Conditions and Surgical Procedures Knees

Arthritis

Osteoarthritis is a degenerative, disabling “wear and tear”, type of arthritis which sees articular cartilage thinning and being replaced by bony spurs. Over time, the arthritic knee joint space diminishes and load bearing activity causes severe pain. There is no cure for arthritis and when conservative treatment no longer helps with pain management, total joint replacement surgery becomes necessary.

Symptoms commonly associated with knee osteoarthritis include:

  • Pain that increases when you are active, but gets a little better with rest
  • Pain that interferes with daily activities
  • Swelling and feeling of warmth in the joint
  • Worse pain in colder weather
  • Stiffness in the knee, especially in the morning or when sitting for a while
  • Long-lasting knee inflammation and swelling that doesn’t get better with rest or medications
  • In advanced cases, moderate or severe knee pain while resting, day or night
  • A bowing in or out of your leg
  • Knock knees
  • Knee stiffness

How common is knee surgery?

According to the Australia’s National Joint Registry, there has been an 88 per cent increase in knee replacement surgeries between 2003 and 2014 – with more than 54,000 Australians undertaking the procedure in 2014.

What does surgery involve?

  • In general, knee replacement surgery consists of replacing the diseased or damaged joint surfaces of the knee with metal and plastic components shaped to allow continued motion of the knee.
  • Knee replacements are performed for severe arthritic knees and can be unilateral (one knee) or bilateral (two knees).          
  • The operation typically involves substantial postoperative pain, and includes vigorous physical rehabilitation.
  • The recovery period may be 6 weeks or longer and may involve the use of mobility aids (e.g. walking frames, canes, crutches) to enable the patient’s return to preoperative mobility. Hospital stay is generally about a week. Most patients can safely drive at 6 weeks and gradually increase walking distances in 6 weeks.

 What are the specific types of surgical replacement procedures Dr Herald offers?

Unicompartmental Replacement of The Knee

  • For osteoarthritis sufferers where the problem is limited to only one side of the knee, a uni compartmental knee replacement is an alternative surgical option to total knee replacement surgery.
  • Your orthopaedic surgeon should be consulted to discuss the extent of your arthritis to determine if a uni compartmental knee replacement is right for you.

Total Knee Replacement

  • Advanced arthritis of the knee is very painful. When non surgical treatments like medications and gentle exercise no longer manage pain, the total knee replacement surgery is an effective way to relieve pain, correct deformity and improve function of the knee.
  • Total knee replacement surgery is also called knee arthroplasty.
  • Knee arthroplasty involves implanting new femoral, tibial, tibial insert and patella components into the knee joint. The implants may be cemented or press fit into position.
  • The goal of surgery is to balance the knee so that future wear and tear of the new joint occurs as evenly over the new implant surface as possible. Physiotherapy is a very important part of the post op recovery process of total knee replacement surgery.

Biomet PSI Total Knee Replacement

  • Whilst your choice of a long lasting total knee replacement prosthesis is important, equally it is important to get the positioning and balance right when putting it in.
  • A combination of using the Biomet Vanguard total knee replacement prosthesis and the Signature personalized (PSI) technology, means you get a powerful combination of durability and fit for the maximum possible life of your joint replacement. A joint tailor-made for your body.

What other conditions require a knee replacement?

Knee replacement is also used for other kinds of knee disease such as:

  • Rheumatoid arthritis
  • Psoriatic arthritis
  • A torn meniscus
  • Cartilage defects
  • Ligament tears
ACL (ACL Reconstruction)

The anterior cruciate ligament is one of the most commonly injured ligaments
of the knee.

Signs of ACL damage include:

  • A loud “pop” or a “popping” sensation in the knee
  • Severe pain and inability to continue activity
  • Swelling that begins within a few hours
  • Loss of range of motion
  • A feeling of instability or “giving way” with weight bearing.

What does surgery involve?

Thankfully surgical reconstruction is generally a very successful operation if done before any permanent chondral or meniscal damage occurs (Dr Herald will assess this with examination and imaging).

As ACL generally does not heal, the surgical reconstruction is performed using either the patient’s own tendon (auto graft form hamstring or patella tendon) or that of a cadaver’s (allograft).

The procedure is usually a day surgical procedure but the reconstructed ligament matures over a one year period so return to sport requires intensive rehab.

 OTHER LIGAMENT INJURIES 

Posterior Cruciate Ligament Injuries

  • The PCL is located at the back of the knee and stops the tibia moving backwards. It is less common to injure the PCL than other types of knee ligaments.
  •  Impact injuries like dash boards of cars hitting the knee or hyper-extension injuries are the typical mechanisms of injury. The PCL injury may be categorised as a grade 1, 2 or 3 injury, where grade 3 is a complete rupture.
  • Complete rupture presents with pain, swelling, instability and loss of range of motion. Surgical treatment may be advised if the patient wishes to return to a high level of function.

Collateral Ligament Injuries

  • Collateral ligaments of the knee are the ligaments which brace the sides of the knee joint.
  • There is the Medial Collateral Ligament (MCL) and the Lateral Collateral Ligament (LCL).
  • As with other types of ligament tears, collateral ligament injuries are categorised as a grade 1, 2 or 3 injury, where grade 1 is slightly stretched and grade 3 is a complete tear or rupture.
  • The MCL is more frequently damaged than the LCL due it being easier to create a valgus strain versus a varus strain. Pain, swelling and instability are the symptoms and typically immobilisaton without surgery is the recommended treatment.

Combined Knee Ligament Injuries

  • Combined knee ligament injuries are complex injuries and an assessment of which ligaments have been affected and the recovery expectation of the patient need to be carefully considered. Multi ligament tears present with pain, swelling and inflammation. Treatment is often surgical and best soon after the injury.
  • Arthrofibrosis or scar tissue of the joint is a risk factor to consider for surgery of these conditions.
Arthroscopy
  • Arthroscopic knee surgery is generally a day surgery where small keyhole incisions are made in the knee (as opposed to formal, open incisions) which leads to a quicker recovery and less pain.
  •  Arthroscopy is generally used in evaluating conditions such as torn floating cartilage (meniscus); removing loose bodies (cartilage or bone that has broken off); patellofemoral (knee-cap) disorders, reconstruction of the Anterior Cruciate ligament or to wash out infected knees.
  • Physiotherapy is usually required post operatively and recovery takes around a month.
Discoid Meniscus
  • A discoid meniscus is an abnormally shaped meniscus in the knee.
  • People with discoid meniscus are more prone to injury than those with a normal meniscus.
  • Squatting and twisting motions are the typical mechanisms of injury.
  • Symptoms are more frequent in the young.
  • There are 3 types of discoid meniscus, incomplete, complete and hypermobile wrisberg.
  • Meniscal injuries present with pain, stiffness, swelling, catching, locking, and altered range of motion.
  • MRI scans can verify meniscal pathology which is best treated surgically.
Fractures

A knee fracture is a break or crack in 1 or more of the bones in the knee joint.  Common knee fracture injures include:  

Kneecap fractures

Some kneecap fractures can cause just a tiny crack in the bone, while others may cause the bone to shatter or stick out through the skin. This kind of injury generally results from a fall or blow to the knee.

Symptoms of kneecap fractures include:

  • Pain when your knee is touched or when you move your leg
  • You have swelling and bruising around your knee
  • You are able to straighten your leg but you cannot bend it
  • You cannot stand up or put weight on your injured leg

What is the treatment?

  • Treatment can be open reduction-internal fixation surgery where Dr Herald puts the broken bones back together with pins, wires and screws – or removes pieces to damaged to repair.
  • Alternatively the kneecap can be removed (either part or all of the kneecap).
  • After this surgery the knee can still be extended but the extension strength will be weaker.
  • Contact sports should be avoided and stationary bikes and non-weight bearing sports are recommended.

Distal Femar (thighbone) fracture of the knee

  • Fractures of the top part of the knee are called distal femur fractures.
  • They typically occur in the elderly or in high impact injuries such as a car crash.
  • Distal femur fractures can be described as transverse (straight across), comminuted (many pieces) or intra-articular (extend into the knee joint).
  • Additionally these types of fractures may be open (where the skin is broken), or closed (where the skin is intact).
  • Due to the strong musculature around these fractures, it is common for the muscles to shorten and move the bony fragments away from correct alignment.

What are the symptoms?

  • Pain with weight bearing
  • Swelling and bruising
  • Tenderness to touch
  • Deformity — the knee may look “out of place” and the leg may appear shorter and crooked.

What is the treatment?

  • Surgery is often indicated for distal femur fractures.

Proximal Tibia (below knee) fracture

  • Fractures of the bottom part of the knee joint are called proximal tibia fractures. While most of these fractures occur as a result of trauma, they can also occur as a result of stress fracture or compromised bone due to infection, cancer or osteoporosis.
  • Fractures of this region are described as transverse, comminuted or intra-articular.
  • Intra-articular fractures involve fracture of the tibial plateau, a much softer part of the tibia which sometimes presents as a depression in the bone rather than a fracture.
  • Surgical correction and immobilisation are recommended in proximal tibial fractures.

Symptoms of Proximal Tibia (below knee) fracture include:

  • Pain upon movement or when bearing weight
  • Tenderness
  • Limited ability to bend the knee
  • Deformity around or below the knee joint
  • The foot may be cold and pale (reduced blood supply)
Knee Dislocation (Multi-Ligament Reconstruction)
  • Multi-ligament knee injuries or knee dislocations are serious conditions that require immediate hospital assessment.
  • These injuries often occur as a result of a high impact injury such as a car accident or fall from a height.
  • They can also occur from sports or work injuries and involve multiple major ligaments being injured. If all four major ligaments are injured the knee may be dislocated.

What are the symptoms of dislocation?

  • Severe pain
  • Severe swelling
  • Inability to walk
  • The knee feeling unstable, loose and wobbly

What does surgery involve?

  • The knee needs to be reduced urgently and checked for vascular or neural damage.
  • Often the leg is splinted until swelling has reduced sufficiently to allow major surgery.
  • There is no real role for non-operative treatment in this scenario and staged surgeries are often performed to reconstruct the ligaments with a combination of autograft (patient’s own tendon), allograft (tendon from a cadaver) and synthetic grafts (artificial ligaments). Recovery is up to a year long.
Patellofemoral Pain Syndrome (Runner's Knee)
  • The patella or the knee cap sits in a groove at the front of the knee and should glide painlessly up and down through your femoral groove.
  • However this is not always the case and Patellofemoral Pain Syndrome is one of the most niggling and common knee complaints of both young and old.
  • It is generally caused by poor kneecap alignment and instead of gliding, the kneecap maltracks to one side and grates against the femur.

Symptoms of Patellofemoral Pain Syndrome include:

  • Pain around the knee. The pain is felt at the front of the knee, around or behind the kneecap (patella).
  • The pain comes and goes
  • Stairs, squatting, kneeling, hopping, running are often painful
  • There may be a grating or grinding feeling or noise when the knee moves
  • Sometimes there is fullness or swelling around the patella
  • If the groove or the patella is unusually flat the knee cap may be predisposed to dislocating
  • Running and jumping sports like netball and football, running, volleyball, skiing and basketball all see a high level of patellofemoral pain
  • As the condition progresses the pain may be more noticeable while walking and even at rest

What is the treatment?

  • The good news is that the majority of Patellar Pain Syndrome patients will benefit from physiotherapy intervention, (a mcconnell, along with Rest, Ice and Protection or taping))
  • Aim to stay away from kneeling and sporting activities until the knee pain is gone
  • Apply ice every 20 minutes for several hours at the onset of pain or if your knee feels warm to the touch
  • Speak to your physiotherapist about taping, mobilisation and other treatments along with techniques to improve your kneecap pain.
  • Surgery will only be required if there if there is continued maltracking despite an extensive course of physiotherapy..

Patellar Dislocation and Instability in Children

  • A child’s kneecap should sit in the middle of the knee in a groove of the femur called the trochlear groove.
  • During knee movement, the kneecap should move up and down within the groove.
  • When the patella slips out of the groove, it is known as a partial or complete dislocation of the kneecap.
  • This is a very painful experience associated with loss of movement, even if the kneecap returns to the groove after it has slipped out.
  • If the kneecap remains dislocated the child should be taken to emergency to have it reduced.
  • Pain and inflammation should be managed with physiotherapy including immobilisation and VMO quads strengthening.
  • Surgical treatment is only necessary if the patient experiences multiple dislocations.
Patellar Instability - (Medial Patellofemoral Ligament Reconstruction)

Patellar Instability

When the knee is functioning properly, the kneecap runs smoothly in a grove of the femur called the trochlear groove. If the kneecap slides out of this groove, the kneecap will become unstable. Anatomy anomalies like shallow or uneven grooves may cause the kneecap to slide out, or an injury such as a heavy fall or sharp blow to the kneecap may cause it to dislocate. Bracing and strengthening exercises treat minor and single episode dislocations while surgery is advised to correct multiple dislocation injuries.

What does surgery involve?

  • Persistent pain should not be ignored as recurrent dislocations can cause damage to the delicate chondral surfaces of the knee joint and predispose to arthritis.
  • There are a number of surgical procedures that may help in this situation  depending on your anatomy.
  • A Medial Patellofemoral Ligament Reconstruction (MPLF) is a surgical procedure indicated in patients with more severe patellar instability.
  • An MPFL reconstruction will reconstruct and tighten loose medial ligaments; a lateral release will release tight lateral structures; while a tibial ubercle transfer will realign the whole extensor mechanism by breaking the bone that the patella tendon is attached to and moving it with the patella into a more suitable position.
  • Dr Herald will work with you to find the most appropriate surgery and the rehabilitation for you.

Patellar Tendinitis or Tendon Tears

  •  The patellar tendon is a very strong tendon and resistant to injury.
  • Frequent running or jumping can cause a weakening of the tendon via overuse tendinitis or caused by disrupted blood flow to the tendon.
  • X-Ray and MRI scans will confirm degeneration and tearing or even a rupture of the patellar tendon, which is best treated by surgical repair.
  • Most tendon re-attachments are done as inpatient procedures, however, some treatments for tendinitis such as PRP may be done as outpatient procedures.
  • Post-surgery, a combination of knee immobilizer, crutches or walker may be used to prevent you from placing too much weight on the repaired knee.
  • Most tendinitis treated early with physiotherapy can avoid surgery.
Meniscal Tear

Meniscal tears are one of the most common types of knee injuries.The meniscus is commonly described as cartilage and is the shock absorber of the knee sitting on the tibia and below the femur. It is relatively easily torn by heavy squatting and twisting movements. There is a medial meniscus and a lateral meniscus making up menisci of the knee. Tears are described as longitudinal tears, parrot beak, bucket handle, transverse, radial, flap, and mixed or complex tears.

What are the symptoms of a meniscal tear?

  • Pain especially when twisting or rotating the knee
  • Stiffness
  • Swelling
  • Catching
  • Locking
  • A popping sensation
  • Altered range of motion
  • Difficulty straightening the knee fully
  • MRI scans can verify meniscal pathology which is best treated by surgical repair.

What is the treatment for meniscal tear?

  • Initially, rest your knee, and use crutches to avoid any weight bearing on the joint. Avoid any activities that worsen your knee pain.
  • Ice your knee every three to four hours for 30 minutes.
  • Compress or wrap the knee in an elastic bandage to reduce inflammation.
  • Elevate your knee to reduce swelling

Surgical treatment is usually an day surgery, using minimally invasive techniques.

PSI (Patient Specific Implant)

Whilst your choice of a long lasting total knee replacement prosthesis is important, equally it is important to get the positioning and balance right when putting it in.

By using preoperative CT scans to create a prosthetic module that fits your knee, we can use technology to create a tailor-made cutting jig – that helps accurately implant a prosthesis in the best position for your joint.

Quadriceps Tendon Tear
  • The quads tendon sits above the knee, joining the quads muscles to the top of the patella.
  • Tears are more common in middle aged populations. The mechanism of injury is an eccentric (lengthening) contraction of the quads resulting in a painful disabling condition.
  • Tendon weakness caused by tendinitis or chronic disease will result in higher risk of sustaining a quads tendon tear. Most large quads tendon tears should be treated surgically.

What are the symptoms of a tear?

  • A popping or tearing sensation
  • Pain and swelling
  • Inability to straighten the knee
  • An indentation at the top of your kneecap where the tendon tore
  • Bruising
  • Tenderness
  • Cramping
  • Your kneecap may droop because the tendon is torn
  • Difficulty walking due to the knee buckling or giving way

What is the treatment?

  • Small tears may heal with brace immobilization, crutches and physical therapy.
  • However most complete   tears require surgery to repair the torn tendon. Surgery involves reattaching the torn tendon to the top of the kneecap.
  • Results are better if the repair if performed soon after the injury to prevent tendon scarring or the tendon shortening and tightening.
Shin Splints
  • The term “shin splints”, refers to pain along the inner edge of the shin bone.
  • Shin splints are an over use injury, involving inflammation of the muscles, tendons and bone of the tibia.
  • Shin splints occur with a sudden change of frequency and load of exercise.
  • Those with poor arch support or flat feet are at higher risk of developing shin splints.
  • Shin splints may develop into stress fracture, tendinitis or chronic exertional compartment syndrome. Treatment involves rest from exercise, inflammation management and arch supports for feet. Surgical treatment is not indicated.
Osgood-Schlatter Disease

What is it?

Osgood-Schlatter disease is an overuse injury of the knee  that typically affects children and adolescents experiencing growth spurts. Kids who are involved in running and jumping sports and other activities which involve swift change of direction are more prone. These include soccer, basketball, netball, ballet and football.

What are the symptoms?

  • Pain
  • Swelling
  • Tenderness below the kneecap
  • Painful lump below the kneecap
The condition usually resolves on its own, once the child’s bones stop growing.

What is the treatment?

  • This is usually a resolving condition, and tends to improve when the child’s bones stop growing.
  • Treatment includes a course of non steroidal anti inflammatory drugs (NSAIDs).
  • In some patients, Osgood-Schlatter’s may last 2-3 years, but in most cases passes at the end of the growth spurt at 14-16 years old.