Category Archives: Knee Injuries

Return to driving after lower extremity orthopedic procedures

There are a number of components going into the decision as to when it safe to return to driving.  First of all, whether your procedure involves your driving leg, and whether or not you have an automatic or a manual transmission.  In addition to the functional ability to break in time there is also the concern of medication effect on reaction time.  We would never recommend returning to driving while taking narcotics.  Beyond the narcotics question the other issues are how quickly you can move your foot from the gas to the brake and then how forcefully you can press the brake.  Studies have shown that the force of depressing the brake pedal is probably the most important factor in returning to safe driving.  In general, my advice is to sit in the driveway and pretend a child just ran out into the street in front of you If you can quickly get from the gas to the brake and slam it on hard you are probably ready to drive that said there have been a number of studies looking at this question.  On average it is safe to return to driving 4 weeks after a right knee replacement and 2 weeks after a left knee replacement.  In general patients can return to driving after a right hip replacement a week or 2 earlier than a right knee replacement.  Operative repair of an ankle fracture or Achilles tendon repair often results in 6 to 9 weeks postoperatively with inability to drive.  Typically, you want to wait at least 2 weeks after coming out of a cast before driving.  ACL reconstruction is similar to a knee replacement; it oftentimes takes 4 to 6 weeks after surgery for a right knee ACL reconstruction.

There are many other factors that play a role in safe returning to driving after an orthopedic surgery.  For example, medication side effects and preoperative function.  If he were slow to push the brake preoperatively, it will take that much longer to recover postoperatively. Please sit in the driveway and slam the break a few times to assess how competently you can break before you try driving.

What to Expect After a Meniscectomy

Injury knee painDr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more.

When it comes to meniscal injuries, many patients have little knowledge about the types of treatment options available and their outcomes.  The meniscus, a significant cushion or shock absorber in your knee, is a c-shaped disc of soft cartilage that sits between the femur and the tibia.  When the knee meniscus tears, the cushioning effect diminishes and can cause knee pain and arthritis, eventually requiring treatment. One option is a meniscectomy, a surgical removal of all or part of a torn knee meniscus. A survey conducted by Brophy et al of 253 patients evaluated for meniscal pathology found 62 percent rated their knowledge of the meniscus as “little or none,” and another 28 percent had no idea that meniscectomy procedure–and not a meniscal repair–is the most common surgical treatment for surgical repair. Did you know that?

Since many meniscal tears can require surgical intervention, there’s a clear need to educate patients on options and postoperative considerations: overall outcomes, the risk of needing a subsequent surgery, the ability to return to sport (RTS), the postoperative risk of developing osteoarthritis (OA), the risk of progression to total knee arthroscopy (TKA). Meniscus tear can also affect knee stability, particularly when combined with an anterior cruciate ligament (ACL) injury. A group of doctors at the University of Colorado School of Medicine in Aurora reviewed the current literature on postoperative considerations to help orthopedic surgeons educate their patients on post-meniscectomy expectations.

The review found:

  • Successful return to sport after meniscus surgery was more likely with these circumstances: patients of a younger age, medial meniscectomy and a smaller meniscal resection. The amount of meniscus resected is a function of the size of the tear. All these factors affect the time until patients are able to return to sport.
  • Failure rates after meniscectomy are low when compared to meniscal repair and discoid saucerization procedures. Meniscus repair is done rarely for a large tear, most often in conjunction with ACL reconstruction. The majority of the meniscus has no blood supply and will not heal, so the majority of meniscus surgery involves removing the torn tissue and smoothing the remaining meniscus. Failure rates are increased in patients undergoing lateral meniscectomy.
  • Improved clinical outcomes for non-obese males can be expected in those undergoing medial meniscectomy with minimal meniscal resection. Conversely, if a preexisting angular deformity exists, varus or valgus, which results in an imbalanced load across the knee, the success rate is less predictable. Preexisting degenerative knee changes (damage to the articular cartilage attached to the bones), and anterior cruciate ligament (ACL) deficiency will negatively impact outcomes following a meniscectomy.
  • The risk of developing post-surgical osteoarthritis over the next 10-20 years should be discussed. Meniscectomy increases the risk of developing knee osteoarthritis, particularly in obese females who undergo a large meniscal resection. The development of arthritis after meniscectomy may lead to the need for knee replacement. However, leaving a mobile large meniscus tear clicking around in the knee will more likely result in early arthritis.
  • Meniscectomy is a viable and successful intervention for pain relief and functional improvement for symptomatic meniscal tears, but nonsurgical care should be used first in older patients with preexisting degenerative changes. These patients will likely end up with knee replacement, and an arthroscopic meniscectomy may be an unnecessary step along that path.

If you would like to learn more about meniscal injuries or understand post-surgical outcomes related to meniscectomy, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Hamstring Injuries

Young women sport has thigh muscles injury ,Health conceptDr. Stickney, a Kirkland orthopedic surgeon, is an expert in sports medicinehamstring injuriesexercise and health, and more.

Hamstring injuries are a common, and often frustratingly persistent, source of limitation for both elite athletes and weekend warriors. These injuries can involve either the muscle belly or the tendinous attachment of the muscle to bone. The hamstring is one of the longest muscle bellies in the body as it stretches from the pelvis to the tibia spanning the hip and the knee. Hamstring tears, knee muscle tears and related injuries make up nearly 30% of all lower extremity muscle tendon injuries. These injuries are commonly sustained while running particularly with running uphill. They are very common in soccer, football and all sports associated with acceleration or kicking. Hamstring injuries also are common in weightlifting, skating, or water-skiing. This can be the result of a rapid uncontrolled Hip Flexion with knee extension. If the injury is associated with a loud pop that often signifies a tendon avulsion. In that case, the tendon has pulled off of bone. On the other hand, if there is acute muscular tearing pain followed by bruising and a palpable defect in the muscle, this typically signifies an intermuscular tear. Injuries that do not adequately heal or get adequate therapy can result in scar tissue which is prone to reinjure.  Hamstring injuries have a very high rate of recurrence as a result.

    The hamstring muscles in the posterior thigh, as well as the quadriceps muscle in the anterior thigh, work in concert during running jumping, acceleration, and deceleration. A muscular balance between these 2 muscles as well as flexibility of both muscles is crucial to preventing injuries. Core muscle development and hip muscle strengthening can also help prevent hamstring injuries. Hamstring injuries more commonly occur during eccentric contraction. Eccentric contraction means the muscle is firing but at the same time it is lengthening. During running the quadriceps extends the knee as your foot reaches forward near the end of that extension the hamstring slows down the extension while the foot is still moving forward just before impact. This is an eccentric contraction of the hamstring and this is the phase of running most commonly associated with hamstring injuries. These are typically intermuscular injuries. These commonly lead to bleeding into the muscle and then the development of scar tissue in the muscle which is less flexible than muscle, and more vulnerable to tearing in the future. As a result, an athlete with a hamstring injury has a 25% rate of recurrence of hamstring injury in the following season despite rehabilitation.

     A very good study was done in professional soccer players to try and prevent initial hamstring injuries and to prevent recurrence of hamstring injuries. The results of that study is the Nordic hamstring exercise protocol. In professional athletes, this protocol led to an 80% reduction in primary hamstring injuries and a 65% reduction in recurrent injuries. The Nordic protocol is a progressive strengthening of the hamstrings through eccentric loading. This protocol is best visualized on a YouTube video.

     Once a hamstring injury occurs it is very important to establish whether or not the tendon has pulled off bone or if it is an intermuscular injury. If the tendon has pulled off bone it is important to repair it in the early period after injury. On the other hand, most intermuscular injuries require rest, elevation, icing, compression (RICE) and then range of motion with deep massage. There have been a few studies to suggest that injection of platelet rich plasma with growth factors can enhance healing.  And some other studies suggested injection of steroids may decrease the likelihood of developing scar tissue. The time to recovery is largely dependent on the location and extent of injury. Most minor hamstring injuries can be treated with physical therapy and return to sport in approximately 6-12 weeks. It is very important to regain full flexibility and equal strength before returning to competitive sports to prevent future recurrent injuries.

Considering Injections for Knee Osteoarthritis

kneeDr. Stickney, a Kirkland orthopedic surgeon, is a knee expert specializing in new knee surgery procedures, knee reconstruction surgeryexercise and health, and more.

Recently, the prevalence of knee osteoarthritis (OA) has climbed swiftly because of an increase in human life expectancy, physical activity, and obesity. With knee OA on the rise, doctors are in search of the best treatment for their patients. As a result, interest in intra-articular hyaluronic acid (HA) injections and platelet-rich plasma (PRP) knee injections has been rapidly increasing. But which treatment is the most effective, if any? A study on injections for knee OA conducted by Kuan-Yu Lin, M.D., Chia-Chi Yang, Ph.D., Chien-Jen Hsu, M.D., Ming-Long Yeh, Ph.D., and Jenn-Huei Renn, M.D., Ph.D. takes a closer look.

The study’s purpose was to prospectively compare the efficacy of intra-articular injections of PRP and HA with a sham control group (using normal saline solution [NS]) for knee OA in a randomized, dose-controlled, placebo-controlled, double-blind, triple-parallel clinical trial.

The clinical trial involved 53 patients with a total of 87 OA knees who were randomly assigned to one of three groups receiving three weekly injections of either 1. Leukocyte-poor PRP (31 OA knees) 2. HA (29 OA knees) or 3. NS (27 OA knees). To analyze the results, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and International Knee Documentation Committee (IKDC) subjective score were utilized and collected at baseline and at one, two, six, and 12 months after treatment.

The results? While all three groups showed statistically significant improvements after one month, only the PRP group reached the minimal clinically important difference in the WOMAC score at every evaluation and the minimal clinically important difference in the IKDC score at six months, while sustaining significant improvement in both the WOMAC score and IKDC score at 12 months. Also interestingly enough, there was no significant difference in the functional outcomes between the HA and NS groups at any point in time.

The most significant finding of this study was that intra-articular injections of leukocyte-poor PRP can in fact provide clinically significant functional improvement for at least one year in patients with mild to moderate osteoarthritis of the knee. If you want to learn more and discuss whether or not PRP injections are the right treatment for you, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Meniscectomy Biomechanics and Clinical Outcomes

Stickney_kneeThough the knee meniscus is just a small part of the knee, it plays a very important biomechanical role in regular knee function including load bearing, shock absorption, and joint stability. Unfortunately, meniscus tears are one of the most common injuries orthopedic surgeons encounter, and thus, partial meniscectomy is one of the most common procedures performed.

But not all tears require surgery. In fact, according to Biomechanics and Clinical Outcomes of Partial Meniscectomy by Freeley, Briant T., MD; Lau, Brian C. MD published in Journal of the American Academy of Orthopaedic Surgeons, an MRI study found that 61% of aging asymptomatic patients had a meniscus tear identified on imaging.

Because orthopedic physicians must identify patients who will likely benefit from a partial meniscectomy, it’s vital that they understand the biomechanical implications and knee surgical outcomes of partial meniscectomy. As a patient, it’s always best to be educated on the latest research as well, so you can be an advocate for your own health.

For cases that do require partial meniscectomies, there has been extensive research conducted evaluating the biomechanical consequences and knee surgical outcomes. It was found that as the portion of the meniscus that is removed increases, the greater the contact pressure experienced by the Articular cartilage attached to the bone. This can lead to altered knee mechanics and early cartilage wear. However, leaving a mobile meniscus tear untreated in an otherwise healthy knee, which is creating mechanical symptoms of popping or locking, can result in further tearing of the meniscus and early wear of the cartilage above and below the tear. This leads to early arthritis.

It’s important to note that the use of partial meniscectomy to manage degenerative meniscus tears in knees with mild preexisting arthritis and mechanical symptoms can be beneficial; however, its routine use in the degenerative, arthritic knees is not likely to provide long term benefit. Physical therapy may be more successful in this situation . In younger age groups, partial meniscectomies may provide long-term symptom relief, earlier return to activity, and lower revision surgery rate compared with meniscal repair. If a large peripheral tear in the vascular part of the meniscus is present in a young person this would be where meniscal repair can result in a near normal knee long term.

Perhaps the most valuable takeaway from this biomechanical study is a greater understanding of the implications of meniscectomy. Orthopedic surgeons must subscribe to the current principle of maintaining as much meniscal tissue as possible. Partial meniscectomy remains a mainstay of treatment for unstable, central meniscus tears and offers favorable clinical outcomes with a low risk to patients when done correctly. Treatment should always be patient specific in a shared decision-making process with the patient.

Dr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more. Contact Dr. Stickney to return to your healthy, pain-free lifestyle.

ACL Tears Are on the Rise in Kids

ACL Tears are on the Rise in KidsOnce considered an adult injury, ACL tears are occurring more often in the legs of elementary and middle school-age children, orthopedic specialists report. The increase, which stems in part from better diagnostic tools and a dramatic increase in children playing competitive, organized sports, has created a vexing problem: What is the best way to fix it? Sports medicine experts are looking closely at the uptick in pediatric knee injuries, notably ACL tears.

For years, doctors have advised delaying surgery until the bones are finished growing, usually around age 14 for girls and 16 for boys. In the meantime, children were prescribed physical therapy and encouraged to remain active while using a knee brace, with the exception of cutting, pivoting and contact sports.

But postponing surgery hasn’t worked very well, in part because it’s difficult to keep children from further damaging the knee while they wait, In some cases for years. Athletic youngsters often must stop playing sports they love, a loss that can lead to depression and affect a child’s identity and friendships.

The anterior cruciate ligament, or ACL, which connects the thigh bones and shinbones inside the knee joint, is a crucial stabilizer during sports like basketball, football, soccer and lacrosse. Its job is to protect the knee from shifting, rotating and hyperextending as an athlete runs, jumps or lands. An easy way to tear the ligament involves simultaneously decelerating and twisting.

In adults, surgery is not always necessary, especially for those with sedentary lifestyles. Though skiing and soccer might be out, it is possible to walk, run and even play tennis with a fully torn ACL.

Risks are higher for children because it is hard to get them to modify their activity. A study published last year in The American Journal of Sports Medicine found that young athletes who delay surgery five months or more have a higher chance of suffering a secondary knee injury. Waiting can lead to progressive damage to other parts of the knee, including the meniscus and cartilage, multiple studies show.

Though official statistics are scarce, orthopedic specialists estimate that thousands of children and teens are tearing their ACLs each year. Researchers at Children’s Hospital of Philadelphia found a 400 percent increase in youth ACL injuries over the last decade, according to findings presented at the American Academy of Pediatrics 2011 annual meeting. Girls have up to eight times the risk of an ACL tear as boys; though no one knows exactly why.

Dr. Stickney in an expert in sports medicine who specializes in hip, knee and shoulder surgery at his Kirkland and Redmond locations. If you are experiencing knee issues or have questions about treatment options, contact our office to schedule your next appointment! Watch Dr. Stickney’s video and learn more about orthopedic surgery.