Ski Knee Injury: From ACL Repair to Knee Replacements

It's been over three years since we last talked about skiing and snowboarding ACL injuries with top consultant orthopaedic surgeon, James Lewis. So what has changed and what is the prognosis for skiers and snowboarders with knee pain and injury including knee replacements?

What are the most significant advances in surgery and treatments for ACL injuries in the past three years?

As always medicine advances in leaps. The biggest are an increasing interest and availability of repair - this is stitching the torn cruciate ligament back, and supporting it while it heals. This is repair, rather than the common removal of torn ends and substitution.

We have a greater understanding of which sub-types this works best for - ideally when the anterior cruciate ligament has torn of the femur (thigh bone) rather than in the middle of the ligament. The key advantage is a much quicker recovery, there is nothing removed and seemingly better results - in part because the original stretch receptors are retained. Additional no 'graft' is required (taken) from elsewhere.

The second is a widespread adoption of a lateral extra-articular tenodesis - this takes an extra 10 minutes and uses part of the iliotibial band. It functions a little like a seat belt in that if the newly reconstructed knee is about to rotate leading to re-rupture it prevents the excursion. Simply put it reduces the risk of re-rupture from about 6-7 percent down to 1 percent.

My own observations are that patients seem to have a better outcome with no stretching of the new ACL graft. The downside is the early recovery is a little slower - as there is more surgery initially.

How long between injury and surgery, on average?

In general by the time one has had an MRI, consultation and allowed the soft tissues to settle, six weeks is ideal.

Are ACL replacements still available for over 60s?

Indeed, though uncommon, but they still 'work' in the over 60s.

Now more mature (over 60s) people want to  continue skiing or snowboarding but commonly have knee issues which prevent them. How feasible is it to have a knee replacement(s) and be able to ski / snowboard into old age?

Exercise is key to well-being and longevity. In the UK 89 percent of knee replacement patients are overweight. On the slopes you tend to see more slim older skiers rather than heavy ones.

In general, a normal body weight is key to an active, healthy and long life. The amazing Ski Mojo (a British device too!) will help most mature people ski longer and harder with their own knees. 

It is now considered normal to ski with a knee replacement. Surgeons and engineers become nervous regarding high forces across the knee replacement and thus early failure. Most surgeons are happy for gentle blues and reds. A heavy fall may lead to fracture but this is unusual and most fractures are in non knee replacement patients.

Naturally it makes sense to have insurance in place - may be more so with Brexit (please note the Government advice 'travelling to Europe after Brexit'. If the UK leaves the EU without a deal on 31st October 2019, your EHIC might not be valid anymore.

Some knees are more stable than others. A medial pivot design knee or a Conformis custom knee (96 percent congruent) both have excellent congruity and thus stability - compare this to the 76 percent of common knee replacements. In all knee replacements.

I would recommend wearing a simple neoprene knee sleeve, which will increase the feedback from the tissues around the knee - something called proprioception. If you close your eyes and someone moves one of your joints you can generally tell where it is. These sensors are lost in knee replacement. A neoprene knee sleeve helps make up the deficit and thus the fine control of movement.

Partial or full knee replacement (which is most common)?

Ninety-one percent are total knee replacements and 9 percent are partial. We get amazing data from the National Joint Registry. The total knees last longer and are much better than they used to be. In my view there is still a very good role for a partial knee in a slim male with slight or moderate bowing of the knee.

How many over 60s have knee replacements these days compared to, say, five years ago! How 'bullet-proof' is a knee replacement (ie will it last a long time and allow you to continue to be active)?

Generally as the population gets heavier, arthritis comes on earlier- thus the average age is coming down.

A good knee replacement  transforms lives. Patient satisfaction varies widely, in part because of the design of the knee and in part how it is 'implanted'.

A well implanted good quality knee would be expected to function well at 15 years. The data is that 98 percent are in place at 10 years and 95 percent at 15 years. It is fair to say that these are average figures - the 'lasting' percentages are not so good in the 55s or 60s but still good and, considering the alternatives, quite remarkable..

Again it really is worth dropping down to a normal weight for the new knee and perhaps to protect the other knee and hips.

How long does it take on average to get a knee replacement on the NHS in the UK? How much does it cost to go private?

The average wait in my region (West Sussex) is now out to 18 months. This is a real pity after so much work to get the wait down to 18 weeks, but it has drifted. Privately it is two weeks for an off the shelf knee and eight weeks for a custom knee.

Costs are £11k off the shelf and 15K for the custom. 

What should we do to protect our knees so we can ski / snowboard longer?

The number one prevention is a normal weight. The science of weight reduction using in intermittent fasting regime is strong. I favour an 18/6 regime with the six hour eating period (noon to 6pm) being ultra low carb ketogenic diet. It simply works, always and is easy. One's energy shoots up so its a win-win. It is also anti-inflammatory in its own right as it abolishes insulin resistance which is inflammatory to joints.

In the run up to skiing, gluteal and core training are key. I favour a gluteal bridge on a stabilty ball - or a chair if you haven't got one - who does? And clam shells with a theraband. 

If you have the beginnings of knee pain give the Ski Mojo a try - it's simply amazing.

Are you still skiing? How are your knees?

Still living the dream.

Anything else we should know about knee treatments?

Probably ease back on those 'shots' of cortisone - they damage the knee over the long term. One is probably OK but newish data reveals what we have known for a long time. Better injections are platelet rich plasma, which provide growth factors for the knee and may be stem cells in the future but we don't have quite enough data on it yet. 

For more information go to: www.mrjameslewis.co.uk

SKIING LIFE AFTER KNEE INJURY

Both Yvonne and Steve Ray (image below) who regularly spend all season skiing in the French Alps, have knee injuries - arthritis and ruptured ACL respectively. This is how, for them, ski life goes on...along with his 'n' hers knee braces.

YVONNE RAY, 61, PARTIAL KNEE REPLACEMENT

I had a long history of wear and tear, starting in my 20s with a squash accident which broke my knee. In my 30s I had a couple of ski accidents and, as always, you injure the weakest knee! This resulted in arthritis between the patella (knee cap) and the femoral groove.  I got to a stage where I was skiing with a Ski Mojo one day and having to rest for three days for the swelling to go down. I could play squash but not competitively as this also caused swelling prior to my op. Jogging was a no-no. No cycling. Pretty boring stuff really.

I was advised perhaps not to play squash or ski in latter years

Over the years. I had an MRI every few years as the pain increased. I saw more than one consultant both NHS and private. Advice from the consultants was to take pain killers. It was assessed as slow-growing so physio, pain killers and ice when necessary. Only do what my knee would let me. If it got to a stage where it was affecting my quality of life that was when surgery would be an option. I was advised perhaps not to play squash or ski in later years. Yeah right not an option for me.

But, finally, by increasingly restricting my activities, it was affecting my quality of life. Big Time .

I was worried that most consultants did not advise skiing following knee replacement. I contacted Jonathan Bell at Wimbledon Clinics and he saw no reason why I should not carry on an active life after surgery. He actually encouraged it. He recommended the surgeon in Leicester, who was nearer to home and, therefore, an advantagel in case of any infection - and after further tests he felt the patella femoral op would be a good idea as the arthritis was only in the patella and there was no evidence that it would spread after surgery. Job done 10th July 2017 and looking forward to a better life.

 I turned over in bed and had a huge pain in my knee

Recovery was a lot longer than I had anticipated! Six weeks into recovery I turned over in bed and had a huge pain in my knee. The following day my knee would not bend and it was no longer weight-bearing. The physio had no idea what had happened and the consultant was unsure. He advised steroid injection to try to calm the pain down to allow me to continue with the physiotherapy. This appeared to work a little but over the next three months the swelling refused to go down. I saw the consultant in December and it was decided to give it more time.

I have had copious amounts of physio

May 2018 and I was having arthroscopic surgery as my knee became unbearably painful and swollen. They found a piece of cartilage had come away on the tibia. Obviously this happened six weeks after the initial op but had not been picked up. Now a year later I am a lot better but I have been told cartilage does not heal and it may be an on-going problem.

I have had copious amounts of physio, I have swum and cycled (electric bike only to protect the kneecap); walking has been hard but it is getting easier especially with a cartilage rebound brace that I have purchased. And eventually I have skied this season from December as we spend our winters in the French Alps. I was even ski touring in May (images above and below).

STEVE RAY, 62, RUPTURED ACL 

I ruptured my ACL skiing off piste in April, 2018. I damaged ligaments both sides, worn meniscus, to my right knee.

I was advised that If my knee became unstable it would require ACL surgery, but this would be done only as a last resort as this particular operation at my age (61) was not advised by the doctors in France as it could reduce the functionality of the knee permanently. I had Intense physiotherapy. and used a full knee brace during recovery and while participating in impact sports.

I do at least one, sometimes two or three disciplines every day

My biggest concern was that my knee would never be strong enough to continue with my sports. Swimming, gym weights, cycling, walking, running, I do at least one, sometimes two or three disciplines every day and daily specific stretches and exercises. And then there's skiing, which I do all winter in the French Alps (with wife Yvonne above), including plenty of sidecountry off piste.

Around 10-12 months later and my knee felt stronger and I started to feel more confident using it, I still used a brace when skiing last wnter and now feel I'm at a similar ability, prior to my accident. 

I worry I may twist my knee and undo all the good work

However, sometimes my knee feels ratcheted (although less often now) and my left knee can be painful after exercising, I assume this is due to favouring my left knee over the last 14 months.

In general I feel strong and fit but I worry I may twist my knee and undo all the good work. However, I've bought new wider freeride skis Rossignol Soul 7 HDs with Salomon Shift (toe release Alpine touring bindings, better for knees) and Scarpa Maestrale touring boots after ski touring for the first time in May (see ski blog) so, this winter 2019/20 I fully intend to hit the backcountry.