Certain knee conditions may require surgery – especially if conservative treatment options have not been successful. For example, an anterior cruciate ligament (ACL) tear often requires reconstruction to regain stability in the knee. Meniscus tears may also require surgery to remove or repair the damaged tissue and prevent the knee from catching or locking. Some knee surgeries can be done with an arthroscope. During this surgery, your surgeon places their surgical instruments through two small incisions to make repairs. An arthroscope causes less harm to healthy tissues and greatly reduces recovery time compared to traditional surgery. Some common knee problems that can be treated with arthroscopy include meniscus tears, cartilage damage, ligament tears, and arthritis – just to name a few. Often times, multiple knee conditions can be addressed at one time with arthroscopic knee surgery.
Knee arthroscopy is an outpatient procedure, which means you do not have to stay overnight in the hospital. For this procedure, you will arrive at the facility about an hour before your actual surgery time. Our staff will check you in and conduct a brief health check by listening to your heart and lungs and checking your blood pressure, pulse, and temperature. We will then start an IV to give you fluids and medications. The anesthesia staff will discuss your options for medications during surgery. Often times, a monitored anesthetic will allow you to relax and fall asleep without the effects of a general anesthetic. At the end of your surgery, a local anesthetic is injected into the knee, which helps manage initial discomfort. Your surgery time can vary depending on how much repair needs to be done, but can last anywhere from 30 minutes to an hour.
Once you are fast asleep in the operating room, your knee gets filled with saline. Saline helps expand your joint, making it easier for your surgeon to move surgical instruments and better see tissues. To be able to see inside of your joint, your surgeon puts an arthroscope into your knee, which is a tiny camera hooked up to a large computer screen. This magnifies the structures in your knee and allows your surgeon to view it with their own eyes. Once your surgeon can see in the joint, they make another incision to insert their surgical instruments and are able to repair the damaged tissue. While in your knee, your surgeon will usually fix any repairable damage they find, even if it was not expected before surgery. Even MRIs can miss damage in your knee, but during an arthroscopy, your surgeon can see exactly what is problematic. A Physician Assistant (PA) often helps your surgeon throughout surgery and understands everything that was done during your surgery.
After surgery, your surgeon will explain what they found in the operating room to your family and discuss any limitations you will have in using your leg. You will be placed on crutches for the first day and remain on crutches until you regain full sensation in your knee. Before weaning off the crutches, you should be able to bear full weight and walk comfortably. If more intensive work was done, you may need to use crutches for a few weeks and avoid placing any weight on the leg. Usually, your surgeon will ask you to just rest and recover for a few days after surgery. After those few days, you may take off the bulky dressing from surgery and are allowed to shower. As you can imagine, it can be difficult to care for yourself after a knee arthroscopy, and you may find you need extra help. Your surgeon will be sure to tell your family if you have any specific restrictions after surgery.
After an arthroscopy, patients can expect to be seen by either their surgeon or a Physician Assistant in 7-14 days. At that time, they will discuss with you what they found during your surgery, what was done, and your recovery process. You will be asked to do ankle pumps right after surgery to help increase blood flow and help prevent a blood clot from forming in your leg. This is important since your activity level will decrease right after surgery. On average, it takes most patients four to six weeks before they are back to their daily activities; however it can take up to six months to a year before they no longer notice any knee pain.
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Hard Cartilage Damage and Chondroplasty
Your knee joint is the area of your leg in which the thighbone fits neatly onto the shinbone. Your patellofemoral joint is the area in which the kneecap glides on the thighbone. These bony surfaces are covered by hard cartilage and should ideally be smooth. If there is a defect or flap in the hard cartilage it can cause your knee to have a painful catch or click, which can limit the motion of your knee and make it hard to walk. A damaged hard cartilage flap can catch and cause damage to the remaining healthy tissue in your knee. If the defect is relatively small, it can sometimes be polished and smoothed out with gentle motion exercises, like using an exercise bike with no resistance. If the hard cartilage damage is severe, surgical intervention may be required to remove the unstable flap of tissue.
A knee chondroplasty is an arthroscopic procedure to smooth out damaged hard cartilage. Once the problematic area is known, a surgical instrument is used to remove the fraying or flapped hard cartilage and smooth down the remaining tissue. After this procedure, you are often placed on crutches and can begin to wean from them as you tolerate. Your surgeon will tell your family exactly what your restrictions are after surgery.
ACL Tears and Autograft vs. Allograft Reconstructions
The thighbone and shinbone are stacked on top of each other and are held to each other with tendons and ligaments. The anterior cruciate ligament (ACL) prevents the shinbone from moving forward in relation to the thighbone. The ACL is responsible for maintaining the stability of the knee. This is commonly injured in sports, as motions like cutting and twisting place a big demand on the ligament. The ACL is one of a few ligaments in the body that does not repair itself; it must be surgically reconstructed to regain the knee’s stability.
An ACL reconstruction is an outpatient procedure that is done with a general anesthetic in conjunction with a nerve block. This provides more initial pain relief after your surgery. Your surgeon will start with two small incisions, one on each side of your kneecap, in which your surgeon will use surgical instruments to go in the knee and evaluate the damage. When you tear your ACL there is often damage done to one or both menisci. These tissues are evaluated and repaired or cleaned up. The ACL is evaluated and the remnants of the ligament are cleaned up. The notch in the end of the thighbone is sometimes widened to allow increased space for the new ligament.
The ACL reconstruction is done using a ligament or tendon graft. There are two types of graft; donated ACL ligament from a cadaver (allograft) or tissue from ligament or tendon from your own body (autograft). An ACL reconstruction done using an allograft allows for a quicker return to everyday activities as it involves less surgery. However, it takes a minimum of nine months before you are able to return to cutting and twisting type activities. If you are returning to a sport or cutting and twisting type activities are important to you, then an autograft is typically used to reconstruction the ACL. There are a few tendons in your body that can be used to reconstruction your ACL, however the gold standard is to use a patellar tendon graft. Your surgeon will harvest the middle one-third of your patellar tendon, with a small piece of bone from your shinbone and kneecap. Since an autograft involves more surgery, the initial recovery is slower and you may be on crutches a bit longer than those who use an allograft. However, with autograft ACL reconstructions you can return to cutting and twisting activities, including sports as soon as six months after surgery.
Regardless of the graft choice for ACL reconstruction, a hole is drilled through your shinbone and to your thighbone to place the graft. The graft is drilled into place with a screw made of a bone-like substance. After the graft is in place, your surgeon will move your knee around to make sure the newly reconstructed ACL is in the correct location and is tight without any pinching. If an autograft was used, the incision will be sewn up and a local anesthetic is injected for initial pain control.
After this procedure, you will be on crutches but can begin to wean off of them as you are able to tolerate weight bearing. This typically takes between one and three weeks. You will begin physical therapy the day or two after surgery. Your therapist will help determine when you are ready to walk without the crutches. Your surgeon will tell your family exactly what your restrictions are after surgery.
Meniscus Tears and Debridement vs. Repairs
Between the thigh and shin bone is the meniscus – two c-shaped pillows of soft cartilage that provide shock absorption, increase stability, and lubricate the knee. The meniscus is often injured with a twisting type mechanism in a squatting position, like lifting a box, or a misstep on uneven ground. This can cause pain, popping, and a feeling of instability in your knee. The meniscus can fray or completely tear causing a flap of tissue to catch within the knee joint. Sometimes a piece of the meniscus can get flipped up and stuck, causing the knee to lock.
This condition can be treated with an arthroscopy. If the meniscus has small fraying, it will be cleaned up and smoothed out. A surgical instrument is used to remove the fraying or flapped meniscus and smooth down the remaining tissue. After only a meniscal debridement you are often placed on crutches and can begin to wean from them as you are able to tolerate. For a completely torn meniscus that requires repair, your surgeon will repair the tear using sutures with attached anchors to fasten the meniscus to the joint capsule. The number of sutures used during surgery will depend on the size and severity of your injury. After a meniscal repair, your surgeon will give you specific instructions but you can expect to use crutches for about 6 weeks after surgery. Your surgeon will tell your family exactly what your restrictions are after surgery.