I am one of only a few UK trauma and orthopaedic surgeons specialising in cutting edge, minimally invasive, custom made (bespoke) knee surgery.
Please note that Mr Ghoz's advice is based on his experience and the experience he has gained throughout his training and career based on experts opinions.
Bespoke Knee Bespoke Knee - Short Version
Knee Replacement Surgery
Knee Arthritis & Stem Cells PRP or ACP
Knee Cap (Patellar) Problems & Instability
Anterior Cruciate Ligament Injury
Seen by physiotherapist 1 week post surgery
- Eliminate swelling/inflammation
- Adequate analgesia
- Regain active quads and VMO control
- Be able to perform SLR with no lag
- Restore patella mobility
- Maintain full hyperextension
- Restore normal gait pattern
- At least 90 degrees knee flexion
- Patient confident with rehab process and goals
- Patient education regarding rehabilitation
- Patella mobilisations
- Maintain 0-90 ROM
- Quad strengthening- Closed chain- mini squats
- Hamstring/ glut strengthening- Closed chain- Shoulder bridges (double leg)
- Hamstring stretches, inc prone knee hangs
- Calf raises (bilateral)
- Hip Abduction/Extension, +/- theraband
- Gait re-education, progress to FWB
- Seen at 2 weeks for removal of clips
- Wean off crutches if not done so already
- Eliminate any remaining swelling
- Maintain full hyperextension
- Gradual increase of knee flexion to full
- Restore proprioception/ neuromuscular control, without torsional forces
- Gradual return to normal ADLs
- Return to driving when safe
- Short haul flights if essential
- Remove clips
- Advice on scar massage
- Continue to strengthen quads- Wall squats, step ups/ step downs
- Progress shoulder bridges onto gym ball/ single leg
- Progress calf raises to single leg
- Address any trunk / pelvic muscle imbalance
- Proprioceptive re-ed: rope walking, heel/toe walking
- Static bike
- Week 6- ACL clinic appointment, X-ray on arrival
- Swimming, but no breastroke until 3 months
- Free cycling
- Full squat
- Unrestricted walking
- Progress single leg strength
- Progress proprioception wobble board, trampette, reaching out of base of support
- Jogging on trampette with no pain/swelling
- Hopping without pain or swelling
- Maintain flexibility
- Note: Exercise will progress during this stage, but the graft is at its greatest risk of failure during this stage as it is going through the process of revascularisation and ligamentisation.
- Single leg squats
- Single leg sit to stand
- Wii fit
- Jogging on trampette
- Plyometrics- Progress from double leg to single leg
- Can begin free cycling
- Can return to golf 10-12 weeks
- Open chain tibial rotation exercises
- Able to fly long and short haul if necessary
- Week 12- ACL clinic appointment
Can return to physically active job
- Enhance lower limb confidence and function
- Increase functional activities and endurance/general fitness
- Maintain motivation
- Able to hop and jump with good control and no exacerbation of symptoms
- Able to walk 15 mins everyday pain free with no swelling immediately after and the next morning
- Start running and gentle sport specific training
- Progress plyometric work
- Quick feet
- Pivoting exercises/ figure of 8
- Gentle sport specific exercises
- Increase speed of balance reactions and improve coordination
- Advice about returning to chosen sport and exercises to continue with
- Prepare physical and psychological ability to complete return to sporting activity
- Progress sport specific exercises and drills
- Shuttle runs
- Changes of direction at speed
- Work on slopes (inclined bench- up, down, sideways, gradually increase speed and angle)
- Work to fatigue point
- Increase sport specific training gradually. Non competitive
6 Months- Return to sport
- Return to training for chosen sport and may have started to integrate into competitive game.
- Advise 3 months training prior to full competition to retrieve skill levels and regain confidence
- Emphasise importance of warm up and cool down.
The Anterior Cruciate Ligament (ACL) is a ligament that connects the tibia (lower leg) to the femur (thigh). It helps to keep your knee stable.
The ACL may be stretched, partially or fully ruptured. A stretched or partially torn ligament maybe repaired or augmented with a graft.
A fully torn ACL is replaced using a graft either from your hamstring tendons or patella tendon attached from your kneecap to the tibia (shin bone).
If you have your ACL reconstructed using your hamstring tendons, the graft is made by taking your Semi-tendinosis, and Gracilis tendons. A long piece of each tendon is removed before being folded and braided to produce a quadruple thick strand. The new tendon graft is fixed by an anchor to the femur and a screw to the tibia stabilising the knee joint. Alternatively, a strip of tendon is taken from the tendon joining your patella (kneecap) and tibia, with small blocks of bone either side.
It takes about 6 months for the new ligament to incorporate and gain full strength. The graft is at its most vulnerable during the first 3 months.
Physiotherapy exercises and advice post operatively is extremely important in achieving the best outcome following the operation. There is a risk that you can re-tear the ligament if you don’t follow the advice.
After the operation
- You will wake up with your knee in a bandage
- Your leg may feel numb following surgery, as often an injection of local anaesthetic is given near to the nerves which go to your leg (a nerve block) to help with pain relief. You may also find that you are unable to move the leg properly and the leg will not be able to support you when standing. It is very important that you do not attempt to get up on your own and await instruction from a Nurse or Physiotherapist.
- The Nurse or Physiotherapist may apply ice to the knee for swelling once you return to the ward \
- You may be given a knee brace, which is to be worn when walking. You may remove your brace for your exercises and normally when in bed at night, but this will be confirmed.
- After the surgery you will be shown how to walk on your crutches by the Physiotherapist, and practice stairs if necessary prior to discharge. Crutches are used for about 2-3 weeks as guided by your Physiotherapist. You are normally allowed to fully weight-bear with the help of the elbow crutches, however sometimes there are restrictions on weight bearing and you will be advised of this.
Following this technique to ensure it is comfortable and safe when using your stairs.
- Crutches to the step below
- Operated leg joins the crutch
- Un-operated leg completes the step
- Un-operated leg goes up first
- Operated leg then follows
- Crutches last to join
The Physiotherapist will show you how to perform the following exercises before discharge and an outpatient physiotherapy appointment will be arranged for your exercises to be progressed.
Move your feet up and down regularly to keep the circulation moving, as soon as you can after the operation
Do these exercises hourly for the first few days.
Lying or sitting with your leg out in front.
Slide your feet towards your bottom, keeping your heel in contact with the bed/floor.
Bend as far as comfortable up until 90 degrees, don’t force it.
(Note: be careful when you move your knee from a 30o bend to straight as this can stretch the new graft).
Repeat this 10x 3 x a day.
With your leg straight out in front.
Push your knee down into the bed,
straightening it as much as possible (don’t force it).
Hold for 10 seconds.
Repeat 10x 3x a day.
Sitting with your leg out in front of you.
At varying angles of bend in the knee, try pressing your heel down into the bed without moving the knee joint (i.e. to create a contraction of the hamstring muscle in the back of your thigh).
Hold for 10 seconds.
Repeat 10 times
Lie on your back. Gently squeeze both buttocks together
Hold for 10 seconds.
Repeat 10 times 3 x a day
Stand holding onto support for balance.
Push up onto your toes.
Repeat up to 20x 3x/day.
This exercise start normally from week 2 after your operation
Things to remember:
It is very normal for your knee to swell initially following surgery. If the knee is swollen you can try the following to reduce it:
Sitting with your leg up on a stool or raised up high on pillows.
Apply ice or a cold compress – such as a bag of frozen peas – wrapped in a damp tea towel. Apply for 10-15 minutes maximum 3-4 times a day.
People who are known to have circulation problems or have sensory deficits will need to seek advice from your Physiotherapist or Consultant before using ice therapy.
Never apply ice directly to the skin as ice burns may occur, always have a layer between your skin and the ice.
Pivoting/turning/twisting on a loaded leg for 3 months
Squats/lunges for 3 months
Resistance work, including cycling for 6 weeks
Fully straightening your leg from the last 30 degrees without the support of your other leg.
You can normally return to driving normally at about 3-4 weeks post-operatively, provided you feel confident to do so. You must have good muscle control, be able to walk well without crutches and be able to do an emergency stop safely.
Returning to Work
This is largely dependent on the type of job you do. Normally it is about 2 weeks for non-manual jobs, but longer for manual jobs. Please be guided by your Physiotherapist and Consultant.
Swimming – You can go in the pool once your wound has completely healed, just to walk forwards and backwards. No actual swimming should be carried out for 8-12 weeks.
Running – Usually not for the first 12 weeks – as guided by your Physiotherapist.
Sport – Normally not for 6 months and no competitive or contact sports for the first 9 months. You will be guided by your Physiotherapist or Consultant.