FAQ Category: Knee

How people view themselves has always been a key factor in how well they get along. This is true whether they have diabetes, arthritis, or a hangnail! The concept is called self-efficacy. It refers to a person’s belief about his or her ability to complete a task or activity.

The key to getting your father back to his “normal” or status quo is to motivate him to want to try and to keep trying until he gets there. A recent study from the University of Kentucky suggests better patient education is the way to go. When a patient knows more about the disease, the better his or her self-efficacy. Patients need to know more realistically what they can expect with their condition.

Other studies have shown that balance is linked with function. An exercise and rehab program can help reduce pain, improve balance, and increase function. Likewise, improving these areas increases self-efficacy. A win-win situation!

You pose a very good question that hasn’t been fully answered yet. It’s easy to think patient motivation may be a key factor. But a new study may shed some light on this problem.

It’s true that recovery from a complete tear of the ACL can occur without surgery but
with a good rehab effort. It’s likely this is possible when no other injury has occurred in the knee. But when ligaments, tendons, cartilage, or capsule are torn in the back
corner of the joint, the joint loses its stability.

A very important structure is one of the hamstring tendons in this area. It works to hold the joint steady. Without this action, a torn ACL can’t cope and becomes even more unstable. Researchers think it’s possible this is the same reason why some repaired ACLs fail. If the inside back corner of the knee isn’t fully functioning, the knee is unstable.

Sometimes repairing just the ACL isn’t enough. Doctors must look carefully for any other damage, especially in the posteromedial corner.

Patient-controlled analgesic (PCA) pumps work quite well to control pain without causing addiction. Although the patient controls how much drug is given, there is a lock-out mechanism. The pump is set to only give X number of milligrams of drug every X number
of minutes. If the patient hits the button over and over, nothing else is given until the next dose is due.

There’s also a way to program the pump so that the patient never gets more than the maximum dosage allowed over time. If there’s breakthrough pain while on the PCA, then additional painkillers can be given by mouth (orally).

Most patients use the PCA for the first 24-hours. Once they are up and moving again, postoperative pain is replaced by soreness and aching. Patients seem to be able to handle the sore, aching pain with over-the-counter analgesics like ibuprofen or tylenol.

It’s possible but not likely. Studies show permanent nerve damage after nerve blocks is very low. In fact when nerve damage occurs, most patients recover completely within three months’ time. Minor long-term problems can occur such as mild muscle weakness or a small
patch of numbness.

Ask your doctor what his or her experience has been using nerve blocks. Find out what other problems can occur and how often this happens. Consider the benefits of a preoperative nerve block: less pain and less use of morphine or other painkillers after the operation.

Studies show a single-injection femoral nerve block is a simple and safe way to reduce pain after total knee replacement.

Many patients getting a TKR are on Medicare. Most Medicare patients getting their first total knee replacement (TKR) are 65 years or older. Medicare is interested in reducing their costs through better outcomes after a TKR. This means fewer deaths and lower rates of infection, pneumonia, and blood clots.

One way to do this is to regionalize medical care. This means having patients go to a hospital in their area where all TKRs would be done by the same doctor(s). Research shows that patients managed at hospitals by doctors with high volumes of TKR have fewer problems.

Based on these studies you may want to help your mother find a surgeon who accepts Medicare patients and who performs many TKRs each year. Larger regional hospitals where TKRs are done routinely may be better than smaller hospitals.

Researchers are studying this question. In fact, Medicare is starting to pilot some regional centers for total hip and knee replacements.

Doctors from six large medical centers took a look at the results of their Medicare patients after total knee replacement. They found patients had fewer problems at a large, high-volume hospital. They counted number of deaths and rates of infection, pneumonia, and blood clots. Everyone in the study was followed for 90 days.

According to the authors of the study, doctors who do TKRs more often have better results. The best option may be a large center where the same surgeon does many joint replacements. More research is needed to find out long-term results.

More than a quarter million people have total knee replacements (TKRs) every year in the United States. More than 90 percent of those patients get good pain relief and improved function. Only a small number of patients have problems requiring another operation.

There are two ways to improve TKRs. One is to improve the joint implant itself. Companies that make the implant are looking for ways to make it last longer with less wear and tear. They also want an implant that works well with all activities.

The second way to improve results of TKR is to give good medical care. The fewer problems patients have, the better the outcome. Improving hospital care can reduce the number of deaths, infection, and pneumonia or blood clots.

Take your doctor’s advice when you are ready. Joint replacements improve the lives of 1000s of sufferers every year. Your best bet is to find a surgeon who does this operation in the same hospital many times each year.

It depends. Younger men (less than 66 years) who can still walk two blocks or more without using a cane or walker are good candidates for discharge directly home from the hospital.

If your father is already depending on community services such as meals-on-wheels or home health, he may need extra time in the hospital or rehab center first before coming home.

Ask your father what he can and can’t do now before the operation. It’s likely these things won’t change much in the early days after the operation. This may help you plan for his release from the hospital to the right place, whether that’s your home, his home, or an extended care facility.

If all goes well, most patients recover and regain lost motion and strength at a regular pace during the first four to six weeks. Some extra help may be needed even if your father goes to his own home. What and how much will depend on his status before the operation and how well the surgery goes.

Patients who are discharged directly home after a total knee replacement do spend some time in the hospital before going home. This is usually somewhere between three and five days. Discharging her “directly home” means when she’s released by the doctor, she goes from the hospital to her home.

Patients are discharged directly to home when they are medically stable. They must be able to get in and out of bed, walk, and get in and out of a car. They are able to go to the bathroom by themselves. Self-care such as bathing and meal preparation may still be
limited for a time.

Some patients need to go to an extended care facility for a period of time before going home. Others need more intensive care and go to a rehab facility (usually part of the same hospital complex). They are discharged from the hospital to one of these other
centers.

Messages from the muscles to the nerves can be blocked with a drug injected into the nerve. The drug works like Novocain and numbs the area. Sensation and motor function are stopped for that nerve up to 16 hours. For a nerve block with total knee replacement, the patient can expect numbness along the front and inner aspect of the thigh.

By reducing pain, the numbing agent prevents spasm of the leg caused by the pain after surgery. Studies show a nerve block is also narcotic-sparing. This means the patient needs and uses much less pain medication during the first 24-hours after surgery.

Overall nerve block before joint replacement is a simple and safe way to control post-operative pain.

The ideal timing for ACL repair is after the joint swelling has gone down and the patient can move through the full range of motion. There should be no problem walking normally (without a limp). There should be no swelling.

Studies show that a strong quadriceps muscle before ACL repair is linked to a faster recovery after the operation. Delaying ACL repair gives the athlete a chance to strengthen the quadriceps muscle first.

Regaining strength and function in the first months depends somewhat on the width of the tendon graft used to repair the torn ACL. Large tendon width has a better outcome early on. One study showed that results are the same after two years no matter what tendon width is used.

For the athlete who wants to get back to training and competition quickly, tendon width and muscle strength are two key factors. These should be considered when making the decision about when to schedule the operation.

Doctors are interested in knowing family member’s concerns ahead of time. It’s important for a doctor to know about a previous history of drug use or abuse. It’s best to make this information available before the surgery.

Patient-controlled analgesia (PCA) is not likely to cause problems with drug addiction. The unit is programmed to allow the patient small doses of a pain medication
on a regular basis. This helps keep the pain from getting out of control. Many patients don’t even need oral narcotics when using the PCA.

The units can come with a locking cover. This will prevent a patient from changing the program. If changes are needed, the patient will have to return to the doctor’s office. The pump reports the total amount of drug used. It also keeps track of how often the patient pushes the button and how many times a dose is given.

Patient-controlled analgesia (PCA) works well for most adults. Doctors are using it more and more when post-operative pain keeps the patient from carrying out his or her rehab program. PCA also reduces the need for narcotics and the unwanted side effects of those drugs.

PCA in children is in experimental stages at this time. It’s not used widely by all doctors. The main concern is safety. Safe and effective dosages must be determined for children. Use based on age, gender, and size must be studied before routine use is advised.

You can certainly ask your doctor about this problem. Perhaps PCA is already in use in your area.

You can choose to have the surgery without delay. However research shows that patients get better faster after ACL repair when the quadriceps muscle is strong going into the operation. These results apply to results in the early months after ACL repair. One study
showed the same results in muscle strength when measured two years after the operation.

Your doctor may have tested your muscle strength and found it to be lacking. Poor strength may be defined as less than 75 percent of the normal leg. Even if you’re not an athlete, you can avoid further injury and damage to the knee when the muscles around the joint are strong. This may be why your doctor has recommended rehab before and after the ACL repair.

Having this kind of information before the operation can prevent problems later. A recent study showed tendon width makes a difference in the first months of rehab after ACL repair. However, two years later there’s no difference in final results.

When the graft tendon is too small, the doctor can choose an alternative site for donor tissue. This can come from the hamstrings tendon and/or from the other leg. Graft material is often taken from the opposite leg when there is any indication that the injured leg is weak.

Quadriceps muscle weakness before surgery is linked with slower return of strength after the repair. This could be important if you’re an athlete hoping to get back on the field.

Doctors in favor of the minimally invasive surgery (MIS) say there’s less blood loss and shorter hospital stays. Some early studies also suggest patients use less pain medication and get better faster. They regain joint motion and muscle strength faster.

Patients who’ve had MIS report improved sense of satisfaction after this type of surgery compared to the more traditional, open incision approach. The rates of infection and problems with the wound are less with MIS. All of these benefits translate into money saved, too.

There are some possible problems to consider. Doctors must use special instruments made smaller to fit in the small opening. Sometimes the shape of the patient’s knee just doesn’t allow for easy access and a larger incision must be made. The more operations a
doctor does, the better his or her skills become in this procedure. It may be best to find someone who has done quite a few of these operations.

You’ll have to ask your doctor in order to know for sure what was meant in your case. Obesity and severe knee deformities are the most likely reasons why a patient wouldn’t be considered for the new minimally invasive surgery (MIS).

Sometimes too much loss of knee motion is a problem. Other risk factors include brittle bones (osteoporosis), diabetes and/or smoking (poor wound healing), and previous surgery on that knee.

If a doctor is just learning to do the procedure, he or she might only take patients who have no known risk factors. Age may play a factor, as does the presence of other diseases or illness.

Certainly, you can ask your doctor “what happened”? Don’t be surprised if you find out a smaller cut just wasn’t possible. The new minimally invasive surgery or MIS does try to limit the size of the incision. But sometimes it isn’t possible to keep it down to
only five inches.

In some cases the doctor is just learning how to do this operation. Making a larger incision may be needed until the surgeon gets better at the technique. Space is limited
for the surgical tools. Special smaller-sized surgical instruments must be used.

The cuts made must be done in a specific order. With each cut, more room is made. The strategic order of the cuts isn’t as important as when doing the traditional knee replacement.

And finally, sometimes the shape of the patient’s bones makes a difference and a larger incision is needed.

High levels of pain and disability can follow orthopedic surgery. How long the patient is laid up depends on many factors. Older age, smoking, obesity, and other problems like diabetes can put a patient at increased risk for problems after any operation.

Knee surgery is no longer thought of as “major” when it’s done arthroscopically. The doctor uses a long thin instrument with a tiny TV camera on the end to look and work inside the joint. Two or three puncture holes are all that’s needed. Large incisions to open the joint aren’t needed.

Even so, some patients have quite a bit of pain after the operation. Recovery can be slowed down. Return to work may also be delayed more than expected. For this reason doctors try to control patients’ pain in a variety of ways. Pain relievers, anti-inflammatories, cold therapy, acupuncture, and even hypnosis have been used.

Most of the time it’s just a matter of getting on top of the pain and staying there during the first hours and days after the operation. Usually, this can be done with a non-narcotic pain reliever such as Tylenol. Sometimes Tylenol is combined with a mild narcotic for the first 24- to 48-hours. You shouldn’t have any problem if you follow your doctor’s advice carefully.

Arthroscopic surgery has decreased knee pain compared to an operation with an open incision. But some patients still have more pain than expected afterwards. And it’s often more pain than they can handle. If you wait until the pain becomes severe, medications won’t help you “catch up” with the pain.

Increased pain leads to loss of function. The more it hurts, the less you do. The more inactive you become, the more it will hurt. A vicious cycle can occur. Usually after arthroscopic knee surgery patients are given an oral narcotic combined with Tylenol. They
are told to take it on an “as needed” basis.

Doctors say it’s best to get control and keep control of postoperative pain. Take your pain pill before pain is unbearable. Take it only when you need it. Some people ask their doctors about taking the smallest dose possible for their weight and metabolism.