Get in touch

555-555-5555

mymail@mailservice.com

Knee Surgery

The following information is provided as a guide, every patient is different and treatment can be tailored to suit each patient and their individual needs. If you are after a particular type of treatment, please discuss this with your surgeon at the time of your appointment. Please click on the links below to go direct to the information of interest.

Arthroscopy Of The Knee Joint
Total Knee Replacement
Anterior Cruciate Ligament Reconstruction (ACL)
ACL Reconstruction Hamstring Tendon
ACL Reconstruction Patellar Tendon
Bakers Knee Cyst
Meniscal Tear
Unicondylar Knee Replacement
Revision Knee Replacement

Arthroscopy Of The Knee Joint

Arthroscopy is a surgical procedure in which an arthroscope is inserted into a joint. Arthroscopy is a term that comes from two Greek words, arthro-, meaning joint, and -skopein, meaning to examine.

The benefits of arthroscopy involve smaller incisions, faster healing, a more rapid recovery, and less scarring. Arthroscopic surgical procedures are often performed on an outpatient basis and the patient is able to return home on the same day.

The arthroscope is a fiber-optic telescope that can be inserted into a joint (commonly the knee, shoulder and ankle) to evaluate and treat a number of conditions. A camera is attached to the arthroscope and the picture is visualized on a TV monitor. Most arthroscopic surgery is performed as day surgery and is usually done under general anesthesia. Knee arthroscopy is common, and millions of procedures are performed each year around the world.

Arthroscopy is Useful in Evaluating and Treating the Following Conditions

Torn floating cartilage (meniscus): The cartilage is trimmed to a stable rim or occasionally repaired
Torn surface (articular) cartilage
Removal of loose bodies (cartilage or bone that has broken off) and cysts
Reconstruction of the Anterior Cruciate ligament
Patello-femoral (knee-cap) disorders
Washout of infected knees
General diagnostic purposes

Basic Knee Anatomy

The knee is the largest joint in the body. The knee joint is made up of the femur, tibia and patella (knee cap). All these bones are lined with articular (surface) cartilage. This articular cartilage acts like a shock absorber and allows a smooth low friction surface for the knee to move on. Between the tibia and femur lie two floating cartilages called menisci. The medial (inner) meniscus and the lateral (outer) meniscus rest on the tibial surface cartilage and are mobile. The menisci also act as shock absorbers and stabilizers. The knee is stabilized by ligaments that are both in and outside the joint. The medial and lateral collateral ligaments support the knee from excessive side-to-side movement. The (internal) anterior and posterior cruciate ligaments support the knee from buckling and giving way. The knee joint is surrounded by a capsule (envelope) that produces a small amount of synovial (lubrication) fluid to help with smooth motion. Thigh muscles are important secondary knee stabilizers.

Investigations

A routine X-Ray of the knee, which includes a standing weight-bearing view is usually required. An MRI scan which looks at the cartilages and soft tissues may be needed if the diagnosis is unclear. There is little value in the use of Ultrasound in investigating knee problems.

Meniscal Cartilage Tears

Following a twisting type of injury the medial (or lateral) meniscus can tear. This results either from a sporting injury or may occur from a simple twisting injury when getting out of a chair or standing from a squatting position. Our cartilages become a little brittle as we get older and therefore can tear a little easier. The symptoms of a torn cartilage include

Pain over the torn area i.e. inner or outer side of the knee
Knee swelling
Reduced motion
Locking if the cartilage gets caught between the femur a tibia

Cartilage Tears

Once a meniscal cartilage has torn it will not heal unless it is a very small tear that is near the capsule of the joint. Once the cartilage has torn it predisposes the knee to develop osteoarthritis (wear and tear) in 15 to 20 years. It is better to remove torn pieces from the knee if the knee is symptomatic.

Torn cartilages in general continue to cause symptoms of discomfort, pain and swelling until the loose, ragged pieces are removed. Only the torn section is removed and the knee should recover and become symptom free. If the entire meniscus is removed, the knee will develop osteoarthritis in 15 to 20 years. It is standard to remove only the torn section of cartilage in the hope that this will delay the onset of long-term wear and tear osteoarthritis.

Occasionally, provided the knee is stable and the tear is a certain type of tear in a young patient (peripheral bucket handle tear), the meniscus may be suitable for repair. If repaired, one has to avoid sports for a minimum of three months.

Articular Cartilage (Surface) Injury

If the surface cartilage is torn, this is most significant as a major shock-absorbing function is compromised. Large pieces of articular cartilage can float in the knee (sometimes with bone attached) and this causes locking of the joint and can cause further deterioration due to the loose bodies floating around the knee causing further wear and tear. Most surface cartilage wear will ultimately lead to osteoarthritis. Mechanical symptoms of pain and swelling due to cartilage peeling off can be helped with arthroscopic surgery. The surgery smooths the edges of the surface cartilage and removes loose bodies.

Anterior Cruciate Ligament Injuries

Rupture of the Anterior (rarely the posterior) Cruciate Ligament (ACL) is a common sporting injury. Once ruptured the ACL does not heal and usually causes knee instability and the inability to return to normal sporting activities. An ACL reconstruction is required and a new ligament is fashioned to replace the ruptured ligament. This procedure is performed using the arthroscope.

Patella (Knee-Cap) Disorders

The arthroscope can be used to treat problems relating to kneecap disorders, particularly mal-tracking and significant surface cartilage tears. Patients may need to stay overnight if a lateral release has been performed as knee swelling is quite common. The majority of common kneecap problems can be treated with physical therapy and rehabilitation.

Inflammatory Arthritis

Occasionally arthroscopy is used in inflammatory conditions (e.g. Rheumatoid Arthritis) to help reduce the amount of inflamed synovium (joint lining) that is producing excess joint fluid. This procedure is called a synovectomy. After the surgery a drain is inserted into the knee and patients generally require one or two nights in hospital.

Bakers Cysts

Bakers cysts or popliteal cysts are often found on clinical examination and ultrasound / MRI scan. The cyst is a fluid filled cavity behind the knee and in adults arises from a torn meniscus or worn articular cartilage in the knee. These cysts usually do not require removal as treating the cause (torn knee cartilage) will in most cases reduce the size of the cyst. Occasionally the cysts rupture and can cause calf pain. The cysts are not dangerous and do not require treatment if the knee is asymptomatic.

New Technology

Isolated areas of articular cartilage loss can be repaired using cartilage transplant technology. This is a new and exciting field that is developing in the treatment of specific isolated cartilage defects in younger patients

The process is called Autologous Chondrocyte Grafting . It involves harvesting cartilage cells from the affected knee, sending these cells to a laboratory and then culturing the cells to multiply into many cells. The large amount of cells produced are then placed back into the affected knee into the defect requiring resurfacing. Results are still short-term follow-up but are looking encouraging.

After a major cartilage or ligament injury has been treated the knee can return to normal function. There is however a small increase in the risk of developing long-term wear and tear (Osteoarthritis) and depending on the degree of injury activity modification may be required. Activities that help prevent knees deteriorating quickly include:

Low impact sports like swimming, cycling and walking
Reducing weight and maintaining a healthy diet

Arthroscopy of the Knee: Patient Information

Please stop taking Aspirin and Anti-inflammatory medications 5 days prior to your surgery. You can continue taking all your other routine medication. If you smoke you are advised to stop a few days prior to your surgery.

You will be admitted on the day of surgery and need to remain fasted for 6 hours prior to the procedure.

The limb undergoing the procedure will be marked and identified prior to the anesthetic being administered.

Once you are under anesthetic, the knee is prepared in a sterile fashion. A tourniquet is placed around the thigh to allow a ‘blood – free' procedure.

The Arthroscope is introduced through a small (size of a pen) incision on the outer side of the knee. A second incision on the inner side of the knee is made to introduce the instruments that allow examination of the joint and treatment of the problem.

Post-Operative Recovery

You will wake up in the recovery room and then be transferred back to the ward.

A bandage will be around the operated knee.

Once you are recovered your IV will be removed and you will be shown a number of exercises to do.

Your Surgeon will see you prior to discharge and explain the findings of the operation and what was done during surgery.

Pain medication will be provided and should be taken as directed

You can remove the bandage in 24 hours and place waterproof dressings (provided) over the wounds.

It is NORMAL for the knee to swell after the surgery. Elevating the leg when you are seated and placing ice packs on the knee will help to reduce swelling. (Ice packs on for 20 min 3-4 times a day until swelling has reduced)

You are able to drive and return to work when comfortable unless otherwise instructed.

Please make an appointment 7-10 days after surgery to monitor your progress and remove the 2 stitches in your knee.

Risks of Arthroscopy

General Anesthetic risks are extremely rare in Australia. Occasionally patients have some discomfort in the throat as a result of the tube that supplies oxygen and other gasses. Please discuss with the Specialist Anesthetist if you have any specific concerns.

Risks Related to Arthroscopic Knee Surgery Include

Postoperative bleeding
Deep Vein Thrombosis
Infection
Stiffness
Numbness to part of the skin near the incisions
Injury to vessels, nerves and a chronic pain syndrome
Progression of the disease process

The risks and complications of arthroscopic knee surgery are extremely small. One must however bear in mind that occasionally there is more damage in the knee than was initially thought and that this may affect the recovery time. In addition if the cartilage in the knee is partly worn out then arthroscopic surgery has about a 65% chance of improving symptoms in the short to medium term but more definitive surgery may be required in the future. In general arthroscopic surgery does not improve knees that have well established Osteoarthritis.

Post-Operative Exercises and Physical Therapy

Following your surgery you will be given an instruction sheet showing exercises that are helpful in speeding up your recovery. Strengthening your thigh muscles (Quadriceps and Hamstrings) is most important. Swimming and cycling (stationary or road) are excellent ways to build these muscles up and improve movement.

Frequently Asked Questions

How long am I in the Hospital?

A: Approximately 4 hours

Do I need crutches?

A: Usually not required (Unless you are having Anterior Cruciate Ligament Reconstruction)

When can I get the knee wet?

A: After 24 hrs remove the bandage and apply a waterproof dressing.

When can I drive?

A: After 24 hrs if the knee is comfortable.

When can I return to work?

A: When the knee feels reasonably comfortable.

When can I swim?

A: After removal of the stitches.

How long will my knee take to recover?

A: Depending on the findings and surgery, usually 4 to 6 weeks following the surgery.

When can I return to sports?

A: Depending on the findings, 4-6 weeks after surgery.

Total Knee Replacement

Introduction

A Total Knee Replacement (TKR) or Total Knee Arthroplasty is a surgery that replaces an arthritic knee joint with artificial metal or plastic replacement parts called the ‘prostheses'.

The procedure is usually recommended for older patients who suffer from pain and loss of function from arthritis and have failed results from other conservative methods of therapy.

The typical knee replacement replaces the ends of the femur (thigh bone) and tibia (shin bone) with plastic inserted between them and usually the patella (knee cap).

Arthritis

Other causes include

Trauma (fracture)
Increased stress e.g., overuse, overweight, etc.
Infection
Connective tissue disorders
Inactive lifestyle e.g., Obesity, as additional weight puts extra force through your joints which can lead to arthritis over a period of time
Inflammation e.g., Rheumatoid arthritis

In an 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.

Diagnosis

The diagnosis of osteoarthritis is made on history, physical examination & X-rays.

There is no blood test to diagnose Osteoarthritis (wear & tear arthritis).

Benefits

The decision to proceed with TKR surgery is a cooperative one between you, your surgeon, family and your local doctor.

The benefits following surgery are relief of symptoms of arthritis. These include

Severe pain that limits your everyday activities including walking, shopping, visiting friends, getting in and out of chair, gardening, etc.
Pain waking you at night
Deformity- either bowleg or knock knees
Stiffness

Prior to surgery you will usually have tried some conservative treatments such as simple analgesics, weight loss, anti-inflammatory medications, modification of your activities, canes, or physical therapy.

Once these have failed it is time to consider surgery. Most patients who have TKR are between 60 to 80 years, but each patient is assessed individually and patients as young as 20 or old as 90 are occasionally operated on with good results.

Pre-Operation

Your surgeon will send you for routine blood tests and any other investigations required prior to your surgery
You will be asked to undertake a general medical check-up with a physician
You should have any other medical, surgical or dental problems attended to prior to your surgery
Make arrangements for help around the house prior to surgery
Cease aspirin or anti-inflammatory medications 10 days prior to surgery as they can cause bleeding
Cease any naturopathic or herbal medications 10 days before surgery
Stop smoking as long as possible prior to surgery

Day of Your Surgery

You will be admitted to the hospital, usually on the day of your surgery
Further tests may be required on admission
You will meet the nurses and answer some questions for the hospital records
You will meet your Anesthetist, who will ask you a few questions
You will be given hospital clothes to change into and have a shower prior to surgery
The operation site will be shaved and cleaned
Approximately 30 minutes prior to surgery
You will be transferred to the operating room

Surgical Procedure

Each knee is individual and knee replacements take this into account by having different sizes for your knee. If there is more than the usual amount of bone loss, sometimes extra pieces of metal or bone are added.

Surgery is performed under sterile conditions in the operating room under spinal or general anesthesia. You will be on your back and a tourniquet applied to your upper thigh to reduce blood loss. Surgery takes approximately two hours.

The surgeon cuts down to the bone to expose the bones of the knee joint.

The damaged portions of the femur and tibia are then cut at the appropriate angles using specialized jigs. Trial components are then inserted to check the accuracy of these cuts and determine the thickness of plastic required to place in between these two components. The patella (knee cap) may be replaced depending on a number of factors and depending on the surgeon's choice.

The real components are then inserted with or without cement and the knee is again checked to make sure things are working properly. The knee is then carefully closed and drains usually inserted, and the knee dressed and bandaged.

Post-Operation Course

When you wake, you will be in the recovery room with intravenous drips in your arm, a tube (catheter) in your bladder and a number of other monitors to check your vital observations. You will usually have a button to press for pain medication through a machine called a PCA machine (Patient Controlled Analgesia).

Once stable, you will be taken to the ward. The post-op protocol is surgeon dependant, but in general your drain will come out at 24 hours and you will sit out of bed and start moving you knee and walking on it within a day or two of surgery. The dressing will be reduced usually on the 2nd post op day to make movement easier. Your rehabilitation and mobilization will be supervised by a physical therapist.

To avoid lung congestion, it is important to breathe deeply and cough up any phlegm you may have.

Your Orthopaedic Surgeon will use one or more measures to minimize blood clots in your legs, such as inflatable leg coverings, stockings and injections into your abdomen to thin the blood clots or DVT's, which will be discussed in detail in the complications section.

A lot of the long term results of knee replacements depend on how much work you put into it following your operation.

Usually, you will remain in the hospital for 5-7 days. Then, depending on your needs, either return home or proceed to a rehabilitation facility. You will need physical therapy on your knee following surgery.

You will be discharged on a walker or crutches and usually progress to a cane at six weeks.

Your sutures are sometimes dissolvable but if not, are removed at approximately 10 days.

Bending your knee is variable, but by 6 weeks should bend to 90 degrees. The goal is to obtain 110-115 degrees of movement.

Once the wound is healed, you may shower. You can drive at about 6 weeks, once you have regained control of your leg. You should be walking reasonably comfortably by 6 weeks.

More physical activities, such as sports previously discussed, may take 3 months to do comfortably.

When you go home you need to take special precautions around the house to make sure it is safe. You may need rails in your bathroom or to modify your sleeping arrangements, especially if they are up a lot of stairs.

You will usually have a 6 week check up with your surgeon who will assess your progress. You should continue to see your surgeon for the rest of your life to check your knee and take X-rays. This is important as sometimes your knee can feel excellent but there can be a problem only recognized on X-ray.

You are always at risk of infections especially with any dental work or other surgical procedures where germs (Bacteria) can get into the blood stream and find their way to your knee.

If you ever have any unexplained pain, swelling or redness or if you feel generally poor, you should see your doctor as soon as possible.

Risks and Complications

As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.
It is important that you are informed of these risks before the surgery takes place.

Complications can be Medical (General) or Local Complications Specific to the Knee

Medical complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. 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 Serious medical problems can lead to ongoing health concerns, prolonged hospitalization or rarely death.

Local Complications

Infection

Infection can occur with any operation. In the knee this can be superficial or deep. Infection rates vary. If it occurs, it can be treated with antibiotics but may require further surgery. Very rarely your new knee may need to be removed to eradicate infection.

Blood Clots (Deep Venous Thrombosis)

These can form in the calf muscles and can travel to the lung (Pulmonary embolism). These can occasionally be serious and even life threatening. If you get calf pain or shortness of breath at any stage, you should notify your doctor.

Stiffness in the Knee

Ideally your knee should bend beyond 100 degrees but on occasion, the knee may not bend as well as expected. Sometimes manipulations are required. This means going to the operating room where the knee is bent for you and under anesthetic.

Wear

The plastic liner eventually wears out over time, usually 10 to 15 years and may need to be changed.

Wound Irritation or Breakdown

The operation will always cut some skin nerves, so you will inevitably have some numbness around the wound. This does not affect the function of your joint. You can also get some aching around the scar. Vitamin E cream and massaging can help reduce this.

Occasionally, you can get reactions to the sutures or a wound breakdown that may require antibiotics or rarely, further surgery.

Cosmetic Appearance

The knee may look different than it was because it is put into the correct alignment to allow proper function.

Leg Length Inequality

This is also due to the fact that a corrected knee is more straight and is unavoidable.

Dislocation

An extremely rare condition where the ends of the knee joint lose contact with each other or the plastic insert can lose contact with the tibia (shinbone) or the femur (thigh bone).

Patella Problems

Patella (knee cap) can dislocate. This means it moves out of place and it can break or loosen.

Ligament Injuries

There are a number of ligaments surrounding the knee. These ligaments can be torn during surgery or break or stretch out any time afterwards. Surgery may be required to correct this problem.

Damage to Nerves and Blood Vessels

Rarely these can be damaged at the time of surgery. If recognized they are repaired, but a second operation may be required. Nerve damage can cause a loss of feeling or movement below the knee and can be permanent.

Fractures or breaks in the bone can occur during surgery or afterwards if you fall. To repair these, you may require surgery.

Discuss your concerns thoroughly with your Orthopaedic Surgeon prior to surgery.

Summary

Surgery is not a pleasant prospect for anyone, but for some people with arthritis, it could mean the difference between leading a normal life or putting up with a debilitating condition. Surgery can be regarded as part of your treatment plan—it may help to restore function to your damaged joints as well as relieve pain.

TKR is one of the most successful operations available today. It is an excellent procedure to improve the quality of life, take away pain and improve function. In general 90-95% of knee replacements survive 15 years, depending on age and activity level.

Surgery is only offered once non-operative treatment has failed. It is an important decision to make and ultimately it is an informed decision between you, your surgeon, family and medical practitioner.

Although most people are extremely happy with their new knee, complications can occur and you must be aware of these prior to making a decision. If you are undecided, it is best to wait until you are sure this is the procedure for you.

Anterior Cruciate Ligament Reconstruction

The anterior cruciate ligament (ACL) is one of the major stabilizing ligaments in the knee. It is a strong rope like structure located in the centre of the knee running from the femur to the tibia. When this ligament tears unfortunately it doesn't 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 incisions and low complication rates.

ACL Reconstruction Hamstring Tendon

Introduction

The anterior cruciate ligament is one of the major stabilizing ligaments in the knee. It is a strong rope like structure located in the centre of the knee running from the femur to the tibia.

When this ligament tears unfortunately it doesn't 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 incisions and low complication rates.

Function

The ACL is the major stabilizing ligaments in the knee. It prevents the tibia (Shin bone) moving abnormally on the femur (thigh bone). When this abnormal movement occurs it is referred to as instability and the patient is aware this abnormal movement.

Often other structures such as the meniscus, the articular cartilage (lining the joint) or other ligaments can also be damaged at the same time as a cruciate injury & these may need to be addressed at the time of surgery.

History of Injury

Most injuries are sports related involving a twisting injury to the knee
It can occurs with a sudden change of direction, a direct blow e.g., a tackle, landing awkwardly
Often there is a popping sound when the ligament ruptures
Swelling usually occurs within hours
There is often the feeling of the knee popping out of joint
It is rare to be able to continue playing sport with the initial injury

Once the initial injury settles down the main symptom is instability or giving away of the knee. This usually occurs with running activities but can occur on simple walking or other activities of daily living.

Diagnosis

The diagnoses can often be made on the history alone.

Examination reveals instability of the knee, if adequately relaxed or not too painful.

An MRI (Magnetic Resonance Imaging) can be helpful if there is doubt as well as to look for damage to other structures within the knee.

At times the final diagnoses can only be made under anaesthetic or with an Arthroscopy.

Treatment

Initial

Rest
Ice
Elevation
Bandage

Long Term

Not everyone needs surgery. Some people can compensate for the injured ligament with strengthening exercises or a brace.

It is strongly advised to give up sports involving twisting activities, if you have an ACL injury.

Episodes of instability can cause further damage to important structures within the knee that may result in early arthritis

Indications for Surgery

Young patients wishing to maintain an active lifestyle.

Sports involving twisting activities e.g., Soccer, netball, football Giving way with activities of daily living.

People with dangerous occupations e.g., Policemen, firemen, roofers, scaffoulders.

It is advisable to have physiotherapy prior to surgery to regain motion and strengthen the muscles as much as possible.

Surgery

Surgical techniques have improved significantly over the last decade, complications are reduced and recovery much quicker than in the past.

The surgery is performed arthroscopically. The ruptured ligament is removed and then tunnels (holes) in the bone are drilled to accept the new graft. This graft which replaces your old ACL is taken either from the hamstring tendon or the patella tendon. There are advantages & disadvantages of each with the final decision based on surgeons preference.

The graft is prepared to take the form of a new tendon and passed through the drill holes in the bone.

The new tendon is then fixed into the bone with various devices to hold it into place while the ligament heals into the bone (usually 6 months).

The rest of the knee can be clearly visualized at the same time and any other damage is dealt with e.g., meniscal tears.

The wounds then closed often with a drain and a dressing applied.

Post-Operation

Surgery is performed as a day only procedure or an overnight stay.
You will have pain medication by tablet or in a drip (Intravenous).
Any drains will be removed from the knee.
A splint is sometimes used for comfort.
You will be seen by a physiotherapist who will teach you to use crutches and show you some simple exercises to do at home.
Leave any waterproof dressings on your knee until your post-op review.
You can put all your weight on your leg.
Avoid anti-inflammatories or aspirin for 10 days.
Put ice on the knee for 20 minutes at a time, as frequently as possible.
Post-op review will usually be at 7-10 days.
Physiotherapy can begin after a few days or can be arranged at your first post-op visit.

If you have any redness around the wound or increasing pain in the knee or you have temperature or feel unwell, you should contact your surgeon as soon as possible.

Rehabilitation

Physiotherapy is an integral part of the treatment and is recommended to start as early as possible. Preoperative physiotherapy is helpful to better prepare the knee for surgery. The early aim is to regain range of motion, reduce swelling and achieve full weight bearing.

The remaining rehabilitation will be supervised by a physiotherapist and will involve activities such as exercise bike riding, swimming, proprioceptive exercises and muscle strengthening. Cycling can begin at 2 months, jogging can generally begin at around 3 months. The graft is strong enough to allow sport at around 6 months however other factors come into play such as confidence, fitness and adequate fitness and training.

Professional sportsmen often return at 6 months but recreational athletes may take 10 -12 months depending on motivation and time put into rehabilitation.

The rehabilitation and overall success of the procedure can be affected by associated injuries to the knee such as damage to meniscus, articular cartilage or other ligaments.

The following is a more detailed rehabilitation protocol useful for patients and physiotherapists. It is a guide only and must be adjusted on an individual basis taking into account pain, other pathology, work and other social factors.

Acute (0-2 Weeks)

Goals

Wound healing
Reduce swelling
Regain full extension
Full weight bearing
Wean off crutches
Promote muscle control

Treatment Guidelines

Pain and swelling reduction with ice, intermittent pressure pump, soft tissue massage and exercise
Patella mobilisation
Active range of motion knee exercises, calf and hamstring stretching, contraction (non weight bearing progressing to standing), muscle control and full weight bearing. Aim for full extension by 2 weeks. Full flexion will take longer and generally will come with gradual stretching. Care needs to be taken with hamstring co contraction as this may result in hamstring strains if too vigorous. Light hamstring loading continues into the next stage with progression of general rehabilitation. Resisted hamstring loading should be avoided for approximately 6 weeks
Gait retraining encouraging extension at heel strike

Stage 2 - Quadriceps Control (2-6 Weeks)

Goals

Full active range of motion
Normal gait with reasonable weight tolerance
Minimal pain and effusion
Develop muscular control for controlled pain free single leg lunge
Avoid hamstring strain
Develop early proprioceptive awareness

Treatment Guidelines

Use active, passive and hands on techniques to promote full range of motion
Progress closed chain exercises (quarter squats and single leg lunge) as pain allows. The emphasis is on pain free loading, VMO and gluteal activation
Introduce gym based exercise equipment including leg press and stationary cycle
Water based exercises can begin once the wound has healed, including treading water, gentle swimming avoiding breaststroke
Begin proprioceptive exercises including single standing leg balance on the ground and mini tramp. This can progress by introducing body movement whilst standing on one leg
Bilateral and single calf raises and stretching
Avoid isolated loading of the hamstrings due to ease of tear. Hamstrings will be progressively loaded through closed chain and gym based activity

Stage 3 - Hamstring/Quadriceps Strengthening (6-12 Weeks)

Goals

Begin specific hamstring loading
Increase total leg strength
Promote good quadriceps control in lunge and hopping activity in preparation for running

Treatment Guidelines

Focal hamstring loading begins and is progressed steadily throughout the next stages of rehabilitation
- Ative prone knee flexion which can be quickly progressed to include a light weight and gradually increasing weights
- Bilateral bridging off a chair. This can be progressed by moving onto a single leg bridge and then single leg bridge with weight held across the abdomen
- Single straight leg dead lift initially active with increasing difficulty by adding dumbbells
With respect to hamstring loading, they should never be pushed into pain and should be carefully progressed. Any subtle strain or tightness following exercises should be managed with a reduction in hamstring based exercises
Gym based activity including leg presses, light squats and stationary bike which can be progressively increased in intensity as pain and control allow. It is important to monitor any effusions following exercise and if it is increasing then exercise should be toned down
Once single leg lunge control is comparable to the other side hopping can be introduced. Hops can be made more difficult by including variations such as forward/back, side to side off a step and in a quadrant
Running may begin towards the latter part of this stage
Prior to running certain criteria must be met
- No anterior knee pain
- A pain free lunge and hop that is comparable to the other side
- The knee must have no effusion
- Before jogging start having brisk walks, ideally on a treadmill to monitor landing
- Action and any effusion. This should be done for several weeks before jogging properly
Increased proprioceptive manoeuvres with standing leg balance and progressive hopping based activity
Expand calf routine to include eccentric loading

Stage 4 - Sport Specific (3-6 Months)

Goals

Improve leg strength
Develop running endurance speed, change of direction
Advanced proprioception
Prepare for return to sport and recreational lifestyle

Treatment Guidelines

Controlled sport specific activities should be included in the progression of running and gym loads. Increasing effusion post running that isn't easily managed with ice should result in a reduction in running loads
Advanced proprioception to include controlled hopping and turning and balance correction
Monitor potential problems associated with increasing loads
No open chain resisted leg extension exercises unless authorised by your surgeon

Stage 5 - Return to Sport (6 Months Plus)

Goals

A safe return to sporting activities.

Treatment Guidelines

Full training for 1 month prior to active return to competitive sport
Preparation for body contact sports. Begin with low intensity one on one contests and progress by increasing intensity and complexity in preparation for drills that one might be expected to do at training
To improve running endurance leading up to a normal training session
Full range, no effusion, good quadriceps control for lunge, hopping and hop and turn type activity. Circumference measures of thigh and calf to within 1 cm of other side

Risks & Complications

Complications are not common but can occur. Prior to making the decision of have this operation. It is important you understand these so you can make an informed decision on the advantages and disadvantages of surgery.

These can be Medical (Anaesthetic) complications and surgical complications.

Medical (Anaesthetic) Complications

Medical complications include those of the anaesthetic and your general well being. Almost any medical condition can occur so this list is not complete. 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. Serious medical problems can lead to ongoing health concerns, prolonged hospitalization. The following is a list of surgical complications. These are all rare but can occur. Most are treatable and do not lead to long term problems.

Infection

Approximately 1 in 200. Treatment involves either oral or antibiotics through the drip, or rarely further surgery to wash the infection out.

Deep Vein Thrombosis

These are clots in the veins of the leg. If they occur you may need blood thinning medication in the form of injections or tablets. Very rarely they can travel to the lung (Pulmonary Embolus) which can cause breathing difficulties or even death.

Excessive Swelling & Bruising

This is due to bleeding in the soft tissues and will settle with time.

Joint Stiffness

Can result from scar tissue within the joint, and is minimized by advances in surgical technique and rapid rehabilitation. Full range of movements cannot always be guaranteed.

Graft Failure

The graft can fail the same as a normal cruciate ligament does. Failure rate is approximately 5%. If the graft stretches or ruptures it can still be revised if required by using tendons from the other leg.

Damage to Nerves or Vessels

These are small nerves under the skin which cannot be avoided and cutting then leads to areas of numbness in the leg. This normally reduces in size over time and does not cause any functional problems with the knee. Very rarely there can be damage to more important nerves or vessels causing weakness in the leg.

Hardware Problems

All grafts need to be fixed to the bone using various devices (hardware) such as screws or staples. These can cause irritation of the wound and may require removal once the graft has grown into the bone.

Donor Site Problems

Donor site means where the graft is taken from. In general either the hamstrings or patella tendon are used. These can be pain or swelling in these areas which usually resolves over time.

Residual Pain

Can occur especially if there is damage to other structures inside the knee.

Reflex Sympathetic Dystrophy

An extremely rare condition that is not entirely understood, which can cause unexplained and excessive pain.

Summary

Anterior Cruciate Ligament reconstruction is a common and very successful procedure. In the hands of experienced surgeons who perform a lot of these procedures 95% of people have a successful result. It is generally recommended in the patient wishing to return to an active lifestyle especially those wishing to play sports involving running and twisting.

The above information hopefully has educated you on the choices available to you, the procedure and the risks involved. If you have any further questions you should consult with your surgeon.

Uni Condylar Knee Replacement

Introduction

Unicondylar Knee Replacement simply means that only a part of the knee joint is replaced through a smaller incision than would normally be used for a total knee replacement.

Unicondylar Knee Replacements have been performed since the early 1970's with mixed success. Over the last 25 years implant design, instrumentation and surgical technique have improved markedly making it a very successful procedure for unicompartmental arthritis. Recent advances allow us to perform this through a smaller incision and therefore is not as traumatic to the knee making recovery quicker.

Total Knee Replacement surgery replaces the ends of the femur (thigh bone) and tibia (shin bone) with plastic inserted between them and usually the patella (knee cap).

Arthritis

Arthritis is a general term covering numerous conditions where the joint surface (cartilage) wears out. The joint surface is covered by a smooth articular surface that allows pain free movement in the joint.

When the articular cartilage wears out, the bone ends rub on one another and cause pain. There are numerous conditions that can cause arthritis and 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 e.g., overuse, overweight, etc.
Infection
Connective tissue disorders
Inactive lifestyle- e.g., Obesity, as additional weight puts extra force through your joints which can lead to arthritis over a period of time
Inflammation e.g., Rheumatoid arthritis

In an 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.

Diagnosis

The diagnosis of osteoarthritis is made on history, physical examination & X-rays
There is no blood test to diagnose Osteoarthritis (wear & tear arthritis)

Advantages & Disadvantages

The decision to proceed with Knee Replacement surgery is a cooperative one between you, your surgeon, family and your local doctor.

The benefits following surgery are relief of symptoms of arthritis. These include
Severe pain that limits your everyday activities including walking, shopping, visiting friends, getting in and out of chair, gardening, etc.
Pain waking you at night
Deformity- either bowleg or knock knees
Stiffness

Advantages

Smaller operation
Smaller incision
Not as much bone removed
Shorter hospital stay
Shorter recovery period
Blood transfusion rarely required
Better movement in the knee
Feels more like a normal knee
Less need for physiotherapy
Able to be more active than after a total knee replacement

The big advantage is that if for some reason it is not successful or fails many years down the track it can be revised to a total knee replacement without difficulty.

Disadvantages

Not quite as reliable as a total knee replacement in taking away all pain
Long term results not quite as good as total knee

Who is Suitable?

Ideally should be over 50 years of age
When pain and restricted mobility interferes with your lifestyle
One compartment involved clinically and confirmed on X-ray

Who is Not Suitable?

Patients with arthritis affecting more than one compartment
Patients with severe angular deformity
Patients with inflammatory arthritis e.g.. rheumatoid arthritis
Patients with an unstable knee
Patients who have had a previous osteotomy
Patients who are involved in heavy work or contact sports

Pre-Operation

Your surgeon will send you for routine blood tests and any other investigations required prior to your surgery
You will be asked to undertake a general medical check-up with a physician
You should have any other medical, surgical or dental problems attended to prior to your surgery
Make arrangements for help around the house prior to surgery
Cease aspirin or anti-inflammatory medications 10 days prior to surgery as they can cause bleeding
Cease any naturopathic or herbal medications 10 days before surgery
Stop smoking as long as possible prior to surgery

Day of Surgery

You will be admitted to the hospital usually on the day of your surgery
Further tests may be required on admission
You will meet the nurses and answer some questions for the hospital records
You will meet your Anesthetist, who will ask you a few questions
You will be given hospital clothes to change into and have a shower prior to surgery
The operation site will be shaved and cleaned
Approximately 30 minutes prior to surgery, you will be transferred to the operating room

Surgical Procedure

Each knee is individual and knee replacements take this into account by having different sizes for your knee. If there is more than the usual amount of bone loss sometimes extra pieces of metal or bone are added.

The Patient is positioned on the operating table and the leg prepped and draped.

A tourniquet is applied to the upper thigh and the leg is prepared for the surgery with a sterilizing solution.

An incision around 7cm is made to expose the knee joint.

The bone ends of the femur and tibia are prepared using a saw or a burr.

Trial components are then inserted to make sure they fit properly.

The real components (Femoral & Tibial) are then put into place with or without cement.

The knee is then carefully closed and drains usually inserted, and the knee dressed and bandaged.

Post-Operation Course

When you wake, you will be in the recovery room with intravenous drips in your arm, a tube (catheter) in your bladder and a number of other monitors to check your vital observations. You will usually have a button to press for pain medication called a PCA machine (Patient Controlled Analgesia).

Once stable, you will be taken to the ward. The post-op protocol is surgeon dependant, but in general your drain will come out at 24 hours and you will sit out of bed and start moving you knee and walking on it within a day or two of surgery. The dressing will be reduced usually on the 2nd post-op day to make movement easier. Your rehabilitation and mobilization will be supervised by a physical therapist.

To avoid lung congestion, it is important to breathe deeply and cough up any phlegm you may have.

Your Orthopaedic Surgeon will use one or more measures to minimize blood clots in you legs, such as inflatable leg coverings, stockings and injections into your abdomen to thin the blood clots or DVT's, which will be discussed in detail in the complications section.

A lot of the long term results of knee replacements depend on how much work you put into it following your operation.

Usually you will remain in the hospital for 3-5 days. Depending on your needs, you will then return home or proceed to a rehabilitation facility. You will need physical therapy on your knee following surgery.

You will be discharged on a walker or crutches and usually progress to a cane at six weeks.

Your sutures are sometimes dissolvable but if not, are removed at approx 10 days.

Bending your knee is variable, but by 6 weeks it should bend to 90 degrees. The goal is to obtain 110-115 degrees of movement.

Once the wound is healed, you may shower. You can drive at about 6 weeks, once you have regained control of your leg. You should be walking reasonably comfortably by 6 weeks.

More physical activities, such as sports previously discussed may take 3 months to be able to do comfortably.

When you go home you need to take special precautions around the house to make sure it is safe. You may need rails in your bathroom or to modify your sleeping arrangements especially if they are up a lot of stairs.

You will usually have a 6 week check up with your surgeon, who will assess your progress. You should continue to see your surgeon for the rest of your life to check your knee and take X-rays. This is important as sometimes your knee can feel excellent, but there can be a problem only recognized on X-ray.

You are always at risk of infections especially with any dental work or other surgical procedures where germs (Bacteria) can get into the blood stream and find their way to your knee.

If you have any unexplained pain, swelling, or redness or if you feel generally poor, you should see your doctor as soon as possible.

Risks and Complications

As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages
It is important that you are informed of these risks before the surgery takes place

Complications can be Medical (General) or Local Complications Specific to the Knee

Medical complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. 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
Serious medical problems can lead to ongoing health concerns, prolonged hospitalization or rarely death

Local Complications

Infection

Infection can occur with any operation. In the hip this can be superficial or deep. Infection rates are approximately 1%. If it occurs, it can be treated with antibiotics but may require further surgery. Very rarely your hip may need to be removed to eradicate infection.

Blood Clots (Deep Venous Thrombosis)

Fractures or Breaks in the Bone

Fractures or breaks can occur during surgery or afterwards if you fall. To repair these, you may require surgery.

Stifness in the Knee

Ideally, your knee should bend beyond 100 degrees but on occasion, may not bend as well as expected. Sometimes manipulations are required. This means going to the operating room where the knee is bent for you while under anesthetic.

Wear

The plastic liner eventually wears out over time, usually 10 to 15 years and may need to be changed.

Wound Irritation or Breakdown

Occasionally, you can get reactions to the sutures or a wound breakdown that may require antibiotics or rarely, further surgery.

Cosmetic Appearance

The knee may look different than it was because it is put into the correct alignment to allow proper function.

Leg Length Inequality

This is also due to the fact that a corrected knee is more straight and is unavoidable.

Dislocation

An extremely rare condition where the ends of the knee joint lose contact with each other or the plastic insert can lose contact with the tibia (shinbone) or the femur (thigh bone).

Patella Problems

The Patella (knee cap) can dislocate. This means it moves out of place and it can break or loosen.

Ligament Injuries

There are a number of ligaments surrounding the knee. These ligaments can be torn during surgery or break or stretch out any time afterwards. Surgery may be required to correct this problem.

Damage to Nerves and Blood Vessels

Rarely these can be damaged at the time of surgery. If recognized they are repaired but a second operation may be required. Nerve damage can cause a loss of feeling or movement below the knee and can be permanent.

Discuss your concerns thoroughly with your Orthopaedic Surgeon prior to surgery.

Summary

Surgery is not a pleasant prospect for anyone, but for some people with arthritis, it could mean the difference between leading a normal life or putting up with a debilitating condition. Surgery can be regarded as part of your treatment plan it may help to restore function to your damaged joints as well as relieve pain.

Revision Knee Replacement

Introduction

Revision Knee Replacement means that part or all of your previous knee replacement needs to be revised. This operation varies from very minor adjustments to massive operations replacing significant amounts of bone. The typical knee replacement replaces the ends of the femur (thigh bone) and tibia (shin bone) with plastic inserted between them and usually the patella (knee cap).

Why does a Knee Replacement Needs to be Revised?

Pain is the primary reason for revision. Usually the cause is clear but not always. Knees without an obvious cause for pain in general do not do as well after surgery.

Plastic (polyethylene) wear - This is one of the easier revisions where only the plastic insert is changed.
Instability - This means the knee is not stable and may be giving way or not feel safe when you walk.
Loosening of either the femoral, tibial or patella component - This usually presents as pain but may be asymptomatic. It is for this reason why you must have your joint followed up for life as there can be changes on X-ray that indicate that the knee should be revised despite having no symptoms.
Infection - usually presents as pain but may present as swelling or an acute fever.
Osteolysis (bone loss) - This can occur due to particles being released into the knee joint that result in bone being destroyed.
Stiffness - This is difficult to improve with revision but can help in the right indications.

Pre-Operation

Your surgeon will send you for routine blood tests and any other
Investigations required prior to your surgery
You will be asked to undertake a general medical check-up with a physician
You should have any other medical, surgical or dental problems attended to prior to your surgery
Make arrangements for help around the house prior to surgery
Cease aspirin or anti-inflammatory medications 10 days prior to surgery as they can cause bleeding
Cease any naturopathic or herbal medications 10 days before surgery
Stop smoking as long as possible prior to surgery

Day Surgery

You will be admitted to the hospital usually on the day of your surgery
Further tests may be required on admission
You will meet the nurses and answer some questions for the hospital records
You will meet your Anesthetist, who will ask you a few questions
You will be given hospital clothes to change into and have a shower prior to surgery
The operation site will be shaved and cleaned
Approximately 30 minutes prior to surgery, you will be transferred to the operating room

Surgical Procedure

The Patient is positioned on the operating table and the leg prepped and draped.

A tourniquet is applied to the upper thigh and the leg is prepared for the surgery with a sterilizing solution.

An incision around 7cm is made to expose the knee joint.

The bone ends of the femur and tibia are prepared using a saw or a burr.

Trial components are then inserted to make sure they fit properly.

The real components (Femoral & Tibial) are then put into place with or without cement.

The knee is then carefully closed and drains usually inserted, and the knee dressed and bandaged.

Post-Operation Course

Once stable, you will be taken to the ward. The post-op protocol is surgeon dependant, but in general your drain will come out at 24 hours and you will sit out of bed and start moving you knee and walking on it within a day or two of surgery. The dressing will be reduced usually on the 2nd post-op day to make movement easier. Your rehabilitation and mobilization will be supervised by a physical therapist.

To avoid lung congestion, it is important to breathe deeply and cough up any phlegm you may have.

A lot of the long term results of knee replacements depend on how much work you put into it following your operation.

Usually you will be in hospital for 3-5 days and then either go home or to a rehabilitation facility depending on your needs. You will need physical therapy on your knee following surgery.

You will be discharged on a walker or crutches and usually progress to a cane at six weeks.

Your sutures are sometimes dissolvable but if not are removed at approximately 10 days.

Bending your knee is variable, but by 6 weeks it should bend to 90 degrees. The goal is to get 110-115 degrees of movement.

Once the wound is healed, you may shower. You can drive at about 6 weeks, once you have regained control of your leg. You should be walking reasonably comfortably by 6 weeks.

More physical activities, such as sports previously discussed may take 3 months to be able to do comfortably.

You will usually have a 6 week check-up with your surgeon who will assess your progress. You should continue to see your surgeon for the rest of your life to check your knee and take X-rays. This is important as sometimes your knee can feel excellent but there can be a problem only recognized on X-ray.

You are always at risk of infections especially with any dental work or other surgical procedures where germs (Bacteria) can get into the blood stream and find their way to your knee.

If you ever have any unexplained pain, swelling, redness or if you feel unwell you should see your doctor as soon as possible.

Risks and Complications

As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages
It is important that you are informed of these risks before the surgery takes place

Complications can be Medical (General) or Local Complications Specific to the Knee

Medical complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. 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
Serious medical problems can lead to ongoing health concerns, prolonged hospitalization or rarely death

Local Complications

Infection

Infection can occur with any operation. In the hip this can be superficial or deep. Infection rates are approximately 1%. If it occurs it can be treated with antibiotics but may require further surgery. Very rarely your hip may need to be removed to eradicate infection.

Blood Clots (Deep Venous Thrombosis)

Fractures or Breaks in the Bone

Can occur during surgery or afterwards if you fall. To repair these, you may require surgery.

Stiffness in the Knee

Ideally your knee should bend beyond 100 degrees but on occasion the knee may not bend as well as expected. Sometimes manipulations are required, this means going to the operating room where the knee is bent for you under anesthetic the knee.

Wear

The plastic liner eventually wears out over time, usually 10 to 15 years and may need to be changed.

Wound Irritation or Breakdown

Surgery will always cut some skin nerves, so you will inevitably have some numbness around the wound. This does not affect the function of your joint. You can also get some aching around the scar. Vitamin E cream and massaging can help reduce this.

Occasionally, you can get reactions to the sutures or a wound breakdown that may require antibiotics or rarely further surgery.

Cosmetic Appearance

The knee may look different than it was because it is put into the correct alignment to allow proper function.

Leg Length Inequality

This is also due to the fact that a corrected knee is more straight and is unavoidable.

Dislocation

An extremely rare condition where the ends of the knee joint lose contact with each other or the plastic insert can lose contact with the tibia (shinbone) or the femur (thigh bone).

Patella Problems

The Patella (knee cap) can dislocate. This means it moves out of place and it can break or loosen.

Ligament Injuries

There are a number of ligaments surrounding the knee. These ligaments can be torn during surgery or break or stretch out any time afterwards. Surgery may be required to correct this problem.

Damage to Nerves and Blood Vessels

Discuss your concerns thoroughly with your Orthopaedic Surgeon prior to surgery.

Summary

Surgery is not a pleasant prospect for anyone, but for some people with arthritis, it could mean the difference between leading a normal life or putting up with a debilitating condition. Surgery can be regarded as part of your treatment plan it may help to restore function to your damaged joints as well as relieve pain.

Office Hours

Monday – Thursday: 8.30am – 5.00pm

Friday: 8.30am – 4.00pm

HOME | PRIVACY | OUR DOCTORS | OUR LOCATIONS | CONTACT