Knee

Did I just tear my ACL? What do I do?

Anterior Cruciate Ligament (ACL) tears are one of the most common knee ligament injuries.  These injuries occur in collision sports but are increasingly common as non-contact injuries as well.  Typically, occurring with a quick pivot or change of direction, a sudden pop is usually felt with painful swelling developing within several hours. ACL injuries can significantly impair agility and rob athletes of their ability to stop and start quickly.  Untreated, it is difficult to regain your previous level of agility.  Furthermore, there is evidence that untreated ACL tears in younger patients, even those who do not participate in athletics, can lead to earlier development of arthritis. If you suspect you have an ACL tear, an evaluation at a sports orthopedic office such as MCO can help quickly diagnose these injuries.  We will always get you in the same or next business day for an evaluation of this type of injury.

How are ACL injuries treated?

Fortunately, these injuries are very treatable.  Unless you live a very sedentary lifestyle, surgical reconstruction is recommended.  Because the ACL is located within (rather than outside) the joint, it lacks the ability to heal on its own.  An MRI is necessary to confirm the diagnosis and to assess collateral damage.  Within several weeks of the injury, walking and non-athletic activities will start to feel relatively normal.  However, with pivoting or cutting activities, a sense of giving way is often experienced.  Several weeks of rehabilitation and swelling reduction are recommended prior to any surgical correction.

Does my ligament get repaired?  Or reconstructed?  What is the difference?

The current gold standard for athletes who sustain a tear of the ACL is a reconstruction of the ligament.  This requires tissue to fashion a new ligament and typically involves using hamstring tendons, quadriceps tendon or the patellar ligament.  While cadaver tissue is frequently used in many centers, it is recommended that the patient’s own tissue be preferentially used in patients under 30 years of age.  Drs. Frush, Silas and Bak are well versed in a variety of graft choices and, although reconstruction using one’s native tissue is considered more technically challenging and time-consuming, this is the preferred method for our young athletes and we have extensive experience with this.

ACL repair is a newer concept–certain tear patterns have been identified for which repair of the torn ligament may be possible.  This requires a specific pattern of tearing with good ligament tissue.  MCO is one of the few centers with experience in this newer procedure and current recommendations are that the repair be performed with an internal brace which is the technique performed by Drs. Frush, Silas and Bak.

How successful is ACL surgery?

ACL surgery typically allows a high percentage of athletes to return to their prior level of activity.  However, there are nuances created by associated injuries that require appropriate treatment in conjunction with modern ACL surgery.  Injuries to the meniscus as well as subtle injuries to other surrounding knee ligaments can occur in the setting of an ACL injury.  Unfortunately, these can be overlooked and failure to address these less obvious injuries appropriately can make the difference in joining the 90% plus of patients who return to sport and the 10% who don’t.  Often an afterthought in ACL surgery, meniscus tears are frequently treated with partial removal where the main focus is treating the ACL.  At MCO, knee joint preservation is of paramount importance and we are aggressive about repairing and retaining meniscal tissue where appropriate. Our physicians are always looking at each individual case to ensure that each injury’s nuances are both recognized and treated appropriately.

What is recovery from ACL surgery like?  When can I return to my athletics?

ACL surgery is done as an outpatient and a brace may be worn for several weeks.  Physical therapy starts immediately and is as important as the surgery.  Recovery can be rigorous but we guide you through the entire process until we are certain that you have returned to your activities.  In the rare case that return to activity is delayed, we will aggressively address any anomalies that slow your recovery.  Current recommendations are a 6-8 month recovery period prior to return to high-level athletics.

What is a Meniscus Tear?

There are two cartilage structures in the knee known as the medial and the lateral meniscus.  These are made of a different type of cartilage than that found on the surface of the femur and tibia; meniscal cartilage is like a hard rubber shock absorber and serves to allow the flat tibial surface to conform to the rounder femoral surface.  Essentially, the medial and lateral meniscus “cup” the rounded femoral surface. Tears in the meniscus occur most commonly with twisting injuries or with injuries to the knee ligaments.  

How do I know I have a Meniscus Tear?

When a meniscus tears, it can become unstable and frequently catches or gets pinched as the femur glides back and forth on the tibia.  Pain is therefore not necessarily constant with these injuries and, in fact, it is more common to have “episodes” of pain or certain movements that consistently elicit a painful catch. In some cases, the meniscus can “lock” the knee and prevent the ability to fully straighten. With a meniscus tear, it is common to have pain on either the inside or the outside of the knee rather than directly in front or behind the knee.  However, many other things cause similar pain and therefore an examination, xray and often MRI are needed to make the diagnosis of meniscus tear.

Does a Meniscus Tear always require surgery?

However, it is important to realize that meniscus “tears” also occur as arthritis begins to affect the knee joint.  While these are called tears, frequently this just represents a natural breakdown of the meniscal cartilage as the arthritis begins to erode the cartilage in general.  These types of tears frequently do not need surgery as management of arthritic symptoms will generally minimize any symptoms due to the meniscus.  It is important for your surgeon to determine which type of tear you have as degenerative tears may not respond as dramatically to surgery as a traumatic tear.  This is why we review your MRI films rather than just rely on the reports–often the type of tear can be determined by the MRI.

Further, these degenerative tears are not dangerous nor do they cause further damage to the knee.  Occasionally, when degenerative tears of the meniscus do not respond to symptomatic treatment and cause prominent mechanical symptoms, surgery may be a consideration.

Rarely is a true mechanical meniscus tear in an area where it can spontaneously heal, therefore, non-degenerative meniscus tears frequently require surgery to eliminate the pain and dysfunction they cause.  

What kind of surgery is performed for a Meniscus Tear?

Surgical treatment involves an outpatient procedure called knee arthroscopy.  Your surgeon will make 2-3 small incisions the size of a pencil on your knee and insert a camera to view the tear.  Special micro instruments are then used to either remove the damaged part of the meniscus or place stitches into it.  Most tears do not occur in the region where the meniscus has adequate blood supply.  What this means is that the tear does not have healing capacity and therefore an attempt at repair may not be successful; in these situations, removal of the damaged segment of meniscus is performed and symptoms typically rapidly improve.  If the tear occurs in the vascular zone, a repair may be performed.  In some cases this can be done through the same tiny incisions.  In certain tears, a larger incision on the side of the knee may be necessary to complete the repair.  

How long is the recovery after meniscus surgery?

The recovery depends heavily on whether a repair or partial removal is performed.  In a repair, the repair needs to be protected so often a period of minimal walking/crutch use is recommended and it may be several months before the knee is ready for vigorous activity and sports.  On the other hand, if a partial removal is performed, usually you will be allowed to walk on it immediately and, depending on the activity, return to sports and normal activities may occur within 2-6 weeks.

Drs. Bak, Frush and Silas are highly experienced with injuries to the meniscus and determination whether your particular injury will do better with surgical or non-operative management.  Furthermore, the surgeons at MCO are aggressive about joint preservation and repair of the meniscus whenever possible.  In fact, successful meniscus repair (as opposed to meniscus removal) is performed by MCO surgeons with a far greater frequency than most centers in the Midwest.

What is Knee Arthritis?

Arthritis of the knee is a progressive and debilitating condition that can ultimately lead to a lifestyle of minimal mobility.  This affects 20% of Americans over age 45 and can occur due to injuries occurring many years prior to the development of arthritis.  Certainly wear and tear and a physically taxing lifestyle can contribute to the development of arthritis but ultimately, genetics and body mass play large roles in whether or not an individual will develop knee arthritis.  

Early stage arthritis may involve just some mild clicking and pain but as the disease worsens, constant pain and limping become progressively worse.

What can be done for my arthritic knee short of a Knee Replacement?

• Oral Tylenol or NSAID’s such as Ibuprofen or Aleve
• Physical therapy in earlier stages of disease
• Healthy diet and exercise to promote weight control
• Cortisone injections can provide temporary relief
• Viscosupplementation or “gel” injections
• Platelet-rich plasma and stem cell injections in certain patients

Knee arthroscopy has not been shown to make a significant difference in the treatment of isolated knee osteoarthritis although in certain patients with loose cartilage fragments or a specific pattern of meniscus damage, it can be helpful.

What happens during a Total Knee Replacement?

The worn bone and cartilage in an arthritic knee joint is removed and replaced with metal and polyethylene surfaces that are implanted directly onto the patella, femur and tibia.  This is done through an incision on the front of the knee and takes approximately an hour.  

What is the recovery from Total Knee replacement like?

In many patients, these are now safely done as an outpatient procedure.  Physical therapy is vital to full recovery and begins the afternoon of your surgical day.  Several months of therapy are often necessary but full weight bearing occurs on day 1 after knee replacement surgery.  Most people see near-complete recovery by 3 months after surgery and at that point may return to low-impact activities and sports. 

Drs. Knesek and Frush are highly experienced with primary and revision knee replacement.  Additionally, they were recruited to Ascension Providence due to their years of experience with robotic-assisted knee arthroplasty.

What is a Partial Knee Replacement?

Knee replacement is a surgical procedure that refers to either partial knee replacement or, more commonly, total knee replacement. This involves replacement of the worn bone and cartilage in an arthritic knee joint with metal and polyethylene surfaces that are implanted directly into the knee joint. The knee is thought of as having 3 different “compartments.”  The medial (inner), lateral (outer) and patellofemoral (kneecap).  In a “Partial” knee replacement, just one of these compartments is replaced as opposed to all 3 compartments in a traditional “Total” knee replacement.

Why Partial instead of Total Knee Replacement?

There are several advantages of a partial replacement.  It is less invasive and typically done on an outpatient basis.  The mechanics of the knee remain more natural and therefore allows patients to maintain a higher level of activity than with total knee replacement.  Additionally, a conversion of a partial replacement to a total replacement is thought to be more straightforward than a complete “re-do” of a complete replacement.

Partial knee replacement is an option in patients who have arthritis confined to only one of the three compartments.  Most patients with knee arthritis will have some degree of arthritis in 2 or more compartments which is why total knee replacement is more common than partial.

When Is Surgery Indicated?

Surgery is recommended for end stage osteoarthritis when all conservative treatments fail including but not limited to cortisone injections, viscosupplementation, physical therapy, bracing and activity modification. Some patients may be candidates for osteotomy surgery rather than knee replacement.

What Is The Typical Recovery? 

This is done largely on an outpatient basis and we recommend a session of therapy the day of surgery to get you up and walking.  Full weight-bearing is encouraged right away on the surgical knee, certainly this involves some mild discomfort.  We expect that normal gait and low-level activities are quite comfortable within 4-6 weeks.  Full recovery and return to all activities generally requires up to 3 months.

Drs. Knesek and Frush have years of expertise with Partial Knee Replacement and were recruited to Ascension Providence due to their high-volume experience with robotic partial knee replacement.

What is Robotic Knee Replacement?

Robotic hip and knee arthroplasty is cutting edge technology that combines surgical innovation, an operative plan specific to you, and robotic precision.  This allows surgeons to provide a soft tissue-sparing, perfectly balanced knee replacement.  

Does a robot actually do the surgery?

No the robot does not perform the surgery–Drs. Knesek and Frush make the approach, set the parameters for the robot and simply sculpt your knee using feedback from the robotic arm to ensure impeccably precise alignment of the new joint.

What is the advantage of Robotic Knee Replacement?

The application of robotic assisted arthroplasty has enabled all surgeons to execute their surgical plans more accurately and consistently while protecting soft tissues and ligaments from inadvertent injury.  It also allows us to limit soft tissue disturbance leading to less postoperative pain and swelling.  

Applications of robotic assisted hip and knee arthroplasty range from partial knee replacements to direct anterior hip arthroplasty.  

Dr. Knesek and Dr. Frush are both certified in robotic assisted partial and total knee arthroplasty and have many years of experience doing these procedures.

Dr. Knesek is also certified in the emerging field of robotic assisted total hip arthroplasty.  

What Is A Quadriceps Tendon Rupture?

The quadriceps tendon connects the top of the patella (kneecap) quadriceps muscle. The quadriceps muscle is the large muscle in the front of the thigh. The quadriceps tendon works with the patellar tendon to extend and straighten the knee. Quadriceps tendon ruptures typically occur from a sudden direct trauma or an eccentric load such as the downstroke of a heavy squat exercise. 

What Are The Symptoms?

A patient may hear or feel a pop at the time of the injury. Patients will experience sudden pain, swelling and bruising in the front of the knee. Many patients experience significant instability and are unable to straighten or bear weight on the injured knee. Some patients may notice the patella is positioned lower than normal.

How Is It Treated?

The majority of patients with quadriceps tendon ruptures will require surgery. Initial treatment is usually provided in an ER or Urgent care setting and the knee is placed in a knee immobilizer. Patients are encouraged to use ice and NSAIDs to control pain and swelling. 

When Is Surgery Recommended? 

Surgery is recommended for quadriceps tendon ruptures to restore the patient’s ability to fully extend and straighten the leg. It is an outpatient surgery that requires an open incision to visualize and repair the two torn ends of the tendon back together. Patients are required to wear a hinged knee brace and attend physical therapy following surgery. 

This is a procedure regularly seen by Drs. Frush, Bak and Silas, including complex and revision repairs sent to us from other parts of the Midwest.

What Is A Patellar Tendon Rupture?

The patellar tendon connects the patella (kneecap) to the tibia or shin bone. The patellar tendon works with the quadriceps tendon to extend and straighten the knee. The patellar tendon also helps keep the patella in place during athletic activity. Patellar tendon ruptures typically arise from an eccentric load to the tendon (essentially, landing from a jump) or sudden direct trauma to the front of the knee. 

What Are The Symptoms?

A patient may hear or feel a pop at the time of the injury. Patients may experience pain, swelling and bruising in the front of the knee. Many patients experience significant instability and are unable to straighten or bear weight on the injured knee. Some patients may notice the patella is positioned higher than normal.

How Is It Treated?

The majority of patients with complete patellar tendon ruptures will require surgery. Initial treatment is usually provided in an ER or Urgent care setting and the knee is placed in a knee immobilizer. Patients are encouraged to use ice and NSADs to control pain and swelling. 

When Is Surgery Recommended? 

Surgery is recommended for complete patellar tendon ruptures to restore the patient’s ability to fully extend and straighten the leg. It is an outpatient surgery that requires an open incision to visualize and repair the two torn ends of the tendon back together. Patients are required to wear a hinged knee brace and attend physical therapy following surgery. 

Drs. Silas, Frush and Bak are experienced in the diagnosis and repair of these injuries.

What Is A MCL Sprain ?

The medial collateral ligament (MCL) is one of the 2 collateral knee ligaments and is the one found on the inside or medial side of the knee. The collateral ligaments stop the side to side movement of the knee. An injury to the MCL usually occurs when a person is bearing weight and the knee is forced inward by a blow to the outside of the knee. 

What Are The Symptoms?

Pain is located on the inside or medial aspect of your knee. A patient may hear or feel a pop, experience swelling, stiffness, and feel that their knee is unstable particularly with twisting movements. MCL sprains are graded from 1 to 3:

• Grade 1- Mild sprain where the ligament is stretched but not town
• Grade 2- Moderate sprain with partial tearing of the ligament
• Grade 3- Severe sprain with complete tear of the ligament 

How Is It Treated?

Unlike the ACL, the MCL has an excellent blood supply, therefore the majority of patients with MCL injuries will get better with conservative treatments but may require activity modification until symptoms resolve. Grade 1 sprains may be treated with ice, NSAIDs and compression bandages to help with swelling reduction. Treatment for Grade 2 sprains may also include a specialized hinged knee brace, crutches, and physical therapy. Most Grade 3 tears will likewise heal without surgery but can take 6-10 weeks for complete healing.  Selected MCL tears may be candidates for accelerated healing with PRP injections.

When Is Surgery Recommended? 

Surgery is indicated for certain patterns of Grade 3 MCL sprains or Grade 2 or 3 MCL sprains that remain unstable despite conservative treatments. This is an outpatient surgery and requires a small open incision on the inside of the knee to repair or reconstruct the torn ligament.  Drs. Frush, Silas, Bak and Moore all treat MCL injuries.