FAQ Category: Knee

A little bit of anatomy will help explain this injury. Let’s start with the patella — more commonly known as the “kneecap”. The patella moves up and down in front of the knee joint along a built-in track called the patellofemoral groove.

The kneecap is held in place by several ligaments on either side and by the patellar tendon (attached to the quadriceps muscle). The quadriceps muscle is the large, four-part muscle along the front of the thigh.

Although you can take your hands and passively move the kneecap from side to side, this is not an active movement you can make your patella do without assistance. We call that side-to-side (medial-to-lateral) movement accessory motion. The up-and-down and side-to-side accessory motions are referred to as patellar glide.

As part of the patellar tendon, there are slips of ligamentous fibers that help hold the patella in place and keep it from moving too far to one side or the other. On the inside of the kneecap is the medial patellofemoral ligament. On the outside is the lateral patellofemoral ligament.

Without the medial patellofemoral ligament, the kneecap dislocates laterally (in a direction sideways away from the other knee). Because the medial patellofemoral ligament is connected with other ligamentous structures, complete rupture will likely damage other areas as well. The medial patellofemoral ligament attaches above to the femur (thigh bone) and below to the tibia (lower leg bone).

Most ruptures of the medial patellofemoral ligament occur at the femoral attachment. But the ligament can tear away from the tibial attachment or even in the middle (not at either bone attachment). This type of tear is called an intrasubstance tear.

A medial patellofemoral ligament injury can be treated conservatively without surgery. The knee may have to be immobilized in a splint for a number of weeks to allow for healing. Physical therapy, taping, and a home program of exercises prescribed by the therapist begin after the period of immobilization. The rehab program must be given the good old college try: in other words, for more than a few days or weeks. It can take months to rehab this injury.

But if nonoperative care fails and the patella dislocates again, then surgery may be the next step. The surgical approach that works best depends on the underlying damage and specific patient factors. The surgeon will decide if the torn ligament can be reattached to its original insertion on the bone. This is a repair procedure.

More complex injuries with damage to the surrounding tissues may require reconstructive surgery (taking graft material and using it to replace the ruptured ligament). Overall results for repair or reconstructive surgery are good to excellent. Many active patients (teens to adults) are able to resume full physical activities, including sports participation.

Today physicians understand and try to teach their patients that osteoarthritis is more than just a disease of wear and tear. The entire joint complex is involved. Treatment should be a program of self-management directed by a team of health care professionals.

Patient education and nonpharmacologic treatment are the first steps. The goal is to preserve and protect the joints while maintaining motion and function. It’s not that medications can’t be used — they just shouldn’t be the first thing patients are given. There’s plenty of evidence that a nonpharmaceutical approach for osteoarthritis works well and prevents unnecessary exposure to drugs and surgery.

Today’s research evidence does indeed call for a nonpharmacological approach first. Simply stated, that means “without drugs”. This approach requires more time to educate the patient about the process and about his or her choices and responsibilities. There is much less focus on a magic pill to cure-all.

More and more, patients are being called upon to be proactive for themselves. They are encouraged to learn about the disease and find ways to protect their joints. But patients don’t have to do this all alone. A team approach is advised with orthopedic surgeon, primary care physician, and physical and occupational therapists to offer advise, counsel, and guidance.

Some of the tools shown to make a difference include various types of joint braces, shoe inserts or shoe modifications, supportive neoprene sleeves, exercise, and weight loss. Modalities such as heat, cold, electrical stimulation, and acupuncture can be helpful during acute flare-ups. Assistive devices such as a walking stick, cane, or walker may be helpful to off-load the joint and protect the joint surface from further damage.

When medications are indicated, acetaminophen (Tylenol) is the first choice. When used as directed, it is a safe and effective pain reliever. Acetaminophen does not have any antiinflammatory effects. There is a danger of liver damage with too much acetaminophen so patients must be advised carefully and monitored closely to prevent any adverse effects from occurring.

Other medications can be used if acetaminophen in combination with the management program isn’t enough to reduce pain and improve function. These include nonsteroidal antiinflammatory drugs (NSAIDs), capsaicin (topical agent rubbed on the skin to produce a counter irritant), steroid injections, hyaluronic acid injections, and glucosamine and chondroitin sulfate (supplements).

Many people like to start with good nutrition, supplementation, and exercise to manage their symptoms and delay progression of disease. Your physician can guide you in finding not only an evidence-based approach but also one that works best for you.

It may take a little bit of time to fine tune the process but the relief from pain, improved motion, and increased function will be well worth the wait.

As you have discovered, there are two popular places where the tissue can be harvested. The first is from the patellar tendon just below the kneecap. This graft is referred to as the bone-patellar tendon bone (BPTB) graft. As the name suggests, the harvested tendon comes with a tiny piece of bone.

The second is a hamstring graft. Tissue is taken from two separate sites of the hamstring muscle. Each graft is folded over to form a quadruple (four-part) graft. This is the strongest graft and referred to as quadruple hamstring graft.

Either source of tissue (patellar tendon or hamstring) can be an autograft (your own tissue) or an allograft (tissue from a donor bank). There are indeed advantages and disadvantages for each one.

Orthopedic surgeons from the Department of Orthopaedic Surgery and Sports Medicine at the University of Kentucky have published an article stating their preferences. This is probably a good list to start with:

No matter what type of graft is used, surgeons agree that the results are better when the reconstruction mimics the natural anatomy. The graft tissue is placed inside the knee using tunnels that are predrilled through the bone. Screws hold the graft in place until it is incorporated into the tunnel and healing takes place.

Studies have shown that nonanatomic reconstructions just don’t produce the same good-to-excellent results of anatomic techniques. And, it is absolutely necessary to match the length of rehabilitation with the type of graft used for each patient.

For example, allograft tissue (from a donor bank) takes longer to heal within the bone tunnels. Rehab is extended to allow for that delay. Patients who intend to return-to-play in a competitive or high-intensity sport must also be given additional time to train. And the surgeon and rehab therapist must take into consideration that high-level athletes will put the graft to the test with running, jumping, quick turns, and sudden stops.

It’s clear now from several decades of surgical treatment that every patient must be evaluated individually. There is no “one-graft-fits-all” choice for anterior cruciate ligament (ACL) repairs.

First, is the patient male or female? Women are more likely to experience graft failure with hamstring autografts (tissue taken from the patient). Next, what sport is involved? Many patients participate in multiple sports year-round. The surgeon must consider each graft type based on the activity and intensity level.

Autografts involve donor site morbidity — in other words, problems that develop where the tissue was taken from or harvested. Bone-patellar tendon-bone (BPTB) autografts present the greatest donor site problems.

There can be pain when kneeling — that’s the main difficulty after the reconstruction has taken place. Fracture of the patella (kneecap) and loss of knee extension are two other possible complications of autograft BPTB. You can see why this might not be the best choice for someone who isn’t fully invested in the rehab program or who has a low threshold for pain tolerance.

But the bone-patellar tendon-bone (BPTB) graft provides a good, stiff ligament needed to maintain knee stability. It is less likely to stretch out and more likely to heal well compared to the hamstring graft. The autograft has a better track record in these two areas compared to a BPTB allograft. These features of the BPTB graft make it a better choice for the active young adult who is eager to get back into strenuous sports activity.

Now what about that hamstring graft choice? We mentioned it is the strongest graft material. There are fewer problems at the donor site. But it takes longer to heal compared with the BPTB graft. Athletes must rehab a full month longer (at least). The rehab program must pay close attention to getting full hamstring strength back. And the risk of graft stretching and losing tension is greater with a hamstring graft.

Studies also show that graft failure is more likely with the hamstring graft. There’s more joint laxity (looseness) with this type of graft. Women already have greater knee laxity than men so the hamstring graft may not be ideal for them.

Finally, there’s nothing more disappointing than a graft failure in a young athlete eager to get back into action. Allografts seem to have a higher failure rate in this patient population. It is suspected that the reason for this is the sterilization process used to make sure the graft doesn’t harbor any infections or other diseases.

There are risks and benefits with any soft tissue graft. As each patient faces the decision of choosing one over the other, conversation with the surgeon is important. Selecting the graft type is a personal choice based on each patient’s needs, activity level, goals, and preferences. The decision will be influenced by surgeon experience and preference as well.

There is always the risk of complications and problems with any surgery. Fortunately, the number of patients affected is low at most hospitals or centers for joint surgery. But they can occur and being prepared ahead of time helps mobilize the family into action when necessary.

The most serious complication is death from blood clots, heart attacks, or strokes. Poor wound healing, deep infection, and implant failure head the list of other more common problems. Who is at risk?

According to a recent review study, it looks like patients who have other health issues have an overall higher rate of complications and increased risk of poor outcomes with their knee implant. Dislocations, deep infections, and implant loosening and failure were observed in the group at-risk due to poor health.

Implant failure requiring reoperation is most commonly linked with infection. Risk factors include male sex, patients with rheumatoid arthritis, and history of bone fracture anywhere around the knee. Infection is less likely when implants are put in place with cement that has antibiotic in it or when the patient is receiving intravenous (IV) antibiotics directly to the bloodstream.

Additional factors that increase the risk of infection include obesity (body mass index greater than 50), diabetes, and younger age. Diabetes was actually a major complicating factor. Patients with diabetes were more likely to suffer serious complications of surgery such as stroke, delayed wound healing, and amputation because of deep, uncontrolled infection.

Consider going with your parents to their appointments and asking the surgeon what risk factor your parents have, the likelihood of problems developing, and what you can do to help. Preparation and prevention are two important keys to reducing complications. You are well on your way to making a difference for your parents just by asking the right questions!

The number of surgeries to replace part or all of the knee joint has tripled in the last 10 years. Along with that increase has come many changes in the way reconstructive knee surgeries are done.

Just as you have discovered with your new employment, there’s been a trend away from hospital-based surgeries. More surgeons are specializing in a particular procedure such as reconstructive knee surgery. That has led to high-volume specialty centers where surgeons perform many knee joint replacements each week. The result has been improved outcomes, fewer complications, and lower costs.

With improved technology, surgeons have been able to offer patients improved standard of care. For example, computer navigation and tools to make more specific cuts have reduced differences that occur from surgeon to surgeon. More careful attention to the mechanical axis of the implant has also improved how long the implants last. A natural outcome of that focus has been improved function for patients.

Another change in how surgeries are done has been the move from open incision to minimally invasive surgery. Along with smaller incisions that preserve the soft tissues has come a concept called rapid recovery rehab. Patients are up and walking and putting weight on the knee right away. Everything in the rehab protocol is speeded up.

But even as some things have changed, many other things have stayed the same. Your basic nursing skills and experience dealing with anxious or post-operative patients will serve you well as you head back into active nursing practice. Good luck!

With a sleeve fracture, the quadriceps tendon is torn so severely, it separates from the muscle and takes a piece of the cartilaginous patella with it. It also takes the top layer of bone called the periosteum. When the periosteum is peeled away with a fragment of the underlying bone still attached, it is called a sleeve avulsion.

A little anatomy might help explain what happened and why surgery is usually required. The quadriceps tendon is wrapped around the kneecap to hold it in place. At the upper end, the tendon is attached to the large four-part quadriceps muscle along the front of the thigh.

Together, the quadriceps muscle and its tendon extend or straighten the knee. The quadriceps tendon continues down below the knee cap where it inserts or attaches to the tibia (lower leg bone). The patella acts like a pulley system to help the quadriceps muscle pull the lower leg up in order to straighten the knee.

Surgery is usually needed to bring the pieces of the patella back together (reduction) and hold them in place with pins or screws (internal fixation) until healing takes place. The procedure is called open reduction and internal fixation or ORIF. The leg is put in a cast with the knee straight for about six weeks. Physical therapy begins as soon as the cast is removed. Restoring full knee motion and strength are the two main goals of therapy.

With careful placement of the sleeve fracture during surgery, normal quadriceps function is possible. Improper treatment can result in deformity and poor timing of the quadriceps’ ability to contract and release normally.

Conservative (nonoperative) care may be possible in skeletally mature patients (bones have stopped growing) if there is no change in the fragment position as the knee bends and straightens. In order to know if the fragment moves, the knee must be observed under fluoroscopy, a special type of 3-D X-rays that allow the surgeon to see the joint as it moves.

Without surgery, the patella may end up shifting location (moving up or down depending on which type of sleeve fracture occurred). The quadriceps may develop an extensor lag and start to atrophy (weaken and waste away). An extensor lag means the quadriceps tendon that straightens the joint doesn’t pull back far enough to get full knee extension. The knee remains slightly flexed no matter how hard the person tries to straighten it.

The decision to do surgery is determined by your age, the extent of damage, and your activity level (participation in sports is a big factor). Most children and teens gain back their motion and strength after surgery within the first two to four months. Excellent results have been reported in most cases.

You are probably not familiar with the term sleeve fracture of the patella (kneecap) because this is a very rare injury. Of all the bone breaks children have, the kneecap is only involved in about one per cent of the cases. And sleeve fractures make up about half of those patellar injuries.

What’s a sleeve fracture? A little anatomy will help explain what happens. The patella or kneecap sits in front of the knee joint. It isn’t attached by a piece of bone or bone bridge. Instead, it moves freely up and down, gliding along a set pathway or patellar track. The kneecap is held in the track by the quadriceps tendon.

The quadriceps tendon is wrapped around the kneecap to hold it in place. At the upper end, the tendon is attached to the large four-part quadriceps muscle along the front of the thigh. Its job is to straighten the knee. The quadriceps tendon continues down below the knee cap where it inserts or attaches to the tibia (lower leg bone).

With a sleeve fracture, the quadriceps tendon is torn so severely, it separates from the muscle and takes a piece of the cartilaginous patella with it. It also takes the top layer of bone called the periosteum. When the periosteum is peeled away with a fragment of the underlying bone still attached, it is called a sleeve avulsion.

Sleeve fractures of the patella can actually occur at the top of the kneecap (called the superior pole) or at the bottom (inferior pole). Most sleeve fractures involve the inferior pole.

In children who are not fully grown yet (we say they are skeletally immature), the patella is still more cartilage than bone. The softer cartilaginous patella in the skeletally immature child tears more easily than solid, hardened bone in a skeletally mature individual.

Sleeve fractures were first described in the literature in 1979. Boys are affected five times more often than girls. Most are between the ages of eight and 16 years old. Increased high-intensity sports activity may be one reason this type of injury has started to show up.

You will be relieved to know most children are able to recover fully. They resume full participation in all activities and sports. There may be some occasional knee pain with certain activities like running and jumping. But for the most part, the fracture heals, the kneecap tracks normally, and the quadriceps muscle bulks up again.

Knee injuries resulting in anterior cruciate ligament (ACL) tears are fairly common — especially in athletes and sports participants. With full tears, ACL reconstruction is usually required. And with so many people affected, this is a common subject of many research studies.

Most people (especially athletes) are concerned with how soon can they get back into action on the court or in the field. That’s one area of research interest. An equally important question is: how well does the new ACL hold up over time? Is osteoarthritis inevitable?

To address this question, a group of sports physical therapists and orthopedic surgeons performed a long-term (15-year) study of patients who had an ACL injury. Some of the patients had just the ACL tear. Others had additional damage done at the same time (e.g., meniscal injury, cartilage lesions, other ligament damage).

Everyone in both groups had an ACL reconstruction surgery. The goal of surgery was to restore stability and function of the knee joint. The graft used to replace the ruptured ACL was taken from the patellar tendon (just below the knee cap). This graft procedure is called a bone-patellar tendon bone (BPTB) autograft. Autograft means the graft tissue came from the patient’s own knee.

Results for these two groups were compared in terms of motion, function, strength, and activity level. Everyone was followed early on (six months after surgery, one year later, two years later) and then rechecked at 10 and 15 years after the procedure.

X-rays were used to document any signs of osteoarthritis. Narrowing of the joint space, presence of bone spurs, and deformity of the bones at the joint were evaluated to grade the severity of arthritic changes.

Knee function was improved and maintained for a long time after ACL reconstruction surgery.
The results of the study showed that improved knee function can be expected for patients with an isolated ACL injury as well as for those who have combined injuries.

However, osteoarthritis was common after these surgeries. Three-fourths of the patients (74 per cent) did have X-ray evidence of osteoarthritis. More patients in the combined injury group had osteoarthritis (and more severe arthritis) compared to the isolated ACL injury group.

The researchers concluded that ACL reconstruction surgery does not prevent osteoarthritis. Patients with isolated ACL injuries seemed to have mild arthritic changes. Patients with combined injuries were more likely to develop moderate to severe osteoarthritis. But not everyone with X-ray evidence of arthritis had symptoms.

It’s not clear why some people developed more arthritis than others and why some patients had pain with their arthritic changes and others didn’t. The next step in researching this topic is to look for risk factors for developing osteoarthritis. Discovering predictive factors of who will have arthritis might help surgeons find ways to prevent this natural progression of events.

There might be several things you will want to consider in making this decision. Does your surgeon think conservative care with a rehab program is enough to get you by if you aren’t playing hard?

Less active adults (usually older) may be able to avoid surgery if 1) the anterior cruciate ligament isn’t fully ruptured, 2) there are no other areas of damage (e.g., meniscal tears, holes in the cartilage, other ligaments torn), and 3) you are committed to complete the necessary rehab program and keep up with a maintenance program for life.

Many studies have shown that athletes can return to sports activities at the same level as before the injury. But many times, the ACL injury and reconstructive surgery does tend to mark a dividing point in how active patients are. There is a fair number of athletes who don’t return to full participation in their previous sport. Sometimes, they switch to a different sport instead.

Another thing to consider is the importance of staying physically active throughout the adult years. There’s plenty of research showing the importance of exercise to stay healthy and prevent problems like diabetes, heart disease, obesity, and cancer (to name just a few). Will you be able to do that if your knee is unstable, painful, or weak?

It might be helpful to you (and your surgeon) if you came up with a list of goals you have for the next 10 to 20 years. What activities do you want to participate in? At what level would you like to join in the fun?

Be specific in terms of how often you would practice or play. Consider how competitive you are — you may think a leisurely pick-up game of basketball or soccer will be fine but when you are on the court, do you suddenly become highly competitive? An unrepaired ACL tear may not hold up under those circumstances.

Again, these are all things you should discuss with your surgeon. He or she will be the best one to advise you based on clinical testing performed on the knee (motion, laxity, str

The best way to measure results is usually by comparing tests administered before surgery to values for the same tests re-administered after surgery. This information can come from before and after X-rays, range-of-motion, and strength testing.

Some facilities (usually at a university clinic or hospital setting) are set up to conduct gait analysis. The patient walks along a platform or special floor that has force plates built into it. A video camera records your movements from all sides.

Using this type of video data and computer software analysis, it is possible to see what kind of weight-bearing pattern you may have and how it changes from before to after treatment.

Without this more specialized testing, there are several well-known tests (e.g., Lysholm knee scale, Hospital for Special Surgery knee rating system) that can be used to assess symptoms, function, motion, strength, deformity, and stability. Your surgeon or physical therapist will help you complete these tests. By repeating the tests after a set period of time (e.g., every month), you will be able to see measurable results.

Of course, using a more casual approach is also possible. You can keep track of how many steps you take each day or how long it takes you to get up and down a set of steps in your home for example.

You can also keep a log of knee motion by measuring how close you can bring your heel toward your buttock when lying down (hip and knee bent, foot flat on the floor, slide heel toward your bottom). Use a ruler to measure the distance between heel and bottom.

There are many other ways you can gauge your own progress if you think about measuring any aspect of your daily activities and exercises. Think in terms of time, distance, number of repetitions, and so on.

Younger adults (65 or younger) who want to delay or avoid a total knee replacement may have other treatment options. One of these options is a surgical procedure called osteotomy.

In this procedure, a pie-shaped wedge of bone is removed from one side of the tibia (lower leg bone). The osteotomy is usually done at the upper end of the tibia just below the knee.

There are two different methods: the opening-wedge medial osteotomy or the closed-wedge lateral osteotomy. These are done on opposite sides of the knee. The goal is to change the angle of the knee and thus alter the weight-bearing pattern.

Who can benefit from this approach? Well, as the technique describes, patients who put too much weight on one side of the knee might do well with this type of osteotomy. By shifting the weight more towards the middle of the knee, ground forces up through the foot when walking are evened out. The result can be to prevent medial (most common) or lateral compartment arthritis and put off (or even eliminate) the need for a joint replacement.

This surgery is not usually recommended if the patient can’t bend the knee past 70 degrees or has an unstable knee joint. Instability is judged by how much the tibia can slide back and forth under the femur (thigh bone). More than a one-centimeter subluxation (movement toward dislocation) can be a reason to exclude patients. These findings are more suggestive of someone who really needs a joint replacement and wouldn’t benefit from an osteotomy.

Your orthopedic surgeon is the best one to advise you on this. He or she will take into account results from X-rays, MRIs, and arthroscopic exam to determine what you need. Your age, goals, and activity level are important factors. You may be a good candidate for this type of surgery but if not, there are other treatment options as well such as a hemiarthroplasty (to replace just the arthritic side).

Osteochondritis dissecans (OCD) is a disorder of the bone with a fracture in the joint surface that doesn’t heal naturally. The problem can affect children, teens, and adults. In younger patients, the cause of the problem and treatment might differ from adults.

Treatment is more likely to begin conservatively in younger patients who are still growing and therefore still have a rich blood supply to the bone. In older patients who are skeletally mature (no longer growing), the detached fragment has no blood supply and will die. Adults also tend to have more fibrous scar tissue formed between the joint and the detached lesions.

The prognosis for adults who don’t have surgery to treat this problem is poor. Based on many studies, we know that healing isn’t likely to occur without some surgical intervention. And even with surgery, the risk of developing arthritis later is pretty high.

The real question for you might be more along the lines of what type of surgery would the surgeon suggest? There are many different options right now and no clear sense of which one is superior to the others.

Your surgeon will be evaluating the size, location, and type of lesion(s) present in making the treatment decision that’s best for you. Your age, activity level, and overall general health will also be important considerations.

Osteochondritis dissecans (OCD) is a disorder of the bone with a fracture in the joint surface that doesn’t heal naturally. The problem can affect the elbow, ankle, or knee. OCD of the knee mostly affects the rounded end of the lower femur (thigh bone). This area is called the femoral condyle of the knee. Like most joint surfaces, the femoral condyles are covered in articular cartilage. Articular cartilage is a smooth, rubbery covering that allows the bones of a joint to slide smoothly against one another.

The problem occurs where the cartilage of the knee attaches to the bone underneath. The area of bone just under the cartilage surface is injured, leading to damage of the blood vessels to the bone. Without blood flow, the area of damaged bone actually dies. This area of dead bone can be seen on an X-ray and is sometimes referred to as the osteochondritis lesion.

The lesions usually occur in the part of the joint that holds most of the body’s weight. This means that the problem area is under constant stress and doesn’t get time to heal. It also means that the lesions cause pain and problems when walking and putting weight on the knee. It is more common for the lesions to occur on the medial (inside) femoral condyle, because the inside of the knee bears more weight.

At age 17, your son has probably reached skeletal maturity so falls in the adult treatment category. In the skeletally mature adult, the best treatment remains unclear. Surgeons try to preserve the bone fragment(s) by reattaching them to the bone with screws, pins, nails, darts or some combination of these fixation devices.

Newer bioabsorbable fixation is now available for this problem. But the results of using this type of fixation that gets absorbed by the body (and doesn’t have to be removed) are unknown.

In a recent report from a study at the Mayo Clinic, there were many problems using bioabsorbable fixation devices and a low healing rate. In two-thirds of the group, the fragment adhered to the bone in what is referred to as fragment union. One-third of the group ended up having the loose piece taken out in a separate surgery later.

Bioabsorbable nails (with no threads like the screws) had a tendency to break or back out. When that happened, the patient had a new hole in the joint surface of the femur and sometimes another one on the tibial (lower leg bone) side.

The authors concluded that in all honesty they couldn’t recommend bioabsorbable fixation for OCD lesions in skeletally mature adults. This treatment approach clearly is not superior to others such as using metal fixation or drilling tiny holes into the joint surface to stimulate healing, a procedure called microfracture.

Your surgeon is the best one to advise you in this decision. Patient factors such as severity of the lesion(s), skeletal maturity of your son, future living location, and so on all factor into the final treatment choice.

Revision surgery for failed anterior cruciate ligament (ACL) rupture is uncommon but sometimes a necessary procedure. The surgeon confirms there is ACL deficiency with clinical testing and (if necessary) arthroscopic examination.

Physical therapy can be helpful to correct any postural issues related to the knee. The therapist will teach you activity modifications to help prevent further injury or damage.

A program of manual therapy and exercises will help restore kinesthesia (awareness of movement), proprioception (joint sense of position), and motor control (coordination of brain, nerve, and muscle function). Flexibility, strength, and endurance are three other areas the therapist will address.

Give the conservative (nonoperative) approach plenty of time before considering surgery. It can take two to six months to recover lost strength, incorporate correct alignment, and regain normal motor control.

Compliance on your part with your home program is a key factor in success. If the knee remains unstable despite all rehab efforts, then a second (revision) surgery may be needed. The surgeon will have to evaluate your situation carefully.

A second ACL reconstructive surgery will probably require another graft to replace the failed graft. Graft tissue may be taken from your other knee or from a donor bank. The source of the graft material may depend on where the first graft came from (your injured knee, your other knee, or donor bank).

Studies in the past seem to indicate that the most common reasons for ACL reconstructive graft failure are technical problems. The number one reason may be tunnel malposition (the tunnel is where the graft is threaded through and then attached to the bone).

And, in fact, a recent large combined U.S./Canadian study confirmed that technical considerations are important. But age, type of graft (bone-patellar tendon-bone), and injury to the knee cartilage are also significant factors. The source of the graft (whether taken from the patient or from a donor bank) might be important but this study was unable to prove that one way or the other.

Your surgeon will be able to advise you more directly once you have completed the recommended rehab program. It is entirely possible for you to recover function through a carefully designed rehab program. Stick with it and good luck!

Revision surgery (a second procedure) to reconstruct a ruptured anterior cruciate ligament (ACL) is fairly rare — thank goodness! They call this a low volumesurgery. But that makes it difficult to study the results of the first surgery and predict outcomes for the second (revision) procedure.

That’s why a group of surgeons from the American Orthopaedic Society for Sports Medicine (AOSSM) got together and formed the MARS group. MARS stands for Multicenter ACL Revision Study Group. By combining patients from multiple centers under the care of multiple surgeons (87 total), it was possible to gather data on 460 patients.

By combining data from a large number of patients, it is possible to conduct a research analysis called a multivariable analyses. With all the various factors that could affect treatment outcomes, this type of research design allows the surgeons to find variables that might predict treatment success or failure.

This study showed that multiple factors are probably the reason(s) why ACL grafts fail. The results of previous (much smaller) studies seemed to point to technical problems such as tunnel malposition for the graft as the most likely reason for graft failure.

And, in fact, this study confirmed that technical considerations are important. But age, type of graft (bone-patellar tendon-bone), and injury to the knee cartilage were also significant factors. The source of the graft (whether taken from the patient or from a donor bank) might be important but this study was unable to prove that one way or the other.

Women tended to reinjure their knees after the first surgery at an earlier age than men. Most ACL failures (62 per cent) occurred two or more years after the initial reconstructive surgery. About one-third presented during the first or second year post-op.

Most reinjuries occur as a result of trauma. Sports that require jumping or cutting/changing directions suddenly top the list of activities patients are engaged in when a previously reconstructed ACL gives way.

Soccer and basketball are the two sports activities named most often but skiing, volleyball, gymnastics, football, and baseball or softball were also reported. A smaller number of patients were engaged in “other” activities listed as biking, cheerleading, dancing, martial arts, roller skating, tennis, hockey, jumping on a trampoline, or wrestling.

Why you? It’s not usually a clear-cut ‘this’ or ‘that’ reason for these types of injuries. Your surgeon may be able to glean some of the reasons ‘why’ but usually it is a combination of many factors.

There is a risk that your revision surgery will fail but your chances for a good outcome are much greater than the risk of a second failure. Your surgeon is really the best one to assess your risk factors and likelihood of a surgical success.

Damage to the articular layer of cartilage that lines the joint can cause pain, swelling, and eventually degenerate into arthritis. It doesn’t have the ability to heal itself when damaged so that’s why treatent is important.

Surgical treatment of holes in the articular cartilage of the knee has taken a decided turn in the last 15 years. Surgeons have found ways to either repair or replace the cartilage. Results have steadily improved so the question now is: which method works best?

Repair techniques involve marrow stimulation such as abrasion arthroplasty, drilling, and microfracture. Replacing the cartilage defect with healthy donor cartilage consists of autologous chondrocyte implantation, osteochondral autograft, and mosaicplasty.

Each one of these procedures has its pros and cons (advantages and disadvantages). And results of studies vary from no difference from one treatment to another to each one being better than all the others. Experts who review the studies suggest there’s probably some research bias in there. Sometimes one approach has faster results than others but over time the outcomes seem to even out.

The best approach to cartilage defects (also called lesions) remains unknown. There have been many studies done on the various techniques. And researchers have even taken the time to review all of those studies and try to summarize what is known for each one. This latter type of study is called a systematic review.

What they have found is that there are some individual patient and defect factors that can make a difference. Things like your age, activity level, size of the defect, and location of the defect can predict which method might work best for you.

Your surgeon will have all this in mind when he or she recommends a plan of care that’s best for you. Having the information here will help you understand what is advised for you. You will be able to ask questions to help sort out what’s best for you.

Surgery to repair damage to the surface of a joint has been around since the early 1950s. But some of the more modern chondrocyte-based therapy (as it’s now called) is a more recent phenomenon. The word chondrocyte refers to cartilage cells.

Studies so far have shown some pretty good results with autologous chondrocyte implantation (ACI). It’s a two-part operation designed to restore rahter than repair damaged cartilage. The surgeon removes some of the healthy cartilage (chondrocytes) from an area of the joint that doesn’t see much action (force or load during weight-bearing activities).

The cells are taken to a lab where they are treated to grow additional cells. When there are enough cells, you go back to the operating room and the surgeon places the new cells into the holes like a plug. A special cover is placed over the plug to protect it while the joint incorporates the new cells.

But how does it compare to other restorative techniques used? And now that surgeons have found a variety of different ways to do the ACI procedure, which one works best? To find out, a group of surgeons from the Sports Medicine Center at Ohio State University compare autologous chondrocyte implantation (ACI) against other surgical treatment techniques for this problem. They conducted a review of all the studies already published on this topic and analyzed the data. Here are a few brief findings:

Autologous chondrocyte implantation has the most durable results. The repair tissue that forms holds up better than other repair techniques. Autologous chondrocyte implantation has better short-to medium-term results than microfracture but equal results with osteochondral autograft transplantation.

Long-term results aren’t available yet to show a clear front-runner of the various restorative techniques.Outcomes have been improving over time as the surgical techniques improve. The method used to cover the graft (periosteal, collagen, scaffolds) and protect it doesn’t seem to matter. Results are comparable among the various choices.

Certain patient characteristics do make a difference. Younger, more active patients have the best results, especially if they have the surgery early when the lesion is small. The best outcomes occur in patients who have not had any previous knee surgeries and who don’t have any other injury or damage to the knee ligaments or other knee cartilage.

So, although the autologous chondrocyte implantation procedure is safe and effective, long-term results for large numbers of patients just aren’t available yet.

It’s not uncommon for patients to feel this way after a long period of time working closely with their surgeons. The trauma of the attack by a bear, the fear of losing a limb, and the need for close personal attention draw you close to your physician. But recovery from complex injuries of this kind usually require the efforts of an entire team.

At this point, the main part of the surgeon’s job may be done. Close monitoring and follow-up are his or her primary focus on you now. That will mean contact (appointments) with the surgeon but with longer periods of time in between visits.

The nursing staff, physician’s assistant, physical therapist, and other health care professionals who have been (or who are now) part of your team will guide you through the next phase of recovery.

Your work has just begun. Rehab and recovery may take another set of stages over a period of weeks to months. The more damage present, the more extensive the surgery, and the longer the recovery time. You will be progressed through a series of range-of-motion exercises, strength training, and return to daily activities. Return-to-work and/or return-to-sports for athletes can be achieved with a work- or sports-specific rehab program.

Given your particular circumstances and the way you are feeling, you might want to consider a short course of counseling. The counselor can help you understand and process your feelings. What you are feeling is natural but you just may not be equipped to deal effectively with the many changes in your life these past weeks to months.

Knee injuries so severe that there is dislocation, fracture, and/or multiple ligaments ruptured require careful consideration when planning treatment. The surgeon must quickly but thoroughly assess the extent of damage to the bones, soft tissues, nerves, and blood vessels in the leg. Knee dislocations are notorious for causing nerve injury even when the patella (knee cap) automatically reduces (goes back into place).

Tools used to conduct the evaluation begin with visual inspection (e.g., location of the injuries, signs of blood loss) and include testing for blood supply (e.g., Doppler, CT angiography, ultrasound). The presence of any damage to blood vessels or loss of blood supply to the area means a vascular surgeon must scrub up along with the orthopedic surgeon to perform the necessary procedures.

Before surgery can be done, X-rays and MRIs are taken to identify the extent of ligament injury (location and severity). This information helps the surgeon plan what must be done in the operating room. A plastic surgeon may be needed if there has been so much soft tissue damage that the wound can’t be closed without a graft. Sometimes there are torn or ruptured ligaments that get put on the back burner (repaired later) because of the need to restore blood supply and save the leg first.

Most complex injuries with fracture, dislocation, and/or ligament rupture of the knee require staged procedures. That means everything that needs to be done can’t be completed in one day or during one operation. They try and treat any fractures or dislocations the first day. Blood supply is restored and stabilized.

Reconstruction of soft-tissue injuries may be delayed for up to one week before the next stage of treatment can begin. Ligament reconstruction (phase three) takes place three to four weeks later. There may even be a stage or phase four if the knee is still unstable and further reconstruction is needed.