Roots of Post-Surgical Knee Nerve Damage Uncovered

Roots of Post-Surgical Knee Nerve Damage Uncovered

in , , , ,

Article Featured on PPP

Two recent studies1,2 have uncovered tiny cutaneous nerves on the anterior and medial thigh and around the knee using high-resolution ultrasound imaging, which may explain the occurrence of chronic pain following knee operations. Previously, it has been deemed impossible to demonstrate that these tiny cutaneous nerves (less than 1-mm thick) exist around the knees.

In the first study,1 a team of researchers at the Medical University of Vienna, Austria located the entire course of ramus infrapatellaris (a sensitive nerve branch in front of and below the kneecap) with high-resolution ultrasound imaging. They showed that neuropathy of the intermediate and medial femoral cutaneous nerve can be reliably visualized throughout the course of the nerves, both in anatomical specimens and in patients.

The second study,2 also led by researchers at the Medical University of Vienna, Austria, highlighted the branched anterior cutaneous branches of the femoral nerve, nervus femoralis, confirming the reliability to visualize these branches using high-resolution ultrasound in anatomic specimens and in healthy volunteers, which could enhance the diagnostic and therapeutic management of patients with anteromedial knee pain. It was also found that the nerve pathways are highly variable for each patient.

To accurately isolate the nerve branches causing the pain, it is essential to carry out a “diagnostic blockade,” according to lead researcher Georg Riegler, MD, lead researcher from MedUni Vienna’s Department of Biomedical Imaging and Image-guided Therapy. “Since the nerve supply is so variable, it is essential to first make sure which of these tiny nerves [are] causing the pain,” he said in a press release.3 “This can only be done by selectively temporarily anesthetizing, or blockading, the suspected nerve, with a maximum of 1 mL of anesthetic. If the pain is significantly reduced immediately after a blockade has been done and returns once the anesthetic has worn off, then we have located the problem.”

One of the first options for treating nerve pain in the knee is to use localized pain patches or physiotherapy, followed by ultrasound-guided treatment. Other possibilities include cortisone injections, radiofrequency ablation, and surgical procedures. Dr. Riegler urged the importance of determining the exact position of the damaged nerve fibers before giving any targeted treatment to combat nerve pain.

View Sources

New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Surgery for Lower Back Pain

Surgery for Lower Back Pain

in ,

By John Peloza, MD | Article Featured on Spine Health

Surgery may be considered if for severe lower back pain that does not get better after a 6 to 12-week course of nonsurgical treatments. It is almost always the patient’s decision to have back surgery, and only in rare situations is immediate surgery performed for low back pain.

Some factors to consider before having back surgery include:

Ability to function. If it is possible to complete daily life activities with manageable pain levels, and if pain does not interrupt sleep or activity, nonsurgical treatments are usually recommended. Surgery is more likely to be recommended if the patient has limited ability to function in everyday life.

Healing process and lifestyle. Surgery vs. nonsurgical care require varying degrees of time commitment. It is important to consider how the healing process after surgery will affect the patient, as compared to continued non-surgical care.

Type of surgery. Some surgeries are considerably more invasive than others, and include lengthier healing periods, more or less significant pain during recovery, and varying inpatient hospital stays. With modern surgical approaches and an experienced surgeon, many types of spine surgery can now be done on an outpatient basis with a shorter recovery period.

Mental health. Several studies have indicated that mental and emotional well-being have a positive correlation to improvement and satisfaction after surgery. Patients who feel more in control of their health, for instance, report a more positive recovery and outcome after surgery.1 Understanding how a patient is likely to respond to surgery can help guide more effective post-operative care.

Spine surgery is usually not recommended for mild to moderate back pain, or for pain that has lasted for less than 6 to 12 weeks. Additionally, back surgery is not an option if the cause of the pain is not detectable through imaging tests.

Decompression Surgeries

A decompression surgery removes whatever is pressing on a nerve root from the spinal column, which might include a herniated portion of a disc or a bone spur. There are two primary types of decompression for low back pain.

  • Microdiscectomy is a minimally invasive procedure for patients with a lumbar herniated disc causing radicular leg pain (sciatica).
  • Laminectomy removes part of the layer of the bone or soft tissue that is compressing a nerve or multiple nerve roots. A laminectomy will typically be performed for someone with leg pain and/or weakness from spinal stenosis caused by changes in the facet joints, discs, or bone spurs.

A decompression surgery can be performed with open or minimally invasive techniques with relatively small incisions, and minimal discomfort and recovery before returning to work or other activities. Most of these procedures are now being done as day surgery or with one overnight stay.

Lumbar Spinal Fusion Options

Fusion surgery basically removes the soft tissues between two or more adjacent vertebral bones and replaces them with bone or metal. This procedure enables the bones to grow together over time—typically 6 to 12 months—and fuse into one long bone to stabilize and eliminate motion at those spinal segments.

In the lumbar spine, fusion can be done from the back (posterior approach), the front (anterior approach), the side (lateral approach), or combined. Modern techniques, implants, navigation, and biologics have made the surgery more predictable with easier recovery and return to normal activity and work.

The most reliable indications for lumbar spinal fusion include spondylolisthesis, fracture, instability, deformity, degenerative disc disease, and stenosis. For lower back pain caused by sacroiliac joint dysfunction, fusion of the sacroiliac joint is an option. Tumors and infections are also treated with fusion surgery, but these conditions are far less common.

Other Surgical Options

Some newer surgical options that are being used for some cases of low back pain include:

  • Lumbar artificial disc. For some patients, disc replacement is a potential alternative to fusion surgery for symptomatic degenerative disc disease. This procedure has the potential for a quicker recovery and to maintain more spinal motion than lumbar fusion. Long-term data is still being collected.
  • Posterior motion device. The Coflex inter-laminar device is an alternative to fusion for stenosis and mild degenerative spondylolisthesis. The goals of this approach are for similar results as fusion but with a smaller surgery and faster recovery. Long-term data is still being collected.

This is not a complete list of surgical options. Several others exist or are in development. Technologies that are being utilized today and in development include stem cells, nanotechnologies, and robotics.

Lower Back Surgery Post-Operative Care

The recovery period after low back surgery depends on a number of factors, including the patient’s condition before the surgery, the extensiveness of the surgery, and the surgeon’s skill and experience. For example:

  • A microdiscectomy for a lumbar herniated disc is considered minimally invasive, and the patient usually has no overnight hospital stay and recovery time is about a week.
  • A lumbar fusion may involve an overnight hospital stay, slow return to everyday activities, and possibly some activity restrictions as the fusion sets up over the next 3 to 12 months.

Physical therapy is typically prescribed to rebuild strength, range of motion, and encourage healing. Patients are also commonly prescribed painkillers or muscle relaxants, and some patients may be advised to use a back brace or special beds, shower stools, or supportive pillows to ease the healing process.

Patients in recovery are typically advised to take a short period of rest while the spine and surrounding tissues heal. Most patients take brief time off from work—a few weeks to a couple months—to avoid overexertion of the spinal structures.

New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

What to Expect After a Hip Replacement

What to Expect After a Hip Replacement

in , , ,

Article Featured on Home Care Assistance

Have You Decided it is Time for Hip Replacement Surgery?

That aching, painful and stiff hip has reduced your quality of life. You can’t enjoy the activities you used to love, like a good golf game, a walk around the block or even playing with the grandkids, without constant pain.

Over 300,000 people have hip replacement surgery each year in the United States. Before you decide to join this group, it is important to know what to expect following surgery. What will you experience after your hip replacement? When will you feel back to normal? What can you do to speed your recovery?

Pain After a Hip Replacement

First things first, hip replacement surgery will hurt. All surgery does! Be prepared that you will experience a significant amount of discomfort in the first three days following surgery. Your mobility will be limited, and you will need to depend on others to help you with your regular activities of daily living. Even simple things like going to the bathroom will require assistance.

On the first day, a significant amount of surgical pain medication will be in your system. You may feel groggy but not as uncomfortable. On the second day, you will likely be able to get out of bed and start moving with assistance. Although you had surgery on the largest joint in your body, you will be walking on it in only one or two days.

Be ready for the third day after surgery. You will probably feel like you got hit by a truck. After surgery, your body sends a large number of inflammatory cells to the injured area in order to help with the healing process. These levels will be at the highest on day three. Inflammation means swelling and swelling means pain. Talk to your doctor their recommendations for using ice and taking an anti-inflammatory medication starting on the day of surgery. But remember, typically, once you get through day three the swelling and pain will get better.

Walking After Hip Replacement Surgery

Most likely, you will be up and walking the day after your surgery. Take it slow and don’t push yourself beyond what you can handle. Getting up and active following surgery is vital to speeding up your recovery after a hip replacement. Try to exercise for 20-30 minutes at a time. The first day that might just mean getting out of bed and to the hallway. Don’t feel discouraged by this!

Moving around will not only speed up your recovery but will also increase the circulation to your legs and feet which will reduce your chance of getting a blood clot. Blood clots are a serious risk following all types of surgery but can be prevented by early movement and exercise.

Getting out of bed will also help to maintain and increase your muscle strength while preventing your new hip from getting stiff. You’ll want to take full advantage of that new level of hip movement. Don’t forget that getting out of bed and being able to walk with a walker or cane is one of the goals you need to accomplish before going home from the hospital.

Your Hip Replacement Recovery Checklist

Typically, after two to four days you will be discharged from the hospital to either your home or to a rehabilitation facility. Here are some goals to use as a checklist when transitioning back to your home. Make sure that:

  • You can get out of bed by yourself.
  • Your pain is adequately under control. This doesn’t mean you’re pain-free but it should be manageable.
  • You can eat, drink, sleep and go to the bathroom.
  • You can walk with a cane, walker or crutches.
  • You’re ready to do home exercises on your own.
  • You know what you need to do to protect your new hip from an injury.

Before you go home, you will need to have someone available to help you at home. This can be a friend, family member or a caregiver. At home, you will want to make sure that your furniture is set up so that you can get around your house easily.

What Will Hip Replacement Recovery be Like?

It’s normal to have questions about what the healing process will look like after surgery. So we’ve gathered the answer to common questions.

When Can I Shower?

You will not be showering until you get the go-ahead from your surgeon because you need to keep the incision dry. But a sponge bath will feel heavenly when you get home! The first two weeks you will be at your highest risk of infection, so report any signs of redness, drainage or fever. Your surgical staples will usually come out on day 10-14 and then you can bathe or shower again.

When Can I Start Walking?

After your surgical staples are removed, you’ll be able to start to work on walking without a walker or cane. Don’t forget to move around as much as you can while at home. Make sure you do the physical therapy exercises you have set up, go for light walks and remember to rotate your ankles, bend your knees and practice leg raises while sitting up or lying down.

When Can I Drive?

You can usually start driving within three to six weeks following hip replacement surgery. However, you will need to make sure that you are no longer taking any pain medication that affects your response time or makes you groggy. Initially, you will likely find that an automatic transmission is easier to drive. Also, make sure you can tip your foot up and down without pain prior to driving. This can depend on which hip is operated on. If you had surgery on the side you use to drive, it may take longer to get behind the wheel.

When Can I Have Sex?

Yes, it is a question every patient has but often hesitates to ask. This can be especially awkward if it is your parent that has had a hip replacement and you are accompanying them to a doctor’s appointment. Check with your doctor to be sure, but it is usually safe to resume sexual activity six weeks to two months following a hip replacement. Remember, as with all activities, to listen to your body! Do not attempt to do more than you feel capable of and to stop or slow down if you notice increased pain.

Dr. Mehran, an orthopedic surgeon, shares this rule of thumb, “If you are still needing to use a walker, you are probably not ready for sex yet.” Still using a walker usually means that you have not yet regained enough strength and balance.

What Should I Eat After Hip Replacement Surgery?

The healthier you eat, the better you heal! The food that you put into your body will provide you with the energy and nutrition needed to fight off infections, accelerate healing, increase your strength and energy and build up your nutrition stores. Speed up the recovery process by eating healing foods like berries and dark leafy greens.

6 Tips for a Successful Hip Replacement Recovery

Along with following your surgeon’s discharge plan for exercise and physical therapy, it’s important to make a few changes to your home.

“Preparing your home with the same care shown to your physical recovery will set you up for success,” says Barbara Bergin, M.D. of Texas Orthopedics, Sports and Rehabilitation Associates. She suggests starting with the following six steps.

1. Remove Tripping Hazards

Slips and falls are common reasons for hip replacement surgeries in the first place. To avoid hospital re-admission with an injury to your other hip, or damaging the replacement, Bergin suggests removing all throw rugs, floor mats, etc. from your home.

“You’ll be shuffling your feet for a while,” says Bergin. As a result, you can trip on throw rugs, including those you use in the bathroom or kitchen. If you prefer to keep the rug where it is, Bergen suggests “fastening them using carpet tape to keep the edges down.” However, she says that the best bet is removing the tripping hazard to eliminate any concerns about a fall.

2. Upgrade the Bathroom

Installing a handicap or comfort height toilet is a better option than a temporary elevated toilets apparatus, says Bergen. “Not only do the temporary appliances get dirty easily, but it’s also recommended to use a comfort height toilet permanently after a total joint replacement.” Doing so, she says, will improve the quality of your life, along with that new joint.

You should also use a shower chair. Make sure that you have a sturdy chair that is higher than average and firm. You will find this easier to get up from. To get in and out of the shower easily, you also might want to consider having a grab bar installed in the bathroom.

3. Raise ‘em up

“Elevating the legs helps get that swelling down,” Bergin says. Swelling can limit your ability to get your life back to normal. She suggests, “Using big pillows or wedges to elevate your legs if recommended.” This includes having a pillow to place in between your legs while sleeping. “A nice, fat body pillow provides comfort and helps promote restful sleep.”

4. Gather the Right Tools

Bergin says over time, you may easily perform many daily activities once again. But in the first days and weeks at home, some of life’s little tasks like getting dressed or feeling steady while retrieving something from a cabinet might be challenging. She encourages people to have a few handy gadgets to make these tasks as stress-free—and safe—as possible.

“Sock donners and handy grabbers that extend your reach are absolute musts,” she says. Other helping hands include leg lifters, bendable bath sponges and a long-handled shoe horn. Many companies sell these items together as a “hip kit” package.

5. Raise Your Seat

If you can afford it, Bergen suggests asking your doctor for a prescription for a lift chair. She says, “Your knees, hips and arms will appreciate it, and that your other bad hip will really appreciate it!” Although insurance doesn’t cover the cost of the chair, having a prescription can avoid the need to pay sales tax in some areas.

6. Borrow, Don’t Buy

Many of the items you’ll need to speed down the road to recovery post hip replacement will only be required for a few weeks or so. Instead of paying the full price out-of-pocket (medical equipment is frequently not covered by many insurance plans) or even your deductible’s portion of these items, check in your area for free or low-cost community resources. These can alleviate the sting of having to outfit your home with several new tools and medical equipment.

“Family members and/or patients may borrow this equipment for little or no cost from community medical equipment lending programs, also known as medical equipment reuse programs or loan closets,” says Janice Selden, Director of Great Lakes Loan Closets.

These organizations accept medical equipment from community members who no longer need it. “They clean the equipment, check to make sure it is safe, and lend it back out to members of the community who need it. Typical equipment includes wheelchairs, walkers, shower aids, and dressing aids,” explains Selden.

Organizations like these usually provide an online directory of locations that provide these services throughout the country and can be very helpful for patients.

Do’s and Don’ts After a Hip Replacement

The dos and don’ts might be different depending on what type of surgical technique your doctor used. Your doctor and physical therapist can give you a specific list to remember. These precautions are pretty standard to prevent your new hip from dislocating and to help with a quick and thorough recovery.

Do

  • Keep your operated leg facing forward.
  • Make sure your operated leg is in front of you as you sit or stand.
  • Use chairs that are high enough that your knee is lower than your hip when bent.
  • Use ice to reduce swelling.
  • Use heat before exercising to warm up the muscles for 15-20 minutes. This will help you to have better movement.
  • Reduce the amount of exercise you do if you are in pain but continue to stay active and resume your exercises as soon as possible.
  • Ask your doctor about safe sleep positions.
  • Limit the amount of weight you carry.

Don’t

  • Cross your legs for six to eight weeks.
  • Allow your knees to sit higher than your hips.
  • Lean forward while sitting, especially to pick something up off the floor.
  • Turn your foot in or out when you bend down.
  • Bend at the waist beyond 90 degrees.
  • Twist your hips.

How Long Until You Feel Good Again After a Hip Replacement

It will take time before you are out dancing again! Hip replacement is an excellent option to increase your health and quality of life. The American Academy of Orthopedic Surgeons report that 95% of patients who undergo a hip replacement stated the procedure was successful. They reported relief from hip pain and were able to be more active and connected with their loved ones following the surgery.

These results are encouraging but it is not an overnight cure. You can expect it to take 10-12 weeks before you are able to return to all your favorite activities. At some point, you are going to feel like your recovery is taking too long. It’s important to remind yourself that feeling frustrated and limitations to physical ability are a normal part of the healing process.

Take a break and relax from pushing yourself. Do something you can enjoy. Get help if you need it, think about how far you have already come, then get back up, keep on moving and eating healthy. 10-12 weeks will feel like a long time, but once you are enjoying a pain-free stroll or game of golf, that time will be just a memory.

New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Hip or knee replacement - after - what to ask your doctor

What to ask your doctor after hip or knee replacement

in ,

Article Featured on Medicineplus.gov

You had surgery to get a new hip or knee joint while you were in the hospital. Below are some questions you may want to ask your health care provider to help you take care of your new joint.
Read more

Do I Need Carpal Tunnel Surgery

Do I Need Carpal Tunnel Surgery?

in ,

Article Featured on WebMD

Most of us use our hands almost every minute of the day without ever giving it a second thought. But if you have carpal tunnel syndrome, the pain, numbness, and tingling in your fingers get your attention. Treatments like wrist braces and corticosteroids can help, but in more severe cases, you may need surgery.

Carpal tunnel syndrome is caused by pressure on your median nerve. This is what gives you feeling in your thumb and all your fingers except your pinky. When the nerve goes through your wrist, it passes through the carpal tunnel — a narrow path that’s made of bone and ligament. If you get any swelling in your wrist, that tunnel gets squeezed and pinches your median nerve. That, in turn, causes your symptoms.

Whether you’ve decided to have surgery or are still thinking about it, you should know what to expect.

When Would My Doctor Suggest Surgery?

Over time, carpal tunnel syndrome can weaken the muscles of your hands and wrists. If symptoms go on for too long, your condition will keep getting worse. If any of these sound like your situation, your doctor might suggest surgery:

  • Other treatments — like braces, corticosteroids, and changes to your daily routine — haven’t helped.
  • You have pain, numbness, and tingling that don’t go away or get better in 6 months.
  • You find it harder to grip, grasp, or pinch objects like you once did.

What Are My Surgery Options?

There are two main types of carpal tunnel release surgery: open and endoscopic. In both cases, your doctor cuts the ligament around the carpal tunnel to take pressure off the median nerve and relieve your symptoms. After the surgery, the ligament comes back together, but with more room for the median nerve to pass through.

  • Open surgery involves a larger cut, or incision — up to 2 inches from your wrist to your palm.
  • In endoscopic surgery, your surgeon makes one opening in your wrist. He may also make one in your arm. These cuts are smaller, about a half-inch each. He then places a tiny camera in one of the openings to guide him as he cuts the ligament.

Because the openings are smaller with endoscopic surgery, you may heal faster and have less pain. Ask your doctor which operation is best for you.

Results and Risks

Most people who have carpal tunnel surgery find that their symptoms get cured and don’t come back. If you have a very severe case, surgery can still help, but you may still feel numbness, tingling, or pain from time to time.

Risks come with any operation. For both types of carpal tunnel release surgery, they include:

  • Bleeding
  • Damage to your median nerve or nearby nerves and blood vessels
  • Infection of your wound
  • A scar that hurts to touch

What’s the Surgery Like?

First, you’ll get local anesthesia — drugs to numb your hand and wrist. You may also get medicine to help keep you calm. (General anesthesia, which means you will not be awake during surgery, is not common for carpal tunnel syndrome).

When the operation is finished, your doctor stitches the openings shut and puts a large bandage on your wrist. This protects your wound and keeps you from using your wrist.

Your doctor and nurses will keep an eye on you for a little while before letting you go home. You’ll likely leave the hospital the same day. Overnight stays are rare.

How Long Does It Take to Heal?

You may get relief from symptoms the same day as your surgery, but complete healing takes longer. Expect to have pain, swelling, and stiffness after the operation. Your doctor will let you know what medicines might help. You may have some soreness for anywhere from a few weeks to a few months after surgery.

Your bandage will stay on for 1-2 weeks. Your doctor may give you exercises to do during this time to move your fingers and keep them from getting too stiff. You can use your hand lightly in the first 2 weeks, but it helps to avoid too much strain.

Slowly, you can get back to more normal activities, like:

  • Driving (a couple of days after surgery)
  • Writing (after a week, but expect 4-6 weeks before it feels easier.)
  • Pulling, gripping, and pinching (6-8 weeks out, but only lightly. Expect 10-12 weeks before your full strength returns, or up to a year in more severe cases.)

Your doctor will talk to you about when you can go back to work and whether you’ll be limited in what you can do.

Will I Need Occupational Therapy?

If you do, your doctor will suggest it once your bandage comes off. You’ll learn exercises to improve your hand and wrist movement, which can also speed up healing.

Some people find that their wrists aren’t as strong after surgery as they were before. If this happens to you, occupational therapy can help increase your strength.

New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Do you need bunion surgery

Do you need bunion surgery?

in ,

Article Featured on AAOS

Most people with bunions find pain relief with simple treatments to reduce pressure on the big toe, such as wearing wider shoes or using pads in their shoes. However, if these measures do not relieve your symptoms, your doctor may recommend bunion surgery.

There are different types of surgeries to correct a bunion. Bringing the big toe back to its correct position may involve realigning bone, ligaments, tendons, and nerves.

Are You a Candidate for Surgery?

In general, if your bunion is not painful, you do not need surgery. Although bunions often get bigger over time, doctors do not recommend surgery to prevent bunions from worsening. Many people can slow the progression of a bunion with proper shoes and other preventive care, and the bunion never causes pain or other problems.

It is also important to note that bunion surgery should not be done for cosmetic reasons. After surgery, it is possible for ongoing pain to develop in the affected toe — even though there was no bunion pain prior to surgery.

Good candidates for bunion surgery commonly have:

  • Significant foot pain that limits their everyday activities, including walking and wearing reasonable shoes. They may find it hard to walk more than a few blocks (even in athletic shoes) without significant pain.
  • Chronic big toe inflammation and swelling that does not improve with rest or medications
  • Toe deformity—a drifting in of the big toe toward the smaller toes, creating the potential for the toes to cross over each other.

Photo and x-ray of foot deformed by a bunion

(Left) A bunion that has progressed to deformity with the big toe crossing over the second toe. (Right) An x-ray of the same bunion shows how far out of alignment the bones are.

Reproduced from Wagner E, Ortiz C: Proximal Oblique Sliding Closing-wedge Osteotomy for Wide-angle Hallux Valgus. Orthopaedic Knowledge Online Journal: Vol 12, No 4, 4/1/2014; Accessed December 4, 2015.

  • Toe stiffness—the inability to bend and straighten the big toe
  • Failure to obtain pain relief with changes in footwear
  • Failure to obtain pain relief from nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen. The effectiveness of NSAIDs in controlling toe pain varies greatly from person to person.

Deciding to Have Bunion Surgery

After bunion surgery, most patients have less foot pain and are better able to participate in everyday activities.

As you explore bunion surgery be aware that so-called “simple” or “minimal” surgical procedures are often inadequate “quick fixes” that can do more harm than good. Although many bunion procedures are done on a same-day basis with no hospital stay, a long recovery period is common. It often takes up to 6 months for full recovery, with follow-up visits to your doctor sometimes necessary for up to a year.

It is very important to have realistic expectations about bunion surgery. For example, bunion surgery may not allow you to wear a smaller shoe size or narrow, pointed shoes. In fact, you may need to restrict the types of shoes you wear for the rest of your life.

As you consider bunion surgery, do not hesitate to ask your doctor questions about the operation and your recovery. Some examples of helpful questions to ask include:

  • What are the benefits and risks of this surgery?
  • What are the possible complications and how likely are they to occur?
  • How much pain will there be and how will it be managed?

Be sure to write down your doctor’s answers so you can remember them at a later time. It is important to understand both the potential benefits and limitations of bunion surgery.

Surgical Procedures

In general, the common goals of most bunion surgeries include:

  • Realigning the metatarsophalangeal (MTP) joint at the base of the big toe
  • Relieving pain
  • Correcting the deformity of the bones making up the toe and foot

Because bunions vary in shape and size, there are different surgical procedures performed to correct them. In most cases, bunion surgery includes correcting the alignment of the bone and repairing the soft tissues around the big toe.

Your doctor will talk with you about the type of surgery that will best correct your bunion.

Repairing the Tendons and Ligaments Around the Big Toe

In some cases, the soft tissues around the big toe may be too tight on one side and too loose on the other. This creates an imbalance that causes the big toe to drift toward the other toes.

Surgery can shorten the loose tissues and lengthen the tight ones. This is rarely done without some type of alignment of the bone, called an osteotomy. In the majority of cases, soft tissue correction is just one portion of the entire bunion corrective procedure.

Osteotomy

In an osteotomy, your doctor makes small cuts in the bones to realign the joint. After cutting the bone, your doctor fixes this new break with pins, screws, or plates. The bones are now straighter, and the joint is balanced.

Osteotomies may be performed in different places along the bone to correct the deformity. In some cases, in addition to cutting the bone, a small wedge of bone is removed to provide enough correction to straighten the toe.

As discussed above, osteotomies are normally performed in combination with soft tissue procedures, as both are often necessary to maintain the big toe alignment.

Foot x-rays showing a bunion corrected with osteotomy

X-rays taken from the top and the side of the foot show a bunion corrected with osteotomy.

Arthrodesis

In this procedure, your doctor removes the arthritic joint surfaces, then inserts screws, wires, or plates to hold the surfaces together until the bones heal. Arthrodesis is commonly used for patients who have severe bunions or severe arthritis, and for patients who have had previous unsuccessful bunion surgery.

X-rays of an arthritic foot before and after arthrodesis

The x-ray on the left shows severe arthritis of the MTP joint. After arthrodesis (shown on the right), the entire foot is realigned. An advantage of arthrodesis is that no additional procedures are necessary to correct the bunion.

Exostectomy

In this procedure, your doctor removes the bump from your toe joint. Exostectomy alone is seldom used to treat bunions because it does not realign the joint. Even when combined with soft tissue procedures, exostectomy rarely corrects the cause of the bunion.

Exostectomy is most often performed as one part of an entire corrective surgery that includes osteotomy, as well as soft-tissue procedures. If a doctor performs exostectomy without osteotomy, however, the bunion deformity often returns.

X-rays of a bunion before and after exostectomy

The x-ray on the left shows a mild bunion bump before exostectomy. After the procedure (right), the bump has been shaved but the toe deformity remains and is actually worse; the big toe drifts closer to the other toes and the metatarsal bone sticks out further.

Resection Arthroplasty

In this procedure, your doctor removes the damaged portion of the joint. This increases the space between the bones and creates a flexible “scar” joint. Resection arthroplasty is used mainly for patients who are elderly, have had previous unsuccessful bunion surgery, or have severe arthritis not amenable to an arthrodesis (see above). Because this procedure can change the push off power of the big toe, it is not often recommended.

X-ray of a failed resection arthroplasty and photo of a shortened big toe

This x-ray shows a failed resection arthroplasty. Although the damaged bone of the MTP joint was removed, scar tissue did not fill the space between the bones. The bone edges are still in contact. The photograph shows that without the needed scar tissue, the big toe is shortened. This makes it more difficult to push off while walking.

Preparing for Surgery

Medical Evaluation

Before your surgery, you may be asked to visit your family doctor for a complete physical examination. He or she will assess your health and identify any problems that could interfere with your surgery. If you have a heart or lung condition or a chronic illness you will need a preoperative medical clearance from your family doctor.

Medications

Tell your doctor about any medications you are taking. He or she will tell you which medications you can continue taking and which you should stop taking before surgery.

Tests

You may require several preoperative tests, including blood counts, a cardiogram, and a chest x-ray. You may also need to provide a urine sample.

To help plan your procedure, your doctor may order special foot x-rays. These x-rays should be taken in a standing, weight bearing position to ensure your doctor can clearly see the deformity in the foot. These x-rays assist your doctor in making decisions about where along the bone to perform an osteotomy in order to provide enough corrective power to straighten the toe.

Your Surgery

In planning your surgery, your doctor will consider several things, including how severe your bunion is, your age, your general health and activity level, and any other medical issues that may affect your recovery.

Almost all bunion surgery is done on an outpatient basis. You will most likely be asked to arrive at the hospital or surgical center 1 or 2 hours before your surgery.

Anesthesia

After admission, you will be evaluated by a member of the anesthesia team. Most bunion surgery is performed with anesthesia that numbs the area for surgery but does not put you to sleep.

  • Local anesthesia. An ankle block numbs just your foot.
  • Regional anesthesia. A popliteal block works for a longer period of time compared to an ankle block and numbs more of the leg. The numbing medicine is injected behind the knee.
  • Spinal anesthesia. This injection will numb your body below your waist.
  • General anesthesia. This form of anesthesia will put you to sleep.

The anesthesiologist will stay with you throughout the procedure to administer other medications, if necessary, and to make sure you are comfortable.

Procedure

Depending upon your bunion and the procedures you need, your doctor will make an incision along the inside of your big toe joint or on top of the joint. In some cases, more than one incision is needed to correct the bunion deformity.

Surgical photo of an osteotomy

This surgical photograph shows a saw cutting the bone to perform an osteotomy.

The surgical time varies depending on how much of your foot is malaligned. Surgery will take longer if your deformity is greater or if more than one osteotomy is required. Every bunion correction is a little bit different, and there is no reason to be concerned if your surgery takes more time.

Afterward, you will be moved to the recovery room. You will be ready to go home in an hour or two. Be sure to have someone with you to drive you home.

Photo and x-ray of a foot after osteotomy for a bunion

(Left) The bunion that was shown at the beginning of this article as it appeared immediately after surgery. (Right) An x-ray showing the bones in alignment after surgery. Osteotomies were performed on both bones; screws and plates hold the bones in place. Reproduced from Wagner E, Ortiz C: Proximal Oblique Sliding Closing-wedge Osteotomy for Wide-angle Hallux Valgus. Orthopaedic Knowledge Online Journal: Vol 12, No 4, 4/1/2014; Accessed December 4, 2015.

Complications

As with any surgical procedure, there are risks associated with bunion surgery. These occur infrequently and are usually treatable — although, in some cases, they may limit or extend your full recovery. Before your surgery, your doctor will discuss each of the risks with you and take specific measures to avoid complications.

The possible risks and complications of bunion surgery include:

  • Infection
  • Nerve injury
  • Failure to relieve pain
  • Failure of the bone to fully heal
  • Stiffness of the big toe joint
  • Recurrence of the bunion

Recovery at Home

The success of your surgery will depend in large part on how well you follow your doctor’s instructions at home during the first few weeks after surgery. You will see your doctor regularly for several months — occasionally up to a year — to make sure your foot heals properly.

Dressing Care

You will be discharged from the hospital with bandages holding your toe in its corrected position.

Because keeping your toe in position is essential for successful healing, it is very important to follow your doctor’s directions about dressing care. Do not disturb or change the dressing without talking to your doctor. Interfering with proper healing could cause a recurrence of the bunion.

Dressing applied to foot after osteotomy

Legend: Your doctor will apply your dressing in a specific way to keep the bones in correct position.

Reproduced from Hirose CB, Coughlin MJ: Proximal and Distal First Metatarsal Osteotomies for Hallux Valgus, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 535-539.

Be sure to keep your wound and dressing dry. When you are showering or bathing, cover your foot with a plastic bag.

Your sutures will be removed about 2 weeks after surgery, but your foot will require continued support from dressings or a brace for 6 to 12 weeks.

Medications

Your doctor will prescribe pain medication to relieve surgical discomfort. The most effective medications for providing postsurgical pain relief are opioids. These medications are narcotics, however, and can be addictive. It is important to use opioids only as directed by your doctor.

As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

In addition to pain medicine, your doctor may prescribe antibiotics to help prevent infection in your wound for several days after surgery.

Swelling

Keep your foot elevated as much as possible for the first few days after surgery, and apply ice as recommended by your doctor to relieve swelling and pain. Never apply ice directly on your skin. It is common to have some swelling in your foot from 6 months to a year after bunion surgery.

Bearing Weight

Your doctor will give you strict instructions about whether and when you can put weight on your foot. Depending upon the type of procedure you have, if you put weight on your foot too early or without proper support, the bones can shift and the bunion correction will be lost.

Some bunion procedures allow you to walk on your foot right after the surgery. In these cases, patients must use a special surgical shoe to protect the bunion correction.

Many bunion surgeries require a period of no weightbearing to ensure bone healing. Your doctor will apply dressings, a brace, or a cast to maintain the correct bone position. Crutches are usually used to avoid putting any weight on the foot. A newer device called a knee walker is a good alternative to crutches. It has four wheels and functions like a scooter. Instead of standing, you place the knee of your affected foot on a padded cushion and push yourself along using your healthy foot.

In addition to no weightbearing, driving may be restricted until the bones have healed properly — particularly if the surgery was performed on your right foot.

No matter what type of bunion surgery you have, it is very important to follow your doctor’s instructions about weightbearing. Do not put weight on your foot or stop using supportive devices until your doctor gives approval.

Physical Therapy and Exercise

Specific exercises will help restore your foot’s strength and range of motion after surgery. Your doctor or physical therapist may recommend exercises using a surgical band to strengthen your ankle or using marbles to restore motion in your toes.

Marble pick-up exercise for foot

Specific exercises such as the marble pick up exercise will help restore full motion to your foot.

Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Always start these exercises slowly and follow instructions from your doctor or physical therapist regarding repetitions.

Shoe Wear

It will take several months for your bones to fully heal. When you have completed the initial rehabilitation period, your doctor will advise you on shoewear. Athletic shoes or soft leather oxford type shoes will best protect the bunion correction until the bones have completely healed.

To help prevent your bunion from recurring, do not wear fashion shoes until your doctor allows it. Be aware that your doctor may recommend that you never return to wearing high-heeled shoes.

Avoiding Complications

Though uncommon, complications can occur following bunion surgery. During your recovery at home, contact your doctor if:

  • Your dressing loosens, comes off, or gets wet.
  • Your dressing is moistened with blood or drainage.
  • You develop side effects from postoperative medications.

Also, call your doctor immediately if you notice any of the following warning signs of infection:

  • Persistent fever
  • Shaking chills
  • Persistent warmth or redness around the dressing
  • Increased or persistent pain, especially a “sunburn” type pain
  • Significant swelling in the calf above the treated foot, especially if there is a “charley horse” pain behind the knee, or if your develop shortness of breath.

Outcomes

The majority of patients who undergo bunion surgery experience a reduction of foot pain, along with improvement in the alignment of their big toe. The length of your recovery will depend upon the surgical procedures that were performed, and how well you follow your doctor’s instructions.

Because a main cause of bunion deformity is a tight-fitting shoe, returning to that type of shoe can cause your bunion to return. Always follow your doctor’s recommendations for proper shoe fit.

New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Does an ACL Injury Require Surgery

Does an ACL Injury Require Surgery

in ,

The following article provides in-depth information about treatment for anterior cruciate ligament injuries. The general article, Anterior Cruciate Ligament (ACL) Injuries, provides a good introduction to the topic and is recommended reading prior to this article.

The information that follows includes the details of anterior cruciate ligament (ACL) anatomy and the pathophysiology of an ACL tear, treatment options for ACL injuries along with a description of ACL surgical techniques and rehabilitation, potential complications, and outcomes. The information is intended to assist the patient in making the best-informed decision possible regarding the management of ACL injury.

Anatomy

normal knee anatomy

Normal knee anatomy.  The knee is made up of four main things: bones, cartilage, ligaments, and tendons.

The bone structure of the knee joint is formed by the femur, the tibia, and the patella. The ACL is one of the four main ligaments within the knee that connect the femur to the tibia.

The knee is essentially a hinged joint that is held together by the medial collateral (MCL), lateral collateral (LCL), anterior cruciate (ACL) and posterior cruciate (PCL) ligaments. The ACL runs diagonally in the middle of the knee, preventing the tibia from sliding out in front of the femur, as well as providing rotational stability to the knee.

The weight-bearing surface of the knee is covered by a layer of articular cartilage. On either side of the joint, between the cartilage surfaces of the femur and tibia, are the medial meniscus and lateral meniscus. The menisci act as shock absorbers and work with the cartilage to reduce the stresses between the tibia and the femur.

Description

ACL tear

The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee.  In general, the incidence of ACL injury is higher in people who participate in high-risk sports, such as basketball, football, skiing, and soccer.

Approximately half of ACL injuries occur in combination with damage to the meniscus, articular cartilage, or other ligaments. Additionally, patients may have bruises of the bone beneath the cartilage surface. These may be seen on a magnetic resonance imaging (MRI) scan and may indicate injury to the overlying articular cartilage.

arthroscopic images of normal ACL and ACL tear

(Left) Arthroscopic picture of the normal ACL. (Right) Arthroscopic picture of torn ACL [yellow star].

Cause

It is estimated that the majority of  ACL injuries occur through non-contact mechanisms, while a smaller percent result from direct contact with another player or object.

The mechanism of injury is often associated with deceleration coupled with cutting, pivoting or sidestepping maneuvers, awkward landings or “out of control” play.

Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes in certain sports. It has been proposed that this is due to differences in physical conditioning, muscular strength, and neuromuscular control. Other hypothesized causes of this gender-related difference in ACL injury rates include pelvis and lower extremity (leg) alignment, increased ligamentous laxity, and the effects of estrogen on ligament properties.

Doctor Examination

Immediately after the injury, patients usually experience pain and swelling and the knee feels unstable. Within a few hours after a new ACL injury, patients often have a large amount of knee swelling, a loss of full range of motion, pain or tenderness along the joint line and discomfort while walking.

When a patient with an ACL injury is initially seen for evaluation in the clinic, the doctor may order x-rays to look for any possible fractures. He or she may also order a magnetic resonance imaging (MRI) scan to evaluate the ACL and to check for evidence of injury to other knee ligaments, meniscus cartilage, or articular cartilage.

MRI of ACL tear

An MRI of a complete ACL tear. The ACL fibers have been disrupted and the ACL appears wavy in appearance [yellow arrow].

In addition to performing special tests for identifying meniscus tears and injury to other ligaments of the knee, the physician will often perform the Lachman’s test to see if the ACL is intact.

If the ACL is torn, the examiner will feel increased forward (upward or anterior) movement of the tibia in relation to the femur (especially when compared to the normal leg) and a soft, mushy endpoint (because the ACL is torn) when this movement ends.

Natural History

What happens naturally with an ACL injury without surgical intervention varies from patient to patient and depends on the patient’s activity level, degree of injury and instability symptoms.

The prognosis for a partially torn ACL is often favorable, with the recovery and rehabilitation period usually at least 3 months. However, some patients with partial ACL tears may still have instability symptoms. Close clinical follow-up and a complete course of physical therapy helps identify those patients with unstable knees due to partial ACL tears.

Complete ACL ruptures have a much less favorable outcome without surgical intervention. After a complete ACL tear, some patients are unable to participate in cutting or pivoting-type sports, while others have instability during even normal activities, such as walking. There are some rare individuals who can participate in sports without any symptoms of instability. This variability is related to the severity of the original knee injury, as well as the physical demands of the patient.

About half of ACL injuries occur in combination with damage to the meniscus, articular cartilage or other ligaments. Secondary damage may occur in patients who have repeated episodes of instability due to ACL injury. With chronic instability, a large majority of patients will have meniscus damage when reassessed 10 or more years after the initial injury. Similarly, the prevalence of articular cartilage lesions increases in patients who have a 10-year-old ACL deficiency.

Nonsurgical Treatment

In nonsurgical treatment, progressive physical therapy and rehabilitation can restore the knee to a condition close to its pre-injury state and educate the patient on how to prevent instability. This may be supplemented with the use of a hinged knee brace. However, many people who choose not to have surgery may experience secondary injury to the knee due to repetitive instability episodes.

Surgical treatment is usually advised in dealing with combined injuries (ACL tears in combination with other injuries in the knee). However, deciding against surgery is reasonable for select patients. Nonsurgical management of isolated ACL tears is likely to be successful or may be indicated in patients:

  • With partial tears and no instability symptoms
  • With complete tears and no symptoms of knee instability during low-demand sports who are willing to give up high-demand sports
  • Who do light manual work or live sedentary lifestyles
  • Whose growth plates are still open (children)

Surgical Treatment

ACL tears are not usually repaired using suture to sew it back together, because repaired ACLs have generally been shown to fail over time. Therefore, the torn ACL is generally replaced by a substitute graft made of tendon.

  • Patellar tendon autograft (autograft comes from the patient)
  • Hamstring tendon autograft
  • Quadriceps tendon autograft
  • Allograft (taken from a cadaver) patellar tendon, Achilles tendon, semitendinosus, gracilis, or posterior tibialis tendon

Patient Considerations

Active adult patients involved in sports or jobs that require pivoting, turning or hard-cutting as well as heavy manual work are encouraged to consider surgical treatment. This includes older patients who have previously been excluded from consideration for ACL surgery. Activity, not age, should determine if surgical intervention should be considered.

In young children or adolescents with ACL tears, early ACL reconstruction creates a possible risk of growth plate injury, leading to bone growth problems. The surgeon can delay ACL surgery until the child is closer to skeletal maturity or the surgeon may modify the ACL surgery technique to decrease the risk of growth plate injury.

A patient with a torn ACL and significant functional instability has a high risk of developing secondary knee damage and should therefore consider ACL reconstruction.

It is common to see ACL injuries combined with damage to the menisci, articular cartilage, collateral ligaments, joint capsule, or a combination of the above. The “unhappy triad,” frequently seen in football players and skiers, consists of injuries to the ACL, the MCL, and the medial meniscus.

In cases of combined injuries, surgical treatment may be warranted and generally produces better outcomes. As many as half of meniscus tears may be repairable and may heal better if the repair is done in combination with the ACL reconstruction.

Surgical Choices

Patellar tendon autograft prepared for ACL reconstruction

Patellar tendon autograft prepared for ACL reconstruction.

Patellar tendon autograft. The middle third of the patellar tendon of the patient, along with a bone plug from the shin and the kneecap is used in the patellar tendon autograft. Occasionally referred to by some surgeons as the “gold standard” for ACL reconstruction, it is often recommended for high-demand athletes and patients whose jobs do not require a significant amount of kneeling.

In studies comparing outcomes of patellar tendon and hamstring autograft ACL reconstruction, the rate of graft failure was lower in the patellar tendon group. In addition, most studies show equal or better outcomes in terms of postoperative tests for knee laxity (Lachman’s, anterior drawer and instrumented tests) when this graft is compared to others. However, patellar tendon autografts have a greater incidence of postoperative patellofemoral pain (pain behind the kneecap) complaints and other problems.

The pitfalls of the patellar tendon autograft are:

  • Postoperative pain behind the kneecap
  • Pain with kneeling
  • Slightly increased risk of postoperative stiffness
  • Low risk of patella fracture

Hamstring tendon autograft. The semitendinosus hamstring tendon on the inner side of the knee is used in creating the hamstring tendon autograft for ACL reconstruction. Some surgeons use an additional tendon, the gracilis, which is attached below the knee in the same area. This creates a two- or four-strand tendon graft. Hamstring graft proponents claim there are fewer problems associated with harvesting of the graft compared to the patellar tendon autograft including:

  • Fewer problems with anterior knee pain or kneecap pain after surgery
  • Less postoperative stiffness problems
  • Smaller incision
  • Faster recovery

Hamstring tendon autograft prepared for ACL reconstruction

Hamstring tendon autograft prepared for ACL reconstruction.

The graft function may be limited by the strength and type of fixation in the bone tunnels, as the graft does not have bone plugs. There have been conflicting results in research studies as to whether hamstring grafts are slightly more susceptible to graft elongation (stretching), which may lead to increased laxity during objective testing. Recently, some studies have demonstrated decreased hamstring strength in patients after surgery.

There are some indications that patients who have intrinsic ligamentous laxity and knee hyperextension of 10 degrees or more may have increased risk of postoperative hamstring graft laxity on clinical exam. Therefore, some clinicians recommend the use of patellar tendon autografts in these hypermobile patients.

Additionally, since the medial hamstrings often provide dynamic support against valgus stress and instability, some surgeons feel that chronic or residual medial collateral ligament laxity (grade 2 or more) at the time of ACL reconstruction may be a contraindication for use of the patient’s own semitendinosus and gracilis tendons as an ACL graft.

Quadriceps tendon autograft. The quadriceps tendon autograft is often used for patients who have already failed ACL reconstruction. The middle third of the patient’s quadriceps tendon and a bone plug from the upper end of the knee cap are used. This yields a larger graft for taller and heavier patients. Because there is a bone plug on one side only, the fixation is not as solid as for the patellar tendon graft. There is a high association with postoperative anterior knee pain and a low risk of patella fracture. Patients may find the incision is not cosmetically appealing.

Allografts. Allografts are grafts taken from cadavers and are becoming increasingly popular. These grafts are also used for patients who have failed ACL reconstruction before and in surgery to repair or reconstruct more than one knee ligament. Advantages of using allograft tissue include elimination of pain caused by obtaining the graft from the patient, decreased surgery time and smaller incisions. The patellar tendon allograft allows for strong bony fixation in the tibial and femoral bone tunnels with screws.

However, allografts are associated with a risk of infection, including viral transmission (HIV and Hepatitis C), despite careful screening and processing. Several deaths linked to bacterial infection from allograft tissue (due to improper procurement and sterilization techniques) have led to improvements in allograft tissue testing and processing techniques. There have also been conflicting results in research studies as to whether allografts are slightly more susceptible to graft elongation (stretching), which may lead to increased laxity during testing.

Some published literature may point to a higher failure rate with the use of allografts for ACL reconstruction. Higher failure rates for allografts have been reported in young, active patients returning to high-demand sporting activities after ACL reconstruction, compared with autografts.

The reason for this higher failure rate is unclear. It could be due to graft material properties (sterilization processes used, graft donor age, storage of the graft). It could possibly be due to an ill-advised earlier return to sport by the athlete because of a faster perceived physiologic recovery, when the graft is not biologically ready to be loaded and stressed during sporting activities. Further research in this area is indicated and is ongoing.

Surgical Procedure

Before any surgical treatment, the patient is usually sent to physical therapy. Patients who have a stiff, swollen knee lacking full range of motion at the time of ACL surgery may have significant problems regaining motion after surgery. It usually takes three or more weeks from the time of injury to achieve full range of motion. It is also recommended that some ligament injuries be braced and allowed to heal prior to ACL surgery.

The patient, the surgeon, and the anesthesiologist select the anesthesia used for surgery. Patients may benefit from an anesthetic block of the nerves of the leg to decrease postoperative pain.

The surgery usually begins with an examination of the patient’s knee while the patient is relaxed due the effects of anesthesia. This final examination is used to verify that the ACL is torn and also to check for looseness of other knee ligaments that may need to be repaired during surgery or addressed postoperatively.

If the physical exam strongly suggests the ACL is torn, the selected tendon is harvested (for an autograft) or thawed (for an allograft) and the graft is prepared to the correct size for the patient.

Passage of patellar tendon graft during ACL reconstruction

Passage of patellar tendon graft into tibial tunnel of knee.

After the graft has been prepared, the surgeon places an arthroscope into the joint. Small (one-centimeter) incisions called portals are made in the front of the knee to insert the arthroscope and instruments and the surgeon examines the condition of the knee. Meniscus and cartilage injuries are trimmed or repaired and the torn ACL stump is then removed.

post-operative x-ray of ACL reconstruction

Post-operative X-ray after ACL patellar tendon reconstruction (with picture of graft superimposed) shows graft position and bone plugs fixation with metal interference screws.

In the most common ACL reconstruction technique, bone tunnels are drilled into the tibia and the femur to place the ACL graft in almost the same position as the torn ACL. A long needle is then passed through the tunnel of the tibia, up through the femoral tunnel, and then out through the skin of the thigh. The sutures of the graft are placed through the eye of the needle and the graft is pulled into position up through the tibial tunnel and then up into the femoral tunnel. The graft is held under tension as it is fixed in place using interference screws, spiked washers, posts, or staples. The devices used to hold the graft in place are generally not removed.

Variations on this surgical technique include the “two-incision,” “over-the-top,” and “double-bundle” types of ACL reconstructions, which may be used because of the preference of the surgeon or special circumstances (revision ACL reconstruction, open growth plates).

Before the surgery is complete, the surgeon will probe the graft to make sure it has good tension, verify that the knee has full range of motion and perform tests such as the Lachman’s test to assess graft stability. The skin is closed and dressings (and perhaps a postoperative brace and cold therapy device, depending on surgeon preference) are applied. The patient will usually go home on the same day of the surgery.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Rehabilitation

Physical therapy is a crucial part of successful ACL surgery, with exercises beginning immediately after the surgery. Much of the success of ACL reconstructive surgery depends on the patient’s dedication to rigorous physical therapy. With new surgical techniques and stronger graft fixation, current physical therapy uses an accelerated course of rehabilitation.

Postoperative Course. In the first 10 to 14 days after surgery, the wound is kept clean and dry, and early emphasis is placed on regaining the ability to fully straighten the knee and restore quadriceps control.

The knee is iced regularly to reduce swelling and pain. The surgeon may dictate the use of a postoperative brace and the use of a machine to move the knee through its range of motion. Weight-bearing status (use of crutches to keep some or all of the patient’s weight off of the surgical leg) is also determined by physician preference, as well as other injuries addressed at the time of surgery.

Rehabilitation. The goals for rehabilitation of ACL reconstruction include reducing knee swelling, maintaining mobility of the kneecap to prevent anterior knee pain problems, regaining full range of motion of the knee, as well as strengthening the quadriceps and hamstring muscles.

The patient may return to sports when there is no longer pain or swelling, when full knee range of motion has been achieved, and when muscle strength, endurance and functional use of the leg have been fully restored.

The patient’s sense of balance and control of the leg must also be restored through exercises designed to improve neuromuscular control. This usually takes 4 to 6 months. The use of a functional brace when returning to sports is ideally not needed after a successful ACL reconstruction, but some patients may feel a greater sense of security by wearing one.

Surgical Complications

Infection. The incidence of infection after arthroscopic ACL reconstruction is very low.  There have also been reported deaths linked to bacterial infection from allograft tissue due to improper procurement and sterilization techniques.

Viral transmission. Allografts specifically are associated with risk of viral transmission, including HIV and Hepatitis C, despite careful screening and processing. The chance of obtaining a bone allograft from an HIV-infected donor is calculated to be less than 1 in a million.

Bleeding, numbness. Rare risks include bleeding from acute injury to the popliteal artery, and weakness or paralysis of the leg or foot. It is not uncommon to have numbness of the outer part of the upper leg next to the incision, which may be temporary or permanent.

Blood clot. Although rare, blood clot in the veins of the calf or thigh is a potentially life-threatening complication. A blood clot may break off in the bloodstream and travel to the lungs, causing pulmonary embolism or to the brain, causing stroke.

Instability. Recurrent instability due to rupture or stretching of the reconstructed ligament or poor surgical technique is possible.

Stiffness. Knee stiffness or loss of motion has been reported by some patients after surgery.

Extensor mechanism failure. Rupture of the patellar tendon (patellar tendon autograft) or patella fracture (patellar tendon or quadriceps tendon autografts) may occur due to weakening at the site of graft harvest.

Growth plate injury. In young children or adolescents with ACL tears, early ACL reconstruction creates a possible risk of growth plate injury, leading to bone growth problems. The ACL surgery can be delayed until the child is closer to reaching skeletal maturity. Alternatively, the surgeon may be able to modify the technique of ACL reconstruction to decrease the risk of growth plate injury.

Kneecap pain. Postoperative anterior knee pain is especially common after patellar tendon autograft ACL reconstruction. The incidence of pain behind the kneecap varies greatly  in studies, whereas the incidence of kneeling pain is often higher after patellar tendon autograft ACL reconstruction.

New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

An Experts Guide to Avoiding Back Pain

Deciding whether to have spine surgery

in , ,

By Alan S. Hilibrand, MD | Featured on AAOS

Orthopaedic surgeons encourage “shared decision-making” when it comes to treating patients, because the doctor and patient each provide information needed to make a decision about surgery.

Read more

Knee Replacement Surgery for Arthritis

What Can I Do After Knee Replacement Surgery? When to Return to Normal Activity

in , , ,

Article Featured on AAOS

After having a knee replacement, you may expect your lifestyle to be a lot like it was before surgery— but without the pain. In many ways, you are right, but returning to your everyday activities takes time. Being an active participant in the healing process can help you get there sooner and ensure a more successful outcome.

Even though you will be able to resume most activities, you may want to avoid doing things that place excessive stress on your “new” knee, such as participating in high-impact sports like jogging. The suggestions here will help you enjoy your new knee while you safely resume your daily activities.

Hospital Discharge

Your hospital stay will typically last from 1 to 4 days, depending on the speed of your recovery. If your knee replacement is performed on an outpatient basis, you will go home on the same day as surgery.

Before you are discharged from the hospital, you will need to accomplish several goals, such as:

  • Getting in and out of bed by yourself.
  • Having acceptable pain control.
  • Being able to eat, drink, and use the bathroom.
  • Walking with an assistive device (a cane, walker, or crutches) on a level surface and being able to climb up and down two or three stairs.
  • Being able to perform the prescribed home exercises.
  • Understanding any knee precautions you may have been given to prevent injury and ensure proper healing.

If you are not able to accomplish these goals, it may be unsafe for you to go directly home after discharge. If this is the case, you may be temporarily transferred to a rehabilitation or skilled nursing center.

When you are discharged, your healthcare team will provide you with information to support your recovery at home. Although the complication rate after total knee replacement is low, when complications occur they can prolong or limit full recovery. Hospital staff will discuss possible complications, and review with you the warning signs of an infection or a blood clot.

Warning Signs of Infection

  • Persistent fever (higher than 100 degrees)
  • Shaking chills
  • Increasing redness, tenderness or swelling of your wound
  • Drainage of your wound
  • Increasing pain with both activity and rest

Warning Signs of a Blood Clot

  • Pain in your leg or calf unrelated to your incision
  • Tenderness or redness above or below your knee
  • Increasing swelling of your calf, ankle or foot

In very rare cases, a blood clot may travel to your lungs and become life-threatening. Signs that a blood clot has traveled to your lungs include:

  • Shortness of breath
  • Sudden onset of chest pain
  • Localized chest pain with coughing

Notify your doctor if you develop any of the above signs.

Recovery at Home

You will need some help at home for several days to several weeks after discharge. Before your surgery, arrange for a friend, family member or caregiver to provide help at home.

Preparing Your Home

The following tips can make your homecoming more comfortable, and can be addressed before your surgery:

  • Rearrange furniture so you can maneuver with a cane, walker, or crutches. You may temporarily change rooms (make the living room your bedroom, for example) to avoid using the stairs.
Home recovery center

Prepare a “recovery center” by placing items that you use frequently within easy reach.

  • Remove any throw rugs or area rugs that could cause you to slip. Securely fasten electrical cords around the perimeter of the room.
  • Get a good chair—one that is firm with a higher-than-average seat and has a footstool for intermittent leg elevation.
  • Install a shower chair, gripping bar, and raised toilet seat in the bathroom.
  • Use assistive devices such as a long-handled shoehorn, a long-handled sponge, and a grabbing tool or reacher to avoid bending over too far.

Wound Care

During your recovery at home, follow these guidelines to take care of your wound and prevent infection:

  • Keep the wound area clean and dry. A dressing will be applied in the hospital and should be changed as often as directed by your doctor. Ask for instructions on how to change the dressing before you leave the hospital.
  • Follow your doctor’s instructions on how long to wait before you shower or bathe.
  • Notify your doctor immediately if the wound appears red or begins to drain. This could be a sign of infection.

Swelling

You may have moderate to severe swelling in the first few days or weeks after surgery. You may have mild to moderate swelling for about 3 to 6 months after surgery. To reduce swelling, elevate your leg slightly and apply ice. Wearing compression stockings may also help reduce swelling. Notify your doctor if you experience new or severe swelling, since this may be the warning sign of a blood clot.

Medication

Take all medications as directed by your doctor. Home medications may include opioid and non-opioid pain pills, oral or injectable blood thinners, stool softeners, and anti-nausea medications.

Be sure to talk to your doctor about all your medications—even over-the-counter drugs, supplements and vitamins. Your doctor will tell you which over-the-counter medicines are safe to take while using prescription pain medication.

It is especially important to prevent any bacterial infections from developing in your artificial joint. Some patients with special circumstances may be required to take antibiotics prior to dental work to help prevent infection. Ask your doctor if you should take antibiotics before dental work. You may also wish to carry a medical alert card so that, if an emergency arises, medical personnel will know that you have an artificial joint.

Diet

By the time you go home from the hospital, you should be eating a normal diet. Your doctor may recommend that you take iron and vitamin supplements. You may also be advised to avoid supplements that include vitamin K and foods rich in vitamin K if you taking the blood thinner medication warfarin (Coumadin). Foods rich in vitamin K include broccoli, cauliflower, brussel sprouts, liver, green beans, garbanzo beans, lentils, soybeans, soybean oil, spinach, kale, lettuce, turnip greens, cabbage, and onions.

Continue to drink plenty of fluids and avoid alcohol. You should continue to watch your weight to avoid putting more stress on the joint.

Resuming Normal Activities

Once you get home, you should stay active. The key is to not do too much, too soon. While you can expect some good days and some bad days, you should notice a gradual improvement over time. Generally, the following guidelines will apply:

Driving

In most cases, it is safe to resume driving when you are no longer taking opioid pain medication, and when your strength and reflexes have returned to a more normal state. Your doctor will help you determine when it is safe to resume driving.

Sexual Activity

Please consult your doctor about how soon you can safely resume sexual activity. Depending on your condition, you may be able to resume sexual activity within several weeks after surgery.

Sleeping Positions

You can safely sleep on your back, on either side, or on your stomach.

Return to Work

Depending on the type of activities you do on the job and the speed of your recovery, it may take from several days to several weeks before you are able to return to work. Your doctor will advise you when it is safe to resume your normal work activities.

Sports and Exercise

Continue to do the exercises prescribed by your physical therapist for at least 2 months after surgery. In some cases, your doctor may recommend riding a stationary bicycle to help maintain muscle tone and keep your knee flexible. When riding, try to achieve the maximum degree of bending and straightening possible.

As soon as your doctor gives you the go-ahead, you can return to many of the sports activities you enjoyed before your knee replacement.

  • Walk as much as you would like, but remember that walking is no substitute for the exercises prescribed by your doctor and physical therapist.
  • Swimming is an excellent low-impact activity after a total knee replacement; you can begin swimming as soon as the wound is sufficiently healed. Your doctor will let you know when you can begin.
  • In general, lower impact fitness activities such as golfing, bicycling, and light tennis will help increase the longevity of your knee and are preferable over high-impact activities such as jogging, racquetball and skiing.

Air Travel

Pressure changes and immobility may cause your operated leg to swell, especially if it is just healing. Ask your doctor before you travel on an airplane. When going through security, be aware that the sensitivity of metal detectors varies and your artificial joint may cause an alarm. Tell the screener about your artificial joint before going through the metal detector.

New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

4 Tips For Senior Citizens Recovering From Knee Surgery

4 Tips For Senior Citizens Recovering From Knee Surgery

in , ,

BY JOAN TIMPSON | Article Featured on Sunrise Care

As senior citizens age, their bodies become increasingly vulnerable to conditions that decrease mobility and cause chronic pain. One of the most commonly experienced diseases that impacts the joints and muscles of older adults is osteoarthritis, which affects approximately 8.75 million people, according to Arthritis Research UK. As a result of osteoarthritis and other forms of arthritis, many senior citizens turn to knee replacements for relief from pain and to regain mobility.

Read more