Orthopedic surgeons, physical therapists, athletic trainers, and other sports medicine professionals spend their lives caring for the musculoskeletal system. This system consists of muscles, which provide movement, and bones, which form your body's internal frame. Muscles consist of multiple fibers that get larger and more efficient with exercise. There are more than four hundred muscles in the body, connecting more than two hundred bones. The muscles attach themselves to the bones via tendons.

Ligaments are tough fibrous tissues that connect bones to other bones. Ligaments can be thought of as similar to ropes because they have no ability to change their length. Due to this ropelike quality, we refer to ligaments as "static stabilizers." Conversely, muscles and tendons shorten and lengthen with motion and thus are called "dynamic stabilizers." Luckily, many ligament tears heal naturally on their own with time and activity modification. The medial collateral ligament of the knee is one such ligament (discussed later in this chapter).

Despite reasonable care, certain ligaments do not repair themselves. These include the anterior cruciate ligament (ACL) (connecting the femur to the tibia) and the capsular ligaments in the shoulder (dislocated shoulder). A rehabilitation program for an ACL tear or a dislocated shoulder will attempt to strengthen the muscles and tendons around the joint, but unless these ligaments are repaired surgically, the joint will always be vulnerable.

A joint is where two bones come together. At joints that have significant motion, the bone ends are covered with a smooth layer called articular or surface cartilage. In some joints, including the knee, there is a second type of cartilage called meniscal cartilage. Menisci are pieces of gristle that give extra stability and cushioning to the joint. In the case of the knee, the wrong type of motion can tear this piece of gristle. This typically results in the most common type of cartilage injury--a meniscus tear--but the same event can also injure the surface cartilage. Both types of cartilage have a poor nerve and blood supply and therefore little ability to heal once injured.

In a healthy knee, all of the structures--bone, surface cartilage, meniscal cartilage, muscles, tendons, ligaments, bursa, and skin--work together in a beautiful symphony of motion. Unfortunately, when any part of the orchestra isdamaged, it can affect the function of the entire joint. Damage to a ligament causes instability and undue pressure on the cartilage. A tear of the meniscus can cause inflammation and a sense of locking with some movements. A pulled muscle limits motion and thus can cause scarring of other structures. The list of possible maladies can be long, but the treatment of most is the same: Repair the injured structure and proceed to regain full range of motion, strength, coordination, balance, etc.

Except for TKR, almost all other knee surgery involves the arthroscope for at least some part of the procedure. Arthro refers to joints, and the scope is just a stick about the size of a pencil that contains a fiber-optic light. We attach a camera to one end, allowing the image of the inside of your knee to be projected on a TV screen. When the scope is used, salt water(saline solution) is pumped into your knee to allow the surgeon to move the camera safely and see the various knee structures.

Through another portal or "keyhole" poked in the knee, instruments are inserted that remove any damaged cartilage, put in stitches, drill holes, and so forth. Your surgeon will describe what was done at your first post-op appointment with the help of models and photographs.

The process of pumping up the knee with saline, all by itself, causes the knee to be upset. Because of this trauma, even a high-level athlete will be out for a few weeks after arthroscopic surgery, even if only minor damage was found in the knee.

Doctors describe anterior cruciate ligament surgery as being "arthroscopically aided" since after the small arthroscopic portals are established, longer incisions are also made to drill bone tunnels that will contain the new graft. This extra work makes ACL surgery more traumatic to your knee and thus lengthens the recovery period, making a proper rehab program even more important.

Most TKRs, on the other hand, are done through a reasonably long incision down the center of your knee, allowing the surgeon to move the kneecap and get to all the surface cartilage. This is definitely not "keyhole" surgery. This is the most aggressive of the common knee operations and is the reason why most patients spend up to a week in the hospital afterward. Some surgeons are now doing what is called a "mini-incision" TKR, but it is still major surgery and does not change the program for recovery outlined in this book.

People often assume that if their knee is swollen and painful, they need surgery to get it fixed. This is simply notthe case. As I mentioned earlier, there are many knee injuries--including torn knee cartilage, mild arthritis, and some ligament sprains--that often calm down on their own with the appropriate nonsurgical treatments. As a result, orthopedic surgeons do not sharpen their knives the minute someone enters the office. They might order X-rays to make sure there is no bone damage. Occasionally a magnetic resonance image (MRI) is obtained so the doctor can take a look at the soft tissues (ligaments, tendons, and cartilage) that cannot be seen on an X-ray. After most knee injuries, doctors discuss ways to make the knee feel better (described in the following chapters), recommend home exercises or formal physical therapy, and schedule a follow-up exam. The doctor might also recommend an anti-inflammatory like Advil or Aleve. These medicines help decrease swelling and pain. (For a more detailed discussion of this topic, see Chapter 6.)

As long as you can fully straighten (extend) and fully bend (flex) your knee, you can let it "declare itself." In other words, if it seems to be getting better, you can hold off on any operation. There are lots of folks out there with torn or damaged cartilage who are doing just fine. Again, it is the rare person over forty who does not have some cartilage damage. MRI reports are not a reason to have knee surgery. A painful knee with a repairable problem is.

This might be a good time to mention another unhappy aspect of injuring your knee: It usually costs money. Luckily, with most insurance schemes, once you meet your deductible (and you will almost always meet your deductible with any significant problem) insurance will cover 80 percent or more of your expenses. This includes X-rays, MRIs, physical therapy, braces, and so on. Some insurances will also help with the cost of health clubs, personal training, exercise equipment, massage therapy, shoe inserts, etc., with a prescription from your doctor. Get familiar with what paperwork you need, whether from your primary care doctor ororthopedic doctor. A little research and a couple of phone calls up front could save you significant grief later.

 

 

[Just as you should not have surgery until your knee is ready, you should not have surgery until your mind is ready. No matter what part of your knee is damaged, doctors still call knee surgery "elective," that is, it can usually be done when it fits into your life. I routinely schedule surgery months in advance to correspond to the end of summer, school vacation, or even just to be ready for ski season. The important thing is to come to the operating room firing on all cylinders, physically and mentally. If you're worried about work or your kid's soccer game, you won't give your knee the attention it deserves. Schedule your surgery when you can dedicate the time and energy it needs to get better. This usually means completely clearing your calendar for at least one week for a knee arthroscopy, three weeks for an anterior cruciate ligament reconstruction, and two months for a total knee replacement.]

 

 

As I mentioned, when it comes to your body there is no such thing as "minor" surgery. Furthermore, there is no such thing as minor surgery if it involves a trip to the hospital and an anesthetic. These are significant stressors on your mind and body, and you want to--and need to--prepare for them. There are certain details of your surgery that are beyond the scope of this book, but that doesn't mean that you should not understand the planned procedure. The more you know, the easier it will be for you and the medical staff. Ask questions! Injuring your knee, having surgery, dealing with hospitals, and living with a scar (and possibly metal parts) forthe rest of your life are not things we look forward to. They are, however, better than the alternative, which is to give in to your disability and end up on the sidelines watching other people being active and having fun. I cannot stress enough how important it is that you take an active role in your surgery and rehabilitation. The road you are taking is one you must endure for your own sake, but it's not one you have to travel alone. Every page in this book is designed to help you get better faster and with less pain. Take this "portable knee doctor" along as your guide.