Thank you for choosing The Orthopaedic Speciality Clinic for your orthopaedic care. We know that a healthy body is something many of us take for granted until illness, injury, or the normal aging process threatens to take it all away. Your immense trust in our knowledge and expertise is very important to us.Our commitment is to provide you with an accurate assessment and evaluation coupled with immediate, early intervention and the best possible medical care in the most compassionate and caring manner. At The Orthopaedic Speciality Clinic, we offer a full range of orthopaedic services to help relieve pain and restore your lifestyle. We look forward to serving you.
Dr. Sachin Tapasvi
OPD time: 2:30pm to 6:30pm (Mon, Fri)
Phone Nos: 8928405250/(020) 66020365
Address:2 Tehmi Terrace, Next to Ruby Hall, Lane before Gold field Plaza, Sassoon Road.(020) 26167643
OPD Time: 2:30pm to 6:30pm (Tues); 4:30pm to 7:30pm (Thurs)
Phone Nos: 8928405250/(020) 66020365
Address: Status Chamber, 4th Floor, Wrangler Paranjpe Lane, Lane adjacent to Hotel Vaishali. Off Fergusson College Road. (020) 25510109
OPD Time: Thursday 2pm to 4pm
Phone Nos: (020) 40151100/ 40151540
Address: Near Mhatre Bridge, Pune, Maharashtra 411004
OPD Time: Wednesday 2:30pm to 6:30pm
Phone Nos: 020 2799 2799
Address: Pimple Nilakh Road, Balewadi-Baner, Pune - 411045, Near Dr Ambedkar Bridge Opposite Rutuparna Apartment
The fellowship involves working at Oyster and Pearl Hospital and OPD clinics attended by Dr. Sachin Tapasvi. The fellowship also involves outpatient work, preparation for operations, and with assistance, consulting at the Orthopedic Speciality Clinic.The fellow develops surgical experience through private assisting and supervised operating. The fellow develops full responsibility for surgery at approximately one operating list per fortnight. The exposure is approximately 20 surgical procedures per week...
Pune Knee Course was started by Dr Sachin Tapasvi in 2011 to impart knowledge and spread awareness in the ever evolving field of knee arthroscopy. Knee arthroscopy sees new advances every day and it is difficult to keep ourselves updated every few months by visiting centers of excellence abroad. Hence Dr. Tapasvi introduced the concept of bringing national and international experts home to teach and update us. This enables all surgeons to learn from them and also watch them perform live surgeries.
As Dr Sachin Tapasvi puts it “The sole purpose of Pune Knee Course is to impart knowledge, and to benefit from the expertise of best practitioners in the field”.
To Register or Know More Visit : Pune Knee Course Official Website
After the football accident, and an ACL tear, I was unable to walk. All I remember is being lifted up and getting home. It was a nightmare of pains and fear of not playing again. I met Mr. Sachin Tapasvi through a reference. After surgery, he asked me to walk without support in the very first hour! With regular physiotherapy, I recovered faster than many others who might have sailed in my ship. Doc gives special attention, care and respect to his patients and considers them as his friends. Its been almost 8 years after my surgery and I am still going strong. Being an avid runner, trekker and cyclist, I have bagged multiple accolades. I still consider Sachin Sir as a reason of everything. My first medal is dedicated to him and I will hand it over when I visit him next!! I want to thank Dr. Tapasvi from the bottom of my heart for treating me to the best, showing me a way where I was lost and directing me to new ventures when all seemed shattered. For me, he's not only the best doctor, but a larger than life human being. I am glad I met him.
Fellowship under Dr. Tapasvi was an experience that will count for the rest of my life. This fellowship under Sir was the one that has made the difference.
My approach towards problems underwent a complete change after the fellowship under Dr. Tapasvi. He is the perfect “GURU” guiding his fellows whenever they require him. An avid photographer- you are a true rockstar Sir. Nothing is impossible for me as long as i have BOSS behind me.
Working as a Fellow under the guidance of Dr. Tapasvi was a wonderful experience.He is a role model to me in a lot of aspects. Apart from being an excellent surgeon he is a very friendly guide and a great teacher. A truly admirable personality, someone whom i would always look up to with greatest regards & respect.
Working with Dr. Tapasvi made me question what I thought was possible as he constantly pushed to improve my knowledge and skills. He is truly gifted as a surgeon and a master of his art. He is a source of inspiration, a guiding light, a “guru” in every sense of the word. The Fellowship was an honor and his association a blessing for life.
Working with Dr. Tapasvi really changed my outlook and approach towards Orthopaedics. Sir taught us that nothing is impossible if one has a will to learn. Thank you for having given me an opportunity to work with you and may your good work continue to benefit young doctors like me as well as patients.
In my opinion he is the only surgeon in india who can perform revision rotator cuff repair as well as re-revision of hip arthroplasty with the same competency. During my fellowship I saw a high volume of - scopy and -plasty surgeries of the knee, hip and shoulder. In the true sense I consider him as my mentor.
It was a great learning experience for me to work with such a versatile surgeon. Thank you Sir!!
My mentor, my teacher, my friend. During my early days I was a little intimidated considering Sir's surgical acumen and watching him operate so meticulously and effortlessly. The best teachers are those who make surgery seem easy. Even after starting my practice, Sir has always there as a mentor ready to help.
Words are not enough to describe him but he can rightly be called as the most inspiring teacher ever. Sir, thanks a lot for your support and inspiration.
I have never seen such a perfect person. He is a talented surgeon, ultra-fast thinker, has a great sense of humour. After my fellowship, as an arthroscopy surgeon I am more confident and can foresee complications. If given a chance I would gladly do one more fellowship under him to gain further knowledge of arthroscopy.
My mentor, guide and inspiration, Dr. Tapasvi is by far the best knee surgeon in the country and probably amongst the top surgeons in the world today. No praise is enough to describe the influence Sir has had on all those privileged to have learnt from him. The legend has made his mark and we as fellows will continue his legacy!
In April 2015, Dr. Tapasvi successfully performed ACL reconstruction surgery on my left knee. I suffered a knee injury during a cricket match at PYC gymkhana and it took me 9 months to get back to cricket. After 9 months of break I played the Friendship Cup cricket tournament and won the final match. I was selected as the Man of the Match at the finals and the Best Batsman of the tournament. On the 22nd April this year, I completed the - Annapurna Base Camp (4130 m) Trek in just 7 days. My sincere thanks to Dr. Sachin Tapasvi and the support team who successfully operated me and completed my rehabilitation in a record time. All this has been possible only because of the support and guidance I got during the rehabilitation program. I would sincerely like to thank you and your team for making this an encouraging experience.
Oxford Dictionary Definition – the cracking or breaking of a hard object or material.
A bone is fractured when there is a break in the continuity of the bone cortex. Similar terms used to describe a fracture include broken, crack, greenstick or buckle; all are used to refer to the same thing – a broken bone. The break is often described by its location (i.e. bone) and its direction (horizontal, oblique, transverse).
Fractures can happen in a variety of ways. Most fractures are due to trauma, while others are due to pathological conditions or overuse. Trauma can vary from high-energy injuries such as motor vehicle accidents to low energy injuries such as simple falls.
The human body heals fractures by forming a blood clot that calcifies, connecting the broken pieces of bone. For a good recovery, the bones must be held in the correct position and protected while healing occurs. This may be simply by a plaster, or if the fracture is displaced, surgery may be needed to put the bone back into the correct position for adequate healing to occur. Fractures that do not heal are called non-unions. Fractures that heal in the wrong position are called mal-unions. Non-unions and mal-unions may require further surgery to be corrected (see limb reconstruction).
Limb reconstruction surgery is the field of trauma and orthopaedic surgery that deals with the management of deformities of upper and lower limbs, reconstruction of limb defects and limb equalization techniques. The aim of limb reconstruction surgery is to achieve maximum function form a deformed limb.
A range of modern surgical techniques are used to perform limb reconstruction surgery, including:
The techniques used are customized for each individual case and often involve a combination of above techniques.
Common deformities treated include:
The knee joint is a frequent source of problems requiring the attention of an orthopaedic surgeon.
The joint is primarily formed by the two large bones of the lower limb, the femur (thigh bone) and the tibia (shin bone). The patella (kneecap) articulates with the femur at the front of the knee. The fibula joins with the tibia on the lateral (outside) side of the knee. Together, the femur, tibia and patella make three compartments (medial, lateral and patellofemoral). Each of the bones has a bearing surface of articular or hyaline cartilage. In addition there is a meniscus in each of the medial and lateral compartments. The menisci are like cushions or spacers and are made of fibrocartilage. They often simply referred to as the cartilages.
The direction of movement of the bones is controlled by the ligaments and the muscles make the joint move. The major ligaments are the anterior and posterior cruciate ligaments and the medial and lateral collateral ligaments. In addition, the collateral ligaments have important associated ligaments towards the back of the knee. The major muscle groups are the quadriceps at the front of the thigh and the hamstring muscles at the back. Muscles attach to bones via tendons. The main tendons around the knee are the quadriceps and patellar tendons which attach to the top and bottom of the patella respectively. The iliotibial band is like a tendon on the lateral side of the knee.
There is a wide range of pathology and problems in the knee.
The menisci can be torn as a result of an injury, although most meniscal tears are the result of a degenerative process and a specific injury may not be recalled. Not all meniscal tears require treatment, but if they do, this is usually done by arthroscopy. The tear can either be resected (cut out) or repaired.
The articular cartilage can wear away. This is called osteoarthritis. Treatment depends on the severity of the disease and can range from quadriceps strengthening exercises to a realignment procedure called an osteotomy or to joint replacement. Isolated injuries may also occur causing local defects for which there may be specific treatment to try to restore the surface. Osteochondritis dissecans is a condition that involves an area of articular cartilage and the underlying bone and usually occurs in teenagers. The appropriate treatment depends on many factors.
The bone underlying the articular cartilage may occasionally be affected by a condition called avascular necrosis in which the blood supply to an area of bone becomes disrupted. It may recover spontaneously or deteriorate to the point that intervention such as joint replacement may need to be considered. The cause of avascular necrosis is poorly understood.
Ligaments can be torn. Medial collateral ligament injuries usually heal without surgery but may require bracing. Anterior cruciate ligament injuries are often treated by reconstruction, but there are also situations in which they do not need surgical intervention. Posterior cruciate ligament injuries are not usually treated with reconstruction unless they are combined with other injuries or have been causing instability. Lateral ligament injuries are often associated with other injuries and may require surgery.
The patellofemoral joint is a frequent source of problems. There can be the same articular cartilage problems as in other parts of the knee. In addition there can be problems with instability of the patella as well as maltracking of the patella in its groove in the femur. Physiotherapy is often the first line treatment for many of these problems, but surgery may be required for recurrent dislocation of the patella. There are a variety of stabilization procedures that can be used depending on the specific problems of an individual.
Tendons can be torn and usually require repair. However the more common problem is tendinopathy that results in local pain and which is usually treated without surgery, although surgical intervention may occasionally be required for symptoms that fail to resolve. The iliotibial band can impinge on the lateral aspect of the femur causing pain with running. It can usually be managed without surgery but surgical release is sometimes performed in chronic situations.
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.
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.
While most patients are happy with the outcome of their surgery, there are nonetheless some risks, which need to be borne in mind.
Always involve some kind of risk, but these are statistically minimal.
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.
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.
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.
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.
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.
Osteoarthritis of the knee is a common condition and is becoming an increasingly important problem for the community as a whole.
In the normal knee joint the ends of the bones are covered with a type of gristle called articular cartilage. This surface has special characteristics that make it an ideal bearing surface. The articular cartilage needs to be distinguished from the meniscus, commonly called “the cartilage” The meniscus is like a gasket around the margins of the joint and fills in the gap between the rounded end of the femur and the relatively flat surface of the tibia.
Osteoarthritis is a condition where the articular cartilage breaks down and is essentially worn away leaving the underlying bone exposed. On an X-ray this appears as a loss of the space between bones.
There are many factors that can contribute to the development of osteoarthritis. Some individuals probably have a hereditary predisposition to the condition, as it does seem to run in some families. Females are more at risk of developing osteoarthritis than males. Obesity is a very important contributory factor as the biomechanics of the knee are such that the effect of extra weight is magnified in the knee joint. The effect is like a stiletto heel, where all the force goes through a very small area. Injuries to the knee can also contribute to the development of osteoarthritis. Such injuries include damage to the meniscus or articular surface itself and a tear of the anterior cruciate ligament. The treatment of osteoarthritis depends on the severity of the condition, the symptoms, the lifestyle of the individual, as well as their age and general health. In general, treatment can be divided into non-surgical and surgical options. As a basic principle it is always better to try all non-surgical options before proceeding down a surgical path.
Non-surgical treatment starts with ensuring that there is adequate strength in the muscles around the knee and in particular the quadriceps muscle at the front of the thigh, and getting one's weight back to a normal level. Obviously it is difficult for many patients with osteoarthritis of the knee to exercise because of their pain. However, riding an exercise bike is a good way of strengthening the quadriceps muscle and at the same time burning calories, which will help in efforts to lose weight. However, dietary intake also needs to be modified and it may be helpful to seek specific advice from a dietician. As one loses weight and builds up strength in the quadriceps muscle it generally becomes easier to walk and this in turn will help with losing weight.
Using simple painkillers can be a very effective way of relieving symptoms and improving function. Paracetamol should be the mainstay of pain relief. Various formulations are available but the basic principle is that the total dose should not exceed 4 grams per day (8 standard 500mg tablets). It is often helpful to take a larger dose (1000 - 1500 mg) in the morning and again at night. This will help get over morning stiffness and pain and relieve night pain, two of the most troublesome symptoms of osteoarthritis.
Anti-inflammatory medications can also provide good relief of symptoms, both pain and swelling. However, they can all be associated with significant side-effects including indigestion and stomach ulcers, aggravation of high blood pressure and heart disease, and impairment of kidney function. They should therefore not be used indiscriminately and preferably only for short-term benefit. If your knee causes you most difficulty with activities such as golf or tennis, one strategy is to take anti-inflammatory medication on the day you are playing sport and perhaps the following day but then not again until you play sport the next time.
There are a number of so-called nutraceutical preparations that have become very popular. These include glucosamine, chondroitin sulphate, fish oil and green-lipped mussel extract (Lyprinol). Some individuals find that they get good relief from these types of preparations but it is difficult to predict who will respond positively to them. At present there is little in the way of good quality scientific evidence to support their use. Fortunately they do not seem to have any significant side effects, so there is little harm in trying them. It would seem logical to try only one at a time. If it is unclear whether the preparation is helping, then it is probably worth taking it for 3 to 4 months and then ceasing it. If your symptoms do not deteriorate once you stop taking the preparation then there is little reason to recommence it. There is no convincing evidence to suggest that one formulation of glucosamine is better than another, or whether the addition of chondroitin sulphate provides an additional benefit.
There are two groups of injections that can also be used in the treatment of the osteoarthritis. The first are cortisone preparations and these can be used for the relief of an exacerbation of symptoms, particularly if there is significant swelling. It is probably not a good idea to have a lot of injections of cortisone into the knee, as each injection is associated with a very small risk of infection of the joint. The second group of injections are the so-called viscosupplements. These are basically preparations of hyaluronic acid, which is one of the substances that make up the articular cartilage. There is some evidence to indicate that the use of viscosupplementation provides relief that is similar to that achieved with the use of anti-inflammatory medication or cortisone injections for up to 3 to 6 months.
It is very important to realise that the use of anti-inflammatory tablets, cortisone injections, or viscosupplementation does not affect the progression of osteoarthritis in the longer term. These options are simply to provide relief of pain.
Surgical options can be divided into three groups: arthroscopy, realignment procedures, and joint replacement.
Whilst arthroscopy is a relatively small and simple procedure and the idea of a “clean-up” operation seems attractive, there is increasing evidence to suggest that the use of arthroscopy for the treatment of the osteoarthritis provides little benefit compared to non-surgical options over a period of a couple of years. It does however still have a role in some situations. It seems to work better if there is swelling of the knee. It can be useful to address associated pathology such as a tear of the meniscus. It can also be useful by allowing unstable articular cartilage to be removed along with fragments floating in the joint. Once again, an arthroscopy is only aimed at relieving symptoms and does nothing to slow the progression of the osteoarthritis. Indeed, it occasionally seems to aggravate the process and may bring on the need for a knee replacement more quickly than if the arthroscopy had not been performed all.
Realignment procedures are called osteotomies. These involve cutting the tibia or femur bone and changing the overall alignment of the leg to make it more “knock-kneed” or sometimes more “bow-legged”. The aim is to take weight away from the part of the knee that is affected by osteoarthritis. Such procedures can only be used in certain patterns of osteoarthritis and are better suited to people under the age of 55. They can however provide good long-term relief and put off the need for joint replacement, whilst at the same time allowing an individual to remain quite active.
Replacement involves shaping or cutting the bone ends and applying a metal or polyethylene component to the surface. Usually both sides of the joint are replaced. One can either replace all parts of the knee, which is a total knee replacement or just one part of the knee, which is a partial replacement. Like osteotomies, partial replacement can only be used for certain patterns of osteoarthritis. In general we try to put off joint replacement procedures for as long as possible because of concerns about long-term wear and loosening. In addition, replacement procedures are only compatible with low impact sporting activities. Golf, social or doubles tennis, cycling, and snow skiing are reasonable whereas running, basketball, netball, or any type of football should not be considered, because of the risk of premature wear and loosening of the prosthesis.
Osteoarthritis is essentially loss of the articular cartilage on the bone surfaces of a joint. Articular cartilage (also known as hyaline cartilage) is normally a very smooth surface with special biomechanical properties that make it particularly suitable as a bearing surface. However when the surface is disrupted, a process of breakdown commences and eventually the articular cartilage coating is worn off the bones. Unfortunately, articular cartilage has a poor capacity to heal.
For treatment purposes, the knee joint can be considered to consist of three compartments. One compartment is between the patella and the femur (patellofemoral compartment), and the other two are between the tibia and femur. One is on the medial (inside) half of the knee, and the other is on the lateral (outside) half of the knee. If the osteoarthritic process is isolated to either the medial or lateral compartment, one surgical option for treating significant symptoms is an osteotomy.
The principle of an osteotomy is to realign the lower limb in order to shift the line of weight bearing away from the affected half of the joint and into the good half of the joint. In other words, if the osteoarthritis is isolated to the medial compartment, the aim is to shift the line of weight bearing into the lateral compartment. The main aim of this realignment is to reduce the symptoms from the osteoarthritis and delay the need for joint replacement surgery. Realignment may also slow down the rate of its progression of the osteoarthritis. It is important to be aware that realigning the leg will result in an altered appearance of the shape of the leg. If people have medial compartment osteoarthritis, they are usually somewhat bow-legged and the osteotomy will make the leg slightly knock-kneed. The opposite applies for lateral compartment osteoarthritis. Prior to surgery the person is usually knock-kneed, but after surgery the leg is straight or slightly bow-legged.
Osteotomies can be performed above or below the knee joint. For medial compartment osteoarthritis, osteotomies are most commonly performed by operating on the upper tibia. If the osteoarthritis is in the lateral compartment, the osteotomy is usually performed in the lower femur.
The osteotomy procedure itself involves cutting the bone virtually completely. There are then two ways of realigning the bone. One is to take out a wedge of bone and the other is to make a cut and open up a wedge and fill it with either bone or a bone substitute. If bone is used it can either be allograft bone which is taken from a cadaver, or autograft bone which is taken from the patient, usually from the hip region. Some kind of metallic fixation device, usually a plate with screws, is then used to stabilise the osteotomy while it heals. In general there has been a trend moving away from so-called closing wedge osteotomies, where a wedge of bone is taken out, towards opening wedge osteotomies, where a cut is made and the wedge is opened. There are potential advantages and disadvantages of each technique and a decision regarding the most appropriate method will be based on your individual situation.
The surgery is usually undertaken under spinal anaesthetic. You are usually admitted on the day of surgery. Most people are in hospital for 2 or 3 nights. After surgery there is usually a drain tube in the wound, which is removed the morning following surgery. Depending on your surgeon’s preference, a brace may or may not be fitted after surgery.
Initially you will commence walking with the aid of crutches. You may be able to partially weight bear immediately or remain non-weight bearing for up to 6 weeks following the procedure, depending upon your surgeon’s preference. An X-ray will be taken at about 6 weeks after surgery and depending on how things are progressing, you should be able to gradually increase your weight bearing and discard your crutches over the next 2-6 weeks.
Like all surgery, osteotomies are associated with the risk of complications. The specific risks of an osteotomy include delayed healing of the osteotomy, infection, deep venous thrombosis, and incomplete pain relief.
Because a cut is made through the bone, there is effectively a fracture of the bone, which needs to heal. With opening wedge osteotomies in particular, this process can be relatively slow. If the osteotomy fails to heal, further surgery is necessary to encourage the process.
Infection is a risk of any surgery, not specifically related to osteotomy. Should infection occur, this will usually either be treated with oral antibiotics (tablets) or occasionally with intravenous antibiotics. Occasionally further surgery will be required to clean up the infection. This involves admission to hospital for a number of days during which intravenous antibiotics are given.
This is a blood clot in the veins of the leg. Precautions are taken to reduce the risk and this usually involves 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 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 of 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.
Osteotomy is a useful procedure for people with unicompartmental osteoarthritis who are not suitable for joint replacement, usually because of their relatively young age. However, the outcome of surgery is probably less predictable than a joint replacement. Although most patients are happy with the result, pain relief is not always complete. In the longer term the underlying osteoarthritis will progress and one can expect knee pain to return.
In addition, surgery around the front of the knee is often associated with difficulty kneeling. This is more of a problem with tibial osteotomies than with femoral osteotomies. The metallic plate that is used to fix the osteotomy can be prominent, particularly in thin people. If this is the case the metallic hardware can be removed after about 12 months following surgery. This is usually done as a day or overnight case. Sometimes the metallic hardware is removed routinely after 12 months, although this is at the discretion of your surgeon. However, if a knee replacement is planned the hardware will need to be removed prior to this procedure.
Patellar dislocation occurs when the patella or kneecap slips out of its groove on the front of the lower end of the femur (thigh bone). A subluxation is a partial dislocation in which the patella slips but immediately goes back into place. In a true patellar dislocation the patella goes back into place as a distinct movement, usually when the knee is straightened. This may occur seconds to hours after the dislocation. The term knee dislocation is often used for a patellar dislocation but this is incorrect. A knee dislocation is a major injury and involves the tearing of the main ligaments around the knee.
When a patella dislocates the chance of another dislocation is immediately quite high, somewhere between 15% and 45%. The specific risk for an individual is difficult to calculate, but it is greater if there are associated predisposing factors. Predisposing factors include such things as the alignment of the leg, the shape of the groove in the femur for the patella, how high the patella sits in relation to the rest of the knee joint, and the alignment of the foot and ankle.
When the patella dislocates on more than one occasion the term recurrent patellar dislocation is used. After two dislocations, the risk of further episodes of dislocation is very high, somewhere in the order of 60% to 80%
If your patella has dislocated only once or maybe twice, and you do not have any or relatively minor predisposing factors, nonsurgical treatment may be recommended. The emphasis of nonsurgical treatment is to build up the quadriceps muscle on the front of the thigh and in particular the vastus medialis (VMO) muscle which is the part of the quadriceps muscle just above the inside of the knee. Attempts may also be made to stretch the structures on the outside of the knee. These include the iliotibial band (ITB) and the lateral retinaculum. In addition, orthotics may be used to improve the alignment of the foot and ankle.
If it has been decided that surgery is the appropriate way to manage your condition there are many different options that have been described and that can be used. The particular operation that is selected for you will depend on the alignment of your knee and patella as well as your age. Special X-rays and a CT or MRI scan may be used to measure the alignment more accurately. An MRI scan may also provide information about the state of the surfaces of the patella part of a joint.
Whatever realignment procedure is suggested, it will probably have an arthroscopy as part of it. The role of the arthroscopy is to clean up any damage on the bone surfaces and to remove any loose fragments that may be within the joint.
When the patella dislocates the first time there is a ligament on the medial, or inside, aspect of the patella that is almost always torn. The ligament is called the medial patellofemoral ligament (MPFL). The ligament can be reconstructed by using a piece of hamstring tendon and passing it through drill holes made in the patella and femur. This involves making two or three short incisions over the inside part of the knee and upper shin. The tendon is fixed in the tunnels with screws or some other type of anchor.
If the patella is sitting too high it can be moved downwards and into its groove on the femur by moving part of the tibia called the tibial tuberosity. This is the bony lump on the front of the upper end of the shin. The patella is attached to the tibial tuberosity by the patellar tendon. By moving the tuberosity downwards the patella is also moved downwards. Screws are used to hold the tuberosity in its new position until it heals. These usually need to be removed at a later date because they are prominent and can be uncomfortable when kneeling.
Sometimes the tibial tuberosity needs to be moved medially, or towards inside of the shin in order to improve the tracking of the patella in its groove on the femur. This medial shift may also be combined with a downward, or distal, shift. Again, the tuberosity is held in place with screws until it heals.
Another option, which is used less commonly, is to deepen the groove for the patella on the lower end of the femur. This operation is called a trochleoplasty. It involves removing some bone and deepening the surface of the groove and holding it in place with nails or stitches, both of which are reabsorbed by the body with time.
Whatever operation is used to treat your knee, it will usually involve at least one night in hospital. The length of stay will depend on the complexity of your surgery as well as the response of your knee to surgery. However, most people can be discharged on the first or second day after surgery.
When you go home you will be putting weight through your leg on an as tolerated basis and using crutches for support. With some operations, usually those involving shifting the tibial tuberosity downwards, you may be required to wear some kind of brace or splint for the first few weeks after surgery. However, during this period you will be able to take the knee out of the brace to get it moving.
Most people are walking without support by four weeks. The focus of the early rehabilitation is to reduce the swelling, restore the function of your quadriceps muscle, and to get the knee bending and straightening normally.
If the tibial tuberosity has been moved then it is important to make sure the bone is healed before more aggressive rehabilitation is commenced. The same applies for a trochleoplasty. Healing can be monitored with X-rays.
Once the swelling has reduced and any bone healing has taken place, progression is essentially on an as tolerated basis. It usually takes up to 3 months before one can recommence running. From here it is really a matter of function and comfort before one can resume sporting activities. Depending on the procedure that has been performed, it will take 4 to 6 months to be able to resume sport on a competitive basis.
All surgery is associated with some risk of complications. There are general complications and there are specific complications.
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, which is a serious complication and requires re-admission to hospital, additional surgery and intravenous antibiotics.
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. Once again, the risk is low. An injection may be given at the time of surgery as well as following the operation to further reduce the risk.
If a shift of the tibial tuberosity or a trochleoplasty has been performed there is a risk that the bone will be slow to heal or may not heal at all. In either case additional surgery may be required to encourage bone healing. The end result is usually satisfactory.
If the medial patellofemoral ligament has been reconstructed there may be some pain on the inside of the knee with deep flexion. It is usually a matter of working through this. It is not usually a long-term problem.
If the hamstring tendon has been harvested to reconstruct the ligament there may be some pain at the back of the knee or thigh some 3-12 weeks after surgery. This may be associated with some bruising but does settle and is not usually a cause of any long-term problems.
It is important to restore quadriceps function as early as possible. A delayed recovery of quadriceps function may be associated with some shortening of the patellar tendon. This may pull the patella lower than ideal and may be associated with some pain in front of the knee.
Whenever there has been recurrent patellar dislocation or a patellar stabilisation has been performed there can be discomfort with kneeling. This is often accentuated after surgery but may be helped by removing screws that have been used to hold the tibial tuberosity in place while it heals. The cuts used for surgery may result in some numbness or altered sensation on the front of the knee and shin. This usually improves with time.
It is common for there to have been some damage to the surface of the patella or femur prior to surgery. This is essentially early osteoarthritis and there may be some ongoing discomfort at the front of the knee.
Whatever surgery has been performed, there is always a risk of further episodes of patellar dislocation. The risk of a further dislocation is usually less than 10% but the nature of the condition means that we cannot reduce it to 0%.
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
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.
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 to hospital is usually on the day of surgery. Occasionally you will be admitted earlier than this depending on your general health status.
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.
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.
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:
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.
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 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.
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.
The shoulder is a shallow ball and socket joint. This allows fantastic range of movement. The joint capsule, ligaments and rotator cuff muscles are important for shoulder stability, but also need to be flexible and elastic to allow movement to occur.
Shoulder stiffness may occur without any history of injury. This is often called adhesive capsulitis. The shoulder may also become painful and stiff following trauma or shoulder surgery, where the body has a vigorous inflammatory response that results in excessive scar formation, and subsequent loss of motion.
It affects 2% of the population, and is more common in women than men. It most commonly affects people between the ages of 40 and 60 years.
The cause of a frozen shoulder is not completely understood. It is associated with a number of medical conditions including diabetes, thyroid disease, heart disease, and Parkinson’s disease.
Pain from a frozen shoulder is usually a dull ache that often radiates towards the elbow. Pain may also be felt around the shoulder blade (scapula) as well. It is often present at rest, and worse with movement. It also may be worse at night and affect sleeping. Over time, the shoulder becomes stiffer.
|1. Freezing (inflammatory).||Slow onset of pain Shoulder becomes stiffer and more painful with time.||6 weeks to 9 months.|
|2. Frozen.||Slow improvement in pain but remains stiff.||4 to 9 months.|
|3. Thawing.||Movement slowly returns to normal.||5 to 26 months.|
It is important to get an X-ray of the shoulder in order to rule out other causes of shoulder stiffness, such as arthritis.
A frozen shoulder usually gets better on it’s own, but it may take more than 2 years to do so. Initial treatment is focussed on controlling pain and maintaining range of movement with physiotherapy.
Simple pain relief, such as paracetamol, taken regularly is a safe starting point. Simple anti-inflammatories, such as ibuprofen, can be taken in combination with this.
Steroid injections are powerful anti-inflammatories that can be injected directly into the joint.
Physiotherapy can help restore movement, with a program of stretching and strength exercises. Applying heat to the shoulder before exercising may help “loosen up” the joint.
More than 90% of patients will improve with these simple measures.
Surgical treatment is rarely required. Where stiffness is failing to improve despite treatment with anti-inflammatories and physiotherapy, a manipulation under anaesthesia and arthroscopic capsular release may be performed with good results. It is important not to do this whilst the shoulder is in the inflammatory (freezing) stage, as it may make the condition worse.
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.
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.
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:
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.
It is an operation usually performed under general anaesthesia. A small camera is placed into the joint through a small incision. This allows the tissues of the shoulder to be examined and / or repaired. To do a repair, an additional 3-4 small incisions may need to be made.
The following procedures may be performed during the surgery:
This involves repair of torn tendons with sutures and suture anchors placed into the bone.
This involves removal of inflamed tissue (bursitis) above the rotator cuff tendons as well as smoothing over any sharp spurs that could be rubbing on the tendons.
The arthritic end of the collar bone is removed. The aim of this is to significantly improve your pain.
This involves re-attaching the torn labrum (cartilage) to the edge of the shoulder socket as well as tightening stretched ligaments. The aim of this procedure is to stop the shoulder from dislocating.
At the end of the procedure, the incisions are closed with stitches and dressings are applied. The shoulder / arm is placed in a sling. Images of the procedure are usually recorded and discussed with you once you’ve recovered from the anaesthetic.
After the procedure, you will usually need to wear a sling. This may be for 6 weeks if you have a tendon repair performed. Your expected recovery will vary from 1 to more than 6 months – depending on the type of procedure done. Physiotherapy is usually required to help regain your range of movement, strength and co-ordination.
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.
Our preference is to perform open carpal tunnel release. This is through an incision that is usually less than 2cm long in the palm, between the muscles on either side of the palm. We prefer the open technique because it allows us to look at the nerve after the tunnel has been released to identify any problems and to look at the back of the tunnel to ensure that there are no lumps or bumps in the canal. You cannot do this if you use an endoscopic technique.
Carpal Tunnel Syndrome is the most common nerve compression syndrome with characteristic symptoms and signs due to pressure on one of the main nerves of the hand, the median nerve, at the wrist.
Most commonly there is no specific cause identified, known as idiopathic. The tunnel in the syndrome is formed by a tough ligament (transverse carpal ligament or flexor retinaculum) and by the curved carpal bones. The ligament helps keep the structures (9 tendons and 1 nerve) that pass under it in place and provide protection for the nerve. It can arise due to swelling of the contents of the canal or thickening of the ligament.
Ganglions are by far the most common lumps in the hand and wrist. They are not cancers and don’t turn into cancers. They are filled with a jelly like material and can be soft, firm or even feel hard.
The most common sites are:
The cause is usually not clear but they may appear after an injury. Often they cause no symptoms but can be painful if pressed on by surrounding structures. This may occur with heavy activities or extremes of motion.
The old fashioned treatment (especially dorsal wrist ganglions) was to hit with a large book to “pop” the cyst, traditionally a bible.
A bending force to the tip of the finger leads to the tendon that straightens the tip becoming incompetent. This can be due to the tendon itself being pulled off the bone or a fracture of the bone with the tendon attached to it.
This leads to the tip of the finger “sagging” which can worsen with time and importantly can lead to a problem with the joint adjacent to it which can be even more disabling “swan neck deformity”.
Initially clinical with a loss of extension of the tip of the finger. An x-ray should be obtained to determine if there is a bony fracture and to make sure that the joint is reduced.
The majority of these injuries can be treated non-operatively with splinting alone. The length of time the splint is worn depends on whether the injury involves the bone or not.
Tendon takes longer to heal than bone, therefore:
Tendon only: Splint for 8 weeks full time then night splint for a further 4 weeks.
Bone: Splint for 6 weeks full time and then night splint for 4 weeks.
There are a number of splints available but a comfortable fit is important without undue pressure on the skin and this can be best achieved with a custom-made splint. These can then be adjusted as swelling improves.
If the splint needs to be taken off the joint must be maintained in a straight position. If the tip of the finger droops at all with the splint off, the clock is reset and splinting has to start all over again.
During the period of splinting the other joints in the finger need to be moved to maintain motion.
As the splint is weaned, motion should be gradually regained to protect the tendon, especially in tendon avulsions.
Not usually needed. The main need for surgery is if the joint is unstable and starts to dislocate, usually due to a relatively large fracture fragment. The results of surgery in simple cases are inferior to non-operative treatment.
A cause of painless or painful catching of the finger or thumb flexor tendon after you bend the digit with a “pop” or locking as you straighten it. On occasion, the finger will lock in a bent position and need to be manually straightened into full extension. This can eventually lead to contracture of the finger joints.
Each tendon passes through a tight tunnel to help the motion of the finger and keep the tendon close to the joint(s) it moves. Triggering is due to increased pressure especially with repeated power grip at the edge of the tunnel that causes thickening of the edge of the tunnel and/or swelling of the tendon.
Trigger finger is most common in middle-aged women. It can involve several fingers. In patients with multiple trigger digits, the most commonly affected digit is the thumb, followed by the ring, long, little, and index. It is associated with diabetes, gout, renal disease, rheumatoid arthritis and other rheumatic diseases and is associated with a worse prognosis in these conditions. It can seem like the locking is occurring at the joint.
A history of catching or locking of the digit on bending, occasionally with pain in the palm. Often worse in the morning and may be locked bent first thing in the morning but improve throughout the day. More significant cases have demonstrable catching with contracture of the finger joint.
Most primary trigger digits in adults can be successfully treated non-surgically with the use of a steroid injection. This has a low complication rate and is successful in up to 75% of cases, depending on chronicity – i.e. the longer you have had the trigger the less likely a steroid injection will fix it. Diabetics may experience a transient rise in blood glucose levels. Splinting can be considered and is effective 50-60% of the time.
Trigger finger is not a dangerous condition. Your decision on whether to have surgery is based on the symptoms and how problematic they are for you. If your finger is stuck bent surgery may help prevent permanent stiffness.
The aim is to “release” the opening of the tunnel so that the tendon can slide without catching. This is usually done as a day case and often under local anaesthetic.
The surgery is performed through a small incision in the palm and the tunnel is cut (released) so there is more room for the tendon to move through it.
Reproduced and adapted from Griffin LY (ed): Essentials of Musculoskeletal Care. 3rd Ed. Rosemont, IL. American Academy of Orthopaedic Surgeons, 2005.
Wrist fractures are very common injuries. This usually refers to a fracture of the radius, the larger of the two forearm bones just before the wrist joint. They tend to occur in two age groups.
In the young adult they are often high-energy injuries (e.g. motor vehicle accidents, sports) and in the older age group, lower energy (e.g. simple fall). A fall onto an outstretched hand is a common story. The joint may or may not be involved in the fracture.
They are often referred to as Colles fractures.
There are many different ways of treating these injuries depending on the significance of the injury and the demands of the patient. These treatments range from simple cast immobilisation to operative stabilisation.
The decision on which method of treatment is often made on regular x-rays but in some cases a CT scan may be obtained to get better 3-dimensional information, especially when the joint is involved. The aim of treatment is to reduce disability and restore motion and strength. Even with the best treatment some people don’t regain full function.
Fractures treated non-operatively usually require 6 weeks in a cast and x-rays at various time periods to gauge healing depending on the initial displacement. Fractures that need a reduction (pushing the bone back into place) need x-rays at 1 week and 2 weeks after the reduction to make sure it does not move and then again at the end of cast treatment to check healing.
More significant fractures may need operative stabilisation. This is most commonly with a plate and screws, which are applied to the bone once it has been put back in position. These are not routinely removed. After 2 weeks the dressing is removed and the patient is placed in a removable brace.
It is very uncommon for these fractures not to heal but the overall recovery of strength and motion can take up to 6 months.
Patients are often referred to hand therapy for range of motion and exercises.
Arthritis of the hip joint is a common condition. It usually affects middle age and older people resulting in over 40,000 hip replacements being performed in Australia per year to relieve sufferers of their pain. It comes about when the cartilage which overlies the femur (leg) bone or lines the acetabulum (pelvic) bone wears out and exposes “bone on bone” articulation resulting in pain, stiffness and disability.
Many forms of arthritis have been described. Osteoarthritis is the most common form characterized by the break-down of the joint’s cartilage. The exact cause of osteoarthritis is unknown but it may occur in families (genetic predisposition), post injury or as a result of infection in the joint.
The next most common form of arthritis is known as rheumatoid arthritis. This is a chronic inflammatory disease of the joint and soft tissues often resulting in the rapid onset of pain, swelling and stiffness with marked joint destruction. Rheumatoid arthritis is more common in women, and is caused by the body’s own immune system attacking the joints, often affecting the small joints of the body first i.e. those of the hands and fingers before involving the larger lower limb joints.
Other forms of arthritis are less common and broadly categorized into the term “inflammatory arthritis” including such conditions as ankylosing spondylitis, systemic lupus erythematosus (SLE), gout and juvenile arthritis.
Arthritis of the hip joint often has an insidious onset characterized by groin, lateral thigh or less commonly buttock pain which may radiate down the leg to the knee and beyond. The pain is worse with activity, limits walking distance and often will cause disturbance of sleep. Early morning stiffness is a common symptom and increases as the disease progresses, often resulting in the inability to reach down to put on ones socks and shoes.
The diagnosis of arthritis is usually made on the basis of the symptom pattern, stiffness and irritability of the joint along with X-ray changes.
The early management of arthritis involves non-surgical modalities. These include a modification of activities to avoid the aggravating factors e.g. cessation of running / jumping pursuits and substituting those with more suitable activities e.g. walking, cycling or swimming. Weight optimization and the cessation of smoking will increase the lifespan of the remaining cartilage as can dietary supplementation with glucosamines and fish oils. Simple analgesia in the form of paracetamol combined with anti-inflammatory medication is first line pain control. Physiotherapy and hydrotherapy are used to strengthen the muscles surrounding the joint and walking aids in the form of a stick or frame can make ambulation safer and less painful. A walking stick should be held in the opposite hand to the hip that is affected.
When these first line measures for managing the pain from your arthritic hip fail to provide effective relief then it may be time to consider hip replacement surgery.
Arthroscopy of the hip joint is a “keyhole” procedure for the treatment of multiple pathologies of the hip joint without large incisions. It allows faster return to sporting and recreational activities than open procedures, and normally only requires an overnight stay in hospital.
Pain in the hip and groin region may be due to many pathologies both inside and outside the hip joint itself. Common pathologies seen inside the joint are cartilage tears, loose bodies, bony bumps that cause impingement-cam or pincer (Figures 1 and 2), inflammation of the joint lining and tears of the ligaments that provide the joint with stability.
Pathology outside of the joint may also be contributing to your pain e.g. Tendonitis of the surrounding muscles, inflammation in a bursa (fluid filled sac), osteitis pubis or even a hernia. Clinical evaluation of your problem in combination with appropriate X-rays, CT and / or an MRI scan helps to establish the cause of your pain prior to surgery being undertaken.
Hip arthroscopy is performed in the operating theatre under a Spinal anaesthetic. Whilst asleep you are rolled onto your side and the legs are placed into a traction device to distract the affected joint and allow entry of the arthroscope.
X-ray imaging is used in the operating theatre to confirm the site of your pathology and correct positioning of the arthroscope and working instruments. Usually only 2 small incisions are made on the outer aspect of the hip to allow the instrument placement but occasionally a 3rd incision may be required to complete the procedure.
The common pathology of impingement (either cam or pincer) is treated via burring away of the bony bump (figure 4) plus repair of the torn cartilage (labrum).
The procedure usually takes approximately 1 hour to complete, whereupon the joint is infiltrated with local anaesthetic prior to you exiting the operating room. Following an overnight stay in hospital you will be discharged home fully weight bearing on the affected hip, using crutches for support.
Post-operative physiotherapy follow-up will be arranged and most patients can expect to be walking comfortably within 4-7 days. You should refrain from driving for this same period. Physiotherapy is initially targeted at retraining and strengthening the small muscles around the hip responsible for its stability prior to retraining and strengthening the larger muscle groups of the hamstrings, gluteals and quadriceps. Return to work is dependent upon your occupation but generally is at the 1-week mark following surgery for sedentary occupations and 3 weeks for heavy manual labouring work. Running and jumping activities should not be undertaken for 10-12 weeks with most patients ready to return to sporting activity soon thereafter.
The complications of hip arthroscopy should be discussed with your surgeon prior to the procedure but may include those related to the anaesthetic e.g. nausea and vomiting, allergic reaction to the drugs, throat pain or swelling, and damage to the teeth. Complications related to the arthroscopy may include infection, deep venous thrombosis (DVT) and pulmonary embolism (PE), numbness in the anal, genitalia or inner thigh regions, and / or bruising and swelling in the same areas.
Hip arthroscopy is a safe procedure and provides good symptomatic outcomes for the pathologies listed above.
Please discuss the specifics of your particular condition with your surgeon.
The operation of a total hip replacement is a well established, long lasting procedure for relieving the pain involved with hip arthritis. This type of surgery has been used effectively now for over 40 years and remains the treatment of choice to achieve an excellent quality of life for sufferers of hip arthritis.
The type of anaesthetic that is used for the procedure will vary according to each patient’s co-existent medical conditions and also your wishes. Our group of anaesthetists are all competent in both general and regional (spinal) anaesthetics and will discuss with you prior to the procedure the benefits and risks of each technique.
Through an incision approximately 12-15cm long centred over the side of the hip and curving gently towards the buttock, the hip joint can be entered with minimal trauma to the surrounding muscles. The hip is dislocated and the femur bone is cut through its neck to expose both the pelvic and leg sides of the joint. Depending upon the quality of the bone and the age of the patient either a cemented or cementless component is fixed to the pelvis and similarly to the femur. The ball and socket mechanism of the joint is then reconstructed with either a metal on plastic (polyethylene) articulation or ceramic on ceramic articulation. Computer navigation may be used to ensure that the leg length obtained is correct and the orientation of the components is optimal to provide for maximum range of motion of the new hip.
Following the surgery you will be able to mobilize fully weight bearing on the hip the day after the procedure. You will be aided by the physiotherapist and nursing staff and taught how to safely use a frame initially and then graduate onto crutches.
Your hospital stay will be between 5-7 days and depending upon your home supports and progress.
Most people will be able to dispense with their crutches approximately 4-6 weeks following the surgery. During this time period you should sleep flat on your back, not cross your legs and use a seat raise for the toilet. These precautions will be emphasised by the physiotherapist during your hospital stay.All our patients are routinely put on home based physiotherapy post discharge.
Driving the car is not allowed for 6 weeks following the surgery and car travel as a passenger should be minimised during this period. These restrictions minimise the chance of the hip dislocating whilst the muscles and soft tissues around your hip heal.
At 6 weeks following the procedure you will be reviewed by your surgeon. Most patients are then given the all clear to return to recreational walking, swimming, cycling, golf, tennis, bowls, gymnasium workouts and other recreational pursuits as desired. It is not advised that you undertake running or jumping activities following a hip replacement.
What are the risks involved with the procedure?
There are general risks associated with any surgery, these are those of the anaesthetic (please speak to your anaesthetist prior to the operation), bleeding, blood clots (deep vein thrombosis (DVT) and pulmonary embolization (PE)), infection and vascular injury. Specific to the surgery are the risks of dislocation of the hip prosthesis, leg length inequality, fracture of the pelvis or femur, wear and loosening of the implants, audible ‘squeaking’ of the articulating components (ceramics), nerve injury.
When can I return to work?
Most people should be able to return to work at 6 weeks post-surgery. This may be extended if you perform a job involving heavy manual labour.
When can I resume sexual activity?
Sexual intercourse can safely be undertaken 6 weeks following the surgery.
How long do I need to keep taking pain-killing medicine for?
When you leave the hospital you will be given tablet analgesia for pain. You should take this for as long as you have pain when walking or at night. Most people are able to cease analgesics by 4 weeks following the surgery.
Do I need to do physiotherapy when I go home?
You will be given a sheet of exercises from the physiotherapist when you leave the hospital. You should do these exercises as instructed. You do not need to visit a physiotherapist once discharged.
Ankle arthroscopy is keyhole surgery used to treat a variety of ankle problems. It is commonly used to treat and assess problems such as:
The surgery is performed as day case surgery. A general anaesthetic will usually be given and local anaesthetic is placed into the incisions to numb some of the pain following surgery.
Two or three ‘keyholes’ are made for small telescopes and instruments to see into the joint and ‘clean up’ or treat lesions.
The surgery usually takes between 45 minutes to one hour.
After surgery you will go home a few hours later once you have recovered. (You will need someone else to pick you up from hospital).
Crutches are required for the first few days until it is comfortable to walk on your foot unaided.
Generally, ‘Full weight bearing’ as much as is comfortable is allowed – Occasionally you may be instructed by your surgeon to be ‘Non weight bearing’ (this is sometimes required following a ‘microfracture’ procedure).
Please REST and ELEVATE your foot strictly for the first 36-48 hours and then keep it mostly rested and elevated for the first week. Icing for 20 minutes twice or three times daily for the first 3-5 days can help with swelling and pain.
The outer soft bandage can be removed 48 hours after surgery and then an elastic ‘tubigrip’ applied to help control swelling. The stick-on plastic dressings should be left on until your review – if these fall off please replace with a bandaid. A small amount of bleeding on the dressings is normal.
The foot and ankle should be moved up and down and in circles to prevent stiffening and blood clots.
Physiotherapy may be started after 10 days if required. Stationary bike exercise can start 5-7 days post-op.
No driving right foot for 1 week or until walking comfortably with no crutches.
|Time Off Work|
|Desk work||4-7 days|
|Light duties||1-2 weeks|
|Standing / heavy work||3-5 weeks|
|Full recovery||3-4 months|
The risks of arthroscopic ankle surgery are rare but include: Anaesthetic complications, Infection, Nerve damage, Blood clots (DVT) and Stiffness.
Ankle sprains are one of the most common sporting injuries. Usually the injury recovers with suitable rest and physiotherapy. Ankle instability occurs when the ankle repeatedly gives way during sporting or daily activities. This leads to recurrent ankle sprains, joint pain, swelling, inflammation, and further damage to the ligaments around the ankle. Some people experience intermittent ankle pain, which occur with episodes of instability, whilst others feel that their ankle aches more often. Recurrent instability episodes can cause damage to the joint surface cartilage, the formation of bony spurs (osteophytes), and arthritis.
The first line of treatment for ankle sprains is rest, ice, compression, elevation with painkillers and anti-inflammatories (if tolerated). Physiotherapy is then useful to regain range of movement, strength, balance and joint position sense (proprioception). An ankle brace may be useful for people who have tried all these measures and experience ongoing problems with sporting or daily activities. Finally, a targeted PRP injection may offer relief from ankle inflammation and help settle symptoms so that physiotherapy can continue.
When all these non-operative measures fail, and recurrent ankle instability becomes an ongoing problem, surgery is indicated. The ankle ligaments are assessed clinically and an MRI scan may be necessary to identify any problems within the ankle joint itself or the tendons and ligaments around the joint. There are 2 components to the surgery. An incision is made over the outside of the ankle where the ligaments have been torn away and the ligaments are reconstructed in an anatomical fashion and reinforced with overlying tissue (modified Bröstrum-Gould repair). If indicated, the tendons behind the ankle are inspected and repaired. At the end of the operation a backslab (half plaster) is applied to immobilise the ankle and protect the reconstruction and wounds.
In addition to the ligament repair, an arthroscopy is initially performed through 2 small incisions at the front of the ankle. The joint surfaces are inspected, inflammatory and scar tissue is removed, and any bony spurs (osteophytes) are trimmed away.
As with all reconstructive surgery your rehabilitation and postoperative physiotherapy regime forms a vital part of your recovery from surgery and return to normal activities. The first 2 weeks are dedicated to reducing the swelling with elevation of the foot and mobilising non-weight bearing with crutches to allow the wounds to heal. You will then be allowed to wear a lace up ankle brace and gradually increase your weight bearing status and work on range of motion. 6 weeks after surgery the brace is removed for daily activities and an intensive strengthening and balance program begins. The brace is to be worn for all sporting activities and you should be able to return to sport 3-6 months after surgery. The ankle may always be a bit stiffer than the normal side, but this is rarely a significant problem.
No surgery is completely risk free. The risks and complications will be assessed and discussed with you. There is always a small risk of infection, blood clots, nerve injury and anaesthetic problems and measures are taken to reduce these. There is approximately a 5% chance of experiencing problems with recurrent instability and this is usually due to a fresh injury or sprain. A good outcome is achieved in more than 90% of cases.
|Hospital stay||1 night|
|Rest & elevation||7-10 days|
|Plaster = crutches (non-weight bearing)||2 weeks|
|Lace-up brace/cam walker (full time - 2 weeks partial then 2 weeks full weight bearing)||4 weeks|
|Lace-up brace (training)||6 weeks|
|Ankle strapping (competition)||12+ weeks|
|Time off Work|
|Heavy Physical Work||12 weeks|
Following surgery, a formal recovery protocol will be given to you to pass on to your physiotherapist.
Ankle replacement surgery is an option for end stage ankle arthritis. This may have been discussed with you or planned for your ankle arthritis problem.
One recent study showed that people with end stage ankle arthritis suffer just as much pain and disability as people with end stage hip arthritis (not surprising really).
Ankle replacement technology has been improving over recent years. The original ankle replacements performed over 30 years ago were not very successful. Newer technology and experience in ankle replacements has meant over the last 10 years newer designs have had improved results.
Ankle replacements are still uncommon and ankle arthritis is 20 times less common than hip or knee arthritis. Therefore not many people have heard of ankle replacements and usually you will not have heard of ‘someone who has had one done’ – compared to hips and knees. The current replacements are having good results although still not quite as good as hip and knee replacements.
Overall approximately 80% (8 out of 10) ankles will last for more than 10 years without any major problems. As with any artificial joint they can wear out, become loose or infected. Care must be taken not to over stress the joint as this may lead to premature wear. However, regular day-to-day activities such as walking, golf, swimming, snow skiing and bike riding should be possible. Running is usually not possible and not encouraged (Except to get out of the way of an oncoming car)!
A small percentage of ankles will have minor troubles such as scar tissue impingement or early wear of the plastic liner that may need minor adjustment surgery within the first few years.
Of the 10-20% that may wear out over 5-10 years then the main option is to remove the ankle and then fuse the ankle joint. Occasionally a ‘redo’ or revision of the ankle prosthesis may be possible.
(A: Metallic components – tibia and talus, B: Roughened surface allows bone attachment, C: Articulating plastic (polyethylene) component.)Pain relief is the main aim of any ankle arthritis surgery and an ankle replacement will generally give good to excellent relief of pain (equivalent to an ankle fusion). Sometimes there may be an occasional ‘niggle’ as it is an artificial joint with moving parts and not ‘normal’.
The advantage of an ankle replacement is the ability to maintain movement in the joint. This encourages a more normal walking gait pattern and therefore better functional outcome. It also helps ‘protect’ the surrounding joints (e.g. subtalar joint) compared to an ankle fusion. With an ankle fusion the surrounding joints have to ‘work harder’ after the surgery and may have progressive arthritis, which requires fusion of more joints in the foot (not ideal). An ankle replacement will not allow full normal movement but certainly gives a good useable range of movement.
Overall most people are very happy with their ankle replacement and get back to a relatively active lifestyle without the severe pain of ankle arthritis.SURGERY
The surgery is done generally under general anaesthesia or spinal anaesthetic. The operation takes approximately 2 hours.
An incision is made over the front of the ankle. The worn out surfaces of the ankle joint are carefully resected and special instruments are used to help guide the insertion of the prosthesis. There is a metal component (made of titanium and chrome cobalt) on the bottom of the shin bone (tibia) and one on the top of the ankle bone (talus), in between these is an articulating biocompatible plastic (polyethylene).
The components are ‘uncemented’ – meaning they have a roughened surface that allows the bone to slowly grow onto the prosthesis so that it becomes permanently fixed to your bone.
Occasionally other procedures are required at the same time to lengthen a tight Achilles tendon, stabilise ligaments or realign / fuse surrounding bones or joints. When you wake up your leg will be in a plaster splint. An anaesthetic nerve block is usually placed into your leg during surgery to help reduce pain after surgery.RECOVERY
Usually 3-4 days are spent in hospital until pain has subsided and you have learnt to hop on crutches or a frame.
The first 2 weeks at home are spent with the leg elevated recovering from surgery. This is critical to minimise swelling and give the wound the best chance of healing well.
After 2 weeks the cast and sutures are removed. You then may be placed into a moon boot or further cast depending on your surgery.
At 6 weeks full weight bearing is usually allowed and physiotherapy begun. Your moon boot may still be required for some support for a few more weeks.
By 2-3 months you will be walking well. It is not uncommon to have some ‘inflammation’ phase around 3 months –this will generally settle.
More full recovery of swelling, strength and general comfort in your ankle will take 6+ months.RISKS
Possible risks of the surgery include: Anaesthetic risks, infection, fracture, DVT (blood clots), nerve damage, bleeding/ bruising, stiffness, scarring, loosening of the replacement, pain, failure of the prosthesis and need for further surgery.
|Hospital stay||1 night|
|Rest & elevation||7-10 days|
|Plaster = crutches (non-weight bearing)||2 weeks|
|Lace-up brace/cam walker (full time - 2 weeks partial then 2 weeks full weight bearing)||4 weeks|
|Lace-up brace (training)||6 weeks|
|Ankle strapping (competition)||12+ weeks|
|Time off Work|
|Heavy Physical Work||12 weeks|
Foot and ankle surgery is a specialised area of orthopaedic surgery. The surgery can be quite challenging and every patient is different with unique needs and goals.
You will need to follow instructions, perform appropriate exercises, and modify your activities during your healing process.
This requires patience, persistence, and a desire to get better. If you are unable to complete the post-operative instructions it will affect your results and you should consider alternative treatments.
Successful results from surgery require a contribution from you.
Whenever surgery is considered we always try to minimise the risks. You are already on this path by consulting an experienced orthopaedic surgeon who is a specialist in foot and ankle disorders. The body is a very complex and varied structure so although we aim for perfection, no specialist can give perfect results every time.
It is important that you read all of the information carefully. The information provided is intended to be a guide and not all-inclusive. If you have any questions, concerns, or are not certain about the benefits, risks, limitations, or alternatives to your treatment, please do not hesitate to ask your surgeon.
A local anaesthetic block may be given to you during surgery. This will produce numbness around the nerves in the region of your surgical procedure. It will provide you with pain relief for approximately 12-18 hours post-operatively, enabling you to be comfortable and allow sleep after your surgery. It will also allow time to take some of your oral painkillers prior to the block wearing off and prevent a sudden onset of pain.
It is best to take your painkillers regularly for the first 1-2 weeks. Initially, prescription medication is usually necessary and after the initial 2-3 days, regular Panadol or Panadeine is usually all that is required.
It is also worthwhile taking painkillers prior to your first post-operative visit to ensure that plaster and suture removal is more comfortable.
Remember, pain is better managed if you get on top of it before it gets on top of you.
Swelling often increases over the first 6 weeks and then usually reduces over the next 6 weeks. Depending on the nature and magnitude of the surgery, it may take up to 12 months to fully settle. This is the normal way the body heals. Rest and elevation is helpful. As the foot swells it is common to have stiffness and mild nerve pain so attention to swelling is important.
However, do not overdo it. Too much too early can be just as bad as not doing enough. This includes sport. Your surgeon is happy to liaise with your trainers to get you back on the field as quickly as possible without compromising your recovery process and long-term health.
Fortunately complications are uncommon. Nevertheless they do occur and you need to be aware of them. The following is a non-exhaustive list of some of the more frequent. You should also be aware that several factors can increase your chance of having a complication. These include smoking, diabetes, and obesity. You can reduce this risk by quitting smoking, good blood sugar control, and losing weight.
This occurs when the wound is invaded by bacteria, usually from your surrounding skin. Signs you may have an infection include heat, tenderness, unusual fluid, or an odour coming from your wound. You may also have a fever or feel generally unwell. Most infections can be treated with antibiotics but more serious ones require admission to hospital and further surgery to clean out the wound.
Normal wound healing requires adequate blood flow and active healing cells. Being too active early after surgery causes bleeding and swelling which can cause part of the wound to open. The foot is very delicate in this respect. It is important that you rest and keep your foot elevated as much as possible for the first 7-10 days to encourage healing and discourage wound break down. Risks of infection and healing problems are much higher if you smoke or are diabetic. If you are able to give up smoking before and for a few weeks after your surgery this will help your healing process.
Nerves are the electrical system of the body. It is extremely rare for nerves to be cut but nerves are commonly affected by swelling after surgery. This can cause partial numbness and sometimes burning pain. This generally resolves as the swelling subsides. In rare cases this can persist.
Both injury and surgery create scar tissue. Some people are prone to develop excess scar tissue. When this is combined with post-operative swelling it may lead to joint stiffness. Most of this can be addressed through good quality rehabilitation techniques and your own involvement in recovery.
Surgeons can only create the environment for bone healing. It is your body that performs the final joining process. This can fail if there is too much mobility (i.e. you walk on it too early) or if there are other issues such as smoking, blood flow problems or infection. If the bone fails to heal it may require further surgery.
These fortunately are very rare events but can have serious consequences. Signs you may have a DVT include swelling that is not reduced with elevation of the leg, colour changes or coldness of the toes, calf pain or tenderness. Signs you may have a PE include chest pain or shortness of breath. Seek immediate medical attention if you are concerned.
This can be a sign of a variety of complications following surgery, with many mentioned previously. On very rare occasions a chronic regional pain syndrome can develop in addition to these and require further prolonged management.
Any concerns should be discussed with your anaesthetist during the pre-operative consultation.
After surgery you should notify your surgeon / GP / Emergency department if you have any of the following:
For most surgeries it takes a minimum of 3 months to be recovering reasonably well (75%), 6 months until 90% recovered and 12 months until complete recovery. Swelling is normal for the first 3-4 months and can take 6-12 months before full recovery is expected.
Lesser toe deformities can cause problems in a variety of ways. ‘Hammer’ or ‘claw‘ toes are the most common toe deformities that require surgical treatment. They can cause problems relating to the prominent knuckle joint (PIP joint) on the toe sticking up and rubbing on shoe-wear and causing corn formation and ulcers. The deformity of the toe may cause pain itself from inflammation in the main joint (MTP joint) at the base of the toe or damage and stretching of the ligament under the toe and ball of the foot. Sometimes the toe deformity causes extra pressure under the ‘ball’ of the foot with a feeling of pain or even a sensation of walking on a ‘pebble’.
The cause of these problems can be multifactorial:
Non-surgical methods of treatment should always be considered first before any surgery. This can involve things such as:
If these measures fail to work or are unsatisfactory then surgery can be performed to straighten the toe.
Surgery can involve a number of small procedures on the toe depending on the degree of deformity and the exact problem.
Usually the bent knuckle in the middle of the toe (the PIP joint) will need to be straightened and possibly fused. This may require a pin in the toe which is left just 5mm out of the toe. This will then be removed after 4-6 weeks. Removal of the pin is straight forward. It takes just a few seconds and is no more painful than having stitches removed. No anaesthetic is required. Sometimes an internal pin or dissolvable pin can be used without the need for an external pin.
Other adjustments such as lengthening tight tendons or shortening the Metatarsal head (knuckle bone at bottom of toe joint) – which is called a ‘Weil osteotomy’ –may also be required.
Surgery is generally performed as day surgery unless combined with bunion or other surgery, which may require an overnight stay.
Weight bearing is allowed in a post-operative sandal. Elevation for at least the first 5-7 days is important. Reasonable recovery occurs by 4-5 weeks once the bones are healing. The toe can remain swollen for up to 3 months but will recover.
Some stiffness of the toe is common as the toe cannot be made perfect again once the previous damage has already occurred. The toe however should be straighter and more comfortable.
Hallux rigidus (HR) refers to stiffness (rigidus) of the joint at the base of the great toe (hallux). This joint is called the great toe metatarsophalangeal joint (MTPJ). The usual cause of HR is arthritis or wear and tear of the smooth cartilage that lines the joint. HR may be caused by a previous injury or it may be part of a general medical condition e.g. gout. Often the cause is unknown; it just develops, particularly as people get older.
HR presents with stiffness and pain in the great toe MTPJ. If the symptoms are severe, it may limit walking distance, and compromise work and recreational activities. Bony spurs (osteophytes) develop around the great toe MTPJ and can cause pain by rubbing against tight fitting shoes. In an attempt to off-load the painful great toe, some people will preferentially walk on the outer border of the foot, causing transfer pain to the lesser toes.
The main aims are to relieve pain and decrease loading and movement through the great toe MTPJ. In it’s mildest form, HR may not need operative treatment. Simple lifestyle and activity modifications including weight loss, the use of a walking aids and the avoidance of high impact activities may be all that is necessary. In addition, taking painkillers (Panadol and anti-inflammatories), and wearing appropriate shoe wear and orthotics (stiff insoles or shoes with a rocker bottom) can all be helpful. High heels and shoes with a narrow toe box should be avoided. Finally, a cortisone injection may offer relief of inflammation but as with most treatments, the degree and extent of relief varies from patient to patient.
Surgery is considered when the previous measures fail. There are two main surgical options to relieve pain and improve quality of life. The first option includes motion-preserving procedures such as joint debridement +/-osteotomy, and the alternative is an arthrodesis or fusion of the MTPJ. The best option for an individual patient depends on many factors including the severity of arthritis, the age and functional demands of the patient, and the presence of arthritis in adjacent joints. The final choice is a joint decision between surgeon and patient.
If the HR is mild, affecting only the upper part of the joint, this upper portion may be trimmed and the joint washed out. This is often combined with a realignment procedure (Moberg osteotomy) of the bone at the base of the great toe (proximal phalynx). More recently, this has become possible using a minimally invasive technique. This allows the use of smaller incisions and generally results in a more rapid recovery and an improved cosmetic result.
In more advanced cases, the joint debridement may be combined with resection of part of the proximal phalynx and the insertion of some of the surrounding soft tissue into the resulting cavity (Hamilton-Thompson Interposition Arthroplasty). This combination can provide long lasting pain relief with improved movement of the great toe in the appropriate patient.
In around 20% of patients who have undergone either of these procedures, the arthritis is progressive and symptoms may return to a point where further procedures such as joint fusion may be required.
Artificial joints that replace the surfaces of the diseased bone (in a similar fashion to hip and knee replacements) have been used to treat advanced arthritis. However, previous implants have shown poor results and any subsequent procedures (such as fusion) have become more difficult.
The current generation of implants appear to show more promising results but as yet, long-term reliability has not been established and for this reason, your surgeon does not currently recommend or perform this procedure.
This is the ‘gold standard’ procedure for moderate to severe arthritis. The remaining cartilage in the joint is removed, the bones on either side of the joint are fused together and held with screws in isolation or a combination of screws and a plate. 90-95% of patients will experience good pain relief with this. However, the joint is stiffened and this limits the wearing of high heels and makes running difficult. There is a small risk of developing arthritis in the next joint along the big toe but this is rarely troublesome.
Less than 5-10% will develop a complication that may require further intervention. These include wound-healing problems, infection, damage to nerves and blood vessels, incomplete relief of symptoms, and in the case of arthrodesis, failure of the bones to knit together requiring further surgery.
|Hospital stay||1 night|
|Rest & elevation||10 days|
|Crutches / Frame||1-2 weeks|
|Foot swelling||12 weeks|
|Hospital (Fusion)||6 weeks|
|Hospital (Debridement)||4-6 weeks|
|Fashionable||Up to 6 Months|
|Time off Work|
|Time off Work(Seated)||3-4 weeks|
|Time off Work(Standing)||6-8 weeks|
|Result Times (pain relief & function)|
This brochure is a brief overview of the surgical management of hallux rigidus and not designed to be all-inclusive. If you have any further questions, please do not hesitate to contact your surgeon.
Bunions are a common deformity in the community. They are thought to occur due to a muscle imbalance that is often inherited. Inappropriate footwear may exacerbate the condition however is not usually the underlying cause. Bunions worsen with advancing age and can eventually cause pain and deformity. The bunion may also result in damage to other parts of your feet. Pain is felt because of their size and abnormal biomechanics. The time to have treatment is when they cause significant pain or you have difficulty in finding comfortable footwear.
The operative treatment of bunion correction that is utilized by your surgeon is the Scarf and Akin osteotomy. Many operations for bunions have been tried over the years with varying levels of success. Most have failed due to high recurrence rates, excessive joint stiffness, or by transferring problems to other parts of the foot. The Scarf / Akin osteotomy solves many of these problems. The procedure has been popularised by Mr Louis Barouk (French orthopaedic foot surgeon) and it is the most common style of bunion operation performed in Europe. The keys to its success are that it is restores foot mechanics, allows early return of joint motion, and has low recurrence rates.
The procedure has 5 components performed through 2 incisions. Initially, one of the tight ligaments and the tight muscle on the opposite side of the bunion is released. The bunion is then shaved. The metatarsal bone is cut and adjusted to narrow the foot and realign the joint. This is called a Scarf osteotomy, and 2 small screws are placed in the bone to provide solid fixation. After this a wedge of bone is removed from the phalanx bone to straighten the big toe. This is the Akin osteotomy, and a small staple or screw is used to hold the bone in place. The joint capsule is finally tightened where the bunion has stretched it and the skin is closed. The metalwork usually does not need to be removed.
More recently, this procedure has become possible for may patients using a minimally invasive technique. This allows the use of smaller incisions (usually 5 or 6 incisions around 3-5mm in length) and generally results in a slightly more rapid recovery and an improved cosmetic result. As the underlying bony procedure is almost identical to that of the open technique, the longer-term results are very similar
mmediate weight bearing is possible in a postoperative stiff soled shoe and plaster is not required. The way your foot has been bandaged assists in holding the big toe in place, with the post-operative shoe protecting the toe when you walk. This takes the place of a plaster and accordingly is required for between 4 and 6 weeks. As with all foot surgery, swelling occurs and this is the main limitation to activity and footwear in the early stages. Swelling often increases over a 6-week period and then reduces over a further 6 weeks. As such your final result will begin 3 months after surgery. As the mechanics in your foot have been substantially changed, your body will go on making subtle adjustments over a 12-month period.
Foot surgery without appropriate pain relief is extremely uncomfortable. While the operation is performed under general anaesthetic, a nerve block is also usually inserted, which puts the foot to sleep for around 12-18 hours. You should wake up from surgery with minimal pain and it is now uncommon for injectable pain relief to be required. When the block wears off you can take simple oral pain relief. It is important to start taking your oral pain relief prior to the block wearing off as once the pain becomes intense, it can become difficult to manage.
No surgery is risk free. The risks and complications will be assessed and discussed with you. There is always a small risk of infection, blood clots and anaesthetic problems with lower limb surgery and measures are taken to reduce these. In bunion surgery there is also a 5% chance of recurrence of the deformity, overcorrection of the big toe, or problems with bone fixation. Very rarely, the toe can become numb or hypersensitive for a prolonged period. Conversely, a successful outcome is achieved in more than 90% of patients.
|Hospital stay||1 night|
|Rest & elevation||10 days|
|Crutches / Frame||1-2 weeks|
|Foot swelling||12 weeks|
|Hospital||< 6 weeks|
|Fashionable||Up to 6 Months|
|Time off Work|
|Lifting / Carrying||8-12 weeks|
This brochure is a brief overview of the surgical management of hallux rigidus and not designed to be all-inclusive. If you have any further questions, please do not hesitate to contact your surgeon.
The plantar fascia runs along the length of the sole of the foot and along with various ligaments and muscles of the foot, functions to assist in maintaining its inner arch (like the string of a bow, with the bones of the foot being the bow itself).
Plantar fasciitis is an inflammation of the origin of the fascia at the calcaneus (heel bone). It is a result of a repetitive strain / tear and repair of the fascia from traction forces that have worn it out. It can be likened to an elastic band that has been left out in the sun and stretched too many times; it loses its stretch and has many micro-tears in it.
Heel spurs have long been associated with heel pain, and were originally thought to be its cause. Heel spurs occur at the origin of the flexor digitorum brevis muscle, which lies just beneath the plantar fascia. However, heel spurs are NOT the cause of heel pain associated with plantar fasciitis and for this reason, it is unnecessary for them to be removed. They probably form because of the local inflammation in the soft tissue, with the body forming bone mistakenly in its attempt to repair the plantar fascia.
Initial management of plantar fasciitis involves a multi-modal non-operative approach. For 90% of people, this is all that is required. This initially includes analgesics, anti-inflammatories, massage, applying ice, and exercises that stretch the fascia and strengthen the muscles. Orthoses including cushioning heel pads and night splints may also be helpful, along with corticosteroid or PRP injections, and other alternative modalities such as ultrasound or shock wave therapy.
For those patients who have ongoing pain despite adequate non-operative management, operative intervention may be required. Conventionally this procedure has been performed through a large incision on the in-step of the foot. In recent times an endoscopic technique has been developed.
Our recent study of over 100 patients comparing the results of the traditional open procedure with the more modern endoscopic technique demonstrated the endoscopic procedure to be superior. This included improved patient satisfaction, less post-operative pain, quicker recovery times, and a lower complication rate.
The procedure involves making 2 x 10mm incisions; 1 on each side of the foot. This enables a telescopic camera and instrumentation to be inserted to complete the release of the plantar fascia. Patients are then allowed to weight bear as tolerated, and quite often have less pain than prior to the procedure within 1-2 weeks. By 4 weeks, patients are usually walking well, and may commence returning to sport by 6-12 weeks.
Complications are rare with this procedure. There is always a small risk of infection, nerve injury and blood clots, and anaesthetic problems with lower limb surgery and measures are taken to minimize these risks. A small proportion of patients may also experience a persistence of their preoperative pain despite surgery.
Finally, and uncommonly, discomfort in the outer part of the top of the foot may occur following any technique of plantar fascia release. Very seldom is this enough of a problem to require further surgery and generally improves with the use of insoles (orthotics). Overall, a successful outcome is achieved in approximately 90% of patients.
|Hospital stay||1 night|
|Rest & elevation||10 days|
|Crutches / Frame||1-2 weeks|
|Foot swelling||12 weeks|
|Time off Work|
This brochure is a brief overview of the surgical management of plantar fasciitis and not designed to be all-inclusive. If you have any further questions, please do not hesitate to contact your surgeon.
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