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PATIENT KNEE RELATED QUESTIONS

Join Dr Liew in answering your questions. Post a comment on the Facebook Post specific for this page, and Dr Liew will read, and answer most questions on here. The current segment is focussing on Knee Pain and Knee Arthritis and Sports injuries of the Knee. Please note that sensitive medical information will not be disclosed on this page. This area will be used for general questions that can be used to help others that may have the same questions as you. A specific focus here will be on Total Knee Replacements and ACL Reconstructions.

ACL reconstruction 4 years ago. Pain when walking/running. What can I do?

I had surgery to repair my acl around 4 years ago. Since then i had another surgery to clean out my knee however no matter how often i go to the gym every time i leave it even for a few weeks all the muscles surrounding the knee disintegrate. Also i still suffer quite a bit of pain when walking/running etc. What can i do?

Thank you for your question. Anterior Cruciate Ligament surgery is usually a very successful operation. There have been some advances in recent times enabling us to learn more about the correct position of an ACL graft. There is still some general controversies with respect to some finer points of where to position the graft, but in general, the consensus is that functional stability is more important than stability when testing on the examination table. This means that grafts have gone more to a more horizontal position within the knee, rather than a vertical position. This is generally accepted as the best method and alignment of a graft.

Sometimes the graft may not be situated exactly right, or you might have some irritation from the graft within the knee. The other causes for constant knee swelling include infection, graft failure, bone expansion from the graft, or implant failure (The part that holds the graft in). It also depends now hat type of graft you have. Bone patellar bone vs hamstring grafts are the main choices, with hamstrings being much more prevalent now, especially in those people who cannot tolerate anterior knee pain (Much more common in those having bone patellar bone grafts).

It seems strange that your muscles deteriorate so much in such a short period of time. I would assume that you have gone through a good physiotherapy program. In actual fact, just returning back to normal activities, and sport should be enough. You certainly should not be having much pain in your knee when walking and running. I suggest you ask to have some further investigations to your knee, including an MRI.

If everything is normal, there may not be a lot more you can do, but generally, those who have ACL grafts, tend to do very well. I hope this helps you.

MRI showing degenerative medial meniscus. 59yo. Is there an exercise that can help?

I have had an MRI on my right knee, issue is Degenerative medial meniscus with secondary extrusion in to the medial gutter. Anterior and posterior root attachments intact.My GP says I am too young (59) for a knee replacement. Is there an exercise I can do to help. At times extremely painful, any suggestions on pain relief.

Thank you for your query. With the meniscus being the only finding on MRI, this may indicate that you may be a candidate for a knee arthroscopy rather than a knee replacement. With this being said, as you exit from the age group that are sustaining acute meniscal injuries from sport, the success rate from a debridement (removal) of the torn portions of your meniscus decrease. Especially if you have underlying osteoarthritis. Degenerate tears of the meniscus often occur in the presence of osteoarthritis. Sometimes the MRI’s don’t pick it up well.

If you have severe osteoarthritis, then we would treat you based on your symptoms, rather than age. Yes, it is best to wait until you are older to have a knee replacement, but if you are truly struggling, then the difference of a year or two is not going to make a big difference on the longevity of your final knee replacement. The research shows that those under 55yo have an approximately 15% chance of a revision at 15 years, compared to about 7.5% of all patients requiring a knee replacement. As you can imagine, these figures are very general, and are not relevant in every case.

In your case, the first step is to ensure that you are being treated for the correct condition. If you have a meniscal tear, which is causing pain, especially mechanical type pain such as clicking, locking or catching, then this should be treated with keyhole surgery (Arthroscopy). If you have osteoarthritis, then all the methods described in the answers below should be attempted prior to consideration of a total knee replacement. As you are over the age of 55yo, then I would suspect that you would be suitable for a knee replacement once you have exhausted all options in the treatment of your osteoarthritis.

As far as exercises go, making sure your quadriceps and hamstrings are in good condition will certainly reduce the pain experienced from osteoarthritis as they help to stabilise your knee on a daily basis. Performing seated leg extensions and hamstring curls will be a suitable way to do this, as squats and load bearing exercises can sometimes irritate your knee, making your pain worse. Try to avoid impact activities. Concentrate on cycling, walking and swimming.

I hope this helps to answer your question.

TKR 2 years ago, still swelling. Good flexibility. Normal Perth Protocol.

I had a total knee replacement almost 2 years ago it is still swelling when I walk or stand too long.. I have very good flexibility have had several X-rays and a Perth protocol on my last visit to the service provider and told it is in perfect alignment but I feel it is not right … I need my other knee done asap as that is very painful

Thank you for your comment. It can be difficult sometimes to determine why a knee replacement is not feeling quite right. There can be a variety of reasons, and it sounds like the correct test was done on your knee. A Perth protocol looks at your knee and determines whether the prosthesis was placed in a good position. We rarely need to perform this test, but it is something that is done in cases where the knee does not seem to be meeting the expectations of each patient. The other potential things to look for are low grade infections, loosening of the prosthesis, and whether or not the prosthesis size is good for you. You’ve mentioned that you have very good flexibility, which is excellent. The other side of this, is to determine if you have good stability. If your knee is not stable, then this can certainly cause you to have some irritation when walking and standing. At 2 years down the line, I wouldn’t expect that you should have a lot of swelling or pain.

There are various designs to knee replacements, and our goal is to make your knee replacement feel as normal as possible. Knee replacements have come a way since their original designs, and we believe that our current techniques and designs improve the overall outcome somewhat.

If you have gone through all of your tests and investigations and your knee has come up normal, then the only thing left to do is ensure that its not your muscles contributing to the discomfort/swelling. If you have weak muscles around a knee replacement, it can cause you to feel that your knee is weak, or even swell if there is a slight amount of abnormal movement within the knee, whilst having good alignment of your knee replacement. If everything has been exhausted and there are not abnormalities, then I would suggest that perhaps that prosthesis design might not be the best for your knee. For your other knee, a different style can sometimes make all the difference.

I hope this helps you.

No Medicare of Private cover - how much for the knee replacement in Australia.

My mum suffers from severe OA of knee , this has affected to her quality of life , she is in constant pain 
She does not. have Medicare or Pvt health cover 
How much it will cost for her to get knee replacement in Australia

Thank you for your enquiry. Whilst I do not know exactly how much, I believe the cost would be in the order of $30,000-$50,000, depending on her comorbidities, number of days in hospital etc. The main issue with self funding is the potential for costs to increase significantly if something occurs that is not according to plan. For example, if your mother required a stay in an intensive care unit for whatever reason (i.e. she has a heart attack, or lung issue) or for any reason her treatment needs to extend, then this can be quite expensive. I believe the daily cost of an intensive care bed is around $5000, but I do not know exact figures as this has yet to happen for us. For those with Medicare, some of the $30,000 is refunded, but I am not sure how much this is.

At the end of the day, some patients do chose to self fund, especially if they have not paid for private health insurance all their lives, and whilst the usual scenario is that things go according to plan, and are straight forward, there is always that potential for things not to go smoothly, and the costs can certainly increase. I hope this helps you.

Leg bowing - can it be fixed with strengthening.

My leg is bowing. Can it be fixed with sport strengthening or does it need to be operated on. Had a knee reconstruction decades ago.

Thank you for your question. Bowing of the legs is quite common, and it is important to work out if this is just normal for you, or if it is due to a developing condition. In general, some cultures have more bowing than others. Those of asian decent often have more bowing than caucasians. If you have noticed that one of your knees is bowing then it is almost certainly due to a developing condition.

There are two ways that the knee can bow. The usual way is called a VARUS deformity, which is where your knees bow outwards, (when you stand with your feet together, your knees cannot touch each other). This is in contrast to a VALGUS deformity (which is essentially knock knees). The reason for development of this as an adult are in general due to one of two reasons:

  • Osteoarthritis causing narrowing of one of the compartments more than the other.
  • Rupture of a ligament resulting on a deformity when load bearing.

Other causes that are not as common that may make your knees appear to bow include pathology of your foot or ankle, which results in  compensatory bowing of your knee to “straighten” your leg.

Bowing on its own is not a reason to operate, unless it is painful, or if you are losing function. The first step is to determine why your knees are bowing, and then to treat that. The most common reason for bowing of your knees later in life is due to osteoarthritis. Usually the medial (inside) aspect of your knee narrows, and this causes your knee to bow. If this is the case, then managing this with strengthening will not straighten your knee, but may improve your symptoms, so this is a good start.

If it is a ligament injury, then it is important to work out what other symptoms you might have – such as instability. This needs to be treated first.

Below, there is a diagram of the difference in alignment of the knee. I hope this helps to answer your question.

Varus and Valgus alignment of the knee

Varus and Valgus alignment of the knee

Netball injury years ago. Multiple surgeries. Grade 3 Patella wear and MFC ulcers. What treatments?

I sustained a knee injury playing netball many years ago. I have had multiple surgeries over the years. My last scope 3 years ago revealed grade 3 patella wear and MFC ulcers. I have increasing pain and am wondering what treatment, if any, might be suitable?

Thank you for your question. For others that are reading this, I will just expand a little on what you have written. A scope is an arthroscopy which is keyhole surgery of the knee. A scope can be performed on many joints, but by far, the most common is an arthroscopy of the knee.

Grade 3 Patella wear indicates that you are getting very close to the bone. When grading osteoarthritis, we grade this out of 4 usually. 0 means no arthritis and 4 indicates that you have no cartilage left, and the surface is down to bone. The grading only relates to the cartilage that is attached to bone, and does not get used when describing things like meniscal tears (where this is still cartilage, but its function is different to bone cartilage). There are 3 main compartments of the knee joint. The medial, lateral and patellofemoral. You have disease in 2 of these compartments, with wear in your patellofemoral joint and your medial compartment.

MFC stands for medial femoral condyle, which is the inside aspect of your knee. Ulcers, erosions or areas of osteoarthritis can either be widespread or in small areas. Ulcers are usually just small areas. Whilst this can mean that your X-rays look reasonable, you might have a fair bit of pain. The best option with small erosions are to manage them non operatively, unless the areas are very discrete. A specific operation that can be performed is called “Microfracture” which is where we would drill very small holes in the defect, to promote bleeding. This causes the defect to fill up with scar tissue (which is fibrocartilage, and not hyaline cartilage as in normal bone cartilage) and can slow the deterioration. This is not quite as good as normal cartilage, but it is better than bone. The rate of success for this procedure is not high, but it is definitely worth trying if you have a very discrete ulcer, are young, and can successfully stay off your leg for a period of time (up to 6 weeks). If you cannot have this, then non operative management as described in a few of the answers below would be suitable. Generally speaking, a repeat arthroscopy would not be useful, unless you had another acute injury.

When you are over the age of 55yo, and you have exhausted all your non operative measures, and you are struggling from a pain and functional perspective, then a total knee replacement may be considered. You would to be suitable for a partial knee replacement, as you have 2 compartments out of 3 affected.

I hope this answers your question.

Previous knee replacement. Other knee playing up. Will a 3rd arthroscopy provide relief?

I had a knee replacement 4 years ago due to osteoarthritis. My other knee has started to play up. Will (a third) arthroscopy provide relief for awhile or is it true that they are of no significant use?

Thank you for your query. Without knowing your past history with your knee and the findings of your previous 2 knee arthroscopies, I will give you some general advice. In a general sense, another knee arthroscopy will probably only provide you with short term relief. If your knee is already arthritic, and following in the footsteps of your previously replaced knee, then another arthroscopy will benefit you, for only a short time. From that perspective, we would generally advise you not to have another knee arthroscopy if your previous ones already were showing advanced osteoarthritis.

The only reason to perform another knee arthroscopy is if you have had another injury causing new onset pain, associated with some mechanical symptoms such as clicking, locking or catching. If you do not have these, and it is just a slow deterioration of your knee pain, then I suggest that nothing should be done. Try to maximise your non operative management first (see some of the answers below) and when you are ready to have a total knee replacement, and you’re struggling despite a good trial of non operative management, then look at options for knee replacements.

I hope this helps.

Fall onto knee cap onto rock. Bubble of fluid causing sharp pain.

I fell very heavily, my whole weight impacting onto my knee cap and a rock. I haven’t had any trouble walking but if I rub my kneecap there feels like there is a bubble of fluid there that when pressed, or knelt on, generates a sharp excruciating pain. Therefore I kneel only on the the other knee. After 6 months it has improved slightly…

Thank you for getting in touch. It sounds like something might have occurred under your patella (knee cap). This might be a fracture or cartilage damage, or it can even be a loose body. All of these 3 can cause sharp pains in your knee when kneeling. Even a scar in the skin around your knee can also make things painful when kneeling. I would recommend you have someone examine your knee to see if an MRI would be useful. An MRI would give the most accurate assessment of what might be happening in your knee, but they are no always fully correct. A loose body might be hard to detect on an MRI.

If this is the case, and your knee continues to not improve, then a loose with a knee arthroscopy (key hold surgery) would be appropriate if you were really having functional loss. If you can wait longer, it might get better. Once your progress plateaus, then see what you’re left with and if it bothers you. If it does, then an MRI would be the next most appropriate thing to do.

I hope this helps to answer your question.

54yo F, bad Achilles Tear and subsequent Knee pain. Needs TKR but can't have one due to weight.

Hello I am a 54 year old woman. 2 years ago I suffered a bad achilles tear which ended me up in a moon boot for 6 months. I told the surgeon at the hospital that my knee was beginning to ache & he didn’t want to know about it. Said see gp. Now my knee is totalled.I have been told I need a total knee replacement but the hospital wont do it unless I drop 20kgs. I used to be very active walking my dogs on 5km walks 4x a week. Something I am unable to do now. They have offered me an operation to lengthen the tendon on my knee. But my whole knee buckles & gives way on me. When I walk I can hear & feel the bones crunching right down my shin. I have my knee taped up very thickly to try to stop the buckling . But it has still given out on me. Unfortunately I have no private health cover. What else can I do?

Thank you for your question and history. Firstly, sorry to hear about your difficulty with your Achilles tendon tear. Generally, this shouldn’t affect your knee, unless you had underlying osteoarthritis to start with, and your altered gait put pressure on areas that were already degenerating. It sounds like you’ve been having a lot of troubles with your knee.

There are a few things which I am unsure of, as lengthening your tendon around the knee is not a common operation. Unless there is a real reason to do something like this, then this would be unusual. The only main tendons around the knee include the main quadriceps and patellar tendon, as well as the hamstring tendons. The only lengthening procedure would be a tibial tubercle transfer, which effectively lengthens the tendon by shifting bone. This may be what was offered to you, if you had mainly isolated patellofemoral joint degeneration. A similar procedure is also used when your knee cap is dislocating.

You have eluded to some giving way in your knee – this can be due to several reasons. The frequent cause is just due to pain. Taping your knee may symptomatically give you some sensation of more stability, but it rarely helps. It can give you some proprioception with respect to what your knee is doing, but it is too weak to exert a major influence if you had actually lose a ligament or tendon. Maintaining an ideal weight is extremely important, and something that I would recommend, as it can decrease the pain that you experience in the one, without doing much else. If you can achieve that, then it is an excellent way to reduce knee pain. At the end of the day, it sounds like a knee replacement is what you require. The other methods are similar to what I have written previously. Regular Panadol Osteo, Glucosamine and Fish oil, and intermittent use of an anti-inflammatory, along with physiotherapy, a dietician and a healthy diet would help considerably.

At the age of 54yo, you have a 15% chance of requiring a knee revision by 15 years. So your revision rate is higher than the general population, purely based on age. After that, there are other consideration, prior to preceding with a knee replacement. Weight is only one of these.

I hope this helps to answer your question.

Son diagnosed with Osgood Schlatters - knee aching. How to reduce pain.

My son was diagnosed with Osgood Schlatters, his knees ache a lot, what can he do to help decrease the pain before during and after sports please??

Thanks for your question, and I can see that you’ve had some advice from a friend which is excellent. I’ll expand on the answer already given to give you a little bit more background on the condition etc.

Osgood Schllaters is considered a  “Pulling” osteochondritis of the tibial tubercle. The tibial tubercle is the part of the tibia (lower leg bone) that is the attachment point for the patellar tendon. This is the part that joints your knee cap (Patella) to the tibia. It is vital to the overall function of the knee, as the entire unit of quadriceps, patella, patella tendon and tibial tubercle make up the main way your body will straighten the knee, for all tasks.

It usually starts in early teens, equally between males and females. It usually occurs at the same time your child is having a growth spurt. For males, this is usually between the ages of 12-14 and for females, a yer younger. In 30% of patients, it happens in both knees, and is definitely more prominent in athletes, where there is a 4x times of developing OS. We believe that it is due to a traction injury due to repetitive micro trauma in an immature insertion site for the tendon, but it does not occur in everyone, so there are other factors that we do not know about. There is usually no history of a traumatic event to cause them to start.

Patients will often report pain, especially when kicking and jumping, as well as kneeling. Athletes will report the most functional loss. We would normally organise an Xray which will show some fragmentation to the tibial tuberosity. It is really just used to exclude other causes for the knee pain.

Treatment of OS usually consists of just supportive care, like anti-inflammatory medications, hamstring stretching with a physiotherapists, restriction of provocative activities and isometric quadriceps exercises. There is NO ROLE for steroids – they are contra-indicated here, so please do not inject the tendon to decrease the inflammation, as this can weaken the tendon considerably. In time, almost all patients will grow out of having pain in the area. Persistent ones may require removal of an ossicle of bone later in life, but this is not common.

I hope this answers your question.

Surgery for tear in the knee, with bone bruising, is there anything other than a knee replacement?

After surgery to correct a tear to my knee i have bone bruising this is restricting my ability to exercise and lengthy periods of walking i always have difficulty moving after periods of sitting and limp until i get moving
Is there anything i can do to improve my ability and pain without having a knee replacement

Thankyoufor your question. I would say that it is most likely that you had a tear to your knee that was the bone cartilage that was involved, rather than just the meniscus. After an isolated meniscal tear, generally recovery is extremely quick, and you certainly should not be feeling that you have a lot of pain after a few weeks to months at most. If there is underlying cartilage damage to the actual bone cartilage, then this would be the main issue there. The bone bruising usually relates either to an acute trauma (which it doesn’t sound like you had), or it can suggest full thickness cartilage loss, where the fluid in the joint is being pumped into the bone itself. This can be quite painful.

When you are sitting for a long period of time, knee osteoarthritis tends to cause your knee to feel very stiff, and this seems to be worse after you’ve been sitting for a longer period, like long car rides, or sitting at your desk, working. Depending on how bad your knee osteoarthritis is, there are a few options. As I have written below, there are a few non operative measures that should be maximised in any case, prior to considering having a total knee replacement. This includes, physiotherapy to strengthen your knee muscles, simple analgesia, glucosamine and fish oil, as well as anti-inflammatories. Maintenance of an ideal body weight will make a big difference to your walking as well. Once these are maximised, then there is not a lot left, except to either increase your pain relief or consider a total knee replacement. Stems cells, and knee injections tend not to make much of a difference after a few months.

I understand the trepidation with respect to having a total knee replacement. They are extremely precious procedures. Things have come far over the decades, and knee replacements are becoming more accurate, with less invasive measures, and improved function. Some of these techniques have increased the patient satisfaction overall, and the goal with knee replacements now, are to bring you closer to feeling like you have a “forgotten knee”. This is the holy grail, and one we strive for on an everyday basis. If your pain is getting out of control, or your function has dropped considerably, then considering a total knee replacement after maximising your non operative management is a good option.

I hope this helps to answer your question.

 

Pain after being the knee past 45 degrees. Had previous surgery.

I have incredible pain in my left knee. Every time I bend it past 45 deg it’s incredibly painful, I had my right knee operated on a couple of years ago on had my meniscus trimmed and my patella trimmed, this is more painful but not as swollen as my right knee was and seems to be a constant pain.

Thank you for getting in touch. If you are struggling to bend past 45 degrees, then this is a problem. Generally, even arthritis won’t cause you to lose that amount of range. It can be for a variety of reasons. The possible causes include:

  • A loose body that is jammed in the joint.
  • A displaced meniscal tear.
  • Infection.
  • Fracture with resulting deformity.
  • A dislocated patella.
  • Very severe osteoarthritis.

The first stem would be to obtain weight bearing plain X-rays, and then possibly an MRI to see if there is any evidence of the above. Constant pain suggest osteoarthritis. A thorough assessment would be the first best option as the causes are many. Start with the X-rays, and work forwards from there.

I hope this helps you.

2nd knee replacement at a different hospital. Will the same type be used?

If i have my second knee replacement at a different hospital will the surgeon use the same type of replacement ?? My right knee is absolutely marvellous

Thank you for your question. Generally, surgeons chose their prosthesis if they truly believe in its design, or philosophy. For example, I truly believe in patient specific technology using a knee design that allows a slight amount of knee rotation during flexion. I also believe in doing as much pre-operative planning as possible. For some prostheses, this process is easy.

When it comes time to chose your prosthesis, my advice would be to allow your surgeon to make the choice for you. The surgeon you chose will have good reasons why they use the prosthesis that they do, and they would have been trained in its use. Not all prostheses are the same, and in some surgeons hands, certain prostheses perform better than others.

In short, the hospital will not dictate what knee prosthesis you will have, but rather the surgeon. This is different in the public sector, where there are particular tenders in place, due to cost restraints and research units of a particular prosthesis, meaning that in fact, the hospital will matter. If you had a great experience with your first knee, I would recommend going back to the same surgeon in the same hospital if you can. If you are using the same surgeon, then more than likely they use the same implant in all the hospitals they attend.

I hope this answers your question.

1/3rd of lateral meniscus torn. Advice for continuing sport.

1/3 of lateral meniscus torn from sports training; if training was continued after surgery and recovery, does this make the individual more prone to subsequent meniscus tears?

P.S. Any advice if one was to continue sports training after surgery?

Thank you for your question. The meniscus is the C shaped cartilage on both sides of the knee. They are either the Medial or Lateral meniscus. They act as shock absorbers in the knee to allow the knee to be congruent as the bones are not congruent with one another. They have a very important function. The medial meniscus is generally quite static, and the lateral meniscus moves as the knee bends, due to the slight rotation of the knee joint during bending and straightening.

The blood supply to the meniscus is very little in adulthood, making repairs uncommon. Only particular types of menisci can be fixed, and this is not the usual case.

1/3rd of your lateral meniscus was torn – and generally, tears require removal, and smoothing off of the edges to prevent further tearing. This usually alleviates pain as well, and allows you to mobilise and play sport without your knee locking, clicking or catching. A knee arthroscopy is usually required in sportspeople.

If the tear has been debrided (tidied up) appropriately, then the risk of further tears is not very high, but due to the fact that your meniscus has been torn before, and that you are losing some of the structure of the meniscus, then you would be at a slightly higher chance of tearing in the future. Removal of some of the meniscus will change the function of that part of the knee slightly, however, not doing something about a large meniscal tear is worse for the knee, and if continually left inside the knee during active sport, can make the knee worse by tearing further or damaging the cartilage of the knee joint.

My main advice to attempt to reduce the risk of further tearing is to maintain good musculature around your knee, to prevent your knee from being unstable during sport. You should also try to decrease inflammation within your knee to prevent further cartilage damage. This means icing your knee after games, or long efforts, to prevent swelling. Knee swelling generally causes your knee to be damaged from the inflammatory cells, so reducing this can certainly help.

If your knee has not had the tear debrided, then I would certainly recommend this.

I hope this answers your question.

TKR done 3 years ago. 85 degree bend. What can be done?

I had a TKR done about 3years ago and I still have only about 85 degree bend. Is it possible to have it re-done (TKR) or maybe having the scar tissue cracked to get more bend back. I spoke to the surgeon that did the opp, and he said they have to be careful not to break the leg in the process. I guess that information out me off having it done. I did all the right things after my TKR, stayed for 10 days at a rehabilitation hospital, I continued with physio and water therapy when I came home. I am 67 years old and disappointed with the lack of bend in my knee.

Thank you for your query. A total knee replacement is used to improve quality of life, mobility, and reduce pain. In most cases, the range of motion can be improved. Research currently shows that the biggest determinant of post operative range is the pre-operative range. If your range is extremely poor before operation, then you tend not to achieve the maximal achievable bend on the knee after the operation.

As a general rule, the minimal requirement for a total knee replacement is 0-90 degrees. This, however, will not allow you to walk down stairs with ease, so with my own patients, we try to push for minimum 110 degrees. 3 years down the line, a manipulation under anaesthetic is not going to be successful as all of the scar tissue would have matured by now. Breaking your leg in the process is extremely rare, and would not occur unless excessive, rapid force was applied, or if you were severely osteoporotic.

A revision operation to achieve more bend can sometimes be performed. The first step is to determine if there are any alignment issues with your knee replacement. This involves a specific CT scan, and plain X-rays to review the angles that your knee replacement was placed. If all of this is correct, then a revision operation to remove as much scar tissue as possible can be contemplated. It sounds like you have done all the correct things post operatively, however your result is not up to your expectations.

There are certainly things that can be done, but there is also a chance that your knee will not improve with surgery as each operation brings with is, more scar tissue.

I hope this helps you.

Pin in knee from breaking it years ago. Pain.

I have pin in my knee from breaking it years ago needs a replacement now the ligaments playing up can the pin move its starting hurting from all my weight over there after knee replacement to other one

Thank you for getting in touch. You’re asking whether the pin can move. Depending on what the pin is, and where it is, it can move. However, generally if it is placed for a fracture, after the bone has healed, the pin/nail/rod/plate would remain in a stable position, as there is no longer any movement at the fracture site. If the fracture has not fully healed and you have a “non union” then the metal implant can definitely move, or even break.

Im not entirely sure what your last statement said, but if you have arthritis and a non union, then the non union should be addressed first, and then the arthritis after. If they can be addressed in one go, then this is preferable.

I would recommend you obtain new X-rays, and potentially an MRI if appropriate, to see what is happening in your knee. A CT scan may also be useful if a non-union is suspected. Depending on where the fracture is, what kind of metal you have in, and what other treatments you have tried, there would be a variety of options. This may include removal of the metal, or a knee replacement.

I hope this answers your question.

44yo with osteoporosis and pain after partial knee reconstruction.

ive had a few surgeries on both knees over the last 12 yrs originally from a car accident 10 yrs earlier on left knee, have had arthroscopys and lateral releases on both knees, about 9yrs ago I had a partial knee reconstruction on left knee 1 and half yrs later needed the 2 screws re done as they had moved, no major problems until 2-3 yrs ago have a large lump that raises up over the screwed area on leg gets worse the more stuff I do, knee still gets swollen and clicks a lot, have had xrays and mri over last few months to try and get referral just for appointment at public hosp as was referred a yr ago and still hadn’t heard anything so we did the tests in the hope to move them along but the films show nothing 🙁the radiologist reports say the screws are fine but I know something isn’t right from the raised/swollen lump I get everyday and radiating pain up and down knee and leg, do u have any idea what the reason for the lump seems to be? I also have osteoporosis and I’m 44 thanks

Thank you for your query. When you say partial knee reconstruction, I am assuming you had a partial knee replacement. Most of the partial knee prostheses designs don’t have screws, so perhaps you are talking about an ACL reconstruction or similar, as some people use screws for this. Either way, I can still try to help answer your query.

Partial knee replacements are performed when the arthritis is limited to one compartment. Although generally their use has been dropping, the results are excellent in the correct patient. If you have had this, and your knee is still painful, then potentially the prosthesis may be loose, there might be an infection, or you may have arthritis building up in the other compartments. Conversion to a total knee replacement is usually the answer here, but you are very young for this, so I would use caution here, as the exact cause should be identified first, before diving into a revision operation.

If you had an ACL reconstruction or similar, some people consider this a partial knee reconstruction, because the other 3 main ligaments are left intact. If this is the case, then the ACL graft may be placed in a slightly more vertical or horizontal orientation, compared to your original one. This can sometimes cause irritation around the graft, and within the knee. Sometimes scans will not show anything wrong here, but a knee arthroscopy may show impingement of the graft in the notch or similar.

having osteoporosis at your age is unusual. It would be best to be reviewed by your GP and potentially an endocrinologist to ensure that you do not have any issues with absorbing calcium or vitamin D. Sometimes supplementation is required.

A bone scan may be a good next step in seeing where the problem lies. This can show us if there is an issue in a particular spot in your knee/body but it may not be able to tell us exactly what that is. After an assessment by an orthopaedic surgeon, or your GP, then this may be a good next stem.

I hope this general information has helped you somewhat.

ACL re-ruptured. What activities do you recommend leading up to getting it redone.

My Acl reconstruction has re-ruptured. What activities / exercises so you recommend I do leading up to getting it re-done?

Hi, and thank you for your question. Without knowing specifically what type of graft you’ve had, how long its been in and what other damage might be in your knee, it can be hard to determine how unstable your knee is. I would assume that you have recently re-ruptured your ACL. Depending on the type of graft that you had in the first place will also determine the graft options for your future operation.

Before embarking on a revision operation, we would normally perform a CT as well as an MRI. The Ct scan can really show if your tunnels have significantly expanded. A tunnel is used to hold the graft in, and if it is larger than normal, then it needs to be bone grafted first, and then a subsequent operation can be performed. If the tunnel is in an unusual position, then sometimes we can just put a new tunnel near it, and it will be fine.

You’ve specifically asked about exercises. Maintaining good quads and hamstring exercises is essential prior to an ACL reconstruction. Twisting and pivoting exercises are not recommended, as your ACL is re-ruptured, making your knee prone to further damage if you land in an awkward way, or twist on an unstable knee. I would suggest a gym program to strengthen your quads and hamstrings.

The tricky part of an ACL re-rupture is to work out if the bone quality, tunnel size, previous implants, graft choice and soft tissues have any specific considerations prior to getting it redone. Some of our techniques now, can cause less damage when putting in an ACL graft.

I hope this helps, and I wish you a speedy recovery!

Pain under the patella with no arthritis.

I have pain under the patella it is not arthritis, x-Ray showed nothing, any ideas

Thank you for your question. Pain under the patella can also be caused by fat pad impingement. The fat pad is a large piece of fat that is attached to the under side of your patellar tendon. It acts to protect the patellar tendon, but in some cases, it can get quite inflamed and cause pain in a similar region to your patella.

The first step is to obtain an MRI to see if this can diagnose pain in the region from fat pad impingement. Another cause is quadriceps tendinopathy, meaning that your tendon is inflammed.

If you have fat pad impingement, then the treatment is to start first with physiotherapy and an ultrasound guided local anaesthetic and steroid injection into the fat pad. If this is unsuccessful, then an arthroscopy and partial removal of your fat pad is sometimes warranted.

If you have quadriceps tendinosis, then a period of rest, anti-inflammatories and physiotherapy are all that is required.

I hope this helps to narrow the search.

66yo with a meniscal tear and a Bakers cyst. Is an arthroscopy advised?

I am 66 years old with a meniscus tear and Bakers cyst. Would an arthroscopy to clean it be advised?

Thanks for your question. I wrote a small amount on Bakers cysts in a query below. A Bakers cyst is a small out pouching of fluid that develops in the back of your knee after something occurs within your actual knee joint to cause the production of fluid. The Bakers cyst in itself is actually not pathological, but it can be annoying and painful. They often increase and decrease in size, with activity, but can also remain in place, when the fluid inside them dehydrates and cannot get back into the knee to be reabsorbed.

If your knee only has a meniscal tear, then an arthroscopy is absolutely warranted. This is a straight forwards surgery that can remove the tear and alleviate pain. Whilst the chances of an isolated meniscal tear in your knee is lower at your age, than say, a 20 year old footballer, it is still possible, and I see this from time to time. The result of an arthroscopy is excellent if you have isolated pathology.

If your knee has the meniscal tear due to underlying osteoarthritis, then a knee arthroscopy may not make a difference. The key here is to work out if you have clicking, locking or catching of your knee, or if you have trouble twisting on your knee when performing your normal duties. If you have no rest pain, this is a good sign as well as rest pain is a typical sign of osteoarthritis.

I hope this answers your question.

Car accident and smashed knee against the dash board. Can't kneel and very tender.

I had a car accident 3-4 years ago and I smack my knee against the dash it was pretty nasty open mainly adipose tissue exposed. The structure of my right knee is intact I can weight bare, run etc but I can’t kneel on it it’s still too tender so I cant really play with the kids on the ground or it’s just hard to get up but I’m young and I cope. I had a bit of issues with bursitis but the fluid has resolved and it feels like every now and than for no reason it pops out of place. I opted for no surgery and to wash out the wound and suture. Complications were dehiscence and infection but that has resolved too. There’s just no real tissue protecting the front of my knee should I get it looked into further or is it just going to be the way it is?

Thank you for your question. It sounds like your issues are mainly with the soft tissues on the front of the knee, rather than the internal structure of the knee. This is probably a good thing, as you would not notice the issues unless you are trying to kneel down etc. Even so, I can appreciate that it is probably also very debilitating, especially as playing with the little ones can be up and down off the ground a lot!

When you mention that your knee pops out of place, this suggests that something is wrong with the internal structure of the knee. You had some kind of infection in your wound as well, which hopefully is all healed now. This can cause a lot of scar tissue to build up, and may well cause you to have some pain from this. There may be an option to cut this out, but your knee would need to be assessed first with a few scans, such as an ultrasound, MRI and plain X-rays as a baseline.

When we make cuts on the front of anyones knee, there is a chance that the knee becomes slightly tender when kneeling. I know this, as I have some mild discomfort when kneeling after my own ACL reconstruction. I have learnt how to put up with this, and it no longer bothers me, unless I am kneeling on hard ground repeatedly.

If you have bursitis, then this can be treated, potentially with an excision. Otherwise, a soft tissue injury with some tenderness may well be something you’re left with for ever. The first step is to get an assessment and decide if you would be willing to have surgery if there was a moderate chance of improvement.

I hope this helps to answer your question.

41yo with glass trauma to the knee. 4 arthroscopies and arthritis.

Good day i am 41 and 20 years ago i smashed into a plate glass door which cause some trauma to my knee and the hospital also left glass inside the joint which cause further damage. I have had around 3-4 arthroscopies, with the last being about 4 years ago. I know i have arthritis in my joints and pretty much bone on bone due to a shortening gap. I am at a point now where i have constant pain and it makes it difficult to work a full time job without a lot of pain killers. I was advised last operation that i will in time need a full knee replacement but being 41 it was suggested to wait a little longer. Is there a certain amount of scrape outs that are a general rule and would it be worth my looking at having another clean out, or at this stage does it seem like i am heading for a knee replacement. I have hear that a knee replacement without private health cover is around $20,000 or more and i want to know more facts before i proceed. When there is full body weight on the joint it is constant pain, which also make me doubt the strength of my joint. Any advice would be welcomed.

Hello, and thank you for your query. A few things going on here, so I will break each of your points down.

Leaving glass inside a joint is a very bad thing. Unless there were extenuating circumstances, all foreign bodies are usually taken out. This may involve multiple X-rays, and a few trips to the operating theatre after a few more scans to try to identify and remove glass. Glass fragments can be very hard to find, especially if they are embedded within the tissue. Generally, they should always be removed, as they can either act as a loose body in the joint, causing damage, or they can cause ongoing infections.

You have had 3-4 arthroscopies, so by now, it should be fairly clear what is happening within your joint. The last arthroscopy would have confirmed whether there was any major arthritic surface within the joint, or whether there was any ligament damage.

When you mention a shortening gap, I am assuming you mean that your joint space looks narrower on Xray. Generally, the length of the limb doesn’t change that much with knee osteoarthritis as it does with hip osteoarthritis. If you have severe knee wear, then certainly, your leg length may be shorter, but you would probably not notice it. What might be happening is that your knee is unable to fully straighten, which effectively makes your limb functionally short. This would cause you to limp and may start to affect the muscles surrounding your hip and pelvis, as well as your lower back.

Constant pain is a tough thing to deal with, and only those who have it, would really know the impact on their lives. If you have maximised your non operative management (please read some of the answers below), then sometimes a total knee replacement is warranted. At your age, the potential for a revision later in life is very high. Current statistics suggest a 15% revision rate at 15 years for patients under 55yo. If you can wait longer, and you are able to manage your pain to cope with everyday life, then this is preferable to having a total knee replacement at your age. If you are struggling significantly, then a knee replacement may be the best course of action, despite your age.

Knee arthroscopies (or scrape outs) are unlikely to help you for an extended period of time. They can help if you have an acute injury, but if your knee is just worn down from osteoarthritis, then a knee arthroscopy will not improve you for much longer than a few weeks. Without knowing what your X-rays, functional limitations, pain scores, and surrounding joint quality is like, it is hard to advise on whether or not you need a TKR, but from what you have written, I would presume that you would be getting very close to needing one.

A total knee replacement without private cover is somewhere in the vicinity of 22 – 30K, but the exact figure is unknown to me. It can be dependent on your medical health, how long you  are expected to stay in hospital etc. The problem here is that if something goes wrong (i.e. you get sick after your operation) or you need something else done, then you will need to be able to fund that. Whilst that is very rare, a trip to a private ICU can cost upwards of 5K per day! A better solution would be to take up private health insurance, or to go onto the public waiting list early. I am not an expert in the financial and public sector side of things, but I hope that the general information here can help you.

75yo with chronic knee osteoarthritis. I don't want surgery on my knees

I’m 75 yrs. old now so I don’t want surgery on my knees, do you have other way other than 
Replacement for my chronic knee osteoarthritis ?

Thank you for your question. The options other than surgery for knee osteoarthritis should always be maximised before even contemplating surgery. Generally, people who need surgery have already tried everything and are at the stage where they want to maintain a certain quality of life. Total knee replacement surgery is never essential – it is something that we offer to improve mobility, decrease pain, and improve function.

The options for management of knee osteoarthritis are a number of non operative measures. This includes:

  • Maintaining ideal body weight.
  • Maintaining good musculature around your knee through an exercise/physiotherapy program.
  • Taking a baseline of Panadol Osteo, Glucosamine and Fish oil.
  • Taking the occasional anti-inflammatory (If safe, after discussion with your general practitioner)
  • Avoiding impact activities (Cycling, swimming and walking should be maintained first)

Current evidence doesn’t really support the use of other items like injectable agents into the knee (steroid is short lived, PRP and Stem cells have limited researched benefit).

As a surgeon, it is up to us to discuss with our patients about the pros and cons of surgery and give you an accurate expectation of how you are likely to recover and what the risks are. After a discussion based upon each individuals patients specific case, this can sometimes show us whether or not surgery is indicated. If you are very much against a knee replacement, then we would never want you to go forwards with it.

At 75yo, you are certainly of an ideal age for a total knee replacement if you satisfy the criteria to have one. Unless you have major medical conditions precluding a safe anaesthetic, or if you have significant medical problems that may impact wound and tissue healing, then a knee replacement may be a good option for you.

Your first step should be the above methods, with a focus on pain reduction whilst maintaining an active lifestyle.

I hope this helps.

What would cause a knee replacement to fail? Particularly the tibial post area

What would cause a knee replacement to fail? Particularly the tibial post area

Thanks a lot of the question. This is the source of a lot of concern, but current methods and materials are being used to try to decrease the failure of implants. In general, the rate of failure is extremely low. If we look at some specific statistics, the following is derived from the recent Australian Joint Replacement Registry that has been running for the last 15 years.

  • Unicompartmental knee replacement: (Partial knee replacement) – Revision rate of 21% at 15 years.
  • Unispacer: (Medial or Lateral femorotibial compartment articular spacer – Revision rate of 77% at 10 years.
  • Patella/Trochlear: (Knee cap) – Revision rate of 27% at 10 years
  • Total knee replacement – Revision rate of 7% at 15 years.

As you can see, there is quite a difference in the rates of revision, ranging from 7% at 15 years to 77% at 10 years! The Unispacer is really not used as much, and the rate of unicompartmental knee replacements was dropping over the last 14 years until the last year.

For a total knee replacement, the reasons for revision include:

  • Loosening (28% of all cases)
  • Infection (22%)
  • Patellofemoral pain (11%)
  • Pain (8%)
  • Instability (6%)

From these causes, we can see that there are a lot of remaining causes to account for the 25% of cases. What is known is that knees fail for various reasons. There is a school of thought that suggests that improper alignment or failure to put the implant in the correct alignment will cause it to work in an abnormal way, which is logical, and suggests that the knee replacement may fail early. This is why I choose to use patient specific technology which enables a lot of pre-operative planning.

Infection is also a risk, and as you can see, it is quite high. In the absence of other reasons, we always look for infection as a cause, as it may not present with a large amount of symptoms, but may only cause the prosthesis to fail. In general, cemented prostheses have a lower rate of revision than cement less prostheses. To combat infection, I choose to use disposable instruments for my total knee replacements in the hope that this will remove one element that can contribute to the potential for infection.

Your question suggests that your tibial side is what is failing. This is the more common side, and can be due to a few factors, such as patient weight, incorrect positioning, or severe osteoporosis.

This answer is very general, as each situation is very specific and is assessed very specifically on a case by case basis. This includes a full workup of blood tests, X-rays, CT scans, Bone scans and potentially biopsies.

Once the cause is found, generally a revision operation is required.

I hope this answers your question.

Healing a patella tendon from blunt force trauma

What can be done to assist the healing of a patella tendon from blunt force trauma?

Thank you for your query. Blunt force trauma generally will not cause the disruption of your patellar tendon fibres to the point of requiring surgery. An exception to this is when there is a significant eccentric force placed across the patellar tendon in an awkward way which may cause the tendon to snap. If the tendon snaps, you will definitely know about it, as you would not be able to straight leg raise at all.

The patellar tendon is the tendon linking your knee cap (Patella) to your shin bone (Tibia). This works to extend (straighten) your knee, such as when walking, or performing squats. It is a vital part of your knee function and loss of its use will render the knee unable to hold your weight up when walking.

If you tendon has snapped completely, then surgery asap is required. If the tendon is just bruised, or partially torn, then a period of rest, ice, elevation and compression (RICE) is the best first step, and then if the symptoms last longer than about 6 weeks, then an assessment with ultrasound or an MRI may be useful. Generally, blunt force trauma should not cause a major long lasting problem with the knee.

Anti-inflammatory medication taken for short spurts would be appropriate to help with the swelling. Maintaining good nutrition and ensuring that you don’t re-injure the tendon during its healing process is very important. Try to avoid sports, jumping or running whilst it is healing. Walking is fine, and gentle cycling is OK. Essentially, these injuries should heal themselves, and no real treatment is necessary as long as you’ve given it enough time to heal.

I hope this helps.

Is there any remedy for bakers cysts?

Is there any remedy for bakers cysts.

Good question, and one that is asked a lot. A Baker cyst is a collection of fluid around the back of the knee that increases in size as the inflammation within your knee joint increases. The Bakers Cyst is actually not pathological in itself, but is more of a marker of something else going on within the knee. The Bakers Cyst is located in the posterior (back) part of your knee, and when your knee is swollen, the Bakers Cysts can protrude backwards like a golf ball.

Typically speaking, the aim of treatment of a Bakers Cyst is to find out what the cause of it is. If it is due to arthritis, or a meniscal tear, then the underlying cause should be addressed. The Bakers Cyst in itself is rarely treated although occasionally an aspiration and injection with steroids can be helpful if the underlying cause is undetermined.

Occasionally the Bakers Cyst can rupture and after about 2 weeks, all of the discomfort from the cyst disappears. We do not generally operate on a Bakers Cyst itself, due to its close proximity to the nerves and bloods vessels supplying the lower leg, as well as the fact that it will probably come back.

Your main focus should be finding out why you have the Bakers Cyst in the first place, and then going from there.

I hope this help you.

Smashed kneecap and leg from a fall and now arthritic. Torn ligament on other knee. What do to?

I have a smashed kneecap and leg bone from a bad fall on the rhs which now has arthritis. I tore the medial (?) inner ligament of the lhs knee doing sideways running. They say I’m too young for replacements. I can barely walk most times, when I stand up I have to bend the lower legs up and down to be able to walk, can’t bend leg in direction of putting socks on. I now get sciatic pain and lower back pain and foot pain from
Standing off kilter. What exercise can I do? I’m currently limited to aquarobics. Physio gives small massage of medial and that’s it. Wouid accupuncture help?

Thanks for your question. It sounds like you have two bad knees. A smashed kneecap (Patella) can affect your patellofemoral joint, and cause post traumatic arthritis in the joint due to damage to the cartilage surface. Usually a knee cap fracture will almost always damage the cartilage. If fixed correctly, this can prolong the time until your knee degenerates.

Your other knee has a tear of the medial collateral ligament. Generally, an isolated medial collateral ligament tear can be treated non operatively with a brace and crutches. The brace is kept on for 6 weeks. The functional result after treatment this way is very good. When you have damaged more than one ligament in the knee, and your knee is not that arthritic, then we would opt to fix the ligaments. The usual combination if with an Anterior Cruciate Ligament (ACL) rupture and a Medial Collateral Ligament (MCL) rupture. In this combination, both can be fixed. A brace is still required.

Your knee pain can also affect other areas of your body, and this might be why you are starting to get some sciatic, lower back and foot pain. This might be due to how you are walking, so I would recommend you see a physiotherapist first for an assessment of your gait. There are exercises, footwear modifications and braces that may be of value, but an assessment would be required.

If your knees are arthritis, or unstable, then try to stick to exercises which won’t cause you to fall over if your knees fail. Swimming and cycling are favourite amongst people with knee arthritis, so try those first. Going to the gym is possible, but stick to machine weights to avoid the potential of your knee giving way with free weights on board. Acupuncture can help, especially if you are getting a lot of inflammation. Essentially I see acupuncture as a deep massage, and this is best done for muscles that might be spasmed or knotted.

For you, I think the first step is to maximise your non operative management and then go from there. If you are still struggling, an earlier knee replacement might be required, although you will need to be aware of the risks of doing so.

I hope this helps to answer your question.

Arthritis with bone crunching feeling. What should I do?

I’m having problems with my right knee again I have arthritis and it feels like my bones are crunching together I’ve been told there’s not much cartilage left my knee also keeps giving way and locking what should I do

Thanks for your question. Giving way of your knee is often due to pain, so try to determine if this is the case. There shouldn’t be any major ligamentous deficit in your knee to cause your knee to give way if you just have arthritis in the knee. It sounds like you have had previous knee arthroscopy, as you have been told that you don’t have much cartilage left in your knee. This usually means that you may soon require a total knee replacement.

The locking of the knee, in the absence of major knee arthritis is usually due to either a loose body, or a torn meniscus that is flicking into the wrong position in the joint. When the knee locks due to arthritis, this is often due to pain.

If you have maximised your non operative therapy (See answers below) and you are struggling from a mobility, pain and functional level, then a total knee replacement is likely to be suitable for you.

The first step is to obtain new weight bearing X-rays. There are usually 3 views that are required. An AP view, Lateral View and a Skyline view. This will show different compartments of the knee, to determine how bad your arthritis is, and what the overall alignment of your knee is like. This will also show whether there are any cysts in your bone due to the arthritis that might need to be bone grafting during the surgery.

I hope this help answer your question.

Grade 3-4 osteoarthritis with meniscal tears. Had stem cell implant. What can be done?

Thanks for this opportunity to ask a question about knee issues. I am physicaly active with walking and tennis. I have developed significant cartiilage wear in my knees grade 3 – grade 4. I have bilateral mensical tears in both knees. I have had stem cell implant with moderate result s about 2 years ago. My knees are Ok but get very stiff. My question is what to do to prevent further degeneration to result in significant OA. What therapies if any are available to prevent worsening or even regenerate articular cartilgae in the knees. I take krill oil and something I got off the net but who knows it actually works or is proven. I want to keep physically active as long as possible

Thank you for your question. Firstly, grade 3-4 if a grading system that we use to determine how bad knee arthritis is. Grade 4 basically means that its bone on view, and this is not good for pain and functional status. What this means is that you are down to bone, and generally, this means that you are close to requiring a knee replacement. Each patient responds different to grade 4 arthritis, and whilst some people are grade 2-3 and have severe pain, some patients go on many years with grade 4 arthritis without major issues. We don’t know exactly why this is, but this means that time needs to be spent talking to each patient to ensure that they are having trouble on a pain and functional perspective before embarking on a total knee replacement.

The meniscal tears are likely to be degenerate tears, and not the same type of tears that you hear about in football and netball players. An acute meniscal tear is best treated with surgery, to remove the tear, prevent it from tearing further, and alleviate pain in the knee. Often a meniscal tear is associated with locking, clicking or catching in the knee. A degenerate tear is often not best treated with surgery as it is usually due to osteoarthritis, which we know won’t improve much with a knee arthroscopy. Even so, there are some circumstances where a knee arthroscopy (keyhole surgery) into the knee is worthwhile in these situations, but these are really on a case by case basis.

Stems cells have been around for a while, and until they show some evidence that they can indeed work in normal people with osteoarthritis, then I do not recommend it. Generally stem cell therapy works for people with discrete, small full thickness areas of cartilage loss. The large summary of many research papers (Lookup Meta Analysis of Stem Cell for Arthritis) did not show a significant improvement in most people. The costs are prohibitive, and personally I have yet to see a single patient who has had a good recovery from Stem Cells after having known osteoarthritis.

Unfortunately there are no therapies that can regenerate cartilage in the knee. Whilst cartilage can be grown, we find it hard to tell it where to stick to. This makes things like injectable stem cells hard to be successful at, as it is hard to target the correct area.

The best way to manage osteoarthritis is by the modalities that I have detailed in my previous answers below. Generally:

  • Maintain a healthy weight
  • Strengthen the muscles around the knee
  • Baseline Panadol Osteo, Glucosamine and Fish oil.
  • Occasional use of anti-inflammatories.

A total knee replacement will let you remain physically fit and healthy, so don’t dismiss that as an option when your knee pain worsens. The only real thing that you can do after a knee replacement is run, and perform repetitive impact activities. I allow my patients to return to Tennis, Cycling, Swimming, Walking, Hiking, Snow skiing etc.

I hope this helps to answer your question.

Knee arthritis and alternatives to surgery

I have chronic knee osteoarthritis in my right leg & my left knee is also affected tho not as bad as the right! I don’t want knee replacement , do I still have chance to improve my mobility & cud there be treatment w/ my osteoarthritis aside from knee replacement or surgery?

Thanks for your question. This does depend on whether or not you are symptomatic. This means:

  • Does your knee hurt all the time.
  • Are you having trouble sleeping, or does it wake you from sleep at night.
  • Have you tried all the baseline pain medications, like Panadol Osteo, Glucosamine and Fish oil, without success.
  • Is your walking limited.
  • Are you having trouble with normal day to day activities and leisure activities.

A total knee replacement is an operation to improve quality of life, and therefore, there is no “correct” time to have one. The main modalities to delay your knee replacement have been detailed below. You should try all of these first, and if they are unsuccessful, you should consider a knee replacement.

A good first step is to see a physiotherapist who can help you maintain your muscles, maintain a good body weight, and improve your mobility. A walking stick will also be a good start (used in the opposite hand to your most painful leg), as it offloads your knee. This can definitely prolong the time before you require a total knee replacement.

What I tell my patients to do, is look back at the 3 months before seeing me, and decide if they felt that their knee stopped them from doing the things they wanted to, was painful all the time, and was constantly on their mind. If these are all yes, and the X-rays and physical examination confirm the diagnosis, then a knee replacement can help. Current evidence do not support the use of PRP, Stem Cells or Injectable Hyaluronic acid.

I hope this helps answer your question.

TKR 8 weeks ago and has only 90 degrees of flexion. Considering a manipulation under anaesthetic

Hi. My husband had a TKR 8 weeks ago and still has only 90 degrees flexion. There is tightness laterally that he just can’t seem to push through. Is this likely to continue to progress or should he be considering a manip under anaesthetic?

Thank you for your query. Whilst your husband is still in the early phase of his total knee replacement, generally we try to achieve more than 90 degrees. Current research shows that the post operative knee range is somewhat dependent, or closely related to the pre-operative knee range. What this means is that if your husband had very bad knee range before the surgery, then he is unlikely to achieve a large range after. Of course, this is a generalisation.

Without knowing your specifics, I can only comment on my own experience and patients. My aim is to achieve 0-120 degrees. This allows full normal function (as 110 will do as well), specifically, the ability to walk up and down stairs easily. Not all patients achieve this, for various reasons, but I will always ensure that a patient can get to at least this range before they come off the operating table.

At 8 weeks, 90 degrees is not enough, unless you feel that he had less than this before the operation. I would be speaking to my surgeon and asking if a manipulation is warranted. A manipulation is when you are put under a general anaesthetic, and the knee is bent for you, to ensure that all the scar tissue isn’t restricting your range. Generally if it is required, you are in hospital overnight for pain management, and we may put you in a machine called a CPM (Continuous Passive Motion) machine to help to decrease scar tissue formation after tearing the scar tissue that was there before.

Part of the decision relies upon an appropriate assessment and measurement. We use a “goniometer” which measures the angle of the knee. One of the most important aspects of the range of movement after TKR is extension. This means, getting the knee fully straight. Whilst flexion can be improved with a manipulation, extension is much harder. I advise all my patients to ensure they can achieve extension all the time, and once the dressings are off, I review them at 2 weeks. Generally most are achieving at least 90 by 2 weeks. By my next review at 3 months, they should be getting 110+. I will always advise my patients to come to see me sooner if they feel like they have plateaued with their range.

Ultimately, it does come down to your expectations, and progress. If you feel that he should have more range, and he is not improving week on week, then a manipulation may be warranted.

The first step is to discuss these concerns with your surgeon directly.

I hope this helps.

Knee pain since 14yo with hip, back and ankle pain. Now 23yo with functional loss.

I have had knee pain (in the inner side of my patella) since i was 14 and was always told i needed orthotics and would ‘grow out of it’ by the time i was 18. I am now 23 and no longer play tennis or netball and have significant hip, back and ankle pain all from the alignment of my legs. Have had orthotics, months of regular physio, countless daily exercises and nothing has worked. Have been to foot and ankle specialists and rheumatologists who have not given any other suggestions for the source of my pain. I have been told i am like to get arthritis at a young age – is there anything else I can do to delay this process?

Thank you for your question. It sounds like there are a few things going on here, and the first step is to determine what the cause of your problems is. It can originate from any of the areas that you have mentioned, and generally each one should be investigated until the source is found. This can take some time, as various different scans can provide different information. From what you have written it sounds like the main issue is in your foot/ankle as you have had orthotics to realign your leg from the ankle up. If this is the case, then addressing your foot/ankle should be your first priority. If you have already seen a foot and ankle specialist, then there may not be a lot more that you can do.

If you have a rheumatologist, this suggests that you have a generalised arthritic condition, like rheumatoid arthritis, or SLE or similar. Without being fully aware of what you have, these conditions are generally treated with medicates to manage the generalised inflammatory state rather than each joint, until they become difficult to manage.

At your young age of 23, joint replacements are not recommended. As I have written in some of the answers below, the first step is to try the non operative measures first, and then to consider surgery on the affected areas only if there is a definite reason to.

To delay the process, ensure that you maximise your non operative management first, and that you get fully assessed for the source of your issues.

I hope this helps your situation.

52yo with osteoarthitis requiring a total knee replacement. What are the costs?

I am in the same predicament as Brad, I am 52 and have been told both knees need a full replacement due to osteo arthritis. I would also like to know whether I should have it done now or wait until I am older. Can you also let me know the costing – I have full private health insurance and also pay that bit more for knee/hip replacements.

Thank you for your query. I won’t touch on the same details as the answer I gave below, however I can advise you on the 2nd part of your question in general terms. I have consulted with our finance department to obtain the information below.

Firstly, it is important to note that the total cost of a total knee replacement is approximately $30,000 which includes the surgeon fee, assistant, anaesthetist, hospital stay, knee prosthesis costs, theatre time hire, nursing staff, physiotherapy and all the aspects of a knee replacement from the moment you walk into the hospital to the moment you walk out. This is how much you would have to pay if you did not have private health insurance.

Private health insurance covers part of your hospital stay (usually a lot of it) and usually partially covers the fee for the surgeon and anaesthetist. Each private health fund will pay a different amount. Medicare also covers part of the $30,000.

For someone who is privately insured, I can tell you that the additional fee (copayment) to have your total knee replacement performed is usually less than $500 unless you are with certain health insurers. Some of them have determined that they will pay nothing for the surgery, and cover partially your hospital stay. This is what you might have in your health insurance policy and it is a good idea to clarify this before contemplating surgery.

The benefit of being privately insured, is that you can choose who your surgeon is, when you would like it done, and generally where you have it done. For example, I perform almost all my joint replacements at Burnside War Memorial Hospital for many reasons. I feel that this hospital has an excellent reputation when it comes to providing the best care to my patients who have joint replacements.

I hope this helps to clarify the financial side of things. Whilst I am not directly involved in this side of things, I understand that the space is evolving, depending on many factors such as health insurance policy changes, and type of knee replacement being performed.

I hope this answers your question.

52yo needing total knee replacement due to osteoarthritis - When to have it done

I am 52 years old, have been told I need a full knee replacement by my orthopaedic surgeon due to osteo arthritis, pain is manageable but restricts activities such as walking and general exercise, is it best to wait or get it done now and risk having to have it done again when I’m older ?

Thank you for your question. This is a great topic, as it is often asked by patients – When should I have my total knee replacement? Generally, the rule is to wait until your knee is significantly impacting on your quality of life. With age, there is no ideal age to have a knee replacement, however as a general rule, based off the Australian Joint Replacement Registry – those over 55yo tend to have a lower rate of revision surgery than those who receive their knee replacement under 55yo. This is arbitrary and each individual should be assessed on their own merits.

It sounds like you are coping from a pain management aspect. This is one aspect of the picture when it comes to managing osteoarthritis. The general questions to ask yourself are:

  • Am I in pain constantly, including at night?
  • Do I restrict the activities that I want to do like walking, due to the pain?
  • Have I tried all the non operative measures without success?

Some patients feel that they should have their knee replacement performed when they are of good health, rather than wait until later when they might be more at risk of an anaesthetic. Whilst this might be somewhat true in a few circumstances, it is generally not the case. It is better overall to wait until you have maximised your non operative management and are still finding a significant impact on your quality of life, before embarking on your joint replacement.

Current evidence suggests that joint replacements last a long time. The Australian joint registry has been running now for 15 years, with the latest report only being released a few years ago. This specifically looked at the outcome of primary total knee replacements in patients aged less than 55yo. This information includes 33,897 patients who received their knee replacement when they were less than 55yo. The key points were:

  • 15 year revision rate of 15.7% (compared with 10% for those aged 55-64 and 3.8% for those aged >75yo)
  • If the primary diagnosis is rheumatoid arthritis, rather than osteoarthritis, the revision rate is far lower.
  • Cemented fixation has a lower rate of revision in younger patients for the first few years, and the same after that.

The main aim here is to evaluate and treat each patient individually. This means that a thorough assessment of your goals, medical conditions, and functional limitations should be done to ensure that the best outcome is given to you for a long time. The information above shows that if you can get over the age of 55yo, then revision rate does drop a lot, but sometimes this is not achievable.

Whilst in general, it is best to wait, I do offer total knee replacements to patients if they are struggling with pain and have a significantly decreased quality of life.

I hope this helps to answer your question.

Knee surgery in March for a meniscus and still can't straighten the knee

I had knee surgery (meniscus tear) in March and I still can’t straighten my knee fully. I still get a jarring pain on the inside left every now and then. Is this as good as it will be?

Thank you for your query. Generally a knee arthroscopy (key hole surgery) is performed for a meniscal tear. This uses two small holes on the front of the knee which enables us to view and treat a wide variety of injuries within the knee. Generally the recovery after a knee arthroscopy is very good, and you should usually walk out of hospital better than you walk in.

If you have underlying osteoarthritis, then a knee arthroscopy is unlikely to improve this aspect of your knee. Osteoarthritis can stop your knee from fully straightening, which will not change after knee arthroscopy. If you have no arthritis in the knee, then there is absolutely no real reason for why you shouldn’t be able to straighten your knee.

The potential reasons why you can’t fully straighten your knee (if you don’t have arthritis) is if there is a loose body within the knee, or if there is still some of the tear left there. Your surgeon should be able to show you some photos of what your knee looked like on the inside.

The normal cohort of patients receiving knee arthroscopies are sports people such as football players, netballers and soccer players. This results in a tear of the meniscus (cartilage within the knee) after an injury. The meniscus has limited blood supply, so the torn areas will need to be smoothed off. Think of this like a torn piece of paper. If you leave the tear there, the paper is more prone to keep tearing. By removing the tear, the paper becomes stable, and won’t tear.

In a small number of cases, the meniscus can be repaired. This is only when the tear is situated in a specific place. I would say that this only occurs in about 1 in 20 knee arthroscopies.

I hope this answers your question.

26yo with bone on bone arthritis

My Son has Bone on Bone and no cartridge left. What is his options . He is only 26. Found out this through knee operation a few years ago

Thank you for your question. Being only 26, the options are limited. Depending on where the area of bone on bone arthritis is, will depend on what is offered. There are numerous things that can be done, both non operatively, and operatively, depending on the site of the underlying arthritis. At the age of 26, I cannot recommend joint replacement – your son is far too young, unless there are very strange circumstances surrounding the arthritis.

The first step is to maximise the non operative measures. This includes:

  • Ideal weight maintenance
  • Maintaining good musculature around the knee
  • Regular Panadol Osteo, Glucosamine and Fish Oil.
  • Occasional use of anti-inflammatories (if cleared by your general practitioner)
  • Avoiding impact activities

If these measures fail, then there are certainly some options available for certain types of osteoarthritis of the knee in young patients.

  • High tibial osteotomy – this is where the top of the lower leg bone (Tibia) is cut to change the angle of the joint. This then changes where the weight is directed when walking and performing activities which can offload arthritic areas. This is really only suitable for those with very specific patterns of osteoarthritis, but can be successful for decades. When a total knee replacement is eventually required, the high tibial osteotomy allows this to occur with only minor modification to the overall plan.
  • Injections with Steroid or other agents – these are temporary at best, and if it is already bone on bone, will be unlikely to give a benefit over 6 months.

Unfortunately, current evidence does not support the use of stem cells, hyaluronic acid injections or PRP into the joint, although, if cost is not an issue, these can be attempted. We do not advocate for their use as the success rate is low and there is a chance of infection.

I would advise the first step for your Son would be to maximise the non operative measures first, and when it becomes bad enough, to obtain plain weight bearing X-rays of the knee, and an MRI.

I hope this helps you.

Patella removed at age 19, lots of arthroscopies, now has osteoarthritis

Hi, I had my patella removed when I was 19, then an advancement of the tibia tendon at 24 due to lots of falls. Lots of arthroscopies after. Now at 59yrs, I have osteoarthritis in that knee. Is there any progress in surgery to strengthen the knee without a patella or can you have a replacement patella?

Thanks for your query. It sounds like your knee has been through a lot. Firstly, well done on lasting until you are 59yo before contemplating a knee replacement, as it sounds like you may have been suffering for quite a while. 59yo is an appropriate age for a total knee replacement. You have osteoarthritis in your knee, and when bad enough, generally you will require a total knee replacement. As I wrote in a question below, having your patella removed still allows you to have a total knee replacement, but with it some additional rehabilitation is required to ensure that you achieve good bending and straightening of your knee, and good walking ability after your operation.

There have been replacement patellas on the market, but often these are not very good, regularly coming loose from the tissue. If you have had a patellectomy, performing a total knee replacement without putting in a patella can be done.

There is no surgery that can strengthen your knee unfortunately, but a well directed physiotherapy or exercise program would be a good start. If the pain in your knee is getting to be difficult, then a total knee replacement would be suitable.

I hope this has helped your situation.

Twisted knee replacement at 5 weeks with 7 weeks of pain

finally had the knee replacement and then at week 5 twisted and tore all muscles and tendons. how long will these take to heal and will the arthritis return ever. I did ask some questions back in October but since then have had 7 weeks of pain and why is this I had 1st knee replacement at 57yrs and 2nd at 58yrs the second been total hell

I’m very sorry to hear about your knee problems with your knee replacement. It certainly sounds like you have had a difficult time with your knees after twisting it. I would assume that nothing happened to the prosthesis when you twisted your knee, or else you would have required surgery.

It is not fully clear if you have had both of your knees replaced, or if you have had 1 done twice, 1 year apart. If it is a year apart on the same knee, then this is done usually when something has not quite gone according to plan. The number of things it could be are numerous, but thankfully, is not common at all.

If you have severely damaged some of your ligaments, this can be a problem. If you have torn one of the side ligaments (collaterals), then this can cause your knee to become unstable, which will severely impact the function of your total knee replacement. If this is the case, then reoperation is required, with a “constrained” implant. This provides stability of the knee through the implant itself, but generally, knees that are constrained do not provide the most normal feeling.

It definitely depends on what muscles and tendons you have torn as to the recovery time. This can take up to 3 months to improve to a point where you were before tearing your muscles and tendons. An ultrasound or MRI can help in working out which parts have been damaged, and then if anything is required.

I would definitely recommend you return back to your surgeon to ask these questions, as there might be something that needs to be done, if you have severely damaged a structural part of your knee replacement or the surrounding ligaments. If you have done this, and all the main parts of your knee are intact, then time will heal this well, and in a few months, you should not have similar pain. Make sure you keep walking, and maintaining good range so your knee doesn’t stiffen up whilst you recuperate.

I wish you all the best. I hope this helps.

79yo who can hardly walk, with Diabetes.

My mother is 79 can hardly walk without a lot of pain is a diebetic does not want a knee replacement will this be any good for her?

Knee arthritis can be quite debilitating, and can reduce a persons quality of life. Being Diabetic is not a major problem when it comes to performing knee replacement surgery, however if it is not controlled well, can increase the risks of a knee joint infection after a knee replacement. This is very bad, and we try to do anything we can to minimise infections at all times. For me personally, we use disposable instruments to try to decrease the risk of infection during knee replacement surgery, and this has worked well for us.

If she is not walking well, then I suspect she does not have a good quality of life. Especially if she is in a lot of pain. Whilst a total knee replacement may be suitable for her, we would never offer one to someone who was adamant that they did not want one. There may be a lot of reasons why people do not want a joint replacement, and this should be fully respected.

With this in mind, there are a few things that a surgeon will look at in determining a patient’s suitability for a joint replacement. This includes:

  • Pain experienced
  • Previous treatments attempted
  • Functional loss and expected demands
  • Medical problems
  • Walking distance

Sometimes people do not want a knee replacement because they have heard or seen something. In reality, total hip and knee replacement are some of the most successful operations that can be performed today, with excellent results and patients often achieving their best function well within the usual year of rehabilitation.

I hope this helps to answer your question for your mother.

Surgery for people who have had both knee caps removed.

Is this surgery any good for someone who has had both knee caps removed

I am guessing that you are referring to Total Knee Replacement surgery. When you have had your knee caps (patella) removed, a knee replacement does become less predictable. having your knee caps removed is certainly not a normal thing to do, and is usually only done in end stage circumstances. It is not done routinely anymore.

When your knee caps have been removed, this alters the way your muscles straighten your knee when you are walking, and moving. This can cause a “extension lag” where you cannot fully straighten your knee using your own muscles. It is important to work out if you can indeed fully straighten your knee at all (Try putting your leg flat on the ground and see if you can push your knee to be fully straight). If your knee can fully straighten, but you can do it using your own quadriceps (driver muscle), then you have an extension lag. This can be a slight issue when performing a total knee replacement, however it is certainly possible.

I would recommend having new X-rays and seeing what the state of your knees are. Also, a physical examination would show a lot of the issues. Knowing what you are like with respect to pain and function would determine whether or not you needed a total knee replacement.

All the best, I hope this has helped.

Different gait after spinal damage with work out knee and bad feet.

I have a very different gait after spinal damage in car accident. Have worn out knee , but also bad feet. Have been warned that knee replacement may cause me more problems in feet back or hip.

Thank you for your question. Firstly, I’m sorry to hear about your injuries from your car accident. Those involving the spine can be difficult to manage at times, as nerve related pain can be hard to deal with.

With your knee, I am guessing that you also have an arthritic knee. Without knowing your specific situation, I cannot agree that a total knee replacement will affect your feet, back or hip. Certainly, they are all interrelated, but depending on your situation, fixing a knee issue may well help to realign the leg and prevent other issues from arising. For example, if you have an abnormal bend in your knee, your hip and ankle will try to compensate for that, and can put extra strain on those joints. Fixing the alignment when performing a knee replacement is one of the main goals of a knee replacement. This helps to bring your other surrounding joints back into the correct alignment.

Sometimes, if you have such bad problems with your back, hip or feet, we would need to determine if you would improve enough to warrant a total knee replacement. For example, if your back was so bad that you wouldn’t be able to walk even if you had no pain in your knee, then it might not be worth going through with a knee replacement.

I hope this helps. In the answer below yours, there are a few modalities to try to reduce knee pain without surgery.

45yo with Osteoarthritis in the knee. Ligaments are intact.

I have osteoarthritis and slowly wearing away my knee joint and knee cap, I am 45. Is it worth going down the road for a knee replacement even though my ligaments are in tack?

Thank you for your question. At 45yo, you are at the younger end of the spectrum, and current evidence suggests that those under 55yo will have a jump in the requirement for a revision operation later in life. This can be due to various reasons, but generally we like our patients to be over 55yo when thinking about having a total knee replacement.

Your ligaments being intact play no role in whether or not you have a knee replacement. There are 4 main ligaments in the knee.

  • Medial Collateral
  • Lateral Collateral
  • Anterior Cruciate
  • Posterior Cruciate

In most people, your collaterals are usually in good shape, unless you’ve had a major injury such as a knee dislocation. Your anterior cruciate ligament can be damaged from sport, and this is the one that the footballers injure.

The best way to determine if you are ready for a total knee replacement is to go through a simple checklist

  • Do you have constant pain, which also affects you at night or wakes you from sleep.
  • Is your walking distance severely restricted
  • Do you struggle to climb in and out of a car, climb stairs or bend down to pick things up from the floor.

A knee replacement can be performed many different ways, and sometimes, only a partial knee replacement is required. In Australia, partial knee replacements are dropping as they generally are reserved for very specific circumstances, that not a lot of patients fulfil. When performed in the correct patient, they can last a long time, but in the wrong patient, they tend not to last long. A total knee replacement is generally more reliable.

Try to avoid a knee replacement until you are older if you can do a few things to cope with it. I would recommend:

  • Trailing a course of Glucosamine and Fish Oil for a period of 3 months. If it works, continue.
  • Regular Panadol Osteo
  • Occasional use of an anti-inflammatory such as Nurofen/Voltaren etc (As cleared with your regular doctor)
  • Physiotherapy or an Exercise Class to maintain the muscles surrounding your knee.
  • Modifying your diet to ensure that you are not overweight (reduces the force going through your painful knee).

I hope this helps in answering your query.

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Dr Chien-Wen Liew

Dr Chien-Wen Liew

Orthopaedic Surgeon

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