Orthopedic Surgeries

A list of all Bone Surgeries

Orthopaedic Surgery of Bones

Arthroscopy (also called arthroscopic or keyhole surgery) is a minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope, an endoscope that is inserted into the joint through a small incision.

Arthroscopy (also called arthroscopic or keyhole surgery) is a minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope, an endoscope that is inserted into the joint through a small incision.

Total joint replacement is a surgical procedure in which parts of an arthritic or damaged joint are removed and replaced with a metal,plastic or ceramic device called a prosthesis. The prosthesis is designed to replicate the movement of a normal, healthy joint.

Total joint replacement is a surgical procedure in which parts of an arthritic or damaged joint are removed and replaced with a metal, plastic or ceramic device called a prosthesis. The prosthesis is designed to replicate the movement of a normal, healthy joint. Hip and knee replacements are the most commonly performed joint replacements, but replacement surgery can be performed on other joints, as well, including the ankle, wrist, shoulder, and elbow. Several conditions can cause joint pain and disability and lead patients to consider joint replacement surgery. In many cases, joint pain is caused by damage to the cartilage that lines the ends of the bones (articularcartilage)—either from arthritis, a fracture, or another condition. If nonsurgical treatments like medications, physical therapy, and changes to your everyday activities do not relieve your pain and disability, your doctor may recommend total joint replacement. Recovery and rehabilitation will be different for each person. Most patients will experience some temporary pain in the replaced joint because the surrounding muscles are weak from inactivity, the body is adjusting to the new joint, and the tissues are healing. This pain should resolve in a few months. Exercise is an important part of the recovery process. Physical therapist will provide you with specific exercises to help restore movement and strengthen the joint.

Inflammation is one of your body’s normal reactions to injury or disease. In an injured or diseased shoulder joint, inflammation causes swelling, pain, and stiffness. Injury, overuse, and age-related wear and tear are responsible for most shoulder problems.

Shoulder surgeries

Inflammation is one of your body’s normal reactions to injury or disease. In an injured or diseased shoulder joint, inflammation causes swelling, pain, and stiffness. Injury, overuse, and age-related wear and tear are responsible for most shoulder problems. Shoulder arthroscopy may relieve painful symptoms of many problems that damage the rotator cuff tendons, labrum, articular cartilage, and other soft tissues surrounding the joint.
Common arthroscopic procedures include:
 Rotator cuff repair
 Bone spur removal
 Removal or repair of the labrum
 Repair of ligaments
 Removal of inflamed tissue or loose cartilage
 Repair for recurrent shoulder dislocation
Surgery to repair a torn rotator cuff most often involves re-attaching the tendon to the head of humerus (upper arm bone). A partial tear, however, may need only a trimming or smoothing procedure called a debridement. A complete tear is repaired by stitching the tendon back to its original site on the humerus. Medications are often prescribed for short-term pain relief after surgery. Rehabilitation plays a vital role in getting you back to your daily activities. A physical therapy program will help you regain shoulder strength and motion. Immobilization. After surgery, therapy progresses in stages. At first, the repair needs to be protected while the tendon heals. To keep your arm from moving, you will most likely use a sling and avoid using your arm for the first 4 to 6 weeks. How long you require a sling depends upon the severity of your injury. Passive exercise. Even though your tear has been repaired, the muscles around your arm remain weak. Once we decide it is safe for you to move your arm and shoulder, a therapist will help you with passive exercises to improve range of motion in your shoulder. Active exercise. After 4 to 6 weeks, you will progress to doing active exercises without the help of your therapist. Moving your muscles on your own will gradually increase your strength and improve your arm control. At 8 to 12 weeks, your therapist will start you on a strengthening exercise program. Most patients have a functional range of motion and adequate strength by 4 to 6 months after surgery.

Shoulder Arthritis
In severely painful shoulder due to arthritis it may require a partial or complete shoulder replacement surgery.

Modalities of treatment for Low Back Pain

Conservative Treatments

The vast majority of symptoms related to spinal conditions can be treated conservatively with relative rest, education, activity, and/or work modification, bracing, medication, and/or active physical rehabilitation. These measures are almost always incorporated into the treatment program of spinal conditions as they empower patients to be proactive with acute management and can be crucial in achieving long-term success.

Activity Modification

Short periods of relative rest and/or restriction or modification of certain activities may be prescribed depending on any given patient’s diagnosis and unique work or lifestyle.

Orthotics (Braces)

Bracing may be required for certain types of spinal conditions, most commonly to stabilize spinal fractures post-operatively.

Passive Rehabilitation

The utilization of heat, ice, mild electrical stimulation, ultrasound, relaxation techniques, pool therapy, etc. may be recommended for certain spinal conditions and commonly associated adjuvant conditions.

Medication

Medication may be utilized to assist in pain tolerance, muscle spasm control, and sleep deprivation in order to facilitate physical rehabilitation and functioning.

Physical Rehabilitation

Diagnosis-specific physical therapy programs are commonly prescribed with a physical therapist who has expertise in the rehabilitation of spinal conditions to help maximize patient function and return to an active lifestyle. This includes Exercise programs and Yoga therapy protocols.

Minimally Invasive procedures

Facet injection

A facet injection is a minimally invasive procedure that can temporarily relieve neck or back pain caused by inflamed facet joints. The cause of facet joint pain (arthritis, injury, degeneration) is not well understood and can be similar in nature to disc pain. The procedure has two purposes. Firstly, as a diagnostic test to see if the pain is actually coming from your facet joints. Secondly, as a treatment to relieve inflammation and pain caused by various spine conditions. The effects of facet injections tend to be temporary, providing relief for several days or even years.

 

Epidural steroid Injections

An epidural steroid injection (ESI) is a minimally invasive procedure that can help relieve neck, arm, back, and leg pain caused by spinal stenosis, arthritis, or disc herniation. A long-lasting corticosteroid and a numbing medicine are injected near the inflamed spinal nerves to reduce swelling and pain. The effects tend to be temporary. Pain relief may last for several days or even years. Injections can be repeated up to three times a year.

Lumbar Root Blocks

A lumbar nerve root block is performed for pain that is caused by an irritated nerve root. The aim of the procedure is to reduce the inflammation of the nerve root and also to block the pain impulse from travelling up the nerve to the brain. This will then bring partial or complete (but usually temporary) relief of the pain.

The reason why your specialist performs this procedure is to first of all correctly diagnose whether this nerve root is causing the pain that is felt in the leg and secondly to bring temporary relief from the pain. It is the usual practice to use a mixture of long-acting local anaesthetic and steroids when injecting around the nerve root.

Nucleoplasty

Nucleoplasty or Percutaneous Discectomy is a procedure utilized for the treatment of chronic back pain caused by a contained herniated disc. This minimally invasive procedure uses a needle that is placed into the center of the disc where a series of channels are created to remove tissue from the nucleus. The needle is inserted into the herniated disc under x-ray guidance and a special type of radiofrequency energy field called coblation, or controlled ablation, creates channels within the center of the herniated disc allowing for the herniated portion to resorb back to fill the channel via a negative pressure effect and relieve the pressure on the spinal nerve. IV pain medication is given throughout the procedure to control discomfort.Tissue removal from the nucleus acts to decompress the disc and relieve the pressure exerted by the disc on the nearby nerve root.

Prolapsed Intervertebral disc causing Low back pain & Leg pain

If back and leg pain does not respond to nonsurgical treatment and continues for six weeks or longer, the physician may prescribe diagnostic tests, such as X-ray imaging, MRI or a CT scan, to verify the source of the pain. If a diagnosis of herniated disc is confirmed, open discectomy may be recommended.

Open discectomy

Open discectomy is the most common surgical treatment for rupturd or herniated discs of the lumbar spine. When the outer wall of a disc, the annulus fibrosus, becomes weakened, it may tear allowing the soft inner part of the disc, the nucleus pulposus, to push its way out. This is called disc  herniation, disc proplapse or a slipped or bulging disc. Once the inner disc material extends out past the regular margin of the outer disc wall, it can press against very sensitive nerve tissue in the spine. The disc material can compress or even damage the nerve tissue, and this can cause weakness, tingling or pain in the back area and into one or both legs. Open discectomy uses surgery to remove part of the damaged disc and thus to relieve the pressure on the nerve tissue and alleviate the pain. The surgery involves a small incision in the skin over the spine, removal of some ligament and bone material to access the disc and the removal of some of the disc material.

Microdiscectomy

Microdiscectomy, also called microlumbar discectomy (MLD), is a very common MIS decompression procedure performed in patients with a symptomatic lumbar herniated disc.     A 1- to 2-cm longitudinal incision is made in the midline of the lower back, directly over the area of the herniated disc. Special retractors and an operating microscope are used to visualize the region of the spine, with minimal or no cutting of the adjacent muscles and soft tissues. After the retractor is in place, an x-ray is used to confirm that the appropriate disc is identified. A small amount of bone of the superior lamina may be removed first to expose the disc herniation. The nerve root and neurologic structures are protected and carefully retracted so that the herniated disc can be removed. Surrounding areas are checked to ensure that no additional disc fragments are remaining. This procedure typically takes about 1 hour to perform.

Minimally invasive discectomy

Microsurgical discectomy is a procedure to remove a herniated disc and bone spurs in the spine. A 1-inch incision is made into one side of your back. The muscles are gradually dilated with increasingly larger tubes to form a tunnel to the spine. Through this tunnel, the ruptured portion of the disc is removed along with any bone spurs pinching the nerve. The entire disc is not removed. Your doctor may recommend a discectomy if physical therapy or medications fail to relieve your leg, arm or back pain. Patients go home the next day.

Spinal decompression (laminectomy)

Spinal decompression (laminectomy) is a surgery to remove the bony overgrowth caused by spinal stenosis. The incision is made in the back of the spine. The arched portion of the bone (lamina) is removed to expose the spinal cord. Thickened ligaments and bone spurs are also removed. The overgrown facet joints may be trimmed to give more room for the spinal nerves. One lamina (single-level) or more (multi-level) may be removed. Decompression does not cure spinal stenosis nor eliminate arthritis; it only relieves the symptoms. The surgery can be performed in an open or minimally invasive technique.

Preparing for spinal fusion

Spinal fusion is a surgical procedure performed to permanently join together one or more bony vertebrae. It will stop the motion in the painful area of your spine allowing you to return to a more normal lifestyle—though one that may not be totally pain-free. Because back pain responds well to physical therapy and exercise, make sure you have done your part toward a successful rehabilitation before considering surgery. What you do before and after surgery can help get you back on your feet sooner. It’s important to have realistic expectations and prepare properly for your recovery.

Transforaminal Lumbar Interbody Fusion

Transforaminal Lumbar Interbody Fusion (TLIF) is a minimally invasive surgery to permanently join together one or more bony vertebrae of the spine. A 1-inch incision is made in the lower back. The muscles are gradually dilated (widened) with increasingly larger tubes to form a tunnel to the spine. Through this tube, the damaged disc is removed and a bone graft is inserted into the empty disc space. Over time, new bone growth will fuse the two vertebrae together. The surgery is done without splitting the back muscles, takes 1 to 2 hours, and patients often go home the in two days.

Dynamic Intervertebral stabilization : DIAM

The DIAM™ (Device for Intervertebral Assisted Motion) Spinal Stabilization System provides flexible support of the lumbar spine while treating spinal degeneration.

Potential benefits of the DIAM™ Spinal Stabilization System:

  • Provides an alternative to spinal fusion
  • Fits between the interspinous processes and functions as a shock absorber that reduces loads on the surrounding vertebrae
  • Only requires a small incision to implant, which can reduce scarring, shorten surgery time and decrease recovery time

Spinal Operations for deformity

Spondylolisthesis

 

When pain from spondylolisthesis does not diminish with conventional treatment methods, such as physical therapy or a back brace, spinal fusion surgery may be your best option. Some cases of isthmic and degenerative spondylolisthesis that do not respond to nonsurgical forms of treatment respond well to spinal fusion surgery, which can help reduce your pain and other symptoms. Isthmic spondylolisthesis. occurs when a vertebra slips out of position due to spondylolysis—a condition that causes spinal fractures. Degenerative spondylolisthesis occurs when one or more spinal bones move out of position as they weaken with age.There are several types of spinal fusion surgery available to treat spondylolisthesis. The aim of these procedures is to stabilize your spine and reduce pain.

Posterior Fusion

During this type of spinal fusion surgery, your surgeon will approach the affected area from the back. A piece of your pelvic bone will be removed and placed between your slipped vertebrae, allowing them to fuse to the spine and form a stable piece of bone.

Posterior and Transforaminal Lumbar Interbody Fusion

This type of spinal fusion surgery involves approaching the affected area through the lower back, although the surface area is limited when using this technique. Posterior transforaminal fusion is best used to treat localized spondylolisthesis located in the lower back.

Anterior Lumbar Interbody Fusion

This type of spine surgery involves approaching the affected area of your spine through the abdomen, which offers a larger surface area for the procedure. Anterior fusion surgery is usually preferred for treating spinal deformities caused by isthmic spondylolisthesis. Like posterior spinal fusion surgery, anterior fusion involves placing a piece of pelvic bone between spinal bones and allowing them to fuse to your spine.

Spinal Operations for fractures

Vertebroplasty / Kyphoplasty

Vertebroplasty and kyphoplasty are minimally invasive surgeries performed to treat vertebral compression fractures (VCF) of the spine. These fractures, which can be painful and limit mobility, are often caused by osteoporosis, spinal tumors, and injury. Traditional treatments of bed rest, pain medication, and braces are slow to relieve the pain. By injecting bone cement into the fractured bone and restoring the vertebra height, these procedures offer patients faster recovery and reduce the risk of future fractures in the treated bone. Kyphoplasty, involves an added procedure performed before the cement is injected into the vertebra. Through small stab incisions, the bone is drilled and one balloon (called a bone tamp) is inserted on each side. The two balloons are then inflated with contrast medium (which are visualized using image guidance x-rays) until they expand to the desired height and removed. The spaces created by the balloons are then filled with the cement. Kyphoplasty has the added benefit of restoring height to the spine.

Fixation of Thoraco-lumbar fractures

 

Fracturing can be due to any number of causes, including osteoporosis, but is often associated with violent impacts such as those experienced in automobile and motorcycle accidents, as well as in falls from heights. Compression fractures must be treated correctly to avoid severe complications that include possible paraplegia. In most instances, lumbar spine fractures will require immobilization and stabilization. Depending on the severity and location of the damage, this can be done with plates and pedicle screws, as well as hooks and wires. In all instances, the goal is to fuse the bone fragments together.

Scoliosis Correction

 

Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty. While scoliosis can be caused by conditions such as cerebral palsy and muscular dystrophy, the cause of most scoliosis is unknown. Severe scoliosis can be disabling. An especially severe spinal curve can reduce the amount of space within the chest, making it difficult for the lungs to function properly.

Children who have mild scoliosis are monitored closely, usually with X-rays, to see if the curve is getting worse. In many cases, no treatment is necessary. Some children will need to wear a brace to stop the curve from worsening. Others may need surgery to keep the scoliosis from worsening and to straighten severe cases of scoliosis.

 

Most scoliosis surgeons agree that children who have very severe curves (45-50° and higher) will need surgery to lessen the curve and prevent it from getting worse.

The operation for scoliosis is a spinal fusion. The basic idea is to realign and fuse together the curved vertebrae so that they heal into a single, solid bone.

With the tools and technology available today, scoliosis surgeons are able to improve curves significantly.

Osteoarthritis is a slowly progressive degenerative condition affecting the knee joint cartilage and the underlying bone and resulting in gradual loss of the articular or chondral cartilage covering the knuckles of the knee. In its most severe forms the covering cartilage is lost completely allowing the bare knuckles to rub together during normal standing and walking, and producing the bone on bone contact sometimes visible on plain x-rays.  The underlying bone gradually stiffens and produces projections or buttresses at the margins of the joint called osteophytes, and these bony lumps can sometimes be felt beneath the skin.

Knee rehabilitation & Bracing

 

Treatments

Injections: Synvisc-One® (hylan G-F 20) is a viscosupplement injection. Made from a natural substance that lubricates and cushions your joint, it can provide up to six months to one year of knee pain relief with just one injection.

 

 

Arthroscopic Debridement : Knee arthroscopy can be done in lower grade osteoarthritis to remove degenerate meniscus or fibrillated cartilage. This gives pain relief to many patients for few years before a knee replacement surgery is contemplated.

 

Total Knee replacements

If nonsurgical treatments like medications and using walking supports are no longer helpful, you may want to consider total knee replacement surgery. Joint replacement surgery is a safe and effective procedure to relieve pain, correct leg deformity, and help you resume normal activities.  Severe osteoarthritis is the commonest indication for knee replacement.

I have performed more than 400 successful total Knee replacement surgery. Most of my patients are doing well. The youngest patient to have had TKR was 40years and oldest was 85years old.

Why do you need Knee Replacement Surgery

  • Severe knee pain or stiffness that limits your everyday activities, including walking, climbing stairs, and getting in and out of chairs. You may find it hard to walk more than a few blocks without significant pain and you may need to use a cane or walker
  • Moderate or severe knee pain while resting, either day or night
  • Chronic knee inflammation and swelling that does not improve with rest or medications
  • Knee deformity — a bowing in or out of your knee
  • Failure to substantially improve with other treatments such as anti-inflammatory medications, cortisone injections, lubricating injections, physical therapy, or other surgeries
Realistic Expectations

  • An important factor in deciding whether to have total knee replacement surgery is understanding what the procedure can and cannot do.
  • More than 90% of people who have total knee replacement surgery experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living. But total knee replacement will not allow you to do more than you could before you developed arthritis.
  • We advise against  high-impact activities such as running, jogging, jumping, or other high-impact sports for the rest of your life after surgery.
  • Realistic activities following total knee replacement include unlimited walking, swimming, golf, driving, light hiking, biking, ballroom dancing, and other low-impact sports.
  • With appropriate activity modification, knee replacements can last for many years.

 

Failed Knee Replacement Surgery

All knee replacements contain a polythene bearing, and over a period of many years wearing of this bearing results in the accumulation of tiny fragments of polythene debris within the knee joint.  This causes a chronic inflammation, softening and damaging the supporting bone and eventually resulting in loosening of the replacement, which is the commonest mode of failure. Occasionally the polythene bearing collapses completely allowing the metal running surfaces to wear directly against each other releasing metallic debris, and very occasionally the replacement itself or the supporting bone cracks or fractures. Other causes of failure include deep infection or instability of either the knee cap joint or the knee joint itself.

 

Revision Knee Replacement

Most people who have a knee replacement have excellent relief of pain and a restoration of their quality of life. However, some people develop pain, or problems with their knee replacement that requires further surgery. This may be due to wearing of the bearing surfaces, loosening of the components, or infection. In this event you may need a revision of your knee replacement. If you are having trouble with your knee following a total knee replacement, Dr Debnath will assess, and advise you or your options regarding a revision knee replacement, and whether this is appropriate.

Whilst over 90% of people undergoing a total knee replacement have a good to excellent result, there are always potential problems which may complicate your recovery. Knee replacement surgery is major surgery, and while every effort is taken to minimize the risk of surgery, complications can still occur.

Patello femoral conditions

Anterior Knee Pain

Anterior knee pain usually develops because of pathology developing in the kneecap or patellofemoral joint.  Less commonly it can also arise in any part of the mechanism responsible for straightening the knee against resistance, including the tendons above and below the kneecap, and the bone to which they are attached.  In the vast majority of cases symptoms are relatively mild and precipitated by certain types of exercise, particularly exercise involving lunging or stepping.  After appropriate investigation, treatment usually consists of activity modification, specific patellofemoral physiotherapy (sometimes including the use of tape applied to the skin around the knee), and in selected cases the use of contoured orthotic insoles.   Surgical treatment is rarely required.

Patellar Tendinitis

Patella tendonitis is an inflammation of the patella tendon close to its insertion into the bottom of the kneecap, and results in the development of anterior knee pain, usually fairly well localised to the kneecap and adjacent patella tendon, and reliably exacerbated by activity.  The diagnosis is usually confirmed by medical imaging (MRI scan) and the condition usually responds to conservative treatment consisting of specific physiotherapy exercises including eccentric quadriceps contractions.  In rare cases or cases resistant to conservative treatment, and particularly when inflammation is associated with the presence of a spike of bone irritating the tendon, surgical treatment may be required which is usually undertaken arthroscopically.

Arthroscopy

An arthroscopy is a procedure on the knee when a small camera is inserted to allow the surgeon to see. The advantage of this surgery is that the operation can be performed through small stab incisions(<1cm), rather than long arthrotomy incisions (generally >10cm). By doing surgery arthroscopically your recovery time and pain is less, and operative risks are reduced. The knee is able to be examined in greater detail, and throughout the entire knee, something that cannot be done with conventional surgery.

Procedures that can typically be treated arthroscopically include :
Meniscal tears
Chondral lesions/ Ostechondritis dessicans
Removal of loose bodies
Washout of inflamed or infected joints
Synovectomies
Anterior and Posterior Cruciate Ligament Reconstructions

Knee arthroscopy is performed as a day case procedure. It is performed under a light general anaesthetic or spinal anaesthetic, with the patient being able to go home later the same day. You are able to walk on your operated leg as tolerated, but you will be supplied with crutches if needed. You will be encouraged to rest at home for the first three days after your operation, and to ice your knee regularly. Ice will help control your swelling, control your pain, and improve your recovery. After three days, your compression bandage can be removed, leaving the underlying waterproof dressings intact until reviewed by Dr Debnath- typically two weeks post-operatively. While the wounds from surgery are usually well healed by two weeks, tissue healing within the knee may continue for 4-6 weeks, depending on the surgery undertaken.

Meniscal trimming or Repairs

A meniscus tear is a common injury to the cartilage that stabilizes and cushions the knee joint. The pattern of the tear can determine whether your tear can be repaired. Radial tears sometimes can be repaired, depending on where they are located. Horizontal, flap, long- standing, and degenerative tears-those caused by years of wear and tear-generally cannot be repaired. Your age, your health, and your activity level may also affect your treatment options. In some cases, the surgeon makes the final decision during surgery, when he or she can see the how strong the meniscus is, where the tear is, and how big the tear is.

 

  • If you have a small tear at the outer edge of the meniscus (in what doctors call the RED ZONE), you may want to try home treatment. These tears often heal with rest.
  •  If you have a moderate to large tear at the outer edge of the meniscus (RED ZONE), you may need surgical repair. These kinds of tears tend to heal well after arthroscopic or open surgery.
  •  If you have a tear that spreads from the red zone into the inner two-thirds of the meniscus (called the WHITE ZONE), your decision is harder. Repair may not work. Trimming of the torn meniscus is required.
  •  If you have a tear in the WHITE ZONE of the meniscus, and its causing symptoms then it is better to do trimming of the torn meniscus.

Knee Reconstruction

Anterior Cruciate Ligament reconstruction

The anterior cruciate ligament is one of the major ligaments stabilising your knee. Unfortunately, it is also one of the most common ligaments to be injured. It is an essential stabiliser of the knee when running and turning at speed, or cutting or twisting activities are performed. It is commonly injured during sports e.g. football or rugby. A knee reconstruction involves the replacement of the torn ligament with a “new” one. This typically comes from a couple of hamstring tendons or patellar tendon grafts. A Knee reconstruction will give you a 90% chance of returning to the level of activity you were at before your injury.

The surgery is done through arthroscopy (key hole surgery). The operative procedure takes approximately 1 hour.

Initial Post-Operative period

After surgery you will have an ice pack applied to your leg in recovery. This helps with pain, and swelling. You will be encouraged to use ICE intermittently for the first week after your surgery as it help with pain and swelling. Physiotherapy commences immediately to regain quadriceps strength, and assist you with mobilisation.

A splint which maintains your knee in extension is applied for two weeks, after which it is removed, and with the assistance of a physiotherapist, range of movement is regained. During this period you are able to fully weight bear on your operated leg.

Most patients will be discharged 48 hours after surgery.

Post-operative Rehabilitation

Ongoing physiotherapy is an essential part of your recovery. An intensive programme will be undertaken until you regain a full range of motion and good quadriceps strength. A gradual return of activities is encouraged as your new graft becomes incorporated, and regains its strength.
As a guide, walking, cycling and swimming are allowed, as soon as the wounds are healed (2 contact sports, or those requiring twisting, or cutting movements is allowed at 12 months post- operatively.weeks). Jogging is allowed at 3 months, with light sporting activities at 6 months. Return to contact sports, or those requiring twisting, or cutting movements is allowed at 12 months post-operatively.

 

Posterio Cruciate ligament reconstruction

The posterior cruciate ligament, or PCL, is one of the main ligaments in the knee and injury to this ligament may be seen in a variety of settings. In general, most partial or isolated PCL tears can be treated non-operatively because the PCL, with its synovial covering, has some ability to heal. However, surgical reconstruction is usually recommended for PCL tears that occur in combination with other ligament tears of the knee. It is usually recommended that acute PCL tears in combination with and ACL, posterolateral corner, or MCL complex tears be reconstructed within the first three weeks of injury. In rare occasions, the PCL may be repaired when it occurs as a peel off or bone avulsion injury. In patients with chronic PCL injuries, who are symptomatic for pain and instability, reconstruction may be indicated.

Arthroscopic assisted or open PCL reconstructions involve removing the remaining native PCL. Once the tunnels are drilled, sharp edges and soft tissues around the tunnel exit site are smoothed off with the use of a rasp. The graft is then passed into the joint and fixed in its femoral tunnel (usually with a cannulated interference screw). The graft is then tensioned distally while the knee is cycled several times to remove any slack in the graft. The graft is then fixed to the tibia, usually with staples, while the knee is flexed to 90º, distal traction is placed on the graft, and an anterior force is applied to the tibia.

Rehabilitation

Postoperatively, it is recommended that the patient remain in full extension for a period of 2 to 4 weeks for isolated PCL reconstructions. In multiligament reconstructions, the patient is often placed into a continuous passive motion (CPM) machine for range of motion. Patients are non weight bearing with quad sets and straight leg raises in the immobilizer only started the 1st postoperative day. It is especially important for PCL reconstruction patients to not have any posterior sag of their tibia which would stretch out the graft. Pillows or other support under the tibia is required for the first two months after surgery. After 8 weeks, weight bearing is initiated and more active rehabilitation is started.

Articular Cartilage Repair Surgery (Stem Cell or Cartilage cell transplant)

Indication and Procedure Description

This procedure is indicated for those patients who have an isolated full thickness articular cartilage defect in the knee, which is causing symptoms such as pain and clicking. This injury is generally from an acute injury, but can also occur over time, due to repeated injuries. The knee is generally swollen and pain is located over the site of the cartilage injury. It is not a suitable procedure for established osteoarthritis as yet.

The procedure involves taking a biopsy (sample) of the healthy cartilage from the knee through an arthroscopy (keyhole surgery). The size of the defect will also be assessed at this time. Depending on the size of the defect it is decided whether a stem cell implantation or a cartilage cell implantation is required. If Stem cell implantation is performed then it could be done under the same surgery with a prior consent. If the defect is large (approximately 2cm) and required cartilage cell transplant then a biopsy is done followed by processing in a laboratory. The cartilage cells will be cultivated in a matrix and this takes approximately four to six weeks. Once the matrix or cartilage is ready, it will then be re-implanted. The re-implantation occurs through an arthrotomy where the joint is opened through a small incision to allow accurate placement of the cartilage graft.

Pre-operative Preparation

After a thorough clinical assessment of the joint, the patient will generally have plain X-rays and an MRI scan of the knee to help accurately assess the location and size of the cartilage defect. At times, the patient may have previously had an arthroscopy. A range of motion brace will be organised prior to the surgery and this will restrict the joint movement and protect the cartilage graft.

HOSPITAL STAY

The initial arthroscopy for the biopsy is preformed as a day surgery procedure. The implantation surgery requires a hospital stay of two to three days. The procedure is usually performed under a general anaesthetic and supplemented with a femoral nerve block to help the post-operative pain.

Post-operative Care

Knee brace. A knee brace will be required for a period of up to three months, depending on the exact location and size of the cartilage defect. The range of motion that will be allowed in the knee brace will also be determined by the exact location and size of the cartilage defect. Generally the patient's weight bearing is restricted for the first six weeks.

Physiotherapy. This will be commenced immediately and range of motion will also be determined by the exact size and location of the cartilage defect. Initial physiotherapy is concentrated on static quadriceps and hamstring exercises to maintain muscle bulk. The post-operative rehabilitation regime will be coordinated through Dr Debnath and the physiotherapist. nThe patient will be seen at two weeks, six weeks, three months and one year post operatively. Return to sport is generally at one year. Sport specific exercises however can be commenced at six months. There will be no jogging or running unsupervised until six months. Some sports, such as swimming and cycling, can be commenced at six months; however no contact or high impact sport can be played for one year.

 

Medial Patellofemoral Ligament reconstruction

MPFL Reconstruction surgery involves a general or spinal anaesthetic as a day case or overnight stay. The aim of the operation is to rebuild the torn Medial patello-femoral ligament using the hamstring tendon along the same principles as an ACL reconstruction. The procedure is usually performed using arthroscopic assistance and is aimed at replacing the deficient ACL with a graft ligament to stabilise the knee.The semitendinosus hamstring tendon is normally used as the graft to form the new ligament. This graft is taken through a small incision (4cm approximately) over the inner aspect of the shin just below the new.

The tendon is passed through drill hole in the femur and patella so that it lies in the same position as the medial patello-femoral ligament. This requires further small incisions over the femur and inner aspect of the patella. It is held in place with a screw or similar device in the femur and patella.

This procedure recreates an ‘anatomic’ MPFL and is effective in preventing further dislocation inmore than 90% of patients.

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