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A painful knee can severely affect your ability to lead a full, active life. Over the last 25 years, major advancements in artificial knee replacement have improved the outcome of the surgery greatly. Artificial knee replacement surgery (also called knee arthroplasty) is becoming increasingly common as the population of the world begins to age.

This article will help you understand:

• what your surgeon hopes to achieve with knee replacement surgery
• what happens during the procedure
• what to expect after your operation

What is the normal anatomy of the knee?

The knee joint is formed where the thighbone (femur) meets the shinbone (tibia). A smooth cushion of articular cartilage covers the end surfaces of both of these bones so that they slide against one another smoothly. The articular cartilage is kept slippery by joint fluid made by the joint lining (synovial membrane). The fluid is contained in a soft tissue enclosure around the knee joint called the joint capsule.

The patella, or kneecap, is the moveable bone on the front of the knee. It is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the lower leg bone. The surface on the back of the patella is covered with articular cartilage. It glides within a groove on the front of the femur.

What does the surgeon hope to achieve?

The main reason for replacing any arthritic joint with an artificial joint is to stop the bones from rubbing against each other. This rubbing causes pain. Replacing the painful and arthritic joint with an artificial joint gives the joint a new surface, which moves smoothly and without causing pain. The goal is to help people return to many of their activities with less pain and with greater freedom of movement.

How should I prepare for surgery?

The decision to proceed with surgery should be made jointly by you and your surgeon. The decision should only be made after you feel that you understand as much about the procedure as possible.

Once you decide to proceed with surgery, several things may need to be done. Your orthopedic surgeon may suggest a complete physical examination by your regular doctor. This is to ensure that you are in the best possible condition to undergo the operation. You may also need to spend time with the Physical Therapist who will be managing your rehabilitation after the surgery. The Physical Therapist will begin the teaching process before surgery to ensure that you are ready for rehabilitation afterwards.

One purpose of the preoperative visit is to record a baseline of information. This includes measurements of your current pain levels, functional abilities, the presence of swelling, and the available movement and strength of each knee.

A second purpose of the preoperative Physical Therapy visit is to prepare you for your upcoming surgery. You will practice some of the exercises used just after surgery. You will also be trained in the use of either a walker or crutches. (Whether the surgeon uses a cemented or noncemented artificial knee will determine how much weight you will apply through your foot at first while walking.) Finally, an assessment will be made of any needs you will have at home once you’re released from the hospital.

You may be asked to donate some of your own blood before the operation. This blood can be donated three to five weeks before the operation, and your body will make new blood cells to replace the loss. At the time of the operation, if you need to have a blood transfusion you will receive your own blood back from the blood bank.

What happens during the operation?

Before we describe the procedure, let’s look first at the artificial knee itself.

The Artificial Knee

There are two major types of artificial knee replacements:

Both are still widely used. In many cases a combination of the two types is used. The patellar (kneecap) portion of the prosthesis is commonly cemented into place. The decision to use a cemented or uncemented artificial knee is usually made by the surgeon based on your age, your lifestyle, and the surgeon’s experience.

Each prosthesis is made up of three main parts.

The tibial component (bottom portion) replaces the top surface of the lower bone, the tibia. The femoral component (top portion) replaces the bottom surface of the upper bone (the femur) and the groove where the patella fits. The patellar component (kneecap portion) replaces the surface of the patella where it glides in the groove on the femur.

The femoral component is made of metal. The tibial component is usually made of two parts: a metal tray that is attached directly to the bone, and a plastic spacer that provides the slick surface. The plastic used is so tough and slick that you could ice skate on a sheet of it without damaging the material much. The patellar component is usually made of plastic as well. In some types of knee implants, the patellar component is made of a combination of metal and plastic.

A cemented prosthesis is held in place by a type of epoxy cement that attaches the metal to the bone. An uncemented prosthesis has a fine mesh of holes on the surface that allows bone to grow into the mesh and attach the prosthesis to the bone.

To begin the procedure, the surgeon makes an incision on the front of the knee to allow access to the joint.

Several different approaches can be used to make the incision. The choice is usually based on the surgeon’s training and preferences.

Once the knee joint is opened, a special positioning device (a cutting guide) is placed on the end of the femur.

This cutting guide is used to ensure that the bone is cut in the proper alignment to the leg’s original angles, even if the arthritis has made you bowlegged or knock-kneed. With the help of the cutting guide, the surgeon cuts several pieces of bone from the end of the femur.

The artificial knee will replace these worn surfaces with a metal surface.

Next, the surface of the tibia is prepared.

Another type of cutting guide is used to cut the tibia in the correct alignment.

Then the artificial surface of the patella is removed.

The metal femoral component  is then placed on the femur. In the uncemented prosthesis, the metal piece is held snugly onto the femur because the femur is tapered to accurately match the shape of the prosthesis. The metal component is pushed onto the end of the femur and held in place by friction. In the cemented variety, an epoxy cement is used to attach the metal prosthesis to the bone.

Metal Femoral Component

The metal tray that holds the plastic spacer is then attached to the top of the tibia. This metal tray is either cemented into place, or held with screws if the component is of the uncemented variety. The screws are primarily used to hold the tibial tray in place until bone grows into the porous coating. (The screws remain in place and are not removed.)

The plastic spacer is then attached to the metal tray of the tibial component. If this component should wear out while the rest of the artificial knee is sound, it can be replaced. The replacement procedure is called a retread.

The surgeon then sizes the patellar component andd puts it into place behind the patella. This piece is usually cemented in place.

Patellar Component

Finally, the soft tissues are sewn back together, and staples are used to hold the skin incision together.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following artificial knee replacement are:

• anesthesia complications
• thrombophlebitis
• infection
• stiffness
• loosening

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible after surgery. Two other commonly used preventative measures include

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection can be a very serious complication following an artificial joint surgery. The chance of getting an infection following artificial knee replacement is probably around one percent. Some infections may show up very early, even before you leave the hospital. Others may not become apparent for months, or even years, after the operation. Infection can spread into the artificial joint from other infected areas. Your surgeon may want you to take antibiotics when you have dental work or surgical procedures on your bladder and colon to reduce the risk of spreading germs to the joint.

Stiffness

In some cases, the ability to bend the knee does not return to normal after knee replacement surgery. To be able to use the leg effectively to rise from a chair, the knee must bend at least to 90 degrees. A desirable range of motion is greater than 110 degrees.

The most important factor in determining range of motion after surgery is whether the ligaments and soft tissues were balanced during surgery. The surgeon tries to get the knee in the best alignment so there is equal tension on all the ligaments and soft tissues.

Sometimes extra scar tissue develops after surgery and can lead to an increasingly stiff knee. If this occurs, your surgeon may recommend taking you back to the operating room, placing you under anesthesia once again, and manipulating the knee to regain motion. Basically, this allows the surgeon to break up and stretch the scar tissue without you feeling it. The goal is to increase the motion in the knee without injuring the joint.

Loosening

The major reason that artificial joints eventually fail continues to be a process of loosening where the metal or cement meets the bone. Great advances have been made in extending how long an artificial joint will last, but most will eventually loosen and require a revision. Hopefully, you can expect 12 to 15 years of service from an artificial knee, but in some cases the knee will loosen earlier than that. A loose prosthesis is a problem because it usually causes pain. Once the pain becomes unbearable, another operation will probably be required to revise the knee replacement.

What happens after surgery?

Some orthopedic surgeons recommend a device known as a continuous passive motion (CPM) machine immediately after surgery. The unit is thought to help prevent blood clots and speed healing of the wound. It may help patients get by with less need for medication. The unit may help improve knee mobility after knee replacement surgery. However, patients seem to do equally well in regaining knee motion by doing their exercises.

You may also have Physical Therapy treatments once or twice each day as long as you are in the hospital. Therapy treatments will address the range of motion in the knee. Gentle movement will be used to help you bend and straighten the knee. If you are using a CPM device, it will be checked for alignment and settings. Your leg may be elevated to help drain extra fluid in the leg.

Your therapist will also go over exercises to help improve knee mobility and to start exercising the thigh and hip muscles. Ankle movements are used to help pump swelling out of the leg and to prevent the possibility of a blood clot.

When you are stabilized, your Physical Therapist will help you up for a short outing using your crutches or your walker.

Most patients are able to go home after spending two to four days in the hospital. You’ll be on your way home when you can demonstrate a safe ability to get in and out of bed, walk up to 75 feet with your crutches or walker, go up and down stairs safely, and access the bathroom. It is also important that you regain a good muscle contraction of the quadriceps muscle and that you gain improved knee range of motion. Patients who still need extra care may be sent to a different unit until they are safe and ready to go home.

Most orthopedic surgeons recommend regular checkups after your artificial joint replacement. How often you need to be seen varies from every six months to every five years, according to your situation and what your surgeon recommends. You should always consult your orthopedic surgeon if you begin to have pain in your artificial joint, or if you begin to suspect something is not working correctly.

Most patients who have an artificial joint will have episodes of pain, but when you have a period that lasts longer than a couple of weeks you should consult your surgeon. The surgeon will examine your knee in search of reasons for the pain. X-rays may be taken of your knee to compare with X-rays taken earlier to see whether the artificial joint shows any evidence of loosening.

What should I expect during my rehabilitation?

When you begin your First Choice Physical Therapy  rehabilitation program, our Physical Therapist may use heat, ice, or electrical stimulation to reduce any remaining swelling or pain.

You should continue to use your walker or crutches as instructed. If you had a cemented procedure, you’ll advance the weight you place through your sore leg as much as you feel comfortable. If yours was a noncemented procedure, place only the toes down until you’ve had a follow-up X-ray and your Physical Therapist directs you to put more weight through your leg (usually by the fifth or sixth week postoperatively).

Our Physical Therapist may use hands-on stretches for improving range of motion. Then strength exercises are added to address key muscle groups including the buttock, hip, thigh, and calf muscles. Endurance can be achieved through stationary biking, lap swimming, and using an upper body ergometer (upper cycle).

First Choice Physical Therapy Physical Therapists sometimes treat patients in a pool. Exercising in a swimming pool puts less stress on the knee joint, and the buoyancy lets you move and exercise easier. Once you’ve gotten your pool exercises down and the other parts of your rehab program advance, we may instruct you in an independent program.

When you are safe in putting full weight through the leg, our Physical Therapist will choose several types of balance exercises to further stabilize and control the knee.

Finally, we will use a select group of exercises to simulate day-to-day activities, such as going up and down steps, squatting, rising on your toes, and bending down. Specific exercises may then be chosen to simulate work or hobby demands.

Many patients have less pain and better mobility after having knee replacement surgery. Our Physical Therapist will work with you to help keep your knee joint healthy for as long as possible. This may require that you adjust your activity choices to keep from putting too much strain on your new knee joint. Heavy sports that require running, jumping, quick stopping or starting, and cutting are discouraged. Cycling, swimming, and level walking are encouraged, as are low impact sports like golfing or bowling.

At First Choice Physical Therapy, our goal is to help you improve knee range of motion, maximize strength, and improve your ability to do your activities. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

When the anterior cruciate ligament (ACL) in the knee is torn or injured, surgery may be needed to replace it. There are many different ways to do this operation. One is to take a piece of the hamstring tendon from behind the knee and use it in place of the torn ligament. When arranged into three or four strips, the hamstring graft has nearly the same strength as other available grafts used to reconstruct the ACL.

This guide will help you understand:

• what parts of the knee are treated during surgery
• how surgeons perform the operation
• what to expect before and after the procedure

What parts of the knee are involved?

Ligaments are tough bands of tissue that connect the ends of bones together. The ACL is located in the center of the knee joint where it runs from the backside of the femur (thighbone) to the front of the tibia (shinbone).

ACL

The ACL runs through a special notch in the femur called the intercondylar notch  and attaches to a special area of the tibia called the tibial spine.

Intercondylar Notch

The hamstrings make up the bulk of the muscles in back of the thigh. The hamstrings are formed by three muscles and their tendons: the semitendinosus, semimembranosus, and biceps femoris. The top of the hamstrings connects to the ischial tuberosity, the small bony projection on the bottom of the pelvis, just below the buttocks. (There is one ischial tuberosity on the left and one on the right.)

Hamstrings

The hamstring muscles run down the back of the thigh. Their tendons cross the knee joint and connect on each side of the tibia. The graft used in ACL reconstruction is taken from the hamstring tendon (semitendinosus) along the inside part of the thigh and knee. Surgeons also commonly include a tendon just next to the semitendinousus, called the gracilis.

Hamstring Tendons Crossing Knee Joint

The hamstrings function by pulling the leg backward and by propelling the body forward while walking or running. This movement is called hip extension. The hamstrings also bend the knees, a motion called knee flexion.

What does the surgeon hope to accomplish?

The main goal of ACL surgery is to keep the tibia from moving too far forward under the femur bone and to get the knee functioning normally again.

There are two grafts commonly used to repair a torn ACL. One is a strip of the patellar tendon below the kneecap. The other is the hamstring tendon graft. For a long time, the patellar tendon was the preferred choice because it is easy to get to, holds well in its new location, and heals fast. One big drawback to grafting the patellar tendon is pain at the front of the knee after surgery. This can be severe enough to prevent any pressure on the knee, such as kneeling.

For this reason, a growing number of surgeons are using grafted tissue from the hamstring tendon. There are no major differences in the final results of these two methods. When it comes to symptoms after surgery, joint strength and stability, and ability to use the knee, either method is good. However, with the hamstring tendon graft, there are generally no problems kneeling and no pain in the front of the knee.

What do I need to know before surgery?

You and your surgeon should make the decision to proceed with surgery together. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

You may also need to spend time with the Physical Therapist who will be managing your rehabilitation after surgery. This allows you to get a head start on your recovery. One purpose of this preoperative visit is to record a baseline of information. Your therapist will check your current pain levels, your ability to do your activities, and the movement and strength of each knee.

A second purpose of the preoperative visit is to prepare you for surgery. Your therapist will teach you how to walk safely using crutches or a walker. And you’ll begin learning some of the exercises you’ll use during your recovery.

On the day of your surgery, you will probably be admitted to the surgery center early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during the operation?

Most surgeons perform this surgery using an arthroscope, a small fiber-optic TV camera that is used to see and operate inside the joint. Only small incisions are needed during arthroscopy for this procedure. The surgery doesn’t require the surgeon to open the knee joint.

Arthroscopy

Before surgery you will be placed under either general anesthesia or a type of spinal anesthesia. The surgeon begins the operation by making two small openings into the knee, called portals. These portals are where the arthroscope and surgical tools are placed into the knee. Care is taken to protect the nearby nerves and blood vessels.

An incision is also made along the inside edge of the knee, just over where the hamstring tendons attach to the tibia. Working through this incision, the surgeon takes out the semitendinosus and gracilis tendons. Some surgeons prefer to use only the semitendinosus tendon and do not disrupt the gracilis tendon.

The tendons are arranged into three or four strips, which increases the strength of the graft. The surgeon stiches the strips together to hold them in place.

Tendon Strips

Next, the surgeon prepares the knee to place the graft. The remnants of the original ligament are removed. The intercondylar notch (mentioned earlier) is enlarged so that nothing will rub on the graft. This part of the surgery is referred to as a:

Notchplasty

Once this is done, holes are drilled in the tibia and the femur to place the graft. These holes are placed so that the graft will run between the tibia and femur in the same direction as the original ACL

The graft is then pulled into position through the drill holes. Screws or staples are used to hold the graft inside the drill holes.

To keep fluid from building up in your knee, the surgeon may place a tube in your knee joint. The portals and skin incisions are then stitched together, completing the surgery.

What can go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following hamstring tendon graft reconstruction of the ACL are:

• anesthesia complications
• thrombophlebitis
• infection
• problems with the graft
• problems at the donor site

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible after surgery. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Following surgery, it is possible that the surgical incision can become infected. This will require antibiotics and possibly another surgical procedure to drain the infection.

Problems with the Graft

After surgery, the body attempts to develop a network of blood vessels in the new graft. This process, called revascularization, takes about 12 weeks. The graft is weakest during this time, which means it has a greater chance of stretching or rupturing. A stretched or torn graft can occur if you push yourself too hard during this period of recovery. When revascularization is complete, strength in the graft gradually builds. A second surgery may be needed to replace the graft if it is stretched or torn.

Problems at the Donor Site

Problems can occur at the donor site (the area behind the leg where the hamstring graft was taken from the thigh). A potential drawback of taking out a piece of the hamstring tendon is a loss of hamstring muscle strength.

The main function of the hamstrings is to bend the knee (knee flexion). This motion may be slightly weaker in people who have had a hamstring tendon graft to reconstruct a torn ACL. Some studies, however, indicate that overall strength is not lost because the rest of the hamstring muscle takes over for the weakened area. Even the portion of muscle where the tendon was removed works harder to make up for the loss.

The hamstring muscles sometimes atrophy (shrink) near the spot where the tendon was removed. This may explain why some studies find weakness when the hamstring muscles are tested after this kind of ACL repair. However, the changes seem to mainly occur if both the semitendinosus and gracilis tendons were used. And the weakness is mostly noticed by athletes involved in sports that require deep knee bending. This may include participants in judo, wrestling, and gymnastics. These athletes may want to choose a different method of repair for ACL tears.

The body attempts to heal the donor site by forming scar tissue. This new tissue is not as strong as the original hamstring tendon. Because of this, there is a small chance of tearing the healing tendon, especially if the hamstrings are worked too hard in the early weeks of rehabilitation following surgery.

What should I expect after surgery?

You may use a continuous passive motion (CPM) machine immediately afterward to help the knee begin moving and to alleviate joint stiffness. The machine straps to the leg and continuously bends and straightens the joint. This continuous motion is thought to reduce stiffness, ease pain, and keep extra scar tissue from forming inside the joint. The CPM is often used with a form of cold treatment that circulates cold water through hoses and pads around your knee.

Most ACL surgeries are now done on an outpatient basis. Many patients go home the same day as the surgery. Some patients stay one to two nights in the hospital if necessary. The tube placed in your knee at the end of the surgery is usually removed after 24 hours.

Your surgeon may also have you wear a protective knee brace for a few weeks after surgery. You’ll use crutches for two to four weeks in order to keep your knee safe, but you’ll probably be allowed to put a comfortable amount of weight down while you’re up and walking.

What will my recovery be like?

Patients usually take part in formal Physical Therapy after ACL reconstruction. When you visit First Choice Physical Therapy, our first few Physical Therapy treatments are designed to help control the pain and swelling from the surgery. Our goal is to help you regain full knee extension as soon as possible.

Our Physical Therapist will choose treatments to get the thigh muscles toned and active again. Patients are cautioned about overworking their hamstrings in the first six weeks after surgery. We may show you how to do isometric exercises for the hamstrings. Isometrics work the muscles but keep the joint in one position.

As the rehabilitation program evolves, our Physical Therapist will choose more challenging exercises to safely advance the knee’s strength and function. We’ll use specialized balance exercises to help the muscles respond quickly and without thinking. This part of treatment is called neuromuscular training. If you need to stop suddenly, your muscles must react with just the right amount of speed, control, and direction. After ACL surgery, this ability doesn’t come back completely without exercise.

Neuromuscular training includes exercises to improve balance, joint control, muscle strength and power, and agility. Agility makes it possible to change directions quickly, go faster or slower, and improve starting and stopping. These are important skills for walking, running, and jumping, and especially for sports performance.

When you get full knee movement, your knee isn’t swelling, and your strength and muscle control are improving, you’ll be able to gradually go back to your work and sport activities. Our Physical Therapist may prescribe a functional brace for athletes who intend to return quickly to their sports.

Ideally, you’ll be able to resume your previous lifestyle activities. However, athletes are usually advised to wait at least six months before returning to their sports. Most patients are encouraged to modify their activity choices.

You will probably be involved in a our progressive rehabilitation program for four to six months after surgery to ensure the best result from your ACL reconstruction. Although recovery time varies, in the first six weeks following surgery, expect to see the Physical Therapist two to three times a week. If your surgery and First Choice Physical Therapy rehabilitation go as planned, you may only need to do a home program and see your therapist every few weeks over the four to six month period.

The meniscus is very important to the long-term health of the knee. In the past, surgeons would simply take out part or all of an injured meniscus. But today’s surgeons know that removing the meniscus can lead to early knee arthritis. Whenever possible, they try to repair the tear. If the damaged area must be removed, care is taken during surgery to protect the surrounding healthy tissue.

This guide will help you understand:

• what parts of the knee are treated during meniscal surgery
• what operations are used to treat a damaged meniscus
• what to expect before and after meniscal surgery

What parts of the knee are involved?

There is one meniscus on each side of the knee joint. The C-shaped medial meniscus is on the inside part of the knee, closest to your other knee. (Medial means closer to the middle of the body.) The U-shaped lateral meniscus is on the outer half of the knee joint. (Lateral means further out from the center of the body.)

The menisci (plural for meniscus) protect the articular cartilage on the surfaces of the thighbone (femur) and the shinbone (tibia). Articular cartilage is the smooth, slippery material that covers the ends of the bones that make up the knee joint. The articular cartilage allows the joint surfaces to slide against one another without damage to either surface.

Articular Cartilage

Most of the meniscus is avascular, meaning no blood vessels go to it. Only its outer rim gets a small supply of blood. Doctors call this area the red zone. The ends of a few vessels in the red zone may actually travel inward to the middle section, the red-white zone. The inner portion of the meniscus, closest to the center of the knee, is called the white zone. It has no blood vessels at all. Although a tear in the outer rim has a good chance of healing, damage further in toward the center of the meniscus will not heal on its own.

Red Zone

What does my surgeon hope to accomplish?

The meniscus is a pad of cartilage that acts like a shock absorber to protect the knee. The meniscus is also vital for knee stability. When the meniscus is damaged or is surgically removed, the knee joint can become loose, or unstable. Without the protection and stability of a healthy meniscus, the surfaces of the knee can suffer wear and tear, leading to a condition called osteoarthritis.

Most tears of the meniscus do not heal on their own. A small tear in the outer rim (the red zone) has a good chance of healing. However, tears in the inner part of the meniscus often require surgery. When tears in this area are causing symptoms, they tend to get bigger. This puts the articular cartilage on the surfaces of the knee joint at risk of injury.

Surgeons aim to save the meniscus. If an injured part must be removed, only the smallest amount of the meniscus is taken out. Preserving the nearby areas of the meniscus is vital for keeping the knee healthy. If a tear can possibly be repaired, surgeons will recommend a meniscal repair.

A torn meniscus may cause symptoms of pain and swelling and sometimes catching and locking. The goal of surgery is to take these symptoms away. When the knee locks and you have to tug on it to get it moving, a small flap from a meniscal tear may have developed.

Flap from Meniscal Tear

The flap may be getting caught in the knee joint as you bend it. Or a small piece of the meniscus could actually be floating around inside the joint. This fragment, called a loose body, can get lodged between the moving parts of the knee, causing the knee to:

Lock

In these cases, surgery may be needed, sometimes right away, to fix the flap or to remove the loose body.

What do I need to know before surgery?

You and your surgeon should make the decision to proceed with surgery together. You need to understand as much about the procedure as possible. If you have concerns or questions, be sure and talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

You may also need to spend time with the Physical Therapist who will be managing your rehabilitation after surgery. This allows you to get a head start on your recovery. One purpose of this preoperative visit is to record a baseline of information. The Physical Therapist will check your current pain levels, ability to do your activities, and the movement and strength of each knee.

A second purpose of the preoperative visit is to prepare you for surgery. The Physical Therapist will teach you how to walk safely using crutches or a walker. And you’ll begin learning some of the exercises you’ll use during your recovery.

On the day of your surgery, you will probably be admitted for surgery early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during meniscal surgery?

Meniscal surgery is done using an arthroscope, a small fiber-optic TV camera that is used to see and operate inside the joint. Only small incisions are needed during arthroscopy. The surgeon does not need to open the knee joint.

Before surgery you will be placed under either general anesthesia or a type of spinal anesthesia. The surgeon begins the operation by making two or three small openings into the knee, called portals. These portals are where the arthroscope and surgical instruments are placed inside the knee. Care is taken to protect the nearby nerves and blood vessels.

Partial Meniscectomy

The procedure to carefully remove a damaged portion of the meniscus is called partial meniscectomy. The surgeon starts by inserting the arthroscope into one of the portals. A probe is placed into another portal. The surgeon watches on a screen while probing the meniscus. All parts of the inside of the knee joint are examined. When a meniscal tear is found, the surgeon determines the type and location of the tear. Surgical instruments are placed into another portal and are used to remove the torn portion of meniscus.

When the problem part of the meniscus has been removed, the surgeon checks the knee again with the probe to be sure no other tears are present. A small motorized cutter is used to trim and shape the cut edge of the meniscus. The joint is flushed with sterile saline to wash away debris from the injury or from the surgery. The portals are closed with sutures.

Meniscal Repair

Suture Repair

Using the arthroscope and a probe, the surgeon locates the tear. The probe is used to push the torn edges of the meniscus together. A small rasp or shaver is used to roughen the edges of the tear. Then a hollow tube called a cannula is inserted through one of the portals. The surgeon threads a suture through the cannula and into the knee joint. The suture is sewn into the two edges of the tear. The surgeon tugs on the thread to bring the torn edges close together. The suture is secured by tying two to three knots. Additional sutures are placed side by side until the entire tear is:

Fixed

An alternate method is to pierce the knee joint with one or two curved needles. The needle goes from the outer edge of the meniscus completely through the tear. The surgeon may feed a suture from another portal into the end of the needle. Or the suture can be threaded into the needle from the outside of the knee. Both ways get the suture through the tear and allow the surgeon to sew the torn edges of the meniscus together.

Suture Anchor Repair

Special fasteners, called suture anchors, are sometimes used to anchor the torn edges of the meniscus together. These implants are biodegradable, meaning they eventually break down and are absorbed by the body. Suture anchors have barbed shafts and are pointed like an arrow. They work like a staple or straight pin to hold the healing tissues together.

Repairs using suture anchors work best for younger patients who have a single tear near the outer rim (red zone) of the meniscus. (As described earlier, this part of the meniscus has the richest blood supply.) A probe is often used to line up the torn edges of the meniscus. Then the surgeon uses a small surgical tool to punch an arrow through the damaged part of the meniscus. Usually only two or three arrows are needed. Larger tears may require up to six arrows. The arrows anchor the two torn edges together while the tear heals. It takes about six months before the arrows begin to be absorbed by the body.

Meniscal Transplantation

If the meniscus cannot be repaired or has been previously removed, a new form of treatment may offer a way to slow the onset of knee arthritis. Meniscal transplantation uses borrowed tissue to take the place of the original meniscus.
Experiments have been tried using various replacement materials. One material that is showing promise is an allograft. An allograft is tissue that is from a donor, usually preserved human meniscus tissue. Because it is so new, this surgery is currently only available for select patients in a limited number of locations.

Using the arthroscope, the surgeon removes remnants of the old meniscus. Next, the allograft is prepared. Small sutures are placed around the edges of the allograft. The surgeon slides the allograft with the sutures into the knee through a small incision. The allograft is sewn in place onto the tibia bone. Surgical instruments, including a cannula or needle (described earlier), may be used to secure additional sutures. Some surgeons also use special anchors to firmly fix the allograft in place. A probe is used to make sure the transplanted meniscus holds securely. The arthroscope is removed, and the portals are sewn shut.

What can go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following meniscal surgery are:

• anesthesia complications
• thrombophlebitis
• infection
• suture anchor problems
• graft failure
• slow recovery
• ongoing pain

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible after surgery. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Following surgery, it is possible that the skin portals can become infected. This will require antibiotics and possibly another surgical procedure to drain the infection.

Suture Anchor Problems

Suture anchors can cause problems. If one breaks, the free-floating piece may hurt other parts inside the knee joint, particularly the articular cartilage. Also, the end of the anchor may poke too far through the meniscus. If so, the point may rub and irritate nearby tissues. A second surgery may be needed to fix problems with suture anchors.

Graft Failure

Surgeries where tissue is grafted into the body, like bone marrow or kidney transplants, have a high risk that the body will reject the graft. This is not so in meniscal transplant surgery. The preserved graft contains no live cells, so it doesn’t have to be matched up with the person getting the graft. Also, the properties of meniscal tissue makes rejection of a transplanted graft rare. The main reason for graft failure in meniscal transplant surgery occurs when patients try to do too much, too soon after surgery. Doing sports where there are quick starts and stops, sharp pivoting, and jumping can cause the graft to fail. If the graft tears, another transplant surgery will be needed.

Slow Recovery

Not everyone after meniscal surgery gets quickly back to routine activities. Some people feel better and have less swelling, but they still find it hard to do normal activities even several months after surgery. Others with damage in their knee ligaments or in the articular cartilage also tend to have a slower recovery.

Ongoing Pain

Pain relief does not always occur with meniscal surgery. If you have pain that continues or becomes unbearable, talk to your surgeon about treatments that can help control your pain.

What happens after meniscal surgery?

Meniscal surgery is done on an outpatient basis. Patients usually go home the same day as the surgery. The portals are covered with surgical strips, and the knee may be wrapped in an elastic bandage.

Crutches are used after meniscal surgery. They may only be needed for one to two days after a simple meniscectomy. Surgeons specify how much weight can be borne after meniscal repair or allograft transplant. Patients having meniscal repair are usually told not to place any weight on the foot for four to six weeks after surgery. After a transplant procedure, most patients are instructed to touch only the toes of the operated leg on the ground for four to six weeks. Some sugeons allow their patients to place a comfortable amount of weight on the foot four weeks after repair or transplant surgery.

Patients who have had a meniscal repair or transplant usually wear a knee brace for at least four weeks. The brace keeps the knee straight. It is removed often during the day to do easy range-of-motion exercises for the knee.

Follow your surgeon’s instructions about how much weight to place on your foot while standing or walking. Avoid doing too much, too quickly. You may be told to use a cold pack on the knee and to keep your leg elevated and supported.

What will my recovery be like?

Your rehabilitation will depend on the type of surgery you had. You may not need a lot of formal Physical Therapy after partial meniscectomy. Most patients can do their exercises as part of a home program. If you require outpatient Physical Therapy, you will probably need to attend therapy sessions for about two to four weeks. You should expect full recovery to take up to three months.

Many surgeons have their patients take part in formal Physical Therapy after meniscal repair and transplant procedures. When you visit First Choice Physical Therapy, our first few Physical Therapy treatments are designed to help control the pain and swelling from the surgery. Our Physical Therapists also work with patients to make sure they are putting only a safe amount of weight on the affected leg.

For the first six weeks after a meniscal repair, you should avoid bending the knee more than 90 degrees. Then it is safe to gradually bend the knee fully. However, you should avoid squatting for at least three to four months while the repair fully heals. It is not advisable to run, jump, or twist the knee for at least four to six months. Although recovery rates vary, patients sometimes resume sport activities within four to six months after surgery to repair the meniscus.

Your First Choice Physical Therapy therapist will start your range-of-motion exercises right away after your transplant. Our goal is to get the knee to bend to 90 degrees within four weeks after surgery. As time goes on, we will choose more challenging exercises to safely advance your knee’s range of motion, strength, and function.

Ideally, patients will be able to resume their previous activities. Some patients may be encouraged to modify their activity choices, especially if an allograft was used.

At First Choice Physical Therapy, our goal is to help you keep your pain under control and improve your knee’s range of motion and strength. When your recovery is are well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

The anterior cruciate ligament (ACL) is a major stabilizer of the knee joint. This key knee ligament is commonly torn during sports activities. The standard operation to fix a torn ACL is with a patellar tendon graft. The surgeon takes out the middle section of the patellar tendon below the kneecap (patella). This new graft includes the strip of tendon, along with attached plugs of bone on each end. For this reason, it is sometimes referred to as a bone-patellar-tendon-bone graft. The surgeon removes the torn ACL and puts the new graft into the knee, making sure to line it up just like the original ligament.

Many types of tissue grafts have been tried. The patellar tendon graft has proven to be one of the strongest for ACL reconstruction. Patients who have this operation generally get back to their usual activities and sports. They often do so faster than people who have their ACL reconstructed with other types of tissue grafts.

This article will help you understand:

• what parts of the knee are treated during surgery
• how surgeons perform the operation
• what to expect before and after the procedure

What parts of the knee are involved?

Ligaments are tough bands of tissue that connect the ends of bones together. The ACL is located in the center of the knee joint where it runs from the backside of the femur (thighbone) to the front of the tibia (shinbone).

ACL

The ACL runs through a special notch in the femur called the intercondylar notch and attaches to a special area of the tibia called the tibial spine.

Intercondylar Notch

The patellar tendon is a thick and strong band of connective tissue on the front of the knee. It starts at the bottom of the patella and fastens just below the knee to a bony bump on the front of the tibia, called the tibial tubercle. When using the patellar tendon as an ACL graft, surgeons remove a strip from the middle of it. The graft includes the bony attachments from the bottom of the patella and from the tibial tubercle.

What does the surgeon hope to accomplish?

The main goal of ACL surgery is to keep the tibia from moving too far forward under the femur bone and to get the knee functioning normally again.

Many surgeons prefer to use the patellar tendon when reconstructing the ACL. The graft is often chosen because it is one of the strongest ACL grafts. It’s easy to get to, holds well in its location, and generally heals fast.

The anatomy of the graft helps to speed healing and to create a solid connection. When the surgeon implants the new graft, the bony plugs on each end of the graft fit inside a tunnel of bone. This means there is bone-to-bone contact. The body treats the contact of these two bony surfaces as it would a broken bone. It responds by healing the two surfaces together. Healing at the bone-to-bone surface fixes the patellar tendon graft in place.

What do I need to know before surgery?

You and your surgeon should make the decision to proceed with surgery together. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

You may also need to spend time with the Physical Therapist who will be managing your rehabilitation after surgery. This allows you to get a head start on your recovery. One purpose of this preoperative visit is to record a baseline of information. Your therapist will check your current pain levels, your ability to do your activities, and the movement and strength of each knee.

A second purpose of the preoperative visit is to prepare you for surgery. Your therapist will teach you how to walk safely using crutches or a walker. And you’ll begin learning some of the exercises you’ll use during your recovery.

On the day of your surgery, you will probably be admitted to the surgery center early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during the operation?

Most surgeons perform this surgery using an arthroscope, a small fiber-optic TV camera that is used to see and operate inside the joint. Only small incisions are needed during arthroscopy for this procedure. The operation doesn’t require the surgeon to open the knee joint.

Before surgery you will be placed under either general anesthesia or a type of spinal anesthesia.

The surgeon begins the operation by making two small openings into the knee, called portals. These portals are where the arthroscope and surgical tools are placed into the knee.

Care is taken to protect the nearby nerves and blood vessels.

A small incision is also made below the patella. Working through this incision, the surgeon takes out the middle section of the patellar tendon, along with the bone attachments on each end. The bone plugs are rounded and smoothed. Holes are drilled in each bone plug to place sutures (strong stitches) that will pull the graft into place.

Bone Plugs

Next, the surgeon prepares the knee to place the graft. The remnants of the original ligament are removed. The intercondylar notch (mentioned earlier) is enlarged so that nothing will rub on the graft. This part of the surgery is referred to as a:

Notchplasty

Once this is done, holes are drilled in the tibia and the femur to place the graft. These holes are placed so that the graft will run between the tibia and femur in the same direction as the original ACL.

The graft is then pulled into position using sutures placed through the drill holes. Screws are used to hold the bone plugs in the drill holes.

To keep fluid from building up in your knee, the surgeon may place a tube in your knee joint. The portals and skin incision are then stitched together, completing the surgery.

What problems can happen with this surgery?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following patellar tendon graft reconstruction of the ACL are:

• anesthesia complications
• thrombophlebitis
• infection
• problems with the graft
• problems at the donor site

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible after surgery. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Following surgery, it is possible that the surgical incision can become infected. This will require antibiotics and possibly another surgical procedure to drain the infection.

Problems with the Graft

After surgery, the body attempts to develop a network of blood vessels in the new graft. This process, called revascularization, takes about 12 weeks. The graft is weakest during this time, which means it has a greater chance of stretching or rupturing. A stretched or torn graft can occur if you push yourself too hard during this period of recovery. When revascularization is complete, strength in the graft gradually builds. A second surgery may be needed to replace the graft if it is stretched or torn.

Problems at the Donor Site

Problems can occur at the donor site (the area below the patella where the graft was taken from the knee). A major drawback of taking out a piece of the patellar tendon to reconstruct the ACL is that most patients end up having difficulty kneeling down long after surgery. Lingering pain in the front of the knee is also common.

A portion of bone is taken from the bottom of the patella during the graft procedure. This can weaken the patella. In rare cases, heavy use of the quadriceps muscle (on the front of the thigh) can cause the patella to fracture. This often requires a second surgery to repair the broken patella.

Taking tissue from the center of the patellar tendon can also cause problems. The body attempts to heal the area but sometimes produces too much scar tissue. The extra scar tissue that forms around the donor site may prevent normal motion in the knee. The patellar tendon is not as strong as it was before surgery. In rare cases, this has been linked to a tear in the patellar tendon. Also, the patellar tendon may become easily inflamed. And problems in this area can keep the quadriceps from regaining normal control and strength.

What should I expect after surgery?

You may use a continuous passive motion (CPM) machine immediately afterward to help the knee begin moving and to alleviate joint stiffness. The machine straps to the leg and continuously bends and straightens the joint. This continuous motion is thought to reduce stiffness, ease pain, and keep extra scar tissue from forming inside the joint. The CPM is often used with a form of cold treatment that circulates cold water through hoses and pads around your knee.

Most ACL surgeries are now done on an outpatient basis. Many patients go home the same day as the surgery. Some patients stay one to two nights in the hospital if necessary. The tube placed in your knee at the end of the surgery is usually removed after 24 hours.

Your surgeon may also have you wear a protective knee brace for a few weeks after surgery. You’ll use crutches for two to four weeks in order to keep your knee safe, but you’ll probably be allowed to put a comfortable amount of weight down while you’re up and walking.

What will my recovery be like?

Patients usually take part in formal Physical Therapy after ACL reconstruction. When you begin your First Choice Physical Therapy program, the first few Physical Therapy treatments are designed to help control the pain and swelling from the surgery. Our goal is to help you regain full knee extension as soon as possible.

Following surgery, you may be told by your surgeon to avoid putting weight on the leg and limiting any active quadriceps contractions for up to six weeks. You may also have to wear a rigid brace at all times except when showering or during rehabilitatin for the first few weeks.  Our Physical Therapist will choose treatments to get the quadriceps muscles toned and active again when there is no risk to the graft or remaining patella tendon. Muscle stimulation and biofeedback, which involve placing electrodes over the quadriceps muscle, may be needed at first to get the muscle going again and to help retrain it.

As your First Choice Physical Therapy rehabilitation program evolves, we will choose more challenging exercises to safely advance your knee’s strength and function. Our Physical Therapist will use specialized balance exercises to help the muscles respond quickly and without thinking. This part of treatment is called neuromuscular training. If you need to stop suddenly, your muscles must react with just the right amount of speed, control, and direction. After ACL surgery, this ability doesn’t come back completely without exercise.

Our neuromuscular training includes exercises to improve balance, joint control, muscle strength and power, and agility. Agility makes it possible to change directions quickly, go faster or slower, and improve starting and stopping. These are important skills for walking, running, and jumping, and especially for sports performance.

When you get full knee movement, your knee isn’t swelling, and your strength and muscle control are improving, you’ll be able to gradually go back to your work and sport activities. Our Physical Therapists may recommend a functional brace for athletes who intend to return quickly to their sports.

Ideally, you’ll be able to resume your previous lifestyle activities. However, athletes are usually advised to wait at least six months before returning to their sports. Most patients are encouraged to modify their activity choices.

Although the time required for recovery varies, you will probably be involved in a First Choice Physical Therapy progressive rehabilitation program for four to six months after surgery to ensure the best result from your ACL reconstruction. In the first six weeks following surgery, expect to see our Physical Therapist two to three times a week. If your surgery and rehabilitation go as planned, you may only need to do a home program and see our Physical Therapist every few weeks over the four to six month period.

The posterior cruciate ligament (PCL) is one of the less commonly injured ligaments of the knee. Understanding this injury and developing new treatments for it have lagged behind the other cruciate ligament in the knee, the anterior cruciate ligament (ACL), probably because there are far fewer PCL injuries than ACL injuries.

This guide will help you understand:

• where the PCL is located
• how a PCL injury causes problems
• how doctors treat the condition

Where is the PCL, and what does it do?

Ligaments are tough bands of tissue that connect the ends of bones together. The PCL is located near the back of the knee joint. It attaches to the back of the femur (thighbone) and the back of the tibia (shinbone) behind the ACL.

PCL

The PCL is the primary stabilizer of the knee and the main controller of how far backward the tibia moves under the femur. This motion is called posterior translation of the tibia. If the tibia moves too far back, the PCL can rupture.

Ruptured PCL

More recent research has shown us that the PCL also prevents medial-lateral (side-to-side) and rotatory movements. This confirms the suspicion that the PCL’s effect on knee joint function is more complex than previously thought.

The PCL is made of two thick bands of tissue bundled together. One part of the ligament tightens when the knee is bent; the other part tightens as the knee straightens. This is why the PCL is sometimes injured along with the ACL when the knee is forced to straighten too far, or hyperextend.

Both bundles of the PCL not only change length with knee flexion and extension, but they also change their orientation (direction of the fibers) from front-to-back and side-to-side. This function allows the ligament to keep the tibia from sliding too far back or slipping from side-to-side.

How do PCL injuries occur?

PCL injuries can occur with low-energy and high-energy injuries. The most common way for the PCL alone to be injured is from a direct blow to the front of the knee while the knee is bent. Since the PCL controls how far backward the tibia moves in relation to the femur, if the tibia moves too far, the PCL can rupture.

Sometimes the PCL is injured during an automobile accident. This can happen if a person slides forward during a sudden stop or impact and the knee hits the dashboard just below the kneecap. In this situation, the tibia is forced backward under the femur, injuring the PCL. The same problem can happen if a person falls on a bent knee. Again, the tibia may be forced backward, stressing and possibly tearing the PCL.

Other parts of the knee may be injured when the knee is violently hyperextended, but other ligaments are usually injured or torn before the PCL. This type of injury can happen when the knee is struck from the front when the foot is planted on the ground.

What does an injured PCL feel like?

The symptoms following a tear of the PCL can vary. The PCL is not actually enclosed inside the knee joint like the ACL. So unlike an ACL tear, which swells the joint with blood, PCL injuries don’t make the knee swell as much. Most patients with a PCL injury sense a feeling of stiffness and some swelling. Some patients may also have a feeling of insecurity and giving way of the knee, especially when trying to change direction on the knee. The knee may feel like it wants to slip.

The pain and moderate swelling from the initial injury will usually be gone after two to four weeks, but the knee may still feel unstable. The symptom of instability and the inability to trust the knee for support are what requires treatment. Also important in the decision about treatment is the growing realization by orthopedic surgeons that long-term instability leads to early arthritis of the knee.

How do doctors identify the problem?

The history and physical examination is probably the most important tool in diagnosing a ruptured or deficient PCL. During the physical examination, special stress tests are performed on the knee. Three of the most commonly used tests are the posterior Lachman test, the posterior sag test, and the posterior drawer test. The posterior drawer test is a very sensitive and specific test for PCL injuries. The doctor will place your knee and leg in various positions and then apply a load or force to the joint. Any excess motion or unexpected movement of the tibia relative to the femur may be a sign of ligament damage and insufficiency.

Tests are also done to see if other knee ligaments or joint cartilage have been injured. Damage to the PCL along with damage to the posterolateral corner (PLC) of the joint cartilage often leads to rotatory instability. This means the tibia slides back on the femur and twists or rotates at the same time. Rotatory instability can affect walking ability. Failure to diagnose a PCL injury can be a major cause of failure of surgery to repair a ruptured anterior cruciate ligament (ACL). The doctor may order X-rays of the knee to rule out a fracture. Ligaments and tendons do not show up on X-rays.

The magnetic resonance imaging (MRI) scan is probably the most accurate test without actually looking into the knee. The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This machine creates pictures that look like slices of the knee. The pictures show the anatomy, and any injuries, very clearly. This test does not require any needles or special dye and is painless.

In some cases, arthroscopy may be used to make the definitive diagnosis if there is a question about what is causing your knee problem. Arthroscopy is a type of operation where a small fiber-optic TV camera is placed into the knee joint, allowing the surgeon to look at the structures inside the joint directly. The vast majority of PCL tears are diagnosed without resorting to this type of surgery, though arthroscopy is sometimes used to repair a torn PCL.

Nonsurgical Treatment

Initial treatment for a PCL injury focuses on decreasing pain and swelling in the knee. Rest and mild pain medications, such as acetaminophen, can help decrease these symptoms. You may need to use a long-leg brace and crutches at first to limit pain. Most patients are given the okay to put a normal amount of weight down while walking.

Less severe PCL tears are usually treated with a progressive rehabilitation program. Patients intending to return to high-demand activities may require a functional knee brace before returning to these activities. These braces are designed to replace knee stability when the PCL doesn’t function properly. They help keep the knee from giving way during moderate activity, but they can give a false sense of security and won’t always protect the knee during sports that require heavy cutting, jumping, or pivoting. These braces are not the type you can buy at the drugstore. Most orthopedists will recommend wearing a brace for at least one year after a reconstruction, so even if you decide to have surgery, a brace is probably a good investment.

Most patients receive Physical Therapy treatments after a PCL injury. Physical Therapists treat swelling and pain with the use of ice, electrical stimulation, and rest periods with your leg supported in elevation.

Exercises are used to help you regain normal movement of joints and muscles. Range-of-motion exercises should be started right away with the goal of helping you swiftly regain full movement in your knee. This includes the use of a stationary bike, gentle stretching, and careful pressure applied to the knee by the therapist.

Exercises are also given to improve the strength of the quadriceps muscles on the front of the thigh. As your symptoms ease and strength improves, you will be guided in specialized exercises to improve knee stability.

Surgery

If the PCL alone is injured, nonsurgical treatment may be all that is necessary. When other structures in the knee are injured, patients generally do better having surgery within a few weeks after the injury. Long-term studies show that without reconstructive surgery, over time, knee instability and joint degeneration develop.

If the symptoms of instability are not controlled by a brace and rehabilitation program, then surgery may be suggested. The main goal of surgery is to keep the tibia from moving too far backwards under the femur and to get the knee functioning normally again. New studies also suggest the need to restore medial-lateral (side-to-side) and rotational stability, too.

Even when surgery is needed, most surgeons will have their patients attend Physical Therapy for several visits before the surgery. This is done to reduce swelling and to make sure you can straighten your knee completely. This practice reduces the chances of scarring inside the joint and can speed your recovery after surgery.

Most surgeons now favor reconstruction of the PCL using a piece of tendon or ligament to replace the torn PCL. This surgery is most often done using the arthroscope (mentioned earlier). Incisions are usually still required around the knee, but the surgery doesn’t require the surgeon to open the joint. The arthroscope is used to perform the work needed on the inside of the knee joint. Most PCL surgeries are now done on an outpatient basis, and most patients stay either one night in the hospital, or they go home the same day as the surgery.

In a typical surgical reconstruction, the torn ends of the PCL must first be removed. Once this has been done, the type of graft that will be used is determined. One of the most common tendons used for the graft material is the patellar tendon. This tendon connects the kneecap (patella) to the tibia.

About one third of the patellar tendon is removed, with a plug of bone at either end. The bone plugs are rounded and smoothed. Holes are drilled in each bone plug to place sutures (strong stitches) that will pull the graft into place. Then holes are drilled in the tibia and the femur to place the graft. These holes are placed so that the graft will run between the tibia and femur in the same direction as the original PCL. The graft is then pulled into position using sutures placed through the drill holes. Screws are used to hold the bone plugs in the drill holes.

Another very common graft involves using two of the three or four strips of the hamstring tendons, the graft has nearly the same strength as a patellar tendon graft.

The gracilis and semitendinosus tendons can be taken out without really affecting the strength of the leg because bigger and stronger hamstring muscles will take over the function of the two tendons that are removed.

Other materials are also used to replace the torn PCL. In some cases, an allograft is used. An allograft is tissue that comes from someone else. This tissue is harvested from tissue and organ donors at the time of death and sent to a tissue bank. The tissue is checked for any type of infection, sterilized, and stored in a freezer. When needed, the tissue is ordered by the surgeon and used to replace the torn PCL. The advantage of using an allograft is that the surgeon does not have to disturb or remove any of the normal tissue from your knee to use as a graft. For this reason the operation also usually takes less time.

Nonsurgical Rehabilitation

Nonsurgical treatment of an injured PCL will typically last six to eight weeks. You will be able to return to your sport activities when your quadriceps muscles are back to near their normal strength, your knee stops swelling intermittently, and you no longer have problems with the knee giving way.

After Surgery

You may use a continuous passive motion (CPM) machine soon after your operation to help the knee begin to move and to alleviate joint stiffness. The machine straps to the leg and continuously bends and straightens the joint. This continuous motion is thought to reduce stiffness, ease pain, and keep extra scar tissue from forming inside the joint.

Your surgeon may also have you wear a protective knee brace for up to six weeks after surgery. You’ll probably use crutches for two to four weeks in order to keep your knee safe and will probably be instructed to put only a limited amount of weight down while you’re up and walking.

Patients usually take part in formal Physical Therapy after PCL reconstruction. The first few Physical Therapy treatments are designed to help control the pain and swelling from the surgery. Physical Therapists will begin to focus on range of motion exercises within three weeks. They take care to avoid letting the tibia sag back under the femur, as this can put strain on the healing graft.

Strengthening exercises for the quadriceps muscle on the front of the thigh are safe to begin right away. Muscle stimulation and biofeedback, which both involve placing electrodes over the quadriceps muscle, may be needed at first to get the muscle going again and help retrain it. As the rehabilitation program evolves, more challenging exercises are chosen to safely advance the knee’s strength and function.

When you get full knee movement, your knee isn’t swelling, and your strength is improving, you’ll be able to gradually get back to your work and sport activities. Some surgeons prescribe the use of a functional brace for athletes who intend to return quickly to their sport.

Ideally, you’ll be able to resume your previous lifestyle activities. However, athletes are usually advised to wait at least six months before returning to their sport. And most patients are encouraged to modify their activity choices.

You will probably be involved in a progressive rehabilitation program for four to six months after surgery to ensure the best result from your PCL reconstruction. In the first six weeks following surgery, expect to see the Physical Therapist two to three times a week. If your surgery and rehabilitation go as planned, you may only need to do a home program and see your Physical Therapist every few weeks over the four to six month period.

Over the past 30 years, artificial knee replacement surgery has become increasingly common. Millions of people have gotten a new knee joint. The first time a joint is replaced with an artificial joint the operation is called a primary joint replacement. As people live longer and more people receive artificial joints, some of those joints begin to wear out and fail. When an artificial knee joint fails, a second operation is required to replace the failing joint. This procedure is called a revision arthroplasty.

This article will help you understand:

• why revision surgery becomes necessary
• what happens during the operation
• what to expect during your recovery

What part of the knee is affected?

The knee joint is formed where the thighbone (femur) meets the shinbone (tibia). A slick cushion of articular cartilage covers the ends of both of these bones so that they slide against one another smoothly. The articular cartilage is kept slippery by joint fluid made by the joint lining (synovial membrane). The fluid is contained in a soft tissue enclosure around the knee joint called the joint capsule.

The kneecap (patella) is the moveable bone on the front of the knee. It is wrapped inside a tendon that connects the large muscles on the front of the thigh (the quadriceps muscles) to the tibia. The back of the patella is covered
with articular cartilage. The patella glides within a groove on the front of the femur.

Why does a knee revision become necessary?

The most common reasons for knee revision arthroplasty are:

• mechanical loosening
• infection in the joint
• fracture of the bone around the joint
• instability of the implant
• wear of one or more parts of the implant
• breakage of the implant

Mechanical Loosening

Mechanical loosening means that for some reason (other than infection) the attachment between the artificial joint and the bone has become loose. There are many reasons why this can occur. It may be that, given enough time, all artificial joints will eventually loosen. This is one reason that surgeons like to wait until absolutely necessary to put in an artificial joint. The younger you are when an artificial joint is put in, the more likely it is that the joint will loosen and require a revision. Mechanical loosening can occur in both cemented and uncemented artificial joints. (The different types of joints are described later.)

Infection

If an artificial joint is infected, it may become stiff and painful. It may also begin to lose its attachment to the bone. An infected artificial joint will probably have to be revised to try to cure the infection.

In the knee joint, operations to exchange the original implant (prosthesis) with a new one have a good chance of success. The decision to do a revision surgery depends in part on the type of bacteria that has infected the joint. In some uncommon cases, the type of bacteria is so harmful that a revision is not possible. In these unfortunate cases, the surgeon may suggest placing a cement spacer filled with antibiotics in the knee and having the patient wear a knee brace for support. In rare cases, the knee may need to be fused together, or possibly even amputated. In less aggressive infections, the infected artificial joint is removed at one operation. Antibiotics are given for up to three months until the infection is gone. Then a second operation is done to insert a new artificial knee.

Fracture

A fracture may occur near an artificial joint. It is sometimes necessary to use a new artificial joint to fix the fracture. For example, if the femur (thighbone) breaks where the prosthesis attaches, it may be easier to replace the femoral part of the artificial joint with a new piece that has a longer stem that can hold the fracture together while it heals.

This is similar to fixing the fracture with a metal rod.

Instability

Instability means that the artificial joint dislocates. This is very painful when it happens.

It is unlikely that the knee joint will completely dislocate. However, it can happen. It is more common for the knee joint to be either too tight or too loose.

If the knee joint is too loose, it can cause unsteadiness and pain. If the joint is too tight, the knee is usually painful and doesn’t have a good range of motion.

Wear

With the rise in knee joint replacements, surgeons have begun to see wear in the plastic parts of the artificial joints. In some cases, if the wear is discovered in time, the revision may only require changing the plastic part of the artificial joint. If the wear continues until the metal is rubbing on metal, the whole joint may need to be replaced.

Breakage

Finally, the metal of the artificial joint can break due to the constant stress that the artificial joint undergoes everyday. In weight-bearing joints like the knee, this is greatly affected by how much you weigh and how active you are.

Break of Artificial Joint

What happens before surgery?

Your surgeon will carefully plan the revision operation. Before the operation, many possible options and complications will have to be taken into account. Your surgeon will discuss these with you. Be sure to ask if there are parts of the procedure, your recovery, or the risks associated with a revision joint replacement that you have questions about.

Once the decision to proceed with surgery is made, several things may need to be done. Your orthopedic surgeon may suggest a complete physical examination by your medical or family doctor. This is to ensure that you are in the best possible condition to undergo the operation.

You may be scheduled for a bone scan so the surgeon can check for loosening of the artificial joint. When an artificial joint is loose, the bone around the joint reacts by trying to form new bone, a process called remodeling. The bone scan is done by injecting you with a weak radioactive chemical. Several hours later, a large camera is used to take a picture of the bone around the artificial joint. If the artificial joint is loose and there is remodeling going on, the picture will show a hot spot where the chemical has been added to the newly forming bone. The brighter the hot spot, the more likely it is that the artificial joint is loose.

If your surgeon suspects that the artificial knee is loose, other tests may be necessary to find out why the joint is loose. Before any plans are made to revise the artificial joint, most orthopedic surgeons will want to make sure that the knee is not loose because of infection. To check for infection, blood tests may be ordered. Your surgeon may also need to aspirate your knee. This involves inserting a needle into your knee joint, removing fluid, and sending the contents to the laboratory. Replacing any artificial joint that is infected is much more involved than replacing a noninfected, loose artificial joint. In some cases, infection will make a revision impossible.

Skin problems are common for people having knee revision arthroplasty. People who have low levels of lymphocytes (white blood cells that form antibodies to fight off infection) have an even greater risk of incision problems. Your surgeon may request a blood count before surgery to make sure you have adequate numbers of lymphocytes.

Past incisions in the knee can further complicate the planned revision procedure. People needing a knee revision will have at least one previous knee incision. Most surgeons who do knee revision surgery prefer to make an incision that runs down the center of the knee. This may not be possible due to previous knee incisions. The second choice is usually toward the outer (lateral) side of the knee. (Lateral is the side furthest from your other knee.) If the skin appears to be too tight for a planned incision to close, the risk of wound complications is high after the revision procedure. The orthopedic surgeon may need to consult with a plastic surgeon to ensure the best approach and result.

Another option is to use soft-tissue expanders. These are placed just under the skin next to where the revision incision will eventually go. The expanders stay in for up to eight weeks and are removed when you go in for the revision surgery. The idea is that the skin will have stretched enough so that, when the revision procedure is done, the edges of the skin can be closed and sutured together.

Before surgery, you may also need to spend time with the Physical Therapist who will manage your rehabilitation after the surgery. The Physical Therapist begins the teaching process before surgery to ensure that you are ready for rehabilitation afterwards. One purpose of the preoperative therapy visit is to record a baseline of information. This includes measurements of your current pain levels, functional abilities, and the available movement and strength of each knee. Any swelling in the artificial knee is noted.

A second purpose of the preoperative Physical Therapy visit is to prepare you for your upcoming surgery. You will begin to practice some of the exercises you will use just after surgery. You will also be trained in the use of either a walker or crutches. Finally, an assessment will be made of any needs you will have at home once you’re released from the hospital.

You may be asked to donate some of your own blood before the operation. This blood can be donated three to five weeks earlier. Your body will make new blood cells to replace the loss. If you need a blood transfusion during the operation, you will receive your own blood back from the blood bank.

What happens during the operation?

Before describing the revision procedure, let’s look at the revision prosthesis itself.

There are two major types of revision implants:

• cemented prosthesis
• uncemented prosthesis

A cemeted prosthesis is held in place by a type of epoxy cement that attaches the metal to the bone. An uncemented prosthesis has a fine mesh of holes on the surface that allows bone to grow into the mesh and attach the prosthesis to the bone.

Both are still widely used. In many cases a combination of the two types is used. The patellar (kneecap) portion of the prosthesis is commonly cemented into place. The decision to use a cemented or uncemented artificial knee is usually made by the surgeon based on your age, your lifestyle, and the surgeon’s experience.

Each prosthesis is made up of three main parts.

The tibial component (bottom portion) replaces the top surface of the lower bone, the tibia. The stem of the tibial component used in revision surgery is usually much longer than the type used for primary knee replacements. This is because the bone of the tibia is usually not the same as when the initial replacement was done. The bone may be weaker, or there may be areas inside the tibia where bone is missing. A longer stem can reach further down the tibial canal and distribute your body weight better. It also gives the body a greater surface area for healing, which can improve fixation of the implant to the bone inside the tibia.

The femoral component (top portion) replaces the bottom surface of the upper bone (the femur) and the groove where the patella fits. Like the tibial component used in revision, the femoral component often has a long stem.

The patellar component (kneecap portion) replaces the surface of the patella where it glides in the groove on the femur.

The tibial component is usually made of two parts: a metal tray that is attached directly to the bone, and a plastic spacer that provides the slick surface. The femoral component is made of metal. In some types of knee implants, the patellar component is made of a combination of metal and plastic.

To begin the procedure, the surgeon makes an incision down the front of the knee to allow access to the joint. The surgeon attempts to open the knee joint with the least amount of damage to the muscles and ligaments around the joint.

Next, the original artifical joint is removed. When the primary artificial joint was put in with cement, the cement has to be removed from inside the canal of the femur and the tibia. Because the bone is often fragile and the cement is hard, removing the cement can cause the femur or tibia to fracture during the operation. This is not unusual, and in most cases the surgeon will simply continue with the operation and fix the fracture as well.

Samples of bone and marrow tissue are usually removed during the surgery and sent to a laboratory to see if any infection is present. If an infection is present, a new artificial joint will probably not be put in (see below).

Revision joint replacements are much different from primary joint replacements. One reason that revision procedures are not routine is that there is almost always bone loss around the primary prosthesis. The surgeon deals with this problem by placing a bone graft or some other material around the artificial joint to reinforce the bone. This bone graft may come from your own body, such as bone taken from the pelvis during the same operation. This type of graft is called an autograft.

If the amount of bone needed is too large to take from your body, your surgeon may choose to use bone graft from the bone bank. This type of bone graft has been taken from someone else and placed in the bone bank. This type of transplant is called an allograft.

After application of bone and other materials to rebuild the tibia and/or femur, a new prosthesis is implanted. It is challenging to imitate the natural shape of the bones after rebuilding the bone, so a specially designed prosthesis is usually needed. All of this is carefully planned by the surgeon before the operation.

To get the best and sturdiest fit between the tibial and femoral components, the surgeon adjusts and balances the soft tissues that surround the knee joint. This may require cutting or tightening the ligaments on each side of the knee. Afterward, the surgeon checks the fit of the new knee components with the knee bent and then with the knee straightened. Further adjustment is made by changing out a thicker plastic portion of the tibial component. In the end, the surgeon tries to get the best fit so that the knee is stable through a full range of movement.

When the tibial and femoral components are in place and the soft tissues have been balanced, the surgeon will address the patella. In some cases, the patella may not need to be revised, especially when the surgeon sees good fixation of the original patellar implant. Sometimes the old patella component is simply removed, allowing the bone on the back of the patella to glide against the smooth surface on the front of the revision femoral component. In either case, the surgeon checks to see that the patella is lined up correctly and that it rides normally within the groove in the front of the femur.

Finally, the soft tissues of the knee are sewn back together, and metal staples or stitches are used to hold the skin incision together.

A revision joint replacement of the knee is more complex and unpredictable than a primary joint replacement. Since many factors can influence its longevity, your surgeon will not be able to say exactly how long your revision will last. Also, keep in mind that because revision surgery is more complicated than primary joint replacement, it may take up to a year to be able to perform your routine daily activities. Often people continue to need a walking aid because knee pain increases when they are on their feet for prolonged periods. There is also a greater chance that the knee will be tight and unable to bend all the way after knee revision surgery.

In some cases, if an artificial joint fails, it may not be possible to put another artificial joint back in. This can occur if the primary joint has failed because of an infection that cannot be controlled, if the bone has been destroyed so much that it will not support an artificial joint, or if your medical condition will not tolerate a major operation.

Sometimes a choice other than knee revision is best because a big operation might result in a failure, or even death. Removing the prosthesis and not replacing it doesn’t mean the patient can’t walk anymore. The surgeon may suggest fusing the joints of the knee, placing a spacer in the joint, or in some cases amputating the leg.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following revision arthroplasty of the knee include:

• anesthesia complications
• thrombophlebitis
• infection
• myositis ossificans
• loosening
• incision complications

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but it is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when the blood in the large veins of the leg forms blood clots. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection can be a very serious complication following an artificial joint revision. Some infections may show up very early, even before you leave the hospital. Others may not become apparent for months, or even years, after the operation. Infection can spread into the artificial joint from other infected areas. Your surgeon may want to make sure that you take antibiotics when you have dental work or surgical procedures on your bladder and colon to reduce the risk of spreading germs to the joint.

The risk of infection is higher in revision arthroplasty than in primary joint replacement. In a primary knee replacement, the risk of infection is less than one percent. It goes up to two percent or more in revision cases. These figures are only an estimate and vary between different scientific studies.

Myositis Ossificans

Myositis ossificans is a curious problem that can affect the knee after both a primary knee replacement and a revision knee replacement. The condition occurs when the soft tissue around the knee joint begins to develop calcium deposits. Myositis means inflammation of muscle, and ossificans refers to the formation of bone. This can lead to a situation where new bone actually forms along the sides and top of the knee. This leads to stiffness and a loss of motion in the knee joint. It also causes pain.

Myositis ossificans is more common in people who have a long history of osteoarthritis with multiple bones spurs. Something about the genetic makeup in these people makes them more likely to produce bone tissue. Major reconstruction operations such as a knee revision seem to do more damage to the surrounding tissues than primary knee replacements. The operation is simply longer and harder to do. Calcium deposits are also more likely to form.

The treatment of myositis ossificans may actually begin before you get it. In cases where you are at high risk for developing this condition, your surgeon may recommend that you take medications such as indomethacin after surgery. This medication reduces the tendency for bone to form and may protect you from developing myositis ossificans.

A much more effective method that has been used a great deal to prevent the development of myositis ossificans involves radiation treatments immediately after surgery. These are the same type of radiation treatments used to treat cancer. Several short radiation treatments begun the day after surgery and continued for three to five days seem to drastically reduce the risk of developing myositis ossificans.

If myositis ossificans forms despite these precautions, treatment will depend on how much it affects your knee. Your surgeon will note how much pain it causes and how much it restricts motion. In some severe cases, you may choose to have a second operation to remove the calcified tissue that has formed. This is usually followed by radiation treatments to prevent the calcium deposits from returning.

Loosening

The major reason that artificial joints eventually fail continues to be from loosening where the metal or cement meets the bone. A loose revised prosthesis is a problem because it causes pain. Once the pain becomes unbearable, another revision surgery may be needed. The rate of loosening is higher after revision surgery than in primary arthroplasties.

Incision Complications

Poor healing of the incision is a fairly common complication of knee revision arthoplasty. This is because the tissue is often scarred and thinner than when the original knee replacement was done. The blood supply to the skin may not be normal due to damage to the blood vessels from one or more previous knee surgeries. As mentioned earlier, previous skin incisions can make it hard for the incision to close after knee revision surgery, leading to complications. When the incision doesn’t heal right, the chances of infection go up. The wound may continue to ooze, creating optimal conditions for bacterial growth.

Poor incision healing is more likely to occur in patients with one or more of the following factors:

• anemia
• obesity
• past wound healing problems
• weak immune system
• tobacco habit
• poor circulation
• diabetes mellitus

Your surgeon’s goal is to prevent problems with the incision. If problems do happen, however, one or more additional surgeries will likely be needed.

What happens after surgery?

After surgery, your knee is covered with a padded dressing. Special boots or stockings are placed on your feet to help prevent blood clots from forming.

If a general anesthesia was used, a nurse, Physical Therapist, or respiratory therapist will visit your room to guide you in a series of breathing exercises. You’ll use an incentive spirometer to improve breathing and avoid possible problems with pneumonia.

Several measures may be taken for patients who are at risk of incision problems. Some surgeons believe it is important to place a drain in the knee for a few days after surgery. The idea is that the drain will help keep swelling down. Too much swelling can pull the new incision apart and allow the wound to ooze. These factors place the knee at risk for infection. The practice of putting a drain in the knee is controversial, however, as some surgeons think that implanting the drain carries by itself an even bigger risk of infection.

A second measure to improve wound healing is to supply extra oxygen for three to four days through a nasal cannula. (A nasal cannula delivers oxygen through two small prongs placed into the nose.) The idea is that the added oxygen circulating in the blood stream will speed up the healing process and reduce the risk of incision problems.

You may also have Physical Therapy treatments once or twice each day as long as you are in the hospital. Therapy treatments will address the range of motion in the knee. Your therapist may also demonstrate exercises to improve knee mobility and engage the thigh and hip muscles. Ankle movements help pump swelling out of the leg and prevent the possibility of a blood clot.

When you are stabilized, your Physical Therapist will help you up for a short outing using your crutches or walker. After surgery, you may not be allowed to put weight on the affected leg for a period of time. This varies from surgeon to surgeon.

Most patients are able to go home after spending four to seven days in the hospital. You’ll be on your way home when you can get in and out of bed, walk up to 75 feet with your crutches or walker, go up and down stairs safely, and access the bathroom. It is also important that you regain a good muscle contraction of the quadriceps muscle and that you gain improved knee range of motion. Patients who need extra care may be sent to a different unit of the hospital until they are safe and ready to go home.

Most orthopedic surgeons recommend that you have routine checkups after your revision surgery. How often you need to be seen varies from every six months to every five years, according to your situation and what your surgeon recommends. You should always consult your orthopedic surgeon if you begin to have pain in your artificial joint or if you begin to suspect something is not working correctly.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

Portions of this document copyright MMG, LLC.

What should I expect during my recovery?

Your staples will be removed about two weeks after surgery. Patients are usually able to drive within eight weeks and walk without a walking aid by two to three months. Upon the approval of our therapist, patients are generally able to resume sexual activity by six to eight weeks after surgery.

When you begin your First Choice Physical Therapy rehabilitation, our Physical Therapist may first use heat, ice, or electrical stimulation if you are still having swelling or pain. During this time, you should continue to use your walker or crutches as instructed. If you had a cemented procedure, you’ll advance the weight you place on your sore leg as much as you feel comfortable. If you had a noncemented procedure, place only the toes down until you’ve had a follow-up X-ray and our Physical Therapist directs you to put more weight through your leg (usually by the fifth or sixth week after surgery). Although recovery time varies, most patients progress to using a cane in six to eight weeks.

Our Physical Therapist may use hands-on stretches for improving your range of motion, then strength exercises to address key muscle groups including the buttock, hip, thigh, and calf muscles. Endurance can be improved through stationary biking, lap swimming, and using an upper body ergometer (upper cycle).

Our Physical Therapists sometimes treat patients in a pool. Exercising in a swimming pool puts less stress on the knee joint, and the buoyancy lets you move and exercise easier. Once you’ve gotten your pool exercises down and the other parts of your rehab program advance, our Physical Therapist
may instruct you in an independent program.

When you are safe in putting full weight through the leg, our Physical Therapist will choose several types of balance exercises to further stabilize and control the knee. Finally, we will use a select group of exercises to simulate day-to-day activities, such as going up and down steps, squatting, and walking on uneven terrain. Other specific exercises may then be chosen to simulate work or hobby demands.

Our Physical Therapist will work with you to help keep your revised knee joint healthy for as long as possible. This may require that you adjust your activity choices to keep from putting too much strain on your revised knee joint. Heavy sports that require running, jumping, quick stopping and starting, and cutting are discouraged. Patients may need to consider alternate jobs to avoid work activities that require heavy lifting, crawling, and climbing.

At First Choice Physical Therapy, our goal is to help you maximize strength, walk normally, and improve your ability to do your activities. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Knee osteoarthritis often affects only one side of the knee joint. When this occurs, realigning the angle made between the bones of the leg can shift your body weight so that the healthy side of the knee joint takes more of the stress. The procedure to realign the angles of the lower leg is called a proximal tibial osteotomy.

This guide will help you understand:

• what your surgeon hopes to achieve with the procedure
• what happens during the surgery
• what to expect after your operation

Which parts of the knee are involved?

The knee joint is formed where the thighbone (femur) meets the shinbone (tibia). Two bony knobs on the end of the femur, called condyles, sit on the top surface of the tibia. The inside condyle (the one closest to the other knee) is called the medial femoral condyle. The lateral femoral condyle is on the outer half of the femur (farthest from the other knee). The top of the tibia bone forms a flat surface called the tibial plateau.

The knee is divided into two halves, or compartments. The medial compartment is the inside half of the knee and is formed by the connection of the medial femoral condyle and the tibial plateau. The lateral compartment is the outside half of the knee and is formed by the connection of the lateral femoral condyle and the tibial plateau.

Articular cartilage covers the ends of bones. It has a smooth, slippery surface that allows the bones of the knee joint to slide over each other without rubbing. This slick surface is designed to minimize pressure and friction as you move.

Articular Cartilage

What does the surgeon hope to achieve with surgery?

Osteoarthritis of the knee sometimes affects one side of the knee far more than the other. While either side can suffer greater damage, usually the inside half of the knee joint (the medial compartment) is more affected. When this uneven damage occurs to one side of the knee, the other side may still have good cartilage on the joint surfaces.

In some cases, surgery to realign the angles in the lower leg can result in shifting pressure to the other, healthier side of the knee. The goal is to reduce the pain and delay further degeneration in the weaker half of the knee.

This procedure is most often used for younger, active patients and for those who have osteoarthritis in only one side of their knee joint. This operation may increase the life span of the joint and prolong the time before a knee replacement surgery becomes necessary.

How should I prepare for surgery?

The decision to proceed with surgery must be made jointly by you and your surgeon. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

On the day of your surgery, you will probably be admitted to the hospital early in the morning. You shouldn’t eat or drink anything after midnight the night before. The amount of time you spend in the hospital varies and depends on how quickly you recover.

What happens during the operation?

There are two methods to realign the knee joint. One involves taking out a wedge of bone; the other involves adding a wedge of bone. Any operation for cutting through a bone is called an osteotomy. In a closing wedge osteotomy, the surgeon cuts though the tibia on the lateral side, removes a wedge of bone, and pins the open edges together. In an opening wedge osteotomy, the surgeon cuts though the tibia on the medial side and opens a wedge, adding a bit of bone graft to hold the wedge open.

Closing Wedge Osteotomy

In the closing wedge osteotomy, an incision is made in the lateral side of the knee to allow the surgeon to see the upper end of the tibia. Care is taken to protect the nerves and blood vessels that travel across the knee joint.

Once the tibia bone is exposed, two cuts are made through the upper tibia in the shape of a wedge. The surgeon uses either X-rays or a fluoroscope, a special kind of X-ray machine that casts images on a fluorescent screen, to make sure the wedge is the right size and is placed correctly.

The surgeon takes out the wedge, and the two sides of the tibia are brought closer together and held in position with a metal plate or pins. This changes the angle of the tibia and helps straighten the alignment of the knee. After fixing the two edges of bone with a plate or pins, the surgeon stitches the skin together, and the leg is placed in a padded splint to protect the knee joint.

Changing the Angle of the Tibia

Opening Wedge Osteotomy

In the opening wedge osteotomy, an incision is made in the medial side of the knee. Again, care is taken to protect the nerves and blood vessels that travel across the knee joint.

Once the tibia bone is exposed, one cut is made through the upper tibia. A fluoroscope or X-rays are used to make sure the cut is in the right place.

After the bone is cut, the two sides of the tibia are separated to form a wedge-shaped opening.

This opening is then filled with bone graft. The bone graft is usually taken from pelvis bone, through an incision in the side of your hip.

The bone graft is held in position with a metal plate or pins.

After fixing the two edges of bone with a plate or pins, the surgeon stitches the skin together, and the leg is placed in a padded splint to protect the knee joint.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following tibial osteotomy are:

• anesthesia complications
• thrombophlebitis
• infection
• scar tissue formation
• nonunion of the bones

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible after surgery. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Following surgery, it is possible that the surgical incision can become infected. This will require antibiotics and possibly another surgical procedure to drain the infection.

Scar Tissue Formation

The most common complication after a tibial osteotomy is the formation of scar tissue in the joint below the kneecap. Bleeding and swelling from the surgery can cause the body to form scar tissue. When scar tissue builds up just below the kneecap, the knee can’t straighten completely. When this happens, another operation may be required to remove the scar tissue.

Nonunion of the Bones

Sometimes the two bone edges do not heal as planned. This is called a nonunion. This condition requires another operation to add bone graft and perhaps additional metal plates or pins. The bones need to be completely immobilized to fuse, or heal together firmly, so an external fixator may be needed to help hold the bones in position as they heal. The external fixator is worn over the skin and connects to the metal pins to hold them firmly in place. Because the bone of the upper tibia is wide and has a good blood supply, nonunion is rare.

Continued Pain

In some cases the tibial osteotomy simply does not achieve the results expected. This can occur due to more advanced osteoarthritis in other areas of the joint, especially in the cartilage behind the kneecap. If you continue to have pain or do not achieve the results that you expect from the operation, the next step is usually to replace the knee joint with an artificial joint.

What happens after surgery?

Your surgeon may have you use a continuous passive motion (CPM) machine immediately after surgery to help the knee begin moving and to alleviate joint stiffness. The machine straps to the leg and continuously bends and straightens the joint. This motion is thought to reduce stiffness, ease pain, prevent blood clots from forming, and prevent extra scar tissue from forming inside the joint.

Along with the CPM, you may be seen by a Physical Therapist to maximize your range of motion. As your condition stabilizes, your Physical Therapist will also help you up for a short outing using your crutches or your walker.

Most patients are able to go home after spending one or two days in the hospital. You’ll be on your way home when you can demonstrate a safe ability to get in and out of bed, walk up to 75 feet with your crutches or walker, go up and down stairs safely, and access the bathroom. It is also important that you regain a good muscle contraction of the quadriceps muscle in the thigh and that you gain improved knee range of motion.

A tibial osteotomy in the best of circumstances is probably only temporary. It is thought that this operation buys some time before a total knee replacement becomes necessary. The benefits of the operation usually last for five to seven years if successful.

What should I expect during my rehabilitation?

You will probably wear a knee brace for up to six weeks after surgery to protect the knee joint as you recover. Your stitches will normally be removed in 10 to 14 days. Although the time required for rehabilitation varies, recovery after a tibial osteotomy typically takes two to three months.

During your recovery period, you should use your walker or crutches as instructed by our Physical Therapist. If you had a closing wedge osteotomy, you probably won’t have to limit how much weight you place on your foot. But with an opening wedge procedure, you’ll need to protect the healing bone graft by only placing the toes of the operated leg on the floor when you walk. Your surgeon will take a follow-up X-ray to see when the graft is safe for you to begin putting more weight down when you walk. This is usually six to eight weeks after surgery.

Your Physical Therapist can begin assisting you with treatment shortly after surgery. Our Physical Therapist may use heat, ice, or electrical stimulation if you have swelling or pain. We may also use hands-on stretches and show you exercises to improve knee range of motion. Then strength exercises will be used to address key muscle groups including the buttock, hip, thigh, and calf muscles. Endurance can be achieved through stationary biking, lap swimming, and using an upper body ergometer (upper cycle).

Our Physical Therapists sometimes treat patients in a pool. Exercising in a swimming pool puts less stress on the knee joint, and the buoyancy lets you move and exercise easier. Once you’ve gotten your pool exercises down and the other parts of your rehab program advance, we may instruct you in an independent program.

When you are safe in putting full weight through the leg, our Physical Therapist can choose several types of balance exercises to further stabilize and control your knee.

Finally, we will utilize a select group of exercises to simulate day-to-day activities, such as going up and down steps, squatting, rising on your toes, and bending down. Other specific exercises may then be chosen to simulate work or hobby demands.

Many patients have less pain and better mobility after a tibial osteotomy procedure. Our Physical Therapist will work with you to help keep your knee joint healthy for as long as possible. This may require that you adjust your activity choices to keep from placing too much strain on your knee.

At First Choice Physical Therapy, our goal is to help you improve knee range of motion, maximize strength, and improve your ability to do your activities. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

A painful knee can severely affect your ability to lead a full, active life. Over the last 25 years, major advancements in artificial knee replacement have improved the outcome of the surgery greatly. One of the more recent advances in knee replacement surgery is the unicompartmental knee replacement (also known as a unicondylar knee replacement). This type of knee replacement is less invasive than a full knee replacement. The operation is designed to replace only the portions of the joint that are most damaged by arthritis. This can have significant advantages, especially in younger patients who may need to have a second artificial knee replacement as the first one begins to wear out. Removing less bone during the initial operation makes it much easier to perform a revision artificial knee replacement later in life.

This guide will help you understand:

• what your surgeon hopes to achieve
• what happens during the procedure
• what to expect after your operation

What is the normal anatomy of the knee?

The knee joint is formed where the femur (thighbone) meets the tibia (shinbone). A smooth cushion of articular cartilage covers the end surfaces of both of these bones so that they slide against one another smoothly. The articular cartilage is kept slippery by joint fluid made by the synovial membrane (joint lining). The fluid is contained in a soft tissue enclosure around the knee joint called the joint capsule.

Synovial Membrane

The patella, or kneecap, is the movable bone on the front of the knee. It is wrapped inside a tendon that connects the large muscles on the front of the thigh, the quadriceps muscles, to the lower leg bone. The surface on the back of the patella is covered with articular cartilage. It glides within a groove on the front of the femur.

There are two femoral condyles in each knee. The medial femoral condyle (the one closest to the other knee) and the lateral femoral condyle (on the outside half of the knee joint).

Rationale

What does the surgeon hope to achieve?

The main reason for replacing any arthritic joint with an artificial joint is to stop the bones from rubbing against each other. This rubbing causes pain. Replacing the painful and arthritic joint with an artificial joint gives the joint a new surface, which moves smoothly and without causing pain. The goal is to help people return to many of their activities with less pain and with greater freedom of movement.

How should I prepare for surgery?

The decision to proceed with surgery should be made jointly by you and your surgeon. The decision should only be made after you feel that you understand as much as possible about the procedure.

Once you decide to proceed with surgery, several things may need to be done. Your orthopedic surgeon may suggest a complete physical examination by your regular doctor. This is to ensure that you are in the best possible condition to undergo the operation. You may also need to spend time with the Physical Therapist who will be managing your rehabilitation after the surgery. Your Physical Therapist will begin the teaching process before surgery to make sure you are ready for rehabilitation afterwards.

One purpose of the preoperative visit is to record a baseline of information. This includes measurements of your current pain levels, functional abilities, the presence of swelling, and the available movement and strength of each knee.

A second purpose of the preoperative therapy visit is to prepare you for your upcoming surgery. You will practice some of the exercises used just after surgery. You will also be trained in the use of either a walker or crutches. Whether the surgeon uses a cemented or uncemented artificial knee will determine how much weight you will initially apply through your foot while walking. Finally, an assessment will be made of any needs you will have at home once you’re released from the hospital.

What happens during the operation?

Before we describe the procedure, let’s look first at the unicompartmental artificial knee itself.

There are two major types of artificial knee replacements:

• cemented prosthesis
• uncemented prosthesis

Both are still widely used. In many cases a combination of the two types is used. The decision to use a cemented or uncemented artificial knee is usually made by the surgeon based on your age, your lifestyle, and the surgeon’s experience.

Each prosthesis is made up of two main parts.

The tibial component (bottom portion) replaces the top surface of the lower bone, the tibia. The femoral component (top portion) replaces the bottom surface of the upper bone (the femoral condyle).

The femoral component is made of metal. The tibial component is usually made of two parts: a metal tray that is attached directly to the bone, and a plastic spacer that provides the slick surface. The plastic used is so tough and slick that you could ice skate on a sheet of it without much damage to the material.

A cemented prosthesis is held in place by a type of epoxy cement that attaches the metal to the bone. An uncemented prosthesis has a fine mesh of holes on the surface that allows bone to grow into the mesh and attach the prosthesis to the bone.

To begin the procedure, the surgeon makes an incision on the front of the knee to allow access to the joint. Several different approaches can be used to make the incision depending on whether the outer half (the lateral compartment) or the inner half (the medial compartment) is being replaced. The incisions used to perform the unicompartmental knee replacement are much smaller than those used to perform a traditional artificial knee replacement. For this reason, this surgery is sometimes referred to as minimally invasive.

Once the knee joint is opened, a special positioning device (a cutting guide) is placed on the end of the femur. This cutting guide is used to ensure that the bone is cut in the proper alignment to the leg’s original angles, even if the arthritis has made you bowlegged or knock-kneed. With the help of the cutting guide, the surgeon cuts several pieces of bone from the end of the femur. The artificial knee will replace these worn surfaces with a metal surface.

Next, the surface of the tibia is prepared. Another type of cutting guide is used to cut the tibia in the correct alignment.

The metal femoral component is then placed on the femur. In the uncemented prosthesis, the metal piece is held snugly onto the femur because the femur is tapered to accurately match the shape of the prosthesis. The metal component is pushed onto the end of the femur and held in place by friction. In the cemented variety, epoxy cement is used to attach the metal prosthesis to the bone.

The metal tray that holds the plastic spacer is then attached to the top of the tibia. This metal tray is either cemented into place or held with screws if the component is of the uncemented variety. The screws are primarily used to hold the tibial tray in place until bone grows into the porous coating. The screws remain in place and are not removed.

The plastic spacer is then attached to the metal tray of the tibial component. If this component should wear out while the rest of the artificial knee is sound, it can be replaced. The replacement procedure is sometimes called a retread.

Finally, the soft tissues are sewn back together, and staples are used to hold the skin incision together.

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following artificial knee replacement are:

• anesthesia complications
• thrombophlebitis
• infection
• stiffness
• loosening

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible after surgery. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Infection can be a very serious complication following an artificial joint surgery. The chance of getting an infection following artificial knee replacement is probably around one percent. Some infections may show up very early, even before you leave the hospital. Others may not become apparent for months, or even years, after the operation. Infection can spread into the artificial joint from other infected areas. Your surgeon may want you to take antibiotics when you have dental work or surgical procedures on your bladder and colon to reduce the risk of spreading germs to the joint.

Stiffness

In some cases, the ability to bend the knee does not return to normal after knee replacement surgery. To be able to use the leg effectively to rise from a chair, the knee must bend at least to 90 degrees. A desirable range of motion is greater than 110 degrees.

The most important factor in determining range of motion after surgery is whether the ligaments and soft tissues were balanced during surgery. The surgeon tries to get the knee in the best alignment so there is equal tension on all the ligaments and soft tissues.

Sometimes extra scar tissue develops after surgery and can lead to an increasingly stiff knee. If this occurs, your surgeon may recommend taking you back to the operating room, placing you under anesthesia once again, and manipulating the knee to regain motion. Basically, this allows the surgeon to break up and stretch the scar tissue without you feeling it. The goal is to increase the motion in the knee without injuring the joint.

Loosening

The major reason that artificial joints eventually fail continues to be a process of loosening where the metal or cement meets the bone. Great advances have been made in extending how long an artificial joint will last, but most will eventually loosen and require a revision. Hopefully, you can expect 12 to 15 years of service from an artificial knee, but in some cases the knee will loosen earlier than that. A loose prosthesis is a problem because it usually causes pain. Once the pain becomes unbearable, another operation will probably be required to revise the knee replacement.

What happens after surgery

Some orthopedic surgeons recommend a device known as a continuous passive motion (CPM) machine immediately after surgery. The unit is thought to help prevent blood clots and speed healing of the wound. It may help patients get by with less need for medication. The unit may help improve knee mobility after knee replacement surgery. However, patients seem to do equally well in regaining knee motion by doing their exercises.

You may also have Physical Therapy treatments once or twice each day as long as you are in the hospital. Physical Therapy treatments will address the range of motion in the knee. Gentle movement will be used to help you bend and straighten the knee. If you are using a CPM device, it will be checked for alignment and settings. Your leg may be elevated to help drain extra fluid in the leg.

Your Physical Therapist will also go over exercises to help improve knee mobility and to start exercising the thigh and hip muscles. Ankle movements are used to help pump swelling out of the leg and to prevent the possibility of a blood clot.

When you are stabilized, your Physical Therapist will help you get up for a short outing using your crutches or your walker.

Most patients are able to go home after spending one to two days in the hospital. In some cases, minimally invasive unicompartmental surgery can be done as an outpatient – meaning you can go home the same day.

You’ll be on your way home when you can demonstrate a safe ability to get in and out of bed, walk up to 75 feet with your crutches or walker, go up and down stairs safely, and access the bathroom. It is also important that you regain a good muscle contraction of the quadriceps muscle and that you gain improved knee range of motion. Patients who still need extra care may be sent to a different unit until they are safe and ready to go home.

Most orthopedic surgeons recommend regular checkups after your artificial joint replacement. How often you need to be seen varies from every six months to every five years, according to your situation and what your surgeon recommends. You should always consult your orthopedic surgeon if you begin to have pain in your artificial joint, or if you begin to suspect something is not working correctly.

Most patients who have an artificial joint will have episodes of pain, but when you have pain that lasts longer than a couple of weeks you should consult your surgeon. The surgeon will examine your knee in search of reasons for the pain. X-rays may be taken of your knee to compare with x-rays taken earlier to see whether the artificial joint shows any evidence of loosening.

What should I expect during my rehabilitation?

When you visit First Choice Physical Therapy, our Physical Therapist may first use heat, ice, or electrical stimulation to reduce any remaining swelling or pain.

You should continue to use your walker or crutches as instructed. If you had a cemented procedure, you’ll advance the weight you place through your sore leg as much as you feel comfortable. If yours was a noncemented procedure, place only the toes down until you’ve had a follow-up x-ray and our Physical Therapist directs you to put more weight through your leg (usually by the fifth or sixth week postoperatively).

We may use hands-on stretches for improving your range of motion, then strength exercises to address key muscle groups including the buttock, hip, thigh, and calf muscles. Endurance can be achieved through stationary biking, lap swimming, and using an upper body ergometer (upper cycle).

Our Physical Therapists sometimes treat patients in a pool. Exercising in a swimming pool puts less stress on the knee joint, and the buoyancy lets you move and exercise easier. Once you’ve gotten your pool exercises down and the other parts of our rehab program advance, you may be instructed in an independent program.

When you are safe in putting full weight through the leg, our Physical Therapist can choose several types of balance exercises to further stabilize and control the knee.

Finally, we’ll use a select group of exercises to simulate day-to-day activities, such as going up and down steps, squatting, rising on your toes, and bending down. Specific exercises may then be chosen to simulate work or hobby demands.

Many patients have less pain and better mobility after having knee replacement surgery. Our Physical Therapist will work with you to help keep your knee joint healthy for as long as possible. This may require that you adjust your activity choices to keep from putting too much strain on your new knee joint. Heavy sports that require running, jumping, quick stopping or starting, and cutting are discouraged. Cycling, swimming, and level walking are encouraged, as are low impact sports like golfing or bowling.

At First Choice Physical Therapy, our goal is to help you improve knee range of motion, maximize strength, and improve your ability to do your activities. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

The use of arthroscopy has revolutionized many different types of orthopedic surgery. During arthroscopy, a small video camera attached to a fiber-optic lens is inserted into the body to allow a physician or surgeon to see inside without making a large incision (arthro means joint, scopy means look). The knee was the first joint in which the arthroscope was commonly used to both diagnose problems and to perform surgical procedures inside a joint.

This guide will help you understand:

• what parts of the knee are involved
• what types of conditions can be treated
• what to expect after surgery
• what First Choice Physical Therapy’s approach to rehabilitation is

What parts of the knee are involved?

The knee joint is formed where the femur (lower end of the thighbone) connects with the tibia (upper end of the main lower leg bone). On the front of the joint is the patella (kneecap). The patella is what is called a sesamoid bone that is a part of the extensor mechanism of the knee joint. The extensor mechanism connects the large muscles of the thigh to the tibia such that contracting the thigh muscles pulls on the tibia and allows us to straighten the knee. The parts of the extensor mechanism include the thigh muscles, the quadriceps tendon, the patella and the patellar tendon.

The knee joint is surrounded by a water-tight pocket called the joint capsule.

This capsule is formed by the knee ligaments, connective tissue, and synovial tissue. When the joint capsule is filled with sterile saline and is distended, the surgeon can insert the arthroscope into the pocket that is formed, turn on the lights and the camera, and see inside the knee joint as if looking into an aquarium. The surgeon can see nearly everything that is inside the knee joint including: (1) the joint surfaces of the tibia, femur and patella, (2) the two menisci, (3) the two cruciate ligaments, and (4) the synovial lining of the joint.

There is one meniscus on each side of the knee joint. The C-shaped medial meniscus is on the inside part of the knee, closest to your other knee (medial means closer to the middle of the body.) The U-shaped lateral meniscus is on the outer half of the knee joint (lateral means further out from the center of the body.)

The menisci (plural for meniscus) protect the articular cartilage on the surfaces of the thighbone (femur) and the shinbone (tibia) and help to create a deeper joint surface, which aids in joint stability. Articular cartilage is the smooth, slippery material that covers the ends of the bones that make up the knee joint, as well as most other joints. The articular cartilage allows the joint surfaces to slide against one another without damage to either surface.

Ligaments are tough bands of tissue that connect the ends of bones together and help to keep the bones together, creating a stable joint. The anterior cruciate ligament (ACL) is located in the center of the knee joint where it runs from the backside of the femur, or thighbone’s joint surface to connect to the front of the tibia, or shinbone’s joint surface.
The ACL runs through a special notch in the femur called the intercondylar notch and attaches to an area of the tibia called the tibial spine.

The ACL is the main controller of how far forward the tibia moves under the femur. This is called anterior translation of the tibia. If the tibia moves too far, the ACL can rupture. The ACL is also the first ligament that becomes tight when the knee is straightened. If the knee is forced past this point, or hyperextended, the ACL can also be torn.
The posterior cruciate ligament (PCL) is located near the back of the knee joint. It also attaches to the femur’s joint surface and the tibia’s joint surface, but crosses behind the ACL such that the two ligaments (the ACL and PCL) form somewhat of an X inside the joint (the term ‘cruciate’ means shaped like a cross.)

The PCL is the primary stabilizer of the knee and the main controller of how far backward the tibia moves under the femur. This motion is called posterior translation of the tibia. If the tibia moves too far back, the PCL can rupture.

What does my surgeon hope to accomplish?

When knee arthroscopy first became widely available in the 1970’s it was used primarily to look inside the knee joint and make a diagnosis. Today, knee arthroscopy is used in performing a wide range of different types of surgical procedures on the knee joint including confirming a diagnosis, removing loose bodies, removing or repairing a torn meniscus, reconstructing torn ligaments, repairing articular cartilage and fixing fractures of the joint surface.

Your surgeon’s goal is to fix or improve your problem by performing a suitable surgical procedure; the arthroscope is a tool that improves the surgeon’s ability to perform that procedure. The arthroscope image is magnified and allows the surgeon to see better and clearer, and perform surgery using much smaller incisions than with traditional surgery. This results in less tissue damage to normal tissue and can shorten the healing process. Remember, however, that the arthroscope is only a tool. The results that you can expect from a knee arthroscopy depend on what is wrong with your knee, what can be done inside your knee to improve the problem, as well as your effort at rehabilitation after the surgery.

What do I need to know before surgery?

You and your surgeon should make the decision to proceed with surgery together.  Sometimes arthroscopic surgery is done as an immediate treatment for an injury, such as in the case of a knee with a torn meniscus that limits the knee from fully straightening. Sometimes, however, arthroscopic surgery is performed as a last resort to treatment, for example if Physical Therapy treatment combined with a home exercise program has failed to ease the pain of a worn down patellar joint surface, an arthroscopic surgery may be suggested.

You need to understand as much as possible about the surgical procedure. If you have concerns or questions, be sure and talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

If you have not already tried Physical Therapy for your injury, you should spend time at First Choice Physical Therapy before the surgery with the Physical Therapist who will be managing your rehabilitation after surgery. This allows you to get a head start on your recovery. One purpose of this preoperative visit is to record a baseline of information. Your therapist will check your current pain levels, your ability to do specific activities, and the movement and strength of each knee.

A second purpose of the preoperative visit to First Choice Physical Therapy is to prepare you for surgery. Your therapist will teach you how to walk safely using crutches or a walker and you will begin learning some of the exercises you’ll use during your recovery.

On the day of your surgery, you will probably be admitted for surgery early in the morning. You shouldn’t eat or drink anything after midnight the night before.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

What happens during the procedure?

Before surgery you will be placed under either general anesthesia or a type of spinal anesthesia. In simple cases, local anesthesia may be adequate. Special braces are attached to the operating room table, which are used to safely cradle the leg and allow the surgeon to move the leg and bend the knee easily. Finally, sterile drapes are placed to create a sterile environment for the surgeon to work. There is a great deal of equipment that surrounds the operating table including the TV screens, cameras, light sources and surgical instruments.

The surgeon begins the operation by making two or three small openings into the knee, called portals. These portals are where the arthroscope and surgical instruments are placed inside the knee. Care is taken to protect the nearby nerves and blood vessels. A small metal or plastic tube (or cannula) will be placed through one of the portals to inflate the knee with sterile saline, which allows the tissues inside the joint to be more easily visible.

The arthroscope is a small fiber-optic tube that is used to see and operate inside the joint. It is a small metal tube about 1/4 inch in diameter (slightly smaller than a pencil) and about seven inches in length. The fiber-optics inside the metal tube of the arthroscope allow a bright light and a TV camera to be connected to the outer end of the arthroscope. The light shines through the fiber-optic tube and into the knee joint. A TV camera is attached to the lens on the outer end of the arthroscope. The TV camera projects the image from inside the knee joint onto a TV screen next to the surgeon. The surgeon actually watches the TV screen (not the knee joint) while moving the arthroscope to different places inside the knee joint.

Over the years since the invention of the arthroscope, many very specialized instruments have been developed to perform different types of surgery using the arthroscope. Due to these inventions many surgical procedures that once required large incisions for the surgeon to see and fix the problem can now be done with much smaller incisions. For example, simple removal of a torn meniscus or loose body can be done using two small incisions that are approximately 1/4 inch or 6mm. More extensive surgical procedures such as ligament reconstruction or fracture repair may require larger incisions, however, they are still much smaller incisions than what was needed prior to the invention of the arthroscope.

Once the surgical procedure is complete, the arthroscopic portals and surgical incisions will be closed with sutures or surgical staples.  Small pieces of surgical tape are also applied to assist the skin to heal as smoothly as possible.  Often a large bandage is applied from mid thigh to the toes. Wrapping the entire leg with a compressive bandage reduces swelling and helps prevent blood clots in the leg. Once the bandage has been placed, you will be taken to the recovery room.

What happens during the procedure?

Before surgery you will be placed under either general anesthesia or a type of spinal anesthesia. In simple cases, local anesthesia may be adequate. Special braces are attached to the operating room table, which are used to safely cradle the leg and allow the surgeon to move the leg and bend the knee easily. Finally, sterile drapes are placed to create a sterile environment for the surgeon to work. There is a great deal of equipment that surrounds the operating table including the TV screens, cameras, light sources and surgical instruments.

The surgeon begins the operation by making two or three small openings into the knee, called portals. These portals are where the arthroscope and surgical instruments are placed inside the knee. Care is taken to protect the nearby nerves and blood vessels. A small metal or plastic tube (or cannula) will be placed through one of the portals to inflate the knee with sterile saline, which allows the tissues inside the joint to be more easily visible.
The arthroscope is a small fiber-optic tube that is used to see and operate inside the

joint. It is a small metal tube about 1/4 inch in diameter (slightly smaller than a pencil) and about seven inches in length. The fiber-optics inside the metal tube of the arthroscope allow a bright light and a TV camera to be connected to the outer end of the arthroscope. The light shines through the fiber-optic tube and into the knee joint. A TV camera is attached to the lens on the outer end of the arthroscope. The TV camera projects the image from inside the knee joint onto a TV screen next to the surgeon. The surgeon actually watches the TV screen (not the knee joint) while moving the arthroscope to different places inside the knee joint.

Over the years since the invention of the arthroscope, many very specialized instruments have been developed to perform different types of surgery using the arthroscope. Due to these inventions many surgical procedures that once required large incisions for the surgeon to see and fix the problem can now be done with much smaller incisions. For example, simple removal of a torn meniscus or loose body can be done using two small incisions that are approximately 1/4 inch or 6mm. More extensive surgical procedures such as ligament reconstruction or fracture repair may require larger incisions, however, they are still much smaller incisions than what was needed prior to the invention of the arthroscope.

Once the surgical procedure is complete, the arthroscopic portals and surgical incisions will be closed with sutures or surgical staples.  Small pieces of surgical tape are also applied to assist the skin to heal as smoothly as possible.  Often a large bandage is applied from mid thigh to the toes. Wrapping the entire leg with a compressive bandage reduces swelling and helps prevent blood clots in the leg. Once the bandage has been placed, you will be taken to the recovery room.

What happens after surgery?

Knee arthroscopy is usually done on an outpatient basis meaning that patients go home the same day as the surgery. More complex ligament reconstructions that require larger incisions and surgery that alters bone may require a short stay in the hospital to control pain more aggressively, monitor the situation more carefully, and to begin Physical Therapy.

As mentioned above, the portals are covered with surgical strips.  The larger incisions may have been repaired with either surgical staples or sutures and the knee may be wrapped in an elastic bandage. Crutches are commonly used after knee arthroscopy even though they may only be needed for one to two days after a simple procedure.

Patients who have had more complex reconstructive surgery may need to wear a knee brace for several weeks. The brace helps to protect the healing tissue inside the knee joint. You may be allowed to remove the brace at times during the day to do gentle range-of-motion exercises and to have a bath.

It is crucial that you follow your surgeon’s instructions about how much weight to place on your foot while standing or walking. Most often you are allowed to weight bear as tolerated, but there are instances where your surgeon may request that you do not fully weight bear, such as in the case of a joint surface bone repair.  You may be instructed to use a cold pack on the knee and to keep your leg elevated and supported.

What might go wrong?

As with all major surgical procedures, complications can occur during knee arthroscopy. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems, which are:

• anesthesia complications
• thrombophlebitis
• infection
• equipment failure
• slow recovery

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the specific drugs used, problems related to other medical complications, and problems due to being under anesthesia. Be sure to discuss the risks of anesthesia and any specific concerns related to your own health or pre-existing conditions with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but they are more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lungs, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take the risk of DVT and preventing it very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is to get you moving as soon as possible after surgery. Two other commonly used preventative measures include the use of pressure stockings to keep the blood in the legs moving, and medications that thin the blood and prevent blood clots from forming in the first place.

Infection

Following knee arthroscopy, it is possible that a postoperative infection may occur. Fortunately getting an infection is very uncommon and happens in less than 1% of cases. If, however, you do get a postoperative infection you may experience symptoms such as increased pain, swelling, fever and a redness or drainage from the incisions.

Infections are of two types: superficial or deep. A superficial infection may occur in the skin around the incisions or portals. A superficial infection does not extend into the joint and can usually be treated with antibiotics alone. If the knee joint itself becomes infected, this is a serious complication and will require antibiotics and possibly another surgical procedure to drain the infection. You should alert your surgeon immediately if you think you are developing an infection.

Equipment Failure

Many of the instruments used by the surgeon to perform knee arthroscopy are small and fragile. These instruments can be broken resulting in a piece of the instrument floating inside the knee joint. The broken piece is usually easily located and removed, but this may cause the operation to last longer than planned. There is usually no damage to the knee joint due to the breakage.

Different types of surgical devices (screws, pins, and suture anchors) are used to hold tissue in place during and after arthroscopy. These devices can also cause problems. If one breaks, the free-floating piece may hurt other parts inside the knee joint, particularly the articular cartilage. Another issue may be that the end of a tissue anchor pokes too far through the tissue and may rub and irritate other nearby tissues. A second surgery may be needed to remove the device or fix problems associate with failure of these devices.

Slow Recovery

Not everyone gets quickly back to routine activities after knee arthroscopy. Because the arthroscope allows surgeons to use smaller incisions than in the past, many patients mistakenly believe that less surgery was necessary, however, this is not always true. The arthroscope allows surgeons to do a great deal of reconstructive surgery inside the knee without making large incisions. How fast you recover from knee arthroscopy depends on what type of surgery was done inside your knee. Simple problems that require simple procedures using the arthroscope generally get better faster. Patients with extensive damage to the knee ligaments or articular cartilage tend to require more complex and extensive surgical procedures. These more extensive reconstructions take longer to heal and have a slower recovery. You should discuss this with your surgeon and make sure that you have realistic expectations of what to expect following arthroscopic knee surgery.  How fast you recover also depends on how compliant you are to your individual rehabilitation program. If you have difficulty completing the exercises that your Physical Therapist at First Choice Physical Therapy has prescribed for you, you should discuss this with them.  Modifications to your program can be made to ensure that although recovery may not be as quick as it could be by completing the entire rehabilitation program, you will at least always be moving in the forward direction with regards to improvement of your surgical knee.

What will my recovery be like?

Rehabilitation after knee arthroscopy should begin as soon as possible at First Choice Physical Therapy once you are discharged from the hospital.  There are a few cases where your surgeon may delay a start in your therapy because they want the tissues to heal with rest before any further stress is placed on the joint. Each surgeon will set his own specific restrictions regarding when to begin treatment at First Choice Physical Therapy based on what was done during the surgical procedure, their personal experience, and whether your tissues are healing as expected. In regards to overall recovery time, generally speaking, the more complex the surgery, the more involved and prolonged your rehabilitation program will be.

If you are still using crutches by the time we first see you at First Choice Physical Therapy, your Physical Therapist will ensure you are using the crutches safely, properly, and confidently and that you are abiding by your weight bearing restrictions if you have been given any. We will also ensure that you can safely use your crutches on stairs. If you are no longer using crutches, or once you no longer need them, your Physical Therapist will focus on normal gait re-education so you are putting only the necessary forces through the surgical side with each step, and are not compensating in any way.  Until you are able to walk without a significant limp, we recommend that you continue to use your crutches, or at least one crutch or a cane/walking stick. Improper gait can lead to a host of other pains in the knee, hip and back so it is prudent to use a walking aid until near normal walking can be achieved. Your First Choice Physical Therapy Physical Therapist will advise you regarding the appropriate time for you to be walking without any walking aid at all.
During your first few appointments at First Choice Physical Therapy your Physical Therapist will focus on relieving any pain and inflammation that you may still have from the surgical procedure itself. We may use modalities such as ice, heat, ultrasound, or electrical current to assist with decreasing any pain or swelling you have around the surgical site or anywhere down the leg. In addition, your Physical Therapist may massage your leg and ankle to improve circulation and help decrease your pain.

The next part of our treatment will focus on regaining the range of motion in your knee.  Your Physical Therapist at First Choice Physical Therapy will prescribe a series of exercises that you will practice in the clinic and also learn to do as part of a home exercise program. Range of motion in the knee generally comes back very quickly after an arthroscopic surgery, but it still depends on what your surgeon has done inside your joint, how much swelling is present, and how controlled your discomfort is.  More complicated reconstructive surgeries will take longer to regain range of motion.  During the exercises you may experience a small amount of discomfort at the end ranges of motion initially.  Despite this discomfort it is still important to perform the range of motion exercises prescribed because moving the joint also helps to move the swelling, get fresh blood to the healing area, and provide nutrition to the surface of the joint. Only mild discomfort, however, is permissible. Any sharp or moderate discomfort should be heeded. An exercise bike at this stage of your rehabilitation is very useful to assist in gaining back the knee range of motion. Even if you are unable to fully rotate the pedals of the bike using it is still encouraged.  Performing the simple back and forth motion forces fluid through the joint, which helps to move the swelling and bring fresh blood to the healing tissues.

One goal after an arthroscopic surgery is to regain full bending and straightening of your knee joint. Without this full range of motion, areas of the joint surface cartilage can become weak and start to wear down.  In addition, without full range of motion the biomechanics of the knee do not function as they have been designed to, and this contributes to early wearing down of the joint. Often prior to arthroscopic surgery fully extending or bending the knee is not possible and the goal of the surgery in the first place is to deal with any issues inside the joint that are limiting this motion.  For this reason, your Physical Therapist at First Choice Physical Therapy will be strict in encouraging you to regain both the full bending and straightening of the knee joint.  There are a few limited instances where the knee joint will not regain its full range of motion even after an arthroscopic surgery and this limited range of motion in these few cases is accepted.

These instances, however, are rare and your surgeon will inform you if your knee is one of these exceptions.  In all other cases, it is crucial that you regain the full bending and straightening of your knee in order to maximize the functioning of your knee and avoid further problems in the future.

In addition to you yourself doing range of motion exercises your Physical Therapist may mobilize your knee joint to assist in regaining motion. This hands-on technique encourages the knee to move gradually into its normal range of motion. Mobilization of the knee may be combined with therapist-assisted stretching of any tight muscles around the surgical site.

As soon as possible your therapist will also prescribe strengthening exercises for your knee and lower extremity. These exercises will focus on the muscles on the top of your thigh, called the quadriceps, and will also focus on the muscles of the hip. Hip exercises are particularly important, as the hip is the main controller of the position of the knee.  The muscles at the back of your thigh, the hamstrings, as well as your calf muscles, will also require strengthening post surgically.

After a knee surgery the quadriceps muscle becomes very low in tone and difficult to activate voluntarily, despite no injury to the muscle itself or the nerve that innervates it.  This phenomena is termed reflexive inhibition, and it is said to occur in response to several factors including the initial injury itself, the swelling in the joint, the reaction of receptors in the knee joint, pain, joint immobilization, and the surgical intervention itself. Reflexive inhibition of the quadriceps muscle after surgery occurs even if you had highly defined thigh muscle tone prior to the surgery. This decrease in tone if prolonged will contribute to poor recovery after a knee surgery; therefore exercises to get the quadriceps muscles activated are crucial.  It is often noted that the more tone you had prior to the surgery, the quicker the tone returns post surgically. For this reason doing a pre-operative exercise program is highly recommended!

The initial strengthening exercises that your Physical Therapist prescribes after an arthroscopic surgery might be as simple sitting and tightening the quadriceps or buttocks muscles without moving the joint (these exercises are termed isometric.)  Your therapist may use an electrical muscle stimulator to assist you in contracting the muscles.  It is important, however, for you to perform weight bearing exercises and those involving motion of the joint as soon as you are able to in order to build up the muscles of the leg in a functional position, such as standing or squatting.  Exercises that work the muscles while in standing most effectively assist with daily activities such as walking and stair climbing.  Exercises such as squatting, or slowly stepping up or down a step are excellent exercises to encourage the activation of both the quadriceps and hamstrings muscles, as well as the muscles of the hip.  Again, your therapist may use an electrical muscle stimulator to assist your muscles to contract while you perform these functional exercises as well.  Exercises may also include the use of Theraband, exercise machines, or free weights to provide some added resistance for your thigh and hip.  As soon as you are able, and your knee will safely tolerate it, your therapist will advance your exercises to include quicker movements, such as hopping. They will also encourage more repetitions of each exercise in order to help regain muscle endurance.  If you have access to a pool, your therapist may suggest you go to the pool to do your exercises. The buoyancy of the water along with the warmth of the water (provided it is a heated pool) can assist greatly in providing comfort to the knee joint and often allows you to exercise through greater ranges of motion.

As a result of any injury, the receptors in your joints and ligaments that assist with balance and proprioception (the ability to know where your body is without looking at it) decline in function. A period of immobility and reduced weight bearing will add to this decline. If your balance and proprioception has declined, your joints and your limb as a whole will not be as efficient in their functioning and the decline may also contribute to further injury in the future. As a final component of our treatment your Physical Therapist at First Choice Physical Therapy will prescribe exercises for you to regain this balance and proprioception. These exercises might include activities such as standing on one foot or balancing on an unstable surface such as a wobbly board or a soft plastic disc.  Advanced exercises will include agility type exercises such as hopping on one foot or moving side to side.

As your range of motion, strength, and proprioception improve, your therapist will advance your exercises to ensure your rehabilitation is progressing as quickly as your body allows. As soon as it is safe to do so, your therapist will add more aggressive exercises such as running, jumping to or from a height, or exercises that mimic the sports and recreational activities that you enjoy participating in.  During all of your exercises your therapist will pay particular attention to your technique to ensure that you are not using any compensatory patterns or are developing bad habits in regards to how you use your knee and lower extremity.  If you do not pay close attention to how you use your joint and limb post-surgically these patterns often continue to occur even once the source of your pain has been eliminated by the arthroscopic surgery.  The advice from your Physical Therapist at First Choice Physical Therapy is crucial regarding correcting these patterns and developing new, efficient patterns during your daily activities.

Aside from directly rehabilitating the knee after surgery, at First Choice Physical Therapy we also highly recommend maintaining the rest of your body’s fitness with regular exercise while your knee is recovering.  Cardiovascular exercise can begin very early post-surgically.  If you are not yet able to use a normal stationary cycle an upper body bike can be used instead, or your surgeon may approve of you doing gentle aerobic exercises in a pool as an alternative.  A stationary bike, however, is often the best cardiovascular activity once your ranges of motion and pain levels allow it.  Weights for the upper extremities and your other leg are also strongly encouraged.  Advanced exercises such as the stepper or elliptical machines may be used once your knee has recovered to an acceptable level.  Your Physical Therapist at First Choice Physical Therapy can provide a program and advice for you to maintain your general fitness while you recover from your surgery.

Today, the arthroscope is used to perform quite complicated major reconstructive surgery using very small incisions. Remember, however, that just because you have small incisions on the outside, there may be a great deal of healing tissue on the inside of the knee joint.  Recovery may still take several months despite the small surgical incisions healing fairly rapidly.

When you are well under way, regular visits to First Choice Physical Therapy will end.  Your therapist will continue to be a resource for you as your recovery continues, but you will be in charge of doing your exercises as part of an ongoing home program.

Generally the rehabilitation after arthroscopic knee surgery responds very well to the Physical Therapy we provide at First Choice Physical Therapy.  If for some reason, however, your pain continues longer than it should, your range of motion is slow to return, or your general therapy is not progressing as your Physical Therapist would expect, we will ask you to follow-up with your surgeon to confirm that the knee is tolerating the rehabilitation well and to ensure that there are no complications that may be impeding your recovery.

Articular cartilage problems in the knee joint are common. Injured areas, called lesions, often show up as tears or pot holes in the surface of the cartilage. If a tear goes all the way through the cartilage, surgeons call it a full-thickness lesion. When this happens, surgery is usually recommended. However, these operations are challenging. Repair and rehabilitation are difficult. Your surgeon will consider many factors when determining the procedure that’s best for you.

This guide will help you understand:

• what your surgeon hopes to achieve
• what happens during the procedure
• what to expect after surgery

Where is the articular cartilage, and what does it do?

Articular cartilage covers the ends of bones. It has a smooth, slippery surface, which allows the bones of the knee joint to slide over each other without rubbing. This slick surface is designed to minimize pressure and friction as you move.

When the surface of the cartilage is injured, it is usually not painful at first. This is because cartilage tissues are not supplied with nerves. However, any holes or rough spots in the cartilage can throw off the intricate design of the joint. If this happens, the joint can become inflamed and painful. If the injury, or lesion, is large enough, the bone below the cartilage loses protection, and pressure and strain on this unprotected portion of the bone can also become a source of pain. Finally, if the cartilage injury isn’t treated, it may eventually cause other problems in the joint.

Surgeons classify defects in the knee cartilage using a grading scale from I (one) to IV (four). In a grade I tear, the cartilage has a soft spot. Grade II lesions show minor tears in the surface of the cartilage. Grade III lesions have deep crevices. In grade IV lesions, the tear goes all the way to the underlying bone.

The following images show each type of defect

Grade I

Grade II

Grade III

Grade IV

A grade IV lesion goes completely through all layers of the cartilage. It is diagnosed as a full-thickness lesion. Sometimes part of the torn cartilage will break off inside the joint. Since it is no longer attached to the bone, it can begin to move around within the joint, causing even more damage to the surface of the cartilage. Some doctors refer to this unattached piece as a loose body.

Grade IV – All Layers

Cartilage lacks a supply of blood or lymph vessels, which normally nourish other parts of the body. Without a direct supply of nourishment, cartilage is not able to heal itself if it gets injured. If the cartilage is torn all the way down to the bone, however, the blood supply from inside the bone is sometimes enough to start some healing inside the lesion. In cases like this, the body will form a scar in the area using a special type of cartilage called fibrocartilage. Fibrocartilage is a tough, dense, fibrous material that helps fill in the torn part of the cartilage. Yet it’s not an ideal replacement for the smooth, glassy articular cartilage that normally covers the surface of the knee joint.

What does the surgeon hope to accomplish?

Articular cartilage lesions do not always cause symptoms. In fact, surgeons many times happen upon lesions in the knee joint cartilage while doing knee surgery for a completely different problem. Just because there isn’t any pain does not mean the lesion is not causing problems. In general, partially torn lesions do not heal by themselves. And they often get worse over time, not better.

Likewise, full-thickness lesions may not cause any symptoms at first. The fibrocartilage that fills in the injured space often doesn’t match the shape of the joint surface. The body may have problems adapting to the altered shape of the joint, which can eventually even change the way the joint works.

When the lesion causes pain, surgery will most likely be recommended. If the lesion is not causing symptoms, there is less certainty about what to do. Will surgery help? Or could it make the situation worse? In these cases, surgeons will weigh many factors before recommending surgery, such as the patient’s age and lifestyle, the overall condition of the knee, and how bad the lesion actually is.

Even if patients have pain, they may not have surgery right away. Doctors may start by recommending ways to manage the symptoms. This could be as simple as applying heat or ice and taking prescription medication. Often, doctors will recommend patients work with a Physical Therapist. A knee brace or shoe orthotic may be issued to improve knee alignment to ease pressure on the sore knee.

What should I expect before surgery?

Before surgery, your surgeon will need to find out as much as possible about your knee. In addition to your physical exam, you will need more X-rays and possibly other imaging tests, such as magnetic resonance imaging (MRI) and bone scans. Your surgeon may also need to use an arthroscope (discussed later) to check the lesion’s location, size, and depth.

What happens during surgery?

Many types of surgery have been developed for fixing articular cartilage injuries in the knee. When the decision is made to go ahead with surgery, the surgeon will consider whether to do a procedure to restore or to repair the cartilage. A reparative surgery can help fill in the lesion, but it doesn’t completely restore the actual makeup and function of the original cartilage. (Sometimes that simply isn’t possible given the amount of damage in the knee.) Reparative procedures may provide pain relief and improve knee motion and function.

Your surgeon would ideally like to help your knee return to its natural state, with full function and no pain. This requires restorative surgery, meaning that the end result is a lesion filled to the full depth by tissue identical to the original. Surgeons rely on some fairly new procedures to substitute or replace the original cartilage. One method is to transplant cartilage and underlying bone from a nearby area in the knee joint. Another method is to take some chondrocytes (the primary cells of cartilage) from your knee cartilage, grow them in a laboratory, and then use the newly grown tissue to fill in the lesion at a later date.

The final decision about which surgery to use will be based on your specific injury, age, activity level, and the overall condition of your knee.

These procedures are used to stimulate the body to begin healing the injury. They are considered reparative surgeries because the lesion mainly fills in with fibrocartilage.

Arthroscopic Debridement

Surgeons use an arthroscope, a tiny camera inserted into the knee during surgery, to see into the joint and clean up the joint by trimming rough edges of cartilage and removing loose fragments. Sometimes this procedure is referred to as chondroplasty.

It is only intended to be a short-term solution, but it is often successful in relieving symptoms for a few years. This procedure is usually used when the lesion is too large for a grafting type procedure or the patient is older and an artificial knee is planned for the future.

Abrasion Arthroplasty

When osteoarthritis affects a joint, the articular cartilage can wear away, leaving bone rubbing on bone.

This causes the bone to become hard and polished. During arthroscopy the surgeon can use a special instrument known as a burr to perform an abrasion arthroplasty. In this procedure, the surgeon carefully scrapes off the hard, polished bone tissue from the surface of the joint. The scraping action causes a healing response in the bone. In time new blood vessels enter the area and fill it with scar tissue (fibrocartilage) that is like articular cartilage. Fibrocartilage is weaker than normal articular cartilage. Because this is not true articular cartilage, it does not function as well for weight bearing as articular cartilage. The fibrocartilage that forms may not be strong enough to remove all the symptoms of pain in the knee. This usually is a temporary solution. Symptoms may return after this surgery.

Abrasion Arthroplasty

Microfracture

Surgeons use a blunt awl (a tool for making small holes) to poke a few tiny holes in the bone under the cartilage. Like abrasion arthroplasty, this procedure is used to get the layer of bone under the cartilage to produce a healing response. The fresh blood supply starts the healing response and triggers the body to start forming new cartilage (mainly fibrocartilage) inside the lesion.

Microfracture Procedure

In these procedures, tissue is placed inside the lesion in hopes of restoring the normal structure and function of the original cartilage. The stimulation methods and these newer procedures are showing improved results in helping people return to normal activity.

Periosteal and Perichondral Grafting

Experiments have been done to implant tissues from the covering of bone and cartilage into the lesion. Few of these surgeries have actually been done in humans. The results are promising because the cartilage that forms tends to be articular cartilage, rather than fibrocartilage. These procedures are still in the experimental stage, but they could eventually become a way for surgeons to restore articular cartilage.

Autologous Chondrocyte Implantation

This is a new way to help restore the structural makeup of the articular cartilage. Surgeons may recommend this procedure for active, younger patients (20 to 50 years old) when the bone under the lesion hasn’t been badly damaged, and when the size of the lesion is small (less than four centimeters in diameter). A short surgery is scheduled to allow the surgeon to take a few chondrocytes from inside the knee cartilage. These cells are grown in a laboratory. At a later date, the patient returns for a second surgery, during which the surgeon implants the newly grown cartilage into the lesion and covers it with a small flap of tissue. The cover holds the cells in place while they attach themselves to the surrounding cartilage and begin to heal.

Osteochondral Autograft

An autograft is a procedure for grafting tissue from the patient’s own body. The place where the graft is taken is called the donor site. In this case, surgeons graft a small amount of bone (osteo) and cartilage (chondral) from the donor site to put into the lesion. Usually, the donor site for this procedure is on the joint surface of the injured knee. Surgeons are careful to take the graft from a spot that won’t cause a lot of problems, usually on the top and outside border of the knee cartilage. Even then, people sometimes end up with problems around the donor site. The osteochondral autograft procedure has mostly been used to treat osteochondritis dissecans (OCD), a condition where a chunk of the cartilage and the layer of bone beneath have died.

The fragment often gets dislodged and becomes a loose body in the joint. Surgeons have gotten good results with this surgery, but it is challenging to contour the graft to be just the same shape as the covering of the joint.

Osteochondral Allograft

An osteochondral allograft is a lot like the osteochondral autograft described above. But instead of taking tissue from the patient’s donor site, surgeons rely on tissue from another person, much like using donor hearts, kidneys, and other organs. The osteochondral allograft procedure is mostly used for OCD after other surgeries have failed. It is not recommended for patients with osteoarthritis. One of the problems with this kind of procedure is the limited supply of donor tissue. Even though there are technical difficulties with this type of surgery, the success rate is generally high. This procedure usually involves placing rather large pieces of cartilage and bone in the joint. The allograft is usually held in place with metal screws or pins.

Osteochondral Allograft

What might go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following articular cartilage surgery are:

• anesthesia complications
• thrombophlebitis
• infection
• hardware failure
• failure of surgeryAnesthesia Complications

  Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

  Thrombophlebitis (Blood Clots)

  Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible after surgery. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Any time surgery is performed there is a risk of infection. The infection can be only in the skin incision or it can spread deeper to involve the joint. A wound infection that only involves the skin incision is considered a superficial infection. It is less serious and easier to treat than a deeper infection. Surgeons take every precaution to prevent infections. You will probably be given antibiotics right before surgery, especially if bone graft or metal screws or plates will be used for your surgery. This is to help reduce the risk of infection.

If the surgical wound or the joint becomes red, hot, and swollen, and if it does not heal, it may be infected. Infections usually cause increasing pain. You may run a fever and have shaking chills. The wound may ooze clear liquid or yellow pus. The drainage may smell bad.

Contact your surgeon immediately so the wound can be treated and antibiotic medication can be prescribed if necessary. A superficial wound infection can usually be treated with antibiotics (and perhaps removing the skin stitches). Deeper wound infections can be very serious and will probably require additional operations to drain the infection. In the worst cases, any bone graft and metal screws and plates that were used may need to be removed.

Hardware Failure

In many different types of joint operations, metal pins or screws are used as part of the procedure. These metal devices are called hardware. Once the bone heals, the hardware is usually not doing much of anything. Sometimes before the surgery is completely healed the hardware either breaks or moves from its correct position. This is called a hardware failure. Hardware failures may require a second operation to either remove or replace the hardware.

Failure of Surgery

In some cases, surgery doesn’t relieve symptoms in the way the patient expected. In rare cases, surgery can even create new problems in your joints. This is especially true when you are trying an experimental surgery or have a very injured joint.

What happens after surgery?

After surgery, patients go to the post-anesthesia care unit (PACU) for specialized care until they awaken. Then they are either transferred to the nursing unit or released from the hospital. Many of the procedures for treating articular cartilage are done on an outpatient basis, meaning you can leave the hospital the same day.

Since surgeons use different methods when treating articular cartilage lesions in the knee, the instructions patients need to follow after surgery depend on the surgeon and the way the surgery was done.

Portions of this document copyright MMG, LLC

What should I expect during my recovery?

When you begin your Physical Therapy at First Choice Physical Therapy, our first few Physical Therapy treatments are designed to help control the pain and swelling from the surgery. We will also work with you to make sure you only put a safe amount of weight on the affected leg.

With the exception of those who undergo a simple debridement, our patients will be instructed to avoid putting too much weight on their foot when standing or walking for up to six weeks. This gives the area time to heal. Our patients treated with an allograft are often restricted in their weight bearing for up to four months.

We strongly advise you to follow our recommendations about how much weight is safe. You may require a walker or pair of crutches for up to six weeks to avoid putting too much pressure on the joint when you are up and about.

Depending on the type of surgery, our Physical Therapist may have you use a continuous passive motion (CPM) machine to help your knee begin to move and to alleviate joint stiffness. This machine is used after many different types of surgery involving joints and is usually started immediately after surgery. The machine straps to the leg and continuously bends and straightens the joint. This continuous motion has been shown to reduce stiffness, reduce pain, and help the joint surface heal better with less scarring.

Your Physical Therapist will choose exercises to help improve knee motion and to get your muscles toned and active again. At first, we will place emphasis on exercising the knee in positions and movements that don’t strain the healing part of the cartilage. As your program evolves, we will choose more challenging exercises to safely advance the knee’s strength and function.

Ideally, patients will be able to resume their previous lifestyle activities. Some patients may be encouraged to modify their activity choices, especially if an allograft procedure was used.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, ensure safe weight bearing, and improve your strength and range of motion. When your recovery is well under way, regular visits to our office will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

When the anterior cruciate ligament (ACL) in the knee is torn or injured, surgery may be needed to replace it. There are many different ways to do this operation. One is to take a piece of the hamstring tendon from behind the knee and use it in place of the torn ligament. When arranged into three or four strips, the hamstring graft has nearly the same strength as other available grafts used to reconstruct the ACL.

This guide will help you understand:

• what parts of the knee are treated during surgery
• how surgeons perform the operation
• what to expect before and after the procedure

What parts of the knee are involved?

Ligaments are tough bands of tissue that connect the ends of bones together. The ACL is located in the center of the knee joint where it runs from the backside of the femur (thighbone) to the front of the tibia (shinbone).

ACL

The ACL runs through a special notch in the femur called the intercondylar notch and attaches to a special area of the tibia called the tibial spine.

Intercondylar Notch

The hamstrings make up the bulk of the muscles in back of the thigh. The hamstrings are formed by three muscles and their tendons: the semitendinosus, semimembranosus, and biceps femoris. The top of the hamstrings connects to the ischial tuberosity, the small bony projection on the bottom of the pelvis, just below the buttocks. (There is one ischial tuberosity on the left and one on the right.)

Hamstrings

The hamstring muscles run down the back of the thigh. Their tendons cross the knee joint and connect on each side of the tibia. The graft used in ACL reconstruction is taken from the hamstring tendon (semitendinosus) along the inside part of the thigh and knee. Surgeons also commonly include a tendon just next to the semitendinousus, called the gracilis.

Hamstring Tendons Crossing Knee Joint

The hamstrings function by pulling the leg backward and by propelling the body forward while walking or running. This movement is called hip extension. The hamstrings also bend the knees, a motion called knee flexion.

What does the surgeon hope to accomplish?

The main goal of ACL surgery is to keep the tibia from moving too far forward under the femur bone and to get the knee functioning normally again.

There are two grafts commonly used to repair a torn ACL. One is a strip of the patellar tendon below the kneecap. The other is the hamstring tendon graft. For a long time, the patellar tendon was the preferred choice because it is easy to get to, holds well in its new location, and heals fast. One big drawback to grafting the patellar tendon is pain at the front of the knee after surgery. This can be severe enough to prevent any pressure on the knee, such as kneeling.

For this reason, a growing number of surgeons are using grafted tissue from the hamstring tendon. There are no major differences in the final results of these two methods. When it comes to symptoms after surgery, joint strength and stability, and ability to use the knee, either method is good. However, with the hamstring tendon graft, there are generally no problems kneeling and no pain in the front of the knee.

What do I need to know before surgery?

You and your surgeon should make the decision to proceed with surgery together. You need to understand as much about the procedure as possible. If you have concerns or questions, you should talk to your surgeon.

Once you decide on surgery, you need to take several steps. Your surgeon may suggest a complete physical examination by your regular doctor. This exam helps ensure that you are in the best possible condition to undergo the operation.

You may also need to spend time with the Physical Therapist who will be managing your rehabilitation after surgery. This allows you to get a head start on your recovery. One purpose of this preoperative visit is to record a baseline of information. Your therapist will check your current pain levels, your ability to do your activities, and the movement and strength of each knee.

A second purpose of the preoperative visit is to prepare you for surgery. Your therapist will teach you how to walk safely using crutches or a walker. And you’ll begin learning some of the exercises you’ll use during your recovery.

On the day of your surgery, you will probably be admitted to the surgery center early in the morning. You shouldn’t eat or drink anything after midnight the night before.

What happens during the operation?

Most surgeons perform this surgery using an arthroscope, a small fiber-optic TV camera that is used to see and operate inside the joint. Only small incisions are needed during arthroscopy for this procedure. The surgery doesn’t require the surgeon to open the knee joint.

Before surgery you will be placed under either general anesthesia or a type of spinal anesthesia. The surgeon begins the operation by making two small openings into the knee, called portals. These portals are where the arthroscope and surgical tools are placed into the knee. Care is taken to protect the nearby nerves and blood vessels.

An incision is also made along the inside edge of the knee, just over where the hamstring tendons attach to the tibia. Working through this incision, the surgeon takes out the semitendinosus and gracilis tendons. Some surgeons prefer to use only the semitendinosus tendon and do not disrupt the gracilis tendon.

The tendons are arranged into three or four strips, which increases the strength of the graft. The surgeon stiches the strips together to hold them in place.

Tendon Strips

Next, the surgeon prepares the knee to place the graft. The remnants of the original ligament are removed. The intercondylar notch (mentioned earlier) is enlarged so that nothing will rub on the graft. This part of the surgery is referred to as a:

Notchplasty

Once this is done, holes are drilled in the tibia and the femur to place the graft. These holes are placed so that the graft will run between the tibia and femur in the same direction as the original ACL.

The graft is then pulled into position through the drill holes. Screws or staples are used to hold the graft inside the drill holes.

To keep fluid from building up in your knee, the surgeon may place a tube in your knee joint. The portals and skin incisions are then stitched together, completing the surgery.

What can go wrong?

As with all major surgical procedures, complications can occur. This document doesn’t provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following hamstring tendon graft reconstruction of the ACL are:

• anesthesia complications
• thrombophlebitis
• infection
• problems with the graft
• problems at the donor site

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible after surgery. Two other commonly used preventative measures include:

• pressure stockings to keep the blood in the legs moving
• medications that thin the blood and prevent blood clots from forming

Infection

Following surgery, it is possible that the surgical incision can become infected. This will require antibiotics and possibly another surgical procedure to drain the infection.

Problems with the Graft

After surgery, the body attempts to develop a network of blood vessels in the new graft. This process, called revascularization, takes about 12 weeks. The graft is weakest during this time, which means it has a greater chance of stretching or rupturing. A stretched or torn graft can occur if you push yourself too hard during this period of recovery. When revascularization is complete, strength in the graft gradually builds. A second surgery may be needed to replace the graft if it is stretched or torn.

Problems at the Donor Site

Problems can occur at the donor site (the area behind the leg where the hamstring graft was taken from the thigh). A potential drawback of taking out a piece of the hamstring tendon is a loss of hamstring muscle strength.

The main function of the hamstrings is to bend the knee (knee flexion). This motion may be slightly weaker in people who have had a hamstring tendon graft to reconstruct a torn ACL. Some studies, however, indicate that overall strength is not lost because the rest of the hamstring muscle takes over for the weakened area. Even the portion of muscle where the tendon was removed works harder to make up for the loss.

The hamstring muscles sometimes atrophy (shrink) near the spot where the tendon was removed. This may explain why some studies find weakness when the hamstring muscles are tested after this kind of ACL repair. However, the changes seem to mainly occur if both the semitendinosus and gracilis tendons were used. And the weakness is mostly noticed by athletes involved in sports that require deep knee bending. This may include participants in judo, wrestling, and gymnastics. These athletes may want to choose a different method of repair for ACL tears.

The body attempts to heal the donor site by forming scar tissue. This new tissue is not as strong as the original hamstring tendon. Because of this, there is a small chance of tearing the healing tendon, especially if the hamstrings are worked too hard in the early weeks of rehabilitation following surgery.

What should I expect after surgery?

You may use a continuous passive motion (CPM) machine immediately afterward to help the knee begin moving and to alleviate joint stiffness. The machine straps to the leg and continuously bends and straightens the joint. This continuous motion is thought to reduce stiffness, ease pain, and keep extra scar tissue from forming inside the joint. The CPM is often used with a form of cold treatment that circulates cold water through hoses and pads around your knee.

Most ACL surgeries are now done on an outpatient basis. Many patients go home the same day as the surgery. Some patients stay one to two nights in the hospital if necessary. The tube placed in your knee at the end of the surgery is usually removed after 24 hours.

Your surgeon may also have you wear a protective knee brace for a few weeks after surgery. You’ll use crutches for two to four weeks in order to keep your knee safe, but you’ll probably be allowed to put a comfortable amount of weight down while you’re up and walking.

What will my recovery be like?

Patients usually take part in formal Physical Therapy after ACL reconstruction. The first few Physical Therapy treatments are designed to help control the pain and swelling from the surgery. The goal is to help you regain full knee extension as soon as possible.

The Physical Therapist will choose treatments to get the thigh muscles toned and active again. Patients are cautioned about overworking their hamstrings in the first six weeks after surgery. They are often shown how to do isometric exercises for the hamstrings. Isometrics work the muscles but keep the joint in one position.

As the rehabilitation program evolves, more challenging exercises are chosen to safely advance the knee’s strength and function. Specialized balance exercises are used to help the muscles respond quickly and without thinking. This part of treatment is called neuromuscular training. If you need to stop suddenly, your muscles must react with just the right amount of speed, control, and direction. After ACL surgery, this ability doesn’t come back completely without exercise.

Neuromuscular training includes exercises to improve balance, joint control, muscle strength and power, and agility. Agility makes it possible to change directions quickly, go faster or slower, and improve starting and stopping. These are important skills for walking, running, and jumping, and especially for sports performance.

When you get full knee movement, your knee isn’t swelling, and your strength and muscle control are improving, you’ll be able to gradually go back to your work and sport activities. Some surgeons prescribe a functional brace for athletes who intend to return quickly to their sports.

Ideally, you’ll be able to resume your previous lifestyle activities. However, athletes are usually advised to wait at least six months before returning to their sports. Most patients are encouraged to modify their activity choices.

You will probably be involved in a progressive rehabilitation program for four to six months after surgery to ensure the best result from your ACL reconstruction. In the first six weeks following surgery, expect to see the Physical Therapist two to three times a week. If your surgery and rehabilitation go as planned, you may only need to do a home program and see your Physical Therapist every few weeks over the four to six month period.