Knee 2



  1. Knee Arthroscopy

    Knee Arthroscopy

    Knee arthroscopy is a surgical procedure that allows doctors to view the knee joint without making a large incision (cut) through the skin and other soft tissues. Arthroscopy is used to diagnose and treat a wide range of knee problems.

     During knee arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your knee joint. The camera displays pictures on a video monitor, and your surgeon uses these images to guide miniature surgical instruments.

    Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions, rather than the larger incision needed for open surgery. This results in less pain for patients, less joint stiffness, and often shortens the time it takes to recover and return to favorite activities.

  2. Anatomy


    Your knee is the largest joint in your body and one of the most complex. The bones that make up the knee include the lower end of the femur (thighbone), the upper end of the tibia (shinbone), and the patella (kneecap).

    Other important structures that make up the knee joint include:

    • Articular cartilage. The ends of the femur and tibia, and the back of the patella are covered with articular cartilage. This slippery substance helps your knee bones glide smoothly across each other as you bend or straighten your leg.
    • Synovium. The knee joint is surrounded by a thin lining called synovium. This lining releases a fluid that lubricates the cartilage and reduces friction during movement.
    • Meniscus. Two wedge-shaped pieces of meniscal cartilage act as «shock absorbers» between your femur and tibia. Different from articular cartilage, the meniscus is tough and rubbery to help cushion and stabilize the joint.
    • Ligaments. Bones are connected to other bones by ligaments. The four main ligaments in your knee act like strong ropes to hold the bones together and keep your knee stable.
      • The two collateral ligaments are found on either side of your knee.
      • The two cruciate ligaments are found inside your knee joint. They cross each other to form an «X» with the anterior cruciate ligament in front and the posterior cruciate ligament in back.
  3. When Knee Arthroscopy is Recommended

    When Knee Arthroscopy is Recommended

    Your doctor may recommend knee arthroscopy if you have a painful condition that does not respond to nonsurgical treatment. Nonsurgical treatment includes rest, physical therapy, and medications or injections that can reduce inflammation.

    Knee arthroscopy may relieve painful symptoms of many problems that damage the cartilage surfaces and other soft tissues surrounding the joint.

    Common arthroscopic procedures for the knee include:

    • Removal or repair of a torn meniscus
    • Reconstruction of a torn anterior cruciate ligament
    • Removal of inflamed synovial tissue
    • Trimming of damaged articular cartilage
    • Removal of loose fragments of bone or cartilage
    • Treatment of patella (kneecap) problems
    • Treatment of knee sepsis (infection)
  4. Preparing for Surgery

    Preparing for Surgery

    Evaluations and Tests

    Your orthopaedic surgeon may recommend that you see your primary doctor to assess your general health before your surgery. He or she will identify any problems that may interfere with the procedure. If you have certain health risks, a more extensive evaluation may be necessary before your surgery.

    To help plan your procedure, your orthopaedic surgeon may order preoperative tests. These may include blood tests or an electrocardiogram (EKG).

    Admissions Instructions

    If you are generally healthy, your knee arthroscopy will most likely be performed as an outpatient. This means you will not need to stay overnight at the hospital.

    Be sure to inform your orthopaedic surgeon of any medications or supplements that you take. You may need to stop taking some of these before surgery.

    The hospital or surgery center will contact you ahead of time to provide specific details of your procedure. Make sure to follow the instructions on when to arrive and especially on when to stop eating or drinking prior to your procedure.


    Before your surgery, a member of the anesthesia team will talk with you. Knee arthroscopy can be performed under local, regional, or general anesthesia:

    • Local anesthesia numbs just your knee
    • Regional anesthesia numbs you below the waist
    • General anesthesia puts you to sleep

    Your orthopaedic surgeon and your anesthesiologist will talk to you about which method is best for you.

  5. Surgical Procedure

    Surgical Procedure


    Once you are moved into the operating room, you will be given anesthesia. To help prevent surgical site infection, the skin on your knee will be cleaned. Your leg will be covered with surgical draping that exposes the prepared incision site.

    At this point, a positioning device is sometimes placed on the leg to help stabilize the knee while the arthroscopic procedure takes place.


    To begin the procedure, the surgeon will make a few small incisions, called «portals,» in your knee. A sterile solution will be used to fill the knee joint and rinse away any cloudy fluid. This helps your orthopaedic surgeon see the structures inside your knee clearly and in great detail.

    Your surgeon’s first task is to properly diagnose your problem. He or she will insert the arthroscope and use the image projected on the screen to guide it. If surgical treatment is needed, your surgeon will insert tiny instruments through other small incisions.

    Specialized instruments are used for tasks like shaving, cutting, grasping, and meniscal repair. In many cases, special devices are used to anchor stitches into bone.


    Most knee arthroscopy procedures last less than an hour. The length of the surgery will depend upon the findings and the treatment necessary.

    Your surgeon may close each incision with a stitch or steri-strips (small bandaids), and then cover your knee with a soft bandage

  6. Complications


    The complication rate after arthroscopic surgery is very low. If complications occur, they are usually minor and are treated easily. Possible postoperative problems with knee arthroscopy include:

    • Infection
    • Blood clots
    • Knee stiffness
    • Accumulation of blood in the knee
  7. Recovery


    After surgery, you will be moved to the recovery room and should be able to go home within 1 or 2 hours. Be sure to have someone with you to drive you home and check on you that first evening.

    While recovery from knee arthroscopy is faster than recovery from traditional open knee surgery, it is important to follow your doctor’s instructions carefully after you return home.

    Pain Management

    After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

    Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

    Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.


    In addition to medicines for pain relief, your doctor may also recommend medication such as aspirin to lessen the risk of blood clots.


    Keep your leg elevated as much as possible for the first few days after surgery. Apply ice as recommended by your doctor to relieve swelling and pain.

    Dressing Care

    You will leave the hospital with a dressing covering your knee. Keep your incisions clean and dry. Your surgeon will tell you when you can shower or bathe, and when you should change the dressing.

    Your surgeon will see you in the office a few days after surgery to check your progress, review the surgical findings, and begin your postoperative treatment program.

    Bearing Weight

    Most patients need crutches or other assistance after arthroscopic surgery. Your surgeon will tell you when it is safe to put weight on your foot and leg. If you have any questions about bearing weight, call your surgeon.

    Rehabilitation Exercise

    You should exercise your knee regularly for several weeks after surgery. This will restore motion and strengthen the muscles of your leg and knee.



  1. ACL Injury: Does It Require Surgery?

    ACL Injury: Does It Require Surgery?

    The following article provides in-depth information about treatment for anterior cruciate ligament injuries. The general article, Anterior Cruciate Ligament (ACL) Injuries, provides a good introduction to the topic and is recommended reading prior to this article.

    The information that follows includes the details of anterior cruciate ligament (ACL) anatomy and the pathophysiology of an ACL tear, treatment options for ACL injuries along with a description of ACL surgical techniques and rehabilitation, potential complications, and outcomes. The information is intended to assist the patient in making the best-informed decision possible regarding the management of ACL injury

  2. Anathomy

    The bone structure of the knee joint is formed by the femur, the tibia, and the patella. The ACL is one of the four main ligaments within the knee that connect the femur to the tibia.

    The knee is essentially a hinged joint that is held together by the medial collateral (MCL), lateral collateral (LCL), anterior cruciate (ACL) and posterior cruciate (PCL) ligaments. The ACL runs diagonally in the middle of the knee, preventing the tibia from sliding out in front of the femur, as well as providing rotational stability to the knee.

    The weight-bearing surface of the knee is covered by a layer of articular cartilage. On either side of the joint, between the cartilage surfaces of the femur and tibia, are the medial meniscus and lateral meniscus. The menisci act as shock absorbers and work with the cartilage to reduce the stresses between the tibia and the femur.

  3. Description

    The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee. In general, the incidence of ACL injury is higher in people who participate in high-risk sports, such as basketball, football, skiing, and soccer.

    Approximately half of ACL injuries occur in combination with damage to the meniscus, articular cartilage, or other ligaments. Additionally, patients may have bruises of the bone beneath the cartilage surface. These may be seen on a magnetic resonance imaging (MRI) scan and may indicate injury to the overlying articular cartilage.

  4. Cause

    It is estimated that the majority of ACL injuries occur through non-contact mechanisms, while a smaller percent result from direct contact with another player or object.

    The mechanism of injury is often associated with deceleration coupled with cutting, pivoting or sidestepping maneuvers, awkward landings or «out of control» play.

    Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes in certain sports. It has been proposed that this is due to differences in physical conditioning, muscular strength, and neuromuscular control. Other hypothesized causes of this gender-related difference in ACL injury rates include pelvis and lower extremity (leg) alignment, increased ligamentous laxity, and the effects of estrogen on ligament properties.

  5. Doctor Examination

    Doctor Examination

    Immediately after the injury, patients usually experience pain and swelling and the knee feels unstable. Within a few hours after a new ACL injury, patients often have a large amount of knee swelling, a loss of full range of motion, pain or tenderness along the joint line and discomfort while walking.

    When a patient with an ACL injury is initially seen for evaluation in the clinic, the doctor may order x-rays to look for any possible fractures. He or she may also order a magnetic resonance imaging (MRI) scan to evaluate the ACL and to check for evidence of injury to other knee ligaments, meniscus cartilage, or articular cartilage.



  1. Anesthesia for Hip and Knee Surgery

    Anesthesia for Hip and Knee Surgery

    Before your joint replacement surgery, your doctor will discuss anesthesia with you. The selection of anesthesia is a major decision that could have a significant impact on your recovery. It deserves careful consideration and discussion with your surgeon and your anesthesiologist.

    Several factors must be considered when selecting anesthesia, including:

    • Your past experiences and preferences. Have you ever had anesthesia before? Did you have a reaction to the anesthesia? How do other members of your family react to anesthesia?
    • Your current health and physical condition. Do you smoke? Are you overweight? Are you being treated for any condition other than your joint replacement?
    • Your reactions to medications. Do you have any allergies? Have you ever experienced bad side effects from a drug? What medications, nutritional supplements, vitamins, or herbal remedies are you currently taking?
    • The risks involved. Risks vary, depending on your health and selection of anesthesia, but may include breathing difficulties, allergic reactions and nerve injury. Your surgeon and anesthesiologist will discuss specific risks with you.
    • Your healthcare team. The skills and preferences of your surgical and anesthesia team play an important role in the selection of anesthesia.
  2. Types of Anesthesia

    Types of Anesthesia

    There are three broad categories of anesthesia: local, regional and general.

    Local Anesthesia

    Local anesthesia numbs only the specific area being treated. The area is numbed with an injection, spray or ointment that only lasts for a short period of time. Patients remain conscious during this type of anesthesia. This technique is reserved for minor procedures. For major surgery, such as hip or knee replacement, local anesthesia may be used to complement the main type of anesthesia that is used.

    Regional Anesthesia

    Regional anesthesia involves blocking the nerves to a specific area of the body, without affecting your brain or breathing. Because you remain conscious, you will be given sedatives to relax you and put you in a light sleep.

    The three types of regional anesthesia used most frequently in joint replacement surgery are spinal blocks, epidural blocks and peripheral nerve blocks.

    • Spinal Block. In a spinal block, the anesthesic drug is injected into the fluid surrounding the spinal cord in the lower part of your back. This produces a rapid numbing effect that wears off after several hours.
    • Epidural Block. An epidural block uses a catheter inserted in your lower back to deliver local anesthetics over a variable period of time. The epidural block and the spinal block are administered in a very similar location; however, the epidural catheter is placed in a slightly different area around the spine as compared to a spinal block.
    • Peripheral Nerve Block. A peripheral nerve block places local anesthetic directly around the major nerves in your thigh, such as the femoral nerve or the sciatic nerve. These blocks numb only the leg that is injected, and do not affect the other leg. One option for a peripheral block is to perform a one-time injection around the nerves in order to numb the leg just long enough for the surgery. Another option for this type of block is to keep a catheter in place, which can deliver continuous local anesthesia around the nerves for up to several days after surgery.

    Advantages to regional anesthesia may include less blood loss, less nausea, less drowsiness, improved pain control after surgery, and reduced risk of serious medical complications, such as heart attack or stroke that — although rare — may occur with general anesthesia.

    Side effects from regional anesthesia may include headaches, trouble urinating, allergic reactions, and rarely nerve injury.

    General Anesthesia

    General anesthesia is often used for major surgery, such as a joint replacement. General anesthesia may be selected based on patient, surgeon, or anesthesiologist preference, or if you are unable to receive regional or local anesthesia. Unlike regional and local anesthesia, general anesthesia affects your entire body. It acts on the brain and nervous system and renders you temporarily unconscious.

    • Administration. With general anesthesia, the anesthesiologist administers medication through injection or inhalation. The anesthesiologist will also place a breathing tube down your throat and administer oxygen to assist your breathing.
    • Risks. As with any anesthesia, there are risks, which may be increased if you already have heart disease, chronic lung conditions, or other serious medical problems.

    General anesthesia affects both your heart and breathing rates, and there is a small risk of a serious medical complication, such as heart attack or stroke.

    The tube inserted down your throat may give you a sore throat and hoarse voice for a few days.

    Headache, nausea, and drowsiness are also common.

  3. Pain Relief After Surgery

    The goals of postoperative pain management are to minimize discomfort and allow you to move with less pain in order to participate in physical therapy after surgery. The first few days after hip and knee surgery are usually painful. Your doctor will use a combination of oral medications or intravenous medications to help control your pain and keep you comfortable.

    Oral Pain Medications

    Oral pain medications may include a combination of non-narcotic pain relievers such as acetaminophen (Tylenol), nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen, or muscle relaxants such as methocarbamol, and opioid-based medications such as hydrocodone, oxycodone, or tramadol.  You should use opioids only as directed by your doctor. Although opioids can help relieve pain after surgery, they are a narcotic and can be addictive. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

    Intravenous Pain Medications

    Intravenous (IV) pain medications such as morphine and hydromorphone (Dilaudid) are generally used to supplement oral pain medication during severe episodes of pain.  The advantage of IV pain medications is that they take effect quickly. It is important to use IV pain medications sparingly in order to avoid serious side effects.

    Another method of pain control is called «patient-controlled anesthesia» or «PCA.» With PCA, you will be able to control the flow of intravenous medication, within preset limits, as you feel the need for additional relief.

    If an epidural or peripheral nerve block was used for your surgery, the epidural or peripheral catheter can be left in place and anesthesia can be continued in the postoperative period to help control pain. You may also have control over the amount of pain medication you receive in these catheters, within preset limits. You will be closely monitored to avoid complications, such as excessive sedation or falls.

    The proper use of pain relievers before, during and after your surgery is an extremely important aspect of your treatment. Proper use of pain medication can encourage healing and make your joint replacement a more satisfying experience. Take time to discuss the options with your doctor, and be sure to ask questions about things you do not understand.



  1. Articular Cartilage Restoration

    Articular Cartilage Restoration

    Articular cartilage is the smooth, white tissue that covers the ends of bones where they come together to form joints. Healthy cartilage in our joints makes it easier to move. It allows the bones to glide over each other with very little friction.

    Articular cartilage can be damaged by injury or normal wear and tear. Because cartilage does not heal itself well, doctors have developed surgical techniques to stimulate the growth of new cartilage. Restoring articular cartilage can relieve pain and allow better function. Most importantly, it can delay or prevent the onset of arthritis.

    Surgical techniques to repair damaged cartilage are still evolving. It is hoped that as more is learned about cartilage and the healing response, surgeons will be better able to restore an injured joint.

  2. Cartilage Damage

    Cartilage Damage

    Hyaline Cartilage

    The main component of the joint surface is a special tissue called hyaline cartilage.When it is damaged, the joint surface may no longer be smooth. Moving bones along a tough, damaged joint surface is difficult and causes pain. Damaged cartilage can also lead to arthritis in the joint.

    The goal of cartilage restoration procedures is to stimulate new hyaline cartilage growth.

    Identifying Cartilage Damage

    In many cases, patients who have joint injuries, such as meniscal or ligament tears, will also have cartilage damage. This damage may be hard to diagnose because hyaline cartilage does not contain calcium and cannot be seen on an X-ray.

    If other injuries exist with cartilage damage, doctors will address all problems during surgery.

    Patient Eligibility

    Most candidates for articular cartilage restoration are young adults with a single injury, or lesion. Older patients, or those with many lesions in one joint, are less likely to benefit from the surgery.

    The knee is the most common area for cartilage restoration. Ankle and shoulder problems may also be treated.

  3. Surgical Procedures

    Many procedures to restore articular cartilage are done arthroscopically. During arthroscopy, your surgeon makes three small, puncture incisions around your joint using an arthroscope.

    Some procedures require the surgeon to have more direct access to the affected area. Longer, open incisions are required. Sometimes it is necessary to address other problems in the joint, such as meniscal or ligament tears, when cartilage surgery is done.

    In general, recovery from an arthroscopic procedure is quicker and less painful than a traditional, open surgery. Your doctor will discuss the options with you to determine what kind of procedure is right for you.

    The most common procedures for cartilage restoration are:

    • Microfracture
    • Drilling
    • Abrasion Arthroplasty
    • Autologous Chondrocyte Implantation
    • Osteochondral Autograft Transplantation
    • Osteochondral Allograft Transplantation


    The goal of microfracture is to stimulate the growth of new articular cartilage by creating a new blood supply. A sharp tool called an awl is used to make multiple holes in the joint surface. The holes are made in the bone beneath the cartilage, called subchondral bone. This action creates a healing response. New blood supply can reach the joint surface, bringing with it new cells that will form the new cartilage.

    The goal of microfracture is to stimulate the growth of new cartilage by creating a new blood supply.

    A sharp tool called an awl is used to make multiple holes in the joint surface. The holes are made in the bone beneath the cartilage, called subchondral bone. This creates a healing response. New blood supply can reach the joint surface. This will bring new cells that will form cartilage.


    Drilling, like microfracture, stimulates the production of healthy cartilage. Multiple holes are made through the injured area in the subchondral bone with a surgical drill or wire. The subchondral bone is penetrated to create a healing response.

    Drilling can be done with an arthroscope. It is less precise than microfracture and the heat of the drill may cause injury to some of the tissues.

    Abrasion Arthroplasty

    Abrasion arthroplasty is similar to drilling. Instead of drills or wires, high speed burrs are used to remove the damaged cartilage and reach the subchondral bone.

    Abrasion arthroplasty can be done with an arthroscope.

    Autologous Chondrocyte Implantation (ACI)

    ACI is a two-step procedure. New cartilage cells are grown and then implanted in the cartilage defect.

    First, healthy cartilage tissue is removed from a non-weightbearing area of the bone. This step is done as an arthroscopic procedure. The tissue which contains healthy cartilage cells, or chondrocytes, is then sent to the laboratory. The cells are cultured and increase in number over a 3- to 5-week period.

    An open surgical procedure, or arthrotomy, is then done to implant the newly grown cells. The cartilage defect is prepared. A layer of bone-lining tissue, called periosteum, is sewn over the area. This cover is sealed with fibrin glue. The newly grown cells are then injected into the defect under the periosteal cover.

    ACI is most useful for younger patients who have single defects larger than 2 cm in diameter. ACI has the advantage of using the patient’s own cells, so there is no danger of a patient rejecting the tissue. It does have the disadvantage of being a two-stage procedure that requires an open incision. It also takes several weeks to complete.

    Osteochondral Autograft Transplantation

    In osteochondral autograft transplantation, cartilage is transferred from one part of the joint to another. Healthy cartilage tissue — a graft — is taken from an area of the bone that does not carry weight (non-weightbearing). The graft is taken as a cylindrical plug of cartilage and subchondral bone. It is then matched to the surface area of the defect and impacted into place. This leaves a smooth cartilage surface in the joint.

    A single plug of cartilage may be taken or a procedure using multiple plugs, called mosaicplasty, may be performed.

    A single plug of cartilage may be transferred or a procedure with multiple plugs, called mosaicplasty, may be done.