Knee

Arthroscopy of the Knee Joint

• Knee arthroscopy is a surgery that allows the surgeon to look inside the knee with a small camera and address problems through a few small incisions. The surgery is done as an outpatient and patients can walk on their operative leg the day of the operation.

  Not all knee pain and problems are correctable with a knee scope. Knee arthroscopy can address unstable meniscus tears, abnormal synovial tissue and loose bodies. If you have pain, one or more of these conditions and have failed a conservative management treatment program an arthroscopy may be an option.

  Arthroscopy cannot fix or remove arthritis. If you have more advanced arthritis you may be a candidate for total knee replacement.

  Complications after knee arthroscopy are rare but may include infection, blood clots, stiffness, swelling or the need for further surgery.

  A through history, physical examination and x-rays are needed for your evaluation. Occasionally an MRI may be needed.

  After surgery you will be given a home exercise program. Most patients return to activity within a number of weeks.

Total Knee Replacement

• Knee arthritis is an inflammation of the knee joint due to loss of cartilage. Arthritis may be due to wear and tear and age (osteoarthritis), injury and fractures (post-traumatic arthritis), or systemic diseases (rheumatoid arthritis or psoriatic arthritis).

  Knee arthritis can lead to pain, stiffness, limp, instability, swelling and inability to be an active individual. The diagnosis is made by taking a careful history, a physical examination and x-rays. When conservative care has failed to relieve pain and symptoms a person may be a candidate for total knee replacement.

  A knee replacement resurfaces the ends of the bone where cartilage is normally present. A few millimeters of bone is removed off the shin bone (tibia), the thigh bone (femur) and the knee cap (patella). Those surfaces are covered with metal and plastic. The parts are glued or cemented onto the bone.

  As with any surgical procedure there are risks which may include infection, blood clots, stiffness, leg length discrepancy, pain, injury to nerves or vessels, fractures, dislocation, bleeding and/or the need for transfusions or the need for additional surgery.

  Knees can wear out over time or with excessive activity. If your knee replacement wears out you may need a revision.

  You can find more detailed information about knee replacement surgery, as well as information about the risks, benefits and the recovery here.

  • Total Knee Replacement

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Partial Knee Replacement

• Knee arthritis is an inflammation of the joint due to loss of cartilage. Some people have isolated arthritis that is limited to one part of the knee, sparing the rest of the joint. If conservative treatment options do not control their pain they may be a candidate for a partial knee replacement.

  A partial knee replacement only replaces a part of the knee, so most patients have an easier recovery and their knee may feel more like a normal knee when compared to a total knee replacement.

  A partial medial compartment arthroplasty, sometimes called a uni, replaces the medial side or inside half of the knee. The end of the thigh bone (femur) and the top of the shin bone (tibia) are replaced with metal and plastic.

  Another partial knee replacement is a patellofemoral arthroplasty. This replaces the knee cap joint of the knee. The back of the knee cap (patella) is resurfaced with plastic and part of the thigh bone (femur) is resurfaced with metal.

  As with any surgical procedure there are risks which may include infection, blood clots, stiffness, leg length discrepancy, pain, injury to nerves or vessels, fracture, dislocation, the need for a transfusion or the need for additional surgery.

  Not all patients are candidates for partial knee replacement. If you have a significant deformity or more global arthritis a knee replacement {link to knee replacement page} may be a better surgical option.

  Like all joint replacements, a partial knee replacement may fail over time and require a revision.

  You can find more detailed information about partial and total knee replacement surgery, as well as information about the risks, benefits and the recovery here.

Revision Knee Replacement

• Total knee replacements occasionally need to be revised or redone. This may be due to fractures, infections, instability, stiffness or wear.

  When fractures occur around a knee replacement they can be fixed. If the implant is stable the femur (thigh bone) or tibia (shin bone) can be fixed with plates and screws or a rod depending on the type and location of the fracture. If the knee replacement parts have been destabilized by the injury they will have to be revised.

  Infections can occur early after the surgery or many years after the initial operation. If an infection occurs you will need one or more surgeries and a course of intravenous antibiotics.

  Knees can develop laxity over time or after a fall or trauma. A revision can address the instability and may relief symptoms. Occasionally this can be addressed with changing the plastic insert or bearing. At times all of the parts may need to be revised.

  Some knees develop significant stiffness after surgery. If an aggressive physical therapy program and a manipulation under anesthesia have not helped some patients have a revision. The goal of the surgery is to remove scar tissue within the knee to improve range of motion.

  All knee revisions are big surgeries. The surgery is usually longer than a routine knee replacement and the recovery may be longer. Complications can occur including infections, blood clots, stiffness, leg length discrepancy, pain, injury to nerves or vessels, fracture, dislocations, bleeding and/or the need for transfusions or the need for additional surgery.

Minimally Invasive Knee Joint Replacement

• Many patients ask about minimally invasive surgery (MIS) or less invasive surgery (LIS).

  Decades ago knee replacements were performed through very long incisions and patients were sometimes immobilized in splints or braces.  It was not uncommon to be at bed rest after surgery.

  Approximately 10 years ago, there was a push toward MIS.  It was thought that a smaller incision would be less painful and make recovery easier.  Unfortunately, the extra small incisions tended to not heal as well, and some complications were felt to be due to inadequate visualization and over stretching of the skin.

  So, total knee incisions went from very big, to very small, to the current incision length which is about 10 – 12 centimeters.  A better way to describe the measurement is that the skin incision will be about 2 ½ to 3 times the length of your knee cap.  Patients, who are larger or have bigger bones, and therefore bigger implants, tend to have bigger incisions and vice versa.

  Other changes that have occurred include sliding the kneecap off to the side and using a mobile window.  The mobile window approach allows me to work on parts of the knee without pulling (retracting) the tissue unnecessarily.  All of these changes have led to less soft tissue irritation and pain.

  What was also found was that the most important part of the recovery in MIS patients was early rehab and better pain management.  Those two things were actually more important than the length of the incision.  While the implants and retractors have allowed us to complete the surgery through a smaller incision, the appropriate length is the length that allows the implants to be placed optimally for a good outcome.

TKA Pain Management

• Knee replacement has been known to be a painful operation.  Many things have been done to lessen pain post-operatively.  When patients have less pain after surgery they are able to participate in therapy and improve their outcomes.

  Pain management begins with education.  Reading the information packet and attending the class will help prepare you for what to expect after the surgery.  Additional questions are answered at the consult and pre-operative visit.

  Prior to surgery you will receive a pre-operative “cocktail” which includes acetaminophen, an anti-inflammatory, a pain pill and an anti-nausea pill.  Giving medicine before the operation, so the medicine has time to work, lessens the pain after surgery.

  You will also receive a nerve block.  The block is the administration of numbing medicine given by the anesthesiologist prior to your surgery which will lessen the pain for approximately 24 hours.

  The next thing which is important is early range of motion and physical therapy.  By moving the knee early and regularly it will improve motion, decrease the risk of scar tissue and lessen pain.

  The other important thing in pain management is scheduled non-narcotic medicine.  Narcotics have a number of side effects including constipation, itching, dependence and others.  I have my patient go on around the clock acetaminophen and around the clock anti-inflammatories after surgery and they continue this for a minimum of two weeks.  In the hospital you will also receive another pill to decrease nerve pain.  The narcotics, typically oxycodone, are then used only for breakthrough pain.

  Other modalities such as ice can be very beneficial.  A simple ice bag or ice pack works just fine.  Some patients like the convenience of an ice machine.