FAQ Category: Knee

Many studies show the benefit of exercise for people with knee osteoarthritis. But pounding the pavement (or treadmill) can increase pain as you have noticed. Aquatic therapy in a pool of warm, supportive water is one way to get the needed exercise without the added stress.

In a recent study from the University of Florida, the effects of walking on a treadmill underwater were compared with walking on a land treadmill. It was a small study with 14 adults in ages ranging from 43 to 64. All participants had been formally diagnosed with knee osteoarthritis (OA). A few had OA of the hip or ankle as well.

Everyone was treated with a 20-minute session on a treadmill at zero incline (flat). The 20-minute period was broken into four stages each lasting five minutes. Pace or speed of walking increased slightly with each stage. By the last five minute segment, the patients were walking at a moderate-to-somewhat hard level of perceived exertion.

Three sessions were completed in one week on the aquatic treadmill with water temperature holding steady at 86 degrees Fahrenheit. Then there was a one-week rest period and the same protocol was used on a land treadmill. Some patients did the land treadmill the first week while others were assigned to the aquatic treadmill first. Who did what first was randomly assigned using a computer program.

Aquatic treadmill walking has also been shown to decrease the impact on the knee. The buoyancy of the water reduces the force from the ground starting at the foot and traveling up to the knee (called the ground reaction force). In the study mentioned, it was hypothesized that decreasing the joint load by using an aquatic treadmill would reduce pain and improve exercise quantity and quality. Let’s see if that is what happened for those patients.

Results were measured within 24 hours of completing the three sessions (on either treadmill). They used two main outcomes: change in pain level and joint kinematics. Kinematics refers to how the joints move (speed or velocity, joint angle, step length, step rate).

Changes in pain and kinematics can affect a person’s gait (walking) pattern. Joint kinematic measurements were taken while the patients walked on land in a biomechanics lab. The researchers measured angular velocity for knee extension during stance (weight on that leg) and knee extension and internal rotation during swing (leg moving forward).

The angular velocities measured did improve more after aquatic therapy. Angular velocity gain for left knee extension during stance improved significantly (38 per cent) after aquatic walking. Gain for knee internal rotation was 65 per cent and 20 per cent improved for knee extension during leg swing. Pain was significantly greater (100 per cent more) after land exercise. The number of steps taken and the length of steps did not change with either form of exercise.

The authors pointed out that these kinds of changes in angular velocity indicate that the pattern of movement of the arthritic knee is improved during walking. That is important for restoring normal gait (walking), improving balance, and preventing falls. The actual mechanism for increasing angular velocity and joint kinematics remains unknown. It is thought that the combination of increase in fluid resistance, warmth and pressure of the water, and unloading of the joints work together to create these beneficial effects.

With only three sessions each (aquatic and land) on the treadmill, these outcomes are considered short-term. But evidently there was enough effect on the neuromuscular system to create these changes. Future research will be needed to see if the changes last (and for how long) and whether a longer period of time with more sessions would enhance the benefits even more.

The authors concluded that aquatic therapy may be a good alternative to walking on land for patients with painful and limiting knee osteoarthritis. This treatment approach can help patients experience pain relief and improve walking ability. Why don’t you give it a try (say three sessions) and see how you feel afterwards and if the extra self-care is worth the time for you.

As your dentist has explained, the practice of prescribing prophylactic (preventive) antibiotics for patients with joint replacements having dental work done is to avoid infection, which can have serious complications for anyone with a joint replacement.

Bacteria in the mouth can travel through the bloodstream and seems to have a preference for the joints. Once a joint with an implant is infected, serious damage and destruction can occur. Another surgery may be needed to clean the joint or even to remove and replace the implant.

Exactly why bacteria seems to target joints remains unknown. But there does seem to be a direct link between the gut and the joints. People with inflammatory bowel disease such as Crohn’s disease (regional enteritis) or ulcerative colitis, and anyone with “leaky gut syndrome” are at increased risk for joint problems.

There is some evidence that increased permeability (allows substances through easily) of the intestinal lining increases exposure to foreign substances. Bacteria is one of the things that seems to move out of the gut into the blood stream and heads for the joints. Joints that have been previously disrupted surgically may be at increased risk over other joints that haven’t been touched. But this has not been studied extensively or defined more clearly.

Each surgeon has his or her own post-operative “protocol” (way of doing things) after a total knee replacement. Physical therapy is an important part of the immediate post-operative period. Once you are discharged to go home, some surgeons may insist on a short-term follow-up period with your therapist. But not everyone needs a full-blown functional exercise program.

Those who can benefit from a more tailored rehab program may be folks who were more fearful about movement before surgery. Their level of pain caused them to start avoiding certain movements and activities at home and work. This pattern of behavior is called fear-avoidance. People who become fearful of movement are said to be kinesiophobic.

This pattern of pain-related fear does not automatically go away after the joint is replaced. That’s why physical therapy is needed to restore full motion and function without the element of fear preventing recovery and return to all activities. Functional exercises is a popular way to achieve these goals.

Functional exercises refers to a type of program designed to do more than just regain 90-degrees of knee flexion or lift the leg off the bed ten times. Functional exercise-based rehabilitation programs are geared toward improving motion and strength while preventing blood clot formation and while restoring specific activities. Walking; climbing stairs; and making sudden starts, stops, and turns are just a few examples of the skills functional exercises work to restore.

If you are kinesiophobic (e.g., unwilling to go out shopping or to run a few errands, afraid to go for a walk, feel uncertain about returning to work), you might benefit from some coaching. The physical therapist will show you how to practice physical activities and movements at home. You will be encouraged to perform all these things without fear. The goal of therapy is to increase activities previously considered “dangerous” (i.e., before surgery).

It is possible to pre-identify (before surgery) patients whose recovery from a total knee replacement may be compromised by fear-avoidance thinking and behaviors. Education and exercise can help correct these behaviors and aid patients in overcoming barriers to full recovery. Addressing and treating kinesiophobia in this way puts the burden of responsibility for recovery from mistaken beliefs and thoughts squarely on the patient’s shoulders.

Be sure and bring this question up to your surgeon before the procedure is scheduled. Working out all the details ahead of time can speed up your recovery and may help prevent ongoing disability.

Platelet-rich plasma (PRP), also known as blood injection therapy, continues to be investigated by researchers. They are looking for a way to control painful symptoms from knee osteoarthritis. Efforts to regenerate lost joint cartilage using this type of treatment may also help slow down the disease process.

Scientists still aren’t quite sure how these therapeutic proteins aid in cartilage repair. The basic idea is to remove platelets from the patient’s own blood and inject it into the joint. The blood plasma is prepared in such a way as to include three to four times more than the normal amount of platelets.

Platelets have growth factors that may speed up the body’s natural healing process. This treatment may shorten recovery time from acute soft tissue injuries. In the case of chronic joint degeneration, it may stimulate a healing process in the joint cartilage (called chondrogenesis).

But in a recent study from India, the benefit reported by patients (decreased pain and stiffness and increased motion and function) came after only slightly more than two weeks. And that might be too quick to really be caused by true joint regeneration. The authors suggest perhaps the platelet-rich plasma improves overall joint environment making it possible for the joint to “feel better” even when cartilage tissue isn’t changed directly.

We may not know for a while just how PRP therapy works. But studies like this one will help determine the best way to administer the treatment for optimal results. Experts suggest that platelet-rich plasma (PRP) injections may not be the “wonder drug” some say they are but they do provide significantly more symptom relief. A single injection may be all that is needed every six months to aid in managing the pain and stiffness.

This type of “staged” treatment approach may provide enough improvement in patient function to make it worth the expense. Until more is understood about how PRP works, it may be enough to use the treatment as a temporary management tool against the early effects of osteoarthritis. In the interest of patient safety, there will be many physicians like yours who prefer to wait for the evidence to support the clinical practice before making the leap.

Platelet-rich plasma (PRP), also known as blood injection therapy, continues to be investigated by researchers. They are looking for a way to control painful symptoms from knee osteoarthritis. Efforts to regenerate lost joint cartilage using this type of treatment may also help slow down the disease process.

Scientists still aren’t quite sure how these therapeutic proteins aid in cartilage repair. The basic idea is to remove platelets from the patient’s own blood and inject it into the joint. The blood plasma is prepared in such a way as to include three to four times more than the normal amount of platelets.

Platelets have growth factors that may speed up the body’s natural healing process. This treatment may shorten recovery time from acute soft tissue injuries. In the case of chronic joint degeneration, it may stimulate a healing process in the joint cartilage (called chondrogenesis).

The benefits reported by patients (decreased pain and stiffness and increased motion and function) come after only slightly more than two weeks. And that might be too quick to really be caused by true joint regeneration. Experts suggest that the platelet-rich plasma improves overall joint environment. This effect makes it possible for the joint to “feel better” even when cartilage tissue isn’t changed directly.

We may not know for a while just how PRP therapy works. But a recent study from India might help determine the best way to administer the treatment for optimal results. There were a total of 78 patients (156 knees) who received either one PRP injection, two PRP injections (spaced three weeks apart), or a placebo (injection containing just a saline solution).

Results were compared among the three groups using patient report of pain levels, stiffness, physical fitness, and complications. They also asked about patient satisfaction with treatment. They found that patients started noticing a difference in their symptoms anywhere between 13 and 19 days after the first injection. There was a significant improvement in patients who actually received the platelet-rich plasma compared with the placebo injection. But the benefits reported weren’t any better or greater with two injections compared with one.

Everyone was followed for up to six months to see the long-term effects of platelet-rich plasma (PRP) injection therapy. Two-thirds of the two groups who received PRP injections were satisfied with the results. That compared with almost 90 per cent of the placebo group who were NOT happy with the results. Patients with milder osteoarthritis seemed to get the most benefit from the PRP treatment.

It was apparent from analysis of the data collected between the six weeks period to six months that the positive results started to decline over time. The trend was for a gradual worsening of symptoms as time went by. But the pain, stiffness, and function were still much better than before the injection therapy.

The authors concluded that platelet-rich plasma (PRP) injections do provide significant symptom relief. A single injection may be all that is needed every six months to aid in managing the pain and stiffness. This type of “staged” treatment approach may provide enough improvement in patient function to make it worth the expense.

Hamstring injuries are fairly common among athletes, including dancers and cheerleaders. Pain, swelling, and bleeding into the muscle can take some time to resolve. The usual advice to apply ice, compression, elevation, and rest are helpful in the first 24 to 48 hours. Gentle movement (no stretching!) is advised after that.

Knowing the full extent of the injury (location and severity) can help in planning treatment and rehab. X-rays are not needed unless there is some suspicion of bone injury. MRIs have been shown to be helpful but studies show that the majority of MRIs do not show any abnormalities after mild to moderate injuries. The added cost of MRIs might be a consideration.

Usually the clinical exam performed by the physician or physical therapist is enough to provide a fairly accurate prediction of recovery time. The player’s response to treatment also aids in progressing the rehab program. The physical therapist starts with controlling symptoms and facilitating healing. Eventually the athlete is moved through stretching and strengthening. The rehab program is individualized for the type of movement and activities the athlete is involved in.

MRIs do have some important prognostic value. Hamstring injuries involving the central tendon take much longer to heal. The central tendon runs down the center of the muscle for the full length of the hamstrings. The reason this tendinous portion of the muscle is important is because injury to this area often means a longer, slower recovery.

MRIs can help identify this type of injury early, which in turn, can help direct treatment and return-to-sports accordingly. Central tendon disruption can be seen on MRIs and is considered a new prognostic sign. If she has not been seen by an orthopedic surgeon, now might be a good time to have an evaluation and find out the full extent of the injury so she can get the best treatment possible.

Matrix autologous cartilage transplantation is a tissue bioengineering treatment designed to help cartilage regenerate itself. There are three main goals of the MACT procedure. One is simply to provide the patient with pain relief. A second is to stop (or at least slow down) the progression of osteoarthritis. And the third is to eliminate the need for a joint replacement, especially in young patients.

MACT is a three-step process: first normal, healthy cartilage cells are taken from a non weight-bearing area of the patient’s own knee. Then these cells are transferred to a lab where they are placed on a special scaffold. More cells are grown (forming a matrix). The last step is to implant the bioengineered tissue into the defect.

Studies show that in the short-term, this procedure works quite well for most patients. It does take quite a while for the graft to take and mature. But over time, the results start to deteriorate. As a salvage procedure, it still might buy some time before having a knee replacement, which is a much more extensive procedure.

In a study from Italy, surgeons looked at long-term outcomes using the matrix autologous chondrocyte transplantation in younger adults. They reported the best results in patients who did NOT have a previous meniscectomy partial or complete removal of the meniscus). But 40 per cent of the group were unhappy with the results and would not have the procedure done if they had to do it over again.

Despite those findings, surgeons say this procedure is still a good option for some patients (especially young adults) trying to avoid or put off joint replacement. Matrix autologous chondrocyte transplantation is an acceptable salvage procedure in these circumstances. Patients must be advised by their surgeons what to expect in order to be realistic about the potential for poor long-term results.

When you say “matrix cartilage” treatment, we assume you are referring to matrix-assisted autologous chondrocyte transplantation (MACT). There are three goals in mind when using this procedure: 1) provide pain relief, 2) stop or at least slow the progression of osteoarthritis, and 3) eliminate the need for a joint replacement.

MACT is a three-step process: first normal, healthy cartilage cells are taken from a non weight-bearing area of the patient’s own knee. Then these cells are transferred to a lab where they are placed on a special scaffold. More cells are grown (forming a matrix). The last step is to implant the bioengineered tissue into the defect.

According to a recent study from Italy, clinical outcomes using this treatment in young adults with knee osteoarthritis from cartilage damage may be disappointing. They treated 44 patients between the ages of 20 and 58 years of age who had osteoarthritis from damage to the knee joint cartilage.

Each one had a hole or defect in the joint cartilage that went all the way down to the bone. Symptoms of knee pain, swelling, locking and giving way and the formation of degenerative arthritis brought them in for treatment. Prior treatment failed and each one in the group was either too young for a joint replacement or did not want a prosthetic implant.

After the procedure, everyone had at 12 or more weeks of rehab. Follow-up was at least seven years with some patients being in the study for up to 10 years. Half the group said they were no better off than before the surgery. And almost 40 per cent said they wouldn’t do it again if they had it to do over.

The surgeons suggest that one of the factors that affected the results was previous treatment. Patients who had removal of part or all of the meniscus (meniscectomy) had the poorest clinical outcomes. It didn’t seem to matter whether the amount of osteoarthritis already present was mild, moderate, or severe. The reported results were the same for all levels of degeneration.

The surgeons concluded from this study that the use of a scaffold-based or matrix of bioengineered tissue to aid cartilage regeneration may not be advised in young adults. In particular, clinical results were unfavorable in young adults with knee osteoarthritis who had prior knee surgery.

In other words, matrix-assisted autologous chondrocyte transplantation (MATC) for knee osteoarthritis from this type of damage to the cartilage may not be the best salvage approach. Your orthopedic surgeon is really the best one to advise you based on your age, condition of the knee, your activity level, and what you hope to achieve from treatment.

One of the biggest reasons joint replacements fail is due to joint infection. Bacteria (sometimes referred to as “bugs”) and fungi can travel through the bloodstream. These pathogens can be carried by the blood to anywhere in the body including the joints. Once in the joint, they can form a biofilm on the surface of the implant.

Periprosthetic infection (in or around the joint) can develop anytime from early on (within the first six weeks of surgery) up to months or years later. Diagnosis can be a challenge. For example, this effect doesn’t show up on ordinary imaging studies such as X-rays. And it isn’t usually until the patient develops serious symptoms such as fever, nausea, and fatigue that there is even any awareness of the problem.

In some cases (like your mother), a channel from the joint out through the skin (called a sinus tract) is the first sign of a problem. The patient develops pain and oozing (infectious) drainage that sends him or her to the physician or clinic for help.

Early detection of joint infection requires constant diligence for patients who are at increased risk of joint infection. These can include older age, low socioeconomic status (poor nutrition and self-care), obesity, male gender, and knee implant. Poor general health due to comorbidities (other diseases) such as diabetes, cancer, or rheuatoid arthritis are additional risk factors.

Additionally, anyone who has had a previous joint replacement in the same joint is at increased risk of infection. Patients receiving a joint replacement who were in surgery for more than three hours or who received a blood transfusion from a donor (rather than using their own blood) face an increased risk of periprosthetic infection.

Even when there is suspicion of a periprosthetic infection, it isn’t always clear from the results of tests to diagnose periprosthetic joint infection that there is a problem. A suspected (but not confirmed) infection must be evaluated more carefully. Because of the biofilm that forms around the joint, the pathogens stick tight. They don’t always show up on blood tests. In the meantime, they become resistant to antibiotics.

So you can see the problem of recognizing and diagnosing joint infection for patients who received a joint replacement years ago is a sticky one. There are many factors and variables involved, not the least of which is the fact that these bacteria (“bugs”) hide in clever ways.

And as we pointed out, diagnostic testing and evaluation is not a simple process. However, there is hope that more sensitive and reliable diagnostic tests can be developed in the near future. Researchers are currently looking for telltale biomarkers in synovial fluid. Simple, inexpensive strips have been designed that can use one drop of synovial fluid to detect an enzyme present with bacterial infections. Other molecular techniques to detect fungi, viruses, bacteria, and other pathogens are also under investigation.

These tools won’t help your mother but hopefully, they will help prevent similar scenarios for other patients (including your mother should she ever have another joint replacement).

One of the biggest reasons joint replacements fail is due to implant loosening causing chronic pain and disability. Loosening from joint infection is referred to as septic failure. Loosening from other (noninfectious reasons) such as bone fracture, brittle bones that can’t hold the implant, or some other mechanical problem is aseptic (without infection).

Bacteria (sometimes referred to as “bugs”) and fungi can travel through the bloodstream. These pathogens can be carried by the blood to anywhere in the body including the joints causing infection.

This type of periprosthetic infection (in or around the joint) can develop anytime from early on (within the first six weeks of surgery) up to months or years later. Diagnosis can be a challenge. For example, this effect doesn’t show up on ordinary imaging studies such as X-rays. And it isn’t usually until the patient develops serious symptoms such as fever, nausea, and fatigue that there is even any awareness of the problem.

It isn’t always clear from the results of tests to diagnose periprosthetic joint infection that there is a problem. A suspected (but not confirmed) infection must be evaluated more carefully because if treatment is delayed or not given at all, the joint can (and often does) loosen. Sorting out loosening implants from septic (infectious) causes and aseptic (without infection) causes is important in planning the most appropriate treatment.

For septic joints, systemic antibiotics with or without surgical irrigation (washing out the joint to remove these pathogens and keep them from spreading) may be the first line of treatment. But sometimes nothing short of removing the implant works. All the more reason why early recognition of a developing infection and quick intervention are important (to save the joint if possible).

Mechanical problems such as loosening from bone fracture around the implant or fracture of the implant itself may also require surgery. The failed implant is removed and replaced if possible — or the cause of the implant failure is treated if it’s not caused directly by the implant.

Once your surgeon confirms what is going on for you, a plan of care based on the specific cause of the loosening (septic or aseptic) will be developed.

It is a well-known fact that women athletes are at greater risk for knee injuries compared with men. In particular, anterior cruciate ligament (ACL) injuries seem to plague female athletes much more often than men.

In the last 20 years, we have learned a lot more about why ACL injuries seem to affect women so often. There are two types of risk factors that contribute to the sex differences in rates of ACL injuries between men and women. The first is intrinsic, meaning things inside the body that affect the ACL. Intrinsic risk factors include anatomic and biomechanic variables. For ACL injuries, research has shown that the number of degrees of the Q-angle, the geometry of the intercondylar notch, the size of the ACL, and the slope of the tibia are contributing factors.

Hormone differences between men and women and genetic predisposition may be two additional risk factors. But data collected from studies so far has been insufficient to prove or disprove the role of either one in ACL injuries.

Extrinsic risk factors remain under investigation, too. One thing we know that does NOT seem to bear any influence on ACL injuries is the lack of playing experience among women. The rate of ACL injuries among women hasn’t changed in the last 15 years. The number of females participating in sports HAS increased and along with that increase has come more injuries (not less as you might expect with increased experience).

Other extrinsic factors under consideration include shoe-to-playing surface interaction (increased friction) and shoe construction. Shoes with larger cleats and more cleats seem to increase torsional force on the knee (transferred up to the knee from the foot-to-surface effect). There is even evidence that turf surface and climate (dryer climate) can increase the shoe-playing torsional factor.

Prevention is possible now and an important focus in training for female athletes — especially soccer, volleyball, and basketball players. Physical therapists have identified landing position as a key area to focus on. When female athletes jump and land with both feet in control, both hips and knees deeply bent and facing straight ahead, and equal weight on both feet, there are fewer injuries.

But if even one leg is out of balance or the landing is compromised in any way, then the risk of ACL injury increases dramatically. The two different positions are referred to as the position of safety and the position of no return. Teaching women how to stay in the safety position (and having them practice this position daily) has proven to be successful in preventing ACL injuries.

This type of neuromuscular and proprioceptive training under the guidance of a physical therapist significantly decreases the incidence of ACL injuries in soccer and basketball players. Studies show up to an 88 per cent reduction of ACL injuries in the first year the prevention program was started.

Additionally, it has been determined that for the best results, the prevention program must be done three times a week for 10 minutes over a period of at least two months. The neuromuscular and proprioceptive program of exercises should be accompanied by other exercises as well (e.g., agility drills, core training, plyometrics). And a maintenance program is advised to avoid the effects of deconditioning.

If your daughter’s coaching staff are not aware of these principles, it might be a good idea to bring them to their attention. Asking a sports physical therapist to advise the team is also a possibility.

Female athletes are at greater risk for knee injuries, especially the anterior cruciate ligament (ACL). The Q-angle (which stands for quadricapes angle) is a risk factor for ACL injuries but surgery is not the first step in addressing this issue and preventing knee trauma.

The Q-angle is measured from the hip to the knee and assesses the position of the patella (knee cap) in relation to the hip. A knee cap that is pulled off center laterally (away from the other knee) by the quadriceps muscle puts the ACL in a position where it is more likely to rupture.

There are two types of risk factors that contribute to the sex differences in rates of ACL injuries between men and women. The first is intrinsic, meaning things inside the body that affect the ACL. Intrinsic risk factors include anatomic and biomechanic variables. For ACL injuries, research has shown that the number of degrees of the Q-angle, the geometry of the intercondylar notch, the size of the ACL, and the slope of the tibia are contributing factors.

Hormone differences between men and women and genetic predisposition may be two additional risk factors. But data collected from studies so far has been insufficient to prove or disprove the role of either one in ACL injuries.

Extrinsic risk factors remain under investigation, too. One thing we know that does NOT seem to bear any influence on ACL injuries is the lack of playing experience among women. The rate of ACL injuries among women hasn’t changed in the last 15 years. The number of females participating in sports HAS increased and along with that increase has come more injuries (not less as you might expect with increased experience).

Other extrinsic factors under consideration include shoe-to-playing surface interaction (increased friction) and shoe construction. Shoes with larger cleats and more cleats seem to increase torsional force on the knee (transferred up to the knee from the foot-to-surface effect). There is even evidence that turf surface and climate (dryer climate) can increase the shoe-playing torsional factor.

So you can see there are many modifiable factors that can be addressed to help prevent ACL injuries among female athletes. Physical therapists have identified landing position as a key area to focus on. When female athletes jump and land with both feet in control, both hips and knees deeply bent and facing straight ahead, and equal weight on both feet, there are fewer injuries.

But if even one leg is out of balance or the landing is compromised in any way, then the risk of ACL injury increases dramatically. The two different positions are referred to as the position of safety and the position of no return. Teaching women how to stay in the safety position (and having them practice this position daily) has proven to be successful in preventing ACL injuries.

This type of neuromuscular and proprioceptive training under the guidance of a physical therapist significantly can be done even with athletes who have excessive Q-angles; it decreases the incidence of ACL injuries in soccer and basketball players. Studies show up to an 88 per cent reduction of ACL injuries in the first year the prevention program was started.

The neuromuscular and proprioceptive program of exercises should be accompanied by other exercises as well (e.g., agility drills, core training, plyometrics). And a maintenance program is advised to avoid the effects of deconditioning.

Before beginning any treatment, it might be a good idea for your daughter to have an examination by a sports physician, orthopedic surgeon, or sports physical therapist. A posture assessment, examination of alignment (including the Q-angle), range of motion, and strength testing can be very helpful. This information can be used when planning a program to prepare for sports participation and prevent (or at least decrease the risk of) all injuries (not just ACL ruptures).

Many athletes involved in running sports (including basketball) with fast starts and sudden stops injure their hamstring muscle. Like you, the first thing they naturally ask is: how long will it take to recover and get back in the game? The answer is not always so easy to provide. It seems recovery time varies significantly from player to play. Not only that, but second injuries to the same muscle can occur, especially if the player goes back to the game too soon.

A recent study of hamstring injuries has some interesting findings that might help you discuss your prognosis with the physician you are working with. Researchers from Australia evaluated the use of MRIs to predict recovery time from hamstring injuries. They particularly focused on hamstring injuries that involved disruption of the central tendon.

The hamstring muscle is the large muscle along the back of the thigh. It is made up of three muscles and their tendons: the biceps femoris, semimembranosus, and semitendinosus. The central tendon runs down the center of the muscle for the full length of the hamstrings.

The reason this tendinous portion of the muscle is important is because injury to this area often means a longer, slower recovery. So it’s good to know exactly where your injury is, what portion of the hamstring (muscle or tendon or both) is involved and how severe is the injury.

MRIs showed that central tendon disruption only occurred in injuries involving the biceps femoris. Almost half (45 per cent) of the hamstring muscle injuries of the biceps femoris included central tendon disruption. Comparing recovery times, it was clear that recovery took much longer for injuries involving the central tendon.

In general for all the players combined, recovery time varied from as short as two weeks up to six weeks. Comparing injuries to the three hamstring muscles (semimembranosus, semitendinosus, and biceps femoris), the recovery time was the same. In other words, there was no significant difference in recovery time for the three hamstring muscles.

Recovery time for central tendon injuries of the biceps femoris was much longer (72 to 91 days). Tendons have less blood supply than muscle fibers so this delay in recovery when the central tendon is injured makes sense. The shorter time (72 days) was for players with this type of injury who were treated conservatively (without surgery). The longer recovery time (91 days) was associated with players who had surgery to repair the damage.

Using MRIs to assess hamstring muscle injury might aid your physician in making predictions about expected length of time for recovery. Returning to sports activities too soon is linked with an increased risk of reinjury. Avoiding recurrent damage to the hamstring muscle is an important goal.

The meniscus is a very important structure in providing the knee with normal function. It also helps prevent damage to the joint surface and degenerative arthritis. And until very recently, it was believed that meniscal healing was more likely if the ACL injury was also repaired. Short-term results suggested that better blood flow caused by the ACL reconstruction and alignment of the meniscus with the ACL meant a lower chance of failed surgery.

But we now know there is a 24 per cent failure rate for meniscal repairs five years after the operation. This is true whether you have a medial or lateral repair. The rates are the same if you have an intact or damaged anterior cruciate ligament (ACL). And the five-year outcomes are the same if the damaged ACL is repaired or reconstructed.

These are the results of a systematic literature review and meta-analysis conducted by researchers at the Washington University School of Medicine in St. Louis. The study was done by the Sports Division of their Department of Orthopaedic Surgery. By pooling the data from 13 high-quality studies, the authors were able to provide a five-year perspective for the modern arthroscopic repairs used most often.

Although they hypothesized and hoped that short-term results (after two years) that were previously reported would be maintained long-term, that was not the actual fact. Instead, nearly one-fourth of all patients continued to experience mechanical symptoms (knee pain, clicking, locking) or recurrent tears requiring additional surgery.

This large failure rate was consistent for open surgery as well as arthroscopic procedures (using all types of surgical repair techniques). The rate was similar no matter what type of rehab program was used (nonweight-bearing for four weeks, early weight-bearing, early range, of motion, or immobilization with cast, splint, or brace).

The authors did not offer any suggestions or reasons why the failure rate following meniscal repairs is so high. This is one of the first studies to take a look at medium-term outcomes with the more modern arthroscopic approaches to meniscal repairs. The 24 per cent failure rate was consistent across all studies no matter what variables were analyzed. Most of the failures developed after two years post-operatively. Data on results past five years is not available yet.

So, despite what are considered improved surgical techniques, long-term results are not improved. Further studies are needed to resolve this issue. It would seem that you were given the best evidence-based advice available at the time. That doesn’t change your circumstances but may help explain the recommendations and treatment you received.

Unfortunately, yes — meniscal tears are common and reinjury is common. In fact, there is evidence of a 24 per cent failure rate for meniscal repairs five years after the operation. This figure is based on a systematic literature review and meta-analysis conducted by researchers at the Washington University School of Medicine in St. Louis.

The study was done by the Sports Division of their Department of Orthopaedic Surgery. By pooling the data from 13 high-quality studies, the authors were able to provide a five-year perspective for the modern arthroscopic repairs used most often.

Although they hypothesized (and hoped) that short-term results (after two years) that were previously reported would be maintained long-term, that was not the actual fact. Instead, nearly one-fourth of all patients continued to experience mechanical symptoms (knee pain, clicking, locking) or recurrent tears requiring additional surgery.

This large failure rate was consistent for open surgery as well as arthroscopic procedures (using all types of surgical repair techniques). The rate was similar no matter what type of rehab program was used (nonweight-bearing for four weeks, early weight-bearing, early range, of motion, or immobilization with cast, splint, or brace).

And it was true whether there was a medial or lateral repair. The rates were the same if patients had an intact or damaged anterior cruciate ligament (ACL). And the five-year outcomes are the same if the damaged ACL is repaired or reconstructed.

That is different than what has been believed all along. Meniscus tears accompanied by ACL injury were routinely both repaired with the notion that without all soft tissues being reconstructed, the patient would be at increased risk of failure. Further studies are definitely needed to resolve this issue.

You are ahead of the game by even knowing to ask the question! Most people don’t realize that a total knee replacement can involve three component parts. There is the femoral side of the joint (the bottom portion of the femur or upper thigh bone). Then there is the tibial side of the joint (the upper part of the tibia or lower leg bone). Those two components make up the main knee joint as we think about it.

But there is a third piece and that’s the patella (knee cap). The patellofemoral joint (patella sliding and gliding up and down over the front of the knee) is an important part of the entire knee complex. Resurfacing means the back of the patella is lined with a polyethylene (plastic) dome to allow it to move freely and smoothly once again.

There is considerable debate among orthopedic surgeons about the benefits and disadvantages of patellar resurfacing — what you refer to as the pros and cons. The first and most important advantage was just stated: removing any uneven areas, pits, and divets along the back of the knee cap will help it slide and glide more freely up and down over the knee.

If there isn’t a significant amount of degenerative changes along the back of the patella, then this procedure may not be needed. It does take more time in surgery and the risks of complications and/or problems (e.g., bleeding, infection, blood clots, nerve damage) can increase as a result.

But studies comparing outcomes of resurfacing versus nonresurfacing really don’t show any difference between the two groups. Knee pain, motion, and function are reportedly similar when comparing patients with and without patellar resurfacing after knee replacement.

The only statistically significant difference between the two groups appears to be a much higher rate of reoperation in the nonresurfaced group. Most of these second surgeries are done because of knee pain. There is no clear proof that continued knee pain in patients who do not have patellar resurfacing is really due to lack of patellar resurfacing.

Some patients who have patellar resurfacing do have additional surgery because of complications. But studies show the rate is much lower in the resurfacing group compared with the nonresurfacing patients.

There are many variables to consider when trying to compare something like patellar resurfacing versus not resurfacing. For example, there are different designs of knee implants to choose from, differences in surgeon experience, and many different surgical techniques.

In the end, the decision to resurface (or not resurface) the patella as part of the knee replacement must be made together by the patient and surgeon. Surgeons must keep up with the results of current studies in order to consider all the current evidence available when advising and counseling patients individually.

You might find the results of a recent meta-analysis helpful. Meta-analysis means the results of all the studies published on a particular topic are pooled together and analyzed for statistical significance. This type of study is helpful when each individual study of the problem has only a few patients (or a fairly small number of patients). Without enough numbers in a study, finding statistical significance can be a challenge.

As you are finding out, there isn’t a clear consensus among surgeons about whether or not the patella should be resurfaced during the total knee replacement procedure. Resurfacing means the back of the patella is lined with a polyethylene (plastic) dome to allow it to move freely and smoothly once again. There is considerable debate among orthopedic surgeons about the benefits and disadvantages of patellar resurfacing.

In the recent meta-analysis we found, researchers reviewed randomized controlled studies reported from as early as 1995 to the present time. A total of 3,465 knee replacements were included, divided evenly into two groups: those who had patellar resurfacing as part of their knee replacement and those who did not.

The three main measures of patient outcomes included: pain, function, and patient satisfaction. Other secondary results compared were rate of reoperation, complications, operative time, and X-ray findings.

There isn’t much to report because except for rate of reoperation, there were no significant differences between the two groups. Pain levels after surgery, patient reported knee motion and function were the same, and 89 to 90 per cent of both groups were happy with the results. The rate of post-operative infection was low (between one and two per cent) for both groups. And the amount of time in surgery wasn’t different enough to be considered significant from a statistical point-of-view.

The only statistically significant difference between the two groups was a much higher rate of reoperation in the nonresurfaced group. Most of these second surgeries were done because of knee pain. Some of the patients in the patellar resurfacing group had to have additional surgery because of complications but the rate of problems was much lower in the resurfacing group compared with the nonresurfacing patients.

In theory, resurfacing should take more time and increase the risk of infection. But as this study showed, in practice this just isn’t the case. Most of the results from this meta-analysis don’t favor routine resurfacing as part of a total knee replacement. There is not clear proof that continued knee pain in patients who did not have patellar resurfacing was really due to lack of patellar resurfacing.

The decision to resurface (or not resurface) the patella as part of the knee replacement must be made together by the patient and surgeon. Surgeons must keep up with the results of studies like this one in order to consider all the current evidence available when advising and counseling patients individually.

Infection after any surgery is a major concern. One that lasts longer than 30 days is considered “chronic.” Treatment options change when an infection is no longer “acute” (early on). Often, the bacteria are what we call “super bugs” — they are resistant to the antibiotics we have available.

You have probably already gone through a procedure known as irrigation and debridement (cleaning the joint out of bacteria and diseased tissue). And it’s likely you have also had many weeks of intravenous (IV) and oral antibiotics.

The usual approach is a six week period of time on IV antibiotics (delivered directly to the blood stream). Patients must remain infection-free for another four to six weeks before the implant can be replaced. Blood tests are used to determine your status. Tissue and/or fluid in the joint may be tested as well.

Removal and replacement of any affected implant parts is the next step. The replacement procedure is referred to as an exchange arthroplasty. The exchange arthroplasty can be a one-step or two-step process (also known as one-stage or two-stage exchange arthroplasty).

As the names suggest, in a one-stage procedure, everything is done in one surgery. In a two-stage exchange, the implant is removed but not replaced just yet. Instead a spacer that contains high-dose antibiotics is put in place instead.

Once the infection is under control, then the spacer is removed and the replacement implant installed. It is important to make sure the areas down into the bones (both the femur — the thigh bone and the tibia — the lower leg bone) are free of infection before putting the replacement implant in. Using long, thin antibiotic dowels down into the canals along with the spacer helps solve this problem.

The more extreme options of joint fusion or even amputation are only considered when all other treatment methods have failed. Amputation may be necessary when the infection cannot be stopped and the patient is either in terrible pain or their life is threatened by the infection spreading throughout the body. In all cases, every effort is made to save the leg, save the joint, save the implant. Fusion and/or amputation are only considered when all else has failed.

Hopefully, you are a long way from either of these more invasive procedures. Your surgeon is the best one to advise you about what is next and what are your potential options. The surgeon will take into consideration several factors when making treatment decisions. For example, your health, the type of bacteria present, length of time since the primary surgery, and other risk factors must be reviewed and assessed before advising you. Your own goals and desires will also be taken into account since the final decision about what you want to do is ultimately yours.

All indications are from studies reported that infection after total knee replacement is a problem that is on the rise. With “bugs” (bacteria) more resistant than ever to antibiotics, it can be a challenging problem to treat. It may require removal of the implant and revision surgery to put in a second implant.

Treatment depends somewhat on the type of knee infection present. These are classified as one of four types: 1) infection present at the time of the primary total knee arthroplasty, 2) infection develops within the first 30-days after surgery, 3) infection goes into the blood but symptoms only last four-weeks, and 4) a chronic infection lasting more than 30-days.

Treatment is based on the infection type and condition of the patient. Treatment choices include: antibiotics, irrigation and debridement, removal and replacement of the implant, arthrodesis (fusion), and (worse case scenario): amputation. Who gets what treatment?

Antibiotics alone (called antibiotic suppression) is very ineffective (20 per cent success rate) and only used for a small number of patients. These are folks who are too sick for surgery, who have a stable implant (not loose), and a bacteria that is considered “low virulence” (in other words, not terribly strong or destructive).

The preferred treatment is actually more of a combined management approach. Open incision with irrigation and debridement works best for acute infections. But the surgeon must take into consideration several factors when using just this approach. For example, your health, the type of bacteria present, the length of time since the primary surgery, and other patient risk factors must be reviewed and assessed before choosing the best treatment option for each patient.

More often, it is necessary to remove the infected implant, clean out the joint, and replace some of the component parts of the implant. The replacement procedure is referred to as an exchange arthroplasty. The exchange arthroplasty can be a one-step or two-step process (also known as one-stage or two-stage exchange arthroplasty).

As the names suggest, in a one-stage procedure, everything is done in one surgery. In a two-stage exchange, the implant is removed but not replaced just yet. Instead a spacer that contains high-dose antibiotics is put in place instead.

Once the infection is under control, then the spacer is removed and the replacement implant installed. Usually the antibiotics are used for at least six weeks with another four to six weeks time period off antibiotics before reimplantation can take place. Once the lab tests show the infection is cleared up, then the exchange can take place.

The more extreme options of joint fusion or even amputation are only considered when all other treatment methods have failed. Amputation may be necessary when the infection cannot be stopped and the patient is either in terrible pain or their life is threatened by the infection spreading throughout the body. In all cases, every effort is made to save the leg, save the joint, save the implant. Fusion and/or amputation are only considered when all else has failed.

Since your infection has been identified early, you are in a good position to receive the medical care necessary to prevent any of these more extreme measures. Once the surgeon assesses your situation, he or she can give you a better idea of your choices. What we presented here is a range of possibilities.

There’s no doubt that treatment for infection after joint replacement can vary. But it’s not necessarily because of where you live (though that can be a factor). Joint and implant infection after joint replacement is a complex and challenging problem to solve for a number of reasons.

First of all, general health and nutrition are very, very important in preventing infections or in the case of infections that do develop, in getting better. A healthy adult who is not overweight and does not have other problems has a better chance of recovery with less invasive treatment.

Second, older adults are living longer with more comorbidities. Comorbidities refer to other diseases and illnesses present at the time of the joint replacement surgery. For example, high blood pressure, heart disease, obesity, diabetes, cancer, thyroid problems, gout, and arthritis are just a few of the more common problems seniors have — and most patients facing joint replacement have many health conditions referred to as multiple comorbidities.

Third, it’s no secret that bacteria have become “superbugs” now. This means they are able to resist antibiotics previously used to kill them. They actually change their own structure and genetic code to shield themselves from the effects of antibiotics. So depending on the type of infection you both had, you may experience different treatment and different results.

And finally, infections that develop later or that are not treated early can become chronic. These types of infections are even more difficult to stop. Even with treatment to clean out the joint, remove, and replace the implant, these bacteria linger and can resurface when the second surgery is done. Bacteria that enter the blood stream can also travel throughout the body, sometimes even causing death from a condition known as septicemia.

The fact is, infection after joint replacement is possible, affects up to two per cent of patients receiving their first implant, and costs four times the price of the replacement surgery. Surgeons are working hard to gather data and information that might help first with infection prevention and second with treatment.

Forty years of research has shown that cleaning the joint (a procedure called irrigation and debridement) isn’t always enough. Current clinical guidelines based on evidence gathered over time recommend irrigation and debridement alone (preserving the original implant) only for certain patients.

These select individuals 1) are in good health with good nutrition and good immune system function, 2) do NOT have the type of bacteria that are antibiotic resistant, 3) DO have an acute infection (early on after surgery) that is diagnosed quickly, and 4) are able to follow their physician’s advice about taking antibiotic therapy as directed. Your brother likely met all of this criteria.

Only those patients who meet the criteria just described should be selected for this more conservative care. There is plenty of evidence that irrigation and debridement alone will result in poor results and a poor prognosis with a high rate of implant failure. It sounds like you both received the best, most appropriate treatment for your individual differences — and that’s what is important!