Too active for a total knee replacement

This gentleman had a torn anterior cruciate ligament and had also sustained significant damage to the one condyle (rounded end) of his femur.

This patient represents a fairly common scenario where you have some who chronologically is no longer 20 but biologically still extremely active! In fact he is in his 60s and semi-retired!

He ruptured his ACL 17 years previously playing football and was managed conservatively, that is he did not have reconstructive surgery for the ACL.

Pain was his main problem for seeking help now, although he also had some quite significant instability issues with giving way approximately once per day and crepitus. If he sat in his car for a long time, the knee would become very painful. He used to be extremely active until very recently, playing squash 2-3 times per week and skiing once or twice per year, but now he was walking was with a limp and said he would not be able to walk 18 holes of golf. He would have to hold the railing on coming down the stairs. At rest there was no pain, but he would wake approximately once per week with night pain. Pain was managed with ibuprofen.

His main concern with asking for help was that he wanted to continue to be active and in particular to enjoy his sport.

His x-rays were really quite impressive with severe grade IV bone-on-bone arthritis in the medial compartment of his knee, and many years before he had sustained an ACL rupture which had started the natural progression towards this common scenario.

I was impressed by the amount of activity that he could still do but he was limited and couldn’t do any type of running, pivoting sports or engage himself in the activities that he really enjoyed such as skiing and squash.

Currently if someone presents in their 60s to an orthopaedic surgeon with this type of arthritic picture the options are often very limited in terms of what the patient is offered, and many surgeons would just suggest a total knee replacement. This quite frankly would be a disaster for this patient as he doesn’t fulfil the criteria for someone who would do well with a total knee replacement because of his level of activity prior to surgery and his desire to continue to be active. Total knee replacement surgery really is the last option available and should only be used in appropriate patients where we can’t do joint preserving surgery.

In Paul’s case there were two issues, one was the arthritis and the other was the lack of the ACL. To give him the best option I felt partial knee replacement surgery was the way to go but because of the ACL deficiency I needed to provide him with an ACL as well. So having had discussions we decided to go down the route of this combined and complicated surgery of ACL reconstruction and medial partial knee resurfacing.

I am delighted to say that I have just signed Paul off and he is 12 months out having a really fantastic result. He walks miles without pain and has got back to a very high level of activity. He is about to book his skiing holiday and felt so strong and so good that he asked permission to return to squash which of course I granted!

It’s a good example of how with modern technology and modern procedures we really can achieve a very high level of function in a situation where we have been very limited before in terms of what we can offer. My mantra is all about joint preservation and Paul really epitomises how far we can take that and the success that we can achieve.

The procedure went well, and rehabilitation has left him eager to restart his sports and he has even returned to squash !!

adrian wilson

Prof Wilson

"When you get older but are still very active, then it is important to look for alternatives to total knee replacement".

What is the difference between a total knee replacement and a partial (or unicompartmental) one?

knee compartment

The blue circle defines the medial 'compartment' - where the bones of femur and tibia articulate via the rounded condyle. Similarly on the other side is the lateral compartment. In a total knee replacement both compartments are replaced at once with a large implant. In a partial knee replacement, only the one side is replaced.

Jigs are used to cut away only that amount of bone on both sides to accommodate the implant. The meniscus is discarded and its function replaced by the implants.

The video below gives the details of the procedure. Note that the details are pretty graphic and if you are squeamish then perhaps it is best not to watch.

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