Procedures

If the meniscus has sustained unrepairable damage and mechanical symptoms are dominant, then partial meniscectomy can beindicated. Do be aware, that notbecause a meniscus shows damage on MRI, thisneeds surgery. The best indicationis mechanical luxated flap tears, which typically cause intermittent symptoms.During surgery, the philosophy is to retain as much tissue as possible and inparticular, to preserve the outer rim which is mechanically very important.After even partial meniscectomy, the knee has to go through an adaptationphase, because the mechanical contact pressure is increased, and the bodyresponds to this by strengthening the bone plate underneath the cartilage. Thisis more true for the lateral side than the medial side, for which return to sportsis much slower. In some cases, the degeneration in the operated compartment,evolves, with continued swelling, pain, and in most of the cases a bone marrowedema. Other supportive measures may be necessary to correct this.

In some cases, a meniscus tear can be repaired with sutures, if located in the outer third towards the capsule. Also root insertions can be repaired. Success rate of the procedure depends highly on the quality of the tissue, good for recent tears in younger people. A sutured meniscus will never be as strong as anormal meniscus and will always be seen on MRI even if healed well.

Even a partial loss of meniscus can lead to cartilage overload and pain. One of the first scaffolds to replace a part of a meniscus, Collagen Meniscus Implant, was developed by Dr. R. Steadman and W. Rodkey at Vail Colorado, made of collagen type I of Achilles Bovine tendon. I was involved myself in developing the fully arthroscopic technique. We have been performing this since 2001 and published a lot about this. Indications are very strict and rehab is slow and strict to allow the tissue of the patient to grow into the scaffold. My main indications are loss of lateral meniscus, and failed ACL surgery with big loss of medial meniscus, where at revision of the ACL, we combine this with the scaffold.

This is a very good technique for almost full meniscus loss. The only problem is the availability. Rejection of these transplants are very rare. Best results are obtained in young patients with limited cartilage damage, although we have a lot of very good results in still young people with considerable cartilage damage, and we were able to postpone prosthetic surgery for over 15 years.

Loose cartilage flaps which cause locking symptoms can be treated just by shaving and cleaning the lesion.

This technique consists in creating pin point holes in the subchondral bone , to allow stem cells from the bone marrow to make a layer into the defect, and regrow a cartilage-like repair tissue, sometimes augmented with a Gel (Car-gel)or a membrane. Best indication is a well defined lesion less than 2,5 cm2 with stable borders from traumatic origin in a young patient. Rehab is long but essential with crutches for six weeks, return to running after 4 months and sports after 5 months. We performed this in a lot of top football players with very good results.

This technique was developed back in the nineties and consists of harvesting cylinders of cartilage, subchondral plate and bone from zones in the knee where there is cartilage that is not making contact, and placing this in the lesion into pre drilled tunnels. This technique works very well on lesions with bone involvement. The limitation of this technique is the amount of graft you can take, without compromising the knee, so for lesions up to 2,5 maximum 3cm2.

This procedure is a two stage intervention, where first cartilage is harvested, then cultured in a lab for 6- 10 weeks and then implanted in the lesion underneath a membrane.We stopped this promising technique due to cost issues and problems with the binding on the subchondral bone plate.

The torn ligament is replaced by a tendon of the same patients, usually hamstrings, patellar tendon, or Quadriceps tendon. It is placed in the knee through two tunnels and fixed with screws and devices. This tendon will undergo a biological proces of healing over 5-6 months, called neo-ligamentization. This is all done through arthroscopy and the possibleassociated lesions are treated at the same operative session.
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In high active and young pivot sports patients, a monoloop extra-articular reinforcement is added to augment the stability, and also to diminish the chance of rupture after a new trauma. This technique was developed in our own center by prof. Martens, Dr. Declercq and myself in the mid nineties. I have gained have enormous experience in this technique, that I have used also in many high level soccer players (see INTERNATIONAL PATIENTS), allowing them to return quicker to play and with excellent long term results.
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Main complication of ACL surgery is arthrofibrosis, an excessive scar tissue formation in the knee post surgery, mainly observed in female rather than in male patients. Risk factors for this complication are, stiff knees post ACL trauma, associated medial of lateral capsular injury, ski injuries and bad rehab. This can be  treated with good physiotherapy and in some cases with a small arthroscopic procedure, preferably at least 8 months after surgery when the scar tissue cooled down, so it does not recur. The incidence of this intervention is about 1% in the male patients, but over 5 – 6% in the female patients.Lots of basic research is done in this field to try to solve this issue. However, even if we still do not know how to prevent it, it does not have to be seen as a failure of the ACL reconstruction. Rather, we see this as a too enthusiastic healing of the body, given the fact that in these cases the ACL graft always looks of great quality.
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Infection rate has always been very low, and with use of adequate antibiotics it has become even less frequent. However, in case of doubt of too much swelling and even light raise in temperature, punction of the joint and even an arthroscopic wash out of the joint should be performed.
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Adequate Rehabilitation after surgery is mandatory and is as important as the surgery itself. For this reason I strictly collaborate with the best physiotherapists who share with me the right approach to make the patient to fully recover. Running is allowed at 4 months, technical individual sports exercises at 5 months, and gradual return to full training as off 6 months.

In high active and young pivot sports patients, a monoloop extra-articular reinforcement is added to augment the stability, and also to diminish the chance of rupture after a new trauma.
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This technique was developed in our own center by Prof. Martens, Dr. Declercq and myself in the mid nineties. We have enormous experience in that field , also in the high level soccer players, with quicker return to play and excellent long term data.

I have personally validated this technique biomechanically in collaboration with the Musculoskeletal Surgery Group of the Imperial College in London lead by Prof. A. Amis, and we published the results of this study in in 2020 in Knee Surgery, Sports Traumatology and Arthroscopy (KSSTA) journal, the official journal of ESSKA (European Society of Sport Traumatology, Knee Surgery and Arthroscopy).  This technique is very powerful in the control of anterolateral stability of the knee, which often is not obtained using only an intra articular reconstruction.

We also ran a big retrospective study of our own patients, 5 to 7 years of follow up in young sports active patients,  with far better results in return to sport at the same level, significant less meniscus problems after surgery and above all, very significant lower rate in rerupture of the graft( 1%  vs  10%) . These data will be published soon.

This technique is actually a modification of the older Lemaire and McIntosh  procedure. We prelevate a strip of iliotibial band, leave the attachment on the tibial side intact, route this underneath the lateral collateral ligament, posterolateral capsule , inter muscular septum, where it is fixed at the distal femur with a staple or screw (cfr video).

We associate this procedure in all our young pivot sports active patients, today over 50% of our ACL reconstructions, and for sure in all revision cases.

In very selected cases, we can perform an ACL repair instead of reconstruction. This is only in the case when the rupture is at the femoral insertion only, very often seen in ski injuries, but it does not work in high demand pivot patients. The repair is reinforced with a tape which we call internal bracing.
In my practice this procedure represents about 2-3% of the all ACL surgeries. Sometimes it is indicated in the very young patient with open growth plates, but again if the rupture is on the femoral insertion.

PCL injury is commonly caused by a contact injury and tears differently from ACL. Lots of goal keepers have this injury, and play like this without being treated surgically. Indeed PCL usually elongates and has the capacity to scar up much more than an ACL. Initial treatment is therefore usually non operatively, combining bracing and physiotherapy, unless the injury is more important with other ligaments involved (multi-ligament injury).

If PCL is not functioning there is a big increase of load on the medial and patellofemoral compartment. If this becomes symptomatic, a reconstruction has to be performed. I prefer the double bundle technique which recreates great stability and real PCL function (cfr video).Rehab is long: for 6 weeks use of crutches and return to play between 8 and 10 months.

This procedure is based on the ability of blood growth factors, cytokines, and bioactive molecules to play a role in joint tissue homeostasis, as well as in immunoregulation and inflammatory modulation.
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In particular, PRP exploits a gradient centrifugation procedure aimed at concentrating peripheral blood platelets so that, once activated, they can release the content of their α-granules that is growth factors (such as PDGF, TGFβ , FGF-2, IGF-1 and -2, VEGF, EGF, KGF, CTGF) and cytokines (IL-8), which can promote proliferation of the cells residing in damaged tissue, vascularization and modulation of inflammation.
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The treatment starts with the blood harvest from the patient’s arm like for a normal blood test. The blood is then put in centrifuge to obtain a product with a higher concentration of platelets and of the bio-active molecules herein contained. The final product, produced following the most severe sterility rules, is then injected into the affected area. 

I started using this for tendon disorders in 2005 and for joint diseases in 2010. In the latter indication, this is most effective in the inflamed and swollen irritated knee accompained by synovitis, but also in many cases of patellar chondromalacia.
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In addition to be injected, PRP can be also used in combination with surgical procedures. I have personally an extensive experience in the use of PRP combined with surgery to increase the healing respons of articular cartilage, to help meniscus regenerate after partial resection, to increase maturation of ACL graft in revision ACL, to treat bone marrow or edema (cfr video).

Most tissues of our body contain a cell population called mesenchymal stem cells. These cells have been shown to contribute to tissue healing both by direct differentiation towards specific cell lines (osteoblasts, chondrocytes) that have been lost during damage or progression of the disease, and through the production of a wide range of growth factors, anti-apoptotic, anti-fibrotic and immunomodulatory molecules. All these molecules can counteract the pathological microenvironment, for example in the presence of chronic inflammation, and restore correct tissue homeostasis, promoting healing of tendon and muscle disorders, joint degeneration, and also in case of osteoarthritis. 

The smartest sources of mesenchymal stem cells are bone marrow and adipose tissue. These tissues, once harvested in small amount from the own patient, can be processed using commercially available disposable medical devices to produce bone marrow concentrate and stromal vascular fraction or micro-fragmented adipose tissue, respectively. These products can easily obtained at the point of care, therefore the require only one procedure. A correct indication is the key to the success of these therapies and therefore the experience of the specialist plays a very important role. I have been using microfragmented adipose tissue with the Lipogems technology since 2017 with very good result in selected patients affected by osteoarthritis. In particular, also for this treatment it seems that the more reactive knees respond better and the effect seems to last longer.This approach can be used alone as an injectable product or in association with some surgical procedures.