Phase 1: Recovery from surgery

The initial post-operative phase usually lasts the first 6 weeks. The main priorities during this period are to control inflammation and swelling.A key part of the operation is the postoperative care and there are many factors to be considered during rehabilitation after meniscal transplant.  Movement and function have to be balanced against allowing the meniscus to heal in place.

Weight Bearing

You will be taught how to use elbow crutches before you leave hospital. You should use these to help you to be non-weight bearing for the first 4 weeks after surgery. You must not put any weight through you operated leg until after 4 weeks from your operation as guided by your consultant.

When you are standing at rest e.g. cleaning your teeth, making food/drink you may rest your foot on the floor – however you must still not take any weight through your operated leg.

Knee Bending

For the first 6 weeks bending is limited to 90 degrees. Beyond that will compromise healing of the graft.

Bracing

After meniscal transplant surgery you will be fitted with a brace to help limit your range of movement and also provide you with some support. The brace should be worn day and night for the first two weeks after surgery (it can be removed for washing and dressing). After this two week period the brace can be removed at night to sleep.

A functional brace will be issued at 4 weeks post-operatively which has offloading feature to help protect the new meniscus. Once fitted with this DJO OA Nano brace it is acceptable to begin partial weight bearing through the operated leg (50% of your weight). , The aim is to progress to full weight bearing by 6 weeks after your surgery.

Ice Treatment

Ice treatment after your surgery is very important, aiming to keep the swelling of your knee under control. You should use an ice pack or Cryocuff (ICEMAN) on your knee for 30-45 minutes every two hours during the day for the first 7-10 days after your operation.

It is expected that your knee will continue to swell for up to 3 months after your surgery, and icing helps reduce that swelling.

Elevation

During the first phase of your rehabilitation you should aim to be resting your operated leg for most of the time. Your knee should be elevated with leg straight and your ankle raised above your hip. This helps to keep the swelling under control in your knee.

Numbness

Patients often describe an area of numbness around the operation site. This is not unusual as the small skin nerves are cut in the operation. Moderate symptoms of numbness and tingling around the knee are common. However if you are concerned or these symptoms worsen please advise your physiotherapist.

Excercises

The success of your surgery will be in a large part due to the amount of effort you are willing to invest into your own rehabilitation. Although you are likely to be in some discomfort after your surgery it is vital you start to complete the exercises below to regain movement and activate muscles after your operation. A physiotherapist will teach you these exercises prior to your discharge home.

Range of Movement

Knee flexion

Sitting on a firm surface, gently bend your knee. Slide your heel towards your buttocks. You may find it easier to do this with a plastic bag under your heel. Do this 10 times. Repeat up to 5 times daily.

Remember not to push flexion beyond 90 degrees for the first 6 weeks.

Knee extension

Sit with a rolled towel under your ankle without anything underneath your knee. Allow gravity to help to passively stretch your knee. Start this for 2 mins and gradually build up as your pain allows. Repeat 5 times daily.

It is very important to regain full straightening of your knee in the first 6 weeks.

Strengthening

Static Quadriceps

Sit or lie with leg out straight, tighten your thigh muscles and push knee down firmly against the bed. Hold and for 5 secs. Repeat 10 times.

Don’t be tempted to do exercises that bend the knee while not supported on the bed, otherwise this puts high load on the graft.

Static Hamstrings

Sit on bed or floor, bend your knee slightly, then push your heel into the bed keeping knee slightly bent. Hold for 5 secs. Repeat 10 times.

Stretching

Calf stretches

Standing with support facing a wall. Keeping one leg forward, foot flat on the floor, extend your opposite leg straight backwards placing your heel flat on the floor. Try to keep your back knee straight and gently bend the front knee. Lean in towards the wall until you feel a stretch in your back calf. Hold for 30 seconds, repeat 3 times on each leg.

Hamstring stretches

Sitting on a firm surface, with both legs out straight in front of you. Try to ensure both legs are as straight as possible. Lean forwards trying to reach your toes. Hold for 30 seconds. Repeat 3 times.

Muscle Stimulation

After surgery some patients initially struggle to regain good quadriceps control and activation. You may be issued with a muscle stimulation device to help with this. It is advisable to use this as per your physiotherapists’ guidance. It is at your consultant and physiotherapists discretion if you will require this device as part of the rehabilitation program.

Criteria for progression to Phase 2:

• Full extension to 0 degrees

• 90 degrees flexion

• Minimal swelling

• Minimal pain

• Straight Leg Raise without lag

Phase 3: End stage rehabilitation and return to appropriate activity (approx. 4–6 months after surgery)

Continued Strengthening

All major muscle groups of the core and lower limb will need to be strengthened further. Large deficits in individual muscle groups can have a significant effect on functional ability and your eventual return to function. Effectively you are only as good as the weakest link in the chain. Our aim is that each patient should be assessed individually to identify the specific areas of weakness needing to be addressed.

There also needs to be a balance of the types of exercises undertaken. Exercises such as squats and lunges work the muscles hard, but they also put a high degree of force through the joint and meniscus, which is not advisable e.g. Deep squatting >90degrees, high weight leg press. There needs to be a balance of continued endurance and strength training.

Functional Movement Retraining

Good movement patterns will need to be retrained and practiced to help maximise the life of the new meniscus as well as ability to return to functional goals. This is all about trying to make the muscles work well together as a team. Muscles are your shock absorbers.

Poorly controlled and co‐ordinated movements when stood still, and then when moving will potentially put excessive load through the knee and meniscus. Return to sport and function will then have a higher risk of failure, e.g. When bending on one leg your knee should stay in line with your second toe, and your pelvis level and straight. This pattern will be perpetuated through functional return unless trained otherwise. This is similar to the skills training done in all sports to maximise ability. This stage takes time and practice: it is about quality of movement, not number of repetitions. Some movement patterns may have been present for a long time and will feel automatic and normal, although they are not ideal, and should be trained out with focussed work.

Low load safe guarded return to sport

Aim for progression through increasing level of skills and drills as strength and movement patterns progress. It is imperative this is patient specific and depends on goals for return to activity. This is the vital last piece of the jigsaw. If muscles of the lower limb are not used in a safe co-ordinated way then the hard work of rehabilitation to this point will not be best put in to practice.

The table below illustrates the characteristics of sports we feel should be avoided following meniscal transplant. Discussions should be had at twelve months following transplant surgery to finalise end stage goals. These goals will be dependent on a number of factors including state of the meniscus and joint surfaces of the knee at this stage.

High Risk Sports

• Repetitive impact with cutting and pivoting

• Contact sport

• Competitive situation

• Playing position on field

Low Risk Sports

• Aerobic low impact sports

• Moderate sports participation

• Non-contact sports

• Cycling

A note from your Consultant**

Meniscal Transplant (MT) surgery has been performed for over 20 years worldwide, it is no longer experimental and is  available option in patients who no longer have a functional meniscus.  Patients who  have concurrent ligamentous injury or mechanical malalignment (knocknees or bowleggedness) may need additional procedures. Your surgeon will discuss with you the importance of correcting these together with the meniscal transplantion procedure.

Meniscal transplantation is an exciting option to improve symptoms in the knee due to lack of the cushioning effect of the Meniscus. As a donor graft tissue from someone else it cannot be considered normal and we remind you that the aim is to buy time for the knee – improving your function and enjoyable activity level, and maybe preserving the joint.

You are clearly part of the process. As surgeons we have half the job and the other half is down to you and the physio, hence the detail in this rehab guide.

It takes a year or so for the knee to fully mature after this surgery and your help is needed in buying into this concept of preserving your knee. We have had many successes and a few less successful results. We wish you all the best in your recovery

Lastly we ask that you will be part of our Surgery Outcome Program, responding to our questionnaires documenting your progress. This helps us optimise treatment for you and others.

— Iswadi Damasena