knee arthroscopy

Even though the team at Orthosports are surgeons, a number of knee conditions are treated non-surgically.  Non-surgical treatments usually involve a combination of:

• Medications
• Physiotherapy
• Injections – steroids or PRP
• Splints
• Braces
• Taping
• Activity modification
• Weight loss

Medications –Medications are used for periods of time to try and help control some of the symptoms while the knee is been rehabilitated.  There are different types of anti-inflammatories and pain relief medication that can be used and this should be discussed with the team at your appointment. For some knee conditions long term use can help symptoms.

Physiotherapy – The team here at Orthosports believe that the involvement of physiotherapists and trainers to help guide patients through a strengthening programme, specifically of the quadriceps and the gluteal muscles, is a very important part of all non-operative interventions.  It is also an important part of the prehabilitation and rehabilitation, if surgery is indicated. 

Injections – Often in combination with a strengthening programme, injections can be used.  Steroid injections can be indicated for certain condtions.  Hyaluronic Acid injections (Synvisc), although not routinely used, may have some specific indications.  Platelet Rich Plasma (PRP) is something that is being pioneered by the team at Orthosports in the management of knee arthritis in New Zealand and it is something that is offered to many patients.  Stem cell therapies, although stem cells have received a lot of press recently, it is not backed up yet by literature for its routine use in the knee.

Splints, Braces and Taping – For some people, for some knee conditions, wearing a knee brace as part of the management of your condition may be indicated. These are often used in consultation with an orthotist.  There can also be the need for braces in the post-operative period during rehabilitation to help stabilise the knee or to help unload the knee.  This will be discussed with you if it is indicated for your injury.

Activity Modification – This can sometimes be indicated to modify the sporting activities while rehabilitating the knee or managing your knee condition.  Sports involvement is very important to the members of Orthosports and there is always our goal to work with patients to try and help return them to the level of sport that they would like to be involved in. 

Weight Loss – Unfortunately obesity is becoming an important health issue in New Zealand, as it is in many countries.  As part of the treatment of your knee condition, if you are overweight, the team at Orthosports can happily refer you to a dietician or if you are extremely overweight, we may discuss referral to gastric surgeons to discuss a surgical option to reduce your weight prior to knee surgery.  The reasons this is undertaken is that extra weight places a large amount of extra stress through your knee joint and it may accelerate the progression of certain conditions.  Weight loss has been shown to be an effective at alleviating some of the symptoms associated with arthritis, but will also have a positive effect on blood pressure, diabetes, risk of heart disease and strokes.

Arthroscopy is a surgical procedure formed from several small cuts within the knee.  It leads to a faster recovery than the more traditional, larger incision techniques. It is usually performed under general anaesthetic and this is usually undertaken as a day-stay procedure.  This means that you come in and leave the hospital on the same day.  The surgery usually involves incisions either side of the kneecap.  An arthroscopic camera is placed through one of the holes and into the other side an instrument can be placed.  Sometimes additional incisions can be made to gain further procedures. Depending on what is undertaken, most patients do not require crutches. If your job is sedentary you can usually return after a few days to a week and return to driving, usually by 3 days and sporting activities at 6-12 weeks.

Arthroscopy is a very safe procedure and complications are uncommon. 

 Possible serious complications include infection and deep vein thrombosis.  Infections around the wound can occur, although significant precautions are undertaken.  Before surgery the area is cleaned with antiseptic and you will be given antibiotics before the surgical procedure which is undertaken intravenously.  If it is a superficial infection, these are often treated with antibiotics, but if infection gets into the joint, then this is a serious condition which can have long-term consequences and would require a surgical wash-out.

 Deep vein thrombosis is a clot in the leg.  This can cause persistent swelling in the foot and the ankle, and can become dislodged which carries the risk of having a pulmonary embolism, resulting in chest pain and breathing difficulties. The risk for deep vein thrombosis, unless there is a family history, is significantly very low.

 There are several nerves that run around the knee and these can be damaged by the incisions, usually the symptoms of numbness around that area do settle quickly with time.

A meniscectomy involves removing a torn piece of the meniscus, commonly referred to as cartilage.  Meniscal repair is performed when the type of tear makes it possible for the meniscus to heal.  There are a number of different methods of repair which involve putting implants into the knee, sometimes they require additional incisions to be made. 

Chondroplasty involves shaving off areas of unstable articular cartilage; this may also involve a microfracture which involves making holes in the underlying bone to stimulate the formation of cartilage.

The most important diagnostic tool we have when evaluating knee complaints is a thorough history regarding the onset of symptoms, the type of symptoms experienced and what limitations these have.  Once a thorough history has been undertaken, a targeted examination allows us to determine the diagnosis.  Often, to aid the diagnosis – x-rays (weight-bearing and often long leg alignment films to check the alignment of the limb) and MRI scans are used to confirm this diagnosis and aid in management decisions.

Osteoarthrosis is essentially loss of the articular cartilage of the bone surface of the joint.  The articular cartilage (hyaline cartilage) is normally very smooth with very special biomechanical properties that allow it to glide without creating friction.  However, when this surface is disrupted this can breakdown and damage the articular cartilage which can result in the development of osteoarthrosis.  Unfortunately articular cartilage has a poor capacity to heal itself.  

We often discuss the knee being divided into 3 compartments, the medial compartment, the lateral compartment and the patellofemoral compartment.  When one of these compartments develops osteoarthritic changes, one surgical option for treating these significant symptoms is an osteotomy.  The principle of the osteotomy is to realign the limb, to shift the line of weight-bearing away from the affected half of the joint, into the half of the joint where the articular cartilage is still good.   For example – if the medial side of the knee is wearing out and the weight-bearing is through the mid medial tibial plateau, one option is to do an osteotomy to change the weight-bearing line through the lateral compartment. 

Osteotomies can be performed above or below the knee joint. For medial compartment osteoarthrosis these are usually performed in the upper tibia.  For osteoarthrosis in the lateral compartment, it is usually performed in the lower femur. 

The osteotomy procedure itself involves cutting the bone virtually completely and wedging it open.  This is then held in place by plates and screws and often bone grafted with the patient’s own bone graft or allograft.  Most people are in hospital for two days and mobilise for six weeks on crutches.

The anterior cruciate ligament, when damaged, can lead to functional instability of the knee joint.  This is felt with the knee giving-way when changing direction.  This can risk damage to the cartilage and in turn result in premature osteoarthrosis.  Although the aim is of reconstructive surgery, it is unclear whether reconstructing the ACL reduces the risk of developing osteoarthrosis.  The main reason for reconstructing the ACL is to stop or prevent knee instability and allow people to return to full activities. 

In many situations, instability can be present soon after the injury occurs and the decision can be made without the development of instability within the knee.  However, in some situations people may wish to rehabilitate the knee and try to return to their normal activities.

The term knee reconstruction is often referred to when the anterior cruciate ligament is reconstructed.  The ligament connects the femur to the tibia and is particularly important for twisting and turning movements, such as those that are required for snow skiing, rugby, football, hockey and basketball. 

The surgical techniques includes taking a piece of tendon tissue, this is usually from the hamstring tendon, the patella tendon or the quadriceps tendon from the same knee, although the graft differs, the technique is essentially the same, where through arthroscopic incisions drill holes are made in the femur and the tibia, and a new graft is held in place. Post-operatively you are on crutches for two weeks and then guided through a rehabilitation plan.  The first week after surgery it is very important to rest the knee.  Allowing rest, ice, compression and elevation (RICE) to restore full extension to the knee.

The amount of time you will require off work varies depending on the job and if it is a deskbound job you can usually return within two weeks.  If it is heavy manual work, it may be 2-3 months.  Usually people are on crutches for two weeks.

Returning to sport, most patients are able to commence some form of sporting activities by 3-4 months (closed chain activities such as cycling), however a full return to play is usually 9-12 months.  Patients do continue to improve for another 6-12 months after that.