Knee
Knee Fractures | Other Ligament Injuries | Meniscus Tear | Patella Malalignment
Anterior Cruciate Ligament Tear
About the Anterior Cruciate Ligament (ACL)
The anterior cruciate ligament is one of 4 major ligaments that maintains knee joint stability. As a result of traumatic injury, the ACL can be torn. An injury that results in disruption of the ACL causes acute knee pain and swelling. In cases of substantial partial or complete tearing of the ACL, the knee can become what is known as ‘ACL deficient’.
Symptoms
Symptoms of ACL insufficiency include knee pain, weakness, intermittent swelling and episodes of the knee giving out or buckling. In cases of acute ACL injury, symptomatic treatment is recommended initially with pain management, bracing and a physical therapy program to restore motion and diminish inflammation in the knee. In cases of ACL injury where the sufferer is deemed ‘low ACL demand’, non-surgical treatment is initially recommended. Low ACL demand would include individuals with sedentary work and lifestyles with minimal recreational sports activity.The likelihood of symptomatic instability in this patient group is low, and under these circumstances ACL reconstruction is not necessary. In cases of ACL injury where the sufferer is deemed ‘high ACL demand’, a surgical reconstruction is likely the best treatment. High ACL demand clients include those that work at physically stressful jobs and/or are engaged in routine athletics and sports activity. The likelihood of symptomatic instability in this group is moderate-high, and under these circumstances an ACL reconstruction is recommended.
The Procedure
At Regional Orthopedics, ACL reconstruction is performed as an outpatient procedure and is done arthroscopically utilizing hamstring tendon as the graft material. The tissue for ligament reconstruction can be harvested locally from the patient at the time of ACL surgery (autograft) or can be taken from a tissue bank (allograft). The procedure is done in a minimally invasive fashion which limits postoperative discomfort. Recovery time is minimized with an allowance of full weight bearing after the procedure. Typically the patient should be walking without a cane by the end of the second week and riding a stationary bicycle. Recovery time for return to competitive sports is 3-6 months.
Other ligament Injuries- other ligaments that can be injured include the medial collateral (MCL), lateral collateral (LCL) and posterior cruciate (PCL). Injury to these ligaments along with the ACL can occur individually or can occur in combination (multiligamentous injury). Depending on the pattern of injury and the nature and extent of knee instability, non-surgical management in a brace or surgical repair/reconstruction of the ligaments may be indicated. At Regional Orthopedics, PCL reconstructions are done arthroscopically utilizing allograft tissue, LCL reconstructions are done through an open incision based over the lateral aspect of the knee (autograft and/or allograft tissue is utilized), and MCL repairs are done through an open incision over the medial aspect of the knee and typically do not require the use of tissue grafting. These procedures are performed on an outpatient basis. Recovery time is variable depending upon extent of the reconstructive procedure.
Cartilage Defect
About Cartilage Transplantation
A healthy knee has an uninterrupted layer of articular cartilage on all bone surfaces. As a result of traumatic injury or degeneration, the articular cartilage layer can become damaged. This is a common cause of knee pain and is the precursor of osteoarthritis. In cases where the articular cartilage damage is limited to a focal area, a cartilage transplant can be performed.
The Procedure
At Regional Orthopedics, 3 methods of cartilage transplantation are available: Osteochondral Autograft Transplantation, Osteochondral Allograft Transplantation and Autologous Chondrocyte Implantation. The best procedure to use is dictated in large part by the size and location of the lesion. The procedure can be performed on an outpatient basis by arthroscopy or arthrotomy. Recovery time is variable but typically involves a period of 6-12 weeks of limited/protected weight bearing.
Deformity Correction
About Osteotomy
Lower extremity alignment is normally neutral with the mechanical axis of the limb falling through the center of the knee. This neutral alignment allows for evenly distributed physical stress on both the medial and lateral weight bearing compartments of the knee. In cases of lower extremity malalignment, the mechanical axis is shifted to either the medial or lateral weight bearing compartment. This condition causes mechanical overload of the compartment and causes progressive deterioration of the joint cartilage in that area- osteoarthritis. If this condition is left uncorrected, the end result will be complete loss of the articular cartilage surface with advanced degenerative arthritis and the need for a knee replacement. Symptoms of lower extremity malalignment are ‘bow legged’ (varus) or ‘knock knee’ (valgus) deformity with associated knee pain.
The Procedure
At Regional Orthopedics, this condition can be surgically treated with a corrective osteotomy. This procedure involves realignment of the tibia or femur so that the mechanical axis is repositioned to the center of the knee. The end result will be correction of the deformity and equalized joint surface stresses.
Knee Arthritis
The knees are major weight bearing joints and are therefore subject to extreme physical stresses, which can over time result in the deterioration of the cartilage within the joint. This is the most common type of arthritis to affect the knee and is a condition called osteoarthritis, or ‘wear and tear’ arthritis. Other types of arthritis include post traumatic arthritis, which is arthritis secondary to a fracture or traumatic injury to the knee, and inflammatory arthritis, which is related to connective tissue diseases such as rheumatoid arthritis. The symptoms associated with knee arthritis are knee, thigh and leg pain, limping, weakness and joint stiffness. Typically there will be a progressive inability to perform routine activities such as putting on shoes and socks. Treatment for cases of minor or moderate arthritis are oral anti-inflammatory medications, injections, exercise and physical therapy.
Treatment
In cases of mild to moderate arthritis where non-invasive treatment has not been effective, injectable medication to cushion and lubricate the joint can be used. This medication is a form of hyaluronic acid which is the normal lubricant and cushion in the knee and tends to lose its biomechanical properties as part of the degenerative process. By restoring the level of hyaluronic acid in the knee to normal, symptoms of pain and stiffness can be substantially relieved. The level of response to this treatment and the duration of the effect is variable but may be near complete relief of symptoms in some cases and can last for more then a year. In cases where the relief is substantial and long-lasting, the injections can be repeated every 6 months. In some cases where arthritis is associated with loose bodies and meniscus tearing, an arthroscopic procedure is recommended prior to injection for the purpose of optimizing the mechanics of the environment and eliminating any other potential sources of pain from the knee. When this is done, it is an ambulatory procedure and injections can start within 1-2 weeks of the procedure.
In cases of moderate or severe arthritis where other less invasive treatments have not been effective, more invasive procedures can provide relief. These include such things as realignment osteotomy, cartilage transplantation (see other section), unispacer, partial knee resurfacing or total knee replacement.
Unispacer is a procedure preformed typically for unicompartmental degeneration affecting either the medial or lateral weight bearing compartment. It is a device that is implanted into the knee and functions to separate the bones helping to correct the alignment of the joint and also add a cushion to the surfaces. It is an ambulatory procedure and performed through a small 3 inch muscle sparing incision. Weight bearing can begin immediately and healing time is 4-8 weeks.
In advanced cases or cases where medical treatment has not provided adequate relief, a knee replacement is recommended. At Regional Orthopedics, 2 types of knee replacement are offered, partial knee resurfacing and total knee replacement. Both procedures are performed through a minimally invasive small 4 inch incision over the anterior aspect of the knee. The procedure that we employ is an advanced technique whereby the muscles are not detached from the bone. This allows for not only for much less postoperative pain and a more rapid recovery, but also allows for the restoration of natural joint mechanics and improved joint stability. This procedure will typically involve a 1-2 day hospital stay for partial replacement or a 3-4 day hospital stay for total knee replacement. ( See also cartilage transplant and osteotomy)
Knee Arthroscopy
About Arthroscopy
A minimally invasive procedure that involves the placement of a small camera into the knee. The inside of the knee can be visualized on a monitor. Through a separate small portal, a probe can be inserted to examine the structures within the knee. Based on direct visualization and probing, damaged tissue can be found and a diagnosis can be made. This is a useful procedure to establish a diagnosis related to knee pain, weakness or instability. In most cases these problems can be immediately addressed and corrected at that time. Meniscus repair, meniscectomy, cartilage repair, debridement, removal of loose bodies, anterior cruciate ligament repair and ligament reconstruction can all be performed utilizing arthroscopic techniques. The benefits of this minimally invasive procedure to the patient include a quicker recovery with less pain and less knee stiffness.
Knee Fractures
About Fractures
Fractures in the area of the knee may involve the distal femur, femoral condyles, tibia plateau and proximal tibia. These fractures can be complex and can have long-term consequences if not treated appropriately. These fractures, if incorrectly treated, can result in deformity and malalignment of the lower extremity, post-traumatic arthritis of the knee, knee stiffness, persistent gait alteration and chronic pain.
The Procedure
The recommended course of treatment may consist of non-surgical intervention with casting, protected weight bearing and bracing or surgical intervention. Surgical intervention is indicated with displaced and/or unstable fracture patterns, as well as intra-articular fractures with disruption of the joint surface. The goal of surgical intervention in these cases is restoration of the normal skeletal anatomy with a smooth and congruent joint surface and to maintain this physical relationship between the fractured fragments with rigid internal fixation during the time until bone union so that joint motion may be instituted early in an effort to prevent/minimize the occurrence of knee stiffness and muscle atrophy.
At Regional Orthopedics, we have mastered the techniques and surgical implants that are available to achieve these goals.
Other Ligament Injuries
Other ligaments that can be injured include the medial collateral (MCL), lateral collateral (LCL) and posterior cruciate (PCL). Injury to these ligaments along with the ACL can occur individually or can occur in combination (multiligamentous injury). Depending on the pattern of injury and the nature and extent of knee instability, non-surgical management in a brace or surgical repair/reconstruction of the ligaments may be indicated.
The Procedure
At Regional Orthopedics, PCL reconstructions are done arthroscopically utilizing allograft tissue, LCL reconstructions are done through an open incision based over the lateral aspect of the knee (autograft and/or allograft tissue is utilized), and MCL repairs are done through an open incision over the medial aspect of the knee and typically do not require the use of tissue grafting. These procedures are performed on an outpatient basis. Recovery time is variable depending upon extent of the reconstructive procedure.
Meniscus Tear
About The Meniscus
The knee has 2 menisci, the medial and lateral meniscus. These structures are fibrocartilaginous rings that sit between the femur and tibia bone. They function during weight bearing to cushion the joint and protect the articular cartilage surfaces from being damaged. As a result of ‘wear and tear’ or injury, the meniscus can become damaged and torn.
Symptoms of a Tear
Symptoms of a torn meniscus are typically knee pain, joint swelling, limping, knee clicking or locking, and an inability to run or perform at a previous baseline level of activity. Treatment for a torn meniscus in some cases is pain management. This can include the use of oral anti-inflammatory medications, steroid injections, knee bracing and exercises. In other cases, surgical treatment is recommended.
The Procedure
At Regional Orthopedics, meniscus surgery is performed arthroscopically as an ambulatory procedure, utilizing in most cases only a local anesthetic. Depending on the pattern and size of the tear, it may be amenable to surgical repair (meniscus repair). If a surgical repair is not possible, then the torn portion of the meniscus is removed (partial meniscectomy). In each scenario the pain associated with the tear is typically resolved. Recovery time can be a few days for meniscectomy and up to 4-6 weeks with protected weight bearing for meniscus repair. In cases where the entire meniscus is torn and irreparable, a meniscus transplant can be considered.
Patella Malalignment
About The Patella
The patella or ‘kneecap’ is a convex bone normally positioned at the center of the knee within a concave groove of the distal femur called the trochlea. With flexion and extension of the knee the patella is designed to glide within the trochlear groove and remain centered. Patella malalignment is a condition whereby the patella does not centrally align within the trochlea. This is often present as a result of congenital malalignment, but can also develop or be made symptomatic by associated muscle imbalances which can develop over time. Symptoms related to patella malalignment include anterior knee pain, intermittent knee swelling, knee crackling, knee buckling and occasionally patella dislocation.
The Procedure
At Regional Orthopedics, patella malalignment can often be treated with a combination of bracing and exercises to correct muscle imbalances. In some cases where the malalignment is severe or the knee has not responded to physical rehabilitation surgical correction of the alignment is necessary. At Regional Orthopedics, this is typically performed as an outpatient procedure utilizing arthroscopy and/or mini-arthrotomy. Soft tissue and skeletal imbalances are corrected. Recovery time to normal activities is variable depending on the extent of the procedure required.
