Knee replacement, ACL reconstruction and arthroscopy are common procedures in my practice – please click on the links for some video content, or visit http://www.markhurworth.com.au
Knee arthroscopy is a simple operation which gives great visualisation of the knee cartilage, meniscus, cruciate ligaments and synovium (lining).
It is relatively low risk in terms of surgery, and typically used for treating meniscal tears (resection or repair), ACL injuries (reconstruction) and chondral defects (grafting or CARGEL). It is also used for removing loose bodies, and in conjunction with other procedures such as patellofemoral reconstruction.
Whilst low-risk, there are some things typically that it is not indicated for. In particular, some surgeons have been criticised for being too interventional with this procedure in the arthritic knee, where arthroscopy is generally not supported by the evidence except in very specific cases.
Have a listen to the video if you want to know more:
A knee replacement is a big operation and should not be entered into without proper consideration of the time involved in rehabilitation, or the potential for complications. In that sense, it’s a bit like a marriage – once you have a prosthetic joint, you will always have a prosthetic joint (hopefully).
So hang on to your own joint for as long as possible.
See the next section for a discussion on non-operative options.
If you are under the age of 65, I recommend exploring all non surgical treatment options before saying yes to surgery as this operation is a big one, it’s painful and recovery is prolonged.
The knee is not a simple joint. It involves flexion, extension and rotation. It has a complex pulley system for the patella/quadriceps mechanism.
Proliferation in design is common for knee replacements as the market is huge, but design of the knee replacement, and surgical technique, is increasingly viewed as only part of the puzzle for getting a good result.
How well you will do will depend on a range of factors, including:
- how long can you wait – the longer you wait, generally the better result you will have. Time is a good healer, if you just wait, often the knee will get better. Don’t be crazy and wait too long, however, especially if you are starting to lose sleep and not responding to simple pain killers.
- how much weight can you lose ? – the elephant in the room is exactly that. Knee replacements are much more common in the obese, and complications much higher in direct proportion to your weight.
- how fit can you get even though your knee is symptomatic? Yes you can actually get fit with a worn-out knee, just try something different.
- cognitive therapy is a good idea – i.e. go and see someone who can help you see things in perspective – a good physio is worth his/her weight in gold
An Anterior Cruciate Ligament (ACL) rupture is a relatively common injury in Australia, usually but not always in the context of sport. Around two thirds the time, the injury will be in a non contact scenario, that is, there will not necessarily be tackle or contact with another player, but the incident will happen in a simple run-twist combination, or else coming down from a jump.
Generally if there is ongoing instability most people will have their ACL reconstructed, which in most cases involves a double hamstring graft from the affected leg.
Reconstruction is generally recommended if you are young and still playing contact sports. If left alone, probably two-thirds of knees will remain symptomatic, but non-operative treatment is an option, especially if there is no meniscal or other injury in the knee.
Surgical treatment involves some risks and a long pathway to recovery, as the graft remains vulnerable to re-injury especially in the first 100 days post surgery. Typically it will be 12 months before we let you back to contact sports.
I am increasingly seeing patients who are older than 80 whose joints are wearing out. This reflects our ability to stay alive for longer, which is great but unfortunately the longer you stay above ground, the more time there is for things to wear out!
It is important to try and understand the risk/benefit analysis or ratio in this age group for this sort of surgery i.e. what chance do you have of benefiting from surgery, over what timeframe, and what chance is there that surgery will end up making you worse. Obviously the gap narrows the older you get.
Of particular concern in the 80’s age group is that rehabilitation takes generally longer, so optimising your pre-operative function is important (yes getting on the bike is a good idea even if it’s painful).
In summary, pick your battles carefully when it comes to surgery in your 80’s. Make sure you have adequate gas in the tank (unfortunately you never have as much as you think, so take 50% off), have supportive community or family around you, and don’t have surgery without carefully considering the other options.