PRs usually get a higher level of subsidy from the hospital. However, the exact amount of subsidy for PR will depend on the nature of the operation and the kind of implant that is used.
Some hospitals have subsidies for lower income patients but this will depend on the patient’s income level and whether the patient qualifies for the Assistance Schemes provided by the Ministry of Health. On top of that, the level of subsidy provided by the hospital will vary. Usually, the larger restructured hospital will have more subsidies and they are usually given to patients who opt to have surgery done at a teaching hospital. The type of ward a patient chooses will also affect the cost. A patient who opts to stay in an air-conditioned single room will expect to pay more than a patient who chooses to stay in a multi-bedded non air-conditioned ward.
Predicting the actual cost of knee surgery in Singapore is a complex process. The cost of a knee surgery is affected by many factors ranging from the type of hospital a patient chooses to whether a patient is a foreigner or a PR. Patients are advised to consult their surgeons on the actual cost of their surgery. This advice is based on the complexity of providing a close estimate for the cost of the surgery for a particular patient. But to provide an overall view of the knee surgery cost Singapore, the factors affecting the cost of the surgery need to be considered.
Factors Affecting the Cost of Knee Surgery
Class A/B1 hospitals charge higher prices for operation and admission in comparison to the other classes due to the increased comfort and privacy provided. However, from the standpoint of medical safety and satisfactory clinical outcome, there is almost no difference between a Class A/B1 surgical procedure and a Class B2/C2 surgical procedure. Hence, patients who choose to go through knee surgery in a Class A/B1 ward are effectively paying for a higher level of comfort and privacy. On the other hand, a patient who is assured that the clinical outcome of his surgery will not differ in a lower class ward may opt to go through the surgery in a lower class ward.
One of the key factors contributing to the cost of knee surgery is the type of hospital class that the surgery is performed in. Hospital class in Singapore is stratified into Class B2/C2, Class B1/C1, and lastly Class A/B1. For Class B2/C2 wards, the hospital bed is located in a large 10-bed ward with no air-conditioning and 4 toilet facilities shared between 40 beds. Class B1/C1 wards are 4-bedded wards with air-conditioning and an attached bathroom. Class A/B1 wards provide single bed or double bed rooms with full air conditioning and an attached bathroom.
Average Cost of Knee Surgery in Singapore
Three studies on the knee surgery cost in Singapore were found. The first was a local prospective study conducted in 1999. It estimated the cost of unilateral total knee arthroplasty to be S$8,563 for a five-day hospital admission. The second was conducted in an acute care general hospital; the study compared the costs incurred on knee replacement surgery using the traditional inpatient care pathway and minimally invasive surgery with the use of an accelerated discharge and home rehabilitation program. The third was done to compare the costs of offloading devices for patients with knee osteoarthritis. It found that a sleeve-type orthosis would be more costly than a knee-ankle-foot orthosis over a two-year time frame. Although the study was a cost comparison of devices and not knee surgery, it did offer useful information on the cost of treating knee osteoarthritis. The data suggests that the average cost of knee surgery in Singapore is relatively expensive. This is due to the high standard of healthcare services available. The first study conducted in 1999 had an estimated cost of S$8,563 for a five-day hospital admission for a unilateral knee replacement. The high hospitalization costs would push the overall costs higher and is a major factor determining the cost for knee surgery. A more recent study estimated a cost of US$7,750 for unilateral knee replacement. This higher cost was attributed to a regional category higher than the surgery date joint category. This suggests that the cost of knee replacement will escalate with the improvement in medical technology and the increasing costs of healthcare services. High healthcare costs are also attributed to the more costly, new and developing techniques to treat knee disorders such as viscosupplementation therapy or arthroscopic techniques. This would eventually result in a higher cost of knee treatment in the future.
Insurance Coverage for Knee Surgery
The extent of insurance coverage varies between MOH (Ministry of Health) restructured hospitals, private hospitals, and day surgery centers. In a MOH restructured hospital, eligible patients will be able to pay for their surgery using the Medisave withdrawal program. Generally, the amount that can be withdrawn from Medisave ranges between $1100 to $2050, depending on the complexity of the procedure. Any remaining balance after Medisave withdrawal and cash payment can be further subsidized by the patient using the appropriate Integrated Shield Plan and rider. This would effectively reduce the out-of-pocket expenses on the part of the patient to the co-payment bill, as the balance would then be billed directly to the insurance company.
Preoperative investigations and conservative treatments for knee conditions are covered by most insurance policies. These include conditions from minor injuries such as a meniscal tear to severe degenerative knee conditions requiring knee replacement. In most cases, if surgery is deemed to be the necessary next step for treatment of the knee condition, part or the entire cost of surgery would be covered by insurance.
Insurance coverage for knee surgery varies from one patient to another. Whether knee surgery is covered is dependent on the cause of the knee problem, the types of treatment available, and the patient’s type of insurance coverage.
Choosing the Right Surgeon and Hospital
It is also important to consider the experience of a surgeon. This is a very difficult thing to measure and it is not always a direct reflection of how long they have been doing knee surgery. Some surgeons have a good understanding and knowledge of the technical aspects of knee surgery after a few years. It may be more appropriate to ask a surgeon how many of a specific type of operation they have done and what their complication rate is. This can give you a better idea of their level of experience in that specific operation.
It is important to know that there is a knee qualification for surgeons – FRCS (Tr&Orth). There are many surgeons who do not have this qualification who are still doing knee surgery. It is within your rights to ask for information on your surgeon’s qualifications and to make sure that they have this qualification. While this does not guarantee a successful surgery, it is important that a surgeon doing a knee operation has specific and shows an appropriate level of commitment to knee surgery.
When referring to a knee surgeon and hospital, it can be difficult to know where to begin. There are many different surgeons who have varying degrees of experience and there are also hospitals with varying levels of care, service, and rehabilitation facilities. Making the right choice in surgeon is important as they have a large effect on the success of the surgery, but it is also important to consider the hospital where the surgery will be conducted and the rehabilitation process will begin.
Qualifications and Experience of the Surgeon
Ask about the surgeon’s recent experience, especially if you are considering a newer technique for your knee problem. How many of these operations has the surgeon performed, and what are the results? For some surgeons, it can be difficult to admit that they have only performed a small number of a particular type of operation. However, it is in your best interests to find a surgeon who is experienced in the operation that you require. Surgeons who have a specialist interest in a certain area of knee surgery are often aware of recent developments, and it may be worth trying to find a knee surgeon who has a specialist interest in your type of knee problem.
It is a good idea to inquire with your surgeon about their qualifications and experience in performing knee surgery. Ask about their general medical training, where they gained their qualifications, and what experience they have in performing knee surgery. Can they carry out all different types of knee surgery, including total knee replacement and knee arthroscopy? If so, how often do they perform these operations? Do they take an interest in patients with knee problems, and what are their post-operative results like?
Reputation and Success Rate of the Hospital
A knee surgery is an important undertaking, it is not unfair for the patient to expect the best possible service. Consider the reputation of the hospital. Although the newspapers are full of impressionable advertisements, the true reputation will be known by word of mouth in the medical field. If people of the community are speaking highly of a particular establishment, it is likely that the establishment is providing a good service. In the event that the surgeon mostly operates out of a single hospital, it would be wise to consider having the surgery done in that hospital. This is especially true if the surgeon has admitting rights to a hospital that is not at the top of your list. Surgeons usually prefer to operate in hospitals at which they feel comfortable and many believe that they can provide the best patient care at hospitals where they admit their own patients.
Majority of reputable hospitals keep past records of the success rates of all the past surgeries carried out in the hospitals. Though past performance is not a complete indicator of the future results, it should always be taken into account. If the knee surgeon with the desired qualification has a choice between two hospitals, it would be wise to choose the one with the higher success rate. It is not easy to obtain records or statistics from the hospital regarding the success rates but any good quality establishment should have no qualms in providing you with the information if you request it.
Patient Reviews and Recommendations
Patient reviews and recommendations are useful, but can be subjective. Any poor review will sound louder physically than numerous positive ones. Don’t be put off too soon – ensure that you ask your surgeon about any review that worries you. The nature of the surgery and age of the patient should be taken into account. For example, total knee replacement has a high success rate in terms of pain relief, improvement in knee function, and generally patient quality of life. That is not to say that it is not a traumatic experience for some, take into account any bad experience in light of statistical evidence for the proposed surgery. If the volume of bad reviews contradicts the evidence, you may want to pick a different surgeon/hospital. Some data has suggested that higher volume surgeons and those working in hospitals with a high success rate for orthopedic surgery result in significantly fewer complications for patients. Patient recommendations may be received either directly through friends and family or through the surgeon themselves. In terms of gathering information through other patients, it is useful to find those who have had the same procedure. Success rates for different procedures can often vary, and a surgeon who is very experienced in knee arthroscopy may not be suitable for a total knee replacement. Gather as much information as you can and try to go directly to the source for a patient’s experience, as word of mouth stories can be distorted. If you know someone who works in healthcare in your local area, they may have a good idea of any surgeons in the area. They cannot always give a recommendation due to patient confidentiality, but it is worth asking. If you have had a consultation with a surgeon and are unsure on whether you should go through the procedure, it is often worthwhile asking for a second opinion from another surgeon. This does not imply you have no faith in the current surgeon and is the best way of knowing if knee surgery is really right for you.
Accessibility and Facilities of the Hospital
It is no use in undergoing knee surgery if there is nothing wrong with it. So, when choosing the right knee surgeon and hospital, patients need to first find out the exact problem with their knee. Usually, the knee surgeon will explain what is wrong with the knee and what needs to be done, but it is important to understand the problem, so it is best to ask as many questions as possible. The problem with the knee will usually determine what sort of surgery needs to be performed – there is no point performing a total knee replacement if the patient’s problem can be solved with a less invasive arthroscopy. Be sure to ask the surgeon what options are available and then from that start setting goals for what you want to achieve. This will eliminate any confusion when surgery is about to be performed. Step one in deciding what type of knee surgery is required is still to visit the GP. The GP will then refer the patient to a knee surgeon, but the patient does have the option to request a particular knee surgeon that they have found through their own research.
An essential factor in deciding on the right surgeon and hospital is to look at the accessibility and facilities of the hospital. Accessibility is important because after the surgery, the patient’s movement will be greatly affected and may be unable to utilize public transport or climb stairs for quite some time. As almost all knee surgeries are done as inpatient procedures, this then becomes vital. Facilities of the hospital will also have a great influence on your recovery as hospital resources determine what can and cannot be done.
