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Knee

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Normal anatomy of the knee joint

The knee joint is made up of the bottom end of the thigh bone (femur), the top end of the shin bone (tibia) and the knee cap (patella) and consists of three compartments, the medial, the lateral and the patellofemoral. It is a joint which allows flexion and rotation and relies for support upon the ligaments on the sides, called the medial and lateral collateral ligaments (MCL and LCL), and the ligaments on the inside called the anterior and posterior cruciate ligaments (ACL and PCL).

The joint surfaces are covered in articular cartilage which is the fixed shock absorber on the end of the bones, and the mobile shock absorbers (medial and lateral menisci). Damage to the fixed joint cartilage shock absorber is called osteoarthritis, or arthritis for short. Tears of the ACL and PCL are called ruptures, and often times requires surgery to repair or reconstruct these structures. Tears to the medial collateral ligament are often treated   non-surgically in a hinged knee brace which allows range of motion. Tears of the menisci are often painful and may require either repair or trimming usually performed by keyhole arthroscopic surgery.

 

 

Our knee procedures:

 

Arthroscopy of the Knee Joint

Knee arthroscopy surgery is keyhole surgery the knee generally performed with two small incisions in the skin on either side of the patella. This allows access to majority of the knee joint, and allows treatment such as repair or resection of the meniscus, smoothing of roughened cartilage surfaces and reconstruction of the anterior or posterior cruciate ligament. Patients are generally fully weight bearing after a knee arthroscopy and the recovery time is reduced when compared to open knee surgery. 


Total Knee Replacement (TKR)

A total knee replacement (TKR) or total knee arthroplasty is a surgery that resurfaces an arthritic knee joint with an artificial metal or plastic replacement parts called the ‘prostheses’.  The National joint replacement registry of Australia shows that around 95% of knee replacements are still functioning well 15 years after they have been implanted in our community. Knee replacements do not usually feel equal to a normal knee but function much better than a worn out arthritic knee. Certain newer balancing techniques may improve the patient satisfaction with a total knee replacement.


The anterior cruciate ligament is one of the major stabilizing ligaments in the knee. It is a strong rope like structure located in the centre of the knee running from the femur to the tibia. When this ligament tears unfortunately it doesn’t heal and often leads to the feeling of instability in the knee.

ACL reconstruction is a commonly performed surgical procedure and with recent advances in arthroscopic surgery can now be performed with minimal incisions and low complication rates.  ACL surgery can be performed using either hamstring tendons, patella tendons, or even tissues from the donor tissue bank (allograft). Artificial ligaments are also available, but are used less commonly for ACL reconstruction as the results of patients own tissue are generally the best.

Anterior Cruciate Ligament ACL Reconstruction


This simply means that only a part of the knee joint is replaced through a smaller incision than would normally be used for a total knee replacement. The knee joint is made up of 3 compartments, the patellofemoral and medial and lateral compartments between the femur and tibia (i.e. the long bones of the leg). Often only one of these compartments wears out, usually the medial one. If you have symptoms and X-ray findings suggestive of this then you may be suitable for this procedure.A unicondylar knee replacement is less painful to undergo and has a more rapid rehabilitation.

Unicondylar Knee Replacement


Revision Knee Replacement

This means that part or all of your previous knee replacement needs to be revised. This operation varies from very minor adjustments to massive operations replacing significant amounts of bone and requires special techniques in terms of surgical approach, use of more complex revision prostheses and techniques such as bone grafting.

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Find out more about Revision Knee Replacement with the following links.


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Knee Arthroscopy


Prepatellar bursitis is inflammation of the bursa or lubricating sac over the front of the knee. The one directly over the patella was known as housemaids knee, and the one over the tibial tubercle where the patella tendon attaches was known as clergyman's knee because kneeling on each area was different depending on your occupation, and led to irritation. The majority of bursitis is treated non-operatively but occasionally a bursa can become painful or infected and in that situation operative surgery with resection may be required.

Kneecap (Prepatellar) Bursitis


A meniscal tear refers to a tear of one of the two mobile shock absorbers within the knee joint. These can occur either after a twisting injury, and can be at any age. In later life is common for people to have tears of the meniscus which may be painful. Meniscal tears can be treated with arthroscopic surgery if they do not settle down and re-heal on their own. When someone has a meniscal tear, and also has significant arthritis in the knee, oftentimes the meniscal tear will not represent the major cause of their overall pain, and other surgery which is more involved may be necessary.

Meniscal Tear


Meniscal transplants refer to taking the meniscus from another person, generally an organ donor, and implanting those into the knee. This surgery is complex and is not commonly performed in Australia, but on the horizon is the possibility of collagen scaffolds which may be used instead of a donor meniscus. Those treatments are experimental at the moment, and will require significant further testing and evidence before they become mainstream.

Meniscal Transplants


Minimally invasive knee surgery refers to smaller incisions to reduce post-operative pain. The majority of studies do not support any significant improvement in the longer term performance of knees with minimally invasive surgery, and is important not to compromise the positioning of components for the sake of a small incision on the front of the knee. The place of minimally invasive surgery has reduced with new techniques in anaesthetics and other medications around the time of the surgery which make post-operative pain improved.

Minimally Invasive Total Knee Replacement


Nonsurgical Treatment Options for Osteoarthritis of the Knee

Non-operative treatment sheet below:


Osgood-Schlatter disease refers to an irritation of the growth plate on the tibial tubercle where the knee cap tendon attaches to the shin bone. It is common in the early teenage years, and occurs in children who are athletic and play a lot of sport. Sometimes taping can assist with this, and this is a self-limiting problem but players may need to actually have time off sport, even a whole season, until this passes.

Osgood-Schlatter Disease (Knee Pain)


Osteonecrosis of the knee refers to a reduction in blood supply to the bone, typically one of the femoral condyles, and can be very painful. The term osteonecrosis strictly means death of the bone, although the bone will regenerate over time, but it can be painful during this period and the shape of the bone may change or collapse leading to joint damage. Oftentimes osteonecrosis the knee will settle down with non-operative treatment, a period of limited weight-bearing and anti-inflammatory tablets. The diagnosis is made on examination of the knee, x-ray and sometimes on MRI scanning.

Osteonecrosis of the Knee


The posterior cruciate ligament (PCL) stops the shin bone moving backwards on the thigh bone at the knee. It can be torn by twisting injuries, or direct force pushing the knee backwards. Oftentimes this can be treated non-operatively for the lower severity injuries, but reconstruction surgery can be performed arthroscopically, generally using the hamstrings to reconstruct the ligament. PCL rupture is less common than anterior cruciate ligament (ACL) injury. 

Posterior Cruciate Ligament (PCL) Tear


Patellofemoral pain or runner's knee is often fell behind the kneecap or in the tendons or muscles which attach to the top or bottom of the kneecap. It is often related to increasing degrees of exercise, and can be quite debilitating. It is usually treated with ice, rest, physiotherapy and stretching as well as taping or bracing. Occasionally if there is degeneration of the tendon, excision of the degenerate tissue and reattachment may be beneficial. The majority of patellofemoral disorders are treated non-operatively. If a patient develops wear of the cartilage behind the kneecap (osteoarthritis) and this becomes resistant to all other treatment, knee replacement may be necessary.

Runner’s Knee (Patellofemoral Pain)


Surgical treatment of osteoarthritis of the knee depends on the page and activity levels of the patient, and the particular anatomy that person may have. Younger people may be treated with joint realignment surgery (known as high tibial osteotomy or HTO) with the aim of moving the weight from the worn compartment of the knee to that which has more normal cartilage shock absorber. Some patients can delay a knee replacement surgery for ten to fifteen years with an HTO.

High Tibial Osteotomy (HTO)


The unstable kneecap or patellar instability, is common in adolescents and patients who have generalised ligamentous laxity (sometimes referred to as being double jointed). In a complete dislocation of the kneecap joint, the patella slips all the way out of the groove on the thigh bone and falls down onto the outer side of the knee, and this is very painful. The kneecap can spontaneously reduce itself back into position but often people need to go to the hospital and have some sedation to have the kneecap push back in again. Subluxation (partial dislocation) is where the kneecap slips out and back again recurrently without complete dislocation. This can cause significant apprehension and pain for patients. The treatment is generally physiotherapy to strengthen the quadriceps to hold the kneecap in position, stretching exercises to loosen the tight band on the outer side, and knee guards or braces when playing sport. For resistant cases surgical intervention to rebalance the ligaments around the knee can be performed. This can be a soft tissue procedure or bony procedure, or a combination of both depending on the individual circumstances and anatomy.

Patellofemoral Instability / Unstable Kneecap


Viscosupplementation Treatment for Arthritis

Viscosupplementation refers to the injection of lubricant into the knee joint to try to improve the lubrication and reduce pain. Various injectables are available, such as hyaluronic acid and can be performed either by an orthopaedic surgeon or a radiologist. The results of these injections are often good, but can be variable, and also depend on the severity of the arthritis within the knee. The more severe the arthritis, the less valuable an injection may be. Injections of platelet rich plasma (PRP) have also been shown to be beneficial for reducing inflammation and pain in patients with arthritic knees. A PRP injection involves having some of your own blood taken, spun down in a centrifuge and then a few millilitres are removed, which include platelets which have healing factors and anti-inflammatory mediators, and then this precipitant is then injected into the knee.

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ACL Injury: Should it be fixed?

An ACL will often not repair itself as it is surrounded by synovial joint fluid which washes away healing clot and does not allow the ligament to heal. The ACL is important for sports in which people change direction at speed, such as sidestepping, pivoting and twisting on a fixed foot. In general anyone who engages in sports such as soccer, rugby, basketball, tennis or anything requiring significant pivoting will require their ACL reconstructed.

This decision also depends on the age and wishes of the patient and the general state of their knee, because many people can run for long distances in a straight line when they do not have an ACL.

 

Activities After a Knee Replacement

Studies show that a knee replacement does not feel the same as a normal knee but it's much better than a worn out knee. The replacements are find for walking long distances, bushwalking, bicycle riding, tennis, yoga, skiing, gardening, kneeling and most other activities. It Is generally not recommended that people run on their knee replacement as this may lead to increased wear of the prosthetic joint. 


There are various different disorders of the paediatric and adolescent knee which require treatment. Common problems such as Osgood-Schlatters disease (pain at the insertion of the knee cap tendon to the shin bone), cartilage or meniscal tears and knee cap dislocations require investigations and, occasionally, surgery.  If pain is severe or physically limiting and has lasted for a few months, it is definitely worth being checked.

Adolescent Anterior Knee Pain


Arthritis of the knee refers to loss of the articular joint cartilage which is the fixed shock absorber of the knee. When this is severe it is known as 'bone on bone', and generally requires surgery to deal with this. Operations include half or total knee replacement, or realignment procedures such as a high tibial osteotomy to unload the arthritic joint. There are non-operative treatments such as glucosamine or chondroitin, fish oil, tumeric, paracetamol and anti-inflammatory tablets such as Nurofen. Knee guards are often helpful and walking sticks can reduce the load on the joints and increase walking distance. Weight loss is probably the most valuable intervention available to improve the pain and function of arthritis of the knee, and exercise is also been shown to be excellent for reducing pain and function.  Surgery is generally the last resort after all other modalities of treatment have been exhausted.

Arthritis of the Knee


DVT refers to a blood clot in one of the deep veins of the leg. This can occur after surgery as the body tends to make the blood thicker to stop bleeding as a reaction to trauma, fractures or surgery.  The risks of DVT depend on the extent of the surgery, the ability to weight bear after surgery, the amount of immobility which the patient has, and can also be related to inherited factors which increase the risk of people plotting. Surgeries such as knee arthroscopy do not require anticoagulation to prevent DVT as the likelihood is low, whereas bigger operations such as knee replacement or hip replacement may require calf pumps, stockings and medications such as aspirin, heparin or other blood thinners.  Your surgeon will make a decision based upon your history and risk profile as to what anticoagulation maybe necessary if surgery is indicated. 

Deep Vein Thrombosis DVT

 

Our specialist knee surgeons are:

 
  Dr Alexander Burns  MB BS, FRACS(Orth)

Dr Alexander Burns
MB BS, FRACS(Orth)

Dr Al Burns graduated in medicine from the University of Sydney in 1995, and completed his advanced orthopaedic training in Sydney.

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  Dr Phil Aubin  MB, FRCSC, FRACS, FAOrthA

Dr Phil Aubin
MB, FRCSC, FRACS, FAOrthA

Dr Aubin is a graduate (Magna Cum Laude) from the University of Ottawa, Canada. His Orthopaedic training took place at the University of Calgary hospitals.

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  Dr Nicholas Tsai  MB BS, FRACS(Orth)

Dr Nicholas Tsai
MB BS, FRACS(Orth)

  Dr Gawel Kulisiewicz  MB BS, FRACS

Dr Gawel Kulisiewicz
MB BS, FRACS

  Prof Paul Smith  BM BS, FRACS, FAOrthA

Prof Paul Smith
BM BS, FRACS, FAOrthA

A graduate of the University of Sydney Dr Nicholas Tsai did his internship and residency in Westmead Hospital. 

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Dr Kulisiewicz graduated from the University of Sydney in 1998, then went on to work at The Canberra and Calvary Hospitals as an intern...

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Professor Paul Smith graduated in medicine from The Flinders University of South Australia 1986, and completed orthopaedic surgical training in 1995.

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