FAQs: Knee Surgery with the Sports Medicine Center

Preparation

1. What should I do to prepare for the surgery?

Several days before the surgery, wash the area to be operated several times to get it as clean as you can. This decreases the risk of infection. Be careful not to get any scratches, cuts, sunburn, poison ivy, etc. The skin has to be in very good shape to prevent problems. You do not need to shave the area.

You should have nothing to eat or drink after midnight on the evening before surgery. It is very important to have a completely empty stomach prior to surgery for anesthesia safety reasons. If you have to take medication, you can usually take the medication with a sip of water early in the morning prior to surgery (but later tell the anesthesiologist you have done so).

2. Where do I go the day of the surgery?

Report to the Surgical Day Care Unit on the third floor of the Wang Ambulatory Care Building at Massachusetts General Hospital.

3. What type of anesthetic will I be given?

This depends on the type of shoulder surgery being performed as well as your preference. You may be given a general anesthetic that will enable you to sleep throughout the entire procedure, or you may remain awake after receiving an injection that prevents you from feeling any pain.

Arthroscopy

4. What is arthroscopy?

Arthroscopy is a surgical procedure that orthopaedic surgeons use to visualize, diagnose and treat problems inside a joint. In an arthroscopic examination, the doctor makes a small incision and inserts pencil-sized instruments that contain a small lens and lighting system to magnify and illuminate the structures inside the joint. Light is transmitted through fiber optics to the end of the arthroscope. By attaching the arthroscope to a miniature camera, your surgeon is able to see the interior of the joint through this very small incision rather than the large incision needed for conventional "open" surgery. The television camera attached to the arthroscope displays the image of the joint on a television screen, allowing your surgeon to look, for example, throughout the shoulder ° at cartilage and ligaments. The doctor can determine the amount and type of injury, and usually repair or correct the problem, if it is necessary.

5. Why is knee arthroscopy necessary?

Diagnosing joint injuries and disease begins with a thorough medical history, physical examination, and usually X-rays. Additional tests such as MRI, or CT scan also may be needed. Seeing the inside of the joint through the arthroscope is the accurate way to determine the nature of the problem. Also, many problems can be corrected at the same time.

6. How is knee arthroscopy performed?

Arthroscopic surgery, although much easier in terms of recovery than "open" surgery, still requires the use of anesthetics and the special equipment in a hospital operating room or outpatient surgical suite. You will be given a general, spinal, or regional anesthetic.

A small incision (about the size of a small buttonhole) will be made to insert the arthroscope. Several other small incisions may be made to see other parts of the joint or insert other instruments.

When indicated, corrective surgery is performed with specially designed instruments that are inserted into the joint through the accessory portals. Many conditions can be treated arthroscopically.

For instance, most meniscal tears in the knee can be treated successfully with arthroscopic surgery. A torn anterior cruciate ligament (ACL) can be replaced with a graft. Some problems associated with arthritis also can be treated. Several disorders are treated with a combination of arthroscopic and standard surgery.

After Arthroscopy

7. What happens after arthroscopic surgery?

The Novocain that is put in the knee at the time of arthroscopy keeps the knee numb for about six hours. Therefore, you can walk on the knee and go home comfortably. Before being discharged, you will be given instructions about care for your incisions, what activities you should avoid, and which exercises you should do to aid your recovery.

The novocaine wears off by evening. You should take the pain medication and apply ice to the knee. After two or three days, the pain subsides.

You should make an appointment to see the doctor in about 7-10 days after surgery.

8. What are the possible complications?

Although uncommon, complications can occur during or following arthroscopy. Infection, phlebitis (blood clots of a vein), excessive swelling or bleeding, joint stiffness, damage to blood vessels or nerves, and instrument breakage are the most common complications. These are infrequent and occur in far less than one percent of all arthroscopic procedures.

9. What are the advantages?

Most patients have their arthroscopic surgery as outpatients and are home several hours after surgery. The incision s are smaller and recovery is usually much quicker than with open surgery.

Recovery

10. How long does it take to recovery after arthroscopy?

The small puncture wounds take several days to heal. The operative dressing can usually be removed the morning after the surgery and band-aids can be applied to cover the incisions. Although the puncture sounds are small and the pain in the joint that underwent arthroscopy is unusually not severe, it takes several weeks (6-8, sometimes longer) for the joint to maximally recover. A specific activity and rehabilitation program may be suggested to speed your recovery and protect your future joint function. It is not unusual for patients to go back to work or school or resume daily activities within a few days.

When a torn anterior cruciate ligament (ACL) has been reconstructed with the aid of the arthroscope, the rehabilitation is different than the following more simple arthroscopic operation.

Remember, though, that people who have arthroscopy can have many different diagnoses and preexisting conditions, so each patient's arthroscopic surgery is unique to that person. Recovery time will reflect that individuality. It is rare that your recovery will be the same as that of a friend of family member who also had "arthroscopic surgery."

Procedure

11. How is the ACL surgically repaired?

Surgical reconstruction of a torn ACL involves replacing the torn ACL with a tendon (called a graft) from another part of the knee and putting it into a position to take the place of the torn ACL. The most commonly used graft is taken from the middle third of the patellar tendon (the tendon connecting the knee cap to the tibial bone). Hamstring tendon grafts taken from the inner thigh to the back of the knee are also used. Occasionally, tendon grafts are taken from cadavers (referred to as allograft). For most of these procedures, the operation is done arthroscopically instead of making big incisions. The knee is examined arthroscopically and associated injuries such as torn menisci, loose bodies, etc. are treated.

If the middle third of the patellar tendon is used, a small incision is made on the inner side of the leg just below the knee to take the graft (this results in numbness on the front of the knee). While viewing the inside of the joint through the arthroscope, guides are used to create bone tunnels in the exact positions to allow proper placement of the graft. The graft is then pulled into the bony tunnels. Absorbable screws are placed in the tunnels to wedge the bone graft against the wall of the tunnel to give immediate stability and allow healing of the bone graft. Thus, the bone plug on one end of the graft is secured to the tunnel in the femur and the bone plug on the other end of the graft is secured to the tunnel in the tibia. The piece of patellar tendon graft between the two bone plugs becomes the new ACL.