Dr Gautam Tawari is a UK fellowship trained and accredited Sports and Knee arthroscopy surgeon. He undertakes arthroscopic ACL surgery, Meniscal repairs, Knee Cartilage surgery and Stem cell treatment in the knee joint.
The Knee Joint (tri-compartmental joint) consists of three compartments – the Medial compartment (inside), the Lateral Compartment (outside) and the Patelo-Femoral compartment (knee cap). The bones are covered with cartilage to allow smooth movement.
There is medial & lateral meniscus (cushions) – that function as shock absorbers. It has two internal cruciate ligaments (ACL & PCL) and two external collateral ligament (MCL & LCL) that provide stability.
Sports injuries to the knee result in damage of the ligaments or the cushion, that often requires arthroscopic (key hole) surgery. Damage to the cartilage is treated with Cartilage Regeneration therapies.
Common Knee Problems and Related Information
Anterior cruciate ligament is one of the major ligaments of the knee that connects the femur (thigh bone) to the tibia (shin bone) and helps stabilise the knee joint. It prevents excessive forward movement of the the tibia in relation to the femur and also limits excessive rotational movements of the knee. A tear of this ligament results in feeling of lack of control of the knee on movement.
An ACL injury most commonly occurs during sports that involve twisting or overextending your knee, sudden directional change or slowing down while running, landing from a jump incorrectly or direct blow to the side of the knee, such as during a football tackle.
Anterior cruciate ligament reconstruction is a very common and a very successful procedure. It is indicated in patients wishing to return to an active lifestyle especially those wishing to play sports involving running and twisting. Reconstruction of the ligament tightens the knee and restores stability. The commonest form of reconstruction is by using patients own hamstring tendons to replace the injured ACL.
The procedure is performed under general anesthesia and is arthroscopic (keyhole). A hamstring tendon graft is prepared and is pulled through the predrilled holes in the tibia and femur. The new tendon is fixed into the bone with screws while the ligament heals into the bone.
Rehabilitation begins in 1 week and a physiotherapist provides specific exercises to strengthen and restore knee movement. Competitive sports are avoided for 5 to 6 months to allow the new graft to incorporate into the knee joint.
Menisci are two C-shape cartilage pieces present inside the knee joint, often referred as cushions. They stabilise the knee joint and act as “shock absorbers”. Meniscus tear is the commonest knee injury in athletes, especially those involved in contact sports. A sudden bend or twist of the knee cause the meniscus to tear. Elderly people are more prone to degenerative meniscal tears as the meniscal tissue wears out and weakens with age.
Torn meniscus causes pain, swelling, stiffness, catching or locking sensation of the knee. The knee is unable to move through its complete range of motion.
The treatment depends on the type, size and location of tear as well as age and activity level of the patient. Knee arthroscopy is often required for meniscal tears. Surgery is performed using arthroscope (pencil like camera) which enables to visualise and treatment is carried out with special instruments.
The arthroscopic treatment options include excision of damaged part of meniscus (partial meniscectomy), meniscus repair or meniscus replacement. During meniscectomy, small instruments called shavers or scissors may be used to remove the torn meniscus. In arthroscopic meniscus repair the torn meniscus is pinned or sutured to its rim.
Meniscus replacement or transplantation involves replacement of a torn cartilage with the cartilage obtained from a donor or a cultured patch obtained from laboratory. It is considered as a treatment option in very young patients with loss of meniscus.
The collateral ligaments connect the femur to tibia. It control the sideways motion of the knee and braces against unusual movement. The knee has 2 collateral ligaments – medial or “inside” collateral ligament and the lateral or “outside” collateral ligament (LCL). Injury to ligaments are considered as “sprains” and are graded.
Grade 1 Sprain – The ligament has been slightly stretched, but is still able to help keep the knee joint stable.
Grade 2 Sprain – The ligament stretches to a point where it becomes loose. This is often referred to as a partial tear.
Grade 3 Sprain – The ligament is split into two pieces. This is often referred as complete tear.
Injuries are often contact injuries, but not always. Medial collateral ligament tears occur as a result of a direct blow to the outside of the knee. Blows to the inside of the knee tears the lateral collateral ligament. The MCL is injured more often than the LCL.
- Pain at the sides of your knee. If there is an MCL injury, the pain is on the inside of the knee; an LCL injury may cause pain on the outside of the knee.
- Swelling over the site of the injury.
- Instability — the feeling that your knee is giving way.
Initial treatment includes icing, knee brace, activity modification, physiotherapy and painkillers.
Surgery is advocated on failure of conservative treatment, location of the tear in the ligament or associated injuries. Chronic instability require ligament reconstruction.
Kneecap (patella) rests in a groove of the thighbone (femur). When the knee bends and straightens, the patella moves straight up and down within the groove.
- Direct blow or a fall onto the knee, common in high-impact sports, such as football.
- A shallow or uneven groove in the femur can make dislocation more likely.
- Loose ligaments, making joints extremely flexible and more prone to patellar dislocation. This id common in girls and affects both the knees.
- Conditions causing muscle imbalance like Cerebral palsy, Down syndrome
- Pain, popping sound when the patella dislocates
- Feeling of kneecap shifting or sliding out of the groove, knee buckling or giving way
- Swelling, deformation of the knee
- Apprehension or fear when running or changing direction.
Dislocation often damages knee tissue and the patella remains unstable. Exercises, such as cycling, can help strengthen quadriceps muscles in the thigh and prevent future patellar dislocations.
Multiple dislocation or instability warrants surgery. Surgical treatment involves arthroscopic (keyhole) reconstruction of the ligaments that hold the patella in place. Presence of bone deformity require more complex surgical treatment.
The major tendons responsible for extension (straightening) of the knee joint are the quadricep tendon and the patellar tendon. The patellar tendon attaches the bottom of the kneecap (patella) to the top of the shinbone (tibia). Injury to any of these tendon results in loss of extensor mechanism of the knee.
Quadriceps tendon / Patellar tendon rupture
A complete tear of the quadricep/patellar tendon results in separation of the tendon from the kneecap, causing inability to straighten the knee.
A very strong force or a weakness in tendon results in rupture. Injury from a heavy fall or landing from a jump is common. Weakness of the tendon could result from tendinitis (Jumper’s Knee), use of cortisone injection, chronic diseases like renal failure, Rheumatoid arthritis, Diabetes mellitus, metabolic disease, infection and previous surgery (total knee replacement).
Tearing or popping sensation with pain and swelling. Inability to straighten the knee. An indentation can be felt above the kneecap (quadricep tendon) or at the bottom of the kneecap (patellar tendon) with bruising and cramping. Difficulty walking with knee giving way.
Surgery is required to regain knee function. Surgical repair reattaches the torn tendon to the kneecap. Splint is worn for 6 weeks following surgery with physiotherapy started at 3 weeks. It can take 6-9 months for return to sports.
Knee arthritis causes serious disability and affects everyday activities, like walking or climbing stairs.
Osteoarthritis (wear-and-tear) – commonest
Post-traumatic Arthritis (After knee trauma)
- Pain – generally develops slowly over time, worse after sitting.
- Stiffness and swelling of the joint
- Restricted movement with difficultly to bend and straighten the knee.
- Locking, creaking, clicking or snapping of the knee.
There is no cure for arthritis, treatments help to relieve the pain and disability.
- Lifestyle modifications – Switching from high impact activities (like jogging or tennis) to lower impact activities (like swimming or cycling), losing weight reduces stress on the knee joint and improves function.
- Physiotherapy and Exercises – Exercises help increase range of motion, flexibility and help strengthen the leg muscles.
- Assistive devices – Walking stick, knee brace or knee sleeve, elastic bandages may all help to support the knee.
- Medications – Non steroidal anti-inflammatory medications, a COX-2 inhibitor and non narcotic medication.
- Injections – corticosteroids injections (limited the number of injections to three or four per year, per joint, due to possible side effects.
- Disease-modifying anti-rheumatic drugs (DMARDs) are used in rheumatoid arthritis.
- Visco-supplement/PRP injections – This involves injecting special substances to improve the quality of the joint fluid.
- Glucosamine and chondroitin sulphate tablets
- Arthroscopy – Arthroscopic surgery is used in younger patients with an accompanied degenerative meniscal tear
- Cartilage grafting – Considered for younger patients with smaller area of cartilage damage.
- Osteotomy – Knee osteotomy is used in young patients with damage to one side of the knee joint. It shifts the weight on the normal side.
- Partial (Half) knee replacement (uni-compartmental) – Indication for this procedure are strict and requires pre-requisites in patients. The longevity of the procedure is debated and requires surgical accuracy for a good long term outcome.
- Total knee replacement (TKR) – Helps relieve pain and improve mobility. Current survival results are unto 20 years.