The knee joint is made up of the femur (thigh bone), tibia (lower leg bone), and patella (kneecap). All these bones are lined with articular cartilage. This articular cartilage acts like a shock absorber and allows a smooth, low friction surface for the knee that allows it to move. Between the femur and tibia lie the medial meniscus and the lateral meniscus. The menisci are stabilizers and act as shock absorbers by dispersing the weight of the body and reducing friction during movement. The knee is also stabilized by ligaments that are both inside and outside the joint. The medial and lateral collateral ligaments support the knee from excessive side to side movement. The (internal) anterior and posterior cruciate ligaments support the knee from buckling and giving way. The knee joint is surrounded by a capsule that produces a small amount of synovial (lubricating) fluid to help with smooth motion. The plica is an extension of the protective synovial capsule of the knee that is located along the medial side of the knee. It can cause pain aggravated by activity on the medial side of the knee.  The Iliotibial (IT) band is a band of tissue that runs from your hip down the outside of the knee and can commonly cause pain on the lateral side of the knee.

A knee arthroscopy is a minimally invasive surgical procedure in which an examination and treatment of a joint is performed using an arthroscope. During the arthroscopy, the surgeon examines and repairs your injured or diseased joint with the help of an optical instrument called an arthroscope. An arthroscope is a thin fiber-optic scope which is about the diameter of a drinking straw.  It is fitted with a miniature camera and light source. Other tools used include tissue shavers, lasers, and a type of biting tool.

Procedures

Conditions treated with arthroscopic surgery of the knee include torn meniscus, torn anterior cruciate ligament (ACL), inflamed or damaged lining of the joint, misalignment of the kneecap/patella, bone spurs or loose bodies, arthritis, and scarring or tissue inflammation within joints.

Indications

An arthroscopy may help if you have persistent pain, catching, or swelling in your knee, and you have tried conservative treatment, such as Physical Therapy, anti-inflammatories, injections etc., If you have persistent pain and instability, you may need to consider arthroscopy as a solution to your condition.

Anesthesia

General anesthesia is used unless contraindicated.  You will receive certain medications through your IV that make you unconscious and unable to feel pain during your surgical procedure.

Surgery Time

In most arthroscopic surgeries of the knee it will take approximately 15-20 minutes. ACL and cartilage repair procedures can take 30-60 minutes. Arthroscopic surgery is safe and very effective in almost every instance.

Hospital Stay

You will be in the hospital or outpatient surgery center approximately 5 hours. This is an outpatient procedure and rarely do you have to stay overnight. You will go home the same day and immediately start your recovery and rehabilitation.

Average Total Recovery Time

Total recovery time is from 2-4 weeks for a simple arthroscopy, and from 6 to 8 weeks for an ACL repair to normal activities.  ACL repair recovery may require longer term rehab to return to high intensity sports activities.

Minimally Invasive Surgery (MIS) Procedures

• Meniscectomy is the surgical removal of part of a torn or frayed meniscus. The torn portion or unstable meniscal fragments are removed, and the edges of the remaining meniscus are shaved to make the meniscus smooth. It is very simple surgically and fortunately, easy for patients to recover, making this a great procedure to provide treatment. Swelling and some soreness are the main symptoms post-op, yet most cases recover quickly and get back to activity within 1-4 weeks.

• Plica resection is the surgical resection of a thick fibrous band of tissue on the medial side of the knee joint. The plica irritates and rubs the distal femoral condyle as you flex and extend your knee.  This tissue can be resected during arthroscopy.  It serves no function, and most people do not have one.  If this band of tissue is present and causing pain, it may require resection. This is more prevalent in young female athletes.

• Lateral retinacular release is a surgical procedure to release tight capsular structures, for example, the lateral retinaculum on the outer aspect of the kneecap. This is usually performed because the kneecap is being pulled over to the outer side of the knee and is not tracking properly in the groove of the femur bone as the knee bends and straightens.  This release is performed on patients with chronic kneecap pain when squatting, climbing stairs, working out, etc.  A lateral release is very effective in treating mal tracking kneecap pain.

• Synovectomy-Debridement is the cleaning out of the knee joint and the smoothing of the surfaces of the joint.  It is not uncommon for patients who have had knee surgery (total knee replacement, ACL repair, Rheumatoid Arthritis) to have chronic synovial disease, which when cleaned out respond very positively with a reduction of pain associated with activity. With rehabilitation, this procedure is very effective in most cases.

• Anterior Cruciate Ligament (ACL) Reconstruction is a surgical tissue graft replacement of the ACL. The torn ligament is removed from the knee before the graft is inserted. The graft can be an autograft or an allograft. An autograft is an option which involves the medical grafting of tissue from the patient’s body (usually patellar tendon). An allograft is taken from a donor cadaver tissue. The recovery time for this procedure is 6-8 weeks. You will start wearing a range of motion brace the day of surgery and you will wear this for approximately 4-6 weeks. You will have motion set at 0-30 degrees until you see your surgeon at your follow-up appointment, and it should be worn at all times. You may remove the brace when you are sleeping, but if you get up to use the restroom you should put it back on. It is important for you to see your surgeon in the office 2-4 days after surgery and will then be instructed on exercises and possible physical therapy.  Our patients undergoing ACL surgery are progressed very quickly to have independence and functioning with a goal of normal Range of Motion and 90% functional capacity within 6-8 weeks.  This procedure has a 95% success rate with significant improvements in the last 10 years.  The rehabilitation process does take some effort on the patient’s part, which yields an overall highly predictable favorable outcome.

Post-Op Considerations Following Minimally Invasive Arthroscopic Surgery

Incision

Two ½ inch incisions underneath the kneecap.  These keyhole incisions are closed with stitches under the skin that will dissolve over time. You will have the two stitches underneath the patella for an ACL repair, and a 2-inch incision below the kneecap which will be closed with staples.

Possible Complications

Complications include infection, nerve damage, circulatory damage, and an anesthesia risk. These are standard issues with any surgery, with a very low prevalence with minimally invasive arthroscopy.

Before being discharged

• Make sure you void before leaving the hospital
• Make sure your drain is removed before being discharged
• Be certain to have all your questions answered
• Make sure you are able to get around. Crutches or a walker are available on request.

Normal Post-Operative Occurrences

You may experience swelling, redness, pain or discomfort, bruising of the thigh or lower leg, and blood-tinged drainage on your dressing. This is normal. You may also have an elevated temperature for a few days after surgery just from having surgery; this can be treated with Tylenol.  If your temperature stays above 101⁰ and is not brought down with Tylenol, please let us know.

Ice your knee every hour or so for 20 minutes for the pain and swelling initially.  This may be continued as needed to help with pain, inflammation, and swelling for the next 2-4 weeks.

You should also elevate your foot straight up in the air either on the back of your couch or on the headboard of your bed for 20 minutes 4 times a day if you have significant swelling.

Dressing

For the first 24-48 hours you will have a large, soft dressing, which starts 10-12 inches above the knee and extends to your ankle. Please wear something loose fitting to the hospital which will go over this bandage when it is time to be discharged home.

Shower

A shower is permitted after removing the bandages 24-48 hours after your surgery.  Rinse incisions, but do not rub or use soap. Clean your incisions with alcohol after getting out of the shower and apply Band-Aids or gauze. Wrapping your knee with the ace wrap that was the top layer of the bulky dressing can help with swelling.

Medications

Your prescription after surgery will consist of pain medication, usually either Norco or Percocet.  Phenergan or Zofran may also be given for nausea if needed. You will also receive Robaxin for muscle spasms. You may resume your anti-inflammatory medicine (Advil, Mobic, Celebrex, Lodine, Indocin, or Aleve) the day after surgery. Pain medication and anesthesia can cause constipation, so increase the bulk in your diet; and if needed, you can take an over the counter stool softener like Colace or a laxative. Over-the-counter medications are less likely to cause this problem so the sooner you can get off pain medicine the better you will feel.

Tylenol and Advil or Aleve can be taken together for pain to help decrease the need for narcotics. Two and Two, Twice a day will help reduce pain and narcotic use. (2 Tylenol & 2 Advil/Aleve together twice daily).  If you have a prescription arthritis medication that takes the place of Advil/Aleve.

You may resume your home medications in the morning after surgery.

Pain

You will experience some degree of pain after surgery. Pain and swelling may increase based on your activity level, so be sure to elevate and ice when this occurs.  Moving around is to your advantage, the sooner you mobilize, the quicker your recovery and pain level will improve.

Sleep

If you have difficulty sleeping, we recommend a hot shower right before bed.  You can also take your muscle relaxer (Robaxin/Methocarbamol) and/or Benadryl to help you sleep.

Icing After MIS Arthroscopic Knee Surgery

We highly recommend a Game Ready ice machine for icing your knee. It is a machine with a sleeve that covers your knee from mid-thigh to mid-calf and is connected to a hose and a reservoir that holds ice and water. Instead of using ice from the freezer, you can freeze 14- 8-oz bottles of water. Use 7 of them in the Game Ready reservoir at a time. It helps with pain, bruising, and swelling. We highly recommend you rent a Game Ready since physical therapy is not required. Reserve a Game Ready before your surgery by calling the representative for Game Ready, Kameron, at 205-269-0200. Insurance does not cover it and your cost is $120 a week.  Most people use this for 2 weeks and return it to our office at their post op appointment.

Activity

You may need crutches or a walker for a couple of days after surgery until you are able to walk without assistance. For the first two days you should take it easy. Elevate your leg on 3-4 pillows above the heart.  Use ice 20-30 minutes every hour for swelling and pain. While in recovery you may start exercising doing quad isometric exercises. You can begin riding a stationary bicycle 3 to 4 days after surgery or walking on level ground. Remember to start out slow and increase your exercising gradually. Always ice after exercising. 

Exercises

Remember to ice your knee after exercising.

1. Quad isometric exercises:

Extend your leg and flex your foot toward your face. Tighten your quads. Hold for 20 seconds.  Repeat 10 times. Do this 3-4 times a day or as often as you like. More is better!

1. Pumping your feet:

Pump your feet throughout the day and hold them static when resting. This helps with blood flow and to reduce the risk of a blood clot.

1. Recumbent bike:

Ride a recumbent bike starting 3-4 days after surgery if you can bend your knee past 90 degrees. Start out riding the bike 10 minutes, increase your time gradually, until you are riding the bike 30 minutes. Remember, only ride it EVERY OTHER DAY.

1. Knee Flexion/Extension Exercises:

Lean back in chair or lie down on bed. Raise operative leg up and grasp your thigh with both hands, slowly straighten leg, and let knee bend letting gravity pull foot down. Do this 3-4 times slowly, three or four times a day. 

Returning to Work

You should be able to resume desk work and light duty activity in 3 to 7 days, and more strenuous activity in 2 weeks. Job duties will dictate return to work. If excessive walking is required and light duty cannot be arranged.  You should be able to return to work in 2 weeks.  If a great deal of climbing and lifting is required, you may need to be off work 3-4 weeks. 

Return to Office

Your post-op appointment will need to be 2 weeks after surgery. Please call (205) 783-5900 to make that appointment.

Please call the office if any problems arise or if you have any questions.