FAQ Category: Knee

There are many helps for people with arthritis. The National Arthritis Foundation can be reached at http://www.arthritis.org. The Arthritis Foundation puts out a good magazine called Arthritis Today. The magazine and information on arthritis are available on-line at http://www.arthritisfoundation.com.

The National Institutes of Health (http://www.nih.gov)
has information on many diseases and conditions, including arthritis. Once you go to the home page, type in ‘knee osteoarthrits’ in the SEARCH box.

An excellent book often available at your public library is Arthritis: Pain Free, Side Effect Free. Written by Dr. Howard Kaye, this book is easy-to-read and offers practical advice about managing the symptoms and the disease.

This is always a difficult question to answer. If there’s only one operation the bill for the operating room and anesthesia is less. If you have one hospital stay and replace the knees four to seven days apart, then there are two operating room and two anesthesia bills to pay.

Either way with a single hospital stay you’ll save money if you are there fewer days in the hospital when compared to having each knee done one at a time. Patients having both knees replaced four to seven days apart but during a single hospital stay are there an average of nine days. This is four days longer than when both knees are done at one time.

The real determining factor is whether or not there are any problems after surgery. Complications can be minor or major. Minor problems include blood clots, bladder infections, or heart palpitations. Major problems can range from blood clot in the lung, heart attack, and even death. With the exception of death, any of these can prolong your hospital stay and increase the total cost.

The best way to get an estimate of the costs is to talk with the surgeon’s and the hospital’s accounting office. At least you can find out how the costs compare given the average patient with no problems afterwards.

There are actually three different ways to have surgery done to replace both knee joints. The operation is called a bilateral total knee arthroplasty (TKA). A single hospital stay with both knees replaced four to seven days apart is a staggered TKA.

Having both knees done during a single operation is called a sequential TKA. The third choice is the staged TKA. In this operation the patient has one knee replaced at a time separated by weeks to months. Two separate hospitalizations are needed.

There are pros and cons to each type of surgery. If the patient is healthy the staggered or sequential methods are possible. There is the chance of greater blood loss and transfusions required with either of these methods.

Patients with more serious health problems may have to use the staged operations instead. On the other hand the staged group seem to need less rehab. Having the first knee replaced helps them prepare for what to expect when the second one is done later.

Research shows that injury or trauma to a joint puts it at increased risk of
osteoarthritis later on. The risk may be less when surgery is done to repair the damage. Restoring the normal joint alignment and muscle balance helps the joint function
optimally.

Problems are more likely to occur when the damage is left unrepaired. Uneven load and force through the joint create changes in the cartilage leading to osteoarthritis.

Long-term results of anterior cruciate ligament (ACL) repair aren’t known yet. Studies show that gait patterns don’t return to normal for at least a year after ACL repair. Reduced knee flexion can occur with the patellar tendon graft method of ACL repair. Without full knee flexion, normal shock absorption is altered. This could put the joint at risk for early arthritic joint changes.

Right now the emphasis is on rehab after surgery to restore normal motion and strength. Until more is known, retraining the muscles and receptors in the joint is your best bet for a good long-term result.

ACL repairs are done using a tendon graft from either the patellar (knee) tendon or the hamstring tendon. Which choice is better is a topic of ongoing debate and the subject of many studies.

We do know the patellar tendon graft makes it difficult for the patient to kneel on that side. This could make a difference depending on your daughter’s event(s). Patients who hop and land on one leg have a little more trouble when the patellar tendon graft is used. This may be something to consider for many gymnastic events.

Make sure the surgeon is aware of your daughter’s plans to return to gymnastics. The type of surgery and rehab program may be based on her long-term goals to compete.

It takes many patients up to a year or more to return to a normal walking pattern after ACL repair. Researchers aren’t sure why there’s such a slow return. It could be patients change the way they walk early on to avoid pain. Then the pattern is hard to break.

There may be slight changes in how the knee functions as a result of the surgery. Most ACL repairs are done with donor tendon from either the patellar tendon or the hamstring tendon. Problems with the donor site can make a difference.

A recent study from Australia found slight changes in knee motion based on the type of ACL graft used. With the hamstring tendon graft the knee had less knee extension when walking. Patients with patellar tendon grafts had less knee flexion.

Check with your doctor and physical therapist for their assessments. Watching you walk, measuring your motion, and checking the internal movements of the joint may help them
pinpoint the problem and a solution.

Knee pain after total knee replacement (TKR) is the most common problem patients face when the kneecap (patella) isn’t replaced. Surgeons aren’t always sure why this happens. Uneven cartilage and abnormal patellar shape may be part of the cause. Pain can occur if the patella doesn’t track normally up and down over the joint.

Inflammatory and arthritic changes seen on X-ray before the operation are usually a big sign that the patella must be replaced called resurfacing. But it’s possible to have normal preoperative X-rays and a poor result afterwards. Scientists think their may be unseen changes present. The patella in an affected joint may look quite normal, yet still have pathology that dooms it to failure.

Talk to your doctor about this problem. A simple revision surgery may be all that’s needed to replace the patella and eliminate the pain.

Studies show a general trend toward better results with kneecap (patellar) replacement during total knee replacement (TKR). Replacing the patella is called resurfacing. Patients with their own patellas (nonresurfaced) are more likely to have knee pain afterwards. The pain is worse when going up and down stairs.

Anyone with good cartilage can keep the patella. Young, active adults who are not obese are good candidates for nonresurfacing. Difficulty tracking the patella up and down over the knee joint is one reason to replace it. Inflammatory changes, abnormal shape, or bone spurs are all good reasons to replace (resurface) the patella.

Ask your surgeon to give you his or her best opinion based on the condition of your kneecap now and the type of implant you’ll be getting.

It’s not uncommon for patients with knee arthritis to have many other health problems at the same time. After all, advancing age is linked to both osteoarthritis and other diseases and illnesses.

Some patients are afraid if they don’t do both knees at once, they won’t ever have the second knee done at all. Being laid up all at once rather than having two separate perations makes more sense to them. Your concerns about your aunt’s health are well stated. The surgeon will take them into consideration when advising your aunt about the knee surgery.

If it’s possible, it may be a good idea to visit with the doctor either by appointment with your aunt or by phone if you are far away. If your aunt has both knees replaced at the same time, she may have a longer hospital stay and more rehab before going home. She may also need more help once she returns home. Let the doctor know if there is family available to assist during the transition.

Probably not. The weight of the implant is just slightly more than the weight of the bone and cartilage removed. Right after surgery there may be some swelling and water retention but this will go back down as you start to move your knee and walk around.

A recent study at the Insall Scott Kelly Institute in New York actually measured the body weight of 20 patients before and after total knee replacement (TKR). For men with larger implants there was a three-quarters of a pound increase in body weight. This was just seen right after surgery.

Within a year’s time, body weight was back to the patient’s normal weight. Some patients might expect to see a slight weight loss if the new knee allows them to become more active.

The straightforward answer to your question is ‘Yes’ but with a few ifs, ands, or buts. First of all it’s not likely he will be wearing his suits right after surgery when swelling may make a difference.

Most patients enter a rehab program for a short time and find gym clothes or sweat pants much easier to get on and off. Loose fitting or pants that stretch will be helpful during
this time.

By the time your husband re-enters the work world his regular suits should fit him once again. Total body weight gain/loss may occur anytime someone is off work or has had major surgery. This weight change will not be related to the size and weight of the joint implant.

There are two major ligaments that criss-cross inside the knee joint to give it stability. One is the anterior cruciate ligament (ACL) and the other is the posterior cruciate ligament (PCL).

ACL tears don’t regenerate tissue and heal on their own. In minor ACL injuries surgery may not be needed. Instead knee rehab is used to regain motion and strengthen the muscles around the knee. More serious injuries may need surgery to repair or reconstruct the torn
ligament.

Unlike the ACL, the PCL does have the ability to heal. This has been shown with MRI studies. Healing does depend on how severe the injury is–more severe injuries may need surgery to improve laxity.

Without surgery it’s not clear yet how long the healing process takes. The PCL doesn’t return to normal but motion, strength, and control are regained.

The answer to your question may depend on what you mean by “pretty loose.” Joint laxity in the knee can be graded from one to three with a test called the drawer test. An anterior drawer test measures laxity of the anterior cruciate ligament (ACL). A posterior drawer test grades the posterior cruciate ligament (PCL).

Studies show the PCL doesn’t return to “normal” after surgery. The goal of the operation is to improve joint laxity. PCL repair usually reduces laxity by a full grade or more. Even with the best results there’s often a trace amount of laxity.

Even though your joint may be loose, the real measure of success is to compare the laxity before and after the operation. Talk to your surgeon if there doesn’t seem to be any difference. Ask if your knee is stable enough to return to normal sports and activities.

According to several studies patients with PCL injuries treated without surgery go back
to their previous level of sports or activities:

Total knee replacement (TKR) has become a very popular way to treat pain and loss of function from osteoarthritis of the knee. Although the knee joint itself may need replacing, sometimes the kneecap (patella) is just fine. It moves up and down over the joint just fine.

Some researchers suggest it’s best to leave the patella alone when:

When the knee joint is replaced the surgeon has two choices about the kneecap (patella). He or she can leave the patient’s patella in place or remove it and replace it with an implant. Unresurfaced or nonresurfaced means the patient’s patella is cleaned up but left alone. Any bits of uneven bone are usually smoothed over. Pits and dings in the cartilage are also evened out.

If the patella is removed and replaced, then a plastic backed implant is used most often. Early patella replacements were made of metal but bits of metal kept breaking off causing problems.

One of the jobs of the anterior cruciate ligament (ACL) is to keep the lower leg bone (tibia) from sliding too far forward on the upper leg bone (femur). A weak, lax, or insufficient ACL means higher stress on the knee cartilage.

The medial meniscus is affected the most. This is the C-shaped piece of cartilage on the inner (medial) side of the knee joint. Repairing the ACL will unload the medial meniscus and make it less prone to further damage or degeneration.

Your surgeon will be able to guide you in making this decision based on your symptoms, the result of tests, and the peek he or she had inside the joint during the meniscal repair. The results of many studies suggest a better long-term result if the ligament is repaired either at the same time as the meniscal tear or soon after.

Graft material for bones and ligament come from two sources: from the patient (called an autograft or from a donor (allograft). An autograft of meniscal tissue isn’t possible at this time.

Scientists are working on removing a small number of cells and regenerating tissue in a laboratory that could be re-injected into the same patient. This is many years away yet.

Allografts are taken from donors who have died from injuries or acute disease. Most donors have been killed in a car accident or had a stroke.

The tissue is screened carefully for any diseases or infection. Tests can be done to look for hepatitis or HIV/AIDS. Donors must not have received steroids or other potent drugs prior to their death. Healthy donor tissue is frozen and matched to the candidate by size.

Research is underway to make an artificial (synthetic or plastic) meniscus.

Years ago a torn meniscus was just taken out. Since then we’ve discovered just how important this little C-shaped piece of cartilage is. Saving it and restoring the joint is the focus of treatment for knee meniscal injuries today.

Surgeons try to return patients to their former activity level. They understand the need to avoid future joint surgery.

One of the today’s more exciting developments in joint restoration is cartilage regeneration and transplantation. Cartilage transplants aren’t for everyone yet. Right
now younger, active patients with good joint alignment are the best candidates. They’ve either had 50 percent or more of the meniscus already removed or there’s a recent tear that can’t be repaired for some reason.

Cartilage transplantation isn’t offered everywhere. You’re in luck because the New York City area does have surgeons who are doing this type of work. You can go on-line and Google the words: ‘meniscus transplant New York City’ and find the centers that offer this service near you.

Continuous passive motion (CPM) was first used in the 1980s when a well-known orthopedic surgeon did some studies with it to help joints heal after fractures. It’s use after total knee replacement has been debated for years.

Some studies show CPM helps patients get more motion back faster. Others say it doesn’t make a difference. Some studies show a shorter hospital stay for patients using CPM. Others don’t show any difference at all.

Researchers suggest different study designs and methods of research may explain these varied results. For example, in one study the CPM was only used for 24 hours after the operation. Another study used it for three hours twice a day for five days.

Sample size (the number of patients in the study) can make a difference in results, too. Smaller studies may not be as valid as larger studies. Finally surgery has improved over the years making the use of CPM less necessary. Patients are already able to move freely after the operation with fewer muscles cut and less swelling. They don’t need a machine to passively bend and straighten the knee for them.