Knee

Meniscus tear can be repaired and use of knee restored
  • ACL Reconstruction

    Day of surgery

    Surgery will typically be done as an outpatient. You will come in and go home the day of surgery.

    Activity Once You Return Home

    You will be given crutches. You should not bear weight on your operated leg until given clearance to do so. See the Rehabilitation section for more details.

    Wound Care

    You likely will have a brace on your knee. In general I find it simplest if patients leave the brace in place until their 1st post-operative appointment 4-5 days after surgery. At that point the dressing will be changed and sutures removed. Usually only Band Aids will be necessary from then on. We will review how to properly remove and reapply the brace.

    Post-Operative Pain Management

    In addition to local anesthetic at the time of surgery I will typically prescribe several medications that work in combination to treat pain by different pain pathways. Always begin with the lower end of the dose range and increase if needed for more pain relief.  Ice is an excellent additional way to help decrease pain.   Ice should not be applied directly to the skin.   Apply at intervals like 1 hour on then 1 hour off.  Stay with this plan for regular ice application for the first 5-7 days after surgery.  If you have inadequate pain control I or someone at my office will always be available to assist you.

    Rehabilitation/Post-Operative Exercises

    This process begins the day of your surgery. Much like what is emphasized to my knee replacement patients the early focus is “straightening, strengthening, and bending!” Once I have done my best to reconstruct your knee, you have the most control over the outcome. After your 1st post-operative visit you will usually be referred to physical therapy but even at that point you will likely only see the therapist 3 days per week for 1 hour each visit. You will have approximately 16 waking hours each day to rehabilitate your knee. You can accomplish useful things for your knee whether you are lying in bed or sitting up in a chair if you understand the goals and the techniques to achieve those goals. Working together, my aim is to give you both the knowledge and the tools to succeed on your own. This gives you confidence, and gives me comfort, as patients may sometimes live far from my office, have therapists with whom I am unfamiliar, or have limited access to therapy services.

    The best way to work on bending is while out of bed and sitting in a chair. This should begin the day of surgery in most cases when you are out of bed for meals. Choose a firm chair on a smooth surface like a kitchen chair. First, if your brace is locked unlock it to allow bending. Sit with your knee bent to whatever degree you can easily manage. With your foot flat on the ground use your hands to gently pull up on your thigh, taking the weight off of your foot, and making it easier to slide your foot back towards the chair and increase the knee bend. Usually you will move it only an inch or so with each attempt. This is fine. If you hold it in this position with the increased bend the tightness and pain will subside. Then repeat sliding back another inch. Keep doing this and you will be amazed at the gains you will make! It is not unusual for me to do this with patients during the course of a post-operative visit and see them make 20-30 degrees of gain within 5 or 10 minutes. You are in charge! No therapist, no pushing, no one hurting you. As you get more advanced try to scoot yourself forward on the chair to increase your bending even further. When you tire or fatigue, slide your foot forward and take a rest. You should work on this during every meal and once you are home at least 4-6 times each day for 5-10 minutes each time. Your basic initial goal will be to achieve 90 degrees of bending by 10 days after surgery at which point you will have your second post-operative visit.

    The next activity is straightening. Spend some time with the foot propped up off of the ground with the knee out straight. Gravity will help you regain full straightening. You can also lean forward and gently push on your shin. Do not ever lay with a pillow under your knee! This is what I call “no man’s land.” Your knee in this position is not straight nor is it bent to a useful degree. Work on straightening and bending as reviewed above avoiding time spent in “no man’s land.”

    The final piece of “straightening, strengthening, and bending” is your strengthening exercise. Your leg will feel heavy after surgery and your thigh muscle will feel weak. This is normal but again with knowledge and specific exercises you can overcome this. The critical exercise is the leg raise. You need to be in bed lying flat. It is important to practice lifting your leg up in the air while it is out straight early on (the first 4-12 hours after surgery). Slight assistance from a friend or family member lifting gently under your foot is fine, but you should strive to be free of this help. The faster you gain a strong independent straight leg raise the easier you will move about without assistance and the better your walking will be. Once you have a strong straight leg raise we will be able to wean you from your brace and your crutches. your goal should be 10 straight leg raise attempts each hour. Even if you can’t always raise the leg off of the bed, the act of trying will keep blood moving in your leg helping to prevent clots, reeducate your muscle, and move you closer to independence. If you don’t try today, tomorrow will be no different. That’s not what we want.

    In most cases by 7-14 days after surgery I expect that you will be in physical therapy and working to be off of your crutches and out of your brace.  This can vary depending upon other factors like associated meniscus repair surgery.   Therapy will usually continue for some number of months. The exact duration will vary from patient to patient depending upon their personal rate of progress and their personal activity goals. Someone expecting to return to high intensity athletics will typically have different strength and agility requirements than someone who had the procedure done primarily because their knee was unstable with activities of daily living and doesn’t really anticipate sports participation.

  • Knee Arthoscopy Meniscus Surgery

    Day of Surgery

    Procedures are typically done on an out-patient basis where you will come in and go home the day of surgery.

    Activity Once You Return Home

    Activity will depend upon whether you had a “repair” or a “partial menisectomy.” If a repair has been done you will be in a brace or so called knee immobilizer and will be given crutches to remain non-weight bearing on the operated leg. If you have had a partial menisectomy or the meniscus has just been trimmed you will not have a brace and typically will not need crutches and may put your weight on the operated leg as your pain allows. For all patients I ask them to ice their knee as much as possible for the first several days to help control pain and swelling. See the Rehabilitation section for more details.

    Wound Care

    You will have a sterile bandage and ACE wrap applied in the operating room. These can be removed all the way down to the skin on the 3rd day after surgery. Whether a partial menisectomy or a repair has been performed there typically will 2 incisions each closed with one or several black stitches. You may shower at this point. No tubs, pools, or spas. When done, simply pat the wounds dry and then cover them with Band Aids. Use your ACE wrap during the day when you are up and around and apply ice periodically to continue to help control your swelling. Typically swelling will be worst on the 2nd or 3rd day after surgery and then will begin to subside. Follow up in my office typically is done 4-5 days after surgery and sutures will be removed at that time.

    Post-Operative Pain Management

    You will be given a prescription for pain medication. Most commonly this will be Norco or hydrocodone plus Tylenol. Most patients seem to find that this works effectively for this operation. It can be supplemented with Motrin or Aleve if needed for additional pain relief. I typically will inject the knee with a long acting local anesthetic at the end of the operation. This can significantly decrease your initial post-operative pain and overall is very helpful. I caution my patients, however, that they should not be “faked out” if they have little to no pain for the first 12-24 hours and be prepared to take your pain medication, adjust your activity level, and ice your knee to help if the pain increases.

    Rehabilitation/Post-operative Exercises

    Just like more involved knee surgeries such as knee replacements and ligament reconstructions the early focus after knee arthroscopy for meniscus surgery is focused on straightening, strengthening, and bending.

    Partial Menisectomy

    If you have had a partial menisectomy or trimming of your meniscus you can put your weight on your knee without restriction. You should begin straightening, leg raising, and bending exercises the day of your surgery. The early goal should be for full straightening and bending to 90 degrees by your first visit 4-5 days after surgery. Depending upon your progress and specific recovery goals you may or may not be referred for formal therapy. That will be determined at your 1st post-operative visit.

    Meniscus Repair

    If you have had a repair you will be in a brace after surgery. You may remove it on the 3rd day after surgery so that you can change your dressing (see Wound Care). Even though you may shower at this point you should maintain your activity restrictions—no weight bearing on your operated leg and no bending of your knee. You should begin your leg lifting exercises and your straightening exercises the day of surgery. We will discontinue your brace 3 weeks after your surgery and begin your bending exercises. You will remain on crutches non-weight bearing on your operated leg for a total of 6-8 weeks following surgery. I typically recommend that patients refrain from deep squatting or cutting/pivoting athletics for 3-4 months following surgery.

  • Knee Replacement/Makoplasty

    Hospital Course

    If you have had a complete or “Total Knee Replacement” you will typically spend 1 or maybe 2 days in the hospital. Patients with the Makoplasty or “Partial Knee Replacement” will usually go home the day of  surgery although some will stay overnight following the procedure. Ultimately that will be individualized for your comfort and optimal medical care.

    Rehabilitation/Post-operative exercises

    I ask all my patients to be active participants in every phase of their rehabilitation. If you haven’t heard it already, you are going to hear me say over and over “straightening, strengthening, and bending!” These are the absolute focus of the early post-operative rehabilitation or exercise plan. Once I have done my best to reconstruct your knee, you have the most control over the outcome. While in the hospital you will typically work with the therapist twice daily. Following discharge, whether you are at home with a visiting therapist or traveling to an outpatient therapy facility, you will usually see a therapist for one hour 3 times per week. The simple fact is that you will have approximately 16 waking hours per day to focus on the recovery from your surgery. You can accomplish useful things for your knee whether you are lying in bed or sitting up in a chair if you understand the goals and the techniques to achieve those goals. Working together, my aim is to give you both the knowledge and the tools to succeed on your own. This gives you confidence, and gives me comfort, as patients may sometimes live far from my office, have therapists with whom I am unfamiliar, or have limited access to therapy services.

    Your rehabilitation will begin the day of surgery for both total knee replacement and Makoplasty.  Therapists and nurses will have you out of bed and walking on your new knee.   For those going home the day of surgery, which is becoming increasingly common with improved pain management and surgical techniques, they will be able to walk at least 100 feet, climb steps, and lift there leg to get in and out of bed independently.   My patients are usually able to tolerate this well as all of my patients will receive a long acting numbing medicine or “local anesthetic” during the surgery and most will be given a preventative or “prophylactic” dose of long acting pain medication by mouth just before the surgery starts.  You may have heard of patients using a CPM or bending machine.  The scientific literature is clear at this point and these devices do not improve outcomes.  My goal, and yours if you have had a total knee replacement, will be to achieve 0-90 degrees of motion under your own power the day of surgery and maintain/increase that in the weeks following.

    The best way to work on bending is while out of bed and sitting in a chair. This will begin the day of surgery when you are out of bed for meals.  When home choose a firm chair on a smooth surface like a kitchen chair. Sit with your knee bent to whatever degree you can easily manage. With your foot flat on the ground use your hands to gently pull up on your thigh, taking the weight off of your foot, and making it easier to slide your foot back and increase the bend. Usually you will move it only an inch or so. This is fine. If you hold it in this position with the increased bend the tightness and pain will subside. Then repeat sliding back another inch. Keep doing this and you will be amazed at the gains you will make! It is not unusual for me to do this with patients during the course of a post-operative visit and see them make 20-30 degrees of gain within 5 or 10 minutes. Once again you are in charge! No therapist, no pushing, no one hurting you. As you get more advanced try to scoot yourself forward on the chair while keeping your foot stationary on the floor.  This will increase your bending even further. When you tire or fatigue, slide your foot forward and take a rest. You should work on this during every meal and once you are home at least 4-6 times each day for 5-10 minutes each time.

    Straightening is just as important as bending.  This straightening is important in all patients but especially important if your knee was stiff and did not straighten before surgery as this problem will have a tendency to recur after surgery. Do not ever lie with a pillow under your knee! This is what I call “no man’s land.” Your knee in this position is not straight nor is it bent to a useful degree.  In the beginning patients will always perceive some sense of stiffness while post operative swelling and pain resolve.  After working on bending as outlined above there will be some stiffness as knee is brought back out straight.  I repeatedly tell patients that I really don’t care how many times they bend the knee back and forth but rather the focus should be on maintaining full straightening and achieving full bending.  The range in the middle of the extremes of full straightening and full bending will get easier as recovery proceeds.  Spend time with the foot propped up off of the bed or couch with the knee out straight. Gravity will help you regain full straightening.   While sitting in a chair you can also lean forward and gently push on the front of your knee. I will show you how to do this. Once again you are in charge.  Work on straightening and bending as reviewed above avoiding time spent in “no man’s land.”

    The final pieces of “straightening, strengthening, and bending” are your strengthening exercises. Your leg will feel heavy after surgery and your thigh muscle will feel weak. This is normal but again with knowledge and specific exercises you can overcome this. The critical exercise is the leg raise. You need to be in bed lying flat in bed or on the couch.  Almost all of my patients can accomplish this immediately after surgery if they try. It is critical that you try. It is important to practice lifting your leg up in the air while it is out straight early on (the first 4-12 hours after surgery) while your local anesthetic is likely to be the most effective. During this period you will see that you can lift your leg and gain confidence. This will help you maintain this ability as this medicine wears off. Slight assistance from your nurse or family lifting gently under your foot is fine, but you should strive to be free of this help. The faster you gain a strong independent straight leg raise the easier you will move about without assistance and the better your walking will be.  Your goal should be 10 straight leg raise attempts each hour. Even if you can’t always raise the leg off of the bed, the act of trying will keep blood moving in your leg helping to prevent clots, reeducate your muscle, and move you closer to independence. If you don’t try today, tomorrow will be no different. That’s not what we want.

    Care of Your Wound and Control of Post-operative Swelling

    Typically you will have an “impervious” or water proof dressing in place. This will allow you to safely shower immediately after surgery. These bandages are designed to remain in place until your first follow up visit. The exact date of that visit will be planned before you leave the hospital but it will typically be 10-12 days after your surgery. You should not immerse your knee in pools or tubs/spas until I have given you clearance to do so. The bandage may develop some blood or fluid staining on it. This is not a problem and totally normal. If any fluid is leaking from the sides, or the bandage appears saturated, you should contact the office for additional instructions. Someone will always be available to assist you. Any staples or stitches will be removed at this first visit.  Patients should apply ice to the knee for 30 minutes or so every several hours for at least the first week after surgery.  Do not apply directly on the skin. A clean towel or light clothing should cover the knee before ice is applied.  You will be fitted with compression stockings following  surgery.  These help prevent blood clots and assist along with ice and occasional elevation in controlling swelling.    I ask my patients to wear these until their swelling is minimal and they have resumed substantial near normal walking.  The stockings may be removed for bathing.  Along with all of these exercises it is important to occasionally elevate and achieve reasonable control of swelling.

  • Exercises

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