FAQ Category: Knee

It’s true that exercise has been shown helpful to patients with osteoarthritis — especially knee arthritis. And studies show that although individuals who exercise may have increased musculoskeletal soreness, there are no other adverse effects of exercise.

It may be helpful to take a look at what kind of exercise(s) you are doing and if there might be a better way to exercise. For example, is there a pool-based program available in your community? Many people find that exercising in a pool helps reduce their joint pain right after the session. And that pain relief lasts into the next day.

This type of pain relief may be a major advantage of pool-based therapy since pain is the main reason patients with advanced osteoarthritis don’t exercise. Many people with arthritis are overweight or obese, so pool-based exercise with its buoyancy may have been a benefit in reducing joint pain after exercise.

If there isn’t a pool program in your area (or if getting to the pool is difficult due to transport problems), there are other ways to approach this problem. It’s possible that the type of exercise(s) you are doing or the way you are doing them is contributing to your increased soreness. This is something a physical therapist can help you with. Even one or two sessions can help get you on the right track and make exercise more enjoyable and less painful.

Your doctor can help you regulate any pain medication you may be taking. Taking pain relievers at just the right time can help maximize their effectiveness about the time you might feel increased pain or soreness after exercise. Be sure and talk with your physician or a pharmacist about ways to use your medications in conjunction with exercise.

For patients with painful arthritic changes on one side of the knee, a complete and total joint replacement may not be needed. Since 1964, surgeons have been using and perfecting the concept of a unicompartmental knee implant. Results with these devices have continued to improve greatly in the last few years.

Surgeons have come to understand the importance of patient selection in assuring a successful result for unicompartmental knee arthroplasty (UKA). Adults with unicompartmental (one-sided) knee pain while at rest seem to do best with the UKA. If there are major limitations to motion or significant anatomical deformities, then a total knee replacement is advised.

Patients with osteoarthritis (rather than rheumatoid arthritis) and who are not overweight or obese are the best candidates for a UKA. Studies have shown that being overweight is directly linked with the need for a revision after UKA. And, of course, if there’s arthritic damage to the other side of the joint, the patient should really have a total joint replacement.

Age used to be an important factor. No one under 60 years old would be considered for a UKA. But with improved implant designs and better surgical techniques, the range of acceptable ages has expanded. Younger, more active patients between the ages of 40 and 60 are now considered for this procedure. A few studies have reported patients as young as 35. But there is a concern that the patient will need too many revision surgeries in a lifetime to start so young with even a unicompartmental joint replacement.

There is one other patient factor to consider when choosing patients for a UKA — and that’s the diagnosis. Patients with posttraumatic arthritis don’t do as well as those who have osteoarthritis associated with aging. More studies are needed before firm guidelines can be made regarding this patient characteristic.

The UKA implant also lasts longer with fewer problems when the patient has a normal (intact) anterior cruciate ligament. Without this important restraint, joint deformity develops. There is uneven motion of the bones forming the knee joint as they against each other. Over time, this factor reduces the survival rate of the implant because of increased or uneven wear and then loosening of the implant.

Your surgeon may have had one (or more) of these factors in mind when she told you your options. To find out exactly why this recommendation was made, ask the surgeon who made the comment just what your factors are that would suggest that the UKA is a good choice for you.

Osteonecrosis of the knee is fairly rare. Osteonecrosis of the hip is a much more common problem. The term osteonecrosis means the death of bone tissue. There are three types of knee osteonecrosis: 1) spontaneous (occurs without a known cause), 2) post-arthroscopy (occurs after an arthroscopic procedure), and 3) secondary to some other condition such as lupus, use of steroids, or alcohol abuse.

The type you have is spontaneous osteonecrosis of the knee — also referred to as SPONK. It usually occurs in one compartment or section of the knee. Secondary osteonecrosis (caused by disease or medical therapy) affects more than one compartment. In most cases (no matter what the cause), the bottom, round part of the femur (thighbone) called the femoral condyle is the area damaged.

Spontaneous osteonecrosis usually occurs in patients older than 55 years, while secondary osteonecrosis can occur at any age. Women are affected by SPONK three times more often than men. The reason for this is unknown.

Osteonecrosis after arthroscopy is rare. It usually occurs when some form of heat such as laser or other thermal devices were used during the procedure. The patient starts to develop worse pain after arthroscopy than before. Knee swelling is a common feature of this problem.

Not much is really known about this condition — who gets it, what causes it, or even what is happening at the cellular level. For those patients who get it without an obvious reason, the physician looks for potential risk factors such as a traumatic accident or injury, alcohol use, blood disorders, history of previous knee surgery, and autoimmune disorders.

Sometimes, none of these are positive and we are left scratching our heads. Further research may help identify specific reasons. It’s likely that the problem occurs as a result of many factors, not just one cause.

Osteonecrosis (death of bone) after arthroscopic surgery is rare but can occur. It’s not clear what causes it, but scientists think there may be some problem with the meniscus, joint cartilage, or underlying bone.

Tissue samples examined under a microscope show that this type of osteonecrosis is very much like other kinds that occur for no apparent reason at all. In either case, it’s probably not spontaneous and without a true cause. We just don’t know what it is yet.

It’s likely that the development of osteonecrosis after arthroscopic exam or surgery is multifactorial. That means when all the right conditions line up, the person develops pathologic changes at the cellular level that lead to death of bone cells.

Men and women appear to be affected equally by osteonecrosis following surgery. That statistic differs from osteonecrosis of no known cause, which is far more common in women than men. Again, just exactly what that means remains a matter of speculation.

Studies of people with this condition are few and far between. MRIs before and after don’t show anything would help surgeons pinpoint patients at risk for this condition. There was some question about whether a tiny bone fracture might be linked with osteonecrosis after arthroscopy. But there wasn’t enough evidence to prove this theory.

That brings us back to the drawing board with no clearer idea of what causes this condition than we had before. In time, MRIs, bone scans, and operative findings might help identify predictive factors. If that occurs, then surgeons will be able to screen patients ahead of time and suggest an alternative treatment for those at risk for postoperative osteonecrosis.

Before considering a fusion, there are two other possible options. You may want to ask your surgeon if you are a candidate for either one. The first is an osteotomy. Osteotomy refers to the removal of a wedge-shaped piece of bone from one side of the knee. The remaining bone is moved to fill in the area where the wedge was removed. This procedure helps realign the bones and joint and redistribute weight and load.

This is a corrective procedure. It is used most often in younger adults to unload one side of the joint that is bearing the brunt of the burden. Arthritis affecting just one side of the knee joint is called unilateral or single-compartment degenerative disease. By unloading the side affected by arthritis the most, the knee can be spared much longer. Osteotomy buys the patient time before a total joint is needed.

Patients who benefit from osteotomies usually had a fracture around the knee that resulted in a leg length difference. Malunion or deformity after fracture or ligamentous healing can be treated with an osteotomy. The technique allows the surgeon to restore a more normal mechanical axis (center) of movement while spreading out the forces across the entire joint surface.

There’s an alternate surgical procedure that can be done when osteotomy isn’t enough or isn’t possible in the young patient. That’s an allograft transplantation. Bone from a donor or bone bank is used to replace bone lost. The transplanted bone dies but the body generates new blood to the area and forms its own bone to replace the allograft. Over a period of months to years, the body fills in with its own bone.

When none of these salvage procedures can be done, the surgeon may have to fuse the joint. This is called an arthrodesis. A fusion allows the patient to bear weight and walk on the involved leg. Of course, there are some problems with walking stiff legged.

It’s hard to get dressed when you can’t bend your knee. Putting on shoes and socks, cleaning the foot, cutting the toenails, even getting up from a chair or toilet can be difficult. And eventually, the hip and back start to hurt because of the altered biomechanics and movement. If you already have back pain, this may not be the way to go.

There isn’t a quick and easy answer to your question. There are lots of things to consider here. Your age first. Younger, active patients will need to hold onto their joint for as long as possible. That could mean a different kind of salvage procedure.

Two choices come to mind immediately: an osteotomy or an arthrodesis. Osteotomy refers to the removal of a wedge-shaped piece of bone from one side of the knee. The remaining bone is moved to fill in the area where the wedge was removed. This procedure helps realign the bones and joint and redistribute weight and load. Arthrodesis is a fusion of the joint.

Older patients who are less active may go ahead with the joint replacement. With any of these choices, the surgeon has a lot to consider. Past injuries, leftover hardware, scars from the incisions, fibrosis from scar tissue, and bone loss are just a few potential problems that must be addressed before the next surgical procedure.

Before any decisions can be made, an orthopedic evaluation is in order. Location and quality of pain are noted. Range of motion is measured. The patient’s gait (walking pattern) is examined and analyzed. Tests for knee instability are performed. X-rays are taken to look for limb malalignment, fractures, and status of the hardware. And finally, lab tests are ordered if there is any suspicion of joint infection.

The surgeon takes into consideration the patient’s age, expectations, and goals, along with current activity level and desired activity level. The condition of the knee joint is also a deciding factor in what surgical option is best.

Once you’ve had this done, then the surgeon can outline what your options are and the any pros and cons for each one. The long-term outlook for total knee replacement for traumatic arthritis is fair-to-good. Patients experience a reduction in pain, increased motion, and improved function. The results aren’t always perfect. The postoperative range-of-motion depends on how much motion was there before surgery.

Sometimes the patella (knee cap) doesn’t move up and down like it should. This motion is called patellar tracking and is important for normal knee function. If scar tissue or muscle contracture is preventing normal patellar tracking, then additional surgery may be needed to correct the problem. In some cases, the old patella is removed and a new one installed as part of the joint replacement.

Tendon rupture, failure of the wound to heal, and even implant failure are common problems that may be encountered. Patients should be counseled ahead of time what can happen and what to expect. The surgeon can expect and should watch for a high rate of complications after total knee replacement for these posttraumatic arthritis patients.

You are asking about the natural history of patellar (kneecap) dislocations. In other words, what happens over time with these injuries? That’s a good question and one that others have tried to investigate. At least one large study (100 patients) with a primary (first-time) patellar dislocation showed that a significant number of patients had arthritic changes. About one-third of the group had degenerative changes of the affected bone and joint within a dozen years of the injury.

There are many factors that can play into this. For example, patients with patellar dislocation and soft tissue damage (torn or ruptured ligaments) are more likely to develop alignment problems. Uneven loading of the joint can lead to arthritic changes from uneven wear and tear.

There may be some differences in what happens depending on what kind of treatment is given. Early surgery to repair the damaged soft tissues and stabilize the knee may be advised in active, healthy adults. This can reduce the risk of reinjury and/or redislocations. A second or third patellar dislocation increases your risk for arthritic changes.

But there could be a different reason for the twinges you are having in the knee. The leg is a single link in a long chain of biomechanical structures from head to toe. For example, muscle weakness or flexibility imbalances in the hip or ankle can affect the knee. It’s always a good idea to get help sooner than later for musculoskeletal problems. With a history of patellar dislocation and now these new symptoms, you would be a good candidate for a re-evaluation. An orthopedic surgeon or physical therapist can perform a detailed exam and perhaps identify what’s going on and what can be done about it.

There are some wonderful new ways to treat osteoarthritis in young, active adults.

The half-knee joint replacement that you mentioned is called a unicompartmental knee arthroplasty (UKA).

That works well for people with more arthritis on one side of the knee than on the other. Most often, it’s the medial side of the joint (side closest to the other knee) that wears down and develops painful knee arthritis. So the surgeon just replaces that side of the joint with an implant.

But what about patients like you who are too young or too early in the course of their disease (osteoarthritis) to qualify for a unicompartmental knee arthroplasty (UKA)? What can they do to stay active, participate in sports, or keep up in their jobs when their knee pain limits them?

The high tibial osteotomy (HTO) may be a good alternative. In this procedure, a wedge-shaped piece of bone is removed from the upper part of the tibia (lower leg bone that forms the bottom half of the knee joint). The remaining two edges of the bone are lined up at in a position of slight valgus (angled inward). The medial collateral ligament (MCL) along the inside of the knee may be partially cut. This step is taken to decrease the amount of pressure placed on the medial side of the knee.

The remaining bone is usually held together with a metal plate and several screws until healing takes place. The hole made by removing the pie-shaped piece of bone may or may not filled in with bone graft. If left alone, the body fills in the gap. When bone remodeling is complete, then the hardware can be removed (usually around one-year after the initial surgery).

There aren’t a lot of studies showing what happens to patients years after their HTO. There is one that was recently published comparing activity level before and after surgery. Understandably, patients’ activities were curtailed before surgery due to pain and loss of motion.

After surgery, they were able to resume at least at the level of activity they engaged in before the operation. They could do so with less pain and greater ease. Only about a quarter of the patients needed pain medication to engage in their desired level of sports and activities.

Most patients did not increase their sports participation. The patients didn’t say so directly, but the authors of the study thought perhaps the patients were more aware of the need to protect the joint so they didn’t return to a high level of activity.

High tibial osteotomy is considered an effective way to deal with early stages of arthritis that affect only one side of the joint. Active patients of all ages can qualify for the procedure.

There are several benefits of high tibial osteotomy (HTO). Patients can return to an active, busy lifestyle, including sporting activities after healing and recovery. It’s a good middle step between conservative care and a unicompartmental knee replacement (implant replaces one side or the other of the damaged knee joint). It can help active, younger adults with the start of painful knee arthritis to stay in the game so-to-speak.

There may be a need to modify some activities such as switching from running or jogging to walking. It’s possible to have the HTO procedure along with other repair work on the knee. Two or three procedures at one time doesn’t seem to affect outcomes either. Surgeons know they can make other necessary repairs without fear of affecting the results.

Overall, it looks like the HTO procedure has good results and some excellent advantages. It’s not necessary to cut through the tibialis anterior muscle when doing the procedure like osteotomies done a little lower on the tibia or osteotomies done on the opposite side. There’s less risk of damage to the peroneal nerve. There are fewer problems with shortening of the leg. And best of all, it can improve symptoms and delay total joint replacement by preventing disease progression.

Minimum time of recovery for an injury of this type is six weeks. Surgery would delay recovery by another six weeks since you would still have to complete the rehab program. Treatment is usually guided by your activity level, age, type and severity of injury, and the presence of any bleeding or loose fragments of bone or cartilage in the patellofemoral joint. The patellofemoral joint is between the patella (kneecap) and the femur (thigh bone).

There is at least one study of military recruits published that compared surgical treatment versus bracing and exercise for patellar dislocations in active recruits. All patients had a traumatic injury either from a military exercise or a sports activity. All of the patients were in the military. Most were men between the ages of 19 and 22.

The real question behind the study was: should a primary (first-time) patellar dislocation be treated right away with surgery? Or can it be managed nonoperatively with a knee orthosis (brace). What are the long-term results of both approaches?

Everyone was randomly placed in one of two groups: either surgery or bracing. Except for gender, the patient make-up of the two groups was very similar. Surgeons performing the operations could use any surgical technique they thought was best. No one was told to follow a specific surgical protocol. The brace group received a knee brace designed to hold the kneecap in place. This is called a patellar stabilizer.

Patients in both groups followed the same rehab program after their treatment. So, that part of their management was the same. The only difference was one of timing: the surgical group began the exercise program 24 to 48 hours after surgery. The orthotic group began their exercise program right away. Exercises were prescribed and supervised by a physical therapist.

The main outcome measure was whether the patella dislocated (partially or fully) and whether another operation was needed during the follow-up period. Patients were followed for an average of seven years. What they found was that there were far fewer redislocations in the follow-up period for the surgical group. Nearly one-third of the nonoperative (bracing and exercise) group had a second patellar dislocation. If partial dislocations called patellar subluxation are included, then almost half of the nonoperative group had patellar instability.

The authors concluded that early surgical stabilization and repair of the surrounding damaged soft tissue structures can reduce the risk of redislocation in young, active military recruits. Criteria for surgery used by these surgeons were: a traumatic patellar dislocation with ligament injury along the inside edge of the patella. This ligament is the medial patellofemoral ligament.

You have a valid concern. But even more important is the question of whether or not you are at an increased risk of redislocation. In many places, a six-week course of conservative (nonoperative) care is the standard of care. If you can make a follow-up visit with the therapist, perhaps you can ask for an earlier reevaluation with these concerns in mind.

More and more older adults are being proactive in asking for treatment they feel will improve their quality of life. Joint pain is definitely one of those things that can be very limiting. Pain and loss of motion decrease function and keep folks from being more active.

The recommendations made by your father’s surgeon may have more to do with preventing infection and ensuring a successful outcome than trying to delay surgery intentionally. Studies show that the condition of the teeth and gums before surgery can have an impact on the rate of infectious bacteria that can enter the body and then travel to the joint and cause destruction.

In the same way, dry skin and infrequent washing can increase the risk of cracks, sores, and other ways for bacteria to get past the body’s first line of defense. The effect can be the same: joint infection that results in implant failure.

A simple program of improved personal hygiene can be very effective in reducing the risk of post-operative infection. And with older adults, immune system failure is also more likely. So, as the old saying goes, An ounce of prevention is worth a pound of cure.

Encourage your father to take the surgeon’s advice. If he is in doubt as to the reason for these steps, just have him call the surgeon’s office. The nursing staff is probably very tuned in to the need for patient education. They can explain to you and to your father the reasons for these recommendations.

Infection is one reason why total knee replacements fail or have to be replaced themselves. Surgeons do everything they can to keep this from happening. Experts advise surgeons to take every preventive measure possible.

To accomplish this, the patient should be given intravenous (IV) antiobiotic treatment and antibiotic impregnated cement when the implant is glued in place. These two measures together may help prevent septic failure of the first joint replacement. If infection does occur, the same two preventive steps must be taken when performing a revision surgery.

Studies show that results are significantly better when both preventive steps are taken. There was a time when surgeons thought that just using the cement with antibiotic in it was enough. There was some evidence that the initial burst of antibiotics released coated the implant with a protective biofilm.

Postoperative infections were reduced but not as much as when intravenous antibiotics were combined with the special cement. The results are especially dramatic when used in patients who have other health issues that put them at increased risk for infection such as diabetes or heart disease.

The cost of the added step is likely pennies compared to the cost of a revision (second) surgery to remove and replace an infected joint replacement.

Infection after knee replacement surgery is a well-known risk and one everyone would like to avoid. Early problems are usually superficial (on the surface). The problem could be a failure of the incision to close, skin or scar infection, or continued drainage from the wound.

Once it happens, it must be treated quickly to avoid getting worse. Conservative (nonoperative) care is usually given at first. The wound is cared for and motion that might aggravate the healing wound is limited. This could include range-of-motion exercises and walking. Antibiotics may be needed. Depending on how soon the diagnosis is made and how severe the infection is, the surgeon may recommend topical, oral, or intravenous antibiotic therapy.

The goal is to prevent minor, superficial wounds from progressing to become deep infections requiring surgical treatment. Fortunately, this doesn’t happen very often (less than one per cent of the time). This is very low but still devastating for the patient.

You can help by encouraging your mother to follow all advice given by the nursing staff and/or surgeon(s). If needed, make sure she takes her antibiotics as scheduled and for the full amount of time prescribed. If walking and other activities involving movement are limited, she’s going to need some help with daily chores, getting groceries, and getting to her appointments.

Don’t hesitate to call the physician and/or get her back in to see someone if the wound is suspicious looking or doesn’t seem to be responding. Early intervention is the key to success. For anyone who has diabetes, maintaining good control is extremely important. With or without diabetes, good nutrition is essential for wound healing. Making or providing meals can be very helpful following this type of complication after surgery.

Small or superficial (close to the surface) infections can become major problems if not treated properly and quickly. If you don’t want to take an antibiotic, check with your surgeon to see if a short trial of topical antibiotic cream would be sufficient.

If not, follow your doctor’s advice and complete the entire prescription exactly as directed. If you have any risk factors that might delay wound healing (e.g., diabetes, smoker, heart disease), it’s best to practice prevention. It’s best to reduce your risk of potentially serious results that can occur without treatment.

One other potential pitfall is the diagnosis. Studies show that the risk of serious, deep, progressive infection goes up when surgeons use their clinical judgment to diagnose infections. What can sometimes look like a superficial infection could in fact be a deep infection that is already affecting your new implant. There are specific tests (culture of the tissue) that can be used to find out if there was a significant infection.

The result of missing deep periprosthetic (around the implant) infections is that a simple treatment early on gets passed by. Eventually, the patient needs much more extensive surgery to take care of the problem. The missed diagnosis increases the risk that the patient could lose the implant. In a few cases, amputation is even necessary.

If your surgeon has recommended an antibiotic, you most likely need to take it. If you want to pursue this further, talk to your surgeon about further testing and other options available.

Patients are getting good results with total knee replacements (TKRs). Pain is reduced and function is improved. There are very few complications. And the final outcome is a better quality of life. As the current saying goes, What’s not to like?

As you saw in your surgeon’s office, there are, indeed, many types and sizes of implants now. Little by little, total knee implants have been improved over the years. But it hasn’t happened by magic. Makers of the implants sponsor studies to evaluate what works, what doesn’t, and what changes are needed to improve the results. Better quality of life and longer lasting implants are two main goals with total knee replacements (TKRs).

Each surgeon trains and practices new techniques before using them on patients. Like anything else, practice makes perfect. The more replacements the surgeon does, the better he or she is at that procedure. Each patient is evaluated carefully for the best implant. The size and shape of your knee are taken into consideration. Any muscle imbalances or joint alignment problems are also assessed and corrected as much as possible.

Studies to examine key features of implants are ongoing. For example, a large study comparing three design components was recently published. The focus of attention was on: 1) metal backing on the tibial portion of the implant, 2) patella resurfacing, and 3) a metal bearing between the tibia (lower leg bone) and the femur (thighbone).

Each of these design features was compared between two groups of total knee replacement patients. One group received the particular component. The other group did not. Surgeons performed the procedures according to their own standard methods. Outcomes were measured in terms of cost, effectiveness, complications, function, and quality of life. The study had a follow-up period of two years.

There were many findings from the study such as complication rate (equal among all groups), operative time (longer in the metal backed group), and hospitalization (average was nine days for all groups). In addition, 95 per cent of all patients went home directly from the hospital. Pain was reduced and function improved within the first three months. Gradual improvement continued after that initial recovery period.

But the bottom-line was that the overall results were the same from group to group. Everyone improved equally by the end of two years. Rates of complications during that time were the same and functional recovery was no different from group to group. Outcomes were measured according to results important to the patients (not the surgeons).

That’s all good news, but it doesn’t exactly answer your question. That’s because even with all their expertise, the authors of that particular study couldn’t recommend one implant over another just yet. But the hope is that with long-term results, patterns of design wear and the pros and cons of each will be more obvious. The wide range of surgical centers and techniques may have some effects on the results. These factors will be taken into consideration over time as well.

They explain why it’s so difficult for surgeons to tell if the ligament is intact (okay) or not. Sometimes, a partially torn ligament looks perfectly fine. But it’s really damaged and over time, it starts to lengthen or stretch out. Ligaments don’t really stretch and bounce back like a rubber band. They are more likely to stretch and stay stretched out. And without a strong connection to hold the bones together, the knee joint can become unstable and give way underneath you.

Sometimes a partially torn ACL can be treated conservatively with nonoperative methods such as antiinflammatories and an exercise or rehab program. The surgeon’s task is to determine which patients can be treated this way and who needs surgery to repair or reconstruct the ligament.

Making the right decision is important because ligaments don’t have much of a blood supply. That means self-repair of a partial tear is not possible. Under the right conditions, it will eventually tear completely. Avoiding such an injury is often the goal, especially with athletes who are trying to stay in the game despite a partial tear.

How does the surgeon accurately diagnose the problem? That can be a problem in itself. When clinical tests commonly used by examiners are positive (e.g., Lachman test, pivot-shift test), then it’s clear that there is an ACL tear. But studies show that these hands-on tests can appear normal when up to 75 per cent of the ligament is torn.

Surgeons are advised to perform the pivot-shift test under anesthesia when the ligament appears to be torn. In this way, the effects of muscle spasm and guarding are eliminated and the results are more accurate.

This test is performed with the patient lying supine (on his or her back) with the hip passively flexed or bent to 30 degrees. The examiner stands beside the patient. The lower leg and ankle are grasped keeping the lower leg internally rotated about 20 degrees. The knee is allowed to sag into full extension. Force is applied to the outside of the knee while it is slowly straightened. If the tibia (lower leg bone) clunks into place as the knee is extended, there is likely a tear of the ACL.

Studies show that the pivot-shift test is only 24 per cent sensitive when the patient is awake compared to 92 per cent sensitive when under anesthesia. Results of the pivot-shift test while in the operating room can be misleading if there is other soft tissue damage inside the joint. The surgeon must take the opportunity to double-check for problems such as cartilage, bone, or meniscal fragments in the joint.

If the pivot-shift test is truly negative, the ligament is not functionally deficient. In other words, even though the ligament is partially torn, it can still function to some extent. Those are the patients who can do well with a rehab program instead of surgery. A nonoperative course of treatment is especially indicated if the individual isn’t very active and/or doesn’t have much in the way of symptoms.

With soft tissue injuries such as the anterior cruciate ligament (ACL), there are degrees of damage. Some experts categorize strains and sprains differently. Others claim these are on a continuum from mild to severe.

The American Medical Association (AMA) has defined ligament damage as first degree, second degree, or third degree sprains. First degree is a mild sprain with a minor tear of the ligament fibers. Patients present to the physician with pain and/or tenderness but usually without swelling or much (if any) loss of motion.

A second-degree sprain is a partial tear of the ligament resulting in a moderate sprain. There is pain, moderate loss of function and disability, and slight-to-moderate abnormal knee motion. There is a risk of reinjury.

Third-degree sprains are severe and involve a complete rupture of the ligament. Tenderness, pain, swelling, hemorrhage, instability, and loss of motion are typical with a full-thickness tear of the ligament.

Some physicians prefer to estimate how much of the ligament is torn in terms of a percentage (e.g., 25 per cent, 50 per cent, 75 per cent). Anything 75 per cent or less is considered a partial tear. Others refer to partial ligament tears as low-grade (less than 50 per cent) or high-grade (50 per cent or more).

And finally, there are articles published on this topic showing orthopedic surgeons’ preferences for a battery of clinical findings necessary before a diagnosis of partial ACL tear can be made. There are clinical tests such as the Lachman test or the pivot-shift test that help guide the diagnosis.

Several other diagnostic tests are available when the surgeon suspects a partial ACL tear. The first is the KT-1000 arthrometer test. This test provides a measure of joint laxity or looseness. Some people have naturally loose ligaments, so the injured knee is always compared to the uninjured side. More than three millimeters of difference from side-to-side is a red flag sign of pathologic injury. This test can fool the clinician. It simply isn’t always a sensitive enough test. Results of the test can appear normal when there is a partial ACL tear.

Some suggest relying on MRIs for the diagnosis. But even with today’s more advanced MRI systems, up to half (or more) of the partial ruptures will be missed using MRIs. A more reliable (but still not always 100 per cent accurate) method of identifying partial ACL tears is the arthroscopic exam.

Even with a scope inside the joint, if the outer covering of the ligament is intact, the surgeon won’t see the torn fibers inside the sheath. And sometimes scar tissue mimics a normal appearing ligament support structure. Surgeons are advised to perform the pivot-shift test under anesthesia when the ligament appears to be torn.

In this way, the effects of muscle spasm and guarding are eliminated and the results are more accurate. Studies show that the pivot-shift test is only 24 per cent sensitive when the patient is awake compared to 92 per cent sensitive when under anesthesia. Results of the pivot-shift test while in the operating room can be misleading if there is other soft tissue damage inside the joint. The surgeon must take the opportunity to double-check for problems such as cartilage, bone, or meniscal fragments in the joint.

Seeing is believing, and that’s the benefit of an arthroscopic exam. The surgeon can get a direct look at the ligament and determine whether or not it is torn and by how much (either in degrees or percentages). Ask your surgeon to tell you what criteria he or she used to make your diagnosis. That’s the only way to know for sure how severe the injury is.

With any surgery, there is always the possibility of problems called complications. Some of the more serious complications can include death. But these are rare and usually occur in patients with other problems, such as a pre-existing condition (heart disease, high blood pressure).

Blood clots are always a potential danger in any hip or knee surgery. Surgeons take every precaution to prevent these. Special medications are prescribed (blood thinners to prevent excessive clotting), pneumatic pumps are used on the legs to keep circulation going and prevent swelling, and patients wear special support hose to accomplish the same goals. All of these things combined together are very helpful in reducing the risk of a life-threatening blood clot.

Amputations have been reported. But these are rare. For example, in one large study, three patients out of 2,318 required amputation after a total knee replacement. In all three cases, there were other health problems contributing to the loss of limb. One patient had peripheral vascular disease that resulted in a loss of blood supply to the knee. Another patient fell and needed surgery to repair a torn tendon. An infection developed and spread. These are rare, but very unfortunate incidences.

Don’t hesitate to bring your questions and concerns up with your surgeon. Your own past medical history, current health, and level of fitness will affect your results. Knowing the risk factors and how to minimize and prevent complications is important.

Athletes like your son are often at risk for full-thickness (down to the bone) chondral (cartilage) injuries caused by acute or repetitive trauma. Patients with severe damage to the knee cartilage have several treatment options. Usually surgery is required. Surgical repair procedures include debridement, microfracture, drilling or abrasion, or osteochondral grafting.

The one you are thinking of is called autologous chondrocyte implantation (ACI). It was originally designed for patients who had a failed primary (first) procedure. In autologous chondrocyte implantation (ACI), healthy cartilage cells are harvested from the patient and used to grow more healthy cells to fill in the defect. Most of these patients have had prior treatment with one of the other methods to treat damage to the articular (joint) cartilage.

Although the procedure was originally intended for patients with no other treatment options, the use of this repair method has expanded. It’s still reserved for the repair of lesions on the severe end of the spectrum. It’s been around for 20 years now, so we have reports of long-term studies to rely upon to support its safety, effectiveness, and durability.

Patients are still handpicked by surgeons for the procedure. It’s not just done on anyone. Patients must meet certain criteria. This may differ from surgeon to surgeon. For example, age may be a factor (patient can’t be too young or too old). They may not be eligible if they have had a previous ACI treatment on the same knee, removal of the meniscus (meniscectomy), or knee arthritis (osteoarthritis or rheumatoid arthritis).

And not all surgeons have the advanced skill and training to perform this particular procedure. When you find the surgeon you are most comfortable with, listen to his or her counsel, ask questions, and then make your decision.

Most surgeons use a minimum of three months of rehab after a chondrocyte (cartilage) implantation before considering the procedure a failure. Although you’ve completed that much time in rehab, remember that’s the minimum. Sometimes, the body is very slow to recover and needs more time.

If you have diabetes, smoke or use tobacco products, if you are overweight, or have poor circulation in general, you could be at risk for delayed healing. It’s possible that you put too much compression too soon during rehab. Backing off a bit may help with the recovery and repair process.

Your surgeon is the best one to advise you. It may be necessary to take a look inside the joint to see what’s going on. At the very least, X-rays and a clinical exam are needed. Range-of-motion, strength, and pain pattern will be assessed. An arthroscopic exam may be recommended next. Once the condition of the repaired site is determined, then an appropriate plan of care can be decided upon.

Sometimes, it’s just a matter of reshaping the healing area. There could be a frayed edge of cartilage or loose fragment causing the painful symptoms. One of the most common problems after chondrocyte implantation is the overgrowth (hypertrophy) of the bone around the implantation. Shaving down this area is usually very successful in putting an end to patients’ painful symptoms.