A normal knee is a complex joint with freedom of movement in six axis. This allows Flexion, Sideways and twisting movements. It consists of three bones: patella (kneecap), femur (thigh bone) and tibia (shin bone). The joint is held together by ligaments (bands) and is supported by muscles. The ends of the bones are covered with very smooth articular cartilage that enables them to move easily over each other. Between the femur and tibia are two spacer-like structures known as meniscus .
The knee joint is most often injured typically during sports activities (football, rugby, skiing etc), an accidental fall, road traffic accident or some other direct impact. The most frequently damaged structures are meniscus, ligaments, articular cartilage and bones.
Arthritis- Osteoarthritis is a age related degenerative condition but can affect young age group after Injury , instability and infection.
Rheumatoid arthritis is an inflamatory condition which commonly affect either single or multiple joints with increasing deformity which cam affect all age groups.
Infection - Septic arthritis is a serious and life threatening condition.
Meniscus (torn cartilage) These are half moon shaped tough elastic structures, which act like shock absorbers. A meniscus tear is quite common in a twisting injury. It can be associated with ligament damage and fractures involving the knee joint. It can affect both young and older patients.
Torn Meniscus Common complaints pain, locking, clicking, giving way and the feeling of something trapped inside the knee joint. Diagnosis & investigation examination of the patient. MRI scans are quite sensitive but the image be normal in 15% cases even if a tear is present. Treatment this often requires key hole surgery or in some cases repair. Recovery very good results following surgery. Torn Meniscus Torn Meniscus
Ligaments provide stability to the knee joints. The two collateral (medial & lateral ) provide sideways stability and the two cruciates (anterior & posterior) provide stability in a front and backward direction. Anterior cruciate and medial collateral ligaments are commonly injured.
Cruciate ligament injury This ligament is usually torn in the middle and cannot be repaired. Rarely it is pulled out with a piece of bone at the end in which case it can be repaired.
Torn Anterior Cruciate ligament often causes marked swelling of the knee & moderate to severe pain shortly after injury. The knee usually starts to give way 4-6 weeks later. Diagnosis & investigation examination of the patient, X-Ray & MRI scan. Key hole surgery and examination of the knee under General anaesthesia may be required. Treatment - Not all patients with cruciate ligament injury will require surgery. Reconstruction of the ligament is required if the knee keeps giving way and is uncomfortable and swollen after activity. If untreated it may lead to tear of the menisci. Reconstruction of the ligament is done by either using a patellar tendon or a hamstring tendon as a graft. Recovery rehabilitation usually takes 6 weeks to three months and full recovery may take 6-9 months.
Medial collateral ligament An injury to a medial collateral ligament is usually associated with injury to other structures like meniscus, cruciate ligament and bone bruise. In the majority of cases the ligament heals without surgery. However surgery may be required especially when other structures are injured or the patient’s lifestyle or profession places a high physical demand on the knee.
Articular cartilage is an extremely smooth and resilient structure, which covers the bone’s articulating surfaces (those surfaces that come into contact with other bones). Its function is to allow for the smooth gliding between two bony surfaces of the joint. It has no blood supply and once injured often leads to permanent damage. Injury to articular cartilage is quite common and is often not diagnosed. Recent advancement in the understanding, diagnosis and treatment of articular cartilage injury has now made it possible to effectively manage and provide treatment in the majority of patients. We have experience in providing treatment for these injuries in the form of articular cartilage transplantation, Autologus Grafting, Chondroplasty and Microfracture. Injury to the articular cartilage usually occurs after sports injuries. It commonly affects the Tibio femoral (main weight bearing) or the Patellofemoral (knee cap) joint. Injuries resulting from a forceful impact on the knee joint, such as a tackle in football or rugby are commonly associated with injuries to other structures within the joint such as Anterior cruciate ligament, Posterior cruciate ligament and damage and tear of the Meniscus. Direct impact on the knee cap (Patella) or dislocation of the patella can also cause damage to the articular cartilage. Sometimes spontaneous damage can occur in conditions like Osteochondritis Disseacans, in which part of the bone and its covering articular cartilage becomes dead due to lack of blood supply. Types of Damage Damage is graded from I-IV and can vary from obvious defects in the bone (grade IV) to very minor microscopic damage (grade I). Injury to the articular cartilage causes inflammation and pain in the knee joint and in the long term may accelerate the onset of osteoarthritis.
Injured Articular cartilage often cause recurrent pain and swelling in the knee joint . Usually the pain is mild and aching in nature usually after activity or at rest. Feeling of roughness and locking inside the knee joint (Crepitaion). Knee movements may be associated with audible ‘clunks’ or ‘clicks’. Articular cartilage injuries can sometimes be difficult to diagnose.
Diagnosis is based on the following: Listening to the patient’s history and mechanism of injury Surgeon’s expertise in the field of knee surgery X-ray and MRI scan. In some cases damage cannot be seen even though it is present. Gold standard – Direct visualisation by performing Keyhole surgery (Arthroscopy)
Treatment options -What can Patients do? Rest, Ice, Anti inflammatory and simple movement and exercise. If problem continues then surgery may be required. Surgery Various types of surgery are performed for articular cartilage injuries. These depend on the severity and type of injury, size, area affecting inside the knee, other associated injury and cause of injury. Brief description of these techniques:
Debridement- The surgery involves making the rough area as smooth as possible by removing loose edges.
Microfracture- The surgery stimulates scar cartilage to grow and fill the lesion. Scar cartilage has limited life span and will degrade with time.
Replacement of cartilage Oseochondral Autologus grafting – It is a technique by which a piece of cartilage and the bone underneath is taken from the area of least use and transplanted to the area of missing cartilage and bone. This technique is quite effective and has good success rate. It can be done either by arthroscopic or open surgery.
Autologus cartilage implantation (ACI) -This involves Open surgery and transplantation of cartilage to the injured area of the knee. Patients are in hospital for 2-3 days. They use the walking aid for 6 weeks and also have physiotherapy. Average recovery time for normal activity is 6-8 weeks and return to sports is 6-9 months. Success rate of surgery is around 80-90 percent depending upon surgeon’s experience and patient’s motivation and strict adherence to the rehabilitation programme.
Arthritis simply means inflammation of the joint. This initially causes pain, swelling and stiffness that gradually deteriorates with time. At a later stage it leads to deformity and destruction of the joint. There are various types of arthritis.
Osteoarthritis is the commonest form and is caused by gradual wear and tear of the joint. Diseases like Osteoarthritis and Rheumatoid arthritis damages the smooth articular cartilage covering the ends of bone. As the cartilage starts to wear away, the bone ends are exposed and then rub against each other and in severe cases themselves become worn. This causes the knee to become painful, stiff, and deformed and affects all aspects of life including sleep. Osteoarthritis (degenerative arthritis) commonly affects middle to late age patients. However it can also affect younger patients if they’ve had a previous injury or knee-joint surgery.
Osteoarthritic Treatment Different modes of treatment are available which can improve and control early symptoms of osteoarthritis. painkillers, anti-inflammatory tablets and local cream improve pain and swelling. Local injections provide temporary pain relief. Arthroscopic surgery usually improves mechanical symptoms of osteoarthritis often caused by meniscal tear and loose pieces of bone. Minor adjustments in lifestyle and sports activity. regular exercise to improve muscle strength and movement of the knee joint
Joint Replacement surgery - Total or Partial
What is arthroscopic knee surgery (keyhole surgery)? It is usually a day case surgical procedure in which the inside of the knee is examined with a camera inserted through small cuts in the skin (usually one cut on each side of the knee cap). In most cases, performing the corrective surgery at the same time can solve the problem. In some cases further operation may be required.
Why should you have an arthroscopy?- In the majority of cases, surgery for torn meniscus, removal of a loose piece of bone, biopsy and articular cartilage lesions can be performed using special instruments. The advantage of arthroscopic surgery over conventional surgery is less pain and usually quicker recovery. Investigation required before surgery is MRI scan to identify the problem affecting the knee, an x-ray of the knee joint may be needed. in some cases a simple blood test and ECG (tracing of heart) may be required.
Types of anaesthesia -Various anaesthetic techniques are used and the consultant anaesthetist will recommend the best type after discussing the options with you before surgery. Be assured, you will not feel any pain during the operation.
What happens on the day of operation? You will be admitted to hospital 1 to 2 hours before surgery. The consultant surgeon and the anaesthetist will once again explain the procedure to you in detail. You’ll have the chance to ask them any questions about the surgery or aftercare. You’ll then be asked to sign a consent form and the surgeon will put an arrow mark on your leg, which requires surgery. A nurse will also ask you certain questions about your general health. Depending on the specific procedure, surgery can take between 20 and 40 minutes. After the operation, the surgeon will explain the findings and discuss options for further care. A physiotherapist will also advise you about an exercise plan. Please take time to read the leaflet provided about the surgery and aftercare.
Aftercare following arthroscopy -Your knee will have a support bandage, which should be removed after 24-48 hours. You’ll need to attend a follow-up appointment two weeks after surgery when your stitches will be removed. You should walk naturally as soon as possible and try not to limp. A physiotherapist will give you a sheet of exercises. These are designed to strengthen your thigh muscles. It is important that you do them regularly. Keep your wound and dressing clean and dry till the stitches are removed. Keep your leg elevated on a footstool while sitting to avoid swelling. Take painkillers regularly as prescribed. Do not consume alcohol, drive or operate any machinery. If you had a general anaesthetic then it is advisable to take rest and a responsible adult should stay with you overnight. Take one – two weeks off work. It is advisable not to drive for two weeks. Please check with your insurance company. Your knee may have some swelling for 3-6 weeks depending upon the type of surgery.
Bleeding – It is not uncommon to see dry blood on the dressings after 48 hours. However, if you see fresh blood coming from the wound then you should contact the hospital.
Infection – The risk is extremely low (1 in 1000). You will receive one dose of intravenous antibiotic during your operation. If you start to run a temperature or if your knee becomes hot, painful, red and swollen then you should immediately contact the hospital.
Blood clots (Thrombosis)- The risk is 1-2%. If the calf muscles become swollen and painful then you should contact the hospital. Numbness around the scar – This is rare and should recover with time. How can you help? If you are overweight, then try to lose weight. It reduces the risk of complications. If you’re prescribed warfarin then you should stop taking it at least three days before surgery. Make sure your surgeon knows that you take warfarin. It is advisable to try to stop smoking at least 6 weeks before surgery. It reduces the risk of complications after general anaesthesia.
Diseases like osteoarthritis and rheumatoid arthritis damage the smooth articular cartilage covering the ends of bone. As the cartilage starts to wear away, the bone ends are exposed and then rub against each other and in severe cases themselves become worn. This causes the knee to become painful, stiff, and deformed.
When do you need a new knee joint? The decision is straightforward if you have one or all of the following:
Severe pain, both day and night that is not relieved by painkillers or other treatment. If you can’t walk far.
Compromise in Lifestyle activity- Shopping, Leisure and Household
If you develop increasing deformity of the knee.
X- ray shows arthritis.
In the majority of cases, patients are aged 60 or over. It is not wise to delay the operation because with time the muscles become weaker, stiffer and more deformed. This reduces the chances of a successful outcome after surgery.
Your new knee joint and how it works.- A new knee joint procedure simply means replacing the worn surface of the bones with prosthesis. The thighbone (femur) is resurfaced by a single piece of metal. The shinbone (tibia) is replaced by a metal plate and a plastic is placed over the metal to act like a cartilage. This allows a smooth movement and marked improvement in pain, function and mobility. Recent advances in knee replacement allow better range of movement and longer working life of the implant. In certain cases only part of the knee joint is replaced (unicondylar knee). The choice of implant depends on the condition of the knee joint, the physical demand placed on the knee and the age of the patient.
What’s new in knee joint replacement surgery?-New design in implants allows higher degree of flexion and better longevity of the implant.
What can you expect from a knee replacement? -The success following total knee replacement depends upon the surgeon’s experience, the type of implant and the condition of the knee before surgery. The patient’s expectation, motivation and cooperation during rehabilitation are also factors. Contrary to common belief, total knee replacements are as successful as total hip replacements. About 95% of the knee replacement will last more than 15 years.
Pain relief – Majority of patients report 95% improvement in pain following surgery.
Flexion (bend) – 90% of patients will achieve knee flexion of 100-110 degrees. The most recent knee implant designs allow an even better range of movements and tend towards normal, provided the patient has the normal range of movement before surgery.
Walking distance – Most patients can walk 45 minutes or more with little or no discomfort. As the walking distance increases patients generally feel fitter with time.
Function – a majority of patients find it much easier to perform a wide range of daily activities (climbing stairs, shopping, dressing and personal hygiene etc). Leisure & Sports – activities like swimming, general fitness exercise and golf are possible after knee replacement.
Limitations – kneeling, heavy impact exercises & heavy manual work should be avoided. Please remember a replaced knee joint will never act or behave like a normal knee.
What can you do to get a better result?- Try to lose weight if you are overweight. exercise your thigh muscles regularly before and after surgery. Miss a meal do not miss your exercise, keep moving your new knee joint, keep motivated and well informed.,try to stop smoking at least 6 weeks before surgery.
What happens before the operation? -Your surgeon will explain to you in detail about the total knee replacement procedure: the advantages, disadvantages, and possible complications. You can also ask him questions about the surgery to remove any doubts from your mind. He will ask you about your general health, medication and any allergies. If you are on warfarin then please make sure your surgeon knows about it. Investigations like an x-ray of the knee joint, a chest x-ray, heart tracing (ECG), a routine blood test and cross match are all required before surgery. These investigations help us decide whether you are fit enough for the operation and most hospitals now perform them in a pre-operative assessment clinic. If you have any source of infection in your body then it is critical that you tell the nurse or your surgeon about it. Potential source of infection are: open wound or ulcers on the skin mouth, teeth or gum cough, cold or chest infection bladder and groin area skin space in between your toes.
What happens on the day of admission?- You will be admitted to hospital a day before surgery. The nurse, surgeon and the anaesthetist will see you. They will once again ask you questions about your general health and fitness for surgery. Your surgeon will explain once again about surgery and ask you to sign a consent form for surgery. Your leg will be marked. You will have the opportunity to ask your team about all aspects of the surgery – from the anaesthesia to the aftercare. You will be asked to shower using an antiseptic soap on the day of admission and on the day of surgery before going to operating theatre.
Type of anaesthesia Your anaesthetist will decide the most appropriate anaesthesia for you. Commonly a combination Spinal anaesthesia and Local block is used. This involves inserting a needle in your back to freeze the body from the waist down.The effect of block usually lasts 12-24 hours. In certain medical conditions General anaesthesia may be used in certain cases.
After your operation You will return to the ward after a short stay in the recovery room. Your leg will have a bandage and a drain tube which helps reduce bleeding and collection of blood. This will be removed after 24-48 hours. Due to the nerve block, you may not have much feeling in your leg. This also helps reduce the pain after surgery. You will have a drip in your arm, which may be used to give medications, fluid and blood if required. It is usually removed after 48 hours. You will receive oxygen. The nursing staff will check your pulse, blood pressure, temperature and your leg at regular intervals. They will place ice packs (cryocuffs) over the knee joint to reduce bleeding.
Total knee replacement is a major surgery and some degree of discomfort after surgery is expected. The following steps help to reduce pain. Nerve block – The effect usually lasts 12-48 hours. Patient controlled analgesia, pain killing injections are given through a pump controlled by a button. Tablets to be taken while in hospital and to be taken home on discharge. The majority of the pain will subside in 2-3 weeks. Minor discomfort may last up to 3-6 months. A decreasing dose of painkillers and anti-inflammatory agents may be required for 3 months.
Bleeding and transfusion Some bleeding is expected after major surgery. We will monitor it and take steps to minimise it. In a small number of cases a blood transfusion may be required. It is wise to take it easy for the first 6 weeks.
Swelling following knee replacement is common. Usually major swelling will settle down in 6 weeks and minor swelling may be present up to 12 months. Swelling of the ankle may occur for 3 months. You can minimise it by moving your ankle and toes.
Range of Movement- Most knee implants allow you to achieve a functional range of movement from 0 – 110 degrees. New implant design allows an even better range of movement. There are several factors that affect this movement range: Range of movement of the knee before surgery ,Muscle strength, Experience of the surgeon, Type of implant ,Motivated and well informed patients The knee may feel slightly warm up to 12 months after surgery
Rehabilitation & Physiotherapy -Exercise is vital to your recovery. It will start on the day of the operation and continue till you are back on your feet and achieving good knee function. A physiotherapist will visit you daily and help with therapeutic exercises: They will help you sit out of bed the day after your operation and stand with support.
Early mobilisation reduces the risk of blood clots and pressure sores. You will be shown the correct exercises for your knee. These help to strengthen your muscles and regain movement, balance and function. You must continue these exercises at home. It is important to do them for at least 10 minutes twice daily throughout your life. Exercise that strengthens your quadriceps muscle is the key to success. Most patients are able to walk with one or two stick within 4-5 days. Most patients are allowed to return back to light work at around 6-8 weeks. Driving is usually allowed at 6 weeks. Try to avoid heavy lifting and twisting on your knee. If you’re a golfer, you can play again after 3 months. It is not advisable to go back to heavy manual work after knee replacement.
Discharge from hospital (going home) -This varies with age and medical conditions. Most patients go home safely between 3-4 days. You should be able to walk along the corridor without help. Able to manage steps and stairs independently. Able to easily bend your knee to about 90 degrees. You will go home when you, your surgeon, physiotherapist, and nurses are happy with your progress. Your stitches will be removed 2 weeks from the day of surgery.Review in clinic You will be seen in the outpatient department at 2 weeks, 6 weeks, 3 months and 6 months after surgery. Further appointments may be required in some cases.
Main risk of Knee replacement - Replacement surgery is a major operation. The risk and complications are very low. Precautions are taken at each and every step to avoid them.
Infection – it is accepted that despite best efforts, infection can occur in some cases. Deep infection is a rare but serious complication. This may require hospital admission, further surgery, antibiotics and in the worse case, removal of the knee implant. To reassure you, Mr Singh’s infection rate is 0% in private practice and 1% in the NHS. Avoiding infection Surgery is performed in an operating theatre with a laminar airflow and use of body exhaust system. Shower with antiseptic soap Use of antibiotics Small wound and shorter surgery time Minimal wound handling after surgery
Thrombosis – A blood clot can occur either in hospital or at home after surgery. The patient will experience pain, swelling and a slight discolouration of the calf or leg. It normally gets better with treatment. Avoiding thrombosis Anti-embolism (TED) stockings and a foot pump to improve blood flow. Blood thinning Injection given for 10-14 days after surgery. Getting out of bed next day with early mobilisation. Sometimes Oral tablets are used to thin the blood
. General complications – Complications like heart attack, stroke, clot in lung and even death are extremely rare and can occur in less than 1% of cases . Consultation Enquiry To enquire about a consultation with specialist Knee Surgeon Mr Singh Contact us on 0121 446 1664