FAQ Category: Knee

It’s not always easy to compare one knee problem to another because they have different degrees of severity, treatment, and outcomes. Patient age, general health, and specific diagnosis all contribute to the surgeon’s decision about the best way to treat a problem and the ideal timing in which to do it.

Surgical treatment for cartilage defects (cracks, fissures, or holes) doesn’t have such a great track record yet. The three most common surgical procedures include microfracture, autologous chondrocyte implantation (ACI), and mosaicplasty have been studied extensively. Researchers have not been able to show that one method is better than another.

In fact, there’s enough evidence to suggest that patients who don’t have surgery do just as well as those who do have surgery. That calls into question the cost-vs-benefits of conservative (nonoperative) care versus surgical treatment of this condition.

There’s no doubt that the degree of patient complaints with chondrocyte lesions is greater than for patients with other conditions like anterior cruciate ligament (ACL) tears or osteoarthritis. Patients with cartilage defects suffer more pain and have worse function, mobility, and health-related quality of life when compared with patients who have other knee problems.

Surgeons, scientists, and other researchers are actively looking for better ways to treat this problem. Until we have enough evidence to point to one treatment technique over another, don’t be surprised if the surgeon doesn’t jump right into scheduling an operation to treat the problem surgically. Each patient must work with the surgeon to understand their condition and the treatment options to choose from.

Don’t be afraid to ask your surgeon what she is thinking in your case. You may find that she is giving careful consideration and looking at all factors when forming a plan of care for you. Your own individual patient characteristics as well as the evidence published in medical journals will guide the final decision.

Cartilage lesions of the knee joint can be difficult to repair in order to restore painfree function. Full-thickness (clear through the cartilage to the bone) can be especially problematic. Patients are often unable to cope with the pain.

In fact, a recent study from Norway comparing patients with chondrocyte (cartilage cell) damage to other knee problems was published. Patient complaints were measured and reported for three groups of patients with different knee problems.

One group had a ruptured anterior cruciate ligament (ACL), another group had knee osteoarthritis, and the third group had full-thicknes cartilage defects. Complaints were categorized as pain, other symptoms, daily activities, ability to participate in sports and recreational activities, and health-related quality of life.

The patients with ACL tears were the ones most distressed by their inability to participate in physical activities. Their quality of life was more influenced by that factor than the older adults who couldn’t get around because of pain from knee arthritis. Patients with cartilage defects reported that their quality of life was affected equally by pain, inability to get around to do their daily activities, and the inability to participate in sports and recreational activities. This was true no matter what type of surgery they had to repair the cartilage.

Some experts have wondered if patients with cartilage lesions that severe should just go ahead and have the knee joint replaced. But the problem with that is that these patients are usually much younger than patients in need of a knee replacement for arthritis. Joint replacements don’t last a lifetime — they are usually good for 10 to 15 years. So that treatment option isn’t really realistic for younger adults.

You really need to go back to your surgeon and report what’s going on. It may be time to step back and re-evaluate your situation before going on. There may be a simple step that can be taken to help you feel better and regain some of the function you’ve lost before considering a total knee replacement.

We have some information that might help you. Back in 1995 when surgeons first started using a technique called autologous chondrocyte implantation (ACI), a group of surgeons from around the United States set up a special study to track results of this treatment.

They called the collection of data from patients at various clinics and surgical centers the Cartilage Repair Registry or Registry for short. The goal was to follow patients long enough to see how well this treatment worked over time. The results of this research help answer the question of just how durable is this repair procedure?

Autologous chondrocyte implantation (ACI) refers to the filling in of cracks and holes in the knee joint cartilage with the patient’s own chondrocytes (cartilage cells). These lesions or defects occur as a result of trauma, injury, or repetitive damage to the joint. Autologous means that normal, healthy cartilage cells are taken from a place in the patient’s own knee joint. The cells come from an area that isn’t damaged and doesn’t bear a huge load when the person is upright and weight-bearing. The harvested chondrocytes have the advantage of being accepted (not rejected) by the patient’s body.

Five years ago, results from the registry were reported. An area of key interest was the durability of the implantation. At that time, results were good-to-excellent for the majority (80 per cent) of patients. There was even evidence that as time went by in the early years, patients continued to improve. Now the researchers present results after 10 years. They used the outcomes after five years and compared it with the results after 10 years to assess durability.

Success was defined as a confirmed defect filling, patient satisfaction with results, and no need for further treatment for the problem. Failure was determined as the need to remove the graft for any reason, the need for partial or complete joint replacement, and failure of the defect to fill in (seen on imaging studies). Most of the failures (17 per cent) occurred early on (in the first two and a half years)

Those who improved in the first five years stayed that way — they didn’t get better or worse. The authors take this to mean that early improvement after autologous chondrocyte implantation is maintained years later. The authors concluded that autologous chondrocyte implantation (ACI) is a successful procedure for full-thickness (clear to the bone) holes in the articular cartilage of the knee. Pain, swelling, and knee function can be resolved in most patients who are carefully selected for this procedure. The results occur early and last up to 10 years, which is considered long-term.

Autologous chondrocyte implantation (ACI) refers to the filling in of cracks and holes in the knee joint cartilage with the patient’s own chondrocytes (cartilage cells). These lesions or defects occur as a result of trauma, injury, or repetitive damage to the joint. Autologous means that normal, healthy cartilage cells are taken from a place in the patient’s own knee joint. The cells come from an area that isn’t damaged and doesn’t bear a huge load when the person is upright and weight-bearing. The harvested chondrocytes have the advantage of being accepted (not rejected) by the patient’s body.

This procedure has been around since 1994 — long enough now to have some long-term data collected on patients who had this repair technique done. There are two studies published with data to show how patients fare one, five, and 10 years later.

And the news is good! Eighty (80) to 84 per cent of the patients report being satisfied with the results. Their pain is better if not gone — same for the swelling and loss of function. The results last well into the 10th year, a full decade after the procedure. So before you slide down the slippery slope of regret and remorse, rejoice and see yourself in that successful majority!

Patients who became listed as failed implantation procedures were more likely to have knee alignment problems or large defects. You said your lesion was small (though deep). That’s in your favor. You can always check in with your surgeon to see how he or she thinks you are doing and ask what are your chances for a good-to-excellent recovery. Having this information and a little perspective on your situation may calm your fears and allow you to move forward with complete and successful healing, recovery, and rehab.

Anterior cruciate ligament (ACL) reconstructions are one of the most commonly performed surgical procedures among young athletes today. Rehab is often advised first in order to save the athlete from having surgery. But when this conservative step fails to restore joint stability, then the surgeon may recommend reconstruction to replace the ruptured tendon with a tendon graft.

As you’ve discovered, there are two graft sites for harvesting the needed tissue (hamstring tendon or the patellar tendon). And patients have the choice of using their own tissue (an autograft) or using tissue from a donor bank (an allograft).

Allografts have become increasingly popular with surgeons based on the fact that these are easy to use, come in a wide variety of sizes to choose from, decrease the time the patient is in surgery, and eliminate pain and problems at the donor site when patients use their own tissue. But the question arises: is the risk of infection higher with donated tissue?

And the same question arises for the two types of graft collection sites. Is the risk of infection greater using one type over another?

According to a recent study from the Hospital for Special Surgery in New York City, the overall incidence of infection is very low (less than one-half of one per cent). The authors reviewed the charts of 3126 patients at their facility who had this type of surgery. The rate of infection wasn’t any higher in the allograft (donor bank) tissue than for patients using their own tissue (autograft).

However, hamstring autografts did seem to have a higher risk of infection than patellar tendon grafts. This result has been reported by other researchers. There is some thought that the way in which the hamstring tendon grafts are sterilized might be the reason for an increased risk of infection with these grafts.

As far as recovery time, the rehab for ACL reconstructions is about the same regardless of graft type used (hamstring versus patellar tendon). The main difference is between allografts and autografts. With allografts from a donor bank, there are no painful symptoms or donor site problems to deal with. There is a (low) risk of tissue rejection that doesn’t happen with autografts because the autograft uses the patient’s own tissue. But autografts can be very painful, develop scar tissue, and restrict tendon mobility.

Your surgeon is the best one to advise you in this decision. It’s good to have some idea of the pros and cons of each treatment approach. Each surgeon also relies on his or her experience in doing this procedure. He or she may have a preferred method and operative technique. Ask if this is the case. The surgeon may have a specific recommendation that can help you make this decision.

Don’t panic. If you are under the care of a surgeon, the graft site can often be saved. The treatment consists of several steps. First the infection is confirmed by removing some fluid from the joint and testing it for bacteria. Staphylococcus aureus (staph infection) is the most common organism found.

It sounds like you’ve had this testing done and the infection was confirmed. There are other types of infectious agents that can complicate things even more — for example the methicillin-resistant staphylococcus aureus organism can be difficult to deal with because it is resistant to antibiotics.

The joint is irrigated with a cleansing liquid called saline solution. The surgeon removes any infected tissue through a procedure called debridement. And finally, intravenous (IV) antibiotics are given for at least six weeks.

The process of irrigation and debridement may have to be repeated more than once. In a recent large study at a special joint surgical hospital, one-third of the patients needed this type of repeated surgery. That’s about average for what is reported in other studies of this kind. Studies show that between two-thirds and three-fourths of all infected grafts can be saved. If this is not possible, then you may be facing a second surgery to remove the graft and start over.

The anterior and posterior cruciate ligaments hold the knee stable from inside the joint where they form a criss-cross. The anterior cruciate ligament keeps the tibia (lower leg bone) from sliding too far forward under the femur (thigh bone). The posterior cruciate ligament does the opposite: it keeps the tibia from sliding too far backwards under the femur. It sounds like maybe those two ligaments are okay but the surgeon will probably double check them just in case. The tests are simple hands-on done by the surgeon while you rest quietly.

There are other ligaments that hold the knee together from the outside. These will be tested as well. Three ligaments that provide posterior (to the back) and lateral (to the side) support and stability to the knee include the fibular collateral ligament (FCL), popliteus tendon (PLT), and popliteofibular ligament (PFL). Instead of keeping the bones in the knee from sliding too far forward or too far backward (the job of the cruciate ligaments), these posterolateral structures protect the knee from bowing out to the side too far or the tibia from externally rotating too far under the femur.

The fibular collateral ligament connects the top of the fibula (bone along the outside of the lower leg) to the bottom of the femur (thigh bone). It gives lateral (side) support to the knee to keep it from bowing out too far. The popliteus tendon starts midway along the bottom portion of the femur and angles back to connect to the back of the upper tibia (shin bone in the lower leg). This tendon supports the knee and keeps it from rotating too far in one direction. And the popliteofibular ligament connects the back of the tibia to the back and side of the fibula. The fibula and tibia sit side by side as the two bones in the lower leg.

Tests used to make the diagnosis may include imaging studies such as X-rays, MRIs, and/or CT scans. The surgeon will perform additional hands-on tests to look at joint movement, feel for tenderness around the joint where each ligament attaches, and assess strength. Pressure applied against the joint will show any excess gapping of the bones from weak or damaged ligaments that would normally hold the joint together and prevent excess movement.

With posterolateral instability, there is a widening of the joint space along the outside (lateral edge) of the knee when pressure is applied in that direction. There may be an increase in external rotation of the tibia under the femur and a positive posterolateral drawer test. The drawer test is done by applying pressure to the lower leg (tibia) and seeing or feeling too much backward movement of the tibia under the femur. Sometimes there is even a clunk as the bone shift too far back. This occurs because the ligaments are damaged and don’t hold the tibia in place as they should.

The surgeon uses all of these tests and measures to make a diagnosis. It’s always good to let the doctor know that you are a bit nervous. Don’t be shy about asking for an explanation of the tests done and what to expect. This can help you understand what is going on and the results as you see and feel them yourself during the exam — and good luck!

When an injury is not treated in the first few weeks, it can become a chronic problem. Instability and reinjury are common weeks to months to years later — especially in more active adults. Sometimes a rehab program makes it possible to avoid (or delay) surgery. But when chronic instability becomes your norm, then surgery to repair the damage is needed.

Chronic injuries may require more than just a repair of the torn tissue. Left over time, the torn ligaments and/or tendons retract (pull away from the bone) and scar tissue fills in. If that happens, then the procedure is more likely to be one involving reconstructing the tissues using tendon graft material. Depending on which tissues are damaged, the surgery can become quite complex.

Healing takes time. The graft has to become incorporated into the bone and be strong enough to withstand forces placed on the soft tissues with running, jumping, twisting, and turning required by activities like jogging, tennis, and basketball.

Rehab is a key component to recovery following knee reconstruction. Even top athletes must follow the surgeon’s protocol and work their way through range-of-motion and strengthening exercises. With your activity level, you’ll likely want to include endurance training and activities to restore proprioception (joint sense of position). All of this will take four to six months. But with a good outcome, you can be back on the court in good form!

Yours is not an uncommon question from many older adults who fall and end up with musculoskeletal injuries. Tendon tears, sprains, and broken bones are often perceived as the result of the fall, not the cause. But more folks are speaking up and sharing their experiences. Some say there was a sudden pain and then a loss of support or stability and down they went.

Others report that they did indeed feel a fall coming on and tried to brace themselves but lost their balance anyway. In the process, the knee was locked in an extended position and the force of the fall was more than it could handle. Soft tissues tear when age-related degeneration is present. Bones break when there is osteoporosis (brittle bones from loss of bone density).

The end-result is the same: injury and potential disability with loss of function and independence. Either way, the treatment approach is the same. The important thing is to concentrate on healing and recovery. Rehab to restore motion, strength, and stability will be very important to help avoid future episodes.

There are different ways to repair a complete quadriceps tendon rupture. The surgeon may use drill holes, screws, sutures, suture anchors, or wires to reattach the tendon to the bone. It all depends on the location of the rupture, the condition of the tissues, and the extent of damage. It may be necessary to reinforce the defective tendon, especially if the patient is older with obvious signs of tissue degeneration.

The leg is protected in a brace or cast that holds the knee in 30 degrees of flexion. That means the patient can’t straighten the knee all the way. This position allows the tendon to heal without any pulling on the fixation site from the muscle contracting.

After surgery, patients may begin walking on the leg right away. That’s a fairly new approach based on studies that show early mobilization actually helps tendons heal. Some surgeons tell their patients to put full weight on the leg. Others recommend only partial weight-bearing for the first six weeks and then progress to full weight.

A follow-up look at patients who have a repair or reconstruction of tendon ruptures can develop problems. Some patients don’t get their full motion (extension) back. That means they won’t have full strength or full function of that knee and leg. Even those who do get their full motion back don’t get full strength. In fact, studies show that half of all repaired quadriceps tendon ruptures result in quadriceps muscle weakness even years later. Rerupture of the tendon is always a concern.

There are some early studies that suggest that early motion with some tension on the healing tendon tissue may stimulate faster recovery with better results. There haven’t been enough comparison studies done yet to show clearly which approach works best. You may want to double check with the hospitalist about this point. If necessary, ask him or her to clarify your surgeon’s orders and intentions for you before going home.

When a patient tears or ruptures the ACL ligament inside the knee, surgery is often needed to restore the stability that the anterior cruciate ligament (ACL) provides the knee. The best way to do this is to take tissue (usually a tendon) from some place else around the patient’s own knee (that’s an autograft) or from a donor bank (allograft) and stitch it in place.

More than a quarter of a million ACL reconstruction surgeries are performed in the United States each year. About 80 per cent of those use autografts. Autografts have the advantage of a very low (rare) rejection rate. Since it’s your own tissue, your body is less likely to attack the tissue, so the graft takes successfully. On the flip side, there is the disadvantage with autografts of causing problems at the donor site such as infection, persistent pain, and possible deformity.

Allografts eliminate those problems but have their own issues with potential tissue rejection by the patient. According to a recent study comparing results from of autografts to allografts, allografts tend to produce a knee that isn’t as stable as joints treated with autografts. In other words, there’s greater joint laxity (looseness) with allografts when using joint stability tests described.

Failure can be defined differently by different surgeons and by individual patients. The graft may not die and slough off (that’s for sure a failure), but the residual joint laxity can interfere with function. Or for the athlete, failure might be described as the inability to get back to a preinjury level of sports participation.

The probability of graft failure is rare but not completely eliminated. Ask your surgeon to review your situation for any risk factors (age, general health, use of tobacco or other chemicals that can slow or delay healing). Assess your own risk for graft failure. It’s likely that you will have a very low risk for graft failure but it would be good to have some reassurance about this concern.

Minor tears of ligaments like the anterior cruciate ligament (ACL) in the knee can be treated conservatively with a rehab program. Muscles around the knee are strengthened to provide external stability usually offered internally by the ACL ligament inside the knee. For older adults or anyone of any age who isn’t an athlete actively engaged in sports competitions, the nonoperative approach often works quite well.

But for the individual who is very active surgical repair may be possible. The surgeon clears away any frayed edges and debris following the injury and stitches the ligament back together. A post-operative rehab program follows to help the patient regain full motion, strength, and function of the knee.

On the other hand, major ACL tears and full tears (ruptures) usually require reconstructive surgery. The surgeon can use a tendon graft from a donor bank called an allograft. Or the graft can be an autograft, which means it is taken from some other area of the patient’s own knee. Whichever source is used, the graft replaces the damaged ligament. Eight out of 10 ACL repairs are done with autografts. The graft is either a bone-patellar tendon-bone graft (from the front of the knee just below the knee cap) or a hamstring graft (taken from behind the knee).

The surgeon tries to provide the most ideal graft possible. The patient’s anatomy and biomechanics of the knee (and especially of the previously healthy ACL) are considered. When using the patient’s own tissue, the autograft quickly gets incorporated into the knee and starts providing stability quickly. Allografts take a bit more time but there are fewer problems overall because there’s no donor site to deal with. Patients are more likely to complain about persistent pain at the donor site than any report any problems at the surgical site.

An overall review of studies comparing patellar to hamstring graft reconstruction for ACL injuries show fairly even results between the two. Good-to-excellent outcomes are reported. Surgeons using either type of graft approach continue to look for (and find) ways to fix the graft in place yielding better and better results all the time.

Long-term studies are still needed comparing the two types of grafts to see what happens over time. Does the failure rate differ between the two techniques 10 or 20 years down the road? Is there a greater risk of gradual deterioration or loss of stability over time with either graft type? These are questions for which we don’t have answers just yet.

Knee replacements are an increasingly common surgeries, particularly as our population ages. Some people, however, don’t need to have the full knee replaced, but only part of it. If the problem affects more than one part of the knee, then a total replacement is needed.

The decision as to whether it is a full or partial replacement that is needed depends on the diagnosis, the surgeon and the availability of the equipment necessary.

Knee replacements, as with any joint replacement, can fail for a variety of reasons. If the implant fails enough to cause pain and restrict movement, a replacement or revision may be done, depending on if it is feasible.

Some common reasons for revision surgery include infection in the joint, breakage of the implant, and breakage of the bone holding the joint.

Imaging studies can be very helpful when trying to assess the cause, location, and extent of damage contributing to knee pain from injury, trauma, or age-related degeneration. What’s the condition of the joint? How bad is the tear? Could it heal on its own? These are all questions the surgeon must address before recommending a treatment plan.

Small tears along the edges of the cartilage have a better chance of healing because there is a better blood supply there. An MRI will help show how much blood supply there is and give the surgeon an additional tool when predicting who might get better with nonoperative versus surgical care. Tears on the inner aspect of the meniscus (especially large tears in multiple directions) don’t heal well and often need a little surgical help.

By taking a look at the cartilage using an arthroscope, it’s possible to see what condition the meniscus is in and how much degeneration has occurred. Too much degeneration and the meniscus won’t heal itself and can’t be saved. Likewise, if the tear is too long, too deep, or too displaced, then it might be necessary to actually remove part (or all) of the cartilage. This procedure is called a meniscectomy. No matter what, the surgeon always tries to preserve tissue and knee function.

The most difficult injuries to deal with are large tears in more than one direction (vertical and horizontal) and bucket handle tears. With a bucket handle tear, half the meniscus has pulled up away from the rest — like a bucket handle lifting up away from the bucket. One end of the meniscus can get folded back on itself.

Meniscal repair in young patients with a stable knee and tear in the outer portion of the meniscus is 80 to 95 per cent successful. Athletes or active, young adults in this group are able to get back into full sports and recreation at a level equal to before the injury. Partial meniscectomy in someone who has good articular cartilage underneath has a 90 per cent chance of successful healing. This same procedure is only successful 60 per cent of the time when there’s damage underneath the torn meniscus or when the knee is unstable or misaligned.

Removing any portion of the meniscus will eventually result in degenerative changes in the joint. This may not happen for five to 10 years, and it is somewhat dependent on how active the patient is — more activity puts added stress on the joint and increases the risk.

Early intervention can help save the cartilage and preserve knee function — that’s one important reason why patients are encouraged to get an early diagnosis and treatment rather than waiting too long and risking further injury to the meniscus and/or knee.

When deciding on the best plan of care for a meniscus problem, the surgeon considers the age and activity level of the patient. The surgeon looks at how long the patient has had this problem (acute versus chronic). The chances of healing in a long-term injury (one that occurred months to years ago) are less than in a more recent injury.

The surgeon will also consider the condition of the joint. How bad is the tear? Could it heal on its own? Small tears along the edges of the cartilage have a better chance of healing because there is a better blood supply there. An MRI will help show how much blood supply there is and give the surgeon an additional tool when predicting who might get better with nonoperative versus surgical care. Tears on the inner aspect of the meniscus (especially large tears in multiple directions) don’t heal well and often need a little surgical help.

Sometimes patients are advised to try a conservative (rehab) program first. Older adults who aren’t very active may do just fine with a rehab program of modified activity and strengthening exercises. If symptoms are resolved and activities can be resumed, then great — surgery won’t be needed. But if after a trial of rehab lasting up to three months, there’s no improvement or pain persists with activities, then it’s time to think about surgery. The most successful operations are performed within the first 10 to 12 weeks after the injury first occurs.

When it comes to surgery, the goal is to save the meniscus but also stabilize the knee. It may be possible to repair the tear and/or reattach the torn edges. The surgeon shaves down any ragged edges in a procedure called debridement. Debridement may be all that’s needed to stimulate a healing response. In some cases, the surgeon may opt to suture loose edges back in place or even remove part of the damaged meniscus.

By taking a look at the cartilage using an arthroscope, it’s possible to see what condition the meniscus is in and how much degeneration has occurred. Too much degeneration and the meniscus won’t heal itself and can’t be saved. Likewise, if the tear is too long, too deep, or too displaced, then it might be necessary to actually remove part (or all) of the cartilage. This procedure is called a meniscectomy. No matter what, the surgeon always tries to preserve tissue and knee function.

Traumatic knee dislocations are fairly rare so we don’t have a lot of data from high-quality studies to base treatment recommendations on. The surgeon assesses the damage; takes into consideration the patient’s age, general health, and activity level; and formulates the best plan of action possible.

Most of the time, knee injuries severe enough to cause the joint to dislocate also cause significant soft tissue damage. Multiple ligaments are torn or ruptured requiring surgery. There can also be damage to the nerves and blood vessels in the knee creating even more complications.

Although there’s no way to predict for sure the final result being a joint replacement, there are ways to work against that outcome. A rehab program aimed at increasing joint stability through muscle strengthening is advised. The physical therapist will check for any postural problems that might add uneven load or force to the joint and help you achieve better alignment if possible. Specific training will be needed to restore joint proprioception (joint sense of position) and kinesthesia (awareness of movement).

Rehab to prevent joint replacement is the type of approach that requires some discipline and dedication on your part. You won’t be able to follow the exercise program for six weeks and call it quits. This type of prevention requires ongoing perserverance. But it can pay off in the end as many patients (especially athletes) can report.

There aren’t a lot of studies of patients with this type of injury because fortunately, there aren’t large numbers of patients who dislocate their knees. What we do know comes from a recent systematic review of evidence collected since the 1950s. Even with 50 years of data to look at, only 24 studies for a total of 396 knees qualified for inclusion in this review.

Results of treatment were assessed using objective measures such as range-of-motion, joint stability, and patients’ return-to-work or return-to-sports status. The need for manipulation was another outcome measure reported on. Manipulation refers to an operative procedure under anesthesia. The surgeon moves the joint through its full range of motion, gently breaking any adhesions or scar tissue that are keeping the joint from moving and causing severe stiffness and pain.

It was possible to see a pattern of treatment times that results could be based on. These were divided into acute treatment (first three weeks following the injury), chronic treatment (three or more weeks after injury), and staged treatment. Staged repairs often take place throughout the time periods. The first surgery in a staged procedure is done during the acute phase with follow-up operations during the chronic phase.

Rehabilitation corresponded with these same time periods and could be divided into two major groups: mobilization (early movement) and immobilization (no movement). Data for all patients was put together and analyzed to compare each treatment option with each phase of treatment.

They found that patients who had acute (early) treatment were more likely to end up with knee instability (joint laxity/looseness) or the opposite: joint stiffness requiring manipulation. Acute treatment followed by immobilization had the worst results. These patients were the least likely to get back-to-work or back-to-athletics.

Patients in the chronic treatment group (treatment three or more weeks after injury) regained their knee joint motion better than the other two groups and were less likely to need a joint manipulation. But results for this group varied and couldn’t be predicted. Staged surgeries seemed to have the best results. Patients who had staged treatment were also more likely to rate their results as good-to-excellent. However, they did have just as much stiffness as the acute group requiring manipulation later.

In terms of the rehabilitation programs, getting patients up and moving rather than putting them in an immobilizing splint or brace didn’t seem to cause joint instability. In fact, in some cases it prevented instability. But it didn’t prevent joint stiffness later.

The most significant findings regarding postoperative treatment involved that acute treatment group. Patients treated surgically in the acute phase (within three weeks of the injury) who also had early mobility had fewer problems with joint stability. This combination (acute treatment with early mobilization) was more likely to get patients back to work. The results suggest that early aggressive rehab after acute treatment may be advised. But, in the end, taking it one step at a time seems to work best. Your surgeon will be able to guide you through this process based on your own individual factors.

A hole in the knee cartilage usually refers to damage in the articular cartilage. This area of the joint is a smooth, fibrous covering over the two bones that form a joint. If you were to look at this structure on a chicken leg, it is the equivalent of the gristle at the end of the drumstick.

The purpose of the articular cartilage is to protect the bone while making it possible for the knee joint to slide and glide as it bends and straightens. Damage to this part of the joint can create cracks and even holes called defects that must be treated to prevent erosion of the underlying bone. Without treatment, the eventual outcome is painful knee osteoarthritis.

There are three main surgical treatment techniques for this type of condition: 1) osteochondral autologous transplantation (OAT), 2) microfracture (MF), and 3) autologous chondrocyte implantation (ACI).

Microfracture is a way to repair the defect. The surgeon drills tiny holes through the articular cartilage into the bone. This causes bleeding and the formation of tiny blood clots to fill the defect. The body then sets up a healing response that causes new chondrocytes (cartilage cells) to form. Transplantation and implantation are restorative techniques. The surgeon uses a plug of cartilage and bone taken from a healthy area of the patient’s own cartilage for the transplantation procedure or the patient’s own cartilage for implantation procedures to fill in the hole.

According to a recent review of the evidence supporting these procedures, you can expect to get good results no matter what procedure is used. Reduced pain and improved knee function are routinely reported. Studies show that repair with microfracture seems best for small lesions (less than 2.5 cm2).

The osteochondral autologous transplantation (OAT) transferring a plug of cartilage and bone into the defect works better than microfracture for medium-sized defects (2.8 cm2). And restorative techniques with transplantation or implantation have the best results when used with the more active patients.

Age does make a difference in selecting the best treatment technique. Patients under 30 seem to respond better than patients 30 and older no matter what treatment was used. But there are other factors to consider such as the location of the defect, your body mass index, and the type of training your surgeon has received in treating these types of lesions.

The number of athletes who injure their knees and need anterior cruciate ligament (ACL) repair or reconstruction is on the rise. Every year, almost one-quarter of a million ACL surgeries are performed in the United States. That doesn’t count the number of ACL injuries treated conservatively without surgery.

There are many factors that can affect the success of a reconstructive surgery. Experience of the surgeon, type of graft used to reconstruct the ligament, age of the patient, sex, and compliance with instructions during the post-operative period are just a few. A recent patient study of over 400 ACL surgeries showed that young patients and females are more likely to end up with a lax loose knee joint after ACL reconstruction than older or male patients.

The reasons for this remain a mystery though there are some theories being tested. It is possible that younger patients are less likely to follow the post-operative program as they are instructed. Weaker (less dense) bone and smaller-sized grafts might help explain greater instability among females.

Your daughter falls into the risk category for three factors: younger age, female sex, and failure to follow the postoperative protocol as prescribed. But whether or not those three factors can be directly linked with the laxity now seen in her knee is unclear. The goal now is to complete a strengthening and rehab program that can help prevent any future knee injuries in the presence of joint laxity.