FAQ Category: Knee

We can think of two reasons why this might happen. There may be others. First, let’s review the drug Vioxx®. This nonsteroidal anti-inflammatory (NSAID) is part of a group of
drugs called COX-2 inhibitors. This means they reduce inflammation. At the same time they keep an enzyme (cyclo-oxygenase-2) in the GI tract from causing GI bleeding.

The drug was taken off the market several months ago. Studies showed it increased the risk of stroke and heart attack. Other similar drugs (Celebrex, Arcoxia) are now getting a second look. Research already done by scientists using Vioxx® can still bring valuable
information to doctors and other researchers.

The idea behind the study can be duplicated with these other drugs for comparison. Perhaps Vioxx® itself can’t be used, but another drug can for the same effect. Take for example the study you saw. Vioxx® was used to reduce postoperative pain after knee
arthroscopy. A single dose given before the operation had very good results afterwards. The patients had less pain, used fewer narcotics, and got better faster. Other COX-2 inhibitors still available may work the same way.

Second the study was probably sent in and accepted for publication before Vioxx® was taken off the market. Sometimes things like this can’t be pulled back in time and the
report goes through. In the publish or perish world, this may still benefit those who spent so much time and effort on a study.

A recent multi-country study might suggest so. Researchers compared the results of total knee replacement (TKR) in patients across three countries. This included the United Kingdom (UK), United States, and Australia. They found that patients in the UK waited an average of two years longer than patients anywhere else.

The delay may keep patients from getting the best results possible. Patients are treated on a first-come, first-served basis, not on the basis of severity of disease and symptoms. Another important factor in the UK is the lack of rehab. Most patients go home without rehab at the hospital or after discharge.

Before making this decision, check on finances. Your sister will need to know if her insurance will cover the cost of the care needed. There are many parts to this figure: doctor’s fees (surgeon and anesthesiologist), hospital fees, rehab costs, and of course, travel.

The answer is: yes and no. Whether you get the $10.00 may depend on how you placed your bet. A recent study followed patients across multiple centers in different countries. They report in each country, women were much worse before the surgery than the men. Women are more likely to delay the surgery. They get worse and worse before finally going in.

After surgery, men and women have equal outcomes in terms of pain and function. These findings remain the same when measured up to two years after surgery. This is true despite the big differences between men and women before the operation.

Actually, there is a series of desensitization activities you can perform to help with this problem. A physical or occupational therapist can get you set up with a home program
to do this on your own.

The therapist will show you how to massage the scar using vitamin E oil. Then you will be rubbing different things across and along the scar. At first even soft materials can seem
painful. Firm pressure will help to start. Over time lighter contact is possible. You’ll also be able to change from soft to firm to rough materials. Each one will be used with firm pressure gradually applying light pressure.

A clean roller like what you see on a bottle of deodorant will also be used to help desensitize the area. The roller is pressed across and along the scar tissue just like the other materials. You can expect to be given a packet of items to use daily (or more often as your schedule allows). It usually only takes a few days to a few weeks to
desensitize painful scar tissue.

The answer to your question isn’t a straight “yes” or “no.” Scientists are studying this question and so far very little information is available. There are some factors to consider. First, can you get up and down easily? If you lose your balance, can you catch yourself before falling on the knee?

How tall are you and how much do you weigh? In other words, how much weight and force will you be putting through that new joint? And how new is it? Certainly, you must wait until the scar tissue is all healed and you have motion and strength back.

A recent study from the McClure Musculoskeletal Research Center at the University of Vermont reports limited kneeling is probably okay from time to time. They X-rayed knee joint implants in two different kneeling positions. The contact points and position of the bones was about the same in both kneeling positions as when squatting and climbing
stairs.

Ah, the amazing wonders of modern technology. X-rays haven’t changed much, but the new computer software and digitized photography makes it all possible. Not only does the
program show where the implant is located, it separates it from the bone and soft tissues around it while also analyzing its position.

So a two-dimensional picture can show how much slide and glide occurs in the joint as well as how much rotation or twisting occurs. It’s possible to compare the movement of the implant with known “normal” movements in knees without an implant. This helps
researchers find out which implant works the best for each type of knee patient.

It may be very possible to make some changes that will help improve your health. If you smoke or use tobacco in any form: stop. Get help from your medical doctor to do this.

Ask your doctor for a referral to a nutritionist for help in choosing the right foods for you. There are several “heart healthy” food plans available. Which one is best for you depends on your age, blood pressure, and specific heart issues.

Find out if there is a cardiac fitness program in your community. Begin an exercise program that is supervised by your doctor. Let your family and friends know what you are doing. Studies show that patients involved with a support group are more likely to stick
with the program. You’ll be more likely to succeed in weight loss and achieve better results.

Finally, be patient with the patient (you!). Take it a day at a time and set your goals in short increments. Give yourself time (for example: one month, six months, one year) to make small gains. Making the decision to change your lifestyle is the first important
step. You can do this!

This is a question scientists are trying to answer. Several long-term studies have been done comparing obese to nonobese patients who have a total knee replacement (TKR). The results aren’t always clear.

Obese patients tend to have lower activity levels. This may counter the negative effects of excess weight on the new joint. On the other hand, in some cases, obese patients have been able to increase their activity once the pain is gone. Weight loss becomes possible
again.

Even without any weight loss, obese patients may get enough pain relief and increase in function to make it worth having the operation, even if it doesn’t have a perfect result.

A recent study reported results in obese patients 15 years after a TKR. There were more failures in this group compared to the control (nonobese) group. But the failures didn’t occur until after 14 years with the joint replacement. Most joint implants are only expected to last 15 years, so this result may not be so unusual.

Your aunt may do very well if she is in good health.

Is there a lack of motion in trying to do this movement? Or does it feel like you don’t have enough strength to hold you? You may have both issues to contend with. Most large ballet companies have a physical therapist on staff or associated with the company. This would be a good question to refer to that person.

A recent study on hamstring graft recovery after ACL repair may help you understand what’s going on. It seems that when a piece of the hamstring is removed to graft in as a substitute ACL, the graft site grows back, but the full hamstring strength doesn’t return. Researchers compared one leg to the other and measured strength in three
positions.

They found the greatest loss of knee flexion strength occurs just in the position you are having trouble with: full or deep knee flexion. It’s most noticeable when lying prone (face down) while trying to bend the knee fully. Dancers and gymnasts report problems
with knee flexion while standing. Wrestlers have trouble with a hooking action used to pin an opponent.

You may be able to get this final motion with strength back. A specific rehab program will have to be devised based on your joint motion and muscle strength.

Most likely your nonoperative side has been compensating for the weak side during the last six months. This would account for it gaining strength since the operation. Over time both legs should even out to a more normal strength pattern.

You didn’t give any specifics about the test results of the operated leg. How close to normal was the strength? Research shows hamstring strength will return to almost normal (what it was just before surgery). Most patients won’t have any problems in daily
activities.

Athletes using specific movements may have some trouble with deep knee flexion. It doesn’t sound like this is a problem for you. Ask your doctor to explain the results of your tests. Be prepared with any specific questions you may have, and ask for his or her
opinion about your knee.

Just as you thought, rehab and recovery after an anterior cruciate ligament (ACL) repair to the knee will keep your son on the bench this season. Even prime athletes need four to six months to fully recover from this operation. Many athletes are out a full year, but they can come back to competitive play.

In the case of wrestling, your son may have to work to get back all the moves he needs. It depends on the type of surgery he has to repair the torn ligament. For example there
are some leg positions needed to control the opponent. Leg locks and hooking action needed for these maneuvers may be weaker after surgery and rehab than before. This is especially true when a graft from the hamstring tendon is used to replace the torn ligament.

When your son has his doctor’s approval to return to wrestling, the coaching staff will help him develop some alternate positions and options until he gets his full motion and strength back.

Healing tissue, whether it’s bone, cartilage, muscle, or tendons has about a four to six week healing cycle. Nothing we’ve come up with has changed that. Recent studies (first on animals then on humans) show that sound waves in the form of ultrasound can speed up bone healing.

One study reported faster healing time in lower leg bone fractures of 37 days. This is a savings of thousands of dollars in health care costs. It has been proven that electric current can stimulate bone growth and enhance the healing process.

Insurance companies do not approve these treatment methods unless the fracture hasn’t healed after three months or more.

Researchers are also looking for drugs to stimulate bone growth and repair but this isn’t ready yet. For now everyone is held to the same standard: four to six weeks’ healing time unless problems occur.

At one time there were several types of synthetic (manmade) materials on the market for ACL repair. But the synthetic grafts weren’t like the normal ligament. They didn’t have the ability to repair or remodel. Other (human) graft material works much better.

When using a synthetic graft, the graft tension isn’t very “forgiving.” For example too much tension could result in a stiff joint. Not enough tension places the joint at risk of instability. Human tissue has a certain amount of “give” to it, allowing the graft to loosen up a little if it’s too tight. This is called viscoelasticity. The synthetic graft has no viscoelastic properties.

On the plus side, synthetic grafts were free from problems at the harvest site. There was no disease transmission as can occur with tissue from a donor bank. Synthetic grafts were available off the shelf anytime a patient needed an ACL repair. Synthetic grafts can’t repair themselves like natural ligaments can.

There are many different kinds of tissue grafts that can be used to repair a torn or ruptured anterior cruciate ligament (ACL). The bone-patellar tendon-bone (BPTB) is called the “gold standard.” It’s used the most with the best results.

The graft is made up of the middle third of the patellar tendon and a piece of bone on either end. The bone is taken at one end from the kneecap and at the other end from the lower leg bone (tibia).

This graft works well because the patellar tendon has a high strength and stiffness. The bone plugs make it possible to get a good solid hold with screws to keep it in place. The graft seems to take hold quickly.

There are a few problems with the BPTB. Some patients have pain and swelling where the graft is taken from. It can be very difficult to kneel. Other patients report numbness, most likely caused by damage to a branch of the saphenous nerve. Loss of quadriceps muscle strength and even fracture of the patella are also possible problems.

You didn’t mention the cause of your meniscal tear. Were you in an accident or playing sports of some kind? Most meniscal tears occur in athletes, overweight adults, and aging adults.

In the case of young adults and meniscal injury, a force with a twist is usually what causes a meniscal tear. In obese or older adults, break down of the cartilage occurs over time. The cartilage may thin out and disintegrate over time. A sudden force can dislodge it.

The meniscus is a C-shaped piece of tough cartilage in the knee. There’s one on each side of the knee joint: medial (inner edge) and lateral (outer edge). Medial meniscus tears are by far the most common. Next come lateral tears followed by tears of both at the same time.

In a recent study of 150 adults between 17 and 113 years old, 90 had a medial tear and 28 had a lateral tear. Only 9 had tears of both menisci.

Yes. Diagnosing a meniscal tear can be difficult even for experienced doctors. MRIs are fairly accurate but expensive. Doctors still rely on the patient’s history and physical exam the most.

Standard tests for meniscal tear include McMurray’s test and joint line tenderness (JLT). Most doctors will use these tests first before doing an arthroscopic exam. During arthroscopy a long thin needle is inserted into the joint. A tiny TV camera on the end of
the needle gives the doctor a view inside the joint. A tear of the meniscus can be seen and repaired at the same time.

Other tests for meniscal tears are being studied. One such test is a standing McMurray’s test called the Ege’s test. The patient must be able to squat from a standing position with the feet and knees turned in and turned out. This test mimics the original cause of the problem and may help doctors find meniscal tears more easily in the future.

Ege’s test for meniscal tears in the knee were first described by Ridvan Ege, M.D. in 1968. It’s the first clinical test that mimics the actual mechanism of injury. Most meniscal tears occur in the standing position. The foot is planted on the ground and the
upper leg twists over the knee, tearing the cartilage.

Two standard tests for a torn meniscus are McMurray’s test and joint line tenderness (JLT). McMurray’s test is done with the patient lying down. The knee is flexed fully. The examiner uses the foot to twist the lower leg inward while straightening the knee. If the
meniscus is loose this action causes a snap or click. The patient may also have pain with this test.

This test relies on the experience of the examiner. Force applied through the foot must be enough to catch the torn fragment of cartilage between the leg bones. The standing McMurray’s test, also known as Ege’s test, may be more sensitive. The patient is standing
and applies enough force in weight-bearing to show a positive result when the meniscus is torn.

The test is done by placing the feet eight to 10 inches apart with the feet turned out. The patient squats down as far as possible while keeping the feet flat on the floor. This position tests the medial meniscus. Pain or a click are felt when the knee is bent about
90 degrees. The test can be repeated with the feet turned in for the lateral meniscus.

Research studies on frontal impact car collisions aren’t very common. Based on data collected by insurance companies soft tissue injuries are more common with low-speed frontal collisions than we think. In fact up to 70 percent of the people in frontal impacts have neck injuries.

Now a new study from the Biomechanics Research Lab at Yale University has some information to offer. They studied the effect of frontal impacts on soft tissues in the cervical spine. They found even low impact collisions can cause enough strain on a ligament to snap it. This occurs when the force of the impact is greater than the physiologic strength of the ligament.

So it’s possible there was nothing wrong with your ligament before the accident. Any past accidents, injuries, or strains could increase the risk of rupture with a low-impact accident.

One of the main problems is the transmission of disease. An infected allograft can transfer the infection to the surgical site. The result can be a failed graft or even death from septic shock.

Today’s handling of donor tissue has reduced many of these problems. The tissue is screened first for infections and then sterilized. The screening step can detect HIV, hepatitis, and syphilis.

Other possible problems with allograft material include delayed graft healing and an allergic response to the donor tissue. The plus side of donor bank tissue is the lack of donor site trauma.

Death is a possible complication with any surgery. It’s certainly the most serious one. Death rates after knee replacement (one or both) are very low. Reports do show an increased number of deaths when both knees are replaced at the same time compared to doing one knee at a time.

Data from a large study of 339,152 total knee replacements shows the death rate to be less than one percent (0.99 percent). This figure shows deaths in the first month after the operation when both knees were done at the same time. The death rate for patients having the second knee done three to six months later was lower (0.30 percent).

In either type of surgery, the risk of death is higher if the patient has a history of heart or lung disease. Older age (over 70 years) is also a risk factor.