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Knee

The knee is a vulnerable joint that bears a great deal of stress from everyday activities, such as lifting and kneeling, and from high-impact activities such as jogging and aerobics.

The knee is formed by the following parts:
Tibia. This is the shin bone or larger bone of the lower leg.
Femur. This is the thighbone or upper leg bone.
Patella. This is the kneecap.

Injections For Knee Pain

Each bone end is covered with a layer of cartilage that absorbs shock and protects the knee. Basically, the knee is two long leg bones held together by muscles, ligaments, and tendons.
There are two groups of muscles involved in the knee, including the quadriceps muscles (located on the front of the thighs), which straighten the legs, and the hamstring muscles (located on the back of the thighs), which bend the leg at the knee.
Tendons are tough cords of tissue that connect muscles to bones. Ligaments are elastic bands of tissue that connect bone to bone. Some ligaments on the knee provide stability and protection of the joints, while other ligaments limit forward and backward movement of the tibia (shin bone).

 

ACL Repair

What are some common knee problems?
Many knee problems are a result of the aging process and continual wear and stress on the knee joint (i.e., arthritis). Other knee problems are a result of an injury or a sudden movement that strains the knee. Common knee problems include the following:
Sprained or strained knee ligaments and/or muscles. A sprained or strained knee ligament or muscle is usually caused by a blow to the knee or a sudden twist of the knee. Symptoms often include pain, swelling, and difficulty in walking.
Torn cartilage. Trauma to the knee can tear the menisci (pads of connective tissue that act as shock absorbers and also enhance stability). Cartilage tears can often occur with sprains. Treatment may involve wearing a brace during an activity to protect the knee from further injury. Surgery may be needed to repair the tear.
Tendonitis. Inflammation of the tendons may result from overuse of a tendon during certain activities such as running, jumping, or cycling. Tendonitis of the patellar tendon is called jumper's knee. This often occurs with sports such as basketball, where the force of hitting the ground after a jump strains the tendon.
Arthritis. Osteoarthritis is the most common type of arthritis that affects the knee. Osteoarthritis is a degenerative process where the cartilage in the joint gradually wears away, and often affects middle-age and older people. Osteoarthritis may be caused by excess stress on the joint such as repeated injury or being overweight.
Rheumatoid arthritis can also affect the knees by causing the joint to become inflamed and by destroying the knee cartilage. Rheumatoid arthritis often affects persons at an earlier age than osteoarthritis.

Meniscal Tear

How are Knee Problems Diagnosed?
In addition to a complete medical history and physical examination, diagnostic procedures for knee problems may include the following:
X-ray. A diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
Magnetic resonance imaging (MRI). A diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body; can often determine damage or disease in a surrounding ligament or muscle.
Computed tomography scan (also called a CT or CAT scan). A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays
Arthroscopy. A minimally-invasive diagnostic and treatment procedure used for conditions of a joint. This procedure uses a small, lighted, optic tube (arthroscope) which is inserted into the joint through a small incision in the joint. Images of the inside of the joint are projected onto a screen; used to evaluate any degenerative and/or arthritic changes in the joint; to detect bone diseases and tumors; to determine the cause of bone pain and inflammation.
Radionuclide bone scan. A nuclear imaging technique that uses a very small amount of radioactive material, which is injected into the patient's bloodstream to be detected by a scanner. This test shows blood flow to the bone and cell activity within the bone.

Osteoarthritis

Treatment for Knee Problems
Specific treatment for knee problems will be determined by your doctor based on:
  • Your age, overall health, and medical history
  • Extent of the disease, injury, or condition
  • Your tolerance for specific medications, procedures, or therapies
  • Expectations for the course of the disease, injury, or condition
  • Your opinion or preference
  • If initial treatment methods do not provide relief, and X-rays show destruction of the joint, the orthopaedist may recommend total joint replacement for the knee.

    PATIENT GUIDE: KNEE REPLACEMENT

    When Surgery Is Recommended
    There are several reasons why your doctor may recommend knee replacement surgery. People who benefit from total knee replacement often have:

    A knee that has become bowed as a result of severe arthritis

  • Severe knee pain or stiffness that limits your everyday activities, including walking, climbing stairs, and getting in and out of chairs. You may find it hard to walk more than a few blocks without significant pain and you may need to use a cane or walker
  • Moderate or severe knee pain while resting, either day or night
  • Chronic knee inflammation and swelling that does not improve with rest or medications
  • Knee deformity - a bowing in or out of your knee
  • Failure to substantially improve with other treatments such as anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy, or other surgeries
  • There are no absolute age or weight restrictions for total knee replacement surgery.
    Recommendations for surgery are based on a patient's pain and disability, not age. Most patients who undergo total knee replacement are age 50 to 80, but orthopaedic surgeons evaluate patients individually. Total knee replacements have been performed successfully at all ages, from the young teenager with juvenile arthritis to the elderly patient with degenerative arthritis.

    An evaluation with an orthopaedic surgeon consists of several components:

  • A medical history: Your orthopaedic surgeon will gather information about your general health and ask you about the extent of your knee pain and your ability to function.
  • A physical examination: This will assess knee motion, stability, strength, and overall leg alignment. X-rays :- These images help to determine the extent of damage and deformity in your knee.
  • Other tests: Occasionally blood tests, or advanced imaging such as a magnetic resonance imaging (MRI) scan, may be needed to determine the condition of the bone and soft tissues of your knee.
  • (Left) In this x-ray of a normal knee, the space between the bones indicates healthy cartilage (arrow). (Right) This x-ray of an arthritic knee shows severe loss of joint space and bone spurs (arrows).

    Your orthopaedic surgeon will review the results of your evaluation with you and discuss whether total knee replacement is the best method to relieve your pain and improve your function. Other treatment options - including medications, injections, physical therapy, or other types of surgery - will also be considered and discussed.
    In addition, your orthopaedic surgeon will explain the potential risks and complications of total knee replacement, including those related to the surgery itself and those that can occur over time after your surgery.

    Realistic Expectations
    An important factor in deciding whether to have total knee replacement surgery is understanding what the procedure can and cannot do.
    More than 90% of people who have total knee replacement surgery experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living. But total knee replacement will not allow you to do more than you could before you developed arthritis.
    With normal use and activity, every knee replacement implant begins to wear in its plastic spacer. Excessive activity or weight may speed up this normal wear and may cause the knee replacement to loosen and become painful. Therefore, most surgeons advise against high-impact activities such as running, jogging, jumping, or other high-impact sports for the rest of your life after surgery.
    Realistic activities following total knee replacement include unlimited walking, swimming, golf, driving, light hiking, biking, ballroom dancing, and other low-impact sports.
    With appropriate activity modification, knee replacements can last for many years.

    Possible Complications of Surgery
    The complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in fewer than 2% of patients. Major medical complications such as heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur, they can prolong or limit full recovery.
    Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.

    Blood clots may develop in leg veins.

    Infection: Infection may occur in the wound or deep around the prosthesis. It may happen while in the hospital or after you go home. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.

    Blood clots: Blood clots in the leg veins are the most common complication of knee replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program, which may include periodic elevation of your legs, lower leg exercises to increase circulation, support stockings, and medication to thin your blood.

    Implant problems: Although implant designs and materials, as well as surgical techniques, continue to advance, implant surfaces may wear down and the components may loosen. Additionally, although an average of 120° of motion is generally anticipated after surgery, scarring of the knee can occasionally occur, and motion may be more limited, particularly in patients with limited motion before surgery.

    Continued pain: A small number of patients continue to have pain after a knee replacement. This complication is rare, however, and the vast majority of patients experience excellent pain relief following knee replacement.

    Neurovascular injury: While rare, injury to the nerves or blood vessels around the knee can occur during surgery.

    Medical Evaluation
    If you decide to have total knee replacement surgery, your orthopaedic surgeon may ask you to schedule a complete physical examination with your family physician several weeks before the operation. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such as a cardiologist, before the surgery.

    Tests
    Several tests, such as blood and urine samples, and an electrocardiogram, may be needed to help your orthopaedic surgeon plan your surgery.

    Medications
    Tell your orthopaedic surgeon about the medications you are taking. He or she will tell you which medications you should stop taking and which you should continue to take before surgery.

    Dental Evaluation>br/> Although the incidence of infection after knee replacement is very low, an infection can occur if bacteria enter your bloodstream. To reduce the risk of infection, major dental procedures (such as tooth extractions and periodontal work) should be completed before your total knee replacement surgery.

    Urinary Evaluations
    People with a history of recent or frequent urinary infections should have a urological evaluation before surgery. Older men with prostate disease should consider completing required treatment before undertaking knee replacement surgery.

    Social Planning
    Although you will be able to walk on crutches or a walker soon after surgery, you will need help for several weeks with such tasks as cooking, shopping, bathing, and doing laundry.
    If you live alone, your orthopaedic surgeon's office, a social worker, or a discharge planner at the hospital can help you make advance arrangements to have someone assist you at home. They also can help you arrange for a short stay in an extended care facility during your recovery, if this option works best for you.

    Home Planning
    Several modifications can make your home easier to navigate during your recovery. The following items may help with daily activities:

  • Safety bars or a secure handrail in your shower or bath
  • Secure handrails along your stairways
  • A stable chair for your early recovery with a firm seat cushion (and a height of 18 to 20 inches), a firm back, two arms, and a footstool for intermittent leg elevation
  • A toilet seat riser with arms, if you have a low toilet
  • A stable shower bench or chair for bathing
  • Removing all loose carpets and cords
  • A temporary living space on the same floor because walking up or down stairs will be more difficult during your early recovery
  • You will most likely be admitted to the hospital one day before your surgery.

    Anesthesia
    After admission, you will be evaluated by a member of the anesthesia team. The most common types of anesthesia are epidural, or regional nerve block anesthesia (you are awake but your body is numb from the waist down) or general anaesthesia (you would be put to sleep). The anesthesia team, with your input, will determine which type of anesthesia will be best for you.

    Procedure
    The procedure itself takes approximately 1 to 2 hours. Your orthopaedic surgeon will remove the damaged cartilage and bone, and then position the new metal and plastic implants to restore the alignment and function of your knee.

    Different types of knee implants are used to meet each patient's individual needs.

    The x-ray appearance of a bilateral total knee replacement. Note that the plastic spacer between the bones does not show up in an x-ray.

    After surgery, you will be moved to the recovery room, where you will remain for several hours while your recovery from anesthesia is monitored. After you wake up, you will be taken to your hospital room.

    You will most likely stay in the hospital for 5-7 days.

    Pain Management
    After surgery, you will feel some pain, but your surgeon and nurses will provide medication to make you feel as comfortable as possible. Pain management is an important part of your recovery. You will be put on Continuous PCA pump which will lessen your pain to a great degree. Walking and knee movement will begin soon after surgery, and when you feel less pain, you can start moving sooner and get your strength back more quickly. Talk with your surgeon if postoperative pain becomes a problem.

    Blood Clot Prevention
    Your orthopaedic surgeon may prescribe one or more measures to prevent blood clots and decrease leg swelling. These may include special support hose, inflatable leg coverings (compression boots), and blood thinners.
    Foot and ankle movement also is encouraged immediately following surgery to increase blood flow in your leg muscles to help prevent leg swelling and blood clots.

    Physical Therapy
    Most patients begin exercising their knee the day after surgery. A physical therapist will teach you specific exercises to strengthen your leg and restore knee movement to allow walking and other normal daily activities soon after your surgery.

    Preventing Pneumonia
    It is common for patients to have shallow breathing in the early postoperative period. This is usually due to the effects of anesthesia, pain medications, and increased time spent in bed. This shallow breathing can lead to a partial collapse of the lungs (termed "atelectasis") which can make patients susceptible to pneumonia. To help prevent this, it is important to take frequent deep breaths. Your nurse may provide a simple breathing apparatus called a spirometer to encourage you to take deep breaths.

    The success of your surgery will depend largely on how well you follow your orthopaedic surgeon's instructions at home during the first few weeks after surgery.

    Wound Care
    You will have stitches or staples running along your wound or a suture beneath your skin on the front of your knee. The stitches or staples will be removed two weeks after surgery. A suture beneath your skin will not require removal.
    Avoid soaking the wound in water until it has thoroughly sealed and dried. You may continue to bandage the wound to prevent irritation from clothing or support stockings.

    Diet
    Some loss of appetite is common for several weeks after surgery. A balanced diet, often with an iron supplement, is important to help your wound heal and to restore muscle strength.

    Activity
    Exercise is a critical component of home care, particularly during the first few weeks after surgery. You should be able to resume most normal activities of daily living within 3 to 6 weeks following surgery. Some pain with activity and at night is common for several weeks after surgery.

    Your activity program should include :

  • A graduated walking program to slowly increase your mobility, initially in your home and later outside
  • Resuming other normal household activities, such as sitting, standing, and climbing stairs
  • Specific exercises several times a day to restore movement and strengthen your knee. You probably will be able to perform the exercises without help.
  • You will most likely be able to resume driving when your knee bends enough that you can enter and sit comfortably in your car, and when your muscle control provides adequate reaction time for braking and acceleration. Most people resume driving approximately 4 to 6 weeks after surgery.
  • Guidelines for Home Recovery Consult with your internist about duration and dosage of iron (ferrous sulfate) after your discharge. Caring for Surgical Site Leave the Primapore Dressing until your sutures are removed. After removal of your sutures, leave the incision open unless instructed otherwise. Please inform your surgeon if increasing redness of or drainage from your incision. Pain Medication Take your pain medication as prescribed. To control pain, take your pain medication before the pain becomes severe. If your pain medication seems weak, or if you are experiencing unpleasant side effects, do not hesitate to call your surgeon. If you are taking pain medication, avoid alcoholic beverages and recreational drugs. If you experience discomfort during your ongoing physical therapy, take your pain medication at least 45 minutes prior to your subsequent therapy sessions. This will allow enough time for the medication to take effect. Preventing Infection Having undergone surgery increases your risk of infection. However, antibiotics can help protect you and should be used in the following situations : With any medical or surgical procedure, performed by your physician or dentist During certain diagnostic procedures, such as catheterization and endoscopy, or those involving intestines, lungs, bladder and kidney With serious infections elsewhere in your body Tell your internist and dentist that you have an artificial joint so that they can prescribe antibiotics. Total knee replacement patients who require dental work on gums or roots must adhere to the following antibiotic procedure regimen : For patients not allergic to Penicillin: Cephalexin, Cephradine or Amoxicilin: 2 grams orally 1 hour prior to the dental procedure For patients allergic to Penicillin: Clindamycin: 600mg orally 1 hour prior to the dental procedure. Patients should adhere to this regimen for the first two years following joint replacement. Immunocompromised patients, including those with inflammatory arthropathies, rheumatoid arthritis, drug or radiation-induced immunosuppression, insulin-dependent diabetes or any other major medical problem should follow this antibiotic routine indefinitely. Antibiotics can reduce the risk of infection but cannot completely eliminate that risk. Preventing infection must be the concern of all the healthcare professionals who treat you. MAKE SURE YOU INFORM YOUR PHYSICIAN AND DENTIST THAT YOU HAVE HAD A TOTAL KNEE REPLACEMENT.

    After full recovery, some patients enjoy light sports activities. Activities you can enjoy after total knee replacement include walking, bicycling, bowling, swimming, golf and doubles tennis. Avoid high impact activities, such as:

  • Jogging
  • Running
  • Jumping
  • Skiing
  • Knee Flexion

  • Sit on the edge of a table or chair.
  • Try to bend your operated knee as much as you can, assisting with the opposite leg.
  • Hold for 10 seconds.
  • Do 15 repetitions, 3 times per day.

  • Quad Sets / Extension
  • Sit or lie on your back with your leg straight.
  • Press the back of your knee downward. This will tighten the muscle on top of your thigh and move your kneecap.
  • In a sitting position, press your knee down using both hands to apply additional pressure.
  • Hold for 10 seconds.
  • Do 15 repetitions, 3 times per day.
  • Knee Flexion
  • Place your foot on a low stool
  • Lean your weight forward to bend the knees so that you can feel a stretch.
  • Hold for 10 seconds.
  • Do 15 repetitions, 3 times per day.
  • Calf Raises
  • Stand up, holding on to a sturdy surface, such as a table
  • 2. Raise yourself up onto the balls of your feet.
  • Hold for 10 seconds.
  • Do 15 repetitions, 3 times per day.
  • Your New Knee is Different

    You may experience skin numbness around your incision, and knee stiffness, particularly with excessive bending activities, such as getting in and out of a low chair or a car. Though possibly uncomfortable, kneeling is not harmful. At times, you may notice soft clicking. These symptoms will gradually improve over several weeks and months. The benefits of total knee replacement usually become fully evident 6-8 months after surgery.

    You do not have to do every exercise at each session and you do not have to follow a particular order.Doing the lying exercises in sequence is easier and more convenient.
    The Home Recovery Program allows you to choose from the four exercises you were taught in the hospital. The number of times you do each exercise depends on your capacity, which will increase as you progress towards recovery. Recovery doesn't happen overnight, so don't be discouraged, and don't try to do too much too soon. The exercises should not cause pain. If they do, eliminate them from your program.
    Continue to follow precautions outlined by your surgeon.

    Climbing Stairs
    The following are instructions (NOT exercises) for climbing and descending stairs.

    If you have one (1) total knee:
    UPSTAIRS

  • The non-operated leg goes first
  • The operated leg goes second
  • The crutches go last (at the same time as the operated leg)

  • DOWNSTAIRS
  • The crutches go first
  • The operated leg goes second
  • The non-operated leg goes last

  • If you have two (2) total knees:
    UPSTAIRS
  • The stronger leg goes first
  • The weaker leg goes second
  • The crutches go last(at the same time as the weaker leg)

  • DOWNSTAIRS
  • The crutches go first
  • The vast majority of patients are able to resume safe and enjoyable sexual intercourse after knee replacement. Patients whose sexual function had been impaired by preoperative knee pain and stiffness welcome their new pain-free mobility. However, gaining full confidence with your new knee may take several weeks.

    In general, intercourse can be resumed safely approximately eight weeks after surgery. Though individual recovery time varies greatly, this timeframe allows the incision and the muscles around the knee to heal. If you recuperate rapidly, you will be able to resume sooner, as long as you are free of pain.

    Total knee replacement precautions need to be observed during all activities, including sexual intercourse. In general, you should avoid excessive knee flexion (knee toward chest), adduction (leg towards center of body), and internal rotation (toes turned inward).

    Most patients, male and female, prefer 'passive' intercourse in the 'bottom' position, an option some find less fatiguing. As your knee heals, you may resume a more active role. After a few months, patients can resume sexual activities in any comfortable position.

    Blood Clot Prevention
    Follow your orthopaedic surgeon's instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He or she may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.

    Warning signs of blood clots. The warning signs of possible blood clots in your leg include :

  • Increasing pain in your calf
  • Tenderness or redness above or below your knee
  • Increasing swelling in your calf, ankle, and foot

  • Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include:
  • Sudden shortness of breath
  • Sudden onset of chest pain
  • Localized chest pain with coughing

  • Preventing Infection
    A common cause of infection following total knee replacement surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. These bacteria can lodge around your knee replacement and cause an infection.
    After your knee replacement, you must take preventive antibiotics before dental or surgical procedures that could allow bacteria to enter your bloodstream.

    Warning signs of infection. Notify your doctor immediately if you develop any of the following signs of a possible knee replacement infection:
  • Persistent fever (higher than 100°F orally)
  • Shaking chills
  • Increasing redness, tenderness, or swelling of the knee wound
  • Drainage from the knee wound
  • Increasing knee pain with both activity and rest
  • Avoiding Falls
    A fall during the first few weeks after surgery can damage your new knee and may result in a need for further surgery. Stairs are a particular hazard until your knee is strong and mobile. You should use a cane, crutches, a walker, hand rails, or have someone to help you until you have improved your balance, flexibility, and strength.
    Your surgeon will help you decide what assistive aides will be required following surgery and when those aides can safely be discontinued.

    How Your New Knee Is Different
    Improvement of knee motion is a goal of total knee replacement, but restoration of full motion is uncommon. The motion of your knee replacement after surgery can be predicted by the range of motion you have in your knee before surgery. Most patients can expect to be able to almost fully straighten the replaced knee and to bend the knee sufficiently to climb stairs and get in and out of a car. Kneeling is sometimes uncomfortable, but it is not harmful.
    Most people feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending activities.
    Most people also feel or hear some clicking of the metal and plastic with knee bending or walking. This is a normal. These differences often diminish with time and most patients find them to be tolerable when compared with the pain and limited function they experienced prior to surgery.
    Your new knee may activate metal detectors required for security in airports and some buildings. Tell the security agent about your knee replacement if the alarm is activated.

    Protecting Your Knee Replacement
    After surgery, make sure you also do the following :

  • Participate in regular light exercise programs to maintain proper strength and mobility of your new knee
  • Take special precautions to avoid falls and injuries. If you break a bone in your leg, you may require more surgery
  • Make sure your dentist knows that you have a knee replacement. You should be given antibiotics before all dental surgery for the rest of your life
  • See your orthopaedic surgeon periodically for a routine follow-up examination and x-rays, usually once a year

  • Extending the Life of Your Knee Implant
    Currently, more than 90% of modern total knee replacements are still functioning well 15 years after the surgery. Following your orthopaedic surgeon's instructions after surgery and taking care to protect your knee replacement and your general health are important ways you can contribute to the final success of your surgery.

    Expect to have routine follow-up visits at the Ranawat Orthopaedics as follows:

  • Suture removal 10-14 days from surgery
  • 6 weeks following day of surgery
  • 3 months following total knee replacement
  • 1 year following total knee replacement
  • 3 years following total knee replacement
  • 5-6 years following total knee replacement
  • 8-10 years following total knee replacement
  • Every year thereafter.
  • This follow-up schedule may vary from patient to patient.

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