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The following is what can be expected prior to tibial plateau fracture surgery:

Examinations: X-rays will be taken and a CT scan or MRI may also be needed to identify 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. 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
Tuesday, 20 January 2015 00:00

Tibial Plateau Fracture Treatment Options

Fracture of the tibial plateau affects knee alignment, stability and movement. Early detection and appropriate treatment of tibial plateau fractures are critical for minimising damage to the knee and reducing the risk of further complications such as osteoarthritis.

Treatment is aimed at achieving a stable, aligned, mobile and painless joint as well as minimising the risk of post-traumatic osteoarthritis following the fracture.

Conservative treatment options involve immobilisation in an above knee plaster cast or a brace with a period where no weight baring is  allowed. This period can vary from eight weeks to a few months or untill evidence of fracture union is shown on x-ray. However, this method of treatment is becoming less favourable by both clinicians and patients due to the prolonged period of immobilisation involved.

Surgical options involve and open reduction and internal fixation surgery. This is often a two-part surgery where the broken bone is first reduced (put back into place) followed by an internal fixation device placed on the bone. This can be achieved using screws, plates, rods or pins to hold the broken bone together.

This is an appropriate course of action for patients with joint depression, open fracture, neurovascular injury and compartment syndrome.

There are two main approaches taken when performing this surgery; anterolateral and posteromedial.

However, after extensive review of the literature and prolonged experience with various operative techniques used to fix different types of tibial plateau fractures Professor Munjed Al Muderis has developed his preferred method to fix any kind of tibial plateau fracture. This technique utilises arthroscopic technology (key hole surgery) to visualise the fracture and secure its accurate reduction, followed by internal fixation using a pre-contoured periarticular plate via a minimally invasive (small incision) technique.

 

 Advantages of this minimally invasive technique compared to traditional anterolateral and posteromedial techniques include:

  • Allows for accurate reduction of the fracture. This is due to the arthroscopic camera which provides direct visualisation of all injured structures including intra-articular soft tissues, both menisci and the cruciate ligaments
  • Minimises the soft tissue dissection which preserves the vital blood supply to the injured tissue
  • Does not cause any complications for potential future surgery such as a total knee replacement, if such surgery is required down the track. This is a result of the minimal scar in this approach which is far away from the midline. The midline is where the standard incision for total knee replacement is usually.  However, the traditional anterolateral incision favoured in traditional tibial plateau fracture surgery could compromise the possibility of making a future midline incision since the skin bridge is very narrow and could compromise the blood supply to the flap that is created by the two incisions. 
  • Allows for treatment of any meniscal tears at the same time of fracture fixation
  • Minimises the exposure area which decreases the chance of wound infection
  • Reduces surgical time
  • Faster rehabilitation and restoration of range of movement, with partial weight baring allowed from day one post-surgery 
  • No need for cast or bracing in the vast majority of cases

 

Published in Information
Tuesday, 20 January 2015 00:00

Tibial Plateau Fracture Information

The tibial plateau located on the upper extremity of the tibia (shin bone) and is one of the most critical load-bearing areas in the body.  It is composed of two slightly concave condyles (the round prominences of a bone) separated by an intercondylar eminence and the sloping areas both in front and behind it. 

It can be divided into three areas:

  • The medial tibial plateau (the part of the tibial plateau that is nearer to the centre of the body and contains medial condyle). It is larger than the lateral tibial plateau and has a concave surface. Its mechanical axis passes medial to midline and carries 60% of the load.
  • The lateral plateau (the part of the tibial plateau that is farthest away from the centre of the body and contains the lateral condyle). It is smaller than the medial tibial plateau and has a convex surface.
  • The central tibial plateau (located between the medial and lateral pleateaus and contains intercondylar eminence)

 

A standard tibial plateau fracture involves either cortical interruption, depression or displacement of the articular surfaces of the proximal tibia (the top of the tibia) without significant injury to the knee capsule or ligaments.

However depending on the injury, there may also be significant soft tissue damage as well as damage to the meniscus and ligaments of the knee. 

The peak age for tibial plateau fractures is 30-40 years old in men and 60-70 years old in women. About half of patients who present with a tibial plateau fracture are aged 50 years and older.

 

Signs and Symptoms of Tibial Plateau Fractures:

  • Tenderness, swelling and bruising of the knee
  • The knee may appear deformed due to displacement and fragmentation of the tibia
  • Blood in the soft tissues and knee joint which can lead to bruising and a dough like feeling in the knee
  • Difficulty moving the knee
  • Inability to bear weight

 

Common Causes of Tibial Plateau Fractures: 

Tibial plateau fractures can be dived into low energy or high energy fractures: 

  • Low energy fractures occur as a result of a disease affecting the bone. This category of fractures are largely caused by osteoporosis particularly in older females. 
  • High energy fractures are often the result of a motor vehicle accident, a fall from a high height or a sports related injury. High energy fractures make up the majority of tibial plateau fractures found in young patients.

 

Please see Tibial Plateau Fracture Treatment Options for treatment options. 

Published in Information
Wednesday, 14 January 2015 00:00

Patella Malalignment Surgical Procedure

Professor Munjed Al Muderis differs from the conventional approach towards treating patella malalignment and has modified a minimally invasive surgical technique to reconstruct the Medial Patellofemoral Ligament (MPFL). 

The first part of the procedure includes knee arthroscopy to remove any loose bodies and fix any other intra-articular pathologies that may be associated with the injury.

The second part of the procedure includes a minimally invasive open approach to the patella. A 3-4cm vertical skin incision is made over the outer one third of the patella. Through this incision a lateral release of the patella is performed and then under image intensifier 5mm horizontal drill is guided over a guide wire through the centre of the patella.

A patella tendon type LARS ligament is then passed through the patella drill hole from lateral to medial, using a special wire passer. The lateral end of the LARS ligament is sutured to the lateral edge of the patellar at the insertion site using a strong suture to prevent pull through the ligament. Usually the LARS ligament has a metal pin like button, which adds stability to the structure.

Using an image intensifier, a second 1-2cm incision is made over the natural attachment of the MPFL. Using long forceps a tunnel is created in the soft tissue between the two incisions. The LARS ligament is then passed through this soft tissue tunnel.

Under the image intensifier a second 5mm drill tunnel over a guide wire is made and the LARS ligament is then passed through this second tunnel entering at the medial side and exiting at the anterolateral corner of the distal femur.

In a skeletally immature patient this tunnel has to be accurately positioned in the epiphysis to avoid injury to the growth plate.

The patient’s knee is then positioned at full flexion with the patella fully engaged within the femoral trochlea (femoral groove). The LARS ligament distal end is gently tugged to avoid over loosening or over tightening. Then over a blunt guide wire a 6mm interference screw is inserted through the inside incision. The knee is then taken through a range of motions to check tracking and patella stability. The distal end of the LARS ligament is then trimmed and final radiographs are taken. The wound is closed in layers and a bandage dressing is then applied with no need for a brace.

Published in Information
Wednesday, 14 January 2015 00:00

Patella Malalignment Treatment Options

In the past patella dislocation was primarily treated conservatively with close reduction (reducing a bone without surgery) followed by immobilisation in a brace for up to 6 weeks. Treatment involved physiotherapy and rehabilitation with a strong focus on:

•       Quadriceps, VMO strengthening exercises.

•       Inner range quads exercises with knee at 0-30°.

•       Stretching of hamstrings, ITB, and retinaculum.

•       Patellar taping, proprioceptive exercises.

•       Behavioural modification.

 

If conservative treatment failed and the patient continued to complain of pain or developed recurrent dislocations of the patella, then surgical management was the next step. There are more than 100 procedures described to treat patella malalignment, which suggests there is no one proven technique to be the best in treating this condition.

 

Professor Munjed Al Muderis’ approach:

It is common that there is intra-articular damage resulting from patella dislocation. A physical examination can reveal instability of the knee but the best current method of identifying a torn or damaged medial patellofemoral ligament (MPFL) is by using both plain radiograph and MRI scans in order to reach the appropriate diagnosis.

If surgery is indicated then the best evidence based medicine suggests restoration of anatomy and early mobilisation provides the best outcome. Professor Al Muderis applies this principle by reconstructing the ruptured MPFL thus restoring anatomy.  Early rehabilitation starts the first week after surgery with the primary aim to increase the range of movement. The aim is to achieve more than 90 degrees of flexion in the first six weeks as well as restoring the muscle strength during this same period.

 

LARS Ligaments:

This type of aggressive rehabilitation can only be achieved by using a strong reliable graft such as the LARS (Ligament Augmentation and Reconstruction System) ligament, which is strong enough to provide initial stability of the joint and a scaffold for the natural ligament to heal and grow back over the graft. This technique has been used with a high success rate and minimal adverse outcome.

LARS ligaments are artificial ligaments used for the intra or extra-articular reconstruction of ruptured ligaments. Used to reconstruct a torn MPFL they 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. 

The ligaments are precisely selected according to the weight and activity level of each patient.

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

Traditional surgeries such as tibial tubercule osteotomy, patellar tendon transfer, VMO advancement and trochealioplasty all involve significant modification to the patient anatomy, which may make future surgery such as knee arthroplasty much more difficult and this may eventually lead to a poor outcome. However, the MPFL Reconstruction using LARS ligaments does not involve any major alteration to the patient’s anatomical structures, which makes it easy to perform any further surgeries in the future if they are required.

Published in Information
Wednesday, 14 January 2015 00:00

Patella Malalignment Pre-Surgery Information

The following is what can be expected prior to MPFL Reconstruction Surgery to fix patella malalignment:

Examinations: X-rays will be taken and a CT scan or MRI may also be needed to identify 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. 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

Professor Munjed Al Muderis differs from the conventional approach towards treating patella malalignment and has modified a minimally invasive surgical technique to reconstruct the medial patellofemoral ligament (MPFL). 

The first part of the procedure includes knee arthroscopy to remove any loose bodies and fix any other intra-articular pathologies that may be associated with the injury.

The second part of the procedure includes a minimally invasive open approach to the patella. A 3-4cm vertical skin incision is made over the outer one third of the patella. Through this incision a lateral release of the patella is performed and then under image intensifier 5mm horizontal drill is guided over a guide wire through the centre of the patella.

A patella tendon type LARS ligament is then passed through the patella drill hole from lateral to medial, using a special wire passer. The lateral end of the LARS ligament is sutured to the lateral edge of the patellar at the insertion site using a strong suture to prevent pull through the ligament. Usually the LARS ligament has a metal pin like button, which adds stability to the structure.

Using an image intensifier, a second 1-2cm incision is made over the natural attachment of the MPFL. Using long forceps a tunnel is created in the soft tissue between the two incisions. The LARS ligament is then passed through this soft tissue tunnel.

Under the image intensifier a second 5mm drill tunnel over a guide wire is made and the LARS ligament is then passed through this second tunnel entering at the medial side and exiting at the anterolateral corner of the distal femur.

In a skeletally immature patient this tunnel has to be accurately positioned in the epiphysis to avoid injury to the growth plate.

The patient’s knee is then positioned at full flexion with the patella fully engaged within the femoral trochlea (femoral groove). The LARS ligament distal end is gently tugged to avoid over loosening or over tightening. Then over a blunt guide wire a 6mm interference screw is inserted through the inside incision. The knee is then taken through a range of motions to check tracking and patella stability. The distal end of the LARS ligament is then trimmed and final radiographs are taken. The wound is closed in layers and a bandage dressing is then applied with no need for a brace.

Published in Surgery

The following can be expected following MPFL Reconstruction surgery to treat patella malalignment:

  • MPFL Reconstruction surgery usually involves a hospital stay of one or two nights
  • On discharge the patient does not need any bracing and is able to walk with full weight bearing using walking aids such as crutches for the first few weeks until they feel comfortable to walk unaided
  • An ice pack should be applied regularly for 20 minute intervals until swelling subsides
  • The bandage dressing will be removed at the first postoperative visit, one week after surgery. The wound will be checked and x-rays of the knee taken
  • Bending and straightening of the knee is encouraged immediately following surgery
  • 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 the quadriceps muscles and vastus medialis oblique fibres (VMO). 90 degrees range of motion of the knee should be achieved by six weeks post surgery
  • It is common to experience pain on the inner side of the knee along the graft for a few months following the surgery
  • The knee swelling will decrease significantly after six weeks post surgery, however, some swelling may last for up to six months

 

Weight bearing status and driving:

  • Weight bear as tolerated initially with crutches. Crutches can be discontinued when you can achieve full extension of the knee without an extensor lag and you are able to walk comfortably without a flexed knee gait pattern
  • You can return to driving once there is no need for crutches

 

Return to Activity:

  • Returning 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
  • Full range of motion is expected at about three months post surgery. A return to full activity including contact sport can also be expected three months post surgery.

 

Published in Post Surgery

The following can be expected following Medial Patellofemoral Ligament Reconstruction (MPFL) surgery:

  •  MPFL Reconstruction surgery usually involves a hospital stay of one or two nights
  • On discharge the patient does not need any bracing and is able to walk with full weight bearing using walking aids such as crutches. It is advised that for the first few weeks walking is assisted with walking aids until it feels comfortable to walk unaided
  •  An ice pack should be applied regularly for 20 minute intervals until swelling subsides
  • The bandage dressing will be removed at the first postoperative visit, one week after surgery. The wound will be checked and x-rays of the knee taken
  • 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 the quadriceps muscles and vastus medialis oblique fibres (VMO). 90 degrees range of motion of the knee should be achieved by six weeks post surgery
  • It is common to experience pain on the inner side of the knee along the graft for a few months following the surgery
  • The knee swelling will decrease significantly after six weeks post surgery, however, some swelling may last for up to six months

 

Weight bearing status and driving

  • Weight bear as tolerated, initially with crutches. Crutches can be discontinued when you can achieve full extension of the knee without an extensor lag and you are able to walk comfortably without a flexed knee gait pattern
  • You can return to driving once there is no need for crutches

 

Return to Activity

  • Returning 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
  • Full range of motion is expected at about three months post surgery. It is at this point that a return to full activity and contact sport can be commenced

 

 

Published in Post Surgery
Wednesday, 14 January 2015 00:00

MPFL Reconstruction Surgical Procedure

Professor Munjed Al Muderis differs from the conventional approach to medial patellofemoral ligament (MPFL) reconstruction surgery and has modified a minimally invasive surgical technique to reconstruct the MPFL. 

The first part of the procedure includes knee arthroscopy to remove any loose bodies and fix any other intra-articular pathologies that may be associated with the injury.

The second part of the procedure includes a minimally invasive open approach to the patella. A 3-4cm vertical skin incision is made over the outer one third of the patella. Through this incision a lateral release of the patella is performed and then under image intensifier a 5mm horizontal drill is guided over a guide wire through the centre of the patella.

A patella tendon type LARS ligament is then passed through the patella drill hole from lateral to medial, using a special wire passer. The lateral end of the LARS ligament is sutured to the lateral edge of the patellar at the insertion site using a strong suture to prevent pull through the ligament. Usually the LARS ligament has a metal pin like button, which adds stability to the structure.

Using an image intensifier, a second 1-2cm incision is made over the natural attachment of the MPFL. Using long forceps a tunnel is created in the soft tissue between the two incisions. The LARS ligament is then passed through this soft tissue tunnel.

Under the image intensifier a second 5mm drill tunnel over a guide wire is made and the LARS ligament is then passed through this second tunnel entering at the medial side and exiting at the anterolateral corner of the distal femur.

In a skeletally immature patient this tunnel has to be accurately positioned in the epiphysis to avoid injury to the growth plate.

The patient’s knee is then positioned at full flexion with the patella fully engaged within the femoral trochlea (femoral groove). The LARS ligament distal end is gently tugged to avoid over loosening or over tightening. Then over a blunt guide wire a 6mm interference screw is inserted through the inside incision. The knee is then taken through a range of motions to check tracking and patella stability. The distal end of the LARS ligament is then trimmed and final radiographs are taken. The wound is closed in layers and a bandage dressing is then applied with no need for a brace.

Published in Surgery