Knee 2

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.

Anesthesia

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.

Positioning

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.

Procedure

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.

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.

Medications

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

Swelling

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.

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.

Microfracture

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

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.