Conditions and treatments

If you tear the anterior cruciate ligament in your knee, you may need to have re-constructive surgery. The anterior cruciate ligament (ACL) is a tough band of tissue joining the thigh bone to the shin bone at the knee joint. It controls front to back and, most importantly, pivoting or twisting movement.

ACL injuries

Knee injuries can occur during sports such as skiing, tennis, squash, netball, football and rugby. ACL injuries are the most common type of knee injury, accounting for around 40% of all sports injuries. You can tear your ACL when twisting, pivoting or with a direct blow. Regular giving way can lead to secondary damage to the menisci (shock absorbers) and articular cartilage (joint surface) as well as making twisting and turning difficult.

A ligament graft is required using material taken from the front of the knee or from the hamstring tendons behind the knee, both of which are able to re-grow to some extent.

Hamstrings or Bone-Patella-Bone grafts are used depending on which is the most suitable for the individual patient. Allographs from other donors can be used.

Common causes of an ACL injury include:

• landing incorrectly from a jump
• stopping quite suddenly
• changing direction
• collision, such as during a rugby tackle

If the ACL is torn, your knee will become very unstable and have a reduced full range of movement. This can make it difficult to perform certain movements, such as turning on the spot. Some sports may be impossible to play with such an injury.

How is it treated?

The ACL cannot easily be repaired so it is best treated by reconstruction where a piece of the patients own tissue (HAMS or BTB) is taken and put in it’s place. Successful ACL reconstruction surgery is a highly successful operation and post people can return to their previous level of sport from 6 months onwards after surgery.

A Baker's cyst is no more than another name for a swelling at the back of the knee caused by an out-pouching of the knee capsule. The capsule is the bag which contains the knee joint's lubricating fluid called synovial fluid. Synovial fluid is produced by the synovium which is the inner lining of the knee capsule.

The cyst can be caused by a sports-related injury or blow to the knee or a number of health conditions, including:

• Osteoarthritis – usually caused by age-related “wear and tear” of joints, it particularly affects the knees, hips, hands and big toe
• Rheumatoid arthritis – a less common but crippling type of arthritis caused by the immune system attacking the joints
• Gout – a type of arthritis that usually affects the big toe caused by a build-up of uric acid (waste product) in the blood

A Baker's cyst is more common in women than men, probably because women are more likely to develop osteoarthritis and rheumatoid arthritis. It usually develops in people aged over the age of 40, although it can affect people of any age, including children.

You can relieve any pain and reduce the swelling using over-the-counter painkillers, bandages or an ice pack

It's important that any underlying condition is properly managed as the cyst may go away when the condition causing it has been treated.

Surgery is almost never indicated. Treating the underlying condition usually allows the Bakers cyst to resolve.

There are a number of different types of inflammatory arthritis including rheumatoid, sero-negative, post viral or infective.

Rheumatoid arthritis, a type of inflammatory arthritis, is a chronic inflammatory disease of the joints. The immune system normally protects us from infection but with rheumatoid arthritis the body mistakenly attacks the thin membrane that lines the joints. This can result in joint damage, pain, swelling, inflammation and loss of function. Rheumatoid arthritis, commonly affects the knees, hands, wrists, feet, elbows and ankles.

Patients with inflammatory arthritis will be referred to a Rheumatologist.

Iliotibial Friction Syndrome is one of the most common causes of what is often referred to as ‘Runner’s Knee’ and can account for up to a quarter of over-use injuries in runners. Being an over-use injury, it is caused by repeated trauma rather than a specific incident.

The iliotibial friction band attaches to the outer border of the tibia or shin bone. It crosses the knee and rubs on the lateral femoral epicondyle. It slides forwards and backwards across this bony point. This repetitive sliding can create excess friction, especially when the knee is bent at 30 degrees, which commonly happens just as your foot touches the ground when running. This region of 30 degrees of knee flexion is called an ‘impingement zone’ or pinching of irritated structures over the outside of the knee, thereby producing ITB Friction Syndrome.

What is the Iliotibial Band?

The iliotibial band is a long, thin band of fibrous tissue that runs down the outside of your thigh. At the top of your thigh it is attached to your Tensor Fascia Latae (TFL) muscle and Gluteus Maximus, and at the bottom it attaches to your tibia (lower leg bone) and femoral condyle on lower outside portion of the thigh bone.

What causes ITB Syndrome?

ITB friction syndrome is caused by altered running biomechanics due to underlying muscular imbalances. Your biomechanics can alter due to a muscle imbalance (weakness or tightness), fatigue and ground impact issues.

The most common causes:

• Poor biomechanics (running technique); particularly inwards rolling knees and hips
• Weak hip / gluteal muscles
• Weak hip rotators
• Weak inner quadriceps
• Weak core muscles
• Poor foot arch control
• Worn out or unsuitable trainers
• Sudden increase in mileage for training
• Excessive hill training (particularly downhill)
• Endurance running (training for ½. and full marathons, ultra-marathons)

The most common symptom includes, sharp or burning pain just above the outer part of the knee; pain that worsens with continuance of running or other repetitive activities; swelling over the outside of the knee; pain during early knee bending; gradual onset of symptoms which if they persist for greater than 4 weeks can cause major interference for any sport or activity.

How is it treated?

The mainstay for treatment is physiotherapy and podiatry which will address muscle tightness and balance. A steroid injection can speed recovery. Surgery is almost never required.

A lateral collateral ligament (LCL) injury is when the ligament on the outside of the knee is injured. The ligament can be a partial tear, stretch or complete tear of the ligament. The lateral collateral ligament (LCL) is positioned from the top part of the fibula (the bone on the outside of the lower leg) to the outside part of the lower thigh bone and helps keep the outer side of the knee joint stable.

The LCL is usually injured by pressure that pushes the knee joint from the inside, which results in stress on the outside part of the joint.

Symptoms of a tear in the lateral collateral ligament include knee swelling, locking or catching of the knee with movement, pain or tenderness along the outside of the knee, the knee gives way or feels like it is going to give way when it is active.

A medial collateral ligament (MCL) injury is when the ligament on the inner part of the knee is injured. It can be a stretch, partial tear, or complete tear of the ligament. The medial collateral ligament (MCL) goes from the inside surface of the upper shin bone to the inner surface of the bottom thigh bone. The ligament helps keep the inside portion of the knee joint stable.

The MCL is usually injured by pressure or stress on the outside part of the knee or a block to the outside part of the knee.

The MCL is often injured at the same time as when an anterior cruciate ligament (ACL) injury occurs. Symptoms of a tear in the medial collateral ligament are knee swelling, pain and tenderness along the inside of the joint or when the knee gives way or feels like it is going to give way when it is active. Swelling is less common.

Housemaid’s knee is caused by inflammation of the bursa (a small fluid-filled sac) in front of the kneecap. It more commonly occurs in people who spend long periods of time kneeling and treatment is usually supportive only and the outlook is generally very good.

The bursa is a small sac of fluid and has a thin lining. The function of a bursa is to help reduce friction and allow maximal range of motion around joints. When there is inflammation within a bursa (bursitis), the bursa swells due to an increase in the amount of fluid within the bursa sac.

There are four bursae located around the knee joint, all of which are prone to inflammation. However, the prepatellar bursa (the bursa in between the skin and the kneecap) is most commonly affected. Another condition is Clergyman’s knee; inflammation to the infrapatellar busae and this can be superficial or deep. The superficial infrapatellar bursa is located between the tibial tubercle and the overlying skin, whereas the deep infrapatellar bursa is located between the posterior aspect of the patellar tendon and the tibia.

There are a number of different things that can cause housemaid’s knee:

A sudden injury to the knee

Re-current minor injury to the knee. This usually happens after spending long periods of time kneeling down, putting pressure on the kneecap (patella). Historically, this was typical of housemaids who spent long periods of time on their knees scrubbing floors; hence, the term housemaid’s knee.

A co-existing inflammatory disease such as synovitis related to rheumatoid arthritis.

Normal articular cartilage is tough and hard wearing. In many people it will not wear out and lasts a lifetime of coping with a million steps per year. Two normal cartilage surfaces lubricated with normal knee synovial fluid rubbing on each other have a coefficient of friction that is very slippery; more slippery than two ice cubes rubbing together.

Chondral damage means that there is an area of damage in the rubbery cartilage that covers the ends of the bones inside the knee joint. This cartilage acts as a shock absorber, and allows the bones to move smoothly over one another.

What causes Knee Joint Surface damage?

Chondral damage can be caused by an injury such as a twist, fall or direct blow to the knee, or the cartilage can wear away with time (known as osteoarthritis). Chondral damage caused by an injury often accompanies injury to a ligament, for example an anterior cruciate ligament injury.

In teenagers, sometimes a piece of the cartilage breaks away with a piece of bone, causing a type of damage known as osteochondritis dissecans.

There are no nerves in the cartilage so there are sometimes no symptoms at first. However, damage can disrupt the normal function of the joint and cause on-going pain and inflammation, as well as limiting mobility.

A diagnosis made during a medical examination can be backed up with an MRI scan to show the extent of the damage. You may also be offered an arthroscopy which allows the knee specialist to examine the joint and, in some cases, treat it at the same time.

How is it treated?

Cartilage does not have the ability to repair itself, so you may need knee arthroscopy to treat the condition.

An injury to the knee joint surface may occur with any trauma to the knee. When a fragment of cartilage breaks free this causes severe pain, swelling and catching in the knee. It is occasionally possible to re-attach these loose fragments and reconstruct the joint surface.

The most common situation is that the fragments need to be removed with keyhole (arthroscopic) surgery. The damaged area may simply require tidying up or chondroplasty to remove any loose edges. If the joint surface damage is more significant, surgery can then be carried out to try and encourage new cartilage to form, in the form of a Microfracture Procedure.

Articular cartilage has very low potential for self-repair. Once damaged, it does not tend to heal. Several procedures are available to regenerate joint surface cartilage in the form of Microfracture, OATS, and Cartilage Transplantation (MACI) though restoration to complete normality is usually not possible.

Normally, the kneecap (patella) sits over the front of the knee joint. It glides over a groove in the joint when you straighten or bend your knee. When the kneecap dislocates, it moves out of this groove and the supporting tissues can overstretch or tear. A dislocated kneecap should be treated promptly and investigated properly.

What are the common causes?

Kneecap dislocation is an uncommon injury usually caused by a sudden change in direction or when the leg hits the ground. It often happens during sports or dancing moves, but can also occur with every day activities. It’s often seen in teenagers.

When a kneecap dislocates, it shouldn’t be hard to spot as the knee usually looks deformed. Other signs and symptoms are:

• sometimes you hear a ‘crack’
• kneecap may feel out of joint
• surrounding tissue swells up very quickly
• extreme painful
• unable to walk

Very often the kneecap will spontaneously correct itself soon afterwards, which can mean the diagnosis is not made when it’s later seen by a knee specialist.

If it’s not the first time you’ve dislocated your kneecap and you’ve managed to gently manipulate the kneecap back into place, with no major injury, there may be no need to go to hospital. Sit with your leg outstretched and keep it still. Either straighten your knee or ask someone to gently lift up your foot. The kneecap will usually correct itself and the pain should rapidly fade. You can manage any swelling by holding an ice pack to your knee for 10 to 15 minutes every hour for the first day of your injury, and every few hours for the few days that follow. If the kneecap dislocates for the second time or more, a surgical procedure is often necessary to correct the problem and prevent further dislocation.

How is it treated?

If it’s the first time you’ve dislocated your kneecap, the leg will be immediately splinted by paramedics and you’ll be taken to your nearest hospital A&E department. If the kneecap hasn’t corrected itself by the time you get to hospital, a doctor will need to manipulate the kneecap back into place in a procedure called a reduction. You may be given medication to sedate you to ensure you are relaxed and free from pain. When the kneecap is back in place, you may have further tests to check the bones are in the correct position and there is no other injury.

You’ll need about six weeks of physiotherapy to recover. A physiotherapist will give you some exercises, such as straight leg raises, to do at home or in the gym to help strengthen the leg muscles and improve the movement of your knee. You probably won’t need supervised treatment if you’re managing recurrent dislocations yourself. There is a better chance of preventing the kneecap dislocating again if you regularly do the exercises your physiotherapist recommends.

Surgery would only be necessary if there is a fracture with a piece of bone floating in the knee.

Osteoarthritis can affect any joint in the body, but the most common areas affected are the knees, hips, and small joints in the hands. Often, you will only experience symptoms in one joint or a few joints at any one time.

If you have osteoarthritis in your knees, it is likely both your knees will be affected over time, unless it has occurred as the result of an injury or another condition affecting only one knee.

You will experience most painful when you walk, particularly when walking up or down stairs.

Sometimes, your knees may ‘give way’ beneath you or make it difficult to straighten your legs. You may also hear a soft, grating sound when you move the affected joint.

What causes osteoarthritis of the knee?

Osteoarthritis of the knee is most common if you’re in your late 50’s or older. Osteoarthritis is often thought of as wear and tear of your joints (gradually) over time. Osteoarthritis is more common and more severe in women. If you’re overweight this increases the chances of developing osteoarthritis and of it becoming gradually worse.

You are also more likely to develop osteoarthritis of the knee if your parents or siblings have had osteoarthritis, you’ve had a knee injury, you’ve had an operation on your knee or repairs to your cruciate ligaments, you do a hard, repetitive activity or a physically demanding job, you have another type of joint disease which has damaged your joints, for example rheumatoid arthritis or gout.

How is it treated?

The mainstay of treatment for osteoarthritis is pain relief such as paracetamol or an anti-inflammatory drug, if you can tolerate them. Stretching and strengthening the muscle around the joint with gentle exercises or physiotherapy can help. Injections of steroid or cortisone can occasionally be used. There are a number of different surgical procedures for Osteoarthritis such as partial or Total Knee Replacement and Osteotomy. These procedures can be highly successful. New techniques to resurface the joint with articular cartilage, replace menisci and realign the limb remain in the research phase but Mr Neil Bradbury will be happy to discuss them with you.

If you have severe pain from osteoarthritis or it has a significant impact on your life, your knee specialist may suggest you have surgery. Which type of surgery you’re offered will depend on your individual circumstances. This could an operation to replace part, or the whole, of your affected joint with an artificial one. Keyhole surgery or arthroscopy is rarely indicated for pure osteoarthritis but can be used if there are mechanical problems such as locking or catching due to loose bodies in the joint. Your knee consultant will discuss these options with you to help you make a decision that’s right for you.

Surgery may help to ease your pain if other treatments haven’t been effective for you. As with every procedure, there are some risks associated with having surgery for osteoarthritis.

For osteoarthritis sufferers a single protein injection, called Intra-Articular Protein Injection, harvested from a patient’s blood could replace the need for knee surgery. We now have 3 year results for nSTRIDE - the take home message is 70% of patients are still experiencing 70% relief of knee pain symptoms 3 years after Nstride injection. This compares with no more than a few weeks with steroids.

Patellofemoral pain syndrome is a common cause of pain around the front of the knee. It happens when your kneecap (patella) and cartilage in your joint is affected by imbalances in the muscles or wear/damage to the articular cartilage behind the kneecap or in the groove in which the kneecap runs called the trochlear groove. It usually gets better with simple treatments such as physiotherapy and exercises. You may need to adjust your training programme if you do a lot of sport.

What causes Patellofemoral Pain?

It is probably due to a combination of different factors which put extra strain on the knee joint and on the surrounding muscles and ligaments.

The most common cause is overuse of the knee, associated with certain sports such as running, particularly at times of increased training. Some people may have a slight problem in the alignment of the knee; this may cause excessive stress on one part of the patella-femoral joint. The pain may also be due to the way the knee has developed or it may be due to an imbalance in the muscles around the knee. If one side of the quadriceps muscles pulls harder than the other side, then the patella may not glide correctly and may rub on one side.

Foot problems can play a part, for example, where the feet do not have strong arches (flat feet). This makes the foot roll inwards (pronate), which means the knee has to compensate for the inward movement.

Symptoms include pain around the knee. The pain is felt at the front of the knee, around or behind the kneecap. Often, the exact site of the pain cannot be pinpointed; instead the pain is felt vaguely at the front of the knee.

The pain may come and go and is typically worse when going up or down stairs or with certain sports. Also, it may be brought on by sitting still for long periods. There may be a grating or grinding feeling or noise when the knee moves. This is called crepitus. Sometimes there is fullness or swelling around the patella.

What is the treatment for patellofemoral pain?

You will be advised to avoid strenuous use of the knee – until the pain eases. Symptoms usually improve in time if the knee is not overused. Aim to keep fit, but to reduce the specific activities which cause the pain.

In the longer term, certain treatments aim to correct some of the underlying causes – for example, by strengthening muscles and helping with foot problems. Treatments include:

Physiotherapy – improving the strength of the muscles around the knee will ease the stress on the knee. Also, specific exercises may help to correct problems with alignment and muscle balance around the knee. For example, you may be encouraged to do exercises which strengthen the inner side of the quadriceps muscle. You may also be taught exercises to stretch tight ligaments. The specialist physiotherapist can give advice tailored to your individual situation.

Taping of the patella – this is a treatment which may reduce pain. It is where adhesive tape is applied over the patella, to alter the alignment or the way the patella moves. Some people find this helpful.

Surgery is not often used for patellofemoral pain. However, it may be helpful in certain situations. For example, surgery to correct the alignment of the patella.

Posterior cruciate ligament injury happens far less often than injury to the anterior cruciate ligament (ACL). The posterior cruciate ligament and ACL help to hold your knee together. If either ligament is torn, you may experience pain, swelling and a feeling of instability.

Ligaments are strong bands of tissue that attach one bone to another. The cruciate ligaments connect the thighbone (femur) to the shinbone (tibia). The anterior and posterior cruciate ligaments form a cross in the centre of the knee.

While a posterior cruciate ligament injury generally causes less pain, disability and knee instability than does an ACL tear, it can still cause knee pain for several weeks or months.

Causes include road accidents and contact sports. A dashboard injury occurs when the driver’s or passenger’s bent knee slams against the dashboard, pushing in the shinbone just below the knee and causing the posterior cruciate ligament to tear. Athletes in sports such as football and rugby may tear their posterior cruciate ligament when they fall on a bent knee with their foot pointed down. The shinbone hits the ground first and it moves backward. Being tackled when your knee is bent can also cause this injury.

The main symptoms following a PCL injury are pain at the back of the knee. Instability is less common than in ACL injuries. In people who have injured the PCL months or years before, pain at the front of the knee can become a problem as the knee struggles to maintain stability and the kneecap cartilage wears out.

What treatments are there for Posterior Crucial Ligament Injury?

Treatment depends on the extent of your injury and whether it just happened or if you’ve had it for a while. In most cases, surgery isn’t required.

A physiotherapist can teach you exercises that will help make your knee stronger and improve its function and stability. You may also need a knee brace or crutches during your rehabilitation.

Aspiration uses a syringe to remove fluid from the joint. Aspiration may be performed if you have significant swelling of the knee that interferes with the joint’s range of motion and your ability to use your knee or leg muscles.

If your injury is severe, especially if it’s combined with other torn knee ligaments, cartilage damage or a broken bone, you may need surgery to reconstruct the ligament. Surgery may also be considered if you have persistent episodes of knee instability despite appropriate rehabilitation. This surgery can usually be performed arthroscopically by inserting a camera and long, slender surgical instrument through several small incisions around the knee.

Patellar tendinopathy is a common overuse injury. Jumping causes repeated strain to the patellar tendon resulting in changes to its structure such as small tears or cysts.

You’re more likely to get patellar tendinopathy if you have recently changed your training programme, shortened the length of your rest times, experienced problems with body movement (biomechanics), or have poor muscle flexibility.

What is the treatment for Patellar tendinopathy?

Patellar tendinopathy doesn’t usually get better on its own, so it’s important to seek medical treatment. A sports medicine professional, such as a physiotherapist or sports medicine doctor, will be able to diagnose the problem and give you a treatment plan. This will involve an exercise programme, usually strengthening exercises, and massage.

A biomechanical assessment may be recommended by the knee specialists, as well as treatment from a podiatrist to prevent the injury from happening again.

There’s no quick fix for patellar tendinopathy. You may need a long period of rehabilitation before your symptoms go completely. However, the earlier you get treatment, the quicker your recovery.

New treatments such as PRP (platelet rich plasma) injections or shock wave treatment can speed up the recovery from patellar tendinopathy.

The meniscus acts as a shock absorber, and allows the bones to move smoothly over one another. The meniscus, sometimes called ‘footballers cartilage’ or semi-lunar cartilage as it looks like a full moon should not be confused with articular cartilage which is the slippery gristle that covers the weight bearing surface of joints, allowing the joints to move smoothly. Meniscal pain worsens on twisting/turning on the affected joint and is often painful when squatting or on deep knee bends.

Meniscal cartilage injuries

The knee is commonly injured in sports, especially rugby, football and tennis. You may tear a meniscus with a forceful knee movement whilst you are weight bearing on the same leg. The classic injury is for a footballer to twist (rotate) the knee while the foot is still on the ground. An example is a tennis player who twists to hit a ball hard, but with the foot remaining in the same position. The meniscus may tear fully or partially. How serious the injury is depends on how much is torn and the exact site of the tear.

Meniscal tears may also occur without a sudden severe injury. In some cases a tear develops due to repeated small injuries to the cartilage or to wear and tear (degeneration) of the meniscal cartilage in older people. In severe injuries, other parts of the knee may also be damaged in addition to a meniscal tear.

Meniscal cartilage does not heal very well once it is torn. This is mainly because it does not have a good blood supply. The outer edge of each meniscus has some blood vessels, but the area in the centre has no direct blood supply. This means that although some small outer tears may heal in time, larger tears, or a tear in the middle, tend not to heal.

What are the symptoms of a meniscal tear?

The symptoms of a meniscal injury depend on the type and position of the meniscal tear. Many people have meniscal tears without any knee symptoms, especially if they are due to degeneration.

• The pain is often worse when you straighten the leg. If the pain is mild, you may be able to continue to walk. You may have severe pain if a torn fragment of meniscus catches between the tibia and femur. Sometimes, an injury that you had in the past causes pain months or years later, particularly if you injure the knee again.
• The knee often swells within a day or two of the injury. Many people notice that their knee is slightly swollen for several months if the tear is due to degeneration.
• You may be unable to straighten the knee fully. In severe cases you may not be able to walk without a lot of pain. The knee may lock from time to time if the torn fragment interferes with normal knee movement. Some people notice a clicking or catching feeling when they walk. A locked knee means that it gets stuck when you bend it and you can’t straighten it without moving the leg with your hands.

For some people, the symptoms of meniscal injury go away on their own after a few weeks. However, for most people the symptoms persist long-term, or flare up from time to time, until the tear is treated.

What is the treatment for a meniscal tear?

When you first hurt your knee the initial treatment should follow the simple PRICE method:

• Protect from further injury.
• Rest (crutches for the initial 24-48 hours).
• Ice (apply ice (wrapped in a towel, for example) to the injured area for 20 minutes of each waking hour during the first 48 hours after the injury).
• Compression (with a bandage, and use a knee brace or splint if necessary).
• Elevation (above the level of the heart).

These actions, combined with painkillers, help to settle the initial pain and swelling. Further treatment will then depend on:

• The size of the tear.
• The severity of symptoms.
• How any persisting symptoms are affecting your life.
• Your age.
• Your general health.

Non-operative treatment

Small tears may heal by themselves in time, usually over about six weeks. Some tears which do not heal do not cause long-term symptoms once the initial pain and swelling subside, or cause only intermittent or mild symptoms. In these cases, surgery may not be needed. You may be advised to have physiotherapy to strengthen the supporting structures of the knee, such as the quadriceps and hamstring muscles.

Surgery

If the tear causes persistent troublesome symptoms then surgery may be advised. Most operations are done by arthroscopy. The types of operations which may be considered include the following:

• The torn meniscus may be able to be repaired and stitched back into place. However, in some cases this is not possible.
• In some cases where repair is not possible, a small portion of the meniscus may be trimmed or cut out to even up the surface.
• Sometimes, the entire meniscus is removed.
• Meniscal transplants are possible. The missing meniscal cartilage is replaced with donor tissue, which is screened and sterilised much in the same way as for other donor tissues.
• There is an operation in which collagen meniscal implants are inserted. The implants are made from a natural substance and allow your cells to grow into it so that the missing meniscal tissue regrows.

Arthroscopy

This is a procedure to look inside a joint by using an arthroscope. An arthroscope is like a thin telescope with a light source. It is used to light up and magnify the structures inside a joint. Two or three small (less than 1 cm) cuts are made at the front of the knee. The knee joint is filled up with fluid and the arthroscope is introduced into the knee. Probes and specially designed tiny tools and instruments can then be introduced into the knee through the other small cuts. These instruments are used to cut, trim and take samples (biopsies) inside the joint. Arthroscopy can be used to diagnose and also to treat meniscal tears.

Following surgery, you will have physiotherapy to keep the knee joint active (which encourages healing) and to strengthen up the surrounding muscles to give support and strength to the knee.

ACL reconstruction can improve the stability and the function of your knee following an injury. It involves replacing the ACL in your knee, usually using a tendon from another part of your body. You will meet the surgeon carrying out your procedure to discuss your care and can discuss the procedure in detail. It may differ from what’s described here as it will be designed to meet your individual needs.

What is an anterior cruciate ligament reconstruction?

The anterior cruciate ligament (ACL) is one of the two large ligaments within the knee. It controls front to back and, most importantly, pivoting or twisting movement. The ACL can be torn or ruptured during sports activities and once broken, it rarely heals and the knee may give way.

Regular giving way can lead to secondary damage to the menisci (shock absorbers) and articular cartilage (joint surface) as well as making twisting and turning difficult.

A ligament graft is required using material taken from the front of the knee or from the hamstring tendons behind the knee, both of which are able to re-grow to a large extent.

Successful ACL reconstruction will mean your knee will no longer give way and you can return to sport and everyday activities.

What does this involve?

Anterior cruciate ligament reconstruction is usually performed through keyhole surgery under general anaesthetic. You would normally be admitted on the day of the operation and some people go home the same day or have an overnight stay in hospital.

You will not be able to eat for eight hours prior to surgery although you will be able to drink small amounts of water up to four hours before.

The operation takes about one hour and your surgeon will make some keyhole incisions in your knee to allow small specially designed instruments to be introduced. The torn ligaments are trimmed and the knee is prepared for the replacement graft of suitable tissue. Part of the patellar tendon (which runs from the lower end of your kneecap to the top of your shin bone) is normally used. The top and bottom ends of the replacement ligament are fixed into place with special screws into holes drilled into your bones.

The incisions are closed with stitches or adhesive strips

When will I recover?

Recovery from the anaesthetic is rapid and you will be awake very soon after the operation although you may feel drowsy for an hour or two. You will be allowed to go home once you are weight bearing with the assistance of crutches.

You may shower with the waterproof dressing on and your physiotherapists will give you advice on how to exercise your leg before you leave and may arrange outpatient physiotherapy, if needed. You will be given a cold compress along with instructions on how to cool your knee, which is important and aids recovery. You will see your knee consultant two weeks after your operation to review your progress.

You may need to take 4-6 weeks off work and driving following the operation and your surgeon may want you to wear a knee brace for a few weeks.

When your knee has settled down, you will need to start intensive physiotherapy which may continue as long as six months.

What risks should I know about?

Anterior cruciate ligament reconstruction is commonly performed and generally safe but there can be potential complications. These only affect less than 4% of patients.

Infection can occur although our theatres have ultra-clean air operating conditions keeping infection rates at 1:1000. We give antibiotics to reduce the risk

Blood clots are rare. We use established prevention methods including aspirin.

Damage to the nerves around the knee leading to weakness, numbness or pain in the leg or foot – this usually settles on its own. Risk is less than 1%.

A break of the kneecap can occur during or after surgery but only if your surgeon uses a patella tendon graft – 1% risk.

Risk of re-rupture or stretching is 1% per year; this means that 10 years from surgery there is a 90% chance that the graft will still be functioning well.

The Chondrotissue Graft is the latest development in articular cartilage repair and or replacement surgery.

Damage to articular cartilage or damage to both the cartilage and the underlying bone does not repair itself spontaneously and results in joint pain and poor function. Thinning and roughening of the articular cartilage can progress to severe wear and eventually patches of bare bone rubbing on bare bone in the knee leading to arthritis.

Such damage, which is common after trauma, can lead to osteoarthritis if left untreated. The knee is the most commonly affected joint. Articular cartilage has no blood supply and therefore doesn’t heal on its own or repair itself. There are a number of surgical techniques available for cartilage repair and or replacement, and each has its own specific indications.

Microfracture

Microfracture is an excellent technique for treating small patches (less than 1cm² defects). It can be performed easily via keyhole (arthroscopic) surgery and does not require complicated equipment. It can give 80% success rates at 5-years follow-up. However, the bigger the area of cartilage damage, the worse the results tend to be, and microfracture does not tend to work well with areas of damage much greater than about 2cm².

For bigger cartilage defects, the best options currently available are either MACI (Matrix-induced Articular Cartilage Implantation/transplantation) or the use of a Chondrotissue Graft.

Chondrotissue Graft

The Chondrotissue Graft is a high-tech scaffold that is a sterile absorbable matrix sponge-like textile made of non-woven polyglycolic acid treated with hyaluronic acid. It has been shown to induce mesenchymal progenitor cells (stem cells) to differentiate into cartilage cells. The larger patch of cartilage damage is treated by microfracture, but the Chondrotissue Graft is then fixed over the defect. The graft then ‘captures’ the blood, bone marrow cells and stem cells released by the microfracture, giving them a scaffold in which to grow and mature into new cartilage tissue.

Studies have shown that the new cartilage produced with Chondrotissue Grafts is superior in quality to that produced by microfracture alone, and highly encouraging clinical results are beginning to be reported in the scientific literature. It is, however, only with further time that we will have results to show us what the long term outcomes are comparing the Chondrotissue Graft to other techniques such as MACI.

One of the main attractions of the Chondrotissue graft is that more invasive procedures such as MACI require two separate operations – the first to harvest cartilage cells for culture, and the second to implant the cultured cells whereas Chondrotissue can be implanted by a single-stage operation.

The latest advance that we are now using in articular cartilage replacement surgery, in conjunction with Chondrotissue, is a biological glue called Vivostat Platelet Rich Fibrin (PRF).

Biological glue called Vivostat Platelet Rich Fibrin (PRF)

Vivostat PRF has been used extensively for years in cardiac surgery, vascular surgery and plastic surgery. It involves taking a blood sample from the patient, spinning the blood down and extracting the fibrin (part of what forms a natural blood clot), combined with a high concentration of platelets (which also contact growth factors). This forms a biological glue that can be sprayed around the edges and over the top of the Chondrotissue graft, to help fix it firmly in place in the knee.

In the past we used to use Tisseel glue to secure grafts in place. However, Tisseel is a fibrin glue that’s manufactured from pooled blood donations (i.e. from multiple donors, all mixed in together), and it doesn’t contain platelets.

Vivostat, on the other hand, comes from the patient’s own blood (autologous), so there are less concerns about potential disease transmission or infection. Also, Tisseel doesn’t contain platelets, whereas Vivostat PRF does. Therefore, Vivostat PRF is not just a biological bioabsorbable glue, but it is also autologous and ‘bioactive’ – to help try and promote healing of the tissue and in-growth of new cartilage.

Knee Arthroscopy is better known as ‘keyhole surgery’ and allows your knee surgeon to look inside your knee joint through a camera inserted through a small cut in the skin. This allows a diagnosis of any problems, probably cartilage related, and treatment using special designed surgical instruments – often at the same time.

What does this involve?

Knee Arthroscopy surgery is usually done as a day case procedure under general anaesthetic and takes around twenty minutes.

Your surgeon can make two small cuts in your skin around the knee joint. The first is used to pump sterile fluid into the joint and the second is for the arthroscope to be introduced. An arthroscope is a small flexible tube about the length and width of a drinking straw which contains a light source and a digital camera that sends images to a video screen or your surgeon’s eyepiece.

If treatment is required, such as trimming a cartilage, then another cut in the skin is made which will allow specially designed instruments to be introduced into the joint so that the surgeon can undertake the necessary work.

The fluid is drained out and the cuts are closed with stitches or adhesive strips. A dressing or bandage is wrapped around the knee.

When will I recover?

You will be admitted into hospital as a day case procedure so you will normally be able to go home on the same day. Your physiotherapist may give you some exercises to help you get back to normal living and you may need to take a week off work and driving.

What risks should I know about?

Knee Arthroscopy is an extremely safe procedure but there is always a small risk of complications which can include:

• Damage to nerves around the knee leading to some weakness, numbness or pain in the leg or foot. This usually settles on its own but may be permanent.
• Developing a lump under the wound after surgery. This is caused by a small amount of bleeding under the skin and usually settles after a few weeks.
• Infection in the joint which may need treatment.

The knee can be divided into three joints; medial (inside), lateral (outside) and patello-femoral (kneecap). If the kneecap alone is affected by arthritis then an artificial joint can replace this part.

There are advantages of a patella replacement over a full knee replacement in that there would be a smaller incision, less post-operative discomfort, quicker recovery, a better range of motion and the retention of your own main knee joint.

What does this involve?

Knee cap replacement surgery is carried out in hospital under general anaesthetic and local anaesthetic is injected into your knee at the end of the operation so you wake up with no pain

You will not be able to eat for eight hours prior to surgery although you will be able to drink small amounts of water up to four hours before.

The operation itself takes around 60 minutes and your surgeon will make a small cut down the front of your knee. The kneecap is removed and replaced with a patello-femoral artificial joint and the incision is closed with stitches or clips. An acrylic cement is usually used to bond the new joint directly onto your bones.

Afterwards your knee will be tightly bandaged to help minimise swelling and fine drainage tubes may also be left in for up to 48 hours.

When will I recover?

You are likely to stay in hospital for two to three days after your operation and your physiotherapists will give you exercises that help you walk the day after the operation. You will gradually progress from using crutches to using walking sticks and you will be allowed to go home once you are fully weight bearing and can manage stairs and to care for yourself.

The knee dressing can be peeled off easily several days after the surgery and, as the stitches are internal, they do not need to be removed. You will be given a cold compress or ‘Cryocuff’ along with instructions on how to cool your knee, which is important and aids recovery. You will see your consultant once again six weeks after your operation to review your progress.

Patella surgery recovery is moderate and reasonably quick. You are likely to need four to six weeks off work and driving following the operation.

What risks should I know about?

Kneecap replacement surgery is a relatively new procedure which has given good results to date with the promise of a long lasting solution to this particular problem. There are some potential complications you should be aware of. These only affect less than 4% of patients.

Infection can occur although our theatres have ultra-clean air operating conditions keeping infection rates at 1-2%.

Blood clots are possible in any major joint replacement surgery but again are in the 1-4% category and have well established treatments including aspirin.

A small patch of numb skin can be present on the outer part of the knee near the kneecap, this will improve over time

The knee will have some stiffness after the operation although we are aiming for 0-125 degrees of movement once things have settled down.

In the knee, there are areas of cartilage tissue which act like shock absorbers in the joint – these are called menisci. There are also areas of cartilage covering the ends of the long bones at the knee joint – these are called articular cartilages. Both of these areas of cartilage may become damaged causing significant problems for patients.

When doctors talk about a cartilage injury to a knee, they usually mean an injury to one of the menisci. See meniscus repair surgery.

However, the knee also has cartilage covering the ends of the bones in the joint – this is called articular cartilage – and damage can occur here as well.

Symptoms of cartilage damage include swelling, joint pain, stiffness and a decreased range of movement in the affected joint. Cartilage covers the surface of joints, enabling bones to slide over one another while reducing friction and preventing damage. It helps to support your weight when you move, bend, stretch and run.

Articular cartilage damage is one of the most common and potentially serious types of cartilage damage, and usually affects the knee joint. The damage can result in pain, swelling and some loss of mobility.

Non-surgical treatments, such as physiotherapy and non-steroidal anti-inflammatory drugs (NSAIDs), are usually recommended for minor to moderate cases of cartilage damage.

What does surgery involve?

There are a number of surgical techniques available, such as encouraging the growth of new cartilage, or taking a piece of healthy cartilage from elsewhere in the joint and using it to replace damaged cartilage.

The Chondrotissue Graft is the latest development in articular cartilage repair and or replacement surgery. This is a high-tech scaffold that is a sterile absorbable matrix sponge-like textile made of non-woven polyglycolic acid treated with hyaluronic acid. It has been shown to induce mesenchymal progenitor cells (stem cells) to differentiate into cartilage cells.

Microfracture is an excellent technique for treating small patches (less than 1cm² defects). It can be performed easily via keyhole (arthroscopic) surgery and does not require complicated equipment.

In the most serious cases, the entire joint may need to be replaced with an artificial joint, such as a knee replacement or hip replacement.

Watch Neil Bradbury performing a meniscal transplant and cartilage repair. The Holy Grail of orthopaedics has always been the regeneration of articular cartilage.

Knee osteotomy is commonly used to realign your knee structure if you have arthritic damage on only one side of your knee. The aim is to shift your body weight off the damaged area to the other side of your knee, where the cartilage is still healthy. When surgeons remove a small section of your shinbone from underneath the healthy side of your knee, the shinbone and thighbone can bend away from the damaged cartilage.

Osteotomy is also used as an alternative treatment to total knee replacement in younger and active patients. Because prosthetic knees may wear out over time, an osteotomy procedure can enable younger, active osteoarthritis patients to continue using the healthy portion of their knee. The procedure can delay the need for a total knee replacement for up to ten years.

What is knee realignment (osteotomy) surgery?

Depending on where osteoarthritis has damaged your cartilage, an osteotomy removes a section of bone from different areas of your shinbone. The most common type of osteotomy performed on arthritic knees is a high-tibial osteotomy, which addresses cartilage damage on the inside portion of your knee.

During a high-tibial osteotomy, surgeons remove a sectione of bone from the outside of your knee, which causes your leg to bend slightly inward. It is like realigning a bowlegged knee to a knock-kneed position. Your weight is transferred to the outside (lateral) portion of your knee where the cartilage is still healthy.

The knee joint includes the patella, the lower end of the femur and the upper tibia, all are enclosed within the same sleeve of synovial membrane and supported by the surrounding ligaments and muscles. Functionally there are three separate compartments: the patellofemoral joint between the deep surface of the patella and the front of the femur; the medial compartment between the medial femoral condyle and the medial tibial plateau on the inner aspect of the knee; and the lateral compartment between the lateral femoral condyle and the lateral tibial plateau on the outer aspect of the knee.

Osteoarthritis can affect one, two or all three of these joint compartments to a greater or lesser degree. As a result of this we can choose to replace just the affected part of the joint in about 50% of cases of osteoarthritis rather than the whole joint. The big advantage of this is that it is a smaller operation than a total knee replacement, with less blood loss and a shorter stay in hospital. It also results in a more normal feel to the knee and better overall function.

Partial replacements of just one compartment are called uni-compartmental knee replacements; two compartments – bi-compartmental knee replacements and three compartments – total knee replacements.

Resurfacing rather than replacement

The procedure of uni-compartmental or bi-compartmental knee replacement is more of a resurfacing procedure rather than a replacement, although the word replacement is still most commonly used. In effect a relatively thin layer of bone and cartilage is removed no thicker than 9 mm in most cases from the affected surfaces and replaced with a ceramic on metal surface with a plastic or high density polyethylene bearing. It is important to realise that during a UKR there is always the potential for the surgeon to have to switch to a total knee replacement for technical reasons if the knee is just not suitable for a partial knee procedure. Your surgeon will discuss this with you during consultation. Generally speaking partial knee replacements are not suitable for patients with inflammatory conditions arthritis such as rheumatoid arthritis.

The most common type of arthritis is osteoarthritis, where there is gradual wear and tear of a joint. Arthritis eventually wears away the normal cartilage covering the surface of the joint and the bone underneath becomes damaged. Where this occurs in the knee, your consultant may recommend a knee replacement.

The damaged and worn surfaces of the knee joint are carefully removed and resurfaced with a Cobalt/Chrome metal joint that is sized to fit. High-density polyethylene (a type of plastic) sits between the metal surfaces and acts as a bearing surface. The back of the kneecap is also usually resurfaced with the same material.

Knee replacement surgery can be provided using the very latest in robot-assisted surgery through the Mako system.

Knee replacements last at least fifteen to twenty-five years and will return you to normal movement and activity levels with less pain.

What does this involve?

Knee Replacement surgery is carried out in hospital under general anaesthetic although most people also have a spinal anaesthetic to make the legs completely painless for a few hours.

You will not be able to eat for eight hours prior to surgery although you will be able to drink small amounts of water up to four hours before.

The operation itself takes up to 90 minutes and your surgeon will make a 15 to 30 cm cut down the front of your knew. The kneecap is moved to one side so that the joint can be reached. Once the joint has been replaced the incision is closed with stitches or clips. An acrylic cement is usually used to bond the new joint directly onto your bones.

Afterwards, your knee will be tightly bandaged to help minimise swelling and fine drainage tubes may also be left in for up to 48 hours.

When will I recover?

You are likely to stay in hospital for one to four days after the operation and your physiotherapists will give you exercises that help you walk the day after the operation. You will gradually progress from using crutches to using walking sticks and you will be allowed to go home once you are fully weight bearing and can manage stairs and to care for yourself.

The knee dressing can be peeled off easily ten days after the surgery and, as the stitches are internal, they do not need to be removed. You will be given a cold compress or ‘Cryocuff’ along with instructions on how to cool your knee, which is important and aids recovery. You will see your Consultant once again six weeks after your operation to review your progress.

Knee replacement is a major operation and recovery takes place over 6-12 weeks. At six weeks, some patients will still be using a walking stick but most are walking well and independently at twelve weeks although you may not see the full benefit of surgery for up to a year.

What risks should I know about?

Knee replacement surgery is a very successful operation but there are some potential complications you should be aware of. These only affect less than 4% of patients.

Infection can occur although our theatres have ultra-clean air operating conditions keeping infection rates at 1-2%.

Blood clots are possible in any major joint replacement surgery but again are in the 1-4% category and have well-established treatments including aspirin.

A small patch of numb skin can be present on the outer part of the knee near the kneecap, this will improve over time

The knee will have some stiffness after the operation although we are aiming for 0-125 degrees of movement once things have settled down.

Your patella (kneecap) is positioned in a groove at the end of your thighbone protecting your knee joint. It moves within the groove allowing up and down motion which is required to bend your knee.

If wear and tear or an injury causes the patella to move out of the groove from side to side (dislocate) the result can be very painful and have major impact to your mobility.

Before proceeding with any treatment your knee consultant will need to assess the cause of your patella dislocation. This may involve an x-ray or MRI scan. If this is the first time you have experienced a dislocation your consultant may recommend physiotherapy to strengthen the muscles around your knee joint or a brace to help hold the joint in place.

Unfortunately many patella dislocations reoccur. If you continue to experience this your knee consultant may recommend surgery.

What happens during patella stabilisation?

Patella stabilisation is usually performed under general anaesthetic. The surgery performed will be dependent on your individual situation. Sometimes torn ligaments are repaired. In other cases a tendon may be repositioned to stop the patella from being pulled sideways. Most patella stabilisation procedures can be performed arthroscopically.

Your length of hospital stay will depend on what procedure is performed. You will have the opportunity to discuss this with you consultant.

After patella stabilisation

Please arrange for someone to drive you home following your surgery. You will not be able to drive for 4 to 6 weeks depending on your recovery.

Depending on your procedure you may go home using crutches or a walker. You may not be allowed to put full weight on your operated side for several weeks. Take any pain relief medication as prescribed. Icing and elevating your leg may help control swelling and stiffness.

Your consultant may prescribe physiotherapy to help you regain strength and mobility. You will need a series of follow-up appointments to assess your progress and help with rehabilitation.

The knee can be divided into three joints; medial or inside, lateral or outside and patello-femoral or kneecap joint. If the kneecap alone is affected by arthritis then an artificial joint can replace this part.

There are advantages of a patella replacement over a full knee replacement in that there would be a smaller incision, less post-operative discomfort, quicker recovery, a better range of motion and the retention of your own main knee joint.

What does this involve?

Knee cap replacement surgery is carried out in hospital under general anaesthetic and local anaesthetic is injected into your knee at the end of the operation so you wake up with no pain.

You will not be able to eat for six hours prior to surgery although you will be able to drink small amounts of water up to four hours before.

The operation itself takes around 60 minutes and your surgeon will make a small cut down the front of your knee. The kneecap is removed and replaced with an Avon patello-femoral artificial joint and the incision is closed with stitches or clips. An acrylic cement is usually used to bond the new joint directly onto your bones.

Afterwards your knee will be tightly bandaged to help minimise swelling and fine drainage tubes may also be left in for up to 48 hours.

When will I recover?

You are likely to stay in hospital for two to three days after the operation and your physiotherapists will give you exercises that help you walk the day after the operation. You will gradually progress from using crutches to using walking sticks and you will be allowed to go home once you are fully weight bearing and can manage stairs and to care for yourself.

The knee dressing can be peeled off easily several days after the surgery and, as the stitches are internal, they do not need to be removed. You will be given a cold compress or ‘Cryocuff’ along with instructions on how to cool your knee, which is important and aids recovery. You will see your consultant once again six weeks after your operation to review your progress.

Patella surgery recovery is moderate and reasonably quick. You are likely to need four to six weeks off work and driving following the operation.

What risks should I know about?

Kneecap Replacement surgery is a relatively new procedure which has given good results to date with the promise of a long lasting solution to this particular problem. There are some potential complications you should be aware of. These only affect less than 4% of patients.

Infection can occur although our theatres have ultra-clean air operating conditions keeping infection rates at 1-2%.

Blood clots are possible in any major joint replacement surgery but again are in the 1-4% category and have well established treatments including aspirin.

A small patch of numb skin can be present on the outer part of the knee near the kneecap, this will improve over time

The knee will have some stiffness after the operation although we are aiming for 0-125 degs of movement once things have settled down.

Robots are fast becoming assistants in the operating theatre, but they are still controlled by surgeons with years of training and experience.

Robotic surgery is performed at hospitals who have embraced innovative technology and installed the state-of-the-art Stryker Mako robotic-arm, enabling the highest standards of the knee replacement.

This highly advanced robotic arm-assisted technology transforms the way knee replacement surgery is performed. The technology enables a more predictable surgical experience with increased accuracy. The Stryker Mako system facilitates higher level alignment and positioning during surgery and for the patient recovery times are much shorter and post-operative pain is reduced.

This latest advancement in surgical technology helps patients to get back to their active lifestyle quicker, whether it be gardening, cycling or even just walking the dog.

What does robotic-arm assisted surgery involve?

Before surgery, the surgeon uses Mako technology to create a personalised surgical plan based on the patient's unique requirements. A CT scan of the joint is taken to create a 3D model of the joint. The surgeon can then use this 3D model to plan the surgery, generating greater accuracy.

During the surgery, the surgeon guides the robotic-arm in a pre-defined area, based on the original pre-operative surgical plan. Robotic-assisted surgery delivers a more accurate placement and alignment of the implant.

It is important to understand that the surgeon is in control of the surgery at all times, guiding the robotic-arm to position the implant in the knee joint. The robotic-arm does not perform the surgery, make decisions on its own, or move without the surgeon guiding it. The technology simply assists the surgeon.

Enhanced results

Even without robot assistance, Neil Bradbury achieves excellent results. Robotic-arm assisted surgery simply pushes results beyond what we've been able to expect in the past. Higher accuracy means the replacement fits as well as it possibly can and ensures the joint functions as normally as possible after surgery.

For patients, robotic-arm assisted surgery has been shown to result in shorter hospital stay, quicker recovery and higher satisfaction. There's also strong evidence of decreased pain and complications following surgery.

When will I recover?

Recovery periods vary for each patient but it's important to understand what can be expected after the procedure. Immediately after surgery your surgeon and the team will closely monitor your condition and progress. Your rehabilitation will begin before you leave the hospital.

Your physiotherapist will talk you through rehabilitation exercises and what to expect in the days and weeks after surgery.

Support doesn’t end here. You will be given information on follow up appointments and contact details when you.

For patients in which all of a meniscus is lost and a meniscal scaffold is not suitable it is possible to insert a meniscal allograft. An allograft is a human meniscus from a donor in much the same way that patients can have corneal or kidney transplants but without the need to prevent rejection with on-going drugs. The patient’s knee is sized by X-ray and MRI scan and a matching meniscus is ordered for implantation. There are a number of sources for this type of implant for example Hospital Innovations.

This is complex surgery but can be performed using a keyhole technique. It is a relatively new technique and tends to be reserved for younger people in whom other treatments have failed. Rehabilitation following this type of procedure is lengthy and patients require several weeks off work and months off sport.

There are two shock absorbers in the normal knee each called a meniscus. They are frequently injured or torn and tend not to heal because only the outer edge has a blood supply. Some tears can be repaired by stitching the meniscus so that it can heal.

The majority of meniscal tears are removed with an arthroscopy (keyhole surgery). If the amount removed is small most patients have no further problem but in patients where a large part of the meniscus is lost there is a risk of developing pain and early arthritis in the joint.

One solution for some patients is insertion of a meniscal scaffold. This is a procedure where a meniscus like scaffold is sewn into place with the aim of allowing the body’s tissue to grow into the scaffold and produce a new meniscus like shock absorber. It is a relatively new technique which has shown promising results. There are two most frequently used scaffolds, the CMI implant http://www.ivysportsmed.com/en/collagen-meniscus-implant and the Actifit implant http://orteq.com/healthcare/the-actifit-procedure/. We offer both types of surgery.

Rehabilitation following this type of procedure is lengthy and patients require several weeks off work and months off sport.

Meniscus repair surgery

Sometimes the meniscus can be repaired using small sutures (stitches) to hold the torn section together. However, menisci do not heal very well, due to poor blood supply, so not all tears can be repaired.

Partial meniscectomy

Partial meniscectomy is where the damaged part of the meniscus is removed during arthroscopic surgery.

Are there any risks from this type of surgery?

Complications following meniscal surgery are rare. However, they can include:

• Infection
  The chance of infection is less than 1% and can usually be treated effectively with antibiotics. Usually only the skin is affected, but if bacteria get into the knee itself then it may be necessary to have a further arthroscopy to wash the knee out with saline solution and give stronger antibiotics via a drip.
• Deep vein thrombosis (DVT)
  The risk of this is less than 1% and is unusual if you move around as much as possible after surgery. Symptoms include pain, swelling, warmth and redness of the calf. Less commonly, a DVT can also present in the thigh area.
• Swelling
  A small amount of swelling is very common after meniscal surgery, often just above the kneecap or around the incision sites. If the swelling becomes painful, you should contact the team for advice.
• Stiffness
  Most people experience some stiffness in the joint after an operation, but this should improve with exercise and physiotherapy.

Follow-up appointments

Everyone is different, so healing and post-operative programmes vary from person to person. However, the follow-up appointments below are typical:

• Two weeks: wound check and removal of stitches
• Six weeks: post-operative check up

If there are any complications with your rehabilitation your physiotherapist may refer you back to your consultant for a further review and will liaise directly with the consultant about any issues

Getting back to normal

• Following the operation you will have a small dressing around your knee.
• You will be allowed up once you have recovered from the anaesthetic.
• If you have had a partial meniscectomy you will be allowed to fully weight-bear as pain allows straight away.
• Following meniscal repair you may not be able to fully weight-bear straight away.
• In some instances you may need to wear a brace to restrict movement in your knee while it heals.
• You may need to have crutches to help you to walk.
• Your knee may be swollen and bruised so you should keep your leg elevated (raised) when you are not walking or exercising.
• A physiotherapist will give you some simple exercises to help with your recovery.

When can I return to work?

This depends on the type of work you do and how quickly you recover. As a general guide, if your job involves sitting down for most of the time, you should be able to return to work a few days after surgery. If it involves being on your feet for longer periods of time, but does not require manual duties such as heavy lifting and kneeling, you may return to work within two to three weeks.

Jobs that require a greater degree of manual work and physical demand, for example lifting and running, may require four to six weeks or more following partial meniscectomy and up to three months or more following meniscal repair.

When can I return to sport?

People recover at different rates for many reasons so returning to sport will be based on how ready you are both physically and psychologically, rather than on a set timeframe.

Following a partial meniscectomy you may be able to return to road cycling at two to four weeks and jogging or light individual sports, for example non-competitive golf, at four to six weeks. These timeframes are doubled following meniscal repair.

The time it takes to return to high performance/contact sports, for example rugby, football and skiing following partial meniscectomy will be six to eight weeks or more. Again, this timeframe will be doubled for meniscal repair.

Am I more likely to get osteoarthritis after meniscal surgery?

One of the important roles of the menisci is to spread your body weight over as big an area of your knee joint lining as possible. If the menisci are injured and can no longer do this properly, then areas of your joint lining are put under more load. Sometimes the lining is put under too much load and can slowly deteriorate over time eventually leading to loss of the lining of the knee. This is called osteoarthritis (OA).

The risk of developing OA in later life may increase if you have a meniscal injury while you are young or if the injury means a large amount of meniscus is lost. Wherever possible, your surgeon will try to preserve as much meniscal tissue as possible to minimise this risk.

Watch Neil Bradbury performing a meniscal transplant and cartilage repair. The Holy Grail of orthopaedics has always been the regeneration of articular cartilage.

Personalised knee implants offer unique advantages comparatively to the more traditional knee replacement as no two patients have exactly the same knee anatomy.

Custom made knees

Each implant is created specifically for you and exactly mirrors the surface contours of your knee, providing bone preservation. The implants also provides an anatomic fit with less bone cutting than traditional treatments.

Patients with unicompartmental disease are able to preserve their knee for future treatments and may also experience faster recovery time and reduced post-operative pain than with traditional total knee replacement. In addition, the unique instrumentation can improve alignment and provide a more natural feel to the knee, which can reduce implant wear and extend the life of the knee joint.

More about the ConforMIS iUni personalised knee implants

• Created for each patient, based on their individual anatomy
• Minimally invasive, minimally traumatic procedure
• Bone and cartilage preserving
• Appropriate for young and active patients
• Potential for less post-operative pain and shorter post-operative recovery
• Preserves the ability to move to other treatment options in the future

Should you and your knee specialist decide that it is clinically appropriate for you to have a personalised iUni partial knee replacement, you will have CT scan of your knee, the results of which will be sent to ConforMIS for review and implant production. Your individualised knee resurfacing device will be available approximately six weeks after the scan. The personalised implant will and personalised surgical instruments derived from your CT scan will be given to your knee specialist to guide the the precise placement of your implant.

Personalised knee implants allow noticeably more bone preservation than traditional knee replacements preserving bone for potential future treatment. The ConformMIS iUni (the “i” stands for individualised) is a unicompartmental knee resurfacing device designed for patients with arthritic damage limited to either the medial or lateral compartment. It provides patients with a range of partial knee resurfacing options in earlier stages of arthritis.

Matching precise geometry of the knee

New custom made partial knee replacement prostheses matches the precise geometry of a patients knee, are bone preserving and are providing excellent functional outcomes.

Personalised knee implants are designed for patients with arthritic damage limited to either the medial or lateral compartment.

PCL reconstruction can improve the stability and the function of your knee following an injury. It involves replacing the ACL in your knee, usually using a tendon from another part of your body. You will meet the surgeon carrying out your procedure to discuss your care and can ask any questions you need. It may differ from what’s described here as it will be designed to meet your individual needs.

What is posterior cruciate ligament repair?

The posterior cruciate ligament (PCL) is one of the two large ligaments within the knee. It controls front to back movement. The PCL can be torn or ruptured during sports activities or from a direct blow to the knee. Once broken, it may heal but is usually a longer length than normal. This can cause the knee to give way, but more usually causes pain and in the longer term, osteoarthritis or wear of the knee.

Minor or moderate lengthening of the PCL is treated by physiotherapy or muscle strengthening. A severe injury of the PCL will require reconstructive surgery.

A ligament graft is required using material taken from the front of the knee or from the hamstring tendons behind the knee, both of which are able to re-grow to a large extent.

Once fixed in the knee the graft is able to form a new ligament. This process takes up to a year but you would normally be able to return to sports activity after six months.

What does this involve?

Posterior cruciate ligament reconstruction is usually performed through keyhole surgery under general anaesthetic. You would normally be admitted on the day of the operation and have an overnight stay in hospital.

You will not be able to eat for eight hours prior to surgery although you will be able to drink small amounts of water up to four hours before.

The operation takes about one hour and your Surgeon will make some incisions in your knee to allow small specially designed instruments to be introduced. The torn ligaments are trimmed and the knee is prepared for the replacement graft. The top and bottom ends of the replacement ligament are fixed into place with special screws into holes drilled into your bones.

The incisions are closed with stitches or adhesive strips

When will I recover?

Recovery from the anaesthetic is rapid and you will be awake very soon after the operation although you may feel drowsy for an hour or two. You will be allowed to go home once you are weight bearing with the assistance of crutches, if necessary, for security.

You may shower with the waterproof dressing on and your physiotherapists will give you on how to exercise your leg before you leave and may arrange outpatient physiotherapy if needed. You will be given a cold compress or ‘Cryocuff’ along with instructions on how to cool your knee, which is important and aids recovery. You will be in a knee brace or sometimes a plaster cast and you will see your consultant once again two weeks after your operation to review your progress.

You may need to take four to six weeks off work and driving following the operation and rehabilitation following a PCL reconstruction is extensive. You will require physiotherapy once a week for two to three months and less frequently up to nine months.

What risks should I know about?

Posterior cruciate ligament reconstruction is commonly performed and generally safe but there are some potential complications you should be aware of. These only affect less than 4% of patients.

Infection can occur although our theatres have ultra-clean air operating conditions keeping infection rates at 1-2%.

Blood clots are possible but again are in the 1-4% category and have well established treatments including aspirin.

A small patch of numb skin can be present on the outer part of the knee near the kneecap, this will improve over time.

Intra-articular protein therapy

nSTRIDE Autologous Protein Solution (APS) therapy is a form of regenerative surgery using a patient’s own blood. The treatment is designed to treat pain and slow the progression of cartilage degradation and destruction of the knee in patients with osteoarthritis.

This groundbreaking procedure involves the extraction of blood from the patient, separation in a centrifuge to obtain a concentrated suspension of platelets via plasmapheresis, followed by injection of part of the fluid into the knee.

To find out more about regenerative surgery click here.

Osteoarthritis

Osteoarthritis, the most common type of arthritis is a progressive disease of the joints. Osteoarthritis occurs when the top layer of cartilage, the slippery tissue that covers the ends of the bones in a joint and help absorb the shock of movement, breakdown and wears away. This causes the bones to rub together causing pain, swelling and less comfortable movement. Later stages in the disease cartilage will disintegrate and subchondral microfractures will expose the bony surface.

Protein Injections

So once osteoarthritis pain starts it is hard to stop. The nSTRIDE APS Kit is designed to produce a groundbreaking autologous therapy to treat pain and slow the progression of cartilage degradation and destruction in the knee.

The nSTRIDE APS Kit is a self-contained, sterile-packaged, single-use device system. It is designed to separate anti-inflammatory cytokines and growth factors from whole blood. The device system is to be used at the point of care to create an autologous solution.

The nSTRIDE APS Kit uses a small sample of the patient’s own blood to create an autologous solution. This device system consists of two parts: the nSTRIDE Cell Separator and the nSTRIDE Concentrator. The nSTRIDE Cell Separator utilizes centrifugal force to process the blood sample and separate the cellular components from plasma and red blood cells. This step takes 15 minutes. The cell suspension is then loaded into the nSTRIDE Concentrator, which uses centrifugal filtration through polyacrylamide beads to concentrate the injectable output. This step takes 2 minutes.

The final product contains concentrated white blood cells, platelets, and plasma proteins in a small volume of plasma. The output is approximately a 2 to 3 cc anti-inflammatory solution.

The proposed APS mechanism of action is a process of reducing OA-related upregulated inflammatory cytokines by introducing antagonistic cytokines, which inhibit the inflammatory cytokine activity. APS has been shown to reduce the production of proteins associated with osteoarthritic inflammation and pain responses in vitro.

There is growing evidence to support its use for select indications in osteoarthritis (Kellgren-Lawrence Grade 2-3). Clinical studies have demonstrated the effectiveness of one single injection. Studies suggest one injection can last at least 12 months, with new evidence shows evidence up to 2 years post-injection.

How is nSTRIDE APS given?

The 2 – 3 cc of fluid concentrate is injected directly in the knee joint.

Are there any side effects?

You may experience side effects (e.g. bruising, local pain or swelling) associated with the blood draw, knee injection, MRI or X-Ray procedures.

Will nSTRIDE APS cure my osteoarthritis?

There is no cure for osteoarthritis however successful treatment with nSTRIDE APS may reduce or relieve your pain increasing your mobility and comfort. Your osteoarthritis may not improve or may get worse.

When will the treatment start to work?

Pain relief can be expected after one week.

How long can I expect the benefits to last?

Based on preclinical and early clinical results, patients should expect to see benefits for at least 12 months.

Many knee problems can be successfully treated with physiotherapy and other non-invasive treatments. If you have a problem that requires physiotherapy we will refer you to a suitable specialist.

Millions of people suffer from knee arthritis which causes pain, stiffness and usually a decrease in activity levels. Exercise is a recommended treatment for both osteoarthritis and rheumatoid arthritis as it reduces pain by strengthening the surrounding knee muscles.  It also increases range and function and supports healthy cartilage stay healthy.

Consulting with a specialist physiotherapist can increase the strength of the muscles supporting the knee and reduce pain. Physiotherapy can help stabilise the knee, allowing better toleration of natural movement.

Specialist physiotherapists offer excellent multidisciplinary care for injury prevention and repair as well as providing post-operative therapy after your knee surgery. 

A biomechanical assessment involves an examination of the lower limbs, looking at their structure, alignment, strengths and weaknesses.

The examination focuses on the foot, pelvis, legs and knees, assessing the relationship between them. It is important to examine the lower limbs as a whole because they are closely connected and pain in one area can be due to a weakness or structural problem in another area. A biomechanical assessment is a starting point for understanding the cause of your problems and provides a comprehensive understanding of any underlying issues in the lower limbs.

The lower limb kinetic chain can be influenced by any joint-segment; the biomechanics assessment aims to highlight these compensatory movements through gait analysis, allowing the specialists to make the right decision about the best treatment for you.

We take a multi-disciplinary approach to the biomechanics assessment and work closely with other members of the clinical team. Specialist physiotherapists will work with you on exercises to improve muscle strength or flexibility however, if appropriate, you may also be referred to an osteopath, sports doctor or rheumatologist.

Patient may also be referred for imaging such as X-rays, MRI’s or CT-scans.

By working with our sports medicine doctor we can ensure conservative approaches are used, where appropriate.

Sporting and physically active people place high demands on their body to achieve their best performance. This can lead to overuse or traumatic injury.

Sports physiotherapy is a specialised branch of physiotherapy which helps athletes recover from sporting injuries as well as encourage prevention of injury and enhancement of sporting performance.

Our specialist physiotherapists will use sports specific knowledge and a multitude of treatment techniques to rehabilitate and treat your injury. This includes using the latest technologies.

If you are a keen sports person wanting to prevent injury or improve your performance we provide specialist assessments. We look at your posture, your biomechanics, your joints and muscle balance.

We can then put together a treatment programme combining hands-on treatment and exercise rehabilitation to address your areas of weakness.

Physiotherapy can be used to help in the prevention of injury and assist in the rehabilitation of athletes establishing normal performance levels. Your physiotherapist will work closely with you to make sure you are in a better position to avoid recurring injuries by enabling you to identify early signs and by introducing exercises to prevent problems.

Your physiotherapist will work with you, your strength and conditioning coach and your knee specialist to reach an agreement on your short, medium and ultimately long term goals and determine what support is required to achieve these goals.

Soft tissue therapy is the treatment of soft tissue structures during training, competition and injury, aiding recovery and helping to prevent injuries.

Rehabilitation after a knee injury is determined based on your progress from one phase to another and not on a pre-specified period of time.

Initially, your specialist physiotherapist will focus on restoring your range of motion, pain modulation, inflammatory control, modification of activities, and gait training.

The next phase is about regaining your full range of motion, your normal gait pattern and basic to advanced strengthening and flexibility.

The third phase allows functional return to prior activity level. This phase includes a sport/occupational-specific functional progression with a rehabilitation specialist who will allow you to return to your prior level of knee function.

Our experts have access to the latest equipment to help your recovery:

• AlterG anti-gravity treadmill - reduces recovery time through improved mobility
• 3D gait analysis - looks at biomechanics
• Hydro physio - helps relieve joint and muscle pain while increasing range of motion.

Your rehabilitation programme is an integral part of your recovery and will be individually tailored for you. Our specialist physiotherapists will work with you to manage your expectations and encourage you to complete the programme, gaining the best possible outcome from surgery.

Our orthopaedic physiotherapy team are highly experienced in providing rehabilitation for a wide range of knee issues. Your physiotherapist will work closely with the knee specialists and nursing staff to facilitate your recovery and ensure the highest level of care and guidance are achieved.

Your physiotherapist will assess your current capabilities in terms of strength, range of motion, mobility, and posture as well as find out about your lifestyle and goals following surgery. We will then create a tailor made rehabilitation programme based on your condition and the type of knee surgery that you have received.

The inpatient stay is often only the beginning of your recovery from surgery and further physiotherapy support is needed when you leave hospital to return you to full function. We will be involved in your rehabilitation whether it’s through the experienced outpatient physiotherapy department at the hospital or our associate physiotherapy programme. We will be there to help you fully achieve your goals and be there for you for life.

We will provide you with a comprehensive in-depth guide which gives you a step by step description of your operation, answers a range of related questions and includes illustrations of exercises forming part of your rehabilitation programme.

An X-ray is an image of the internal structures of your body which is produced by exposure to a controlled source of radiation and stored on a special computer system. Despite all the development of more sophisticated forms of scanning, an X-ray examination remains one of the most accurate ways of detecting many knee problems.

It is the best modality for imaging bone and is particularly useful for identifying fractures. CT scanners combine X-rays taken from many different angles, to create cross-sectional images of the inside of your knee.

It is more commonly used during pregnancy, but it can also be useful to diagnose a variety of other problems and conditions within muscles, joints, tendons, ligaments and soft tissue. The images are visible at the time of the scan, meaning an ultrasound is also a useful tool to help consultants administer treatments.

An MRI allows knee specialists to see soft tissues such as ligaments, tendons, cartilage and muscles in great detail. The information from the scanner passes to a computer that produces an image of the internal structure of the knee.