Knee Conditions

Anterior cruciate ligament injuries | Meniscus injuries | Osteoarthritis and knee replacement | Complex multiligament knee injuries | Pediatric knee surgery | Osteotomy

Anterior cruciate ligament injuries

The ACL (Anterior Cruciate Ligament) is a ligament that connects the lower end of the thigh bone (femur) to the top of the lower leg bone (tibia). This ligament is commonly injured in sporting activities and can be problematic because it does not heal well. The poor healing capacity of the ACL is due to the fact that it is bathed in synovial fluid (the fluid that is normally in the knee) and that it is not well vascularized (ie: the ACL does not have an abundant blood supply).

How it happens

ACL injuries occur most commonly in patients who play sports. They can also occur with other types of trauma, such as falls or motor vehicle accidents. The most common mechanism of ACL injury is a twisting or pivoting injury on the knee, where the foot remains planted and the knee twists. It also occurs commonly when landing from a jump, when the knee buckles or twists. The patient usually feels a “pop,” when the anterior cruciate ligament tears. The knee will also usually swell up within the first twenty-four to forty-eight hours.

How it feels

After the knee is injured and the ACL is torn, the knee will often feel very painful due to the ligament injury and the swelling. Patients often have difficulty walking after a tear of the anterior cruciate ligament. Patients may also feel knee instability after they tear their ACL. The knee may feel unstable early after the ACL injury, or in some cases, patients will feel instability after they recover from the injury to the anterior cruciate ligament.

How it is fixed

Patients who are very active and participate in cutting and pivoting sports, such as basketball, soccer, and football, will have a very high incidence of knee instability after an ACL injury. For these individuals, surgery is recommended to avoid the risk of future instability related to their anterior cruciate ligament, which can also lead to further meniscus and cartilage damage. For patients who do not participate in cutting and pivoting sports, non-operative management may be considered. This consists of physical therapy and strengthening. For patients who elect to undergo surgery, the anterior cruciate ligament is reconstructed with a tendon. The ACL reconstruction can be done either with a tendon from the patient’s own knee, or using an allograft (or transplant) from a donor.

Recovery/Post-Surgery

ACL reconstruction is done as an outpatient procedure, meaning that the patient goes home the same day. After ACL reconstruction, a brace is used for a few days and then patients can walk with crutches. Knee motion is started the day after surgery, and most patients can walk normally within one month of the ACL reconstruction. After anterior cruciate ligament reconstruction, patients initially work on range of motion and strengthening and then start light jogging at three to four months after surgery. A full return to sports requires at least six months of recovery after the procedure. The vast majority of patients are able to return to their previous level of activity in sports following successful ACL reconstruction.

Meniscus injuries

The knee can bend and straighten in a smooth and fluid fashion thanks to the cartilage on the ends of the thigh bone (femur) and leg bone (tibia). This cartilage is similar to the smooth shiny surface on the end of a chicken bone. There is also another type of cartilage in the knee called the meniscus. The meniscus is localized between the ends of the bones and acts as a shock absorber and stabilizer. It is a very important structure, because studies have shown that if the entire meniscus is removed, the knee can develop arthritis.

How it happens

The meniscus is frequently injured in sports and also when lifting weights in the gym. The most common mechanism of injury is a rapid twisting of the knee, but it can occur many other ways such as a forceful flexion. This can happen if a lifter hits the deep full squat position hard and bounces back up. In some cases, you may not remember a specific injury, but the meniscus can tear due to repetitive loads and chronic cartilage degeneration.

How it feels

A torn meniscus is often painful because loose ends of the torn piece can get trapped in the knee. In some cases, the torn piece can lead to mechanical catching or locking of the knee and you will have to maneuver the knee to “unlock” it and allow motion. In other cases, a piece of the meniscus can break off and become a “loose body” that can also lead to the knee catching or locking. Magnetic Resonance Imaging (MRI) is very helpful to confirm the diagnosis and can assist in determining the best course of treatment for the meniscus tear.

How it is fixed

After the onset of symptoms, a trial of physical therapy and anti-inflammatory medications may be warranted. However, mechanical symptoms such as catching and locking will only resolve if the offending fragment of meniscus tissue is removed. This is done with arthroscopic surgery. The procedure is performed through two small holes in the knee, each measuring less than a centimeter. A camera is inserted into the knee through one hole and surgical instruments through the other. The torn pieces from the knee are removed with the surgical instruments. To avoid future problems with the knee, as little tissue as possible is removed. In some cases, the meniscus can be repaired so no tissue is removed. We see our work inside the knee live on a television screen in the operating room. The fiber optics allows a better view of the inside of the knee than can be achieved with open surgery.

Recovery/Post-Surgery

Following the meniscus surgery, rehabilitation is undertaken with a physical therapist. The initial steps in therapy are to reduce swelling and regain full motion of the knee. Crutches are generally used for a few days and most patients are walking normally by one to two weeks following surgery. Strengthening is an important part of the rehabilitation process and return to sports is generally possible by three months. Professional athletes who are in top shape and can dedicate each day to rehabilitation can return to play within a week or two in some cases, depending on their sport.

Osteoarthritis and knee replacement

Arthritis of the knee is a common condition. This occurs when the cartilage in the knee wears down over time leading to discomfort in the knee. When the cartilage completely erodes in the knee, there is bone that rubs against bone, which is painful and uncomfortable. If the arthritis pain becomes very advanced, patients can have difficulty walking and sleeping due to the discomfort. In this fashion, arthritis of the knee can limit patients’ quality of life.

How it happens

Arthritis is generally due to “wear and tear” of cartilage. Some individuals may be more susceptible to knee arthritis than others, possibly due to their genetic makeup. Other patients may develop osteoarthritis related to a previous knee injury.

How it feels

Arthritis pain in the knee is generally felt as a deep, dull ache. The knee pain is usually worse with activities such as walking. When knee arthritis pain is very advanced, running will be impossible. After increased activity, such as a long walk, knee arthritis pain will usually be more severe. Generally, knee arthritis is easily diagnosed with plain x-rays. MRI is generally not required to make this diagnosis.

How it is fixed

Knee arthritis is treated initially with non-operative management. This includes medication, such as non steroidal anti-inflammatory drugs, as well as Tylenol. Chondroitin and glucosamine have been proven to be effective for alleviating pain related to knee arthritis. Physical therapy is a very valuable non-operative management option to improve the pain related to knee arthritis and increase function. Injections may also be useful including cortisone or visco-supplementation (injection of sodium hyaluronate). A brace may help some patients with advanced knee arthritis. A cane can also be of assistance to patients with knee arthritis. If non-operative management does not sufficiently improve the symptoms, surgery may be required. Most commonly, total knee replacement (also known as total knee arthroplasty or TKA) is the procedure of choice. In some cases, a partial knee replacement can be performed. Knee replacement surgery involves resurfacing the ends of the bones with metal and plastic components, so that the bone on bone is eliminated; therefore the pain is reduced.

Recovery/Post-Surgery

After total knee replacement surgery, patients generally stay in the hospital for three to five days. Physical therapy begins the day after surgery, and the patient gets out of bed and begins to walk. Range of motion exercises are also started on the first day after the knee replacement. Patients are usually able to walk without assistance within two weeks, and most patients can walk without a limp (or minimal limp) within two months. The recovery period following total knee replacement usually lasts between three and six months. Physical therapy is required to regain range of motion and to improve walking ability.

Complex multiligament knee injuries

Multiligament knee injuries are also known as knee dislocations and occur when the end of the femur [thigh bone] separates from the tibia [shin bone], causing multiple knee ligaments to tear. These injuries are very severe and lead to gross instability of the knee. Surgery is usually required to reconstruct the ligaments. This surgery is often extensive and technically demanding.

How it happens

Multiligament knee trauma is frequently the result of a high energy injury such as a car accident or fall from a height. It can also occur from a sports injury, or rarely, a fall at work or during everyday activity. In these injuries, two or more of the major ligaments in the knee are severely injured and require surgery. If three or all four of the major ligaments are injured, the knee may be dislocated.

How it feels

These injuries are usually associated with severe pain and swelling of the knee. Patients can generally not walk and in some cases have damage to the nerves or arteries of the leg. Because many ligaments in the knee are injured, the knee is normally unstable after a period of healing. The patient will feel unstable on their knee and it can feel loose and wobbly.

How it is fixed

In some cases, one or more of the ligaments may heal without surgery. In most patients, surgery is required to reconstruct ligaments. Repair may be performed where the ligaments are stitched back together, but frequently the ligaments must be constructed using a graft to make a new ligament. The graft may be taken from the patient, or frequently donor tissue (allograft) is used since many grafts are required for the procedure.

Recovery/Post-Surgery

After multiligament knee reconstruction, patients are in a brace and do not bear weight on the knee for approximately four weeks, depending on the procedure. Physical therapy is required and crutches are generally used for over one month.

Pediatric knee surgery

The most common problems in children’s knees include ACL tears, discoid meniscus, and osteochondritis dissecans [OCD].

How it happens

ACL tears occur usually from a sports injury. Discoid meniscus is a congenital problem, where the child is born with a meniscus that is too large, and they frequently tear and cause symptoms of pain or popping in the knee. The cause of OCD is not clear, but it can cause pain in the child’s knee and require surgery in some cases.

How it feels

When the ACL is torn the knee is painful and swollen. Subsequently, the child may have a sense of instability or giving-way. A discoid meniscus will often cause pain or a sense of catching or locking. OCD lesions generally cause pain that is worse with activity.

How it is fixed

These conditions do not always require surgery in children. When surgery is indicated, Dr. Marx uses specific techniques to avoid growth plate injury in children. These techniques vary depending on the age and skeletal maturity of the child. Discoid meniscus can be treated either through resection of the extra meniscus or repair, depending on the type of meniscus. Lastly, OCD lesions are usually treated with arthroscopic drilling, which is a relatively small procedure. In some cases, more extensive surgery is required.

Recovery/Post-Surgery

Crutches are required following ACL surgery or OCD drilling. If a discoid meniscus is repaired with sutures, crutches are also required, but, if only a portion of the meniscus is removed, crutches may only be needed for a few days. Physical therapy is required after surgery for each of these conditions.

Osteotomy

Arthritis of the knee is a common condition. When the bones of your knee are not properly aligned, this can put extra stress on either the inner (medial) or outer (lateral) side of your knee. This pressure can wear away the cartilage that protects the bones. The result is pain and stiffness. If only one side of the joint is damaged, an osteotomy can redistribute pressure on the arthritic side to a healthier area. This can allow you to return to normal activities without pain.

How it happens

Arthritis is generally due to “wear and tear” of cartilage. Some individuals may be more susceptible to knee arthritis than others, possibly due to their genetic makeup. Poor knee alignment can worsen the arthritic damage on one side of the knee joint.

How it feels

Arthritis pain in the knee is generally felt as a deep, dull ache. The knee pain is usually worse with activities such as walking. When knee arthritis pain is very advanced, running will be impossible. After increased activity, such as a long walk, knee arthritis pain will usually be more severe. Generally, knee arthritis is easily diagnosed with plain x-rays.

How it is fixed

Knee arthritis is treated initially with non-operative management. This includes medication, such as non steroidal anti-inflammatory drugs, as well as Tylenol. Chondroitin (joint supplement that helps reduce osteoarthritis pain) and glucosamine (joint supplement that helps reduce osteoarthritis pain) have been proven to be effective for alleviating pain related to knee arthritis. Physical therapy is a very valuable non-operative management option to improve the pain related to knee arthritis and increase function. Injections may also be useful including cortisone or visco-supplementation (injection of sodium hyaluronate). A brace may help some patients with advanced knee arthritis. A cane can also be of assistance to patients with knee arthritis. If non-operative management does not sufficiently improve the symptoms, surgery may be required. If the arthritis is in its early stage and limited to one side of the knee, an osteotomy may be chosen over a knee replacement. During the procedure, a wedge of bone is removed from the outside of the tibia (shin bone) or femur (thigh bone). The surgeon then closes the wedge, straightening the leg. In some cases, the wedge is “opened” instead of “closed,” and the surgeon adds a bone graft to fill the space.

Recovery/Post-Surgery

In most cases, patients stay at the hospital for 2 days after an osteotomy. Most patients require crutches for 6 to 8 weeks. Rehabilitation includes range of motion and strength exercises. The recovery period for an osteotomy usually lasts between 3 and 6 months.

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