Knee – Arthroscopy & Replacement

The orthopaedic clinic offers advanced surgical platform

Knee Injuries interventions

Knee injuries can happen suddenly, as in a fall, or from wear and tear from everyday movement and activity. When injury occurs, the knee’s ability to function is disrupted, impacting the intricate workings of bones, muscles, ligaments and other structures. Treatments for knee problems range from physical therapy to medications to surgery.

Arthroscopy

Arthroscopic Surgery is a procedure that allows surgeon to see, diagnose, and treat problems inside a joint. The procedure, also called an Arthroscopy, requires only small incisions and is guided by a miniature viewing instrument or scope. Before arthroscopy existed, surgeons made large incisions that affected the surrounding joint structures and tissues. They had to open the joint to view it and perform surgery. The traditional surgery method carries a higher risk of infection and requires a longer time for recovery. In contrast, arthroscopy is less invasive. It has a decreased risk of infection and shorter recovery period. Today, arthroscopic surgery is one of the most common orthopedic procedures.

Anterior Cruciate Ligament (ACL)

The anterior cruciate ligament (ACL) is the main stabilizing ligament on the inside of the knee. Its main function is to prevent the tibia (shin bone) from sliding forward and rotating on the femur (thigh bone). Tears/ruptures of the ligament result in knee instability.

What are the causes?

ACL tears are typically caused by twisting or hyperextension injuries. Sports activity like pivoting or sudden deceleration when running and falls during skiing are considered non-contact causes of ACL tears. Direct trauma to the back or side of the knee during collision sports is considered a contact injury to the ACL.

What are the symptoms?

ACL tears cause immediate pain and often swelling. You may feel something “pop” inside the knee. An initial inability to bear weight on the leg may subside and walking may be possible after several minutes. The knee may feel loose or that it is going to “give out” and return to sport is impossible. Over time, swelling will increase and motion may be lost.

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. Your surgeon will perform maneuvers to check stability of all the knee ligaments and the meniscus. An MRI is helpful to confirm the diagnosis, showing the ACL tear. The type of tear (partial, complete, avulsion from either the tibia or femur) can be defined, which may assist in surgical planning. The MRI may also show bone bruising secondary to the injury.

How is it treated?

Non-operative

ACL tears do not heal. Some patients elect not to have reconstruction surgery. Non-operative treatment increases the risk of “wear and tear” arthritis and meniscus tears because of the instability in the joint. Non-operative treatment consisting of anti-inflammatory medication, physical therapy, cryotherapy and activity modification may be prescribed prior to surgery to decrease the swelling, regain motion and strength, as research has demonstrated that surgery is less complicated and patients have better outcomes. Non-operative treatment in surgical patient may be skipped if other injuries to the meniscus and cartilage are present and need to be repaired immediately.

Operative

Operative management of ACL tears depends on the type of tear. ACL repair may be indicated in patients where the ACL is clearly torn off the wall of the femur (thigh bone) or tibia (shin bone. ACL repair is accomplished through a minimally-invasive arthroscopic procedure and sewed back into place and fixed with screws or buttons. The repair may also be supplemented with high-strength suture.

If formal reconstruction is required, a new ACL graft will be fixed in place of the original ligament. A technique for graft placement and graft choice is a shared decision between you and your surgeon. Most techniques are performed through a minimally-invasive arthroscopic procedure. The graft can be taken from around your knee or from a donor. Postoperative rehabilitation, return to daily activities and return to sport depends on the technique and graft chosen, and is at your surgeon’s discretion.

Posterior Cruciate Ligament (PCL)

The posterior cruciate ligament (PCL) is the other main stabilizing ligament on the inside of the knee. Its main function is to prevent the tibia (shin bone) from sliding backward and rotating on the femur (thigh bone). Tears/ruptures of the ligament results in knee instability. PCL tear is less common than ACL tear.

What are the causes?

PCL tears are typically caused by trauma or a fall on the knee. A direct posterior/backward force on the tibia commonly seen in collision sports or the knee hitting the dashboard in a motor vehicle accident will cause a PCL tear.

What are the symptoms?

PCL tears cause immediate pain and often swelling. You may feel something “pop” inside the knee. An initial inability to bear weight on the leg may subside and walking may be possible after several minutes. The knee may feel loose or that it is going to “give out” and immediate return to sport is impossible. Over time, swelling will increase and motion may be lost. Unlike ACL tears, some patients, even athletes, can return to sport with partial PCL tears (albeit in a knee brace) and never require surgery.

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. Your surgeon will perform maneuvers to check stability of all the knee ligaments and the meniscus. An MRI is helpful to confirm the diagnosis, showing the PCL tear. The type of tear (partial, complete, avulsion from either the tibia or femur) can be defined, which may assist in treatment planning. The MRI may also show bone bruising secondary to the injury.

How is it treated?

Non-operative

PCL tears do not heal. However, some patients may be able to return to normal activity depending on the type and severity of the tear. Non-operative treatment consisting of anti-inflammatory medication, physical therapy, cryotherapy and activity modification may be prescribed to decrease the swelling, regain motion and strength. A brace may be prescribed to return to sports activities. If symptoms persist (pain, instability), reconstruction surgery may be recommended by your surgeon.

Operative

Operative management of PCL tears depends on the type of tear. PCL repair may be indicated in patients where the PCL is clearly torn off the wall of the femur (thigh bone) or tibia (shin bone. PCL repair is accomplished through a minimally-invasive arthroscopic procedure and sewed back into place and fixed with screws or buttons. The repair may also be supplemented with high-strength suture.If formal reconstruction is required, a new PCL graft will be fixed in place of the original ligament. A technique for graft placement and graft choice is a shared decision between you and your surgeon. Most techniques are performed through a minimally-invasive arthroscopic procedure. The graft can be taken from around your knee or from a donor. Postoperative rehabilitation, return to daily activities and return to sport depends on the technique and graft chosen, and is at your surgeon’s discretion.

What is revision ACL reconstruction?

Revision of failed primary ACL reconstruction surgery.Although primaryACL reconstruction is a successful operation, some people may require a re-surgery as a result of failure of 1st surgery.

Why primary ACL SURGERY FAILS?

Graft failure occurs when the reconstructed ligament does not restore stability to the knee.

Causes:

  • Recurrent or acute trauma
  • Biological failure of graft incorporation
  • Unrecognised additional ligamentous injuries(PLC,Medial collateral legament)
  • Lower extremity malalighnment
  • Technical error

The meniscus is cartilage that acts as a shock absorber between the femur (thigh bone) and tibia (shin bone). Each knee has two distinct menisci: the medial (inner aspect of the knee) and lateral (outer aspect of the knee). Medial meniscus tears are more common in general, and lateral meniscus tears are more common when the ACL is injured. Injuries to the meniscus may lead to eventual degenerative changes in the knee (aka – arthritis).

What are the causes?

The meniscus can be injured several ways. Acute meniscus tears result from a sudden twisting or pivoting maneuver. Acute meniscus tears are associated with ACL injuries. The meniscus can also undergo degeneration as patient age increases. The degenerative meniscus is susceptible to tearing with minimal trauma (i.e.-twisting the knee getting into the car).

What are the symptoms?

Meniscus tears, in the acute setting, cause immediate pain over the specific meniscus, potentially swelling and bruising and loss of motion and strength. The patient may feel clicking or catching with walking and increased pain with twisting on the affected foot. If the meniscus tears and gets stuck out of place, the knee may feel locked (aka - bucket handle meniscus).

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. The knee is painful to touch over the affected meniscus. Your surgeon may perform provocative maneuvers to test each meniscus, resulting in pain and clicking if the meniscus is torn. X-rays are usually normal. MRI is helpful to confirm the diagnosis and characterize the tear for surgical planning. Other injuries can also be identified on the MRI.

How is it treated?

Some meniscus tears are treated successfully without surgery. Your surgeon may prescribe anti-inflammatory medication, physical therapy, cryotherapy and activity modification to reduce pain and inflammation, as well as strengthen the muscles around the knee to decrease the force transmitted to the meniscus. Your surgeon may offer you an injection. Patients with continued symptoms (pain, clicking, etc.) may benefit from surgery. Bucket handle meniscus tears are not treated non-operatively and require surgery.

Operative

Meniscus tears can be treated in most cases with a minimally-invasive arthroscopic surgery. Depending on the size and type of tear, as well as the quality of the torn tissue, your surgeon may choose to remove the torn meniscus or repair it with a series of sutures. Removing large portions of the meniscus will lead to expedited degeneration of the joint cartilage (aka- arthritis). Postoperative rehabilitation is at your surgeon’s discretion.

What is the medial patellofemoral ligament (MPFL)?

What is the medial patellofemoral ligament (MPFL)? The medial patellofemoral ligament is a part of the complex network of soft tissues that stabilize the knee. The MPFL attaches the inside part of the patella (kneecap) to the long bone of the thigh, also called the femur. Together, the patella and femur compose the patellofemoral joint. Injury to the MPFL can occur when the patella dislocates or becomes subluxated (partially dislocated) due to a trauma experienced during athletics or an accident, as a result of naturally loose ligaments – most frequently seen in girls and women – or due to individual variations in bony anatomy. People with these injuries are described as having patellar instability.

Injury to the MPFL

In the healthy knee, the bones that make up the patellofemoral joint move smoothly against one another as the joint is flexed or extended. The patella glides in a trochlea (groove) of the femur. The MPFL plays a particularly important role in keeping the patella on track (that is, in this groove) by acting like a leash that restrains the patella's movement.

When patellar dislocation occurs, soft tissues are damaged as the patella “jumps” the track and then comes forcibly back into place. Because the kneecap dislocates toward the outside of the leg, the ligament on the inside of the knee (the MPFL) gets torn.

Left untreated, an injured MPFL can heal on its own. However, when left alone, the ligament heals in a loosened, lengthened position. This causes instability that makes it easier for the patella to become dislocated again in the future. This, in turn can cause damage to the cartilage in the knee. While the pain, swelling and disability associated with a dislocated kneecap are problems in themselves, the greater concern is subsequent injury to the cartilage that covers the ends of the bones where they meet in the knee joint. Once this cartilage is damaged, you are put at a high risk of developing patellofemoral arthritis, a significantly more difficult condition to treat. For this reason, it always advisable to get treatment that will help prevent further dislocations of the kneecap.

What is MPFL reconstruction?

MPFL reconstruction is a surgery in which a new medial patellofemoral ligament is created to stabilize the knee and help protect the joint from additional damage.

It offers an excellent treatment option for people who have experienced more than one dislocation. The procedure is relatively new. Historically, although some patients benefitted from surgery to tighten the damaged ligament, as recently as around 2006, many individuals with damage to the MPFL had few treatment options beyond immobilization and rehabilitation.

What to expect after MPFL reconstruction

Immediately following MPFL reconstruction, patients can bear weight on the affected leg, which is placed in a brace that is worn for six weeks. The brace keeps the leg straight during walking. During recovery, a continuous passive motion machine (CPM) is used at home to avoid scar tissue and stiffness from developing in the joint as the ligament heals. The CPM machine moves the patellofemoral joint without the use of a patient’s muscles.

Once the quadriceps (the major muscle in the thigh) is strong enough to support the joint, the patient can begin physical therapy. This is usually about six weeks after surgery. Other measures that can speed up recovery include devices that provide electric stimulation to the muscles around the knee and Game Ready, a machine that compresses and cools the leg, thereby reducing swelling and pain. (Insurance may not cover the cost of these devices.)

Most people can generally return to sport or play sometime between 4 to 7 months after MPFL reconstruction. If you are considering the surgery, be aware than recovery times may vary and can be dependent on your individual anatomy, capacity to heal and general health prior to surgery.

MCL (MEDIAL COLLATERAL LIGAMENT)

Description

The medial collateral ligament (MCL) is the main stabilizing ligament on the inner aspect of the knee. Its main function is to prevent the knee from buckling inward/knock-knee (valgus motion). Tears/ruptures of the ligament results in knee instability.

What are the causes?

MCL tears are typically caused by trauma. A direct force to the outside of the knee stresses the ligament. This typically occurs in collision sports like football. Overuse injuries in sports/occupations that require repetitive falling to the knees and standing up quickly can also lead to micro tears of the ligament.

What are the symptoms?

MCL tears cause immediate pain and often swelling. You may feel something “pop” on the inside aspect of the knee. Pain is centralized over the ligament (inside aspect of the knee). Walking after the injury may be possible but the knee may feel like it’s going to “give in” depending on the severity of the tear. The MCL is attached to the underlying meniscus. Damage to the meniscus at the time of injury may cause clicking or locking of the knee.

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. Your surgeon will perform maneuvers to check stability of all the knee ligaments and the meniscus. An MRI is helpful to confirm the diagnosis, showing the MCL tear. The type of tear (partial, complete, avulsion from either the tibia or femur) can be defined, which may assist in treatment planning. The MRI may also show bone bruising secondary to the injury.

How is it treated?

Non-operative

Almost all minor MCL tears can be treated non-operatively. Non-operative treatment consisting of bracing, anti-inflammatory medication, physical therapy, cryotherapy and activity modification may be prescribed to decrease the swelling, regain motion and strength. Most patients may be able to return to normal activity without surgery depending on the type and severity of the tear. A brace may be prescribed to return to sports activities. If symptoms persist (pain, instability), reconstruction surgery may be recommended by your surgeon.

Operative

Operative management of MCL tears depends on the type of tear. MCL repair may be indicated in patients where the MCL is clearly torn off the wall of the femur (thigh bone) or tibia (shin bone. MCL repair is accomplished through a series of small incisions and sewed back into place and fixed with screws or buttons. The repair may also be supplemented with high-strength suture.If formal reconstruction is required, a new MCL graft will be fixed in place of the original ligament. A technique for graft placement and graft choice is a shared decision between you and your surgeon. Most techniques are performed through a minimally-invasive incision. The graft can be taken from around your knee or from a donor. Postoperative rehabilitation, return to daily activities and return to sport depends on the technique and graft chosen, and is at your surgeon’s discretion.

LCL (LATERAL COLLATERAL LIGAMENT)

Description

The lateral collateral ligament (LCL) is the main stabilizing ligament on the outer aspect of the knee. Its main function is to prevent the knee from giving way outward (varus motion). Tears/ruptures of the ligament results in knee instability.

What are the causes?

Isolated LCL tears are uncommon. They typically occur from trauma. A direct force to the inside of the knee stresses the ligament. This typically occurs in collision sports like football. LCL tears are also seen in high-energy trauma like motor vehicle accidents and are accompanied by tears in the other ligaments and tendons on the outside of the knee (aka – posterolateral corner injury and knee dislocation).

What are the symptoms?

LCL tears cause immediate pain and often swelling. You may feel something “pop” on the outer aspect of the knee. Pain is centralized over the ligament (outside aspect of the knee). Walking after the injury may be possible but the knee may feel like it’s going to “give out” depending on the severity of the tear.

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam with X-rays. On exam, swelling and loss of motion and strength is present. Your surgeon will perform maneuvers to check stability of all the knee ligaments and the meniscus. An MRI is helpful to confirm the diagnosis, showing the LCL tear. The type of tear (partial, complete, avulsion from either the tibia or femur) can be defined, which may assist in treatment planning. The MRI may also show bone bruising secondary to the injury.

How is it treated?

Non-operative

Almost all minor LCL tears can be treated non-operatively. Non-operative treatment consisting of bracing, anti-inflammatory medication, physical therapy, cryotherapy and activity modification may be prescribed to decrease the swelling, regain motion and strength. Most patients may be able to return to normal activity without surgery depending on the type and severity of the tear. A brace may be prescribed to return to sports activities. If symptoms persist (pain, instability), reconstruction surgery may be recommended by your surgeon. If other structures are damaged (i.e.- Posterolateral Corner), surgery is recommended to reconstruct the knee.

Operative

Operative management of LCL tears depends on the type of tear. LCL repair may be indicated in patients where the LCL is clearly torn off the wall of the femur (thigh bone) or tibia (shin bone. LCL repair is accomplished through a series of small incisions and sewed back into place and fixed with screws or buttons. The repair may also be supplemented with high-strength suture.If formal reconstruction is required, a new LCL graft will be fixed in place of the original ligament. A technique for graft placement and graft choice is a shared decision between you and your surgeon. Most techniques are performed through a minimally-invasive incision. The graft can be taken from around your knee or from a donor. Postoperative rehabilitation, return to daily activities and return to sport depends on the technique and graft chosen, and is at your surgeon’s discretion.

PLC(POSTEROLATERAL CORNER)

Although rare, posterolateral corner (PLC) injuries can result in sustained instability and failed cruciate ligament reconstruction if they are not diagnosed.

The anatomy of the PLC was once thought to be perplexing and esoteric—in part because of the varying nomenclature applied to this region in the literature, which added unnecessary complexity. More recently, three major structures have been described as the primary stabilizers of the PLC on the basis of biomechanical study findings: the lateral collateral ligament, poplit- eus tendon, and popliteofibular ligament. Other structures stated to be in the posterolateral ligamentous complex include the short and long heads tendons of the biceps femoris muscle, arcuate ligament, meniscopopliteal fascicles, and fabellofibular ligament. structures of the PLC are primarily responsible for resisting,varus angulation, sometime referred to as various rotation and external tibial rotation.They act as secondary stabilizers in conjunction with cruciate ligament, to prevent anterior and posterior translation.During early phase of flexion (0-30*).

Articular cartilage is a firm, rubbery material that covers the ends of bones in the knee joint. It reduces friction in the joint and acts as a "shock absorber." When cartilage becomes damaged or deteriorates, it limits the knee's normal movement and can cause significant pain. If damaged cartilage is not treated, it can worsen and eventually require knee replacement surgery.

Who is the candidate for cartilage procedure?

Cartilage repair and regeneration is treatment for an otherwise healthy knee, but not for knees affected by osteoarthritis, a condition that causes natural cartilage deterioration from aging.

The treatment is recommended for patients with knee cartilage damage or deterioration caused by:

  • Trauma including sports injury
  • Osteochondritis dessicans (OCD)

What are the cartilage procedure?

Cartilage tissue’s ability to repair itself is severely limited because it does not contain blood vessels, and bleeding is necessary for healing.The damaged cartilage can either be regenerated by encouraging new cartilage growth or replaced by cartilage replacement procedures.

What cartilage procedure is used will depend on the size of the cartilage injury being treated as well as the surgeon’s expertise and recommendation.

Cartilage regeneration procedures:

  • Knee microfracture, which requires the damaged cartilage to be cleared away completely. The surgeon then uses a sharpened tool called an awl to pierce the bone underneath the damaged cartilage, blood from the micro fracture will facilitate new cartilage cell growth.
  • Knee abrasion arthroplasty,which requires the damaged cartilage to be completely cleared away. The surgeon then uses a special tool to scrape and roughen the affected bone’s surface.

Cartilage replacement procedures:

  • Osteochondral autograft transplantation (OATS) ,uses cartilage from the patient.The surgeon removes a small (<1cm), round plug of healthy cartilage—and a tiny bit of underlying bone—from a non-weight-bearing area of the knee joint. The surgeon transfers the plug to the area being treated.This OATs procedure can be used to repair one or more relatively small cartilage defects in a knee. When more than one plug is used to treat a single cartilage defect, the procedure is called mosaicplasty.The surgery is usually done arthroscopically.
  • Osteochondral allograft transplantation,uses cartilage from outside the patient, usually from a cadaver.The surgeon removes a circular plug of healthy cartilage from an outside donor.An allograft is usually used when cartilage defect being treated is too large for an autograft (≥2cm).This surgery usually requires an open incision.

Autologous chondrocyte implantation,relies on newly grown cartilage cells. It requires two surgeries.

First, the patient undergoes arthroscopic surgery to remove a small piece of healthy cartilage from a non-weight bearing area of the knee joint. That cartilage is cultured, allowing new cartilage cells grow.

Three to five weeks after the first surgery, a second surgery is performed to implant the newly grown cartilage cells into the affected knee joint.

This second surgery is not done arthroscopically; it requires an open incision.

This procedure may be recommended when the cartilage injury is large (up to several centimeters) or there are multiple cartilage injuries to repair.

Replacement

ARTHRITIS

Description

Arthritis is inflammation of a joint. The knee can be divided into three compartments: medial (inside), lateral (outside) and patellofemoral (front). Arthritis can be present in one, two or three compartments. Over time, the loss of the smooth covering on the ends of bones (aka - articular cartilage) causes pain and stiffness. This can lead to pain with motion or at rest, swelling, clicking or grinding and a loss of strength. When the cartilage is damaged or decreased, the bones rub together during joint motion, resulting in “bone-on-bone” arthritis. When arthritis becomes severe, inflammation occurs around the joint and extra bone is formed in an attemptto protect the joint, resulting in limited motion and strength.

What are the causes?

The primary cause of arthritis is osteoarthritis (aka – “wear and tear” arthritis). Trauma and other illnesses like rheumatoid arthritis, systemic lupus, septic arthritis and psoriasis can result in degeneration of a joint, leading to symptoms of pain and lack of motion.

It affects nearly 6% of all adults, but more women are affected than men.“According to a number of published reports, anywhere from 6% to over 13% of men, but between 7% and 19% of women, over 45 years of age are affected, resulting in a 45% less risk of incidence in men.

Age is a determining factor in the development of OA. “As the populationages in demographic terms, the prevalence of OA is expected to rise.From the age of 40 there is an increased risk of OA. Approximately 50% of the 65+ population are affected by OA in the knee, but it can alsoaffect young people.

What are the symptoms?

Arthritis of the knee causes pain, swelling, stiffness and loss of strength. Pain can be isolated to the medial, lateral or patellofemoral aspects of the joint or be generalized discomfort around the knee. Pain and swelling in theback of the knee may be from a Baker’s Cyst, an area of fluid collection thatis caused by arthritis. A 'grinding', 'clicking' or 'locking' sensation may be felt. Loss of motion can become severe, and the patient may have trouble performing tasks, such as walking long distances. Patients suffering from arthritis of the patellofemoral joint will often complain of 'giving way' or buckling of the knee. Patients with patellofemoral arthritis have trouble using stairs, squatting, or standing after prolonged sitting.

How is it diagnosed?

Your surgeon will perform a thorough history and physical exam, which typically includes X-rays. Your surgeon will evaluate the range of motion, stability of the ligament and strength of the muscles surrounding the knee. X-rays may demonstrate decreasing space between the bones (joint space narrowing) and bone spurs (osteophytes) in areas of arthritis. MRI may be helpful to determine if other areas of joint cartilage or the meniscus has damage.

How is it treated?

Non-operative

Knee arthritis can be treated with physical therapy, to strengthen the muscles that support the joint. The stronger the supporting muscles, the less the body will need to rely on bony architecture to stabilize the joint. This will lead to less stress across the arthritic area. Your surgeon may prescribe anti-inflammatory medication or offer an injection to reduce the inflammation. Certain nutritional supplements may be beneficial to decrease pain and inflammation.

Operative

OperativeWhen non-operative treatment does not relieve symptoms, your surgeon may suggest surgery. Three surgical options are available for knee arthritis. Minimally-invasive arthroscopy of the knee, or a 'knee scope', may be beneficial to “clean-out” the knee. Although not a cure, this procedure may provide relief in patients suffering mechanical symptoms, such as catching and locking. The entire knee joint, including joint cartilage, meniscus and ligaments can be evaluated during arthroscopy.The definitive treatment for knee arthritis is joint replacement surgery. Your surgeon will resurface the ends of the bone where the cartilage has worn away, with metal and plastic implants. If the arthritis is localized to a single or two compartments (medial, lateral or patellofemoral), your surgeon will replace only the areas that are affected (unicompartmental or patellofemoral replacement). If the arthritis is present in all three compartments, a total knee replacement is required to alleviate symptoms.PARTIAL

PARTIAL KNEE REPLACEMENT:

A partial knee replacement is an alternative to total knee replacement for some patients with osteoarthritis of the knee. This surgery can be done when the damage is confined to a particular compartment of the knee.

What is a partial knee replacement?

In a partial knee replacement, only the damaged part of the knee cartilage is replaced with a prosthesis.

Who is a candidate for partial knee replacement?

Patients with medial, or lateral, knee osteoarthritis can be considered for partial knee replacement. "Medial" refers to the inside compartment of the joint, which is the compartment nearest the opposite knee, while "lateral" refers to the outside compartment farthest from the opposite knee. Medial knee joint degeneration is the most common deformity of arthritis.

Other factors to consider:

  • You may want to consider a knee replacement if your knee pain persists despite your taking anti-inflammatory drugs and maintaining a healthyweight.
  • Your doctor will ask you to identify the area of pain in your knee, then check your range of motion and the knee's stability. An X-ray of the knee will determine your eligibility for partial knee replacement. However, your surgeon may not know for certain if you are a good candidate until the surgery has begun.
  • You must have an intact anterior cruciate ligament, a sufficient range of knee motion, damage to only one compartment, and a stable knee. The angulation of the deformity is also considered.
  • In the past, a partial knee replacement was considered only in patients older than 60 years who were sedentary but younger, more active patients are increasingly being considered.

A knee replacement (also called knee arthroplasty) might be more accurately termed a knee "resurfacing" because only the surface of the bones are actually replaced. Joint replacement surgery is one of the most successful option to treat osteoarthritis and is a safe and effective procedure to relieve pain, correct leg deformity, and help you resume normal activities. More than 90% of people who have total knee replacement surgery experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living.

What happens during the procedure?

Knee replacement surgery is performed under anesthesia,Your input and preference help the team decide whether to use general anesthesia, which makes you unconscious, or spinal anesthesia, which leaves you awake but unable to feel pain from your waist down.During the procedure surgeon will remove bone and diseased cartilage from where your thigh bone (femur) and shin bone (tibia) meet at your knee joint.Those surfaces are then replaced with a metal implant.

After surgery

Patient spend couple of nights in the hospital.During hospital stay you will be given antibiotics and pain relieving medication and will monitor you for complications.Shortly after operation, a physical therapist will start helping with, weight bearing therapy, including standing and walking, a combinationof physical and occupational therapy to help you adapt to your new knee.

When you are able to perform certain tasks, such as getting out of bed alone and using the bathroom you will be able to go home.You will need to continue the physical therapy at home and you may need to use a cane or walker for a short period of time after your operation.

Bilateral knee replacement

In bilateral or double knee replacement surgery, the surgeon replaces both knees at the same time.If you have osteoarthritis in both knees, this can be a good options it means you only have to go through the procedure and recovery process once.

Double knee replacement surgery may involve one surgery or two surgeries.When both knees are replaced at the same time, the surgery is known as simultaneous bilateral knee replacement.When each knee is replaced at different time, its called staged bilateral knee replacement.

Primary advantage of a simultaneous procedure is that there is only one hospital stay and one rehabilitation period to heal both knees, as a result total cost for the treatment is also reduced.However its not recommended for those with heart disease or lung diseases as the surgery time last longer with more blood loss and requires heavier doses of anesthesia.

In staged bilateral knee replacement, both knees are replaced in two separate surgeries.These surgeries are done a few months apart.The main advantage of a staged procedure is the reduced risk of complication, it also requires a shorter hospital stay.However since this procedure requires two surgeries, the overall rehabilitation period can be much longer, this may delay your return to some of your daily activities, and the overall cost for thetreatment will be increased.

Resuming activities

You should be able to resume most everyday activities within around 3 months, you can drive again usually 4-6 weeks after surgery.Its important tofollow your exercise and rehab program without overexerting yourself.Most people with sedentary employment can return to work after 4-6 weeks, but if your job involves heavy lifting, you may need to wait 3 month to resume work.It can take 6-12 months to get back to full activity levels.

REVISION KNEE REPLACEMENT

Total knee replacement is one of the most successful procedures in all of medicine. In the vast majority of cases, it enables people to live richer, moreactive lives free of chronic knee pain.During primary total knee replacement, the knee joint is replaced with an implant, or prosthesis, madeof metal and plastic components. Although most total knee replacements are very successful, over time problems such as implant wear and loosening may require a revision procedure to replace the original components.

There are different types of revision surgery. In some cases, only one implant or component of the prosthesis has to be revised. Other times, all three components—femoral, tibial, and patellar—need to removed or replaced and the bone around the knee needs to be rebuilt with augments (metal pieces that substitute for missing bone) or bone graft.Damage to the bone may make it difficult for the doctor to use standard total knee implants for revision knee replacement. In most cases, he or she will use specialized implants with longer, thicker stems that fit deeper insidethe bone for extra support.

when is revision knee replacement recommended?

Implant Loosening and Wear

Osteolysis has occurred around the tibial component, causing it to become loosened from the bone . In order for a total knee replacement to function properly, an implant must remain firmly attached to the bone. During the initial surgery, it was either cemented into position or bone was expected to grow into the surface of theimplant. In either case, the implant was firmly fixed. Over time, however, an implant may loosen from the underlying bone, causing the knee to become painful.

The cause of loosening is not always clear, but high-impact activities, excessive body weight, and wear of the plastic spacer between the two metal components of the implant are all factors that may contribute. Also, patients who are younger when they undergo the initial knee replacement may "outlive" the life expectancy of their artificial knee. For these patients, there is a higher long-term risk that revision surgery will be needed due to loosening or wear.

In some cases, tiny particles that wear off the plastic spacer accumulate around the joint and are attacked by the body's immune system. This immune response also attacks the healthy bone around the implant, leading to a condition called osteolysis. In osteolysis, the bone around the implant deteriorates, making the implant loose or unstable.

Infection

Infection is a potential complication in any surgical procedure, including total knee replacement. Infection may occur while you are in the hospital or after you go home. It may even occur years later.If an artificial joint becomes infected, it may become stiff and painful. The implant may begin to lose its attachment to the bone. Even if the implant remains properly fixed to the bone, pain, swelling, and drainage from the infection may make revision surgery necessary.

An antibiotic spacer placed in the knee during the first stage of treatment for joint replacement infection.

Revision for infection can be done in one of two ways, depending on the type of bacteria, how long the infection has been present, the degree of infection, and patient preferences.

  • Debridement. In some cases, the bacteria can be washed out, the plastic spacer can be exchanged, and the metal implants can be left in place.
  • Staged surgery. In other cases, the implant must be completely removed. If the implant is removed to treat the infection, your doctor will performthe revision in two separate surgeries. In the first surgery, he or she will remove the implant and place a temporary cement spacer in your knee. This spacer is treated with antibiotics to fight the infection and will remain in your knee for several weeks. During this time, you will also receive intravenous antibiotics. When the infection has been cleared, your doctor will perform a second surgery to remove the antibiotic spacer and insert a new prosthesis. In general, removing the implant leads to a higher chance of curing the infection, but is associated with a longer recovery.

Instability

If the ligaments around your knee become damaged or improperly balanced, your knee may become unstable. Because most implants are designed to work with the patient's existing ligaments, any changes in thoseligaments may prevent an implant from working properly. You may experience recurrent swelling and the sense that your knee is "giving way." If knee instability cannot be treated through nonsurgical means such as bracing and physical therapy, revision surgery may be needed.

Stiffness

Sometimes a total knee replacement may not help you achieve the range ofmotion that is needed to perform everyday activities. This may happen if excessive scar tissue has built up around the knee joint. If this occurs, your doctor may attempt "manipulation under anesthesia."In this procedure, you are given anesthesia so that you do not feel pain. The doctor then aggressively bends your knee in an attempt to break down the scar tissue. In most cases, this procedure is successful in improving range of motion. Sometimes, however, the knee remains stiff. If extensive scar tissue or the position of the components in your knee is limiting your range of motion, revision surgery may be needed.

Fractures

A periprosthetic fracture is a broken bone that occurs around the components of a total knee replacement. These fractures are most often the result of a fall, and usually require revision surgery.

In determining the extent of the revision needed, your doctor will consider several factors, including the quality of the remaining bone, the type and location of the fracture, and whether the implant is loose. When the bone is shattered or weakened from osteoporosis, the damaged section of bone may need to be completely replaced with a larger revision component.

COMPLEX KNEE REPLACEMENT

Complex knee replacement is, where patients have a painful arthritic knee with other conditions near or involving the knee joint, such as an old fracture of the lower femur or upper tibia which healed in a deformed or malunited position, or previous surgery with internal fixation devices(plates and screws),pronounced deformity due to significant bone stock loss and/ora grossly unstable knee due to stretching or tearing of ligaments, then a standard primary knee replacement may not suffice and a larger, complex primary knee replacement may be necessary.In this setting a variety of additional measures, including the use of more complex implants with longer stems, bone replacing metallic augments, bone grafting and larger plastic liners are often needed to restore the length and correct alignment of the lower limb and replace the missing bone stock, and adequately re-tension the collateral ligaments and other surrounding soft tissue structures.Where increasing degrees of deformity are corrected or previous trauma or surgery have resulted in attenuation of the collateral ligaments, if the degree of laxity is moderate, but there is adequate soft tissue such that,its likely with time and soft tissue healing, that the knee will develop some biological stability, then temporary balancing using a very stable tightly fitting or constrained plastic liner between the femoral and tibial components with a closely fitting cam-post articulation is apropriate.When significant bone stock loss from the shaft of the femur or tibia is present, such as after significant trauma, previous surgery or having to remove a bony or soft tissue tumour or address a non-correctable bony deformity, then a larger “endoprosthesis” may be needed to replace large segments of bone. These implants can be quite large and allow for reattachment of soft tissue structures such as the collateral ligaments and the patella tendons and require considerable preoperative planning and intra-operative attention to detail to try to correctly restore lower limb leg length and rotation of the femur and tibia to allow for adequate functioning of the extensor mechanism and lower limb nerves and blood vessels. Finally, where a combination of bony and soft tissue deficits exist, and it is not possible to achieve stability of the knee through the above described measures, it may be necessary to use a “rotating hinge” type knee replacement, where the mechanical device has a hinge that both flexes andextends and also rotates. These larger implants usually require a longer incision, a wider surgical approach and longer operative and recovery times. If consideration of an endoprosthesis or rotating hinge type implant isnecessary, many of the routine anatomical landmarks will often be absent, making it more difficult and less reliable to achieve the usually desirable range of motion and level of function in the knee, with a necessary shift in the overall goals of surgery away from a high level of function to achieving alower limb with approximately equal leg length with improved pain management and improved ability to stand and mobilise. Careful consideration is usually given to all patients being considered for knee replacements to help best identify in advance, who is likely to require such implants, but occasionally, unexpected intra-operative findings modify the selection of implants from the standard to a more constrained implant. It is still usually possible to achieve a good alignment, acceptable range of motion and stable, pain free or pain improved knee with these more complex knee replacements.

Schedule a visit

Dr. Chirag Thonse is available Monday to Saturday, 06:00 pm to 09:00 pm
at The Orthopaedic Clinic
Also, he is available at Vikram Hospital, Millers Road
(By Appointments only)