November 4, 2003

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Knee1 : Welcome to today's Knee1 discussion with Dr. Thomas DeBerardino!

Knee1 : Dr. DeBerardino is the Chief of Orthopedic Surgery at Keller Army Community Hospital, located at West Point Military Academy in NY.

Knee1 : Dr. DeBerardino has done extensive research on PCL reconstruction and is currently serving as the Research Director of the Joint and Soft Tissue Fellowship, co-located at West Point and the Institute of Surgical Research at Fort Sam Houston in Texas.

Knee1 : He has recently returned to the U.S. after being stationed in Kuwait, where he cared for U.S. troops in the Middle East.

Knee1 : Dr. DeBerardino, thank you for joining us today. Users, we welcome your questions!

student : Why is the knee joint the most frequently injured joint in the body?

Dr. deberardino : There are many reasons really, but one of the main reasons is that it is our main weight bearing joint. We load our knee joints with upwards of 10x our body weight when we ambulate. Combine the loading together with twisting and squatting and you can see why the knee joint is always at risk.

David : Post op from a medial meniscus procedure, what should a pt. do to activate the knee?

Dr. deberardino : The postop protocols after meniscal repair are still evolving. As our repair strength increases with new material and surgical techniques surgeons are beginnning to allow more advanced activities earlier in the rehab cycle. Most surgeons recommend early motion which we know helps the healing process since meniscus and cartilage get their nutrients from the motion of the joint fluid in the knee. Some repairs are stable enough to warrant early weightbearing as well. The geometry of the actual tear often dictates how much weightbearing is allowed within the first 6 weeks. After 6-8 weeks, most repairs will benefit form full weightbearing and near full knee flexion. Flexion is usually limted to 90 degrees up through the first 6 weeks to prevent shearing across the repair site.

Lenette Selle : My daughter injured her MCL the other night by playing soccer. She heard 1 loud pop. We took her to the hospital and they are treating as a sprain. Should she have an MRI? Do MCL injuries heal without surgery and how long does it take?

Dr. deberardino : The vast majority of isolated MCL tears, even the complete "Grade 3" tears, heal uneventfully with adequate protection and rehabilitation without the need for surgery. Often a hinged knee brace is prescribed to protect the injured ligament (MCL) from further damage for up to 6-8 weeks. Early motion in the protective brace is also beneficial.

Elaine in NJ : DR DeBerardino, I have just returned from my local Ortho doc, for a follow up on a hip fx (one year ago) and a femur fracture (5 1/2 yrs ago). Nearly 7 yrs ago, I had bi lateral tkr. They were very successful until the femur fx. Now, my left leg is very unstable, and the femur never healed correctly. My Ortho Doc that did the knees is not local, but my local Ortho suggests that I see him, since he feel I need a revision and a repair to the deformed femur. I am not looking forward to a revision, I understand it is difficult! Explain what a revison is, so maybe I wont be so upset about the prospect, please. I know, I need to see the doc, but I am not looking forward to surgery. I would like to find another way to strengthen the leg without surgery. As I said, I am very unstable, must walk with a cane, all the time, and even use a walker or a chair other times, due to this problem. Is there any other way to fix this problem, without major surgery? thnx Elaine in NJ

Dr. deberardino : From your nice description, it sounds like your knee replacements and hip replacemetn are doing better than the femur fx. Your poor femur fracture healing may be holding back the success of your other operations, so it is warranted to do what it takes to get your femur fracture to heal in order to maximize your potential function and ability to do your normal activities of daily living. Revision fracture surgery is not simple, but in skilled hands, the outcomes can be quite successful. Without surgery, the deformity will not correct itself.

Marie : My husband played Basketball overseas up until last year-his knee was intoo much pain. He was diagosed with MOderate Patellar Tendinitis. He had a knee Debridment in January, though it is 100% better than before surgey still not pain free-will it ever be? How long? What exercises should he be doing? Thanks for any help

Dr. deberardino : Hardcourt sports such as basketball take their toll on our knees over the years. It is likely that the patellar tendinitis that was debrided is only the tip of the iceberg for your husband, depending upon his age. The fact that he obtained significant relief from the debridement of the tendon injury suggests, however, that the 'other' internal damage may be limited. If more than 12-18 months has passed since the surgery, it is likely is recovery has been maximized. Good quadriceps and even hamstring strengthening exercises are always warranted along with careful quadriceps stretching. Minimizing impact aerobic activity may also be warranted at this stage.

Callawaykat : What is the latest developement for treatment for diminished knee cartilage?

Dr. deberardino : Several surgical options now exist. We can simply debride minimally injured isolated or exspansive cartilage lesions. We can take a healthy 'plug' of bone and cartilage from a remote less needful region of the knee and replace it into the injured defect (ala changing the hole from one site of the golf green to another). A newer (10 + years of experience) technique entails harvesting healthycells of cartilage form a good part of your knee and culturing them so that they multiply and are then place in the defect area and held in place under a flap of periosteum (bone coating from the leg) sort of like a tupperware lid holding in the soup. The cells mature under the patch of periosteum and become very similar to the healthy native cartilage they are trying to replace. This last technique is only warranted in lesions that are isolated and with limited concomitant cartilage/ligament damage throughout the rest of the knbee

barb : I am in need of tkr but want to try the synvisk injections first. can you tell me the difference between hyalgan,or supartz compaired the the synvisk? which one has better results

Dr. deberardino : Another technique involves stimulating the cartilage cells from the depths of the lesion to change from stem cells into cartilage cells by 'picking the surface with special instruments to provoke this healing response and thius fill the defect with scar cartilage.

Knee1 : Note to users: Dr. DeBerardino's most recent response was addressing the question regarding diminished knee cartilage.

Dr. deberardino : I honestly cannot say that one synthetic joint fluid supplementtion product is better than another at this point. I have witnessed anecdotal limited success with all the versions on the market.

lovelife : I am worried about using my patella tendon for ACL surgery - due to anterior pain etc. Would you advice using patella tendon or hamstring for the procedure?

Dr. DeBerardino : At West Point, we have a long history of using both the patellar tendon and the hamstring tendon in various controlled clinical trials with essentially equal results. Other Centers also have a similar experience. There are many stuides that say that one technique is superior to the other. In the final analysis, however, it probably comes down to a personal decision on your part once you are gven adequate information. The results can be outstanding with either technique. Definitely use the graft your surgeon is most comfortable using. If you are unhappy with the graft selection by your surgeon, you can always move on.

Jan Daurio : My husband, age 56, had a fall at work where his knee suffered a head-on collision with a wall. After Ortho surgery, the doctor is telling us that the cartilage has broken away under the kneecap and now is bare bone... my husband will always be in pain and there is nothing more that can be done. There must be something that can be done ???

Dr. DeBerardino : The undersurface of the patella is prbably the most difficult part of the knee joint surface to 'fix'. Once the cartilage is siginifcantly damaged, there is little hope of restoring function withthe native cartilage. The patellar resurfacing techniques we mentioned earlier have therr most limited success as well in this region. Some surgeons have studied isolated patellar resurfacing with prosthetic devices with limited results. Once your husbands knee funstion diminishes to the point of greatly limiting his activities of daily living, a total knee replacement may be warranted

all7dunns : I had a doctor tell me that my knee condition was rated at about 80% according to the DeLuca factor, what is this factor?

Dr. DeBerardino : Although I am not an impairment specialist, I beleieve the factor you mention is a a variable used within the Guides to the Evaluation of Permanent Impairment . Here is a web site that refers the the Deluc case from which it was taken: http://www.dav.org/voters/rule_spine_110402.html

pdeb : Is it recommended to have MRI to determine amt of scar tissue before knee manipulation? Or knee manipulation w/o arthro to remove? is it better? I am scheduled for knee manip. nov 13.

Knee1 : Users, thank you for joining us, and Dr. DeBerardino, thank you for lending your expertise in today's discussion.

Knee1 : Stay tuned for upcoming Knee1 discussions!