Sunny Deo

• Time.
• Simple painkillers such as paracetamol.
• Non-steroidal anti-inflammatory drugs (NSAID’s) such as ibuprofen, Voltarol, Naproxen.
• Ice therapy, particularly early on.
• Massage and gentle heat.
• Activity modification including initial rest, avoidance of aggravating activities, exercise that doesn’t aggravate the knee but allows for continued muscle conditioning such as non-breaststroke swimming, X-trainer, cycling, gym exercises.
• Physiotherapy to optimise the above, work of muscle conditioning generally, add additional local modality treatments such as ultrasound, short-wave diathermy, TENS
• Use of a simple knee support, with gradation up to bespoke definitive bracing.

Key priorities are:

1. Minimise symptoms
2. Swelling reduction
3. Restoration of range
4. Muscle conditioning

How to achieve improvement and rapid recovery
Painkillers
Anti-inflammatories
Avoid aggravating activities: this may require protected weight bearing and walking aids
Ice pack or ice bandage
Elevation when resting
Gentle local massage
Gentle range of movement exercises: passive then active
Compression bandage / sleeve or splint
Reflection and understanding what may be wrong with the knee – looking out for clues

Gradual resumption of activities within limits of symptoms
Alternative “knee friendly” exercises eg movement in water, non-breast-stroke kick swimming, use of exercise
bike, cross-trainer/ elliptical, straight leg raises.

The majority of acute knee injuries will settle with time and 1st aid measures. The
commonest cause of an acute knee injury may well occur in  structures outside the joint itself such as surrounding bones, ligaments, muscle and
tendon groups that are located close to the knee joint. The most common acute injury
to the joint itself is, in my experience is actually an injury to the joint lining or synovium. The joint lining is an often
neglected part of the joint and is in normal times a very thin sleeve of tissue that surrounds the key working parts of the knee

These fall into 3 broad categories, the commonly used cortisone injections, for which I tend to use Triamcinalone, the newer Hylan type injections which I generally use Synvisc 1 or Durolane or the newer platelet rich plasma (PRP) injections

Arthroscopy is a common surgical procedure in which a joint (arthro-) is viewed (-scopy) using a small camera. Arthroscopy gives doctors a clear view of the inside of the knee. This helps them diagnose and treat knee problems.

Surgery is undertaken for a large number of specific problems affecting the main structures within the knee most commonly the menisci (cartilages), anterior cruciate ligament, joint surfaces and other ligaments. In addition operations close to the joint can offload forces through the joint to relieve symptoms such as osteotomies.

Keyhole surgery is largely used for sports injuries to the knee involving the menisci (cartilages), joint surfaces and joint lining (synovium), and can also assist major reconstruction operations such as ACL reconstruction and osteotomies. It has limited, yet potentially, highly useful roles in the management of degenerative and arthritis conditions.

Arthroscopy is done through small incisions (commonly 2 small incisions at the front of the knee). During the procedure, an arthroscope (a small camera instrument about the size of a pencil) is inserted into your knee joint. The arthroscope sends the image to a television monitor. On the monitor, the surgeon can see the structures of the knee in great detail.

The surgeon can use arthroscopy instruments to feel, repair or remove damaged tissue. To do this, small, specialised surgical instruments, of which there are now a wide variety, are inserted through the incision.

Common arthroscopic operations:

• Arthroscopic debridement
• Partial meniscectomy
• Meniscal repair
• Microfracture
• Patellar/Quads tendon procedures

Common non-keyhole procedures are:

• Anterior cruciate ligament (ACL) reconstruction
• Medial patella-femoral ligament (MPFL) reconstruction
• Patellar realignment
• Realignment osteotomy
• Other ligament reconstructions
• Chondral replacement surgery (AMIC, MACI)
• Tendon procedures

Many of these surgeries are undertaken in conjunction and are assisted by arthroscopic surgery.

Osteotomy literally means “cutting of the bone.” In a knee osteotomy, either the tibia (shinbone) or femur (thighbone) is cut and then reshaped to relieve pressure on the knee joint.

Knee osteotomy is used when you have early-stage osteoarthritis that has damaged just one side of the knee joint. By shifting your weight off of the damaged side of the joint, an osteotomy can relieve pain and significantly improve function in your arthritic knee.

See also Knee Replacement Surgery and Knee Arthroscopy (Keyhole Surgery) sections on this page.

You may be a candidate for knee replacement if:

• Your pain is disabling. People who need knee replacement surgery usually have problems walking, climbing stairs, and getting in and out of chairs. They also may experience moderate or severe knee pain at rest.
• Your pain affects normal function/sports activities. Your activities and daily life may be ok but you can’t comfortably do what you relaly what you really want or need to. This is a potential area of contention in terms of healthcare rationing.
• You have severe end stage arthritic changes on x-ray or scan.
• Other treatments haven’t helped. Other treatments include weight loss, physical therapy, activity modification a stick or other walking aids, medications, braces, injections (not only cortisone, but hylan) and keyhole surgery
• You have a knee deformity. Knee replacement can be especially helpful for people who have a knee that bows in or out
• You’re 55 or older. Knee replacement is typically performed in older adults, but it may be considered for adults of all ages. Young, physically active people are more likely to wear out their new knees prematurely.
• Your general health is good. Conditions such as restricted blood flow, diabetes or infections can complicate surgery and recovery.

In about 30% of patients, the arthritic wear out process is confined to one part or compartment of the knee. If this is the case and there is no evidence wear in the rest of the knee, nor fixed contractures I will tend to suggest a partial or unicompartmental knee replacement. This has the benefits of being a smaller operation, with a shorter recovery time, reduced risk of major complications and when it works well as good as or even superior results in terms of symptoms and return to normal function.

In my private practice I now undertake as many partial as total knee replacements. I have used the Biomet (now Zimmer-Biomet) Oxford partial knee system for over 20 years.

A total knee replacement (also called knee arthroplasty) is the most commonly undertaken major knee surgery in the UK.
There are three basic steps to a knee replacement procedure.

• Bone joint surface re-section. The damaged cartilage surfaces at the ends of the femur and tibia are removed along with a small amount of underlying bone.
• Position the metal implants. The removed cartilage and bone is replaced with metal components that recreate the surface of the joint. These metal parts may be cemented or “press-fit” into the bone.
• Resurface the patella. The undersurface of the patella (kneecap) is cut and resurfaced with a plastic button. I resurface the patella selectively, only if the patella joint surface is more than 50% worn out. If it is severely maltracking or if it is an abnormal shape. I have used the Stryker Triathlon knee system for over 7 years.

You can get a lot more information about major joint replacements including total and partial knee replacements by visiting the National Joint Registry website at www.njrcentre.org.uk