Arthroscopic Knee Surgery

Arthroscopic knee surgery (also called microsurgery) is performed on the knee for a variety of reasons, among the most common is repair or partial excision of the meniscus (torn knee cartilage) and occasionally - though less common - to repair dislocations or abnormalities of the patella (knee cap). It is also used to reconstruct the knee ligaments, which is most commonly the anterior cruciate ligament.

Pre Surgery Preparation
A complete health assessment and patient profile is given to an anesthesiologist, who is a doctor of medicine experienced in matching the proper anesthetic and dosage to the patient.

Patients are encouraged to fill prescriptions for pain and other medications on or before the day of their surgery, as pain following arthroscopic surgery can be moderate. Pain medication is prescribed by Dr. Sanders and administered to the patient in the operating room.

Medication
Medications that may be prescribed include a mild to moderate narcotic analgesic (Class 3 medication) and strong narcotic analgesics (Class 2 medication) that are generally not necessary for arthroscopic surgery of the knee but occasionally prescribed. Patients are urged to take the prescribed medications as directed, usually not more than one to two pills every three to four hours.

Most of the Class 3 medications are a combination of Hydrocodone (an effective pain relief medication and NOT a form of "Codeine") and Acetaminophen (the active ingredient in Tylenol). These medicines frequently cause side effects such as nausea and/or constipation. Phenergan is prescribed to help with nausea. Taking two Tylenol every four hours is a good alternative.

And Tylenol PM (a preparation that includes Benedryl) is encouraged over other medications late post surgery in the event of sleep disturbance, which is common after such procedures. Ambien, which is also prescribed, is a stronger sleep aid.

Postoperative Care

Rehydration
Too often patients come in for surgery, particularly out patient surgery, having had very little to drink and subsequently become dehydrated following the surgery. It is important that patients rehydrate following a surgical procedure – consuming sufficient quantities of water and a sports aid drink containing sugar and electrolytes. Proper hydration is key for the body, particularly so during recovery.

Dressing
Since the wound is not sutured in order to allow for excess water used during the arthroscopy to drain, the surgical dressing may appear bloody early post-surgery. This is not a cause for concern. The small amount of blood combined with the large amount of water used produces the red color of fresh blood - though it is not. Simply reinforce the dressing should it become saturated.

A Cryo/Cuff® is placed over the dressing, delivering cold therapy as well as compression. With the exception of showering, it should remain on for one complete week.

Avoiding Infection
During surgery, antibiotics are administered by vein to prevent the risk of infection. No other antibiotics are needed, but patients are encouraged to follow all instructions regarding the care of their wound and monitor it closely to further reduce the risk of infection.

The day after surgery the patient may remove the compression stocking and shower. The cuts should be washed with a 50/50 mixture of Hibiclens® (4% Chlorhexidine Gluconate) and water and used as soap. Following the shower and whenever the dressing is changed, the incision should be dressed with triple antibiotic ointment and fresh gauze. The compression stocking is then reapplied and worn for ten days. During this time no baths are allowed, only showers.

If a portion of the surgery was performed through an open incision, the wound may be closed with nylon sutures. The sutures should be left in for three weeks or until determined by Dr. Sanders. Occasionally, there is a small amount of drainage from the wound. This is a normal bodily response and NOT an infection.

Avoiding Blood Clots
It is rare that Thromboembolic disease, or traveling blood clot, occurs after arthroscopic surgery. However the consequences of this condition are serious. Previously, patients were routinely placed on blood thinners, but we have found that the risks of these medications often outweigh the benefits. At this point in time, it is recommended that patients wear a thigh-high TED (thromboembolic deterrent) stocking on their operated leg for ten days, begin an immediate course of weight bearing exercise, and take an aspirin every day. Patients who are at higher risk of developing a blood clot are placed on other more powerful blood thinners which are coordinated with their family physician or internal medicine doctor. Identifying the danger signs of a pulmonary embolism (blood clot that travels to the lung) is of great importance. These signs include:

Excessive swelling of the limb, but does not include echymosis or black and blue marks common and expected following surgery.
Soreness in the calf.
Rapid heart rate.
Rapid breathing rate.
Shortness of breath.
Chest pain.
Fever.

Regaining Mobility

After surgery, patients are encouraged to immediately take weight on the operated leg. Crutches are not used. Patients are able to walk in a normal fashion. Patients must also perform Active Range of Motion exercises in order to put their knee through a range of motion from hyperextension to a complete bend such that the heel touches the buttock.

In order to accomplish this, the knee is fully extended by placing several folded towels under the heel, and a single towel held by both hands under the forefoot. As toes are pulled toward the head, assisted by the towel held in both hands, the patient pushes the back of their knee down toward the bed. This enables physiologic hyperextension, which is important for a return to sports to occur. For knee flexion, the towel is then put over the toes and held with both hands. As it is pulled, the knee bends to a point where the heel touches the buttock. This is followed by a set of 15 straight leg raises, where the patient pulls their toes up towards their nose and actively lifts the leg six inches off the ground with the knee straight - and holds for five seconds, then repeats 15 times. This is followed by a set of 15 straight leg raises, where the patient pulls their toes up towards their nose and actively lifts the leg six inches off the ground with the knee straight - and holds for five seconds, then repeats 15 times.

The Reconditioning Program is begun on the morning after the surgery. A stationary bike is used for one hour per day, with the seat set in order to allow knee flexion to110 degrees and the resistance set to the minimum. Following this, patients perform ten wall slides. A wall slide is performed by standing with the back to the wall and sliding the buttocks slowly down the wall until the knees are bent as much as possible, minimally past 90 degrees. Patients continue their exercise program by adding the Step Box for both legs. This simple device is used for the performance of closed chain knee extension exercises on both legs, beginning with four sets of 25 reps of two-inch excursions each day and gradually increasing until 50 reps can be performed. Once this is accomplished, the same routine is continued with a four-inch excursion. After the same goal is reached, the excursion is increased to six, then eight inches. It is not necessary go beyond four inches on the first day. Following exercises, the knee should be iced down with the Cryocuff for 20 minutes.

This is repeated on subsequent days with mild resistance on the stationary bike, and increasing distances of excursion on the step box. To save time, it is not necessary to start on the two or four inch levels on the step box. Following exercises, the knee should be iced down with the Cryo/Cuff for 20 minutes. As the days progress, it is fine to add activity such as jogging, Stairmaster, elliptical trainer, and/or other sports-specific exercises. Swimming should be delayed until the eighth day post surgery.