Relieving pain and restoring function with personalised, evidence-based knee replacement surgery.

Knee Replacement – Key Points

• Knee replacement is used to treat advanced arthritis causing significant pain and reduced quality of life
• It is considered when non-operative treatments are no longer effective
• Options include partial and total knee replacement, depending on the pattern of arthritis
• Partial knee replacement can offer faster recovery and more natural movement in selected patients
• Most knee replacements last 15–20 years or longer
• Recovery typically takes 3 months for daily activities and up to 12 months for full recovery

What is a knee replacement?

A knee replacement is a surgical procedure in which the damaged surfaces of the knee joint are replaced with artificial components made of metal and plastic.

It is most commonly performed for osteoarthritis, which causes pain, swelling, stiffness, and reduced function.

Why might you need a knee replacement?

Common causes include:

• Osteoarthritis – the most common cause
• Rheumatoid arthritis – inflammatory joint damage
• Post-traumatic arthritis – following previous injury

Knee replacement is usually considered when:

• Pain significantly affects your quality of life
• Walking, stairs, or daily activities are difficult
• Non-surgical treatments have not provided sufficient relief

Non-surgical treatment (first-line management)

Before considering surgery, all patients should undergo appropriate non-operative treatment in line with NICE guidance.

This includes:

• Physiotherapy and exercise (strengthening and aerobic fitness)
• Weight management (even small reductions can improve symptoms)
• Pain relief (topical or oral anti-inflammatories where appropriate)
• Walking aids (e.g. stick)
• Steroid injections (short-term relief in selected cases)

These measures can significantly improve symptoms and may delay or avoid the need for surgery.

Types of knee replacement

Total Knee Replacement (TKR)

Used when arthritis affects most or all of the knee.

• Replaces the entire joint surface
• Provides reliable pain relief and function
• Best option for widespread arthritis

Partial Knee Replacement (PKR)

Suitable when arthritis affects only one part of the knee (most commonly the inner side).

Benefits of partial knee replacement:

• More natural feeling knee
• Better range of movement
• Faster recovery and return to activities
• Lower risk of major medical complications
• Reduced need for blood transfusion
• Higher patient satisfaction in some studies

Considerations:

• Slightly higher lifetime risk of needing further surgery compared to total knee replacement

Patellofemoral Knee Replacement

A form of partial knee replacement used for isolated arthritis under the kneecap.

• Smaller operation than total knee replacement
• Faster recovery
• Requires careful patient selection

Partial vs Total Knee Replacement

If you have arthritis in only one part of the knee, both options may be discussed.

• Partial knee replacement prioritises quicker recovery and more natural movement
• Total knee replacement offers durability and treats the whole joint

The choice depends on:

• The pattern of arthritis
• Your symptoms and expectations
• Your priorities and lifestyle

Benefits of knee replacement

• Pain relief – often significant improvement in pain
• Improved mobility – walking, stairs, and daily activities become easier
• Improved quality of life
• Correction of deformity and alignment
• Long-term durability – most implants last 15–20 years or longer

Risks of knee replacement

Knee replacement is generally very successful, but potential risks include:

• Infection
• Blood clots (DVT or pulmonary embolism)
• Bleeding or need for transfusion
• Implant-related problems (loosening, wear)
• Stiffness or reduced movement
• Nerve or blood vessel injury (rare)
• Persistent pain
• Fracture around the implant
• Anaesthetic or medical complications

These risks are uncommon and will be discussed in detail based on your individual health and circumstances.

The day of surgery

Knee replacement is typically performed as a planned procedure.

• You will arrive a few hours before surgery
• You will meet your surgeon and anaesthetist
• Surgery usually takes 1–2 hours
• Anaesthesia may be general or spinal

After surgery:

• You will be monitored in recovery
• Pain relief will be provided
• Physiotherapy usually begins the same day or next day

Recovery and rehabilitation

Recovery is gradual and structured.

Early phase (0–2 weeks)

• Walking with crutches or a frame
• Pain and swelling management
• Early physiotherapy exercises

Intermediate phase (3–6 weeks)

• Increasing walking distance
• Improving movement and strength
• Transition away from walking aids

Later recovery (6–12 weeks)

• Return to most daily activities
• Driving (typically 4–8 weeks)
• Return to work depending on job type

Long-term (3–12 months)

• Continued strengthening
• Return to low-impact activities (e.g. cycling, swimming, golf)
• Ongoing improvement in strength and function

Long-term outcomes

• Most patients experience significant pain relief and improved function
• Implants typically last 15–20 years or longer
• The risk of needing revision surgery is approximately 2.5–3% at 10 years

Maintaining a healthy weight and staying active helps maximise the lifespan of your knee replacement.

Evidence and research

The TOPKAT trial (UK) compared partial and total knee replacement for medial compartment arthritis.

Key findings:

• Partial knee replacement was more clinically and cost-effective
• Shorter hospital stay
• Similar patient-reported outcomes
• Modest clinical advantages in selected patients

This supports the use of partial knee replacement in appropriately selected patients.

Why choose Mr Smith?

Mr Smith is a leading UK knee surgeon with expertise in both partial and total knee replacement. His approach focuses on careful patient selection, ensuring that each patient receives the most appropriate type of replacement based on their arthritis, anatomy, and goals.

His practice combines high-volume surgical expertise with a strong research background, ensuring treatment is personalised and evidence-based.

What is patellofemoral instability?

Patellofemoral instability refers to a condition where the kneecap (patella) does not move normally within its groove at the front of the knee.

In more severe cases, the patella can:

• Partially slip out of place (subluxation)
• Fully dislocate, usually to the outside of the knee

This can be a one-off injury or a recurrent problem, particularly in younger and active individuals.

Why does it happen?

Patellofemoral instability is often due to a combination of factors affecting the alignment and stability of the kneecap.

Common contributing factors include:

• MPFL injury: The medial patellofemoral ligament (MPFL) is the main soft tissue restraint preventing the patella from dislocating. It is often torn during a first dislocation.
• Shallow trochlear groove (trochlear dysplasia): The groove the patella sits in may be underdeveloped.
• High-riding patella (patella alta): The patella sits higher than normal, reducing stability.
• Abnormal alignment: Increased lateral pull on the patella due to limb alignment or muscle imbalance.
• Increased femoral or tibial rotation: This can alter the tracking of the patella and contribute to instability.

Often, several of these factors are present together.

Symptoms

Patients with patellofemoral instability may experience:

• A feeling of the kneecap “slipping” or “giving way”
• Episodes of dislocation
• Pain at the front of the knee
• Swelling after an episode
• Apprehension or lack of confidence in the knee
• Difficulty with activities such as stairs, squatting, or sport

Assessment and diagnosis

A detailed assessment is essential to understand the underlying causes.

This includes:

• Clinical examination
• MRI scan to assess ligament injury, cartilage damage, and anatomy
• X-rays or CT scans to assess alignment and bony structure

Careful evaluation allows treatment to be tailored to the individual, rather than a one-size-fits-all approach.

Do all cases need surgery?

Not all patients require surgery.

After a first-time dislocation, treatment is often non-surgical:

• Physiotherapy to improve strength and control
• Activity modification
• Bracing in some cases

However, surgery may be recommended if:

• There are recurrent dislocations
• There is significant underlying anatomical abnormality
• Non-surgical treatment has not been successful
• There is associated cartilage damage

Surgical treatment

Surgery is tailored to address the specific causes of instability. In many cases, more than one procedure is required.

MPFL reconstruction

The medial patellofemoral ligament (MPFL) is the primary restraint preventing the patella from dislocating.

• Often torn during the first dislocation
• Reconstructed using a graft (commonly hamstring or quadriceps tendon)
• Restores soft tissue stability

This is one of the most commonly performed procedures for recurrent instability.

Tibial tuberosity distalisation (and/or medialisation)

The tibial tuberosity is the bony attachment of the patellar tendon.

In patients with:

• Patella alta (high-riding patella)
• Abnormal lateral pull

The tuberosity can be surgically repositioned to:

• Improve alignment of the patella
• Reduce the risk of further dislocation
• Optimise tracking within the groove

This is performed as an osteotomy (controlled bone cut) and fixed with screws.

Rotational osteotomy

In some patients, abnormal femoral or tibial rotation contributes significantly to instability.

A rotational osteotomy involves:

• Cutting the bone (femur or tibia)
• Correcting the rotational alignment
• Fixing the bone in a more optimal position

This is typically reserved for:

• More complex or severe cases
• Patients with significant underlying malalignment

Combined procedures

It is common to combine procedures, for example:

• MPFL reconstruction + tibial tuberosity osteotomy
• MPFL reconstruction + correction of rotational alignment

The aim is to address both soft tissue and bony factors to achieve a stable and well-functioning knee.

Recovery and rehabilitation

Recovery depends on the procedures performed.

Typical rehabilitation includes:

• Early controlled movement
• Use of a brace in some cases
• Gradual progression of weight bearing
• Physiotherapy focusing on strength and control

Return to activities:

• Daily activities: 6–12 weeks
• Higher level activity: 4–6 months
• Return to sport: around 6–9 months once clinically cleared

More complex procedures (e.g. osteotomy) may require a slightly longer recovery.

Outcomes

With appropriate treatment:

• Most patients achieve a stable kneecap
• Recurrence rates are low
• Many return to an active lifestyle

Outcomes depend on:

• Addressing all contributing factors
• Surgical technique
• Rehabilitation

Some patients may experience:

• Ongoing anterior knee pain
• Stiffness
• Risk of cartilage wear over time

Research and evidence

At University Hospitals Coventry and Warwickshire NHS Trust, ongoing research is helping to improve our understanding of patellofemoral instability.

The REPPORT trial is a current study aiming to better understand the role of surgery in patients with this condition, including which patients benefit most from surgical intervention and which may be successfully managed without it.

This type of research helps ensure that treatment decisions are:

• Evidence-based
• Individualised
• Focused on achieving the best long-term outcomes

Why choose specialist care?

Patellofemoral instability can be multifactorial and technically demanding to treat.

Specialist care ensures:

• Detailed assessment of all contributing factors
• Individualised surgical planning
• Expertise in both soft tissue and bony procedures
• Structured rehabilitation

Summary

• Patellofemoral instability occurs when the kneecap does not track normally and may dislocate
• It is often caused by a combination of soft tissue and anatomical factors
• Not all cases require surgery, but recurrent instability often does
• Surgical options include MPFL reconstruction, tibial tuberosity osteotomy, and rotational osteotomy
• Good outcomes are achievable with tailored treatment and rehabilitation

Restoring meniscal function to protect the knee and reduce the risk of arthritis.

Meniscal Root Repair – Key Points

• The meniscal root anchors the meniscus to the bone and is essential for normal knee function
• A root tear causes the meniscus to stop working effectively
• High risk of early osteoarthritis if left untreated
• Repair aims to restore normal load transmission through the knee
• Surgery is keyhole (arthroscopic) and usually takes 60–90 minutes
• Recovery requires protection of the repair, typically with restricted weight-bearing for 6 weeks

What is a meniscal root tear?

The meniscal roots are the points where the meniscus attaches to the bone (tibia). These attachments are critical for allowing the meniscus to function properly.

When a root tear occurs—most commonly at the posterior root—the meniscus can no longer transmit load effectively. Biomechanically, this is similar to having the meniscus removed entirely.

Why is root repair important?

Meniscal root tears are a serious injury that should not be overlooked.

If left untreated:

• The meniscus loses its ability to distribute load
• Contact pressures in the knee increase significantly
• Rapid cartilage overload and risk of progression to arthritis
• Symptoms such as pain and swelling often persist or worsen

Repairing the root aims to restore the normal function of the meniscus and protect the joint.

Who is suitable for root repair?

Root repair is typically recommended for:

• Acute or symptomatic root tears
• Patients with minimal or early arthritis
• Active individuals wishing to preserve knee function

In some cases, particularly where there is advanced arthritis, repair may not be appropriate.

What does the operation involve?

Meniscal root repair is performed using arthroscopic (keyhole) surgery.

• The torn root is identified within the knee
• Sutures are placed through the meniscus
• A small tunnel is created in the shin bone (tibia)
• The sutures are passed through the tunnel and secured, restoring the attachment

The procedure typically takes 60–90 minutes.

Risks of meniscal root repair

As with any surgery, there are potential risks:

• Infection
• Blood clots (DVT)
• Failure of the repair (lack of healing)
• Knee stiffness
• Persistent symptoms
• Rare nerve or blood vessel injury

These risks will be discussed in detail based on your individual case.

Recovery and rehabilitation

Recovery is focused on protecting the repair while it heals.

Early phase

• Crutches are required
• Weight-bearing is usually restricted for 6 weeks
• A brace may be used to control movement

Rehabilitation timeline

• 0–6 weeks: Protect the repair, limited weight-bearing
• 6–12 weeks: Gradual return to weight-bearing and movement
• 3–6 months: Progressive strengthening and functional recovery
• 6 months+: Return to higher-level activity

High-impact activities are avoided until healing is complete.

Long-term outcomes

When successfully repaired, meniscal root tears can:

• Improve pain and function
• Restore more normal knee biomechanics
• Reduce the risk of rapid joint degeneration

Without repair, there is a significantly increased risk of early osteoarthritis, due to loss of normal meniscal function.

Why choose Mr Smith?

Mr Smith is a leading UK knee surgeon with a specialist interest in meniscal surgery, including complex and root repairs. His practice focuses on preserving the meniscus and restoring normal knee biomechanics, supported by a leading research programme in knee surgery.

You will receive a personalised treatment plan aimed at protecting your knee and optimising long-term outcomes.

Preserving the meniscus to maintain knee function and protect long-term joint health.

Meniscal Repair – Key Points

• The meniscus is a vital cushion that helps transmit load evenly through the knee
• Tears are common and can cause pain, locking, or instability
• Repair (stitching the meniscus) is preferred over removal where possible
• Preserving the meniscus helps reduce the risk of arthritis
• Surgery is keyhole (arthroscopic) and typically takes 60–90 minutes
• Recovery is longer than trimming procedures, with return to sport usually 4–6 months

What is the meniscus?

The meniscus is a C-shaped piece of cartilage in the knee that acts as a cushion and helps transmit load evenly across the joint. It plays an essential role in:

• Distributing forces through the knee
• Protecting the joint surfaces
• Contributing to stability and smooth movement

Damage to the meniscus can result in pain, swelling, catching or locking, and over time may increase the risk of arthritis.

Why is meniscal repair important?

Where possible, preserving the meniscus is the priority.

A successful meniscal repair:

• Relieves symptoms such as pain and locking
• Restores normal knee function
• Maintains even load transmission across the joint
• Reduces the risk of early arthritis

Not all tears are repairable, but modern techniques aim to preserve as much meniscus as possible.

Which tears can be repaired?

Meniscal repair is most suitable for:

• Tears in the outer (vascular) zone, where healing potential is highest
• Younger or active patients with otherwise healthy meniscus
• Vertical or longitudinal tears, which are more amenable to repair

Careful assessment is required to determine whether a tear is repairable.

Types of meniscal tears

Common tear patterns include:

• Longitudinal tears – run along the meniscus and are often repairable
• Bucket-handle tears – displaced tears that can cause locking of the knee
• Radial tears – extend from the inner edge and are less likely to be repairable
• Root tears – where the meniscus detaches from the bone
• Complex tears – involve multiple patterns and are more challenging to treat

Mr Smith has particular expertise in identifying and managing complex tear patterns to optimise outcomes.

Non-surgical treatment

Some smaller or stable tears can be managed without surgery.

Benefits

• Avoids surgery

Limitations

• Symptoms may persist
• Larger or unstable tears may lead to poorer long-term outcomes
• Loss of normal meniscal function can increase the risk of overload pain and arthritis

What does the operation involve?

Meniscal repair is performed using keyhole (arthroscopic) surgery.

• Small incisions are made around the knee
• A camera is used to assess the joint
• Specialised instruments are used to stitch the torn meniscus
• The repair technique is tailored to the type and location of the tear

The procedure usually takes 60–90 minutes and is typically performed as a day case.

Biological augmentation

Biological augmentation refers to techniques used during meniscal repair to enhance the body’s natural healing response. The meniscus has a limited blood supply, particularly in its inner regions, which can reduce its ability to heal. These techniques aim to improve healing potential and increase the success of repair.

Common methods include:

• Trephination – creating small channels from the outer, well-vascularised part of the meniscus into the tear to encourage blood flow and healing cells
• Rasping – gently roughening the tissue around the tear to stimulate a healing response
• Fibrin clot application – placing a clot (derived from your own blood) into the tear to act as a biological scaffold and promote healing

These techniques are often used in combination with meniscal repair, particularly in more complex tears or areas with limited blood supply.

Why is biological augmentation beneficial?

• Improves the healing environment within the meniscus
• Increases the likelihood of successful repair
• Expands the range of tears that may be suitable for repair
• Supports long-term preservation of the meniscus and knee joint health

Mr Smith routinely incorporates biological augmentation techniques where appropriate, using an evidence-based approach to optimise healing and improve outcomes following meniscal repair.

Risks of meniscal repair

Meniscal repair is generally safe, but potential risks include:

• Infection
• Blood clots (DVT)
• Failure of the repair (lack of healing)
• Knee stiffness
• Rare nerve or blood vessel injury
• General medical or anaesthetic risks

These risks will be discussed with you in the context of your individual case.

Recovery and rehabilitation

Recovery from meniscal repair is longer than meniscal trimming, as the repair requires time to heal.

Early recovery

• A brace may be required
• Crutches are usually needed
• Weight-bearing is often restricted for up to 6 weeks, depending on the tear

Rehabilitation timeline

• 0–2 weeks: Reduce swelling and restore controlled movement
• 2–6 weeks: Gradual improvement in movement and early strengthening
• 6–12 weeks: Progress to full weight-bearing and strengthening
• 3–6 months: Return to higher-level activity and sport

High-impact activities are avoided until the meniscus has healed.

Long-term outcomes

A successful meniscal repair can result in:

• Significant reduction in pain
• Improved knee function
• Return to normal activities and sport
• Preservation of long-term joint health

Outcomes depend on tear type, location, patient factors, and adherence to rehabilitation.

Why choose Mr Smith?

Mr Smith is a leading UK knee surgeon with a specialist interest in meniscal surgery, including complex repairs. His practice focuses on preserving the meniscus wherever possible, using advanced surgical techniques supported by a leading research programme in knee surgery.

You will receive a personalised treatment plan aimed at restoring function while protecting the long-term health of your knee.

Restoring knee stability with advanced, evidence-based techniques tailored to you.

ACL Reconstruction – Key Points

• The ACL stabilises the knee, especially during twisting and pivoting
• A tear can cause instability (“giving way”) and further damage
• Treatment includes physiotherapy or surgery depending on your goals
• Surgery is a keyhole procedure using a tendon graft
• Recovery takes 9–12 months with structured rehabilitation
• The aim is a stable knee and safe return to activity

What is the ACL and why is it important?

The anterior cruciate ligament (ACL) is one of the main stabilising ligaments in the knee. It prevents the shin bone from moving forwards and controls rotation.

When the ACL is torn, the knee can feel unstable or “give way”, particularly during twisting or pivoting movements. This is common in sport but can also affect daily activities. Straight-line activities such as walking are often better tolerated.

ACL injuries are relatively common and often occur during sport, although they can happen in other situations.

Assessment and associated injuries

Following injury, careful assessment is required. This includes clinical examination and imaging, most commonly with X-rays and MRI scans, to confirm the diagnosis and identify any associated damage.

Meniscal tears are very common alongside ACL injuries:

• The lateral meniscus is often injured at the time of the ACL tear, sometimes involving the root
• The medial meniscus is more likely to be damaged later if instability persists

The meniscus acts as a shock absorber in the knee, and untreated tears can increase the risk of arthritis. Where possible, meniscal tears are repaired at the time of surgery.

Do I need surgery?

Rehabilitation (non-surgical treatment)

Physiotherapy focuses on strengthening the muscles around the knee and improving control.

Benefits

• Avoids surgery
• Can improve stability in some patients

Limitations

• Instability may persist, particularly during pivoting activities
• You may need to modify activity levels
• There is a risk of further injury, particularly to the meniscus

ACL reconstruction surgery

ACL reconstruction is a keyhole (arthroscopic) operation to replace the torn ligament with a tendon graft, usually taken from your own body. A recent large trial showed that overall patients that had ACL reconstruction did better than those that had physiotherapy alone.

Benefits

• Restores knee stability
• Reduces the risk of further damage to the knee
• Allows return to sport and higher-level activity

What does the operation involve?

The procedure usually takes 1–2 hours and is performed as a day case.

• Small incisions are made around the knee (keyhole surgery)
• A graft is taken (hamstring, patellar tendon, or quadriceps tendon)
• Tunnels are created in the thigh bone (femur) and shin bone (tibia)
• The graft is positioned and fixed in place using screws or buttons

Graft choice – tailoring surgery to you

There is no single “best” graft—this depends on your age, activity level, and individual risk factors.

• Patellar tendon (BTB)
  Strong graft with excellent long-term results, often used in younger or higher-risk patients. It can occasionally cause pain at the front of the knee.
• Hamstring tendon
  Most commonly used in the UK. Good overall results and well tolerated. Well suited to medium and low risk patients.
• Quadriceps tendon
  A thicker, strong graft with increasing popularity. Often associated with less kneeling pain, but can cause weakness in the quadriceps.
• Allograft (donor tissue)
  Avoids taking tissue from your own body but may take longer to incorporate and is used selectively.

Additional procedures

Lateral extra-articular tenodesis

Some patients benefit from an additional procedure called a lateral extra-articular tenodesis (LET). This reinforces the outside of the knee and has been shown to significantly reduce the risk of graft failure in higher-risk individuals.

Meniscal surgery

Meniscal tears are very common in association with ACL injuries. The meniscus is an important shock absorber in the knee, helping to distribute load and protect the joint. Preserving the meniscus is crucial for long-term knee health.

Where possible, meniscal repair is always preferred over removal, as this helps reduce the risk of early arthritis and maintains normal knee function.

Common types of meniscal tears seen with ACL injuries include:

• Ramp lesions – tears at the back of the medial meniscus
• Root tears – where the meniscus detaches from its attachment to bone
• Bucket handle tears (BHT) – larger tears that can cause locking of the knee

These injuries can sometimes be difficult to detect and require careful assessment at the time of surgery. Mr Smith has particular expertise in identifying and repairing complex meniscal tears, including root and ramp lesions, to optimise long-term outcomes.

If a tear is not repairable, the damaged portion may need to be trimmed (partial meniscectomy), although this is avoided where possible.

Synthetic augmentation

Synthetic augmentation is a newer technique used alongside ACL reconstruction, where a synthetic tape is added to reinforce the graft. The aim is to provide additional stability in the early stages of healing and potentially reduce the risk of re-injury.

Early evidence is promising. A systematic review conducted by Mr Smith has shown that synthetic augmentation may increase rates of return to sport and reduce re-tear rates. However, high-quality evidence is still needed to determine whether these findings are genuine effects of the augmentation.

Mr Smith is Chief Investigator of a £1.9 million NIHR-funded randomised controlled trial investigating synthetic augmentation in ACL reconstruction, helping to define its role in modern knee surgery.

Risks of ACL reconstruction

ACL reconstruction is generally very successful, but potential risks include:

• Infection or blood clots
• Pain and swelling
• Graft re-tear (risk varies depending on age and activity level)
• Stiffness or reduced movement
• Ongoing instability
• Symptoms from the graft harvest site (e.g. kneeling pain or muscle weakness)
• Rare injury to nerves or blood vessels

These risks will be discussed in detail and tailored to your individual situation.

Preparing for surgery

Surgery is usually performed once:

• Swelling has settled
• Movement has returned
• Strength has improved

This “prehabilitation” phase is important and improves outcomes after surgery.

You will usually have the procedure as a day case. You will need someone to take you home and stay with you overnight.

Recovery and rehabilitation

Recovery typically takes 9–12 months.

Rehabilitation progresses through stages:

• Early recovery and movement
• Strength and muscle control
• Balance and proprioception
• Agility and sport-specific training
• Return to sport

Most patients return to sport at around 9–12 months, depending on progress and individual risk.

ACL prevention programmes

There have been several sport specific ACL prevention programmes developed that have been shown to reduce your risk of ACL rupture. Any patient with an ACL reconstruction can apply this to this reconstructed side as well as their other side (which is at an increased risk compared to the general population). It is encouraged that you incorporate these prevention exercises into your rehabilitation, and also continue them into the future.

Football –         FIFA 11+ https://youtu.be/X5YyunLZzBc

PEP  program https://youtu.be/7Lag8uNU6AQ

Rugby –              NSW rugby ‘preparation to perform’ program

https://nsw.rugby/participate/programs/prep-2-perform

Tennis –             Lateral step lunges, forward and backwards running drills

Skiing –              Lateral box stepping and jumping, zigzag hopping

Netball –           Netball Australia’s ‘knee program’ https://knee.netball.com.au

Why choose Mr Smith?

Mr Smith is a leading UK knee surgeon with extensive experience in ACL reconstruction, including complex and high-risk cases. His practice is supported by a leading research programme, including NIHR-funded clinical trials and pioneering work investigating factors such as tibial slope and ACL failure.

You will receive a personalised treatment plan based on your goals, anatomy, and risk profile—using the most advanced, evidence-based techniques available.

Evidence-based treatment focused on improving symptoms while avoiding unnecessary surgery.

Degenerative Meniscal Tears – Key Points

• Degenerative meniscal tears are common, particularly in middle age and beyond
• They are often associated with early wear in the knee rather than a single major injury
• Current BASK-based guidance recommends non-operative treatment first, usually with physiotherapy
• High-quality trials show physiotherapy provides similar outcomes to surgery for many patients
• Some patients may benefit more from surgery, particularly in selected groups
• Around 35–40% of patients may go on to require surgery if symptoms persist
• Meniscal root tears are a separate injury and should be identified early, as they often require surgical repair
• At UHCW, we are investigating which patients may benefit from earlier surgical intervention

What is a degenerative meniscal tear?

The meniscus is a cushion in the knee that helps transmit load evenly through the joint. A degenerative meniscal tear develops gradually as part of the ageing process, rather than from a single injury.

These tears are common and often seen on MRI, but they are not always the primary cause of symptoms. Many patients also have early cartilage wear, which can contribute to pain and stiffness.

First-line treatment

Current UK guidance based on BASK recommends that the vast majority of patients with a degenerative meniscal tear should be treated non-operatively first.

This typically includes:

• Physiotherapy focused on strength and control
• Activity modification
• Simple pain relief where required
• Weight management where appropriate

This approach is important because many degenerative tears improve without surgery, and imaging findings alone do not necessarily mean an operation is required.

What does the evidence show?

Several high-quality studies have compared physiotherapy with arthroscopic meniscal surgery for degenerative meniscal tears.

The METRO study (Bone & Joint Journal) demonstrated that, in selected patients, arthroscopic meniscal surgery resulted in greater improvement in symptoms compared to physiotherapy alone. This highlights that there is a subgroup of patients who may benefit more from early surgical intervention.

In contrast, other large randomised trials, including ESCAPE, have shown that physiotherapy provides outcomes comparable to surgery for many patients, even at longer-term follow-up.

Taken together, this evidence supports a selective and individualised approach, rather than a one-size-fits-all treatment strategy.

Will physiotherapy always avoid surgery?

Not always. While many patients improve with rehabilitation alone, some continue to have symptoms and later choose surgery.

Across multiple randomised trials, approximately 30–40% of patients initially treated with physiotherapy go on to have arthroscopic surgery. This reflects the fact that:

• Physiotherapy is the appropriate starting point for most patients
• Surgery remains an important option for those who do not improve

Important distinction: meniscal root tears

It is important to distinguish degenerative meniscal tears from meniscal root tears, which are a different and more serious injury.

A root tear involves detachment of the meniscus from the bone. This causes the meniscus to stop functioning properly, leading to:

• Loss of normal load transmission
• Increased contact pressures in the knee
• A high risk of rapid progression to osteoarthritis if not treated

Unlike typical degenerative tears, root tears often require early surgical repair and should not be managed with physiotherapy alone.

Careful assessment, including MRI and clinical evaluation, is essential to ensure these injuries are not missed.

When might surgery still be considered?

Surgery may be appropriate in selected patients, particularly where:

• Symptoms persist despite a structured course of physiotherapy
• There are mechanical symptoms such as catching or locking
• Clinical assessment suggests the meniscal tear is the main driver of symptoms

At UHCW, we are actively researching which patients may benefit from earlier surgical intervention, with the aim of improving patient selection and delivering more personalised care.

Why choose Mr Smith?

Mr Smith uses an evidence-based and individualised approach to degenerative meniscal tears, combining current BASK guidance with the latest clinical research. Each patient is carefully assessed to determine whether physiotherapy or surgical treatment is most appropriate.

His practice is supported by ongoing research at UHCW focused on identifying which patients benefit most from early surgery, ensuring treatment is tailored to optimise outcomes.

What is a multiligament knee injury?

A multiligament knee injury occurs when two or more of the major stabilising ligaments of the knee are torn. These are serious injuries that can significantly affect the stability and function of the knee.

The key ligaments of the knee each play an important role:

• Anterior cruciate ligament (ACL): Controls forward movement and rotation of the tibia. Injury often leads to instability with twisting or pivoting.
• Posterior cruciate ligament (PCL): Prevents the tibia from moving backwards. Important for stability when walking downhill or descending stairs.
• Medial collateral ligament (MCL): Provides stability to the inner side of the knee. Often injured in valgus (inward) stress injuries.
• Lateral collateral ligament (LCL) and posterolateral corner (PLC): Stabilise the outer side of the knee and control rotational stability. These are critical for overall knee function and are often involved in more complex injuries.

These injuries often occur following:

• High-energy trauma (e.g. road traffic accidents)
• Sporting injuries (particularly contact or twisting injuries)
• Knee dislocation (which may spontaneously reduce before assessment)

Symptoms

Patients with multiligament injuries may experience:

• Severe pain at the time of injury
• Significant swelling
• A feeling that the knee is unstable or “giving way”
• Difficulty weight bearing
• Reduced range of movement

Because of the severity of these injuries, there may also be associated nerve or blood vessel injury, which requires urgent assessment.

Assessment and diagnosis

A thorough assessment is essential and includes:

• Detailed clinical examination
• MRI scan to assess ligament damage and associated injuries (meniscus, cartilage)
• X-rays or CT scans in some cases

In acute injuries, careful evaluation of the blood supply (vascular status) and nerve function is critical.

Do all multiligament injuries need surgery?

Not all cases require surgery, but many do.

Treatment depends on:

• Which ligaments are injured
• Severity of instability
• Patient activity level and goals
• Associated injuries

Some lower-grade injuries or patients with lower functional demands may be managed with:

• Bracing
• Physiotherapy

However, surgical reconstruction is often recommended in active individuals or where the knee remains unstable.

Surgical treatment

Surgery aims to restore stability to the knee by reconstructing the injured ligaments.

This may involve:

• Reconstruction of two or more ligaments (e.g. ACL + PCL, or ACL + PLC)
• A combination of arthroscopic (keyhole) and open surgical techniques
• Careful sequencing of ligament reconstruction to restore normal knee biomechanics

Graft choice

In multiligament reconstruction, it is common to use a combination of autograft (your own tissue) and allograft (donor tissue).

This approach is used because:

• Multiple ligaments often need to be reconstructed
• Using only autograft may not provide enough suitable tissue
• It helps reduce surgical time and donor site morbidity

Autograft options may include:

• Hamstring tendons
• Quadriceps tendon

Allograft tissue is frequently used for:

• PCL reconstruction
• Posterolateral corner (PLC) reconstruction
• Additional ligament reconstructions where required

The exact graft choice is tailored to the individual injury pattern and patient factors.

Timing of surgery

Surgery may be performed:

• Early (acute setting) in selected cases
• Delayed, once swelling has settled and range of movement has improved
• As a staged procedure, particularly in complex injuries

The timing is carefully planned to optimise outcomes and reduce complications such as stiffness.

Recovery and rehabilitation

Recovery from multiligament knee surgery is longer and more structured than single ligament injuries.

Typical rehabilitation includes:

• Early protected movement
• Use of a knee brace
• Gradual progression of weight bearing
• Physiotherapy focusing on strength, control and stability

Return to activities:

• Daily activities: 3–4 months
• Higher level activity: 9–12 months
• Return to sport: around 12 months once clinically cleared

Outcomes

With appropriate treatment and rehabilitation:

• Most patients achieve a stable, functional knee
• Many return to an active lifestyle

However, recovery can be demanding, and outcomes depend on:

• Severity of injury
• Associated damage (cartilage, meniscus, nerves)
• Adherence to rehabilitation

Some patients may experience:

• Residual stiffness
• Reduced high-level sporting ability
• Risk of longer-term osteoarthritis

Why choose specialist care?

Multiligament knee injuries are complex and relatively uncommon, and optimal outcomes depend on specialist management.

Care includes:

• Accurate diagnosis and surgical planning
• Expertise in complex ligament reconstruction
• Appropriate graft selection
• Structured, closely supervised rehabilitation

Summary

• Multiligament knee injuries involve damage to two or more knee ligaments
• Each ligament plays a distinct role in knee stability
• Surgery is commonly required and often involves multiple reconstructions
• A combination of autograft and allograft is frequently used
• Recovery takes time, but good outcomes are achievable with specialist care

A specialist procedure to restore the meniscus, reduce pain, and improve function in the meniscus-deficient knee.

Meniscal Transplantation – Key Points

• Meniscal transplantation is used for patients who have ongoing pain after previous removal of part or all of the meniscus
• The meniscus is a cushion in the knee that helps transmit load evenly through the joint
• This procedure aims to improve pain and function and restore more normal knee mechanics
• It is most commonly considered in younger, active patients with a symptomatic meniscus-deficient knee
• In selected patients, it can allow return to higher levels of activity
• Recovery is gradual, with return to sport at 12 months, once clinically cleared

What is a meniscal transplant?

Knee compartment without meniscus

Knee compartment following meniscal transplant

A meniscal transplant involves replacing a missing or severely damaged meniscus with a donor (allograft) meniscus.

The meniscus is an important structure within the knee. It acts as a cushion and helps transmit load evenly across the joint. When the meniscus has been removed, the knee can become painful and less able to tolerate activity, and the joint may be at greater risk of further wear over time.

Meniscal transplantation is designed to restore meniscal function and improve symptoms in carefully selected patients.

Who is this procedure for?

Meniscal transplantation is typically considered in patients who:

• Have previously had part or all of their meniscus removed
• Continue to experience pain in the affected side of the knee
• Are relatively young and active
• Do not yet have advanced arthritis throughout the knee

It is particularly useful in patients who remain limited by a painful meniscus-deficient knee despite appropriate rehabilitation and activity modification.

What are the benefits?

Potential benefits of meniscal transplantation include:

• Improvement in pain
• Improved function and ability to remain active
• Restoration of more normal load transmission within the knee
• Protection of the joint compared with leaving the knee meniscus-deficient

For many patients, the aim is to improve quality of life and preserve the knee for as long as possible.

How does it compare to other treatments?

For patients with a meniscus-deficient knee, treatment options are often limited.

• Physiotherapy can help symptoms, but it does not replace the missing meniscus
• Further trimming surgery is usually not beneficial once the meniscus is already deficient
• Knee replacement is generally not appropriate in younger patients

Meniscal transplantation offers a reconstructive option in patients where other treatments may not adequately address the underlying problem.

Meniscal transplantation and cartilage damage

Meniscal transplantation is most predictable when the surrounding joint surfaces are well preserved. However, some patients have already developed cartilage damage by the time they are assessed.

Our research has shown that even in patients with substantial cartilage damage, meniscal transplantation can still lead to a sustained improvement in patient-reported outcomes, although graft survival is lower than in knees without major cartilage damage. This can be helpful when counselling patients with more complex knees.

Return to sport

Historically, there has been concern that returning to high-level sport after meniscal transplantation might increase the risk of failure.

Our published work has shown that patients who returned to competitive sport after meniscal transplantation had excellent medium-term graft survival and superior patient-reported outcomes, with no evidence of increased graft failure compared with those who did not return to competitive sport.

This information is important for active patients considering surgery and helps guide realistic expectations after recovery.

Surgical approach

Meniscal transplantation is performed using keyhole (arthroscopic) surgery, often with small additional incisions.

The operation involves:

• Preparing the knee and assessing the joint surfaces
• Inserting a carefully size-matched donor meniscus
• Securing the transplant to the bone and surrounding soft tissues

In some patients, additional procedures may be needed at the same time, such as:

• Ligament reconstruction
• Osteotomy (realignment surgery)
• Cartilage treatment

This is determined on an individual basis depending on the condition of the knee.

Recovery and rehabilitation

Recovery following meniscal transplantation is gradual and carefully structured to protect the transplant while restoring strength and function.

• Crutches are typically required for approximately 4–6 weeks
• Weight-bearing is progressed gradually under guidance
• A structured physiotherapy programme is essential throughout recovery

Most patients can expect:

• Return to low-impact activities by around 3–4 months
• Return to sport at 12 months, once clinically cleared

Recovery timelines vary depending on individual factors, including any additional procedures performed and progress with rehabilitation.

Expected outcomes

Most patients can expect meaningful improvement in pain and function following meniscal transplantation.

Outcomes depend on a number of factors, including:

• The condition of the cartilage
• Alignment of the knee
• Ligament stability
• Previous surgery
• Adherence to rehabilitation

Meniscal transplantation is a specialist procedure, and careful patient selection is important in achieving the best possible outcome.

A specialist, evidence-based approach

Mr Smith has one of the largest meniscal transplant practices in Europe and has published widely on the outcomes of meniscal transplantation. His work includes prospective outcome studies and randomised trial research in this area. The aim is always to combine specialist surgical expertise with evidence-based decision-making to deliver the best possible care for each patient.

Is meniscal transplantation right for you?

Meniscal transplantation is a highly specialised procedure and is not suitable for everyone.

A detailed assessment, including imaging and clinical examination, is essential to determine:

• Whether your symptoms are due to meniscus deficiency
• Whether a transplant is appropriate
• Whether any additional procedures are needed
• What outcome you can reasonably expect

Key points

• Knee osteotomy is a joint-preserving procedure that realigns the leg to improve how forces pass through the knee
• It works by shifting weight away from the damaged part of the joint to a healthier area
• High tibial osteotomy (HTO) is used for bow-legged (varus) alignment affecting the inner knee
• Distal femoral osteotomy (DFO) is used for knock-kneed (valgus) alignment affecting the outer knee
• Anterior closing wedge osteotomy can reduce tibial slope in revision ACL surgery and protect the graft
• It is particularly suitable for younger, active patients with early arthritis or alignment issues
• Often performed alongside ligament reconstruction or cartilage procedures
• Recovery takes time, but can delay or avoid the need for knee replacement
• Best outcomes are achieved with accurate correction and structured rehabilitation

What is a knee osteotomy?

A knee osteotomy is a surgical procedure used to realign the bones around the knee to improve joint function and reduce pain.

Rather than replacing the joint, an osteotomy rebalances the load across the knee, shifting weight away from a damaged or overloaded area.

It is most commonly used in:

• Younger or active patients
• Patients with early arthritis affecting one side of the knee
• Patients with alignment issues contributing to ligament problems

Why is an osteotomy needed?

In a normal knee, weight is distributed evenly across the joint. However, if the leg alignment is altered, excessive load can be placed on one side.

Common situations include:

• Bow-legged alignment (varus): Increased load on the inner (medial) side of the knee
• Knock-kneed alignment (valgus): Increased load on the outer (lateral) side of the knee
• Ligament instability: Malalignment can place excessive strain on reconstructed ligaments
• Revision ligament surgery: Alignment and slope may need correction to protect grafts

How does an osteotomy work?

An osteotomy works by changing how forces pass through the knee joint.

Before correction (malalignment)

• In varus alignment, most of the body weight passes through the inner (medial) compartment
• In valgus alignment, load is concentrated on the outer (lateral) compartment
• This uneven loading leads to pain, cartilage wear, and progression of arthritis

After osteotomy (realignment)

• The weight-bearing axis is shifted toward the healthier side of the knee
• Forces are more evenly distributed
• Pain is reduced and joint function improves
• This can slow down or delay further joint damage

Types of knee osteotomy

The type of osteotomy depends on the underlying problem and where the deformity arises.

High tibial osteotomy (HTO)

A high tibial osteotomy is performed on the upper part of the tibia (shin bone).

• Commonly used for varus (bow-legged) alignment
• Shifts weight from the worn inner part of the knee to the healthier outer side
• Often used in patients with medial compartment arthritis or overload

Distal femoral osteotomy (DFO)

A distal femoral osteotomy is performed on the lower part of the femur (thigh bone).

• Used for valgus (knock-kneed) alignment
• Reduces load on the outer (lateral) compartment of the knee
• Particularly useful in younger, active patients with lateral compartment symptoms

Anterior closing wedge osteotomy (for ACL revision)

In some patients undergoing revision ACL reconstruction, the posterior tibial slope (PTS) is increased.

An increased slope can:

• Place excessive strain on the ACL graft
• Contribute to graft failure

An anterior closing wedge osteotomy reduces the tibial slope by:

• Removing a wedge of bone from the front of the tibia
• Decreasing the posterior slope
• Reducing forces on the ACL graft

This is a specialised procedure typically performed in selected revision cases.

Surgical technique

Osteotomy involves:

• Making a controlled cut in the bone
• Adjusting the alignment to the desired position
• Fixing the bone with a plate and screws

The procedure may be:

• An opening wedge (creating a gap)
• A closing wedge (removing a section of bone)

The choice depends on the deformity and surgical plan.

Do I need an osteotomy or a knee replacement?

An osteotomy is often considered when:

• You are younger and active
• Arthritis is limited to one part of the knee
• You wish to preserve your natural joint
• There is correctable malalignment

A knee replacement may be more appropriate if:

• Arthritis is advanced and widespread
• Symptoms are severe and persistent

This decision is made on an individual basis following detailed assessment.

Recovery and rehabilitation

Recovery from an osteotomy requires time for the bone to heal.

Typical rehabilitation includes:

• Use of crutches initially
• Gradual progression of weight bearing
• Physiotherapy to restore movement and strength

Return to activities:

• Daily activities: 6–12 weeks
• Low impact activity: 3–6 months
• Higher level activity: 6–12 months

Recovery may vary depending on the type of osteotomy performed.

Outcomes

With appropriate patient selection:

• Osteotomy can significantly reduce pain
• Improve function and activity levels
• Delay or avoid the need for knee replacement

By correcting alignment and redistributing load, osteotomy helps to:

• Protect remaining cartilage
• Improve joint mechanics
• Support ligament reconstructions where required

Why choose specialist care?

Osteotomy is a precise, technically demanding procedure that requires careful planning.

Specialist care ensures:

• Detailed assessment of alignment and biomechanics
• Accurate correction tailored to the individual
• Integration with ligament reconstruction when required
• Structured rehabilitation

Summary

• A knee osteotomy realigns the bones to improve load distribution
• It works by shifting forces away from damaged areas of the knee
• High tibial osteotomy (HTO) is used for varus alignment
• Distal femoral osteotomy (DFO) is used for valgus alignment
• Anterior closing wedge osteotomy can reduce tibial slope in revision ACL surgery
• It is a joint-preserving option, particularly in younger, active patients
• Good outcomes are achievable with appropriate selection and specialist care

The meniscus is a cushion in the knee. It helps to spread out the forces through the knee when doing activities. The menisci in the knee move as the knee bends to allow these forces to be effectively spread, whether you are running, jumping of squatting. If you have a tear in your meniscus, this function is reduced. This can cause pain, sometimes locking type symptoms, as well as increasing the risk of future osteoarthritis.

Meniscal repair

Traumatic meniscal tears occur in an otherwise healthy meniscus and are often caused by a sporting injury. These are often repairable. This can be determined more precisely with an MRI scan. Meniscal repair techniques and equipment have improved considerably over the last decade and now most tears can be repaired. One of the difficulties is that the meniscus has a relatively poor blood supply, especially in the central part of the meniscus (the so-called white zone). This can reduce the chance of a successful repair, and the pros and cons of repair surgery will be discussed with Nick Smith.

Meniscal root repair

If the meniscus tears within 1cm of its attachment into the bone, it is called a root tear. This distinction is important because the operation to repair it is different. It is best repaired by drilling a tunnel through the bone and passing a repair tape through this tunnel. Lateral root tears occur primarily with bigger injuries and may tear at the time of an ACL rupture. Lateral root tears can completely defunction the meniscus. Medial root tears can occur without trauma or with minimal trauma, usually in middle aged people. There is a high chance of progressive osteoarthritis associated with medial meniscal root tears.

Meniscal transplantation

Patients that have had a traumatic meniscal tear and subsequent removal of the meniscus (meniscectomy) are at risk of knee pain, particularly during activities and also progression of osteoarthritis. Some of these patients may be suitable for meniscal transplantation. The meniscus used in transplantation is donor tissue (allograft) and is fixed using the latest meniscal repair techniques. There are only a few surgeons in the UK performing this operation. Nick Smith has extensively researched this topic and has a high-volume clinical practice. He is therefore very well placed to discuss whether this surgery may be right for you or not.

Removal of part of the meniscus (partial meniscectomy)

A degenerative meniscal tear usually happens at the back of medial meniscus (posterior horn). Historically, most people would have been offered surgery. However, there have been a number of trials showing that non-operative treatment (physiotherapy or watch and wait approach) can be equally effective. Some trials had a high crossover rate for patients in the non-operative group (meaning that a high proportion did in fact go on to have surgery). There are now national consensus guidelines on who should be offered surgery and who should be offered non-operative treatment, which is based on the best current evidence. At UHCW NHS Trust, we are further studying these patients to see if we can identify who is likely to benefit from surgery and who is not. It is clear that there is not a one size fits all answer and it is up to the treating team to appropriately assess patients and give informed advice on the treatment options.