Correction of leg axis malalignment

• Helps prevent excess strain and premature osteoarthritis
• Realignment osteotomy of the femur or tibia

Specialised, modern joint replacement surgery

• Only damaged areas of the joint are replaced (resurfacing)
• A natural joint feel with unicompartmental knee replacements
• Computer-assisted navigation for severe deformities
• Surface replacement for the most advanced osteoarthritis

Individual treatment based on the underlying cause

• Microfracture for very small defects
• Advanced cartilage transplantation (ACT)
• Cartilage regeneration for large defects
• Transplantation of osteochondral cylinders (OATS)

Securing stability and function

• Ligament reconstruction using the patient’s own tendons
• Refixation of ligament avulsions close to the bone
• Anatomical anterior and posterior cruciate ligament reconstruction
• Treatment of multi-ligament injuries

Preserving healthy meniscal tissue to maintain your mobility

• Gentle arthroscopic partial removal of obstructions
• Meniscal repair and refixation
• Implantation of a meniscal substitute (CMI)

Correction of instability and maltracking

• Ligament stabilisation (MPFL reconstruction)
• Creation of a normal trochlear groove (trochleoplasty)
• Bony correction of abnormal patellar tracking

For every surgical procedure, the basic principle is to preserve as much healthy tissue as possible. In joint replacement surgery in particular, even the best implant cannot match the patient’s own joint. A gentle procedure that follows this principle is partial knee replacement, also known as a unicompartmental knee replacement. Only the damaged part of the joint is replaced, while the cruciate ligaments are preserved.

At Manhagen, around 50% of knee replacements are partial replacements, compared with only around 5% across Germany. The procedure is technically demanding and requires particular expertise and skill from the surgeon. At the same time, the hospital receives lower reimbursement than for a total knee replacement. Manhagen’s highly qualified surgeons have the freedom to select the procedure that is medically best for each patient.

Despite the good durability of modern implants, a joint replacement may eventually need to be revised, particularly as life expectancy rises. This requires specialist knowledge and particular surgical skill. During revision surgery, the aim is to remove only the old implant wherever possible without damaging the existing bone.

The surgeon must respond to the findings encountered during the operation to secure the new implant in the best possible way. Manhagen’s surgeons have the technical skill and experience this demands.

A tear of the anterior cruciate ligament is one of the most common injuries in sport and leisure activities. A range of techniques has become established over recent decades to restore stability to the knee and prevent premature joint degeneration. These generally replace the torn ligament with one of the patient’s own tendons. Dr Jan Hennings of Klinik Manhagen in Großhansdorf explains that there is another approach. He reconstructs the original cruciate ligament, preserving the joint’s natural characteristics as fully as possible.

Dr Hennings, why do we need the cruciate ligament?

Dr Hennings: The cruciate ligament ensures that the thigh bone and shin bone can move against one another only within very narrow limits. When it tears, the knee loses stability and develops what is known as the drawer sign. If this instability is not corrected, it usually affects more than walking. Over the long term, it also causes wear of the articular cartilage and therefore osteoarthritis of the knee. In the past, surgery was often recommended only for athletes because of the joint’s reduced function. Today, reconstruction is generally the aim.

Most patients today undergo cruciate ligament reconstruction: the torn ligament is removed and replaced with a graft from the patellar, hamstring or quadriceps tendon. You repair the torn ligament instead. How does that work?

Dr Hennings: With the technique we use, the ligament is repaired arthroscopically. This keyhole method, requiring only a few small incisions, is adapted from shoulder surgery. A woven suture is passed through the stump of the torn ligament, which is then reattached at its anatomical centre using bone anchors measuring only 4.5 mm. We also stimulate the ligament stump to encourage stem cells to migrate into the defect, helping the repair to become integrated with new tissue as quickly as possible. This principle is already familiar from the “healing response” technique. In that procedure, however, the torn ligament is not sutured but simply placed in its anatomical position while the leg is immobilised in extension with a brace. This is not necessary with the method we use.

What are the advantages of this approach?

Dr Hennings: Because we do not replace the cruciate ligament, the synovial sheath around it, including all its blood vessels and proprioceptors, is preserved. Patients retain their intuitive coordination and reaction ability, which otherwise has to be retrained with considerable effort. Following conventional cruciate ligament reconstruction, elite athletes in particular need a long period of training to return to their previous form, partly because of this “learning phase”. By contrast, most patients treated with our repair technique report that the knee feels “like it used to” after only a short time and that they do not experience uncertainty in everyday life. Another advantage is substantially faster rehabilitation than after cruciate ligament replacement. Sporting ability is usually restored after only six months. With other techniques, bony integration can take up to a year and complete synovial healing of the graft up to two years.

Which patients are suitable for this procedure?

Dr Hennings: We assume that, in the best-case scenario, between...

Some knee procedures can be performed as outpatient surgery. Whether this is appropriate depends on the procedure, any underlying conditions and the support available at home.

The menisci are two crescent-shaped discs of cartilage in the knee. They act as shock absorbers between the upper and lower leg, stabilise the joint and protect the cartilage. They are therefore essential for smooth, pain-free movement.

Causes

A meniscal tear can have different causes:

• Acute injuries, often during sport or as part of a combined injury such as a cruciate ligament tear
• Degenerative changes caused by long-term overloading, for example through:
  • Excess weight
  • Frequent work in a squatting position
  • Abnormal leg alignment

Because degenerative damage often develops gradually, accompanying cartilage damage is not uncommon.

Symptoms

Typical symptoms of meniscal damage include:

• Pain around the joint line
• Symptoms during bending or loading
• Increasing pain after prolonged activity

Warning signs include:

• Locking of the knee
• A sudden feeling of the joint catching, with restricted ability to straighten it

These symptoms may indicate a bucket-handle tear, which should be treated promptly.

Treatment options

Treatment depends on the type and extent of the damage:

Conservative treatment

A degenerative meniscal tear can often initially be treated without surgery, for example with:

• Rest and carefully managed physical load
• Physiotherapy
• Pain management

Surgical treatment

If symptoms persist, the knee locks or the tear is extensive, arthroscopic surgery may be appropriate.

During the procedure, the meniscus is:

• Repaired with sutures where possible, in order to preserve it
• Or trimmed with a partial resection if repair is not possible

The guiding principle is that preserving the meniscus has the highest priority because it performs an important protective function in the knee.

Personal advice

During our knee surgery consultation, we provide comprehensive advice on the treatment options suitable for you. Our aim is to relieve pain, preserve knee function and prevent further damage.

The cruciate ligaments form the central pillar of the knee joint and are essential to its stability. Injuries to the posterior cruciate ligament are rare, whereas a tear of the anterior cruciate ligament, or ACL, is one of the most common ligament injuries.

The injury typically occurs during sports such as football, skiing or tennis. Common mechanisms include twisting the knee while the foot remains firmly planted or a direct force, for example from another player.

Associated injuries frequently affect the menisci and collateral ligaments. The combination of an anterior cruciate ligament tear with injuries to the medial collateral ligament and medial meniscus is known as the unhappy triad.

Symptoms and consequences

Once the acute pain and swelling have subsided, instability of the knee joint is generally the main problem. A typical symptom is known as giving way, when the knee suddenly buckles and may cause renewed pain or a fall.

This instability:

• makes it more difficult to return to sport
• reduces the knee’s capacity for everyday activities
• increases the long-term risk of osteoarthritis

Treatment options

Treatment is selected according to the patient’s age, activity level and individual requirements:

• For young, active patients, surgery is generally recommended
• In middle age, the decision between non-surgical and surgical treatment is made individually

Surgical treatment: ACL reconstruction

The standard surgical treatment is ACL reconstruction. A tendon graft from the patient’s own body is used, usually:

• a hamstring tendon from the back of the thigh
• alternatively, part of the quadriceps tendon

The graft is anchored through small bone tunnels in the knee and takes over the function of the original cruciate ligament. The procedure is performed arthroscopically using minimally invasive techniques. Associated meniscus or ligament injuries can be treated during the same operation.

Revision surgery for recurrent instability

Repeat tears and recurrent instability present a particular challenge. In these cases, a two-stage procedure is often required:

1. The existing bone tunnels are filled with bone graft
2. Once the bone has healed, after approximately four months, a new ACL reconstruction is performed

Additional procedures to stabilise the structures at the sides of the knee are also often necessary.

Individual advice

Our specialist knee surgery clinic provides advice based on the latest scientific evidence. Our aim is to restore the stability, function and load-bearing capacity of your knee as fully as possible.

It is useful when symptoms occur under load, leg alignment or gait is abnormal, or treatment needs to be planned more precisely.

For certain procedures, technology can assist with planning and implementation. The aim is more precise positioning and a controlled surgical process.

Key areas include cruciate ligament injuries, meniscus damage, cartilage conditions, osteoarthritis and symptoms following sports injuries or accidents.

No. The decision depends on the findings, stability, pain, mobility and your personal needs. Conservative options are always considered.