Enhanced Recovery (ERAS) Total Knee Replacement

Potentially shorten your hospitalisation stay for total knee replacement surgeries, making them a day surgery. Through Alps Orthopaedic Centre’s specialised Enhanced Recovery After Surgery approach, most patients experience fast recovery, less pain and a smaller bill.

When individuals experience severe knee pain that significantly compromises their quality of life and disrupts sleep, orthopaedic surgeons may recommend total knee replacement surgery. Those who require this surgery typically struggle with:

• Pain
• Stiffness
• Walking long distances
• Climbing stairs
• Rising from chairs 
• Swelling 
• Weakness 
• Squatting

When non-surgical treatments like medication, physical therapy, and lifestyle modifications no longer effectively manage knee pain or mobility issues, total knee replacement may be considered as an option.

While knee pain can stem from traumatic injury, arthritis remains the primary reason for undergoing total knee replacement surgery. Arthritic pain typically develops gradually over time because of the wear and tear of the knee joint, often becoming more apparent in older individuals. On the other hand, younger patients are more likely to experience knee pain as a result of sudden injuries,  such as those sustained during trauma episodes or sports activities.

^{What is Total Knee Replacement?}

Firstly, to understand total knee replacement, it is essential to grasp the structure of the knee. The knee is a large, weighbearing joint. In a healthy joint, cartilage cushions the ends of the bones, facilitating smooth and painless movement. 

However, individuals suffering from arthritis often undergo a breakdown of cartilage in their knees, resulting in bones rubbing against each other. Over time, this can lead to a narrowing of the joint space and the development of bone spurs or deformities. In severe cases, orthopaedic surgeons may recommend surgical procedures to replace damaged joint parts, either partially (partial knee replacement) or completely (total knee replacement). Usually, patients in the late stages of arthritis will be recommended to undergo total knee replacement, during which surgeons remove the entire knee joint and replace it with implants.

While total knee replacement has an initial recovery period spanning several weeks to months, opting for this procedure can significantly alleviate pain symptoms and enhance the patient's quality of life. Fortunately, some surgeons specialise in an approach called Enhanced Recovery After Surgery (ERAS) for this procedure. Besides employing a specialised surgical technique to minimise physical trauma, orthopaedic specialists also leverage other methods to provide patients with holistic care that potentially speeds up recovery.

How is the Enhanced Recovery After Surgery (ERAS) approach different from traditional Total Knee Replacement?

Unlike traditional surgeries, the enhanced recovery after surgery (ERAS) approach is an evidence-based and multidisciplinary perioperative care pathway that aims to reduce surgical stress and promote rapid recovery for patients. The ERAS approach involves three main parts: before, during, and after surgery. 

It starts with getting the patient in great shape before the operation. To assist in this process, orthopaedic surgeons can help by providing information and guidance beforehand.

Some of the key steps involved prior to surgery include:

• Counselling before surgery ensures that an individual is ready for the procedure. This may involve various assessments such as lab tests, x-rays, and even financial counselling
• Stop smoking and alcohol use four weeks ahead of surgery
• Check and treat anaemia if present
• Get nutritional advice and checkups; eat foods rich in carbohydrates
• Stick to clear fluid intake (e.g. water, apple juice, clear tea, black coffee) until 2 hours before surgery, with a 6-hour fast for solid food

Subsequently, in an ERAS approach, surgeons also employ minimally invasive surgical techniques during the operation for less tissue damage, reduced pain, and quicker recovery relative to traditional surgery. Consequently, it effectively reduces post-surgical discomfort and pain. After the surgery, a multifaceted postoperative programme will then be implemented to facilitate patient recovery.

How is the ERAS Total Knee Replacement surgery done?

Specifically, our orthopaedic surgeon will utilise the kinematic-alignment technique to restore the patient’s natural knee anatomy, minimising soft tissue damage and optimising joint mechanics. 

1. An incision will be made to the knee

During the surgery, he will create an incision about 10cm to 15 cm down the front of the knee instead of the 15cm to 25cm incision usually made during a traditional Total Knee Replacement surgery. The ERAS kinematic-alignment surgical technique is less invasive than Total Knee Replacement surgery. Hence, it typically results in a smaller scar, less pain, and less tissue disturbance compared to conventional Total Knee Replacement. 

2. The damaged parts will be replaced with a new joint

After the incision, the kneecap will be gently moved aside to access the knee joint with minimal disruption to surrounding tissues. The damaged ends of the shin bone and thigh bone are carefully removed, and replacement parts made of metal alloys and plastic are inserted over the bones to create the new joint. 

3. The surgical wound will be closed

After repositioning the kneecap, the surgeon closes the incision using stitches and then applies a dressing and bandage over it.

What does the postoperative care for ERAS Total Knee Replacement involve? 

After an ERAS total knee replacement, our experienced Orthopaedic team will carry out postoperative care. 

Immediately after surgery, care may include nurses monitoring the patient's vital signs (blood pressure, heart rate, respiration rate, temperature, and pain level), administering food/fluids through IV, and providing bowel care as necessary.

Afterwards, other important ERAS protocols will be followed, including active mobilisation (encouraging patients to start moving and engaging in physical therapy soon after surgery), early feeding with a high-protein diet, prevention of blood clots, and multimodal pain management, to speed up recovery and minimise complications beyond traditional care.

What is recovery like after an ERAS Total Knee Replacement?

At Alps Orthopaedic Centre, patients suitable for our ERAS programme can opt for a day surgery. We aim to enable patients to go back to activities that they love by minimising the recovery period.

After the ERAS Total Knee Replacement surgery, your orthopaedic surgeon will recommend physiotherapy and wound care options to regain strength, flexibility, and stability in the operated knee and aid in a swift return to normal activity. At times, he may also suggest a walking aid to help during the recovery process. Attending a structured rehabilitation programme supervised by healthcare professionals is recommended.

Overall, a patient can expect to walk with aid on the same evening of the surgery. However, take note that each patient's recovery from knee replacement surgery varies based on factors like age, physical health, and the extent of joint damage.

What are the benefits of ERAS Total Knee Replacement?

For individuals experiencing severe knee pain, knee replacement surgery aims to alleviate chronic pain and offer the following benefits to patients:

• Pain relief – significantly reduces pain in the knee joint
• Enhanced mobility – improves the range of motion and function of the knee joint
• Increased activity level – allows most patients to eventually return to their normal activities, such as walking, running, and playing sports independently. Before gradually returning to sports, patients should undergo thorough evaluation to ensure their operated knee joint can stand the demands of rigorous physical activities. This assessment from your surgeon is necessary to prevent complications and ensure safe participation.
• Improved quality of life – boosts the mood for people who suffer from severe knee pain in their daily life.

In a study from the Journal of Orthopaedics labeled The Knee Enhanced Recovers After Day Surgery Total Knee Arthoplasty, the New Standard of Care, An Asian Perspective, 738 patients were put under observation, where 342 were ERAS Day Surgery patients and 396 were ERAS inpatient. 92.4% of patients in the Day Surgery group were successfully discharged within 24 hours, leading to a shorter mean Length of Stay (LOS) of 1.3 days as compared to 4.12 days in the inpatient group. 

The study concluded that patients who received ERAS day surgery for total knee arthroplasty (TKA) experienced comparable enhancements in functional ability and quality of life to those undergoing ERAS inpatient TKA, without an elevated risk of complications.

What are the risks of ERAS Total Knee Replacement?

As with any surgery where general or spinal anaesthesia is used, there's a slight risk of strokes, heart attacks, pneumonia, and blood clots. One possible complication of knee replacement surgery is blood clot formation in the deep veins, known as deep vein thrombosis (DVT). 

In addition, while knee replacement surgeries generally have low risks, there are potential rare risks associated with the procedure. These risks include the possibility of:

• An infection may occur in about 1% of patients, but it can typically be managed easily with antibiotics. However, in rare cases, infection may require removal of the replacement joint and, in severe instances, can be life-threatening if it spreads throughout the body.
• Fracture of the bone around the implant
• Wear and tear( 85% of the implants last more than 20 years)
• Injury to surrounding neurovascular structures (very rare)
• Allergic reaction to the prosthetic component

Recognising the potential risks associated with this procedure underscores the importance of an ERAS approach and the necessity for specialised guidance from an orthopaedic surgeon throughout the preparation, the procedure, and recovery. In general, most complications can be effectively managed. Even if complications arise post-surgery, success can still usually be achieved if pain relief and improved function are attained in the long term.

Is Total Knee Replacement suitable for me?

Your orthopaedic surgeon will diagnose whether you need a total knee replacement. If you're experiencing pain on just one side of the knee, a partial knee replacement might be more appropriate.

Why Alps Orthopaedic Centre?

At Alps Orthopaedic Centre, we specialise in Enhanced Recovery After Surgery (ERAS). Performed as a Day Surgery, the ERAS Direct Anterior Approach in Total Hip Replacement (THR) technique as well as ERAS Total Knee Replacement (TKR), reduces the average hospitalisation stay, utilising techniques which enable the patient to suffer from less pain and recover faster. We are an Orthopaedic clinic in Singapore, which specialises in ERAS and do our utmost to enable patients to return to everyday activities as early as possible. 

Our Orthopaedic clinic provides specialised diagnosis and effective treatment of musculoskeletal problems, especially Day Surgery / Enhanced Recovery After Surgery (ERAS) For Hip and Knee Surgery, Sports Injuries and Trauma Fractures. If you are considering hip or knee surgery or minimally invasive treatments, book an appointment with our experienced Consultant Orthopaedic Surgeon, Dr Jerry Chen, for a thorough assessment and treatment plan. 

Our aim is to boost patient well-being, optimising every aspect of the surgical journey. By minimising the recovery period, patients are able to go back to activities that they love. The Alps team offers comprehensive financial counselling sessions to ensure our patients understand their options and make informed decisions regarding their treatment plans.

^{Dr Jerry Chen}

MBBS (S’pore), MRCSEd, MMed (Ortho), FRCSEd (Ortho)

Fellowship-trained Consultant Orthopaedic Surgeon & Medical Director

• ✅Before starting Alps Orthopaedic Centre, Dr Jerry Chen was a Consultant at Singapore General Hospital (SGH), where he accumulated over 13 years of experience in Orthopaedic Surgery. 
• ✅Dr Chen spearheaded the workgroup for Enhanced Recovery After Surgery (ERAS) for hip and knee replacement surgeries at SGH, where he successfully employed ERAS, benefiting more than 2,000 patients thus far.  
• ✅Having performed over 500 surgeries in a year, he has been instrumental in helping numerous patients recover from injuries and diseases and return to their active lifestyles.
• ✅His clinical interests include Enhanced Recovery After Surgery (ERAS) for Hip and Knee, Sports Injuries, Minimally Invasive Surgery and Robotic Surgery.

Alps Orthopaedic Centre Website: https://www.alpsortho.sg/ 

Dr Jerry Chen Profile: https://www.alpsortho.sg/about-dr-jerry-chen/ 

Appointment Line: +(65) 9088 4555

Email: info@alpsortho.sg 

References

1. Altman, A. D., Helpman, L., McGee, J., Samouëlian, V., Auclair, M. H., Brar, H., Nelson, G. S., & Society of Gynecologic Oncology of Canada’s Communities of Practice in ERAS and Venous Thromboembolism (2019). Enhanced recovery after surgery: implementing a new standard of surgical care. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 191(17), E469–E475. https://doi.org/10.1503/cmaj.180635 
2. Riga, M., Altsitzioglou, P., Saranteas, T., & Mavrogenis, A. F. (2023). Enhanced recovery after surgery (ERAS) protocols for total joint replacement surgery. SICOT-J, 9, E1.
3. Varacallo, M., Luo, T. D., & Johanson, N. A. (2024). Total Knee Arthroplasty Techniques. In StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499896/ 
4. Xu S, Liow MHL, Eric Liu X, Pang HN, Chia SL, Tay KJD, Yeo SJ, Chen JY. Enhanced recovery after surgery (ERAS) protocol reduces need for patient selection for day surgery total knee arthroplasty. J Orthop. 2023 Nov 22;49:18-23. doi: 10.1016/j.jor.2023.11.042. PMID: 38090600; PMCID: PMC10711009. https://pubmed.ncbi.nlm.nih.gov/38090600/
5. Xu S, Liow MHL, Liu XE, Pang HN, Chia SL, Tay KJD, Yeo SJ, Chen JY. Enhanced recovery after day surgery total knee arthroplasty, the new standard of care: An Asian perspective. Knee. 2023 Oct;44:158-164. doi: 10.1016/j.knee.2023.08.003. Epub 2023 Sep 4. PMID: 37672906. https://pubmed.ncbi.nlm.nih.gov/37672906/