What is the patellofemoral joint?

The patella (kneecap) is a bone within the tendon of the quadriceps muscle in the front of the knee joint and it acts like a pulley around the knee joint to direct the action of the quadriceps muscle to straighten (extend) the knee. The patella is attached to the quadriceps muscle by the quadriceps tendon and via the patellar ligament to the front of the tibial bone.

What symptoms arise from this joint?

Common symptoms are pain, swelling, giving way, clicking and catching. In bad cases the patella may dislocate with extreme pain and sudden collapse. Positional stiffness , or pain when getting up from prolonged sitting in one position, as in driving a car or sitting in front of a computer is  often a presenting symptom. Patellofemoral  symptoms are aggravated by squatting, kneeling, going up or down stairs (often worse going down). The symptoms are often absent whilst walking on the flat on even ground.

What can be done about the symptoms?

First of all a definitive diagnosis must be made. There are a great number of causes of patellofemoral symptoms. At LONDON SPORTS ORTHOPAEDICS we pride ourselves in making the correct diagnosis before offering any potential treatments.

The diagnostic process includes an appropriate history and examination. Blood tests may be necessary. Xrays, MRI scanning of the knee joint with specific measurements of the position of the patella in relation to the femoral trochlea, sometimes CT scanning and occasionally radioactive bone scans are taken and carefully analysed by our surgeons themselves and shown to you so that we can pinpoint the problems and discuss their implications. The diagnostic procedure can often be completed in one day but may require a follow-up appointment in some cases.

What treatment options are available?

The treatment plan suggested will depend upon the diagnosis. The treatment options for patellofemoral pain include pharmacological, physiotherapeutic, splintage, soft tissue operations and bony operations. We will consider all of these options with you and discuss them in detail with you.

What are the surgical options?

Arthroscopic surgical procedures

Soft tissue surgical procedures for patellofemoral symptoms can be arthroscopic or open procedures. The arthroscopic procedures are mostly done as day surgery cases or one night stay (see KNEE ARTHROSCOPY ). In many cases chronic patellofemoral pain involves mainly the synovial structures of the knee such as the plicae, or synovial folds which can be successfully treated arthroscopically. All arthroscopic procedures will involve taking appropriate still (jpg) and movie (mpg) pictures.

Open surgical procedures

These are mostly aimed at correcting the unstable patella with maltracking or recurrent dislocation involving chronic or repeated episodes of pain. They may involve soft tissue and/or bony procedures such as tibial tubercle transfer.

Open procedures will involve a longer time in hospital – between 2 and 5 days- and may involve postoperative bracing of the knee or a period using crutches partial weight-bearing for a short period for stabilization and confidence.

Recovery

Physiotherapy will be an important part of the postoperative treatment after the wounds have healed FROM ABOUT 2 WEEKS TO THREE MONTHS. and the total time back to sporting activities such as football and rugby should be about 12 months (you will miss a season).

Getting back to work following an open procedure for patellar instability depends upon the nature of your work and the distance and transport method you may have to use to commute to your place of work.

Further information

For further more-detailed information about anterior knee pain / patellofemoral pain, click here:  http://kneearthroscopy.co.uk/condition/anterior-knee-pain/

For information about patellar realignment surgery, click here:  http://kneearthroscopy.co.uk/treatment/patellar-realignment/

For information about patellofemoral arthroplasty (partial knee replacement at the front of the knee), click here:  http://kneereplacements.co.uk/patellofemoral-arthroplasty/

The post Patellofemoral Surgery appeared first on London Sports Orthopaedics.

This is the condition where a person is born with a kneecap (patella) positioned higher in the front of the knee than the average. They are very often good athletes and seem to do well in high jump, triple jump and basket ball. The problem with patella alta is that the knee cap is very mobile from side to side and is predisposed to dislocation during sporting activities. Once the patella has dislocated several times it is called recurrent dislocation and can be a major nuisance to the sporting individual causing them to give up all sporting activities. It has been the end of many basket-ball and football players’ careers, in whom the condition is common. In some people the dislocation is incomplete and then it is called subluxation of the patella.

In extreme cases the patient may be able to dislocate the patella at will and they sometimes do it as a party trick. This is called habitual dislocation. As its name suggests it can become a habit. It is not clever because it still creates minor damage and will result in osteoarthritis in the longer term.

Both dislocation and subluxation are extremely painful and both result in damage to the hyaline cartilage under the patella and to the groove in which the patella runs (the trochlear groove of the femur) which after a time causes osteoarthritis of the patellofemoral joint with severe pain and weakness of the muscles.

How is Patella alta diagnosed?

Typical picture of ‘Nobbly’ Knees with pain at the tip of the patella.

Clinically the high riding patella is often noticed as a ‘nobbly knee’. With the patient lying down and the knee bent to 90 degrees the patella tends to be on the top of the knee and slightly on one side. The pain is often felt at the tip of the patella.

What do the X-rays look like?

This is a measurement of the amount of overlap between the joint surfaces of the patella and the trochlear groove. In this case there is no overlap at all. The joint surface of the patella is far above the joint surface of the trochlear groove. This patella is very unstable and can dislocate at any time (habitual dislocation). There are other measurements to gauge the severity of the high riding patella and actually make an estimate of where the patella should be.

What does the MRI scan look like?

See the picture below. In the ‘sagittal’ (side view) images of the knee joint the patella is not only high riding, but also there is damage to the undersurface of the patella. Also you will notice that the patella tendon is lax indicating that if the quadriceps muscles were working properly the tendon would be tightened and the patella would move upwards a bit.

Notice also the irregularity on of the undersurface of the patella. It should be covered with hyaline cartilage and this should be smooth and regular in appearance on MRI. In this case the cartilage covering is beginning to degenerate and fragment. This condition is called “chondromalacia” which means softening of the cartilage. It is painful and is the first sign of damage to the joint surface. If the process continues it will result in bone articulating on bone with serious osteoarthritis which may require joint replacement.

What can be done to correct the high riding patella?

First of all the patella and the patellofemoral joint should be inspected by arthroscopy.

The damage to the hyaline cartilage of the patella is clearly seen at arthroscopy.

Under the same anaesthetic a three inch incision is made on the outer side of the patellar tendon with the tibial tubercle about halfway down the incision.

The following is a set of diagrams to show an operation which I pioneered in 1993 and which has become increasingly popular with patients who have patellar instability.

This is a post-operative Xray of a patient’s knee 3 months after the procedure.

Post-op recovery and rehab

Patients are kept in hospital overnight after the surgery, and are normally ready for discharge home the morning after the operation.

You will be given crutches to use and a knee brace to wear. The hinge mechanism of the strap on knee brace is specifically to prevent you from bending your knee too much whilst the bone from the tibial tuberosity osteotomy is healing up. Initially, the brace is usually locked at 0 to 20 degrees flexion, but the range of flexion is often increased as the knee starts to heal. Most people are ready to get rid of the knee brace and the crutches by 6 weeks post-op.

From 6 weeks post-op onwards, you will need to start regular intensive physiotherapy treatments (ideally 2 or 3 sessions a week to start with), to help you regain the movement, strength and then reflexes in your knee. By 3 months post-op most patients’ knees are sufficiently healed for them to be able to start impact-type exercise, starting with lunges then building up to gentle jogging, and then slowly getting back to full exercise/sport whenever your physiotherapist feels that your neuromuscular control and strength is good enough. It can, however, take people anything up to 6 months to fully get over this kind of surgery.

The post Patella Alta – High Riding Patella appeared first on London Sports Orthopaedics.

When is a Partial Knee Replacement needed?

In some patients, the arthritis that affects the inside of a knee may not affect all of the surfaces of the bones. Surgeons tend to consider knees as having three compartments; the medial compartment (between the femur and the tibia on the inside/medial side of the knee), the lateral compartment (between the femur and the tibia on the outside/lateral side of the knee) and the patellofemoral compartment (between the back of the patella/kneecap and the front of the knee – the trochlea).

If arthritis within a knee affects only one compartment, then there are some instances where a partial knee replacement might be appropriate.

Partial replacements of the medial compartment of the knee are referred to as medial unicompartmental knee replacements. Partial replacements of the lateral compartment of the knee are referred to as lateral unicompartmental knee replacements (although these are rarely done). Replacements of the patellofemoral compartment are called patellofemoral replacements.

X-ray of a medial uni-compartmental knee replacement.

The results of partial knee replacements are not quite as good as they are for a total knee replacement, because there is always the risk of a patient developing arthritis in the rest of the knee, and thus requiring further surgery with a total knee replacement (which would count as a ‘failure’ when looking at the results of the original surgery). However, partial knee replacements generally involve smaller, less invasive surgery than a total knee replacement, and so recovery is generally quicker and early complications generally lower. Furthermore, conversion of a partial knee replacement to a total knee replacement at a later date is not too technically demanding, and thus partial knee replacements are sometimes seen as a good alternative for younger patients whose arthritis is localised to one particular area of the knee.

Potential complications of total knee replacement

TKR is a major procedure, which is normally undertaken under a general or a spinal anaesthetic. The operation lasts in the region of 1 to 1 hours, and normally requires a hospital stay of 4 to 10 days, depending on the patient’s age and general fitness. It can then take anything up to 3 months for the muscles around the knee to begin to heal up fully and for patients to begin to feel the real benefit of the surgery.

The main potential complications of the surgery are:

Infection

Bacteria are carried in the air, and are found in our skin, in our mouths, up our noses and all around us. There is a small risk of bacteria getting into a knee at the time of a knee replacement, and causing an infection.

Superficial infections, affecting just the wound and the skin, can often be treated well with just a course of antibiotics. However, deeper infections can be very serious, as the bacteria can get into the bone (causing osteomyelitis) or they can stick onto the surface of the metal of the knee replacement. If the bacteria do stick to the metal of a TKR, then they secrete a sticky membrane around themselves that makes it very difficult for antibiotics to get to them. For this reason, deep infections in a joint replacement can be a very serious complication. In order to treat such deep infections, it may be necessary to remove the knee replacement completely. If the infection then clears up, then it might be possible to put in a new, revision knee replacement. Otherwise, it is sometimes necessary to fuse the knee (an arthrodesis).

We take the risk of infection very seriously, and all TKRs are performed in a laminar airflow theatre, with ultra-filtered air, and full aseptic precautions. Also, patients are given prophylactic antibiotics immediately before, and for two doses after the surgery, to help minimise the risk.

DVTs / PEs

After any major surgery or trauma, the blood becomes more likely to clot. In addition, after surgery on the knee, the leg is less mobile and the blood in the veins may flow more slowly. There is, therefore, a significant risk of patients developing blood clots in the veins of the leg after a knee replacement. A deep vein thrombosis (DVT) is a blood clot within the veins deep in the leg (as opposed to the superficial veins just under the skin). Small DVTs are common and often cause little or no problems. However, larger DVTs can cause painful swelling of the leg, with potential long term complications such as persistent swelling or ulceration of the leg. Clots may also break off larger DVTs and can go off into the circulation and end up lodged in the lung – a pulmonary embolus (PE) – causing chest pain and shortness of breath. Large PEs can, on rare occasions, even be fatal.

The risk of DVTs is therefore taken very serious after TKR. First, patients are encouraged to move their leg and walk as early as possible. When the calf muscles contract they pump the blood through the veins, increasing the flow and therefore decreasing the risk of thrombosis. Patients are therefore told to keep their feet moving by lifting the toes up and pointing the toes down repeatedly after the surgery. In addition, most patients are given low molecular weight heparin (LMWH) injections via a small needle into the skin once a day whilst in hospital after their surgery. The LMWH thins the blood slightly and again reduces the risk of DVT.

Despite the best precautions, the risk of DVT cannot be totally eliminated. If a DVT is suspected post-operatively, then patients are sent for an ultrasound scan of the leg. If a DVT is seen, then a patient may be started on warfarin tablets to thin the blood, and depending on the size of the clot and the patient’s individual risk factors, they may be kept on warfarin tablets for several months, which requires regular blood tests to check the warfarin levels.

Other surgical options for arthritis of the knee

In cases where a patient’s knee is out of line, the weight will not be distributed evenly within the knee, and this may cause excessive wear and pain on one side of the knee. In such cases, it may be possible to realign the knee by cutting the bone (most frequently the top of the tibia), realigning it and fixing it with a metal plate and screws. This is called a realignment osteotomy, and it can give good pain relief and significantly delay the time when a total knee replacement might be needed.

In rare cases, where the damage to a knee joint makes it too difficult to contemplate putting in a knee replacement, there are occasional instances where fusion of the knee joint (arthrodesis) by fixing the tibia and the femur together with the knee slightly bent, can be a good option. Although the knee will then not bend, the operation does remove the pain in a severely arthritic knee and means that a patient can fully weight bear and thus walk, albeit with a limp. Whereas arthrodesis used to be a more common operation in the past, it is only rarely required nowadays.

Further information

For further more-detailed information about partial knee replacements, click here:  http://kneereplacements.co.uk/partial-knee-replacements/

The post Partial Knee Replacement appeared first on London Sports Orthopaedics.

Osteotomy

‘Osteotomy’ means ‘cutting of a bone’. There are various different types of osteotomy. If there is a varus deformity in the knee then probably the best osteotomy is a medial opening wedge proximal tibial osteotomy. For valgus deformities, probably the best osteotomy is a distal femoral lateral opening wedge osteotomy. With these osteotomies, the bone (either the femur or the tibia) is cut, the alignment of the bone is corrected, the gap in the bone that this causes (which is wedged-shaped) is filled with bone graft, and the position of the bone is then held with a metal plate and screws. The bone then heals up just like a fracture does. The angle of correction of the osteotomy is calculated so as to take the weight-bearing axis away from the damaged compartment and across, slightly more into the other normal side.

Investigation and preparation

Prior to any potential osteotomy being performed, first it is essential that full-length standing weight-bearing views of both legs are obtained, to allow accurate measurement on the actual deformity in the knee. From this, one can calculate the number of degrees of angular correction required and hence the size of the osteotomy wedge.

The surgery

The tibia is cut at an angle under X-ray guidance with an oscillating saw blade.

The cut in the tibia is cranked open.

The bone is fixed in its straightened position with a metal plate and screws, and the bone gap is filled with bone graft.

(This particular plate is an Arthrex Titanium Puddu Locking Plate with an Osferion bone-substitute wedge.)

The results

Realignment osteotomy can give very good results; decreasing patients’ pain, increasing their function and keeping their knees going for longer, and delaying the time when they might eventually end up needing a knee replacement anyway. However, it does not ‘cure’ the arthritis in the knee joint – it just buys extra time for those patients who are too young for knee replacement surgery.

X-rays and MRI scans can often be misleading. Therefore, I always tend to perform a knee arthroscopy prior to any realignment osteotomy (either some time in advance, or else immediately prior to the actual osteotomy, during the same anaesthetic). This is for two reasons: first, to double check the knee, and in particular to make sure that the ‘other’ ‘normal’ compartment in the knee is actually in good enough condition for me to be able to proceed with the osteotomy; second, to tidy up the knee as best as possible (remove any loose bits of cartilage, smooth off and stabilize any rough or unstable articular cartilage, and trim any meniscal tears) as this can make a very significant positive difference to the joint and the patient’s symptoms, on top of the effects of the subsequent osteotomy.

Realignment osteotomy is actually quite a big deal. The surgery is performed as an in-patient, under a general or spinal anaesthetic, with a 2 or 3 days in hospital post-operatively. Effectively, the surgery involves breaking the bones to realign them, and it can take several weeks for the bone to heal and for the patient to make a full recovery. I normally initially keep my patients on crutches, partial weight-bearing, for the first 6 to 8 weeks, until X-rays show some evidence of early bone healing. I then recommend a gradual increase back towards full weight bearing. It can take patients 3+ months to really get over the operation, and anything up to 6 months to really feel the full benefits.

Potential risks

As with all surgery, there are potential risks, and these include:-

• infection
• blood clots (DVTs)
• nerve or blood vessel damage
• failure of the osteotomised bone to heal (non-union)

The pain, hassle, risks and time involved with these kinds of procedures are all factors that perhaps contribute to the fact that osteotomy surgery is not actually particularly commonly indicated/performed. However, in those patients with significant deformities and with significant symptoms, but who are too young to go straight for joint replacement surgery, osteotomy does still remain a very good and useful option in appropriate cases.

Further information

For further more-detailed information about realignment osteotomy surgery around the knee, click here:  http://kneereplacements.co.uk/realignment-osteotomy/

The post Osteotomy appeared first on London Sports Orthopaedics.

However, regardless of the advances in the field of surgery and in the areas of infection control and risk management, although the general risks of undergoing surgery can be minimised there is still no such thing as entirely risk free surgery.

Prior to undergoing any kind of surgical procedure your surgeon will first focus with great care on taking a detailed history, performing a thorough clinical examination and potentially supplementing this with special investigations, such as X-rays, ultrasound scans or MRI scans, in order to reach a clear diagnosis. The definitive treatment of many conditions will inevitably involve a surgical solution, for example joint replacement for severely arthritic joints. However, for most conditions, surgery is kept as a last resort, and only undertaken when the potential benefits are felt to outweigh the potential risks, and when all other appropriate non-surgical (referred to as ‘conservative’) treatments have already been tried.

The various non-surgical treatments available are too many in number to list in full, and depend entirely on the actual condition diagnosed as well as the situation of any particular individual patient. However, the following list gives at least some general guidance on the kinds of non-surgical treatment that are available and which might potentially be appropriate for some conditions:-

Rest

Many orthopaedic conditions, particularly repetitive strain type conditions, respond best to simple rest and avoidance of aggravating activities. However, unfortunately, for many people rest and activity avoidance is not always a viable option.

Painkillers

There are many different types of painkiller available, and different painkillers may be best for different patients with different various conditions. The range of painkillers includes:

• Simple painkillers – such as Paracetamol
• Medium painkillers – such as Co-codamol, Co-proxamol or Co-dydramol
• Strong painkillers (based on morphine) – such as DF118, Tramadol or MST
• Anti-inflammatories – such as Voltarol/Diclofenac, Nurofen, Ibuprofen
• Drugs that focus specifically on nerve pain – such as amitriptyline, gabapentin or pregabalin

Each of these drugs can have potential side effects. Medium or strong painkillers can cause drowsiness or constipation. Anti-inflammatories can cause kidney problems, stomach irritation (gastritis) or even stomach ulcers, and can sometimes cause reactions in people with asthma. So, care must be taken to follow the advice that you are given with any prescription or the advice on the bottle.

Physiotherapy

There are many conditions that may respond well to a course of physiotherapy treatments. CLICK HERE for further information about physiotherapy.

Injections

Injections of various types can be particularly useful. Sometimes injections of local anaesthetic are given in clinic at various sites to see whether the injection gives pain relief, as a way of helping clarify a diagnosis.

There are also various injections that can be given as treatments:-

Steroids – steroid (also called cortisone) is a very powerful anti-inflammatory, and so can be very useful for treating conditions where there is inflammation. The steroid is normally mixed with a bit of local anaesthetic. The local anaesthetic works very quickly and gives rapid pain relief but also wears off quickly, after several hours. Steroid, however, can take 24 or even 48 hours to kick in and start working. For the first couple of days after a steroid injection the area may be uncomfortable, with a burning feeling, but this nearly always then disappears.

People are sometimes concerned about the possible side effects of a steroid injection, associating it with the concept of being ‘on steroids’. The significant potential side effects that are sometimes associated with steroid, such as water retention, thinning of the bones, problems with hormones and so on actually relate to patients being given very high doses of steroids or being put on long courses of steroid tablets, and this does NOT apply to being given a local steroid/cortisone injection, which is something that is given very frequently in association with sports injuries or repetitive strain injuries.

The conditions that may respond very well to steroid injections are:

• knee arthritis
• hip arthritis
• shoulder subacromial impingement
• shoulder supraspinatus tendonitis
• shoulder acromioclavicular joint arthritis
• some forms of tendonitis (especially if the tendon sheath is inflamed)
• plantar fasciitis in the heel

Hyaluronic Acid injections

Hylans are molecules that are found within the normal fluid within a joint. They are very long chain molecules, so when provided in a liquid form they are very viscous. There are some people who think that by injecting Synvisc into a knee you are ‘lubricating’ the joint – like changing the oil. There are others who believe that injecting hylans into a joint has a chemical/drug effect. Whatever the actual underlying processes might be, some people believe that injecting hyaluronic acid into a joint can provide symptomatic improvement in maybe 75% of patients, with decreased pain and increased mobility. Some patients may feel symptom improvement straight away after an injection, but in many it can take a few weeks before the full benefit is felt. The degree and length of symptom improvement does vary considerably between patients, but some people gain significant benefit for up to 12 months after an injection.

Some insurance companies will fund Synvisc injections but others won’t, and the injection can cost a fair amount of money. So, if you are covered my medical insurance then it is important that you do check with your insurer that your particular policy does cover this, otherwise you will end up having to cover the hospital bill for the injection yourself.

STOP PRESS — the latest advice from the American Academy of Orthopaedic Surgeons (the world’s largest orthopaedic organisation) is that there is insufficient evidence to support the use of HA injections in patients with arthritic knees, and hyaluronic acid is no longer recommended as part of the standard treatment algorithm for the management of knee arthritis.

To read more CLICK HERE

Further information

For further more-detailed information about the various different non-surgical treatment options for managing knee arthritis, click here:  http://kneereplacements.co.uk/non-surgical-treatments/

The post Non-surgical treatments appeared first on London Sports Orthopaedics.

What are the menisci?

The menisci are wedges of crescent shaped elastic cartilage inside the knee, sitting between the bones of the femur (thigh bone) and the tibia (shin bone). There is one meniscal cartilage on the inner side of the knee – the medial meniscus – with another sitting on the outer side of the knee – the lateral meniscus. The meniscal cartilages are placed between the bones of the knee like little elastic potato wedges, acting as shock absorbers.

View of the top of the tibia (shin bone) with the menisci removed

View of the top of the tibia with the meniscal cartilages in place

Meniscal tears

Meniscal tears are a very common knee injury. In younger people, meniscal tears most commonly occur from sporting injuries, such as a bad football tackle or an awkward skiing fall. As you get older, the meniscal cartilages become gradually more degenerate and lose their elasticity, and they can potentially tear with just minimal trauma (like getting up from kneeling) or even spontaneously.

Arthroscopic (keyhole surgery) view of a torn meniscal cartilage (red arrow).

Tears of the meniscal cartilages can cause knee pain, swelling, clicking, giving way or locking. Unfortunately, the meniscal cartilages have a very poor blood supply, and therefore tears very often fail to heal up on their own.

Meniscal tears that are causing significant persistent symptoms are normally treated by knee arthroscopy (keyhole surgery). A small percentage of tears may be repairable. However, the majority are not, in which case the torn cartilage is trimmed via the keyhole surgery.

As the meniscal cartilages are important shock absorbers in the knee, loss of meniscal tissue leads to increases stresses in the knee joint, with increased wear and tear eventually leading to degeneration and arthritis.

What can be done about a meniscal tear?

If a patient presents with a painful knee after previous trimming or excision of the meniscus (called meniscectomy), then there are two treatment options that may potentially be possible:

1. The Menaflex Collagen Meniscal Implant. This is an engineered scaffold of collagen (which is the main structural component of a meniscus), which can be fixed into the knee to fill a missing defect in a meniscal cartilage. New meniscal tissue grows into the scaffold. However, this option is only suitable in cases where the outer rim of the meniscal cartilage is still intact (click here for further information on the Menaflex Collagen Meniscal Implant).
2. For patients where there is no intact peripheral meniscal rim or where the whole meniscus has been lost, meniscal allograft transplantation can be a potential option.

What are the aims of and reasons for meniscal transplantation?

The most common reason for performing a meniscal transplant is when a patient has previously lost a meniscal cartilage in their knee and they have then gone on to develop early degeneration, with pain in the knee and decreased function.

Another potential reason for performing a meniscal transplant is to replace the shock absorber inside the knee and therefore help protect the knee and reduce the likelihood of the knee developing arthritis in the future.

One further potential indication for meniscal transplantation, which is advocated by some surgeons (for example in some centres in the US) is to replace damaged meniscal cartilages in knees that have significant arthritis, as a means of trying to potentially keep the knee going and delay the time that an actual knee replacement becomes necessary.

What is an allograft?

An allograft is a piece of tissue obtained from a donor – just like kidney/lung/heart donors etc. The donor are screened extremely carefully, and the tissue is tested for bacterial or viral contamination. The tissue is then sterilized using and then frozen and stored.

Meniscal graft prior to preparation

Meniscal graft being prepared

Medial meniscal allograft ready for surgical implantation.

When was it first done and how many transplantations have been performed?

The first reported cases of meniscal transplantation in human was from Milachowski, a German surgeon, in 1987. Since then, there has been intense interest in and research into the field of meniscal transplantation and replacement. To-date, well over 4000 procedures have been performed in the USA. In Europe, the main centres for meniscal transplantation are Gent, Belgium and De Haag, The Netherlands, with Professor Rene Verdonk having performed over 100 meniscal transplants. In the UK, there are very few surgeons trained in and practicing meniscal transplantation, with Mr Angus Strover from LONDON SPORTS ORTHOPAEDICS (at the London Bridge Hospital) having performed probably more transplants than any other UK surgeon, with his tally to-date exceeding 50.

What does the operation entail?

Meniscal transplantation is a technically demanding operation. It is normally performed under a general anaesthetic. Most transplants can normally be performed arthroscopically-assisted (with the aim of keyhole surgery), and thus the scars are relatively small.

The graft has to be fixed into the knee solidly at the front and the back. This normally involves drilling tunnels into the bone of the tibia (shin bone), into which the ‘meniscal horns’ are fixed (see image). The rest of the meniscus is then stitched around its edge to the inside lining of the knee.

Medial compartment of the knee, with a missing medial meniscus

Same view, but with the new meniscal graft fixed in place.

Patients are normally in hospital for 1 or 2 days post-op, before being able to go home, non-weight bearing with crutches and with their leg in a knee brace.

Other related procedures

In order for a knee to be suitable for receiving a meniscal transplant, it is important that:

•  The knee ligaments must be intact and the joint must be stable. If not, then it may be necessary to perform a ligament (eg ACL) reconstruction as well as the meniscal transplant, in order to stabilise the knee and protect the graft.
• The knee alignment must be normal. If the knee is not normally aligned, then there will be excess pressure on one or other of the side of the knee. These increased forces will put additional pressure on a graft, potentially causing failure. Therefore, malalignment of the leg must be corrected first with a surgical realignment (osteotomy) operation.
• Wear and tear: if there is major wear and tear of the layer of articular cartilage that covers the surface of the knee joint, especially if there are patches of exposed bare bone, then this will abrade the surface of the meniscal graft as the knee flexes (bends) and extends (straightens). Therefore, if there are any significant patches of cartilage damage then these may need to be addressed as well as replacing the meniscal tissue. There are various methods for trying to repair damaged articular cartilage (click here).

What about the post-op rehab?

It is essential to restrict knee movements and activities directly after the operation, in order to protect the graft whilst it is healing into the knee.

For the 1st 6 weeks after the operation, patients are normally kept non- or minimally weight bearing with 2 crutches, and with their leg in a strap-on hinged knee brace that prevents the knee from bending up more than about 60o.

After 6 weeks, the meniscus should have healed into the knee, but it will still be fragile. The brace and the crutches are discarded, and patients then start intensive physiotherapy treatments in order to regain the full range of knee movements and the muscle strength and reflexes in the knee.

At 3 months, we advise having a repeat arthroscopy (look inside the knee with keyhole surgery). This is to check that the meniscal graft has fully incorporated into the knee. It is normal that at this arthroscopy for there to be either small flaps of tissue that might need to be trimmed, or additional stitches that might be required into the graft.

After this second arthroscopy, patients are allowed to gradually resume normal activities, under the close supervision of their physiotherapist. Patients are not advised to return to sport until a full 6-months after the transplantation operation.

What about rejection?

The cells within meniscal tissue are ‘locked in’ inside a dense matrix of tissue, made up of fibres of collagen and large spongy molecules called glycosaminoglycans. This means that the body’s immune cells are unable to get to the cells in the meniscal tissue. Cartilage tissue is therefore referred to as ‘immunoprivilegded’, which is to say that donor cells within the graft tissue do not cause an immune response in the patient’s knee. Therefore, with meniscal transplantation, patients can have receive a graft without the need for it being covered with drugs such as steroids or other potentially nasty immunosuppressives.

And what are the actual results?

The published results of meniscal allograft transplantation to-date are encouraging, with good pain relief and good improvement in function. A recent review showed that over 75% of patients are satisfied with the procedure, with over 90% of patients reporting good-to-excellent results in one study. Studies on meniscal transplantation in animals has demonstrated a reduction in the progression of knee arthritis compared to leaving the knee with no meniscus. However, it will take a number of further years before the results of long term research studies will become available to show just how much meniscal transplantation might protect the human knee from future arthritis.

How can I find out more?

For further more-detailed information about meniscal transplantation, click here:  http://meniscaltransplantation.com/

Please note that specific advice for individuals’ personal cases cannot be given over the telephone or by e-mail. However, appointments with one of our consultant specialists can be booked easily by contacting us directly, either by e-mail or by phone.

In this post

• What are the menisci?
• Meniscal tears
• What can be done about a meniscal tear?
• What are the aims of and reasons for meniscal transplantation?
• What is an allograft?
• When was it first done and how many transplantations have been performed?
• What does the operation entail?
• Other related procedures
• What about the post-op rehab?
• What about rejection?
• And what are the actual results?
• How can I find out more?

Article written by
Mr Ian McDermott
Consultant Knee Surgeon
Last updated 8/04/23

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What are the meniscal cartilages ?

The menisci (meniscal cartilages) of the knee are two important crescent shaped wedges of elastic cartilage found within each knee, sitting between the main bones of the thigh (femur) and shin (tibia).

What do the meniscal cartilages do ?

Arthroscopic (keyhole surgery) view of normal meniscus

They help bear weight across the knee joint and act as shock absorbers. Without them, the layer of articular cartilage (the smooth, white, shiny layer of tissue covering the surface of the ends of the bones) becomes subjected to increased forces, leading to excessive wear and damage.

Complete loss of a meniscus increases the risk of arthritis of the knee in later years by 15 times (ie, a 1500% risk !).

What is a meniscal tear ?

Meniscal tears are one of the most common injuries of the knee. In younger patients meniscal tears tend to happen in association with sports injuries, such as bad tackles, falls or twisting of the knee. In older individuals the meniscal cartilages become more delicate and can even tear spontaneously (a degenerate meniscal tear).

Radial meniscal tear

Flap tear of the meniscus

What can be done to treat a meniscal tear ?

Traditionally tears of the meniscus were treated by removal of the torn cartilage (total meniscectomy). Increasingly, where possible, surgeons try to preserve meniscal tissue rather than just surgically remove it. However, the meniscal cartilages have a very poor blood supply and the potential for healing is therefore limited. Only a minority of meniscal tears are actually appropriate for surgical repair. In the rest of the cases, the only option is to surgically trim the torn cartilage, thus removing tissue.

For patients who have completely lost a meniscal cartilage, the procedure of ‘Meniscal Transplantation’ is an option. This involves surgically implanting a new meniscus into the knee using a donor graft. However, this can be a fairly major operation.

Meniscal remnant after resection

For those patients who have lost some, but not all, of a meniscus, there were until now no real surgical options. However, a new surgical implant has now been developed that stands to revolutionise the treatment of patients with problems after partial removal of a cartilage.

The Menaflex Collagen Meniscal Implant from Hospital Innovations

The Menaflex Collagen Meniscal Implant was developed in the USA by a team including Dr Richard Steadman, from Vail. The Menaflex is a biological, resorbable implant made from highly purified collagen. It is arthroscopically (through keyhole surgery) stitched into place to fill a defect in a meniscus to replace missing tissue. The body’s own cells then migrate into the implant, which is highly porous and which therefore acts as a scaffold, utilising the body’s own repairing processes to progressively regenerate new meniscal tissue.

Histological studies have shown that the implant is entirely biocompatible and that after about one year, it is largely absorbed and replaced by native new tissue.

Results from clinical trials in the US and Europe have demonstrated that patients have reduced pain post-operatively, after implantation of the Menaflex implant, and that they tend to regain activity levels comparable to those from before the original injury. Furthermore, use of the Menaflex implant has been correlated with patients being shown to subsequently end up need fewer additional surgical procedures in the future.

To-date, more than 2000 Menaflex implants have been surgically implanted worldwide. The outcome studies have shown that about 90% of patients have regrowth of meniscal tissue, regaining over 70% of their original meniscus tissue volume.

Implantantation of a meniscal scaffold

The Menaflex collagen meniscal implant has only very recently been introduced to the UK and is now available only in a restricted number of specialist centres, from surgeons who have undergone appropriate training on the technique.

Further information

For further more-detailed information about meniscal replacement surgery, click here:  http://meniscaltransplantation.com/

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Meniscal tears

A vertical tear in a meniscus, repaired with a meniscal suture.

Complete loss of a meniscus increases the contact pressures between the femur and the tibia by over 200%, causing increased wear and tear within the knee. This can lead to arthritis. The more tissue is lost, the bigger the risk. If a complete meniscus is removed, then the risk of developing arthritis over the following 20 years increases by about 15-fold.

Many meniscal tears are irreparable. However, in those that can potentially be repaired, there is a very strong argument for attempting a surgical meniscal repair.

How is it done and how successful is it?

With meniscal repair, tiny stitches are placed into the meniscal cartilage to close up and hold a tear. However, like any tissue, this does not guarantee that the tissue will actually heal up. If the meniscal tissue fails to heal then it is likely that eventually the tiny sutures will tear and fail, and the knee will remain symptomatic. However, the average success rate for meniscal repairs healing up successfully is approximately 90%, which is pretty good for any surgical procedure. If the repair does heal up successfully, then a patient should expect to make a full recovery with no major long-term consequences.

The Smith & Nephew FasT-Fix Meniscal Repair Device.
Two plastic achors loaded into a needle, with suture attached with a slip knot.

Arthroscopic view of a meniscal repair suture being inserted using the FasT-Fix repair system.

Arthroscopic view of a bucket handle meniscal tear repaired using two FasT-Fix devices.

Rehabilitation after meniscal repair

If a simple meniscectomy or partial meniscectomy is performed then the recovery after the surgery is normally quick. Patients are advised to rest their knees for the first 1 – 2 weeks and then to gradually and carefully get back to normal as quickly as they feel they can, with no specific restrictions in what they are allowed to do.

However, when a meniscal repair has been performed, it is vital that the tiny stitches are protected, as they can potentially snap if too much force is put on them. Also, when the knee is flexed, the meniscal cartilages are pinched at the back of the knee and this can cause a meniscal repair to tear and fail. Therefore, after meniscal repair, a patient’s knee needs to be protected to give the repair the best possible chance of healing up.

Different surgeons and different physiotherapists have got their own ideas and opinions regarding what kind of rehab is appropriate after meniscal repair, and there is a wide variation of opinion.

However, given that the meniscal repair sutures are so tiny and delicate and that the consequences of a re-tear are so serious, we advocate the following rehab regime:

• the knee is kept in a hinged brace, locked at 0 – 60o flexion for 6 weeks (the brace can be removed intermittently to wash / dress etc, but when the brace is off the knee must be kept straight)
• during this 6 week period, the patient is kept partial weight bearing (about 25% body weight) with 2 crutches
• after 6 weeks, the knee brace and the crutches are discarded. The patient then needs to start a 6-week course of regular intensive physiotherapy rehab, aiming at restoring (in this order):-

1. knee range of motion (the knee will be stiff after having been in a brace for 6 weeks
2. muscle strength (the muscles will be weak and wasted)
3. proprioception (the reflexes to the muscles for balance and stability).

During the 6-week rehab period, the patient should avoid deep squats, running, hopping, skipping or jumping.

Only at the 3-month post-op mark, should the patient start gradually and carefully returning to running and gentle sport.

How do you know if a meniscal repair has actually healed?

Unfortunately, MRI scans are not very good at seeing whether or not a meniscal repair has or hasn’t healed. This is because the resolution of a scan just isn’t good enough to differentiate between scar tissue within the cartilage vs. a tear that has failed to heal.

It would be possible to perform a repeat arthroscopy at the 3-month post-op mark, in order to visualise and probe the meniscal repair and check whether it has healed. However, with meniscal repair having a 90% success rate, this would mean that 9 out of 10 of the repeat arthroscopies would potentially have been unnecessary. This approach therefore really isn’t justified.

Therefore, the only practical way of finding out whether or not a meniscal repair has healed is to gentle test the knee out by slowly returning to normal activities and sports after the 3-month post-op mark. If the knee does well and there are no significant symptoms, then it follows that the tear must have healed up and the repair was successful. If, however, a patient is unlucky enough to develop recurrent symptoms and ongoing problems with the knee, then the assumption is that the attempted repair has failed. In this situation, if the knee symptoms are actually bad enough to warrant having something further done, then the only real option left is to have a repeat arthroscopy, go back into the knee and excise the damaged cartilage by performing a meniscectomy or partial meniscectomy.

To repair or to resect?

It is essential that patients have a full understanding of what their surgeon might potentially find inside their knee, what potential surgical treatment options are available and what particular rehab might be needed.

It is extremely difficult for a surgeon to accurately predict with confidence what rehab any individual patient might need after knee arthroscopy, because this depends entirely on what is found and what is done inside the knee.

Some patients, such as self-employed labourers, might need to get back to work ASAP and may actually prefer to have a partial or even total meniscectomy rather than subject themselves to 6 weeks in a knee brace plus crutches after a meniscal repair. Other patients may simply ask their surgeon to go ahead and do whatever they think is best and most appropriate at the time of the surgery.  My personal approach is to treat each patient’s knee as if it were either my own knee or the knee of one of my family, unless the patient has given me specific instructions pre-operatively to either do or not do something specific.

All of the above details emphasize just how crucial it is that you do spend proper time with your surgeon pre-op and that you do ask as many questions as you feel you need to.

“My Meniscal Repair” by Laura Procter, September 2009

Further information

For further more-detailed information about meniscal repair, click here:  http://kneearthroscopy.co.uk/treatment/meniscal-repair/

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What is the ACL?

The ACL is the most commonly torn knee ligament, and is the ligament often torn by footballers or skiers. In about 50% of patients with an ACL tear, other structures (such as the meniscal cartilages) are also damaged at the same time. The ACL sits in the middle of the inside of the knee like a taught bungie cord surrounded in joint fluid. If the ligament ruptures, then the ends tend to ping apart and fray. Direct repair of a rupture in the middle of the ligament is never normally possible. Some patients will do well without surgery, through intensive physiotherapy to build up the strength of the muscles around the knee to compensate for the absent ACL. However, a large proportion of patient do not do well, and their knee will feel wobbly and will give way on a regular basis. In these patients, surgical reconstruction is recommended.

Ruptures of the PCL are rarer than ACL tears. If the PCL does rupture, then other knee structures are normally also damaged at the same time, particularly the posterolateral corner complex. Isolated PCL tears often do well treated conservatively. However, combined ligament tears, eg the PCL and the Posterolateral Corner, normally require surgical reconstruction.

Sprains (partial tears) or even complete tears of the MCL are normally best left alone, and treated conservatively with a knee brace. This is because the MCL is a wide broad ligament with a very good blood supply, and it therefore has the ability to heal up well on its own.

The LCL is a thinner cord-like ligament. Ruptures of the LCL are frequently associated with damage to the Posterolateral Corner, and often require surgical reconstruction.

The Posterolateral Corner (PLC) is an area of the knee that has been the focus of much attention over recent years. It is now appreciated that a significant percentage (perhaps as high as 10%) of ACL tears are associated with concomitant PLC tears. A missed PLC tear is a common reason for a poor outcome after isolated reconstruction of the ACL, as the ACL reconstruction on its own will not correct the rotational instability caused by deficiency of the PLC. PLC injuries also occur very frequently in association with PCL tears. Deficiency of the PLC with significant rotational instability is an indication for surgical reconstruction.

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Knee replacement surgery is a major op, and not something to be entered into lightly. The operation takes about 1½ hours and is pretty painful early on post-operatively (but that’s what painkillers are for). It can take up to 6 months for people to fully plateau in their recovery from a knee replacement, and an artificial knee is never as good as an original natural knee. The patient satisfaction rates after knee replacement are about 85% with a standard knee prosthesis, and up to about 95% if a custom-made Conformis prosthesis is used – but either way this is not a 100% ‘guaranteed’ operation. The surgery also carries with it small potential risks, such as infection, nerve/blood vessel damage or blood clots.

So, you should only consider having knee replacement surgery if your symptoms and/or functional restrictions actually feel bad enough to justify the pain, the hassle, the time required for the rehab and the potential associated risks of surgery.

Some people say that you should only ever have a knee replacement as a very last resort, and that the surgery should be delayed for as long as possible. This is not actually correct.

It’s certainly true that it’s preferable not to have knee replacement surgery too young. This is because the younger you are when you have an artificial joint, the more you’re likely to use it … hence, the more movement cycles there are through the joint and the greater the forces and any impact will be — and therefore there will be a faster rate of wear and tear in the joint. Knee replacement prostheses consist of a metal surface on the end of the femur, a metal surface on the top of the tibia and a very hard plastic washer in between. These artificial materials do not repair or regenerate themselves with time, and hence any wear is cumulative, and eventually knee replacements can wear out. So, the younger you are when you have a knee replacement and the more you use it, the faster the rate of wear and tear will be and the quicker it will wear out. On top of this, the younger you are, the longer you’re likely to live – and hence the longer you actually need the knee replacement to last.

If a knee replacement is done in a patient in their 70’s, then there is only a risk of about 10% of the prosthesis failing within the patient’s lifetime. If a knee replacement is done in a patient in their 50’s, then there is an approximately 50% chance of it wearing out and failing within the patient’s lifetime.

If a knee replacement fails, then it can normally be removed and replaced with a new one, which is called a revision knee replacement. However, revision knee replacement surgery is twice as complex and difficult as the first one (the primary), with double the potential complication rates and with lower patient satisfaction rates and functional scores. Also, revision knees then tend not last as long as a primary knee. It’s not normally technically possible to just continue revising and revising a knee replacement, and if things get too bad then sometimes it’s necessary to simply fuse the knee (an arthrodesis).

So, the best way to avoid the potential downward spiral of revision surgery and failing knees is not to have a knee replacement too young … but this means ‘not unnecessarily young’. We do sometimes do knee replacement surgery on patients as young as in their 40s – but only ever as a last resort. 50’s is ‘OK’-ish. 60s is perfectly acceptable.

On top of all this, however, it’s important to consider the other side of the timing equation… which is that equally, you shouldn’t actually leave a knee replacement too long!

If you do a knee replacement in a younger patient who’s medically fit and who’s got strong, fit, flexible muscles, and in whom the joint damage is not so severe, then the patient is less likely to suffer complications, they’re more likely to cope better with their rehab and they’re more likely to achieve a better final outcome from the surgery. Conversely, the older a patient is, the more medical problems they have, the less fit they are, the weaker they are, the stiffer the knee, the more deformed the joint and the more bone loss/erosion there is, the poorer the outcome from knee replacement surgery is likely to be.

If you’re able to cope with your knee symptoms, if you’re able to tolerate the pain or manage it through painkillers, anti-inflammatories and/or supplements, and if you’re still able to manage your activities of daily living and you’re still mobile enough to manage some gentle exercise and maintain your fitness levels, then you should not go ahead with knee replacement surgery.

For most people, their symptoms will just gradually get worse with time. When the symptoms cross a certain threshold, which is different for every individual, the knee will then become a significant rate limiting factor and will prevent the patient from being able to exercise and function properly. From this point onwards there’s likely to simply be a continuing downwards slope, with a gradual decrease in function. If/when you hit this point and your symptoms cross that threshold and your function starts deteriorating on that inexorable downward slope…. that’s the time to have your knee replacement surgery.

Ultimately, everyone’s different and everyone’s got their own tolerance levels, their own fears and their own aspirations, and if / when to potentially have knee replacement surgery is a very personal and individual decision. The job of your surgeon is to explain to you what’s actually going on with your knee (the diagnosis) and to explain all the different potential appropriate treatment options, along with their various pros and cons, and to advise you and assist you in gaining an understanding of your condition and coming to the right decision for you about what you might want or need to have done… and if you’re still not clear or not sure, then it’s your job to ask your surgeon for more information or for a further proper face-to-face discussion with them back in clinic.

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