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Q. A month ago, I had a total
knee replacement. I’m working very hard with my
exercises, but the thigh muscle just doesn’t seem to
contract when I try to straighten or lift my leg.
Why is this?
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Q. After having a total knee
replacement on both knees I notice that I stand up
straighter and walk better. I was always a little
knock-kneed before the operations. What do they do
to change things around?
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Q.
After surgery for a total knee replacement, I got a
blood clot in the other leg. The doctor wasn’t even
checking that side. Is this a common problem?
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Q. Are there times when the
kneecap should be left alone when the knee joint is
replaced?
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Q. As I get older I notice
more and more knee pain and stiffness. What are some
simple things I can do to help with this problem?
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Q. Before having a total knee
replacement, my doctor insists that I go to physical
therapy. This is called preoperative treatment. Why
is this necessary? I’m really ready for the
operation.
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Q. Ever since an injury in
college I've had a locking knee joint. I've always
been able to unlock the joint on my own. For the
last 24 hours, my knee has been locked and without
motion. What should I do?
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Q. Following the replacement
surgery for my knee joint, I've tried physical
therapy and a special splint to stretch my knee. I
just don't seem to be getting any more movement in
my knee. What are my options now?
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Q. Have you ever heard of
drilling holes in the knee joint cartilage to get it
to heal? The surgeon who is recommending this
treatment says that it is a well-documented
approach. Is this so? How does it work?
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Q. How are knee injuries
diagnosed?
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Q. How does a doctor decide
what type of replacement to use when you go for a
knee replacement?
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Q. How successful are knee
replacements?
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Q. I am going to have a total
knee replacement in two weeks. The doctor explained
the operation to me. There will be an antibiotic
mixed in with the cement that's used to hold the new
part in place. Is this experimental?
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Q. I am planning to have a
knee replacement soon. What can I expect right after
the surgery?
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Q. I have a brand new knee
replacement (this year). When I travel, I notice
some airport detectors go off and others don't. Why
is that?
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Q. I have a torn cartilage in
my right knee. The doctor tells me I need surgery
because it won't heal on its own. Why won't it heal?
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Q. I have read that people who
have knee and hip replacements may have to have
revision surgeries. What do they mean by that?
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Q. I have very severe
patellofemoral pain syndrome. Would it ever be
possible to just have my kneecaps replaced?
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Q. I'm 62 years old and have
very bad knees from arthritis. I make my living
cleaning other people's houses. If I have a knee
replacement, will I still be able to get up and down
to clean under and behind things? I can't really
afford to retire just yet. |
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Answers
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Q. A month ago, I had a total knee
replacement. I’m working very hard with my
exercises, but the thigh muscle just doesn’t seem to
contract when I try to straighten or lift my leg.
Why is this?
Scientists refer to this as
‘inhibition.’ The muscle along the front of your
thigh is the quadriceps. The surgery disrupts this
muscle and keeps it from contracting with full
force. In other words, the voluntary contraction is
inhibited. Pain and swelling in the joint probably
add to the problem.
You may need a more complete rehab
program with a physical therapist to regain this
muscle function. It will prolong the life of your
implant and reduce your risk of falls.
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Q. After having a total knee
replacement on both knees I notice that I stand up
straighter and walk better. I was always a little
knock-kneed before the operations. What do they do
to change things around?
Knock-knees or the opposite condition
bowlegs must be corrected when knee joint
replacements are done. If the uneven pressure isn't
changed, the new joint implant can wear unevenly
just like the old joint probably did.
Sometimes it's a simple matter to
realign the bones and soft tissues while putting the
new joint in place. In other cases, doctors must cut
bone, ligaments, and joint capsule to make it all
work in balance.
As newer technology improves,
surgeons are finding ways to simplify the soft
tissue releases. The goal is to give the patient
pain free function with a new joint that will last
as long as possible. Standing up straighter is an
added bonus of these new surgical methods.
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Q.
After surgery for a total knee replacement, I got a
blood clot in the other leg. The doctor wasn’t even
checking that side. Is this a common problem?
Blood clots or deep venous thrombosis
(DVT) are very common after hip or knee surgery,
especially after joint replacements. Finding them
isn’t always easy. Ultrasound studies may not show
any sign of clotting when in fact there is some. One
out of every 20 patients will have a blood clot in
the opposite leg.
It’s not standard practice to monitor
both legs after surgery. If the patient has risk
factors for DVT, then more tests may be done.
Preventing DVT is the main goal. Drugs, activity,
and leg pumps work well to accomplish this. The
treatment affects both legs at the same time.
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Q. Are there times when the kneecap
should be left alone when the knee joint is
replaced?
Total knee replacement (TKR) has
become a very popular way to treat pain and loss of
function from osteoarthritis of the knee. Although
the knee joint itself may need replacing, sometimes
the kneecap (patella) is just fine. It moves up and
down over the joint just fine.
Some researchers suggest it's best to
leave the patella alone when:
# The patient has good cartilage on
the back of the patella.
# The patient is young and active.
# The patient is not overweight or
obese.
# The patella moves up and down
(tracks) normally over the joint.
# There's no sign of inflammation
under the patella.
On the other hand some surgeons
always replace the patella. Their results are very
good. What we really need are some long-term studies
that show the results years after the TKR was done.
Results for patients with and without patella
replacement should be compared.
A recent review of studies between
1996 and 2003 was unable to find any clear-cut ways
to decide the issue. Overall it looks like patellar
resurfacing (replacement) results in less pain,
fewer reoperations, and greater knee function.
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Q. As I get older I notice more and
more knee pain and stiffness. What are some simple
things I can do to help with this problem?
Exercise has really been shown over
and over to be most effective for mild to moderate
osteoarthritis. A walking program is used by many
people because it is easy to do and doesn't require
special equipment. A good pair of walking shoes and
comfortable clothing are all you need.
Many communities offer walking clubs
for those who don't want to walk alone. Groups may
meet at the local mall each day. Some combine
walking and hiking for those who prefer an outdoor
experience.
If walking isn't possible but you
have access to a pool, then consider a pool therapy
program. The warmth and buoyancy of the water offer
gravity-free exercise for painful joints.
Strengthening exercises for the
quadriceps muscle may be helpful, too. The
quadriceps muscle is the large four-part muscle
along the front of the thigh. Resistive training
exercises to improve strength have been shown
effective.
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Q. Before having a total knee
replacement, my doctor insists that I go to physical
therapy. This is called preoperative treatment. Why
is this necessary? I’m really ready for the
operation.
Treatment before an operation is to
help the patient understand the surgery and its
expected results. Measurements of joint range of
motion and muscle strength will be taken. This will
help the therapist track your progress after the
operation.
Often, preoperative therapy can
improve motion and strength. Exercise can increase
blood circulation to the area and even help you walk
better. All these things will help you get motion
and function back quickly after surgery. The program
will also help prevent loss of balance and falls.
The therapist will tell you what to
expect after surgery. Preventing blood clots and
dealing with pain are also part of the preoperative
plan.
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Q. Ever since an injury in college
I've had a locking knee joint. I've always been able
to unlock the joint on my own. For the last 24
hours, my knee has been locked and without motion.
What should I do?
See an orthopaedic doctor. A simple
arthroscopic surgery may be all that's needed. The
doctor looks inside the joint, finds the problem,
and repairs it all in one procedure. A special tool
called an arthroscope makes this all possible.
The scope is a slender device with a
tiny TV camera on the end. It is placed through a
small opening made in the skin and goes directly
into the joint. No incision or open cut is needed.
Special tools can be passed through the scope into
the knee. The surgeon is able to see and work inside
of the joint.
Even if you've been able to unlock
the joint in the past, it sounds like it's now time
for diagnosis and treatment. The longer that
problems are left untended, the less likely a simple
repair can be done. For example, torn cartilage in
the knee can be repaired in some cases instead of
having to remove the cartilage completely. Keeping
the cartilage protects the joint much longer than
removing it.
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Q. Following the replacement surgery
for my knee joint, I've tried physical therapy and a
special splint to stretch my knee. I just don't seem
to be getting any more movement in my knee. What are
my options now?
If you're not getting improved knee
movement after aggressive physical therapy and the
splint, your doctor may recommend a procedure called
manipulation under anaesthesia. This involves a
forceful stretch of the knee while you're asleep
from anaesthesia. This treatment is designed to
break up scar tissue and improve knee motion.
Patients usually resume physical therapy after
manipulation.
If you still don't have better
movement in your knee, additional surgery may be
suggested. Choices include surgery using an
arthroscope to remove scar tissue followed by a
forceful stretch of the knee. Less commonly,
surgeons may need to revise or replace the parts of
the prosthesis.
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Q. Have you ever heard of drilling
holes in the knee joint cartilage to get it to heal?
The surgeon who is recommending this treatment says
that it is a well-documented approach. Is this so?
How does it work?
The technique you are referring to is
called microfracture. It is designed to help
full-thickness articular cartilage lesions heal. It
seems that if left alone, the body doesn't heal this
area fully or completely.
It is both a safe and effective
treatment technique. Many studies have been done and
reported on. Results seem to depend on choosing the
right patients. The lesion must be well-contained
and not too large.
Surgical technique is also important.
The surgeon uses an arthroscope to work inside the
joint. The area is cleaned and smoothed in
preparation for the procedure. Any pieces or
fragments of cartilage should be removed.
Then special surgical tools called
awls are used to make tiny holes into the bone
marrow. Tiny drops of blood and fat from the marrow
seep into the holes and fill them. This is the start
of the healing phase. Before leaving the joint, the
surgeon will also take the time to look for any scar
tissue or meniscal tears that require repair or
removal.
By drilling through the subchondral
bone, channels are formed that allow bits of bone
marrow to clot in the holes. A network of blood
clots form into a scaffold. Capillary vessels then
form to supply the area with blood supply. Stem
cells from the bone marrow form into new cartilage
cells.
The fibrocartilage that forms isn't
the same as natural cartilage. The surface is not as
strong and must be protected carefully during
healing.
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Q. How are knee injuries diagnosed?
The history of how you hurt your knee
will give your doctor a good idea of what the
diagnosis will be. Certain movements, activities,
and sports often cause specific types of knee
injuries.
You'll be examined and your doctor
will want to know how well you can move your knee,
whether you can walk on it, and how much pain you
have. When ordering tests, there are several that
your doctor can choose from and, of course, you may
go for more than one to either refine the diagnosis
or to confirm of it.
Most likely, the first test you will
have is an x-ray to see if there is any problem with
the bones. More specific testing can be done with
computerized axial tomography (CT scan) or magnetic
resonance imaging (MRI). Some doctors may ask for a
bone scan to see that the bone itself is ok.
Finally, the doctor may want to look directly into
your knee with an arthroscope. To do an arthroscopy,
the arthroscope - which has a camera attached to the
end - is inserted into the knee through a small
incision.
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Q. How does a doctor decide what type
of replacement to use when you go for a knee
replacement?
There are many types of implants a
doctor can choose from when performing replacement
surgery. There are usually many factors that are
involved in making the choice as to which one to
use. For example, the condition of the bones, the
type of activity the patient does, what type of
damage has been done, what implants are actually
available, cost, and the doctor's experience with
the implants.
Certain types of implants have
advantages over others, depending on several things.
If a patient wants to know more about the type of
implant being used, it's best to speak with the
surgeon and to ask questions about the implant, the
surgery, and the reasons behind everything that is
being done.
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Q. How successful are knee
replacements?
According to the US FDA (2003), 90
percent of people who have knee replacements are
happy with the results. Studies examining the
success of knee replacements found that in about 10
percent of cases, revision surgery was needed after
10 years, and in 20 percent after 20 years.
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Q. I am going to have a total knee
replacement in two weeks. The doctor explained the
operation to me. There will be an antibiotic mixed
in with the cement that's used to hold the new part
in place. Is this experimental?
The use of antibiotics mixed with
cement for total joint replacements has been around
for over 30 years. Some doctors use this with every
patient. Others reserve its use for joint infections
or failed first operations.
A group of doctors at NYU (New York
University) reviewed all of the studies done on this
topic. They found that there isn't one method used
and approved by all doctors. The FDA (Food and Drug
Association) doesn't take a stand on the use of
antibiotics in cement.
It's only experimental in that
researchers continue to study the problem. They are
looking for a product that can be mixed into the
cement without changing the cement's strength.
Future cements with drugs mixed in will have a slow
release of the antibiotic. This will help lower the
infection rate, too.
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Q. I am planning to have a knee
replacement soon. What can I expect right after the
surgery?
You should ask your doctor about the
post-surgery routine at your hospital. There may be
a patient education booklet that outlines what will
be happening but there are some general things for
which you can prepare.
There will be pain afterwards, as
with most surgeries. Be sure to discuss with your
doctor and, importantly, the nurses about how often
you can take your pain medication. It is not in your
best interest to try to be stoic and not take the
pain medication if you need it. If the pain is bad,
you will likely not move your leg enough to be able
to recover quickly.
Because of the general anaesthetic,
you will be asked to do deep breathing and coughing;
this is to make sure your lungs are clear. You may
also be taking medications to thin your blood to
prevent clots. As your doctor or nurses to explain
to you about the particular drug you are taking.
If you are prescribed support hose or
compression boots, be sure to use them as instructed
as they will help decrease the chances of developing
a blood clot. You will likely be encouraged to do
gentle leg exercises and you may have a machine
called a continuous passive motion (CPM) machine.
Finally, you will likely be seen by a
physiotherapist who will teach you how to get in and
out of bed and walk safely, as well as provide you
with some specific exercises to help you regain
movement in your knee.
Q. I fractured the tibial plateau in
my knee. Surgery wasn’t needed, but I’m having quite
a bit of stiffness. What’s the worst that can happen
in these cases?
The tibial plateau is at the top of
the lower leg bone (the tibia). It’s the surface
where the thighbone attaches to the lower leg bone
to form the knee joint.
The risk of problems is greater when
surgery is done. There can be poor wound healing,
infection, blood clots, and dislocation of the
kneecap. If the break is deep enough, it can affect
the joint. Arthritis can develop early, requiring a
knee joint replacement. Often, more than one
operation is needed.
Treatment without surgery suggests a
less serious problem with a better outcome. The
stiffness could lead to joint fusion over time. Most
likely, with exercise and a rehab program, your
range of motion will be restored fully.
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Q. I have a brand new knee
replacement (this year). When I travel, I notice
some airport detectors go off and others don't. Why
is that?
Many people have reported differences
not only from airport to airport but even from time
to time through the same security detector. To solve
this puzzle, Dr. Robert F. Ostrum, Chief Orthopaedic
Surgeon at Cooper University Hospital in Camden, New
Jersey did a little research on the topic.
He found that airport metal detectors
generate a brief magnetic field. When a metal object
passes through the detector, the magnetic field is
reversed and a sharp electrical spike sets off the
alarm. Many other factors come into play as well.
For example, the more metal you have
(say from multiple implants) or the larger the
pieces (mass), the more likely it is that the
detector will sound the alarm. The type of metal can
also make a difference. Anything with iron in it or
other type of metal that can be magnetized increases
your chances of detection.
Detection units can also be set for
higher sensitivity. So on high alert days, you are
more likely to set off the alarm when you walk
through the archway compared to a low-alert status.
Some of the walk-through archways
only have a detection device on one side. If your
implant is on the opposite side, you are less likely
to set off the alarm. The handheld wand detectors
are more likely to detect metal implants but these
are not used routinely.
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Q. I have a torn cartilage in my
right knee. The doctor tells me I need surgery
because it won't heal on its own. Why won't it heal?
Some people consider this a "design
flaw" in the human body. Cartilage anywhere in the
body doesn't have a big blood supply. We say it's
not highly vascularised. This means when it's
injured or damaged in anyway it heals very slowly or
not at all.
The cartilage doesn't have a way to
heal itself. The result is often worse symptoms for
the patient and joint degeneration. Surgery is done
to repair the damage and bring blood to the area to
speed up the healing cycle.
Cartilage has several layers. The
deepest layer just before the bone is called the
tide mark. Just below the tide mark layer are stem
cells that can grow into fibrocartilage. This kind
of cartilage isn't exactly the same as the cartilage
on the surface of the joint, but it's better than
nothing!
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Q. I have read that people who have
knee and hip replacements may have to have revision
surgeries. What do they mean by that?
When a knee or hip has been replaced,
there may be some issues that need to be corrected
later on. In some cases, the hardware itself may
break down or wear out, in other cases, the bones
around the hardware may be causing some problems.
A revision surgery may be done if
there is an infection in the joint, if the bones are
wearing down or if the joint needs to be repaired or
replaced.
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Q. I have very severe patellofemoral
pain syndrome. Would it ever be possible to just
have my kneecaps replaced?
Patello-Femoral Syndrome (PFS) is a
condition that causes pain in and around the kneecap
(patella). In the normal, healthy adult, the patella
moves smoothly over a groove on the femur (thigh
bone). PFS can develop when the patella is not
moving or tracking properly over the femur. This is
a common knee problem in runners and athletes but
anyone can be affected.
Where the patella and femur meet
forms a joint called the patellofemoral joint. Many
muscles and ligaments control this joint. Any change
in alignment of the bone, ligaments, and/or muscles
around the patellofemoral joint can affect how the
patella tracks along the femoral groove.
Patellofemoral joint replacement is
usually a treatment for patients with severe
osteoarthritis. The articular cartilage covering the
back of the kneecap becomes worn and torn causing
painful movement. Replacing the patellofemoral joint
in PFS doesn't address the real problem of soft
tissue imbalance and structure causing tracking
problems.
Conservative treatment for PFS with
bracing and exercise may be the best option. If the
back of the patella has worn more on one side than
the other from the uneven forces of PFS, then the
surgeon can smooth the surface without replacing the
entire bone. An orthopaedic surgeon is the best
person to look at your situation and advise you
about treatment options including patellofemoral
replacement.
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Q. I'm 62
years old and have very bad knees from arthritis. I
make my living cleaning other people's houses. If I
have a knee replacement, will I still be able to get
up and down to clean under and behind things? I
can't really afford to retire just yet.
You have several things working in
your favour: your age and your activity level before
surgery. Younger, healthy adults have a much better
chance for recovery of motion and strength after
joint replacement than older adults.
Pain is relieved after joint
replacement, which makes it possible to do your
daily activities once again. Strength is reduced in
that first month until the muscles around the joint
start to recover. The biggest drawback is that it
may take you longer to do your work than before the
operation.
Getting up and down off the floor may
be difficult. There are some devices that can help
you. First, a foam pad to support your knee when
kneeling will be helpful. Medical supply stores can
provide you with long handled dusters and grabbers
for those times and places you can't quite reach or
bend far enough.
Be sure and tell your surgeon about
your situation. The type of implant and method for
putting it in can make a difference. Expect to take
at least a month off from heavy cleaning. Depending
on your results and recovery, you may be back to
light housekeeping after two weeks.
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