FAQ Category: Knee

You are right but only some patients are candidates for the repair-versus-remove option. Studies show that the long-term result of complete meniscectomy is osteoarthritis of the joint.

Without the cartilage to act as a shock absorber and protector of the joint, degenerative changes speed up. That’s why surgeons are trying to repair the torn meniscus instead of taking it out.

Meniscal tears are more likely to be repaired when healing can occur after surgery. The tear must be located in an area that has good blood flow. Most of the meniscus doesn’t have a blood supply. Only the outer one-third edge of the meniscus is in a zone that has blood vessels.

Small tears in this area are the most likely to heal after surgical repair. The damage must be fairly minimal without degenerative changes. Usually the torn meniscus has occurred as a result of trauma in a young patient.

Middle-aged adults are more likely to have meniscal changes and tears because of the aging process. Degenerative changes of this kind are removed as you described. The surgeon will still preserve as much of the remaining healthy tissue as possible to prevent further changes in the joint.

Your son may be having a procedure called chondral resurfacing using a microfracture technique. This means that the surgeon uses an arthroscope to find the defect.

Then a special tool called a curet is used to scrape the layer clear. Another tool called an awl makes holes in the subchondral bone plate. The subchondral layer is just above the cancellous or spongy bone where the blood supply to the bone is found.

These tiny holes or “microfractures” allow blood to seep down into the cartilage layer forming clots. A healing response is set up and tissue fills in the layer.

Your son’s cooperation is very important for a good result. He must follow the surgeon’s instructions very carefully. For example, putting too much weight on the knee can cause the clot to get displaced. Likewise, premature weight-bearing can limit attachment of the clot to the cartilage base.

Patients must also cooperate with the physical therapist. A postoperative program of exercises will be part of the rehab and recovery. Patients are guided step-by-step through the phases of activities. For example, a continuous passive motion (CPM) machine is worn for at least six hours a day for the first six weeks. The patient is unable to just get up and walk about when using the CPM.

Strengthening exercises followed by low-impact activities are slowly advanced. MRI testing and patient symptoms are used to guide the progression of rehab. Running is not allowed until about four months after surgery. If your son is an athlete, returning to high-impact sports activity takes up to six months or more.

In this procedure tiny holes called are made in the surface of the knee joint. This is called microfracture. The purpose is to release droplets of fat and blood from the bone through the holes into the area of damage or defect.

Tiny clots form filling in and plugging up the holes. A bond forms between the clot, bone, and cartilage. The end result will be a new surface layer of repair tissue where the original defect was present.

The doctor has probably advised you not to put weight on that leg for at least six weeks. By now you are starting to do so and will gradually advance to full-weight bearing. How fast you go depends on the size and location of the lesion. Painful symptoms may also limit you at first.

The surgeon will order repeat MRIs to help assess the status of the healing tissue. Another arthroscopy to look inside the joint isn’t usually required. The MRI will show how much cartilage filling has taken place. The MRI is very sensitive to cartilage and will also show the status of the underlying subchondral bone plate.

Your surgeon will use all of this information to give you guidelines for activity in the weeks and months ahead of your recovery. If you follow his or her advice, you should be very safe.

Comparing a unicompartmental implant to a total knee replacement (TKR) is a little like comparing apples to oranges. These are both implants used for joint destruction caused by osteoarthritis. Patients who only have one side of the joint damaged are better candidates for the unicompartmental implant.

Studies show the unicompartmental implant requires less invasive surgery. There’s a more rapid rehabilitation and a better chance for more normal knee motion and function.

On the downside is the fact that wear and durability may be less for the unicompartmental implant. It is suggested that the TKR has a 15 (up to 20 year) span, whereas the durable life of the unicompartmental is closer to 12 years.

The condition and longevity of both implants depends on your activity level. The more active you are, the greater the stress and load on the implant leading to wear and tear. In the case of the unicompartmental implant, the condition of the other side of the joint at the time of procedure can make a difference. If there are any signs of arthritic changes, there may be progression of the disease leading to joint failure in time.

Overall, results show that for some patients, the unicompartmental implant is a good way to save money while improving quality of life, motion, and function. Later, you can convert from a unicompartmental to a total knee if needed.

A recent study from the University of California (Los Angeles) compared the cost-effectiveness of these two procedures. Both were used for patients with joint damage from osteoarthritis (OA).

The unicompartmental was selected for patients with changes on one side of the joint. The total joint was implanted in patients with generalized joint destruction on both sides.

The unicompartmental implant represented a cost savings of about 25 per cent over a TKR. The value added to the patient’s life in terms of reduced pain and improved function was equal. Complications and problems after surgery can drive the costs up for either type of implant.

Long-term benefit may be less with the unicompartmental because survival of the implant may be less. This is based on studies so far that reflect the long-term outcomes of TKRs. Similar studies for unicompartmental implants are under way.

The Less Invasive Stabilization System (LISS) is a fixation device to hold the bone together while it heals. It was designed to be used with fractures of the femur (thighbone).

The LISS is designed to be inserted percutaneously, meaning through the skin. The surgeon uses a special X-ray called fluoroscopy to see inside and place the device. The LISS consists of a contoured plate that matches the shape and length of the femur. Self-drilling, self-tapping screws lock into the plate.

The LISS has some advantages for treating a fractured femur in a hip or knee with a stable joint replacement that other methods don’t have. For example the locking plates give stability when the bone is osteoporotic (brittle). The plates are less damaging to the bone’s blood supply.

The reported complication rate with the LISS is around five per cent. This is much less than the 15 to 50 per cent associated with other fixation methods. Other treatment options include the traditional plate and screws, cable plates, or bone graft.

Many studies have been done trying to answer these questions. Can an exercise program help athletes avoid surgery? How long does it take? What kind of exercise program is needed? Is an exercise program even needed? Perhaps it’s possible to return to full strength given enough time.

A recent study from a sports lab in Greece compared men with an ACL injury to a group of healthy but very active men. The ACL group did not follow any kind of specific or structured exercise or rehab program. They managed their injury with the old standby approach: Rest, Ice, Compression, and Elevation (R.I.C.E.).

Muscle testing before and after showed that their strength slowly came back but not to the preinjury level. The hamstrings recovered more quickly compared to the quadriceps muscle. Organized rehab is advised as a way to prevent this prolonged weakness.

An early intervention program may be able to improve the joint stability and prevent reinjury. Amateur athletes like yourself may be able to return to preinjury level of sports activity sooner after participating in a structured rehab program.

Thigh muscle weakness is common with ACL injuries both before and after surgical repair. Studies show that muscle strength does improve with time but it may take up to 18 months before the quadriceps strength approaches normal.

Normal may be defined as at least as strong as the other side (if the other side remains uninjured). Normal also suggests a balance between the quadriceps and hamstrings muscles. The hamstrings are more likely to return to near normal strength than the quadriceps in the first year after injury.

There is evidence to show that patients with ACL deficiency have some minor changes in the way the muscles fire and contract. Motor messages are not as fine-tuned as they once were. It may be necessary to complete a rehab program to retune the muscles.

When and how the muscles contract is a process called motor control. ACL injured knees may need to reprogram the muscle activation strategy to function normally. This rehab step is often missing but very important. Helping the joint regain its ability to handle shear force during knee loading will increase its stability and prevent reinjury. This is true after both ACL injury and after ACL repair.

Creating the perfect total knee replacement requires a very delicate balance between bone, implant, muscles, and ligaments. The surgeon may be working with osteoporotic bone or a joint with a natural extra rotation in one direction or another.

Once the arthritic or damaged bone is removed to make room for the implant, the surgeon must choose the right size and type of prosthesis for each patient. Replacing the anterior or front portion of the femoral bone (thighbone) with an implant that is larger than the bone removed is called overstuffing. Too much overstuffing can cause pain and loss of motion (flexion).

There is much debate about this topic. The surgeon has several options available. The patella can be left unchanged while the rest of the joint is replaced. The patella can be resurfaced. This means the back of the kneecap is smoothed. It may be left that way to heal or a smooth, polypropylene (plastic) liner may be attached to the back of the patella.

Knee pain is the main problem with leaving the patella unchanged. Second to that, the arthritis may continue to get worse in the patella. The cartilage along the back of the patella that comes in contact with the rest of the knee joint can get worn unevenly, form bone spurs, or thicken in an attempt to protect the joint. When this happens, the patient may report “tightness” and loss of motion in the joint.

The surgeon will make a judgment call during the operation. Which option to choose is based on the present condition of the patella, your father’s age, and his activity level.

One of the most important considerations in leaving the patient’s patella intact is: how long will the cartilage surface hold up moving against the metal implant. Early studies show that leaving the patella unchanged may not have the best results.

Spongialization is a new way to resurface joints damaged by osteoarthritis. The worn and pitted cartilage is removed. A thin layer of cortical or hard bone just under the cartilage is also removed completely.

This exposes the next layer of bone called cancellous bone. Cancellous bone is soft and spongy. This layer can also be referred to as “spongiosa.” So the outer, bony part of the patella (kneecap) is cortical or hard. The inside is cancellous or soft.

New fibrous tissue can grow from the bony surface once it is opened up. The spongiosa turns into a type of tissue called granulation tissue. The blood supply is very rich to this tissue thereby enhancing healing.

In a spongialization procedure, the cortical bone right under the worn out cartilage is removed, leaving the spongy bone exposed. So far studies show that spongialization works faster and better than removing the patella in patients with severe osteoarthritis. Long-term studies are still needed.

There are several methods used to control pain in the first 24-hours after an anterior cruciate ligament (ACL) repair. Narcotics can be delivered by mouth (oral), by injection into the muscle (intramuscular), by injection into the joint (intraarticular), or directly into the blood stream (intravenously).

A nerve block to the femoral nerve in the leg blocks any pain signals from reaching the brain. The success of the nerve block depends on the placement and dose of the drug. The drug is delivered to the nerve through a needle placed just under the outer lining of the nerve called the nerve sheath.

The surgeon uses a neurostimulator to find the exact location of the nerve. The patient is lightly sedated but awake enough to answer questions. Once the nerve is blocked, the surgeon pinches the skin and muscle to see if it is numb.

Nerve block failure can occur if the drug dose isn’t enough or if the catheter delivering the drug has been displaced or moved by accident. Sometimes the patient just has what’s called breakthrough pain.

With breakthrough pain the patient can receive additional pain medication. This could be via any of the three delivery methods mentioned.

You may have had a nerve block after surgery to control the pain. A narcotic is used intravenously for the first 24-hours. The femoral nerve in the leg is affected so that pain messages from the knee don’t reach the brain.

Surgeons find patients do better in the long run if the immediate pain after surgery is reduced. Faster recovery means fewer complications and a better overall result.

Although the block is meant to stop sensory nerve messages (sensation of pain), the motor portion of the nerve can also be affected. If the motor nerve can’t tell the muscle to contract, you can’t lift the leg. You can still stand and walk because other nerves and other muscles are working just fine.

The effect should be temporary with a reversal of symptoms soon after the nerve block is stopped. Of course, the pain may return, too. Other nonnarcotic pain relievers are used then.

Some surgeons say that complications from iliac crest bone graft harvest can be avoided. They advise improved surgical technique can make a difference. Taking too much bone is the first mistake that’s easy to make.

According to Frank Noyes, MD, a well-known orthopedic surgeon from the Cincinnati Sportsmedicine Clinic, no more than 10 mm (less than half an inch) of bone should be removed from one spot. The surgeon must remove the bone carefully without damaging the muscle. Only the outside layer of bone should be taken.

This type of minimally invasive method has the least amount of problems or complications later. Nerve damage, infections, and blood loss can be avoided in this way. Sometimes patients do report pain whenever they bend forward. This usually only lasts for about four weeks while the donor site is healing. Patients are cautioned to avoid this movement.

Patients can get bone donated from a bone bank to avoid any of these complications. The advantage of using the patient’s own bone is the rapid healing that occurs at the operative site.

More and more surgeons are selecting patients carefully for surgery. Studies now show there are risk factors that predict an increased rate of complications and even surgical failure.

The surgeon has your best interests in mind. You don’t want to spend that much money or time on something that isn’t going to work or will leave you worse off than before the operation. Excess bleeding, poor wound healing, and fractures are just a small list of problems caused by the use of nicotine.

The type of surgery you are describing is well-known for its main complication: delayed or even nonunion of the bone. Delayed union is seen on X-rays as a lack of the bridging callous (bone) forming. This type of presentation three months after surgery is a sign of surgical failure. Tobacco use is linked with delayed union.

The longer it takes the bone to heal fully, the more restrictions there are on how much weight you can put on the leg. Without full weight-bearing, your gait is off-balance. This puts you at risk for other problems like falls, muscle weakness, and tendon shortening.

You can probably find another clinic where the nicotine restriction isn’t in effect. But the best medical practice with your welfare in mind should encourage you to quit smoking before having this operation.

Since joint replacement surgery is becoming one of the most common surgeries performed on adults, scientists are looking for ways to enhance or speed up healing. Patients who get back on their feet with greater motion sooner have the best results. Anything that can improve the postoperative healing is of interest to doctors.

The body’s own natural system uses platelets in the blood to plug up any holes in the blood vessels or damage to the tissues. For big holes, platelets clump together to form a blood clot. The idea behind the new platelet-rich plasma sprayed onto surgical wounds is to enhance or improve tissue healing.

New technology has made it possible to test out theories like this. Surgeons can now remove a small amount of the patient’s own blood during the operation. The blood is processed and prepared then sprayed onto the cut bone, synovium, tendons, and joint capsule.

The system needed to make platelet-rich plasma spray is available commercially. It’s already being used in plastic and cosmetic surgery as well as some dental procedures. Early studies have reported on its use in heart bypass and spinal fusion surgeries. It’s also being tried with chronic skin and soft tissue ulcers in diabetic foot ulcers.

Today’s technology has allowed surgeons to remove a small amount of a patient’s blood and use it in a spray form to speed up the healing process. A special machine spins the blood and separates it into three layers. The top layer is made up of plasma with very few platelets. The second layer is plasma with most of the platelets. The third layer is made up of red blood cells.

In the natural healing process, the body sends large numbers of platelets to an injury site. Upon arrival, the platelets ‘turn on’ and become sticky. They form tiny plugs to close off areas of bleeding. The new method of using platelet-rich plasma may activate platelets faster and in greater numbers.

So far only short-term studies have been reported using this new method of tissue healing. Long-term results are needed to make comparisons in treatment results. However, sometimes improved short-term benefits are enough to make it worth it even if the outcomes are the same 12 months later.

For example, early studies show patients who have the platelet-rich plasma sprayed on the wound after a total knee operation go home from the hospital sooner. They need less pain medication and fewer blood transfusions. The improved knee range of motion reported means faster recovery of function.

All of these things translate into reduced costs and improved quality of life and patient satisfaction. It’s likely that with enhanced healing there are fewer infections or other complications that slow progress. These benefits are theoretical and haven’t been proven yet.

Patello-Femoral Syndrome (PFS) is a condition that causes pain in and around the kneecap (patella). In the normal, healthy adult, the patella moves smoothly over a groove on the femur (thigh bone). PFS can develop when the patella is not moving or tracking properly over the femur. This is a common knee problem in runners and athletes but anyone can be affected.

Where the patella and femur meet forms a joint called the patellofemoral joint. Many muscles and ligaments control this joint. Any change in alignment of the bone, ligaments, and/or muscles around the patellofemoral joint can affect how the patella tracks along the femoral groove.

Patellofemoral joint replacement is usually a treatment for patients with severe osteoarthritis. The articular cartilage covering the back of the kneecap becomes worn and torn causing painful movement. Replacing the patellofemoral joint in PFS doesn’t address the real problem of soft tissue imbalance and structure causing tracking problems.

Conservative treatment for PFS with bracing and exercise may be the best option. If the back of the patella has worn more on one side than the other from the uneven forces of PFS, then the surgeon can smooth the surface without replacing the entire bone. An orthopedic surgeon is the best person to look at your situation and advise you about treatment options including patellofemoral replacement.

Your condition is called isolated patellofemoral arthritis. This means the arthritic changes are confined to the patellofemoral joint rather than throughout the entire knee. The patellofemoral joint is located where the patella (kneecap) fits into a groove at the bottom of the femur (thigh bone).

In the normal knee, the patella moves up and down over the femur. The groove guides the movement and keeps the patella along the right track. The back of the patella is covered by smooth articular cartilage to protect the joint and make movement easier.

Arthritis can cause pits, holes, and tears in this cartilage. The patient with severe patellofemoral joint arthritis has pain and swelling that limits function resulting in disability. Early treatment with antiinflammatory drugs, exercise, and activity modification does help. If you’ve tried these without success, you may be a good candidate for surgery.

Several different operations can be done to treat degenerative patellofemoral joint disease. Sometimes the back of the patella is shaved and smoothed off. If this doesn’t work or the damage is too much, then the patella can be removed.

The patella can also be removed and replaced with a patellar replacement. This type of implant is favored by surgeons for young, active patients. It also works well for older adults who may need a total knee replacement later.

Your next step is to make a follow-up appointment with an orthopedic surgeon. Take a record of what you’ve done so far and the time frame. This will help you and the doctor decide what course of treatment is best.

Forward hopping can be reduced in patients who have had an anterior cruciate ligament (ACL) repair. It may depend on the type of graft used to reconstruct the ruptured ligament.

Two types of tendon grafts are used most often for ACL repairs. The first is the patellar tendon graft. This graft comes from the front of the knee just below the kneecap. It can cause significant knee pain especially when kneeling.

To avoid this, surgeons may use the hamstring tendon graft. A piece of the hamstring tendon behind the knee is used. Although kneeling isn’t a problem, sometimes decreased leg strength is a byproduct of this approach.

Recently, a study done at the University of Louisville in Kentucky measured the strength of 20 patients after ACL repair with a hamstrings graft. They found loss of motion and weakness in the knee up to 2 years after the surgery. Patients were tested in their ability to hop forward. They did tend to jump shorter distances with the ACL-repaired leg compared to the normal side.