Monthly Archives: May 2011

Podiatry and Orthotics

All foot and ankle problems including in-growing toenails, callosities, bunions, sports and degenerative conditions can be treated at Spire Liverpool Hospital.

Physiotherapy

Physiotherapy

Our holistic approach means we take the time to understand the patient’s condition, home-living situation and work environment, so that the best treatment and advice can be given.

Spire Liverpool Hospital Physiotherapy and Sports Injury Clinic offers a dynamic service specialising in musculo-skeletal conditions. The physiotherapists are all highly qualified with more than five years training and are registered with the Chartered Society of Physiotherapists.

The department works closely with consultants and GPs to ensure that patients receive a highly focused course of treatment and care tailored to their individual needs.

Our holistic approach means we take the time to understand the patient’s condition, home-living situation and work environment, so that the best treatment and advice can be given.

In addition to devising and implementing orthopaedic rehabilitation programmes our physiotherapists are highly experienced in sports injuries.

Physiotherapy

Our holistic approach means we take the time to understand the patient’s condition, home-living situation and work environment, so that the best treatment and advice can be given.

Spire Liverpool Hospital Physiotherapy and Sports Injury Clinic offers a dynamic service specialising in musculo-skeletal conditions. The physiotherapists are all highly qualified with more than five years training and are registered with the Chartered Society of Physiotherapists.

The department works closely with consultants and GPs to ensure that patients receive a highly focused course of treatment and care tailored to their individual needs. Our holistic approach means we take the time to understand the patient’s condition, home-living situation and work environment, so that the best treatment and advice can be given.

In addition to devising and implementing orthopaedic rehabilitation programmes our physiotherapists are highly experienced in sports injuries.

Podiatry and Orthotics

All foot and ankle problems including in-growing toenails, callosities, bunions, sports and degenerative conditions can be treated at Spire Liverpool Hospital.

Facilities

MRI Services

Patients benefit from flexible and convenient MRI appointments without waiting.
Spire Liverpool Hospital offers a premier mobile MRI scanning service for patients of Liverpool and the North West of England. The state of the art MRI scanner provides patients with the best image quality available in the industry.

Our scanners are operated by skilled and qualified MRI Radiographers. Patients benefit from flexible and convenient MRI appointments without waiting.
The MRI scanner complements the diagnostic services such as CT scanning, bone densitometry, mammography, ultrasound and X-ray.

Total Knee Replacement

What is a total knee replacement?

A total knee replacement involves replacing a worn out knee joint with a metal and plastic replacement. The femur (thigh bone) has its end resurfaced with metal and the tibia (shin bone) has its top end resurfaced with a flat metal tray. A plastic tray separates the two metal implants. Sometimes the metal tray is substituted for a thicker plastic insert. It is not usually necessary to resurface the patella (knee-cap), but any irregularities of bone are trimmed to make it smooth. The metal components are made of cobalt chrome and the plastic of polyethylene.

A new ceramic-metal called Zirconium is available for the femoral part of the joint. Its surface is an oxidised metal making it act like a ceramic. Theoretically, it has up to 80% less wear than conventional cobalt chrome implants, but no long term data is available as yet.

Are there any alternative treatments to a knee replacement?

Yes there are and include adequate pain relief, knee braces, physiotherapy injections and washout of the knee. Your consultant will explore all these avenues before embarking on a knee replacement.

What happens during the operation?

A 15-20cm vertical cut is made just to the midline of your knee, and the bone is prepared to allow the knee replacement. The metal and plastic components are attached using bone cement which is comparable to grout. Once the new knee is stabilised, it is then washed out and the wound stitched up and bandaged. The operation usually takes about an hour and a half.

What happens after the operation?

Once you have woken up you will be returned to the ward. The next day you will be encouraged to get out of bed and start physiotherapy to get your knee moving. Most people require five to seven days in hospital before they are safe to go home, but it depends on the individual. If you are finding it difficult, you may require a special machine (cpm) to help you bend your knee. The physiotherapists will arrange further physiotherapy as an out-patient.

How long does it take to recover from the operation?

Everyone varies, but in general you should achieve a reasonable range of movement in about three months, but will continue to improve for over a year. You may feel tired for a number of months.

Are there any complications with this surgery?

The overall success rate from this surgery is about 90% although you will need to be aware of the following complications;

  1. Thrombosis describes clots in the leg. These are quite common, but most patients are unaware of them and they cause no problems and resolve with no specific treatment. However, sometimes they can be large and cause considerable problems. If they break off and travel to the lungs they are called embolisms, and can be fatal to 3 in 1000 patients. We will give you specific treatment to try and prevent this.
  2. Infection is a serious potential problem that occurs in about 1% of patients despite the use of antibiotics. If the metalwork gets infected, it is exceedingly difficult to eradicate the infection, and may require numerous operations, with no guarantee of success. We will give you antibiotics to try and prevent infection.
  3. Aseptic loosening is a term used to describe the wearing out of a joint in time. Roughly 95% of total knee replacements last 10 years, but in certain people the lifetime of the joint may be a lot less. Many joints can last far longer, if the patients looks after his or her joint well.
  4. Persistent pain can occur even after an otherwise apparently successful knee replacement. The cause is often not evident and it may be impossible to eradicate it as re-doing the operation does not improve the symptoms.
  5. Stiffness can occur after the operation. The operation is designed to eradicate arthritic pain, not to regain movement and in general the range of movement you had prior to the operation is the range you gain afterwards. However you may loose a few degrees movement and in a few cases the stiffness is severe leaving the patient with less than 90 degrees movement, which can make walking, and getting up from a seated position very difficult.

If the joint wears out in the future can it be replaced again?

Yes it can, but the success rate is not quite as good, surgery is more difficult, the complications are twice as likely and it takes more out of the patient, who is older and perhaps not quite as fit and he or she was the first time around. Your consultant will go through the operation in great detail and allow you to ask any questions you wish.

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Patella tendonitis

What is Patella Tendonitis?

Patella tendonitis is quite a common problem in which part of the patella tendon, usually the deep part just underneath the knee-cap, becomes damaged and causes localised pain. It is usually seen in sports that involve jumping and indeed is sometimes known as jumpers knee.

What is the Patella Tendon?

The patella tendon is the rope like structure that connects the patella to the tibia (shin bone). It is an extension of the quadriceps muscle of the thigh and as such is a continuation of the tendon of that muscle. The patella (kneecap) is a small bone that develops in the middle of that tendon dividing it into the quadriceps tendon above and the patella tendon below. This arrangement makes for better leverage of that tendon, with the bone holding the tendon further away from the knee joint. The patella also has a smooth undersurface like the rest of the knee joint and can act like a modified pulley, running in a groove in the femur (thigh bone) during knee flexion.

What does this tendon do?

A tendon acts as a rope, which when pulled on straightens the knee. It is the only tendon that acts to straighten the knee and is essential for everyday standing and walking. In a jumping athlete however, it is the essential tendon for transmitting the huge forces that enable the quadriceps to snap the knee straight and create a jump.

How does the tendon become damaged?

In the process of jumping huge forces can be experienced within the tendon substance. In fact, the tendon is strong enough to suspend a small car without rupture. Being this strong the normal tendon rarely ruptures due to sudden overload. Whilst it can rupture this way when the tendon substance is damaged (e.g. in chronic illness such as chronic renal failure and in patients on steroids), this situation is also uncommon.

What happens to the tendon when damage occurs?

The situation that occurs in patella tendonitis is thought to be one of a repetitive partial rupture of the microfibres of the tendon that occurs slowly like a fatigue fracture in metals. In general in the body, gradual fatigue wearing tissues is counter balanced by repair and replacement of that tissue. Overall therefore tissues tend to remain strong enough for everyday activities in any one time the old and damaged portion of a tissue is small and of no significance. Two processes can interfere with this process of renewal:

Excessive breakdown of tissue, which is generally in overuse type of injuries. This is frequently seen in the repetitive jumpers and sports such as basketball. Here the amount of breakdown exceeds the capacity for repair and hence slow deterioration of the tendon ensues.

Decreased healing of the tissues, which is generally an age dependent event. The age in which tendon repair starts to deteriorate may be as young as the early twenties. Everybody is different in this regard, but there is no doubt that some peoples tendons are more resistant to damage and also heal better than others. In other words, some tendons (in some people) are more suited to a higher level of activity than others and hence may have a longer career without significant tendon injury.

How is injury diagnosed?

The commonest place for the tendon to generate is in the deep central aspect immediately below the patella itself. Much less commonly it may occur in the tendon insertion on the tibia and rarely may involve the entire tendon. The pain from the area of tendon damage is generally localised and rarely radiates. Hence the commonest symptom is pain immediately below the kneecap. This is worse when the tendon is stressed (running and jumping etc) and better with prolonged rest. There is often associated inflammation and swelling. The pain is often worse after rather than during activity. The usual pattern is for a gradual onset of pain with use which slowly worsens with time. Initially no modification of activity is required, but gradually as the symptoms worsen, one may have to modify training and ultimately limit sporting activity.

The diagnosis is largely clinical with tenderness of the upper (or effected) part of the patella tendon. Tenderness is generally greater with the knee straight. The best tests to confirm the diagnosis are ultrasound and MRI (magnetic resonance imaging). Ultrasound is more sensitive to operated areas than MRI but when performed by a good radiologist can be relied on almost 100% to confirm or deny the presence of tendonitis. Not only can the lesion be identified but often the degree and extent of fibre damage can be noted.

Does the tendon heal?

Where the damage to the tendon is small and where the potential for healing is high (the young), there may be some healing. This is often repaired with localised scar tissue and providing that this area does not hurt, the result will be a fully functional tendon and few if any symptoms. Where the damage is more extensive, the potential for healing is not great. If rested, the area may become less painful and the function may improve but with a return to higher levels of activity the symptoms return.

How is it treated?

In the early phases a conservative programme is undertaken. This includes adequate rest, modification of training to avoid impact loading, jumping or other stimulatory factors, patella tendon strapping to support the tendon and anti-inflammatory type medication. Physiotherapy and related techniques may have some role to play in strengthening and desensitising the tendon to stress but no techniques have shown the potential to increase tendon healing. Cortisone injections have been used in the past but are very rarely used now due to the concern regarding tendon rupture.

Can surgery cure the problem?

If all of the above treatments fail or the damage to the tendon is bad enough to suggest that it may fail, then surgery may be considered. The surgery for this condition is limited to excision of the damaged area of tendon and possibly any impinging areas of bone on the patella. The problem with this treatment however, is that the outcome is not always as good as we would like and indeed sometimes does not seem to help.

The patella tendon can withstand an excision of about 40% of its fibres and patella tendon rupture following this surgery is rare. Of more concern is that the possibility that the tendon will not be significantly less painful after the procedure. If this occurs then treatment is asked for primary tendonitis with repeated conservative programmes. If ultimately this does not settle down then further excision may be undertaken though results are less satisfactory. The tendon can be made more symptomatic with surgery, but fortunately this is very uncommon.

What is the recovery rate from surgery?

The actual operation is not all that major to perform and can be done as a day case under General Anaesthetic. Usually the surgery is performed through an approximately 5cm transverse incision right over the area of tenderness. Over a 9-12 month period this heals such that in most people it becomes difficult to see. Most people can walk on the knee the same day, although this is limited to short walks around the house for the first few days. Generally by 2 weeks most people have stopped limping and the knee improves thereafter.

By 3 months most people can lightly jog albeit it with some discomfort. A few people will be able to train at that time but that would be considered better than average. Over 6-12 months most gradually get back to sport, but some take as long as 2-3 years to fully settle down. In the majority, the tendon is never clinically symptoms free and most are left with some residual ache which is tolerable, does not stop them playing sport and is not bad enough to consider further treatment. The reason for this protracted recovery is uncertain but it does not seem to relate to how bad the tendon was in the first instance or to how much tendon was removed at surgery.

Overall, surgery for this condition can be regarded as good but rarely does it provide excellent results with a totally asymptomatic knee. When the tendon damage is bad enough however, and conservative treatment has failed there is no other satisfactory alternative to excision of the damaged area.

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Posterior crutiate ligament injuries

Can I damage this ligament easily?

The posterior cruciate ligament is the largest ligament in the knee and therefore is not torn as often as are the other ligaments (the anterior cruciate or medial collateral ligaments). It is also implied that a larger force is required to injure this ligament.

How does this particular ligament become injured?

The ligament can be injured in isolation or in combination with other ligaments. When damaged in isolation this can occur in one of two ways. Firstly, as is generally the case in sport, the knee can be flexed up (bent) beyond its normal limits. Secondly, a dashboard type injury may be sustained in which a direct blow to the upper tibia (shinbone) with the knee flexed, drives the tibia posteriorly (backwards) behind the femur (thighbone), thus exceeding the limits normally set by this ligament.

The ligament may also be torn in association with other ligaments, often the anterior cruciate and one of the collateral (side) ligaments. This generally is a direct impact injury of considerable force and fortunately is not common. When it occurs however, it represents a form of true knee dislocation.

The normal anatomy is depicted above. The cruciate ligaments and the collateral ligaments provide stability to the joint. The menisci (meniscal cartilages) function as shock absorbers and they also enhance joint lubrication and nutrition of the articular cartilage as well as providing some stability to the knee joint. The articular cartilage lines the inside of the knee joint and allows for its smooth movement.

Unlike the anterior cruciate ligament, injuries to the posterior cruciate ligament are usually not associated with a popping or tearing sensation in the knee. Also as the ligament is outside the actual cavity of the knee joint there may not be much swelling within the joint itself. Again, unlike the anterior cruciate ligament, the ligament is frequently only partially torn and is less often associated with tears of the meniscal cartilages.

Despite the size of the posterior cruciate ligament, in general, the injury is less significant to the stability of the knee than is an injury to the anterior cruciate ligaments. The knee usually does not give way and often, with a good rehabilitation programme to strengthen ther quadriceps muscle (muscle at the front of the thigh), a good functional knee can result. Unfortunately however, some patients do develop problems of increased wear under the patella (kneecap), which is due to the posterior sag of the tibia. This is difficult to prevent and because it is not possible to predict or get this, early operation is not generally recommended. The other complication that is seen, again unpredictably and unfortunately less commonly is wear and tear arthritis of the inner half of the knee. This is also is not sufficiently common to advocate an early operation in most people.

POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

As the ligament does not heal well and is not readily repairable sometimes reconstruction is considered. This may be done soon after the injury in cases where other ligaments have also been torn and where it is considered that the posterior cruciate ligament is essential to act as a restraint against which other ligaments can work to control the stability of the knee and to prevent it from giving way.

It is also possible to reconstruct this ligament at a later date and this generally occurs either when the absence of this ligament alone is thought to be the cause of the knee instability (which is uncommon) or when the anterior cruciate ligament has to be reconstructed and this requires a good posterior cruciate ligament to function properly.

Reconstruction of the posterior cruciate ligament is probably the most difficult and demanding operation in knee surgery today and whilst our knowledge of this ligament has greatly increased in recent years, only recently with the advent of newer techniques has the operation started to become successful. Because of this difficulty and because of the problem of achieving consistently good results this operation is currently reserved for the more severely injured knees.

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Anterior Cruciate ligament injuries

What is the Anterior Cruciate Ligament (referred to as ACL)?

The anterior cruciate ligament (ACL) is the most commonly disrupted ligament in the knee. Our understanding of this ligament and our recognition of its importance to knee stability has increased greatly over the past 10 years. Along with this our ability to diagnose and treat this injury has substantially improved. As a result an injury which might have once spelt the end of a sporting career can now be viewed much more optimistically.

What is the function of the ACL?

The anterior cruciate ligament is a major and important ligament in the knee which is commonly injured. Treatment depends on the age of the patient, the exact nature of the injury, the nature of any associated injuries, the lifestyle of the patient and their future sporting aspirations. In those patients who are willing to alter their lifestyle a rehabilitation programme may be adequate, but for the keen athlete who is wanting to return to twisting and turning sports a reconstruction may be the better alternative. With the advent of better operative procedures to reconstruct this ligament the problems that used to be associated with this form of surgery are less common and the function results are better. In general 90% of those undergoing reconstruction will be able to return to their previous sport and more than 70% will be able to compete at their previous level.

Nowadays an inability to return to sport at the pre injury level is rarely due to loss of the anterior cruciate ligament with reconstruction of that ligament being generally successful. Rather it is more usually due to unrepairable damage caused to other parts of the knee at the time of this initial injury or in subsequent injuries.

The normal anatomy of the knee can be defined as the following;

The cruciate ligaments and the collateral ligaments (at the side of the knee) provides stability to the joint by holding the bones together. of these ligaments, the anterior cruciate is important in that it holds the knee together during twisting type activities.

During everyday walking and in straight line running, the ACL is hardly used. As soon as any twisting is performed however, this ligament is essential. It is the feeling of coming apart that gives rise to the instability or loss of confidence in the knee that is seen when the ACL is torn. If major, it may occur in everyday activities however, in some it occurs only during training or sporting activities.

What are Meniscal Cartilages?

The menisci (meniscal cartilages sometimes known as the cartilages) function as fillers to spread the load between the surface of the femur (thighbone) and tibia (shinbone). They primarily function somewhat like shock absorbers but they also have a secondary role to enhance lubrication and nutrition of the articular or lining cartilage and do have a part to play in stability of the knee. Loss of the meniscus (particularly the lateral (outer) 1) leads to a poor spread of weight across the joint surface. This means that loads are taken over small areas of the joint and hence pressures are higher causing increased rates of wear of the lining surface. I.e. osteoarthritis.

What are Articular Cartilages?

This covers the ends of the bones of the knee joint and allows for its smooth movement. It is shiny, white, ultra low friction tissue that acts as a bearing surface for the joints. It is very different from the meniscal cartilages and is the most delicate and essentially irreplaceable structure within the knee. Injury to the lining can be treated by debridement which is a process of removing loose fragments and smoothing the remaining damaged surface. The body attempts to repair these areas with a scar like tissue though this does not have the same properties as the original articular cartilage and in essence it is this damage to the bearing surface of the knee that starts off the progressive process known as osteoarthritis. Newer techniques are becoming available which aim to regenerate the articular cartilage and these at the present stage are experimental and are only suitable for certain defined lesions.

How do injuries to the ACL occur?

Injuries to the ACL occur most often in athletic activities (especially twisting and turning sports such as football and rugby), but maybe ruptured in work injuries and non athletic activities. The injury can occur without contact and is often associated with a sudden change in direction (eg side stepping) or a sudden change in speed (a deceleration or slowing down injury). It may also occur with the body falling over a fixed leg or with a hyperextension (over straightening) injury to the knee.

How will I know if the ACL has been injured?

At the time of the injury, the individual will often hear a pop or a snap or experience a sensation of tearing inside the knee. The knee then swells, almost immediately, because of bleeding from the vessels and the torn ligaments. Generally the injured person finds any attempt to weight bear is difficult because the knee feels unstable. The immediate feeling of instability is due not only to the loss of the ligament but also to a loss of the nerve fibres within that ligament. These nerves provide a sense of where the joint is in space which is called proprioception. Loss of that sense causes a loss of sensation on how bent the joint is, how fast it is bending and so on. Without that knowledge there can be no active feedback to the muscles that move the knee or the muscles that protect the knee and hence control of the joint maybe lost leading to a feeling of instability or loss of confidence.

With time the feeling of proprioception improves and this is because the nerve fibres in other ligaments attempt to compensate. This situation is never quite as good as prior to the injury but if demands on the knee are low it maybe sufficient to cope.

What happens once this injury has occurred?

After the injury there is sudden loss of control of the knee which gradually returns and in most people it takes about 2 months to the level where they can think about playing sport again. If by that time however, full confidence in the knee has not been restored then it is unlikely that the knee will be able to perform a twisting turning sport again without reconstruction. If a return to those sports is made whilst the knee is still unstable then a repeat injury is likely and every time the knee gives way there is the chance that more damage can occur particularly to the meniscal cartilages and articular cartilage which increases the likelihood of developing osteoarthritis in the future. Because of this risk it is now considered preferable to reconstruct the unstable knee to prevent any episodes of giving way.

In general patients with ACL injuries may be divided into three roughly equal size groups. The first group contains people who do well and return to their sport without too much trouble. However, it must be emphasised that reconstruction should be seriously considered even if there is only one further episode of giving way to try and prevent as previously mentioned.

The second group contains people who seem to do well until they attempt to play a demanding sport. They may even do well at training but on taking to the field a re-injury soon occurs. If they are prepared to give up sport an alter their lifestyle then reconstruction may not be necessary though for people wanting to play these sports even at low levels reconstruction is recommended.

The third group contains people whose knees feel frankly unstable in everyday life. This group almost uniformly requires surgery to give their knee a feeling of stability. That stability then protects against further injury and damage to the knee.

Which group would warrant surgery?

Overall it may be seen that a large number of people who injure their ACL might eventually benefit from surgery. The exact number is uncertain but currently it is thought that some 50% or more would be helped. This is somewhat age dependent and the requirement for surgery does decrease with age and this is not only because the demands placed on the knee also decrease but it appears that the ability to cope with proprioceptive loss improves with age. There is no age limit for this type of surgery. Clearly it is related to general health, level of activity and feeling of instability.

Those who sustain injuries to other ligaments of the knee in addition to a tear of the ACL and are more likely to fall into the third group i.e. requiring surgery.

Tears of the meniscal cartilages are commonly associated with ACL tears. A meniscal tear may be excised (removed) or occasionally may be suitable for repair. This can often only be determined at the time of surgery. If the cartilage is to be repaired then ACL reconstruction should be considered as the failure rate of meniscal repairs in an unstable knee is unacceptably high.

Can it be treated without surgery?

Treatment for injuries of the ACL cannot be standadised because of individual difference in injury patterns and because of different expectations of patients in regard to returning to sporting activities. In the patient who sees sport purely as recreation and would consider giving it up if it meant that an operation could be avoided a hamstring re-education and rehabilitation programme may provide a satisfactory knee for everyday use. This type of exercise programme however, is not a substitute for ACL reconstruction because the ligament itself never heals. What it achieves is better control over the knee by improving strength and improving the feedback from the other ligaments (proprioceptive training). Given adequate provocation however, the knee may still give way and further injury may occur. Recurrent giving way needs to be avoided as if these episodes are associated with pain and swelling and are frequent then the knee will develop progressive wear and tear arthritis (osteoarthritis). Patients in this situation need to either consider the option of surgical reconstruction or to change the demands that they are placing on the knee.

What does ACL Reconstruction involve?

Reconstruction of the ACL is a complex surgical procedure and there are many different ways for it to be performed. The preferred method at this time is to use a portion of tendon from elsewhere in your body as a graft. In the majority of cases this means using one of the hamstring tendons on the inner aspect at the back of the knee but other tendons can be used. Artificial ligaments have been used but have a tendency to early failure.

The technique for reconstructing the ACL has improved significantly in recent years and can now be done in an arthroscopically (through a telescope) aided manner. However, this does not mean that there are no incisions as the graft still has to be taken in a standard open type manner. The knee joint itself however, is usually not opened as all the work in the joint can be done via the arthroscope. This generally causes less pain and a shorter hospital stay and allows for earlier and often easier rehabilitation.

Reconstruction of the ACL is now an everyday procedure thanks to the very major advances in instruments and techniques that have occurred over the last 5-10 years. Patients are in hospital for 1 or at the most 2 nights and generally no brace is required except in the immediate post operative period. Crutches are necessary for about 2 weeks though as long as the range of motion is being maintained it does not matter if you prefer to stay on crutches for a few weeks and they should certainly be used on long walks, on uncertain ground or in places where the knee may be at risk. Once motion has been regained the next priority is to get all the swelling out of the knee and this generally takes about 6-8 weeks. By this time most people can walk with only a minimal limp and your rehabilitation will be supervised by a physiotherapist.

When first put into the knee, the graft itself is dead. Over a period of time however, it gains a new blood supply and strengthens. Whilst this process probably takes some 2 years to fully complete it is thought that by 4 months some running can be commenced and by 6 months training for sport can be started. Actually getting back to full sport depends on individual progress at that stage including the regaining of proprioception in the knee. Exercises to promote this stability are essential and are encouraged when running is well progressed. Return to full sport is expected at about 9 months.

What is the recovery period?

Patients can generally return to work at 7-10 days provided that the amount of time spent on their feet is limited. They may also wish to use their crutches for a longer period of time. People in a sit down job can usually return in 2 weeks though if the job involves prolonged standing then 4 weeks may be more realistic. 2-3 months is probably the earliest that a return can be made if there is any heavy work to be done and jobs requiring squatting and bending may take a little longer. Jobs requiring the ability to run, work on uneven ground or climb ladders eg on a building site are the most demanding and these may require 6 or more months for adequate recovery to ensue.

Are there any problems associated with this surgery?

Overall the number of people who have problems following ACL reconstruction is small. Nevertheless problems do occur and these need some consideration.

Bruising in the immediate post operative period is the commonest problem. Obviously everybody has some bruising and in some cases it may be quite marked. It causes discomfort particularly when standing and may last for 2-3 weeks.

Deep Vein Thrombosis (DVTs or clots in the leg) also occur but are uncommon (less than 5%). If a patient is at risk for this complication eg previous DVT then some prophylactic thinning of the blood can be performed. This does increase bruising and bleeding however, and thus is not regarded as routine treatment. Patients on the oral contraceptive pill (except progesterone only pill) are at increased risk of a DVT and this should be stopped 1 month prior to surgery and obviously alternative contraception should be used until the pill is restarted. The concern of having clots in the vein is always that they may spread to the lungs (pulmonary embolis or PE) and this is an extremely rare event but does represent the one major and serious complication of this and other lower limb surgery.

Deep Infection is uncommon and occurs in about 1 in every 200 cases. It requires prompt treatment including arthroscopic washout of the knee and antibiotics into the veins and the risk of deep infection is that the graft may be damaged and fail.

Loss of Full Extension of the knee is the most common medium to a long term problem encountered. Some 5 to 10% of people who undergo ACL reconstruction have a scarring and tightening reaction to that surgery and the reason for this is unknown. Less than 5% have any residual loss and in some cases a further arthroscopy is necessary to remove some of the scar tissue. With newer techniques of reconstruction however, this type of secondary surgery is becoming less and less necessary.

Graft Loosening and Failure may also occur. Just as there is a 5 to 10% group at the tight extreme, so there is a 5 to 10% group who seem to progressively loosen with time. This group regains motion early and easily and with their quick recovery tend not to protect the knee as much as perhaps is ideal. In some instances this can cause early failure of the graft.

A cause of late failure (6-12 months) is where the graft fails to get a new blood supply and fails to come back to life. This is uncommon though if it occurs revision reconstruction may then be necessary and is usually successful.

Graft Re-Rupture can and does occur. No graft is as strong as the normal ligament and hence further injury (like the first one) can cause damage to it. Re-rupture rates within the order of 5% at 2 years following surgery though actually it is more common to rupture the ACL in the other leg rather than in the operated leg.

Patello-Femoral Pain or Ache Under the Kneecap (patella), is common once activity has begun. This is mostly due to the muscles being wasted and weak and therefore responds well to exercise and physiotherapy. Patello-femoral pain can also occur from damage to the articular lining of the patella itself. This happens in about 10% of ACL injuries and unfortunately it can prove relatively difficult to treat. Nevertheless this problem is generally minor and usually does not interfere with sporting activities to any great extent.

ACL reconstruction:
Why have I had this surgery?

Your operation has been to reconstruct or replace the anterior cruciate ligament. This has been done in an arthroscopically aided fashion. This does not mean there are no wounds however, because incisions were still made both to obtain the graft that was used for the reconstruction and also to introduce the graft into the tunnels that have been made in the bone for that graft.

What did this procedure involve?

What arthroscopically aided means, is that the capsule of the knee has not actually been formally opened and that all the main work that has been done in your knee was able to be done with the aid of the arthroscope. This is advantageous because it gives rise to less pain and less scarring within the knee and thus movement is easier to regain, progress is quicker and ultimately function is likely to be better. Because all of the joint was able to be inspected the other structures within your knee were clearly seen and where necessary treated.

The following summarises your surgery:

The graft that was used was 2 of the hamstring tendons on the inner aspect of your knee. Graft fixation is generally quite strong thus allowing for earlier movement and exercises with less chance that the graft will pull away at one end or the other. It also means that splints are no longer required (except for the immediate post operative period) for most cases and early walking is encouraged. Only approximately 10 years ago when this sort of procedure started to become widely used the knee was in plaster for anything up to 6 weeks and then slowly mobilised over several months to regain motion. More recently hinged splints have been used to restrict the range of motion of the knee thus providing a combination of moderate motion with some protection. Now, with the advent of better graft fixation, it has been found safe to not only mobilise the knee from day 1 but also to allow full weight bearing in the first 1-2 weeks following surgery. Whilst this does slightly increase the risk of the graft coming loose the benefits of early motion seem to outweigh those concerns.

The loss of the tendons used for the graft does very slightly weaken the hamstrings muscle but in reality it seems to cause remarkably few problems even in the high performance athlete and there is now some evidence to suggest that these tendons regenerate to some extent.

The graft itself is taken up through a hole that is drilled in the tibia (shinbone) across the knee and then into another hole that is placed in the femur (thighbone). As such it lies in exactly the position in the knee as the original anterior cruciate ligament did and is secured in that position so that it functions, as nearly as possible like the original anterior cruciate ligament.

When the graft is first put in the knee is it is very strong, the strength limitation at that stage being related not to the strength of the graft itself but rather to the strength of the fixation at each end. The graft incorporates into its bone tunnels over about 6-8 weeks and during this period when the fixation is becoming permanent the strength of the graft itself is actually decreasing. This is because a new blood supply grows into it and starts to remove some of the main structural fibres from it. It is thought that at 8 weeks the graft is at its weakest and hence care must be taken even at this stage despite the fact that the knee often feels quite good by then and walking is often possible without a limp. Following this period of relative weakness of the graft there is period during which the graft gradually increases in strength again as new structural fibres are laid down. This is a slow process and takes about 15-18 months to be fully completed. By 6 months however, the graft is usually strong enough to do most activities and most of the strength has been regained by then.

What should I do after the operation?

The single most important thing to regain in the early post-operative period is full extension (straightening) of the knee. Generally this can be achieved within a few days though sometimes it does take a little longer. Nevertheless, once it has been achieved, most other potential problems do not seem to eventuate. Despite the importance of regaining this motion it must be realised that full extension does place the graft under some tension and therefore needs to be done gently and passively as the physiotherapist will demonstrate to you. Because of high stresses in the graft when the knee is in extension it is important not to force it into this position by contracting the quadriceps muscle (at the front of the thigh) with the leg straight.

Similarly it is important not to lift the leg with it straight for the first 6 weeks. Studies have in fact established that the leg should be bent to approximately 40 or more before lifting it in the air and this will also be explained to you by the therapist.

Flexion the knee (bending) is much more easily achieved than full extension. As there is some risk to the graft when the knee is taken through to full flexion it is recommended that flexion be limited to 90 or 100 for the first 6 weeks and then slowly increased thereafter. Regaining full flexion is rarely a problem.

For the first 7-10 days most people prefer to use crutches and over that period of time they gradually increase weight bearing so as to wean off the crutches over a couple of weeks.

As long as the range of motion is being maintained it does not matter if you prefer to stay on crutches for a few weeks. Certainly crutches should be used on long walks, on uncertain ground or in places where the knee may be at risk. This having been said however, there is no doubt about the exercise value of walking and early walking does seem to decrease the amount of wasting of the muscles that is an inevitable part of this type of surgery.

You will be admitted on the day of surgery and overall it is expected that you will be in hospital for 1 night and that you will be on crutches about 2 weeks. Once motion has been regained the next priority is to get all the swelling out of the knee and this generally takes about 6-8 weeks. You will be reviewed in my out patient clinic at approximately 2, 6, 26 and 52 weeks. Your post operative rehabilitation will be supervised by a physiotherapist with experience in looking after this sort of reconstructive procedure.

What if I experience any problems after surgery?

If you are having problems with your knee, please contact your physiotherapist or your consultant during office hours. If a problem occurs out of hours you should contact the orthopaedic ward or your GP for advice.

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Patello-Femoral Pain

What is Patello-Femoral Pain?

Patello-femoral pain describes a wide range of conditions beginning with the common mild pain arising from under the knee cap (patella) and extending up to frank arthritis of the patello-femoral joint. Previously the term chondromalacia was used to describe all of these conditions, however, it is now felt that this term should be reserved for those few people with patello-femoral pain who have a demonstrable change to the lining of the patella (articular cartilage).

The word chondromalacia literally means cartilage (chondro) softening (malacia) and whilst this condition can occur in any joint it is most often used to describe the process that occurs under the patella (kneecap). The term chondromalacia patellae refers specifically to a pathological condition resulting in structural changes in the cartilage surface of the patella. The cartilage referred to is the shiny white lining cartilage that forms the bearing surface of all joints and is distinctly different from the meniscal cartilages which are the shock absorbing wedges that are found in the knee and commonly torn.

The changes found in the cartilage lining range from a softening of the normally firm white glistening surface through a stage of fraying, weakening/cracking of the cartilage surface and up to the worse scenario of full thickness cartilage loss with exposure of the underlying bone. This process may be localised to one area or may involve the whole of the patella. Sometimes these changes may affect the underlying groove in the femur (thigh bone) in which the patella tracks.

The whole process can be likened to the development of a pothole in the road. Initially the changes are deep below the surface and cannot be seen. Later on with increased stress the deep layers start to separate from the surface and a blister may develop. After this it is only a matter of time before the blister starts to crack and fissures are seen. Eventually craters may develop exposing the underlying bedrock (or bone in the kneecap). Therefore, as can be appreciated in the majority of instances these changes have been going on for some time before they become apparent. Only rarely is the injury so great as to cause major visible damage immediately.

What are the symptoms?

Just as there is large range in the changes that may be seen in the cartilage lining so the symptoms experienced by patients with this condition may vary tremendously. Unfortunately however, the degree of symptoms experienced may correlate poorly with the underlying pathology and hence some patients who have minimal (if any) changes may in fact be very symptomatic and vice versa. However, once the changes become pronounced the term osteo-arthritis becomes applicable indicating irreversible wear and tear .

The signs and symptoms of patello-femoral pain are variable and different from one individual to another. Generally, there is a dull aching pain across the front of the knee, but it may not be as specific as this and may be felt on the sides of the knee or even at the back of the knee.

The pain may occur during, or more commonly after an aggravating activity. There may be a mild puffiness or feeling of fullness about the knee. There is often a notable popping or grating with knee motion. Prolonged periods of sitting, e.g. long journey or watching a film at the cinema, often results in an aching stiffness. Squatting, climbing stairs, and in particular going down stairs and slopes provoke knee pain. The pain experienced in this condition is felt to result from increased pressure on the bone under the area of stressed lining cartilage.

The pain caused by this may inhibit quadriceps muscle function and this may cause the knee to give way or collapse. In addition the joint may become swollen due to a build up of fluids.

What is the anatomy of the area where this pain occurs?

The patella, a small round bone, lies embedded within the tendon of the quadriceps muscle (see diagram above) whose main function is to extend (straighten) the knee and this occurs when the muscle contracts. The patella aids the quadriceps muscle in extending the knee joint by improving its mechanical advantage. It does this by lifting the tendon out of the groove in the femur. During motion of the knee (flexion and extension), the patella glides (downwards and upwards respectively) in this groove present at the end of the femur.

The patella and femoral groove are each covered by the smooth cartilaginous surfaces discussed above and these allow the patella to glide during knee motion. The cartilage surface of the patella is the thickest such surface in any joint of the body and is about 4-6mms in depth. This cartilage helps to absorb and disperse the large forces placed on the knee during the various activities as well as to provide a low friction gliding surface for the joint. Walking on level ground exerts a force equivalent to half of the body weight on the patello-femoral joint. Climbing on stairs may increase that force up to nearly 3 times body weight and arising from a full squat may generate forces as large as 8-10 times body weight.

What causes this condition?

Patello-femoral pain may develop following an acute injury to the knee such as a direct blow to the patella or a fracture or dislocation of the patella. However, more often it has an insidious onset not specifically related to any one injury. In these cases there may be an underlying anatomical variation of the patella or femoral groove shape, or there may be excessively tight supporting tissues around the patella which increases the pressure under the patella. Malalignment of the lower extremity secondary to excessive rotation of the femur or tibia (shin bone), abnormal angles between these bones at the knee (knock knee or bow leg), or altered foot alignment may be present. In general, any variation which results in maltracking of the patella in the femoral groove during knee motion may expose the cartilage lining to abnormally high loads resulting in abnormal wear of that cartilage.

Who is likely to suffer from Patello-Femoral Pain?

It appears that patello-femoral pain is more common in women than in men. It is seen most frequently during the adolescent and early adult years but may occur at any age. In a number of cases a specific activity can be identified that makes the condition symptomatic. It may be recreational, job related or due to an activity of daily living. It is seen more often in those individuals involved in activities that require a significant amount of kneeling, squatting or even walking (particularly when steps or hills are involved). It is also aggravated in some individuals by running and jumping and, in runners, increased mileage or hilly terrain may bring on the symptoms. Because bent knee activities are mostly to blame even swimmers can develop the problem if they chose to swim breaststroke.

How is the condition diagnosed?

There is no one test that is effective. Generally it is diagnosed on the symptoms of the condition and this is supported by examination findings. However, examination like x-rays may be normal. X-rays can be helpful in more advanced cases or in those cases with definite maltracking of the patella. Similarly arthroscopy may be helpful, though often no abnormality will be seen.

How is the condition treated?

Rarely does patello-femoral pain result in any serious or permanent damage to the knee. This is particularly so in the growing adolescent where, with growth, the anatomy of the patella and its relationship with the femoral groove keep changing. The problem may not stop until a child is fully grown. Typically, the patient with patello-femoral pain will experience ups and downs in their symptoms, usually related to their activities. Part of the treatment therefore is aimed at reducing the frequency and severity of the painful episodes by avoiding or decreasing aggravating activities.

This in turn then allows the lining articular cartilage to stabilise and possibly heal. As this tissue metabolises very slowly it only has the capacity to heal very slowly, and therefore if the condition has persisted for some time it may take longer than expected get better.

A patient with patello-femoral pain needs to identify those activities which cause symptoms and these need to be excluded or modified (where possible) so that they cause less pain. This may involve modification or elimination of several sporting activities, usually those that involve running, jumping or squatting.

A specific exercise programme designed to strengthen the quadriceps muscles and to stretch the hamstring muscles often helps. This may need to be done in association with a taping programme which is designed to help pull the patella across medially. The object of these special exercises is to build up the inside part of the quadriceps muscle (the VMO or vastus medialis obliquus) which is the muscle normally responsible for ensuring the patella tracks correctly in its groove. With a correct exercise programme to build up the muscle, enough strength can be gained to take over from the tape, thus making the tape unnecessary. Once this happens, normal activities including sport, are generally possible.

Where there is an underlying biomechanical abnormality such as squinting patella (kneecaps that turn in to face each other) often caused by pronated or flat feet, a muscle strengthening programme may not in itself be adequate in which case some alteration in the biomechanics may be necessary. The simplest form of this is an orthotic which is placed inside the shoe to alter the position of the feet, which may improve the tracking of the patellae. This technique may be effective particularly where tape is helpful but cannot be dispensed with despite adequate VMO exercises.

Where maltracking continues to be a problem, a stabilising patella brace may be helpful. Though results are often disappointing and rarely totally successful.

Icing down the knee after painful activities or therapy is often helpful and anti-inflammatory medication is sometimes helpful particularly when there is an effusion (swelling) in the knee.

Surgery is very rarely necessary. However, in cases where the problem keeps recurring, an arthroscopy (in which a telescope is placed into the knee joint) may be considered to try and identify and tidy up any damage to the cartilage surfaces. At the same time other causes of this sort of pain can be looked for and treated e.g. rubbing plica (a curtain like membrane that is present in some knees) and fat pad impingement (where the tip of the fat pad gets caught between the patella and the underlying femoral groove). In cases where there are possible maltracking problems, it can help confirm the degree of maltracking and direct treatment appropriately. Whilst arthroscopy can be helpful for a few cases, for the majority it is not an alternative to a good exercise programme which, in the hands of an experienced sports physiotherapist, is approximately 90% successful.

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Knee Arthroscopy

What is Knee Arthroscopy?

This is an operation to look inside the knee without formally opening the joint itself.
Two main cuts are made either side of the lower border of the patella (kneecap). They are about 1cm each. Sometimes another incision is necessary depending on the reason for the arthroscopy this would be above the patella on the outside or inside.

What can be done in an arthroscopy?

A number of conditions can be evaluated and treated arthroscopically. This includes repair or trimming of either of the two meniscii (cartilage) of the knee; debridement of the cartilage covering of the knee; general debridement and washout of the knee in arthritis; and assessment and reconstruction of the anterior cruciate ligament.

How long does the operation last?

Most arthroscopic procedures last less than 25 minutes and most are done as day cases. This will obviously depend on what is done and how medically fit you are. A physiotherapist will see you on the ward afterwards, make sure you are safe (on crutches if necessary) and give you exercises to do before you go home. During the procedure we take pictures and will show you these and explain the findings to you after your operation.

When can I return to work and normal activities?

This depends on what is done, but most people return to work and general activities, including driving within a few weeks, and often sooner. We will inform you exactly what you can and cannot do after your operation.

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Total Hip Replacement

What is a total hip replacement?

A total hip replacement involves replacing a worn out hip joint with a metal and plastic replacement. The femoral head (ball part of the joint) is replaced but a metal equivalent and the acetabulum (cup part of the joint) is resurfaced in plastic. The metal components are made of cobalt chrome and the plastic of polyethylene.

Are there any alternative treatments to a hip replacement?

Yes there are and include adequate pain relief, physiotherapy and injections. Your consultant will explore all these avenues with you before embarking on a hip replacement.

What happens during the operation?

A 25cm cut is made just along the outside of your hip region and the bone is prepared to allow the hip replacement. The metal and plastic components are attached using bone cement which is comparable to grout. Once the new hip is stabilised, it is then washed out and the wound stitched up and bandaged. The operation usually takes about an hour and a half.

What happens after the operation?

Once you have woken up you will be returned to the ward. The next day you will be encouraged to get out of bed and start physiotherapy to get your hip moving. Most people require about seven days in hospital before they are safe to go home, but it depends on the individual. The important aspect is that you are safe to go home. Your physiotherapist will arrange further physiotherapy as an out-patient.

How long does it take to recover from the operation?

Everyone varies but in general you should feel comfortable in about three months, but will continue to improve for over a year. You may feel tired for a number of months.

Are there any complictions with this surgery?

The overall success rate from this surgery is about 90% although you will need to be aware of the following complications;

  1. Thrombosis refers to blood clots in the leg. These are quite common, but most patients are unaware of them and they cause no problems and resolve with no specific treatment. However, sometimes they can be large and cause considerable problems. If they break off and travel to the lungs they are called embolisms, and can be fatal to 3 in 1000 patients. We will give you specific treatment to try and prevent this.
  2. Infection is a serious potential problem that occurs in about 1% of patients despite the use of antibiotics. If the metalwork gets infected, it is exceedingly difficult to eradicate the infection, and may require numerous operations, with no guarantee of success. We will give you antibiotics to try and prevent infection.
  3. Aseptic loosening is a term used to describe the wearing out of a joint in time. Roughly 95% of total hip replacements last 10 years, but in certain people the lifetime of the joint may be a lot less. Many joints can last far longer, if the patients looks after his or her joint well.
  4. Persistent pain can occur even after anotherwise apparently successful hip replacement. The cause is often not evident and it may be impossible to eradicate it.
  5. Dislocation can occur any time after the operation, but most commonly within the first few months. We will teach you various exercises to improve the muscles around your hip to try and prevent this, but most importantly there are certain movements around your hip that you must avoid.

If the joint wears out in the future can it be replaced again?

Yes it can but the success rate is not quite as good. Surgery is more difficult, the complications are twice as likely and it takes more outof the patient who is older and perhaps not quite as fit and he or she was the first time around.

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