Orthopaedics and Sports Medicine

Unique challenges for
total knee replacement in the Middle East


In the Middle East there are unique demands placed on total knee replacement surgery because of cultural and religious requirements – specifically the need for hyperflexion of the knee joint to enable bending for prayer. Professor Dr Heinz Roettinger discusses the issue.

Compared with Europe or North America, in the Middle East, very often there are specific demands placed on orthopaedic operations because of cultural characteristics. This is especially true of operations on the knees, which require maximum flexion to satisfy the demands of social life and religious practice. In such cases hyperflexion is needed, where knee positions flexing up to 150 degrees or more is standard.

Surgeons and orthopaedic manufacturers are required to develop techniques and make implants that meet the expectations of these patients. Particularly in the case of total knee replacements, the implant industry and orthopaedic doctors are making every effort to improve the functional results after surgery.

Knee surgery

When nonsurgical interventions such as medication, physical therapy and the use of a cane or other walking aid no longer help alleviate the pain, an operation with partial or total knee replacement may be an option.

In general, today knee replacement is a routine surgery performed on more than 600,000 people worldwide each year and shows one of the highest success rates medicine actually knows – if done by an experienced, specialised surgeon and his team.

The most common cause of knee pain is osteoarthritis, a degenerative joint disease that causes the cartilage in knee joints to break down. When that layer of cartilage is damaged or worn away, the bones grind against one another, and that grinding hurts. Patients can feel it when they climb stairs, work in the garden, or when simply bending their knees to sit. The pain may even keep them up at night.

In knee replacement surgery, the bone surfaces and cartilage that have been damaged are removed and replaced with artificial surfaces (implants) made of metal and a very durable plastic material.

In cases where significant damage is limited to only one side of the knee joint (unicompartmental osteoarthritis), the surgeon may consider a procedure that preserves the healthy side of the knee, which is called a unicompartmental knee replacement. In this partial knee replacement, only one side (the diseased portion) of the joint is resurfaced, leaving the healthy portion untouched. Unicompartimental knee replacement have excellent functional and long term results, but the pattern of disease indicating this type of implant typically affects only about 8% of sufferers of knee osteoarthritis.

A total knee replacement is usually considered when the surfaces on both sides of the bones, as well as the underside of the patella, are significantly damaged. In total knee replacement surgery, the surface of the joint is replaced with a contoured metal component designed to fit on the bone. In theory the procedure is similar to a crown on a tooth, which also gets a new surface adapted to individual characteristics whereas most of the main portion of the tooth remains.

Multiple studies conclude that total knee replacement is extremely successful, resulting in rapid and substantial improvement in the patient’s pain, functional status, and overall health-related quality of life in about 95% of patients. But also most of the studies show that the range of motion after operation was very often limited to less than 135 degrees in flexion, which is disappointing for Middle East patients, showing the need for even more improvements.

Most recent improvements are based on different categories: gender research, hyperflex implants – that is implants allowing up to 155 degrees flexion – and minimally invasive techniques.

Knee replacement systems

A modern knee replacement system accommodates the active and varied lifestyles of today’s patients by offering a constellation of function and sizing options. Notably, with some 60% of total knee replacements performed on women, modern knee systems are designed specifically for women’s anatomy, which is different to males and also with women’s needs in mind. They incorporate the variable aspect ratio to fit the female anatomy and still accommodate males. Generally the axiom in implant technique is valid: the better the anatomical reconstruction, the better the result. This means the implant should be best adapted in size, shape and position to the patient’s individual characteristics.

The need and desire for high flexion may be dictated by the patients’ favourite activities or cultural background. Many daily activities require the ability to bend the knee beyond 125 degrees. Climbing stairs, for example, requires a range of motion from 75-140 degrees while sitting in a chair and standing up again requires a 90-130 degrees range of motion. Other activities, like gardening, playing golf or kneeling for prayer involve motions that require up to 135-150 degrees of flexion to perform. The hyperflex knees are specifically designed to safely accommodate up to 155 degrees of flexion in patients who had this ability before surgery. This means that with appropriate rehabilitation a patient can resume an active lifestyle after total knee replacement – deeply bending the knee for recreational, religious and other day-to-day activities. Today’s target of operation is to secure a patient’s previous lifestyle or even to improve his options.

Minimally invasive surgery

Minimally invasive knee replacement surgery is a new type of surgery that can have the patient back on his feet faster than ever before. Thanks to a smaller incision and special approach to the joint, there is less trauma to the underlying muscles and soft tissues resulting in a smaller scar, less post-operative pain and a faster return to normal activities. Minimally invasive knee replacement surgery may allow faster recovery compared to traditional knee replacement surgery.

Following minimally invasive total knee replacement (MIS-TKA) patients show higher muscle forces measured in studies at 3, 6 and 12 months postoperatively compared with patients after conventional surgery. Also, these patients were significantly more active on all postoperative days and MIS-TKA patients achieved 80% of their preoperative acceleration in about half of the time as conventional TKA patients.

The implementation of all these improvements into the individualised treatment plan of every patient offers new options for those osteoarthritis patients who want to continue their active lifestyle and their cultural as well as religious customs after total knee replacement.


Rehab begins as soon as the patient is back in his hospital room. The patient-adapted rehabilitation programme will help the patient to regain strength, balance, and range of movement in the knee. This programme is designed specifically for the demands of each patient and may include a "continuous passive motion" machine that gently straightens and bends your knee to help reduce stiffness. Other exercises that promote blood flow to your legs include ankle pumps and pedalling your feet.

Getting up and about soon after the operation is important. In fact, the patient will be asked to stand as soon as six hours after surgery. Within the first 24 hours patients begin to walk initially with the help of a walker and later with crutches. State-of-theart pain management keeps the patient pain free after the operation and helps accelerate recovery. The personalised rehab programme aims to build up enough strength to control the new knee and to gain the maximum range of motion.

Today unicompartimental and total knee replacement are safe and very successful operations. They can improve the quality of life and, for patients who have lead a highly active lifestyle, they can enable the patients to return to this lifestyle, as well as satisfying special cultural and religious demands.

In the hands of a specialised orthopaedic surgeon, approximately 96% of the implants work for at least 15 years or more. If a patient is suffering from knee osteoarthritis, this operation is highly recommended because of the positive outcomes, the safety of the procedure and very good long-term results.

Professor Dr Heinz Roettinger is the Medical and Managing Director of the German Orthopaedic Hospital in Bahrain. www.germanortho.com

ate of upload: 18th Oct 2011


                                               Copyright © 2011 MiddleEastHealthMag.com. All Rights Reserved.