FAQ Category: Knee

That’s a tough problem — especially given the fact that there really isn’t enough high-quality evidence to prove that rest, activity restrictions, and immobilization really make a difference. They may but it just hasn’t been proven with randomized controlled studies.

Randomized controlled studies involve one group of patients with osteochondritis dissecans (OCD) receiving treatment, while another group with the same problem do not receive any treatment. It is not considered ethical to withhold a treatment (proven or believed beneficial) from patients — and especially in the case of OCD when children and teens are the ones affected most often.

It certainly makes sense that a joint damaged by OCD should be given every opportunity to heal itself without ongoing load, shear force, and compression. In the case of unstable or displaced OCD, a piece of cartilage has been gouged out of the joint surface and has moved or shifted.

Now there is a free floating fragment in the joint that may create more trauma and damage to the joint surface as the affected person continues to use that joint. That’s when surgery is usually advised to repair or remove the fragment.

In the end, we know that the overall natural history of OCD (i.e., what happens over time) is that the cartilage will either heal itself or not. We don’t have any clear means of predicting ahead of time which lesions will go on to heal and which ones won’t.

A joint surface damaged by OCD doesn’t heal naturally. Even with surgery, OCD often leads to future joint problems, including degenerative arthritis and osteoarthritis. That’s why surgeons make the recommendations they do — rest, immobilization, and activity modification. Give the joint every opportunity to heal well. Yes, it’s possible to ignore these guidelines and suffer through the pain. But there are long-term consequences that should be considered.

There are actually quite a few things that can cause symptoms as you described them. Given the location of your knee (along the lateral or outside aspect), there can be problems inside the joint (intra-articular) or something coming from outside the joint (extra-articular).

To get an accurate assessment, you’ll need an examination by a qualified health care professional such as an orthopedic surgeon, sports physician, or physical therapist. The examiner takes a patient history with standard questions about possible injuries or trauma to the knee.

He or she will ask the patient questions what makes it better, what makes it worse, and are there any other symptoms? Conducting a physical examination and performing specific tests help in sorting out what could be causing the problem.

X-rays may be ordered and all possibilities are considered. The most common problem causing this type of clinical presentation is a lateral meniscus tear. The meniscus is a thick U-shaped piece of cartilage inside the knee joint.

But there can be other causes coming from outside the joint mimicking a meniscal tear. These would be considered extra-articular and include: 1) iliotibial band syndrome (ITBS), 2) proximal tibiofibular joint instability, 3) snapping tendons (either the biceps femoris or the popliteus tendons), and 4) peroneal nerve compression or inflammation.

The treatment required for the best results depends on the underlying cause. That’s why finding out which of these specific disorders is present is the first step. Early identification and intervention can often prevent chronic, long-term problems from developing.

Pain along the outside or lateral knee can be caused by many things including tibiofibular joint instability. The tibiofibular joint is along the outside of the knee where the tibia (larger of the two lower leg bones) connects to the fibula (smaller of the two lower leg bones).

Some patients with this problem also report tenderness when pressure is applied over the fibular head. Instability usually tells us the joint is loose or shifts either into subluxation (partial dislocation) or into a fully dislocated position. This can be caused by small but significant anatomic variations.

Even slight changes that alter the natural angle of this joint can allow the fibula to slip out of the groove that holds it in place. Or a traumatic injury damaging ligaments and connecting soft tissue can damage the joint resulting in the same type of instability.

Instability may keep some patients from putting weight on that leg. The examiner compares the unaffected knee to the painful one and looks for changes in how the joint moves. Any unnatural shifts in the fibula as it moves against the tibia (called joint translation) will be evaluated with more specific clinical tests.

A tibiofibular joint that has been unstable for a long time can also cause knee popping, clicking, and catching. These symptoms are very similar to a lateral meniscal tear. The meniscus is a thick U-shaped piece of cartilage inside the knee joint. That’s why every effort is made to make sure the diagnosis is correct and the right treatment is applied. The use of X-rays, MRIs, and clinical tests are used to make an accurate diagnosis.

People who suffer one patellar (kneecap) dislocation after another search for ways to prevent this from happening. The obvious first question is: what is causing this to happen? Most often the patella pulls away from the knee in a lateral direction. Lateral means sideways in a direction away from the other knee.

To better understand how this type of knee problem occurs, let’s review a little bit of anatomy. The patella is held in place by its shape and the supporting soft tissue structures such as muscle, tendon, cartilage and ligaments.

As the knee moves, the patella glides up and down in front of the knee joint. There is a groove on the front of the femur (the trochlear groove) of the femur. The back of the patella has a corresponding V-shape that fits inside the groove and helps hold it in place.

Any changes in the shape of the bone, alignment, ligamentous laxity (looseness), muscle weakness, or other soft tissue problems can contribute to patellar instability. Usually finding the right treatment for this problem depends on identifying the underlying cause (or causes — there are often multiple contributors).

It’s likely that your daughter has had X-rays and been examined by an orthopedic surgeon or sports medicine physician. If not, it might be helpful to go back to the beginning and figure out what brought this problem on and feeds into it’s continuation.

Interviewing the patient helps create a picture of what’s happening and when it’s occurring. The duration and severity of the problem will be revealed through this process.

Next, the examiner performs an evaluation looking at motion, strength, alignment, tissue integrity, ligamentous laxity, position of the patella, and so on. One of the most accurate tests for patellar instability is called the apprehension test.

In this test, the patient’s patella is pushed to the side as the knee is bent. A positive response occurs if the patient’s quadriceps muscle starts to contract during this movement or if the patient feels like the kneecap is going to pop off center and dislocate again. Patellar movement is also evaluated with the knee in full extension.

X-rays are next. X-rays help show any unusual patellar shapes that might be part of the problem. There are special views that can be taken to show the position of the patella in the trochlear groove, the depth of the groove, and how well the two bones match up. In some cases of patellar instability, the patella is riding up above the groove. This condition is called patella alta. This is one of the many alignment factors that can put the knee at risk for dislocation.

The radiologist also looks for the presence of the crossing sign on X-rays as an indicator of trochlear dysplasia. Trochlear dysplasia refers to a groove that is shallow — too shallow to hold the patella in place as it glides up and down. The crossing sign is visible when looking at the knee from the side. It is a way to assess the depth of the trochlear groove.

The treatment methods you described will often help someone with patellar instability that is caused by soft tissue imbalances and problems with postural alignment. But bony problems such as trochlear dysplasia may require something more permanent such as surgery.

There are several different surgical approaches that can be taken. For example, the surgeon can perform a trochleoplasty. In this procedure, a piece of bone is removed from the trochlear groove and the area is deepened and reshaped. A different approach would be to use bone graft material to build up the lateral (outside) wall of the groove. Or the surgeon might change the rotational angle of the femur so the two bones (femur and patella) line up as they are supposed to.

It may just be time to step back and reevaluate all that has been done, what has worked, what doesn’t work, and why (or why not). If a comprehensive examination has not been performed, then this may be the next step. A second opinion is often encouraged when patients aren’t making the kind of progress they expect or want.

There are many different ways to approach the problem of an anterior cruciate ligament (ACL) injury of the knee. A partial tear may respond well to conservative (nonoperative) care. But if rehab doesn’t yield the desired results (or in the case of a competitive athlete), the ligament may need surgical repair. The surgeon stitches the ends of the ligament back together.

A fully ruptured ACL often requires surgical reconstruction. It doesn’t work to try and pull the ends of the ruptured ligament back together — instead, a piece of tendon is taken from another area of the knee and used as a graft to replace the damaged ligament. The donor graft comes from one of two places: either the patellar tendon (just below the knee cap) or the hamstrings (behind the knee).

There are many ways to compare which type of graft works best. There are a lot of variables to work through in making the comparison. For example, patients of all ages, sizes, and shapes injure the ACL and need this treatment. Athletes have very different needs than older, less active adults.

It sounds like you are pursuing the patellar tendon graft. And you are right, residual knee pain when kneeling has been reported by many patients who have this graft type. How difficult is that? As you have pointed out, kneeling for long periods of time at church or at home is not a part of your daily activity.

It might be helpful for you to find out (before surgery) how often you use the kneeling position. And while you are evaluating that, you can pay attention to the importance of the activity . In other words, could you find a different way to accomplish the same task without kneeling? Is it something you do often such that not being able to kneel is going to be a big deal?

You can do a self-assessment by just observing your activities for a day or two and judge for yourself how often you use the kneeling position. If you don’t think you’ll remember, you can always tie something around your knee to alert you when you are kneeling. It could be something as simple as a small stone held against your knee with a bandana or as elaborate as a buzzer that would go off everytime pressure was applied to the knee.

To summarize a recent study from Australia on the long-term effects of patellar-tendon grafts for ACL ruptures: results are good-to-excellent. A few problems can crop up such as pain with kneeling, arthritis, and further knee injuries. Efforts to find ways to reduce knee pain after patellar tendon grafting are underway. Patients agree a little knee pain when kneeling is a small price to pay for the excellent long-lasting results they got otherwise.

We welcome your return visit to our website. We appreciate questions that help us all keep abreast of what’s happening in many areas of orthopedics. The question of graft type for the reconstruction of a ruptured or deficient anterior cruciate ligament still remains an area of debate and discussion.

Each graft site and graft tissue has its plusses and minuses. Updated surgical techniques and instruments have helped improve results with both graft types. Results from more long-term studies are coming available to help guide treatment of this problem. The use of arthroscopic/endoscopic approaches have almost eliminated open incision surgery for ACL reconstruction.

One conclusion researchers have come to is the importance of placing the graft in exactly the same way as the natural anatomy. That has answered the question of graft placement (where to attach it). Graft fixation (how to attach it) is still being studied. The goal is to provide a secure graft. It must be one that stabilizes the knee along and holds up under rehab conditions. A speedy recovery through rehab and return to sports (for athletes) is essential.

In an ongoing study, surgeons from Australia have been following a group of patients for 15 years who had an ACL reconstructive surgery. They carefully selected each patient so that the only injury they had was an ACL rupture — there were no other ligamentous or cartilage injuries. They only used the patellar tendon graft, so this doesn’t compare to the hamstring graft.

But what they found might be useful information to you. First of all, the overall group had good results even after 15 years. The biggest problem reported was pain with kneeling. The patellar tendon graft comes from just below the patella (knee cap). Pain from pressure while kneeling on that graft site doesn’t seem to go away for some people.

About one-third of the group ended up injuring the ACL on the opposite side. It seems the younger patients (those who injured the first ACL before age 18) were more likely to injure the opposite side next. A smaller percentage (eight per cent) ruptured the graft through no fault of their own — the graft angle was the reason it ruptured.

With either tendon graft, there are concerns about the development of knee osteoarthritis years later. In this particular study, the patients were selected so that only the isolated ACL rupture was a problem. Most people (two-thirds) come in with a ruptured ACL but also damage to other parts of the soft tissues.

In all groups, there is X-ray evidence early on of arthritic degeneration. All groups refers to those patients who just had an isolated ACL rupture as well as those who have ACL plus additional associated injuries. In the first five years, about one-third showed radiographic signs of arthritis. By the end of 15 years, that number had increased to include half of all patients.

As to which graft choice is best for you — your surgeon is the one best able to answer that question. Many factors will be taken into consideration both in preparation for the selection and at the time of the actual surgery. Once the surgeon gets a look inside the joint, it’s easier to make the final decision about what procedure is needed and the best way to go about providing it.

Your review and preparations will help you in discussing this with your surgeon. Keep up the good work!

It’s possible that no one knows why it happened. Sometimes the surgeon can offer a better explanation after going back in and seeing what’s going on with the graft site and graft material. There certainly are both patient-related and surgeon-driven reasons why ACL reconstruction surgery fails.

For example, what happens on the patient side? Going back to demanding sports activities too soon is one potential error on the part of the patient. Overly aggressive rehabilitation can set the patient back. Too often the patient pushes past the guidance offered by the physical therapist. “More is better” is not the best motto during ACL reconstruction rehab. On the other side of the coin, too little rehab (poor patient compliance) can also contribute to a failed ACL reconstruction.

Surgeons play a role in the success or failure of ACL reconstruction. Poor graft placement, surgical contamination leading to infection, or other poor operative techniques can spell disaster. Putting the graft in the proper anatomical place but with too much or too little tension is another potential surgeon-related error.

There may be anatomical reasons out of the control of patient or surgeon such as quadriceps muscle dysfunction (muscle doesn’t contract the way it’s supposed to). Damage to other soft tissues in and around the joint that have not been identified yet can contribute to graft failures. If you have generalized ligamentous laxity or repeated trauma to the graft, the end result can be the same: graft failure.

You can certainly ask your surgeon and your physical therapist what they think happened. Be prepared to hear you may be part of the problem. More than likely it’s not anyone’s fault and a series of multiple factors were at play here. Certainly, once the surgeon scopes the knee (looks inside), some of the causes may become more obvious.

Injury to the anterior cruciate ligament (ACL) of the knee has become a fairly common problem. Research indicates that with more people involved in high-level sports the chances that this trend will continue are pretty good. What does that have to do with you? Well, more people with ACL injuries means more data from studies to help us guide patients.

We have more information now than ever before about what treatment works, who it works best for, and what techniques give the best results. For years now, partial tears of the ACL have been treated with a rehab protocol that doesn’t involve surgery. This choice seems to work best for individuals who are not top athletes but rather, active but not overly active adults.

Partial tears that do not respond to therapy and/or full ruptures may require surgery. A repair procedure for the tear or reconstruction for the full rupture may be advised. In a repair procedure, the surgeon stitches together the torn ends of the ligament. The ligament is still attached at both ends inside the knee joint offering some stability but at risk for reinjury or full rupture.

In a reconstructive procedure for full rupture, one side of the ligament has either pulled away completely from the joint or a tear has occurred somewhere along the length of the ligament. A rupture is so severe, it has gone all the way through (ripping the ligament into two pieces). A piece of tendon from some other part of the knee is used to replace the torn ligament. The graft material may come from the patellar tendon (just under the knee cap) or the hamstring muscle (behind the knee).

There is concern about further injury or reinjury for patients who don’t fully recover with a rehab program. The damaged or deficient ligament doesn’t recover with rehab. Instead, the muscles around the joint are strengthened to help stabilize the joint. The problem is that muscles doing the job of ligaments means they don’t always do their own job of moving the joint properly.

Without a stable, efficient joint and normal joint and muscle movement, the knee cartilage can get worn down faster. In the highly active individual, degenerative arthritis can develop over time. How well the knee holds up over time is an area of interest but more studies are needed to help us see the natural history (what happens over time) of the ligament and knee as a whole.

Whenever there is a ligamentous laxity from injury, a strengthening program is a good idea — even for the rest of your life. It will be insurance against reinjury of the already damaged ligament as well as prevention of injury of the surrounding soft tissue structures.

You may be referring to a fairly new factor physicians think may be contributing to chronic, recurrent patellar dislocations: trochlear dysplasia. Trochlear dysplasia refers to a groove that is shallow — too shallow to hold the patella in place as it glides up and down.

Let’s back up and take a quick look at some anatomy. The patella (kneecap) is held in place by its shape and the supporting soft tissue structures such as muscle, tendon, cartilage and ligaments. As the knee moves, the patella glides up and down in front of the knee joint. There is a groove on the front of the femur (the trochlear groove) of the femur. The back of the patella has a corresponding V-shape that fits inside the groove and helps hold it in place.

Any changes in the shape of the bone, alignment, ligamentous laxity (looseness), muscle weakness, or other soft tissue problems can contribute to patellar instability (dislocations). Experts in Europe have been exploring the idea of trochlear dysplasia as a possible cause of recurrent (repeated or chronic) patellar dislocation. U.S. surgeons are beginning to take a closer look at this as well. You can expect to see more on this topic in the coming years.

Studies show that not very many people in the general population really have trochlear dysplasia (less than two per cent). But among patients who have patellar instability, as many as 85 per cent do have trochlear dysplasia. A shallow groove by itself may not be enough to really result in chronic patellar instability.

Experts think there are multiple factors contributing to the problem. Each factor must be addressed in treatment in order to keep the patella centered in the trochlear groove. Preventing further patellar dislocations requires evaluation of the bony, soft tissue, and alignment issues. It sounds like trochlear dysplasia may be one of those issues for you.

The decision between a unicompartmental knee arthroplasty (UKA) and total knee replacement (TKA) may boil down to patient preference based on one or two factors. But let us outline the differences as reported in the literature so you can make an informed choice.

The difference between a total knee replacement (TKR) and unicompartmental knee arthroplasty (UKA) is more than just the implant itself but let’s review that first. As the name suggests, with a total knee replacement (TKR), the surgeon removes the entire damaged knee joint and replaces both the upper and lower sides of the joint.

The unicompartmental arthroplasty (UKA) involves just replacement of the inner or outer half of the joint. Most patients having a UKA have problems with knee alignment and have worn out just the medial joint surface. Medial refers to the side closest to the other knee.

The idea behind a UKA is that there’s no need to replace the entire joint when only one-half is compromised. Other advantages of the UKA include a shorter hospital stay, fewer infections, and faster recovery. Studies show patients having a UKA are at lower risk for blood clots. They also have less pain after surgery compared with a total knee replacement (TKR).

The major stumbling block with a unicompartmental knee arthroplasty (UKA) is the revision rate (second surgery). It is twice as high for UKA compared with a total knee replacement (TKR).

There are several reasons for the higher failure rate of the UKA. The unicompartmental implant is more likely to come loose. Bone fractures around the implant are also more common in this group. Patients seem to have more pain after a unicompartmental implant compared with a total knee replacement. And more patients with a UKA developed arthritis severe enough to require further surgery (usually conversion from a UKA to a TKR).

According to some experts, with equal results but higher revision rates associated with the unicompartmental arthroplasty (UKA), it may be better to go with a total knee replacement (TKR). Only patients needing more knee flexion might find the UKA a better choice.

Your surgeon is the best one to advise you on this point. Based on all of your own personal factors, goals, and anatomy, there may be a clear winner when comparing one type of implant over another for you.

It sounds like you have been diagnosed with a condition called medial compartment osteoarthritis (MCOA). MCOA affects just one side of the joint — medial refers to the side closest to the other knee.

Anyone with chronic knee pain who has been evaluated by an orthopedic surgeon and diagnosed with early stages of degenerative arthritis can begin with conservative (nonoperative) care. Activities can be modified to reduce stress and load on the joint. Weight loss is advised for anyone who is overweight. Physical therapy to improve posture, alignment, motion, and strength is often helpful.

Misalignment of the hip, knee, and/or ankle leading to an uneven weight distribution contributes to the development of medial compartment osteoarthritis (MCOA). When the joint is worn down to the end-stages of arthritis, then surgery is often required. Surgery to correct the problem consists of: tibial osteotomy (HTO), unicompartmental knee arthroplasty (UKA), or total knee replacement (TKR).

Tibial osteotomy refers to a surgical procedure where the surgeon removes a wedge-shaped piece of bone from one side of the tibia (lower leg bone). The goal of an osteotomy for medial compartment osteoarthritis (MCOA) is to shift the weight off the medial side of the joint. By shifting the weight-bearing load, the medial joint surface gets a break and the tension on the knee ligaments is corrected.

Unicompartmental arthroplasty is the replacement of the diseased side of the joint with an implant. The device is much like a total knee replacement but only involves one-half the joint. Of course, a total knee replacement removes the entire joint surface on both sides and replaces it with a metal or ceramic joint.

It’s best to talk with your orthopedic surgeon to find out what he or she would recommend. Your age, activity level, type of joint involvement, and any alignment issues contributing to this problem can all make a difference as to which treatment approach is best for you.

We can share with you the results of one surgeon who performed 455 high tibial osteotomies in patients with medial compartment osteoarthritis and then surveyed long-term results up to 19 years later. Let’s review first the type of surgery: high-tibial osteotomy refers to a surgical procedure where the surgeon removes a wedge-shaped piece of bone from one side of the tibia (lower leg bone). The word “high” tells us the wedge is taken out of the tibia at the top of the bone near the knee (rather than down low by the ankle).

There are different ways to do a wedge osteotomy — the bone can be removed from the medial side of the tibia (side closest to the other knee) or from the lateral side (opposite the medial side or the side away from the other knee). The patients in this study all had a high-tibial lateral closing osteotomy. You know that a high osteotomy refers to where the bone is removed from (upper part of the tibia).

A lateral osteotomy is taken from the outside edge of the tibia. A “closing” osteotomy means the two remaining edges of bone are shifted together (the hole made by removing the bone is closed). The goal of a lateral open osteotomy for medial compartment osteoarthritis (MCOA) is to shift the weight off the medial side of the joint. By shifting the weight-bearing load, the medial joint surface gets a break and the tension on the knee ligaments can be corrected.

The surgeon who did the operations wanted to know several things: 1) did the procedure hold up over time? 2) what factors helped predict success or failure? and 3) were the patients satisfied enough that they would do it all over again if they had the chance? It sounds like that’s what you would like to know about other patients who have had this procedure.

They found that 85 per cent said they were satisfied with the results and would have the same procedure again if they had it to do all over again. There were some complications in a few patients with blood clots to the lungs, deep vein clots in the legs, hematoma (pocket of blood) pressing on a nerve, and bone nonunion. One-third of the group did have a second surgery — either to revise the osteotomy or to replace the joint.

The conclusion was that high-tibial osteotomy is an effective way to treat medial compartment osteoarthritis (MCOA) of the knee. Studies have shown that the joint cartilage that’s worn down can regrow when pressure is eased off that area. Results do deteriorate over time but many patients buy as much as 15-years of time before needing a total knee replacement.

When you are under age 50, that’s a pretty significant benefit of the procedure. Reduced pain, improved function, and better quality of life make this a viable treatment option for younger, more active adults who aren’t quite ready for a knee replacement.

The dilemma of staying active and fit in preparation for a marathon while recovering from (not one but two) stress fractures can be quite a challenge. Repeated stress fractures suggest there are some risk factors to pay attention to.

For example, diet and nutrition are important for bone strength. Studies have shown that adequate amounts of calcium and vitamin D are essential in this area. Women (and men) who diet and restrict calories in order to make weight or stay thin for their sport are often at increased risk for stress fractures. These same behaviors can also impair bone healing once a fracture has developed.

As for activities you can still participate in to maintain strength and cardio fitness, consider swimming, pool-running, and bicycling. Check with your physician first, but these are usually safe bets. Free weights or elastic tubing for upper extremity strength training is also a possibility. Overhead lifting can have a cardio effect when performed properly.

When you do return to training, you’ll want to gradually increase your training regimen. Avoiding another stress fracture requires good posture, good bone alignment, and balanced biomechanics. If there are any problems with hip rotation, leg length differences, flat feet or other similar issues, you may want to consider being evaluated for the use of an orthotic (special insert for your shoes).

Your concern matches many other family members watching their senior members get back behind the wheel after major surgery — especially when there were some concerns before the procedure. Total hip and total knee replacements do take some time to recover from. Guidelines for return-to-driving are general at this point and patient-dependent.

For the most part, a 10-day period to resume driving after knee replacement surgery suggests it was his left knee that was operated on. A second assumption is that your father drives an automatic transmission that does not require using a clutch. Brake response time should not have changed for the right leg after surgery on the left leg but this has not been studied formally and verified.

Most of the studies on brake response after knee replacement have focused on the right leg. A typical guideline for return-to-driving after right knee replacement is six to eight weeks. Patients can be evaluated for reactions to driving in stop-and-go kinds of situations using a computer simulated driving test. For a more complete assessment of all driving skills, an on-the-road test can be administered.

Although the surgeon cannot discuss your father with you without your father’s permission, you can certainly contact the surgeon by phone or email (if available) with your concerns and questions. Having a family member raise the question about driving will ensure that the surgeon consider whether there is a problem or not and advise the patient accordingly.

Surgeons say that one of the first questions many patients ask about recovery after a total knee replacement is, “How soon can I drive again?” Driving is often the key to independence for seniors. This is true even when family members (and friends) are willing to drive them anywhere anytime or when public transportation is available.

Delaying a return-to-driving if it is not necessary may create a great deal of inner family conflict. Studies are few and far between on this topic but what we can relay what has been reported. Perhaps this information will help calm your fears.

The usual guideline for return-to-driving is six to eight weeks after surgery. Driving restrictions primarily apply to patients who have had a right knee replacement (assuming they drive an automatic vehicle).

The question has come up about getting back behind the wheel sooner with the new and improved implant procedures. With less soft tissue disruption, muscle strength and motor control should come back even faster than with traditional procedures.

And, in fact, studies show that improved surgical techniques, better pain control, and advanced rehab protocols have now put patients back in the driver’s seat much faster. With less pain, faster return of knee motion and mobility, patients experience better function sooner. Many patients feel ready to quickly regain the social independence driving provides.

The patient’s age and gender don’t seem to make a difference in reaction time when going from acceleration (gas pedal) to braking. A recent study of brake reaction times showed that patients with a right knee replacement preoperative regained their preoperative braking reaction time by the end of four weeks.

If brake reaction time were the only criteria for return-to-driving, then many of the patients would have been ready at the end of two weeks. But there are other factors to be considered that weren’t tested for such as vision, overall reaction time, effect of narcotics or other medications, and other health concerns.

Future studies will be needed to continue investigating this topic and forming guidelines for return-to-driving after right knee replacement. Separate testing should be done for automatic versus standard transmission vehicles. Any one who passes the brake test but who might need additional testing can be evaluated more completely with an on-the-road test.

Joint implants (an implant is also called prosthesis) continue to improve in design and materials. Surgical techniques and tools have also been improved over the years. More and more implants are now available with different design features.

The best implant for you may depend on whether you have strong, stable knee ligaments (or not). Some implants are made with a more porous surface to allow better bone growth around them. This type may not require the use of cement to hold it in place.

Because there are so many competing manufacturers and designs, research comparing them is fairly limited. But there was a recent study in Norway where the results of over 1300 different implants were gathered and analyzed.

The authors of this study compared outcomes for the unicompartmental versus the total knee replacement. As the name suggests, with a total knee replacement (TKR), the surgeon removes the entire damaged knee joint and replaces both the upper and lower sides of the joint.

The unicompartmental arthroplasty (UKA) involves just replacement of the inner or outer half of the joint. Most patients having a UKA have problems with knee alignment and have worn out just the medial joint surface. Medial refers to the side closest to the other knee.

Norway has an established registry for arthroplasties (implants) making this type of comparison possible with a large number of patients. All patients having any artificial joint implants in Norway are registered. Information about their diagnosis, age, joint involved, and surgery performed is included in the database. Baseline pain and function are not part of the registry information, so patients selected to be in the study were sent a survey of questions by mail.

Patient selection was based on current age (less than 85 years) and when the surgery was done (at least two years ago). Differences in results were compared by implant type and brand, patient age, sex (male versus female), and time since the operation.

As shown in previous studies, the unicompartmental knee arthroplasty did have more favorable results with less pain and better function at all time points. But the differences weren’t all statistically significant. And when asked about quality of life, patient ratings were equal between the two groups.

The authors took a closer look at various implant brands (i.e., made by different manfacturers). Again, there weren’t significant differences among the three prostheses included. One difference that did stand out was based on sex. Men with unicompartmental arthroplasties (UKAs) had less pain and better knee motion and function compared with women who had the same implants. The men also had better scores for function based on daily activities, sports, and recreational activities.

There could be any number of reasons why your implant came loose. The fracture as a second complication may (or may not) have been related to the implant loosening. Studies are needed to compare implants and determine patient factors that might suggest one type (design) or brand would be best suited for each individual person.

For the patient who has a total knee replacement, knee stiffness can be very disappointing and limiting. This type of stiffness is fairly common after a knee replacement.

What be done about it? Right now, there are two main options. She can try the conservative route with exercise and manual therapy under the supervision of a physical therapist. If that doesn’t work, then surgery is advised.

The surgeon must choose among three choices: 1) manipulation under anesthesia (MUA), 2) arthroscopic exam and debridement, and 3) open incision with revision. During manipulation under anesthesia, the patient is asleep while the surgeon moves the joint through its full range-of-motion. This forced movement breaks through areas of fibrosis and scar tissue. Debridement refers to gently scraping away any adhesions or fibrotic tissue that is keeping the joint “stuck” or unable to move beyond a certain point in the range of motion.

Arthroscopy allows the surgeon to see inside the joint and find out what’s holding it back from moving normally. Using a long, thin needle with a tiny TV camera on the end (the arthroscope, the surgeon can then correct the problem. If necessary, an improperly positioned implant can be removed and replaced using an open incision.

Your mother should return to her surgeon for a follow-up visit. The surgeon will examine her knee and determine the best approach for her particular problem. There may be several avenues open to her. Earlier treatment is often better than waiting too long as scar tissue and adhesions can continue to form further limiting her motion and function.

Autologous chondrocyte implantation (ACI) is done when there are full-thickness defects in the articular surface of the joint. Essentially, there has been an injury that has pulled off a piece of the layer of cartilage that lines the joint. Full-thickness means the defect goes all the way down to the first layer of bone.

Autologous means the cells harvested for the implantation come from the patient who needs the repair. In other words, you donate your own chondrocytes (cartilage cells). A short surgery is scheduled to allow the surgeon to take a few chondrocytes from inside the knee cartilage. These cells are grown in a laboratory.

At a later date, the patient returns for a second surgery, during which the surgeon implants the newly grown cartilage into the lesion and covers it with a small flap of tissue. The cover holds the cells in place while they attach themselves to the surrounding cartilage and begin to heal.

The procedure has not been recommended for older adults because of changes in the way tissues heal later in life. In the case of cartilage defects, there has been some question about whether aging chondrocytes can really repair themselves. The combination of degenerative changes in the older joint along with decreased growth factor has kept surgeons from using autologous chondrocyte implantation with older adults.

The results of a recent study from Germany may change all that. In that study, the use of autologous chondrocyte implantation (ACI) for cartilage defects of the knee was compared for patients under age 40 to patients over age 40.

Comparisons were made between the two groups by matching patients’ age, defect size, and defect location. The results showed similar improvements in all areas for both groups. Follow-up was for a two-year period of time.

The authors suggest these results bring into question the need for such a strict age limit on this procedure. Of course, longer follow-up is needed to see what happens over time. Extending the age limit up to 50 or 60 years old for autologous chondrocyte implantation may be possible for adults with minimal signs of joint degeneration.

When a patient ends up with a stiff and sticky joint, the surgeon can do something about it. As you have been told, there are three basic choices: 1) manipulation under anesthesia (MUA), 2) arthroscopic exam and debridement, and 3) open incision with revision.

During manipulation under anesthesia, the patient is asleep while the surgeon moves the joint through its full range-of-motion. This forced movement breaks through areas of fibrosis and scar tissue.

Debridement refers to gently scraping away any adhesions or fibrotic tissue that is keeping the joint “stuck” or unable to move beyond a certain point in the range of motion.

Arthroscopy allows the surgeon to see inside the joint and find out what’s holding it back from moving normally. Using a long, thin needle with a tiny TV camera on the end (the arthroscope, the surgeon can then correct the problem. If necessary, an improperly positioned implant can be removed and replaced using an open incision.

But which one of these approaches should be used? And how successful are the procedures? Surgeons from the Department of Orthopedics at the Mount Sinai Hospital in New York City conducted a systematic review in an attempt to answer these questions. They reviewed all of the articles on the three surgical techniques just described published between 1966 and 2008.

They only found a small number of high quality studies on each one. There wasn’t a large number to help guide surgeons in developing a standard of care. Each article was reviewed for information on age of patients, sex (male versus female), timing of the procedure after total knee arthroplasty, technique used, and type of anesthesia used.

Results of each treatment approach were measured using change in knee motion and total motion. Any complications that affected the patients recovery or outcomes were also analyzed. The first question addressed was how soon to do something about a stiff knee after knee replacement. The answers ranged from two weeks to three months after the initial replacement surgery.

Many surgeons send these patients to a physical therapist first before considering manipulation or a revision surgery. After exploring when to do the surgery, they turned their attention to the “How” question. How should the surgery be done? Which technique (manipulation, debridement, revision) should be done to get the best results?

Manipulation under anesthesia (MUA) and arthroscopy work better than open surgery to remove adhesions. MUA alone (without arthroscopy) may gain the most motion. Most of the studies combined MUA with arthroscopy so comparing MUA alone against arthroscopy alone was not possible.

Using an open incision to gain access to the joint had the worst results overall. The exact timing for best results with MUA is unknown. The earlier the MUA, the better the results, but late MUA is still effective. The force required to break adhesions and move the joint may be greater as time goes by and more adhesions develop. With greater force can come more complications (e.g., fractures).

Timing does not seem to be an issue when using arthroscopy. The surgeon simply finds the adhesions and snips them no matter how many there are present. The authors of that review concluded there weren’t enough high-quality studies comparing these three surgical approaches to form a clear plan for everyone with a stiff knee after total knee replacement.

Each patient must be examined by the surgeon who can make recommendations based on what these studies show and your particular situation. Sometimes the final treatment decision isn’t made until during the procedure when the surgeon gets a clearer view of what’s going on inside the joint.

You may be a good candidate for surgery but it’s best to see an orthopedic surgeon for an evaluation before going down that road. A review of your history, injury, time since the injury, conservative efforts tried, and length of time carrying out conservative care are all important factors in the success (or failure) of nonoperative care.

Studies show that 50 per cent of patients with a first-time patellar dislocation will go on to dislocate it again — even with conservative care. The way the ligaments and tendons form around the patella, there is often damage to more than just one soft tissue structure.

The tendons and ligaments are interwoven together and then form an enveloping capsule around the patella. A force strong enough to disrupt this connective tissue structure often causes damage to more than one ligament.

Repair can give up to a 70 per cent chance of a good result and return-to-sports. Reconstruction (replacing the torn or damaged ligament with graft tissue rather than repair (reattaching the torn ligament back in place) yields the best results. This is especially true when there are multiple structures involved. A simple single ligamentous tear can be reattached without reconstructing the entire patellofemoral unit.