Knee Conditions & Procedure
At Joint Preservation Institute, we see a variety of knee conditions ranging from knee sprains to failed knee replacement. Common conditions including meniscus tears, ACL tears, cartilage injuries, tendon injuries, and arthritis.
Ligament Injuries
The knee is a complex joint which consists of bone, cartilage, ligaments and tendons that make joint movements easy and at the same time more susceptible to various kinds of injuries.
Knee problems may arise if any of these structures get injured by overuse or suddenly during sports activities. Pain, swelling, and stiffness are the common symptoms of any damage or injury to the knee. Common causes of knee injury include:
Fracture of the femur (thigh bone) or tibia and fibula (leg bones)
Torn ligament (either anterior or posterior cruciate ligament)
Rupture of blood vessels following a trauma that leads to accumulation of extra fluid or blood in the joint
Dislocation of knee cap (patella)
Torn quadriceps or hamstring muscles
Patellar tendon tear
ACL tear
An ACL injury is a sports related injury that occur when the knee is forcefully twisted or hyperextended. An ACL tear usually occurs with an abrupt directional change with the foot fixed on the ground or when the deceleration force crosses the knee. Changing direction rapidly, stopping suddenly, slowing down while running, landing from a jump incorrectly, and direct contact or collision, such as a football tackle can also cause injury to the ACL.
ACL Tears h-one-line
ACL Tears
The anterior cruciate ligament, or ACL, is one of the major ligaments of the knee that is in the middle of the knee and runs from the femur (thigh bone) to the tibia (shin bone). It prevents the tibia from sliding out in front of the femur. Together with posterior cruciate ligament (PCL) it provides rotational stability to the knee.
An ACL injury is a sports related injury that occur when the knee is forcefully twisted or hyperextended. An ACL tear usually occurs with an abrupt directional change with the foot fixed on the ground or when the deceleration force crosses the knee. Changing direction rapidly, stopping suddenly, slowing down while running, landing from a jump incorrectly, and direct contact or collision, such as a football tackle can also cause injury to the ACL.
When you injure your ACL, you might hear a "popping" sound and you may feel as though the knee has given out. Within the first two hours after injury, your knee will swell and you may have a buckling sensation in the knee during twisting movements.
Diagnosis of an ACL tear is made by knowing your symptoms, medical history, performing a physical examination of the knee, and performing other diagnostic tests such as X-rays, MRI scans, stress tests of the ligament, and arthroscopy.
Treatment options include both non-surgical and surgical methods. If the overall stability of the knee is intact, your doctor may recommend nonsurgical methods. Non-surgical treatment consists of rest, ice, compression, and elevation (RICE protocol); all assist in controlling pain and swelling. Physical therapy may be recommended to improve knee motion and strength. A knee brace may be needed to help immobilize your knee.
Young athletes involved in pivoting sports will most likely require surgery to safely return to sports. The usual surgery for an ACL tear is an ACL reconstruction which tightens your knee and restores its stability. Surgery to reconstruct an ACL is done with an arthroscope using small incisions. Your doctor will replace the torn ligament with a tissue graft that can be obtained from your knee (patellar tendon) or hamstring muscle. Following ACL reconstruction, a rehabilitation program is started to help you to resume a wider range of activities.
ACL Reconstruction
The anterior cruciate ligament is one of the major stabilizing ligaments in the knee. It is a strong rope like structure located in the center of the knee running from the femur to the tibia. When this ligament tears unfortunately, it does not heal and often leads to the feeling of instability in the knee.
ACL reconstruction is a commonly performed surgical procedure and with recent advances in arthroscopic surgery can now be performed with minimal incision and low complication rates.
ACL Reconstruction Hamstring Tendon
Anterior cruciate ligament (ACL) reconstruction hamstring method is a surgical procedure that replaces the injured ACL with a hamstring tendon. Anterior cruciate ligament is one of the four major ligaments of the knee that connects the femur (thigh bone) to the tibia (shin bone) and helps stabilize your knee joint. Anterior cruciate ligament prevents excessive forward movement of the lower leg bone (the tibia) in relation to the thigh bone (the femur) as well as limits rotational movements of the knee.
A tear of this ligament can make you feel as though your knees will not allow you to move or even hold you up. Anterior cruciate ligament reconstruction is surgery to reconstruct the torn ligament of your knee with a tissue graft.
Causes
An ACL injury most commonly occurs during sports that involve twisting or overextending your knee. An ACL can be injured in several ways:
Sudden directional change
Slowing down while running
Landing from a jump incorrectly
Direct blow to the side of your knee, such as during a football tackle
Symptoms
When you injure your ACL, you might hear a loud "pop" sound and you may feel the knee buckle. Within a few hours after an ACL injury, your knee may swell due to bleeding from vessels within the torn ligament. You may notice that the knee feels unstable or seems to give way, especially when trying to change direction on the knee.
Diagnosis
An ACL injury can be diagnosed with a thorough physical examination of the knee and diagnostic tests such as X-rays, MRI scans and arthroscopy. X-rays may be needed to rule out any fractures. In addition, your doctor will often perform the Lachman's test to see if the ACL is intact. During a Lachman test, knees with a torn ACL may show increased forward movement of the tibia and a soft or mushy endpoint compared to a healthy knee.
Pivot shift test is another test to assess ACL tear. During this test, if the ACL is torn, the tibia will move forward when the knee is completely straight and as the knee bends past 30° the tibia shifts back into correct place in relation to the femur.
Procedure
The goal of ACL reconstruction surgery is to tighten your knee and to restore its stability.
Anterior cruciate ligament reconstruction hamstring method is a surgical procedure to replace the torn ACL with part of the hamstring tendon taken from the patient's leg. The Hamstring is the muscle located on the back of your thigh. The procedure is performed under general anesthesia. Your surgeon will make two small cuts about 1/4-inch-long around your knee. An arthroscope, a tube with a small video camera on the end is inserted through one incision to see the inside of the knee joint. Along with the arthroscope, a sterile solution is pumped into the joint to expand it enabling the surgeon to have a clear view and space to work inside the joint. The knee is bent at right angles and the hamstring tendons felt. A small incision is made over the hamstring tendon attachment to the tibia and the two tendons are stripped off the muscle and the graft is prepared. The torn ACL will be removed and the pathway for the new ACL is prepared. The arthroscope is reinserted into the knee joint through one of the small incisions. Small holes are drilled into the upper and lower leg bones where these bones come together at the knee joint. The holes' form tunnels in your bone to accept the new graft. Then the graft is pulled through the predrilled holes in the tibia and femur. The new tendon is then fixed into the bone with screws to hold it into place while the ligament heals into the bone. The incisions are then closed with sutures and a dressing is placed.
Risks and complications
Possible risks and complications associated with ACL reconstruction with hamstring method include:
Numbness
Infection
Blood clots (Deep vein thrombosis)
Nerve and blood vessel damage
Failure of the graft
Loosening of the graft
Decreased range of motion
Crepitus (crackling or grating feeling of the kneecap)
Pain in the knee
Repeat injury to the graft
Post-operative care
Following the surgery, rehabilitation begins immediately. A physical therapist will teach you specific exercises to be performed to strengthen your leg and restore knee movement. Avoid competitive sports for 5 to 6 months to allow the new graft to incorporate into the knee joint.
Anterior cruciate ligament reconstruction is a very common and successful procedure. It is usually indicated in patients wishing to return to an active lifestyle especially those wishing to play sports involving running and twisting. Anterior cruciate ligament injury is a common knee ligament injury. If you have injured your ACL, surgery may be needed to regain full function of your knee.
PCL tear
PCL injuries are very rare and are difficult to detect than other knee ligament injuries. Cartilage injuries, bone bruises, and ligament injuries often occur in combination with PCL injuries. Injuries to the PCL can be graded as I, II or III depending on the severity of injury. In grade I the ligament is mildly damaged and slightly stretched, but the knee joint is stable. In grade II there is a partial tear of the ligament. In grade III there is a complete tear of the ligament and the ligament is divided into two halves making the knee joint unstable.
The PCL is usually injured by a direct impact, such as in an automobile accident when the bent knee forcefully strikes the dashboard. In sports, it can occur when an athlete falls to the ground with a bent knee. Twisting injury or overextending the knee can cause the PCL to tear.
Posterior Cruciate Ligament Injuries
Posterior cruciate ligament (PCL), one of four major ligaments of the knee are situated at the back of the knee. It connects the thighbone (femur) to the shinbone (tibia). The PCL limits the backward motion of the shinbone.
PCL injuries are very rare and are difficult to detect than other knee ligament injuries. Cartilage injuries, bone bruises, and ligament injuries often occur in combination with PCL injuries. Injuries to the PCL can be graded as I, II or III depending on the severity of injury. In grade I the ligament is mildly damaged and slightly stretched, but the knee joint is stable. In grade II there is partial tear of the ligament. In grade III there is complete tear of the ligament and the ligament is divided into two halves making the knee joint unstable.
The PCL is usually injured by a direct impact, such as in an automobile accident when the bent knee forcefully strikes the dashboard. In sports, it can occur when an athlete falls to the ground with a bent knee. Twisting injury or overextending the knee can cause the PCL to tear.
Patients with PCL injuries usually experience knee pain and swelling immediately after the injury. There may also be instability in the knee joint, knee stiffness that causes limping, and difficulty in walking.
Diagnosis of a PCL tear is made based on your symptoms, medical history, and by performing a physical examination of the knee. Other diagnostic tests such as X-rays and MRI scan may be ordered. X-rays are useful to rule out avulsion fractures wherein the PCL tears off a piece of bone along with it. An MRI scan is done to help view the images of soft tissues better.
Treatment options may include non-surgical and surgical treatment. Non-surgical treatment consists of rest, ice, compression, and elevation (RICE protocol); all assist in controlling pain and swelling. Physical therapy may be recommended to improve knee motion and strength. A knee brace may be needed to help immobilize your knee. Crutches may be recommended to protect your knee and avoid bearing weight on your leg.
Generally, surgery is considered in patients with dislocated knee and several torn ligaments including the PCL. Surgery involves reconstructing the torn ligament using a tissue graft which is taken from another part of your body, or a cadaver (another human donor). Surgery is usually carried out with an arthroscope using small incisions. The major advantages of this technique include minimal postoperative pain, short hospital stay, and a fast recovery. Following PCL reconstruction, a rehabilitation program will be started that helps you resume a wider range of activities. Usually, a complete recovery may take about 6 to 12 months.
Surgery is not usually necessary to treat PCL injuries but if an injury displaces the piece of bone with the PCL, your child may have surgery to reattach it again.
PCL Reconstruction
Posterior cruciate ligament (PCL), one of four major ligaments of the knee are situated at the back of the knee. It connects the thighbone (femur) to the shinbone (tibia). The PCL limits the backward motion of the shinbone.
PCL injuries are very rare and are difficult to detect than other knee ligament injuries. Cartilage injuries, bone bruises, and ligament injuries often occur in combination with PCL injuries. Injuries to the PCL can be graded as I, II or III depending on the severity of injury. In grade I the ligament is mildly damaged and slightly stretched, but the knee joint is stable. In grade II there is partial tear of the ligament. In grade III there is complete tear of the ligament and the ligament is divided into two halves making the knee joint unstable.
The PCL is usually injured by a direct impact, such as in an automobile accident when the bent knee forcefully strikes the dashboard. In sports, it can occur when an athlete falls to the ground with a bent knee. Twisting injury or overextending the knee can cause the PCL to tear.
Patients with PCL injuries usually experience knee pain and swelling immediately after the injury. There may also be instability in the knee joint, knee stiffness that causes limping, and difficulty in walking.
Diagnosis of a PCL tear is made based on your symptoms, medical history, and by performing a physical examination of the knee. Other diagnostic tests such as X-rays and MRI scan may be ordered. X-rays are useful to rule out avulsion fractures wherein the PCL tears off a piece of bone along with it. An MRI scan is done to help view the images of soft tissues better.
Treatment options may include non-surgical and surgical treatment. Non-surgical treatment consists of rest, ice, compression, and elevation (RICE protocol); all assist in controlling pain and swelling. Physical therapy may be recommended to improve knee motion and strength. A knee brace may be needed to help immobilize your knee. Crutches may be recommended to protect your knee and avoid bearing weight on your leg.
Generally, surgery is considered in patients with dislocated knee and several torn ligaments including the PCL. Surgery involves reconstructing the torn ligament using a tissue graft which is taken from another part of your body, or a cadaver (another human donor). Surgery is usually carried out with an arthroscope using small incisions. The major advantages of this technique include minimal postoperative pain, short hospital stay, and a fast recovery. Following PCL reconstruction, a rehabilitation program will be started that helps you resume a wider range of activities. Usually, a complete recovery may take about 6 to 12 months.
MPFL Reconstruction
Medial patellofemoral ligament reconstruction is a surgical procedure indicated in patients with more severe patellar instability. Medial patellofemoral ligament is a band of tissue that extends from the femoral medial epicondyle to the superior aspect of the patella. Medial patellofemoral ligament is the major ligament which stabilizes the patella and helps in preventing patellar subluxation (partial dislocation) or dislocation. This ligament can rupture or get damaged when there is patellar lateral dislocation. Dislocation can be caused by direct blow to the knee, twisting injury to the lower leg, strong muscle contraction, or because of a congenital abnormality such as shallow or malformed joint surfaces.
Medial patellofemoral ligament reconstruction using autogenous tissue grafts is done by following the basic principles of ligament reconstruction such as:
Graft Selection: Strong and stiff graft should be selected
Location: The graft should be located isometrically
Correct tension: The tension set in the graft should be appropriate
Secure Fixation: Stable fixation of the graft should be achieved
Avoid condylar rubbing or impingement: The graft should not rub against condyle or cause impingement
Surgical Technique
The surgical procedure of medial patellofemoral ligament reconstruction involves the following steps:
Graft Selection and Harvest: Your surgeon will make a 4-6 cm skin incision over your knee, at the midpoint between the medial epicondyle and the medial aspect of the patella (knee cap). The underlying subcutaneous fat and fascia are cut apart to expose the adductor tendon. The tendon is then stripped using a tendon stripper and its free end is sutured. The diameter of the tendon graft is measured using a sizer.
Alternatively, a graft can be harvested from the quadriceps tendon.
Location of the femoral isometric point: The graft should be placed isometrically to prevent it from overstretching and causing failure during joint movements. A transverse hole measuring 2.5 mm is made through the patella. Then a small incision is made over the lateral side of the patella and a strand of Vicryl suture material is inserted through the hole. Over this strand, a 2.5 mm Kirschner wire (K-wire) is passed and then inserted into the bone besides the medial epicondyle.
An instrument called pneumatic isometer is inserted into the hole made in the patella and the Vicryl isometric measurement suture material is also passed along. The knee is taken through its full range of motion and any changes happening in the length between the medial epicondylar K-wire and the medial aspect of the patella is recorded on the isometer. The position of the K-wire will be adjusted until no deviations are read on the isometer during full range of motion. Once the isometric point is identified, a tunnel is drilled starting from the insertion of the adductor tendon uptil the isometric point is reached. The graft is pulled through this tunnel, then exits at the medial condyle and again passed through another tunnel that is made through the patella.
Correct tension: The tension is set in the graft with your knee flexed up to 90º and the tension should be appropriate enough to control lateral excursion.
Secure fixation: After bringing the tendon graft from the medial to the lateral side through the bone tunnel, it turned onto the front surface of the patella where it is sutured.
Avoid condylar rubbing and impingement: After graft fixation, the range of motion is checked to make sure there are no restrictions in patellar or knee movements. The graft should not impinge or rub against the medial femoral condyle. If it is detected, the graft is replaced into proper position.
Post-operative care
A knee brace should be used during walking in the first 3-6 weeks after surgery. Avoid climbing stairs, squatting and stretching your leg until there is adequate healing of the tendon. Rehabilitation exercises, continuous passive motion and active exercises will be recommended.
Tibial Tubercle Osteotomy
Tibial tubercle osteotomy is a surgical procedure which is performed along with other procedures to treat patellar instability, patellofemoral pain, and osteoarthritis. This is a quite safe procedure and provides excellent access and surgical exposure during a difficult primary or revision total knee arthroplasty. Surgical treatment is indicated when physical therapy and other nonsurgical methods have failed and there is history of multiple knee dislocations. Tibial tubercle transfer technique involves realignment of the tibial tubercle (a bump in the front of the shin bone) such that the knee cap (patella) traverses in the center of the femoral groove. The patellar maltracking is corrected by moving the tibial tubercle medially, towards the inside portion of the leg. This removes the load off the painful portions of the knee cap and reduces the pain.
Surgical technique
The procedure is performed under general anesthesia and you will be completely unaware of the surgery until you wake up in the recovery room. At first, knee arthroscopy will be performed to inspect the inside portions of the knee joint. It involves small incisions or portals through which small instruments are passed and a video camera is used to visualize the anatomy of the knee joint, evaluate patella cartilage and assess patella tracking.
Tibial tubercle osteotomy and transfer is done through an incision made in the front of your leg just below the patella. In osteotomy procedure, a periosteal incision of 8-10 cm length is made at 1cm medial to the tibial tubercle. With the help of an oscillating saw, a cut is made medial to the tuberosity and a distal cut is also made. The tapered design of the distal cut avoids the risk of tibial fracture. Similarly, a proximal cut is made using appropriate instruments such as curved osteotome or reciprocating saw. Then an osteotomy through the bone cortex is performed without cutting off the lateral periosteum. The lateral periosteum serves as a point of attachment for the osteotomy segment. By doing this, a tibial tubercle segment which is more than 2 cm in width, more than 1 cm in thickness and 8-10 cm length can be obtained. It should include all portions of insertion of the patellar tendon. The segment from the tibia is then levered using osteotome to provide access to the medullary canal of the tibia.
The osteotomy segment is then moved under direct vision into a position that assures proper tracking of the patella. The tracking pattern can be confirmed arthroscopically. The mobilized bone is then fixed into its new place using screws, which can be removed later if they cause irritation.
Post-surgery Care
You may have minimal to moderate knee discomfort for several days or weeks after the surgery. Oral pain medications will be prescribed that helps control your pain. Keep the operated leg elevated and apply ice bag over the area for 20 minutes. This decrease swelling as well as pain. You will have a leg brace which may be removed only while sitting with your leg elevated and when using the continuous passive motion (CPM) unit. Physical therapy exercises should be done as it helps in regaining mobility. Eat healthy food and drink plenty of water.
Risks and complications
Risks following tibial tubercle osteotomy surgery are rare but may include compartment syndrome, deep vein thrombosis, infections and delayed bone healing.
Cartilage injuries
Articular or hyaline cartilage is the tissue lining the surface of the two bones in the knee joint. Cartilage helps the bones move smoothly against each other and can withstand the weight of the body during activities such as running and jumping. Articular cartilage does not have a direct blood supply to it so has less capacity to repair itself. Once the cartilage is torn it will not heal easily and can lead to degeneration of the articular surface, leading to development of osteoarthritis.
The damage in articular cartilage can affect people of all ages. It can be damaged by trauma such as accidents, mechanical injury such as a fall, or from degenerative joint disease (osteoarthritis) occurring in older people.
Patients with articular cartilage damage experience symptoms such as joint pain, swelling, stiffness, and a decrease in range of motion of the knee. Damaged cartilage needs to be replaced with healthy cartilage and the procedure is known as cartilage replacement. It is a surgical procedure performed to replace the worn-out cartilage and is usually performed to treat patients with small areas of cartilage damage usually caused by sports or traumatic injuries. It is not indicated for those patients who have advanced arthritis of knee.
Cartilage replacement helps relieve pain, restore normal function, and can delay or prevent the onset of arthritis. The goal of cartilage replacement procedures is to stimulate growth of new hyaline cartilage. Various arthroscopic procedures involved in cartilage replacement include:
Microfracture
Drilling
Abrasion Arthroplasty
Autologous chondrocyte implantation (ACI)
Osteochondral Autograft Transplantation
Meniscal Injuries
The knee is one of the most complex and largest joint in the body, and is more susceptible to injury. Meniscal tears are one among the common injuries to the knee joint. It can occur at any age, but are more common in athletes playing contact sports.
The meniscus is a small, "c" shaped piece of cartilage in the knee. Each knee consists of two menisci, medial meniscus on the inner aspect of the knee and the lateral meniscus on the outer aspect of the knee. The medial and lateral meniscus act as cushion between the thigh bone (femur) and shin bone (tibia). The meniscus has no direct blood supply and for that reason, when there is an injury to the meniscus, healing cannot take place. The meniscus acts like a "shock absorber" in the knee joint.
Meniscal tears often occur during sports. These tears are usually caused by twisting motion or over flexing of the knee joint. Athletes who play sports such as football, tennis and basketball are at a higher risk of developing meniscal tears. They often occur along with injuries to the anterior cruciate ligament, a ligament that crosses from the femur (thigh bone) to the tibia (shin bone).
Various types of meniscal tears that can occur are longitudinal, bucket handle, flap, parrot -beak and mixed or complex.
The symptoms of a meniscal tear include:
Knee pain when walking
A "popping "or "clicking" may be felt at the time of injury
Tenderness when pressing on the meniscus
Swelling of the knee
Limited motion of the knee joint
Joint locking can occur if the torn cartilage gets caught between the femur and tibia preventing straightening of the knee
A careful medical history and physical examination can help diagnose meniscal injury. The McMurray test is one of the important tests for diagnosing meniscal tears. During this test, your doctor will bend the knee is, then straighten and rotate it in and out. This creates pressure on the torn meniscus. Pain or a click during this test may suggest a meniscal tear. Your doctor may order imaging tests such as knee joint X-ray and knee MRI to help confirm the diagnosis.
The treatment depends on the pattern and location of the tear. If the meniscal tear is not severe, your child's doctor may begin with non-surgical treatments that may include:
Rest: Avoid activities that may cause injury. Your child may need to use crutches temporarily to limit weight bearing.
Ice: Ice application to reduce swelling
Pain medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) to help reduce swelling and pain
Physical Therapy: Physical therapy may be recommended for muscle and joint strengthening.
If the symptoms are persisting and conservative treatment fails, your child may need a knee arthroscopic surgery to repair the torn meniscus.
Meniscal Tears
Meniscus tear is the commonest knee injury in athletes, especially those involved in contact sports. A suddenly bend or twist in your knee cause the meniscus to tear. This is a traumatic meniscus tear. Elderly people are more prone to degenerative meniscal tears as the cartilage wears out and weakens with age. The two wedge-shape cartilage pieces' present between the thighbone and the shinbone are called meniscus. They stabilize the knee joint and act as "shock absorbers".
Torn meniscus causes pain, swelling, stiffness, catching or locking sensation in your knee making you unable to move your knee through its complete range of motion. Your orthopaedic surgeon will examine your knee, evaluate your symptoms, and medical history before suggesting a treatment plan. The treatment depends on the type, size and location of tear as well your age and activity level. If the tear is small with damage in only the outer edge of the meniscus, nonsurgical treatment may be sufficient. However, if the symptoms do not resolve with nonsurgical treatment, surgical treatment may be recommended.
Surgical Treatment
Knee arthroscopy is the commonly recommended surgical procedure for meniscal tears. The surgical treatment options include meniscus removal (meniscectomy), meniscus repair, and meniscus replacement. Surgery can be performed using arthroscopy where a tiny camera will be inserted through a tiny incision which enables the surgeon to view inside of your knee on a large screen and through other tiny incisions, surgery will be performed. During meniscectomy, small instruments called shavers or scissors may be used to remove the torn meniscus. In arthroscopic meniscus repair the torn meniscus will be pinned or sutured depending on the extent of tear.
Meniscus replacement or transplantation involves replacement of a torn cartilage with the cartilage obtained from a donor or a cultured patch obtained from laboratory. It is considered as a treatment option to relieve knee pain in patients who have undergone meniscectomy.
Meniscal Injuries
The meniscus is a flexible tissue within the knee which helps to distribute the pressures from the rounded end of the femur onto the relatively flat tibia. The meniscus can often tear due to trauma or in the setting of arthritis. In some cases, the entire meniscus can tear from its edge leading to the appearance of a bucket handle. The source of pain from meniscus tears is not definitely known however one of the theories is that the tear causes traction on the capsule of the joint which is highly innervated. Additionally, a meniscus fragment can be lodged in the joint and can act as a foreign body leading to clicking and even locking the knee in a certain position with substantial pain. The healing potential of a tear of the meniscus depends on the presence of blood supply which can provide cells and chemical mediators to heal the tear. The blood supply is diminished in the central edge of the meniscus. This area is termed the "white zone". Tears in this region are best treated with debridement and removal of the torn segment. In the event of a tear in the outer, more vascular region ("red zone"), the meniscus can be repaired using various techniques. Prior to the advent of arthroscopy and our current knowledge of the importance of the meniscus, surgeons routinely removed the entire meniscus in the event of a tear. Currently, using arthroscopic instruments, most surgeons simply remove the injured region or attempt to repair the meniscus based on the location. If the entire meniscus is severely damaged and has to be removed, that portion of the knee is almost guaranteed to develop osteoarthritis. In such cases, the transplantation of a frozen meniscus cadaveric graft (allograft) is a recently available option. In this procedure, a frozen meniscus with bone plugs at the ends is transferred to the affected compartment. The bone plugs are placed in bone tunnels in the affected tibia and the soft tissue portion of the meniscus is sewn to the outer envelope of the joint (the capsule). The goals of meniscal transplantation is to decrease pain in the knee, to preserve the joint cartilage by reducing high contact pressures exposed to it, and to help restore the stabilizing effect of the meniscus on the knee.
Meniscal Transplantation
In cases of a severely damaged meniscus tear in a young patient with persistent knee pain and evidence of early arthritis, a meniscus transplant may be indicated. In this procedure, a frozen meniscus with bone plugs at the ends is transferred to the affected compartment. The bone plugs are placed in bone tunnels in the affected tibia and suture through the bone tunnels. The soft tissue portion of the meniscus is sewn to the outer envelope of the joint (the capsule). The performance of a meniscus transplant has been shown to decrease pain and improve function in patients with total or subtotal meniscal injuries. Over time, the patients own cells can repopulate the meniscal tissue. The goals of meniscal transplantation is to decrease pain in the knee, to preserve the joint cartilage by reducing high contact pressures exposed to it, and to help restore the stabilizing effect of the meniscus on the knee.
CLINICAL CASE: MEDIAL MENISCUS TRANSPLANTATION
The patient is a 40 year old male with a work related twisting injury to his right knee. He underwent nearly complete medial meniscectomy of his knee at an outside institution. He continues to complain of knee pain on the medial aspect of his knee.
1.The standard radiographs of his knee show minimal evidence of arthritis.
2.Standing alignment radiographs are routinely obtained. These demonstrate a mechanical and anatomical alignment that is within the normal range eliminating the need for corrective osteotomy.
3.A coronal MRI image demonstrates the complete absence of the posteromedial aspect of the medial meniscus.
4.Meniscal allograft transplantation was recommended to the patient based on the overall healthy appearance of his articular cartilage, the normal alignment of the lower extremity, and the near complete absence of the posterior horn of the medial meniscus. In the image at the top of the series of 3 above, the meniscus tissue is shown to be completely absent (black arrow) from the edge (capsule) of the joint. In the image in the center, the allograft meniscus is shown at the time of surgery. On the image at the bottom of the series of 3 above, the post-transplantation images of the graft are shown (black arrow)
Knee Angular Deformities
Angular deformities of the knee are common during childhood and usually are variations in the normal growth pattern. Angular deformity of the knee is a part of normal growth and development during early childhood. Physiologic angular deformities vary with age as:
During first year: Lateral bowing of tibia
During second year: Bow legs (knees and tibia)
Between 3-4 years: Knock Knees
The condition usually becomes more evident when the child is 2 to 3 years old and normally corrects itself by the time a child is 7 or 8 years old. However, if the condition is not corrected it could be a sign of an underlying disease that requires treatment.
A perfectly aligned knee has its load-bearing axis on a line that runs through the hip, knee and ankle. Based on the inward/ outward inclination of the head of tibia/fibula; knee angular deformities are classified as:
Genu valgum (knock-kneed): Head of tibia/fibula (not the joint itself), is inclined away from the midline of the body
Genu varum (bow-legged): Head of tibia/ fibula is inclined toward the midline of the body
Genu Varum (bowed legs): Bowed legs are very common in toddlers. If a child has bowlegs, one or both legs curve outwards. When your child stands, there is a distinct space between the lower legs and knees. Bowed legs are rarely seen in adolescents. In most of the cases, children with bowed legs are significantly overweight.
The common causes of bowed legs include:
Physiologic Genu Varum: Most children below the age of 2, show bowing of the legs as a part of normal physiological process. Normally the bowing will correct by 3 to 4 years of age and the legs may have a normal appearance.
Blount's disease: It is a condition in which there is an abnormality of the growth plate at the upper portion of the tibia (shinbone).
Rickets: It is bone disease that occurs in children due to deficiency of calcium, phosphorus, or vitamin D that are essential for healthy bone growth.
Trauma
Infection
Tumor
The most obvious symptom is bowing of the legs that appear when a child stands and walks. Other common symptoms are awkward walking pattern and turning in of the feet (intoeing). Bowed legs usually does not cause any pain, however discomfort in the hips, knees, and/ or ankles may occur during adolescence.
Genu valgum (knock-kneed)
Knock knees is a condition in which the legs curve inward at the knees. When a child stands, the knees appear to bend toward each other and the ankles are spread apart.
Knock knees most often develop as a part of normal growth. In some cases, especially if the child is 6 years of age or older, knock-knees may occur because of other medical problems such as injury of the shin bone, osteomyelitis (bone infection), overweight, and rickets.
Diagnosis
The diagnosis of bow legs or knock knees is made through a physical examination. In addition, X-rays may be taken if a child is older than 2 ½ years and has symmetrical legs.
Treatment for Bow legs
As the child grows the condition usually corrects itself. For children with severe, unresolved bow legs, doctors may recommend non-surgical treatment options such as bracing, physical therapy, and medications. If non-surgical treatment options do not correct your child's bow legs, then surgery is considered.
Treatment for Knock?knees
Most children with knock knees do not require any treatment, but if the condition persists after age 7, then a night brace attached to an orthopaedic shoe may be recommended. If the separation between the ankles is severe, surgery may be an option.
Osteotomies are the mainstay of the concept of joint preservation surgery. Many of our younger patients are not candidates for joint replacement. Our goal is to provide pain relief and return to activities with their own native joint. Osteotomies are surgeries to realign the bones. They are helpful in cases of localized arthritis or deformities. We use a variety of techniques to make these corrections including combinations of these surgeries with cartilage restoration surgeries and ligament reconstructions.
High Tibial Osteotomy
Osteotomy is defined as "the surgical division or sectioning of bone". Osteotomies are commonly used in the treatment of deformities from congenital or traumatic conditions. Osteotomy has also been applied to cases of knee arthritis isolated to one part of the knee with relative sparing of the other parts. In such cases, the alignment of the leg can be changed to shift the weightbearing line from an area of more damaged cartilage to that of healthy cartilage. High tibial osteotomy is aimed at changing the alignment of the knee to unload the medial (inner) aspect of the knee. It has been widely employed over the past 30 years in cases of isolated medial compartment athritis. The osteotomy for this indication is usually performed on the tibia to maintain the joint parallel to the ground. Early osteotomies were associated with a high rate of complications such as wound breakdown, delayed union, nerve injury, and difficulty with conversion to total knee replacement. More recent advances in fixation technology and our understanding of this procedure have led to a lower complication rate. Traditionally, the osteotomy is indicated in very young patients who would like to continue with an active lifestyle and have isolated arthritis of the medial compartment of the knee such as after a meniscectomy. We perform the procedure using a plate on the inner aspect of the tibia and occasionally use bone graft from the patient's iliac crest or from a bone bank. Patients are kept in the hospital for 1-2 days and are on crutches for about 6 weeks after the surgery.
High Tibial Osteotomy Clinical Case
The patient is a 17 year old male who had a motorbike accident with an upper tibial fracture just below the growth plate. He developed a knock kneed (valgus) deformity which caused him substantial knee pain.
1.This xray at the time of the injury shows the fracture below the growth plate (white arrows)
2.Standing alignment radiographs show that he has developed a knock-kneed (valgus) deformity on the right side.
3.Using a specialized computer program, a computerize preoperative plan is created correcting the deformity and providing us with a guide to achieve complete correction of the deformity.
4.Postoperative images showing the use of a titanium plate and a synthetic graft to achieve the desired correction.
Distal Femoral Osteotomy
In cases of isolated arthritis on the outer aspect of the knee combined with a knock-knee deformity (genu valgum), one potential treatment option is an osteotomy of the end of the femur. An osteotomy is a surgical procedure where the end of the femur bone is cut and the femur is realigned to eliminate the deformity. This procedure is done to correct deformities as well as to better distribute the joint contact pressures onto the medial (inner) part of the knee. The osteotomy is usually stabilized with a plate. Patients remain on crutches for about 6 to 8 weeks until there is evidence of healing of the osteotomy. The osteotomy is a good alternative to partial knee replacement in the younger and more active age population.
Distal Femoral Osteotomy Clinical Case
The following case describes a 20 year old female with knee pain and a severe knock-knee deformity (genu valgum) of both of her knees. She had not responded to physical therapy or medications.
1. This long casette radiograph demonstrates the severe deformity in her femurs that is causing the knock-knee deformity. She elected to undergo a correctional osteotomy of the femur in order to help her pain as well as to decrease the chance of progression of arthritis in the outer part of her knee. The contours of the femur are traced on paper and the correction of the deformity is planned.
2.This final radiograph demonstrates the profound correction of the deformity. The osteotomy takes approximately eight weeks to heal. The patient is kept on crutches throughout this period of time.
References
Insall JN. High tibial osteotomy in the treatment of osteoarthritis of the knee. Surg Annu. 1975;7:347-359.
Mallory TH, Dolibois JM. Unicompartment total knee replacement: a 2--4 year review. Clin Orthop Relat Res. Jul-Aug 1978(134):139-143.
Aglietti P, Rinonapoli E, Stringa G, Taviani A. Tibial osteotomy for the varus osteoarthritic knee. Clin Orthop Relat Res. Jun 1983(176):239-251.
Brouwer RW, Jakma TS, Bierma-Zeinstra SM, Verhagen AP, Verhaar J. Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev. 2005(1):CD004019.
Feeley BT, Gallo RA, Sherman S, Williams RJ. Management of osteoarthritis of the knee in the active patient. J Am Acad Orthop Surg. Jul 2010;18(7):406-416.
Fu D, Li G, Chen K, Zhao Y, Hua Y, Cai Z. Comparison of high tibial osteotomy and unicompartmental knee arthroplasty in the treatment of unicompartmental osteoarthritis: a meta-analysis. J Arthroplasty. May 2013;28(5):759-765.
Gardiner A, Richmond JC. Periarticular osteotomies for degenerative joint disease of the knee. Sports Med Arthrosc. Mar 2013;21(1):38-46.
Bonasia DE, Governale G, Spolaore S, Rossi R, Amendola A. High tibial osteotomy. Curr Rev Musculoskelet Med. Dec 2014;7(4):292-301.
Brouwer RW, Huizinga MR, Duivenvoorden T, et al. Osteotomy for treating knee osteoarthritis. Cochrane Database Syst Rev. Dec 13 2014;12:CD004019.
Osteochondritis Dissecans
Osteochondritis dissecans is a joint condition in which a piece of cartilage, along with a thin layer of the bone separates from the end of the bone because of inadequate blood supply. The separated fragments are sometimes called "joint mice". These fragments may be localized, or may detach and fall into the joint space causing pain and joint instability.
Anatomy
The knee, mostly the femoral condyles are most commonly affected. The two femoral condyles make up for the rounded end of femur (thigh bone). Each knee has two femoral condyles, the medial femoral condyle on the inside of the knee and the lateral femoral condyle on the outside of the knee. Osteochondritis dissecans occurs within the lateral aspect of the medial femoral condyle. The condition can also occur in other joints, including your elbows, ankles, shoulders and hips.
Incidence
Osteochondritis dissecans is more common among boys and young men between 10 and 20 years who actively take part in sports Athletes participating in sports such as gymnastics and baseball may develop osteochondritis dissecans.
Causes
Exact cause for osteochondritis dissecans remains unknown and certain factors such as trauma, fractures, sprains, or injury to the joint are considered to increase the risk of developing the condition. Osteochondritis dissecans may be caused by restricted blood supply to the end of the affected bone that usually occurs in conjunction with repetitive trauma. Following the injury or trauma, the bones in the area may be deprived of blood flow leading to necrosis and finally the bone fragment may break off. This may initiate the healing process however by this time, articular cartilage will be compressed, flattened, and a subchondral cyst will be developed. All these changes in addition to increased joint pressure cause failure of healing of the joint.
The appearance of osteochondritis dissecans in several family members may indicate that the condition is inherited.
Symptoms
Patients with osteochondritis dissecans usually have joint pain, swelling, stiffness, decreased range of motion, and joint popping or locking. Pain usually increases after activity.
Diagnosis
Your doctor will probably order an X-ray of both the right and left knee to see the abnormality in the joint space and to compare them. You may also have a CT or MRI scan that is useful in determining the location of loose fragments within the joint.
Treatment
Your physician may recommend various treatments depending on the reports of diagnostic scans, age, severity, stability of the cartilage and other factors. Goals of treatment are to relieve the symptoms and stop or impede the progression of degeneration of the joint. Conservative treatment approaches such as wait & watch approach, pain medications, and immobilization for 1-2 weeks are recommended if the condition is diagnosed at early stages and if the severity is mild. However, surgery is required if the condition is diagnosed at advanced stage or if the condition is severe.
Surgical correction of osteochondritis dissecans can be done using by open technique or arthroscopic techniques. Some of the surgical procedures include drilling, bone grafting, open reduction internal fixation, osteochondral grafting, or autologous chondrocyte implantation (ACI).
Drilling - In this method multiple small holes are drilled into the bone which allows the growth of new blood vessels in the defect area. This promotes blood flow into defect area thereby initiating the healing response and formation of new cartilage cells inside the lesion
Open reduction internal fixation - Open surgery is performed in cases where the defected area is difficult to reach with arthroscope. Hence an open incision may be required. In this procedure, an incision is made in front of the joint to allow the surgeon to see the joint and the loose bodies are removed. Internal fixation involves fixing the fragments using internal fixators such as metal screws, pins, or wires
Bone grafting - It helps to fill the gap after removal of the dead or necrotic bone. In this procedure bone graft is placed on the damaged site. This procedure may be performed to repair the damaged area or replace the missing bone. Auto graft (harvested from the same individual) or allograft (taken from bone bank) may be required to help in the growth of a new bone
Osteochondral grafting - The procedure involves transfer of healthy cartilage plugs from the non-weight bearing areas of the joint and transferring into the damaged areas of the joint in mosaic pattern. It allows the newly implanted bone and cartilage to grow in the defected area. Grafts may be taken from the same individual (auto graft) or from a donor or bone bank (allograft)
Autologous chondrocyte implantation (ACI) - In this procedure healthy cartilage cells are harvested from the non-weight-bearing joint of the patient and cultured in laboratory. The cultured cartilage tissue patch will be implanted into the defected area which also promotes the growth of new cartilage
Knee Arthritis
Arthritis is a general term covering numerous conditions where the joint surface or cartilage wears out. The joint surface is covered by a smooth articular surface that allows pain free movement in the joint. This surface can wear out for various reasons; often the definite cause is not known. When the articular cartilage wears out the bone ends rub on one another and cause pain. This condition is referred to as Osteoarthritis or "wear and tear" arthritis as it occurs with aging and use. It is the most common type of arthritis.
Causes of Arthritis
There are numerous conditions that can cause arthritis but often the exact cause is never known. In general, but not always, it affects people as they get older (Osteoarthritis).
Other causes include:
Trauma (fracture)
Increased stress such as overuse and overweight
Infection of the bone
Connective tissue disorders
Inactive lifestyle and Obesity (overweight); Your weight is the single most important link between diet and arthritis as being overweight puts an additional burden on your hips, knees, ankles, and feet.
Inflammation (Rheumatoid arthritis)
Symptoms
Knee Arthritis causes pain and decreased mobility of the knee joint. In the arthritic knee there is an absent joint space that shows on X-ray. In the normal knee there is a normal joint space.
Arthritic knee
The cartilage lining is thinner than normal or completely absent. The degree of cartilage damage and inflammation varies with the type and stage of arthritis. The capsule of the arthritic knee is swollen. The joint space is narrowed and irregular in outline; this can be seen in an X-ray image. Bone spurs or excessive bone can also build up around the edges of the joint. The combinations of these factors make the arthritic knee stiff and limit activities due to pain or fatigue.
Management of Osteoarthritis
There are several treatments and lifestyle modifications that can help you ease your pain and symptoms.
Medications: Pain-relieving medications such as anti-inflammatories and simple analgesics may be prescribed. Topical medications such as ointments can be applied to the painful joints. If the pain is very severe, a corticosteroid injection can be given directly into the joint to help ease the pain.
Other Treatments: Your physiotherapist will teach you exercises to keep your joints flexible and improve your muscle strength. Applying hot or cold packs to the joints provides temporary pain relief. Lifestyle modifications can help. Measures such as losing weight and avoiding extra stress on the weight-bearing joints will often afford temporary relief.
Cortisone Injection h-one-line
Cortisone Injection
Cortisone is a corticosteroid released by the adrenal gland in response to stress and is a potent anti-inflammatory agent. Artificial preparations containing cortisone are injected directly into the affected joint to relieve pain and reduce inflammation. The effects may last for several weeks and cortisone injections are recommended in injuries that cause pain & inflammation and those don’t require surgical treatment. One such condition frozen shoulder and cortisone injection into shoulder joint relieves pain & inflammation.
Cortisone injections offer significant relief in pain & inflammation however is associated with certain adverse effects. The most common side effect is a “cortisone flare”, a condition where cortisone crystallizes and cause severe pain for a brief period that lasts for a day or two. Cortisone flare can be minimized by applying ice to the injected area. Other adverse effects include whitening of the skin and infection at the injection site, a transient elevation in blood sugar in patients with diabetes.
Viscosupplementation h-one-line
Viscosupplementation
Viscosupplementation refers to the injection of a hyaluronan preparation into the joint. Hyaluronic acid is a large molecule that is found in our normal joint fluid. It helped to assist in lubrication. It allows smooth movement of the cartilage covered articulating surfaces of the joint.
There are a number of hyaluronan injectables on the market. Supartz is one of the most commonly used hyaluronan preparations. It is indicated in the management of shoulder, knee, hip or ankle osteoarthritis that has not responded to non-surgical treatment options such as pain medications, physical therapy and corticosteroid injections.
Supartz provides symptomatic relief and delays the need for surgery. It is injected directly into the joint to replenish the diminished synovial fluid, thereby enhancing its lubricating properties. A total of three separate doses of Supartz , over several weeks, may be required for optimum benefit.
Some patients may experience mild pain, swelling, warmth and redness at the injection site for up to 48 hours following a Supartz injection. Headache and joint stiffness may also occur in some cases. Ice packs and an analgesic may be used, if required, to ease the discomfort. Any strenuous activity such as jogging or tennis should be completely avoided for 48 hours to a week after the injection and should be resumed only after consultation with your doctor.
Supartz injection not only supplements the hyaluronan in the joint but also stimulates the production of hyaluronan in the treated knee. This provides gradual symptomatic relief over the course of the injections. This effect may last for several months.
Please note: If you have had an injection at our office and develop fever or if the pain and swelling fail to resolve after 48 hours following the injection, please call us immediately.
Platelet Rich Plasma (PRP) h-one-line
Our blood consists of a liquid component known as plasma. It also consists of three main solid components which include the red blood cells (RBCs), white blood cells (WBCs), and platelets. Platelets play an important role in forming blood clots. They also consist of special proteins, known as growth factors, which help with our body’s healing process. Platelet-rich plasma or PRP is a high concentration of platelets and plasma. A normal blood specimen contains only 6% platelets, while platelet-rich plasma contains 94% of platelets and 5 to 10 times the concentration of growth factors found in normal blood, thus greater healing properties.
Indications
PRP is a relatively new method of treatment for several orthopaedic conditions such as muscle, ligament, and tendon injuries; arthritis; and fractures. PRP injections can help alleviate painful symptoms, promote healing and delay joint replacement surgeries.
Procedure
Your doctor will first draw about 10 ccs of blood from the large vein in your elbow. The blood is then spun in a centrifuge machine for about 10 to 15 minutes to separate the platelets from the remaining blood components.
The injured part of your body is then anesthetized with a local anesthetic. The platelet-rich portion of your blood is then injected into your affected area. In some cases, your doctor may use ultrasound guidance for proper needle placement.
Post-Procedural Care
It is normal to feel some discomfort at the injection site for a few days after your procedure.
You will be prescribed pain medications by your doctor.
You may use cold compresses to alleviate your symptoms.
You will be instructed to stop any anti-inflammatory medications.
You may resume your normal activities but should avoid any strenuous activities such as heavy lifting or exercises.
Risks and complications
There are very minimal risks associated with PRP injections. Some of the potential risks include:
Increased pain at the injection site
Infection
Damage to adjacent nerves or tissues
Formation of scar tissue
Calcification at the injection site
Surgery: Knee joint replacement surgery is considered as an option when the pain is so severe (especially night pain) that it affects your ability to carry out normal activities.
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Stem Cell Treatment
Stem cell therapy is a form of regenerative medicine that utilizes the body's natural healing mechanism to treat various conditions.
Stem cells are being used in regenerative medicine to renew and repair diseased or damaged tissues, and have shown promising results in treatments of various orthopedic, cardiovascular, neuromuscular and autoimmune conditions.
Stem cells are present in all of us acting like a repair system for the body. However, with increased age sometimes the optimum amount of stem cells are not delivered to the injured area. The goal of Stem Cell therapy is to amplify the natural repair system of the patient's body.
Types of Stem Cells
There are two major types of stem cells embryonic stem cells and adult stem cells. Embryonic stem cells (ESCs) are stem cells derived from human embryos. They are pluripotent, which means they can develop into almost any of the various cell types of the body.
As the embryo develops and forms a baby, stem cells are distributed throughout the body where they reside in specific pockets of each tissue, such as the bone marrow and blood. As we age, these cells function to renew old and worn out tissue cells. These are called adult stem cells or somatic stem cells. Like embryonic stem cells, adult stem cells can also replicate into more than one cell type, but their replication is restricted to a limited number of cell types.
Use of Stem Cells in Orthopaedics
The unique self-regeneration and differentiating ability of embryonic stem cells can be used in regenerative medicine. These stem cells can be derived from eggs collected during IVF procedures with informed consent from the patient. However, many questions have been raised on the ethics of destroying a potential human life for the treatment of another.
Adult stem cells are most commonly obtained from the bone marrow, specifically the mesenchymal stem cells, which can replicate into cells that form the musculoskeletal system such as tendons, ligaments, and articular cartilage. They can be obtained from the iliac crest of the pelvic bone by inserting a needle and extracting the stem cells from the bone marrow.
Currently, stem cell therapy is used to treat various degenerative conditions of the shoulder, knees, hips, and spine. They are also being used in the treatment of various soft tissue (muscle, ligaments and tendons) as well as bone-related injuries.
Who is a Good Candidate for a Stem Cell Procedure?
You may be a good candidate for stem cell therapy if you have been suffering from joint pain and want to improve your quality of life while avoiding complications related to invasive surgical procedures.
Preparing for the Procedure
It is important that you stop taking any non-steroidal anti-inflammatory drugs (NSAIDs) at least two weeks before your procedure.
Preparing for a stem cell procedure is relatively easy and your doctor will give you specific instructions depending on your condition.
Stem Cell procedure
The procedure begins with your doctor extracting stem cells from your own bone marrow. Bone marrow is usually aspirated from your hip region. Your doctor will first clean and numb your hip area. A needle is then introduced into an area of your pelvic bone known as the iliac crest. Bone marrow is then aspirated using a special syringe and the sample obtained is sent to the laboratory. In the laboratory, the aspirate is spun in a machine for 10 to 15 minutes and a concentrated stem cell sample is separated.
Your doctor then cleans and numbs your affected area to be treated and then, under the guidance of special x-rays, injects the stem cells into the diseased region. The whole procedure usually takes less than one hour and you may return home on the same day of the procedure.
Post-Operative Care
You will most likely be able to return to work the next day following your procedure.
You will need to take it easy and avoid any load bearing activities for at least two weeks following your procedure.
You will need to refrain from taking non-steroidal, anti-inflammatory medications (NSAIDS) for a while as this can affect the healing process of your body.
Advantages & Disadvantages
Stem cell therapy is a relatively simple procedure that avoids the complications associated with invasive surgical procedures.
As stem cell therapy uses the cells derived from your own body it reduces the chances of an immune rejection.
Disadvantages
The disadvantage of adult stem cell therapy is lack of data about its long-term effects as it is a newer evolving therapy.
Risks and Complications
Stem cell therapy is generally considered a safe procedure with minimal complications, however, as with any medical procedure, complications can occur.
Some risks factors related to stem cell therapy include infection as the stem cells may become contaminated with bacteria, viruses or other pathogens that may cause disease during the preparation process.
The procedure to either remove or inject the cells also has the risk of introducing an infection to the damaged tissue into which they are injected. Rarely, an immune reaction may occur from injected stem cells.
Partial Knee Replacement
What is Unicompartmental Knee Replacement?
Unicompartmental knee replacement is a minimally invasive surgery in which only the damaged compartment of the knee is replaced with an implant. It is also called a partial knee replacement.
The knee can be divided into three compartments: patellofemoral, the compartment in front of the knee between the kneecap and thighbone, the medial compartment, on the inside portion of the knee, and lateral compartment which is the area on the outside portion of the knee joint.
What is Arthritis?
Arthritis is the inflammation of a joint that causes pain, swelling (inflammation) and stiffness.
Osteoarthritis is the most common form of knee arthritis, in which the joint cartilage gradually wears away. It most often affects older people. In a normal joint, articular cartilage allows for smooth movement within the joint, whereas in an arthritic knee the cartilage itself becomes thinner or completely absent. In addition, the bones become thicker around the edges of the joint and may form bony spurs. These factors can cause pain and restricted range of motion in the joint.
How is Arthritis Diagnosed?
Your doctor will diagnose osteoarthritis based on your medical history, physical examination, and X-rays. X-rays typically show a narrowing of joint space in the arthritic knee.
What are the Indications for Unicompartmental Knee Replacement?
Traditionally, total knee replacement was commonly indicated for severe osteoarthritis of the knee. In total knee replacement, all worn out or damaged surfaces of the knee joint are removed and replaced with new artificial parts. Partial knee replacement is a surgical option if your arthritis is confined to a single compartment of your knee.
Your doctor may also recommend surgery if non-surgical treatment options such as medications, injections, and physical therapy have failed to relieve the symptoms.
How is Unicompartmental Knee Replacement Surgery Performed?
During the surgery, a small incision is made over the knee to expose the knee joint. Your surgeon will remove only the damaged part of the meniscus and place the implant into the bone by slightly shaping the shinbone and the thighbone. The plastic component is placed into the newly prepared area and secured with bone cement. Now, the damaged region of the femur or thighbone is removed to accommodate the new metal component, which is fixed in place using bone cement. Once the femoral and tibial components are fixed in proper place the knee is taken through a range of movements. The muscles and tendons are then repaired and the incision is closed.
What Does Postoperative Care for Unicompartmental Knee Replacement Involve?
You may walk with the help of a walker or cane for the first 1-2 weeks after surgery. A physical therapist will introduce you to an exercise program to follow for 4 to 6 months to help maintain range of motion and restore your strength. You may perform exercises such as walking, swimming, and biking but high impact activities such as jogging should be avoided.
What are the Risks and Complications of Unicompartmental Knee Replacement?
The possible risks and complications associated with unicompartmental knee replacement include:
Knee stiffness
Infection
Blood clots (Deep vein thrombosis)
Nerve and blood vessel damage
Ligament injuries
Patella (kneecap) dislocation
Wearing of the plastic liner
Loosening of the implant
What are the Advantages of Unicompartmental Knee Replacement?
The advantages of unicompartmental knee replacement over total knee replacement include:
Smaller incision
Less blood loss
Quick recovery
Less postoperative pain
Better overall range of motion
Feels more like a natural knee
Patellofemoral Knee Replacement
What is Patellofemoral Knee Replacement?
Traditionally, arthritis in only one compartment of the knee is treated by partial knee replacement surgery. Patellofemoral knee replacement is a minimally invasive surgical option performed in the patellofemoral compartment only, preserving the knee parts not damaged by arthritis as well as the stabilizing anterior and posterior cruciate ligaments (ACL and PCL).
The smaller implants used with a partial knee replacement surgery are customized to your anatomy based upon CT scans of your knee. A surgical robotic arm assists your surgeon with pre-operative planning and intraoperative component placement, positioning, and alignment. Patellofemoral knee arthroplasty surgery will not alter your ability to eventually move to a total knee replacement in the future should that become necessary.
What are the Compartments of the Knee?
The knee can be divided into three compartments: patellofemoral, the compartment in front of the knee between the kneecap and thighbone, the medial compartment, on the inside portion of the knee, and lateral compartment which is the area on the outside portion of the knee joint.
What are the Indications for Patellofemoral Knee Replacement?
Patellofemoral knee replacement surgery may be recommended by your surgeon if you have not obtained adequate relief with conservative treatment options. This less invasive bone and ligament preserving surgery are especially useful if you are young and active as the implant closely mimics the actual knee mechanics when compared to total knee surgery.
What is the Procedure for Patellofemoral Knee Replacement?
Patellofemoral knee replacement surgery is performed on an outpatient basis as day surgery, under general anesthesia or spinal anesthesia with sedation. Your surgeon makes a small incision, about 3-4-inches long over your knee. With the assistance of the robotic arm, the patellofemoral compartment is prepared for the artificial components by removing the damaged part of the patella and trochlea, the groove at the end of the femur. The new artificial components are fixed in place with the use of bone cement.
The femoral component is made of polished metal and the patellar component looks like a plastic button that will glide smoothly in a groove located on the femoral component. With the new components in place, the knee is taken through a range of movements. Once your surgeon is satisfied with the results, the surgical instruments are removed and the incisions covered with a sterile dressing or biologic glue.
What Does Postoperative Care for Patellofemoral Knee Replacement Involve?
You will be taken to the recovery room and monitored for any complications. You will be given pain medication to keep you comfortable at home. You will need someone to drive you home due to the drowsy effects of the anesthesia. Swelling is normal after knee surgery. Ice, compression, and elevation of the knee will help minimize swelling and pain.
You will be given specific instructions regarding the activity. Usually, there are a few activity restrictions. You will be referred to a rehabilitation program for exercise and strengthening. Eating a healthy diet and not smoking will promote healing.
What are the Risks and Complications of Patellofemoral Knee Replacement?
As with any major surgery, there are potential risks involved with patellofemoral knee replacement. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. Some of the possible complications include:
Allergic reactions to medications
Blood loss requiring transfusion with its low risk of disease transmission
Heart attacks, strokes, kidney failure, pneumonia, bladder infections
Complications from nerve blocks such as infection or nerve damage
Infection
Deep vein thrombosis
Ligament injuries
Injury to blood vessels or nerves
Arthrofibrosis
Wearing out of the prosthesis
Dislocations and fractures
Risk factors that can negatively affect adequate healing after knee arthroscopy include:
Poor nutrition
Smoking
Obesity
Age (over 60)
Alcoholism
Chronic Illness
Steroid Use
Total Knee Replacement
What is Total Knee Replacement?
Total knee replacement, also called total knee arthroplasty, is a surgical procedure in which the worn out or damaged surfaces of the knee joint are removed and replaced with an artificial prosthesis.
What is Knee Arthritis?
The knee is made up of the femur (thighbone), tibia (shinbone) and patella (kneecap). The two menisci, the soft cartilage between the femur and tibia, serve as a cushion and help absorb shock during motion. Arthritis (inflammation of the joints), injury or other diseases of the joint can damage this protective layer, causing extreme pain and difficulty in performing daily activities in an arthritic knee, the cartilage itself becomes thinner or completely absent. In addition, the bones become thicker around the edges of the joint and may form bony "spurs". These factors can cause pain and restrict the range of motion in the joint.
What are the Indications for Total Knee Replacement?
Total knee replacement surgery is commonly indicated for severe osteoarthritis of the knee. Osteoarthritis is a type of arthritis. It is the most common form of knee arthritis in which the joint cartilage gradually wears away, and often affects the elderly. Your doctor may advise total knee replacement if you have:
Severe knee pain that limits your daily activities (such as walking, getting up from a chair or climbing stairs)
Moderate-to-severe pain that occurs during rest or awakens you at night
Chronic knee inflammation and swelling that is not relieved with rest or medications
Failure to obtain pain relief from medications, injections, physical therapy or other conservative treatments
A bow-legged knee deformity
How is the Total Knee Replacement Procedure Performed?
The goal of total knee replacement surgery is to relieve pain and restore the alignment and function of your knee.
The surgery is performed under spinal or general anesthesia. Your surgeon will make an incision in the skin over the affected knee to expose the knee joint. Then, the damaged portions of the femur bone are cut at appropriate angles using specialized jigs. The femoral component is attached to the end of the femur with or without bone cement.
Your surgeon then cuts or shaves the damaged area of the tibia (shinbone) and the cartilage. This removes the deformed part of the bone and any bony growths, as well as creates a smooth surface on which the implants can be attached. Next, the tibial component is secured to the end of the bone with bone cement or screws.
Your surgeon will place a plastic piece called an articular surface between the implants to provide a smooth gliding surface for movement. This plastic insert will support the body's weight and allow the femur to move over the tibia like the original meniscus cartilage.
The femur and the tibia with the new components are then put together to form the new knee joint.
To make sure the patella (kneecap) glides smoothly over the new artificial knee, its rear surface is also prepared to receive a plastic component.
With all the new components in place, the knee joint is tested through its range of motion. The entire joint is then irrigated and cleaned with a sterile solution. The incision is carefully closed; drains are inserted and a sterile dressing is placed over the incision.
What Does Postoperative Care for Total Knee Replacement Involve?
Rehabilitation begins immediately following the surgery. A physical therapist will teach you specific exercises to strengthen your leg and restore knee movement. Knee immobilizers are used to stabilize the knee. You will be able to walk with crutches or a walker. A continuous passive motion (CPM) machine can be used to move the knee joint. Continuous passive motion is a device attached to the treated leg that constantly moves the joint through a controlled range of motion, while you are at rest. Your physical therapist will also provide you with a home exercise program to strengthen your thigh and calf muscles.
What are the Risks and Complications of Total Knee Replacement?
As with any major surgery, the possible risks and complications associated with total knee replacement surgery include:
Knee stiffness
Infection
Blood clots (deep vein thrombosis)
Nerve and blood vessel damage
Ligament injuries
Patella (kneecap) dislocation
Plastic liner wearing out
Loosening of the implant
