KNEE ARTHROSCOPY HANDBOOK

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1 KNEE ARTHROSCOPY HANDBOOK 1450 Ellis Street Suite 201 Bozeman, Montana (406) FAX (406)

2 Your Arthroscopy Handbook Contemplating surgery of any kind leads to many questions. Our goal at Bridger Orthopedics & Sports Medicine is to make you as comfortable as possible about this decision. This handbook is designed to help answer your questions; to give you a general overview of what to anticipate before and after surgery and to outline your responsibilities to help ensure an excellent result. Knee surgery is a team effort. Surgery will address the problem inside your knee, but it will be your hard work postoperatively that will allow you to regain normal use of your knee. Our commitment at Bridger Orthopedic & Sports Medicine is to help you every step of the way. Indications for Knee Arthroscopy Why arthroscopy is indicated: A Meniscus tear is the single most common reason for arthroscopy. Your meniscus is a cartilage designed as a shock absorber or padding between the femur (thigh) and tibia (calf) bones. It protects the smooth coating on the ends of these bones (articular cartilage) from the stresses of daily activities. When the meniscus cartilage is torn, this protection and padding is lost. A meniscus tear can cause pain, joint swelling, and often is associated with a painful sensation of catching or locking within your knee. A tear can be dangerous to your knee because it can lead to early arthritis also known as chondromalacia within your joint. This occurs because of softening and breakdown in the articular cartilage. Once this process begins it is not reversible. Therefore our goal is to limit, and if possible, prevent this process from occurring. Articular cartilage is the smooth cartilage which coats the ends of the bones in the joint. It is responsible for keeping the joint relatively free of friction. Wear in the articular cartilage represents the first phase of early arthritis known as chondromalacia. When this wear pattern begins, knee pain, swelling and occasionally loose pieces of cartilage can result. This represents another reason for knee arthroscopy: to limit progression of arthritis and thereby decrease symptoms of pain. Common Knee Problems Meniscus Tears A sudden twist or repeated squatting can tear the meniscus. This may make your knee hurt or swell. Your knee may also catch or lock when you move it. ACL Ligament Tears A fall, twist, or blow may tear the anterior cruciate ligament. ACL tears can cause pain, swelling, and an unstable knee. Cartilage Wear Aging or injury may wear away articular cartilage. A piece may break off in the joint. You may feel pain, stiffness, or grinding. Preparing for Arthroscopy The best way to prepare for surgery and a quick recovery is to help your injured knee be as strong and flexible as it can be. Before your surgery, start with gentle exercise like riding a stationary bike and lifting weights (leg extention machine, leg press, hamstring curls) to help you increase your knee s range of motion, soothe the injured area and help decrease the chance of scarring after surgery. During your workouts, strive to gain the same range of motion in your injured knee as in your uninjured knee. Cartilage Wear Aging, overuse, or injury may damage cartilage under the patella. This can limit joint movement. Structural problems may cause uneven wearing or pain.

3 Your Knee Arthroscopy Arthroscopy uses a small telescope called an arthroscope. It is attached to a video screen monitor. We insert the arthroscope into your knee through a small incision (less than 1 cm in size). We will then pump fluid into your knee to allow us to see the inside more clearly and to flush out small cartilage particles. We then look at your entire joint looking for signs of a meniscus tear, chondromalacia, or any other loose cartilage within your knee. We make two additional small incisions in your knee. The first is for instruments such as little graspers or the shaver used to remove loose pieces or smooth off roughened edges. The second incision lets out the fluid which is pumped through your knee. Knowing the risks as well as the benefits As with all surgery, there are some risks: Risk of complications with anesthesia (this will be explained by your anesthesiologist) Risk of infection Risk of neurovascular injury Risk of blood clot in your leg which may travel to your lungs Risk of failure of your symptoms to improve or subside Risk of stiffness in your knee due to extra scarring in your knee after surgery The details of these potential problems and others will be explained to you in depth as we prepare for your surgery. Scheduling Your Surgery Our surgery coordinator will schedule your surgery for you at either the Rocky Mountain Surgery Center (RMSC) or Bozeman Deaconess Hospital. Before your surgery you will speak on the phone to a pre-op nurse or your anesthesiologist. This will be your opportunity to get to know the surgical staff and ask any questions about your surgery. We are happy to address any questions or concerns that remain after your visit. This phone visit occurs anywhere from 2-4 days before your surgery. The staff will let you know when you may eat and drink for the last time prior to surgery. They will also give you a time to arrive the day of your surgery.

4 The Day of Your Surgery When you arrive for your surgery you will be registered and assigned a pre-op bed. You will meet your nurse, who will help you get into a gown. Do not bring anything of value with you as we cannot be responsible if something is misplaced or lost. We suggest wearing something comfortable which is easy to slide on and off. All of your street clothes will be placed into a locker and labeled with your name. Remember to leave contact lenses and all jewelry including rings at home. On the day of your surgery, you should plan to bring something to read or help you pass the time. Sometimes delays cannot be avoided during our surgery day. Please have patience with us as we are doing our best for you as well as our other patients that day. Just before your surgery, your nurse will start an IV in your arm. This will be used to give you fluids, antibiotics and your anesthetic. Your anesthesiologist will stop by and talk with you prior to your surgery. This is an excellent opportunity to ask any lingering questions. Before you go to the operating room your anesthesiologist will give you medication through your IV to help you relax. Once in the operating room your blood pressure, heart rate and other vitals will be monitored. You will have your choice of general anesthesia or spinal anesthesia for your knee surgery. It usually takes about 1 hour from the time you are brought back for your surgery until you are returned to the recovery room. Your stay in the recovery room will involve 2 phases: Phase 1 is the wake-up area, where you ll be allowed to wake up. Here your heart rate, respiratory rate and any signs of pain or nausea will be taken care of. You ll spend minutes here. Phase 2 prepares you to go home. You ll sit up in a chair and have a chance to have something to drink. Also, the nurses will go over your discharge instructions. When You Get Home Your first priority when you get home should be to elevate your leg on two to three pillows and apply an ice pack (the surgical staff will send you home with one). While your bandages are in place, you may leave this ice pack on most of the time. Once your dressings are removed (about 2 days after surgery) then you should apply an icepack to your knee 4-5 times per day for minutes each time.

5 Pain Medications Whether you had general or spinal anesthetic at the time of your surgery, you will begin to have pain shortly after surgery. It is best to take your pain medications regularly (as prescribed) for the first 48 hours. You should wake yourself up 4 hours after you go to sleep in order to take your medications again. Do not wait until morning. If you get behind on your pain control you will have a hard time getting caught back up. Within two to three days after your surgery, you can begin to cut back on your pain pills and take them only when you are experiencing pain. We recommend also taking an anti-inflammatory (such as ibuprofen) with your pain medications. We will send you home with prescription strength Ibuprofen (to significantly reduce your swelling). Some of your pain is associated with pressure in the tissues and reducing swelling will in turn improve your pain. This should be taken every 8 hours with food. Wound Care 48 hours after your surgery you may remove your dressings and clean the skin with hydrogen peroxide. At this point you may shower and let water run over your incisions. It is not necessary to cover your incisions unless you experience irritation between your stitches and clothes. If you do, just place a band-aide over the stitches. Place an ice pack on your knee minutes at a time (four or five times each day) for the first week to help bring your swelling down. Continue to use the ice pack after prolonged walking, standing or after exercise as these are times when your knee is more likely to swell. Motion and Activity Within the first hours you should be able to walk without any assistance (crutches or cane). You should do your best to return to a normal walking stride. Once you can walk normally you are free to begin range of motion and strengthening your thigh muscles. Walking, stretching and riding a bicycle are all great exercises to ease you back to your regular activities. In addition, we have included a few exercises you may use over the first several days and weeks after surgery. They are not designed to be a complete exercise program but will give you a good start to regaining motion and strength to your knee.

6 Knee Arthroscopy Exercise Guide Regular exercise to restore your knee mobility and strength is necessary. For the most part this can be carried out at home. Your orthopaedic surgeon may recommend that you exercise approximately 20 to 30 minutes two to three times a day. You also may be advised to engage in a walking program. Your orthopaedist may suggest some of the following exercises. The following guide can help you better understand your exercise or activity program that may be supervised by a therapist at the direction of your orthopaedic surgeon. As you increase the intensity of your exercise program, you may experience temporary set-backs. If your knee swells or hurts after a particular exercise activity, you should lessen or stop the activity until you feel better. You should Rest, Ice, Compress (with an elastic bandage), and Elevate your knee (R.I.C.E.) Contact your surgeon if the symptoms persist. Initial Exercise Program Hamstring Contraction, 10 Repetitions - No movement should occur in this exercise. Lie or sit with your knees bent to about 10 degrees. Pull your heel into the floor, tightening the muscles on the back of your thigh. Hold 5 seconds, then relax. Quadriceps Contraction, 10 Repetitions - Lie on stomach with a towel roll under the ankle of your operated knee. Push ankle down into towel roll. Your leg should straighten as much as possible. Hold for 5 seconds. Relax. Straight Leg Raises, 10 Repetitions - Lie on your back, with uninvolved knee bent, straighten your involved knee. Slowly lift about 6 inches and hold for 5 seconds. Continue lifting in 6-inch increments, hold each time. Reverse the procedure, and return to the starting position. Advanced: Before starting, add weights to your ankle, starting with 1 pound of weight and building up to a maximum of 5 pounds of weight over 4 weeks.

7 Buttock Tucks, 10 Repetitions - While lying down on your back, tighten your buttock muscles. Hold tightly for 5 seconds Straight Leg Raises, Standing, 10 Repetitions - Support yourself, if necessary, and slowly lift your leg forward keeping your knee straight. Return to starting position. Advanced: Before starting, add weights to your ankle, starting with 1 pound of weight and building up to a maximum of 5 pounds of weight over 4 weeks. Intermediate Exercise Program Terminal Knee Extension, Supine, 10 Repetitions - Lie on your back with a towel roll under your knee. Straighten your knee (still supported by the roll) and hold 5 seconds. Slowly return to the starting position. Advanced: Before starting, add weights to your ankle, starting with 1 pound of weight and building up to a maximum of 5 pounds of weight over 4 weeks. Straight Leg Raises, 5 Sets 10 Repetitions - Lie on your back with your uninvolved knee bent. Straighten your other knee with a quadriceps muscle contraction. Now, slowly raise your leg until your foot is about 12 inches from the floor. Slowly lower it to the floor and relax. Perform 5 sets of 10 repetitions. Advanced: Before starting, add weights to your ankle, starting with 1 pound of weight and building up to a maximum of 5 pounds of weight over 4 weeks.

8 Partial Squat, with Chair, 10 Repetitions - Hold onto a sturdy chair or counter with your feet 6-12 inches from chair or counter. Do not bend all the way down. DO NOT go any lower than 90 degrees. Keep back straight. Hold for 5-10 seconds. Slowly come back up. Relax Quadricep Stretch - Standing, 10 Repetitions - Standing with the involved knee bent, gently pull heel toward buttocks, feeling a stretch in the front of the leg. Hold for 5 seconds. Advanced Exercise Program Knee Bend, Partial, Single Leg - Stand supporting yourself with the back of a chair. Bend your uninvolved leg with your toe touching for balance as necessary. Slowly lower yourself, keeping your foot flat. Don t overdo this exercise. Straighten up to the starting position. Relax and repeat 10 times.

9 Step-ups, Forward, 10 Repetitions, - Step forward up onto a 6-inch high stool, leading with your involved leg. Step down, returning to the starting position. Increase the height of the platform as strength increases. Step-ups, Lateral, 10 Repetitions, - Step forward up onto a 6-inch high stool, leading with your involved leg. Step down, returning to the starting position. Increase the height of the platform as strength increases. Terminal Knee Extension, Sitting, 10 Repetitions, - While sitting in a chair, support your involved heel on a stool. Now straighten your knee, hold 5 seconds and slowly return to the starting position. Hamstring Stretch, Supine, 10 Repetitions, - Lie on your back. Bend your hip, grasping your thigh just above the knee. Slowly straighten your knee until you feel the tightness behind your knee. Hold for 5 seconds. Relax and repeat 10 times. Repeat with other leg. If you do not feel this stretch, bend your hip a little more, and repeat. No bouncing! Maintain a steady, prolonged stretch for the maximum benefit.

10 Hamstring, Stretch, Supine at Wall, 10 Repetitions - Lie next to a doorway, with one leg extended. Place your heel against the wall, and, with your knee bent, move your hips toward the wall. Now begin to straighten your knee. When you feel tightness behind your knee, hold for 5 seconds. Relax and repeat 10 times. The closer you are to the wall, the more intense the stretch. Repeat with other leg. Exercise Bike - If you have access to an exercise bike, set the seat high so your foot can barely reach the pedal and complete a full revolution. Set the resistance to light and progress to heavy. Start pedaling for 10 minutes a day. Increase the duration by one minute a day until you are pedaling 20 minutes a day. Walking- An excellent physical exercise activity in the middle stages of your recovery from surgery (after 2 weeks). Running should be avoided until 6-8 weeks because of the impact and shock forces transmitted to your knee. Both walking and running activities should be gradually phased into your exercise program.

11 The following are some exceptions to the previous instructions. If you have one of the procedures discussed below, you should follow these specific instructions. Meniscal Repair Rehabilitation Protocol There are only certain types of meniscal tears which are repairable. In patients where the tear is present near the outer rim of the meniscus, we may attempt to repair the meniscal tissue using stitches to hold the meniscus together. The outer rim of the meniscus is the only region where cartilage has enough blood supply to heal back together. Because we are attempting to allow the meniscus to heal we need to protect the repair and we do this through the following protocol: For the first three weeks after surgery you may bear weight on your knee only when wearing the provided knee brace with the brace locked out straight (full extention) at all times. You may unlock your brace for gentle range of motion exercises within 48 hours after your surgery. At three weeks after surgery, you may unlock your brace for weight bearing. You must still wear the brace for another 3 weeks. Therefore, you will need to be in your brace for a total of 6 weeks. Formal physical therapy begins 3 weeks after surgery. The therapist will help you with your range of motion and with your knee strengthening over a 4 to 6 week period, gradually moving you into a home rehabilitation program. Micro Fracture Rehabilitation Protocol Some articular cartilage damage is severe enough to cause breakdown to the underlying bony surface. When this is widespread or involves two adjacent surfaces such as the femur and tibia or the femur and patella we generally shave the rough edges around this damage and do nothing more. However, in some instances we find an isolated area of breakdown to the bone. In this case we can do a microfracture. This means we take a sharp-tipped probe and poke holes into the bone in order to encourage extra blood flow to enter the area. This is the first step in allowing fibrocartilage (scar cartilage) to fill this defect. Our hope is that this will diminish any symptoms caused by this arthritis and slow the rate of wear and tear to your knee. In order to maximize your ability to heal this defect we ask you to follow the following instructions:

12 You will need to use the CPM for 6-8 hrs/day for a total of 6 weeks. This can be performed in short stretches throughout the day or all in one sitting. People will often adapt to sleeping in the CPM so as not to take as much of their day. You will also need to be on crutches for 6-8 weeks following your surgery. Most patients are allowed to return to sport specific activities 4-6 months following microfracture surgery. We may change these instructions, depending on the location and size of the cartilage defect. Follow-up Care You will go home with a Continuous Passive Motion machine or CPM. This device provides a cradle for your leg to rest in and then slowly bends your knee back and forth. The purpose is to mold the fibro cartilage into the defect of your knee. Your follow-up care is divided into two visits: Your First Post Operative Evaluation and a Six Week Follow-up. If micro-fracture or meniscal repair are performed, then a third and sometimes a fourth visit are scheduled. First Post Operative Evaluation The first visit occurs 8-10 days after your surgery. You will be seen by the Physician Assistant. At this time, we will check your incisions, remove any stitches and evaluate your swelling and motion. We will also go over the arthroscopy pictures and the findings from surgery. This is a time to ask questions about any problems or concerns you may have. In addition, we will discuss your rehabilitation: either home exercise or formal physical therapy. 6 Week Follow-Up Visit At this second appointment we will check your knee motion and strength. Usually by this visit you will be feeling better than before your injury. If everything is going well, we will release you to return to your regular activities. We hope by this point that your knee motion is almost normal. It is common to still experience swelling at the end of each day but it should get better overnight. Any swelling that persists the next morning is a signal to you that you may have slightly overdone it the day before and your knee was not ready to handle that much walking, standing or exercise. It is very important for you to be spending approximately one hour per day on your knee rehabilitation. Activities such as biking, weight training, and weight lifting should be included in this routine. The speed of your recovery greatly depends on your dedication to your knee rehabilitation during the 6-8 weeks following surgery.

13 If all is well at the 6 week visit we have you return to your regular activities and only follow up if other questions or concerns arise. Most people will continue to see improvement in motion and strength for another three to four months. We hope that this handout serves as a helpful resource as you consider Arthroscopic Knee surgery. It isn t designed to answer all of your questions, but should give you a sense of what is to come. If you have any additional questions that aren t addressed by the information in this handout, please call us at (406) Thank you for choosing Bridger Orthopedic and Sports Medicine for your care.

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