Back to tennis after meniscal transplant

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Andrew has been happy to offer the benefit of his personal experience with a distal femoral osteotomy combined with a meniscal transplant.

Andrew had a valgus knee and a destroyed meniscus. To straighten a knee that is sitting in a 'knocked' (or valgus) position 80% of the time we correct on the femur, and that is why we carried out a femoral - as opposed to a tibial - osteotomy. For many years, the preferred approach was to make a single cut on the outer aspect of the bone and open the bone - in other words to do an 'opening-wedge' osteotomy - but more recently we have favoured the 'closing-wedge' technique in the femur. This is because the femur bone is so big and the opening wedge can take a long time to heal. So by taking out a wedge of bone and doing the closing wedge we get bone-on-bone contact and early healing, and this is preferable in the femur, we feel.

He also had a lateral meniscal deficiency and he wanted to continue playing sport. I felt that the best way forward was to give him a new meniscus. So he underwent the combined osteotomy with a lateral meniscal transplant and - as I had hoped - was able to get back to sport, including tennis.

There's no real age criteria for the osteotomy - and in fact there are some very good studies from Japan showing fantastic results in individuals in their eighties! A study comparing the outcome of over- and under-70s showed in that particular group that the over-70s did better.There's no real waiting time for such a procedure privately but the NHS patients really need to seek out the right surgeon who carries out this type of complex knee surgery.The transplantation is fairly routine now. Sadly, many consultants in the UK still consider it to be experimental with poor evidence, but in fact meniscal transplantation has been undertaken now for two decades with the best series from Renee Verdonk in Belgium who has excellent 20-year results. It is very commonly performed on the Continent and also in the States, but sadly less commonly in the UK and this mainly comes down to teaching and experience.

The transplantation is done through a keyhole procedure. Prior to surgery, the patients are all matched according to their MRI scan, so the meniscal allograft tissue is matched so that it is within a millimetre of the original dimensions. These are generally speaking obtained in the States as the UK tissue bank is fairly limited. The meniscus is then frozen, and at the time of surgery thawed out and prepared on the back operating table where we put sutures into the front and back attachment area. Then - using a keyhole procedure - we make tiny tunnels towards the back and the front of the knee where the main attachment point lies of the front and the back of the native meniscus, and we pass our sutures which we then retrieve through the keyhole and pull the meniscus in and down into position through the tunnels that we have created. We then fix the sutures at the front of the shin bone with tiny screws which are made of plastic. The meniscus itself is then stitched from the back to the front using a combination of so-called all-inside smart devices which allow us to do this via a keyhole technique. Then towards the front of the meniscus we use needles which we retrieve through a small incision and that allows us to stitch the meniscus in this way.

Patients are taken fairly slowly post-operatively with just 'egg-shell' weight bearing - in other words very limited weight bearing for six weeks, and we restrict the range of motion in a brace, limiting the range from straight to just 30 degrees for two weeks and then we open the brace so that the bend is to 60 degrees for a further two weeks, and finally unlock it so that the patients can bend to 90 degrees. Patients need to continue with the brace for up to three months. Patients get back to walking normally and generally speaking have very significant pain reduction, and are often pain free, having been in severe pain prior to surgery. They also have a much greater feeling of stability of the knee, because the meniscus itself is an important stabilising structure, and the knee feels 'normal' once more.Gentle sport is possible such as social tennis and skiing, but we don't encourage contact sports. Long term we would hope to see 10 - if not 20 - years of benefit from a meniscal transplant.It is a great operation and, done in the right patients for the right indications, a very good outcome can be achieved in the vast majority of patients. Andrew is such an example and has done very well with this surgery which was carried out five years ago.

adrian wilson

Adrian Wilson


Testimonial from patient, Andrew...

"I was referred to Prof Wilson after continued problems with my right knee after having my cartilage removed when I was seventeen. After years of pain and various ops to try and remedy it was suggested I have a new knee.

"On meeting Prof Wilson he persuaded me to have an osteotomy and meniscus transplant the age of 52. This was really my last chance saloon. However my expectations were not high as I had had so many promises before. However a knee replacement was a worse thought as I knew that they would probably need to re do in 10 years or so.

"Although the surgery was quite painful it was the rehab that took much longer than I thought it would. However within six months I was back on my bike and at last playing tennis again. For the first time in ages i was able to do lateral movements pain free and with no after effects like inflammation. I can therefore play all the sports I want, but would say that you have to continually do rehab to keep the knee strong. Swimming is the best medicine.

Expectations have been exceeded! Anyone thinking of doing this and providing you are reasonably fit, I would go ahead.

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