For many athletes, surgery means arthroscopy. Arthroscopy involves insertion of a small telescope into the knee. Surgical procedures are performed using specialized instruments, usually without a major incision. Meniscus (cartilage) tears and anterior cruciate ligament (ACL) injuries are amongst the most common sports injuries to knees. Both of these problems can be treated with using the arthroscope. The procedures are done on an outpatient basis.
Dr. Branson and Dr. Morgan perform arthroscopic knee surgery in our practice. They have experience working with every level of athlete from casual to collegiate and professional level. The athletes at Graham High School know Dr. Morgan as a fixture on the sideline for many years. Dr. Branson has been team physician for Concord College from 1989 thru 2016, and takes care of Princeton Rays. Our doctors support our local sports programs and schools. Our practice helped renovate the training facilities at Pikeview High School, and supported the Graham athletic facility and the Health and Fitness Center. OCV sports physicals are a 30 year tradition. Over 9000 free comprehensive physicals have been provided by OCV doctors in conjunction with other area physicians and OCV physical therapy. Area pediatricians, general surgeons, urologists, family doctors, OCV physical therapy and office staff donate time to be sure athletes in our area are physically prepared for participation.
Knee injuries and pain:
Knee injuries and knee pain are common in sports. Injuries may result from twisting, pivoting or falling.
When should you see the doctor?
Many patients go to the emergency room immediately following knee injuries. The ER is the best place if you think you may have a displaced fracture , dislocation or infection of the knee. Symptoms of severe injuries include obvious deformity, instability or complete inability to bear even minimal weight.
For most other injuries, including meniscus tears, collateral ligament tears, ACL tears and minor fractures, initial treatment consists of protected weight bearing and management of swelling. In fact most knee injuries can be safely evaluated in the office within the first week or two following the injury.
If you do go to the emergency room, please be sure to get a disc with your Xrays, and copies of any lab work, as the doctor will need to review the actual images and results to evaluate your knee. The hospitals do not send the images to the doctors.
Preparing for your appointment:
Often our physicians have a good idea of what is wrong with your knee just by listening to your history. At your appointment you will be asked about:
- Mechanism and date of injury: How and when did the injury occur
- Swelling: Where is swelling, and did it come on within the first hour of the injury, or gradually / following activity
- Tenderness: Can you put 1 finger on the place where the knee is most painful?
- Stability: Does the knee feel stable, or does it give way, or feel like it is bending the wrong way?
- Stiffness/ locking: Is the movement of the knee restricted
- Specific restrictions: Are there specific activities that increase pain or sypmtoms? Squatting, going up or down stairs, pivoting
- Pain at night: Are symptoms worse at night?
- STUDIES: If you have had xrays, MRI, CT, Bone scan or lab tests please bring copies of the reports and discs of the images, as the doctor will need to review these. If you have had prior surgeries on the knee, bring reports if available as well.
What to expect at your appointment:
- History: your doctor will discuss the details of your injury and prior treatlment.
- Exam: The doctor will manipulate the knee to evaluate for fluid, stability and location of pain
- Xrays: Xrays will be obtained at the office. If you have outside xrays, bring them so the doctor can review them with you. Xrays show bone structure and may detect arthritis, problems with alignment or fracture.
- MRI: Knee MRI shows structures that are invisible to xray including meniscus cartilage, articular cartilage and ligaments. Most insurances have strict regulations on obtaining MRI, typically including at least 3 weeks of conservative care, physical therapy or other non surgical treatment. If you already have an MRI, please bring the report and a copy of the disc with you to your appointment so the doctor can review them.
Structures commonly injured in knees and symptoms:
- Meniscus: Cartilage cushions between the bones. Cause locking, catching and pain where the tibia and femur meet. Twisting or bending of the knee under load can catch the meniscus between the bones causing a tear. Since a portion of the meniscus may catch between the bones, meniscus injuries can cause intermittent locking, giving way and swelling in the knee.
Menisectomy: Damaged portions of the meniscus cartilage is removed. Intact portions of the C shaped menisci are retained.
Meniscus Repair: The damaged portions of the meniscus are sewn back together and retained in the knee.
The meniscus cartilages are a crucial part of the lubricating and stabilizing function of the knee. Arthritis is far more likely after meniscus injuries. That is why we prefer to repair meniscus injuries when possible. The decision to repair or remove the meniscus depends on patient age, tear shape and location and the condition of the meniscus fragments. Repair is suitable for younger patients with tears near the outer edge of the meniscus, with fragments that can be reduced to nearly normal position.
Healing of meniscus repair takes 3-6 months. Frequently, the first 3-4 weeks may be on crutches. Return to sport is typically 9 months post repair. Roughly 20% of repairs will re-tear. Despite these significant downsides, if your meniscus can be repaired, it should be.
Most sport related knee surgery is done with the arthroscope. Surgery is done through 2 small incisions below the kneecap. The arthroscope can be directed between the femur bone and tibia bone of the knee joint. Using specialized instruments, a variety of procedures including meniscus repair, meniscus excision and reconstruction of the ACL can be performed.
Most ruptures are treated with surgical repair. Surgical repair restores better strength by restoring the normal length of the muscle / tendon unit. Non-surgical treatment is indicated for patients who do limited walking and in patients where skin or medical conditions would prohibit surgery.
Patients are in a compression dressing or cast for the first few weeks after surgery. Time to mobilization depends on the severity of the injury and individual patient factors. We typically try to get patients walking within 3 weeks of surgery. Gradual increase in range of motio and stretching typically astarts 3-6 weeks after surgery. Strengthening begins at 8-10 weeks after surgery for most paitents. Return to sport is typically allowed at 9 months after surgery.
ACL TEAR – One of 2 major stabilizing ligaments in the knee. Cause immediate swelling of the knee,feeling of instability or giving way, particularly with pivoting or stopping. MRI can be helpful in confirming the physical examination findings.
Anterior Cruciate ligament injuries are common in sports. They often occur in a non-contact twisting injury, or when athletes try to salvage a fall. They are more common in female athletes compared to male athletes. In most cases, patients may feel or hear a pop, and the knee swells within minutes due to bleeding in the knee.
Non-surgical treatment: Exercise and bracing and modification of activity are the mainstays of non-surgical management of ACL tears. Patients that do not engage in activities that require frequent aggressive change in direction or stopping can do just fine without surgery.
Surgery: ACL reconstruction: For athletes and patients that require more stability in the knee, ACL reconstruction may restore some of the stability and function resulting from ACL injury. Patients with associated injuries to the medial or lateral collateral ligament and meniscus are also more likely to require ACL reconstruction.
ACL reconstruction: Is an outpatient procedure. The ACL is replaced with a graft. At OCV we usually use patellar ligament. Patellar ligament grafts are strong, and achieve rapid fixation to the bone. In autograft, the central 1/3 of the patient’s tendon is used as the graft. Bank or allograft is tissue from the tissue bank. With bank tissue, the procedure can be done through an incision typically less than 1 inch. Following surgery, patients bear 35% weight the first week, 50% the second, 75% the third week, and full weight the fourth week. Return to sport following reconstruction has been subject of debate. The traditional view is return to participation should be delayed for 9 months following surgery to allow the graft to heal. Recently, physicians have been more aggressive in returning patients to participation as soon as they achieve the level of function required for participation.
Can I return to sports? Rule of thirds: Expectation of return to sport data suggests that 1/3 of patients can return to sports with limited or no restriction; 1/3 return to sport at a lower level of function, or with modification. 1/3 of patients have enough symptoms persisting that they significantly restrict participation, or quit altogether.
Collateral ligaments – medial, lateral:
Cause local tenderness over the inner and outer aspect of the knee, feeling of instability. Collateral ligament injuries frequently occur when the knee bends the wrong direction, or may be the result of a blow to the opposite side of the knee.
The medial collateral ligament (MCL) Is on the inner aspect of the knee. The lateral collateral ligament is on the outer aspect of the knee.
Collateral ligament injuries are graded 1 to 3 or 4.
- Grade 1 represents disruption of a few fibers of the ligament. The stability is normal or nearly normal. Grade 1 sprains will typically start to feel better in 2 weeks. Full healing for any ligament injury, including grade 1 sprains takes 3 to 4 months. In grade 1 injuries, most athletes can return to sport as soon as pain subsides and sport specific function returns.
- Grade 2 tears have significantly more torn fibers than grade 1. On exam, there will be an detectable increase in the laxity or looseness of the ligament on exam, but with an endpoint. Most grade 2 lesions may also be treated without surgery.
- Grade 3 injuries, most if not all of the ligament fibers are torn, and there is significant increase in laxity or abnormal movement of the knee. Grade 3 injuries are more frequently associated with ACL or meniscus injuries. For grade 3 sprains not associated with other ligament tears, many patients still respond well to non surgical treatment. For tears associated with ACL or meniscus tear, surgery is more common. In many cases, surgery may be delayed to allow the acute inflammation from the injury to subside, and to regain some range of motion. In combined injuries, frequently the ACL will be reconstructed, and the meniscus tear treated with excision or repair. The MCL may or may not be repaired. The combination of ACL with lateral collateral ligament injury may result in a significant instability known as a “posterior corner injury.” Such injuries may need reconstruction of both the LCL an the posterior corner of the knee combined with ACL reconstruction and treatment of meniscus tear to restore function.
Dislocations frequently feel like the “knee dislocated;” The patella slides toward the outside of the knee. Frequently the patella will snap back into place when the knee is straightened. Usually accompanied by swelling and weakness of the quadriceps muscle. The dislocation may also fracture off a piece of joint cartilage from the patella or the femur resulting in a loose fragment in the joint.
Treatment of patellar dislocation depends on several factors. For patients with normal knee alignment, immobilization with the knee in extension for 3 weeks followed by aggressive rehab may result in satisfactory healing. For others, arthroscopic lateral release may be required. IN arthroscopic lateral release, the tissue on the outer aspect of the patella is divided under direct vision from inside the knee. The purpose of the procedure is lessen the forces pulling the patella to the outside. For other patients, lateral release may be combined with MPFL reconstruction. The Medial patellofemoral ligament is a thickening of the tissue on the inner aspect of the patella that is one of the constraints keeping the patella in line. With lateral dislocation, some if not all of the MPFL is disrupted. MPFL reconstruction often uses graft or suture technique to restore stability to the MPFL. For patients with abnormal alignment of the knee, realignment procedure may be required to prevent recurrent dislocation.
- Patellofemoral: overuse/ pain / Chondromalacia
- Patellofemoral pain: Usually follows increased activity, jumping or suicides. More common in females. Patellofemoral overuse or overload causes pain in the front of the knee, swelling with activity and problems going down stairs. In children, a variant of this problem may cause pain and swelling over the bump on the tibia bone below the patella, or pain on the lowest portion of the patella itself. These overuse syndromes may be more common in overweight patients. Treatment of the overuse is targeted at modification of training, use of NSAID anti-inflammatory medications and exercise.
Baker’s cyst or popliteal cyst is a sack of fluid that forms in the back of the knee. Baker’s cyst is usually caused by arthritis or a torn meniscus. If the cyst is large, it may cause swelling in the lower leg. Baker’s cysts are rarely symptomatic on their own. Symptoms are more commonly related to the underlying arthritis or meniscus tear. In the past, these cysts would be surgically removed. Today, baker cysts are most often left alone. If the swelling or tightness causes problems, the cyst may be drained. Surgery is most often aimed at fixing the underlying meniscus or arthritis problem. In a small number of cases, the cyst may be excised.
Total Knee Replacement:
More than 4.5 million Americans are living with at least one total knee replacement. Nearly 5% of people above the age of 50 has a total knee replacement. Over 600,000 Knee replacements are performed in the US every year.
Knee arthritis can rob vitality and ability to enjoy life. Knee replacement surgery can decrease pain, correct deformity and restore function. The physicians at OCV and the Orthopaedic Center at Princeton Hospital specialize in knee and hip replacement surgery. We perform hundreds of knee and hip replacements each year.
Arthroscopy for knee arthritis:
Arthroscopy has a limited role in treatment of arthritis. For localized artritis, cartilage transfer can be performed. Cartilage transfer moves plugs of cartilage from less used areas of the knee to fill small, contained defects. Once xray shows 50%narrowing of the joint space, only a small percentage of patients will benefit from arthroscopic treatment.
In many arthritic knees, torn meniscus cartilage may be shown on the MRI. When there is extensive arthritis, most patients will not experience relief of symptoms following arthroscopic treatment of the meniscus cartilage tear. Debridement of damage to the normally smooth surface of the joint (articular cartilage) rarely improves symptoms. Overall, arthroscopy has limited application in the arthritic knee.
Do I need a knee replacement?
Knee replacement surgery may be considered for those suffering from arthritic knee pain that severely limits the activities of daily living. His only recommended after careful examination and diagnosis of the particular joint problem and only after more conservative measures including exercise, injections, physical therapy, and medications have proven ineffective.
Partial vs. Total knee replacement:
For most patients, total knee replacement is the best option. For a small percentage of patients, partial knee replacement may be indicated. Patients eligible for partial knee replacement include those with arthritis limited to only one portion of the knee, have reasonable ligamentous stability, and minimal deformity. Your OCV physicians help to determine whether or not you are candidate for the partial procedure.
What kind of knee implant is best?
There are many times and designed the implants available today, and no single design or type is best for every patient. Your OCV physician will discuss options for custom-made, computer design implants versus standard implants. If you have specific questions regarding implants, your OCV Dr. will be happy to answer them.
How long will I be in the hospital?
Our goal is for you to recover in the comfort and privacy of your own home as soon as possible With improvement in surgical techniques and postop carr, many patients are able to go home one or 2 days after their procedure. The majority of patients will be expected to go home, and perform physical therapy on an outpatient basis. If you have both knees replaced at the same time, you will likely stay in the hospital 2 or 3 days. Some patients following replacement of both knees may also go to rehabilitation facility such as Health South, or skilled nursing facility for 10 days to get back on her feet.
How long is the recovery period?
Recovery may vary from person to person. Many people use and ambulation aids such as a walker for the first 3 or 4 weeks. Most people can drive within 2 or 3 weeks of surgery. Activities such as golf and bowling may be resumed in 10-12 weeks.
How successful is the surgery?
Total knee replacement is recognized as one of the most successful procedures in all medicine. Most patients opting for knee replacement found improvements in pain, functional status and overall quality of life. Patients who have been taking narcotic containing pain medications for more than 6-8 weeks, for patients with neuropathy may experience continued pain. Your OCV physician will discuss expectations for outcome with neurosurgery with you on an individual basis.
Non Surgical treatments for arthritis:
What exactly is arthritis?
Arthritis refers to many conditions that cause joint pain. Symptoms of arthritis include pain, swelling and deformity of joints. Arthritis may affect any joints in the body, most commonly involving knees and the base of the thumb. Osteoarthritis is the common “wear and tear” type of arthritis typically associated with advancing age. Osteoarthritis may be called secondary when the arthritis is the result of prior injury. Rheumatoid arthritis is an autoimmune disease, meaning that the body attacks itself. Rheumatoid arthritis may cause inflamed, swollen and painful joints. RA can cause significant hand deformities, and may also affect lungs, kidneys and other internal organs.
Treatment of Osteoarthritis:
- Medications: Over the counter medications include acetaminophen (Tylenol), aspirin, ibuprofen products (motrin) and naproxen (Aleve). Acetaminophen works to relieve pain. Aspirin, ibuprofen and naproxen are non-steroidal anti- inflammatory agents (NSAIDs). They work to block inflammation and decrease pain. Both acetaminophen and NSAIDS yield similar results in terms of pain relief. There are numerous prescription NSAIDS as well. All of the NSAID medications can cause bleeding ulcers and kidney problems. With long term use, they can also increase the risk of cardiac events. Celebrex is a NSAID that may have lower risk for ulcer for some patients. NSAID drugs should not be “stacked.” If you are taking the recommended dose of one NSAID, taking another NSAID will increase your risk of complication.
- Supplements: Glucosamine and Chondroitin: Glucosamine and chondroitin are often combined in a variety of joint supplements. The mechanism of action is unknown. Based on recent studies, the American Academy of Orthopaedic Surgeons suggests these supplements are ineffective. Some European studies suggest some benefit. Despite the negative studies, many patients feel these supplements may work as well as NSAIDS for managing arthritis pain in the early stages.
- Cortisone Shots: Cortisone shots may be used to decrease pain due to arthritis, bursitis, tendinitis and gout. The medication may be injected directly into the joint or affected bursa or tendon. Many patients experience significant improvement in pain and swelling. The results of the injections are temporary. Cortisone improves the symptoms, but does not reverse joint damage caused by arthritis. Cortisone injections may be safely repeated every 3-4 months, with a maximum of 3 to 4 injections in a given joint over the course of a year. Common side effects of cortisone include hot flashes and sleeplessness. Diabetics may experience a temporary elevation of blood sugar following cortisone injection. For a small percentage of diabetics, blood sugar elevation can be severe.
- Viscosupplementation: Commonly called rooster comb injections due to the origin of the material for some injections. Hyaluronic acid and hylan formulations that are manufactured for viscosupplementation are sold under the brand names Hyalgan®, Synvisc®, Gel-One®, Supartz®, Orthovisc® MONOVISC and Euflexxa®.. While these medications are frequently termed “lubricants”, they are thought to work by improving the local chemical environment of the joint. For some patients, viscosupplement injections may last longer than cortisone. Individuals differ in their response to the injections. Some of the medications may result in transient joint pain after injection, and onset of relief may take up to 3 weeks. These medications tend to be expensive, and may require pre certification from your insurance.
- PRP: Platelet rich plasma: Platelet rich plasma is created by processing a sample of your blood to concentrate platelets. These injections are marketed as “regenerative” implying that they stimulate or speed healing and rebuild damaged tissues. . Both come with a hefty price tag. While OCV can offer PRP treatments, we caution that this technology is evolving. Overall, the results do not currently match the hype or price tag for these treatments. Current data is unclear as to the benefit. There is a wide variety of preparations makes it difficult to objectively compare results. Risk of the injection includes pain at the injection site and infection. Most regenerative preparations, including PRP and stem cells are typically not covered by insurance.
- Stem Cell injections: Stem cells can change or differentiate to create healing tissues. In joints, the hope is that the stem cells would regenerate or replace damaged cartilage. Stem cell injections are being performed for shoulder, knee and back problems. Stem cells may be derived from a blood sample, your bone marrow or harvested from umbilical cord blood. Stem cells, like PRP were popularized by elite athletes on the pages of sports magazines and the web. Stem cell treatment is not considered standard care. There is limited data available on the safety and effectiveness of this treatment. Studies to determine safety and effectiveness of stem cell treatments are ongoing. Like PRP, stem cell therapy costly, and not covered by insurance.