How the knee works | What causes knee pain? | Wear and Tear Injuries | ACL Injuries | Ligament Injuries | Osteoarthritis | Inflammatory Arthritis | Other Conditions | When is knee surgery necessary? | When is knee replacement necessary | How to get ready for knee surgery | The day of surgery | After surgery items | If you have a hospital stay | After surgery: Joint Camp

How the knee works

The knee is a joint that connects the femur (thighbone) and tibia (shinbone). Articular cartilage covers the bone ends. It helps the knee move smoothly. The patella (kneecap) is a bone that protects the knee. Inside the knee, the meniscus (pad of cartilage) helps absorb shock. Ligaments connect the leg bones and keep the knee stable. Muscles move the knee joint and help keep it strong.

Stretching and aerobic activity are key parts of your recovery. Strong muscles help prevent knee problems and improve basic fitness. But be sure to check with your health care provider before starting to exercise on your own.

A healthy knee bends easily. The joint absorbs stress and glides smoothly. This allows you to walk, squat, and turn without pain. But when the knee is damaged, the joint may lose its ability to cushion stress. You may feel pain during movement. Sometimes a damaged knee joint will swell and hurt even when you are at rest.

A Healthy Knee

The knee is a hinge joint, formed where the thighbone and shinbone meet. When the knee is healthy, the joint moves freely. This is because the joint is covered with slippery tissue and powered by large muscles.

Cartilage

Cartilage is a layer of smooth, soft tissue. It covers the ends of the thighbone and shinbone, and it lines the underside of the kneecap. Healthy cartilage absorbs stress and allows the knee to glide easily.

Ligaments

Ligaments are another type of soft tissue. They hold the bones of the joint together.

Muscles

Muscles power the knee and leg for movement.

Tendons

Tendons attach the muscles to the bones.

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What causes knee pain?

You use your knee every time you take a step. Because of this, living with a worn or injured knee joint can be painful and frustrating. Even simple things, such as squatting to pick up the morning paper, may cause pain. But you don't have to live this way. In many cases, an orthopaedic surgeon (a doctor who treats bone and joint problems) can replace the damaged knee joint. The surgery is safe and effective. For many people, having a total knee replacement means a return to pain-free movement.

No matter what your age, a problem with the knee joint may keep you from activities you enjoy. Pain and stiffness may even limit the daily tasks you can do. Problems with the knee joint tend to build up over time. Your knee pain may be caused by any of the following:

• A bad injury that did not heal properly

• A chronic illness

• Wear and tear from years of constant use

• Surgery Can Help

You may not have to live with knee pain for the rest of your life. Total knee replacement surgery may reduce joint pain. During this surgery, your damaged knee joint is replaced with an artificial joint (called a prosthesis).
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Wear and Tear Injuries

Articular cartilage helps your knee bones move smoothly. Aging or injury may wear away this cartilage. A piece of bone or cartilage may also break off. Damage from wear and tear can cause knee pain or stiffness.

Assessing the Problem

In mild cases, the cartilage may be slightly worn. In more severe cases, the cartilage may be worn through, exposing the bone. There may also be loose bodies (pieces of cartilage or bone) in the knee joint.

Repairing the Damage

For mild wear and tear, the cartilage may be smoothed out. If bone is exposed, your surgeon may rub it with a special burr. This helps toughen and protect the bone surface. In some cases, healthy cartilage may be transplanted to the worn bone. Any loose bodies are removed.

Your Recovery

Recovery may take from 4 weeks to 6 months, depending upon the procedure you had. To help your knee heal, you may be asked to do some or all of the following:

• Use crutches as instructed.

• Exercise to regain your range of motion and strengthen the muscles that support the knee joint.

• Find ways to protect your knees, such as sitting on a gardening stool or using a golf cart when golfing.

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ACL Injuries

ACL Injuries in Athletes

Peter A. Looby M.D.

The anterior cruciate ligament provides rotational stability and anterior movement of the tibia from the femur. Up to 10% of the population can function athletically without an ACL. People with ACL deficiencies tend to have feelings of instability, giving away and shifting. ACL injuries frequently occur without physical contact.

Jerry Rice is one of the best-known and most beloved players in the NFL. He is also one of a number of very visible examples of how high-level athletes can recover from ACL reconstruction surgery to participate in sport at a world-class level. Other well-known athletes who have successfully returned after ACL surgery include Rod Woodson and South Dakota's own Brian Schwartz.

Tearing of the anterior cruciate ligament or ACL, is one of the most frequent serious sports-related injuries of the knee. The ACL is a bundle of tough fibrous tissue approximately one inch in length and one-half inch in diameter in the center of the knee. The main purpose of the ACL is to prevent the two main bones in the knee, the femur and the tibia, from slipping or rotating abnormally.

ACLs are commonly injured during athletic activities such as football, basketball, skiing, and soccer. This can happen during contact like blocking and tackling or with non-contact twisting injuries of the knee such as those that occur when cutting and pivoting on a basketball court or falling while skiing. The athlete who tears their ACL usually experiences pain and may feel or hear a "pop" at the time of the injury. Knee swelling typically begins that same day.

The majority of people with torn ACL will experience knee instability. While twisting or pivoting, the knee with a damaged ACL will "give way" or "go out." The athlete may feel the two bones in the knee slip or separate. Sometimes the knee instability is so severe that a person may experience this giving way during nonathletic activities such as getting in or out of a car or walking on uneven ground.

While the importance of a functioning ACL has been appreciated for many years, it was not until the 1970's that an effective treatment for torn ACLs was developed. Called ACL reconstruction, this surgery involves using another piece of tissue from the body to make a new ACL. Tissues commonly used for this purpose included a portion of the patellar tendon and one or two of the hamstring tendons.

Rehabilitation after ACL reconstruction is extensive. Weight-bearing and walking on the knee can in many cases begin the day after surgery. At the Orthopedic Institute - Sports Medicine Center we usually have our patients back to running approximately three months after surgery and returning to full sports participation four to six months following ACL reconstruction.

This content is not intended as a substitute for professional medical care. Only your doctor can diagnose and treat a medical problem.
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Ligament Injuries

Ligaments connect the leg bones and support your knee. A severe leg twist or blow to the knee may tear one or more ligaments. As a result, your knee may swell or feel wobbly, or may not be able to support you.

Assessing the Problem

Using arthroscopy, your surgeon may find a partial or complete tear in your anterior cruciate ligament (ACL). The collateral ligaments can't be seen with an arthroscope. So if your surgeon suspects injury to a collateral ligament, you may need open surgery.

Repairing the Damage

A partly torn ACL may not need repair. But your surgeon may reconstruct a fully torn ACL. To do this, he or she uses a graft (healthy tissue often taken from somewhere else in your body). A torn collateral ligament may be repaired with sutures.

Your Recovery

Ligaments take a long time to heal, even if no repair is done. Recovery from a partial tear may take as long as 3 months. If a graft is needed, recovery may take from 6 months to a year. To help your knee heal, you may be asked to do some or all of the following:

• Use crutches as instructed.

• Wear a hinged brace to support your knee. After recovery, you may need to wear a knee brace for certain sports, such as skiing.

• Exercise to regain range of motion and strength in your knee.

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Osteoarthritis

Years of normal use can cause cartilage to crack and wear away (osteoarthritis). As exposed bones rub together, they become rough and pitted. The joint grinds. Being overweight or having an alignment problem, such as knocked or bowed knees, puts extra force on the joint. This may speed up the damage.
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Inflammatory Arthritis

A chronic disease, such as rheumatoid arthritis or gout, can cause swelling and heat (inflammation) in the joint lining. As the disease progresses, cartilage may be worn away and the joint may stiffen.
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Other conditions and common overuse injuries

Patellar Tendonitis

Patellar tendonitis is an overuse condition that occurs in many athletes who are involved in repetitive jumping activities such as basketball or high jumping. The athlete may experience pain localized below the kneecap.

Chondromalacia Patellae

The symptoms of chondromalacia usually have a gradual onset and progress slowly. Athletes may experience pain beneath the kneecap which may increase with activities that require bending (flexion) of the knee. Other complaints are grating or grinding, knee buckling, aching pain after vigorous activity or pain after prolonged sitting.

Osgood-Schlatter Syndrome

This condition involves the bump below the kneecap (tibial tuberosity). It occurs in young athletes. Pain occurs with active use of the quadriceps, such as jumping and running.

Iliotibial Band Friction Syndrome

ITB Syndrome is often seen in runners. It involves an inflammatory process. Pain occurs along the outside (lateral) part of the knee.

Patellar Subluxation

Subluxation (dislocation) may be full or partial. Patellar subluxations usually move to the outside (lateral). Due to their wider pelvis and angulated femurs, female athletes are more prone to patellar subluxation than males. The athlete may complain of giving away, popping or catching in the knee.

Patellar Bursitis

Athletes who sustain repeated trauma to the front of the knee such as falling on the knee or getting hit on the kneecap are prone to bursitis. The condition may be referred to as "water on the knee".

Meniscal Injuries (cartilage)

Meniscal injuries tend to produce swelling. Both pain and associated swelling increase with activity.
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When is knee surgery necessary?

Most knee injuries do not require surgery; however a thorough evaluation and proper instruction in the rehabilitation of the injured area and surrounding structures is highly recommended.

Our surgeons are specifically trained in the treatment and surgical repair of the knee. When surgery is necessary our surgeons provide a variety of surgical treatment options to best care for the injured athlete. The physicians at Orthopedic Institute specialize in arthroscopic procedures of all synovial joints, as well as reconstruction options for ligamentous repair. The good news is that most simple knee surgeries can be performed in outpatient surgery so you are home the same day.

An active lifestyle can lead to knee injuries. A procedure called arthroscopy can help your surgeon treat many of these injuries. By taking an active role in your care, you can help with your treatment and recovery. Read on to learn more.

How Arthroscopy Works

During arthroscopy, your surgeon gently inserts a small tube called an arthroscope into your knee. A camera attached to this tube shows the inside of your knee on a TV screen. This helps your surgeon view problems with the knee. In many cases, repairs to the knee may also be done using the arthroscope. Surgery done through an arthroscope may heal faster and have less scarring than open surgery.

How quickly you heal after arthroscopy depends in part on your age, the kind of knee injury you have, and how well your knee responds to treatment. It also depends on how well you care for your knee and follow your health care provider's instructions.

Together, you and your health care team will set goals for your recovery. These goals can be tailored to your needs. Short-term goals may include walking without crutches or getting back to work. A long-term goal will likely be to regain full use of your knee.

Your surgeon may prescribe physical therapy. This can help relieve pain, increase range of motion, and improve strength. Your physical therapist will design a program for you based on your knee problem and recovery goals.

Your physical therapist can help you set goals and work toward them. But a successful recovery depends on you. Follow instructions and keep your appointments.

Types of Physical Therapy

To help you heal, your physical therapist may use one or more of the following:

• Manual therapy. This may include stretching or massage to reduce stiffness and make your joints more flexible. You may also work your muscles against pressure to make them stronger.

• Weight machines. These machines work and strengthen specific muscle groups.

• Closed kinetic chain exercises. These help make your joints stronger and more stable by keeping one part of the body still while the rest of the body is moving. Squats are an example of these exercises.

• Aerobic exercises. These include biking and walking. They strengthen the leg muscles as well as the heart and lungs.

• Electric stimulation (as needed). This uses a painless electric current to relieve pain, decrease swelling, and rebuild muscles.

• Ultrasound (as needed). This uses sound waves to help heal injured tissue.

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When is knee replacement necessary

If the surfaces in the knee are completely worn to the point that other surgeries cannot repair the damage and relieve pain symptoms, you may be a candidate for artificial knee replacement. During knee replacement surgery, the knee surgeon removes the bottom part of the thighbone (femur) and the top of the shinbone (tibia) and attaches artificial joint surfaces that replaces the damaged surfaces with smooth surfaces of the artificial metal joint. The intent of the surgery is to restore movement without pain.

Your doctor may have tried to reduce your knee pain with medications. You may even have had minor surgery (arthroscopy) to help treat the problem. But if this didn't help enough, total joint replacement might be right for you. To find out, your surgeon will evaluate your knee joint. You'll have a full exam and x-rays. When forming a treatment plan, your surgeon thinks about how surgery can best benefit you over your lifetime.

Your Medical History

Your surgeon will ask you about any past medical problems. He or she is likely to ask where your knee hurts and what makes the pain worse. Tell your surgeon about any other joint problems or any injuries to your knee or leg. If surgery seems likely, be sure to mention any past problems with anesthesia or bleeding.

Your Physical Exam

Your surgeon will fully examine your knee. He or she will feel for swelling around the joint. Nearby muscles and tendons may also be checked. The joint itself will be tested for strength, stability, and range of motion. Your surgeon may also look for other problems, such as a pinched nerve, that may be causing pain in or near the knee.

X-rays

X-rays will be taken to provide an image of your knee joint. An x-ray may show changes in the size and shape of the joint. A buildup of bone (bone spur), a cyst, or pitting in the bone may also show up. These problems often form where cartilage has worn away. X-rays can also help your surgeon plan your knee replacement. He or she may use x-rays to decide exactly where in the bone to place the prosthesis.

Your Treatment Plan

Your surgeon uses the results of your exam and tests to form a treatment plan that is right for you. Depending on your age and the amount of damage to your knee, surgery may offer the best answer to your problem. A total knee replacement lasts many years, and it can often be repeated if the first prosthesis wears out. But if you are still fairly young, your surgeon may suggest delaying surgery. In this case, medications or arthroscopy may help control your symptoms until the time is right for joint replacement.

After a total knee replacement, you may be able to move more easily. Most people gain all of the benefits listed below.

• Reduced joint pain. Even the pain from surgery should go away within weeks.

• Increased leg strength. Without knee pain, you'll be able to use your legs more. This will build up your muscles.

• Improved quality of life by allowing you to do daily tasks and low-impact activities in greater comfort.

• Years of easier movement. Most total knee replacements last for many years.

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How to get ready for knee surgery

You may want to make a few simple changes around the house before surgery. This will help make life easier during recovery. Be sure to see your primary care doctor or dentist. Treating health and dental problems ahead of time helps improve healing after a joint replacement. If you're a smoker, do your best to stop or cut down. Your surgery risks and recovery rate will improve.

Prepare at Home

Make life easier and safer after surgery. Reduce household hazards now. Also, limit the amount of reaching and stair climbing you'll have to do. Try these tips:

Stock up on canned and frozen foods. Store food and supplies between waist and shoulder level.

Prepare a room on the main living level if you normally sleep upstairs. Or set things up so you have to go upstairs only once a day.

After knee replacement, you won't be able to drive for the first few weeks. Perhaps a family member or friend can deliver groceries and help you run errands. If you live alone, ask someone to stay with you for a few days after surgery. By planning ahead now, you'll have less to worry about during recovery.

See Your Doctor

Your primary care doctor makes sure that you're in shape for surgery. You may have an ECG (electrocardiogram) to find out what type of anesthesia is best for you. You also may have a chest x-ray, and lab or blood tests. Your doctor will talk with you about any health problems, such as diabetes and high blood pressure, that need to be treated before surgery.

Discuss Your Medications

Tell your surgeon about all of the medications you take, even over-the-counter ones. This is important. Some medications don't mix well with anesthesia. Others?aspirin, ibuprofen, and blood thinners, for example can increase bleeding. To avoid problems during surgery, you may need to stop taking certain medications before your joint is replaced.

Finish Dental Work

Have tooth or gum problems treated before surgery. Also, finish any dental work that is under way. If you don't, germs in your mouth could enter the bloodstream and infect the new joint. This could delay your recovery. In an extreme case, an infection in the new joint might mean that the prosthesis would have to be removed.

Donating Blood

Blood lost during surgery may need to be replaced. Donating your own blood ahead of time is often best, since there is less risk of reaction this way. If necessary, blood can be provided by a blood bank. This blood is always screened to rule out disease.
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The day of surgery

You will most likely arrive at the hospital on the morning of surgery. In many cases, pre-op tests are done days or even weeks ahead of time. Follow all of your surgeon's instructions on preparing for surgery. When you arrive, you'll be given forms to fill out. You may also talk with the anesthesiologist (the doctor who gives the anesthesia), if you haven't done so already. It's normal to feel a little nervous. But rest assured: This is a common surgery that tends to have very good results.

You will be told when to stop eating and drinking before surgery. If you take a daily medication, ask if you should still take it the morning of surgery. At the hospital, your temperature, pulse, breathing, and blood pressure will be checked. An IV (intravenous) line may be started to provide fluids and medications needed during surgery.

Risks and Complications

As with any surgery, total knee replacement has possible risks and complications. These include the following:

• Reaction to the anesthesia

• Blood clots

• Infection

• Damage to nearby blood vessels, bones, or nerves

• Dislocation of the kneecap

When the surgical team is ready, you'll be taken to the operating room. There you'll be given anesthesia. The anesthesia will help you sleep through surgery, or it will make you numb from the waist down. Then an incision is made on the front or side of your knee. Any damaged bone is cleaned away, and the new joint is put into place. The incision is closed with staples or stitches.

All of the bone surfaces of the joint are shaped to hold the prosthesis. Then the parts of the prosthesis are put in place. At this point, your surgeon tests the fit and alignment of the prosthesis.

If the prosthesis fits correctly, its parts are secured to the thighbone, kneecap, and shinbone. Then these parts are joined. Together they form the new joint.

After surgery you'll be sent to the recovery room, also called the PACU (postanesthesia care unit). Your condition will be watched closely, and you'll be given pain medications. You may have a catheter (small tube) in your bladder and a drain in your knee. A CPM (continuous passive motion) machine may be used on your knee. This machine gently bends the knee to keep it from getting stiff.

Recovery at Home

Taking good care of your knee at home will help you heal faster and better. Be sure to follow your health care provider's guidelines for healing. Don't remove your bandage or take a shower until your health care provider tells you it's OK.

Elevating Your Leg

Elevating your leg helps relieve pain and swelling. Prop your leg on a chair or with a large pillow.

Icing Your Knee

Ice helps numb pain and reduce swelling. Try to ice your knee for 15 to 20 minutes, or as long as your health care provider suggests. Ice your knee every 2 to 3 waking hours for the first few days after surgery. Use an ice pack or a package of frozen peas wrapped in a towel.

Eating Meals

You may have some nausea right after surgery. Choose light, easy-to-digest foods, such as soups. Drink plenty of liquids.

Taking Medication

Use medication as directed. If you're having trouble sleeping, try taking your pain medication at night. Be sure to avoid alcohol.

Doing Circulation Exercises

Moving your foot helps prevent blood clots. Point and flex your toes, and wiggle them as often as your surgeon suggests. In addition, bend and straighten your knee a few times each day to keep it limber.

Using Crutches

If you need crutches, your health care provider can show you the best way to use them. Be sure the hand rests are set at the right height for you. Also, put only as much weight on your leg as you're told.

Your Bandage

A bandage helps keep your incision clean and controls swelling. Talk to your health care provider about how to care for your bandage.

Bathing

You can shower when you can stand without pain for 10 to 15 minutes. You can also take a tub bath if you hold your leg out of the tub. When showering or bathing, you will need to keep your knee dry. Your health care provider may suggest a special stocking for this purpose. Plastic wrap taped around your knee also works. Or put your leg inside one or two clean plastic garbage bags and tape them above your knee.

Getting Back to Work

You may be able to return to a desk job just a few days after your arthroscopy. But if your job is very active, you will likely need to wait longer. Be sure to consult your health care provider before returning to work.
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After surgery items

After surgery, you may have questions about your recovery. Maybe you want to know when you can take a shower or how much weight you can put on your leg. Don't be afraid to ask a member of your health care team.

Things to Know

Before you go home, be sure you know:

• How to take your medication.

• How to use crutches.

• How much weight to put on your leg.

• What exercises to do and how often.

• When your bandage or sutures will be removed.

• When you can shower or bathe.

• When you can start driving again.

• When you can return to work.

• When you can be fully active again.

• When you should schedule follow-up visits.

• The answer to any other questions you may have.

Call Your Doctor If:

Call your surgeon right away if you notice any of the following warning signs:

• You have a fever of 101ºF or higher.

• Your pain does not lessen after taking medication or resting.

• You have increased swelling not helped by elevating or icing your knee.

• The incision site is red, tender or warm.

• You are bleeding through your bandage.

• You have severe nausea.

• You have chest pain or shortness of breath.

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If you have a hospital stay

You'll be moved to your room when you are awake. By then your family or a friend will be able to join you. You can expect to feel some pain. To gain the best pain relief, answer honestly when you are asked how badly you hurt. Soon after surgery, specially trained therapists will start working with you. For the quickest, safest recovery, practice what they teach you.

In Your Hospital Room

• You'll be watched closely on the day of surgery. Any or all of the equipment below may be provided.

• A CPM machine may be used to keep your knee flexible.

• A bar (trapeze) may be hanging over the bed. Use it to help lift your body when you change positions.

• Special stockings may be used to reduce the risk of blood clots. You may also be given medications to help prevent clots.

Managing Pain

You may be given pain medications by injection or IV for the first few days. Expect to feel some pain, even with medication. This is normal. But if the medication doesn't reduce your pain at all, be sure to tell the nurse.

You're in Control with PCA

PCA (patient-controlled analgesia) allows you to control your own pain medication. When you push a button, pain medication is pumped through an IV line. PCA pumps can provide a steady level of pain relief. And with their built-in safety features, you can be assured that you will not get too much medication.

Special Therapies

During your hospital stay, you'll learn skills that will help you return to normal life. You will be shown how to strengthen your leg, walk, and clear your lungs. To make moving easier, use the PCA pump or ask for pain medication before your physical therapy (PT) sessions.

Gaining Strength

Your PT program is likely to start with gentle exercises. You may be shown ways to increase blood flow and control swelling. Working the quadriceps muscles (in the front of your thigh) builds leg strength. This helps protect your new joint by keeping the knee more stable. Exercises also help you bear weight without pain?a goal you can work toward.

Walking Again

You may begin to stand and walk within hours after surgery. An IV and catheter are likely to still be in place, so using the walker may be a little tricky. But don't worry. A physical therapist will help you. You will be taught how much weight, if any, to bear on your new joint. With practice, you'll soon be able to walk with just the aid of a walker.

Clearing Your Lungs

Fluid can collect in the lungs after any surgery. To avoid pneumonia, breathe deeply and cough. You should do this often?a few times an hour, at least. A respiratory therapist or nurse may show you how to use an incentive spirometer. This machine can help you breathe more deeply.
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After surgery: Joint Camp

A program is available for patients having total knee and total hip replacements. This program is available only at Avera McKennan Hospital and emphasizes education and wellness. The surgeons of Orthopedic Institute in connection with Avera McKennan Hospital have developed the Total Joint Center, also referred to as Joint Camp.

Surgeries are scheduled for Mondays and Tuesdays, with patients typically being discharged to their own homes, not another facility or step-down unit, on Thursdays and Fridays. Therapy is delivered in a group setting on the unit, which facilitates camaraderie among the patients. In addition to the therapists working with the patients, each patient has a coach who helps with the recovery. Coaches may be a family member, friend or volunteer. Patients stay in a designated wing of the hospital on the orthopedic unit.

Emphasis on patient education occurs before and after surgery. Patients are given a notebook before surgery and are expected to attend a class. Pre-op education prepares the patient for the surgery, hospitalization, rehabilitation and return to functional activities. Every day at Joint Camp patients receive newsletters with updates on what to expect. Prior to going home, patients are giving videos and handouts explaining what to expect in the days ahead.

Surgeons and staff of Joint Camp believe that patients requiring total joint replacements are often in good overall health. Therefore, there is a wellness approach in the care that is provided. Patients are expected to dress in their own clothes, (loose-fitting) not hospital gowns. Lunches are eaten in the dining area with other campers and coaches.

If you are interested in Joint Camp, visit with your surgeon at Orthopedic Institute to determine if this experience is right for you.
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This content is not intended as a substitute for professional medical care. Only your doctor can diagnose and treat a medical problem. © 1990, 1995, 1998, 2000 The StayWell Company, 1100 Grundy Lane, San Bruno, CA 94066-3030. www.krames.com 800-333-3032. All right reserved.

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