Knee > Patellofemoral Pain Syndrome > Treatments

    Surgical Kneecap Realignment

Preparing for Surgery

The decisions you make and the actions you take before your surgery can be every bit as important as the procedure itself in ensuring a healthy recovery. Make sure you have received any equipment you will need when you get home from the hospital. This may include a knee brace, crutches, ice packs or coolers, or a continuous passive motion (CPM) machine. You should receive prescriptions for any of these from your doctor when your surgery is scheduled.

   Understand the potential risks and benefits of the surgery, and ask your surgeon any questions that will help you better understand the procedure. It can also help to talk to someone else who has undergone the same surgery.

   Any physical problems, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any medication you are taking.

   To reduce the risk of infection, try to refrain from smoking for at least a week prior to surgery.

   If possible, practice walking with your crutches in case you need to use them after surgery.

   Most insurance companies require a second opinion before agreeing to reimburse a patient for a surgical procedure. Getting a second opinion from a surgeon who is as qualified as the surgeon who gave the initial diagnosis is advisable in any case.

   Make sure the orthopedist performing the surgery is board-certified, which can be determined by calling the American Board of Orthopaedic Surgery at 919-929-7103.

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At most medical centers, you will go to "patient admissions" to check in for your surgical kneecap realignment. If your surgery is going to be inpatient, there may be a separate department, so be sure to ask your doctor. After you have checked in to the hospital or clinic, you will go to a holding area where the final preparations are made. The paperwork is completed and your knee area may be shaved (this is not always necessary). You will wear a hospital gown and remove all of your jewelry. You will meet the anesthesiologist or nurse anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). Then, you will walk or ride on a stretcher to the operating room. Most patients are not sedated until they go into the operating room. Here are some important steps to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. This will reduce the risk of vomiting while you are under general anesthesia.

   Because the anesthetic and pain medications may make you drowsy, arrange for someone to drive you home when you are released.

   Wear a loose pair of pants or other clothing that will fit comfortably over your knee bandage when you leave the hospital.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.

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Surgical kneecap realignment usually takes one to one-and-a-half hours. After anesthesia is administered, which may be regional or general, the surgical team sterilizes your leg with antibacterial solution. Then, the instruments are set up.

   A four-to five-inch incision is usually made over the bump at the top of your shin (tibial tubercle).

   A saw is used to free up the tubercle.

   The kneecap is then moved into proper position inside the track along the end of the thighbone. It usually requires the kneecap to be slightly elevated.

   The tubercle is secured in its new location with two screws. The new attachments generally heal as strong as before the injury.

   Incisions are sewn up and the patient is taken to the recovery room.

After surgical kneecap realignment, you usually stay in the recovery room for at least two hours while the anesthetic wears off. You will be given adequate pain medicine, either orally or through an IV (intravenous) line, as well as instructions for what to do over the next couple of days. In addition, you will be given an appointment to return and a prescription for pain medicine. Your knee will be bandaged and may have ice on it. You may have significant pain early on and you should take the pain medicine as directed. Remember that it is easier to keep pain suppressed than it is to treat pain once it becomes present. When you feel the pain coming on take another pill, as long as it is within the time limit on the bottle. Surgical kneecap realignment is usually an outpatient procedure. However, if your surgeon had to do something more extensive, then you may have to stay overnight. You should try to move your feet while you are in the recovery room to improve circulation. Your temperature, blood pressure, and heartbeat will be monitored by a nurse, who, with the assistance of the doctor, will determine when you are ready to leave the hospital or, if necessary, be admitted for an overnight stay. It is likely that you will be able to bear some weight on your leg, but your surgeon may suggest that you use crutches for up to one month. As soon as you are fully awakened, you are usually allowed to go home. You will probably be unable to drive a car so be sure to have arranged a ride home.

Here is what you can expect after surgical kneecap realignment to treat patellofemoral pain syndrome:

   You will likely feel pain or discomfort for the first few days, and you will be given a combination of pain medications as needed. A prescription-strength painkiller is usually prescribed and should be taken as directed on the bottle. Taking one every four to six hours as directed is a good idea in the first 24 hours to suppress pain.

   There may be drainage on the bandage since fluid may have accumulated during the surgery. Expect some blood to show through the bandage during the first 24 to 48 hours.

   You should usually continue with the ice for at least 24 hours and remove the dressing within the first 48 hours. Icing your knee for 20 or 30 minutes a few times a day during the first two days after surgical kneecap realignment will help reduce pain. Ice therapy is most effective in the first 24 to 48 hours.

   As much as possible, you should keep your knee elevated above heart level to reduce swelling and pain. It often helps to sleep with pillows under your ankle.

   Wait until you can stand comfortably for 10 or 15 minutes at a time before you take a shower. Once you can, put your leg in a plastic bag and tie the top around your leg above the knee bandage to keep the bandage dry. Ask your physician about the best place to buy plastic shower bags in your area.

   Crutches or a cane may be needed for about a month following surgical kneecap realignment, but you can usually put a little weight on your knee and begin walking. The pain typically feels like you bumped into a table.

   As soon as possible after surgery, you should begin doing physical therapy as directed by your surgeon.

   For two or three days after surgery, you may experience night sweats and a fever of up to 101. Your physician may suggest acetaminophen, coughing, and deep breathing to get over this. This is common and should not alarm you.

   You may return to work the next day after surgery, depending on the severity of your pain.

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Your physician may prescribe visits to a physical therapist to begin supervised strengthening exercises as soon as possible after surgical kneecap realignment. You can begin therapy immediately after surgery in most cases. Patients should do stretching and strengthening exercises for a minimum of four days a week. The workouts should focus on the knee for at least thirty minutes and be combined with a cardiovascular workout that does not include activities, such as running, that place stress on your knee. Despite your dedication to the rehab program, you may not feel any improvement for up to six weeks or longer and your kneecap pain may recur. Though everyone's rehab program is slightly different, physical therapy after surgical kneecap realignment follows a general pattern. Most people can begin stretching the muscles and tendons around the kneecap within a week. Though your knee may be weak, it is generally strong enough to handle mild stretching and slow movements. Working to restore early range of motion may help reduce swelling and stiffness, and increase your healing time. Rehab progresses into strengthening exercises that focus on the quadriceps and hamstrings – the main stabilizing muscles for your knee. Physicians suggest you gradually increase the amount of weight as your leg muscles get stronger. Strengthening exercises require dedication because results often take weeks and pain may recur. Once the muscles of your injured leg are about as strong as the uninjured leg, the focus of rehab turns to increasing your coordination. After about six weeks of rehab, physical therapy can become activity oriented as you regain the ability to perform complicated movements, using stationary bikes, elliptical machines, and cross-country skiing machines. Physicians usually suggest that you continue strength training even after your kneecap has been rehabilitated. Have your physician periodically check your kneecap for strength and proper tracking.

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To decrease the risk of patellofemoral pain returning after surgical kneecap realignment, physicians generally recommend that you make the stretching and strengthening exercises you learned in rehab part of your everyday routine. Proper rehab will help your new kneecap attachments heal in a normal position so your kneecap moves smoothly in its track. To prevent rupturing your new kneecap attachments while they heal, avoid bending your knee more than 90 degrees. Try to be patient in rehab and do not rush to return to activities. Many of the exercises and activities that are popular for fitness put stress on your knees. To prevent patellofemoral pain it is important to learn knee-sparing exercise techniques by dividing your activities into three components:

   Daily living – the average person takes between 12,000 and 15,000 steps a day, exerting a force between two and five times your body weight on your knees. After a knee injury, take it easy on your knees during the day whenever possible to save them for activities and exercise. Avoid stairs when there is an elevator, take the shortest path when walking, and consider wearing athletic shoes designed to absorb shock rather than hard-soled shoes.

   Muscle strengthening and conditioning – activities themselves are not a substitute for conditioning. Your need for special conditioning to prepare for activities increases with age. The best strengthening programs are low-impact and non-weight-bearing, like stationary bikes and certain weightlifting programs, so that the knees do not have to absorb shock.

   Recreation – sports that require twisting and quick direction changes put great strain on your knee. Any climbing or jumping activity where the knee is bent beyond 90 degrees puts undue pressure on the cartilage surfaces under the kneecap. To prevent injury, stick to light, non-impact activities for your recreation after surgical kneecap realignment. If you decide to return to sports like football and basketball, a physician should carefully examine your kneecap and test it for proper alignment.

After surgical kneecap realignment, if you plan on participating in sports, remember to take it easy during daily activities and to keep your kneecap tracking properly with stretching and strengthening exercises. Your physician may prescribe a brace that should be worn during any recreation to help keep your kneecap in track. A small amount of pain is normal during physical activity, but if you feel so much pain in your knee to warrant taking a painkiller before an activity, you should consider cutting back or stopping.

A surgical kneecap realignment (tibial tubercle osteotomy and elevation) is performed when your kneecap has moved out of position and all other efforts to put it back into the natural kneecap track along the thighbone have failed. This open surgery has the longest recovery time of all patellofemoral pain syndrome treatments.