Search results for: for

Friday, 04 September 2020 13:09

Pre-Surgery Information

The following is what can be expected prior to surgery:

  • Skin preparation: Night prior to and morning of operation patient is required to wash leg, hip and pubic area to the midline with a sponge provided in the pre-admission clinic. Occasionally a Betadine Skin test is used if there is suspicion of an allergy to iodine.
  • Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic. Patient to is required to administer the evening prior to surgery (instruction leaflet given at the pre-admission clinic).
  • Patient education: Physiotherapy assessment will include: instruction of gait training, use of crutches and pre and postoperative exercises. Patient will be fitted for crutches to take home and practice preoperatively.
  • Medications: 
  • Cease aspirin or anti-inflammatory medications 10 days prior to surgery as well as any naturopathic or herbal medications.
  • Anti-inflammatory tablets:  These need to be discontinued one week before the operation  e.g., nurofen, voltaren, celebrex, ibuprofen
  • SGLT2i agents include dapagliflozin (Forxiga), empagliflozin (Jardiance), or a combination with metformin (Xigduo, Jardiamet).Theses drugs should be stopped the two days preoperatively and on the day of surgery. 
  • Panadol, Panadol Osteo and Panadeine are ok to continue
  • Herbal or complimentary medicines:  Any herbal or complimentary supplements which are recommended to be good for the heart or good for the joint generally cause thinning of the blood and therefore bleeding.  Krill oil, fish oil, green lip mussel extract and glucosamine or the like fall into this category. We do ask you to cease these medications approximately one month before surgery or as soon as you book if your surgery if scheduled before this time.  
  • We do however recommend combined Vit D, magnesium and calcium supplement as well as vitamin c supplements.
  • X-rays: We cannot stress enough the importance of taking ALL x-rays, scans and MRI’s applicable to your operation to hospital with you when you are admitted.

Day of Surgery:

Surgical paperwork will be administered by the nurses and the anaesthetist will meet with you to ask a few questions.

A hospital gown will be given and the operation site will be shaved and cleaned.

The area to be prepared extends from the iliac crest (hip bone) laterally down the hip and thigh to the knee (i.e. side of leg only). The pubic/genital region is not touched.

Chlorhexidine skin prep will be applied to above area and wrapped.

All x-rays are to be sent with patient to theatre.

Friday, 04 September 2020 12:17

Complex Revision Hip Replacement

Why consider a hip revision?

The majority of elderly patients who receive a hip replacement retain the prosthesis for 15 to 20 years, sometimes for life. However, some patients may need one or more revisions of a hip replacement particularly if the initial hip replacement surgery is performed at a young age and the patient chooses to have a very active physical lifestyle.

Reasons for hip revision surgery

Revision hip replacement is a relatively infrequent operation. In the United States there are approximately 18 revision hip replacements performed for every 100 hip replacements. The most frequent reasons for revision are:

  • Repetitive dislocation and instability
  • Mechanical failure (implant wear and tear, loosening, breakage)
  • Plastic (polyethylene wear)
  • Infection
  • Osteolysis (bone loss) 

A hip revision can involve part or all of your previous hip replacment needing to be revised and thus the operation varies from minor adjustments to a more significant operation. The surgery can vary from a simple liner exchange to changing one or all of the components of the previous hip replacment. Extra bone (cadavar bone) may be needed to compensate for any bone loss.

Please find below information on hip revision surgery, what to expect prior to and during surgery as well as post hip revision recovery information. 

For more information or to book a consultation to assess whether hip revision surgery is right for you please contact A/Prof Al Muderis' office on 1800 907 905 or +61 2 8882 9011 or book an appointment online.

Friday, 04 September 2020 11:57

Complex Primary Hip Arthroplasty

A hip replacement is considered Complex when there are compromised bony or soft-tissue states, including but not limited to dysplastic hip, ankylosed hip, prior hip fracture, protrusio acetabuli, certain neuromuscular conditions, skeletal dysplasia, and previous bony procedures about the hip. In addition to these, difficulties may arise due to obesity, skin problems, soft tissue patency around the hip joint.

Development dysplasia of the hip is a congenital or developmental deformation misalignment of the hip joint. The hip is a ball and socket joint. In a healthy hip the ball (the femoral head), which is the upper end of the femur, fits firmly in to the socket, which is formed by the acetabulum. In a dysplastic hip the hip joint has not formed normally. The acetabulum is shallow and the femoral head cannot fit firmly into the socket. This greatly increases the risk of dislocation. In some cases the ligaments that assist in holding the joint in place are stretched. The degree of hip dysplasia and hip instability can vary.

The aim of surgery for hip dysplasia is to restore an anatomical centre of rotation whilst maintaining sufficient bony coverage for a stable and firmly fitting femoral head and acetabulum while also ensuring excess tension is not put on the sciatic nerve. Hip dysplasia presents three problems: the position and coverage of the cup, placement of a specific or custom made femoral stem, with an osteotomy if necessary, and finally lowering the femoral head into the cup by freeing the soft tissues or a shortening osteotomy.

Treatment of acetabular protrusio aims to restore a normal center of rotation, and to prevent recurrent progressive protrusion. The use of bone grafts, custom acetabular shells,reinforcement rings are required in some patients.

Femoral deformities may be congenital or secondary to trauma or osteotomy. They must be evaluated to restore hip biomechanics that are as close to normal as possible. 

Most problems that can make total hip replacement a difficult procedure are anticipated with proper understanding of the case and thorough preoperative planning. We have a very efficient pre-operative management and planning system wherein we use various imaging modalities including but not limited to CT scans, EOS scans, MRI’s to have an in-depth view of the patient’s anatomy. We utilise the latest technology including 3D printing of models to help formulate and execute the surgical plan.

 

Patient 1- Left Hip Dysplasia- planning and surgery- custom acetabular shell and femoral shortening osteotomy

 

Patient 2- Bilateral Developmental dysplasia of hip

Friday, 04 September 2020 11:51

Hip Arthroplasty Surgical Procedure overview

 

Over the past few years there has been a significant amount of debate over minimally invasive surgery hip. The results of surgeries using this technique have not necessarily proven to be better than the standard approaches and in fact some studies show an inferior outcome of MIS compared to the standard approach. The use of computer navigation in hip arthroplasty is another controversial subject since it hasn’t shown any significant evidence of a better outcome than using standard approaches. However, each approach has pros and cons and their are advantages and disadvantages for each. 

The common approaches to the hip joint for Hip Replacement are: 

  • The posterior approach: This approach accesses the joint through the back and taking the short external rotators off the femur. This approach gives excellent access to the acetabulum and preserves the hip abductors so the patient has less chance of a limp after surgery. Critics cite a higher dislocation rate, although repair of the capsule and the short external rotators negates this risk. Due to incisions through the posterior muscles recovery time can be slower. 
  • The lateral approach: This is also commonly used for hip replacement. This approach requires elevation of the hip abductors (gluteus medius and minimus muscles) in order to access the joint. The abductors may be lifted up by osteotomy of the greater trochanter and reapplying it afterwards using wires. This approach has lesser chance of dislocation but the patients are more likely to develop a limp after surgery which could be permanent.
  • The anterolateral approach: This develops the interval between the tensor fasciae latae and the gluteus medius. Recently the direct-anterior approach, which utilises an interval between the sartorius muscle and the tensor fascia latae has become more popular especially with the use of a specialised table that allows for hip extension. The advantage of this approach is a small incision and no cutting to any muscle. It is also associated with less pain and faster recovery times. However, it is more technically demanding and requires stringent patient selection since it is very difficult to use this approach on obese or very muscular patients.
  • Anterior approach-The key defining feature of minimally invasive hip surgery compared with traditional hip surgery is the surgical approach taken. In minimally invasive hip surgery the surgeon does not have to cut muscles to access the hip.Anterior means to surgically approach from the front of the hip joint instead of lateral (side) or posterior (back).Muscles do not need to be cut or detached from the pelvis or femur.Recovery from Anterior Hip Replacement surgery is much quicker than recovery from traditional hip replacement surgery.Less post-operative pain than traditional hip replacement surgery.Return to daily activities faster compared to traditional hip replacement surgery.Suitability to this approach is subjective.

 

Professor Al Muderis believes the best approach is the one that the surgeon is most comfortable with performing as long as optimal visualisation of the joint anatomy is obtained using as minimal soft tissue dissection as possible with efficient time utilisation. The best approach will vary from patient to patient depending on their individual situation and needs. 

Depending on the approach taken the procedure will vary slightly but the following is a basic overview of what to expect from hip replacement surgery:

An incision is made over the hip to expose the hip joint. The acetabulum (socket) is prepared using a instrument called a reamer. The acetabular component of the implant is then inserted into the socket. This can sometimes be reinforced with screws or occasionally cemented. The liner part of the prosthesis which is either made of plastic, metal or ceramic material is then placed inside the acetabular component.

The femur is then prepared. The arthritic femoral head is removed and the bone prepared to fit the new metal femoral component. The femoral component is then inserted into the femur. The femoral head component is then placed on the femoral stem. This can be made of metal or ceramic.

All components are fitted together and the muscles and soft tissues are carefully closed.

There are a number of different approaches used when performing hip joint arthroplasty. To date there is no compelling evidence in the literature to show one particular approach is vastly superior over the other, but consensus of professional opinion favours either the posterior approach or the modified anterio-lateral approach (direct-anterior approach).

The key defining feature of minimally invasive hip surgery compared with traditional hip surgery is the surgical approach taken. In minimally invasive hip surgery the surgeon does not have to cut muscles to access the hip.

Anterior Approach Hip Replacement

  • Anterior means to surgically approach from the front of the hip joint instead of lateral (side) or posterior (back)
  • Muscles do not need to be cut or detached from the pelvis or femur
  • Recovery from Anterior Hip Replacement surgery is much quicker than recovery from traditional hip replacement surgery
  • Less post-operative pain than traditional hip replacement surgery
  • Return to daily activities faster compared to traditional hip replacement surgery
  • Suitability to this approach is subjective
Monday, 18 January 2016 14:07

MPFL Reconstruction using LARS Ligaments

LARS Ligaments:

LARS (Ligament Augmentation and Reconstruction System) ligaments are artificial ligaments used for the intra or extra-articular reconstruction of ruptured ligaments. LARS ligaments are used to reconstruct a torn Medial Patellofemoral Ligament (MPFL) and are designed to mimic the normal anatomic ligament fibres in the knee. The intra-articular longitudinal fibres resist fatigue and allow fibroblastic growth. The extra-articular woven fibres provide strength and resistance to stretch.

LARS ligaments can be used in conjunction with suturing to the remaining section of the ruptured ligament, or as a stand-alone reconstruction. 

For each patient the LARS ligaments are precisely selected according to the weight and activity level of each indivdual patient.

Using LARS ligaments can reduce surgery time considerably as no additional harvesting of grafts is needed. Thus the patient can expect a faster return to full function compared with MPFL reconstruction using hamstring tendon grafts. This is largely due to LARS ligaments allowing the original ligament tissues to heal in the absence of traction.

 

Advantages of LARS:

  • Earlier return to work (depending on particular activity level and individual recovery time)
  • Earlier return to competitive training 
  • Earlier return to full contact sports once the sense of motion and muscle strength has completely returned
  • Shorter surgical procedure 

 

Surgical Procedure

Using LARS ligaments MPFL surgery can be performed using minimally invasive surgery, which involves smaller incisions than the conventional MPFL surgery. There are no donor site complications since there is no need to harvest hamstring tendons.

For more information on the surgical procedure please see MPFL Reconstruction Surgical Procedure.

Published in Information
Wednesday, 13 January 2016 12:20

All-Inside ACL Reconstruction

All-Inside ACL Reconstruction is an excellent minimally invasive surgical alternative to traditional ACL reconstruction surgery

Both traditional ACL reconstruction surgery and All-Inside ACL reconstruction surgery involve replacing the ACL with a tendon graft (either LARS ligaments, hamstring tendon, patellar tendon, cadaver graft). The difference between traditional ACL surgery and All-Inside ACL surgery is the approach taken, in particular the drilling of a tibial tunnel. Traditional ACL reconstruction techniques involve drilling a tunnel from the outer tibial cortex into the proximal tibia and knee joint. Through this tunnel the ACL graft is inserted and securely fixed onto the tibia. This tibial tunnel is a significant source of pain following ACL surgery as the peristeum over the tibial cortex is sensitive and a violation of this area is similar to the pain experienced with a fracture. 

However, with All-Inside ACL reconstruction such a tibial tunnel is not created. Instead a specialised tool called a reamer is used to create a tibial socket, which does not violate the tibial cortex. All-Inside ACL surgery also doesn’t involve any formal incisions, only three to four small arthroscopy incisions.

 

The advantages of All-Inside ACL surgery compared with traditional ACL reconstruction surgery include:

  • Less pain following surgery compared with traditional techniques
  • Small incisions and less scarring
  • Recovery from All-Inside ACL surgery is much faster than following traditional ACL surgery
  • Faster healing time resulting in being able to return to daily activities much quicker 
  • Due to the specialised instrumentation used, All-Inside ACL surgery can help to facilitate a more anatomic ACL reconstruction 

 

All-Inside ACL reconstruction is more difficult and technically demanding than traditional ACL surgical approaches. Professor Munjed Al Muderis is both experienced and proficient in this surgery. 

Published in Information

Professor Munjed Al Muderis is a Sydney based orthopaedic surgeon specialising in hip and knee surgery. This video provides a detailed look at the post-surgery recovery process for a Total Hip Replacement using the Direct-Anterior Approach as performed by Professor Munjed Al Muderis. 

This video is Part 4 of a four part video series that provides a detailed look at the process of a total hip replacement by Professor Munjed Al Muderis covering each stage from the initial pre-surgery consultation to recovery. 

Click here to view Part 1 - Initial Consultation

Click here to view Part 2 - Preparing for Surgery

Click here to view Part 3 - Operation

 

Professor Munjed Al Muderis is as Sydney based orthopaedic surgeon specialising in hip and knee surgery. This video provides a detailed look at part of an initial consultation with Professor Munjed Al Muderis and preparation for a Total Hip Replacement using the Direct-Anterior Approach.

This video is Part 2 of a four part video series that provides a detailed look at the process of a total hip replacement by Professor Munjed Al Muderis covering each stage from the initial pre-surgery consultation to recovery. 

Click here to view Part 1 - Initial Consultation

Click here to view Part 3 - Operation

Click here to view Part 4 - Recovery 

 

 

 

Saturday, 02 May 2015 11:37

Hip Arthroscopy Surgical Procedure

The following is what can be expected during hip arthroscopy surgery:

The patient will be admitted into hospital for a day or overnight.

The procedure is performed under general anesthesia or spinal anesthesia.

At the start of the procedure the leg will be put in traction. The hip will be pulled away from the socket enough for the entire joint to be visible and for instruments to be inserted. 

A small puncture (about the size of a button hole) will be made for the arthroscope through which the inside of the hip and its damage can be identified. 

X-ray control using an image intensifier is used to gain access to the joint.

Two or three small incisions (portals) are made just above the bony prominence of the hip and instruments are inserted first to visualise and treat any spurs on the femoral neck or acetabulum then traction is applied and the instruments gain access to the hip joint to treat any pathology intra-articulary on the hip. These instruments can also smooth off rough surfaces, remove loose pieces of cartilage and excise bony osteophytes that may be causing a problem.

Sufficient traction is applied to open the joint by 7-8mm. 

Local anesthetic is injected into the hip and wound following the procedure.

Depending on the approach taken the above overview may vary.

 

Complications:

As with any operation complications are possible but unlikely. Possible hip arthroscopy complications can include:

  • Permanent damage to the lateral femoral cutaneous nerve may occur in around 2% of patients
  • Inadvertent chondral damage
  • Infection in the skin or deep in the hip occurring in less than 1% of patients
  • Vascular injury; resulting in excess bleeding
  • Nerve injury – the pudendal nerve may be damaged by the traction post. This is usually temporary or rarely permanent
  • Ongoing pain: especially if there is significant arthritis 
Published in Surgery