"I had some low level pain in my knee for awhile, but ignored it and continued to play tennis as usual," says G.R.  "One day the pain became very sharp and I had to limp off the court." 

The next day he was still limping and his knee was quite swollen, so co-workers urged him to see Dr. Stone.  "I was at The Stone Clinic by noon, had an exam by Dr. Stone, and an MRI in his office.  The MRI revealed a hole in the articular cartilage of my knee.  It was explained to me that this hole represents the beginning of traumatic arthritis.  I decided to have the knee repaired so I could get back to playing tennis and be ready for a trip I had planned for later that summer."He is a 60-year old avid tennis player who underwent outpatient arthroscopic surgery on May 30, 2001.  The damage to his knee was repaired using the articular cartilage paste grafting technique and a small meniscus tear was treated with a meniscectomy.   He used crutches for four weeks and was "religious" about the strengthening, stretching, and cardiovascular program outlined for him by The Stone Clinic physical therapists.  He rented a stationary bicycle to have in his home to do well-leg biking and then two weeks after surgery he began two-leg biking.  After four weeks He was allowed to put weight through the leg and he began gait training (walking) and balance exercises.  He went on his trip with a travel rehabilitation program from the physical therapist."I began gradual tennis simulation exercises, swam regularly, and worked my way up in strength and endurance over a five-month period.  I was playing singles tennis after six months and today (one year later) I feel great and can play for 3-½ hours!"

The Surgical Process
G.R.'s MRI revealed a tear in the posterior part of his medial meniscus and a complete articular cartilage defect in the medial femoral condyle.  In other words, He had torn the flap of cartilage on the inside part of his knee and had taken a "divot" out of the surface of his knee joint. 

MRI documenting deep injury of medial femoral condyle with torn medial meniscus.

In the operating room, Dr. Stone inspected the entire knee joint through an arthroscope.  He had what Dr. Stone referred to as a "pristine" lateral compartment and great cruciate ligaments (ACL and PCL).  However, the medial, or inside part of his knee was a different story.  He had a complex tear of the medial meniscus and a 25mm x 10mm defect on the femur as well as a floating piece of cartilage.  Using instruments known as a biter, shaver, and bipolar unit, Dr. Stone removed both the damaged part of the meniscus and the loose body.  Next, attention was turned to the articular cartilage defect in the femur.  The base of the damaged bone was "microfractured" with a pick-like instrument to produce bleeding of the bone.  This stimulates a healing response in the joint and creates a bloody bed in which to place the harvested cartilage.  Healthy articular cartilage and its underlying bone were taken from a non-weight bearing area of He's knee and this was crushed into a paste.  This paste was packed into the damaged section of He's femur where it later healed over as a smooth surface area. 

	Loose body, medial compartment.
Full thickness articular cartilage loss, medial femoral condyle, with torn medial meniscus.
	Articular cartilage paste graft harvested from the intercondylar notch of the femur.
Articular cartilage paste grafting, medial femoral condyle.

The Rehabilitation Process
G.R. was at The Stone Clinic the day after his surgery for a dressing change and physical therapy.  His surgery site (which was only three small holes where the surgical instruments entered his knee) was cleaned and wrapped in new dressings.  At his first physical therapy session, he was given the rules to a speedy recovery.  He was told that the first two weeks post-operatively have a huge impact on the rest of his recovery.  The trick during these first weeks is to be very, very kind to the knee and includes the following instructions: 

a)      No weight bearing on the leg.
b)      Elevate the leg ABOVE THE HEART for at least 30 minutes every two hours.
c)      Ice the knee for 30 minutes every two hours.
d)      Use the CPM (continuous passive motion) machine as instructed.
e)      Use the bone stimulating unit as instructed.

Also, at his first physical therapy appointment, his knee was massaged aggressively to decrease swelling.  He did a workout that allowed him to break a sweat without compromising his knee; this was important mentally as well as physiologically.  Finally, in order to stimulate his cardiovascular system, he rode a stationary bicycle for 15 minutes with his surgical leg propped up and out of the way.  This was a daily routine he repeated at home.With guidance from The Stone Clinic physical therapists, he continued his rehabilitation near his home.  After an exam by Dr. Stone at four weeks, he was given the go ahead to put weight through the leg.  He went to The Stone Clinic physical therapy department for gait and balance training and a new set of exercises.  Initially, he used a cane for walking and then weaned off of it after approximately seven days.While on vacation he followed his exercise program carefully.  He returned to The Stone Clinic the following month for another exam by Dr. Stone and a "tune-up" from physical therapy.  He experienced some minor swelling from a misstep on a staircase, but was otherwise feeling good.  The physical therapist did soft tissue mobilization to decrease the swelling and eliminate any unwanted scar tissue areas.  His exercise program was revised to include more aggressive bike riding and swimming as well as some challenging trunk stabilization exercises and a full lower body workout referred to as "The Matrix."  Eight weeks later, he came in for his "Sports Test."  This was a test comparing the strength, endurance, coordination, and mobility of his surgical leg to his non-surgical leg. He passed with flying colors, and therefore, was given a new set of even more aggressive exercises that included tennis simulation.  He was allowed to start hitting tennis balls with the ball machine after two weeks with this new program.  His shoe wear was evaluated and he was told the importance of keeping fresh shoes that fit well and are made for his foot type.  He was also encouraged to put additional shock absorbing material (sofsoles) into his shoes.   He did his homework and a month later, he returned once again for yet another, even more challenging sports test.  He did very well and was taught the final phase of his rehabilitation, which included more dynamic stretches, exercises, and an increase in tennis drills. 

As with all patients, it was emphasized to him that if he wants to preserve his knee, his training would never be officially "over."  He knows he must keep his weight down, stay flexible, and limit the overall amount of high impact activity on his knees.