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Total Knee Replacement INR   0 INR  0
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Total Knee Replacement

Knee replacement is an operation that is performed principally to relieve pain from an arthritic knee. Although the range of motion of a knee may improve following surgery, this is not the primary aim of surgery and extra motion should be regarded as a bonus SURGERY Knee replacement involves replacing the bearing surfaces on the ends of the bones with a synthetic surface. This is usually metallic on the femur and plastic (high density polyethylene) with or without a metallic base plate on the tibia. The surface of the patella (knee cap) can also be replaced with high-density polyethylene. Components can be fixed to the bone using one of two techniques. One can either use bone cement or one can use components coated in such a way that bone grows onto and into their surface. Both methods of fixation have their advantages and disadvantages. A decision will be made regarding the most appropriate fixation for your particular situation. Depending on the nature of your arthritis, your knee may be suitable for a partial replacement rather than a total replacement. The knee can be thought of as having three compartments. There is a medial and a lateral compartment between the femur (thigh bone) and tibia (shin bone). The medial compartment is on the inside (left side of right knee) and the lateral compartment is on the outside (right side of right knee). The third compartment is between the patella (knee cap) and the femur. In a total knee replacement the medial and lateral compartments are replaced and the patella may be resurfaced as well. In a medial (or lateral) unicompartmental replacement only the medial (or lateral) compartment is replaced. Medial unicompartmental replacement is more common than lateral. Patellofemoral replacement involves resurfacing of only the patellofemoral compartment.In general the principles of partial and total knee replacement are similar but a partial replacement is a smaller operation and has a shorter hospital stay and quicker recovery. As a rule of thumb, total knee replacement involves a hospital stay of 3-6 nights (2-5 for partial replacements). In most instances patients are able to go directly home and inpatient rehabilitation is not usually required. Depending on your private health insurer, a physiotherapist may be able to visit you at home. When you are discharged you will be walking with the aid of walker support and will be independent in terms of showering and dressing. The main problem that patients face after a knee replacement is getting their movement back. Pain levels vary considerably from one individual to another, but most people find the period from 24 hours to 72 hours after surgery the most difficult. It is important to keep working at the exercises, particularly bending the knee. This applies both in hospital and after discharge. Pain may persist for 6-8 weeks following the procedure, particularly at night. PREADMISSION Prior to admission a number of steps are taken to reduce the risks of surgery. A number of routine investigations may be performed and these include blood tests, an electrocardiograph (ECG), and analysis of a urine specimen. You may be asked to attend a pre admission clinic at the hospital. The purpose of this clinic is to familiarise you with the planned surgery. If your knee X-ray is more than three months old a new X-ray may be taken, usually on admission to hospital. You should preferably stop taking anti-inflammatory tablets one week before your surgery in order to reduce bleeding during the operation. You can take your normal painkillers as well as low dose (100mg) Aspirin if you are on this for cardiovascular reasons. If you are on anticoagulant medication such as warfarin or clopidogrel, it is important that you notify the doctors as soon as possible as you will need to cease these prior to surgery. Similarly, if you have an artificial heart valve or another implant that requires antibiotic protection when surgery is being performed, you should also notify the office staff. ADMISSION Admission to hospital is usually on the day of surgery. Occasionally you will be admitted earlier than this depending on your general health status. ANAESTHESIA The surgery can be performed using a number of different types of anaesthesia. The anaesthetist will select the most appropriate type of anaesthetic for your situation. Usually a combination of spinal and general anaesthesia is used. A spinal anaesthetic involves an injection into the lower spine, which makes the body numb from the waist down. It wears off after a couple of hours. AFTER SURGERY Following surgery adequate provision is made for pain control. The anaesthetist and nursing staff will explain to you what is to be used in your situation prior to the operation. Physiotherapy will commence on the first day following surgery. You will usually get out of bed on the afternoon of surgery if you have surgery in the morning, or the next morning if you have surgery in the afternoon. Initially you will walk with a walking frame and later with crutches. The physiotherapist will guide you through the various phases of rehabilitation. Depending on your surgeon’s preference, you may spend some time each day with your knee on a CPM (continuous passive motion) machine, which slowly bends and straightens your knee. Usually you can be discharged directly home from hospital. The length of hospital admission varies considerably but is usually somewhere between 4-6 nights. You will not be discharged until you are safe to go home. This decision is usually made during your hospital admission. A follow up appointment will be made for you, usually 2-4 weeks after the operation. You will notice that your knee is warm and swollen for some time after surgery. This has usually settled significantly by three months from surgery, although the swelling may persist for a further few months. You will also notice that the skin on the lateral (outside) side of the incision will be numb. This is normal. The area of numbness usually decreases a little with time but there will always be some numbness of the skin in this area. However, it does not usually cause any problems. RISKS Knee replacement procedures are usually very successful. However, they are associated with some risks and although these are uncommon, they do need to be kept in mind in assessing whether this type of surgery is warranted. These risks include: WEAR AND LOOSENING With time, the bearing surfaces do have a tendency to wear. As a result small particles of debris are produced. The body’s reaction to these particles can cause loosening of the components, which in turn can cause a recurrence of pain. This may necessitate a second (revision) operation, which is usually a significantly more complicated procedure and generally does not lead to as good a result as a primary procedure. VENOUS THROMBOSIS This is a blood clot in the veins of the leg and occurs more frequently after knee replacement surgery than other types of surgery. Precautions are taken to reduce the risk and this may involve the administration of a daily injection of a blood-thinning agent (low molecular weight heparin). Additional measures may be taken if it is felt that you are at greater risk than the average person undergoing surgery. If a venous thrombosis does occur this will usually need to be treated with blood thinning injections followed by anticoagulant tablets (Warfarin), which would need to be continued for at least three months. A small but nonetheless important risk for venous thrombosis is the potential for the blood clot to break off and lodge in the lungs (pulmonary embolus). This can cause significant breathing problems and very rarely can be fatal. INFECTION Infection can occur after any operation. It is potentially more serious following joint replacement surgery, as it is more difficult to eradicate. This can mean that further surgery is required including the possibility of removal of both components for a period of two months during which antibiotics are given intravenously. If the infection has been eradicated, another knee replacement is then performed. Occasionally the knee may need to be permanently stiffened (arthrodesis). Precautions are taken to reduce the risk of infection including the administration of intravenous antibiotics around the time of surgery. STIFFNESS As mentioned earlier, the biggest challenge after a knee replacement is to regain knee movement, especially flexion (bending). Sometimes stiffness is a persistent problem and a manipulation under an anaesthetic is required. This involves coming back into hospital, usually for one or two nights. Occasionally the stiffness may be permanent and may cause difficulties with activities of daily living. Despite all of these potential problems, most patients are very happy with their procedure and recover quite quickly from surgery. However, it is important to remember that improvement occurs for up to 18 months after surgery.

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Rotator Cuff Tear INR   0 INR  0
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Rotator Cuff Tear

The rotator cuff muscles are a group of four muscles that pass from the shoulder blade (scapula) and attach to the top of the ball joint (humerus). These muscles are responsible for rotation and elevation of the arm.FROZEN SHOULDER Rotator cuff tears are very common, especially as we all get older. They frequently cause pain over the upper arm that is made worse by overhead activities, reaching behind your back and lifting. They often ache at night and people find that they are unable to lie on the injured shoulder. They also cause weakness. Rotator cuff tears most frequently occur with general wear and tear, and most people usually don’t remember injuring their shoulder. These “degenerative tears”, if not associated with arm weakness, may be successfully treated without surgery. This involves avoiding overhead activities, regular simple pain relief and gentle physiotherapy. Anti-inflammatory steroid injections can be very helpful in these situations to help manage pain and discomfort. When symptoms fail to improve despite these measures, surgical repair of the tear is indicated. The less common group of rotator cuff tears occur following an injury, and are called “traumatic tears”. People usually remember the exact incident, and often have significant weakness after the injury. Early surgical repair is often indicated. SUMMARY OF TREATMENT OPTIONS Simple pain relief e.g. regular paracetamol, ibuprofen. Physiotherapy: to maintain range of movement and strength. Anti-inflammatory steroid injections: to assist with pain relief. Note that excessive use of cortisone may cause more harm than good. Surgical repair is indicated in 2 circumstances: Following an injury (Acute tear). Degenerative tears that continue to be painful despite regular analgesia, physiotherapy and steroid injections. Injection PRP for partial tears.ROTATOR CUFF REPAIR As a rule of thumb, rotator cuff tears will not heal on their own, and can only do so if a surgical repair is performed. A repair involves re-attaching the torn tendon to bone (humerus) using sutures and anchors. This operation is usually done under general anaesthesia, and may be performed as an open technique or arthroscopically (keyhole surgery). Arthroscopic repair is more technically demanding than open surgery, but this method has advantages including less pain, smaller wounds and lower risk of post-operative infection. Not all tears can be repaired. Risks of surgery include infection, stiffness, ongoing pain and weakness, re-tear of the tendon repair, and very rarely, nerve injury. The risk of the repair tearing again is much greater with large tears and with increasing age (over 70 years of age). Even if the repair does tear again, most people experience an improvement in their pain. The risk of ongoing pain at 12 months following the surgery is approximately 10 to 15%. Antibiotics are given at the time of surgery to minimize the risk of infection. Despite this, infection of the wounds can occur. This is usually easily treated with antibiotics. However, sometimes the infection gets into the joint which is a serious complication and requires re-admission to hospital, additional surgery and intravenous antibiotics. Most patients experience improved shoulder strength and less pain following rotator cuff repair, and each technique has similar medium to long-term results. Factors that decrease the likelihood of a satisfactory result include: Large / massive tears. Patient age (older than 65 years). Poor compliance with restrictions and rehabilitation following surgery. Smoking. Poor tissue quality. Workers compensation claims. Recovery following surgery usually involves staying one night in hospital, and being in a sling for 6 weeks. Most people can drive a car after 6 to 8 weeks. Rehabilitation guidelines to share with your physiotherapist are provided following the surgery, and vary according to the type and size of tear that is repaired. Recovery may take 6 to 12 months, depending on the severity of the tear.

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Shoulder Dislocation and Instability INR   0 INR  0
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Shoulder Dislocation and Instability

The shoulder is a shallow ball and socket joint. This allows fantastic range of movement, but also makes it an inherently unstable joint. The socket is made deeper by a rim of fibrocartilage (labrum). Additional stability is provided by thickenings of the joint capsule (ligaments) and the rotator cuff muscles. Shoulder stability relies upon these ligaments remaining intact and the muscles being strong.A shoulder dislocation occurs when the ball (humerus) comes out of the socket (glenoid). This may be partial (subluxation) or full (dislocation). After the first episode, it is likely that the labrum and ligaments will be torn, putting the shoulder at high risk of recurrent episodes of instability. This is especially true for patients under the age of 30 years.Recurrent shoulder instability following a traumatic shoulder dislocation can be effectively treated by repairing the torn labrum and ligaments. This is most commonly done using keyhole (arthroscopic) surgery and, when using modern techniques, is associated with a high rate of success. The labrum is reattached to the edge of the socket and the ligaments are tightened. This is done using suture anchors inserted into the edge of the socket (glenoid).Recovery following surgery usually involves staying one night in hospital, and being in a sling for 6 weeks. Most people can drive a car after 6 to 8 weeks. Rehabilitation guidelines to share with your physiotherapist are provided following the surgery. Return sport is usually possible at 6 months. Risks of surgery include infection, stiffness, ongoing pain and instability, re-tear of the labral repair, and very rarely, nerve injury. Antibiotics are given at the time of surgery to minimize the risk of infection. Despite this, infection of the wounds can occur. This is usually easily treated with antibiotics. However, sometimes the infection gets into the joint, which is a serious complication and requires re-admission to hospital, additional surgery and intravenous antibiotics. Atraumatic shoulder instability occurs less commonly. This is where the shoulder dislocates with minimal effort and these patients are often described as “loose jointed”. Unlike traumatic shoulder instability, there usually isn’t a labral tear and most patients are treated with physiotherapy.

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Arthroscopic ACL Reconstruction. INR   0 INR  0
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Arthroscopic ACL Reconstruction.

The term knee reconstruction is commonly used to refer to reconstruction of the anterior cruciate ligament (ACL).This ligament is in the middle of the knee and controls the movement of the two main bones of the knee, the tibia and femur (Fig.1). It is particularly important for twisting and turning movements that occur in football, netball, basketball and snow skiing. Rupture (tearing) of the ACL can therefore lead to instability. This is felt as giving way with certain activities, usually those that involve a sudden change in direction. When giving way occurs, there is a risk of damage to the cartilages (menisci) and this in turn puts the knee at risk of developing premature osteoarthritis. Although it is an aim of reconstructive surgery, it is unclear whether anterior cruciate ligament reconstruction actually reduces the risk of developing osteoarthritis. The main reason for reconstructing the ACL is to stop or to prevent instability. In many situations this instability can be predicted soon after the injury occurs and a decision made to operate without waiting for the instability to develop. However, in other cases it may be less clear and people may choose to rehabilitate their knee and try to return to their normal activities without surgery. Whether they can get back to their normal activities without surgery depends on many factors – how much healing of the torn ACL takes place, other injuries to the knee, the intrinsic stability of the knee, rehabilitation, and the individual’s ability to modify their activities. It is important to remember that ACL reconstruction is almost always an elective procedure. From a medical point of view, there is no rush to make a decision, provided the knee is not giving way.If ACL reconstruction is to be performed, it is essential to prepare the knee for surgery. The key is to get back full extension (straightening) of the knee. Although it may feel that there is something in the front of the knee that is blocking full extension, this is rarely the case, particularly after the initial injury. A key component is to reduce swelling by regular icing and wearing a compression bandage or sleeve. Having the heel supported on a rolled towel and using the quadriceps muscle at the front of the thigh to lock the knee out straight is the key exercise (Fig.2). Flexion (bending) is also important and riding an exercise bike will help this, together with strengthening the quadriceps muscle. SURGERY The technique for reconstruction involves taking a piece of tendon (usually from the same knee, but sometimes from the other knee) and using this to replace the torn ligament (Fig.3). The tendon graft is usually taken from the hamstrings on the inside of the thigh or from the patellar tendon at the front of the knee. It can also be taken from the quadriceps tendon, just above the patella (kneecap). Occasionally allografts are used. These are tendon grafts taken from cadavers (people who have died). In recent years there has been increased interest and media coverage of synthetic grafts, specifically the LARS device. The role of the LARS remains unclear, but there are concerns because of problems seen when synthetic ligaments were used in the late eighties.From your point of view, there is a vertical or oblique scar on the front of the knee together with two small scars from stab incisions that allow the arthroscope and surgical instruments to be introduced into the knee. If additional surgery is required to repair a cartilage, a further incision may be made towards the back of the knee on either the outside or inside. A small area of the skin on the outside (lateral side) of the knee is usually numb after surgery. Sometimes there is numbness on the shin. Although the numbness can be permanent, the area of numbness usually gets smaller with time and does not usually cause any problems. Surgery is usually performed under a spinal anaesthetic. At the end of the operation the area affected by the surgery is infiltrated with local anaesthetic. Sometimes an epidural block or a femoral nerve block is also used. If this is the case you will notice numbness and tingling in your legs when you wake up. This gradually wears off over 8 hours or so. After leaving the recovery area pain control can usually be achieved with tablets alone. Anti-inflammatory medication is often used to help with pain control, so it is important that you tell your anaesthetist if you have ever had a history of stomach ulcers or bleeding, as this medication may not be appropriate in that situation. You will be awake within 20 minutes of the operation and should be able to eat and drink after approximately 2 to 3 hours. On return to the ward after the operation, an inflatable cuff (Cryo-Cuff) is placed around the knee. This is filled with iced water to help control swelling. Patients find this very comfortable. Depending on your surgeon’s preference, you may have 1 or 2 drains placed in the knee joint so that unwanted blood does not accumulate and inhibit recovery. These drain tubes are usually removed the day after surgery. A physiotherapist will teach you exercises to get the knee out straight (extension) and regain function in the quadriceps muscle at the front of the thigh as well as make sure that you are confident walking with the aid of crutches. A brace or splint is usually required. You will usually go home on the morning after surgery. Following surgery you will be provided with information regarding rehabilitation. This outlines the rate of progression. Rehabilitation can be undertaken either independently or under the supervision of a physiotherapist.It is very important to rest during the first week after surgery in particular. This means spending most of the time on a bed or couch with the leg elevated and regular icing of the knee. The main aim during this phase is to restore full extension of the knee. The time off work that is required will vary according to your job. If it is mainly deskwork, then patients may be able to work within 2 weeks. If heavy manual work is involved, it may be 2 to 3 months before one can consider return to work. In general, crutches are required for up to 2 weeks. In terms of returning to sport most patients are able to recommence some of their activities by 4 months. By 6 months the majority of patients are able to gradually resume training for their original sports with a view to returning to play from 9 or 10 months. However, improvement continues for another 6 to 12 months after that. COMPLICATIONS While most patients are happy with the outcome of their surgery, there are nonetheless some risks, which need to be borne in mind. ANAESTHETICS Always involve some kind of risk, but these are statistically minimal. INFECTION Antibiotics are given at the time of surgery to reduce the risk of infection. Despite this infection of the wound can occur. This is usually easily treated with antibiotics. However, sometimes the infection gets into the joint. This is a serious complication and requires admission to hospital, additional surgery and intravenous antibiotics. VENOUS THROMBOSIS A thrombosis is a blood clot that may form in the veins in the legs. This can cause persistent swelling of the foot and ankle and can also be dislodged and be carried to the lungs (pulmonary embolus), resulting in chest pain and breathing difficulties. However, the risk of thrombosis is statistically very low.DONOR SITE If you have a hamstring graft it is very common to experience the sensation of tearing something at the back of the knee around 3 to 8 weeks after surgery. This is just stretching of the scar tissue being laid down in the tendon harvest site. Although it may be associated with some pain and bruising, this usually settles over a few days and do not affect the long-term outcome. If you have a patellar tendon graft there can be pain at the lower end of the patella. This can occur as late as 9 to 10 months after surgery but usually settles with time. HARDWARE Occasionally one of the devices used to hold the graft in place while it heals to bone may become prominent some months after surgery. If problematic, the hardware can be removed without risk to the graft. OTHER Persisting problems can occur as a result of poor compliance with rehabilitation, failure of the graft, or significant additional damage to the knee from the original injury such as torn ligaments or cartilages or osteoarthritis.

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