Some knee conditions can be treated conservatively, using medication, ice or heat, activity modification, rest, bracing, and/or physical therapy. For example, for Iliotibial Band Syndrome and Osgood-Schlatter disease, the most effective treatment includes stopping the offending exercise, performing recommended stretching and strengthening exercises, and applying ice. Conservative treatment is also the first-line approach for many mild-to-moderate cases of other knee conditions, such as chondrosis, ligament injuries, tendinitis, and bursitis.

However, when conservative therapy proves inadequate, specialized procedures may be needed. Dr. Farr offers a wide range of contemporary treatment options, including the latest biologically-based procedures, several of which have been adapted for arthroscopic surgery. Some techniques allow for local anesthetics and outpatient treatment. Certain problems may require no more than an overnight hospital stay. Depending on your condition, Dr. Farr may recommend one or more of the following to relieve your knee pain:

Arthroscopy
This procedure, for the repair of articular cartilage defects, uses the arthroscopic approach. The arthroscope is a pencil-sized lens that is attached to a video camera. The scope is inserted into a joint through incisions no longer than a thumbnail. The images are transmitted to a television monitor, allowing the surgeon—and interested patients, if only local anesthetic is used—to have direct view of the inside of the joint. Today, arthroscopy is regularly used not only in treating, but also in diagnosing, knee problems.

Debridement and Microfracture
During arthroscopic debridement, Dr. Farr uses the arthroscope to locate the damaged articular cartilage (chondral tissue), meniscal cartilage, or scar tissue. Using specialized instruments, he then stabilizes the area by trimming away damaged tissue and removing any fragments that could cause further irritation in the joint. When this “clean up” surgery is directed at the articular cartilage, it is called chondroplasty; when directed at meniscal tears, it is called a partial menisectomy.

Sometimes, to further attempt to stabilize the remaining articular cartilage, microfracture is used to assist the body in producing repair tissue. Dr. Farr creates small holes—or microfractures—in the bone at the base of the articular cartilage lesion. This allows healthy cells to enter the defect and produce fibrocartilage.

Meniscal Repair
Over the past 10 to 15 years, orthopaedic surgeons have increasingly recognized the importance of preserving as much of the injured meniscus as possible. This is because of the proven protective function it plays. Without the meniscus, the knee joint is susceptible to premature degenerative changes and possibly osteoarthritis.

Today, in order to maximally preserve meniscal function after a tear, orthopaedic surgeons strive to repair the meniscus using a variety of arthroscopic techniques. Fortunately, many meniscal tears may heal if stabilized. This repair may be performed with a variety of techniques from standard suturing to bioabsorbable screws or tacks.
In rare cases where a tear is not repairable, a partial menisectomy—the removal of only the damaged area of the meniscus—is performed.

Osteochondral Autograft
For patients with more extensive cartilage damage, this procedure involves grafting the patient’s own (autograft) healthy bone and cartilage (osteo-chondral) into the damaged joint surface.

First, Dr. Farr selects the cartilage donor site—an area of the knee subject to minimal stress—and accesses the area with a small incision. Next, he carefully inspects the chondral defect arthroscopically and determines the size of the lesion. Using a donor graft harvester, Dr. Farr removes a small section of healthy cartilage, along with the underlying bone plug. After preparing a receiving socket, the osteochondral graft is transferred to the damaged area. The donor socket may be left open and will naturally fill with bone and fibrocartilage.

Because of the limited amount of tissue available for grafting, the ideal size of the defect area is usually no larger than 2 square centimeters, or slightly larger than a thumbnail. Rehabilitation—range-of-motion exercises, protected weight bearing, and the use of crutches—begins immediately following surgery.

Allograft Osteochondral Transplantation
This procedure is much the same as osteochondral autograft, described above, with an important exception. "Allograft" refers to the use of donor transplant material for grafting and may offer certain advantages over autograft. For example, the allograft may be selected from the exact matching area of the joint and larger quantities of bone can be harvested (osteochondral shell method). For patients needing an osteochondral graft, Dr. Farr will recommend the best approach.

Autologous Cultured Chondrocyte Implantation
For articular cartilage defects greater than 2 square centimeters, and when previous surgery has failed to repair a cartilage defect, Autologous Cultured Chondrocyte Implantation (ACCI) offers a relatively new, advanced approach to cartilage restoration. ACCI uses cell culture technology to enable a small sample, or "biopsy," of the patient’s own articular cartilage to be grown in a laboratory into millions of new cells. These calls (Carticel®) can be implanted into the damaged area of the knee. The goal is to provide cartilage restoration and regeneration without compromising healthy tissue or subchondral bone.

The ACCI procedure takes place in several stages. The first stage—taking the cartilage biopsy—may be performed during arthroscopic assessment of the joint. The harvested material is then sent to a special cell-culture laboratory where the cartilage cells are multiplied over the next 2 to 3 weeks. On the day of implantation, approximately 12 million newly cultured cells are shipped directly to the operating room.

The implantation technique currently requires open knee surgery. The defect area is trimmed and cleaned. Next, a periosteal patch is created to cover the site where the cultured cells will be implanted. The periosteum is living tissue that forms a thin covering on the outside of bones. It can be separated from the bone and has the consistency of a wet paper bag. The patch is tailored to fit the site and is sealed in place using microsutures and fibrin (biologic) glue. The cultured cells are injected under the patch.

Because the Carticel® procedure is a biologic process, recovery is unique for every patient and every knee. In general, the implant must be protected from weight-bearing stress for at least 6 weeks, requiring the patient to remain on crutches and wear a knee brace during that time. After 6 weeks, protected weight bearing is allowed under close supervision by the orthopaedic surgeon. By 6 months, most patients report improvement from their pre-operative condition, and note further improvement at 1 year; at 2 years, benefits appear to stabilize.

While there is no typical recovery from ACCI, Carticel® is a very effective technique when used to treat certain types of articular cartilage lesions. In the proper surgical candidates, Carticel® has a proven track record for relieving knee pain and aiding patients in increasing their level of activity.

Meniscus Transplant
For patients who have previously had a menisectomy or the biomechanical equivalent—that is, the removal of at least 80% of the posterior horn of the meniscus—the Knee Restoration Center offers an innovative solution: the meniscus transplant. This is an outpatient, arthroscopically-assisted procedure that uses a donor meniscus from a tissue bank. Rehabilitation involves use of a knee brace, protected weight bearing for 2 to 6 weeks after surgery, and full weight bearing by 12 weeks post-op.

While meniscus transplants were first performed nearly 15 years ago, the procedure has evolved significantly. Intermediate results (7 years) using these improved techniques are encouraging; long-term results are pending.

Osteotomy
While there are several types of osteotomy, in all cases, this surgical procedure is intended to help relieve pain and delay the progression of osteoarthritis.

Osteoarthritis most commonly affects the inside (medial) compartment of the knee, leading to a bow leg deformity. This condition places more pressure on the medial joint surfaces, which, in turn, leads to more pain and faster degeneration. The outside (lateral) compartment is sometimes affected, producing a knock-knee deformity.

High Tibial Osteotomy (HTO) is a procedure in which bow leg deformity is corrected by cutting the tibia and moving it to a corrected angle. This realignment of the lower extremity shifts the weight-bearing force into the healthier lateral compartment. As a result, pressure and pain are reduced.

HTO is not viewed as a permanent solution to relieving pain if the problem is osteoarthritis. Rather, for those patients, it buys some time—as much as 5 to 7 years—before total knee replacement may be necessary. For the younger patient with a focal chondral defect or absent meniscus, HTO plus cartilage restoration may offer long-term relief.

Proximal Tibial Osteotomy (PTO) is a procedure in which bow leg deformity is corrected by removing a wedge of bone from the lateral side of the upper tibia. This realigns the angle of the extremity and shifts the weight-bearing force into the healthier lateral compartment. As a result, pressure and pain are reduced.

PTO generally results in a significant reduction in pain and, once the bone heals, there are no restrictions to activity level; however, it is not always successful. Like HTO, PTO may delay the progression of the degeneration of the medial compartment, but total knee replacement may be needed in 5 to 7 years.

Distal Femoral Osteotomy (DFO) treats arthritis of the lateral compartment, correcting a knee that angles outward.

Treating Ligament Injuries
When reconstructive surgery is needed to repair a torn ACL, it is usually performed arthroscopically on an outpatient basis. The Knee Restoration Center is one of the few centers in the world to routinely perform ACL reconstruction under local anesthetic with sedation.

Pre-operatively, the surgeon and patient decide the type of graft to be used. The tendons most commonly used for grafting are the patellar and hamstring tendons. Graft material may also be allograft to decrease harvest site pain.

During surgery, the torn ends of the ligament are removed. If the patellar tendon is used for grafting, about one-third of the tendon is harvested along with a plug of bone at either end. The graft material is passed through the inside of the joint and screws are used to rigidly secure the bone plugs in holes drilled in the thighbone and shinbone at the site of the “native” ACL. Surgery is followed by an exercise and rehabilitation program designed to strengthen the lower extremity musculature and restore full joint mobility.

PCL sprains don’t usually require surgery unless combined with another ligament injury, eg, LCL or MCL. In this case, surgery is needed to reconstruct the ligament. MCL injuries are usually treated conservatively, while LCL injuries are often primarily repaired.

Repair of Ruptured Tendons
In cases where the quadriceps or patellar tendon is completely ruptured, the torn ends can be reattached after arthroscopic assessment of the condition. Rehabilitation may require bracing for 3 to 6 weeks and the use of crutches; a prescribed exercise program, lasting up to 6 months, will restore the ability to bend and straighten the knee and to strengthen the knee to prevent a repeat injury. When tissues are marginal, a biologic patch may be used to treat the repair.

Treating Osteochondritis Dissecans
For the patient with Osteochondritis Dissecans, surgery is necessary if spontaneous healing does not occur. If cartilage fragments have not broken loose, Dr. Farr may be able to secure them in place with pins or screws after the bone is stimulated to gain a new blood supply in an effort to heal.

If fragments are loose, the cavity is cleared of debris to reach fresh bone; this is followed by bone grafting, as needed, followed by securing of the fragments. Fragments that cannot be repositioned are removed. The resultant cavity is drilled or scraped to stimulate new fibrocartilage. If this classical technique fails, the use of cartilage cell transplants (ACCI) and other transplant tissues are a treatment option.

Treating Other Knee Conditions
As mentioned earlier, there are a number of knee conditions that usually respond well to conservative treatment. However, when these methods prove inadequate, knee restoration surgery may play a role For example, in rare cases, a patient with iliotibial band syndrome will need surgery to unload the tendon to eliminate constant friction over bone. Patients with plica syndrome or bursitis may need surgery to remove the plica or bursa, respectively.

While it can be frustrating to have a condition that, in spite of your best efforts, does not respond to conservative treatment, be assured that Dr. Farr will strive to help you achieve your goal—relief from knee pain and a return to favorite activities.