Knee Surgery

Arthritis, specifically knee arthritis, refers to degenerative changes within the knee joint. This usually implies that the cartilage lining the joint surfaces of the knee have worn away. Causes of this include natural age-related degeneration, post-traumatic conditions, and inflammatory arthritis such as rheumatoid arthritis. The knee is composed of three compartments: the medial (inside), the lateral (outside), and the patellofemoral joint (underside of kneecap). Knee arthritis may involve one or more of these compartments. Arthritis usually progresses with age, beginning with activity-related pain and, as the disease process progresses, may result in nighttime and rest pain. 

Treatment

Treatment for arthritis begins with non-operative interventions in the early stages. This may include the use of anti-inflammatory medications, physiotherapy, and hydrotherapy. Theepan may also recommend lifestyle modifications such as smoking cessation, weight loss and activity modification. Patients may also wish to trial a corticosteroid injection for pain relief, which may last up to six months. Unfortunately, there is no way of reversing arthritic changes. When the arthritis has progressed or non-operative interventions have failed, the best surgical solution would be joint replacement surgery. This may involve replacement of a single compartment or a total knee replacement, depending on the level of arthritis present.

Currently, Theepan utilises robotic-assisted surgery to help plan and execute his knee replacements. The risks of knee replacement surgery include infections, stiffness, damage to neurovascular structures, and some ongoing pain post-knee replacement, although this is usually much better than pre-operatively. Before undertaking total knee replacement, Theepan will discuss the particular risks with you.

Knee revision surgery may be required for various situations. The most common reasons for knee revision surgery include infection, loosening, and periprosthetic fracture. Infection following knee replacement may occur in the acute period (within six weeks), or it may happen in a delayed timeframe. It is crucial to detect a knee prosthetic joint infection. If there is any concern about this, please contact Theepan's office or attend your nearest Emergency Department. Joint infections can occur when common skin organisms enter the joint directly through the wound or spread from other sources through the bloodstream.

Loosening of a knee replacement occurs when the prosthesis no longer maintains a good fit within the femur or tibia bones following its implantation. Periprosthetic fractures are breaks in the bone that occur adjacent to a knee replacement and may cause the knee replacement to become unstable.

Treatment

The treatment for an infected prosthesis in the acute setting may involve multiple washouts of the prosthesis and a change of the liner whilst retaining the metal implants originally inserted. This would be followed by a course of intravenous antibiotics, which would be coordinated with an infectious disease physician. In a more chronic setting, a knee replacement may need to be removed if the infection cannot be controlled. This may or may not involve a two-stage revision where the implant is removed, an antibiotic spacer is placed in, and treatment with intravenous antibiotics is commenced. Roughly six to eight weeks following this procedure, once the infection is controlled, a revision knee replacement is undertaken with a new prosthesis.

Where a prosthesis has become loose, it may need to be removed and replaced with a special prosthesis with a stem and/or augments, to help gain stability higher up in the bone. There are significant risks associated with knee revision surgery, including infection, damage to the nerves and vessels surrounding the knee joint, stiffness, ongoing pain, and the potential for further surgery if there is failure.

Each knee has two menisci, the medial (inside) and the lateral (outside) meniscus. Tears usually result from a twisting motion to the knee. The symptoms of meniscal injuries usually include pain, as well as mechanical symptoms of clicking, locking, and sometimes the feeling of instability within the knee. The meniscus provides a shock absorber for the knee between the femur and tibia bones. Blood supply for the meniscus can be tenuous in parts and, as such, the healing of meniscus injuries is often guarded. Meniscus injuries can occur in conjunction with other injuries such as ACL tears or ACL ruptures.

Treatment

Treatment for meniscus injuries depends on several factors including the acuity of the injury, the patient's age, and the presence of any arthritic changes. In the presence of severe arthritic joint changes within the compartment of the meniscus injury, current evidence would suggest that non-operative interventions would be beneficial in the first instance. This includes, but is not limited to, physiotherapy, as well as potentially the use of corticosteroid injections to help manage the pain.

Where the injury is more acute or with certain types of meniscal injuries, consideration can be given to meniscal repair versus meniscal debridement. Meniscal repair is usually reserved only for those tears in which there is a higher chance of healing possible, often in younger patients. The recovery from meniscal repair usually takes three to four months, and there is at least a six week period of using crutches. Deep bending is also avoided for a six week period.

Patients who have an irreparable tear, usually a debridement, a procedure may be performed whereby a portion of the meniscus causing issues is 'trimmed out'. This procedure is done by keyhole incisions and usually the recovery is much quicker, with most people walking comfortably without any gait aids at three to four weeks after the surgery.

The risks of meniscal surgery include deep vein thrombosis, infection, failure of repair, and potential post-traumatic arthritis later on in life.

Tibial plateau fractures are fractures of the tibia bone at the level of the knee joint. These fractures involve the joint surface and as such have an increased risk of causing arthritis in the future. Tibial plateau fractures can occur in both young and elderly patients. In younger patients, tibial plateau fractures typically result from a high velocity mechanism. They can be associated with meniscal injuries as well as ligamentous injuries. Later in life, tibial plateau fractures may result from low velocity injuries and may be a sign of osteoporosis. Tibial plateau fractures can also be associated with increased pressure within the leg causing compartment syndrome, which is an orthopaedic emergency. Investigations for tibial plateau fractures may include plain x-rays, CT scans and, occasionally, MRI scans. 

Treatment

The treatment of tibial plateau fractures depends on various factors, including the patient's age and health, as well as the level of displacement of the fracture and any associated injuries. Non-operative treatment of tibial plateau fractures includes immobilisation with a splint for roughly six weeks, followed by physiotherapy. Surgical treatment for tibial plateau fractures often includes the use of plates and screws to help restore the joint alignment. This may be combined with the use of bone grafting to help the fracture heal. Associated injuries with the tibial plateau fracture can be addressed at the same time of the fixation or may be addressed in a delayed fashion.

Complications of tibial plateau surgery include infections, deep vein thrombosis, damage to the neurovascular structures around the knee, as well as non-union and development of arthritis.