“Rehab to Avoid Knee Replacement
Although knee replacement outcomes are very good if you can put off needing or avoid getting a knee replacement, that is preferred. Knee replacement longevity outcomes continue to improve but the current knee replacements last on average about 15 years. So what can be done to put off that surgery? Read on.
Goal 1) Improve your knee range of motion (ROM). Knee motion nourishes the joint’s articular cartilage so the greater your motion the greater area of articular cartilage nourished. This means flex (bend) your knee further and extend (straighten) more to stretch the knee capsule and musculature. But if you get bone on bone pain while stretching then stop that stretch. There is no stretching arthritis. Stretch your muscles too especially your quads, hamstrings, calf and iliotibial band.
Goal 2)  Improve your leg strength focusing on your hip abductors, quads and hamstrings and your core, core core. We recommend avoiding unweighted leg extension exercises but rather do weight bearing exercises ie. ½ squats, thrusts, step-ups, leg press, lunges etc. Other good exercises are calf raises, hip abduction exercises and multiple core exercises.
In a nut shell, stay strong, stay flexible, stay active.”

ACL Reconstruction Treatments

Our goal with rehabilitation after knee surgery ACL reconstruction is to restore your strength, stability, range of motion, function and confidence in your knee so that you may return to the activities you enjoy.  Rehabilitation after ACL reconstruction requires dedication, discipline, motivation, trust and patience from you.

Achieving a successful ACL reconstruction is a two-step process.  The first step entails surgery.  Often people have the misconception that this will be the most challenging step for them.  In fact, as the patient, it is the second step that proves to be the most taxing.  That second step is rehabilitation and training.  Your results will correlate with your efforts.

You must understand that each step is equally important and by having ACL reconstruction you have committed yourself to a minimum of three months of rehabilitation after ACL reconstruction.  Using a combination of formal physical therapy, athletic training for strength and conditioning, daily home exercises and visits with The Stone Clinic team, you will optimize your ability to attain your goals and make a strong recovery.  Our goal is to help you become fitter, faster, and stronger than you were before the ACL reconstruction.

Meniscus transplantation for arthritis involves replacing the key shock absorber in the knee joint to provide pain relief.  The meniscus is torn 800,000 times a year in the U.S. alone.  When torn or lost from previous surgery, the ends of the thigh bone, the femur, rub against the top of the shin bone, the tibia.  The increased contact leads to wear of the covering articular cartilage down to the bone.  New techniques developed at The Stone Clinic in San Francisco permit meniscus transplantation for arthritis by combining meniscus transplantation for arthritis with an articular cartilage repair technique called paste grafting.  This combination procedure, performed as an outpatient, arthroscopic technique, permits patients to return to most sports without fear of damaging an artificial joint.  Patients from young teenagers to century runners in their 70’s have come to The Stone Clinic for meniscus transplantation for arthritis to diminish their joint pain.  A recent 2 – 12 year study of these patients demonstrated an 85% survival rate of the meniscus implant in patients with severe arthritis.  Part of the success is due to a novel surgical technique and part is due to a careful rehabilitation program taught to and customized for each patient.  Meniscus transplantation for arthritis is now part of our biologic knee replacement program to help people delay or avoid knee replacement surgery.

Meniscus Transplantation for Arthritis

Meniscus transplantation for arthritis is expanding the indications for meniscus replacement.  The meniscus cartilage, the key shock absorber in the knee joint, was thought to be replaceable only in young, healthy joints.  However, it is older people with arthritis who most often want a new shock absorber to buy time before considering an artificial joint replacement.  Data published by The Stone Clinic in San Francisco has recently shown that the meniscus replacement for arthritis can be successful in arthritic knees.  The 2 – 12 year study of patients with severe arthritis demonstrated improved pain and function for people who underwent the outpatient arthroscopic procedure when it was combined with treatment of the damage articular cartilage.  These findings open up the indications for this technique.  Meniscus transplantation for arthritis is indicated for active people with knee pain due to arthritis and loss of meniscus cartilage, usually with pain on one side of the joint.  The details of the surgery and rehabilitation are found at meniscus transplantation for arthritis.

What you should know about avoiding knee replacement

Avoiding knee replacement is a reachable goal for many patients with arthritis.  Artificial knee replacement usually involves “open” surgery where the ends of the thigh bone and the top of the tibia are removed and replaced with a metal and plastic joint. 

This procedure is highly effective at removing the pain from severe joint arthritis and has survival rates in the ninety percentiles for 15 – 20 years.  However, artificial joint surgery, and avoiding knee replacement specifically, has some significant limitations and complications.  These include joint stiffness, infection, and early loosening.  Patients are often advised to limit most sports to try and increase the survival of the implant since the first avoiding knee replacement has a higher success rate than subsequent revisions due to lowered quality of the bone with aging and wear. Delaying or avoiding artificial knee replacement is particularly desirable amongst our active patients.

Biologic knee replacement is an outpatient, arthroscopic procedure that treats the damaged articular cartilage with a paste graft of stem cells, marrow and cartilage and replaces the damaged meniscus cartilage with a healthy donor meniscus.  The most common request in our practice is “Doc, isn’t there a shock absorber you can put in my knee?”  The meniscus acts as a new shock absorber protecting the repaired articular cartilage. When necessary, ligament reconstruction is combined with the procedures. These combined techniques have been scientifically-proven to help in delaying or avoiding knee replacement.  Patients then participate in an active rehabilitation program to strengthen their muscles, improve their joint motion, and balance and improve their gait so they can return to an active lifestyle while avoiding knee replacement.

Tips for Avoiding Knee Replacement

What you should know about avoiding knee replacement

What are the keys to avoiding knee replacement. Arthritis is the loss of articular cartilage (the weight-bearing surface of the joint) with changes in the underlying bone and surrounding soft tissue.  In the past, when medical therapy failed, arthritis was treated with an artificial knee replacement.  Patients with arthritis often limp, develop loss of joint range of motion, and experience pain and swelling.  Patients with knee injuries and arthritis are often told to rest their knee and wait for their artificial total knee replacement.  Our current advice is quite different.  To diminish the symptoms, we encourage active massage, soft-tissue mobilization, and range of motion exercises in conjunction with ice, glucosamine, joint lubrication injections, and anti-inflammatory medications.  We encourage active exercises such as bicycling, swimming, yoga, and Pilates and combine these exercises with gait training.  Patients are taught healthy nutrition and weight optimization strategies.  To delay  avoiding knee replacement, we can often surgically replace the damaged meniscus cartilage with a new donor meniscus and graft the damaged articular cartilage with a paste of stem cells, marrow, and cartilage; all in a single, outpatient arthroscopic procedure.  By avoiding  knee replacement using biologic methods, patients may be able to continue with sports without fear of loosening an artificial joint.  We have developed the field of biologic joint replacement so that most of our patients with arthritis, from teenagers to 70 year olds, can be highly active and continue avoiding knee replacement.

What you should know about biologic knee replacement

The revolution in knee replacement, now called biologic knee replacement, has been made possible by advances in outpatient surgical techniques that permit simultaneous articular cartilage, meniscus, and ligament repair and biologic knee  replacement. The three-tunnel technique of meniscus replacement developed by Kevin R Stone, MD, at The Stone Clinic in San Francisco secures the new donor meniscus to the tibial plateau in the knee joint, diminishing the chance of subluxation or displacement of the meniscus in the arthritic joint. The stem cell paste graft technique of repairing damaged and arthritic articular cartilage as a single-step, outpatient procedure re-grows a smooth surface where previously dead arthritic bone existed. These two advances permit a biologic knee replacement (soft tissue) approach rather than a bionic or artificial replacement. For more details, see biologic knee surgery replacement

Biologic knee replacement

Biologic knee replacement involves various combination’s of replacing the missing knee joint meniscus cartilage with a donor tissue, repairing or re-growing the damaged articular cartilage… (usually with a stem cell paste graft technique), and replacing the damaged ligaments of the knee.  Biologic knee replacement is preferred over bionic or artificial knee replacement by younger active people who want to delay or avoid total knee replacement.  Our patients have ranged from teenagers to marathon runners in their 70’s and everyday people in between.  The advantage of biologic procedures are that they can be performed as an outpatient, arthroscopic procedure as opposed to the inpatient, open surgical procedures that artificial joint replacement requires.  Biologic procedures can be easily revised if re-injured and permit most sports.  Further details of biologic knee replacement are posted at www.stoneclinic.com

Meniscus transplantation for arthritis; what you should know

Summary: Meniscal replacement by allograft is increasingly common in our practice. In order to succeed, a replacement must duplicate the mechanical function of the original meniscal cartilage. The technique of replacement described in this article permits minimal disruption of the joint tissues, accurate placement of the meniscal horns, and secure fixation of the meniscal synovial junction…

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“Meniscus Transplantation for Arthritis” – Meniscal cartilage replacement by allograft, prosthesis, and regeneration scaffolds has advanced from the laboratory to clinical practice (1-5). To facilitate meniscal cartilage replacement, specific instruments and techniques have been developed to ensure accurate and reproducible placement of the meniscal implants. For meniscal cartilage replacement to succeed, the following goals must be accomplished:

1. The torn fragmented pieces of native meniscal cartilage must be removed.
2. The attachment sites for the meniscal horns must be anatomically placed.
3. The periphery of the meniscal implant must be attached securely enough to permit axial and rotational loads.
4. The surrounding capsule and ligaments of the knee joint must be neither excessively violated nor constrained by the fixation technique.

To achieve these goals, the following steps are recommended. Initially, complete diagnostic arthroscopy of the knee joint is accomplished in the routine fashion. If anterior cruciate ligament surgery is to be performed simultaneously, the femoral and tibial tunnels for the cruciate reconstruction should be drilled first.

The torn portion of the meniscal cartilage is evaluated. If meniscal repair cannot be accomplished due to severity of the tear or poor quality of the tissue, then preparation of the meniscal rim is undertaken by removing the torn portions of the cartilaginous tissue (Fig. 1). In the setting of allograft replacement, nearly all of the remaining meniscus is removed. Additionally, for allograft replacement, resection of the meniscal horns and preparation of bony tunnels to accept bone plugs may be required. In the setting of scaffold replacement, only the damaged portions are removed, preserving the peripheral rim and horns for attachment of the scaffold. If absolutely no meniscal rim is present, then meniscal scaffolding should not be performed. If the joint is excessively tight, a joint distractor may be applied or the medial collateral ligament may be partially released.

For medial or lateral meniscal replacement, place the arthroscope in the mid-lateral or anterior lateral portal and the tibial guide through the anterior medial portal. The tip of guide is brought first to the posterior horn of the meniscus. It should be noted that the posteromedial horn inserts on the posterior slope of the tibial eminence. A drill pin is then brought from the anterior medial side of the tibial tuberosity to the posterior horn insertion (Fig. 2).

The pin placement can be confirmed by passing the arthroscope through the intercondylar notch and viewing the exit site of the pin. Extreme care must be undertaken to avoid penetration through the posterior capsule of the knee, endangering the neurovascular bundle. When the pin position is confirmed, the pin is then over-drilled with a 4.5-mm cannulated drill bit with the option of a drill stop to prevent posterior capsular penetration (Fig. 3). The bit is left in place and used as a tunnel to pass a suture passer with a #2 Ethibond (Johnson & Johnson) suture. The suture is passed up the bore of the drill bit, the drill bit removed, and the suture left in place.

Attention is now turned to the anterior drill hole. For the medial meniscus, it must be noted that the anterior medial meniscus insertion varies considerably. Most often it can be found anterior to the medial tibial eminence. The anterior horn of the lateral meniscus inserts just posterior to the ACL. Identify this insertion and place the tip of the drill guide so that a relatively vertical hole will be made (Fig. 4). Place the drill pin, then overdrill with the cannulated drill bit, and place the suture passer. Alternatively, the anterior horn of the medial meniscus may be affixed with a suture anchor directly to bone.

Before grasping the suture from the anterior and posterior drill holes, widen the anterior portal to approximately 2 cm. The suture grasper should then be passed through the widened portal, and both the anterior and the posterior sutures brought out simultaneously. This technique prevents the sutures becoming entangled in two different planes of the fat pad and capsular tissue. The importance of this step cannot be overstated; occasionally the posterior suture will pass through one tissue plane, and the anterior through another plane, causing the implant to become stuck in the soft tissues.

The implant is now brought onto the field. Two horizontal mattress sutures of #2-0 ethibond are placed through each horn of the implant with the free ends exiting the inferior surface (Fig. 5).

The two posterior sutures are then drawn through the knee and out the posterior tibial tunnel (Fig. 6). If viewing from a mid-lateral portal, the anterolateral portal can be used for probe insertion to push the implant medially into place through a 1-inch incision. No insertion cannula is required. The anterior sutures are then similarly passed. The horn sutures are then tied over the anterior tibial bony bridge.

Next, zone specific meniscal repair cannulae are brought into place. For medial insertions, a series of small puncture incisions are used to retrieve the sutures Through these multiple small incisions, the suture needles can be captured and the knots placed directly over the capsule (Fig. 7). Although nonabsorbable suture is used for the meniscal horns for added strength, absorbable suture [2-0 polydioxone (PDS)] is recommended for the body of the scaffold. The smooth monofilament is less abrasive and resorbs as the scaffold is metabolized.

When using the meniscal repair needles, the posterior cannulae should be used first, with the sutures placed vertically and evenly spaced. Progress from posterior to anterior so that a buckle is not produced within the implant. Tie each knot as it is placed to avoid the chance of suture tangling. Space the knots approximately 4 mm apart. Cycle the knee through several complete ranges of motion to ensure that the implant moves smoothly without impingement.

When performing a lateral meniscal replacement (Meniscus Transplantation for Arthritis) , we now preserve a bone bridge between the horns of the meniscus and create a trough to secure it on the tibial plateau. The remainder of the insertion technique remains the same, except that great care should be taken to protect the neurovascular bundle when suturing the posterior horn.  We prefer suture knot tying through small puncture holes rather than open posterior lateral or medial incisions.

Routine skin closure and dressings are applied. Thirty milliliters of 0.5% Marcaine (Astra) with epinephrine mixed with 30 cc of lidocaine are always instilled for immediate post operative pain relief in regards to meniscus transplantation for arthritis.