Knee Preserving Surgery
- During your visit we will discuss your symptoms and examine your knee to check for tenderness, stiffness, swelling and any difficulties with movement. In most cases, an X-ray will be arranged to help confirm what is injured within the knee and check if any arthritis is present.
- Additionally, an MRI scan may be suggested to assess any potential damage to the soft tissues, such as cartilage, menisci, tendons, or muscles.
Treatment options depend on a number of factors, including how much the damage is affecting your everyday life and activities.
- Non-surgical treatment includes resting the joint, elevating it, applying ice to minimise swelling and protecting it using a support such as a knee brace. In some cases, this can be enough to reduce your symptoms. However, you may need to make some lifestyle changes, along with having physiotherapy, hydrotherapy, orthotics and taking painkillers. You may also be offered injections to reduce inflammation in the joint. Several different types of injections are available including steroid, visco-supplementation and other anti-inflammatory agents.
- Surgery: it’s unlikely that the cartilage will heal once it has been damaged. However, your consultant can carry out a number of procedures to help repair the damage. These include:
- Knee chondroplasty (cartilage repair)
- Simple microfracture
- Mosaicplasty/OATS
- Knee realignment surgery (osteotomy)
- Partial or total knee replacement surgery
Keyhole surgery is straightforward and low risk. The operation is usually carried out under general anaesthetic. Afterwards, you’ll be taken to the recovery ward and then back to your room. Most patients can return home the same day.
A bandage is applied in theatre that can be removed the day after the procedure. In most cases, you won’t need crutches after surgery and you should be able to walk without help. You won’t need to have a knee brace and you’ll be encouraged to move your knee fully as soon as possible afterwards. The small wounds are closed with paper strips or a single stitch that will eventually dissolve.
You’ll be offered a follow-up appointment between two and six weeks after surgery when there’ll be an opportunity to discuss the results of any tests in detail, using pictures or video taken during the procedure.
You’ll be advised to gradually get back to normal, including walking and driving. Active engagement with physiotherapy is often also advised. Most patients feel comfortable enough to return to work after about a week although there may be some slight discomfort for 4-6 weeks after surgery, depending on the reason for the procedure.
Not everyone who has an ACL injury needs to have surgery. In some cases, it’s possible to regain knee stability with a personalised course of physiotherapy, along with wearing a knee brace when taking part in sport. However, some people have to modify their activities to avoid their knee giving way and pain. If you compete at a high level, where you put additional stress on your knee, you are more likely to need a surgical procedure. If your knee frequently gives way during normal everyday activities, this can cause further damage.
- anterior cruciate ligament (ACL) reconstruction
ACL reconstruction involves removing existing tissue and then carrying out a graft. This uses either the patient’s own tissue (autograft), usually from the hamstrings or patella tendon, or donated human tissue (allograft) to make a new ACL. Tunnels are created in the shin and thigh bone so that the graft can be fixed in place. It’s usually carried out as a day case procedure using keyhole surgery and is a less invasive technique for reconstructing the anterior cruciate ligament.
The knee is divided into three compartments: the medial (inner), the lateral (outer) and the patello-femoral. Any of these compartments can be replaced, without replacing the entire knee joint.
Knee replacement is sometimes the only surgical option available to patients with knee conditions such as arthritis that cause damage to the knee joint, resulting in problems carrying out everyday activities. The aim of the operation is to relieve pain and improve mobility by replacing the worn-out parts of the arthritic knee with specially designed metal and plastic components.
Most knee replacement surgery is carried out on older people, although it can be offered to patients of any age. In most cases, a replacement knee will last over 20 years.
While knee replacement may be the answer for some people, for others – particularly if you are a younger patient, an athlete, or an older patient who is still very active – removing the knee joint, which also means taking away a great deal of healthy tissue, may not be the best option. In some cases, you may be offered knee realignment surgery (osteotomy) instead; this new procedure can significantly delay, or in some cases even avoid, the need for knee replacement surgery.
You are more likely to need total or partial knee replacement surgery if you have:
- Wear and tear arthritis is by far the most common indication.
- Rheumatoid arthritis
- Psoriatic arthritis
- Haemophilia
- Gout
- Arthritis caused by a previous knee injury
- Deformity of bones in the knee
- Bone death due to poor blood supply (avascular necrosis)
There are two types of knee replacement surgery:
- Total knee replacement (TKR) where both sides of your knee joint are replaced
- Partial (half) knee replacement (PKR) where one part of the joint is replaced
In some cases, your consultant may advise that you have an examination of the knee joint under an anaesthetic using keyhole surgery to decide on the option that is best for you.
Total knee replacement (TKR)
This operation, first carried out in 1968, is now very common and involves replacing all the surfaces of your worn-out knee with metal and plastic components. It’s offered when lifestyle modifications, painkillers and physiotherapy haven’t relieved your pain or mobility problems.
Damaged cartilage, along with some bone, is removed and replaced with metal parts to form a new joint surface. These are fixed with specially designed cement. The underside of the kneecap is cut and the surface replaced with a plastic component. A spacer is placed between the metal parts to enable the joint to glide smoothly.
More than 90% of people who have TKR surgery have much less knee pain and find it significantly easier to carry out their everyday activities afterwards.
Even with normal use, the replacement knee will eventually wear out but it should last for at 15 if not 20 years. However, putting excessive stress on the new joint can make it loose and painful.
You should be able to walk as much as you want, swim, play golf, drive, cycle, and take part in low-impact sports.
You’ll be advised not to take part in high-impact sports including team sports, running, jogging or jumping for the first 6 months. After this period these activities may put some extra strain on the artificial joint, however, no study has so far shown that there is an increased revision rate in runners. Some patients have returned to ultra-marathons after a knee replacement. Generally, it is considered that joints may wear out due to a combination of activity type, body weight and whether you are an experienced or newly active athlete.
- The time it takes to recover from TKR will depend on may factors including your age, health, severity of initial arthritis and general wellbeing coming into surgery as well as your commitment to follow your rehabilitation programme once you return home after surgery. It is normal to have some pain after surgery and this will gradually reduce with time. Generally, you will be able to do most normal activities between three months and a year before you get back to normal. Papers have reported continual improvement up to 2 years after a knee replacement if targeted exercises continue.
- To achieve the best possible outcome, it’s important to follow your exercise plan which includes gradually increasing walking, and other low-impact exercises. It’s important to avoid falling or injuring your new knee.
- Let your dentist know that you’ve had a knee replacement as you may need to take antibiotics before certain dental procedures to avoid the chance of an infection in the joint, although in most circumstances no additional antibiotic cover is needed.
- It is safe to drive again usually around 4-6 weeks after surgery. However, you should check with your insurance company and ensure you are able to perform all manoeuvres safely.
This operation is offered if only one of the three knee compartments is damaged. In most cases, this is the medial (inner) compartment. As the procedure involves replacing just one part of the knee, the scar tends to be smaller, recovery is faster with less pain, and the range of movement remains better than with a TKR.
A small incision is made and damaged cartilage in one part of the knee, along with some bone, is removed and replaced with metal parts to form a new joint surface.
There is a smaller wound and a shorter procedure than with TKR, meaning a quicker recovery, less blood loss and less pain afterwards. Because much of the knee is preserved, you are likely to retain a greater range of movement than you would after a TKR.
You may need to have total knee replacement surgery in the future if arthritis causes problems in other compartments of the knee. Having said this the outcome of partial knee replacement is very similar to that for total joint surgery.
- The time it takes to recover from PKR is generally slightly shorter than TKR, however, it will depend on many factors including how closely you follow your rehabilitation programme once you return home after surgery.
- You’ll be able to get up and walk shortly after surgery and will be given physiotherapy exercises to carry out at home, but it’s important to avoid falling or injuring your knee.
- You should also let your dentist know that you’ve had a PKR as you may need to take antibiotics before certain dental procedures to avoid the chance of an infection in the joint, although in most circumstances no additional antibiotic cover is needed.
- Most people can get back to their normal everyday activities after about six weeks.
- It is safe to drive again usually around 4-6 weeks after surgery. However, you should check with your insurance company and ensure you are able to perform all manoeuvres safely.
If your previous knee replacement hasn’t been successful, you can have a second procedure where some or all of the artificial components in the knee are replaced with new ones. Problems with previous surgery may be due to wear and tear or loosening of the new knee joint, instability due to ligament damage, stiffness, a fracture or, in some cases, infection.
Revision surgery tends to take longer, and is often more complex, than the original knee replacement, with extensive planning and rehabilitation needed to achieve a good recovery. You will be advised about your surgical options and help you decide which is likely to have the best outcome.
Knee tendon repair surgery is often carried out to treat a patella tendon tear. The procedure involves reattaching the torn tendon to the kneecap. The sooner this is carried out after an injury, the higher the success rate. Most people can return to their previous activities after surgery, although complete recovery can take 6-12 months.
Surgery to stabilise the kneecap is usually only offered when physiotherapy hasn’t been successful. Options include medial patella-femoral ligament (MPFL) reconstruction, bony realignment surgery and trochleoplasty.
Surgical treatments for kneecap (patella) stabilisation include:
Medial Patella-femoral Ligament (MPFL) Reconstruction
The medial patellofemoral ligament is a broad structure located on the inside of the knee joint. It connects the kneecap (patella) to the thigh bone (femur). The primary purpose of the MPFL is to provide stability to the kneecap; it provides restraint to any movement toward the outside of the knee. MPFL reconstruction is surgery in which a new medial patellofemoral ligament is created to stabilise the knee and help protect the joint from additional damage in cases of serious and recurring dislocation of the kneecap. It offers an excellent treatment option for people who have experienced more than one dislocation. It can be carried out using a combination of keyhole surgery and minimally invasive open surgery. During the procedure, a single hamstring tendon is used to reconstruct the MPFL. The procedure involves making a small tunnel in the kneecap and a second tunnel where the original ligament attached to the thigh bone. The new ligament is then passed as a loop through the tunnel in the kneecap, through the tunnel in the thigh, and secured in position. In most cases, you’ll be able to go home the next day and you should be able to take your own weight, supported by crutches, in a week or two. You can expect to get back to your usual activities around three months after surgery.
Bony Realignment Surgery
If your kneecap instability is caused by having an abnormal anatomy, such as a kneecap that is in a higher position than normal (patella alta), you may be offered a bony realignment procedure. The amount of deformity and how much it needs to be corrected is calculated from an MRI or CT scan of the knee. This is called a TTTG measurement. The procedure involves detaching the kneecap tendon, together with a small block of bone to which it is attached, and moving it towards the midline. It is then fixed in its new position with screws. Most patients are able to go home the next day, with the knee immobilised in a brace. You’ll be able to gradually bear your own weight after around two weeks and by six weeks most patients are able to bear their own weight without using a brace
Trochleoplasty
This is a surgical procedure to restore stability to the knee, alleviate pain and improve mobility if you have been diagnosed with trochlear dysplasia. The procedure reshapes the trochlea to allow the patella to move smoothly, preventing knee instability and pain. It may be performed arthroscopically (keyhole surgery using an arthroscope) which has a camera and a light at one end) or using open surgery. You may need further surgical procedures, such as ligament reconstruction, following your trochleoplasty. A programme of physiotherapy will help you to rehabilitate and regain movement in your knee. It normally takes around six months before you can resume more active sports.
If the menisci, or shock-absorbing cartilages, are damaged or torn, there are a number of different types of surgery available. Wherever possible, the meniscus is repaired, but if this isn’t possible you may be offered meniscal debridement to tidy up the joint.
The type of treatment you’ll be offered depends on a number of factors including your age, activity levels, how long it is since you were injured, and the type of tear. Surgery aims to repair and preserve as much of the meniscus as possible to minimise the long-term effects, which can include arthritis.
Some meniscal tears can be repaired using keyhole surgery, without external incisions. This is known as an ‘ALL-Inside repair’. If there is a large tear, you may need to have a small external incision and this is called an ‘inside-out’ repair. Repairing the meniscus, which has the best results, is challenging surgery but the chance of success is 60-70%. If possible, the meniscal tear is repaired at the same time as the ligament injury so repair is often carried out at the same time as an ACL reconstruction.
The most common type of keyhole meniscus procedure, involves using keyhole surgery to ‘tidy up’ the meniscus. If the meniscus isn’t able to be repaired, the torn area is removed while preserving normal tissue. Surgery involves a short general anaesthetic, and is usually carried out as a day case procedure. After surgery, you’ll be able to gradually return to your normal activities after around 48 hours. You won’t need crutches but you should arrange to take 1-2 weeks off work and 4-6 weeks off sport afterwards.If the rest of your knee is healthy, then most people have an excellent outcome from this type of surgery.