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Wednesday, 14 January 2015 00:00

MPFL Reconstruction Pre-Surgery Information

The following is what can be expected prior to MPFL Reconstruction 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
Wednesday, 14 January 2015 00:00

MPFL Reconstruction Surgical Procedure

LARS Ligaments compared to hamstring tendon graft

To reconstruct the medial patellofemoral ligament (MPFL) the traditional approach has seen surgeons using the hamstring tendon as the graft. However, Professor Al Muderis differs from the conventional approach and has modified a minimally invasive surgical technique to reconstruct the MPFL. Instead of using the hamstring tendon as the graft, Professor Al Muderis uses LARS ligaments (Ligament Augmentation and Reconstruction System). 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 ligaments allowing the original ligament tissues to heal in the absence of traction.

 

MPFL Reconstruction Surgical Procedure:

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 Information
Wednesday, 14 January 2015 00:00

MPFL Reconstruction Information

In a healthy knee the patella (knee cap) sits in a groove (trochlear groove) on the end of the femur (thigh bone). The medial patellofemoral ligament (MPFL) attaches to the inner side of the patella and the inner side of the end of the femur. It is the primary medial stabilise of the patella. The role of this rope like ligament is to prevent the knee from lateral dislocation (dislocating to the outer side of the knee) and subluxation, which is a partial dislocation of the joint. With any lateral movement of the patella the MPFL can be injured or torn. After a patella has dislocated once, the MPFL is often ruptured or stretched and is less reliable in preventing the patella dislocating in the future.

If a patella continues to dislocate or feels unstable, the MPFL can be repaired with a surgical reconstruction to stabilise the patella and return it to its normal state and position within the knee.

A MPFL Reconstruction is a very reliable procedure for stabilising the patella. However in terms of pain, the results are a bit more unpredictable. 

 

Signs and Symptoms of Patella Dislocation

  • Patella dislocation to the outer side of the knee, causing an obvious deformity. The patella often relocates on its own once the knee is straightened, reversing the deformity. However, damage to the ligament is still sustained
  • Tenderness, swelling and bruising of the knee
  • Severe pain when attempting to move the knee
  • The feeling the knee is unstable and might give way

 

Common Causes of Patella Dislocation

  • Direct blow to the knee
  • Twisting or pivoting injury to the lower leg, such as with rapidly changing direction
  • Powerful muscle contraction and increased quadriceps angle. The quadriceps angle is the angle between the line of pull of the quadriceps and the line of the pull of the patella ligament. The wider this angle, the harder the quadriceps muscle will try to dislocate the patella when it contracts
  • Congenital abnormality, such as shallow or malformed joint surfaces
  • Patella Alta, where the patella sits too high in relation to the femoral trochlea

 

Diagnosis

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 MPFL is by using both plain radiograph and MRI scans in order to reach the appropriate diagnosis. 

 

Who is MPFL Reconstruction Suitable For?

A MPFL Reconstruction is recommended for those who have had one or more patella dislocations and have ongoing instability of the knee. It is suitable for those with a normal, shallow or flat trochlear groove. If the groove is severely deformed and is domed, a MPFL reconstruction is usually not an appropriate option and a trochleoplasty (reshaping of the trochlea) may be performed instead.

 

 

Published in Information

The following is what can be expected after having Unicompartmental Knee Replacement:  

Immediately after surgery you will be taken to the recovery room where you will be motioned. Once stable you will then be transfered to the ward.

Following unicompartmental knee replacement surgery, you will be set up with a button to press to administer pain relief through a machine called a PCA machine (Patient Controlled Analgesia).

The post-op protocol will vary slightly from patient to patient, but generally you can expect your drain to be removed after 24 hours. Once this is removed you can sit out of bed and start moving your knee and walking on it within a day or two of surgery. The dressing will be reduced usually on the second day post-op in order to make movement easier. You will be visited by a physiotherapist who will prescribe exercises and assist you with your rehabilitation and mobilisation.

It is expected you will remain in hospital for three to five days post-surgery. Depending on your needs and situation you will either be discharged home or transferred to a rehabilitation hospital. Either way you will need to do physio exercises on your knee following surgery. A large amount of the long-term results and success of knee replacement surgery depends on how much work you as the patient put in following your operation so it is important to continue with the physio exercises prescribed. 

Once discharged you will be expected to walk with a walker or crutches for six weeks at which stage you can progress to a walking stick. Also at the six-week point, once you feel you have confidently regained control of your leg, you can return to driving.

Knee flexion (bend) will vary from patient to patient but it is expected that by six weeks the knee should be able to bend to 90 degrees. The goal post surgery is to obtain 110-115 degrees of movement.

Upon return home post-surgery special precautions will be needed to be taken around the house. An occupational therapist will assess the home and assist you with this. For example you may need rails in the bathroom or if there are a lot of stairs in your home you may need to modify sleeping arrangements temporarily. 

You should be walking reasonably comfortably by six weeks. More physically demanding activities, such as sports may take three months to be able to do comfortably.  

Concerns: Please contact the office if post-surgery you are worried about your level of pain, have significant bleeding, or have fever or redness around the surgical site.

If you require assistance after hours, please contact the hospital where the surgery was performed and they will contact Professor Munjed Al Muderis on your behalf.

Norwest Private Hospital: (02) 8882 8882

Sydney Adventist Hospital: (02) 9487 9111

Macquarie University Hospital: (02) 9812 3000

 

 

Published in Post Surgery

Unicompartmental Knee Replacement surgery is preformed under a spinal or general anaesthesia. The surgery takes approximately two hours.

The patient is placed on their back and a tourniquet applied to the upper thigh. An incision, about 7cm, is made to expose the bones of the knee joint.

The damaged portions of the femur and tibia are then cut at the appropriate angles using specialised jigs. Test components are inserted to check the accuracy of the cuts and determine the thickness of plastic required to place in between the two components. 

Each knee is highly individual and will vary from patient to patient. To cater for this the knee replacement implants range in size and will be chosen and matched according to each individual patient.

If there is more than the standard amount of bone loss extra pieces of metal or bone can be added.

The permanent components are then inserted and the knee is checked again to ensure everything is working properly. The knee is then carefully closed, drains inserted and the knee dressed and bandaged.

 

Published in Surgery

The following is what can be expected prior to Unicompartmental Knee Replacement 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 pre-operatively.

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 anesthetist 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

Unicompartmental Knee Replacement surgery is preformed under a spinal or general anesthesia. The surgery takes approximately two hours.

The patient is placed on their back and a tourniquet applied to the upper thigh. An incision, about 7cm, is made to expose the bones of the knee joint.

The damaged portions of the femur and tibia are then cut at the appropriate angles using specialised jigs. Test components are then inserted to check the accuracy of the cuts and determine the thickness of plastic required to place in between the two components. 

Each knee is highly individual and will vary from patient to patient. To cater for this the knee replacement implants range in size and will be chosen and matched according to each individual patient. If there is more than the standard amount of bone loss extra pieces of metal or bone can be added. 

The permanent components are then inserted and the knee is checked again to ensure everything is working properly. The knee is then carefully closed, drains inserted and the knee dressed and bandaged.

 

Published in Information

Who are suitable candidates for an Unicompartmental Knee Replacement?

  • Arthritis must only be limited to one compartment of the knee which is confirmed by x-ray
  • Ideally patients should be above 60 years of age
  • Patients should have a BMI less than 30

 

Who are unsuitable candidates for an Unicompartmental Knee Replacement?

  • Patients with arthritis affecting more than one compartment of the knee
  • Patients with severe angular deformities
  • Patients with an unstable knee
  • Patients who have undergone a previous osteotomy
  • Patients who are involved in heavy physical work or contact sports
Published in Information

Advantages:

The advantages of a Unicompartmental Knee Replacement compared to a Total Knee Replacement include:

  • Smaller operation with a smaller incision
  • Smaller amount of bone removed
  • Shorter hospital stay
  • Quicker recovery
  • Less pain following surgery
  • Less blood loss with a blood transfusion rarely required
  • Greater movement of the knee
  • Feels more like a ‘natural’ knee post surgery. This is because the bone, cartilage and ligaments in the healthy parts of the knee are untouched
  • A smaller amount of post surgery physiotherapy is required
  • Following surgery, patients are able to be more active than they would be following a Total Knee Replacement
  • If for some reason the Unicompartmental Knee Replacement is not successful or fails many years down the track, it can be revised to a Total Knee Replacement easily and without difficulty

 

Disadvantages:

  • A Unicompartmental Knee Replacement is not as reliable or as predictable in taking away all the pain associated with osteoarthritis as it is with a Total Knee Replacement
  • Potentially there may be the need for more surgery in the future and a Total Knee Replacement may be required if arthritis develops in the parts of the knee that have not been replaced
Published in Information
Monday, 12 January 2015 00:00

Knee Arthroplasty Surgical Procedure

 

Knee Arthroplasty Surgical Procedure

Knee arthroplasty surgery is preformed under a spinal or general anesthesia. The patient is placed on their back and a tourniquet applied to the upper thigh. The surgery takes approximately two hours.

An incision is made to expose the bones of the knee joint.

The damaged portions of the femur and tibia are then cut at the appropriate angles using specialised jigs. Test components are then inserted to check the accuracy of the cuts and determine the thickness of plastic required to place in between the two components. Each knee is highly individual and will vary from patient to patient. To cater for this the knee replacement implants range in size and will be chosen and matched according to each individual patient. If there is more than the standard amount of bone loss then extra pieces of metal or bone can be added. The patella (knee cap) itself may be replaced depending on the condition of the knee.

The permanent components are then inserted and the knee is checked again to insure everything is working correctly. The knee is then carefully closed, drains inserted and the knee dressed and bandaged.

Published in Surgery