Knee Surgery
PART ONE
JOURNEY INTO SURGERY
1
THE ROAD TO KNEE SURGE
The Anatomy and Pathology You Need to Know Before Starting Your Journey
WHETHER WE ARE making our way across an icy parking lot, stepping into a canoe, or just getting out of bed, all of us perform athletic maneuvers daily. When a knee injury becomes part of the equation, the way you get better is no different from the way Tiger Woods recovers. The activity level you return to might be different, but the road traveled is the same.
The knee is a strong, hardworking joint. It helps us walk, get in and out of cars, do yoga, play football, ride horses, etc. Every day we depend on our knees for literally thousands of movements--some that we perform intentionally and others we don't even think about. In spite of their strength, knees tend to get hurt. Whether from arthritis, athletics, oroveruse, almost everyone will have knee pain at some point in his or her life. To complicate matters, the knee has a number of structures that simply do not heal after they are injured. This translates into lots of knees ending up on the operating table. If a knee operation is in your future, you are definitely not alone.
Whether your surgery is for an injury to the cartilage, ligament, tendon, or bone, the goal after the operation (post-op) is to get the knee joint moving fully and for your muscles to regain their functional qualities: balance, flexibility, coordination, strength, speed, and quickness. This is called rehabilitation, or rehab for short. An important part of rehab is having the right mental attitude. As you read the chapters that follow, you will learn concrete, practical steps for your physical and mental rehab that apply to the vast majority of knee injuries and surgeries. The care and feeding of all knees are alike, only the time lines for recovery vary.
Having knee surgery is a big deal and it's okay to be frustrated, angry, even scared. It is okay for now--not forever. Having any kind of physical problem can leave even the toughest person feeling vulnerable and mortal. The good news is that in the twenty-first century, medical technology can make almost any knee useful for most jobs and many sports. But let's not sugarcoat this: Recovery from knee surgery takes work. It's not like brain surgery where you either get better or you don't. Knee rehab involves a physical and mental process which, when performed properly and diligently, helps ensure a good, functional outcome. Another great thing about recovery from knee surgery is you get back more than what you put into it. Each stretch, each exercise, each movement pattern not only improves your knee but also works your back, your hips, your balance, and more. Getting into the habit of caring for your knee translates into caring for total fitness. Thus, with the right attitude, a good doctor, and this book, you will soon be speeding toward a healthier you!
ANATOMY AND PATHOLOGY OF THE KNEE
Before I get started talking about surgery, it will be helpful to develop a working knowledge of the knee's parts and functions. This will help you communicate with your doctor and therapist. As a bonus, this section will also prepare you for future episodes of Jeopardy!
Anatomy
Orthopedic surgeons, physical therapists, athletic trainers, and other sports medicine professionals spend their lives caring for the musculoskeletal system. This system consists of muscles, which provide movement, and bones, which form your body's internal frame. Muscles consist of multiple fibers that get larger and more efficient with exercise. There are more than four hundred muscles in the body, connecting more than two hundred bones. The muscles attach themselves to the bones via tendons.
Ligaments are tough fibrous tissues that connect bones to other bones. Ligaments can be thought of as similar to ropes because they have no ability to change their length. Due to this ropelike quality, we refer to ligaments as "static stabilizers." Conversely, muscles and tendons shorten and lengthen with motion and thus are called "dynamic stabilizers." Luckily, many ligament tears heal naturally on their own with time and activity modification. The medial collateral ligament of the knee is one such ligament (discussed later in this chapter).
Despite reasonable care, certain ligaments do not repair themselves. These include the anterior cruciate ligament (ACL) (connecting the femur to the tibia) and the capsular ligaments in the shoulder (dislocated shoulder). A rehabilitation program for an ACL tear or a dislocated shoulder will attempt to strengthen the muscles and tendons around the joint, but unless these ligaments are repaired surgically, the joint will always be vulnerable.
A joint is where two bones come together. At joints that have significant motion, the bone ends are covered with a smooth layer called articular or surface cartilage. In some joints, including the knee, there is a second type of cartilage called meniscal cartilage. Menisci are pieces of gristle that give extra stability and cushioning to the joint. In the case of the knee, the wrong type of motion can tear this piece of gristle. This typically results in the most common type of cartilage injury--a meniscus tear--but the same event can also injure the surface cartilage. Both types of cartilage have a poor nerve and blood supply and therefore little ability to heal once injured.
In a healthy knee, all of the structures--bone, surface cartilage, meniscal cartilage, muscles, tendons, ligaments, bursa, and skin--work together in a beautiful symphony of motion. Unfortunately, when any part of the orchestra isdamaged, it can affect the function of the entire joint. Damage to a ligament causes instability and undue pressure on the cartilage. A tear of the meniscus can cause inflammation and a sense of locking with some movements. A pulled muscle limits motion and thus can cause scarring of other structures. The list of possible maladies can be long, but the treatment of most is the same: Repair the injured structure and proceed to regain full range of motion, strength, coordination, balance, etc.
Pathology
CARTILAGE INJURIES
As discussed earlier, when you hear about someone tearing cartilage, most often that refers to the meniscal cartilage, pieces of gristle between the femur and tibia that act as gaskets or spacers (see knee anatomy illustration). Their job is stability, cushioning, and protecting the surface (articular) cartilage. Not all meniscal cartilage tears require surgery, but if they cause swelling, catching, and pain, the best chance for a cure is arthroscopy. The surgeon removes the torn bits, or--in a less common situation--throws in some stitches. (A more complete description of arthroscopic surgery comes later in this chapter.)
Damage to the surface (articular) cartilage is called arthritis. The suffix -itis means "inflammation," as in tendinitis (inflammation of a tendon), arthritis (inflammation of a joint), or bursitis (a bursa is a lubricated sac that allows parts of the body to slide smoothly past one another). When a structure is inflamed, it usually has some combination of pain, swelling, redness, stiffness, and heat. After injury or surgery there is always some inflammation, which I discuss further in Chapter 2.
Arthritis can follow a trauma or can happen simply as a result of age and genetics. Almost everyone over forty has some minor damage to this surface cartilage. Thus, after an unusual stress such as a tough hike or a big spring cleaning, you might get some pain or swelling. Luckily, this usually calms down with rest, ice, and other tricks discussed in Chapter 2. If the knee does not cooperate, the unstable pieces are removed with arthroscopic surgery. The addition of "soft workouts" such as cycling and water exercise to your routine will help keep joints healthy and avoid further damage. Water therapy creates a "natural traction" that pulls apart damaged areas and allows pain-free motion and exercise (see Chapter 9).
In some cases of surface cartilage damage, the surgeon might try to repair it by one of three methods: transferring cartilage from a healthy part of the knee (mosaicplasty), stimulation of new cartilage growth by drilling into the bone marrow (microfracture or multiple drilling), or, finally, actually growing new cartilage in the lab for future transplantation to the knee. These patients often require months on crutches and thus will not begin many of the exercises, movement patterns, and aerobic training immediately after surgery. However, pre-op prep, anti-inflammatory measures, range-of-motion stretches, and crutch walking tips do apply to these surgeries. After the initial recovery from these surface cartilage procedures (usually two to three months), your surgeon will clear you to follow my entire program for total recovery.
ACL AND OTHER LIGAMENT INJURIES
The anterior cruciate ligament prevents your femur and tibia bones from sliding past each other--what people used to call a "trick knee" but now call a "blown-out" knee. On any given week during the football or ski season, you will no doubt hear news of athletes who tear their ACL. Because most people who tear their ACL experience this sliding sensation, surgery to reconstruct it is recommended.
The anatomy of the ACL does not allow it to be simply sewn together after it tears (it would be like trying to attach two mop ends). Orthopedic surgeons thus need to reconstruct the ACL, often with tendons borrowed from another part of your own body. This is called an antograft. This may sound like a bad idea, but it actually works quite well. The surgeon can use either a strip of your patella tendon (from the injured knee or from the opposite knee) or two small hamstring tendons. A third choice is to use tendons from a dead person, which is called a cadaver graft or allograft. Your surgeon will describe the risks and benefits of each of these options, and together you will decide which graft choice is better for you.
Two ligament injuries that do not usually need surgery are tears in the medial collateral ligament (MCL) or posterior cruciate ligament (PCL). The MCL, the most commonly injured ligament in the knee, heals on its own 95 percent of the time. PCL injuries are much less common than ACL or MCL injuries. Generally, if the PCL is the only ligament torn, you can recover to the point of doing most of your activities and avoid a trip to the operating room.
SEVERE ARTHRITIS
If you have severe or "end-stage" or "bone-on-bone" arthritis, your doctor might suggest a total knee replacement. The knee is not really "replaced," but the worn joint cartilage is cut away and capped with metal and plastic, much like capping a tooth.
Having an arthritic knee is not a reason to have a TKR. If your knee simply asks for ibuprofen once a week, you do not warrant a trip to the operating room (regardless of what things might look like on your X-ray!). To decide if it might be time to have this procedure on your arthritic knee, ask yourself the following questions: Is knee pain keeping me up at night? Am I dreading the next ball game or graduation because of the walking involved? Does the laundry pile up because I don't want to climb down the stairs to the basement? If the answers to these questions are yes, it might be time to consider a TKR. Perhaps another question that can help you make your decision is: How much do I complain about my knee to the people in my life? Ask them for their input. Life is too short to live with a miserable knee (or with someone who has one).
To recap: Torn meniscal cartilage, ACL injuries, and severe arthritis are the three major maladies indicating surgery and subsequently the rehabilitation program outlined in this book. There are some types of knee procedures, such as cartilage replacement and multiple ligament reconstructions, that would need modifications to this program. One of your doctor's jobs is to make sure you understand just how much the entire process will disrupt your life. Ask questions and arm yourself with as much information as possible.
SURGERY
Arthroscopic Knee Surgery
Except for TKR, almost all other knee surgery involves the arthroscope for at least some part of the procedure. Arthro refers to joints, and the scope is just a stick about the size of a pencil that contains a fiber-optic light. We attach a camera to one end, allowing the image of the inside of your knee to be projected on a TV screen. When the scope is used, salt water(saline solution) is pumped into your knee to allow the surgeon to move the camera safely and see the various knee structures.
Through another portal or "keyhole" poked in the knee, instruments are inserted that remove any damaged cartilage, put in stitches, drill holes, and so forth. Your surgeon will describe what was done at your first post-op appointment with the help of models and photographs.
The process of pumping up the knee with saline, all by itself, causes the knee to be upset. Because of this trauma, even a high-level athlete will be out for a few weeks after arthroscopic surgery, even if only minor damage was found in the knee.
Doctors describe anterior cruciate ligament surgery as being "arthroscopically aided" since after the small arthroscopic portals are established, longer incisions are also made to drill bone tunnels that will contain the new graft. This extra work makes ACL surgery more traumatic to your knee and thus lengthens the recovery period, making a proper rehab program even more important.
Total Knee Replacement
Most TKRs, on the other hand, are done through a reasonably long incision down the center of your knee, allowing the surgeon to move the kneecap and get to all the surface cartilage. This is definitely not "keyhole" surgery. This is the most aggressive of the common knee operations and is the reason why most patients spend up to a week in the hospital afterward. Some surgeons are now doing what is called a "mini-incision" TKR, but it is still major surgery and does not change the program for recovery outlined in this book.
Do I Really Need Surgery?
People often assume that if their knee is swollen and painful, they need surgery to get it fixed. This is simply notthe case. As I mentioned earlier, there are many knee injuries--including torn knee cartilage, mild arthritis, and some ligament sprains--that often calm down on their own with the appropriate nonsurgical treatments. As a result, orthopedic surgeons do not sharpen their knives the minute someone enters the office. They might order X-rays to make sure there is no bone damage. Occasionally a magnetic resonance image (MRI) is obtained so the doctor can take a look at the soft tissues (ligaments, tendons, and cartilage) that cannot be seen on an X-ray. After most knee injuries, doctors discuss ways to make the knee feel better (described in the following chapters), recommend home exercises or formal physical therapy, and schedule a follow-up exam. The doctor might also recommend an anti-inflammatory like Advil or Aleve. These medicines help decrease swelling and pain. (For a more detailed discussion of this topic, see Chapter 6.)
As long as you can fully straighten (extend) and fully bend (flex) your knee, you can let it "declare itself." In other words, if it seems to be getting better, you can hold off on any operation. There are lots of folks out there with torn or damaged cartilage who are doing just fine. Again, it is the rare person over forty who does not have some cartilage damage. MRI reports are not a reason to have knee surgery. A painful knee with a repairable problem is.
This might be a good time to mention another unhappy aspect of injuring your knee: It usually costs money. Luckily, with most insurance schemes, once you meet your deductible (and you will almost always meet your deductible with any significant problem) insurance will cover 80 percent or more of your expenses. This includes X-rays, MRIs, physical therapy, braces, and so on. Some insurances will also help with the cost of health clubs, personal training, exercise equipment, massage therapy, shoe inserts, etc., with a prescription from your doctor. Get familiar with what paperwork you need, whether from your primary care doctor ororthopedic doctor. A little research and a couple of phone calls up front could save you significant grief later.
[Just as you should not have surgery until your knee is ready, you should not have surgery until your mind is ready. No matter what part of your knee is damaged, doctors still call knee surgery "elective," that is, it can usually be done when it fits into your life. I routinely schedule surgery months in advance to correspond to the end of summer, school vacation, or even just to be ready for ski season. The important thing is to come to the operating room firing on all cylinders, physically and mentally. If you're worried about work or your kid's soccer game, you won't give your knee the attention it deserves. Schedule your surgery when you can dedicate the time and energy it needs to get better. This usually means completely clearing your calendar for at least one week for a knee arthroscopy, three weeks for an anterior cruciate ligament reconstruction, and two months for a total knee replacement.]
As I mentioned, when it comes to your body there is no such thing as "minor" surgery. Furthermore, there is no such thing as minor surgery if it involves a trip to the hospital and an anesthetic. These are significant stressors on your mind and body, and you want to--and need to--prepare for them. There are certain details of your surgery that are beyond the scope of this book, but that doesn't mean that you should not understand the planned procedure. The more you know, the easier it will be for you and the medical staff. Ask questions! Injuring your knee, having surgery, dealing with hospitals, and living with a scar (and possibly metal parts) forthe rest of your life are not things we look forward to. They are, however, better than the alternative, which is to give in to your disability and end up on the sidelines watching other people being active and having fun. I cannot stress enough how important it is that you take an active role in your surgery and rehabilitation. The road you are taking is one you must endure for your own sake, but it's not one you have to travel alone. Every page in this book is designed to help you get better faster and with less pain. Take this "portable knee doctor" along as your guide.
KNEE SURGERY: THE ESSENTIAL GUIDE TO TOTAL KNEE RECOVERY. Copyright © 2008 by Daniel Fulham O'Neill. All rights reserved. For information, address St. Martin's Press, 175 Fifth Avenue, New York, N.Y. 10010.
