Preparation prior to surgery

In order to prepare for knee arthroscopy surgery, a number of things should be considered.

Muscle strength and conditioning

There is evidence to demonstrate that patients who improve their quadriceps strength and mobility prior to knee surgery make both a faster recovery and also tended to recover greater function following the surgery. It is recommended that you undertake a strength and conditioning program supervised by a qualified health professional such as a physiotherapist.

Supplements

Prior to surgery, it is critical that you maintain good health. As part of this, some supplements have been shown to be beneficial. These include iron supplementation to boost haemoglobin levels if they are low, along with vitamin C and vitamin D to improve your immune system and bone health. In addition to this, patients should ensure that they have a healthy diet that avoids excessive consumption of alcohol. For patients with diabetes, good blood glucose control is critical for reducing the risk of post-surgery complications, such as infection and wound breakdown.

Iron supplementation may not be recommended in some individuals with certain medical conditions. Advice should be sought from your medical practitioner before commencing this medication.

Recent evidence has emerged showing the use of branched chain amino acid supplements enhances muscle recovery following knee surgery. Whilst this was a small study, it was a randomised controlled trial comparing to a placebo supplement and demonstrated less fatty striations in the leg muscles of patients taken the supplement. Branch chain amino acid supplements are not suitable in patients with kidney disease or poorly controlled diabetes. They can be purchased if the patient wishes to use them as adjunct in their recovery

Pre-existing medical conditions

You will be asked about your medical history. It is important that you accurately inform your specialist of any conditions affecting your heart, lungs, blood pressure, kidneys, or circulation. It is also critical to inform your doctor of any conditions that may affect your immune system, such as diabetes. 

Medications

10 days prior to surgery some medications may need to stop. These may include aspirin, nonsteroidal anti-inflammatories, garlic capsules and fish oil. If you are taking blood thinners such as aspirin, Plavix, or warfarin, these may need to stop but will likely need to be done in conjunction with the advice from either your general practitioner or another specialist, such as a cardiologist. It is critical that you inform your specialist if you are taking these medications.

Skin care

It is vitally important that you have no cuts, scratches, or skin infections, as these increase the risk of infection and may lead to your surgery been postponed. Do not wax or shave your legs in the week prior to surgery.

Smoking

It is recommended to cease smoking for at least 6 weeks prior to surgery. People who smoke have an increased complication rate for events such as a DVT, infection, or wound complications.

The day of the surgery

You will be admitted to the hospital on the day of the surgery. You will meet and discuss your medical anaesthetic history and the type of anaesthetic that will be performed with your anaesthetist often prior to the surgery. On admission, the leg will typically be washed and shaved if necessary. This helps to prevent infection and identify the correct site of surgery. Prior to the surgery you will be repeatedly asked to confirm the side and type of surgery that you are having. This is part of an important preoperative check that the hospital staff perform. Typically, the hospital preadmission clinic will call you the day prior to your surgery to inform you exactly when to come in along with your fasting details. 

The Surgery

The knee arthroscopy is a surgery done through so-called keyhole incisions typically placed on either side of the knee. These incisions are usually 1 cm in length. In some instances, additional incisions may be required for certain procedures. A camera is inserted, and the joint is inspected. Typically, it is used to evaluate and treat the following conditions:

• Meniscal tears

• Articular cartilage injury

• Removing loose bodies

• Diagnosing and treating either joint infection or inflammation

• Taking biopsies

• Removing cysts

Surgery typically takes anywhere from 30 to 90 minutes. The port sites are typically closed with dissolving sutures.

Following the surgery

You will be seen in the recovery area after the surgery. You will be given information about the operation and, if necessary, you will be seen by a physiotherapist prior to going home. If you require crutches or a brace these will be fitted before going home. You will not be able to drive home and will need to arrange transport from the hospital.

In some instances, you will not be permitted to fully weight-bear on the leg and this may require you to use crutches for a period of up to 6 weeks. Typically, this occurs after certain procedures such as meniscal repairs. You will be informed prior to the surgery if this may be the case for your operation. You will be provided with a series of discharge medications that can be collected from the hospital pharmacy prior to discharge. These typically include a variety of pain relief medications, as well as a blood thinning medication to reduce the risk of a deep vein thrombosis.

Pain relief is provided in the form of oral analgesia. In some instances, the patient will be allowed to go home immediately if they are safe on crutches. The physiotherapist will in some cases be needed to assess you walking with crutches. You will be permitted to place some weight on your foot, but the amount will be determined by the operation. Please refer to the surgeon’s instructions regarding this. The knee will typically be allowed to bend from full extension to 90 degrees flexion for the first 6 weeks.

Weight-Bearing

After surgery, weight-bearing will be determined by any meniscal and cartilage injury or associated ligament surgery. Typically, patients are allowed to fully weight-bear with crutches. If weight-bearing is permitted, crutches are still required until the quadriceps have regained control of the knee and walking can be performed safely. Patients typically go home the same day of surgery.  

Bandages and Dressings

On the first after surgery, the bandages on the knee are removed and a compressive bandage called a tubigrip, which has been placed underneath from mid shin to mid-thigh, is left in place. The dressings are kept dry and in place until the wound review, which is performed with the surgeon typically 10 to 14 days after the surgery. If the bandaging becomes soaked either with blood or otherwise the patient should return either to the clinic, or if this is not possible, to the hospital to have the dressings changed.

Stitches in the incisions may be dissolving, however are sometimes still removed between days 10-14 on a return visit to consultation for a wound review. The knee needs to remain dry. Swimming, bathing, spa’s, sauna etc. is not allowed until wound healing is confirmed. To shower, a water-proof sleeve that fits over the knee can be purchased from the chemist.

• Waterproof dressings have been applied to the skin that allow patient to shower

• Small amounts of ooze that can be seen on the dressings are a normal part of the routine post operative experience and are of no concern.

•  If there is a larger amount of blood that leaks from a dressing, this is very rare. Over wrap the area with 2 x extra crepe bandages with a firm pressure. Rest the knee and avoid excessive walking. Contact Dr Shatrov' Practice Manager at the next available time so an urgent review can be arranged. 

Exercises

Exercises to activate the quadriceps and gluteal muscle are performed, and calf pumping exercises encouraged to circulate blood throughout the leg. The focus initially should be on achieving full extension of the knee and activating the quadriceps muscles. Flexion of the knee is typically encouraged as well but may be limited depending on some of the associated injuries or surgery that your knee may have required such as meniscal surgery.

Medications

A blood thinning medication is sometimes prescribed for two weeks following surgery to reduce the risk of DVT’s. 

Pain relief is prescribed and typically involves the following. 

• Paracetamol 1 g every 6 hours (if the patient does not have either an allergy to this medication or pre-existing liver disease) 

• A nonsteroidal anti-inflammatory which is typically either 1 of celecoxib, meloxicam or Volatren. This should not be taken if the patient has kidney problems, high blood pressure, may be pregnant or has reflux. 

Additional pain killers are often prescribed but depend on a variety of factors including the anaesthetist’s preference, the patient's preference, and pre-existing medical conditions as well as their medication history. Local anaesthetic is typically injected around the incisions and graft harvest site at the time of surgery and often wears off 12 to 18 hours after being inserted. This is often accompanied with gradually increasing pain at that time. Medications are to be purchased upon discharge from the hospital. Ongoing scripts if required should be sort from your GP.

Driving 

Driving is not permitted until sufficient muscle control has been regained to allow for emergency breaking. The length of time that this takes varies depending on the surgery and can range from 2 days to 6 weeks. Driving is also not permitted whilst taking certain medications. For more information about this please consult either your general practitioner or your orthopaedic surgeon.

Showering

Showering is permitted but the wound needs to remain dry. A sleeve can be purchased from some chemists. Alternatively, a bag can be wrapped around the leg in order to keep it dry.

Bracing

Bracing is not performed routinely however may be required if MPFL surgery is performed in conjunction with other associated injuries such as meniscal repair, bony procedure or additional ligament surgery.

Physiotherapy

A critical component of MPFL recovery is a supervised rehabilitation program with a physiotherapist. Physiotherapy should be arranged prior to surgery and the details of the physiotherapist shared with the surgeon so they can communicate as required during your recovery. The frequency and duration of therapy will be determined by the physiotherapist but should commence within a week of the surgery.

Returning to activities after arthroscopy

It is important that for the first 2 weeks after your surgery no strenuous exercises are undertaken. A known complication after knee arthroscopy is a tibial stress fracture that can occur due to excessive exercise following knee surgery.

A typical return to work or sport timeline following the arthroscopy includes the following:

• Office work; 2 to 3 days

• Physical work; 2 to 6 weeks

• Light training 2 weeks depending on the swelling

• Competitive sport 4 to 6 weeks depending on progress

This timeline will vary significantly depending on the surgery that you’ve had, not your goals and level of fitness prior to the surgery.

Potential Risks and Complications

Infection

Although infection is rare after knee arthroscopy (1/800), the risk remains serious if the infection enters the joint. If this occurs, you will need to be readmitted to hospital for antibiotics. These may be required for 4 weeks, and you may also even require surgery to help flush out the infection.  The presence of any fever, increasing redness or increasing pain should be immediately reported to the practice. If you are not able to contact the practice, you should attend the nearest emergency department.

Blood clots

Deep vein thrombosis, or DVT, occurs when a large vein of the leg forms a blood clot. This can lead to an even more serious complication called a pulmonary embolism. Pulmonary lesions can be fatal if left untreated. Whilst these are rare due to the fact that there are serious a number of precautions taken to reduce the risk of occurrence, such as early mobilisation, the use of compressive stockings, foot and ankle pumping exercises and taking blood thinning medications after your surgery, the risk is still present. 

Nerve or blood vessel injury

Several major nerves and vessels run very close to the knee and are at risk of injury during the surgery. Whilst this is rare, the risk is still present and, when it occurs, can lead to permanent loss of muscle power in the leg. There are several small nerves that supply the skin in front of the knee and these cuts during the surgery can result in a numb patch on the outside of the leg being noticed by the patient. Whilst it is usually of no functional significance, some patients are aware of it.

Additional complications

Following knee arthroscopy surgery, swelling in the knee is common. This typically resolves within the first 2 weeks following the surgery, but it can persist. Persistent pain is also possible. In some instances, such as meniscal surgery, there is a 10% chance quoted in the literature of possibly being made worse by the surgery. Occasionally, catching symptoms may still occur. Following any meniscal repair work, the risk of the repair failing is said to be approximately 20% and this may require further surgery. Rare complications, such as an anaphylactic reaction to a medication, whilst unusual and uncommon, are serious and can be life-threatening. For this reason, you will be asked on multiple occasions about any drugs allergies when you attend hospital.

Post Operative Appointments

A wound check is performed 2 weeks after your surgery and unless specified is to be done by Dr Shatrov or his team.

Surgeon

At six weeks following your surgery, your surgeon will follow up with you usually via Tele health or maybe in person if arranged otherwise. The frequency of further appointments will be organised on an as needs basis and will vary from individual to individual.

Physiotherapist

You will need to attend physiotherapy following your surgery. This will be performed on an outpatient basis and the frequency and duration will be determined by your therapist. Depending on the procedure performed, some surgeries may have limitations on the type of physiotherapy to be performed. Dr Shatrov will advise on these and the timing of attending physiotherapy following your surgery which is typically commenced within a week of your operation.