Should We Sacrifice The Whole Joint When Only Partial Knee Placement Is Needed?

By Dr Goh Eng Tat
Orthopaedic, Joint Reconstruction & Trauma Surgeon
MBBS (M’lore), M.S. Ortho. (UM), FRCS (Ire), CMIA (M’sia), F’ship in Joint Reconstruction (St. George, Sydney)

If knee pain is affecting your lifestyle, then you need to know this: the new concept in joint replacement surgery is to replace only the worn out portion of the arthritic joint and save as much of the natural knee as possible.

A large number of people with osteoarthritis of the knee have worn out only the cartilage of one of the three compartments in the knee. If this is the case, the individual may only require a partial replacement, preserving the unaffected compartments of the knee and all the ligaments of the joint.

Oxford® Knee Replacement is an implant that can accomplish this task with a proven track record of 95% success at 15 years and beyond. For this reason, the Oxford® makes a total knee joint replacement unnecessary in many cases. In some centres in the US, the number of Oxford® Partial Knee Replacement has reached almost 50% of all joint replacement surgeries.

The photograph below represents one (sided) compartment of bone-on-bone osteoarthritis. This occurs due to wear and tear of the articular cartilage. The other compartment cartilage is still normal. Once this situation develops, the individual usually has severe pain. An Oxford® is ideal for this situation.

The x-ray photographs above demonstrate a pre-operation x-ray and post operation x-ray (after an Oxford® has been placed). One can see that the bone on bone rubbing condition has been replaced by the Oxford® with its mobile bearing (the white horizontal line between the metal).

The Oxford® ® Unicompartmental Knee Replacement System offers these advantages:

• At 15 years following surgery, 95% of implants are still functioning well

• Preserving other compartments of knee while only the affected inner portion of knee is resurfaced

• Preserving all the ligaments of the knee thus allow more normal, natural and physiological motion of the human knee

• Only a portion of the knee is replaced, making this procedure available to a younger population

• Minimally invasive – a small incision is utilized

• Less pain due to a smaller operation scar and dissection

• Blood transfusion is rarely needed

• Two to three nights in hospital

• Quicker recovery – discontinue walking aid as fast as one week

The Oxford® Unicompartmental Partial Knee Replacement prosthesis allows for better range of motion of the knee by replicating the function of the menisci and more normal motion of the human knee. With the Oxford® partial knee replacement, only a portion of the knee is replaced. In performing an Oxford®, the anterior cruciate and posterior cruciate ligaments are always preserved. In performing a total knee replacement, the cruciate ligaments are always removed.

In some cases, this prosthesis may be applicable to individuals who were previously considered too young to undergo a total knee replacement. The Oxford® implant utilizes a minimally invasive procedure in which patients may experience less pain and a quicker recovery time, contrasted with a total knee replacement.

To be qualified to implant an Oxford®, the United States Food and Drug Administration requires an orthopaedic surgeon to attend a special training course. This training is required because the implantation technique for this procedure is very delicate. I personally attended one of the training courses in Chicago in 2011 and have since been using Oxford® with favourable outcome.

If you have substantial pain in your knee, you should go for a complete evaluation of your knee pain problem. You may only require an arthroscopic surgery, you may need an Oxford® knee replacement, or you may need a total replacement. Most substantial knee pain problems can be helped or cured by modern orthopaedic surgery.

EZ welcomes Dr Michelle Lim, MD (MA) Naturopath ND, Dip. Holistic Kinesiology, a pioneer of Alternative Medicine in Malaysia, to our panel of contributors. Starting in our next issue, she will be writing on topics related to health, natural remedies and general wellbeing.

Vivacious, vibrant and oozing vitality, it’s hard to imagine that this lively lady is well into her 60s. Dressed impeccably in the calming hues of turquoise, she recounts her experience travelling around Australia in a camper with her partner, Ian. ‘If you’re on the road and you see something interesting, you can stop, get out and explore!’ And it is this openness to life and living that has propelled her throughout her own existence.

Despite a difficult childhood wrought with rejection and hardships, Lim was resolved from a very young age to build a successful life for herself. Having completed her secondary school examinations, she braved the working world and worked her way up to become supervisor of the whole factory. But with a keen interest in aesthetics, she took up night courses in the subject and trained to become a beautician. Following her graduation she opened up her own business in the 1970s.

This would prove to be the turning point in her life, as marriage and the birth of her three sons followed soon after. Though her marriage would not last, her career as a beautician proved to be a success – albeit having to manage a household on her own. ‘I always felt torn between caring for my children, managing my business and all the chores related to running a household,’ she remembers. But fuelled by her determination, she carried on.

Balancing the demands on her time and attention, Lim went on to open a second branch of her business. It was at this point that she experienced an epiphany that would direct her to the fundamentals of internal health and how this can affect the external appearance.

She studied alternative medicine via correspondence with a training centre abroad and travelled to Australia, Sri Lanka and the States to explore this branch of holistic wellness further. Michelle Herbs Therapy & Complementary Medicine Clinic, the fruit of her extensive training and research, was founded in 1990 in Penang.

Having been in this field for 24 years, Lim is dedicated to identifying and addressing the root causes of chronic illnesses through a ground breaking holistic system called Functional Medicine which employs the art of Listen to Your Body Talk. Lim has since developed a unique programme called Detox & Live, an integrated detoxification plan that targets liver and kidney cleansing, digestive problems, candidas and parasite killing combined with a range of protocal herbs, natural supplements and appropriate nutrition.

Adding to her portfolio of holistic therapies is kinesiology, which combines modern medical knowledge with ancient oriental philosophy. Having recently returned from an intensive study course in Melbourne, Lim uses this skill to tap into one’s subconscious and energy centres to counter the negative influences. ‘I firmly believe that knowledge empowers us to take charge of our lives and our health. Without awareness, we cannot change anything,’ said Lim.

PENANG, May 2014 – Universiti Sains Malaysia (USM) Hamzah Sendut Library (HSL) has conducted a series of community networking programmes in the country such as HSL@Chemor, HSL@Koperasi Tadika Minden, HSL@Tadika Lestari Ilmu, HSL@Al-Itqan and has recently extended its mission abroad to Cambodia through HSL@Cambodia: Reaching the Bottom Billions.

The main objective of the programme is to set up a library in one of the schools in Kampung Poti In, Kampong Cham, Cambodia. This mission was attended by 10 staff members from HSL who brought with them 132 reading materials to be stocked in the library there.

“It is not easy to be in a foreign land where upon arrival at Phnom Penh we had to rush to buy book shelves for the library and then take a 3-hour journey to Kampung Poti In via a winding village road,” said HSL Head of Customer Relations, Radia Banu Jan Mohamad.

“On our arrival at Kampung Poti In, we were joyously greeted by the villagers who then held the akikah feast. The overnight stay at the house of the village chief was a memorable experience as well as an opportunity to learn the culture of the local community which is not much different from Malay culture,” said Radia Banu.

Among the activities carried out were the assembling of book shelves, classifying the books according to their appropriate themes and clean-up of the library with the help of the teachers and students of the An Nikmah Religious School of Kampung Poti In which has about 300 students.

“Besides the mission to set up the library, HSL also took the opportunity to raise funds to supply clean water to villages through the construction of wells and water pump channel.

“A total of 33 wells and water pumps were given to the villagers as a contribution from Malaysia,” said one participant.

This mission is just the beginning and it certainly will not end here. HSL will continue to seek funds to improve the library as well as add to the existing reading material from time to time.

“I call on the USM community and also anyone who wants to help, either in donating reading material or other forms of assistance, to contact us as this programme will be on-going,” said Radia Banu.

Prior to Cambodia, HSL also helped Sekolah Rendah Al-Itqan in Teluk Kumbar, Penang, a private religious school that provides religious education and other subjects to students of Penang and also from other states.

The programme was made ​​possible by a total of 20 HSL staff members who were divided into two groups – one to brighten up the surroundings (painting, murals and arranging the furniture) while the other deals with the technical aspects (system development and cataloguing books).

All the HSL programmes ran without a hitch with the help and support of the library top management.

by Dr Lee Li Ching

Mr M, a 55 year old man walked into my clinic one morning complaining of being unable to breathe. ‘Doc, I have been sleeping in my lazy chair for the last 3 days! I cannot lie flat at all, I feel like I’m drowning … and my legs have been swollen since last week.’ He suffered from a massive heart attack one month prior to the clinic visit. Mr M underwent an emergency stenting to one of the severely blocked heart arteries and had a stormy recovery. Clinically, he was in overt heart failure when I examined him.

There is an estimated 23 million people with heart failure worldwide. It is most commonly due to ischaemic heart disease (coronary artery disease), which is the number one killer worldwide. Aging and prolongation of the lives of cardiac patients by modern therapeutic innovations have led to increasing incidents of heart failure.

What is heart failure?

Heart failure is caused by primary heart muscle injury and also occurs at the end stage of most diseases of the heart. It could be either due to imbalance in pump function in which the heart fails to adequately maintain the circulation of blood to meet the body’s needs or the heart is too stiff and cannot relax enough to fill with enough blood before pumping. The pumping function is usually well preserved in the second type of heart failure. This is subsequently followed by the activation of a series of response mechanisms in the neurohormonal systems, and vasculature causing the signs and symptoms of heart failure.

How do I know that I have heart failure?

Patients with heart failure present a variety of symptoms, most of which are non specific. The lack of blood supply to the body and build up of fluid causes the symptoms, including tiredness, general weakness, shortness of breath on exertion, swollen ankles, swollen abdomen, loss of appetite, nausea and reduced ability to exercise.

Not infrequently, patients complain of worsening cough and breathlessness at night, and they have to use more than one pillow or end up sleeping in a chair. The accuracy of diagnosis by presenting clinical features alone, however, is often inadequate, particularly in elderly or obese patients. Moreover, the above mentioned signs and symptoms can also present in patients with kidney or liver failure.

Why does it happen?

Heart failure is not a complete diagnosis by itself. It is therefore important to identify the underlying disease and the precipitating cause(s). As mentioned earlier, heart failure is the end stage of most heart disease, beside coronary artery disease being the most common cause. Other important causes include hypertension, structural abnormality (congenital or acquired), toxin such as chemotherapy and alcohol, hormonal disorder, infection or inflammation. There are times when the cause is never found or so-called idiopathic cardiomyopathy. Other less common aetiologies are stress-induced cardiomyopathy and pregnancy-related heart failure.

How is heart failure diagnosed?

Heart failure is diagnosed based upon the patient’s medical history, a thorough physical examination, and a series of tests. These tests determine the cause and severity of the heart failure. These includes a series of blood tests, electrocardiogram (ECG), chest x –ray, coronary angiogram and most importantly, an echocardiogram. An echocardiogram is a non-invasive test using ultrasound to assess the size and function of the heart’s chambers as well as the function and structure of the heart valves. Other tests, like biopsy or magnetic resonance imaging, are sometimes used to look for specific diseases.

What are the medications for heart failure? 

There are many treatments for heart failure, but medicines are fundamental in improving the quality of life, reducing hospital admission and more importantly, improving the survival of this group of patients. Among others, diuretics, also called the ‘water pills’, help the body to get rid of excess fluid in the limbs and lung. The ACE inhibitors and the ARBs groups of medications help to strengthen the heart. The betablockers, on the other hand, help the heart to fill more completely and they have been proven to prolong the life of these patients. Digoxin, one of the oldest heart failure drugs, can increase the strength of the heart muscle contractions and hence reduces heart failure symptoms.

Will surgery ‘cure’ my heart failure?

Yes, if the cause of the impaired heart function is due to coronary artery disease or faulty heart valves such as leaky valve or valve that does not open fully. The most common surgery for heart failure is bypass surgery where blood is rerouted around a blocked heart arteries. Damaged valve can either be repaired or replaced.

Device therapy for heart failure

As heart failure progresses, occasionally the Left Ventricular Assisted Device (LVAD) is implanted while waiting for heart transplant. LVAD is basically a battery-operated heart pump that takes over the job of the failing heart by circulating blood throughout the body. LVADs are now sometimes used as an alternative to transplantation.

On the other hand, life-threatening abnormal heart rhythm can sometimes develop in patients with poor heart function. This is one of the most common causes of death in this group of patients. The doctor might recommend a device – Automated Implantable Cardioverter-Defibrillator (AICD) – that shocks the heart and returns it to a normal rhythm. It is usually implanted under the skin in the upper chest with wires leading through the veins to the heart. Nowadays, a biventricular pacemaker (also called cardiac resynchronization therapy) combined with an AICD function is often implanted in people with heart failure. The rationale is that the electrical system in the weak heart makes the heart contracts in an uncoordinated fashion. The pacemaker helps the heart to pump in a more efficient and synchronized manner, improving one’s symptoms.

Living with heart failure

Heart failure has ‘no cure’, unless the underlying cause can be treated. Therefore, it is paramount that one compliant to the medications and the treatment plan prescribed. Cigarette smoking is strongly discouraged. Smoking has adverse haemodynamic effects on patients with heart failure. In addition, it increases the risk of having a heart attack which will definitely damage more heart muscle in an already weak heart. In general, alcohol consumption should be restricted to moderate levels (i.e. one serving of alcohol per day for women, two servings per day for men), given the heart muscle depressant properties of alcohol. A high alcohol intake will also predispose to irregular rhythm that potentially worsens the body fluid balance.

As a general rule, patients with heart failure should limit their fluid and salt intake. Try not to add salt at the table or when cooking. They should also take restricted amounts of canned, frozen and processed food which contains a lot of salt.

How about the outlook?

This is not a myth. The prognosis for heart failure is poor, far worse than some of the common cancers. In general, the mortality following hospitalization for patients with heart failure is about 42.3% at five years, despite marked improvement in medical and device therapy. The two main causes of death in patients with HF are life threatening heart rhythm death and progressive pump failure.