Knee

Knee Treatment

Anterior Cruciate Ligament (ACL) Injury

The Anterior Cruciate Ligament is found inside the knee joint and provides rotational stability to the knee. This is one of the most common and major knee ligament injuries, usually occurring when a ligament is torn during a sudden twisting motion with the knee in hyperextension.

Treatment

Treatment depends on the severity and associated injuries as well as the activity level of the individual. A rehabilitation program or surgery may be recommended.

Surgery - the ligament is either reconstructed or repaired with an arthroscopic procedure. ACL reconstruction surgery commonly uses autograft, (a part of your own body), to replace the ligament or allograft, (a part from a deceased donor).

Posterior Cruciate Ligament (PCL) Injury

The Posterior Cruciate Ligament is located at the back of the knee and is stronger and thicker than the Anterior Cruciate Ligament. It aids in stability for posterior displacement. It is less commonly injured than the ACL and is more difficult to diagnose. Injury is typically caused by force trauma whilst the knee is in flexion. Injuries can range from a stretch to a full rupture of the ligament and usually also damages other elements in the knee.

Treatment

Treatment depends on the extent of damage and associated injuries that generate instability to the knee.

  • Conservative - if only the ligament is involved an extension splint can be used.
  • Surgery - required in acute PCL injuries and if the patient is physically very active, if there is significant instability or associated bone injuries.

Knee Cartilage Damage

Cartilage is a slippery protective connective tissue composed of chondrocytes that covers the osseous extremities of each joint, helping to cushion the mechanical pressure that the knee joint supports. Knee cartilage can be injured from chronic overuse, sudden twists or impacts.

Treatment

  • Conservador: si la lesión no es grave o si el estilo de vida no es muy activo, los AINE y la fisioterapia son buenas opciones. Se puede asociar tratamiento conservador con infiltraciones intraóseas de Plasma Rica en Plaquetas  (PRP) o Células Madre Mesenquimales.

  • Surgery - includes micro-fracture to stimulate protective scar tissue formation and cartilage transplant. Transplants are usually done on young people.

    The two most common cartilage replacement surgeries are:

    • Autologous Chondrocyte implantation - involves extracting the patient’s own healthy cartilage and making it multiply with techniques of cell cultivation which is then transplanted back into the joint.
    • Osteochondral transplant - the direct transplantation of healthy cartilage either from the patient or a donor.

    Depending on the affected area, these procedures can be carried out via arthroscopy or open surgery.

Meniscus Injuries

Each knee has two C-shaped menisci made of very strong fibrocartilage, providing cushioning between the thigh bone and the shinbone. They are important for joint stability intervening in proprioception, force transmission and also lubrication of the knee. Injury to the menisci is frequent and can either be due to trauma or degenerative conditions.

Treatment

  • Conservative - for partial or stable longitudinal tears and minimal radials using knee braces and reduced activity.
  • Surgery -by arthroscopy, depending on the location and type of injury:
  • Meniscal Suture is used for repairing longitudinal bucket handle tears in the peripheral part of the meniscus.
  • Partial Meniscectomy is used for damaged tissue, especially in the peripheral part, which is removed when suturing is not possible.
  • Meniscal Transplant (allograft) consists of transplanting a meniscus from a donor after removing the meniscus either completely or partially.
  • Meniscal Collagen Implant can be performed if the meniscal wall is intact and it is done with purified bovine achilles tendon which is inserted into the knee as a support structure.

Acute Patellar Instability

Acute Patellar Instability

Treatment

  • Conservative - Consisting of immobilization of the knee during six weeks with plaster followed by physiotherapy.
  • Surgery - Involving reconstruction of the internal patellofemoral ligament.

Chronic Patellar Instability

Chronic patellar instability, (subluxation), is where the kneecap partially dislocates and moves out of place when the knee is flexed. It can be caused by extreme activities and sports. The possibility of a second dislocation is high after an initial injury.

Treatment

Treatment aims to realign the patella and correct the flexion of the quadriceps.

  • Reconstruction to rebuild the internal patellofemoral ligament by graft, fixation or tension.
  • Trochleoplasty to modify the trochlea of the femur.
  • Extensor mechanism realignment to correct the alignment of the extensor device.

Patellofemoral Pain

The patella’s main function is to protect the knee joint. Patellofemoral pain, (Runner’s Knee), can be caused by overuse, improper rotation or bad alignment of the hip and knee joints and by repetitive or strong trauma. It is a pain that affects a high percentage of people and athletes and it is the main cause of knee pain in the young.

Treatment

  • Conservative - consisting of modifying activity, stretching, anti-inflammatories, ice and physiotherapy with orthosis and infra-patellar girth.
  • Intra-articular injections of corticosteroids,
  • Mesenchymal stem cell treatment.
  • Surgery - consisting of cartilage regeneration techniques.

Distal Femur Fracture

Distal Femur Fractures occur in the lower extremity of the femur and can be either a fracture located outside the joint, a fracture to part of the joint or a fracture of the whole joint.

Treatment

Treatment will almost always be surgical with the exact technique determined on a case by case basis.

Patellar Fractures

Patellar fractures occur in the knee cap, the small bone that protects your knee joint, where the femur and tibia meet. They can be classified as stable, transverse, lower or superior pole, vertical and osteochondral.

Treatment

  • Conservative - possible in stable non-displaced or vertical fractures and consists of immobilization for six weeks.
  • Surgery - required for all other types of fractures and the technique is determined on a case by case basis.

Tibial Plateau Fractures

Tibial plateau fractures occur at the upper part of the tibia and are a serious injury to the knee joint. They can be classified as extra-articular, partial articular or complete articular.

Treatment

  • Conservative - for non-displaced fractures treatment consists of immobilization without load.
  • Surgery - almost always required for unstable fractures with the aim being to reestablish the stability of the joint.

Knee Replacement 

The most common reason for knee replacement surgery is osteoarthritis which is the result of several factors: age, articular cartilage wearing out, family predisposition, gender (women will often have osteoarthritis of the hands and knees and men in the hips), obesity, repeated micro-trauma from sports or work activity, previous cartilage injuries.

Treatment

Non-Prosthetic Surgical Treatment

  • Intra-articular infiltration: Hyaluronic acid to aid in cushioning and lubrication of the joint.
  • Corticosteroids to reduce inflammation.
  • Platelet-Rich-Plasma (PRP) which helps in the repair of cartilage and pain relief.
  • Arthroscopic Washing and Debridement: A washout or joint lavage is performed to remove any damaged cartilage, bone or debris around the affected joint.
  • Abrasion, perforation and micro-fracture: perforating the subchondral bone, aids in the formation of fibrous tissue in the cartilage, ultimately helping it improve.
  • Osteotomy cuts and reshapes the bone correcting the deformity and angle of the knee. It is customized and only performed in very select cases.

Prosthetic Treatment

Knee replacement is indicated when there is severe pain, major progressive deformity, loss of joint space and when other treatments such as PRP, corticosteroids and stem cells have not been effective.

Unicondylar arthroplasty consists of replacing only the affected articular surface and this is performed in select cases.

Total knee arthroplasty is performed to relieve pain, obtain stability of the joint, angulation, correct mechanical alignment and restore proper joint line. Total knee arthroplasty can be: Unicompartmental, Bicompartmental and Tricompartmental

Types of Knee Prosthesis

Constrained or Hinge Prostheses, (less frequently used), are indicated when there is considerable deformity and great bone loss.

Non-constrained prosthesis, (most frequently used), allow for mobility between the femoral and tibial parts and enables preservation of the Posterior Cruciate Ligament.

  • Cemented
  • Uncemented
  • Hybrid: cemented and uncemented, being the best option in non-ostheoporotic bone
  • Mobile Tibial Polyethylene
  • These alternatives depend on on whether the kneecap is replaced or not
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