The knee is used in a wide range of everyday activities such as sitting, standing, walking, and running. Hence, it is susceptible to a variety of injuries, particularly in athletes. The main movement in the knee is flexion and extension; however, it also has a slight degree of rotation and lateral movement. Given its importance in fulfilling everyday tasks, knee pain can be debilitating and significantly reduce a person’s quality of life.
Anatomy of the knee The knee joint is the largest joint in the body and comprises three main bones: femur, tibia, and patella. It is a modified hinge joint that is held together by the medial (inner) and lateral (outer) collateral ligaments and the anterior and posterior cruciate ligaments. The menisci, which are semicircular-shaped discs of fibrocartilage, act as a cushion for the joint and are located on the tibia plateaus. Articular cartilage, which is a smooth, slippery substance, helps protect the bones and enable them to move easily. The synovium is a thin lining that produces fluid, helping to reduce friction and wear in the joint.
Overview of Knee Pain
Osteoarthritis is the most common cause of chronic knee pain. Osteoarthritis is frequently a primary cause of knee replacement surgery. Although it is mainly a disease of the elderly, it can occur in younger people as a result of injury or be inherited. Osteoarthritis is an inflammatory disease of the joint induced by destruction of the cartilage covering the ends of the bones, resulting in a rough, thin surface. The cartilage is there to act as a cushion and prevent contact between the bones. With its destruction, there is an increase in friction between the bones and the formation of hard projections, called osteophytes. This produces pain and loss of movement in the knee joint.
Knee pain can be divided into two major categories: 1) Acute injuries 2) Medical conditions
Assuming that you are one of many individuals who experience knee pain or someone who knows an individual who encounters knee torment, it is important to comprehend this commonplace condition with the desire of distinguishing the right treatment to alleviate the torment or to discard the cause. Knee torment is the most widely recognized of all the musculoskeletal complaints. The knee joint is extremely vulnerable to both acute injuries and the development of osteoarthritis. Anatomically, it is a simple joint with an extensive range of mobility that supports 80% of the weight of the body. These factors make the knee a commonly injured joint. A deeper understanding of why knee pain occurs can assist us in determining the effective treatment to reduce pain and also decrease the problem.
Importance of Seeking a Knee Pain Specialist
When experiencing knee pain, individuals frequently consult or are referred to a knee specialist. This consultation may be somewhat of an ordeal, especially if a patient has seen a knee pain specialist. The earlier a specialist can be seen, the more the patient is likely to benefit. There are several reasons for this. First of all, most family practitioners and internists are not acquainted with the wide range of problems of the knee. Often they may not order the appropriate tests needed to diagnose the problem accurately. By seeing a specialist, patients stand a better chance of getting an accurate diagnosis the first time. A definitive diagnosis is the most important step in resolving a knee pain problem. Average doctors may refer a patient to physical therapy without a diagnosis, or even worse they may tell the patient to rest without specifying the nature of the rest and appropriate for how long. This often results in wasted time and money. With the assistance of another healthcare provider, a knee specialist can also help coordinate a patient’s care. This is particularly beneficial for the patient who is contemplating surgical options.
Surgical Treatment Options for Knee Pain
Surgical treatments for knee pain are considered when the pain and disability cannot be improved by other measures. The decision to proceed with surgery is made based on the severity of your arthritis, your age, activity level, and overall health. Knee arthroscopy is frequently used in the treatment of meniscal tears. The two most common procedures are meniscectomy and meniscal repair. The specific technique will be based on the tear type, location, and whether the tear is a result of traumatic injury or due to degenerative changes in the meniscus. This technique, which is one of the most common orthopedic procedures, is usually done as day surgery, takes about an hour, and has a quick recovery time. Most patients are able to return to normal activity within 2-3 weeks. The success of meniscal surgery is as high as 75-90% in patients with well-localized meniscal tears, but less in those with osteoarthritis and/or knees with many loose bodies or bone on bone. High tibial osteotomy or a partial knee replacement may be considered in these cases.
Arthroscopy
In knee pain Singapore, arthroscopy can range between $4000 and $7000, depending on the type of injury. It is relatively expensive as it is a new technique and the equipment used is costly. However, the cost-effectiveness of this procedure is exemplified through the high success rate of a 90-95% chance of relieving painful symptoms due to damaged knee tissues. Maintenance of good health should linger in individuals’ minds that the avoidance of putting stress on knees will jog back prevention of arthritic symptoms. Nonetheless, it is comforting to know that arthritic symptoms caused by present damage of the meniscus have a 75% chance of being bettered than doing nothing at all. Without strength in legs, daily life can become cumbersome and preventing onset of disability is more desirable than improving it.
Arthroscopy is a technique that is commonly used in the diagnosis and treatment of knee problems. This surgical procedure enables surgeons to have a clear view of the inside of the knee, which will allow them to accurately determine the cause of the symptoms and treat the problem. During the procedure, a small incision is made and the knee is filled with a small amount of water to ‘blow up’ the knee – creating more space to see into. Then a camera is inserted into the knee, transmitting the image onto a screen in the operating theatre. This image will help the surgeon to identify the problem and if surgical treatment is not possible, he or she could revert to addressing the problem therapeutically. Arthroscopy is useful in treating a range of knee problems such as torn cartilage (meniscus) or ligament damage and is often being used as a substitute to ‘open’ surgery as it is less traumatic, scarring and the recovery period is comparatively shorter.
Partial Knee Replacement
However, patient selection is very important for success with this operation. If it is performed in individuals with arthritis affecting two or three compartments of the knee, the new partially replaced knee joint is at risk for continued progression of arthritis in the other compartments. This would result in a need for further surgery to convert the partial knee replacement to a total knee replacement. Partial knee replacements also may not be as successful in individuals with ligament damage, severe stiffness in the knee, or those who need to do heavy manual labor. During the consultation, the knee surgeon will discuss the potential risks and benefits of the procedure in your particular case.
Partial knee replacements are most successful in individuals that have significant damage to only one part of the knee. If arthritis is affecting two or three compartments of the knee, a total knee replacement is a more appropriate option. This operation offers several advantages over a total knee replacement including smaller incisions, less bone removal and a quicker rehabilitation. Because the bone, ligaments and cartilage in the non-arthritic regions of the knee are left untouched, many patients feel that their knee is more natural and that the knee functions better following a partial knee replacement.
Partial knee replacement is an intermediate option for people who are too young for total knee replacement or for those whose arthritis is limited to one area of the knee. The goal of partial knee replacement is to resurface the damaged areas of the knee with metal and plastic parts. The ends of the bones and cartilage are replaced with metal and plastic components that recreate the surface of the joint. The most common reason for a partial knee replacement is osteoarthritis confined to one part of the knee. Other conditions such as rheumatoid arthritis and trauma to the joint can also lead to the degeneration of one part of the knee. In some cases, the other two compartments of the knee remain relatively free of arthritis. In these situations, a partial knee replacement may be indicated.
Total Knee Replacement
Knee replacements have been performed since the 1960s and are now one of the most common orthopaedic operations. Improvements in surgical materials and techniques have greatly increased its effectiveness. According to the National Joint Registry, there are around 70,000 TKRs performed each year in England and Wales. The operation is predominantly done on people between the ages of 60 and 80, but is not limited to this age group. Primary TKR (i.e. first time knee replacement) is occasionally performed on younger patients with severe arthritic conditions. In Singapore, the Health Promotion Board reported about 5000 knee replacement surgeries in 2013.
Total knee replacement (TKR) is an operation designed to relieve pain and disability from knee osteoarthritis. Osteoarthritis develops through wear and tear over the years. Symptoms include pain in the knee, particularly on weight bearing, and stiffness and deformity of the joint. These symptoms worsen over time, eventually becoming bad enough to affect work and daily activities. Although many people with knee arthritis never need to have a knee replacement, those who have severe pain and loss of function may consider it as an option.
Preparing for Surgery
There are different types of knee replacements, differing implant prosthesis materials, and surgical techniques. These days, joint replacement for a patient with knee OA is often not as beneficial compared to an alternative treatment. So it is essential to have a thorough understanding and a discussion of other possible options for your knee condition. For example, undergoing an osteotomy or a trial of some of the more recent and experimental biological joint cartilage therapy, such as injections of hyaluronic acid or platelet-rich plasma into damaged knee joint cartilage.
Knee arthroplasty (replacing the knee joint with artificial parts) is a common procedure for patients with knee OA. It is an elective surgery, meaning that it is the patient’s decision to proceed with surgery. It is important to have a realistic expectation and understanding of the procedure. This may involve discussions with previous patients who have undergone the surgery, the surgeon himself, or even obtaining a second opinion from another surgeon.
Your knee pain specialist might refer you to a surgeon for a consultation, or you may choose the surgeon independently. Try to come prepared with a list of questions related to your condition or the recommended procedure. It may be helpful to have a list of all the previous treatments and healthcare providers relating to your knee problem. This may help the surgeon to have a clearer understanding of your condition and prior attempts to fix it.
Consultation with a Knee Pain Specialist
A clinical examination will then be performed. Many patients with knee osteoarthritis have relatively normal clinical findings, while the degree of pain and the nature of the pain is disproportionately higher than that expected for what the clinical condition of the knee suggests. This is very similar to what is experienced by those with chronic lower back pain. An MRI scan may be requested if the findings on a clinical examination do not correlate with what the patient is experiencing in order to clarify the diagnosis.
After the initial diagnosis of knee osteoarthritis has been made, you may be referred to an orthopaedic surgeon for a consultation. The surgeon will obtain a detailed clinical history of your knee. This will include the nature and site of your pain, how it started, any mechanical symptoms (locking, clicking), any trauma to the knee, previous treatment, and how all of this may be affecting your quality of life.
Preoperative Tests and Evaluations
Before having a knee replacement, the orthopaedic surgeon will require a complete physical examination by an independent physician, preoperative testing to rule out any urinary infections, and blood tests to assure that you are in optimal health before undergoing surgery. A thorough understanding of your general health condition and any medical conditions is very important to prevent any complications from arising due to undiagnosed disorders. Your surgeon will request an evaluation by an internist or specialist in internal medicine with particular attention to the following: Vascular Assessment – Evaluation for blood clots, varicose veins, or peripheral vascular disease. Complete Blood Count and Chemistry Panel – To rule out any infections, anemia, or electrolyte abnormalities. Urine Analysis and Chest X-Ray – Tests to rule out any infections or disease processes. EKG and Cardiac Evaluation – If you have a history of heart disease, it will be important to receive clearance from a cardiologist or other specialist in this area. This may involve simple tests such as EKG, stress test, or echocardiogram.
Planning for Postoperative Care
Having a plan for postoperative care is important before undergoing surgery. Patients needing knee surgery usually can be classified as either an elderly person who suffers from disabling arthritis or someone who has fractured a bone. Understanding what to expect is the first step in planning for postoperative care. In general, recuperation for a partial knee replacement is about 6 weeks or longer. The key is planning for assistance during this period. Understanding what to expect is the first step in planning for postoperative care. Full recovery from the effects of anesthesia or sedation takes about 24 hours. During this time, you should not make any important decisions or operate machinery. You will need someone to drive you home and help you around the house for a couple of days. Anesthetics can sometimes affect people for a longer period of time. Patients should discuss the expectations regarding the time off work with their surgeon. Following minimally invasive surgery, most patients can return to office work at 2 weeks and more strenuous work at 6 weeks. This may vary, and it is important to get details about specific job requirements. Understanding these needs ahead of time can help plan for taking time off and negotiating a modified workload upon returning to work. It must be mentioned that unlike the advantages seen with partial knee replacement, patients who undergo total knee replacement almost always have a prolonged period of disability, often 2-3 months. Full recovery and rehabilitation after a total knee replacement can be a lengthy process. A better understanding of a patient’s work and outside activity demands will help determine the most appropriate time to have the surgery.
Recovery and Rehabilitation
On arriving home, you should rest. The local anesthesia will take anywhere from 6-12 hours to wear off, so you may not feel anything at all initially. It is very important to elevate your leg above the level of your heart to assist with swelling control. This helps to drain fluid from the knee joint and reduce the inflammatory response that occurs after surgery. The best way to do this is to lie on your bed with 2-3 pillows under your heel. You can move the pillows to the foot of the bed to elevate the leg further. Keep doing this as much as possible between movements to the bathroom and getting food. If you have a recliner chair, this is also an excellent location to rest with the leg elevated. Any movement without elevation will cause increased pain and swelling around the knee. Too much muscle activation around the quadriceps can sometimes also cause the knee to give way.
This first stage of the recovery process starts the moment you wake up from the surgery. For most patients, they will stay in the recovery room for another 1-2 hours before being discharged home. You will have a bulky bandage and sometimes a cryocuff. It is important to keep the bandage clean and dry. You may remove it the following day and replace it with a smaller bandage. Do not shower with the bandages on! You will feel a little groggy from the anesthesia and there may be some pain around the knee. If you are sufficiently recovered, you will be allowed to go home.
For any form of surgery, the recovery process is an important part of the treatment. For arthroscopic knee surgery, most patients typically return to work or school within 2 weeks. The operated knee usually requires another 2 weeks before the patient is able to return to driving. The following is a guideline to help you better understand what to expect from your knee surgery recovery.
Immediate Postoperative Period
You will be taken from the operating room to the recovery room where you will be monitored for a couple of hours. After you have recovered adequately from the anesthesia, you will be discharged to go home. It is essential to have someone at home with you for at least the first night. You have to remember that your surgical knee is still a “sick” knee and will require some caring. Even though you will be encouraged to be up and about, you must also remember that you have to ice and elevate your knee and rest periodically throughout the day. This is the time to catch up on your reading or entertainment from the previous shopping trip that you did for a walker, ice machine, and some easy to prepare foods. You must remember that the more dedicated you are to the RICE philosophy, the better your swelling and pain will be. This will allow you to progress to the next phases of rehabilitation. It is not uncommon for there to be “setbacks” at this phase, whether they are due to increase in activity, unfamiliarity of the knee and its status, or just not being disciplined enough to recover. If you should have an increase in pain and swelling, it usually subsides with a day or two of good “knee caring” and RICE. If the pain and/or swelling becomes severe and is associated with a “popping” or a giving way feeling in the knee, you should contact your surgeon. This may not be more than a tear in scar tissue or it could be a transplant complication. A time will come when you will feel good enough to start venturing out of the house. This is a good time to prepare for the visit to the surgeon in 7-10 days.
Physical Therapy and Rehabilitation Exercises
The rehabilitation program will also involve the use of Cryocuff. This is a clinically proven device that combines focal compression with cold therapy. It is important in reducing post-operative pain and swelling. Finally, as strength and confidence improve, functional exercises such as walking, stationary cycling, and pool therapy will be used to prepare the patient to return to full activity. The success of the rehabilitation program is often the most important factor in determining the outcome of the surgery. Patients can expect the full recovery process to last anywhere from 3-6 months.
It is important to maintain the integrity of the implant and to minimize the stress on the knee joint as it recovers. This can usually be achieved through a well-structured physical therapy program. The program will involve a combination of range of motion and strength exercises. Initially, the focus will be on regaining full knee extension and quadriceps control. This will involve exercises to improve knee straightening with the removal of any extension lag and the performance of straight leg raises. Specialized closed chain exercises such as leg presses, wall squats, and step ups will also be used to improve quadriceps function.
Long-Term Recovery and Maintenance
While many people return to low-impact activities such as golf, gardening, and swimming, patients who have an artificial knee can participate in more rigorous activities such as hiking and downhill skiing in this modern era. In fact, recent studies have shown that post-surgery, a patient can take part in activities that include impact loading such as fast-paced walking or even running without increasing the risk of loosening of the implant. As a general rule, most patients will tell you that the recovery process is similar to the first few months after surgery – incremental improvement with an occasional setback, but the gains are unmistakable.
The primary long-term goal of patients who have had knee replacement surgery is to achieve continued improvement in the range of movement and strength. To a large extent, the full recovery timeline for knee replacements will depend on the patient and his or her commitment, diligence, and patience in extending the rehabilitation process. For those patients who are adamant about achieving the most from their surgery, a return to demanding activities can often be accomplished.
