Knee surgery

Knee pain associated with mechanical symptoms of a feeling of instability, clicking or locking can be due to a meniscus (cartilage) tear in the knee. Persistent or intermittent swelling of the knee is also not normal and may be due to meniscus tear. This can occur at any age and is not always related to an injury. Persistent symptoms for more than two weeks should be assessed by a professional for an opinion.

Anterior cruciate ligament (ACL) injuries are common in sport that is caused by running and changing direction at speed or side impact of the knee. The ACL is a ligament in the middle of the knee and stabilizes the tibia on the femur. Acute injuries of the ACL are painful and can cause immediate swelling of the knee and a feeling of instability of the knee. There is often associated meniscus or joint cartilage damage that may need attention. This is best assessed with an MRI scan.

In most active patients the ruptured ACL will require reconstruction as repair of the ACL is not successful. Reconstruction of the ACL is done with tendons harvested from the knee and fixation in the correct position to restore stability of the knee with good motion. The tendons that are most commonly used are hamstring tendons, patella tendon and quadriceps tendon. The harvested tendon will recover well after surgery with rehabilitation and time and does not cause long term disability.

Osteoarthritis is the loss of articular cartilage and degeneration of the ligaments and menisci in the knee with synovial inflammation.

The knee has two types of cartilage, articular cartilage that covers the bone and is part of the surface of the joint to walk on and meniscus cartilage, a cushion like structure in the knee that assist with stability, weight bearing and shock absorption in the knee. Both structures can be damaged during an injury and both are subject to deterioration due to ageing in the joint.

Cartilage degeneration due to age can be compared to perishing rubber. Young cartilage is elastic and can withstand stretch and impact. Older cartilage dehydrates and becomes brittle and compacted much like perished rubber. Minimal force is required for the cartilage to tear or delaminate. This can lead to mechanical symptoms without an event or injury to account for it. Meniscus damage will be diagnosed as a degenerate meniscus tear and articular damage will be called articular chondromalacia with or without articular cartilage flaps. Patients will report onset of pain without a specific injury. The pain can be associated with swelling of the knee and a progressive increase in pain.

Cartilage cannot be assessed on an X-ray. MRI scan is the best way to assess cartilage damage in a joint. Articular damage due to ageing on MRI scan can usually not be improved by arthroscopy but meniscus damage will benefit from arthroscopic surgery.

Knee pain due to injury that does not settle can be due to ligament, meniscus and articular cartilage injury. Knee pain can also be caused by Osteoarthritis which you can learn more about below.

Your knee may have to be examined to determine the exact structure injured in order to continue appropriate investigations and suggest the best treatment.

Osteoarthritis is the loss of articular cartilage and degeneration of the ligaments and menisci in the knee with synovial inflammation.

This complex of degenerative change and inflammation causes pain and stiffness of the knee that will initially respond to conservative management and after failed conservative treatment a knee replacement is indicated.

Conservative treatment is the first line of treatment and all conservative management options should be exhausted before considering replacement surgery.

Conservative management of knee arthritis includes reduction of high impact activity, analgesics, anti-inflammatory medication and physiotherapy.

Regular low impact activity like cycling will often lead to less analgesics required and longer lasting arthritic joints before replacement is required.

In more advance arthritis intra articular injections with cortisone may reduce the symptoms and if all conservative management options have been exhausted then a Uni-compartment replacement or Total Knee replacement may be the only options available to improve the pain and stiffness.

Total knee replacement surgery is highly successful and can last for 15 to 20 years. Knee replacement surgery is indicated in advanced arthritis of the knee and has been proven to be successful and cost effective procedures to improve the quality of life of patients.

There are several different TKR and Uni-compartment components available and it is best for the surgeon to select the most suitable implant with good long term results. The many new innovations and techniques advertised may not be as durable as claimed and several recently launched products have been discontinued due to poor results.

Total knee replacement is indicated for knees with advanced arthritis and severe pain. The total knee replacement may not be entirely pain free and is thus not indicated in patients with minimal pain and high demand for sport.

The surgical technique of replacement and pre-operative planning with or without scans is dependent on surgeon experience and surgical philosophy.

Deon believes that the natural ligament tension and leg alignment should be restored to offer the most comfortable lasting total knee replacement. This is done with meticulous care to the soft tissues during surgery and balancing of the knee. This technique does not require MRI or CT scans.

There are no true custom made knee replacement implants available, just custom made cutting blocks. Computer designed cutting blocks do not account for soft tissue contractures and may limit intra-operative adjustment to achieve a comfortable replacement.

The most common need to have a total knee replacement is Osteoarthritis.

Other conditions that may cause arthritis and need replacement surgery are Rheumatoid arthritis, post-traumatic arthritis, gout and avascular necrosis.

Deon believes that a conservative approach should be taken for as long as possible.

Arthroscopic knee surgery is keyhole surgery of the knee, which can be done as day case surgery. This is used to treat various knee conditions including Meniscus tear, anterior ligament reconstruction, articular damage and micro fracture, and Chondromalacia and cartilage repair.

• Know that you want to have surgery and that the procedure has been explained to you to your satisfaction and you know what you want to about surgery.
• Have blood tests and bacteriology swabs to ensure that you are fit for surgery. Some patients may have to see a physician for a full medical check. If you feel you still have doubt about your fitness for surgery, then request a Physician appointment. The aneathetist will see you before the surgery for a final check and ensure that you are fit enough for surgery before proceeding.
• Confirm the date of surgery and authorization for the procedure by your medical aid.
• Make sure that you are as fit as you can be, you have taken your regular medication as prescribed and you have no open or septic wounds on your skin as this may lead to you being cancelled on the day. We do not want to take any risks with infection.
• The night before and the morning of surgery you need to shower with Hibiscrub soap (pink liquid). Apply top to toe and leave for 2 minutes before rising. Dry with a clean towel and do not apply any cream or lotion the morning of surgery.
• Nothing to eat or drink from midnight the night before surgery, not even water.

• Bring your regular medication along in original boxes and with a list of your medication
• Toiletries and masks
• Crutches if you have, not a walking frame as we have one
• Comfortable night clothes or clothes to walk around in
• Headphones, chargers and other gadgets you use
• You will have your own lockable cupboard to store small items
• Snacks and drinks if you like something special
• Don’t bring lots of money or jewelery

• Someone to assist you
• Easy access to your bed
• Bathroom access and rails if required to make it safe to go to the loo and get in and out of the shower
• No loose rugs on the floor and open space to move around coffee table to get to your chair in the lounge

Admission day, what to do:

• Go to front desk and get admitted
• You will be escorted to the ward and made comfortable by the nursing staff
• Final few things are done to prepare you for theatre:

  • Blood test and ECG if not already done
  • Meet the aneathetist and get a premed
  • Relax before surgery

  • You will be transferred to a waiting area before going into theatre for surgery
  • You will be out of the ward for approximately two hours

What happens after surgery?

• You can access your phone and contact your family
• You will be offered food and drinks
• Nursing staff will monitor your general condition and pain management will be in place.

• Your legs will be numb and can’t move for a few hours after surgery

• The physio will see you for mobilization once your legs have recovered

• You need to try and empty your bladder as soon as you regain bladder control

3D printing can assist in various ways in hip and knee replacement surgery in both primary and revision surgery. Complicated anatomy can be scanned in a CT scanner and the scanned files converted to printable files. This will enable the surgeon to get a to-scale printed model of the joint. Planning can now be done before surgery to decide on the size of the implant and placement of screws and augments to secure the implant. This will shorten the surgical time and prevent situations where the correct implants and screws are not available in theatre.

Most of the implant companies can now offer custom printed implants to compensate for lost bone in revision operations. These implants are usually printed in titanium alloy, which is compatible with bone and can be fixed directly to bone for immediate stability, allowing the patient to walk soon after surgery.

Total knee replacement is a safe procedure. Complications are rare and reported to be approximately one percent. The risk of complications can be minimized by meticulous peri-operative assessment and identification of potential complications. Despite the best intensions and protocols some complications can occur. I have developed protocols to be followed to limit complications.

Possible complications include but are not limited to: