• Knee Operations
  • Episurf Partial Resurfacing
  • Microfracture Cartilage Repair
  • Post-operative care: Femur or Tibia surface
  • Post-operative care: Patello-femoral surface
  • General Points
  • Rehabilitation : Femoro-tibial Joint Lesions
  • Rehabilitation: Patello-femoral Joint Lesions
  • Osteo-Chondral Allograft Cartilage Reconstruction
  • PCL Reconstruction
  • Knee Replacement
  • Patient Personal Stories
  • ACL Reconstruction
  • Importance of The ACL
  • ACL Reconstruction: The Operation
  • Aims, Results And Expectations
  • Post Operative Rehabilitation
  • Key to Success
  • Summary of Rehabilitation
  • Phase 2 - 4
  • Phase 5 - 6
  • Returning to Sport
  • Arthroscopy of the knee
  • At Home
  • Knee Exercises
  • Autologous Chondrocyte Implantation (MACI Technique)
  • Procedure for Articular Cartilage Repair
  • Indications
  • The MACI operation
  • After Operation - Patient Perspective
  • Rehabilitation
  • General Principles
  • Patello Femoral Joint
  • The importance of correct Rehabilitation
  • Rehabilitation: Femoral Condyle MACI repair
  • CartiOne Articular Cartilage Repair
  • Femoral and Tibial Osteotomy
  • Post-operative care: 6 weeks upwards
  • Knee Gallery
  • Fulkerson Osteotomy
  • Meniscal Reconstruction using Actifit Implant
  • Meniscal Repair
  • Meniscal Transplantation
  • Results Of Frequently Asked Questions
  • Meniscal Transplant Rehabilitation
  • Medial Patello-Femoral Ligament (MPFL) Reconstruction

Knee Operations

If an operation is recommended then you will be given a procedure code for the operation to give to your insurance company in order to seek confirmation of approval. You may need a brief general health assessment by the outpatient nurses in order to confirm fitness for surgery.

Procedure for booking an operation
Sometimes a date for surgery will be agreed with Mr Spalding at the time of the clinic appointment but usually it is best to call Nicki on 01926 772731 to discuss appropriate dates.

After an operation
On discharge from hospital you will be given an appointment for removal of sutures and detail on arranging the first post operative physiotherapy/rehabilitation appointment.You will usually be sent a copy of the operation report to show your physiotherapist as it is important that as much information as possible is passed on. You should clarify the amount of time required off work with Mr Spalding before undergoing the operation so that you can make appropriate arrangements.

Consent Form Information Sheets

  • Attachment -  Knee Arthroscopy Consent and Information : download
  • Attachment -ACL Reconstruction Consent and Information:pdf download of Tims recent publications
  • Attachment - Knee Replacement Consent and Information : download

Episurf Partial Resurfacing

Episurf is a specialist company who have pioneered a customised metal implant for partial resurfacing of the knee

See the website EPISURF: for further information and indications

Mr Spalding is on the medical advisory board for the company Episurf and has produced a surgical technique video.

EPISURF Post Operative Rehabilitation

rehabilitation (n.) recovery, improvement The action of restoring someone to health or normal life through training and therapy after illness. Commonly referred to in its shortened version, “rehab”.

Episurf produce the Episealer®: a product designed for patients who have a cartilage lesion with an underlying bone defect. In young patients these defects are often treated ‘biologically’. Once this window of opportunity has passed and lasting biologic treatments are no longer an option, Episurf produce an innovative treatment option. Episurf have developed technology that allows your surgeon to customise a solution, tailor-made for every patient, targeting only the damaged cartilage. The implant is designed to stop or delay the need for joint replacement and restore your normal function, whilst reducing your pain.

To ensure a perfect fit, the implant is customised based on your anatomy and the area of damaged cartilage, using details obtained from specialised MRI scans.

The implant is manufactured using cobalt chrome alloy. The underside is sprayed with a layer of pure titanium and a top coat of hydroxyapatite on the underside. Once in contact with bone, these specialised materials enable your body to grow onto the implant to keep it firmly in place. The top surface of the implant is polished to an ultra-smooth finish to ensure a smooth articulation in your knee.

Read more

  • Attachment - EPISURF Ppst Operative Rehabilitation download

Further Information

  • Episurf Medical AB
    Karlavägen 60
    114 49 Stockholm
    Sweden

Microfracture Cartilage Repair

This information sheet on Microfracture cartilage repair is in three sections:

• Information on the nature and purpose of cartilage repair surgery utilising the microfracture technique
• An outline of the post-operative rehabilitation and reasons why it is important to follow a gradual specific plan
•Example detailed exercise plan.

Purpose and description of the procedure

The operation is performed to stimulate repair of articular surface damage in the knee which has been worn away or damaged by direct injury resulting in a defect in the surface. Normally, the joint consists of a layer of smooth articular cartilage covering the bone ends providing an almost frictionless articulation. Once damaged the joint surface has unfortunately very little intrinsic capability to repair itself but it is possible to stimulate a form of repair using the microfracture technique.

Small “pick” holes are made in the end of the bone, using a sharp awl, approximately two to three millimetres deep and spaced every five to six millimetres. This allows for the marrow part of the bone to effectively grow onto the joint surface. This bone marrow ‘super clot’ contains specialised stem cells which can then form a new joint surface. It is expected that the repair tissue will gradually mature and improve over six to nine months from surgery.

Approximately 60 – 70% of patients note a significant improvement in symptoms of pain and function, depending on the amount of damage and intended activity. Results are best when the area of damage is small and when the area of damage is surrounded by normal articular cartilage.

Rehabilitation

The rehabilitation process is crucial to optimize the healing of the joint surface. Essentially the program involves a balance between loading the new surface enough to stimulate development of the new surface and avoiding overloading which will damage the growth. Rather like seeding a new lawn it is important to avoid walking on it too soon yet it should be rolled to keep it smooth. To quote the originator Dr Steadman in USA, – ‘when the ideal physical environment is combined with the ideal chemical environment produced by the marrow clot, a repair cartilage can develop that fills the original defect’.

The procedure is usually performed as a day case and carried out at the same time as an ordinary arthroscopy of the knee. There is no extra incision. On return from theatre there is a padded bandage applied to the leg. This bandage is removed on the day following surgery.

The specific program depends on the site of the repaired defect, its size and whether any other surgery was performed at the same time, such as ligament reconstruction.

Post-operative care: Femur or Tibia surface

Weight Bearing:

• MINIMAL TOUCH WEIGHT BEARING (5-10Kg maximum) is essential using crutches for 6 weeks. Again, like avoiding walking on new grass, any greater load through the joint is likely to damage the healing tissue. Even though the knee may feel comfortable the weight must be kept of it to allow the new surface to mature.
• Knee braces are not usually needed.
• For lesions less than 1cm patients are allowed to take weight sooner.

Movement of the knee joint:
• Early movement and bending (flexion) of the knee is encouraged immediately following surgery and a CPM (Continuous Passive Motion) machine may be used. This helps to smooth the growing articular surface, again rather like rolling new lawn without indenting it.
• If a CPM is used then this should be for 4-6 hours a day with range increased as tolerated until full range of motion is achieved with the machine
• Alternatively a static bike can be used without load: 500 revolutions three times a day.

Exercises during first 6 weeks:
• Physiotherapy exercises commence during the postoperative phase with static quadriceps and hamstring exercises while working on range of movement.
• Static one-third knee bends with 90% wt on the unoperated leg begin the day after surgery
• Static bike, with light resistance only, and pool exercises (in deep water) can start from 1-2 weeks.

From 6 weeks:
• Progression to FULL WEIGHT BEARING is allowed at six weeks followed by a gradual increase in exercise activity including elastic cord resistance exercises, cycling with load, cross trainer and eventually step-machines.
• Jogging can start at 3 months earliest if sufficient quads muscle control.
• Free weights and exercises severely loading the joint surfaces are started at 3 – 4 months when balance control is good, strength has returned and there is no swelling in the knee.
• No cutting, turning or jumping activities are allowed for 4 months and this may be longer for competitive or “heavy” patients.
• Return to impact sports is allowed between 4 – 6 months once knee function is satisfactory as measured on functional tests, and there is no swelling in response to activity.

Post-operative care: Patello-femoral surface

Weight Bearing:
• FULL WEIGHT BEARING is allowed in a hinged knee brace with the hinges set to allow 0 – 20 degrees flexion only for 6 weeks.

Movement of the knee joint:

• Early movement (flexion) of the knee is encouraged immediately following surgery and a CPM (Continuous Passive Motion) machine may be used.
• Alternatively a static bike can be used without load: 500 revolutions three times a day, out of the brace.
• The aim is to obtain full passive pain free range of movement as soon as possible

Exercises during first 6 weeks:
• Physiotherapy exercises commence during the postoperative phase with static quadriceps and hamstring exercises while working on range of movement using static bike, CPM and pool exercises.
• Weight should not be put through the knee cap part of the joint, in other words by taking weight on the bent knee. This is because, rather like avoiding walking on new grass, any greater load through the joint is likely to damage the healing tissue. Even though the knee may feel comfortable the weight must be kept of it to allow the new surface to mature.
• With the brace on, then strength training is allowed but only in the 0 – 20 degree range

From 6 weeks:

• The brace is removed and normal walking should be achieved.
• Weight on the involved leg is allowed as tolerated, but it must be limited to the angles of flexion that do not compress the treated surfaces.
• It is important for the physio to know the specific angles that need to be avoided, but often the patient will have been aware of a particular position that the knee cap used to cause pain or catching.
• After six weeks a gradual increase in exercise activity is allowed building up to commencing impact type activities at 4 – 6 months.
• For the patello femoral joint specific closed chain exercises are used to strengthen the muscles controlling the patella without overloading the new surface.
• It is expected that the repair tissue will gradually mature and improve over six to nine months from surgery.

General points

• We use the phrase “as tolerated” to allow a level of activity safe for the repair: symptoms of pain, limp and swelling indicate that too much is being done. Activity levels should then be reduced temporarily.
• Ice should be applied to the knee for 10 - 15 minutes following each exercise session to help reduce swelling.
• The decision to return to sport is based on a joint decision with the surgeon, physiotherapist and trainer as necessary and is based on appropriate testing.
• The timings and exercises are to given as guidelines – some programs can be faster or slower – this is dependent on various factors, from the demands of the patient to the size of the area repaired, and the availability of rehab facilities.

Rehabilitation : Femoro-tibial Joint Lesions

0 - 3 Weeks Rehabilitation:
• Touch weight-bearing for 6/52 after surgery
• Range of motion – free flexion as tolerated aiming for full flexion by 6/52
• Patellofemoral mobilisations
• Assisted knee swings 15 mins 3x/day for 6/52
• Stationary bike after 1 -2/52 when comfortable flexion achieved. 500 revolutions 3 times a day. No or minimal load.
• Cold therapy may be used as required
SLR no lag, Static quads, hamstrings & gluteii Open chain quads no resistance
• Hamstring/ Calf Stretch (long sitting)

3 - 6 Weeks Rehabilitation:
• Remain touch weight-bearing for 6/52
• Core stability in sitting
• IRQs Hip Flex/Ext/Abd/Add with knee Ext
• Knee Flex/Ext (Gym ball – heel on ball)

Week 6 Goals:
• Minimal pain and swelling
• FROM

7 - 8 Weeks Rehabilitation:
• Progress PWB-FWB
• Core stability exs with gymball
• Hamstring/calf stretches in standing
• Stationary bike: increase load as tolerated
• Gym ball:
-Bridging
-Knee Flex/Ext sitting on ball. Double/ single
-Sit to stand

Week 8 Goals:
• Mobilise unaided
• Satisfactory static proprioception

9 - 12 Weeks Rehabilitation:
• Continue with Week 6 Exs
• Knee Flex/Ext in standing with theraband to resist (0-30º)
• Proprioceptive work
• Rowing machine
• Leg press – low resistance (10º - 70º)
• Hydrotherapy/swimming

Week 12 Goals:
• FWB Normal gait
• FROM
• Good knee control

3 – 4 Months Rehabilitation:
• Gait re-education
• Step ups on 10cm (40º) to 15cm (60º) step
• Mini stepper
• Static bike with resistance/outdoor cycling
• Treadmill: slow walking forwards/backwards
• Increase proprioception
-Trampette single leg stands
-Single leg mini squat
-Wobble board
• Lateral step downs on 10cm (40º)step
Forward step downs on 10cm step
• Hip Abd/Add/Flex/Ext in standing + theraband

4 Months Goals:
• Pain free FROM
• Good control of 10cm forward step down
• Increased confidence in knee

4 – 5 Months Rehabilitation:
• Single leg mini squats on trampette
• Step on & off trampette with operated leg
• Full stepper/crosstrainer
• Lateral/forward step down 15cm to 20cm (80º)
• If adequate knee control – can begin fast walk on treadmill, gradually progressing to slow jog under supervision

5 Months Goals:
• Satisfactory knee control fast walking
• Perform 20cm step down & neutral pelvis
• Able to complete 1 hour of light exercise

5 - 6 Months Rehabilitation:
• Circuit training
• Gentle jog/shuttle runs
• Gentle change of direction
• Single leg hurdle/step over
• Accelerate/decelerate up to 50% speed
• Plyometrics: skipping, hopping, star jumps

6 Months onwards: Return to full sport phase
• Should have confidence in knee
• Can now run unsupervised if adequate control
• Accelerate/decelerate runs ¾ speed
• Figure of 8 runs fwds/bwds
• Slalom fwds/bwds
• Gradually introduce cutting/sudden stop
• Run – sit – run
• ↑ distance: sprints 10m – 20m – 50m
• Can begin sports specific training when agreed with consultant and physiotherapist

Rehabilitation : Femoro-tibial Joint Lesions

0 - 3 Weeks Rehabilitation:
• Touch weight-bearing for 6/52 after surgery
• Range of motion – free flexion as tolerated aiming for full flexion by 6/52
• Patellofemoral mobilisations
• Assisted knee swings 15 mins 3x/day for 6/52
• Stationary bike after 1 -2/52 when comfortable flexion achieved. 500 revolutions 3 times a day. No or minimal load.
• Cold therapy may be used as required
SLR no lag, Static quads, hamstrings & gluteii Open chain quads no resistance
• Hamstring/ Calf Stretch (long sitting)

3 - 6 Weeks Rehabilitation:
• Remain touch weight-bearing for 6/52
• Core stability in sitting
• IRQs Hip Flex/Ext/Abd/Add with knee Ext
• Knee Flex/Ext (Gym ball – heel on ball)

Week 6 Goals:
• Minimal pain and swelling
• FROM

7 - 8 Weeks Rehabilitation:
• Progress PWB-FWB
• Core stability exs with gymball
• Hamstring/calf stretches in standing
• Stationary bike: increase load as tolerated
• Gym ball:
-Bridging
-Knee Flex/Ext sitting on ball. Double/ single
-Sit to stand

Week 8 Goals:
• Mobilise unaided
• Satisfactory static proprioception

9 - 12 Weeks Rehabilitation:
• Continue with Week 6 Exs
• Knee Flex/Ext in standing with theraband to resist (0-30º)
• Proprioceptive work
• Rowing machine
• Leg press – low resistance (10º - 70º)
• Hydrotherapy/swimming

Week 12 Goals:
• FWB Normal gait
• FROM
• Good knee control



3 – 4 Months Rehabilitation:
• Gait re-education
• Step ups on 10cm (40º) to 15cm (60º) step
• Mini stepper
• Static bike with resistance/outdoor cycling
• Treadmill: slow walking forwards/backwards
• Increase proprioception
-Trampette single leg stands
-Single leg mini squat
-Wobble board
• Lateral step downs on 10cm (40º)step
Forward step downs on 10cm step
• Hip Abd/Add/Flex/Ext in standing + theraband

4 Months Goals:
• Pain free FROM
• Good control of 10cm forward step down
• Increased confidence in knee

4 – 5 Months Rehabilitation:
• Single leg mini squats on trampette
• Step on & off trampette with operated leg
• Full stepper/crosstrainer
• Lateral/forward step down 15cm to 20cm (80º)
• If adequate knee control – can begin fast walk on treadmill, gradually progressing to slow jog under supervision

5 Months Goals:
• Satisfactory knee control fast walking
• Perform 20cm step down & neutral pelvis
• Able to complete 1 hour of light exercise

5 - 6 Months Rehabilitation:
• Circuit training
• Gentle jog/shuttle runs
• Gentle change of direction
• Single leg hurdle/step over
• Accelerate/decelerate up to 50% speed
• Plyometrics: skipping, hopping, star jumps

6 Months onwards: Return to full sport phase
• Should have confidence in knee
• Can now run unsupervised if adequate control
• Accelerate/decelerate runs ¾ speed
• Figure of 8 runs fwds/bwds
• Slalom fwds/bwds
• Gradually introduce cutting/sudden stop
• Run – sit – run
• ↑ distance: sprints 10m – 20m – 50m
• Can begin sports specific training when agreed with consultant and physiotherapist

Osteo-Chondral Allograft Cartilage Reconstruction

Knee Reconstruction using Osteochondral Allografts

Allografting or, to give its full name, ‘fresh osteochondral allograft transplantation (OCA)’ is an operation in which a damaged or diseased area of a joint is reconstructed using a bone and articular cartilage transplant. The cartilage cells can survive the transplantation only if the tissue is ‘fresh’, which means it has not been exposed to radiation or prolonged freezing.

OCA was pioneered at the beginning of the 20th century, and has had a long and successful history. It is becoming increasingly popular as a treatment for large injuries caused by trauma, osteochondritis dissecans (growth abnormality of bone and joint), and bone death (osteonecrosis) resulting from lack of blood flow to the bone supporting the joint cartilage.

The scientific basis of OCA is the transplantation of fully developed or mature hyaline (joint) cartilage containing living cartilage cells (‘chondrocytes’) that survive the transplant and support the production of the cartilage matrix indefinitely. Theoretically, this maintains the tissue balance (‘homeostasis’) of the joint cartilage. Studies have shown chondrocytes living as long as 29 years after transplant. The graft often includes a portion of bone to help restore missing bone.

Read more

  • Attachment -  Department of Trauma & Orthopaedics : Knee Reconstruction using Osteochondral Allografts download
  • Authors: Consultant Surgeons Mr Tim Spalding, Mr Pete Thompson, Mr Andy Metcalfe, UHCW NHS Trust
  • Contact email: via Desdimina Rai, Secretary to Mr Tim Spalding, Consultant Orthopaedic Surgeon.
  • Tel: 024 7696 5098, Email desdimina.rai@uhcw.nhs.uk

The Trust has access to interpreting and translation services. If you need this information in another language or format please contact and we will do our best to meet your needs. The Trust operates a smoke free policy

    Document History
  • Author Mr Tim Spalding, Mr Pete Thompson, Mr Andy Metcalfe
  • Department Trauma & Orthopaedics
  • Contact Tel No 024 7696 5098
  • Published December 2017
  • Review December 2019
  • Version 1
  • Reference No HIC/LFT/2192/17

Read more

  • Attachment - Osteochondral Grafting post operative rehabilitation download
 

PCL reconstruction

POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION (PCL)

This information sheet provides information on the nature and purpose of the procedure in addition to an outline of the post-operative rehabilitation.

Purpose and description of the procedure

The PCL is the largest ligament in the knee and stops the shin bone (tibia) from moving too far backwards.

It is commonly injured by a blow to the front of the upper shin, such as during a fall onto the flexed knee. Hyperextension (over straightening) and hyperflexion (over bending too far) of the knee can also tear the PCL and it is often torn in high energy injuries dislocating the knee such as falling from a height or in RTA's. Not everyone who has a PCL injury will require surgery as milder or partial isolated tears (no other ligaments involved) can heal just with the aid of an appropriate brace and rehabilitation. When torn the problem symptom is a feeling of ‘looseness’ and a feeling of giving way.

Often a brace is recommended, holding the tibia forwards and controlling stability. This helps predict who would respond well to the operation. The knee can tolerate some looseness associated with a healed PCL ligament but it depends on the required sport and how the ligament heals.   

Download the full bookletdownload

Post-Op Posterior Cruciate Ligament bracing Protocol

  1. On day of surgery Lead Physio to measure patient and order Medi PCL dynamic brace
  2. At the end of operation patient is fitted with Medi PTS brace - PTS brace to be worn at all times including at night for the first 3 weeks - May remove brace for range of motion physio exercises and to wash leg
  3. At 3 weeks PTS brace to be changed to the Medi PCL dynamic brace as initial post-op swelling should have improved - Allow 0-90 degrees of flexion (this is the default setting of the PCL dynamic brace) - Wear PCL dynamic brace at all times including at night until 8 weeks
  4. At 6-8 weeks when reviewed in clinic remove the ‘90’ degree stop from the brace to allow full range of movement - Continue with dynamic brace at all times except physio exercises until 3 months post-op - May stop using brace at night after 3 months
  5. Continue dynamic brace when walking for 4-6 months post-op as decided by

( Click PDF to download by section)

Part 1: Information about knee replacement Knee Part 1 Download

•    What is Knee Replacement (metal and plastic resurfacing)
•    The normal knee and the types of replacements
•    Indications for surgery
•    Expectations and potential problems

Part 2: Information about the time in hospital knee part 2 download

•    Coming into hospital
•    Discharge planning
•    Your anaesthetic
•    Recovery after the operation
•    Going home plans

Part 3: Rehabilitation Physiotherapy exercises following surgeryknee part 3 download

•    Early bed exercises - the first set
•    The second set of exercises
•    Early Functional activities
•    The third set of exercises
•    Next functional activities
•    Advanced and home exercises - the fourth set
•    Further information and follow-up plans

Dave Robinson - Personal Story
This is the story of one patients journey along the road of knee problems culminating in knee replacement. The patient is a 60 year old gentleman and commentary is written by Andrew Caldwell, consultant physiotherapist at Active Therapy based at the Lichfield Golf & Country Club and The Chase Golf, Health Club & Spa. It is written 5 months after surgery. Author: Dave Robinson

The build up
Leading up to my total knee replacement due on December 1st 2014, I fully expected to be ‘up and running’ by February 2015. Indeed, I had even contemplated the idea of going skiing in the March.
The history of my knee issues had been present for some time. When I was 20 (40 years ago), I injured my knee badly playing rugby. I needed a lateral meniscectomy (cartilage op) which left me unable to participate in sport for a considerable amount of time. From that time on I was aware that the internal condition of my knee was deteriorating slowly. By the time I was 30 I could no longer participate in contact sports like soccer or rugby, so I focussed on cricket. As I moved into my 40s the condition of my knee had worsened and at times I had to take pain killers to continue playing sport. I continued to ski but this caused me more and more discomfort as the years passed by. Eventually three or four years ago I thought enough is enough, skiing is now becoming too painful. I decided to have the joint cleaned up (arthroscopy and wash out/debridement). I had physiotherapy treatment post-operatively with my physiotherapist Andrew Caldwell and this appeared successful at the time. I returned to regular exercise participation and golf but my symptoms subsequently began to worsen and in consultation with my surgeon Tim Spalding I decided to opt for knee joint replacement (or arthroplasty).
Having had a number of arthroscopic investigations over the years on the other knee as well, I guess I had been lulled into a false sense of security. When it came to the total knee replacement, I thought I’d put a bit of ice on it, do some exercises and be ‘right as rain’ in a few weeks. It was only when somebody told me that a knee replacement operation was major orthopaedic surgery that I began to realise how much more involved this journey would be.

Andrew Caldwell comments:
When electing for orthopaedic procedures such as knee replacement patients need to be advised and understand that arthroplasty (joint replacement) is a significant operation with a very different recovery to arthroscopy (keyhole surgery) requiring intensive post-operative rehabilitation to achieve optimal outcome.

The initial recovery
The operation went very well and without complication. I received excellent care as an in-patient whilst in hospital and could not have been better looked after. I had the procedure on Monday and went home on Thursday. I mastered the crutches quickly, and did all the basic exercises prescribed without any problems. When I was back at home I had been told to carry on with the flexion and extension exercises, take the pain killers to allow more movement to be achieved and then to elevate and ice the knee. I did this for a week and started to feel good about progress.
Eleven days after the op I had the staples (stitches) removed and then a few days later went for my first physio session. At this meeting my knee flexion was 85 degrees and I was still short of being able to extend the knee joint fully. I was a bit frustrated by my lack of progress at this point. I consequently experienced quite a painful session on this first occasion as the Physio encouraged more bend and extension in the joint. It was December 15th. I returned home but with Christmas looming and the family starting to arrive I neglected the exercises, the painkillers and the ice. For two weeks I probably only iced once a day, took no painkillers because I wasn’t really in any pain, and did not commit anywhere near as much time as I should have to my exercise programme.
It was January 5th before I went for my second physio session. My knee flexion was 80 degrees. I had lost 5 degrees of flexion through inactivity! I was also experiencing pain on the medial side of the knee. The physio was a little frustrated by my deterioration. That session was particularly painful as the physio tried to encourage more flexion and extension into a stiffening knee joint. It was impressed upon me to take the painkillers and to ice regularly. The painkillers would help to mask the pain as I did the exercises and to push myself to improve the range of movement. Finally I had got the message! But I had lost 2 – 3 weeks of potential progress due to complacency. I now realised that the only way this would work was if I was prepared to work hard and go through a bit of pain. I started hydro therapy and at the third physio session recorded 90 degrees of flexion. I was now taking the painkillers and doing as I was told!
The following week (January 12th) I returned to work on a half day basis. I now think this was too soon because it was not easy to do my exercises and get ice at work.

Andrew Caldwell comments:
The decision to return to work is individually specific and influenced by a patients’ occupation but encouraging the earliest and safest return to work with modified hours is advised. Patients  recover better when in their normal social environment but need to arrange that they can continue rehabilitation to achieve optimal results.

By January 19th and the fourth session I was up to 100 degrees but I still had some pain on the medial (inside) of the knee. This was very localised. After the fifth session on January 26th I was up to 115 degrees and started some strengthening exercises also. Mobility was getting better and the medial pain in the knee was starting to subside. I then waited two weeks before my final physio session on February 13th. My knee bend was 125 degrees, but I still could not quite fully extend the joint. Since then I have continued to work hard on the exercises etc and I can now lock out the knee fully. I had 5 hydro therapy sessions (exercises in water) and 6 physio sessions as part of the post operative treatment and care. This was excellent.
I then decided to contact Andrew Caldwell who is a consultant physiotherapist and specialises in sports injury and rehabilitation. Andrew is a colleague and friend who is connected with me through sport and work. He assessed me on February 16th 2015 and advanced my exercise programme to specifically develop strength and flexibility toward sports specific and end stage rehabilitation.

Andrew Caldwell comments:
Some post-operative discomfort is normal whilst the body is recovering from surgery and typically isn’t an indicator of danger or damage to the replacement. During exercise experiencing pain up to 5/10 on a pain score (where 10 is severe pain) during exercise then this is OK. This pain should not persist for more than 30 minutes after exercise. Post exercise icing can ease discomfort.

5 months since surgery
Its now 5 months after the knee replacement and I have been doing Andrew’s exercises (there are 10 of them) everyday religiously since that date in feb. I am still going to the pool at least 3 times a week and doing my exercises in the water.
I would not say my knee is 100% yet but I can do things now (e.g half squats) that I could not do before. The strength is returning quickly to my new knee. It still swells up a little especially if I have done a lot that day. But I am told this can be quite normal. This restricts the movement but it quickly returns with elevation and rest. I am not icing the knee as often, only once or twice a week. However, I did put ice on it 3 or 4 times a day up until the end of February. I have been told by Mr Spalding to start to do other more normal activities eg golf, but to take it slowly. I feel after 15 weeks that I am now getting there.

Andrew Caldwell comments:
Rehabilitation needs to be advanced above the level that each patient requires for their activities of daily life or sport. During rehabilitation they need to exceed the demands placed upon their lower limb to avoid persistent symptoms of tissue overload such as pain, stiffness and swelling. For example the loading on a knee encountered during the golf swing can be equivalent to a 30cm box jump!’

What have I learnt from this?
My advice to anyone thinking about having a knee replacement operation, once you have had the  op, is:
- take painkillers 30 minutes before you exercise
- perform your exercises regularly as prescribed by your physiotherapist. Consistency is the key!
- after exercising, elevate the knee and apply an ice pack for about 20 – 30 minutes.
I would also advise people not to go back to work until they really do feel ready. It is so important that this operation works for you so you have to give yourself the best chance. I also suggest that after your first course of physio has finished, go and get some more. Physio’s know what they are talking about!
After a really good start straight after the operation, I was complacent for 2 to 3 weeks. I thought I didn’t need painkillers, and if I just rested the swelling would go down and the mobility would return naturally. This isn’t the case. You have to push yourself and the joint to both bend and straighten. This can be painful so take the painkillers. That’s what they are for – to help you push yourself. Then get your leg up higher than your hip and put ice on it.
I have been lucky, I am on the road to a very good recovery. I had an excellent surgeon and have had first class post-operative care. It may still be another couple of months before I am starting to do the things I want to. But if I had my time again I would do everything by the book right from the start. Next year I hope to ski again!

Andrew Caldwell comments:
Chartered physiotherapists are rehabilitation specialists who have extensive training and specific expertise to ensure you achieve an optimal outcome from your surgery. Together the surgeon, physiotherapist and patient form a team who work together to achieve the best outcome.

Andrew Caldwell MCSP BSc (Hons) MSc
Consultant Physiotherapist
Clinical Director  - Active Therapy Limited
www.active-therapy.com
admin@active-therapy.com
07970110526


ACL Reconstruction

Anterior Cruciate Ligament Reconstruction

Patient information and Rehabilitation Guidelines

This section provides a summary of information relating to injury to the Anterior Cruciate Ligament, covering what it is, how it is injured and how it is reconstructed. A summary is given of the rehabilitation plan with its stages right up to returning to sport.

Full detail is contained in the rehabilitation and information booklet obtainable from Mr Spalding.

Please select the arrow on the left menu for topics in this section.
Attachment – Consent Form Information Sheet: download

ACL reconstruction

ACL Introduction

The anterior cruciate ligament (ACL) is one of the main restraining ligaments in the knee. It runs through the centre of the knee, from the back of the femur (thigh bone) to the front of the tibia (shin bone), and it acts as a link mechanism between the thigh and lower leg.

The main function of the ACL is to stabilise the knee, especially during rotation, sidestepping, and pivoting movements.

This means that when the ACL is ruptured or torn, the tibia moves abnormally on the femur and comes out of joint, and the knee buckles. The main feeling is a sense of the knee giving way during twisting or pivoting movements, and a sense of not trusting the knee when turning.

It is usual to be able to return to walking and straight line running following a torn ACL but to not trust the knee on rough ground or twisting movements. All too often the diagnosis can be delayed because the knee may recover for straight line activities, giving a false sense of security, but there is no control when returning to pivoting sports.

And when the knee gives way, there is a risk of further damaging the other key structures in the knee – hence the importance of preventing re-injury by making an early diagnosis.

Mechanism of Injury

Typically, the ACL is injured in a non-contact, twisting movement involving rapid deceleration on the leg, or a sudden change of direction, such as during side stepping, pivoting or landing from a jump . Injuries are often associated with a popping sensation followed by swelling in the knee over the next few hours due to bleeding from the torn ligament.

netball-knee-injury

Typical scenarios include a footballer or rugby player who catches his foot in the ground as he tries to change direction, a netball player who jumps and lands awkwardly twisting on their bent knee with their foot out to the side, and a skier who catches the ski at slow speed and twists their leg out to the side.

There are many other scenarios of course and depending on the exact mechanism it is also possible to damage the joint surfaces (articular cartilage), or the meniscus (footballer’s cartilage).

ACL Diagnosis

Injury to the ACL is diagnosed by detecting an increase in the forward movement of the tibia in relation to the femur. Normally such movement is prevented by the ACL. The examining doctor gently grasps the tibia and the femur and tries to detect the increased movement. acl-diagnosis

Another of the tests is the Pivot Shift test which gently reproduces the giving way sensation as the knee is slowly bent. Done carefully these are painless tests and can accurately diagnose a torn ligament.

ACL diagnosis

Often the diagnosis can be made from the story – a pivoting twisting movement associated with a pop sensation and the feeling of immediately not trusting the knee. Others nearby may have heard a pop and thought the leg was broken. Early swelling is common and it is not usually possible to carry on playing – and any attempt to do so often results in the knee giving way again.

The importance of the ACL

ACL-ImportanceThe importance of the ACL is that it is the main stabiliser of the knee and without it fast pivoting and twisting actions become difficult and result in giving way of the knee. It is hard to get back to pivoting type sports without a good ACL. In addition, repeated buckling or giving way of the knee leads to secondary damage of the other important structures of the knee – namely the smooth bearing surface (articular cartilage) and the protective shim between the surfaces (meniscus or footballers cartilage).

Once these become damaged then there is a much higher risk of later problems with the knee such as pain from wear and tear arthritis. Repeated giving way of the knee is therefore not good for the knee.

Types of tears:

Types of tears: functional or non-functional

Several different words are used to describe a torn ACL including ruptured, snapped, injured, torn, and popped for example. Once injured, it can partially heal in some people and this may give sufficient restraint to return to non-pivoting sports. In most, however, the ligament will not heal tight enough to function for sports involving a rapid change of direction.

The principle, therefore, is whether the cruciate ligament is functional or not functional in controlling stability in rotation activities. If the ligament is functional and the requirement to get back to fast pivoting sports is low, then surgery is not likely to be needed.

Proprioception

The special function of the ACL As well as providing restraint to abnormal knee movement, the ACL gives important information to the muscles involved in the reflex control of knee movements. Nerve fibres give the knee a sense of position and movement and this sensory awareness is known as proprioception. It is a normal feature of all joints and helps to give us balance control and confidence in movements.

To some extent, this can be compensated for after ACL injury by special rehabilitation exercises for the hamstrings and quadriceps (thigh) muscles. However, the knee is a complex joint and muscle strength may not be enough alone for individuals who take part in pivoting type sports.

Indications for reconstruction

Surgical reconstruction is indicated in individuals who wish to return to pivoting type sports, and for those who have problems with giving way during day-to-day activities. We have previously outlined how repeated giving way of the knee may lead to damage of other structures within the knee and it is this repeated giving way that is bad for the knee. Reducing the repeated giving way can be achieved by either avoiding pivoting activities, using an ACL specific sports brace or by reconstructing the ligament. knee brace
The decision to undergo reconstruction depends on weighing up all the relevant factors including the degree of instability of the knee and the sporting aims and aspirations of the individual.

For the individual who just wants to get back to light gym work, outdoor walking or skiing for example, surgery may not be required and the knee may feel stable enough after a period of rehabilitation or use of a special ACL brace. ACL TearHowever, for a young keen sportsperson we know that there is a very high risk of sustaining further injury to the other structures in the knee after returning to sport with an ACL deficient knee, and therefore the stabilisation surgery is encouraged. 

 

ACL Reconstruction: The Operation

 

The ‘keyhole surgery’ operation to reconstruct the ACL involves replacing it with other strong tendons from areas around the knee.

ACL Technique

Two main grafts are in common use: the Hamstring Tendon graft and the Patella Tendon graft. Both are considered to be equally good and the choice usually depends on the surgeon’s preference. Currently the Hamstring Tendon graft is favoured in most patients and it is probably best to avoid using the patella tendon if there is significant pre-existing pain in the front of the knee, or where employment involves kneeling or squatting. Postoperative rehabilitation is the same for each graft. The hamstring graft is made from the semi-tendonosis and gracilis tendons, which are cord like structures behind the inner aspect of the knee. These two tendons are taken through a small incision on the front of the tibia and are folded in to make four, five or six stranded structure

The patella tendon graft is made from the central strip of the patella tendon that runs from the knee cap (patella) to the tibia; a small piece of bone is kept attached to the ligament at each end .

Bone graft from the tibia is inserted at the end of the operation into the kneecap to restore contour and to help with kneeling.

Surgery is performed under general anaesthesia and usually takes 1–1/2 hours. The chosen graft is harvested through small incisions and is prepared into a new ligament. The main part of the procedure is performed via keyhole surgery (arthroscopy). The bulk of the old ACL is removed to allow space for the new graft.

The inside of the knee is prepared and tunnels are made in the tibia and femur at the anatomical site of the attachment points of the old ligament. The new Hamstring Graft ligament is then held in place within the tunnels using a small metal bar (endobutton) on the femur and an absorbable screw at the shin bone end. A Patella Tendon graft is held in place by two bio-absorbable screws which are slowly incorporated by the body.

ACL Screw

These fixation devices do not usually need to be removed.

If the meniscus is torn, or the articular cartilage is damaged, then such damage can be tidied up or repaired during the same procedure. This may affect the rehabilitation time scales post operatively.

Meniscal repair using sutures as an example

Aims, Results, And Expectations

The aim of the operation is to prevent repeated episodes of giving way or buckling of the knee. Published research shows that approximately 90% of patients consider their knee to function normally, or nearly normally, after surgery. Full contact sport is allowed after rehabilitation but not everyone gets back to his or her previous level. Return to sport depends on the time period since the injury and other personal or work factors. It is important to emphasise that the new ligament is not a “normal” ligament. Re-creating stability with the graft is only one aspect of attempting to improve knee function after injury. Other problems such as joint surface damage or meniscal tears may co-exist which can interfere with the joint’s ability to tolerate high loads associated with sport and other arduous activities. Also, wear-and-tear arthritis associated with ligament injury is not necessarily prevented by reconstruction surgery and the risk of developing osteoarthritis of the knee in later life is higher once the ligament has been torn.

Potential Problems

Problems can occur. Some are minor but some may need another operation to help. It is clearly important to understand these risks before undergoing surgery.

The main risks include:

  • Failure to provide enough stability in the knee to allow a return to full sporting activities. Either the ligament does not heal in a tight enough position to allow full confidence in the leg, or there is associated damage inside the knee that prevents return to full function.
  • Patella pain or discomfort in the front of the knee joint during activities such as squatting or sitting with the knee bent can develop in 10 – 20% of patients, but this usually improves with specific rehabilitation. More importantly, it can be prevented by appropriate early rehabilitation and by closely following the guidelines and advice in this booklet.
  • Complications of deep vein thrombosis and wound infection can occur as in all operations. The risk is approximately 1 – 2%.
  • Re-rupture of the graft, which occurs in approximately 2 – 4% of cases over 10 years. This is similar to the risk of rupturing the ligament in the other knee.

Concerns Following Surgery

The following is a list of “Normal” common events that can occur following surgery:

  • Swelling: Swelling or “effusion” in the knee is usual until up to three months after surgery. The main aim of the first phase of rehabilitation is to reduce swelling.
  • Difficulty kneeling: After any operation on the front part of the knee it takes a while to tolerate kneeling, but with gradual progression through the use of a cushion then carpet, and finally a hard floor, this usually improves.
  • Bruising: It is usual for bruising to appear down the leg as far as the inner aspect of the heel. It can be surprisingly tender and may take four to six weeks to disappear.
  • Numbness around the knee: Numbness around the scars on the front part of the knee is common as the nerves that supply sensation to the skin crisscross around the front of the knee. This can be quite disconcerting for a few months and some residual area of reduced sensation may persist in the long term. Usually, this does not affect the function of the leg.

Post Operative Rehabilitation

Remember: This is only a guide

alert

Key to Success

The overall rehabilitation plan emphasises the importance of pre-operative exercises followed post operatively by early control of swelling and regaining full extension (straightening) and flexing of the knee (bending). Working on strength can only start once swelling and range of movement have been controlled. Return to function then follows.
Key to Success The key to successful rehabilitation is to regain normal, full straightening of the knee as soon as possible, and to control swelling in the early post operative phase before progressing to strength activities. For the first six weeks, until the new graft is well bedded in and healed in place, exercises are performed gently with the aim of regaining normal bending and straightening as the swelling settles. Repetitive cycling of the knee is restricted during the first 6 weeks as this may overload the fixation of the ligament and lead to slippage of the graft and effective lengthening of the new ligament.

During exercises the foot is initially kept in contact with the ground or with the surface of an exercise machine – these are called ‘closed’ kinetic chain exercises.

Elevation of the leg between exercises to reduce swelling is also important and helps allow the bending to improve.

‘Open’ kinetic chain exercises, where the foot is unsupported, are introduced towards the end of the first six weeks as knee control and strength improves. This allows muscle strength to improve without putting excessive stress on the graft.

General Principles Rehabilitation

Exercises need to be done 4 – 5 times per day: little and often is better than an extensive overload period.

Pain, heat and increasing swelling in the knee are potentially bad: Any of these symptoms can mean that exercises are being overdone. This is unlikely to indicate a serious problem, but these symptoms should be discussed with the physiotherapist.

The difference between good and bad pain: After major knee surgery the knee will be sore. It is important to understand that discomfort is normal - particularly when doing some of the stretching exercises. The knee may also ache after an exercise session. This is expected and normal so long as it is not associated with any significant increase in swelling. ‘Bad pain’ is usually sharp and severe in nature. It may be brought on by pushing too hard, and it may be accompanied by an increase in swelling. Activities causing such a problem should be stopped and advice sought from the physiotherapist.

Summary of Rehabilitation

There are six main rehabilitation phases and example exercises for each phase are given in the sections that follow. Many different exercises are available to achieve the goals and these are tailored to each individual by the physiotherapy team. Various example exercises are outlined in each section.

  • Phase 1: Preoperative preparation/operative period.
  • Phase 2: Initial Post Op Phase: First 2 weeks.
  • Phase 3: Proprioception (sensory awareness) Phase: Weeks 3 – 6.
  • Phase 4: Strength Phase: Weeks 6 – 12.
  • Phase 5: Early Sport Training: Months 3 - 6.
  • Phase 6: Return to Sport: Months 6 – 9.

Specific Follow-up assessment: Outpatient review takes place at the following times and the goals for those stages are detailed in the guidelines:

  • 2 weeks
  • 6 weeks
  • 3 months
  • 6 months
  • 1 year

Phase 1

Preoperative Preparation And Operative Period

Pre Op Rehabilitation begins before surgery in the pre-operative phase to ensure that the individual and their knee are ready for the operation.

  • Ensure full range of movement, especially normal hyperextension, i.e. so the knee extends to the same as the other leg.
  • Exercises to maintain quadriceps and hamstring muscle strength. Start balance control exercises
  • Advice session in the physio department for familiarisation with post op exercises and hospital stay.

Initial Post Operative Period
The aim is to go home comfortable and ready for rehabilitation on the first postoperative day. Sometimes it is possible to go on the day of surgery. The dressings are changed on the 1st postoperative day along with instruction on using crutches the exercises to be performed for the first 2 weeks.

Crutches are required for the first 2 weeks taking partial weight on the leg.

Instructions on Discharge from Ward

The following is a list of instructions and expectations given before leaving the ward.

  • Keep the wound dry for 3 days or until the wound has sealed.
  • Instruction on use of Cryocuff or ice packs to control swelling.
  • Clips or Stitches to be removed at 7 days by a local surgery or district nurse.
  • Appointment for review in clinic or on the ward after 2 weeks.
  • Date for first outpatient physiotherapy appointment.
  • Work Advice: to expect to be able to return to work as follows:
    • Desk work at 3 – 4 weeks
    • Light manual work at 6 weeks
    • Heavy manual work (ladder work etc) at 3 – 4 months.
  • Driving Advice: return to driving at 3 – 4 weeks depending on knee function.

Phase 2

Initial Post Op Phase – First 2 Weeks
Aim The aim of this phase is to regain the range of joint movement and to allow swelling in the knee to settle. The most important aim is to regain normal and full extension (straightening) of the knee. After seeing the physiotherapist on the ward the next appointment is usually one week following surgery to add in extra exercises.


2 Week Review Goals

Range of movement: full knee extension to 1100 flexion
Wound healed
Minimal swelling in knee and around wound
Normal walking pattern
Independent leg control

Phase 3

Proprioception Phase (Sensory Awareness) WEEKS 3 – 6

Aim :rehabilitation knee

The aim of this phase is to work on proprioceptive exercises and to develop light endurance and strength training. This stage is also important for developing core stability to help you progress to full active function. By the end of six weeks your knee should feel normal in activities of daily living.


6 Week Review Goals

Full range of movement including normal hyperextension
Minimal Swelling in knee
Full patella mobility
Minimal discomfort

Phase 4

Strength Phase - Weeks 6 – 12

Aim phase 4 rehab

At six weeks the graft will be solidly fixed into bone so that more vigorous strength training can start. Thigh muscle tone and definition (quadriceps / hamstrings) will be hopefully have been maintained during the first post op phase and now the main strength work can begin. Progress is monitored and controlled by the recovery of strength and muscle control. It is important to avoid too rapid progress, as there is a risk of developing overload complications


3 Month Review Goals

Full range of movement
No swelling
Confident feeling of stability

Phase 5

Early Sport Training Phase - Month 3 - 6

Aim phase 5 rehab knee
Pivoting and cutting movements are introduced at this stage, building up to light sport training. This involves a progressive programme of slow and moderate speed strength training and agility drills. Manual work should be possible within the restraints of the occupation. Exercises for power and agility training are introduced.
Many sport specific skill training exercises can be introduced at this stage and detail for particular sports is given in the next section as there is some overlap during these phases. The new ligament is still at significant risk of re-injury or of stretching out if progress back to full levels of sport is too fast.

There is no one solution that fits all individuals great emphasis is given on the care in progressing through this phase back to sport. Supervision by a Physio, sports coach or trainer is key, as drill and skill acquisition is dependent on individual muscular control patterning in addition to individual relative strength deficits around the hip, knee and ankle.


6 Month Review Goals

Full Range of movement
Functional and Strength tests: 85% of normal side
Return to non contact sports training

Phase 6

Return To Sport Phase – Month 6 – 9 And Beyond

Aim phase 6 rehab
The aim of this phase is to progress sport training and to develop strength and endurance levels to allow return to full sporting activity. This takes time, especially in building up confidence to progress to full contact activities. Return to contact sport is not recommended until strength and functional outcomes are measured at greater than 85% of the normal knee. It should be remembered that the time to regain pre-injury level of skill and performance is very variable but can take 3 – 4 months of training and playing. This confidence can be helped by introducing modified training and specific drills early, often in conjunction with club or team activities. Progress is best achieved in conjunction with a general fitness programme, as this will have reduced over time since the injury and surgery. Full contact sport is, in general, best avoided until able to tolerate a full ­training session with confidence in full fitness and endurance.

The full rehabilitation document outlines the principles of getting back to the same level of sport and draws on the knowledge gained by understanding the possible mechanisms for injuring the ligament in the first place.

Returning to Sport

Introduction

This section describes the techniques to try and optimise return to sport following ACL reconstruction. The first section summarises the overall principles of getting back to sport, and this is then followed by more in-depth concepts for specific sports. Various different rehabilitation experts have contributed to this section.

Getting an individual back to their previous level takes specific rehabilitation tailored to the particular sport. Whilst the goal is clearly to get back to playing the same sport at the same level as before the injury there are various factors that need to be integrated including expectations, confidence, relearning old skills and learning new skills. These need to be identified and discussed.

We outline the main phases of returning to sport, coping with the mind of the athlete and discuss what has been learnt from analysis of why the female is more at risk of rupture of the ACL.

Four key factorsSarah Webb – in the front - winning Olympic Gold Medal after ACL Reconstruction
The factors are as follows and these need to be individualised.

a) Expectations
There may have been a long downtime between injury and finally undergoing surgery such that other events such as age, business or family commitments may alter the ability to get back to sport at the same intensity.

b) Confidence
It can take a long time for an individual to regain the confidence in putting their knee and their body in to such a situation where it may be reinjured again. For the footballer, for example, though they may get back playing at nine months, it may not be until a year after surgery before they have fully forgotten their knee. It seems to be a natural human tendency that after a while injuries are forgotten and the confidence seems to return.

c) Relearning Old Skills
Each sport can be broken down in to the specific drills and processes that are needed to perform well and these need to be identified along with the time intervals and goals before proceeding to the next specific skill. The phases follow a progression through regaining strength and then regaining functional knee control.

d) Learning New Techniques

Sometimes the reason why the ACL ruptured in the first place was because of a poor technique such as poor landing control after jumping, leading to buckling of the knee. This is especially true for the female athletes who have a higher risk of rupturing their ACL as described in the next section. Individuals may need to unlearn some aspects of their sport and relearn new techniques in order to prevent reinjury.

Return to Sport Phases
For every sport the return to activity can be discussed under the following headings:

  • Understanding the specific skill of the sport
  • Ranking the specific skills by difficulty and risk to the knee
  • Drills and techniques to achieve each target
  • Understanding other activities that are safe to perform during rehab

Detail for various sports are given in the full rehabilitation booklet obtainable from Mr Spalding.

This information sheet is intended as a guide to help you before and after your operation. Some of the details may vary according to the particular type of surgery or because of special instructions given to you.

Please select the arrow on the left menu for topics in this section.

Introduction

ARTHROSCOPY of the knee is an operation in which a small camera and surgical instruments are inserted into your knee through two or three small (1cm) puncture wounds. The structures within the knee are assessed including the meniscus (mobile footballer’s cartilage), the synovium (lining of the knee), the articular cartilage (joint surfaces), and the cruciate ligaments (stabilizing structures).

The most common procedures performed include removing a torn portion of a meniscus, removal of a loose fragment within the knee which causes locking or catching of the joint, tidying up of worn areas of the joint articulating surface, and release of fibrous bands which can cause restriction of movement of the joint.

Surgery is performed under a general anesthetic and the procedure takes between 20 – 40 minutes depending on what needs to be done. Surgery is usually performed as a Day Case procedure so that you will usually be able to go home 2 – 4 hours after the operation. Sometimes, for medical reasons, you are required to stay overnight.

Before the Operation

Before the Operation
When you are admitted to the hospital the operating surgeon will re-examine your knee, marking the particular leg and will ask you to sign a consent form. Any last minute questions can be answered. The nursing staff and physiotherapist will also visit you to explain the procedure.

After the Operation

It is important to start exercising your knee as soon as possible because the muscles can become weak quite quickly. After your operation you will have a padded bandage around your knee. You cannot do any harm to your knee by lifting the leg straight, or by bending it, within the confines of the bandage. You can usually take full weight through the knee and you should try and walk as normally as possible. The exercises given to you by the physiotherapist can be started immediately. Start with a few and progress to approximately fifteen of each gradually over the next two weeks.

At Home

The bandage can be removed in the morning following surgery. The puncture wounds will have a stitch or a steristrip tape keeping the wound edges together and will be covered by a small sticky dressing.

Replace the dressing with an Elastoplast dressing if necessary but keep the puncture wounds covered and keep the knee dry for 3 days to allow the puncture wounds to seal.

You can remove the steristrip tapes after 7 days and if you have stitches make an appointment with your practice nurse to have them removed at 7 days after your surgery.

You may be given a Tubigrip support to wear after you have removed the bandage. Wear this during the day, but take it off at night.
You will probably need to take some painkillers such as paracetamol, or ibuprofen for the first few days. This is encouraged to allow you to start exercising the knee in order to avoid developing stiffness of the joint.
Wearing the tubigrip bandage and applying ice packs will help to reduce the swelling. Ice packs (or a bag of frozen peas) can be applied twice a day for ten minutes – remember to protect the skin with a towel.
Your knee may be swollen for a couple of weeks or even longer after your operation. Should this occur you should avoid any strenuous activity until the swelling has nearly gone.

SEVERE PAIN OR MASSIVE SWELLING SHOULD BE REPORTED TO YOUR GENERAL PRACTITIONER OR TO THE HOSPITAL WARD WHERE YOU HAD SURGERY.

 

At Work

Return to work when your knee feels comfortable and when you feel confident that your knee will be able to stand the stresses of your job. If you have an office type job you should be able to return to work after 1 week. If your job is strenuous and involves climbing and squatting then you will probably need two or three weeks off.

Please remember to ask for a certificate if you need one.


Driving

Driving is usually possible after five days when the knee is feeling comfortable. Make sure you can bend and straighten your knee vigorously without pain. Check that you can perform an emergency stop safely.

Sports

Strenuous physical activity and sport can be resumed when the knee is feeling strong and comfortable and is no longer swollen, which is usually after two to three weeks. This may depend on the type of surgery carried out. It is advisable to gradually increase your level of activity. Before returning to competitive sport such as football, squash or rugby, make sure you can hop, squat or sprint with changes of direction, and make sudden stops and starts - all without pain.

Knee Exercises

These exercises should be started as soon as you have regained muscle control of your knee. They will be shown to you by the physiotherapist when you are in hospital.

The exercises are designed to help you regain full range of movement and muscle strength in your leg. It is equally important to be able to bend your leg fully as it is to get it fully straight, and particularly to be able to lock the knee straight. Build up the repetitions of each exercise gradually and aim for two 10 minute sessions per day.

1. Static Quads Exercise: Sit on the bed/floor with your leg straight out in front. Use your thigh muscles to press the back of your knee into the bed/floor as hard as you can. Keep your toes pulled up towards your body. Hold for 5 seconds relax completely and repeat.

2. Quads Exercise over a towel: Place a rolled up towel under your knee to a height of 6 inches. Pull your toes towards your body, tighten the thigh muscles and lift the foot off the floor until the knee locks straight. Do not lift the back of the knee off the roll. Hold for 5 seconds, lower slowly. Relax completely and repeat.

3. Knee Bending on the bed: Practice bending your knee by sliding your heel towards your bottom. Use a slippery plastic bag on the bed or a plastic tray and wear a sock to make it easier. When the knee bends to a right angle then you can progress to the next exercise.

4. Knee bending over the edge of the bed: (This is not suitable if surgery performed to treat problems affecting the knee cap). Sit over the edge of the table with your legs hanging down. Straighten your knee slowly. Hold for 5 seconds and lower gradually. Repeat.

5. Knee bending while standing: Stand with hands on a table to support you. Bend your knee pulling your heel towards your bottom, then lower slowly back to floor. Relax completely and repeat.

Autologous Chondrocyte Implantation (MACI Technique)

Autologous Chondrocyte Implantation Cartilage Repair in the knee

Authors

  • Tim Spalding (Consultant Orthopaedic Surgeon, UHCW NHS Trust)
  • Pete Thompson (Consultant Orthopaedic Surgeon, UHCW NHS Trust)
  • Ivor Hughes (Lead Physiotherapist at Hospital of St Cross, Rugby)
  • Hannah Bakewell (Warwick Medical School)
  • Thomas Hardy (Warwick Medical School)
  • Karen Hambly (Sports Scientist and Physiotherapist, Centre for Sports Studies, University Kent)

Overview and important principles

The MACI procedure (Matrix-induced Autologous Chondrocyte Implantation) is a technique to repair areas of damage to articular cartilage - the normally smooth bearing surface in the knee joint.

Once damaged, articular cartilage normally does not heal itself, and the MACI technique involves repairing the surface with a synthetic membrane seeded with a patient’s own cells. This is fixed in place using fibrin glue and the cells are then able to produce, over time, a new layer of smooth articular cartilage surface.

Two operations are required for this procedure. The first is an arthroscopic day case procedure to take a small area of healthy articular cartilage surface. Articular cartilage cells (chondrocytes) from this sample are cultured in the laboratory and seeded on to a membrane. This is then implanted 6 – 8 weeks later at a second procedure which involves an open operation on the knee joint.

Rather like a new patch of turf this delicate area needs time to fully mature before being subjected to the vigorous impact loads in sport, and therefore the rehabilitation is deliberately slow and restrictive.

The key to success is an understanding of the principles of the way the joint surface heals and matures and this requires knowledge by the treating physiotherapist and rehabilitation expert PLUS buy-in by the patient, who needs to understand what is good and bad for the new joint surface.

Going back to the new turf analogy, it is perfectly possible to immediately walk on a new patch of turf and it may not seem to cause harm, but 6 months later the area that was killed off or dented by the inappropriate weight and shearing force will be painfully clear to see.

Procedure for Articular Cartilage Repair

Articular Cartilage and Damage to the Knee surfaces – the relevance for cartilage repair

Knee Joint

Articular cartilage is the bearing surface on the ends of the bones that allows smooth and easy movement of the knee joint. The joint is enclosed by a capsule rather like a rubber gaiter around an engineering joint and the lubrication is provided by slightly oily fluid called synovial fluid. This makes the surface very slippery but any damage to the surface after injury increases the friction and can lead to catching symptoms and pain in the knee as the joint surfaces move on each other.

The other form of cartilage is the meniscus which is the protective shim between the bones acting as a shock absorber. The MACI procedure for cartilage repair rebuilds the joint surface articular cartilage and not the meniscus (footballer’s cartilage).

The two main moving parts of the knee are between the thigh bone and the shin bone (femur and tibia) and between the kneecap and the front of the thigh bone (patella and trochlea). The first part takes load and forces when walking and landing and the second part takes load on squatting, standing up and activities such as going up and down stairs. Understanding which parts of the joint are loaded in which movements is key to helping the rehabilitation process while the new surface heals.

When damaged articular cartilage does not have the ability to heal itself and untreated defects can cause progressive damage to the joint surface leading to an increased risk of developing osteoarthritis. In addition the symptoms of pain, swelling and limitation of activities can gradually become more intrusive.

Treatment for cartilage damage

Small areas of wear or damage can be helped by reducing activity level and taking occasional painkillers and surgery can often be avoided.

The simplest form of surgery is Arthroscopic debridement which helps by simply tidying up the roughened surfaces to reduce the catching. This is a day case procedure with a short recovery time of a few weeks and may well be enough for mild symptoms.

Small areas of damage can be treated by the Microfracture procedure or insertion of small repair plugs (TruFit plugs). Both these techniques allow the bone marrow cells to grow into the damaged area in order to lay down new repair surface. However these techniques are not suitable for larger areas and this is where the MACI procedure is indicated.

Indications for the MACI procedure

Indications and expectations for the MACI procedure

MACI is indicated for the treatment of areas of damage to the articular surface where more simple treatments such as arthroscopic debridement (smoothing of the worn surface) have not helped and when there are significant symptoms limiting activities of daily living and work. The usual symptoms are pain on activity and mechanical symptoms of crunching, grating, and catching of the roughened damaged surfaces. Technically, the area of damage treated is usually over 3 – 4 cm2 as other procedures can be effective in smaller areas of damage.

The expectation of the procedure is to re-grow a good enough joint surface to last many years to allow good enough function for light sports activities and work. This means that it is not really indicated for patients who just have pain in peak activities such as playing football or other impact sports. It is better in those situations to cut back on activities rather than undergo the procedure of MACI cartilage repair. The results are simply not good enough to predictably enable a return to such sports.

MACI is therefore aimed at younger healthy adults who have suffered damage to the knee joint surfaces and who have significant symptoms. We say ‘young’ because the technology depends on the cells being able to re-grow a new articulating surface, so there is unfortunately a biological age limit on the technique – usually age 50 - 55.

Other factors in deciding indications

Other Factors in Deciding Indications

For the newly repaired area to grow properly and to last it is important to consider treating other problems that may be affecting the knee. If the knee is out of alignment (bowlegs or knock-knees) then this can be corrected with an osteotomy operation cutting through and realigning the bones. If the knee joint is unstable due to a ligament rupture happening at the same time or different time to the original injury then the ligament (e.g. anterior cruciate ligament) can be rebuilt at the same time. Also, it is best if the meniscus cartilage is intact to protect the new surface and if not then it is possible to rebuild this using synthetic scaffold substitutes or a meniscal allograft transplant. Details of these procedures are outside the scope of this booklet.

There are a number of other conditions where the procedure does not help or has limited ability to help, including osteonecrosis, chondrocalcinosis, advanced osteoarthritis, rheumatoid arthritis, and after total meniscectomy where there is no meniscus cartilage to protect the joint surface cartilage. Chronic viral infections such as hepatitis and HIV are also contraindications to this procedure.

Not all people with defects in their cartilage lining are suitable for MACI repair – the recovery period is long and it takes a well-motivated patient to apply themselves to the rehabilitation.

Potential Problems

As with all surgery, there is no guarantee of 100% success and there are problems that can occur. One of the main problems is that the graft may simply not grow well enough to do its job resulting in either persistent symptoms at the same or slightly worse level, or symptoms not allowing the patient to get back to what they would like to do. It is important that the expectations are fully discussed prior to the procedure.

Serious complications such as infection and deep vein thrombosis can occur in any operation and the risk is approximately 1-2%. General medical problems associated with the general anesthetic can also occur and need to be discussed with the surgical team.

The MACI operation

In this procedure a small sample of tissue is taken from a healthy part of the knee articular cartilage, cartilage cells (chondrocytes) are collected from this sample and multiplied in a laboratory over a period of weeks to increase the number of cells. The cells are then seeded on a synthetic membrane made from collagen and the membrane is then implanted into the defect to repair it.

Operation 1:

Fig 1.Arthroscopy – Arthroscopy (keyhole surgery) to take a sample of cartilage (biopsy) from the non-weight bearing part of the joint surfaces.

This biopsy will contain the cartilage producing cells known as the chondrocytes.
This biopsy is sent to a laboratory where the cells are grown over a period of 3-4 weeks generating about 15-20 million cells. These cells are then placed on a membrane ready for implantation.
Operation 2:

Fig 2. a vertical incision 6 – 8 weeks after the initial arthroscopy. This involves an open operation with a vertical incision on the inner or the outer side of the knee to expose the area of damaged cartilage.

Fig 3.cartilage is cut away  The damaged area of cartilage is cut away and prepared for implantation of the new graft.

Fig 4.seeded new chondrocytes  The membrane with seeded new chondrocytes is then cut to size and fibrin glue is placed in the base of the prepared area.

Fig 5. the chondrocytes is glued in place The membrane with the chondrocytes is glued in place over the defective area using fibrin glue, which later incorporates into the membrane and a growing layer of cells without causing damage.
Full details of the procedure are contained in the information booklet produced by GENZYME UK. (www.maci.com)

After Operation – Patients Perspective

Information for the patient: Overview of what happens after your operation

Before being discharged, which usually occurs on the day following surgery or a day later, you will be seen by the ward physiotherapist and the nurses. You will learn how to care for your knee scars, how to get around, what activities you should avoid, and what exercises you should do to aid your recovery. This is an overview. See later for full details.

Follow-up
At a follow-up visit (usually 2 weeks after the operation) your surgeon will inspect your skin incisions, discuss the operative findings and further rehabilitation program.

Home recovery and rehabilitation
The recovery time will depend on the joint problem, extent of surgery, and the rehabilitation goals. Recovery time varies markedly from patient to patient. Elevation and ice can help control swelling and discomfort, and circulation exercises help prevent postoperative complications such as blood clotting in your leg (deep vein thrombosis). Point and flex your foot, and wiggle your toes, every few minutes you are awake for a week or two after arthroscopy.

Crutches
Crutches will be needed to keep weight off your knee as it heals. The amount of weight you are allowed to take will be given to you in detail but usually you will be on crutches for 6 weeks. Your crutches should move with your bandaged leg.

Walking
Helps you regain range of movement in your ankle, knee and hip. Even if you are on crutches and not yet bearing full weight on your leg, you should be able to get up and start walking as soon as possible, to improve circulation and speed the healing process in your leg.

Exercises are very important after knee surgery!
Rebuilding the muscles that support and stabilise your knee (quadriceps, hamstrings and calf muscles) is one of the best ways to help your knee recover fully. However these need to be undertaken according the rehabilitation plan detailed here to avoid overloading the delicate new surface.

Return to impact sport.
This should be avoided for at least 12 months. It takes a long time for the new surface to mature enough to be resilient against the high shearing and compression forces that are associated with impact sports.

Return to work and driving:
Driving is allowed at 6 weeks and return to work usually depends on the individual. Guidelines are as follows:

Sedentary jobs e.g. desk job – from 3 - 6 weeks allowing for the fact the leg should be elevated for periods. Regular exercises should be undertaken throughout the day.

Non-Sedentary jobs – prolonged standing all day: 8 weeks. Jobs involving running and load carrying: up to 6 months. This should be discussed well in advance with your consultant.

Rehabilitation

Rehabilitation of Patients after Cartilage Repair Procedures

A detailed scientific basis for rehabilitation is lacking and this has been criticized in various review papers. In addition to evaluating techniques, compliance with rehabilitation regimes is also difficult to assess. Most surgeons and therapists however realize the importance of rehabilitation in the contribution to the overall outcome.

Another issue is that there remains disagreement over appropriate outcome measures and this has an influence on the scientific drive to improve rehabilitation programs and makes it difficult to undertake evaluation trials.

Overview of Rehabilitation

Articular Cartilage Rehabilitation

Rehabilitation needs to take into account the underlying biological healing process of the new articular cartilage combined with the concept of protecting the repaired tissue while simultaneously trying to first maintain, and then improve general function.

The main phases are as follows:

1. Preoperative phase: Reduction of joint inflammation.

  • Optimizing the knee – re-establishing Joint Homeostasis (no swelling or pain).
  • Prevention of excessive loads on the joint surface

2. 0 – 6 weeks post-surgery: Protection of graft. Reducing post-surgery joint inflammation and promotion of cell proliferation.

  • Range of movement exercises without shear forces on the graft
  • Reduction of swelling. Re-establishment of joint homeostasis

3. 4 – 12 weeks post-surgery: Cell differentiation and the start of the maturation phase.

  • Regain muscle control and normal gait
  • Strength within a safe range, again avoiding shear forces on the graft

4. 10 - 26 weeks post-surgery: Continuing cell differentiation, the formation of tissue, and maturation.

  • Low load activities to promote fitness
  • Rowing and cycling exercises are probably the best

5. 5 – 9 months post-surgery: Tissue formation and maturation.

  • Increase muscle control Isometric control under high load
  • Eccentric exercise, keeping high impact within safe zones

6. 9 – 12 months post-surgery: Tissue formation and maturation.

  • Introduction of sports specific exercises
  • No high impact sports

7. >12 months post-surgery: Maturation.

  • Sport-specific exercises and low impact sports.

General Principles

3.7.1 Nutrition and Joint Circulation Exercises

In order to maintain the nutrition of the articular cartilage, the synovial fluid needs to circulate around the knee, remembering that cells source their nutrition from the joint fluid, not the bone marrow base. This is aided by joint circulation exercises, stimulating synovial fluid production, and nutrition of articular cartilage. Movement exercises need to be undertaken in low load conditions and should be repetitive. The use of the continuous passive motion machine is felt to improve the nourishment of transplanted cells. Exercises for this phase include the use of the CPM (Continuous Passive Motion machine), heel slides, cycling, and rowing activities without resistance.

3.7.2 Protection and Injury Prevention Post-Surgery

Braces are often used to protect the knee joint from overload during the first 6 – 8 weeks after surgery. Types of braces include a post-operative protection brace or a functional unloader brace and the principle is to avoid loading the joint surface in an unsafe position.

The patellofemoral joint is particularly sensitive to shear load over the range of motion and therefore a brace is used to prevent bending of the knee in the first phase. Functional offloader braces may be used for medial or lateral compartment repair in order to reduce load during the maturation phase.

Prevention of re-injury is also important – the injury to the joint surface occurred due to a particular reason and avoiding certain activities may prolong the durability of the repair. This includes analysis of identified risk factors, including poor posture control, overtraining, and muscle control, while remembering that the principle is to avoid excessive shear stress on the new surface.

Individual Rehabilitation Programmes

Rehabilitation can be individualized according to the following factors.

General factors:

  • Age
  • Motivation
  • Social support

Specific local factors:

  • The exact location of the repair
  • Size of repair
  • Condition of the borders of the repair (contained or not contained)
  • Duration of symptoms before surgery (less than twelve months)
  • Pre-injury activity level (professional or nonprofessional, high or low impact activities)
  • Movement dysfunction in lower extremity or core
  • Change in body mass index

Femoral Condyle Repair

Rehabilitation depends on three determining factors: Location of a repaired defect, Size of the lesion, and state of the border (contained or not).

Controlling shear stress and loading in the tibia femoral joint is undertaken by a variety of methods:

  • Understanding of exact location of the repair and how it impinges on the opposing side and at what angles of knee bend.
  • Minimizing weight on the leg in the specific danger zone
  • Controlling training to not overload the repair area, by knowing the geographical location
  • Use of Closed Chain exercises initially, avoiding open-chain exercises
  • Achieve optimal proximal muscle control and avoidance of bad habits.

Patello Femoral Joint

Controlling sheer stress and load is more complex in the patellofemoral joint. The surgeon needs to specify the contact position of the articular cartilage so that exercises can be undertaken outside of this particular movement.

The principle here is that when the area of repair is on the distal part of the patella or proximal trochlea then the point of contact, i.e. loading on the graft with high shear force, is from 0 – 40 degrees of flexion. If the repair is on the proximal part of the patella or distal on the trochlea then the danger flexion zone is 45 degrees onwards.

As shear forces will put a dangerous load on the new tissue then this range needs to be avoided when undertaking strength work. Of course, it has to be remembered that in order to position the knee in a safe range then the knee needs to move through the danger range - hence the need to advise patients on how to get on and off a couch or bed, etc in order to do their exercises.

Over the first 3 to 5 months, therefore, open kinetic chain exercises that are normally aimed at strengthening the quadriceps should be avoided. The excessive stress during open chain exercises will easily damage repair tissue and it is best to stick with closed chain exercise until at least 3 months and they should not be the predominant method until 6 months.

Knowing the particular point of articulation that involves load on the newly grafted area means that open-chain exercises can be introduced earlier, provided the movement is in the arc that does not overload the graft. Fast joint movements under load will result in higher load on the articular surface and these also need to be avoided initially.

Two other factors are vital to reduce shear forces on the graft and to help control the progression of loading the new surface. These are firstly controlling patello-femoral instability with good distal quads control and secondly control of proximal instability with good hip and core stability. Rehabilitation exercises, therefore, need to include activities that maintain hip strength and balance.

The importance of correct Rehabilitation

The Importance of Correct Postoperative Rehabilitation

The main principle in the rehabilitation process is to avoid impact loading and twisting or shearing forces for a minimum of 3 months following surgery as this may damage the repair and prevent growth and maturing of the new healing surface.

To get the maximum benefit from MACI, you should adhere to this detailed and specific rehabilitation programme. This will cover the stages of progressive weight-bearing, range of motion exercises, and muscle strengthening exercises that commence as early as the day after surgery. Rehabilitation is half the battle – allow the newly repaired surface to grow without damaging it!

Using this Rehabilitation Guide

The rehabilitation program here has tried to incorporate a wide range of exercises that can be done to get you back to full fitness as soon as possible after your surgery.

The guide is written for you and for the physiotherapist. The exercises will need clarifying with the physiotherapist to ensure you are doing them correctly. The exercises are a guide and there are often many different techniques to reach the required goals

Consultation with your physiotherapist is essential, as this will ensure you are doing the right exercises, at the right time and the right number of repetitions. Being a hero and beating all targets may not be the best thing for the delicate new healing surface that is not yet man or woman enough for what you want to do to it!

Get into a routine of doing your exercises 3 times a day. The rest of the day is then your own.

Important: Rehab Protocol

Important Information for rehabilitation (to be completed by the surgeon)Location of repair

Rehabilitation: Femoral Condyle MACI repair

Rehabilitation Guide for Femoral Condyle MACI Repair

First 6 weeks: Graft Protection phaseGoals for recovery

First 1 -2 days before going home

  • KNEE EXTENSION SPLINT (BRACE) APPLIED IN THEATRE HOLDING KNEE STRAIGHT until first morning. Then start bending knee on first morning. Leg to stay straight in knee brace when walking and at night for 2 weeks until fully comfortable with mobility.
  • Touch weight bearing as tolerated in knee brace holding knee in extension. CRUTCHES
  • Exercises taught and rehabilitation program explained
  • Discharge plan made including analgesia, physiotherapy and 6 week Outpatient appointment.

Weeks 1-6

Principle: This phase must allow protection of the graft from the shear forces associated with moving the knee under load. Movement without load is vital to aid nutrition of the joint surfaces. Wt bearing is gradually increased to 80% of full wt bearing at 6 weeks, and full wt bearing at 8 weeks.

  • Brace: Locked in extension when walking for first 2 weeks then unlocked. Can be removed between 2 and 4 weeks when comfortable straight leg raise and adequate quads control
  • Weight bearing: Initially touch weight bearing until 2 weeks then progressive increase weekly to 80% of full weight bearing at 6 weeks and full weight bearing at 8 weeks
  • Movement: Passive flexion initially 0-30o, increasing to 90o by 1 – 2 weeks as able. Build to 120 degrees by 6 weeks.

Example Exercises and illustrations
Static quadsstatic quads

  • Tighten the muscle on top of thigh.
  • Push the back of your knee down to bed
  • Hold for 5 seconds. X10 3 times a day.

Straight leg raising with no lag.Straight leg raising with no lag

  • Lie on your back.
  • Keep one knee bent, with foot flat on the floor.
  • Lift operated leg about 30cm while keeping knee straight and toes pointed in the air.
  • Hold for 10 seconds and Repeat 10 times.

Knee flexion/extension - heel on gym ball or sliding on floor or other surface.

Heel slides.heel slides

  • Sit on chair with foot on floor and bend knee. Must be done with minimal friction resistance on the foot - need slippery surface

Static glutei: Tighten buttock muscles and hold for about 5 seconds and then relax. Repeat 10 times

Hamstring and calf stretching when sitting

Control swelling with ice packs (open brace)

Patella mobilisation – to prevent tethering of the patella in scar tissuepatella mobilisation
Sideways: Stand or sit with leg straight, push kneecap outwards, then push towards opposite knee. Repeat 10 times.
Up and down: Push kneecap towards foot, allow to return to position. Repeat 10 times.

Circulation Exercises – Calf PumpingCalf pumping

  • Slowly move your ankles, pulling your toes up towards your head, then point your toes down.
  • Repeat 10 times.

Hip flexion/extension/abduction/adduction with knee in extension.

Exercises Weeks 4-6:

Hamstring stretch in standing.hamstring in standing

  • Stand with leg to be stretched on floor or on stool, pull toes towards you and lean forwards keeping leg straight.
  • Hold for 20 secs. Repeat 3 times each leg.

Calf Stretch in standing (from week 4 only)Calf Stretch

  • Place leg to be stretched behind other leg with feet parallel and back heel flat on floor.
  • Bend front knee until you feel stretch in the back of your calf.
  • Hold for 20 secs. Repeat 3 times.Rowing machine - no hands or lowest load setting.

Exercise bike – build up to 500 revolutions x3 daily (must have 1000 flexion to achieve this).

Hydrotherapy/swimming - no breaststroke until week eight.

Weeks 7-12 Transition and Loading phase

During this phase the aim is to regain full flexion and start strength work without bringing on swelling or putting shear forces on the graft. The swelling determines progress of exercises. Ice after exercise may help.

The brace is removed and normal walking is allowed BUT no excessive load on the patella-femoral surfaces until 3 months

  • Wt bearing: Full weight bearing without crutches
  • Range of movement: Build to full flexion and maintain full extension
  • Strength exercises: closed chain strength work introducing open chain not before 12 week
  • Functional activities: Driving – when safe bend and control at around 8 weeks

Example exercises

  • Functional closed chain activity are allowed including low step ups 0 - 30º of knee bend

Progress proprioception:-

  • Trampette double leg / single leg stand
  • Wobble board
  • Treadmill slow walk
  • ↑ Static Ex Bike / Ordinary Bike
  • Knee Ext 0 - 30º in standing with resistance of T/Band


Month 4 - 6 Maturation phase

4month-review
Increasing strength work and starting functional exercises without bringing on swelling. The graft can begin to tolerate some shear forces from open chain exercises.

During this phase increased load on the articulating surfaces is allowed but the intention remains to keep load off the patella-femoral surfaces for as long as possible.

Therefore the sequence is a gradual increase in functional training with the mainstay being cycling with gradually increasing load.

  • Wall slides are to be avoided
  • Activities that increase swelling are to be avoided
  • Treadmill fast walk – supervised only
  • Stepper / Cross trainer
  • ↑ Walking distance
  • Circuit training
  • No progression to jogging until 6 months
  • Cycling, rowing and cross-trainer but no jumping.
  • Continue strength training as effusion resolves

6 Months Onwards: Return to functional activities
6 month
The graft is now firm – but not fully mature. There may still be some sensation of grating and again swelling is used as the guide to progress. Avoid generating swelling and pain. Gradual progression and aim to begin sports specific training when agreed with consultant/ physiotherapist.

  • Gentle jog, then the gentle change of direction single-leg hurdle/step over-under supervision.
  • Acceleration/Deceleration up to 50% speed.
  • Plyometrics.
  • Skipping and hopping.
  • Star jumps (from 8 months).
  • Acceleration/Deceleration runs ¾ speed (from 8 months).
  • The figure of 8 runs forwards/backwards.
  • Slalom forwards/ backwards.
  • Run–sit–run then gradually introduce cutting/sudden stop.
  • Increasing running distance and progress to sprints 10m-20m-50m.

After 12 months an MRI scan or second look arthroscopy may be performed. If the grafted area is looking good with filling in of the damaged area and good bonding with the surrounding articular cartilage then return to contact sports is allowed.

Exercises are then tailored to the sport and regaining the required skills and endurance. In addition confidence-building and retraining to avoid re-injury is required

Not everyone goes back to their previous level of sport and many choose to conserve the newly repaired knee, knowing that the real goal is a long-lasting knee.

NOTES

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CartiOne Articular Cartilage Repair : POST-OPERATIVE REHABILITATION

cartione logo

Femoral and Tibial Defects

Week 1 Week 2-6 After week 6
Weight bearing Non- weight bearing​ Non- weight bearing Gently commence weight bearing to achieve full weight bearing over 2 weeks
Mobilisation FROM
First 48h 0
After 48h 0-60
FROM
Week 2 0-60
Week 3-4 0-90 Week 5-6 0-120
Free movement
(as pain allows)
Walking, sport Gentle mobilisation Swimming After 8 weeks:static bike without resistance
After 6 months:Light jogging
After 12 months:Skiing
After 12-18 months: contact sports

Patella and trochlear defects

Week 1 Week 2-6 After week 6
Weight bearing Non- weight bearing Non- weight bearing Gently commence weight bearing to achieve full weight bearing over 2 weeks
Mobilisation FROM
First 48h 0
After 48h 0-30
FROM
Week 2 0-30
Week 3-4 0-60
Week 5-6 0-90
Free movement
(as pain allows)

Femoral and Tibial Osteotomy

This information sheet provides information on the nature and purpose of the procedure in addition to an outline of the post-operative rehabilitation

Purpose and description of the procedure

This operation is a correction to the alignment of the leg, e.g. for a bowed leg or knock kneed leg, by cutting through the bone (osteotomy), changing the shape and holding it with a plate and screws. Wear in the medial (inner) compartment of the knee is treated by an opening wedge osteotomy made in the upper inner part of the tibia. This corrects slight bow legged alignment shifting the weight onto the well preserved lateral outer half of the knee. If there is wear or damage in the outer lateral compartment of the knee then an opening wedge osteotomy of the thigh bone is performed from the outer side, again shifting the weight off the damaged side of the knee. A plate and screws hold the position while the gap gradually fills in with bone over 2-3 months.

Indications for the Surgery

The operation is performed when there is early wear in one side of the knee in order to slow down the wear and to ‘buy time’ for the knee. It is also performed in certain ligament injuries where instability of the knee is associated with bowing of the leg.

Pre-operative preparation

Preoperatively in outpatients alignment x-rays of the whole of both legs are taken to help determine the exact amount of correction required. A hinged knee brace is ordered which will support the leg while the bone heals and yet it will allow some early range of movement exercises.

During the Hospital stay

On the day of surgery the leg is marked and final consent obtained. The procedure is usually performed under general anaesthesia and the anaesthetist will discuss post-operative pain relief. This will usually involve nerve blocks, which keep the leg and knee numb for a while, and analgesic tablets.

After the operation the leg is initially held still in a knee brace and depending on progress, gentle bending of the knee and walking with the aid of crutches is started on the first or second day. Most patients are able to go home on day 2 or 3 following surgery, with a date for removal of stitches or skin clips (usually 10 days) and an outpatient appointment (usually 6 weeks) when an x-ray is taken.

Post-operative care: up to 6 weeks

First Phase (up to 6 weeks)
This is directed at regaining range of movement and reducing the swelling combined with patella femoral mobilisation to reduce scar tissue.

Knee Brace: The knee brace should be used at all times when moving around for the first 6 weeks to protect the osteotomy site. For the first 3 weeks it is best for comfort reasons to lock the hinges when moving around but after 3 weeks it is safe to leave the hinges unlocked to help regain free bending of the knee. The brace may be removed at night as comfort and confidence allows.

Weight bearing: Weight bearing as tolerated is allowed in the brace with the aid of crutches and it is usual to use the crutches for the first 6 WEEKS.

Exercises: Early physiotherapy is directed at static quadriceps and hamstring work maintaining muscle bulk. Range of movement exercises aim to achieve a comfortable 90 degrees bend and full straightening (extension) of the knee by 3 weeks and nearly full flexion by 6 weeks.

Exercises allowed up to six weeks include supine knee flexion exercises sliding heel on a bed or board (closed chain exercises only), spinning on a bike without load, patella mobilisation (superior, inferior and medial/lateral), straight leg raising and static quadriceps/hamstring exercises. 90º flexion is expected by three weeks and 110º by six weeks. Further flexion can be pushed after six weeks assuming the bone has healed.

Exercises that are not advised before six weeks include bridging, prone lying with forced knee flexion, open chain extension exercises over a towel and anything putting excessive load across the osteotomy. In the position of prone lying the weight of the tibia is too excessive for the torsional loads on the plate and this position must be avoided.

Post-operative care: 6 weeks upwards

The second phase of rehabilitation from six weeks onwards is directed at building up strength in the leg while the area of bone regrowth becomes stronger. After three months functional activities can be introduced.

At the 6-week follow-up appointment X-rays are taken and, if satisfactory, the brace is removed. Free full weight bearing is allowed.

At 6 weeks when full weight bearing is allowed then proprioception and strength work using bicycle and rowing machines can commence. Exercises would now include strength work building up load on the bicycle progressively taking full weight on the leg and starting low load open chain exercises.

Function gradually increases, tailored to each patient, with the expectation of fast walking by 3 months building up to running and sporting activities at five to six months post surgery.

Post-operative care for osteotomy combined with cartilage repair surgery

The management plan is altered if there is arthroscopic surgery performed at the time of osteotomy to repair the joint surface and this will need to be discussed with the surgeon.

• Weight bearing is restricted to touch wt bearing only for the first 6 weeks.
• Range of movement exercises are encouraged to mould the new surface.
• The overall timetable is much slower, expecting a build up to sport after 6 months rather than 4 months.

Fulkerson Osteotomy (Patella Stabilisation)

This information sheet provides information on the nature and purpose of the procedure in addition to an outline of the post-operative rehabilitation.

The procedure

This operation is performed to improve stability of the knee cap (patella) reducing the sensation of dislocation or giving way of the knee. It is also sometimes used for treating various forms of anterior knee pain (patello-femoral pain) syndrome. It involves releasing the tight tissue on the outer side of the patella (lateral release) and moving the bony attachment point of the tendon controlling the knee cap (patella tendon) into a better position.

The effect of this is to hold the patella within its normal grove or track on the thigh bone, reducing the tendency for it to slide out of position to the outer side (lateral side). The tendon attaches to the tibial tubercle, which is the bony prominence below the patella, and the operation moves this forwards (anteriorly) and to the inner side (medially). It is then held in place with two screws, which usually do not have to be removed.

Pre-operative preparation

Preoperatively in outpatients x-rays of the knee are taken to help determine the amount of correction required. A hinged knee brace is ordered which will hold the leg enough for the osteotomy (bone cuts) to heal, yet will allow early range of movement exercises.

During the Hospital stay

On the day of surgery the leg is marked and final consent obtained. The procedure is usually performed under general anaesthesia and the anaesthetist will discuss post- operative pain relief. This will usually involve nerve blocks, which keep the leg and knee numb for a while, and analgesic tablets.

After the operation the leg is initially held still in a knee brace and depending on progress, gentle bending of the knee and walking with the aid of crutches is started on the first or second day. On the first postoperative day the drainage tube is removed and postoperative x-rays may be taken.

Most patients are able to go home on day 2 or 3 following surgery, with a date for removal of stitches or skin clips (usually 10 days) and an outpatient appointment (usually 4 weeks).

Post-operative care

Knee Brace: The knee brace should be used at all times when moving around for the first 4 weeks to protect the osteotomy site. The hinges on the brace should be locked with the leg out straight when walking as the bone has been weakened by the procedure. The hinges may be unlocked when sitting and free flexion is allowed out of the splint when resting or in bed. The brace may be removed at night as comfort and confidence allows.

Weight bearing: Partial weight bearing as tolerated is allowed in the brace with the aid of crutches for the first 4 WEEKS.

At the 4-week follow-up appointment: If X-rays are satisfactory, the brace is removed and full weight bearing is allowed.

Exercises

Early physiotherapy is directed at patella mobility in addition to static quadriceps and hamstring work maintaining muscle bulk. The most important part of the initial rehabilitation is to maintain patella mobility in the medial/lateral plane as well as the superior/inferior plane. Once the wound has settled then mobilisation of the patella tendon should also start in order to avoid any tethering and over scarring.

Range of movement exercises aim to achieve a comfortable 90 degrees bend and full straightening (extension) of the knee by 2 weeks and nearly full flexion by 6 weeks.

At 4 weeks when full weight bearing is allowed then proprioception and strength work using bicycle and rowing machines can commence.

Further rehabilitation: Initially closed chain exercises are used, protecting the patello-femoral joint. Function gradually increases, tailored to each patient, with the expectation of fast walking by 2 months building up to running and sporting activities at 4 - 6 months post surgery.

Meniscal Reconstruction using Actifit Implant

Meniscal Scaffolds Regenerating the shock absorbers in the knee

The Meniscal Scaffold implant is a new device designed to rebuild the meniscus or ‘footballer’s cartilage’ after part of it has been removed following injury. This procedure of partial meniscectomy is very common and is usually successful in relieving pain. However a small proportion of patients will develop persistent pain felt in the side of the knee due to the lack of the normal thickness of the meniscus.

Actifit Meniscus reconstruction and NICE

NICE has recently provided guidance on approval for Actifit meniscal reconstruction as given below. 
Mr Spalding published  A research paper on Actifit in 2011 which formed part of the basis of the NICE review.

All patients undergoing Actifit implantation are prospectively evaluated, by invitation to complete outcome evaluation scores, Pre-op and at 1,2 and 5 years.   Patients are recommended to undergo MRI evaluation at 12 months.
National Institute for Health and Care Excellence
Mr Spalding is therefore fully compliant with the NICE guidelines. 

Excerpt from NICE guidelines July 2012

1.1 Current evidence on partial replacement of the meniscus of the knee using a biodegradable scaffold raises no major safety concerns. Evidence for any advantage of the procedure over standard surgery, for symptom relief in the short term, or for any reduction in further operations in the long term, is limited in quantity. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research.
1.2 Clinicians wishing to undertake partial replacement of the meniscus of the knee using a biodegradable scaffold should take the following actions.

•    Inform the clinical governance leads in their Trusts.
•    Ensure that patients understand that there are uncertainties about any possible long-term advantage over other surgical options and that considerable rehabilitation is required after this procedure. Clinicians should provide patients with clear written information. In addition, the use of NICE's information for patients ('Understanding NICE guidance') is recommended.
•    Audit and review clinical outcomes of all patients having partial replacement of the meniscus of the knee using a biodegradable scaffold.

1.3 The procedure should only be carried out by surgeons who are highly experienced in arthroscopic meniscal surgery.
1.4 NICE encourages further research and data collection on partial replacement of the meniscus of the knee using a biodegradable scaffold. This should include clear descriptions of patient selection and adjunctive treatments. Outcome measures should include symptom relief and functional ability in the short term and the need for further treatment in the longer term.

Meniscal Scaffolds

The menisci of the knee make the sockets for the thigh bone to rotate in and they provide the shock absorber for impact loads. If a substantial amount is removed after injury then this can result in early wearing of the joint surfaces. Complete loss of the meniscus usually results in early arthritis developing within 10 – 15 years

Meniscal Implants

There are now two types of implants designed to regenerate the meniscus when part of it has been removed: The Menaflex supplied by Hospital Innovations and the Actifit supplied by Orteq. Both act as scaffolds for new tissue to grow into and regenerate the healthy cushion. They are made of slightly different materials and both procedures have been reported to be successful in relieving pain after meniscectomy. However the long term benefit of reducing the severity of later arthritis in the knee is not yet fully clear as the technology has not been around long enough.

If the whole meniscus has been removed then the scaffold synthetic substitute will not suffice and a meniscal transplantation using a donor graft is indicated.
The first of the new synthetic implants was the Collagen Meniscal Implant which is now called the MENAFLEX. It was developed in the USA by several surgeons including Dr Richard Steadman, from Vail. It is made from highly purified collagen and gets absorbed by the body by 12 – 18 months after implantation, after the bodies own cells have taken over and formed new strong tissue. This became available in UK in early 2008. Information from the manufacturer details that more than 2000 Menaflex implants have been surgically implanted worldwide. Studies show that patients regain over 70% of their original meniscus tissue volume.
Actifit was developed in Belgium and is made from a polyurethane polymer and has a very similar appearance to the Menaflex. Laboratory studies indicate the scaffold may still be present 5 years after implantation giving the body longer time to form a new natural regenerated meniscus. Early clinical studies have shown good short time results for improved function and reduction in pain.
There has been no direct comparison between the two implants to know which is better and both are probably equally effective.

Operation and Rehabilitation

The implants are inserted at key-hole arthroscopic surgery which is usually a day case procedure. The incision to get the implant into the joint is about 2 – 3 cm long.
Rehabilitation after surgery naturally has to be slow as the body has to grow tissue into the scaffold and this is a slow process. Full weight on the leg is allowed at 8 – 10 weeks and the specific rehabilitation program is tailored to each patient depending on the state of the knee surfaces and the amount of new meniscus inserted.
Biopsy studies looking at the new tissue under the microscope have shown that the new tissue is fairly strong by 12 months. Impact sport is therefore not allowed for the first 12 months.
For more detailed information see www.menaflex.co.uk and www.orteq.co.uk

Meniscal Repair

This information sheet provides information on the nature and purpose of the procedure in addition to an outline of the post-operative rehabilitation.

Purpose and description of the procedure

This operation involves repair of the meniscus or footballer’s cartilage in the knee. The cartilage acts as a protective weight bearing “shim” helping to transmit weight between the thighbone (femur) and shin bone (tibia). It also acts to protect the articulating surface (articular cartilage) from wear. The meniscus is usually torn in a twisting injury and most tears are treated by removal of the small torn portion. A small number of tears however are much bigger and involve nearly the whole of the meniscus. The meniscus does not have a good blood supply to make it heal well and it is only the larger and more peripheral type of tears that are suitable for repair.

Meniscus repair surgery involves passing sutures or special fixation devices into the knee under arthroscopic control and there are various techniques possible. It may be necessary to make a small incision on the side of the knee in order to tie the sutures.

Protection of the knee in the postoperative phase from re-injury is very important. Because of the difficult healing, the success rate for repair is only approximately 85% and therefore the meniscus must be protected for the time periods below to avoid re-tearing. Remember that the aim of repairing the meniscus is to try and prevent later wear and tear arthritis.

During the Hospital stay
Pre-operatively (or immediately post operatively) a hinged knee brace is ordered which holds the leg in full extension (hinges locked at 0º). This or a temporary cricket splint is applied while in the operating theatre. It is possible to go home on the same day of surgery.

Post-operative care
Following meniscal repair recovery is based on the knowledge that the meniscus is slow to heal and that injury is caused by twisting on the bent knee. This bent knee position needs to be avoided while awaiting full strength of the healing repair.

Weight Bearing:Full weight bearing is allowed with the leg held in extension in the splint.
Knee brace: When sitting the hinges on the brace can be unlocked (or the brace may be removed) to allow flexion up to 90º. Once the leg is comfortable the brace does not need to be worn at night while in bed.
At 4 weeks the splint is removed and full weight bearing is allowed without the splint. Squatting beyond 90 degrees, pivoting, twisting and cutting like manoeuvres must be avoided for 3 months because the repair area may not be strong enough.

Further Rehabilitation:
At 3 months progression to full-unrestricted activity is allowed. At this stage gradual rehabilitation back to sporting activity is commenced. Physiotherapy supervision or trainer advice is recommended. Rehabilitation progresses over the subsequent 3 months while returning to full sporting activities at 4 – 6 months. The exact time for return to contact sport must be discussed with the surgeon and is dependant on the type of tear and the sport.

Meniscal Transplantation

The meniscus is a ‘C’ shaped structure that acts as a cushion to protect the smooth joint surfaces of the knee joint. There are two – one on each side of the knee joint - and if removed at an operation following injury then there is less protection of the bearing surfaces such that the joint will wear out sooner. The symptoms will include pain and swelling of the knee after activity and limitation in tolerance of impact type sports. Symptoms may gradually get worse over the years as the joint slowly wears.
Summary

Overall meniscal transplant is an exciting option for the damaged knee allowing for substantial improvement in the quality of life.

Though a challenging procedure with a long rehabilitation program, the technique alone or when combined with other surgery, provides a realistic biological option for knees, hopefully avoiding, or at least delaying, the need for metal and plastic knee replacement operation
For More information please visit: meniscaltransplant.com

For the latest Rehab information please go to: meniscaltransplant.com/patient/rehabilitation

Attachments:

View the Menical Pathwaydownload

Meniscal Allograft Transplantation Consent Form Information Sheetdownload

Meniscal transplant overview informationdownload

What can be expected after surgery

The quality of the result of the operation is a key factor in deciding the indications as the replacement tissue is, after all, a donor graft that may not be as strong as the original and it takes time for it to fully integrate into the knee. Having invested a year of time in getting it right after surgery the thought of going back to full contact sports such as football and rugby could be considered ill-advised!

Recent research looking at the outcome by the leading surgeons in the US and in Europe would indicate that at 10 – 13 years approximately 70% of patients still have good function and have not had further surgery. Most have been able to do light sports. The occasional professional athlete may report being able to get back to high level but it should be remembered that professional athletes may have different goals.

Following surgery the rehabilitation process involves using a knee brace for the first 6 weeks while the new meniscus heals in place. The rehabilitation regime is given below.

Evaluation Program

Evaluating the benefit of the surgery is important benefitting patients now and in the future. All patients undergoing the operation are asked to be part of an ongoing outcome assessment project, completing short questionnaires assessing symptom and activity levels before and after the surgery.

Only by knowing results in detail can the service be improved – for the benefit of more patients 

At Coventry only 1 patient so far has refused to cooperate in this important process.

Results and Frequently Asked Questions

Meniscal Allograft Transplant

Over 140 procedures have now been undertaken and University Hospital Coventry and Warwickshire NHS Trust remains the leading referral centre for the UK. Mr Spalding and Mr Thompson now have over 10 years’ experience of the technique and through continued analysis and lecturing internationally the team is one of the leading centres in the world.

9 out of 10 procedures have been successful with patients experiencing less pain feeling more active. Only 1.5% have failed when the joint is not significantly worn but some patients have had minor problems of swelling or pain from the stitches holding the meniscus in place resulting in the need for further minor surgery

When Meniscal Transplantation is performed as part of a biological treatment program for patients with advanced wear in the knee then the risk of re-tearing the graft is higher. Each patient is carefully considered and a treatment program is individualised in this situation.

Frequently Asked Questions

How long will I have to wait for a donor meniscus to be found?
Waiting time depends on the availability of a graft. This time can be between six to twelve months.  Once a graft has been identified then we tend to plan two - three months ahead giving you as much notice as possible.  The graft is frozen in a tissue bank and there is then no urgency to use it. It lasts for a few years.

How will you know the result of the operation?
We are very keen to know exactly how you get on. We ask all our patients to complete a short series of questions before the operation and then at set times after. We contact you by email and so far we have only lost contact with two patients out of over 150 - we hope you agree to be part of this evaluation as its the only way to better inform other patients 

What are your results?
We have now undertaken over 160 meniscal transplants, the most in UK, and the results really depend on how worn the knee is to start with. Broadly speaking 8 out of 10 are very happy with the result. When the knee surfaces are still good then currently the failure rate by the graft re tearing is only 3%, but it is higher if the surfaces are worn down to bare bone.  This risk clearly needs to be discussed before surgery.

Do you do any other surgery at the same time?
Yes - it is very important to correct any problem with the knees not being straight (bow legged or knock kneed) if this is putting more load on the damaged side. The leg needs to be straightened by carefully reshaping the bone around the knee.
If the knee is unstable do to damage to the anterior cruciate ligament (ACL) then this can be rebuilt at the same operation.

How long will I be off work after surgery?
This clearly depends on your work and whether you have a sedentary of an active job. Following surgery you are on crutches taking no weight on the operated leg for six weeks then building up to full weight bearing by about 8 weeks.  You could return to desk based work from two to three weeks, prolonged standing work by 3 months, manual work with load carrying or ladder work by 4-6 months but for more active work such as police, security or military type work, we recommend nine months rehabilitation prior to a return to full duties.

How long will I be in hospital for?
You are usually in hospital one to two nights after surgery.  Post op rehabilitation will be back in your home area following our detailed plan given to you. 

What contact is required with you and your team after the operation?
We see you back in clinic at six weeks, three months, six months and a year. One of the research team will also follow up with you at regular intervals to ascertain your progress and collect information on your current activity levels.

What is microfracture? [NOT ROUTINE IN MENISCAL TRANSPLANT SURGERY ALTHOUGH OFTEN COMBINED WHEN AN AREA OF SURFACE DAMAGE IS PRESENT]
We sometimes treat the joint surface damage using the technique of microfracture to try and stimulate new growth.  This makes small holes in the surface of the bone allowing bone marrow stem cells to repair the surface. This is one way to try and encourage repair of the bare bone area. 

You say I have a badly damaged knee with worn surfaces. Will this surgery fail?
Anything we are doing is an attempt to try and salvage the situation with your knee, by putting in a new cushion and resurfacing the knee with a microfracture procedure.  Hopefully this will give you a good functional result but you will still obviously need to look after the knee as it is not ‘normal’.  If we can get 10–15 good years out of the knee after surgery then that would be excellent.  There is always the chance that you will not get a good functional result.  As I am sure you are aware the end result of a worn knee is a metal and plastic new surface but hopefully with our biological techniques we can postpone the need for that.

Can I return to sport after my surgery?
The main goal of meniscal transplantation surgery is to preserve the joint surfaces. Returning to high sporting activity is not the ideal end stage outcome. Non-impact sports such as swimming and cycling are preferable, although you may feel that higher activity levels are possible. At this stage you must consider the higher risks of re-injury to the transplanted meniscus and joint surfaces upon return to sport. Its a bit like trying to conserve your tyres by not driving fast corners all the time.

Meniscal Transplant Rehabilitation

MENISCAL TRANSPLANT POST OPERATIVE REHABILITATION

Knee Surgeon Leads: Mr Tim Spalding and Mr Pete Thompson

Overview:                                      Phase 1 Recovery from surgery

Phase 2 Strength and Neuromuscular control

Phase 3 Rehabilitation

A Note to your Physiotherapist

Overview of the procedure

Meniscal Transplantation involves insertion of a donor Meniscus into the knee in order to treat symptoms of pain in the affected compartment of the knee related to activity. The graft has been stored frozen and is matched by exact dimensions to the patients knee. Sometimes this can take a long time to find a suitable graft but once inserted and healed it can function as a new shock absorber protecting the joint surfaces from wearing.

A key part of the operation is the postoperative care and there are many factors to be considered during rehabilitation after meniscal transplant.  Movement and function have to be balanced against allowing the meniscus to heal in place.

This document aims to guide you through a goal orientated programme to restore good knee function. Loading of the meniscus, through weight bearing and full bending of the knee, must be controlled in the early phases of rehabilitation due to the increased force that is placed on the fixation of the new meniscus.

The meniscus is an important cushion in the knee protecting the joint surfaces and it must heal in the right position before being loaded in activities of sport, running or squatting. Progression through the phases of rehabilitation is based on achievement of criteria and the state of the knee rather than a specific week by week basis. Approximate time points are given as a guide.

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PHASE 1: RECOVERY FROM SURGERY

The initial post-operative phase usually lasts the first 6 weeks. The main priorities during this period are to control inflammation and swelling.

WEIGHT BEARING

You will be taught how to use elbow crutches before you leave hospital. You should use these to help you to be non-weight bearing for the first 4 weeks after surgery. You must not put any weight through you operated leg until after 4 weeks from your operation as guided by your consultant.

When you are standing at rest e.g. cleaning your teeth, making food/drink you may rest your foot on the floor – however you must still not take any weight through your operated leg.

KNEE BENDING

For the first 6 weeks bending is limited to 90 degrees. Beyond that will compromise healing of the graft.

BRACING

After meniscal transplant surgery you will be fitted with a brace to help limit your range of movement and also provide you with some support. The brace should be worn day and night for the first two weeks after surgery (it can be removed for washing and dressing). After this two week period the brace can be removed at night to sleep.

A functional brace will be issued at 4 weeks post-operatively which has offloading feature to help protect the new meniscus. Once fitted with this DJO OA Nano brace it is acceptable to begin partial weight bearing through the operated leg (50% of your weight). , The aim is to progress to full weight bearing by 6 weeks after your surgery.

ICE TREATMENT

Ice treatment after your surgery is very important, aiming to keep the swelling of your knee under control. You should use an ice pack or Cryocuff on your knee for 15-20mins every two hours during the day for the first 7-10 days after your operation.

It is expected that your knee will continue to swell for up to 3 months after your surgery, and icing helps reduce that swelling.

ELEVATION

During the first phase of your rehabilitation you should aim to be resting your operated leg for most of the time. Your knee should be elevated with leg straight and your ankle raised above your hip. This helps to keep the swelling under control in your knee.

NUMBNESS

Patients often describe an area of numbness around the operation site. This is not unusual as the small skin nerves are cut in the operation. Moderate symptoms of numbness and tingling around the knee are common. However if you are concerned or these symptoms worsen please advise your physiotherapist.

EXERCISES

The success of your surgery will be in a large part due to the amount of effort you are willing to invest into your own rehabilitation. Although you are likely to be in some discomfort after your surgery it is vital you start to complete the exercises below to regain movement and activate muscles after your operation. A physiotherapist will teach you these exercises prior to your discharge home.

  1. Range of Movement

 

Knee flexion

Sitting on a firm surface, gently bend your knee. Slide your heel towards your buttocks. You may find it easier to do this with a plastic bag under your heel. Do this 10 times. Repeat up to 5 times daily.

Remember not to push flexion beyond 90 degrees for the first 6 weeks.

Knee extension

Sit with a rolled towel under your ankle without anything underneath your knee. Allow gravity to help to passively stretch your knee. Start this for 2 mins and gradually build up as your pain allows. Repeat 5 times daily.

It is very important to regain full straightening of your knee in the first 6 weeks.

  1. Strengthening

Static Quadriceps

 Sit or lie with leg out straight, tighten your thigh muscles and push knee down firmly against the bed. Hold and for 5 secs. Repeat 10 times.

Don’t be tempted to do exercises that bend the knee while not supported on the bed, otherwise this puts high load on the graft.

Static Hamstrings

Sit on bed or floor, bend your knee slightly, then push your heel into the bed keeping knee slightly bent. Hold for 5 secs. Repeat 10 times.

  1. Stretching

Calf stretches

Standing with support facing a wall. Keeping one leg forward, foot flat on the floor, extend your opposite leg straight backwards placing your heel flat on the floor. Try to keep your back knee straight and gently bend the front knee. Lean in towards the wall until you feel a stretch in your back calf. Hold for 30 seconds, repeat 3 times on each leg.

Hamstring stretches

Sitting on a firm surface, with both legs out straight in front of you. Try to ensure both legs are as straight as possible. Lean forwards trying to reach your toes. Hold for 30 seconds. Repeat 3 times.

MUSCLE STIMULATION

After surgery some patients initially struggle to regain good quadriceps control and activation. You may be issued with a muscle stimulation device to help with this. It is advisable to use this as per your physiotherapists’ guidance. It is at your consultant and physiotherapists discretion if you will require this device as part of the rehabilitation program.

CRITERIA FOR PROGRESSION TO PHASE 2:

  • Full extension to 0 degrees
  • 90 degrees flexion
  • Minimal swelling
  • Minimal pain
  • Straight Leg Raise without lag

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PHASE 2: STRENGTH & NEUROMUSCULAR CONTROL (6 weeks onward)

 
  

Regaining muscle strength, balance and core strength are the goals of phase 2. In order to progress through this stage the knee must be ‘quiet’, increases in pain and/or swelling indicate that the knee is not yet able to tolerate an increase in load of exercise.

  1. Lower Limb Strengthening

Quadriceps

Bed, static, IRQ. Low load. Patient must feel the load in their quadriceps thigh muscles. 

Calf Raises

Stand on the edge of a safe step. Engage your core. Make sure the balls of your feet are solidly planted on the edge of the step with your heels over the edge. For safety, begin this exercise with a wall or railing nearby to hold on to for support. Keeping your legs straight lift your heels up, hold for three seconds and gently lower heels until they are below the step level. Complete 12 times. 

Hip Abduction

Lying supine, with a plastic sheet/bag under the operated leg. Tighten your abdominals and glute muscles. Slowly slide the leg out to the side, ensure not to lift the leg as this will activate a different muscle group. Complete 12 reps, repeat 3 times.

Hip Adduction

Lying with your knees bent, place a pillow between your knees and gently squeeze. Hold the squeeze for 5 seconds. Repeat 10 times. Gently increase repetitions as your pain allows.

Hip Extension

Standing supported by a chair or work surface, tighten your abdominal muscles. Raise one leg backwards, keeping your knee straight until your foot is approximately 3 inches off the floor. Hold for 3 seconds, then slowly lower. Ensure you do not lean forward, remain standing tall. Complete 12 reps, repeat 3 times. 

  1. Core Strengthening

Pelvic tilts

Lying on your back with your knees bent. Flatten your back against the floor by tightening your abdominal muscles and tilting your pelvis upwards slightly. Hold for 10 seconds, repeat 6 times. 

Clam

Lying on your side, arm outstretched in line with your trunk. Allow your head to rest on your arm. Hips bent up to approximately 45 degrees and knees bent up to approximately 90 degrees. Raise the top knee upwards keeping the feet together. Then continue to lower the top leg onto the lower limb.

Plank

In the push up position on the floor, bend your arms to 90 degrees and rest your weight on your forearms. Your elbows should be directly beneath your shoulders and your body should form a straight line from your head to your feet. Aim to hold for 30 seconds with 15 seconds rest, repeat 3 times.

You may also wish to add ‘side plank’ into this exercise for increased core strength. 

Supermans

Start on all fours, place a pillow under the knees if required. Ensure your core is engaged and your back is straight. While keeping one arm and knee on the floor extend the opposite leg and arm to fully straighten them. Slowly return to the starting position and repeat the action 5 times on each side. 

  1. Proprioception

Single leg stance

Remove shoes and socks. Stand still on one leg for 20 seconds without allowing you elevated foot to touch the ground – vary this exercise with eyes open and closed and arms at your sides or raised. You may need to hold on to the wall or a chair to start with. Repeat 3 x 20 secs daily.

Double leg mini-squats on an unstable surface

Standing on a BOSU or a balance board with both feet, gain your balance. Try to spread your weight evenly between the balls of your feet and your heels. Maintaining your balance and trying to keep the surface of the BOSU/board level. Gently lower yourself into a mini-squat (approx. 30-40 degrees knee flexion).

  1. Stretching

Calf : As per phase 1 above.

Hamstrings: As per phase 1 above.

Hip Flexors

Get down on one knee, with the back leg being the one you are about to stretch. Keeping the hips pointing forward and back straight lean forward to feel a stretch around your groin. Hold for 30 seconds and return to starting position. Repeat 3 times on both legs.

  1. Cardio-Vascular

Cycling on a static exercise bike is the most favourable exercise to do at this stage. Given the nature of the surgery you have had, cycling provides the least impact whilst still working the musculature around your knee appropriately. We advise to start on the bike positioned with the seat as high as is comfortable and with no resistance applied. Once you are able to complete 20 minutes of cycling at this level then slowly increase the resistance with each subsequent session.

Walking is also a recommended exercise, on land or in a swimming pool.  Monitor the response of your knee regarding swelling and pain in order to gauge the appropriate time and distance to walk. If your knee does not swell or become painful then you are able to gently increase the time and distance. We do not recommend breaststroke at this stage.

We strictly advise no running or other high impact activities at this stage of rehabilitation.

CRITERIA FOR PROGRESSION TO PHASE 3:

  • At least 120 degrees flexion
  • No pain
  • Minimal swelling
  • 80% quadriceps strength of contralateral side
  • Y-balance test

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PHASE 3: END STAGE REHABILITATION AND RETURN TO APPROPRIATE ACTIVITY (starting approximately 4 -6 months following surgery)

 
  
  1. Continued Strengthening

 

All major muscle groups of the core and lower limb will need to be strengthened further. Large deficits in individual muscle groups can have a significant effect on functional ability and your eventual return to function. Effectively you are only as good as the weakest link in the chain. Our aim is that each patient should be assessed individually to identify the specific areas of weakness needing to be addressed.

There also needs to be a balance of the types of exercises undertaken. Exercises such as squats and lunges work the muscles hard, but they also put a high degree of force through the joint and meniscus, which is not advisable e.g. deep squatting >90degrees, high weight leg press. There needs to be a balance of continued endurance and strength training.

  1. Functional Movement Retraining

 Good movement patterns will need to be retrained and practiced to help maximise the life of the new meniscus as well as ability to return to functional goals. This is all about trying to make the muscles work well together as a team. Muscles are your shock absorbers.

Poorly controlled and co‐ordinated movements when stood still, and then when moving will potentially put excessive load through the knee and meniscus. Return to sport and function will then have a higher risk of failure, e.g. when bending on one leg your knee should stay in line with your second toe, and your pelvis level and straight. This pattern will be perpetuated through functional return unless trained otherwise. This is similar to the skills training done in all sports to maximise ability. This stage takes time and practice: it is about quality of movement, not number of repetitions. Some movement patterns may have been present for a long time and will feel automatic and normal, although they are not ideal, and should be trained out with focussed work.

  1. Low load safe guarded return to sport

 

Aim for progression through increasing level of skills and drills as strength and movement patterns progress. It is imperative this is patient specific and depends on goals for return to activity. This is the vital last piece of the jigsaw. If muscles of the lower limb are not used in a safe co-ordinated way then the hard work of rehabilitation to this point will not be best put in to practice.

The table below illustrates the characteristics of sports we feel should be avoided following meniscal transplant. Discussions should be had at twelve months following transplant surgery to finalise end stage goals. These goals will be dependent on a number of factors including state of the meniscus and joint surfaces of the knee at this stage.

High Risk Sports

and factors

 

Lower Risk Sports

 

Repetitive impact with cutting and pivoting

Aerobic low impact sports

Contact sport

Moderate sports participation

Competitive situation

Non-contact sports

Playing position on field

Cycling

A NOTE FROM YOUR CONSULTANT**

Meniscal Transplant surgery has been performed for over 20 years worldwide and in Coventry for 15 years.

It is an exciting option to improve symptoms in the knee due to lack of the cushioning effect of the Meniscus. As a donor graft tissue from someone else it cannot be considered normal and we remind you that the aim is to buy time for the knee – improving your function and enjoyable activity level, and maybe preserving the joint.

You are clearly part of the process. As surgeons we have half the job and the other half is down to you and the physio, hence the detail in this rehab guide.

It takes a year or so for the knee to fully mature after this surgery and your help is needed in buying into this concept of preserving your knee. We have had many successes and a few less successful results. We wish you all the best in your recovery

Lastly we ask that you will be part of our Surgery Outcome Program, responding to our questionnaires documenting your progress. This helps us optimise treatment for you and others.

 Tim Spalding

Pete Thompson

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A Note to your Physiotherapist please**

 Thank you for taking on the care of our meniscal transplant patient. Due to the relative pioneering nature of this surgery we have provided this document to help guide your rehabilitation strategy. Meniscal transplant surgery is the implantation of a donor meniscus to the patient via arthroscopic surgery. The meniscus is held with fixation sutures through bone tunnels, hence very different surgery to a meniscus repair, where early weight bearing is allowed.

 As per the guidelines above the protection of the new meniscus is paramount in the post-operative rehabilitation. Biomechanical research shows how forces on the meniscus change through ranges of flexion. As the knee flexes beyond 30 degrees, increased force is placed on the posterior horn of the meniscus.  At 90 degrees flexion, the stress on the peripheral meniscal repair site is 4 times higher than in full extension.  Further deep flexion of the knee to a full squat position, causes large translations of the femoral condyles and increased compressive stress on the meniscus and the joint surfaces is designed to protect. Most patients already have some damage on the important joint surfaces.

Due to these findings we strictly advise no squatting/ lunge/ split lunge activities in order to limit the compressive stresses to the new allograft for at least 6 months post operatively.

Open kinetic chain exercises, even without additional resistance has been shown to produce tibio-femoral shear forces in the range of 500N which exceeds the strength of the initial meniscal fixation.

 Cycling and walking put the lowest shear force and compression on the meniscus and joint surfaces. These are the main basis of the protocol for the first 6 months after surgery. The meniscus has to bed into the correct position in order to support the joint hence no impact exercise is advisable until after 6 months.

If you have any questions regarding the rehabilitation of your meniscal transplant patient please do not hesitate to contact our team at University Hospital Coventry & Warwickshire on 02476 965098. 

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Medial Patello-Femoral Ligament (MPFL) Reconstruction

This page is intended to help you understand the operation and the recovery following the surgical procedure to stabilise your kneecap (patella)

It is not intended to be a comprehensive guide, and you should discuss any further queries that you may have with your consultant surgeon.   

What is the medial patellofemoral ligament?
The knee cap (patella) is designed to help the muscles on the front of your thigh to straighten your leg.  As you bend and straighten your leg, the patella glides in a groove at the end of your thigh bone (femur) known as the trochlear groove of the femur.  Sometimes this groove may not be very deep and this can contribute to instability of the patella and a feeling that it may slide out of the groove (dislocate) when the knee moves.  Stability of the patella can also be affected by the alignment of your leg so that patients who are knock-kneed (valgus alignment) have a higher chance of developing patella instability.  This instability may also be caused by an injury that dislocates the patella. 

To aid stability of the patella there are a number of soft-tissues that attach to it.  These structures can weaken over time particularly if there is little stability provided by a flat trochlear groove.  This may lead to recurrent partial dislocations (subluxations) or complete dislocations.  This is painful and causes scuffing (wear) to the under-surface of the patella and may lead to the development of osteoarthritis.  

Of the soft tissue structures that stabilise the knee, the medial patellofemoral ligament (MPFL) is the most important.  It is a thin strip of tough tissue that attaches from the inside edge of your patella to the inner side of the lower end of your femur, to anchor and prevent the patella from sliding out of its groove. 

If your patella feels unstable or is regularly dislocating this can often be improved by strengthening the muscles around the knee using physiotherapy.  If this does not provide much improvement then surgical reconstruction of the MPFL may improve the situation.     

Surgical reconstruction of the MPFL
Surgical reconstruction of the MPFL is carried out under a general anaesthetic. It is a minimally invasive procedure and will require only a few small incisions on the front and side of your knee.  A small camera will be used to look inside your knee and to repair any other damage that may be found in the joint.

One of your hamstring tendons will be used, harvested through one of the small incisions that have been made.  The new ligament is secured by passing it through a small tunnel made on the inner edge of the patella and then fixing it to a short tunnel in the inner side of the femur.  Great care is taken not to under or over tighten the ligament so that it can effectively carry out its new job. 
Intended benefits of the surgery:
The aim of the procedure is to prevent the feeling of instability (giving way) and the recurrent dislocations that occur when the MPFL is disrupted.  This is usually an extremely successful operation with high levels of satisfaction for those who undergo this surgery.

Some of the identified risks with this type of surgery:

Some risks associated with this procedure are:

  • The operation may not to work patients may develop recurrent instability, The risk of this is 5-10%.
  • There will be some bleeding + swelling after the procedure but it is extremely rare for this to cause a serious problem.
  • There is a very small risk of a blood clot forming in the legs (deep venous thrombosis) which may require treatment with medicines to thin the blood (less than 1 in 200 cases). Even more rarely, one of these clots may travel to the lungs (pulmonary embolism) which may be serious.
  • Post-operative infection is very rare but could cause further damage to your knee. Very occasionally further surgery to wash the knee out is required.
  • Patients are often left with an area of numbness over the inner aspect of their knee. This isn’t often troublesome and usually reduces with time.  It can occasionally be permanent.
  • Fixing the MPFL and preventing further instability of the patella does not necessarily protect you from developing osteoarthritis in the future. This is due mainly to any damage that has already been done.
  • A small proportion of patients are left with persistent pain at the front of their knee after any knee operation.
  • Failure of the wound to heal is extremely rare. Certain individuals are at a higher risk of this (e.g. those with diabetes or peripheral vascular disease).  If you are at risk, this will be discussed with you prior to the operation. 

N.B. Many of the above complications apply to all forms of knee surgery
What are the alternatives to an MPFL reconstruction?

The main alternative is to do nothing at all and to continue with the physiotherapy and exercises that you are already doing.  If no improvement has been noticed it is unlikely that any further improvement is going to occur.  You may be happy just to accept the problem and not go through with any surgery.

If it is found that you have a shallow trochlear groove in which the patella glides, an operation that may help you is a Trochleoplasty.  This bigger operation involves lifting the articular surface of the groove and then hollowing out the groove to make it deeper.  The articular surface is then replaced and patella stability is improved as the groove is deeper.  This procedure is only required if your trochlear groove is completely absent.  
Follow up procedure and hospital stay

The majority of people undergoing MPFL reconstruction will have to spend just one night in hospital.  Rarely, a person may need to be kept in hospital if a complication has occurred.

You should be able to resume driving in 4 weeks and it is expected that you can return to sporting activities from 4-6 months. 

Follow-up appointments should be arranged for 4-6 weeks post op and then at 3 months and 6 months

If you have any further queries or concerns after your operation then please contact Nicki on 01926 772731

If you experience any excessive pain, swelling, or discharge then please contact either the hospital or your own GP immediately.

Post-operative rehabilitation

Day of operation / Day 1

  • Return from surgery with a wool / crepe dressing. This dressing will be changed to a Tubigrip before you leave hospital the next day.
  • You will be encouraged to practice full active extension of your operated leg.
  • Your physiotherapist will show you static quadriceps exercises, proceeding on to straight leg raises (you may need to help lift your leg with a towel/belt so that your knee is kept straight when lifting your leg).
  • You will be encouraged to mobilise so that you are full weight bearing - in full extension with crutches (you may have a brace only if you have poor quadriceps control).

Week 1

Goals

  • Diminish swelling / inflammation.
  • Regain active quadriceps / VMO control.
  • Maintain full knee extension / hyperextension.
  • At least 45° knee flexion.
  • Patient education regarding rehabilitation process

Week 2: Wound check and Suture (stitch) removal by nurse

Weeks 2 - 4

Goals

  • Control swelling / inflammation.
  • Gradual increase in range of movement (within limits of pain).
  • At least 90° knee flexion by end of week 2.
  • At least 120° knee flexion by end of week 4.
  • Quadriceps strengthening (especially VMO).

Week 4: begin to drive short distances if able to perform an emergency stop safely.

Week 4: Return to sedentary job.

Weeks 5 - 6

Goals

  • Full flexion.
  • Good activation of quadriceps and straight leg raise with no lag (knee bend).
  • Can start swimming ( not breaststroke until 10-12 weeks post operatively).
  • Can return to work in a physical job if able to carry out light duties with limited walking.

Week 6: Clinic review Ensure appropriate progress.

Weeks 7 - 12

Goals

  • Increase quadriceps and VMO control for restoration of proper patella tracking.
  • Improve muscular strength / control / endurance without exacerbation of symptoms.
  • No altered walking pattern.
  • Functional exercise.
  • Begin kneeling.
  • Able to return to gym (with guidance from physiotherapist).
  • Can start breaststroke when swimming.

Week 12 clinic review: check of progress.

Weeks 12 - 16

  • Goals
  • Knee extension strength at least 70% other knee.
  • Work towards achieving maximum strength and endurance of leg musculature.
  • Functional activity drills.
  • Good active patella control with no evidence of lateral tracking or instability.

Weeks 16+

Goals

  • Full pain free range of movement.
  • Continued improvement in quadriceps strength (80% or greater of contra lateral leg).
  • Improve functional strength and balance reactions.
  • Maximise confidence in returning to appropriate activity level.
  • Functional return to work / sport. ** Return to sports dictated by particular sport, ability, fitness and confidence – minimum 4 months (with guidance from physiotherapist and surgeon)

Tim Spalding 2020