 What are the most common causes of knee pain? As an orthopedic surgeon, what I see in my office commonly are overuse syndromes, traumatic injuries of the knee, and osteoarthritis. Typical weekend warriors go out and try to play basketball, they play it all their lives, and they come home and have a little pain in their knee. And it gets better by the next day. In a traumatic injury, we see sprains and strains and even broken bones. And arthritis is a degenerative process. What is osteoarthritis of the knee? Osteoarthritis is a degenerative process of the knee where you wear your cartilage down and the bone is exposed. I like to work with pictures to educate my patients. So this is a normal knee looking from the front. And the bones, the tibia bone, the femur bone and patella bone are separated from touching each other by two types of cartilage. The articular cartilage, like you'd see on a chicken leg bone, and the meniscal cartilages which act as a cushion. In arthritis, those cartilages are worn away. In this picture, we can see now an osteoarthritic knee. The nice cartilage is no longer there and you can see the bone is exposed. And also, you're forming osteophytes or bone spurs here and that's a hallmark of osteoarthritis. You don't go from a normal knee to a very badly arthritic knee in a day. It takes some time. But usually by this point, the patient has significant pain and disability. How common is osteoarthritis? Unfortunately, osteoarthritis is very common in our population. 80% of us will get osteoarthritis at some point in our lives. In the knee, probably 40 to 50% of people get some form of arthritis over their lifetime. How is osteoarthritis of the knee diagnosed? Well, certainly a trip to your orthopedic surgeon's office is important where he can do a medical history and see how healthy you are and find out how bad the knee has been over time. That'll be followed by a physical examination to make a diagnosis and oftentimes we'll do an x-ray in the office to confirm our diagnosis what we're thinking. Sometimes if the x-rays look more normal and we need more information, I'll send a patient for an MRI scan or a CT scan to see if there's more deformity or torn cartilage. My knee often feels stiff. Our ice packs, proper treatment. You know, I'm asked that question quite often by patients. For stiffness, I like to use heat and gentle range of motion exercises to get rid of the stiffness. But for pain, ice packs for five or 10 minutes are important as well as rest. Sometimes after you do a lot of exercise, I recommend an ice pack to avoid swelling after a strenuous activity. Do all patients need surgery for osteoarthritis of the knee? No, that's not the case. When first diagnosed or having early or moderate osteoarthritis, oftentimes conservative treatment is indicated and very successful. That can include anti-inflammatory medications, rest, heat, gentle exercises to build up the muscles around the knee joint itself. As the arthritis progresses, then sometimes we think about surgery. Besides surgery, are there other things that can help with osteoarthritis pain? Some things I try with my patients is called behavioral modification. I have them use a brace on their knee or a cane to walk. I have them avoid kneeling and squatting, which increases their pain and stay away from those exercises that cause pain. Oftentimes weight loss, if applicable, will take stress off the joints. You know, four to six times our body weight goes through our hip and knees. So if you lose 25 pounds, that takes up almost 150 pounds of force off your knee every step you take. At what point should I seek medical attention for my knee pain? Generally, when patients come to see me, they've tried simple things at home, such as rest and a leave or Advil. If those things don't make your knee feel better within a couple of days, it might be a good idea to call an orthopedic surgeon and have it take a look. What is a total knee replacement and when should a patient consider having it? I think the best answer to that question, I always use my diagrams. And we know that this is a knee with osteoarthritis. What we do in knee replacement is remove these surfaces. They really should have called it a total knee resurfacing procedure instead of replacement because we don't replace your bones. My patients generally consider knee replacement when they fail concerted treatment. Once they've lost the quality of their life, they can't work as they can. They can't do the sports they wanna do. They can't spend time with their grandchildren because the pain, that's when we consider knee replacement. Let me show you a different picture. So this is a representation of a total knee replacement. You can see now there's a metal and plastic device on the tibia and there's a metal cap on the femur and the bones are no longer touching. And besides having the joint replacement, we've corrected the deformity that the patient had as well. So they've given them a straight leg and good balance. Now when we look at a total knee from the side, you can really see why we call it a total knee because not only the tibia is replaced and the femoral surface, but also the little knee cap or patella. All three parts of the joint are replaced and that's why we call it a total knee replacement. What is robotic assisted total knee replacement? Why would you choose to do what? In robotic assisted total knee replacement, we use a computer and a mini robot to help us do the precision very accurately. Total knee replacement is a bone and soft tissue balancing procedure. In conventional total knee replacement, you want to have your hip knee and ankle in a straight line and that way you're about 66% accurate. In robotically assisted total knee replacement, we're over 99% accurate having your hip knee and ankle in a straight line. The literature in recent studies on robotically assisted total knees shows that knees that are not corrected to a straight line have a much higher early risk of failure. It's almost one-third of the patients done conventionally are at risk. Whereas when you use robotic assistance, we minimize that risk and you only have a 1% chance of early failure. So when we say that total knees may fail when they get early loosening, that might cause a re-operation, what we call a revision surgery and you don't want to go through a second operation within the first five years of your first one. So what we're looking at for robotic assisted total knee replacement is long-term results, 20 years, 30 years of good function for the patient. So what we do in robotic assisted total knee replacement is we make a three-dimensional model of the patient's own knee using their own anatomy. There's no CT scan required, no MRI scans required. We create a model of the patient's own knee and in two minutes time, we can have a model of the hip knee and ankle and we can see that model all through the range of motion. The computer will tell us how big the knee is, how much deformity it has, how much arthritis it has. Then we do all the surgery virtually on the computer first before we have to cut the bone once. Once we have a good plan, then we attach the mini robot to the patient's own bone and it takes us to where we have to cut the bone and I can cut it very accurately. Then the computer has a little checker device that we can see if the cut was performed accurately and it can be revised and recut at that point and that's why we're so highly accurate. We can check every part of the procedure all the way through. The computer robot also help us to balance the knee. Once we have the total knee in place, we still have to adjust the ligaments. You can see in this knee, the patient had a very bad deformity and a very unstable knee side to side. But after our corrections, our total knee and soft tissue balancing, we have a perfectly straight line that's right down the middle and very well balanced. So normally post-op, all we'd have is X-rays to look at. Now we have interoperative data that we can use and we can see the correction that we've performed and the X-rays so we can prove we did a good result and good job for the patient. What are some of the potential complications and the risks of total knee replacement and how do you try to lower your patient's risks and prevent them? I believe in the team approach to care and we've trained our team to help take care of our patients. When everybody's on the same page, we do a better job for our patients. Besides that, I believe in patient optimization. So when you come to our office, you're not just a knee problem. We'll look at your blood pressure, your heart, diabetes, smoking, and we'll correct all those problems before we go to surgery. All of our patients go to our joint motion class. They usually bring a friend or family and they spend about two hours educating them about their upcoming surgery. They'll learn everything there is to know about knee replacement. We even give them a book to take home so they can study. We're always worried about infection and joint replacement in general. And because of that, I operate in a special room called a laminar airflow room that filters the air six times every hour. We wear spacesuits to kind of keep our bodies away from the patients and that makes it much safer. All of our patients get appropriate antibiotics at the right time and dose before their surgery as well. We check on that for every single patient. There's always a risk of getting DVTs or blood clots in the legs after any kind of joint replacement and pulmonary embolisms which are broken blood clots that go up to the lungs. To try to prevent blood clots for our patients, we put them on chemical agents that are blood thinners that help prevent them. We also do early mobilization. So you're actually up and walking about three hours after your operation's completed and that seems to lower the risk of blood clots as well. So I always think the best preventative care is having a well-educated surgical team take care of our patient and that's the best thing to do. What is the typical recovery like after total knee replacement? Well, all my patients ask me that question. Generally the operation lasts about an hour and then recovery starts right after that. You'll start walking in the recovery room and most of our patients are in the hospital for only one or two days. Once the patient's able to walk 75 yards with either a walk or a cane and up and down a flight of stairs, we feel that they're safe for discharge to home and we range home care and physical therapy for the home. All of our patients get physical therapy starting in recovery room and then twice a day while they're in the hospital for a range of motion exercises, strengthening and walking. How soon can I get back to driving after a total knee replacement? Once our patients are discharged from the hospital, they typically need four to six weeks of physical therapy, which can start in the home and then go as an outpatient to a local center. I find that 90% recovery for most people takes three to six weeks. At that point you can drive a car again, you can probably return to work or to your activities. So after discharge from hospital, most of our patients will go home and I'll send the Winthrop home care team and physical therapists right to their door. They'll come seven days a week usually for two weeks and get the patients moving every day. After this, the patients can graduate to outpatient physical therapy. They can either come to Winthrop's outpatient apartment or we can go to a local physical therapist close to home. Generally they'll need physical therapy for four to six weeks. 90% of our patients are recovered in three to six weeks but I find the whole first year the knee gets stronger and stronger. As the bone gets stronger and the muscles get stronger over time, the patient's too much better as well. What activities can I expect to do after successful total knee replacement? So after you recover from your knee replacement, it's time to get back to the activities you enjoy. Many of my patients enjoy biking and walking and hiking. They go back to golf and tennis as well. Now it's time to go to the community center and have fun with your friends. I've had many patients walk their daughters down the aisle or the grandmothers enjoy a wedding they could enjoy before. And for our younger patients that have to return to work, that is certainly doable and that's very important for their families. For those of you who might like more information on total knee replacement or a joint replacement program at Winthrop University Hospital, you can call us at 1-866-WINTHRUP or you can search for us online at winthrop.org.