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Thursday, 18 December 2014 00:00

Tibial Osteotomy Surgical Procedure

Tibial osteotomy is a surgical procedure designed to restore function to a knee with osteoarthritis due to malalignment of the joint. The goal of tibial osteotomy is to shift the patient's body weight off the damaged area and onto the other side of the knee where the cartilage is still healthy. This is achieved by removing a wedge of the tibia from underneath the healthy side of the knee. This allows the tibia and femur to bend away from the damaged cartilage.

Prior to surgery x-ray and CT scans are carried out in order to measure the degree of correction and the size of the wedge which will be needed to be removed during surgery. 

In theatre a general anaesthetic is administered and antibiotics given intravenously to prevent infection. A tourniquet is placed around the thigh to stop blood flow and to allow the best visualisation of the operative site.

A 15-20cm incision is made on the outside of the knee and the soft tissues are retracted away from the bone, exposing the tibia where the osteotomy will be performed. At this point, usually the joint between the fibula and the tibia is exposed and divided to avoid pain from here once the osteotomy has been performed. Retractors are placed carefully around the front and back of the tibia protecting important soft tissues from damage from the instruments (eg: patellar tendon, major blood vessels and nerves to the leg which are located just behind the tibia).

X-ray is used to ensure correct placement of the osteotomy.  The wedge of bone is cut and the osteotomy is slowly closed and compressed with a plate and screws used to hold the osteotomy rigidly. 

There are two methods to performing a tibial osteotomy: closing wedge osteotomy and opening wedge osteotomy:

Closing wedge osteotomy involves removing a wedge of bone usually just below the joint in the upper part of the tibia. For patients with arthritis affecting the medial compartment (varus knees) the bone wedge is taken from the outer part of the tibia. Once the wedge of bone is removed the two bone ends are then put together and held with either a metal plate or pins. This has the effect of shifting your body weight from the inner part of the knee to the non-affected lateral compartment.

Opening wedge osteotomy in this technique the surgeon cuts through the tibia on the medial (inner) side and opens a wedge, sometimes by adding a piece of bone graft from the pelvic area to hold the wedge open. In order to stabilise this a plate is inserted once again. This operation is also commonly performed in the upper part of the tibia just below the knee joint.

A final check with x-ray confirms the position and correction of the osteotomy. The wound is then closed and the patient is returned to the ward.

The surgery typically takes between 60 and 90 minutes.

Published in Surgery
Thursday, 18 December 2014 00:00

Tibial Osteotomy Pre-Surgery Information

The following can be expected prior to tibial osteotomy surgery:

Examinations: X-rays will be taken and a CT scan or MRI may also be needed to indentify the extent of the injury and damage. A pre-op assessment will also be undertaken which will include assessment of range of motion, stability and angular deformity of the knee. Isilateral hip function will also be assessed. 

Skin preparation: Night prior to and morning of operation, patient is required to wash leg with a sponge provided in the pre-admission clinic. Betadine Skin test is occasionally 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.

 

Day of Surgery:

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

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

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

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

 

Published in Pre Surgery
Wednesday, 17 December 2014 00:00

Arthritis Treatment Options

Unfortunately there is no cure for arthritis. However, a number of measures can be taken which can greatly reduce the symptoms of arthritis and their affect on daily life.

Treatment of osteoarthritis (degenerative disease of the joint) focuses on decreasing pain and improving joint movement and function. 

Initial treatment for osteoarthritis of the hip or knee is conservative and consists of rest, avoidance of vigorous weight bearing activities and the use of non-narcotic analgesic and/or anti-inflammatory medications. If symptoms become worse a walking stick, crutch or a knee brace may be helpful.

For more severe symptoms an injection of cortisone into the joint can help to relive pain and restore movement of the joint.

Occupational therapy or physiotherapy consisting of specific targeted exercises and heat treatment can also help to alleviate symptoms and free up movement of the joint.

In severe cases once conservative measures have been exhausted, surgery such as a hip or knee replacement (hip or knee arthroplasty) may be recommended. The type of surgery will depend on the patient's age and the severity of the disease. Joint replacements in elderly patients with severe arthritis often have excellent results. For more information on Total Hip Replacement surgery please see Hip Arthroplasty. For more information on Total Knee Replacement please see Knee Arthroplasty. 

 

Ways to help improve symptoms of osteoarthritis:

  • During a pain episode rest the joint until the pain subsides. This helps to prevent further inflammation
  • To ease pain and stiffness of the joint, apply heat to the joint for about 15 minutes at a time once or twice a day using a hot water bottle or heat pack
  • Weight and diet is an important factor in the treatment of arthritis. Being overweight places increased pressure on joints and it is advised to try to reduce weight to reduce the load on weight-bearing joints
  • Participate in regular exercise. Exercise is very important in the treatment of arthritis as it increases lubrication of the joints and strengthens the surrounding muscles, which puts less stress on joints. 
  • Light exercise also helps those with arthritis by reducing joint pain and stiffness and increasing flexibility as well as improving muscle strength and energy. It also helps with weight reduction and improved overall health.
  • Exercise in heated swimming pools and hydrotherapy can be effective in relieving pain and stiffness. 

Published in Arthritis
Wednesday, 17 December 2014 00:00

Osteoarthritis Of The Hip And Knee

Osteoarthritis affects cartilage, which is the tissue that cushions and protects the ends of bones in a joint. Osteoarthritis is a result of this cartilage wearing away over time. In extreme cases, the cartilage can completely wear away which leaves nothing to protect the bones in a joint and causes bone-on-bone contact.

This wearing away of cartliage may be due to excessive strain over prolonged periods of time or due to other joint diseases, injury or deformity.

Primary osteoarthritis is commonly associated with ageing and general degeneration of joints. However, secondary osteoarthritis is generally the consequence of another disease or condition such as: repeated trauma surgery to the affected joint or abnormal joint structures from birth.

 

Contributing factors to osteoarthritis of the hip:

There are certain factors that can predispose the hip to osteoarthritis. 

It tends to affect people as they get older and particularly affects joints that have to take a lot of stresses and strains which can be exacerbated by being overweight.

Other factors include:

  • A previous fracture that involved the hip
  • Growth abnormalities of the hip (such as a shallow socket) 
  • Inactive lifestyle and obesity. Weight and diet has a direct link with arthritis. Being overweight also puts an additional burden on your hips, knees, ankles and feet

 

Contributing factors to osteoarthritis of the knee:

As with the hip, there are certain factors that can predispose the knee to osteoarthritis. Like osteoarthritis of the hip, osteoarthritis of the knee also tends to affect people as they get older and particularly affects joints that have to take a lot of stress and strain which can be exacerbated by being overweight.

Other factors include:

  • Abnormalities of knee joint function resulting from fractures of the knee, torn cartilage and torn ligaments. This can lead to degeneration many years after the injury
  • A mechanical abnormality resulting in excessive wear and tear on the knee joint
  • Inactive lifestyle and obesity. Weight and diet has a direct link with arthritis. Being overweight also puts an additional burden on your hips, knees, ankles and feet

Published in Arthritis
Wednesday, 17 December 2014 00:00

Types of Arthritis

There are more than 100 different types of arthritis. The most common are:

 

Osteoarthritis

Also referred to as degenerative joint disease, this is the most common type of arthritis and occurs most often in older people. This disease affects cartilage, which is the tissue that cushions and protects the ends of bones in a joint. Osteoarthritis is a result of this cartilage wearing away over time. In extreme cases the cartilage can completely wear away which leaves nothing to protect the bones in a joint and causes bone-on-bone contact. Bones may also bulge or stick out at the end of a joint. This is known as a bone spur.

Osteoarthritis causes joint pain and can limit a person's normal range of motion and the ability to freely move and bend a joint. When severe the joint may lose all movement causing a person to become disabled. Disability most often occurs when the disease affects the spine, knees and hips.

 

Rheumatoid arthritis

Rheumatoid arthritis is an autoimmune disease where the body’s immune system (the body’s way of fighting infection) attacks healthy joints, tissues and organs. This disease occurs most often in women of childbearing age (15-44) and occurs two to three times more in women than in men. 

Rheumatoid arthritis inflames the lining (or synovium) of joints. It can cause pain, stiffness, swelling and loss of function in joints. When severe, rheumatoid arthritis can cause a joint to become deformed. This can commonly be seen in the finger joints where the joints can become deformed causing the finger to bend or curve.

Rheumatoid arthritis mostly affects joints of the hands and feet and tends to be symmetrical. The disease affects the same joints on both sides of the body (like both hands or both feet) at the same time and with the same symptoms. There are no other forms of arthritis that are symmetrical. 

 

Fibromyalgia

This chronic disorder causes pain throughout the tissues that support and move the bones and joints. Pain, stiffness and localised tender points occur in the muscles and tendons, particularly those of the neck, spine, shoulders and hips. Fatigue and sleep disturbances may also occur.

 

Gout

Gout occurs when a person has higher than normal levels of uric acid in the blood. The body makes uric acid from many of the foods we eat. Too much uric acid causes deposits, called uric acid crystals, to form in the fluid and lining of the joints. The result is an extremely painful attack of arthritis. The most common joint that gout affects is the big toe. This disease is more common in men than in women.

Gout has been linked with overindulgence of meat, alcohol and foods with high amounts of high-fructose corn syrup. A healthy diet of fresh fruit and vegetables, wholegrain carbohydrates and lean meats with limited processed foods can greatly reduce the occurrence of gout. 

 

Infectious arthritis

An infection, either bacterial or viral, such as Lyme disease can result in arthritis. When this disease is caused by bacteria early treatment with antibiotics can ease symptoms and cure the disease.

 

Reactive arthritis

This is arthritis that develops after a person has an infection in the urinary tract, bowel or other organs. People who suffer from this disease often have eye problems, skin rashes and mouth sores.

 

Psoriatic arthritis

Psoriasis is a common skin problem that causes scaling and rashes. This condition often coincides with arthritis. This particular type of arthritis often affects the joints at the ends of the fingers and can cause changes in the fingernails and toenails. Sometimes the spine can also be affected.

 

Systemic lupus erythematosus

Also known as lupus or SLE, systemic lupus erythematosus is an autoimmune disease. With an autoimmune disease, the immune system attacks itself, killing healthy cells and tissue rather than doing its job to protect the body from disease and infection. Lupus causes inflammation and damage to a person’s joints, skin, kidneys, lungs, blood vessels, heart and brain. 

 

Ankylosing spondylitis

Most often ankylosing spondylitis affects the spine, causing pain and stiffness. It can also cause arthritis in the hips, shoulders and knees. It affects mostly men in their late teenage and early adult years.

 

Juvenile rheumatoid arthritis

This is the most common type of arthritis in children and causes pain, stiffness, swelling and loss of function in the joints. Rashes and fevers can also occur with this disease.

 

Polymyalgia rheumatica

This disease involves tendons, muscles, ligaments, and tissues around the joint and symptoms include pain, aching and morning stiffness in the shoulders, hips, neck and lower back. It is sometimes the first sign of giant cell arteritis, a disease of the arteries characterised by inflammation, weakness, weight loss and fever.

 

Polymyositis

Polymyositis causes inflammation and weakness in the muscles and can affect the whole body, greatly limiting daily activities and can lead to disability.

 

Bursitis

Bursa are small, fluid filled sacs which surround the joints and help reduce friction between bones and other moving structures in the joints. Bursitis is caused by inflammation of the bursa. The inflammation may result from arthritis in the joint, injury or infection of the bursa. Bursitis produces pain and tenderness and can limit the movement and function of nearby joints.

 

Tendinitis

Tendinitis is also known as tendonitis and refers to inflammation of tendons, the tough cords of tissue that connect muscle to bone. It is caused by overuse, injury or a rheumatic condition. Tendinitis produces pain and tenderness and can lead to restricted movement of nearby joints.

Published in Arthritis
Wednesday, 17 December 2014 00:00

Arthritis General Information

Arthritis is often referred to and thought of as a single condition. But it is actually an umbrella term for more than 100 different conditions which affect the musculoskeletal system and joints where two or more bones meet.

The term arthritis means inflammation of a joint but it is generally used to describe any condition in which there is damage to the cartilage.

Cartilage, tissue that covers the ends of bones, is a padding that absorbs stress and allows them to move smoothly and easily against each other. The proportion of cartilage damage and synovial inflammation varies with the type and stage of arthritis. 

Usually when pain associated with arthritis first presents it is due to inflammation. In the later stages, when the cartilage is worn away, most of the pain comes from the mechanical friction of raw bones rubbing against each other.

Inflammation is the body’s natural response to injury. The symptoms of inflammation are redness, swelling, heat and pain.

Arthritis related symptoms can result in joint weakness, instability and deformities which can interfere with basic daily tasks.

Unfortunately arthritis is not yet curable. But there are a number of measures which can lesson the impact of the condition and its interference with daily life.

While there are about 100 forms of arthritis, the three most significant; osteoarthritis, rheumatoid arthritis and gout, account for more than 95% of cases in Australia.??

Other common types of arthritis include:

  • Infectious Arthritis
  • Fibromyalgia
  • Reactive Arthritis
  • Psoriatic Arthritis
  • Systemic Lupus Erythematosus
  • Ankylosing Spondylitis
  • Juvenile Rheumatoid Arthritis
  • Polymyalgia Rheumatica
  • Polymyositis
  • Bursitis
  • Tendinitis

 

Published in Arthritis

The following can be expected following ACL reconstruction surgery:

  • On discharge the large outer dressing is removed leaving the water proof dressing in place
  • Tube-grip bandage may be applied

  • No brace or immobilisation will be needed

  • An ice pack should be applied regularly for 20 minute intervals until swelling subsides

  • Usually there will be a wound check after 14 days performed in Professor Munjed Al Muderis’ rooms

  • Physiotherapy should start at two to five days after surgery with the goal of a quick return to a full range of motion and the strengthening of both quadriceps muscles and hamstrings muscles.

  • Recovery from ACL surgery is a lengthy process and physiotherapy is required to restore full range of motion and function of the knee. A full rehab program complete with daily strengthening exercises will be prescribed and it is crucial that this part of the recovery is not neglected.

 

Range of Motion:

Passive and active range of motion exercises should be preformed to order to ensure full extension is achieved and maintained within one week post surgery. 90 degrees of flexion is the goal by week two followed by progression to full flexion as tolerated.

 

Weight bearing:

Weight bear as tolerated, initially with crutches. Crutches can be discontinued when full extension of the knee can be achieved without an extensor lag and the patient is able to walk comfortably without a flexed knee gait pattern.

 

Muscle rehabilitation:

  • Static quadriceps and co-contraction will commence immediately post operatively
  • Closed kinetic chain exercises are advised for the first two to three months which will be demonstrated and prescribed by the physiotherapist
  • Cycling on an exercise bike, swimming and leg presses may commence after two weeks and proprioception training will begin four weeks after surgery

 

Sports:

Return to full activity should be eased into with care not to overdo it and over stress the knee.

  • As the swelling settles cycling on a stationary exercise bike can begin 
  • Low impact exercises such as swimming can commence after two weeks
  • After six weeks jogging can be commenced
  • Return to sport specific training at 12 to 16 weeks and when quadriceps strength is back to at least 80%.? When quadriceps strength is at least 90% and tolerating sport specific skills without symptoms a full return to sport can occur

 

 

Published in Post Surgery

If the adolescent is close to skeletal maturity the risks are small and a standard ACL reconstruction is usually performed. The surgery is performed arthroscopically. Professor Munjed Al Muderis is skilled in All-Inside ACL Reconstruction which is a 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. The ruptured ligament is removed and the bone prepared in order for it to accept the new graft which replaces the old ACL. Options for the tendon graft are outlined below. 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.

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 as it does in traditional ACL surgery. 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 include less pain and a faster recovery time than traditional techniques. Due to the specialised instrumentation used All-Inside ACL surgery can also help to create a more anatomic ACL reconstruction.

 

ACL Grafts:

There are a number of different surgical options that can be used to reconstruct the ACL ligament. These include the use of autologus hamstring or patellar tendon graft, cadaveric donor grafts and synthetic grafts (LARS). From the literature there is no overall significant difference between any of the options; but each method has its own advantages and disadvantages and one may be better suited in each individual situation.

The graft of choice is then prepared in order to take the form of a new tendon and is passed through into the bone.

The new tendon is then fixed into the bone with various devices to hold it into place while the ligament heals into the bone (this usually takes about six months).

 

There are pros and cons for each graft option:

Graft Type

Pros

Cons

Hamstring tendon

  • Biological
  • Eventually fully replaced by new tissue
  • Scar reasonably small and causes no irritation
  • Relatively weaker than the other options
  • May stretch
  • Donor site pathology (weakness in hamstring)

Patellar tendon

  • Biological
  • Eventually fully replaced by new tissue
  • Stronger than hamstring tendon graft
  • Scar cause irritation especially kneeling
  • Donor site pathology (weaker patellar tendon and bone)

Cadaver graft

  • No donor site pathology
  • Faster operation than hamstring or patellar tendon graft
  • Eventually fully replaced by new tissue
  • Chance of rejection
  • Chance of transmission of infection
  • Weakest of all graft options
  • Depends on availability

LARS

  • No donor site pathology
  • Fastest of all the graft options
  • New tissue integrates with it
  • Minimal scar
  • Strongest of all the graft options
  • Faster return to full activity
  • Requires good experience with the technique and the material
  • Implant does not dissolve with time

 

Alternative Approaches:

In a younger child alternative techniques have been developed to reduce the possibilities of growth complications. These techniques involve placing the ligament graft in a non-anatomic position or one that does not quite duplicate normal ligament function. This is done by either drilling holes that go around rather than through the growth plates or by avoiding drilling holes altogether and instead wrapping the graft around the bone. Growth abnormalities can still occur but the incidence is much less than with standard techniques.  

These procedures are designed to be a temporary measure to control symptoms until skeletal maturity when a traditional reconstruction can be performed. Such procedures have proven to be quite successful with many children returning to sports and not needing a second procedure later on.

 

 

Published in Surgery

The following can be expected prior to ACL reconstruction surgery:

Examinations: X-rays will be taken and a CT scan or MRI may also be needed to indentify the extent of the injury and damage.

Skin preparation: Night prior to and morning of operation, patient is required to wash leg 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.

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.

 

Day of Surgery:

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

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

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

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

Published in Pre Surgery
Thursday, 11 December 2014 00:00

ACL Rupture in Children Treatment Options

Treatment of an ACL rupture in children differs from the standard treatment for an ACP rupture in an adult. A child or adolescent knee varies anatomically and physiologically from an adult knee and thus the treatment needs to be adjusted accordingly.

The main difference is the growth plates or epiphysis in a child’s knee. These are regions at the end of the femur and tibia of developing tissue and provide the majority of the growth of the leg.  These sections are usually the weakest part of the knee. The same injury that would tear a ligament or cartilage in a mature knee is much more likely to fracture the bones through the growth plate in a child.

The complication in children is the growth plates in the knee are directly in the path of where the surgical holes would be drilled in the bone to attach the new ligament. A standard ACL reconstruction in a growing child or adolescent without any consideration for this factor can cause a growth abnormality leading to leg length inequality or to angulatory deformity at the knee. The younger the child the higher the risk of this occurring.

Thus, non-operative treatment is usually suggested initially. This involves strapping the leg and undertaking strengthening exercises as well as abstaining from activity.

When a child stops growing, the growth plate hardens (ossifies) along with the rest of the bone. Girls tend to stop growing earlier than boys; their growth plates usually close around ages 14 or 15, while boys' growth plates close later, at around 16 or 17.

If the adolescent is close to skeletal maturity the risks are small and a standard ACL reconstruction is usually performed. 

In a younger child, alternative techniques have been developed to reduce the possibilities of growth complications. These techniques involve placing the ligament graft in a non-anatomic position or one that does not quite duplicate normal ligament function. This is done by either drilling holes that go around rather than through the growth plates or by avoiding drilling holes altogether and instead wrapping the graft around the bone.  Growth abnormalities can still occur but the incidence is much less than with standard techniques.  

These procedures are designed to be a temporary measure to control symptoms until skeletal maturity when a traditional reconstruction can then be performed. Such treatments have proven to be quite successful with many children returning to sports and not needing a second procedure later on.

 

Rehab and Recovery

Recovery from ACL surgery is a lengthy process and physiotherapy is required to restore full range of motion and function of the knee.

A full rehab program complete with daily strengthening exercises will be prescribed and the child will be on crutches for four to six weeks post surgery. 

Published in Information