FAQ Category: Knee

Your surgeon may have a time frame in mind so be sure to ask for his or her best recommendation. For some patients manipulation is enough. The patient is anesthetized and the surgeon moves the joint through its full range of motion while the body is completely relaxed. Tiny adhesions and fibrotic tissue tear during this process.

Manipulation is best done in the first 90 days after the joint replacement. If the surgeon waits too long, the risk of fracture goes up.

Some patients need a more aggressive treatment. An operation called arthrotomy is done to clean the joint of any scar tissue. Many surgeons debate the timing of this treatment. Some experts suggest this type of surgery only after four to six months of intense physical therapy first.

With either type of procedure, intense rehab for weeks to months is needed afterwards. Exercise may be aided by stretching, bracing, and electrical therapy. The patient should show steady improvement in range of motion over the first two to three weeks in PT. Communication between the patient, therapist, and surgeon is also extremely important for the best outcome possible.

There are many different possible causes of joint stiffness after total knee replacement (TKR). The most common one is stiffness and loss of motion before the surgery. The quadriceps muscle along the front of the thigh and knee gets tight or contracted. This type of extension contracture keeps the knee from bending all the way.

A second problem is body type. Short, stocky patients often have problems regaining their full motion. The situation is made worse if the person is obese with thick thighs preventing the leg from bending more.

Patients who don’t do their rehab program can also end up with a stiff, contracted joint. In other cases there are technical reasons for this kind of result. If the implant is too large for the patient or the plastic insert is too thick, motion is limited.

And finally, sometimes we just don’t know what causes the problem. Some patients just form an excess amount of scar tissue, a condition called arthrofibrosis. In such cases, further surgery and intense rehab are needed to restore and maintain motion.

There are two main methods used to repair a torn or ruptured anterior cruciate ligament (ACL). The patellar tendon graft from the front of the knee is one, and the hamstrings tendon from behind the knee is another.

The hamstrings is made up of three distinct muscle/tendon groups. They are: 1) semimenbranosus, 2) semitendinosus, and 3) biceps femoris. Two other muscles near the hamstrings help flex the knee. These are the gracilis and sartorius muscles.

The semitendinosus and gracilis tendons lay one on top of the other as they insert into the bone along the side of the knee. The semitendinosus-gracilis (STG) tendons can be harvested together, braided, and folded over to make a stronger graft to replace the ACL.

Patients tend to like the hamstring graft better but surgeons often prefer the quadriceps tendon graft. The hamstring graft is more technically difficult for the surgeon, whereas the quadriceps tendon graft often leaves the patient with knee pain, especially if any pressure is applied to the kneecap.

Loss of knee flexor strength is another possible downside to the STG graft. Researchers are studying ways to best rehab each type of graft. As more and more people participate in sports, it’s likely that ACL injuries will continue to rise. The need for a strong graft with good function afterwards is important, especially to get athletes back in action as soon as possible.

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.

The rate of revision surgery for total knee replacements (TKRs) varies from country to country. According to a recent study, England has the lowest revision rate at four percent. New Zealand and Australia have the highest rate at around nine percent. The United States comes in just below that at eight percent.

Research shows that surgeons who do the most number of these surgeries have the lowest rate of problems and revisions. Likewise, high-volume surgery centers also have the best results. They may have a more skilled operative team that coordinates pre- and post-operative care. Rehab teams take up patient management where the operative team leaves off.

There is some evidence to suggest the implants are partly at fault. The hope is that rates of revision will decline as implant design improves and surgeons gain experience using them.

Even with a revision TKR most patients say it was worth the cost and extra hassle. The pain relief and improved function increased their overall quality of health. Health economists say anything that costs less than $20,000 per well-year is an excellent deal.

It’s often the case that physicians with different backgrounds make different recommendations for their arthritis patients. But experts say the decision to have a joint replacement shouldn’t be made based on the type of physician you are seeing.

It would be much better if patients were selected for joint replacement based on a list of standard criteria that all physicians can agree on. So far patient factors to guide this decision haven’t been identified. Recently a group of doctors at the University of Minnesota tried to pinpoint patient factors that would help guide the decision about who should or shouldn’t have a joint replacement.

They found that expert opinion on the need for surgery did vary from physician to physician. Orthopedic surgeons were more likely to suggest ongoing conservative care before doing surgery. They are more likely to know what problems can occur after surgery. They want to make sure the patient should have the operation and that the results will be successful.

If your orthopedic surgeon is not advising surgery, find out what he or she thinks your treatment options are at this time. Perhaps a different drug or combination of medications would help. Physical therapy may be another treatment option. It’s best to try every avenue first before the more permanent surgical approach.

There is at least one option for patients who don’t tolerate general anesthesia. A regional anesthetic called an interscalene block can be done. You would be awake and have complete pain relief during and after the operation. There are some disadvantages and risks, which the doctor will review with you.

One of the main benefits of the block is a reduction of the postoperative nausea that you’ve experienced in the past. And it offers good pain control after the operation making early movement and return of function possible. Earlier discharge is often possible as well.

Sometimes the block can be left in place during the first day after surgery. The joint is continuously bathed in a numbing agent to extend pain relief during the early recovery phase. Another option for postoperative pain control is a special device called a patient-controlled analgesia. With the push of a button the patient is able to release a dose of pain medication into the blood stream or a numbing agent to the surgical site.

Be sure and raise your questions and concerns with the orthopedic surgeon before surgery. Don’t wait until the day of the operation. And when the anesthesiologist meets with you before the operation, express your concerns then as well.

Twenty years ago a ruptured or torn anterior cruciate ligament was stitched back together. This is called a primary repair. The patient was immobilized in a cast or brace. Weight-bearing wasn’t allowed for four weeks after surgery. After that, the patient followed a long rehab program.

There have been many changes in treatment since that time. For one thing the torn ligament is no longer just repaired. Now it is reconstructed using a tendon graft from another part of the knee. Open incisions have been replaced with arthroscopic surgery using tiny and sometimes only one incision.

These new methods mean there is less scarring, less trauma to the joint, and less damage to the surrounding soft tissues. As a result the patient is able to put weight on the leg immediately. Range of motion and strengthening are started right away too. The patient is allowed to move along in the exercise program as fast as he or she can tolerate.

Twenty years ago getting back on the playing field after an ACL repair wasn’t always possible. Rehab and recovery often took a full year. Over time activities that involved pivoting, cutting, or sidestepping could be resumed after 9 months or so. Today with the accelerated rehab program, top athletes can return to full sports six months later.

ACL injuries are more common in females but graft ruptures do not appear to be gender-based. Males and females are equally affected. About 10 percent of patients with an ACL reconstruction experience a graft rupture. It seems that age is the biggest factor. Patients younger than 21 years old are 10 times more likely to have a graft rupture.

Meniscectomy is also a risk factor for ACL graft rupture. Patients who have torn the meniscus along with the ACL and have the meniscus removed are six times more likely to have a graft rupture some time later. There is no common point at which graft rupture occurs. Sometimes it happens early on after the ACL repair. In other cases it can happen years later.

It doesn’t look like luck has much to do with it. Stress and strain on the graft is more likely the culprit. Without the protective cartilage the graft repair is subject to higher forces and loads. The ligament starts to lengthen. Joint laxity develops — in other words, the joint becomes looser over the years.

In the case of young athletes, doctors think rupture occurs because they are more active. This puts the reconstructed knee under greater stress more often.

Researchers at the Steadman-Hawkins Research Foundation in Vail, Colorado have been researching this very problem. They noticed some of their ACL patients were just fine for 10 years — a perfect outcome. Then all of a sudden, they developed arthritis.

They think the problem may be a lack of mobility between the patellar tendon and the tibia (lower leg bone). A condition referred to as patella infera may be part of the problem. With patella infera, there is a permanent shortening of the patellar ligament. The kneecap sits too low in relation to femur (thighbone). The result can be a severely limited range of motion of the knee joint.

Patella infera is a common complication of injury or surgery to the knee joint. It usually doesn’t show up until much time has passed after injury and/or surgical repair.

Treatment options include physical therapy to manually release the kneecap and/or surgery to revise the soft tissues around the knee. If the joint degeneration has gone too far for conservative care to be successful, then total knee replacement may be needed.

There are several tests used to measure hip flexor flexibility. An athletic trainer, physical therapist, or orthopedic surgeon can test you.

One test is called the Thomas flexion test. You lie down on your back on a table with a firm surface. The crease of your buttock should be at the edge of the table. Bring both knees up to your chest. Keeping your back flat on the table, lower one leg until it is straight out. Lower that leg toward the tabletop as much as you can without arching your low back or letting your pelvic bone tilt.

A tight hip flexor muscle will keep you from lowering your leg all the way down to the table. A flexible person will be able to get to a horizontal (normal) or beyond horizontal position (hyperflexible). The physical therapist uses a tool called a goniometer to measure the hip angle during this test.

Another test is the Ober test used to measure flexibility of the iliotibial band (ITB). This band of fascial tissue comes down along the side of the leg from hip to knee. For this test, you lie on your side with the leg in question on top. The lower leg can be bent to help support you on the table.

The upper leg is bent 90 degrees at the knee. The therapist lifts the leg away from the body to a horizontal position and then extends it backwards slightly. The leg is then lowered toward the table until it starts to rotate or can’t go any further.

A normal amount of motion allows the leg to be placed in the horizontal position. With a tight ITB, the leg stays up and won’t drop down towards the table. The extra flexible person can touch the knee to the table.

Treatment for patellofemoral pain syndrome (PFPS) has traditionally relied on quadriceps strength training. Some patients also benefit from neuromuscular training, which focuses more on motor control than improving strength.

So far no one has found a “one size fits all” kind of program. Some people seem to get better with one type of exercise while others have less pain and more function with other types of training.

Some time ago researchers saw that hip strength may be an important key to PFPS. One by one studies have been done to confirm this suspicion. Most recently physical therapists at the Nicholas Institute of Sports and Medicine and Athletic Trauma in New York City studied hip strength and flexibility as it relates to PFPS.

They found that 60 percent of patients with PFPS got better after a six-week training program. Exercises to improve hip flexor strength and flexibility resulted in decreased pain and improved function.

The goal was to prevent inward rotation of the thighbone (femoral rotation). Maintaining good alignment of the patella as it moves up and down over the knee reduces the tension on the soft tissues around the knee. This new treatment approach may help you as well!

Artificial cartilage is still in the laboratory and in experimental studies. Some surgeons are using allograft tissue for young patients with severe meniscal damage. Allograft means it comes from a donor. In this case cadaver tissue is used (meniscus harvested after the donor’s death).

Careful rehab after the transplant can result in return to normal activities including sports. The implant is not foolproof however. New trauma can cause a new tear or injury to the allograft. Surgery to repair it may be all that’s needed. But a complete tear may result in allograft removal.

Postoperative tears are more common in older patients and in people who’ve had multiple knee surgeries already. Most patients have a good to excellent result with graft survival in 90 percent of recent cases reported.

In the last 10 years or so, doctors have seen that taking the entire meniscus out isn’t always such a good idea. Many patients with a total meniscectomy ended up with severe arthritis. Now the surgeon tries to repair the tear and/or remove only as much tissue as is absolutely necessary.

In the meantime, scientists are looking into the use of meniscal allografts for patients like you. An allograft is a donated meniscus from a cadaver (body preserved after death).

Earlier studies suggested that older adults with arthritic changes in the joint wouldn’t do well with this operation. But in fact, a recent large study disputes those findings. Almost 90% of the patients in the study had good long-term results.

It’s likely that improved operative technique accounts for the better results seen with meniscal allografts in this study. It’s possible with a larger number of patients in the study that the results are more accurate. More study is needed to predict patients who will have a good outcome … and patients who won’t.

The orthopedic surgeon is really the best one to advise your mother and answer your questions. He or she has the benefit of knowing your mother’s history and the results of the physical exam. Looking at the joint and leg alignment helps guide the decision. Seeing X-rays of the joint space is also very helpful.

At age 66 your mother is still fairly “young” by today’s longevity standards. If she has severe enough joint damage, then total joint replacement may be the best option. But these days, the goal is to preserve the natural joint for as long as possible.

It sounds like she’s planning to have an arthroscopic debridement. This is a minimally invasive operation. The surgeon makes two or three puncture holes and inserts a long, thin needle (the arthroscope) with a tiny TV camera on the end into the joint. This tool gives a view inside the joint. Tools used to remove loose cartilage or to repair any damaged cartilage are passed through the scope.

Most patients are up and going two or three days later. They wear a knee immobilizer and put partial weight on the leg until they feel up to full weight-bearing. Range of motion exercises are prescribed. Most pain relief occurs within the first six months. Some patients report continued improvement for up to two years after the operation.

It’s a good treatment option for patients with mild osteoarthritis. The ease of recovery makes it worth a try before going to major surgery like a joint replacement.

Study after study show that exercise is beneficial for osteoarthritis (OA). It seems to keep the joint lubricated and the symptoms at a tolerable level. Sometimes finding the right medication, dosage, or combination of drugs is helpful. You may want to work with your doctor to get the best results from this conservative treatment.

If you’re looking for an operative solution, arthroscopic debridement may be a good option. In this procedure, the surgeon inserts a thin needle (arthroscope) into the joint. A tiny TV camera on the end of the scope projects a picture from inside the joint onto a monitor. The surgeon can see how the cartilage looks, remove any loose pieces, and smooth down the edges.

Arthroscopic debridement works well for patients with mild cartilage damage. Results are best for those patients who have good knee alignment. The outcome is not as predictable for patients with moderate OA. Anyone with severe cartilage lesions is best advised to have a total knee replacement.

Any major trauma or injury to the joints seems to be linked with osteoarthritis later on. Studies show that about 10 percent of the patients who have an anterior cruciate ligament (ACL) repair later show signs of arthritis.

At first there is a narrowing of the joint space seen only on X-ray. The patient usually doesn’t have any symptoms yet. Athletes are more likely to start seeing some changes about 10 years after the injury. The problem is delayed in less active adults until closer to age 40 or even 50.

Type of injury and type of surgical repair may make a difference. Patients who had a meniscal tear and an ACL tear at the same time had earlier onset of arthritis than patients who just had an ACL tear. There are fewer cases (four percent) of arthritis in patients who have the ACL repaired with a hamstring tendon graft. This is compared with 18 percent for patients receiving a patellar tendon graft.

So all in all, a small number of folks develop arthritis. There’s probably a combination of risk factors that result in this group having problems while others don’t seem to develop arthritis until older age.

You are probably referring to a procedure called ligament augmentation. A braided length of polypropylene (synthetic plastic) was used. The idea was to protect and reinforce the torn ligament until it could heal. The device was designed to be absorbed by the body. As the ligament healed, mechanical forces were transferred back to the repaired ligament.

Studies didn’t show an advantage to this method. The rate of surgical failures was high because the ligament augmentation device would rupture. Over time research showed that using a live tendon from another area of the knee as a graft worked much better. A simple repair of the torn ACL was abandoned as ineffective. All ACL repairs are augmented now; most are done arthroscopically without opening the knee.

Joint laxity after ACL repair occurs in about 10 to 30 percent of the patients who have a hamstring transplant. It usually has nothing to do with what the patient did or didn’t do.

To keep this from happening the surgeon tries to “tighten up” the reconstructed ligament during the operation. The problem is that the amount of tension to apply to the graft is unknown at this point.

Some surgeons warn that too much tension will increase the pressure on the knee too much. But studies show that the tension on the tendon graft tends to decrease by more than 50 percent with repeated use.

To prevent this from happening the graft is “preconditioned” before being used to repair the torn ACL. The tension is preset and the graft is kept at a lower temperature than normal body temperature. There may be a problem with this preparation. According to a recent study, once the tendon graft warms up to body temperature, it relaxes and loses some of its tension.

It seems there may be several variables at work here that the patient doesn’t have control over. More study is needed to find the right amount of tension to use with ACL repair and to find ways to hold it.

When the hamstring tendon is used to repair the ruptured anterior cruciate ligament, the donor graft is harvested early and “preconditioned.” Basically this means the graft is allowed to reach the same temperature of the operating room — about 20 to 30 degrees lower than the body temperature.

The idea is to increase the tension and stiffness of the tendon graft. Hamstring tendon grafts tend to loosen up more than patellar-tendon grafts. Setting the proper level of tension to start is important. The problem is no one knows just exactly what that is — and it may be different from patient to patient.

Most recently a study done on cadavers (bodies preserved after death for study) showed that cooled tendon grafts warm up once they are placed in the body. So maybe it’s better to keep the tendon grafts warm until implanted. Until an answer is found to this dilemma, surgeons will continue to precondition temperature and tension of tendon grafts in hopes of getting the right amount of joint stiffness and stability.