Dr. Peter McEwen - M.B.B.S. F.R.A.C.S(Ortho).F.A.Ortho.A.DipModLang - Surgery Knee Dr. Peter McEwen - Surgery Knee: (123) 456789
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Arthroscopy of the Knee Joint

The arthroscope is a fiber-optic telescope that can be inserted into a joint (commonly the knee, shoulder and ankle) to evaluate and treat a number of conditions. A camera is attached to the arthroscope and the picture is visualized on a TV monitor. Most arthroscopic surgery is performed as day surgery and is usually done under general anesthesia. Knee arthroscopy is common, and millions of procedures are performed each year around the world.

Arthroscopy is useful in evaluating and treating the following conditions

Find out more about Arthroscopy of the Knee Joint with the following link

Arthroscopy of the Knee Joint

  1. Torn floating cartilage (meniscus): The cartilage is trimmed to a stable rim or occasionally repaired
  2. Torn surface (articular) cartilage
  3. Removal of loose bodies (cartilage or bone that has broken off) and cysts
  4. Reconstruction of the Anterior Cruciate ligament
  5. Patello-femoral (knee-cap) disorders
  6. Washout of infected knees
  7. General diagnostic purposes

Basic Knee Anatomy

The knee is the largest joint in the body. The knee joint is made up of the femur, tibia and patella (knee cap). All these bones are lined with articular (surface) cartilage. This articular cartilage acts like a shock absorber and allows a smooth low friction surface. Between the tibia and femur lie two cartilages called menisci. The medial (inner) meniscus and the lateral (outer) meniscus lie between the tibial and femoral articular cartilage surfaces and are mobile. The menisci also act as shock absorbers and stabilizers. The knee is stabilized by ligaments that are both in and outside the joint. The medial and lateral collateral ligaments support the knee from excessive side-to-side movement. The (internal) anterior and posterior cruciate ligaments support the knee from buckling and giving way. The knee joint is surrounded by a capsule (envelope) that produces a small amount of synovial (lubrication) fluid to help with smooth motion. Thigh muscles are important secondary knee stabilizers.

Investigations

A routine X-Ray of the knee, which includes standing weight-bearing and Rosenberg views is usually required. An MRI scan which looks at the cartilages and soft tissues may be needed if the diagnosis is unclear. There is no value in the use of Ultrasound in investigating knee problems.

Meniscal Cartilage Tears

Following a twisting type of injury the medial (or lateral) meniscus can tear. This results either from a sporting injury or may occur from a simple twisting injury when getting out of a chair or standing from a squatting position. Our cartilages become a little brittle as we get older and therefore can tear a little easier. The symptoms of a torn cartilage include

  • Pain over the torn area i.e. inner or outer side of the knee
  • Knee swelling
  • Reduced motion
  • Locking if the cartilage gets caught between the femur a tibia
  • Cartilage Tears

Once a meniscal cartilage has torn it will not heal unless it is a very small tear that is near the capsule of the joint. Once the cartilage has torn it predisposes the knee to develop osteoarthritis (wear and tear) in 15 to 20 years. It is better to remove torn pieces from the knee if the knee is symptomatic.

Torn cartilages in general continue to cause symptoms of discomfort, pain and swelling until the loose, ragged pieces are removed. Only the torn section is removed and the knee should recover and become symptom free if the joint is otherwise normal. Cartilage tears frequently coexist with osteoarthritis in which case symptoms from the arthritis can persist or recur after surgery. If the entire meniscus is removed, the knee will develop osteoarthritis in 15 to 20 years. It is standard to remove only the torn section of cartilage in the hope that this will delay the onset of long-term wear and tear osteoarthritis.

Occasionally, provided the knee is stable and the tear is a certain type of tear in a young patient (peripheral bucket handle tear), the meniscus may be suitable for repair. If repaired, one has to avoid sports for a minimum of three months.

Articular Cartilage (Surface) Injury

If the surface cartilage is torn, this is most significant as a major shock-absorbing function is compromised. Large pieces of articular cartilage can float in the knee (sometimes with bone attached) and this causes locking of the joint and can cause further deterioration due to the loose bodies floating around the knee causing further wear and tear. Most surface cartilage wear will ultimately lead to osteoarthritis. Symptoms locking and catching due to cartilage peeling off can be helped with arthroscopic surgery. The surgery smoothes the edges of the surface cartilage and removes loose bodies.

Anterior Cruciate Ligament Injuries

Rupture of the Anterior (rarely the posterior) Cruciate Ligament (ACL) is a common sporting injury. Once ruptured the ACL does not heal and usually causes knee instability and the inability to return to normal sporting activities. An ACL reconstruction is required and a new ligament is fashioned to replace the ruptured ligament. This procedure is performed using the arthroscope.

Patella (knee-cap) Disorders

The arthroscope can be used to treat problems relating to kneecap disorders, particularly mal-tracking and significant surface cartilage tears. The majority of common kneecap problems can be treated with physical therapy and rehabilitation.

Inflammatory Arthritis

Occasionally arthroscopy is used in inflammatory conditions (e.g. Rheumatoid Arthritis) to help reduce the amount of inflamed synovium (joint lining) that is producing excess joint fluid. This procedure is called a synovectomy. After the surgery a drain is inserted into the knee and patients generally require one or two nights in hospital.

Bakers Cysts

Bakers cysts or popliteal cysts are often found on clinical examination and ultrasound / MRI scan. The cyst is a fluid filled cavity behind the knee and in adults arises from a torn meniscus or worn articular cartilage in the knee. These cysts usually do not require removal as treating the cause (torn knee cartilage) will in most cases reduce the size of the cyst. Occasionally the cysts rupture and can cause calf pain. The cysts are not dangerous and do not require treatment if the knee is asymptomatic.

New Technology

Isolated areas of articular cartilage loss can be repaired using cartilage transplant technology. This is a new and exciting field that is developing in the treatment of specific isolated cartilage defects in younger patients

The process is called Autologous Chondrocyte Grafting . It involves harvesting cartilage cells from the affected knee, sending these cells to a laboratory and then culturing the cells to multiply into many cells. The large amount of cells produced are then placed back into the affected knee into the defect requiring resurfacing. Results are still short-term follow-up but are looking encouraging.

Cartilage repair is an area of keen interest to the specialty and emerging technologies will continually evolve. Nanomatrix implantation is such a technology and may well become the procedure of choice for cartilage repair in the near future.

After a major cartilage or ligament injury has been treated the knee can return to normal function. There is however a small increase in the risk of developing long-term wear and tear (Osteoarthritis) and depending on the degree of injury activity modification may be required. Activities that help prevent knees deteriorating quickly include:

  • Low impact sports like swimming, cycling and walking
  • Reducing weight and maintaining a healthy diet
  • Arthroscopy of the Knee: Patient Information

Surgery

You will be admitted on the day of surgery and need to remain fasted for 6 hours prior to the procedure.

The limb undergoing the procedure will be marked and identified prior to the anesthetic being administered.

Once you are under anesthetic, the knee is prepared in a sterile fashion. A tourniquet is placed around the thigh to allow a 'blood – free' procedure.

The Arthroscope is introduced through a small (size of a pen) incision on the outer side of the knee. A second incision on the inner side of the knee is made to introduce the instruments that allow examination of the joint and treatment of the problem.

Post-operative Recovery

You will wake up in the recovery room and then be transferred back to the day surgery unit.

You will be discharged with a Postoperative Knee Information document, a script for pain medication and an appointment card. Make sure to read the information provided. Contact Dr McEwen's rooms if unsure about anything.

A bandage will be around the operated knee. This can be removed the day following surgery. Leave the small waterproof dressings on until your postoperative appointment the following week. Replace these dressings if no longer sealed.

Pain medication will be provided and should be taken as directed. Unless otherwise instructed continue using Celebrex until your postoperative appointment as this will minimize swelling.

Unless otherwise instructed you may walk on the knee and bend the joint. Use the crutches for balance and control until you can walk properly without them. Walking without the crutches too soon will stir up the knee and is counterproductive. Most will be walking properly without crutches within a day or so. Begin static quadriceps exercises as instructed on the day of surgery.

Swelling is the best guide as to what level of activity is reasonable after a knee arthroscopy. If the knee is swollen it should be rested, iced and elevated. If the knee is not swollen then it is ready to be used. Begin slowly and increase your activity level as swelling allows. Do not be impatient with the knee. Overdoing things when the knee is swollen will add weeks to your recovery.

Position the knee wherever most comfortable when resting / sleeping (this will be slightly bent over a pillow if on your back or with a pillow between the knees if on your side).

DVT (blood clot) prevention is simple but important. Use the compression stockings provided until your activity level is close to normal. Drink plenty of fluids. Do calf pump exercises if not moving. Most importantly, take a few steps every hour while awake. Remember, it's not how long you're on your feet that counts but how often.

You may drive when you can walk properly without crutches and are not taking narcotic pain medications (Celebrex is not a narcotic. You can drive while taking this).

Blood thinning medications (Aspirin, Clopidogrel, Warfarin, Pradaxa) can cause bleeding into the knee after surgery. You must discuss the recommencement of these drugs with Dr McEwen. Call his rooms for clarification if unsure.

Risks of Arthroscopy

General Anesthetic risks are extremely rare in Australia. Occasionally patients have some discomfort in the throat as a result of the tube that supplies oxygen and other gasses. Please discuss with the Specialist Anesthetist if you have any specific concerns.

Risks related to Arthroscopic Knee Surgery Include:

  • Postoperative bleeding
  • Deep Vein Thrombosis
  • Infection
  • Stiffness
  • Numbness to part of the skin near the incisions

The risks and complications of arthroscopic knee surgery are small. The most common serious complication is deep venous thrombosis. The simple DVT prevention strategy outlined above is important and must be followed.

Knee Arthroscopy and Osteoarthritis

Osteoarthritis is progressive condition that will gradually progress. Pain from osteoarthritis is due to articular cartilage loss from then end of the bones and is aggravated by malalignment (bowed legs) and obesity. Knee arthroscopy does not correct any of this, does not stop the arthritis progressing and is not an effective treatment for painful osteoarthritis. Locking or catching in a knee that has osteoarthritis but is otherwise not particularly painful can be effectively treated with an arthroscopy. As mentioned above osteoarthritis frequently coexists with other knee conditions such as meniscus cartilage tears and will determine how well and for how long pain is relieved following surgery.

Frequently asked questions

How long am I in the Hospital?

A: Approximately 6 hours

Do I need crutches?

A: Canadian crutches for balance and control for a few days.

When can I get the knee wet?

A: The day after surgery. Take the big bandage off. The dressings underneath are waterproof.

When can I drive?

A: When you can walk properly without crutches and free of narcotic pain medications.

When can I return to work?

A:This depends very much on what your work is. Discuss with Dr McEwen.

When can I swim?

A: After 1 week.

How long will my knee take to recover?

A: Depending on the findings and surgery, usually 4 to 6 weeks following the surgery.

When Can I return to Sports?

A: Depending on the findings, 4-6 weeks after surgery.

Dr. Peter McEwen - Surgery of Knee
Dr. Peter McEwen - Surgery of Knee
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Cartilage Repair - Dr. Peter McEwen - Surgery of Knee
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Patient Forms - Dr. Peter McEwen - Surgery of Knee
Am I a Candidate - Dr. Peter McEwen - Surgery of Knee
Multimedia Patient Education - Dr. Peter McEwen - Surgery of Knee
Arthroscopic Partial Medial Meniscectomy Videos - Dr. Peter McEwen - Surgery of Knee
Arthroscopic Partial Medial Meniscectomy Videos - Dr. Peter McEwen - Surgery of Knee
Australian Orthopaedic Association Royal Australasian College of Surgeons
International Cartilage Repair Society International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine
Crocodiles Orthopaedic Research Institute of Queensland
 

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