© 2019 by Orthopaedic Research Clinic Alaska

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The American Board of Orthopaedic Surgery

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Knee

Knee Procedures

The knee is an important part of the anatomy because is it the largest joint in the human body. It is the union of the lower part of the femur, the tibial plateau, and the knee cap. It enables hinge and rotating movements and connects our lower leg to the upper leg. The knee is an articulating joint, which means opposing bone areas are covered by a layer of firm and elastic cartilage so that the desired knee function is fulfilled properly, easily and without friction.

Common knee injuries and conditions require treatments such as total knee replacements and cartilage reconstruction. ORCA advocates nonoperative care whenever possible but understand that operation may be the only solution. 

 
Bracing/Wedges

The purpose of knee braces or wedges is to help realign the position of the knee. Bracing and wedges can also help reduce the pressure on damaged areas in order to restore function and relieve pain. Knee braces are one of the most popular noninvasive methods to treat knee osteoarthritis or delay the need for surgery to replace the knee joint.
According to a new study, 49 people aged 45 to 87 suffering from knee osteoarthritis experienced less stiffness, pain, and disability thanks to wearing a knee brace. These individuals were surveyed about the impact of the knee brace after six months of use.


All 49 selected participants reported that they had led active lifestyles before developing knee osteoarthritis. The study participants also admitted that they hoped to return to their previously active lifestyle. Due to the knee brace, most of the participants were able to return to their active lifestyles and enjoy a higher quality of life.
Some patients who wear knee braces also take over-the-counter and prescription anti-inflammatory drugs to help manage the remaining pain and discomfort. However, many report that they don’t need to take these drugs as often after wearing the brace. Some patients still go on to under joint replacement surgery. Other patients are able to delay joint replacement surgery indefinitely due to the neck brace. Many patients prefer wearing a knee brace or wedges because it is a noninvasive way to reduce pain and discomfort and boost quality of life.


Unfortunately, not everyone who suffers from knee osteoarthritis is a candidate for knee bracing. Individuals who weigh too little or too much may not be able to use knee braces. According to many physicians, knee bracing is an effective way to management knee osteoarthritis. This is especially true if patients combine wearing the knee brace with weight loss and training the muscles of their thigh.

Arthroscopic Knee Surgery

Arthroscopic knee surgery involves the use of a small camera to look inside the knee of a patient. The physician must make small cuts in order to insert the camera and other small surgical tools to perform the procedure. The long-term results of an arthroscopic knee surgery are variable.


In order to perform an arthroscopic knee surgery, a surgeon may administer one of four different types of anesthesia. The surgeon may perform local anesthesia to numb the knee with pain medicine. The patient will remain awake, but or she may be given medicine to promote relaxation. A surgeon may administer spinal anesthesia, also referred to as regional anesthesia, to the patient. The surgeon will inject the pain medicine into the space in the spine. The patient will be awake but he or she will not feel any sensation below the waist. A patient given general anesthesia will be asleep and completely pain-free. The femoral nerve block is another form of regional anesthesia. The surgeon will inject pain medicine in the nerve in the groin. The patient will be asleep for the entire procedure and femoral nerve block will completely block out any pain. That way, the patient will not need as much general anesthesia.


The surgeon may put a cuff-like device around the thigh in order to control bleeding during the surgical procedure. After making cuts around the knee, the surgeon pumps saline into the knee to inflate it. The surgeon will then insert the camera and use the video monitor to fix or eliminate the problem within the knee. Once the issue is fixed, the surgeon will drain the saline and close the cuts with stitches.


Usually, knee arthroscopy is recommended for patients suffering from a torn meniscus, torn or damaged posterior cruciate ligament or anterior cruciate ligament, damaged or swollen lining of the joint, torn or damaged collateral ligament, misaligned kneecap, broken cartilage in the knee joint, fractures in the bones of the knee, repair of defective cartilage, and the removal of Baker’s cysts.

 
Knee Osteotomy

In a knee osteotomy, the surgeon will cut the femur (thigh bone) or tibia (shinbone) and reshape it in order to relieve some of the pressure on the knee joint. Usually, patients who have early-stage osteoarthritis will undergo knee osteotomy. Candidates for knee osteotomy often have one side of a knee joint damaged by early-stage osteoarthritis. The knee osteotomy shifts pressure and weight off the side of the knee joint that is damaged. Therefore, a knee osteotomy has the potential to improve the function of an arthritic knee significantly and relieve pain.


Osteoarthritis can develop when the leg and knee bones are not aligned properly. This misalignment of the knee and leg bones can put additional stress on the outer (lateral) or inner (medial) side of the knee. Over time, the additional pressure will cause the smooth cartilage in the knee joints to wear away. Since this smooth cartilage is intended to protect the bones, the lack of smooth cartilage can cause patients to suffer stiffness and pain in their knee.


Essentially, the main three goals of a knee osteotomy is to prolong the lifespan of the knee joint, transfer weight and pressure to a healthier area of the knee joint, and to correct poor knee alignment. Patients can delay the need for a total or partial joint replacement by undergoing a successful knee osteotomy. After a successful knee osteotomy, patients will be able to enjoy any physical activities, even high impact exercise. However, the recovery process for a knee osteotomy can be more difficult because the patient won’t be able to put weight on the leg and will have to manage the pain.

 
 
Cartilage Repair

Autologous cartilage cell implantation (ACI) refers to a state-of-the-art and new procedure developed to treat isolated full-thickness articular cartilage defects in the knee. The Food and Drug Administration has approved this new procedure to treat cartilage defects that are located at the femur bone end. Physicians also perform ACI to help treat defects of the kneecap and other joints within the body. Autologous chondrocyte implantation is an operative procedure that involves two stages.


A surgeon can perform the first stage of the ACI procedure arthroscopically in about 30 minutes. The surgeon will remove a tiny piece of articular cartilage from the knee of the patient. He will then send the articular cartilage biopsy to the laboratory. Enzymes will be used to treat the biopsy and isolate the chondrocytes, which are the cells of the body that are responsible for producing cartilage. The obtained chondrocytes will then be expanded in number and sent to the surgeon within about two months for implantation.


During the second stage a larger incision into the knee is made, the area of cartilage damage is exposed and prepared.  Once prepared, the MACI® (autologous cultured chondrocyte on porcine collagen membrane) graft, which contains the newly grown cells, is placed over the lesion and secured.  After the completion of the MACI procedure, the patient will be non-weight bearing for 6-8weeks.  Results are reported as good to excellent with adherence to a defined physical therapy protocol.

Dr. Vermillion is the leading expert in Cartilage restoration procedures in Alaska.  He has performed more than 100 autologous cell implantation procedures.

 
Meniscus Allograft

Meniscus allograft transplantation is an operative procedure that involves the placement of a meniscus into the knee. The meniscus is a cartilage ring taken from the cadaver of an organ donor. If a physician determines that a patient is a good candidate for a meniscus allograft transplantation, the physician will take x-rays of the knee. The physician will then use these x-rays to find a meniscus that will be suitable for the shape and size of the knee. Before the procedure, a lab will test the donated meniscus for infection or diseases.


The surgeon can perform other surgeries like cartilage or ligament repairs at the same time as a meniscus allograft transplantation. Patients usually receive general anesthesia prior to the operative procedure. The general anesthesia ensures that the patient remains asleep and unable to feel pain throughout the procedure. Regional anesthesia to numb the leg and knee area is another possibility. Patients who receive regional anesthesia will also receive medication to feel very sleepy during the operative procedure.


Usually, the surgeon will use a knee arthroscopy to perform the meniscus transplant. The surgeon will insert the arthroscope into the knee via a small incision. The arthroscope allows the surgeon to view the inside of the knee during the procedure. The surgeon will use the video monitor to confirm that a meniscus transplant will be appropriate and to rule out severe arthritis. Tissue from the old meniscus will be removed and the surgeon will make an incision to insert and sew in place the donated meniscus. The surgeon may need to use devices like screws to ensure the meniscus remains in place.


During a meniscus allograft transplantation, the surgeon will insert two cartilage rings in the center of the knee. One cartilage ring will go inside the knee while the other will go outside the knee. A torn meniscus can cause significant pain for individuals. Even when the meniscus is removed, some people experience pain, which is why they undergo a meniscus allograft transplantation. Not only can a new meniscus help limit knee pain, but it can also prevent arthritis. Patients with torn menisci who are unable to play sports or participate in other activities or experience knee pain, a weak or unstable knee, and chronic knee swelling are often good candidates for a meniscus allograft transplantation.

 
Meniscus Debridement

The meniscus refers to a rubbery and soft cushion that lies between the leg bone and the thigh bone. In the knee, there are two menisci. One meniscus is medial while the other is lateral. The purpose of the meniscus is to absorb shock and decrease the stress inflicted on the articular cartilage at the end of the leg bone and thigh bone. Meniscus injuries are common and can occur in individuals of any age. Turning, squatting, or twisting during just about any activity can cause a meniscus injury. Catching, locking, and clicking are some of the symptoms that may occur after the meniscus is torn. Another common symptom experienced by individuals with torn menisci is the swelling of the knee. Usually, the pain will be located along the joint line on the outside or inside of the knee. Physical examinations and imaging tests like X-rays can diagnose a damaged meniscus. An MRI will be able to confirm a meniscus tear. Most patients will need to undergo treatment to eliminate the symptoms of a torn meniscus.


In most cases, a patient will undergo a knee arthroscopy in order to remove the damaged fragments. This procedure is referred to as arthroscopic meniscus debridement, which is a common procedure in the orthopedics field. Due to limited blood supply, surgeons are often unable to repair the meniscus. The lack of blood supply makes it difficult for healing factors to reach the meniscus repaired with stitches. Since a patient with a torn meniscus is more likely to develop arthritis within the next two decades, removing the torn meniscus can reduce not just the symptoms but also the risk of developing arthritis.

 
Meniscus Repair

Arthroscopic meniscal repairs refers to an outpatient operative procedure that is intended to repair torn or damaged knee cartilage. Surgeons use a number of different minimally invasive techniques to repair a torn meniscus. Postoperative protection is often necessary to help a patient recover after the operative procedure. Some patients will need to undergo physical therapy for a few months in order to improve the function of the knee.


The main symptom of a damaged or torn meniscus is pain in the area of the tear and swelling of the overall knee joint. Squatting, pivoting motions, and extraneous activities can make these symptoms worse. If the torn knee cartilage gets caught in the joint of the knee, this can cause strange sensations. If the fragment that becomes stuck within the joint of the knee is large enough, this can cause the knee to lock in place and become unable to fully extend or bend.


The main goal of meniscus repair surgery is to preserve as much healthy knee cartilage tissue as possible. Since a meniscus tear needs a supply of blood in order to heal, a surgeon can only repair the outer third portion of the knee cartilage. Usually, repairs are limited to this area of the meniscus.


Unfortunately, many tears of the meniscus are located in regions that don’t receive sufficient blood flow to allow for healing. In such cases, the surgeon will usually simply remove the meniscus.

 
ACL Reconstruction

Anterior cruciate ligament (ACL) reconstruction involves the use of a new surgical tissue graft to replace the damaged anterior cruciate ligament, which is found in the knee. This operative procedure restores function to the knee after an injury. The surgeon will remove the torn ligament from the knee before inserting the graft via an arthroscopic procedure.
The main three sources for the surgical tissue graft replacement used in ACL reconstruction are autografts, allografts, and bridge-enhanced ACL repair. An autograft involves the use of tissue or bone harvested from the body of the patient. An allograft involves the use of tissue or bone from another individual, a live donor or the cadaver of an organ donor. Bridge-enhanced ACL repair involves using a sponge drenched with the blood of the patient to promote the reconnection and healing of the ACL.


A new development with ACL reconstruction is the use of synthetic tissue. However, little data about the effectiveness and reliability of the use of synthetic tissue exists.


Physicians have found that the use of mesenchymal stem cells can improve the recovery time for the ACL surgery, especially for professional athletes. Mesenchymal stem cells are able to differentiate into a number of different cells, such as chondrocytes, adipocytes, and osteoblasts, because they are multipotent stem cells.

 
Collateral Ligament Reconstruction

Collateral ligament reconstruction is typically recommended for patients who have a lateral (or fibular) collateral ligament tear and significant instability with various activities. The purpose of a collateral ligament reconstruction surgery is to restore the knees side-to-side stability and to reduce the chance of varus gaping. A physician diagnoses a lateral collateral ligament tear with varus stress radiographs and a clinical exam. Both the examination and the radiographs will help determine whether there is a complete fibular collateral ligament tear.


The treatment for the LCL injury mainly depends on the severity. In the least severe cases, the physician will recommend compression, elevation, rest, and ice in conjunction with the use of pain relievers and anti-inflammatory medications (NSAIDs) to reduce discomfort and swelling in the knee. Patients may undergo physical therapy to improve range-of-motion and increase strength so that the knee returns to a healthy state more quickly.


Usually, patients with a complete LCL tear will need to undergo collateral ligament reconstruction. Most surgeons perform this operative procedure as an open procedure with the help of arthroscopy. The surgeon will use a tissue graft to replace the damaged fibular collateral ligament. The surgeon will pass the graft through the bone tunnels and use screws to attach the graft to the fibula and femur bone. Most physicians prefer to use an allograft (tissue from another individual) or autograft (tissue from the patient) in order to reconstruct the fibular collateral ligament.


Rehabilitation after this surgical procedure usually involves exercises to improve the range-of-motion of the knee. The patient will start at a minimum no greater than 90 degrees and then go from there.

 
Knee Arthroplasty

Knee arthroplasty, also referred to as total knee replacement, is an operative procedure in which artificial parts are used to replace parts of the knee joint. The purpose of the knee is to serve as a hinge joint between the tibia and fibula and the femur, which is the upper leg bone. However, arthritis, injury, and other conditions can cause the cartilage between these bones to wear out. Common symptoms of a “bad” knee include swelling and pain.


Total knee replacement is a common option for patients who suffer from lack of function and pain due to an arthritic knee. The main reason for knee arthroplasty is the ineffectiveness of other treatments to reduce pain and discomfort associated with arthritis of the knee. Some examples of these treatments include injections, weight loss, medicines, and physical therapy.


The main goals of knee arthroplasty is to improve quality of life, relieve pain, and maintain or boost knee function. People of all ages, except young children, undergo this procedure. Children generally do not undergo this procedure because their bones are still growing. Before considering a knee arthroplasty, an individual must suffer from significant disability or pain. About 700,000 people undergo knee arthroplasty procedures every year in the United States.


The knee arthroplasty procedure is usually performed in an operating room. Patients are administered general anesthesia for the duration of the surgery, which is often two to three hours. After surgery, the patient is monitored in the recovery area until the effects of the general anesthesia wear off.


Most patients stay for up to four nights after the knee arthroplasty procedure. While shorter stays are becoming increasingly common, many surgeons are hesitant to send patients home early for fear of blood clots in the legs, which are referred to as deep vein thromboses. Patients may need to take medicine and remain active in order to prevent blood clots. While lying down, patients may also need to wear compression boots and antiembolism stockings in order to prevent bloods clots in the leg, ankle, knee, and foot. Pain and infections are also two other concerns of surgeons for patients after a knee arthroplasty procedure.

 
Total Knee Revision

While most knee arthroplasty procedures are successful, some fail for a number of reasons. If a knee replacement procedure was not effective, the knee may become swollen and painful. One may have a hard time performing daily activities due to instability and stiffness. One may need to have total knee revision where the surgeon will remove all or just some of the original prosthesis and insert a replacement.


Total knee revision is similar to knee arthroplasty but longer and more complex. The surgeon must do extensive planning and use specialized tools and implants to increase the chances of a good result. Some implants for knee arthroplasty consist of plastic and metal components. Even if the original procedure was successful, the implant may loosen or wear down, making a total knee revision procedure necessary.


There are different forms of total knee revision surgery. Depending on the case, the surgeon may only need to revise one component or implant of the prosthesis. In other cases, all three components of the prosthesis need to be replaced. In such a case, the surgeon may need to use augments or bone graft to rebuild the bone surrounding the knee.


If the bone is damaged, it may be more difficult for the physician to use traditional total knee implants to perform the total knee revision procedure. The surgeon may need to use specialized implants with thicker and longer stem to provide extra support.

 
Medial patella femoral ligament reconstruction (MPFL)

MPFL procedures are exceptionally successful in preventing recurrent patella (kneecap) dislocation. Individuals who have had full dislocation of the patella are typically well aware of the issue. Though other patients may be having subluxation or partial dislocation of the patella may not be aware of what is causing there knee pain and swelling.  

 

The procedure is designed to re-create the normal anatomy of the inside or medial side of the structures aligning the patella. The patella must glide back and forth in relationship to the knee in an anatomic “half pipe” known as the trochlea. An allograft (tissue donation ligament) is employed with a series of sutures and mechanical anchors resulting in proper knee kinematics while preventing lateral patella dislocation. In other words, the patella will be brought back into anatomical alignment after restoring the proper tension to the medial or inside of the knee.

 
Arthroscopic lateral release

This procedure is applicable in a select group of patients who have early or degenerative anterior or behind the kneecap osteoarthritis. For review, the knee has three primary compartments including the medial (inside), lateral (outside), and anterior (front).

 

Anterior compartment osteoarthritis typically manifests itself with pain while going down hill or down stairs. Additional painful activates can include but not be limited to kneeling, running, and squatting. Lateral release is performed when diagnostic imaging and symptoms indicate a lateral deviated patella causing impingement of the anterior femur and the backside or underside of the patella (kneecap).

 

Conservative management begins with physical therapy to attempt to improve patellar alignment resulting in decreased symptoms. If the patient fails conservative therapy, arthroscopic lateral release may be applicable. The procedure is completed by releasing or cutting deep connective tissue on the lateral or outside of the knee to re-align the patella. The results following physical therapy are improved patella alignment which spares anterior compartment cartilage. This leads to longer overall knee health, decreased pain, and return to activities of daily living.