February 13, 2003

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Knee1: Dr. Patel, perhaps we can start by having you tell us a little bit about how you got started in orthopaedics.

Dr. Dinesh Patel: I wanted to subspecialize in surgery...and since I used to be a sportsman, I wanted to get into something which was attractive enough for me to be helpful, and orthopaedics was that discipline.

maybaby: What effect does exercise have on the wear and tear of a replaced knee?

Dr. Dinesh Patel: Exercises after the joint replacement usually maintains the strength and power of the muscles and also maintains the mobility of the joint... so if you do exercises, that would be quite helpful for the joints. The wear and tear of the joint is multifactorial, not just on exercise. Overloading the knee by basketball, if you think that is an exercise, would increase the wear and tear and may even loosen the replaced knee...

Dr. Dinesh Patel: Moderate exercises certainly would be very good for the joint and for the patient himself. And since the ultimate objective is to maintain mobility and to perform activities of daily living without much pain, exercise plays a major role in avoiding unusual problems in the replaced knee.

RASHMIN: I am Gujarati from Mumbai. I am very proud of Dr. Patel. I am a marathon runner since last six years. Recently I have pain in my left knee while going down the staircase. An MRI revealed a tear in the posterior horns of my meniscus. Is the pain due to a meniscus injury or wear and tear? Do you think ART (Active Release Technique) will be helpful?

Dr. Dinesh Patel: It appears from your history that your pain is coming from a torn meniscus, maybe medial (medial means inside.) The chronic loading in the knee from activities like marathon running, the long stride, can put pressure in the back of the knee and maybe cause the pain. But it is also important to know that painful stair climbing in a young lady can be due to the knee cap rubbing against the thigh bone. So it could be that you have two problems: torn medial meniscus and patella chondromalacia (rubbing of the knee cap ). Just because the MRI revealed a tear in the posterior of the medial meniscus, it does not mean that that's the cause of the pain -- it could be the patella. So physical examination really would be very helpful...

Dr. Dinesh Patel: If the orthopaedic surgeon feels that symptoms and examinations are more coming from the joint line and not much from the knee cap, then Arthoscopic surgery involving the removal of the displaced torn part of the medial meniscus would relieve the pain and get the patient back to their activities of life with good quality.

RASHMIN: Dr. Patel, I thank you very much for your advice. My orthopedic doctor says that my pain is due to rubbing of knee cap and not a meniscus tear. He believes Celebrex could reduce pain and does not see a need for surgery. Do you believe I can run a marathon? My dream is to run the Boston Marathon. Can active release help reduce the pain? I am male, 50 years old.

Dr. Dinesh Patel: You have to go one step at a time. You now have a diagnosis so start treatment by good exercises, knee braces with hole for the patella and gradual modification of your activites so you can resume running short distance - no hills, short stride and flexibility can be helpful.

think: For Dr. Patel: I am curious about the success rate for TKR after a patellectomy. At the age of 18, I had a patellectomy in 1960 [chondromalachia related], some "clean up" surgeries in later years and a restructuring of the patellar tendon last March [2002]. I consider myself to be fortunate in having had pretty good mobility for the past 42 years! Quadriceps are [relatively - given the history] strong and I am other wise in good health. Now suffering significant pain, causing sleeping difficulties and stress. Standard analgesics and ice have only minor pain reduction effect. Your kind comments would be appreciated. Thank you.

Dr. Dinesh Patel: If the symptoms are coming from the joint itself, and if the x-rays show arthritis of the tibial-fermoral joint and the patient has gone through non-surgical treatment, then replacing the diseased joint with prosthetic joints will relieve the pain. Because the patella was removed, the rehabilitation will be longer, but since the pain will go away after replacement, the recovery would be quite positive. Ultimately, other alternatives are not as good as prosthetic replacement of the diseased joint.

anu: Hi Dr Patel. Thanks for taking my question. I am very fearful about Arthroscopy of my knee. I had torn medial meniscus in my left knee in 1998. Did not go for surgery. Just 5 months ago my right knee also got large tear in medial meniscus. My question is how do you know one particular surgeon is good? I asked for references from the doctor. Dr. did not answer all my questions; just told me I needed arthroscopic procedure. That's it. I went to another doctor for a 2nd opinion. Same answer. What possibly could get worse, if not better after the procedure?

Dr. Dinesh Patel: I can understand the concerns you have for choosing the right person and that is a big dilemma. My recommendation to you is to select a surgeon who has been board certified, has been in practice for a number of years, and is in a national professional organization in that field to begin with. The other thing you can refer to is your internist, your neighbor who had surgery by him, and to be gentle and polite and ask him all the questions you think you need to know...In Massachusetts, we are fortunate to have Physician profiles started and maintained by the Board of Registration Medicine. This information tells everything about that specific doctor so you can use that as well.

Dr. Dinesh Patel: What possibly can go wrong? You should always have a positive attitude for anything in life and especially for the painful knee, which you are suffering from. Prepare yourself before the surgery. Learn how to exercise, maybe learn crutch walking, as there will be swelling, there will be pain so you will need medication and someone to help you. The complications from this kind of surgery can be infection, blood clots in the leg, stiffness, swelling, pain, not getting better, or taking a long time to get better. But all of these are very rare. And if you are prepared ahead of time, this will be more rare. An experienced orthopaedic surgeon who is going to do the surgery will almost certainly help you reduce this complication.

anu: Also, my doctor never suggested to build the muscles before surgery, arthroscopy for torn medial meniscus. What's frustrating is all the doctor wants to do is surgery. I haven't exercised for a long time because of the pain my both my knees because of torn medial meniscus . What else should I be asking my surgeon regarding surgery and recovery? I live in Virginia and am a 48 yr-old old female. What if I don't go for surgery? My biggest fear is unable to even walk little bit after the surgery. How do I check out my surgeon? Surgeons really don't have time to explain what could possibly go wrong, or if not better. Thanks for taking my question. Right now I am kind of homebound.

Dr. Dinesh Patel: What really matters is your knee. If you are uncomfortable with one doctor then get second opinion. Some times you may have to see a physiatrist for non-surgical management as well as be gentle and see him again and discuss all the possibilities before surgery (rehab, braces, crutches, anti-inflammatory medicine and all the rest), and if the knee stiill bothers you, then proceed with what is best for you based on what the MRI and X-rays show.

JEN: I have chondromalacia in my left knee and it's now starting in my right. I hurt myself at work...a fall down the stairs. I've had one surgery and I don't feel any better. There has been talk of a kneecap replacement. Is there anything I can do to get a normal life back?

Dr. Dinesh Patel: Chondromalacia patella in young ladies is very common. Treatment for most of these conditions is non-surgical to begin with. Get controlled rehabilitation from a good physical therapist, try patella-hole braces, avoid sudden squats and hopefully, with the help of ice, massage, anti-inflammatory medicine, you will restore the muscles around the knee enough, so that your pain will go away. Replacing the kneecap is very uncommon and very few people may do this. There are very many operations on the patella and it is hard to predict the ultimate outcome from soft tissue or bony operations. Follow this conservative route, and see how much better you will get. Eventually, you may even need removal of the kneecap. I would not prefer that route, but if everything else fails, and if the major problem, as seen on x-rays and MRIs, appears to be coming from the patella, then removal is an alternative one should think of...

JEN: I have tried PT. I am currently on my 4th time with the PT. I've tried ice, massage, chiropractic, protonics brace, patella strap brace, anti-inflamatories.... seems like a bit of everything. My self esteem is suffering due to the fact that I can't even go to the grocery store pain-free. I'd like to learn more about the kneecap removal. What are the negative side effects after getting it done?

Dr. Dinesh Patel: Removal of the patella will weaken the thigh muscles. You may also lose all the bending motion becuase the knee cap does not rub. You may have less pain after the surgery...hopefully you do not build up scar tissues, otherwise there would not be any releif. For all of these reasons, stay away from any surgery. You may also want to get another MRI and may want to get second opinion from other orthopedic surgeons. Some times a fresh look may help you understand the problems as well as plan for future as well.

GB: I am a very fit and active 49 male who will be undergoing total knee replacement at New England Baptist. in July. Do I have an "option" of choosing a ceramic version as I read it is much longer lasting.

Dr. Dinesh Patel: The best person to answer that would be your physician. The failure of total knee is not just wear and tear of the plastic, it's much more the cement bond junction or the prosthetic-bone interface. So depending on your x-rays, the quality of the x-rays, and your ability to use it in the way you want to use would determine the type of total knee and the material used for it. 49 is a little young for replacement of the knee, so it would be nice as you're doing it, to go over with the fine orthopaedic surgeon from Baptist. The computer-assisted TKR would certainly replace your knee in a precise manner, so have faith in your discussions with your orthopaedic surgeon and do follow the consensus between the two of you.

jaden: Hi Dr. Patel, I tore the ACL in my right knee a little over 3 years ago. I never had the surgery and have reinjured it on two occasions. The knee is fine for daily use but I'm considering getting the ACL fixed so that I can participate in more active sports without the use of a brace. My question is 1) would there be added complications in the surgery/recovery given that I've waited a few years for the operation - 2) what's your opinion on a patella vs. a hamstring graft?

Dr. Dinesh Patel: The knee is giving you trouble and you're not able to function as well as you'd like to, so your decision to do reconstruction is reasonable. You may want to get an MRI to make sure that you don't have meniscus or cartilage damage and if so, get that taken care of at the time of reconstruction, and this will also help you with the long term success of ACL construction. Whether to use the patella or hamstring tendons for reconstruction really varies from surgeon to surgeon and what is best suited to him to get the maximum benefit. I have used patella, hamstring, and allograft for construction. Ultimately, the determining factor is technique of fixation, biological behavior of the tissues and patient's patience that it does take time no matter what graft you use before one goes for active athletic participation. It may take longer than a year for the reconstructed ligament to remodel and get enough strength, like a normal ligament, to actively participate in athletics.

Marta: Hi, I'm a 21yr old female. I had a skiing accident when I was 12 and I later noticed that I had a lump on my knee that looked as if the bone had shifted. I had no problems with my knees so I didn't do anything about it post seeing a doctor. Later, when I turned 18, every November, my knee would start to hurt, everything from constant pain, to pain if I knelt down. This tends to last till about summer time. All year round though my knee will give out if I run up stairs wrong. If I have it straight for too long it will not bend back without slowly stretching it. Now it's also started if I have them bent for too long I can't straighten them. X-rays have been negative. I ski regularly and generally reasonably active. I've been told to stop jogging because it's too much jarring to my knee and that I should ski with a knee brace and be very careful. Do you have any opinions on what it might be and what I should do?

Dr. Dinesh Patel: I'm sorry to hear that you're going through this trouble. It's difficult for me to say exactly what you have, but if the x-rays and the MRIs are normal, then one would think that you may have a -- and that's only presupposition -- that you may have prominent tibial-tubercle just below the end of the patella. Or you may have patella tendonitis at the bottom of the patella. Pain on kneeling could be related to these two conditions. Perhaps you should use patella hole brace, and if that doesn't work, use a chopart brace, do physical therapy, and see how much you improve.

Santhana: Good evening! Dr. Patel.... I had been procrastinating doing an Arthoscopic surgery for the last 2 years.... recently I had a situation which caused a meniscus tear and had my surgery done just last week... I was concerned before as I had read some negative experiences online (I guess the folks who have a positive experience never take the time to post on any websites)... I can already see a difference and am very pleased with the progress.... and guess who the doctor was... DR. PATEL.... so folks who are procrastinating, make sure you meet the right doctor and get it done.... Dr. Patel made the whole experience physically and psychologically easy. THANKS DR. PATEL!! .... and thanks for taking the time to educate us.

Knee1: Some great feedback from one of our users! We are just about out of time tonight. Thank you, users, for logging in, and thank you, Dr. Patel, for your insightful answers.

Dr. Dinesh Patel: Thank you. That makes life enjoyable.

Knee1: Thank you, Dr. Patel. Good night everyone.