FAQ Category: Knee

Given the fact that anterior cruciate ligament ruptures are very common injuries requiring surgery, you might think the decision about which graft tissue is best would be decided by now. But in fact, despite many studies comparing these different approaches, there are still many unknowns and gray areas.

That’s because different studies use a variety of different outcomes to measure results by. They also don’t follow-up with patients for the same length of time after surgery. Some results may be reported after six months, one year, or two years while others extend outcome measures up to 10-years.

Another factor involves rehabilitation programs. Post-operative protocols may differ from one surgeon to another contributing to differences in results. Not to mention the fact that some patients are athletes who rehab differently while preparing to get back into their sport activity. They may count whether or not they return to full participation in their sport as the litmus test for a successful result.

Not only that but there are different ways to attach each graft type adding to the complexity and challenge for the surgeon in deciding which way to go. Many patients do choose which graft type they want so they aren’t randomly put in treatment groups and compared. This can create a treatment bias.

When we turn our attention to the results, there can be many different ways to measure “success” versus “failure.” For example, results of ACL reconstruction can be measured in terms knee stability, leg strength, function, return-to-sports, patient satisfaction, complications, and cost.

According to the most recent comparative studies, rates of post-operative knee joint stability (joint “give”, laxity, or looseness versus tightness of the joint) may be no different between allografts and autografts. The primary difference is in terms of rupture rate. Improper preparation of allografts (e.g., sterilization, drying) can result in more graft ruptures years later compared with autografts.

Concerning muscle strength. There is agreement among studies that quadriceps strength seems to be equal among the various autografts. The hamstring muscle group is more likely to lag behind in recovering full strength, especially for patients who have a hamstring graft.

Return of overall function seems to be equal among all graft types. But return-to-sports varies widely. The majority of patients (75 per cent) get back to playing but not all return to their preinjury level of participation. Some athletes have to gear down to a lower intensity level of activity while others change the sports activity altogether.

One more area of concern and comparison is complications (e.g., pain, infection, graft failure or rupture). Most patients expect a certain amount of pain right after surgery. But when pain lasts months-to-years later, this symptom becomes a complication. Kneeling pain persists more often with patellar donor grafts. Other long-term annoying symptoms at the harvest site can include numbness, tenderness, or irritation.

Finally, graft failure or rupture is more likely occur when there is significant joint laxity (looseness) after surgery. Another significant risk factor is return to sports that require sudden turns or changes in direction (pivoting), sidestepping, and jumping. Studies show that younger, more active patients are the most likely to experience ruptures with an allograft.

So you can see how evaluating results using different graft types isn’t really a matter of it works or it doesn’t. The factors to consider are much more broad and complex than that. Hopefully, this information will give you some additional thoughts to consider and perhaps generate a few more questions for your surgeon to help you sort through this decision.

A recent study from Germany might answer some of your questions. In this study, surgeons took a closer look at factors that might increase the risk of revision surgery after autologous chondrocyte implantation or ACI.

ACI is a cell-therapy approach to treat deep or large defects in the knee joint cartilage. It involves using cartilage cells (chondrocytes) to help regenerate articular (joint surface) cartilage. Studies show that in about one-fifth of patients who have this treatment, there is a failure of the cartilage cells to regenerate and fill in the hole.

In cases of treatment failure, a second (revision) surgery is required. Surgeons would like to spare patients both the failed results and the need for more surgery. Identifying risk factors that could increase the likelihood of treatment failure would be helpful. Surgeons could screen patients before surgery and perhaps choose a different treatment approach if it looks like there are indicators that autologous chondrocyte implantation (ACI) might fail.

To conduct this study, 413 patients who had the first ACI procedure for a full-thickness defect (down to the bone) were followed. Anyone who had a failed response was examined more carefully. Data collected about patients with failed outcomes was analyzed.

The kinds of information collected included age, sex (male or female), type of defect (size, location), body mass index (BMI, a measure of obesity), smoking history, and number of previous knee injuries or surgeries. Follow-up was a minimum of at least two years. Some patients were followed for up to 11 years.

This next piece of information might be of interest to you. Criteria for a second surgery included continued knee pain, loss of knee function, and MRI evidence of pathology. Just about one-fifth of the group (21.3 per cent) needed revision surgery.

They didn’t all have the same exact problem. Problems ranged from too much cartilage regrowth (called transplant hypertrophy) to not enough (insufficient regeneration). In some cases, there were loose pieces of cartilage in the joint space or bone cysts that formed.

The factors that were most significant for failed ACI included being female, having a previous bone marrow treatment, the use of a periosteum patch to cover the ACI, and previous knee surgery (or surgeries) on that knee. There was no apparent link between age, smoking history, body size, or defect size or location.

A periosteal patch is a thin layer of bone harvested from a nonweight-bearing portion of the knee joint used to cover the implanted cartilage cells. It’s a bit like placing a manhole cover over an open hole. It protects the healing lesion that has been filled with chondrocytes (cartilage cells).

Whenever possible, minimally invasive arthroscopic surgery was done to address the problem. Sometimes the surgeon just had to clean out the area of any bits of debris, bone, or excess cartilage. This procedure is called debridement. This may be all that you need. In some cases, the surgeon opted for a different surgical approach rather than revise or repeat the chondrocyte implantation.

Your surgeon is the best one to advise you. If you haven’t already gone back for a follow-up appointment, this might be a good time to schedule further evaluation. There could be something simple that can be easily corrected if addressed sooner than later. Imaging studies with X-rays or MRIs might be helpful in showing what’s going on and aid the surgeon in making the best choice as to how to change your pain, loss of motion, and decreased function.

Given what you just told us, you might find the results of a recent study of interest. A survey 314 athletes of all ages who had ACL reconstructive surgery was conducted two to seven years after their ACL surgery. They all had surgery with the same surgeon using the same surgical technique. And they all followed the same post-operative rehab program with a physical therapist.

Athletes who filled out the self-report questionnaire answered questions about their level of sports participation before the injury and after the surgery. They also commented on overall knee function. Almost everyone (93 per cent) tried to participate in their sport after their surgery.

Only about half of them were successful. And only one-third were playing competitively two to seven years later. Athletes who returned to sports at their preinjury level by the end of the first year didn’t always stay in their sport competitively. That told the researchers that short-term results (12 months after surgery) aren’t always an accurate reflection of what will happen months to years later.

They noticed that men were more likely than women to get back into the game in that first year. But the final mid-term outcomes weren’t any different between men and women. This could mean that women may take longer to rehab and recover but in the end, the results are the same as for men.

In any case, if someone does not return to full participation in their sport at a preinjury level after ACL surgery in the first year, this does not mean they won’t ever get back their full function later. And that is an important finding physicians, physical therapists, and sports trainers can offer athletes like yourself who have not regained full strength, function, and ability by the end of a year.

You have asked a good question that has been addressed by some experts looking for answer to these questions: what keeps athletes who have had ACL surgery from getting back into the game sooner than later? Why do some athletes stop playing and competing altogether after ACL reconstructive surgery?

Short-term (12 month) studies show that most people have not returned to their preinjury level of sports play following reconstructive surgery for a torn ACL. The authors of a recent study extended the timeline to look at medium-term results to see what happens to these athletes months to years later.

They surveyed 314 athletes of all ages two to seven years after their ACL surgery. Athletes who filled out the self-report questionnaire answered questions about their level of sports participation before the injury and after the surgery. They also commented on overall knee function.

Almost everyone (93 per cent) tried to participate in their sport after their surgery. Only about half of them were successful. And only one-third were playing competitively. Athletes who returned to sports at their preinjury level by the end of the first year didn’t always stay in their sport competitively. That told the researchers that short-term results (12 months after surgery) aren’t always an accurate reflection of what will happen months to years later.

Variables that differed from patient to patient included age, lifestyle factors, and exposure to sports opportunities. Analysis of the data collected included these factors because the researchers thought perhaps younger patients were more likely to be involved in school sports. They would therefore have more opportunities for sports participation. Older patients might be prevented from getting back into play because of family or work. And as it turned out, more patients 25 years old and older were, in fact, not playing anymore compared with the younger (less than 25 years of age) athletes.

This study provided evidence that failure to regain preinjury sports ability is directly linked with the function of the operative leg. Other personal factors also played an important role in the decision to return-to-sport. More study is needed to tease out the differences among groups of same-age/same sex athletes compared with same age/different sex players.

There is plenty of evidence that skin, soft tissue and bone just don’t’t heal as well in smokers versus nonsmokers. The nicotine seems to have a toxic effect on the cells that make up these body parts. In the case of chondrocytes (cartilage cells), the nicotine breaks down the cells and prevents or delays new chondrocytes from forming.

With chondrocyte transplantation (a procedure called autologous chondrocyte implantation or ACI), the newly forming cells are especially sensitive to the effects of nicotine on collagen synthesis. This is when patients are strongly urged to reduce (or stop) their use of nicotine altogether.

Not all studies show the same degree of nicotine influence. The effects of nicotine may be less obvious in the later stages of the transplantation process. More study on the effects of nicotine on healing cartilage from early on to years later are needed. Some smokers seem more affected than others but the exact reasons for this remain a mystery.

Without knowing who will be affected and by how much, it’s easier to just tell all nicotine users to reduce or eliminate this risk factor. Other known risk factors for a failed procedure aren’t as easily modified. For example, previous knee surgeries and female sex have been linked with a higher risk of failed treatment using this treatment approach to cartilage defects. And there’s not much that can be done about either of these factors!

s you know, iliotibial band (ITB) syndrome is an overuse problem that is often seen in bicyclists, runners, and long-distance walkers. Athletes who participate in skiing, rowing, triathlons, and field hockey have also reported ITBS as a problem limiting their sports activities. As mentioned, it causes pain on the outside of the knee just above the joint.

For those who are reading this who don’t know, the ITB is actually a long tendon. (Tendons connect muscles to bone.) It attaches to a short muscle at the top of the pelvis called the tensor fascia lata. The ITB runs down the side of the thigh and connects to the outside edge of the tibia (shinbone) just below the middle of the knee joint. You can feel the tendon on the outside of your thigh when you tighten your leg muscles. The ITB crosses over the side of the knee joint, giving added stability to the knee.

The lower end of the ITB passes over the outer edge of the lateral femoral condyle, the area where the lower part of the femur (thighbone) bulges out above the knee joint. When the knee is bent and straightened, the tendon glides across the edge of the femoral condyle.

The ITB glides back and forth over the lateral femoral condyle as the knee bends and straightens. Normally, this isn’t a problem. But the bursa (fluid-filled protective pad) between the lateral femoral condyle and the ITB can become irritated and inflamed if the ITB starts to snap over the condyle with repeated knee motions while walking, running, or biking.

In long distance runners, impingement of the iliotibial band against the lateral femoral condyle causes enough friction to create this condition. As the knee bends 30 degrees and straightens fully (to zero degrees), the iliotibial band slides through an area called the impingement zone.

People often end up with ITB syndrome from overdoing their activity. They try to push themselves too far, too fast, and they end up running, walking, or biking more than their body can handle. The repeated strain causes impingement leading to this syndrome.

Some experts believe that the problem happens when the knee bows outward. This can happen in runners if their shoes are worn on the outside edge, or if they run on slanted terrain. Others feel that certain foot abnormalities, such as foot pronation, cause ITB syndrome. Pronation of the foot occurs when the arch flattens.

An accurate diagnosis and examination is important so that the proper treatment can be applied. For example, impingement versus bursitis versus flat feet would be treated differently from a tendon that is simply too short and too tight. In almost all cases, conservative care is tried first before considering surgery.

The physical therapist evaluates each patient and performs clinical tests (e.g., Ober’s test, Noble test, Thomas test) that assess iliotibial band tightness and function. A program of activity modification, stretching, manual therapy (e.g., soft-tissue mobilization to break up adhesions), and equipment change are key features of the physical therapy program.

The therapist will also evaluate the athlete’s equipment (shoes, cleat type and position, bicycle seat and handlebars) and make recommendations for changes. Running form and training programs are reviewed and instruction given to reduce iliotibial band impingement.

With your background, it sounds like you can easily apply some of these ideas and at least see if any change can be brought about. If not, then a visit to a sports physician, orthopedic surgeon, or physical therapist may be needed. The goal of all treatment is to return the athlete to pain free full participation in sports and activities.

Pain along the outside (lateral) knee is a common symptom with iliotibial band syndrome. The exact cause of the problem isn’t clearly understood. The possible factors leading up to the syndrome are currently a hotly debated topic among sports enthusiasts. Researchers are looking for evidence-based treatment protocols.

People often end up with ITB syndrome from overdoing their activity. They try to push themselves too far, too fast, and they end up running, walking, or biking more than their body can handle. The repeated strain causes impingement leading to this syndrome.

In long distance runners, impingement of the iliotibial band against the lateral femoral condyle causes enough friction to create this condition. As the knee bends 30 degrees and straightens fully (to zero degrees), the iliotibial band slides through an area called the impingement zone.

Some experts believe that the problem happens when the knee bows outward. This can happen in runners if their shoes are worn on the outside edge, or if they run on slanted terrain. Others feel that certain foot abnormalities, such as foot pronation, cause ITB syndrome. Pronation of the foot occurs when the arch flattens.

An accurate diagnosis and examination is important so that the proper treatment can be applied. For example, impingement versus bursitis versus flat feet would be treated differently from a tendon that is simply too short and too tight. In almost all cases, conservative (nonoperative) care is tried first before considering surgery.

If you have pursued a nonoperative approach for at least three months without a change in your symptoms, then you may be a candidate for surgery. Surgery to release the tissue is the treatment of choice. The surgeon may inject the area with cortisone first before surger to see if the procedure will help. Studies show that patients who respond well to the injection tend to have good surgical outcomes.

Surgery may be done percutaneously (through the skin without a large incision) but open incision may be required. Using diagrams (drawings), the surgeons show and describe the type of surgical Z-lengthening procedure used to lengthen the iliotibial band.

They report being able to increase the stretch of the band by 1.5 centimeters (that’s a little more than half an inch). That may not seem like much but combined with a bursectomy (removal of the inflamed or irritated bursa), it is enough to give relief from the painful symptoms. In many cases, the athletes are able to return to full participation in their chosen sport within eight weeks’ time after the procedure.

To summarize, working with a physical therapist to change posture, form, flexibility, and movement patterns is the first place to start. Only in persistent, chronic cases of inflammation is surgery considered as the preferred treatment method. The goal of all treatment is to return the athlete to pain free full participation in sports and activities.

You are correct that meniscus removal is no longer the first approach to meniscal tears or damage. Whenever possible, the surgeon tries to repair the damage. This may mean shaving any frayed edges or stitching down corners that have lifted up.

But when the meniscus is shredded to pieces or has large holes where chunks of meniscal material have worn through or pulled away, then it may be necessary to remove the meniscus altogether. And long-term studies have, indeed, shown that removing the meniscus is linked with the development of early osteoarthritis.

Efforts are being made to find ways to regenerate body tissues of all kinds including tendons, bone, and cartilage. An actual meniscus replacement is being studied but it’s not available yet for use in the general population. The implants under investigation are called nondegradable synthetic menisci. They are made of a composite material reinforced with polyethylene (plastic) fiber.

Researchers are still looking for ways to match the mechanics of the synthetic implant with the natural meniscus. Two types of implant are being tried: one that has to be inserted and held in place and another that is free-floating. It’s not clear when a “meniscus replacement” of this type might be on the market.

Knee replacements have been around long enough now that their track record is clear. Ninety per cent of these implants last 15 to 20 years without problems. Patients experience a pain free return to normal function. Reports of patient satisfaction are high. But that doesn’t mean problems can’t or don’t occur — they can and they do.

One of those common problems is osteolysis (bone resorption). It might help you make the decision if you have a little more information about this problem. First, what really causes osteolysis after a knee replacement?

The main reason osteolysis occurs is because tiny particles flake off from the polyethylene (plastic) portion of the implant. The body responds to this debris as it would any “foreign invader.” It sets up an inflammatory response to destroy the particles. In the process, bone is destroyed as well.

Studies show the debris can be made up of different sized flakes of material. The smaller pieces are the ones that seem to trigger the inflammation. Larger particles aren’t as likely to start a foreign-body cellular response, but instead delaminate or wear away the smooth surface of the implant. Either way, the end-result can be osteolysis and implant failure.

The implant itself can be a source of problems. Different design features have advantages but also disadvantages. For example, efforts have been made to shape the implant so that it conforms better to the bone. Implants with small contact areas have less surface area to spread the force and load placed on the knee. The increased stress on the implant also increases the risk of wear and osteolysis.

A second design feature is the placement of holes in the baseplate of the implant. The holes actually gave particles of debris a way to migrate or move into the joint. Screws used to hold the tibial portion of the implant in place did the same thing.

The locking mechanism on the implant is another design feature that is intended to hold the implant steady. But even the tiniest movement or slippage of that locking feature and the backside of the tibial implant starts to wear. Over time, the finish on the surface of the implant wears away resulting in delamination, greater stress on the implant, and resulting implant failure.

Not only is the implant itself a potential source of problems, but the way the implant is manufactured has actually been identified as a factor. Off-the-shelf implants that are machined to finish them (rather than compression molded) are more likely to have surface irregularities that lead to delamination.

And one final manufacturing factor that affects how well implants hold up is the method of sterilization used. Of course the sterilization process is important and must be done but the way in which it is done can contribute to oxidation (breakdown) of the polyethylene. When that happens, the same results occur: debris formation, bone osteolysis, and implant failure.

Scientists are studying ways to prevent this oxidation. Additives such as vitamin E have been added to the polyethylene in an effort to maintain the stable properties of the plastic. The hope is that by stabilizing the plastic portion of the implant, there will be less uneven load and better resistance to wear and tear.

Until the problem of osteolysis is solved following a knee joint replacement, there is always a risk of this occurring. There’s no evidence that we know of to suggest the problem is hereditary (i.e., no proof that if your sister developed osteolysis, you will too). It’s common to have questions and doubts about any major surgery. Be sure and talk with your surgeon about this and any other concerns you may have.

Surgeons routinely follow patients to make sure they have a successful outcome. With joint replacements, there can be problems that develop that the patient is totally unaware of. Delayed diagnosis of complications like infection, osteolysis, or delamination of the implant can lead to failure of the implant.

Osteolysis is the resorption of bone to the point that holes form where there has been bone loss. These holes can be tiny pinpoints but they can get much worse over time. Imaging studies such as X-rays, CT scans, and MRIs give the surgeon a better inside view of bone quality. It’s the best way we have to identify and evaluate the degree of the problem.

X-rays are the place to start but they are limited in what they can show. The surgeon will be able to see if there are any fractures in the bone around the implant (or even a fracture of the implant itself). CT scans and MRIs give a better estimation of the extent of osteolysis and damage caused by this problem.

For patients who have small areas of osteolysis that don’t apprear to be growing, treatment is careful monitoring. If the problem starts to get worse, efforts must be made to put a stop to the progression.

Right now, there isn’t a “best known” treatment to halt the progression of osteolysis. Medications such as antiinflammatories and bisphosphonates (prevent bone resorption) are the first thing to try. Studies are really needed to see if this approach is effective. With large bone lesions, the polyethylene liner is removed and replaced.

Every effort is made to prevent bone loss from the osteolysis and during the revision surgery. X-rays, CT scans, and/or MRIs help give the surgeon additional information about the location, size, and extent of the osteolysis. Bone grafting may be necessary to fill in the holes and stimulate bone growth and repair.

Your surgeon may have reason to believe there is something going on that must be further investigated. Or it may be possible your surgeon is a thorough, careful physician who is making sure all is indeed well. Don’t hesitate to ask for his or her reasoning in ordering additional tests when and if you don’t understand their necessity.

We assume you are referring to autologous chondrocyte implantation (ACI), the fairly new cell-therapy for cartilage defects of the knee. The first study published on the topic was in the early 1990s. So it’s been around for about 20 years but it is still being studied and improved upon.

The basic technique involves harvesting healthy cartilage cells from a non-weight bearing surface of the patient’s knee joint. Those cells are transplanted and used to fill in the defect (hole) in the damaged cartilage lining the joint surface. The goal of the procedure is to create biologic remodeling of the cartilage.

Rehab must be guided according to what’s happening with the wound (incision sites) and transplanted tissue. Studies show that these transplanted chondrocytes (cartilage cells) start to stick right away. Care must be taken not to disturb them. Load and shear forces must be avoided. At first, the area remains more liquid than solid (like jello just starting to set up).

Of course, pool therapy is usually held off until the skin wounds have healed. In the meantime, movement is important because the old saying, motion is lotion is still true. Movement and the pumping action of the knee as it bends and straightens is what help deliver blood to the area. Blood with its oxygen and nutrients feeds the chondrocytes.

Passive range of motion (PROM) exercise can be started on day one after surgery. Some surgeons are trying continuous passive motion (CPM) machines with patients. Studies using CPM following knee replacement surgery have not shown an overall benefit. There is limited evidence to support the use of CPM after autologous chondrocyte implantation.

As a physical therapist, you will be addressing other areas as well. The knee joint (including the patella or kneecap) can be mobilized or moved. Mobilization techniques can also be applied to the soft tissues around the joint to keep them soft, moveable and free of adhesions.

Other treatment modalities (tools) used by other therapists during the early post-operative phase include cold therapy (called cryotherapy) and manual lymph drainage. These two therapies may help decrease swelling, pain, and decrease the temperature around the healing cartilage. Cryotherapy is important because studies show that too much heat in a joint can cause breakdown of the chondrocytes (cartilage cells).

When the incisions heal, patients can indeed begin aquatic (water-based) therapy. Aquatic therapy is considered beneficial throughout the postoperative period. As you know, working in the water reduces the effects of gravity and therefore unloads the joint. The weight-bearing force placed on the joint is only 25 percent of the body weight when the water is up to the armpits. Moving through water at waist level reduces the load to 50 per cent of the person’s body weight.

When the repair tissue starts to solidify (moves from a jello to spongy consistency), then there is enough strength to withstand some partial weight-bearing activities. How much weight and how soon the patient can put weight on the knee are still unknown areas. Some therapists have experimented with partial weight-bearing (minimal loading of the knee) as early as two weeks after implantation.

Around eight weeks after surgery, the transplant has filled in the defect and new, healthy cartilage cells are present. As the tissue continues to build and remodel over the next weeks (the patient is now three to six months out from the surgery), the therapist steps up the rehab program. Patients are instructed how to increase weight-bearing and improve walking pattern. Pool-therapy is especially helpful in starting gait training. Full weight-bearing on land is usually allowed eight to 12 weeks after the implantation procedure.

Around six months post-op, the transplanted tissue changes from spongy to the consistency of soft plastic. Now the therapist can progress the rehab program to focus on strengthening, endurance, and functional training. Studies consistently show that quadriceps strength is a major factor in the success of this procedure. Both land-based and aquatic therapies can be used during this phase as well.

Regaining full quadriceps strength is considered the most important goal of rehab following autologous chondrocyte implantation (ACI). Additional areas of focus in rehab include restoring proprioception (joint sense of position) and sensorimotor control.

Full return-to-sports can still take a while. The final healing phase of the chondrocytes is called maturation. If there are no complications (e.g., wound infection, overgrowth of the graft, graft failure), the entire process from start to finish can take two to three years. The biggest deterrent to recovery is putting weight on the joint too early and/or another traumatic injury disturbing the delicate transplanted tissue. Once again, this is where water-based therapy can be so helpful.

Much has been written about the use of autologous chondrocyte implantation (ACI) to treat deep or large defects in the knee joint cartilage. Your question about what happens afterwards is a good one. We found a well-written article on this very topic. A group of orthopedic surgeons from the Department of Orthopedic Surgery at the University Hospital Freiburg in Germany are the authors.

They reviewed all previous studies published on the topic of postoperative rehabilitation following autologous chondrocyte implantation (ACI). They summarized their findings in this article. The goal of the procedure is to create biologic remodeling of the cartilage. The basic technique involves harvesting healthy cartilage cells from a non-weight bearing surface of the patient’s knee joint. Those cells are transplanted and used to fill in the defect (hole) in the damaged cartilage lining the joint surface.

But as you have discovered, that’s only part of the total picture. The athlete still has to regain knee motion and strength. Recovering normal nerve and motor control over all movements is essential. Athletes must be able to make quick changes in direction, move from one position to another, jump, and pivot over and over. Without normal neuromuscular control, reinjury is a real concern.

Rehab must be guided according to what’s happening with the transplanted tissue. Studies show that these transplanted chondrocytes (cartilage cells) start to stick right away. Care must be taken not to disturb them. Load and shear forces must be avoided. At first, the area remains more liquid than solid (like jello just starting to set up).

But movement is important because the old saying, motion is lotion is still true. Movement and the pumping action of the knee as it bends and straightens is what help deliver blood to the area. Blood with its oxygen and nutrients feeds the chondrocytes. So how do we keep the knee moving without walking on it?

That’s where rehab specialists (physical therapists) come in. The therapist moves the leg for the patient starting on day one after surgery. This is called passive range of motion (PROM) exercise. Some surgeons are trying continuous passive motion (CPM) machines with patients. The leg is placed in this motor-driven device and moved continuously bending and straightening the leg for the patient.

Studies using CPM following knee replacement surgery have not shown an overall benefit. There is limited evidence to support the use of CPM after autologous chondrocyte implantation. More studies are clearly needed. Whether passive motion is delivered by hand or by a machine, the goals are the same: prevent scar tissue from building up, restore joint motion, and keep the quadriceps muscle tuned up.

The physical therapist addresses other areas as well. The knee joint (including the patella or kneecap) is manually (a hands-on treatment technique) mobilized or moved. The therapist does this without moving the joint by gently applying traction and tiny oscillations (movements) to the bones that make up the joint. Mobilization techniques are also applied to the soft tissues around the joint to keep them soft, moveable and free of adhesions.

Other treatment modalities (tools) used by the therapist during the early post-operative phase include cold therapy (called cryotherapy) and manual lymph drainage. These two therapies may help decrease swelling, pain, and decrease the temperature around the healing cartilage. Cryotherapy is important because studies show that too much heat in a joint can cause breakdown of the chondrocytes (cartilage cells).

When the repair tissue starts to solidify (moves from a jello to spongy consistency), then there is enough strength to withstand some partial weight-bearing activities. How much weight and how soon the patient can put weight on the knee are still unknown areas. Some therapists have experimented with partial weight-bearing (minimal loading of the knee) as early as two weeks after implantation.

Around eight weeks after surgery, the transplant has filled in the defect and new, healthy cartilage cells are present. As the tissue continues to build and remodel over the next weeks (the patient is now three to six months out from the surgery), the therapist steps up the rehab program. Patients are instructed how to increase weight-bearing and improve walking pattern. Pool-therapy is especially helpful in starting gait training. Full weight-bearing on land is usually allowed eight to 12 weeks after the implantation procedure.

Around six months post-op, the transplanted tissue changes from spongy to the consistency of soft plastic. Now the therapist can progress the rehab program to focus on strengthening, endurance, and functional training. Studies consistently show that quadriceps strength is a major factor in the success of this procedure.

In fact, regaining full quadriceps strength is considered the most important goal of rehab following autologous chondrocyte implantation (ACI). Additional areas of focus in rehab include restoring proprioception (joint sense of position) and sensorimotor control.

Full return-to-sports can still take a while. The final healing phase of the chondrocytes is called maturation. If there are no complications (e.g., wound infection, overgrowth of the graft, graft failure), the entire process from start to finish can take two to three years. The biggest deterrent to recovery is putting weight on the joint too early and/or another traumatic injury disturbing the delicate transplanted tissue.

We hope this information gives you a general idea what to expect. Each athlete is different so rehab may flow at a slightly slower or faster pace. Some of this depends on how strong and coordinated your muscles were before surgery. Patient compliance (following the surgeon’s and physical therapist’s recommendations carefully) can also make a difference.

Surgeons are always looking for ways to improve surgical technique in hopes of better outcomes for their patients. In the case of anterior cruciate ligament (ACL) reconstruction, there’s been a slight shift in how the tunnels are drilled through the bone for the graft tendon. Along with that change comes the ability to place the graft in a more natural position. The net result is a more anatomic reconstruction.

It is always the case that ACL surgery is done with an eye toward restoring all the damaged structures to as normal as possible. That way, the patient has a fighting chance of returning to normal function with a stable knee. But it is also agreed that the anatomy of the anterior cruciate ligament is complex and difficult to mimic.

One of the more difficult aspects of ACL reconstructive surgery has always been drilling through the tibia (lower leg bone) in order to thread the tendon graft through the hole to the right spot for attachment. This type of tunnel is called a transtibial tunnel.

The tunnel drilling technique used until recently often placed the graft in a vertical (up and down) position. As a result of the slightly off-anatomic position, the knee could end up unstable even though the graft was intact.

Over the years surgeons have tried different ways to approach this problem. They have tried changing the way the second tunnel is constructed. This second tunnel is through the femur (thigh bone). They have tried making the tibial tunnel up higher and shorter. And they have used different starting points for the tibial tunnel along the medial side of the knee (side closest to the other knee).

None of these efforts has proved successful. Problems with joint instability, altered joint kinematics (movement), and early degenerative arthritis have occurred. The latest trend has been to drill the two tunnels separately from each other rather than using the entrance to one tunnel (tibial tunnel) to drill the second (femoral) tunnel. This approach is referred to as independent drilling of the tibial and femoral tunnels. The tunnels and subsequent graft line up in a more anatomic center.

Results of studies so far suggest that this more anatomic approach helps improve rotational stability of the knee. Clinical studies of this independent drilling method have confirmed the improved results with shorter recovery time, earlier return to sports activity for athletes, and fewer failed ACL reconstructive surgeries.

It is always the case that ACL surgery is done with an eye toward restoring all the damaged structures to as normal as possible. That way, the patient has a fighting chance of returning to normal function with a stable knee. But it is also agreed that the anatomy of the anterior cruciate ligament is complex and difficult to mimic.

One of the more difficult aspects of ACL reconstructive surgery has always been drilling through the tibia (lower leg bone) in order to thread the tendon graft through the hole to the right spot for attachment. This type of tunnel is called a transtibial tunnel.

The tunnel drilling technique used until recently often placed the graft in a vertical (up and down) position. As a result of the slightly off-anatomic position, the knee could end up unstable even though the graft was intact. This could be the situation you find yourself in.

It’s also possible that there are other soft tissue or bony structures that are damaged in that knee and still require repair or reconstruction. Sometimes these additional areas of injury go undetected until after the primary reconstructive surgery fails.

A second look is warranted and usually requires additional imaging studies (MRIs, CT scans). You may want to consider seeing a different surgeon for a second (independent) opinion. Without a complete history and physical examination any further thoughts would be purely speculation on our part and unfounded by any real evidence.

Injury to the “corners” of the knee joint are often difficult to diagnose and a real challenge to treat. Various studies have been done to determine the best way to treat these injuries. Many questions have been asked and explored.

For example, is surgery even needed? If so, how can this be decided and when is the optimal time to perform the procedure? What type of surgical intervention works best? A recent report from an orthopedic surgeon at the University of Connecticut may help answer some of these questions and give you a little guidance at the same time.

Treatment for any of the corner injuries requires careful and accurate diagnosis. The surgeon depends on the physical examination and imaging studies for this. In the case of a posterolateral corner (the subject of this article), the surgeon tests for ligamentous laxity of the posterior cruciate ligament (PCL), anterior cruciate ligament (ACL), and the medial collateral ligament.

Identifying all of the damaged soft tissues in a knee injury is important. An isolated posterolateral (PLC) injury may not require surgery. Conservative (nonoperative) care for an isolated PLC injury has the same results as doing surgery. Surgery is only advised when PLC injuries are accompanied by damage to the cruciate ligaments as well. When surgery is needed, it should be done within three weeks of the injury.

Early surgery has been shown to have better results compared with delayed procedures. And reconstruction of the corner (rather than just attempting to repair the damage) is more likely to be successful. With reconstruction, there is more knee stability, better function, improved range-of-motion, and less risk of arthrofibrosis (stiff knee from fibrous adhesions).

Since it has been some time since the injury occurred, your son’s injury is now considered to be chronic. The delay in treatment will likely mean reconstructive surgery is needed. There are many different techniques and treatment approaches to the repair of a posterolateral corner injury combined with a cruciate ligament tear.

The basic idea behind a reconstructive procedure is to use tendon graft material (e.g., from the hamstrings muscle), thread it through tunnels placed in the bones around the knee in order to secure it to the bone. One type of screw is used to hold the graft in place. Another screw called the interference screw helps determine the amount of tension places on the graft. The position, angle, and tension of the graft material are very important in restoring the right amount of rotation, motion, and angle of the joint itself.

Recovery takes many months (at least six up to one year or more) with some time in rehab. But the results are usually very good. Young athletes like your son are able to return to their sports and play/compete at a level equal to (if not better) than before the injury.

As you have discovered from your injury, your leg appears round on the outside but the knee actually has corners. Inside your knee are complex bony and soft tissue structures in a location referred to as a corner. Injury to any of these “corners” that goes untreated can create a painful, unstable knee even after surgery for the presenting knee problem.

There are two corners in the front (anterior) and two in the back (posterior. Then add one from each side: medial (side closest to the other knee) and lateral. Combining front and side and back and side gives us corners named anteromedial, anterolateral, posteromedial, and posterolateral.

The corners of the knee are made up of a very complex system of soft tissues woven together. The way in which they share the load makes an injury of one ligament likely to affect the function of others as well. Sometimes where one ligament ends and another begins is impossible to tell. Likewise, many of the ligaments are attached to the joint capsule surrounding the joint (or to the joint itself) in very unique ways. Connective tissue called fascia is also part of the soft tissue structures that helps hold everything together at each corner.

Early surgery has been shown to have better results compared with delayed procedures. And reconstruction of the corner (rather than just attempting to repair the damage) is more likely to be successful. With reconstruction, there is more knee stability, better function, improved range-of-motion, and less risk of arthrofibrosis (stiff knee from fibrous adhesions).

Each surgeon may vary a bit in how and when postoperative recovery and rehab plays out. After surgery, patients are usually in a cast that holds the knee straight and allows for minimal weight-bearing. This period of immobilization lasts about four weeks. During that time, patients are allowed to do leg raises but active knee motion doesn’t begin until the cast comes off in a month. Then the serious business of rehabilitating the knee begins.

A physical therapist supervises a program of active motion, strengthening, and for athletes a return to sports. Most athletes are back to 80 per cent of quadriceps strength between six and nine months. But for some, full return to a pre-injury level of function can take up to a year or more. Manual laborers follow these same guidelines. Your recovery may also be influence by your age, level of preinjury condition, presence of other health problems, or complications that may occur associated with the surgery.

This protocol for rehab and timeline for recovery will give you a general idea of what to expect. Ask your surgeon for his or her recommendations and predictions as well.

any people in need of a knee replacement hold off much longer than they should. The reason? They’ve heard horror stories about how painful the knee will be after surgery. They are told that it’s a different kind of pain — much worse in some ways than the arthritic pain. But in time, the pain will work its way out and they will be able to move pain free once again.

In fact, this bad reputation of postoperative pain after total knee replacement has a large measure of truth. There are many physiologic, biologic, and patient-related reasons for this increased pain. It does sound like your wife’s experience may be at the extreme end. Let’s look at some of the factors and see if any might help explain what’s happening.

Why is the pain so much worse after knee joint replacement? First of all, the surgery sets up an alarm in the nervous system that signals to the brain that there is a problem. But the signals that get started amplify and prolong the initial pain until it becomes severe and chronic.

At the same time, the tissues are injured as the surgeon cuts through the skin and removes the old joint. The body responds with an inflammatory cycle that releases many chemicals and substances that have the effect of lowering the pain threshold. That means it takes very little to set off the pain signals and a lot to turn them off. Not only are the cells of the injured tissue reacting, but so are all the pain receptors in the surrounding tissue that hasn’t even been touched.

Not everyone has the same pain responses so there must be individual factors at work, too. Some people just perceive greater pain than others when given the same stimulus. This could be a matter of coping skills, the presence of psychologic depression, or the lack of certain enzymes needed to benefit from pain medications.

Studies show that patient-controlled narcotic pain medications work much better than nurse-administered methods. Instead of waiting for the nurse to bring the next dose of pain medication, the patient can decide when it is needed. Staying on top of the pain is a key part of successful pain management. Delaying medication too long can make the pain cycle much worse.

There are medications that can help with the nausea and vomiting. These are called antiemetics. Avoiding or minimizing nausea right from the start is the most important thing here. Like pain signals, once the body sets up a nausea response, getting ahead of the vomiting and turning off those signals can be very difficult.

You are best advised to keep working with your surgeon to find the right combination of medications that will help your wife. This could take some time with trial and error before the optimum aproach is discovered. Be patient. Don’t give up. The situation may seem difficult but it is not impossible. Time will help as well but that’s not very comforting when you are suffering.

Complete knee dislocations occur most often in athletes or as a result of a traumatic injury (e.g., car or bike accident, fall). But for some people, knee dislocation can occur during daily activities. Knee dislocations have been reported when stepping off a curb, going down a stair, walking, or even while just standing still. This type of knee dislocation is referred to as a spontaneous dislocation, ultra-low energy trauma, or low-velocity injury.

Fortunately, low-velocity knee dislocations of this type are rare. The most common risk factor for low-velocity knee dislocations (just as you described) is severe obesity. In fact, according to a recent study from the University of Tennessee, the higher the body mass index (BMI), the greater the risk of knee dislocation.

The extreme load from their massive, shifting body weight put more pressure on the soft tissue structures than they could bear. The result can be rupture of the ligaments, shift of the bones, stretching of the nerves, and tearing of the blood vessels. Normal body-mass index (BMI) is less than 25, while severe obesity is anything 40 or higher. The full range of BMIs in the adults in the University of Tennessee study was from 30 to 68.

Analysis of the data collected from patient records in the Tennessee study showed that nerve injuries occurred when the BMI was 42 or higher. Vascular injuries occurred at a BMI of 48 or higher. Patients with a BMI of 51 and higher were at increased risk of both nerve and blood vessel trauma. There is also a potential for serious complications such as loss of limb (amputation) and even death associated with these injuries.

Your friend may very well fall into one of the body-mass index categories reportedly linked with spontaneous knee dislocations such as you witnessed last night. Besides obesity, there could be other factors such as a previous knee (ligamentous) injury that could have contributed to what seemed like a sudden and unexpected injury.

When a knee dislocates, there is usually ligamentous damage and there may be nerve and blood vessel injuries as well. Multiple ligaments can be ruptured including the anterior cruciate ligament, posterior cruciate ligament, and the medial and lateral collateral ligaments.

In some cases, the dislocated knee can be relocated without surgery. But if there’s been damage to the nerves or blood vessels then surgery is required. Surgery to repair or reconstruct the ligamentous support may be needed but may not be possible if the person is at high risk for complications due to severe obesity.

The knee can be stabilized externally with splints, braces, or fixation with external screws and rods of some type to support the area during healing and recovery. According to a recent study at the University of Tennessee, extremely overweight individuals who cannot tolerate surgery (or don’t have surgery for some reason don’t have as good of results as those who can have reconstructive surgery. But even without surgery, some patients are able to recover with rehab.

The biggest problem is for patients who have damage to the blood vessels causing a decrease in blood supply to the knee. The resulting ischemia (lack of blood to the area) can result in limb amputation. In fact, vascular injury occurs in about one-third of all knee dislocations regardless of the person’s body weight and size. Nerve damage is reported in about one-fourth of all knee dislocations. These complications are much higher in severely overweight individuals suffering the same knee injury.

If limb or life are in danger, the surgeon and patient may decide to rsk the surgery anyway. Treatment decisions are based on individual needs and factors and can change as time goes on and the person’s story unfolds. Bariatric surgery (e.g., stomach bypass) may be considered at this time as well. Usually some weight loss is required even before bariatric surgery but unusual cases like this may be the exception.

The new pain management protocol for total knee replacement surgery proposed by some surgeons has two parts. The first is called preemptive analgesia. This refers to the fact that it is easier to prevent pain than to try and get rid of it once it starts. Getting control of pain signals in the disrupted soft tissues before the adjacent nerve cells can start firing is important.

The second part is called multimodal analgesia. This refers to the use of a variety of different medications to achieve pain control. Using low doses of several drugs helps turn off the multiple pathways pain messages are relayed to the brain. The best approach is to combine both approaches (preemptive analgesia and multimodal analgesia).

The program begins two days before surgery when patients are started on an antiinflammatory medication. One hour before surgery, a narcotic (e.g., oxycodone) is given. Then during the surgery, the knee is injected with an antiinflammatory and narcotic.

Pain controlling medications and antiinflammatories are continued after surgery. The patient is sent home with pain relievers, sleep aids, and antiinflammatories. Other medications such as Tylenol, gabapentin, clonidine, and ketamine are also used as needed.

Sometimes medications are combined together and injected as one. This is referred to as a drug cocktail. The authors of this article are actively researching various combinations of medications in these cocktails. They are trying to find the most effective combination and just the right dosages of each individual drug. The mixture is injected into all four quarters of the knee (front, each side, back).

Pain levels, pain intensity, and pain duration are used to measure results. Other measures used to assess outcomes include amount of narcotic needed, any sleep disturbance reported, knee range-of-motion, and nausea/vomiting present.

They are finding that the approach reported here is giving superior pain control and much improved functional outcomes. It is not always pain free but the reduced pain is significant. All of this takes some change and cooperation among the many surgical partners. The surgeons, pharmacists, anesthesiologists, nurses, physical therapists, and patient/family must work together to create as pain free of a surgical response possible. Communication and collaboration are the key but the result is worth the effort.