Knee surgery is one of the most demanded procedures among orthopedic operations. There are many reasons why your knee ceased functioning normally and depending on them you may need different treatment. Specialized orthopedic and trauma centers in Germany offer to their patients various interventional and non invasive methods depending on kind and degree of disease or traumatic condition.
According to Federal Service for National Statistics, the number of patients requiring treatment of orthopedic conditions multiplied by 2.5 during the last 25 years.
The most widespread traumas and conditions of knees are:
- Gonarthrosis – arthrosis of knee joint;
- Tear of crucial ligament;
- Meniscal tear;
- Damage of cartilaginous tissue;
- Knee dearticulation.
When we move during walking and straighten legs or bend, our knee joint is actively working. This is a very flexible connection tissue between the hip and the shin. A healthy knee has the connection of three bones:
- Thighbone (Femur)
- Shin bone (Tibia)
- Knee-cap (Patella)
These bones are covered with smooth cartilaginous tissue in the area of connection and are kept together with the help of ligaments, muscles and tendons. There’s space between bones filled with meniscus that absorb pressure and distribute load evenly.
Disrupt of knee joint can be caused by different reasons. Most often, it is connected with mechanical damage, arthrosis, inborn deficiency in limb development and other rheumatic diseases.
Gradually, cartilaginous tissue of knee joint wears down. Since it cannot regenerate by itself, it wears and disrupts permanently. When the cartilaginous tissue of the knee joint is worn down considerably and bones almost get in contact without being protected by cartilage, every motion causes severe pain.
During such condition, doctors initially prefer traditional knee joint treatment methods. These include physical therapy, wrapping, baths and pain-killers. If these methods don’t bring considerable results, doctors resolve to implantation of an artificial knee joint – patient’s knee joint is replaced by an implant.
An artificial knee joint replaces smooth natural surface of bones composing it. Such implant consists of a thighbone component, meniscus imitator and upper shin bone component. All above mentioned components are designed to bear a high load, which is why high-quality materials are used for production.
The parts for thighbone and shin bone covering are made of metal alloys, mostly – titan or chrome with cobalt. These materials are highly durable and are not typically rejected by human body, just like polyethylene meniscus.
Knee surgery is quite common and does not require any specific conditions. You need to have an operating field prepared and be ready for anesthesia.
The following types of anesthesia are used for knee surgery: endotracheal, intravenous, conduction, and spinal anesthesia. Regional anesthesia with anesthetics like Novocain or Lidocaine can also be used, but it is less common. A proper type of anesthesia is considered based on the surgery type and its extent. Minimally invasive interventions are most often performed under conduction or spinal anesthesia. But whenthe knee joint is replaced, general anesthesiawith muscle relaxants is more suitable, in order to provide easier access to the site of surgery.
Tip: Be serious about choosing the right anesthesia type to ensure minimal negative impact of medications on the body, as you need to reserve all its energy for recovering from surgery. Doctors should not just agree with those patients who often ask for general anesthesia,even with minor interventions, because medications anesthetics can dramatically weaken even a young and healthy body, not to mention the patients with chronic pathologies, and those over 60 years of age.
Make the most of the time remaining before surgery to improve your general health as much as possible. Because the fitter you are before the operation, the faster you will be fit after the operation. Stop smoking. Reduce alcohol consumption as much as possible. Reduce your overweight, eat healthily. Improve your overall fitness, moderately strengthen your muscles. This can reduce the risk associated with each operation.
Arthritis is a main enemy of the joints. If you open Medical Encyclopedia you can find a few dozen of types of the disease. Osteoarthritis and rheumatic arthritis are the most common of them causing degenerative changes of the joints.
Osteoarthritis is a condition when cartilage, which is natural damper of our joints, wears out and reduces in sizes causing the bones rubbing against each other, which produces pain, swelling and stiffness. If you have knee osteoarthritis you may experience continuous pain when moving, climbing stairs and even sitting or lying. Mild osteoarthritis can be treated with conservative methods but from moderate to severe stages surgery is often recommended option.
Osteotomy is cutting and alignment of the bone that allow to balance pressure in the knee joint and get rid of pain. The procedure is normally recommended for patients from mild to moderate degree of the disease, especially for those who have the joint affected only from one side and who are too young to have total knee replacement. It helps to support natural function of knee joint and increase its lifespan. Sometimes reshaping and shifting of the bone helps delaying replacement surgery for years.
When your knee joint severe worn out, you have persistent pain and traditional treatment is not effective you may need total or partial knee replacement. Knee replacement surgery is a leader among replacement surgeries worldwide. Modern technologies allow replacing your degenerative joint with implant of your choice that gives immediate relieve and significant symptom reducing.
Some patients may need revision surgery, which as a rule require for replacing old prosthesis with new and modern one. In this case, it is necessary not only to change joint implants but also to clean everything around, especially, when patients have old metal prosthesis that gives debris.
Arthritis is not the only reason for restorative knee surgery, as many problems are caused with injuries and other damages such as permanent overloading of the joints as result of intense sportive exercises.
Torn Ligaments Surgery
Torn ligament is a problem of athletes but also they can be result of any other accident. There are four ligaments around knee joint and all of them may need reconstructive surgery. Anterior cruciate ligament (ACL) is a most often candidate for the surgery which can be done both with classic surgery and minimally invasive methods.
Microfracture Knee Surgery
Microfracture surgery is one of the modern methods to restore torn meniscus. Traditionally, damaged meniscus is cut but presently many surgeons in Germany apply a technique stimulating natural growth of cartilage. It is possible by drilling micro fractures in the bone that provoke build of new cartilage.
Knee Joint Puncture
Puncture of the knee joint is one of the simplest procedures on the knee. It is performed for arthrocentesis, or collecting a sample of synovial liquid, which is further used for diagnosis, and to administer drugs directly to the site of the problem. Puncture is performed under local anesthesia with a special needle.
A knee injection is not a difficult procedure. It is performed in a treatment roomon a couch, in a sterile environment. In any case, the procedure should only be done by a doctor who knows exactly how and where to introduce the needle for a therapeutic or diagnostic puncture.
Indications for Knee Puncture
Knee joint puncture is used to:
- Remove blood accumulated due to hemarthrosis
- Remove pus or exudate from the knee joint cavity
- Introduce an antibiotic that will help to eliminate an inflammation caused by bacteria
- Inject anestheticand painlessly fix joint dislocation;
- Introduce air into the knee, which may help to eliminate adhesion and restore motor function
- Introduce a corticosteroid to relieve arthritis.
A doctor can decide if puncture is advisable only after complete examination of the knee joint.
When puncture is contraindicated
A doctor should not do a procedure if any wounds, rashes, and plaques indicating psoriasis are present at the spot where a needle is to be introduced.
Performing jointpuncture in despite of these signs can lead to severe joint infection.
Puncture is also contraindicated in people with bleeding. If a patient with this disease has strong indications for knee puncture, he or she should receive some medications before the procedure.
Puncture for Diagnosis
In some cases, puncture helps to accurately and correctly establish a diagnosis. A doctor puts a needle into the joint and extracts fluid substance from the articular cavity. This liquid is examined to determine the nature of the inflammatory process.
Diagnostic puncture is performed in order to find:
- If any “joint mouse” or “rice bodies” are in the joint
- If the meniscus is damaged
- If any accumulation in the knee during the inflammatory process after getting an injury.
In order to diagnose meniscus damage, oxygen is injected into the joint under high pressure.
When pus, blood or exudate is discovered in the knee with the help of a knee injection, it is possible to treat it immediately. First, the discharge is removed, then, the joint capsule is washed and a medication is administered.
Puncture for Therapeutic Purposes
Puncture of the knee is used not only for diagnosis, but also for treatment. Treatment of knee joint disorderscan be much more effectiveand safe when medications are delivered into the joint. For example, in case of oral drug administration, there may be side effects of the digestive system. Topical ointments may be less effective, as they are not completely absorbed into the tissues and assimilated in the body. For treatment of knee disorders, a medication is injected with a needle directly into the affected area. If blood or pus accumulates in the knee, they can be removed with a syringe in seconds.
Therapeutic puncture is done to:
- Remove the blood accumulated in the joint cavity as a result of hemorrhage or injury
- Injectantibiotics to relieve inflammation in the joint
- Introduce anesthetics to correcta joint dislocation without pain
- Introduce oxygen into the knee to restore the motor activity of the knee joint
If puncture has not been performed timely, a hematoma will dissolve slower and itcan lead to knee inflammation with fever and overall deterioration of a patient’s health.
Joint Puncture Explained Step-by-Step
Thanks to the knee anatomy– the patellais located slightly forward – the procedure is very simple and easy. A patient lies on his back with a tight bolsterunder the knee. From the lateral side, a needle is inserted at the middle part of the patella to the depth 3cm. If a puncture is done to the lower part of the joint, the procedure will be painful. The technique of puncture has its own nuances.
Before the procedure, the knee is disinfected. Skin is treated with a solution of iodine and alcohol.
- To introduce oxygen, use a thin needle – 1 mm in diameter. To remove pus or blood you need a needle with a diameter at least2 mm.
- The skin at the injection site should be stretched aside to prevent infection from getting into the blood.
- The needle should be moved slowly until it reaches the articular capsule. After it is also punctured, the needle will move easier. In order not to damage articular cartilage,the needle should not be injected deeper than 3 cm.
- Depending on the type of procedure, medication is injected into the joint or liquid is aspirated from the articular cavity with a syringe witha volume from 10 to 20 grams.
- At the end of the procedure, the puncture site should be wiped with a sterile napkin; a tight bandage is applied on top.
Puncture is a specific procedure, so it is very dangerous for health and knee mobility if you try to perform it by yourself.
Knee Ligament Surgery
Ligament repair is required when ligaments are torn or damaged. You may need stitching with special suture materials. Ruptures can occur with dislocationsand fractures.
First aid if you got an accident: if you suspect a torn ligament, before meeting a doctor, give rest to your knee: to restrict movements in the joint is necessary to get rid an edema, reduce pain and prevent further injuring. Bandaging is also useful. It is very important to apply cold in the very first moments after an injury. This narrows the blood vessels, reducing edema and hemorrhage to the inner tissues.
Anterior Cruciate Ligament Tear
Most often, anterior cruciate ligament (ACL) is torn.
Conservative Treatment for torn ACL
With a complete tear of the ligament, this kind of treatment is not highly effective, but it can be assigned in elderly patients if the joint is relatively stable.
Usually,a treatment course includes:
- Electrotherapy (Functional Electric Stimulation (FES), InterferentialTherapy, etc.) or ultrasound therapy (Phonophoresis) for 10 days (a standard course includes 10 procedures, and it is important to receive them without gaps) to eliminate pain and swelling and prepare the joint for exercise therapy.
- Compresses with ointments(e.g., Lyoton, Voltaren).
- Massage to reduce pain and swelling.
- Physical exercises:at the beginning, withlow intensity andwithout direct pressureto the joint (for example, lying exercises), and, then,more intense exercises to build musclesaround the knee, and strengthen the thigh muscles and lower leg muscles.
The recovery time is approximately 1.5-2 months of regular workouts, but,again, everything depends on the gender and age of the patient, and individual features of the body.
Surgical Treatment for torn ACLis performed up to one week after an injury or six weeks after. This is becausea hematoma is formed within one week after an accident and a lot of blood accumulates in the joint, which complicates surgery.
In essence: a graft (a new ligament) is fixed in the knee joint with titanium screws. Tissues for transplantation can be obtained from several sources. Most often, the graft is taken from the patellar ligament that is located between the patella and tibia. The tendons of the posterior thigh also can be used for the graft.Sometimes, the tendon of the quadriceps muscle,located between the patella and femur, is used, which makes the treatment of the torn ACL somewhat more physiological.
Ligament reconstruction can be performed using open access or with an arthroscope, an endoscopic device that allows less traumatic surgical interventions.
Arthroscopy for ACL repairincludes the following:incision or puncturing tissues; introducingsurgical tools and a camera; cleaning the joint; removingthe torn ligament andcutting the meniscus; taking a graft for a new ligament;makingthenew ligament; fixing the ligament in the joint.
Here you can find a more extended description:
- For arthroscopic surgery, a spinal anesthesiais usually used.Although medication is injected into the spinal canal, this method is absolutely safe, despite myths about “the risk of spinal column damage and, as a consequence, paralysis”that have no any scientific basis.
- Cleaning the joint. When a trauma occurs inside of the joint, ligaments are torn. And when the ligaments are ruptured, the meniscus is often also damaged and has to be cut during surgery to remove torn edges. The old ligament and other unnecessary fibers are “nipped off” by a special tool, releasing a space in the joint.
- The types of the new ligament:made from the patient’s own tissues (it can be taken from the tendons of the inner thigh or from the patellar ligament); combined (made from lavsan and biological tendons or ligaments); completely artificial (from lavsan). Only a doctor can decide on the type of the ligament, and his choice depends on the weight and age of the patient, and his life activities.
- The ligament is fixed with titanium bolts, with one end of the ligament attached to the femur, and another one– to the tibia.
Surgery duration and how long you stay in a hospital: the surgery lasts no more than 1.5 hours. After this, the patient spends 2-4 hours in the intensive care unit, until the anesthesia wear off. The patient is discharged with crutches on the third day after surgery.
Torn Lateral Ligament Repair
A tear of the lateral knee ligaments is characterized by a lower intensity of clinical symptoms, but it also involves pain, swelling in the injured limb, and discomfort. What you have to be aware: there are no any possibilities of spontaneous relief if you have torn ligaments. On the contrary, with time, fibrous deposits may appear, which may lead to the risks of unpleasant sensations in the knee all over the life.
When one is diagnosedwith a torn knee ligament, treatment can be prescribed only by a doctor.
Choosing a method of treatment (conservative or operative) depends on the individual characteristics of a patient, including sex, age, andthe way of life: treatment may differ for professional athletes, people who lead the active lifestyle, and those who are far from being sportive. An opinion of the patient is also taken into consideration.
Conservative treatment is possible only with lateral ligament rupturesof the grades I and II. It is mostlyprescribed to elderly patients (over 55-60 years), as well as the patients who do not engage in sports. But, at the same,the patients are informed that if, after some time,knee pain and instability does not go away, surgery may be an option.
Immediately after an injury, Electrotherapy and ultrasoundcan be applied to alleviate pain and relieve swelling. Additionally, various ointmentsand compresses can be useful, as well as light massage. Treatment of torn ligaments does not take much time, even together with rehabilitation, thanks to modern methods.
Perhaps, the doctor will prescribe wearing an orthosis, and orthopedic device to maintain stability in the joint before and after exercising, while walking outside, etc.
Surgical treatmentis usually prescribed for isolated tears of the grade III, especially if there is a detachment of the superficial medial collateral ligament from the tibia (the ligaments may tear in different locations, and treatment also depends on it).
Surgery is an advisable option for all professional athletes who need to recover and be ready for competitionsin a limited time, and also for the patients who failed with conservative treatment, have persistent pain and apparent instability in the joint.
A method of surgery depends on the time elapsed after the injury. If it is still up to 3 weeks, then,a torn ligament is sewed. With the significant disintegration of ligament fibers, the ligament is strengthened by the fascia or tendon of the adjacent muscles. In this case, the treatment of knee ligamentrupture takes more time, and the risk of complications associated with infections also increases.
After 3 weeks, the ends of the torn ligamentscan no longer be brought together, since they contract, and now they can be repaired with the help of arthroscopy using artificial materials.
Arthroscopy is a minimally invasive or spare operation on knee joint. According to German online statistics collection websites, arthroscopic meniscus and cartilage operations are on the second place after the most widespread surgical procedures in German clinics. Orthopedic surgeons in Germany perform about 305.000 similar operations which proves a high level of their knowledge and professional skills.
Arthroscopy is based on using a special video device – arthroscope. Technically, an arthroscopic operation on a knee joint does not require making big cuts: a few small incisions are made for the instruments to get inside patient’s body. Arthroscope is equipped with lenses and light emitted diodes. Light is shot via an optic fiber wire, knee space is lightened, and camera transmits video signal on computer screen. Precision of the picture reaches 95-100% which allows the surgeon to make the right joint analysis and plan the future actions.
This technology has the following advantages:
- the surgery does not cause trauma;
- it allows making a precise and high-quality diagnosis of knee;
- rehabilitation period shortens considerably (3-4 months maximum);
- it helps to save money.
Indication for the procedure:
- Pathologic defects of cartilage.
- Chronic instability of knee cap.
- Meniscus damage.
- Inflammation of synovial membrane caused by unknown reasons.
- Spontaneous aseptic necrosis, intra-articular bodies, etc.
Keyhole surgery on knee cap is used torn o solve various problems starting from knee cap cleaning and finishing by reconstruction of torn ligaments.
Arthroplasty is a surgery to replace, restore or reconstruct articular surfaces of joints. In modern traumatology and orthopedics, arthroplasty can be classified as follows:
Open reduction is used to re-align bony fragments of fractured joints if they located on the articular surface or very close to it. This procedure involves osteosynthesis, a fixing of the fragments by different devices, such as rods, screws, plates, etc., made of hypoallergenic materials. This immobilization of the joint provides the minimal negative consequences after a fracture.
Resection arthroplasty. In the course of this operation, a resection (excision) of one of the working surfaces of the joint is performed to introduce a tissue complex including ligaments and fascia. This type of operation preventsankylosis and facilitates conditions for restoring the motor activity of the joint. This also includes arthroplasty of the joint articulation, in which ceramic implants covered with bioactive glass-ceramic are used.
Resection of the knee joint is a large-scale surgery, which is indicated in case of purulent-inflammatory diseases of the knee and knee fractures. This intervention involves the removal of not only the joint itself, but also the damaged part of the bone. Most often, after this, another operation follows, such as joint replacement or an amputation of the lower third of the thigh. This is a complex and demanding surgery.
Knee cartilage repair. This intervention is performed to remove defects and ossification of cartilage. Defects are eliminated with the help of special pastes and solutions that, after hardening, have nearly the same density as hyaline cartilage. Surgery is followed by medication with drugs helping to restore the cartilage layer of the joint.
Knee Joint Cyst Removal. Removal of ganglion cysts of the knee joint does not cause any difficulties and lasts about 30-40 minutes. Baker’s cyst is a bit apart from the others.
Also, one of the types of surgery is intervention to replace the patella.
Total Knee Replacement (Arthroplasty)
Prosthesis of the knee joint is a replacement of a biological joint with an implant, which is made of special alloys and polymers. The implants are produced in a variety of sizes and materials in order to fit to the individual featuresof each patient, including sensitivity to implant components. To date, such artificial joints can almost completely restore the function of the lower limbs. In some cases, only the joint surface can be replaced.
Indications for total knee arthroplasty
Indications for knee replacement are considered by atrauma surgeon or an orthopedist, based on the examination results and the patient's complaints. The doctor should discuss with a patient everything concerning the forthcoming knee replacement in details.
The patient should be informed about all the pros and cons of the surgery, existing alternative treatments and possible complications associated with this particular type of surgical intervention.
Total knee arthroplasty: Procedure
Knee joint replacement is elective surgery, which means it scheduled and planned in advance and performed when a patient is duly prepared. After a replacement is considered, first, the patient is thoroughly examined. The results of examination allow make a conclusion onthe patient's overall health andcarry out preoperative preparations based on patient’s individual data.
After the examination and preparations, the surgery date is scheduled. The operation is performed under general or spinal anesthesia.All the nuances of anesthesia,oncoming surgery and subsequent rehabilitation are discussed with the patient in advance.
Surgery is performed by a team of orthopedic and trauma surgeons. There are several options how to perform surgery: with a tourniquet to stop bleeding during the procedure, without a tourniquet, and partiallywith a tourniquet. Each option has its own supporters and opponents.
A decision on the type of anesthesia is taken by an anesthetist together with the patient. Standard uncomplicated surgery lasts for 1.5-2 hours. In the postoperative period, intensive therapy, pain management, and wound dressings are carried out. For prevention of infectious complications, the patient receives antibacterial medications.
To prevent thrombotic complications, the patient is prescribed to takedrugs of the class of low molecular weight heparins. Elastic bandaging and foot movements immediately after surgery are also recommended.
In the postoperative period, the patientwithout fail should bein a hospital on an inpatient basis, under medical supervision. After surgery,anticoagulant therapy can be assigned. Another important component of postoperative rehabilitation is electro- and mechano-therapy that can last from two months to six. In case if the patient strictly follows all the prescriptions of an attending doctor, at the end of the rehabilitation period, he or she can return to normal life and lead an active physical activity in the future.
In the postoperative period, due to damage to the periarticular and intraarticular structures during surgery, fluid accumulates in the knee and it is hurt. This is normal and not considered as a complication if the fluid accumulation accompanied by edema of the tissues around the patellatogether with pain doesnot last longer than expected. These symptoms should be diminished in approx. 3 days, and, by the second week, they tend to cease completely. In the early period, doctors drain the wound and give an antiseptic treatment to reduce puffiness and pain. Extra measures include:
- Limb immobilization by orthopedic means.
- Keeping the leg in an elevated position when the patient is in bed.
- Applyingdry cold.
- Anti-inflammatory drugs.
If edema does not decrease, it is a sign that inflammation is still progressing, and, perhaps, there is local infectious pathogenesis that not only prevents restoring mobility, but also can lead to more complex consequences. For example, if you have got a newly implanted joint, infection can cause the rejection and implant deformation, which may require a revision surgery (removal of the faulty implant) and prolonged antibiotic therapy. If the edema is associated with an excessive synovial fluid and blood in the joint, you will need a joint puncture to remove theexudate.
A range of movements should gradually increase and restore completely by the end of the 6th week. If the amplitude of knee flexion/ extension is not reaching the norm, then it can be qualified as a failure of physical rehabilitation due to mistaken actions of the doctors or the patient. If the leg cannot bend or is not fully straightened, it may be a result of a contracture of the joint that has developed due to the adhesions between the tendons and nearby tissues. If timely noticed, the condition can be is improved by manual stretching and a long, intensive exercise therapy, functional electric stimulation, etc. In case of severe pathology, surgery aimed muscular mobilization and excision of cicatricial fusion with subsequent rehabilitation is the only option.
It should be noted that the life of knee implants is limited. An implant can last 15-20 years, sometimes a little longer.
Mostly, total kneearthroplastyis successful and allows us to achieve quite positive results in restoring the motor function. But it is worth to mention that there are some exceptions. Negative body response to the anesthesia is one of possible complications during the operation and after the surgery. Also scars or extensive hemorrhage may appear after surgery. However, the most dangerous consequence is the infection of in the joint cavity. And with the following revision operation the risk of infection increases. In case of this complication, surgeons have to remove the infected implant.
The recovery period depends on method, kind of problem treated and patient’s health. The recovery after knee surgery is considered as quite easy, patients start working next day after total knee replacement, but in some cases of injuries it is not the same. In any case, it can take from few weeks till several months for complete rehabilitation. This time can be reduced by using minimally invasive technique.
- First days you should take simple measures to avoid complications
- You should start moving immediately after surgery (starting from moving in your bed and continuing walking)
- You will need crutches or other supporting devices for 1-10 days
- You should start exercising and increase load gradually
- You will need physiotherapy for weeks or even months after surgery
- You should observe yourself and report to your physician.
For successful and quick rehabilitation you need:
- Tailored planning of rehabilitation procedures based on a particular condition and individual features of a patient.
- Day-by-day schedule, including all the aspects of treatment, such as medication course, procedures, and physical exercises.
- Well balanced, gradual and correctly apportioned physical activities.
- Careful monitoring how the patient receives all treatment and recovery procedures.
Each patient needs an individual recovery program after knee surgery, specially developed for him by a medical team, including a surgeon, a rehabilitation doctor, a neurologist, a physiatrist, and others if needed. That means there is no single rehabilitation scheme for all patients. The main purposes of rehabilitation:
- Encouraging an early physical activity of the patient.
- Prevention of respiratory system congestion after surgery.
- Stimulation of regional blood circulation and lymph drainage in the lower limbs.
- Reduction of exudate in the knee;
- Rapid elimination of pain syndrome;
- Prevention of muscle weakness, contractures and tissue adhesion.
- Stimulation of metabolism and tissue regeneration.
- Prevention of infectious in the operated tissues.
- Recovering of limb motor functions.
A doctor will explain to you how to rehabilitate your knee after surgery. Do not try on your own! Incompetent treatmentmay be dangerous, remember this if you do not want your knee hurt and cannot move normally after surgery.
In a hospital, you will be trained how to bandage your leg correctly. First, bandaging is done by nurses, but upon returning home, you will have to do it yourself. Be attentive to everything that the medical staff teachesyou, while you are still in a clinic or rehabilitation center.
How to Improve Your Knee after Surgery
You may start exercising in the supine position from 12-24 hours after surgery and continue till 3-7 days. The frequency of repetition and the daily number of sessions is determined by a physiatrist.
- Carefully raise the operated leg, lifting it by 20 cm over the horizontal surface. The healthy leg is bent at the knee. Hold the raised leg for 5 seconds, and, then, gently return it to the original position. Both legs are slightly bent; the heels rest on the bed surface.
- Strain your thigh muscles. When counted to ten, relax. Hands are along the body; the torso is relaxed.
- Perform an isometric contraction of the gluteal muscles, keeping tension 5-8 seconds. Do until the light burning appears.
- Lying on the back with a rolled towel under the foot, try to bend your leg. The ligaments of the popliteal zone and the muscular structures of the lower leg should be strained. After 5 seconds, relax. The main thing is not to make a greater effort, but to increase the load smoothly.
- The legs rest on the bed straitened. Move your feet up and down, while keeping your heel on the bed. It is useful to alternately move your legs apart, sliding on the sheet. Doveryslowly.
Easy exercises are gradually supplemented with more difficult ones. Here are some examples.
- Stand by the wall or next to a chair to have a support. Slowly raise the straightened operated limb forward till 45 degree. Keep your leg in this position for 5 seconds, and gently return it to the original position. Do not forget to hold the support with your hands.
- Do the same exercise as the previous one, but move your foot to the side. With your hands on to the back of the chair, extend the limb aside (without jerking!) and slightly raise it up. Holdon for a few seconds and return to the initial position. Keep your balance.
- Lie down on your back; put a cushion under the operated knee. With support on the cushion, straighten the leg. Keep the straightened position for about 5 seconds, and, then slowly return the leg to its original position. Do this smoothly to prevent chance injuries.
After 2-3 weeks you can do more active exercises, as following:
- Semi-squats near the chair (do not bend your knee at an angle more than 90 degrees) Try to stand on your entire feet.
- Stretching exercises, for example, flexing the knee while holding the foot in your hand and lifting it to the buttocks. If you, at the same time, move the pelvis forward, the stretching effect will increase.
- Resistance exercises using a rehabilitation expander or a rubber tourniquet. You can come up with a lot of exercises with a tourniquet.
- Step (from the front and side) on the step-platform transferring body weight to the operated leg with its further straightening. Alternate the legs when doing this exercise.
- Riding a stationary bikewithan easy mode of pedal resistance, and, then, gradually increasing it to an average and heavy mode. This is the best simulator for rehabilitation.
- Walking on a treadmill: begin with a slow pace for 10-minute, then, gradually increase the speed and time; aqua gymnastics and swimming in the pool. We recommend practicing in the pool.
While exercising, listen to your own feelings: you must control the threshold of acceptable pain, not exceeding it. Overloading is not allowed! Unbalancedeffortscan lead to a painful edema. How long it will last, depends on how much harm you caused the knee. But what is really not good, swelling and pain will slow down the recovery of the joint.
First of all, it is important to pinpoint and define the knee pain. Where, how and when exactly do they occur?
Depending on the location, a distinction is made between four different types of knee pain: the front, the outer and the inner and the popliteal pain.
The anterior knee pain affects the front of the knee joint, thigh and lower leg and kneecap.
The popliteal pain refers to pain that occurs at the back of the knee joint in the popliteal fossa.
Internal knee joint pain is when the inside of the knee joint, the inner knee joint gap and the inner thigh and lower leg are affected.
Analogously, the external knee joint pain originates from the outside of the knee joint and affects the outer knee joint gap as well as the outer thigh and lower leg.
Furthermore, a distinction is made between two types of knee joint pain: acute and chronic knee pain.
The acute knee pain often occurs suddenly and only last a short time (a few hours to several days), while the chronic knee pain usually creeping and persist for a long time (six weeks to three months).
In order to be able to define knee pain accurately, it is also important to know when exactly they occur. Thus, knee pain can occur either with specific movements and stresses on the knee joint, such as when climbing stairs and walking, or even at a standstill with a bent or stretched knee.
In order to be able to successfully treat knee pain, the causes of the pain in the knee must first be clarified. The pain can be caused, for example, due to diseases, injuries, malpositions and over- and wrong strain of the knee. While in younger people, the knee pain is often caused by injury and growth, in older people usually wear and tear is the reason for the suffering.
The most common cause of disease-related knee pain is knee osteoarthritis (gonarthrosis). It involves the wear of the articular cartilage and the consequent loss of lubricity of the knee joint, resulting in the painful rubbing of the articular surfaces.
In addition, inflammatory diseases such as knee arthritis (gonarthritis), ie inflammation of the knee joint, and rheumatoid arthritis of the knee joint (joint rheumatism) may be responsible for knee pain.
The most common knee injuries include the cruciate ligament tear and meniscal tear.
Overload and overuse are usually the result of being overweight or exercising excessively.
In addition, knee deformities such as X- or O-legs as well as knee instability and the stiff knee can be the cause of severe knee pain.
In order to understand which of the causes listed above is responsible for a patient's knee pain, either the family doctor or an orthopedic specialist performs a thorough physical examination with a variety of exercise tests and a patient history taking a first visit to the doctor.
It is important that the doctor, after talking with the patient, knows exactly what type of knee pain is, where and when they occur, and whether they are predominantly exposed to stress or retired.
In addition, the doctor can further reduce knee pain by asking patients about their pre-existing conditions, existing knee injuries and accidents.
Subsequently, x-ray examinations, ultrasound examinations (sonography) and magnetic resonance imaging (MRI) can be used to more accurately visualize and assess the bony structures of the knee joint as well as the ligaments, menisci and articular cartilage. If an inflammatory cause of knee pain is suspected, knee joint puncture may also be performed, taking joint fluid for further laboratory analysis.
Depending on the type of prosthesis and the individual circumstances, one calculates for the operation with one to two hours.
The inpatient stay after the procedure is usually two to three weeks. The physiotherapist begins mobilization on the first day after the operation. Following the hospital stay, an intensive rehabilitation phase follows in a corresponding rehabilitation clinic or on an outpatient basis. It usually takes about three months, in rare cases up to a year after surgery, until you can walk normally.
Arthroscopic Knee Surgery
Before this surgery a patient signs an informed consent statement for operative treatment and anesthesia. These documents define what kind of anesthesia will be applied during the arthroscopic knee surgery. Small incisions are made on skin, in the area of the knee joint. Microsurgical instruments and microscopic digital camera are inserted via these incisions inside. The surgeon tracks all actions during the surgery or diagnostic procedure on the screen. The image can be magnified up to 60x that gives a surgeon maximally precise picture. Due to the arthroscopic knee surgery it is possible to avoid knee joint replacement. One more advantage is the ability to leave bed in a few hours instead of a few days as it was before.
At the beginning, arthroscopy was only a convenient diagnostic method. However, the rapid progress of medical technologies made it possible to switch from diagnostic arthroscopy to therapeutic.
If at the very beginning arthroscopic surgery was limited to the simplest purposes – for example, removing of a damaged part of the ligament and fragments of the meniscus, later on, in the 70s and 80s of the last century, arthroscopy had reached such a level, that the majority of surgical interventions became possible without opening a joint.
Using special micro-tools increases the accuracy of surgery and makes it minimally traumatic, enabling, at the same time,preservationof healthy tissues. To accurately remove damaged areas and, at the same time, to keep healthy parts of the joint as much as possible, a surgeon needs high skilland a lot of experience.
- Anterior cruciate ligament rupture or injury
- Meniscus injury
- Debride in the knee joint cavity
- Rheumatoid arthritis
- The existence of unidentified loose bodies in the cavity (cartilage flaps, loose meniscus fragments).
- Knee arthrosis deformans
- Liquid accumulation
- Failed surgeries performed before
- Joint fractures
- Chronic fat pad hyperplasia
- Arthropathy deformans
Absolute contraindications (conditions in which a surgeon rejects surgery without doubts):
- Poor general health of the patient whenany surgical interventions are contraindicated.
- Purulent inflammation in the tissues around the joint, as infection can get into the joint.
- Infected wounds.
- Bony or fibrous ankylosis, a condition in which the articular cleftis filled with bone or dense connective tissue causing immobilization of the joint. You can see this on anX-ray picture.
This method is used both as a surgical intervention and as a diagnostic procedure. If it is used for both purposes at the same time, we speak about therapeutic and diagnostic arthroscopy.
The knee joint mobility is provided by the ligamentous apparatus - the anterior and posterior cruciate, medial, and lateral ligaments (these ligaments are located on the outside).
Ligament damages often occur in case of injuries (falling, bruises). As a result of trauma the patient experiences strong pain sensations and cannot make full movements, bending a leg in a knee. Therefore, in such cases, the plastic of cruciate ligament is prescribed.
The anterior ligament of the knee joint length is approximately 40 mm, the posterior ligament is 30 mm. Each of them is actively involved in the stabilization of the joint, so if damaged, the patient cannot bend the leg at the knee fully. Arthroscopy procedure allows a physician to diagnose a specific injury area, remove inflammatory processes products and restore ligament tissue.
Knee ligaments arthroscopy is carried out to restore their anatomical mobility, and is performed using live biological tissues (popliteal muscles tendons or patellar tendons) or neutral artificial materials, called transplants.
A bioresorbable element, which is a self-absorbable implant that restores the natural stabilization of the joint, is installed as a fixative.
The anterior cruciate ligament is the most vulnerable to traumatic effects, therefore, injuries of this department are recorded in surgery most often. When talking about the knee stabilization surgery, first of all, the plastic of the anterior ligament is meant.
During arthroscopy procedure damaged tissues are removed through a perforated hole (all doctor's actions are visible on the monitor with 40-60-fold zoom) and replaced with a transplant.
The surgeon must create the anatomical structure as close as possible to the natural one, providing a normal ligaments tension and the natural amplitude of movements. The fact that athletes after surgical arthroscopy show high results in international competitions, without experiencing any pain, excessive fatigue or discomfort during movement is the best evidence of this technique's high efficiency.
The posterior cruciate ligament damage is a severe trauma and, fortunately, not a common one. Causes - a fall from a height, an accident, gunshot and knife wounds. Arthroscopy of the posterior cruciate ligament plastic is classified as a complex operation, and is performed under general anesthesia.
Arthroscopic meniscus resection
Meniscus rupture occurs as a result of a strong mechanical effect (blows, falls). Professional athletes, circus performers, dancers are at the greatest risk. Trauma is accompanied by severe pain and limb mobility loss.
Arthroscopic meniscus resection is a minimally invasive surgery, with the purpose of the removal of the damaged fragments of the articular part. Meniscus rupture can be:
- Total (full);
- Fragmentation (when crushing the knee);
In this case, the operation is prescribed to restore after a meniscus rupture. The main surgery purpose is to remove ruptured parts, as well as products of inflammatory processes, and suppurations.
The damaged part of the meniscus is subjected to resection (cut off), after making a small incision (0.5 cm in diameter). One day after, the patient can already stand on the injured leg, and after 2 weeks he can withstand simple loads. Due to the complete removal of the damaged parts, it is possible to do sports and make heavy loads after 1-2 months using special sports knee pads.
Since the trauma is accompanied by the strongest pain syndrome, the patients do not hesitate visiting the specialist, and this fact increases the chances of a complete cure. After surgical arthroscopy for partial or complete resection of the meniscus, the patient can stand up several hours after operation has been performed, and D/C occurs after 1-2 days if there are no signs of complications.
Sanation of the articular cavity
The efficiency of the knee joint's sanational arthroscopy, prescribed to patients with rheumatoid arthritis, is proven over time. The use of an irrigation device with an outflow system, through which medicinal solutions are injected, allows the removal of pathological formations fragments (urate crystals, cartilage detritus, fibrin flakes, cytokines) from the articular cavity. Anti-inflammatory drugs injection is the final stage of the arthroscopic procedure.
Within a few hours after arthroscopy, a positive therapeutic effect is observed, which is expressed in the cessation of pain, reduction of swelling and hyperemia in the knee area, and expansion of the movements amplitude. This surgical procedure is also valuable thanks to the fact that after it is carried out, the need for taking painkillers and anti-inflammatory drugs that increase the load on the liver is reduced.
As a diagnostic method, this procedure is used to analyze such diseases and disorders:
- Blood in the knee (hemarthrosis);
- peculiarities of the synovial membrane condition – presence/absence of inflammations;
- the presence / absence of chondromic bodies in the joint;
- peculiarities of articular cartilage condition (uniformity of tissue, dimensions and forms of damage, smoothness and elasticity of cartilage surface are checked);
- condition of ligaments (their general condition, density, tone, features of damages);
- joint dynamic characteristics analysis (slipping, displacement);
- condition of the tendons.
Diagnostic knee joint arthroscopy is performed to confirm the diagnosis, especially in cases where the clinical picture remains unclear.
This is a modern method of examination, which allows to determine the cause of the violation with maximum precision and choose the appropriate treatment methods correctly. The diagnostician in the clinic inserts an arthroscope to study the patient's condition and analyze the complications based on the pictures received - this is the essence of the technique. The procedure is not expensive,most patients can afford it.
Skin and soft tissues perforation is performed at the knee joint, in the area of the joint space, (incision length does not exceed 6 mm). An arthroscope with a light source turned on is inserted into the holes, illuminating the area of the intra-articular space.
Joint examination during arthroscopy is carried out in the following sequence:
- Synovial membrane's state examination (color, vascular pattern, folds presence and their state).
- Femoropatellar area examination. The cartilaginous patella tissue is examined for the presence of cracks, necrotic areas, and pathological growths. The density of the cartilage is determined using a probe inserted into the anterior medial part. The condition of the wing folds is assessed.
- Lateral, and medial pockets examination. Pathological hemorrhage sites, as well as pathological intra-articular bodies, ruptures of the synovium in the sites of the lateral ligaments attachment are revealed.
- Medial meniscus examination. The knee is bent at 150 degreesangle, the device is transferred to the plane of the medial joint space. This perspective helps to examine the body of the meniscus, and the articular cartilage of the tibia, with much more precision.
- Detailed examination of the medial joint space. To inspect the back of the lower leg, it should be bent at 100 degreesangle.
- Investigation of the intercondylar hole and adipoid joint area. The joint is bent at 160 degrees, the arthroscope is transferred to the femoropatellar department area and moved along the vertical axis to the point of "the gap".
- Anterior cruciate ligament condition examination. Tension degree, and the state of the synovial membrane are determined.
- Examination of posterior cruciate connection (bending at 90 degrees with internal rotation of the lower leg).
During the examination, the doctor is using the probe, which allows to assess the tissues density.
For better visibility and accuracyduring arthroscopy, the operating field is exsanguinated. For this purpose, a pneumatic tourniquet is applied to the thigh to prevent bleeding, which is attained by inflating the cuff of the tourniquet.
Since using tourniquetsincreases probability of side effects (severe pain, circulatory disorders in the operated limb, thromboembolism, etc.), before it is applied, the limb is tightly wrapped with an elastic bandage to ensure safer exsanguination.
Important! Simultaneous application of the tourniquets on the both legs causes an increase in intracranial and arterial pressure, which can lead to serious complications if a patient has cardiovascular diseases (coronary heart disease or left ventricular hypertrophy). The duration of the surgery should not exceed two hours, as adult patients may develop irreversible damage to the peripheral nerve, whilst in children, a critical increase in body temperature may occur.
Pain derived from squeezing thelimbwith the tourniquet is called a “tourniquet pain”. It is characterized by a gradual increase and resistance to pain management with local anesthetics. This fact is takeninto accountwhen surgery is planned to set a proper duration and type of anesthesia.
Since arthroscopy involves minimally invasive incision of the knee, the anesthesiologist conducts a number of diagnostic activities and pre-selects an effective anesthetic. Besides, when choosing anesthesia, it is important to consider the surgery duration. Here's what you need to learn about anesthesia before the procedure:
- Local anesthesia. It is commonly used when carrying out a diagnostic method for determining the pathology, it has a short-time effect, and provides a mediocre effect.
- Conductive anesthesia. Requires an intra-articular injection of lidocaine, the analgesic effect is maintained for 1-2 hours at most.
- Epidural anesthesia. It's the most common modern anesthesia method with minimum contraindications, which allows the patient to remain conscious and to control the process of the operation.
- General anesthesia. Such an “obsolete” method of anesthesia is used extremely rarely, because it has a lot of medical contraindications and damages health considerably.
The surgery is performed under general anesthesia. Epidural (spinal) anesthesia is possible only in case of serious comorbidity or minor defects requiring minimal correction.
A tourniquet is applied to the middle part of the thigh to stop the blood supply and minimize the intensity of bleeding. For arthroscopy above and below the knee, three small incisions are made: a central one and two lateral ones. Incisions length does not exceed 3-5 cm. Then three specially designed devices, arthroscopes, are inserted into the articular cavity. One of them is a light source that has a camera element attached to the end. The surgeon receives an enlarged, high-resolution image on the screen. All the necessary manipulations inside the knee joint are carried out through the third device. The cavity is filled with a transparent aseptic solution, increasing the pressure in it. For greater convenience and to increase the review,
The main arthroscopy therapy measures include the meniscus removal, ligament stitching, transplant implantation, blood clots aspirations, fibrin, fragments and damaged structures, patella stabilization, etc. At the final stage of arthroscopic surgery, the joint cavity is examined one more time, washed with a sterile liquid, antibiotics, then solutions are completely pumped out. Bleeding vessels are coagulated. The total surgery duration ranges from 40 minutes to 1.5 hours.
The incisions are stitched in layers with several sutures and covered with sterile gauze or plaster. On top of the knee joint a pressure bandage is applied, which is changed as and when necessary. The stitches are removed on the 7th to 10th day after arthroscopic surgery. At the doctor's discretion, drains can be left in the postoperative wound, which are removed the next day.
The main advantage of arthroscopy is no need for almost complete knee joint cavity opening, as well as less affection of the surrounding structures and tissues, significantly reduced healing time, rapid recovery of the patient's function and working ability.
Hospital stay: Knee arthroscopy is usually performed on an outpatient basis or in case of previous illnesses and/or lack of home care. The patient has to be under the doctor's supervision, he receives painkillers (nonsteroidal anti-inflammatory drugs, analgesics). In some cases, there's a possibility of short-term gypsum splints application to immobilize the knee joint. In case of persistent intense pain, the patient stays in the unit for a little while.
To prevent vascular disorders and edema, 7–9 days of hypodermic anticoagulants injections (heparins) are prescribed. To prevent the joint infection development during and after surgery, treatment with a broad-spectrum antibacterial drug is necessary.
During the rest, the leg is fixed in an elevated position, it is allowed to attach a heating pad with ice to the joint for a short time (up to 7-10 minutes several times a day).
A good thromboembolic complications prevention measure after arthroscopy is wearing an elastic tissue bandage made of class 2 compression for the first 10-14 days, which is applied on the operated lower limb from the toes to the middle of the thigh.
The patient is allowed to get up and gradually expand his motions range right from the first day. The use of crutches is not required, except severe cases, elderly patients, and complications. The resumption of the usual knee joint load and flexion movements are allowed a week after the operation. As an additional measure, gymnastics is prescribed 2-3 times a week to prevent the development of muscle weakness, and atrophy. One week after arthroscopy, it is recommended to conduct a stationary bike low resistance training.
Each case requires an individual exercise intensity and time calculation with a gradual increase in loads on the knee joint.
In the early postoperative period, it is advisable to avoid thermal, warming, and water procedures. Visiting the pool, bath, sauna, or solarium is prohibited.
During the year after arthroscopy, it is not recommended to engage in sports such as jogging on a hard surface, jumping, exercises associated with the shuttle movements and maximum knee joint extension with additional load.
Arthroscopic surgery in crucial ligament injury
Anterior cruciate ligament is the main stabilizer of the knee. Injuries give the feel of instability and uncertainty of moves. Instability and problems in joint mechanics lead to further damage of medial and lateral meniscus and cartilage.
Arthroscopic cruciate ligament surgery provides much less load on the joint compared to the open surgery. The key of success is precise location of bone canals in the initial cruciate ligament structure.
Comparing with other surgery techniques, arthroscopy has a number of advantages:
- Low traumatism. It does not involvecutting a 10-20 cm long incisionto open the joint cavity, sothe tissues surrounding the joint get minimal damage. To introduce an arthroscope and surgical instruments, a cut of 0.3-0.5 cm is sufficient. In most cases, the incision is not even sutured: itsuccessfully heals without suturing.
- Withjoint arthroscopy, the patient,as a rule, can be discharged on the same day as surgery, but after open interventions– only after 10-14 days.
- Aarthroscopy is well tolerated by patients as it produces fewer pain, swelling, and joint exudate.
- Postoperative complications, such as cicatricial contracture of the joint, infections of the joint cavity, and excessive bleeding, develop very rarely.
- Prolonged immobilization of the joint with a plaster cast is not required as after open arthrotomy.
- Minimal rehabilitation period:the patient recovers quickly and can return to normal activities soon. After open surgery, workability is restored on average in 4-6 weeks, whilst after arthroscopy in 2-3 weeks.
- The scar left after surgery is small and unobtrusive.
- Some procedures became possible only with the implementation of arthroscopy. For example, removing chondromas that block the joint and cause pain, as well as treating chondromalacia of the joints.
Arthroscopic knee surgery costs approximately 5.600 €. You should plan at least two days of inpatient stay. Complex arthroscopic surgery aimed at fixing meniscal tears costs slightly more: 7.000-8.000 €. Arthroscopic therapy in cartilaginous tissue or cruciate ligament injuries costs 3.500-6.000 €, depending on the amount of damage. Additional diagnostic services such as MRI or CT will cost up to 800 €.
Orthopedic centers provide ability for an accompanying person to stay in one room with a patient, it would cost 55-100 € a night. Our specialists will answer all your questions regarding arthroscopic knee surgery.
Knee Replacement Surgery
In German orthopedic clinics a variety of innovative methods of treatment are applied to treat arthrosis, with the most radical one being a knee replacement surgery. With the help of the complex therapy orthopedic clinics in Germany provide high efficiency of the surgery.
On the pages of our website German medical group, the best clinics in Europe are presented, which offer treatment of such a disease in the field of orthopedics as arthrosis of the knee joint (knee replacement surgery). endoprosthesis replacement (implantation of artificial prostheses) of the knee, shoulder and hip joints. The German orthopedic centers offer the following methods of the arthrosis treatment:
- endoprosthesis revision after knee replacement
- Endoscopic joint surgery on the knee and shoulder joint
- open surgery on the knee, shoulder, hip and ankle joint
- arthroscopy of the knee joint with the usage of the whole range of arthroscopic techniques (surgery on the meniscus, cartilaginous tissue surgery)
- endoprosthesis replacement
- open surgery for knee replacement
Knee repair without cutting the sensitve joint has always been the aim and the desire of the orthopedicians. The realization of this desire has started at the beginning of the 90s. Now it belongs to the very efficient method of knee joint treatment, cruciate ligament, cartilage and meniscus repair. Usually only two small incisions of approximately 3 mm are needed for an arthroscopic operation. Within the arthroscopic procedure the skilled surgeon can assess any damage in the knee joint with the mini camera. The advanced optics used at German orthopedic centers provide the highest precision possible. The cost of such a treatment makes up about 6 000-8 000euro.
However, only the early stages of arthrosis can be treated with the arthroscopic methods. If the knee surgery cannot be avoided, don’t look further than Germany. The German orthopedic surgeons are known all over the world for conducting the most successful knee and hip replacement procedures.
Knee replacement surgery is aimed at replacing the bearing surfaces on artificial implants, which will return motion activity to the limbs. The new parts of the knee are fixed in the femoral bone and shin bone with the help of surgical instruments. In case of the total knee replacement the whole joint is replaced.Together with muscle and other soft tissues the installed implants start to support the axis of the limb, thus restoring its features.
One of the most important components in the treatment of arthritis by means of endoprosthesis is the biocompatibility of an implanted construction with the inner environment of the body. Another important part is age-related changes in the anatomy of the knee joint in men and women. Exactly thanks to such a precautionary approach, his work is appreciated by clients. The German specialists use prostheses, in creation of which the gender differences of the mechanics of the knee joint for the both sexes were taken into consideration. The metal alloy of the medical device includes resistant components: molybdenum, cobalt, and chromium. The sliding surface of the endoprosthesis is made from high-strength plastic material DCM, according to a special pressing technology.
In a partial denture of the knee, certain components of the knee joint are replaced by artificial implants. In contrast to a complete knee prosthesis, however, only parts of the joint are replaced in the partial denture - functioning parts of the knee are thus retained in the partial denture.
Basically, the expert speaks in prostheses to be implanted by an endoprosthesis. Surgery is understandably inevitable for this treatment as damaged or diseased parts of the joint must be removed and replaced with artificial ones.
Depending on how strongly the function of the diseased knee joint is affected, different types of partial dentures are used, the individual condition of the joint is crucial. One of the most commonly used forms of partial denture is the so-called "sled prosthesis". With the aid of this prosthesis, relief can be provided for unevenly damaged cartilage surfaces without immediately replacing the entire knee joint.
Partial prostheses of the knee joint can be used in a variety of diseases, the most common partial denture treated diseases include osteoarthritis, in which the cartilage surfaces of the joints are excessively worn.
Even with joints damaged by advanced arthritis, the use of a prosthesis or partial denture is often necessary.
Partial dentures are now made of high quality materials to allow for optimal durability and compatibility of the implant. As a rule, special alloys are used. Commonly used among other mixtures of cobalt, titanium or chromium. In patients with allergy to certain metals, special alternatives may also be used to minimize an allergic reaction.
Mode of action
The principle of action of the unicondylar joint replacement, also called a sled prosthesis, consists in supplying the arthrosis, which has only been detected on one side, on one side (inside or outside). In this case, only the inside (in 90% of cases) or the outside of the joint (10%) are revealed over a smaller incision than in a complete knee replacement. There, the lower and thigh portions of the prosthesis are then installed on only one side. These are a small metal blade in the area of the thigh and a small plate in the area of the lower leg, which is provided with a movable or non-movable plastic onlay. The advantage of the sled prosthesis is that the procedure is smaller and the patient is thus faster mobile again and that usually lower pain and a lower complication rate are associated with it.
The insertion of a carriage prosthesis is exemplified on the inside. In order to install a medial slide, ie a partial denture for the inside of the knee, only one about 8 cm long cut on the inside of the knee joint is required. Then, assuming that the other cartilage structures are still intact, only the inner upper and lower leg portions are exposed and replaced by prosthetic material. The anchoring can be cemented or cementless. Most of the prostheses are currently implanted cemented. However, there is a trend towards cementless supply.
Prerequisite for slide implantation is, as already mentioned, only one-sided arthrosis with little damage behind the kneecap and an axial deviation in the direction of the built-in carriage. Because in order for an inside slide to be used, the patient must have an axial misalignment in the sense of an O-leg. An overcorrection X-leg direction after installation of the carriage is not desired. It should remain a small malposition.
If a knee joint is replaced by a partial prosthesis, the question of resilience naturally arises for all concerned. This especially for the patients who need a partial denture already at a relatively young age.
Due to the constant progress in medicine and especially in medical technology, today implants can be made that allow the patient a nearly optimal function of the knee joint.
Of course, it takes a certain amount of time before the implant can be loaded after surgery, in addition, a professional support by physiotherapy, especially in the early days is indispensable.
If both surgery and rehabilitation have been completed without complications, even a partial denture in the knee will allow a comfortable life. The burdens of everyday life usually pose no major problems - however, it is of paramount importance that patients seek advice from their doctor in this regard, in order to avoid overburdening.
In the case of an optimally developed treatment even moderate recreational sports such as, for example, Nordic walking, or under certain circumstances also jogging, can be operated even with a partial knee prosthesis. However, this is highly dependent on the degree of damage to the affected knee joint and therefore not possible in all cases, or recommended.
In younger people, the long-term strength of the prosthesis is not guaranteed in some cases until the end of life, even if the prostheses used have become more and more durable over time. This can lead to follow-up operations, which, however, often have to be set only after decades of exposure.
The chances of success of the sled prosthesis are high. It is a successful, quite fast, yet demanding operation. The patient has less pain than with a bicondylar resurfacing and is faster mobile again. However, the revision rate, ie the rate of re-operation of the sled prosthesis in the first ten years, is three times higher than in bicondylar resurfacing. This shows that, on the one hand, it should be very well considered whether joint replacement with a sled prosthesis is really appropriate, and, on the other hand, as scientific studies confirm, surgery should only be performed by a very experienced surgeon.
What are the advantages compared to a full denture?
Partial dentures can be used with so-called "minimally invasive surgical methods". The instruments and prostheses are introduced only by small cuts. Tissue and soft tissue are maximally protected, the blood loss and also the danger of an infection are clearly smaller. The great advantage is that all partial surgical prostheses halve all surgical risks. The procedure itself is technically more sophisticated and more delicate than the implantation of a full denture, but it only takes about 45 minutes. The patient can get up the same day, fully load and move the operated knee. Many patients feel that they can resume their usual activities after only a few weeks. Compared to the total denture, the convalescence time is shortened considerably.
How durable are partial dentures in the knee joint?
The durability of a partial denture is usually between 10 and 15 years. The first two years are critical. When complications occur, then often in this time window. Cause are mostly surgical technical problems. These express themselves, e.g. in pain, because the prosthesis is not sitting properly. When these two years are over, the prosthesis holds 10 years in 95% of the patients, 15 years in 92% and even 25 years in at least 82% of all patients. In the near future, more could do so than the already massive improvements in polyethylene quality in recent years. Significant progress has also been made in surgical techniques: robot surgery supported by computer navigation is on the rise. This will certainly help to make knee joint prostheses even more successful in the future.
In principle, it is advisable to have sufficient advice before using a partial denture in the knee joint and - depending on the possibility - to deal with alternative treatment methods.
If the decision has been made for a partial denture and the implant has already been used, care and proper handling of the joint are still important.
For example, even beyond the rehabilitation phase, special physiotherapeutic exercises should be performed to ensure the function of the prosthesis and to support the entire joint with a strengthened musculature.
In general, the muscles have a major impact on the function of the knee prosthesis, as a strong and healthy muscles can relieve them and thus support.
Of course, the exact exercises should be arranged for safety with trained physiotherapists.
Furthermore, care must be taken to avoid falls or other acts of violence necessarily, since the prosthesis can otherwise be damaged or moved because it does not have the stability of a natural joint in falls etc.
Especially during the rehabilitation phase, patients are often a little unsteady on their feet, so that the risk of falling is not to be underestimated.
For this reason, for example, as a sports activity and training method for the supporting muscles especially the cycling on a stationary device or swimming, since the risk of (fall) injury is low.
In particularly difficult cases a knee prosthesis replaces the whole joint. A total knee replacement replaces the affected joint with the specially manufactured components, eliminating the damaged bearing surfaces and thus eliminating the source of pain.
After conducting operations (endoprosthesis replacement of different joints, arthroscopy, ligament replacement, operations for restoration of the meniscus and other surgery) the othopedic clinics take a compulsory set of measures for rehabilitation in order to eliminate different effects of the surgical intervention (swelling, pain), and restore the joints.
The average joint replacement cost varies from 9 000 EUR-15 000 EUR and more. The total cost depends on many factors. The price includes, as a rule, an intensive rehabilitation course, guided by an experienced physiotherapist.
Kommt eine gelenkerhaltende Therapie aufgrund der Gelenkzerstörung oder altersbedingten Gründen nicht in Frage und sind die bisherigen konservativen und operativen Maßnahmen (Physiotherapie, Schmerzmedikamente, Gelenkspülungen, etc.) ausgereizt, erfolgt das Einsetzen einer Knie-Totalendoprothese (Knie-TEP).
Oberstes Ziel der Operation ist ein schmerzfreies, stabiles und gut bewegliches Kniegelenk, wobei die natürliche Beinachse wiederhergestellt wird. Die in den letzten Jahrzehnten ständig verbesserten Operationstechniken und Implantate machen diesen Eingriff zu einer der häufigsten und erfolgreichsten Routineoperationen (europaweit ca. 150.000/Jahr) in der orthopädischen Chirurgie.
Bikondyläre Prothesen ersetzen die Gelenkoberflächen des inneren und äußeren Gelenkanteils unter weitgehendem Erhalt der körpereigenen Bandstrukturen. Ober- und Unterschenkelanteil sind nicht mechanisch miteinander verbunden. Sind die Bandstrukturen geschädigt kann durch eine zapfenartige Verbindung beider Komponenten eine Stabilisierung des Gelenkes auch bei fehlenden Bändern erreicht werden. Die früher vielfach gebräuchlichen achsgeführten Knieendoprothesen verzichten, unter Resektion großer knöcherner Anteile, gänzlich auf den Erhalt der patienteneigenen Bandstrukturen. Diese Prothesen kommen nur in Ausnahmefällen zur Anwendung.
Die einzelnen Prothesentypen gibt es in verschiedenen Größen; mit Hilfe der präoperativen Planungsskizze werden Modellgröße und Fixation der Prothese bestimmt, wobei hier individuelle Bedürfnisse berücksichtigt werden (Alter, Geschlecht, Knochenform, Körpergewicht, etc.). Anhand der Planung werden auch die Achsen des Beines vermessen und die Prothese in ihrer Ausrichtung geplant.
Bei der Implantation unterscheidet man verschiedene Fixationstechniken: Die zementierte Knie-TEP ist weltweit der Goldstandard. Hierbei werden die Implantate mit antibiotikahaltigem Zement im Knochen fixiert. In seltenen Fällen kann auch eine zementfreie „press-fit“ Verankerung durchgeführt werden. Abhängig von der Fixation bestehen die Komponenten entweder aus Titan oder einer Chrom-Kobalt- Legierung. Als Gleitpartner zwischen den ersetzten Oberflächen wird ein Polyethylen-Einsatz (Inlay) ein-gebracht.
Gelenkersatzoperationen werden ausschließlich unter stationären Bedingungen durchgeführt. Zur Gewährleistung eines optimalen Operationserfolges erfolgt eine frühzeitige postoperative Mobilisation mit Hilfe der Krankengymnastik, wobei abhängig von den erwähnten Implantationstechniken meist eine sofortige Belastung des operierten Beines erlaubt wird. Zum Schutz des Weichteilgewebes müssen für 4-6 Wochen Unterarmgehstützen verwendet werden.
Für den überwiegenden Teil der Patienten schließt sich nach einem Klinikaufenthalt von ca. 7-10 Tagen ein 3-wöchiger Rehabilitationsaufenthalt an. Im Rahmen regelmäßiger, engmaschiger ambulanter Kontrolluntersuchungen werden die Fortschritte der Patienten dokumentiert und ggf. eine ambulante Fortsetzung der mobilisierenden Therapie verordnet.
Gelenkersatz und Sport
Verbunden mit einer schweren Kniegelenkarthrose ist eine deutliche Einschränkung sportlicher Aktivitäten. Die durch den Gelenkersatz erzielte Beschwerdefreiheit lässt den Wunsch nach teilweiser Rückkehr zum Sport aufkommen. International besteht Einigkeit, dass zumindest so genannte „low-impact“ Sportarten, wie Fahrradfahren, Schwimmen, Segeln, Tauchen, Golf und Kegeln unterstützt werden können. Bedingt möglich sind Sportarten wie Tennis, Basketball und Skilaufen. Vermieden werden sollten Kontaktsportarten (Fußball, Handball, etc). Die Empfehlung zu einer bestimmten Sportart ist auch abhängig von dem Leistungsstand des Patienten. Als Faustregel gilt, dass vor der Operation beherrschte Sportarten wieder durchgeführt werden dürfen.
The lаst 10 years witnessed the increаsed number оf knеe replаcement surgeries. Abоut 500 000 of such оperаtiоns аre perfоrmed in Germany аnnuаlly. The аrtificiаl knee jоint is due tо replаce the dаmаged pаrts оf the knee jоint. The аim оf knee replаcement surgery is perfect mоdeling оf the implаnt. The better the аrtificiаl jоint is pоsitiоned, the less mаteriаl аbrаsiоn аrises, which prоlоngs the durаbility оf the prоsthesis.
Usuаlly the knee replаcement implаnts cоnsist оf three prоsthetic pаrts: the twо implаnt pаrts аnd а rоtаting surfаce mаde оf speciаl biоcоmpаtible pоlyethylene mаteriаl. The typicаl knee replаcement implаnts substitute the end pаrts оf the femur (thigh bоne) аnd tibiа (shin bоne). The pоlyethelene pаrt is put between them tо prоvide the smооth rоtаtiоn.
The knee replаcement implаnts prоduced in Germаny аre designed tо fоllоw the cоntоur оf eаch pаtient’s unique knee аnаtоmy, which guаrаntees the mаny yeаrs оf service. The size оf the prоsthetic pаrts is defined individuаlly. А speciаl digitаl X-rаy befоre surgery аnd 3/D mоdeling prоcedures give the surgeоn infоrmаtiоn аbоut the аpprоpriаte size оf the knee jоint prоsthesis.
Generаlly, there аre twо clаssic designs оf the cоmplete knee resurfаcing implаnts: sliding аnd fixed knee systems. The technicаl difference is in this cаse in the mоbility оf the sliding surfаce cоmpоnent. The brаnd аnd design оf the knee replаcement implаnts used by yоur dоctоr оr hоspitаl depends оn mаny fаctоrs, including yоur needs, bаsed оn yоur аge, weight, аctivity level, аnd heаlth.
The knee replаcement implаnt cоmpоunds аre designed sо thаt metаl pаrts аlwаys аlign with plаstic оnes, which аllоw tо eliminаte the weаr.
- Pоsteriоr-stаbilized knee replаcement implаnts
- Cruciаte-retаining knee replаcement implаnts
- Unicоmpаrtmetаl implаnts (pаrtiаl knee replаcement surgery)
The pоsteriоr stаbilized (PS) tоtаl knee replаcement implаnts presuppоse the intercоndylаr femоrаl bоne extrаctiоn priоr tо the implаnt inserting. It mаkes the cruciаte substituting implаnt designs less spаring аnd thus less аpeаling.
If the X-rаy exаminаtiоn shоws thаt оnly оne cоmpаrtment оf the knee is dаmаged (either the mediаl оr lаterаl) а mоre spаring surgery might be the better оptiоn.
Оne аlsо differs between fixed beаring knee replаcement implаnts аnd the mоbile-beаring prоsthesis (knee replаcement implаnt). In the first cаse the pоlyethylene pаrt оf the tibiаl cоmpоnent is аttаched firmly tо the metаl implаnt beneаth. The yоunger pаtients get mоbile-beаring knee replаcement. In this cаse the pоlyethylene pаrt cаn rоll inside the metаl tibiаl compound. Cоmpаred with fixed-beаring implаnt mоdels, the mоbile-beаring knee replаcement implаnts need better suppоrt оf the ligаments аrоund the knee. If the ligаments аre nоt strоng enоugh, mоbile-beаring pаrts cоuld dislоcаte, which is аn indicаtiоn fоr surgicаl revisiоn.
Cemented versus uncemented knee replаcement implаnts
Twо types оf fixаtiоn аre used stаbilize the knee replаcement implаnts. The cemented fixаtiоn uses а fаst-curing bоne cement, which reliаbly fixes the implаnt tо the bоne structures. Cementless fixаtiоn relies оn new bоne grоwing intо the surfаce оf the implаnt. The Germаn speciаlist mаy аlsо use hybrid type оf knee replаcement implаnt fixаtiоn.
It meаns thаt the femоrаl pаrts аre inserted withоut the cement аnd the оther pаrts (the tibiаl аnd the pаtellаr оnes) аre inserted with the cement. Yоur speciаlist in Germany will perfоrm аll the necessаry exаminаtiоns in оrder tо decide whаt kind оf fixаtiоn wоuld be mоre аpprоpriаte аnd reliаble in yоur individuаl cаse.
The use оf cоmputer nаvigаtiоn during оperаtiоns оn endоprоsthesis аllоws tо аchieve the fоllоwing results:
- The lоngevity оf the prоsthesis is increаsed (due tо prоper instаllаtiоn)
- Nо risk оf оf incоrrect pоsitiоning оf the prоsthesis
- Intrаоperаtive mоnitоring оf bоne resectiоn
- Intrаоperаtive mоnitоring аlignment оf the prоsthesis
- Preоperаtive аnd pоstоperаtive cоntrоl оf the cоnditiоnоf sоft tissue structures (ligаments). The visuаlizаtiоn in reаl-time gives аn оppоrtunity tо оbtаin аll the necessаry pаrаmeters оf the instаllаtiоn оf the prоsthesis
The price fоr tоtаl knee replаcement implаntаtiоn (pоsteriоr-stаbilized knee replаcement implаnts оr cruciаte-retаining knee replаcement implаnts) mаkes up аbоut 9 000-15 000 eurо. The pаrtiаl knee replаcement cоsts аbоut 7 000- 9 000 eurо. These аre the аverаge prices including the implаnt design cоst аnd the medicаl services. Usuаlly the pаtient needs аbоut 2-3 weeks rehаbilitаtiоn cоurse tо heаl аfter the surgery аnd get bаck tо аctive life style. The rehаbilitаtiоn cоurse stаrts аlmоst immediаtely аfter the surgery.
We wоuld be glаd tо cоnsult yоu оn аll the issues, cоncerning the knee replаcement implаnts аs well аs methоds аnd cоsts оf implаntаtiоn.
According to the Orthopedic Institute in Berlin 98 percent of people who have undergone a knee replacement can stay active and forget about pain. The success rates of knee replacement in Germany are second to none. The safety of the procedure and the accuracy during the knee replacement are achieved due to the modern systems of computer navigation. According to the recent study, the risk of complications is twice as high at the US clinics than in Germany.
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The satisfaction of patients with knee TEP depends primarily on pre-procedure expectations, extent of functional improvement and pain progression.
Endoprosthetics, one of the greatest success stories of orthopedic surgery, has a new problem: exaggerated expectations on the part of patients, who often hope for complete recovery. "An implant can never completely replace the natural bone", emphasized Prof. Dr. med. med. Henning Windhagen, Director of the Orthopedic Clinic of the Hannover Medical School, at the press conference of the German Society for Endoprosthetics (AE) on the occasion of its annual congress in Hamburg. Patients should be properly selected and carefully informed, especially before implantation of a total knee replacement (TEP).
Proportion of younger patients is also increasing in knee TEPs
The implantation of artificial knee and hip joints is one of the most frequent interventions in German hospitals and is increasing in absolute terms due to the demographic development of the population (1). According to data from the Federal Statistical Office, in 2016 a total of 233,000 patients received hip replacement and 187,000 one knee replacement. Most of those treated were 55 to 84 years old. However, the proportion of younger patients has increased in recent years: about 10% of hip TEP implantations and 8% of knee TEPs occur in patients under 55 years of age.
However, not all patients are satisfied with the implants, especially those with an artificial knee joint. While the satisfaction of patients with hip joint TEP is 95%, it is only 80-85% in patients with knee TEP, according to Windhagen. "A knee prosthesis does not make every patient a happy person," said the AE-President.
It is not uncommon to complain about restricted mobility and pain, which has to do with the complex anatomy of this joint. "The knee joint is guided much more by soft parts than the hip joint," explained Windhagen, and the forms of movement are more complex. A knee is not a pure hinge joint, it rolls, slides and turns outward and inward. The femur and tibial bone remain in contact with the movement of the knee. Therefore, the implantation of an artificial knee is particularly demanding.
All conservative therapies should be exhausted
A nationally or internationally accepted consensus on the exact indication or the optimal time for a knee replacement is not yet. According to Windhagen, the minimum requirements for a knee TEP include structural damage with advanced cartilage wear (usually caused by arthrosis) as well as knee pain, which significantly impairs the quality of life. All conservative therapies should be exhausted.
At least half a year, younger patients over one year, should be tried, the painkillers and physical training to get the symptoms under control before surgery. Patients should also be aware that the procedure is a one-way street, revisions may be needed and the old condition can not be restored, Windhagen said.
The procedures differ considerably from country to country and also regionally in Germany. In some centers implantation is very rapid, but in other centers restrained. The preoperative state of the patients before the implantation of a knee endoprosthesis also varies.
Frequent expectations, especially of younger patients, to have unlimited sports options after the procedure are unrealistic and should be eliminated. "An artificial joint is not a fountain of youth," said Professor Dr. med. med. Karl-Dieter Heller, Chief Physician of the Orthopedic Clinic at the Duchess Elisabeth Hospital in Braunschweig. Should be discouraged the patient from more extreme sports loads such as football or boxing. "The more intensive the load, the greater the risk of premature loosening of the implants," emphasized Heller. Moderate physical stress such as skiing, running, swimming, golfing, cycling or hiking, however, are readily available for patients with joint endoprosthesis.