An arthroscopy is a procedure on the knee when a small camera is inserted to allow the surgeon to see. The advantage of this surgery is that the operation can be performed through small stab incisions(<1cm), rather than long arthrotomy incisions (generally >10cm). By doing surgery arthroscopically your recovery time and pain is less, and operative risks are reduced. The knee is able to be examined in greater detail, and throughout the entire knee, something that cannot be done with conventional surgery.
Procedures that can typically be treated arthroscopically include :
Chondral lesions/ Ostechondritis dessicans
Removal of loose bodies
Washout of inflamed or infected joints
Anterior and Posterior Cruciate Ligament Reconstructions
Knee arthroscopy is performed as a day case procedure. It is performed under a light general anaesthetic or spinal anaesthetic, with the patient being able to go home later the same day. You are able to walk on your operated leg as tolerated, but you will be supplied with crutches if needed. You will be encouraged to rest at home for the first three days after your operation, and to ice your knee regularly. Ice will help control your swelling, control your pain, and improve your recovery. After three days, your compression bandage can be removed, leaving the underlying waterproof dressings intact until reviewed by Dr Debnath- typically two weeks post-operatively. While the wounds from surgery are usually well healed by two weeks, tissue healing within the knee may continue for 4-6 weeks, depending on the surgery undertaken.
Meniscal trimming or Repairs
A meniscus tear is a common injury to the cartilage that stabilizes and cushions the knee joint. The pattern of the tear can determine whether your tear can be repaired. Radial tears sometimes can be repaired, depending on where they are located. Horizontal, flap, long- standing, and degenerative tears-those caused by years of wear and tear-generally cannot be repaired. Your age, your health, and your activity level may also affect your treatment options. In some cases, the surgeon makes the final decision during surgery, when he or she can see the how strong the meniscus is, where the tear is, and how big the tear is.
- If you have a small tear at the outer edge of the meniscus (in what doctors call the RED ZONE), you may want to try home treatment. These tears often heal with rest.
- If you have a moderate to large tear at the outer edge of the meniscus (RED ZONE), you may need surgical repair. These kinds of tears tend to heal well after arthroscopic or open surgery.
- If you have a tear that spreads from the red zone into the inner two-thirds of the meniscus (called the WHITE ZONE), your decision is harder. Repair may not work. Trimming of the torn meniscus is required.
- If you have a tear in the WHITE ZONE of the meniscus, and its causing symptoms then it is better to do trimming of the torn meniscus.
Anterior Cruciate Ligament reconstruction
The anterior cruciate ligament is one of the major ligaments stabilising your knee. Unfortunately, it is also one of the most common ligaments to be injured. It is an essential stabiliser of the knee when running and turning at speed, or cutting or twisting activities are performed. It is commonly injured during sports e.g. football or rugby. A knee reconstruction involves the replacement of the torn ligament with a “new” one. This typically comes from a couple of hamstring tendons or patellar tendon grafts. A Knee reconstruction will give you a 90% chance of returning to the level of activity you were at before your injury.
The surgery is done through arthroscopy (key hole surgery). The operative procedure takes approximately 1 hour.
Initial Post-Operative period
After surgery you will have an ice pack applied to your leg in recovery. This helps with pain, and swelling. You will be encouraged to use ICE intermittently for the first week after your surgery as it help with pain and swelling. Physiotherapy commences immediately to regain quadriceps strength, and assist you with mobilisation.
A splint which maintains your knee in extension is applied for two weeks, after which it is removed, and with the assistance of a physiotherapist, range of movement is regained. During this period you are able to fully weight bear on your operated leg.
Most patients will be discharged 48 hours after surgery.
Ongoing physiotherapy is an essential part of your recovery. An intensive programme will be undertaken until you regain a full range of motion and good quadriceps strength. A gradual return of activities is encouraged as your new graft becomes incorporated, and regains its strength.
As a guide, walking, cycling and swimming are allowed, as soon as the wounds are healed (2 contact sports, or those requiring twisting, or cutting movements is allowed at 12 months post- operatively.weeks). Jogging is allowed at 3 months, with light sporting activities at 6 months. Return to contact sports, or those requiring twisting, or cutting movements is allowed at 12 months post-operatively.
Posterio Cruciate ligament reconstruction
The posterior cruciate ligament, or PCL, is one of the main ligaments in the knee and injury to this ligament may be seen in a variety of settings. In general, most partial or isolated PCL tears can be treated non-operatively because the PCL, with its synovial covering, has some ability to heal. However, surgical reconstruction is usually recommended for PCL tears that occur in combination with other ligament tears of the knee. It is usually recommended that acute PCL tears in combination with and ACL, posterolateral corner, or MCL complex tears be reconstructed within the first three weeks of injury. In rare occasions, the PCL may be repaired when it occurs as a peel off or bone avulsion injury. In patients with chronic PCL injuries, who are symptomatic for pain and instability, reconstruction may be indicated.
Arthroscopic assisted or open PCL reconstructions involve removing the remaining native PCL. Once the tunnels are drilled, sharp edges and soft tissues around the tunnel exit site are smoothed off with the use of a rasp. The graft is then passed into the joint and fixed in its femoral tunnel (usually with a cannulated interference screw). The graft is then tensioned distally while the knee is cycled several times to remove any slack in the graft. The graft is then fixed to the tibia, usually with staples, while the knee is flexed to 90º, distal traction is placed on the graft, and an anterior force is applied to the tibia.
Postoperatively, it is recommended that the patient remain in full extension for a period of 2 to 4 weeks for isolated PCL reconstructions. In multiligament reconstructions, the patient is often placed into a continuous passive motion (CPM) machine for range of motion. Patients are non weight bearing with quad sets and straight leg raises in the immobilizer only started the 1st postoperative day. It is especially important for PCL reconstruction patients to not have any posterior sag of their tibia which would stretch out the graft. Pillows or other support under the tibia is required for the first two months after surgery. After 8 weeks, weight bearing is initiated and more active rehabilitation is started.
Articular Cartilage Repair Surgery (Stem Cell or Cartilage cell transplant)
Indication and Procedure Description
This procedure is indicated for those patients who have an isolated full thickness articular cartilage defect in the knee, which is causing symptoms such as pain and clicking. This injury is generally from an acute injury, but can also occur over time, due to repeated injuries. The knee is generally swollen and pain is located over the site of the cartilage injury. It is not a suitable procedure for established osteoarthritis as yet.
The procedure involves taking a biopsy (sample) of the healthy cartilage from the knee through an arthroscopy (keyhole surgery). The size of the defect will also be assessed at this time. Depending on the size of the defect it is decided whether a stem cell implantation or a cartilage cell implantation is required. If Stem cell implantation is performed then it could be done under the same surgery with a prior consent. If the defect is large (approximately 2cm) and required cartilage cell transplant then a biopsy is done followed by processing in a laboratory. The cartilage cells will be cultivated in a matrix and this takes approximately four to six weeks. Once the matrix or cartilage is ready, it will then be re-implanted. The re-implantation occurs through an arthrotomy where the joint is opened through a small incision to allow accurate placement of the cartilage graft.
After a thorough clinical assessment of the joint, the patient will generally have plain X-rays and an MRI scan of the knee to help accurately assess the location and size of the cartilage defect. At times, the patient may have previously had an arthroscopy. A range of motion brace will be organised prior to the surgery and this will restrict the joint movement and protect the cartilage graft.
The initial arthroscopy for the biopsy is preformed as a day surgery procedure. The implantation surgery requires a hospital stay of two to three days. The procedure is usually performed under a general anaesthetic and supplemented with a femoral nerve block to help the post-operative pain.
Knee brace. A knee brace will be required for a period of up to three months, depending on the exact location and size of the cartilage defect. The range of motion that will be allowed in the knee brace will also be determined by the exact location and size of the cartilage defect. Generally the patient's weight bearing is restricted for the first six weeks.
Physiotherapy. This will be commenced immediately and range of motion will also be determined by the exact size and location of the cartilage defect. Initial physiotherapy is concentrated on static quadriceps and hamstring exercises to maintain muscle bulk. The post-operative rehabilitation regime will be coordinated through Dr Debnath and the physiotherapist. nThe patient will be seen at two weeks, six weeks, three months and one year post operatively. Return to sport is generally at one year. Sport specific exercises however can be commenced at six months. There will be no jogging or running unsupervised until six months. Some sports, such as swimming and cycling, can be commenced at six months; however no contact or high impact sport can be played for one year.
Medial Patellofemoral Ligament reconstruction
MPFL Reconstruction surgery involves a general or spinal anaesthetic as a day case or overnight stay. The aim of the operation is to rebuild the torn Medial patello-femoral ligament using the hamstring tendon along the same principles as an ACL reconstruction. The procedure is usually performed using arthroscopic assistance and is aimed at replacing the deficient ACL with a graft ligament to stabilise the knee.The semitendinosus hamstring tendon is normally used as the graft to form the new ligament. This graft is taken through a small incision (4cm approximately) over the inner aspect of the shin just below the new.
The tendon is passed through drill hole in the femur and patella so that it lies in the same position as the medial patello-femoral ligament. This requires further small incisions over the femur and inner aspect of the patella. It is held in place with a screw or similar device in the femur and patella.
This procedure recreates an ‘anatomic’ MPFL and is effective in preventing further dislocation inmore than 90% of patients.