SPINE
Spinal Stenosis
Lumbar Spinal Stenosis is a narrowing of the canals in the spine where our nerves travel, most often because of degenerative changes. This narrowing is often the result of bone spurs off the back of the disc or growing off the joints in the back of the spine. Stenosis can lead to compression of the nerves. The ligament that lines the inside of the spinal canal can thicken and also lead to spinal stenosis. The symptoms of spinal stenosis can range from pain, numbness, and/or tingling going down the legs, to symptoms of the legs feeling tired after standing or walking for a few moments and relieved by sitting down. Spinal stenosis is extremely common and much of it is not symptomatic or is only symptomatic when flared up. In these cases, oral medications, physical therapy, and/or epidural steroid injections can be quite helpful. Patients who have had symptoms for greater than 3 months or who have worsening symptoms are much more likely to require surgical intervention.
Spondylosis (Arthritis)
Lumbar spondylosis is a medical term that simply refers to arthritis, or degeneration of the joints in the lumbar spine. As we age, it is common to see arthritic changes in the lumbar spine and many of these are not significantly symptomatic. Some people will develop more severe degeneration of the joints in their lumbar spine with more consistent symptoms and seek treatment. Maintaining an ideal body weight and keeping your core muscles strong is the first line of treatment and if this is not done, the results of almost any other type of treatment will be quite limited. Physical therapy and daily core exercises are of benefit in some patients. For problems above and beyond that, patients will often see pain management physicians for injections. Our office often refers patients to physicians for evaluation for a rhizotomy (radiofrequency ablation). This is a procedure in which a pain management physician can use a thermal probe to ablate the small nerves that go to the joints in the back of the spine, so that the patient no longer feels the pain from those joints. We do not perform this procedure but often make referrals for it.
The vast majority of arthritis in the lumbar spine does not require surgical intervention. If a patient fails all nonoperative measures and has severe degeneration, surgical intervention can be performed in the form of a lumbar fusion. This will remove the arthritic pain generators from the levels that are operated on.
Lumbar Degenerative Spondylolisthesis
A lumbar degenerative spondylolisthesis is a common condition in which the joints in the back of the spine wear out. This leads to one bone sliding forward on another bone. As this occurs, this leads to narrowing of the nerve tunnels, which can cause pain into the buttock, and possibly into the legs. The condition can present many different ways. Symptoms may consist of mild back pain from the arthritic component, severe pain in the back, severe pain in the legs, or even weakness in the legs. The best way to understand this condition is to think of it as mild, moderate, or severe. In many ways, it is not that different than knee arthritis. People with mild knee arthritis often respond to physical therapy and an injection and do not need a knee replacement. People with severe degeneration of their knee joint that can only walk 100 feet before they have pain are probably not going to get better until they have a complete knee replacement. It is similar in patients with a lumbar degenerative spondylolisthesis. People with early/mild degeneration often respond to physical therapy, weight loss, core conditioning and possibly epidural steroid injections. People with severe erosion of the joints in the back of their spine with significant instability and 3 months of progressively worsening symptoms are very unlikely to have resolution of their symptoms without surgical intervention. The decision for surgery is based on combining the patient’s history, response to previous treatments and what is found on x-rays and advanced imaging studies. Many patients with this condition require a lumbar fusion for resolution of their symptoms. It is one of the more common reasons a lumbar fusion is performed in the United States.
Cervicalgia (Neck pain)
Neck pain is relatively common and most people will have an episode of neck pain in their lifetime. Most episodes of neck pain are self-limited and resolve on their own within 6 to 12 weeks, regardless of treatment. Patients that have neck pain that goes on for more than 3 months are more likely to have a structural problem that has led to their persistent symptoms. We find that the four most common causes of prolonged neck pain are disc degeneration, disc herniations, arthritis of the joints in the back of the spine (facet joints), and/or nerve impingement. If a patient who is interested in surgical treatment has pain in their neck without symptoms in their arms, a relatively complicated work-up is typically required to isolate where their pain is coming from. This is because degenerative changes on imaging do not always cause symptoms. Therefore, treatment is guided by imaging, symptoms, and the duration of symptoms. Surgical treatment of patients who have neck pain as their dominant complaint is considered controversial in the world of spinal surgery. Therefore, if a patient is seen by several spine surgeons, they will likely receive several, very different opinions. Our philosophy, in general, is to spend the time necessary to isolate what appears to be the primary pain generator. If the patient fails all appropriate nonoperative care, a surgical solution will be offered that focuses on those problems that are actually causing symptoms, as opposed to focusing on simple degenerative changes that are not symptomatic.
Lumbago (Low back pain)
Episodes of low back pain are extremely common and 90% of people will have a major episode of back pain in their lifetime. Most episodes of low back pain resolve on their own, within 6 to 12 weeks. If the patient has lower back pain without any symptoms into the legs, then we believe initial treatment does not require spinal surgery consultation. I would generally recommend that the patient ask their Primary Care Physician, for anti-inflammatory or steroid medication to help calm down the inflammation which leads to many episodes of back pain and to consider physical therapy. It is also important for the patient to understand that even though symptoms can be quite severe at first, it can be surprising how much resolution of symptoms happen on their own within a few weeks to a few months.
In patients that have back pain that continues to trend in a negative direction over several months, is intractable, or is persistent for greater than 3 months, I believe it is reasonable to obtain an MRI to try to reach a more definitive diagnosis. In our practice, we do not have one specific timeline for when it is appropriate to get an MRI, as every patient is different. In some people, they clearly do not require an MRI and others should have it performed much sooner than many guidelines recommend. Our goal is to obtain the appropriate imaging when it makes the most sense for the patient. The most important thing in treating chronic back pain is to first come up with the correct diagnosis, as treatment varies markedly depending on the primary cause. The most common causes of chronic lower back pain are arthritis of the joints, lumbar stenosis, and spinal instabilities like lumbar spondylolisthesis or disc degeneration. It is common to have these problems on an MRI Scan without them being the cause of the patient’s symptoms. Thus, there is need for a thorough evaluation to determine the exact origin of symptoms. Once a diagnosis has been obtained, we are in a much better position to determine if surgery is indicated.
Lumbar Disc Herniation
The lumbar disc is basically the cushion that sits between the bones of the lumbar spine, which provides stability and shock absorption. Over time, everybody’s discs degenerate to some degree and this is part of normal aging. A disc is made up of several parts, primarily a tough outer part and the soft inner core. A lumbar disc herniation is when the soft inner part pushes through the tough outer part. When the soft inner disc material pushes through the outer part and lands against a nerve, the patient can develop pain in the distribution of that nerve. Disc herniations can occur at any level in the spine but are most common in the lower lumbar spine. When this occurs, patients will often develop pain in the buttock going down into their legs. Many disc herniations improve without surgical intervention, as the natural history of many disc herniations are to improve on their own. Over time, the body can resorb or wall off the disc material that entered the spinal canal, at which time patient quits being symptomatic from it.
Surgical intervention is considered when a patient has a neurologic deficit from the disc herniation or significant discomfort that is failing to improve with nonoperative measures. Different disc herniations have what I would call different personalities; some are quite mild, and others are extremely severe. When it comes to surgical intervention, most disc herniations can be treated by a procedure known as a lumbar microdiscectomy. This is an out-patient procedure which has the goal of removing the herniated disc material. If a patient’s primary complaint prior to surgery is pain in the buttock and down the leg, the procedure has a very good success rate for relieving this. If a patient has a disc herniation in the central portion of the disc with a primary complaint of back pain, the results of a microdiscectomy are more variable, as some patients with this type disc herniation have pain coming from their disc herniation and others have it coming from structural damage to the disc itself. A lumbar microdiscectomy will not fix back pain from structural damage to the disc. The results of surgery on this type of disc herniation are best determined through a thorough discussion with a surgeon who knows the history of your disc herniation, the history of your back pain, and has reviewed your MRI images.
Cervical Strain/Whiplash
A cervical whiplash injury is when a hyperflexion or hyperextension event occurs to the cervical spine. This is commonly seen in motor vehicle accidents in which the patient is restrained by a seat belt and their vehicle is struck by another vehicle. The majority of whiplash injuries resolve on their own and healing might be accelerated by physical therapy. A small percentage of patients develop persistent neck pain that does not resolve. For those patients that have symptoms for more than a year, it is much less likely that they will improve on their own. This is often because there is some sort of structural injury to the cervical spine. Patients in this situation will find if they go to several different surgeons, that they will get a multitude of different opinions as to what to do, ranging from being told surgery cannot help to those who will suggest multi-level fusions with the hope of improving symptoms. In our practice, for those that clearly have symptoms that are not getting better, we do our best to use advanced diagnostics to isolate the origin of symptoms and see if there is a reasonable surgical option. If the primary pain generator can be identified, many patients may be candidates for cervical disc arthroplasty.
Lumbar Strain
A lumbar strain is an injury to the muscles or tendons of the lumbar spine secondary to a physical overload of the spine. Lumbar strains should improve on their own over 2 to 3 months. We often see patients who were told that they had a lumbar strain, however, they continued to have symptoms that lasted more than 3 months. In that case, we believe that it is less likely that the primary problem is a pulled muscle or tendon, and more likely some sort of structural injury to another part of the spine. Muscles and tendons would have healed within that time period. In a case of back pain in a patient who was previously told that it was simply a lumbar strain, further diagnostics are required to reach a true diagnosis.
Degenerative Disc Disease
Many patients say that they are suffering from degenerative disc disease and that they have a family history of it. The term degenerative disc disease is somewhat misleading in that everybody’s discs degenerate as they age. It is normal to have some degree of disc degeneration. What is important to know, is that most degenerated discs are not major pain generators and simply having a degenerated disc does not mean that this is the main cause of the patient’s symptoms. Knowing this, there are a number of people that do have symptomatic disc degeneration. Depending on the severity of symptoms, and lack of successful non-operative care, there are often surgical treatment options. As we age, everybody develops some degree of degeneration of the discs in their cervical and lumbar spine. This is part of normal aging.
Most disc degeneration is painless, or symptoms are relatively mild. There are, however, a subsection of patients who develop chronic neck or back pain that does not respond to physical therapy and/or pain management treatment. In those cases, some surgeons recommend surgical intervention, and some do not. Surgical treatment of cervical and lumbar disc degeneration is a controversial area in spine surgery. We believe in carefully selecting cases in which surgical intervention can be of benefit. However, the majority of degenerating discs do not require surgical intervention.
Cervical Myelopathy
Cervical myelopathy is a pathologic condition in which the patient develops compression of the spinal cord in their cervical spine. It is common to see varying degrees of compression of the spinal cord in the cervical spine. If patients are not symptomatic, we generally do not recommend surgical intervention, as we do not believe that the data supports automatically operating on a spinal cord compression. On the other hand, when a patient presents with symptoms of spinal cord compression (numbness, weakness in the arms or legs, decreased balance, or decreased hand coordination), we strongly recommend surgical intervention. The goal of surgery is to take pressure off the spinal cord and stop the progression of the neurologic loss. There is no guarantee of recovery of neurologic function after surgery. Patients who are treated earlier, often do significantly better. Thus, this is one of the areas of spinal surgery that we will be more aggressive in recommending surgical intervention. It should be noted that compression of the spinal cord is not necessarily a painful condition, which is different than many other spinal conditions.
Cervical Radiculopathy
Cervical radiculopathy is a condition in which patients have numbness, tingling, or weakness into their arms because of compression of the small nerve roots that grow off of the spinal cord forming the nerves that go down into the arms. Cervical radiculopathy is relatively common, and, in many cases, patients get better without surgical intervention. It is also common to see tightness or narrowed tunnels around the nerve roots as they leave the cervical spine, but this is not always symptomatic. Surgical treatment of cervical radiculopathy is very successful and is performed for patients that are developing a neurologic deficit or that have symptoms that persist or progressively worsen over time.
Lumbar Radiculopathy
Lumbar radiculopathy is a condition in which a patient develops symptoms from compression or inflammation of a nerve root in the lumbar spine. The most common symptoms are pain, numbness or tingling going through the buttock down into the legs. Some patients will present with weakness of varying degrees. The two most common causes of lumbar radiculopathy are lumbar disc herniations and lumbar stenosis. A large percentage of patients with symptoms from a disc herniation improve without surgical intervention, as many disc herniations can resorb over time. This leads to spontaneous improvement of symptoms. Nonoperative treatment is aimed at controlling symptoms while the body tries to heal itself. A lumbar microdiscectomy is performed for cases that are more severe and fail to have a good response to nonoperative care. Patients that have lumbar radiculopathy from lumbar spinal stenosis are less likely to have resolution of their symptoms with nonoperative care. Lumbar stenosis is caused by degenerative changes, which do not have a natural history of resorption. It should be noted that the patient with lumbar stenosis causing lumbar radiculopathy will at times improve without surgical intervention. Patients that have symptoms for more than 3 months on a consistent or worsening basis, are less likely to have long term resolution of their symptoms without surgical intervention.
Coccydynia (Tailbone pain)
Often a patient will come in telling us that they “broke their tailbone”. If indeed they fractured their sacrum or their coccyx, these bones will heal on their own while being uncomfortable for a few months. When a patient has fallen on their tailbone and has had symptoms for more than 3 months, it is less likely that it is from a fracture of the bone, and more likely that it is from an injury to the joint that connects the coccyx, or tailbone, to the sacrum. Nonoperative care for this consists of physical therapy and injections. Patients who have symptoms that go on for more than 6 months and have failed nonoperative treatment can be evaluated to see if they are a candidate for a coccygectomy. The structure that is causing the persistent pain is the joint, and by removing the coccyx, the painful joint is removed as well. This can be done because we do not need our coccyx or the sacrococcygeal joint. This is different than almost every other joint in the body, in which we need the joint to function properly. A coccygectomy is an outpatient procedure.
Bulging Discs
In general, we do not like the term bulging disc. It is not a good diagnostic term and is ambiguous. Many patients come in telling us that they have bulging discs and that is the source of their pain; however, this is an assumption.
The disc is made up of a softer inner part and a tougher outer part. When we are young, the middle part of the disc is well hydrated, making the discs tall. As we age, the middle of the disc can dehydrate causing loss of height. This causes the outer part of the disc to bow out. Think of a tire that is low on air and how the tire contacting the ground bows out at its edges. The tire itself is fine, it is simply low on air. A bulge of a disc develops because the disc has degenerated to some degree, and the outer part is bowing out.
This bowing out of the disc is significant when it causes narrowing of the nerve tunnels. There typically has to be other degenerative changes, along with the bulging of the disc, to cause compression of the nerves. When this occurs, we refer to it as lumbar spinal stenosis. Many patients have lumbar disc herniations and call them bulging discs, but these are really two different things. A disc herniation is a rupture of disc material through the outer part of the disc, known as the annulus, whereas a bulging disc has an intact annulus. The natural history of a disc herniation in many cases is to improve on its own. Once a disc has degenerated, it will always have a bulge, which is often not symptomatic.
Failed Back Syndrome/Surgery
There are multiple reasons a patient can undergo a surgery on their lumbar spine and not have a good outcome. In our practice, it is common for us to see a patient that had surgery previously, and still has persistent symptoms. One reason for this is when a patient had only decompressive surgery but would have done much better with a lumbar fusion. Patients who had a lumbar fusion that did not heal, a non-union, also experience this issue. Some patients had a successful surgery, and then developed a new problem at a different level, but assumed the problem was coming from the same place that their original pain came from. There are also cases of people that have disc herniations treated surgically, and then have another herniation at the same level, which has not yet been diagnosed. Additionally, there are patients that do not do their part to improve the health of their back. Choosing to maintain ideal body weight and strengthen core muscles can help avoid further issues postoperatively.
Other
Compression Fractures
Discogenic Neck and Back Pain
HAND
What Is It?
DeQuervain’s tendinitis is a condition brought on by irritation or swelling of the tendons found along the thumb side of the wrist (Figure 1). The irritation causes the compartment (lining) around the tendon to swell, changing the shape of the compartment; this makes it difficult for the tendons to move as they should. The swelling can cause pain and tenderness along the thumb side of the wrist, usually noticed when forming a fist, grasping or gripping things, or turning the wrist.
What Causes It?
The cause of deQuervain’s tendinitis is an irritation of the tendons at the base of the thumb. For example, awkward hand positions required by a new mother in caring for an infant is a common cause of this condition.
Signs and Symptoms
Pain over the thumb side of the wrist is the main symptom. The pain may appear either gradually or suddenly. It is felt in the wrist and can travel up the forearm. The pain is usually worse with use of the hand and thumb, especially when forcefully grasping things or twisting the wrist. Swelling over the thumb side of the wrist is noticed and may be accompanied by a fluid-filled cyst in this region. There may be an occasional “catching” or “snapping” when moving the thumb. Because of the pain and swelling, it may be difficult to move the thumb and wrist, such as in pinching. Irritation of the nerve lying on top of the tendon sheath may cause numbness on the back of the thumb and index finger.
Diagnosis
A Finkelstein test is generally performed. In this test, the patient makes a fist with the fingers over the thumb. The wrist is then bent in the direction of the little finger (Figure 2). This test can be quite painful for the person with deQuervain’s tendinitis. Tenderness directly over the tendons on the thumb-side of the wrist is the most common finding, however.
Treatment
The goal is to relieve the pain caused by the irritation and swelling. In some cases, your doctor may recommend resting the thumb and wrist by wearing a splint. Anti-inflammatory medication taken by mouth or injected into that tendon compartment may help reduce the swelling and relieve the pain. In some cases, simply not doing the activities that cause pain and swelling may allow the symptoms to go away on their own.
When symptoms are severe or do not improve, surgery may be recommended. The surgery opens the compartment (covering) to make more room for the irritated tendons (Figure 3). Normal use of the hand can usually be resumed once comfort and strength have returned. Your hand surgeon can advise you on the best treatment for your situation.
What is Carpal Tunnel Syndrome?
Carpal tunnel syndrome (CTS) is a disorder resulting from pressure on the Median nerve at the wrist. The nerve passes through the carpal tunnel with nine tendons. Swelling around the tendons can eliminate the space available for the nerve resulting in nerve compression. Symptoms often consist of pain, numbness and tingling in the thumb, index and middle fingers. Numbness at night and in the morning is experienced by many patients.
What causes Carpal Tunnel Syndrome?
The cause of Carpal Tunnel Syndrome is most often not known. Diseases such as Diabetes, Hypothyroidism, and Rheumatoid arthritis are often associated with CTS. Any disorder that causes fluid retention can precipitate the symptoms of CTS. Use of a computer keyboard does not cause CTS. However, heavy use of the hands may aggravate the symptoms.
What is the treatment of Carpal Tunnel Syndrome?
The treatment of CTS in the early stages is splinting and avoiding aggravating activities. Splints worn at night help relieve pressure on the nerve, and may be the only treatment needed. Your Doctor may recommend modification of your work or recreational activities.
If splinting fails to adequately control your symptoms your Doctor may recommend an injection of steroids into the carpal tunnel. Steroid injection into the carpal tunnel significantly reduces symptoms in most patients. In addition, up to 22% of patients may be permanently relieved by a single injection. However, in many patients the symptoms return over a period of time.
Surgery is recommended when other treatments fail or if nerve conduction studies show an advanced stage of nerve damage. Carpal tunnel release surgery is an outpatient surgery performed under local anesthesia. If you desire, heavy sedation may be administered during surgery. You can usually return to light activity the day after surgery. Full activity is typically well tolerated after 4 to 6 weeks.
The results of surgery can vary between patients. Numbness and tingling in the hand typically resolves immediately. However, patients with more advanced disease may experience immediate partial recovery followed by gradual improvement over several months in the remaining symptoms. Soreness in the palm is the last symptom to resolve after surgery. Grip strength usually continues to improve for three months after surgery.
What is Cubital Tunnel Syndrome?
Cubital tunnel syndrome is a compression of the Ulnar nerve (Funny Bone) at the elbow. Patients with this syndrome usually complain of numbness and tingling in the ring and small fingers, clumsiness of the hand, and weak grip. Some also experience pain in the elbow, arm and hand. Symptoms are often aggravated by bending the elbow or resting on the elbow for long periods of time.
What causes Cubital Tunnel Syndrome?
The cause is most often not known. Prolonged periods of elbow bending may bring on the symptoms. Injuries to the elbow may lead to scaring and compression of the nerve.
How is Cubital Tunnel Syndrome diagnosed?
Your Doctor can make this diagnosis by history and physical exam. Nerve conduction studies may be ordered to confirm or establish the severity of your problem.
How is Cubital Tunnel Syndrome treated?
Initial treatment consists of elbow padding to protect the nerve and night time splinting. Pressure around the nerve is greatest when the elbow is bent. Therefore, wearing a splint at night prevents sleeping with the elbow bent, and thus allows the nerve to rest. In addition, your Doctor may discuss modifications to your work or other activities to prevent long periods of resting on a bent elbow. In most cases these simple changes will relieve the symptoms. Physical therapy is not usually helpful for this condition.
Surgery may be recommended when the above treatments fail or if your condition is too severe. The surgery is outpatient and is performed with local or general anesthesia (your choice). The results of surgery vary depending on the severity of your problem. Most patients experience some immediate relief of symptoms followed by a gradual improvement in remaining symptoms over several months. Patient can return to light activity within a few days and can usually resume heavy activity in 4 to 6 weeks. Ask your Doctor for more details.
What is a trigger finger?
Tendons are like long cables that connect the muscles of the forearm to the bones of the fingers. Pulleys are loops of tissue that hold the tendon close to the bone. A finger or thumb triggers when there is a swelling in the tendon that prevents it from gliding smoothly through the tendon pulley. Triggering results in a catching sensation when you attempt to bend or straighten the finger. Often the symptoms are worse in the morning, and symptoms may be absent for periods of time.
What causes a trigger finger?
Triggering is caused by swelling that result in a lump in the tendon. It is often the result of inflammation, but the cause is not always clear.
How is trigger finger diagnosed?
The diagnosis is easily established by history and physical examination. Often the pain is in the finger, however the triggering occurs in the palm. A lump may be felt in the tendon.
How are trigger fingers treated?
The treatment of trigger fingers is aimed at reducing inflammation in the tendon. Reducing the inflammation and swelling may relieve the triggering. The wearing of a splint or taking anti-inflammatory medication may be recommended. Injection of steroid around the tendon is successful in eliminating triggering in 80% of patients. These treatments are less successful in patients with Diabetes Mellitus.
If non-surgical treatment fails to improve your symptoms, your Doctor may recommend surgery. The goal of surgery is to release the first pulley of the tendon sheath so the tendon may glide more freely. This surgery is performed on an outpatient basis under local anesthesia, and it is very effective. Normal use of the hand may be resumed as soon as the incision pain resolves. Occasionally some patients have more pain and swelling than others, and hand therapy may be required to help resolve this.
What Is It?
Dupuytren’s disease is an abnormal thickening of the fascia (the tissue between the tendons and the skin in the palm) that may limit the movement of one or more fingers. In some patients a cord forms beneath the skin that stretches from the palm to the fingers. The cord can cause the fingers to bend into the palm so they cannot be fully straightened. (see figure 1)
What Causes It?
The cause of Dupuytren’s is unknown and there is no permanent cure for it. The disease is usually painless. This is a non-cancerous condition. Dupuytren’s mainly affects white people with ancestors from Northern Europe. Injuries to the hand do not directly cause Dupuytren’s.
Signs & Symptoms
Dupuytren’s disease occurs slowly. It is usually noticed as a small lump or pit in the palm. This tends to start in the crease of the hand nearest to the base of the ring and small finger. (see figure 2) With time a cord may develop between the palm and the fingers. The disease is usually noticed when the palm can no longer be placed flat on a table. In more severe cases the fingers may be drawn into the palm.
Treatment
There is no permanent cure for Dupuytren’s disease. Surgery can relieve the bending of the fingers into the palm, but the condition can return with time. The goal of surgery for Dupuytren’s disease is to restore the use of the fingers. Your doctor should advise you on whether surgery is recommended in your case.
Presence of the lump in the hand does not mean that surgery is required. Bending of the fingers into the palm at the base of the fingers is usually correctable by surgery.
The primary treatment for Dupuytren’s contracture is surgery. Dupuytren’s does not respond to medication, physical therapy, or splinting. The goal of surgery is to remove all cords that are causing contracture. Surgery may not completely relieve bending of the fingers at the joints in the fingers.
It is important to remember that surgery is not a permanent cure for this disease. After surgery, thickening of the palm and development of new cords may return in the same place, or at a new place within the hand.
Sometimes skin grafts are needed to cover open areas in the fingers. Sometimes splints are used after surgery to help keep the fingers straight.
A hand therapist may help with your postoperative care to help control swelling and to help with finger motion.
What is a ganglion cyst?
A ganglions cyst is a small fluid filled sac that originates from a tendon or joint. The cysts are benign growths (not cancer) that occur most commonly on the back of the wrist and less commonly on the palm side of the wrist. They often change in size with activity level, and they may spontaneously disappear. The cysts do not cause any damage to the surrounding tissues, but they do cause pain by getting in the way of tendons and joints.
What causes a ganglion cyst?
The cause of a ganglion cyst is not known. They are one of the most common causes of a lump on the hand or wrist.
How is a ganglion cyst diagnosed?
The diagnosis is easily established by history and physical examination. X-rays may be ordered to rule-out other associated conditions.
How are ganglion cysts treated?
The treatment of a ganglion cyst is most often observation. If a cyst becomes intolerably painful or is limiting activity, then other treatment may be recommended. Wearing a splint may help reduce the pain caused by a cyst.
The least invasive treatment of a cyst is draining it with a needle. This is successful in reducing symptoms and size of the cyst in about 50% of patients.
If non-surgical treatment fails to relieve the symptoms, removal of the cyst may be recommended by your surgeon. Cyst removal is successful in relieving symptoms in most cases. However, cysts on the back of the wrist may recur in up to 5% of cases. Cysts on the front, or palm side, of the wrist may recur in up to 20% of cases.
Surgery for cyst removal is an outpatient procedure, and is performed under local anesthesia. Typically, you may return to work within a few days of surgery. Ask your doctor for further details.
What is the TFCC?
The TFCC (triangular fibrocartilage com-plex) is a ligament and cartilage complex that hold the two forearm bones together in the wrist. The motion and stability of this joint allows rotation of the forearm.
What Does a TFCC Tear Feel Like?
Pain on the small finger side of the wrist is common. Many patients experience painful clicking with movement of the wrist and forearm.
How is the TFCC Injured?
The TFCC can tear from a variety of inju-ries. Common mechanisms of injury in-clude a fall on an outstretched hand, heavy or awkward lifting, extreme twist-ing of the forearm. Many tears are asso-ciated with other injuries such as a frac-ture of the wrist.
What are the Treatment Options for a Torn TFCC?
Activity modification and anti-inflammatory medication may reduce but not eliminate the pain. Physical therapy may be helpful. If the pain is tolerable then the problem can be observed. If sur-gery is need to correct the problem it can be delayed to a convenient time. The surgical treatment is performed arthro-scopically on an out patient basis. This consists of trimming the torn cartilage and/or repairing back to the bone. The repair requires an additional small incision on the side of the wrist.
How Long Does it Take to Recover From Surgery?
Generally it is a 2 to 3 month process. Recovery time is determined by the se-verity of the problem. When the TFCC is repaired back to bone the recovery is longer. Recovery is faster if the torn TFCC is simply trimmed. The type of treatment is determined at the time of surgery based on surgical findings. If the TFCC is repaired the first 4 to 6 weeks after surgery activity is very restricted. Lifting is limited to a few pounds and overhead activities are avoided. Progres-sive therapy starts at 4 to 6 weeks after surgery and full recovery is expected by 10 to 12 weeks. Time may vary widely depending on associated problems.
What are the Expected Results of Treatment?
Roughly 80% of patients achieve a good or excellent result. Thus, about 20% have some continued symptoms which maybe significant. A small group of patients may require additional surgery. The most common additional procedure done is an ulnar shortening osteotomy.
What Is It?
Any condition that irritates or destroys a joint is called arthritis. In a normal joint, cartilage covers the ends of the bones and allows them to move smoothly and painlessly against one another. With osteoarthritis (also called degenerative arthritis), the cartilage layer wears out and the bones rub against each other. As the cartilage layer continues to wear out, symptoms of arthritis develop and the joint is eventually destroyed.
In the hand, the second most common joint to develop osteoarthritis is the joint at the base of the thumb, or basilar joint. The basilar joint of the thumb is formed by a small wrist bone and the first bone of the three bones in the thumb (see Figure 1). The shape of these bones gives the thumb a wide range of movement – up and down, across the palm, and the ability to pinch with each finger.
Who Gets It?
Arthritis in the basilar joint of the thumb is more common in women than in men. It usually starts after age 40. Past injuries to this joint such as fractures, sprains, etc., may increase the chances of developing this type of arthritis.
Signs & Symptoms
The first symptom of basilar joint arthritis is pain with activities that involve gripping an object with the thumb and fingers (pinching). These activities could include opening jars, turning door knobs, opening car doors, and turning keys. Heavy use of the thumb may also cause pain in the basilar joint, as can changes in weather, such as a change in humidity or temperature. As the disease worsens, less activity is needed to produce pain. Pinching strength decreases and swelling may develop when using the thumb. As the arthritis continues to worsen, the basilar joint begins to look bigger and “out-of-joint.” At this point, movement of the thumb becomes limited.
Diagnosis
Close inspection will sometimes show a lump at the base of the thumb that can be swelling in the joint or displacement of the thumb’s first bone. Also, forcing the thumb firmly against the wrist bone while moving the joint will usually produce pain and may produce a gritty feeling. The pain and gritty feeling means that the bones are rubbing against each other . Early on, movement of the thumb is normal. Later, movement becomes more difficult, especially when sticking the thumb out to the side. In worse cases, as the joint wears away, the thumb’s first bone collapses into the palm when gripping smaller objects. The collapse of the first bone then causes the second joint to overextend when gripping larger objects.
Treatment
The pain of early basal joint arthritis will usually respond to non-surgical treatment: limiting movement of the thumb (placing a splint on the thumb) and using medicine (oral or local injection) to decrease swelling and pain. Patients with more severe cases may require surgery. Your doctor can advise you on the best treatment for your situation.
Initially, symptoms may be controlled with splints and anti-inflammatory medicine. In more severe case steroid injected into the joint may be needed to control the symptoms. Surgery is recommended when pain is limiting function of the hand and other treatment have failed to control the symptoms.
The surgery for thumb basal joint arthritis is done as an out patient. Use of the thumb is restricted for six weeks, and full power pinch strength take 12 weeks to recover. The surgical reconstruction has a very high success rate, and the results do not deteriorate with time. Ask you Doctor for more details.
ELBOW
What is Lateral Epicondylitis?
Lateral epicondylitis is a disorder caused by inflammation of forearm tendons at their attachment to the elbow. These tendons are responsible for extending the wrist. Therefore, lifting the wrist and hand can cause pain in the forearm and at the elbow. The lateral epicondyle (a bony prominence on the outside of the elbow) is where these tendons attach and the muscles in the forearm can become very painful.
What Causes Lateral Epicondylitis?
Routine use of the arm or trauma to the area can trigger inflammation at the attachment of the muscles. Generally, this is seen in people who perform activities or lifting with the palm side of the hand facing down and repetitive activities.
What Are the Symptoms of Lateral Epicondylitis?
Most of the pain is in the outer side of the elbow, near the lateral epicondyle (see Diagram). There may also be pain with gripping and wrist extension. The discomfort may extend into the forearm or towards the upper arm. In severe case the motion of the elbow may be limited.
How is it Treated?
Treatment for lateral epicondylitis starts with limiting the activities that cause pain (ie. palm down lifting) and physical therapy for stretching and strengthening exercises plus other inflammation reducing techniques. An elbow strap can help the limit the pull of the muscles on their bone attachments. A steroid injection may be used to relieve some of the discomfort. Anti-inflammatory medicine may also be recommended. Recovery is often slow requiring months for healing to occur.
In severe cases, which fail other treatments, your doctor may recommend surgery. The surgical procedure removes the chronic inflammation from the tendon. Tendon healing and complete recovery takes about 3 months. During recovery the hand and wrist can be used for light activity and lifting is avoided.
What is Medial Epicondylitis?
Medial epicondylitis is a disorder caused by inflammation of forearm tendons at their attachment to the elbow. These tendons are responsible for flexing the wrist. Therefore, lifting the wrist and hand can cause pain in the forearm and at the elbow. The medial epicondyle (a bony prominence on the inside of the elbow) is where these tendons attach and the muscles in the forearm can become very painful.
What Causes Medial Epicondylitis?
Routine use of the arm or trauma to the area can trigger inflammation at the attachment of the muscles. Generally, this is seen in people who perform activities or lifting with the palm side of the hand facing up and repetitive activities.
What are the Symptoms of Medial Epicondylitis?
Most of the pain is in the inner side of the elbow, near the medial epicondyle (see Diagram). There may also be pain with gripping and wrist flexion. The discomfort may extend into the forearm or towards the upper arm. In severe case the motion of the elbow may be limited.
How is it Treated?
Treatment for medial epicondylitis starts with limiting the activities that cause pain (ie. palm up lifting) and physical therapy for stretching and strengthening exercises plus other inflammation reducing techniques. An elbow strap can help the limit the pull of the muscles on their bone attachments. A steroid injection may be used to relieve some of the discomfort. Anti-inflammatory medicine may also be recommended. Recovery is often slow requiring months for healing to occur.
In severe cases, which fail other treatments, your doctor may recommend surgery. The surgical procedure removes the chronic inflammation from the tendon. Tendon healing and complete recovery takes about 3 months. During recovery the hand and wrist can be used for light activity and lifting is avoided.
SHOULDER
What is a Labral tear?
A labral tear is a cause of shoulder pain. The labrum is a cartilage ring which surrounds the shoulder socket. The biceps tendon, which comes from the muscle on your arm, goes through the shoulder joint and attaches to the top of the labrum.
How does a Labral tear occur?
Many times, a Labral tear occurs from repetitive trauma in overhead throwers, such as baseball or volleyball. It can also occur from a traction injury to the arm, such as lifting a heavy object off the ground, or getting your arm jerked.
How do I know I have a Labral tear?
Many patients with a Labral tear have pain in the front of the shoulder or deep inside the joint. There also may be a feeling of catching or grinding in the joint. The examination in the office usually confirms the presence of a Labral tear.
Do I need x-rays, an MRI, or any other test?
A set of x-rays is usually ordered to make sure there are no fractures in the shoulder. An MRI is helpful to confirm the tear of the labrum or biceps tendon, and evaluate other areas of the shoulder like the rotator cuff. Sometimes we order a test called an MR arthrogram. This is an enhanced MRI were they inject fluid into your shoulder, and if there is a tear the fluid will like into areas it does not belong. This is the best test for the confirmation of Labral tears.
Is there other damage to the shoulder in cases of Labral tears?
There can be other damage to the labrum seen with Labral tears, usually in the cases of shoulder instability. The biceps tendon itself can also be frayed or torn. Typically there is not a rotator cuff tear associated with this, but it is possible depending on how the injury occurred.
What are the treatment options for Labral tears?
The treatment primarily depends on your activity level and symptoms. Since Labral tears can often be difficult do diagnose, they are often first treated with physical therapy. The therapy is designed to restore range of motion and strength to the shoulder. The therapy does not eliminate the tear. Labral tears untreated do not heal because of the lack of blood supply in the area. In cases of persistent pain and disability, surgery is recommended.
How are Labral tears treated with surgery?
Labral tears are repaired arthroscopically. The arthroscope is a fiber optic instrument (narrower than a pen) which is put into the joint through small incisions. A camera is attached to the arthroscope and the image is viewed on a TV monitor. The arthroscope allows me to fully evaluate the entire shoulder joint, including the ligaments, the labrum, the biceps tendon, the rotator cuff, and the cartilage surface. Small instruments ranging from 3-5 millimeters in size are inserted through additional incisions so that I can feel the joint structures for any damage, diagnose the injury, and then repair, reconstruct, or remove the damaged tissue. With Labral tears, the damaged labrum is identified and then repaired back to the socket. This usually performed by using suture anchors to sew the labrum back in place. Occasionally, the biceps tendon is too damaged to repair. In this case, the tendon is cut and reattached in the upper arm (biceps tenodesis).
What are some of the possible complications?
While complications are not common, all surgery has associated risk. Possible complications include stiffness of the shoulder after surgery or recurrent pain. The use of arthroscopic techniques attempts to limit these complications. Other complications include an infection, bleeding, nerve damage, or problems with the anesthesia.
What do I need to do to prepare for surgery?
Our staff will help to set up the surgery through your insurance company and will instruct you on any paperwork that may be necessary. If you are over the age of 50, or have significant health conditions you may require an EKG and chest x-ray. You may also need to see your internist or family doctor to obtain a Letter of Medical Clearance. The day before the surgery, a member of the hospital or surgery center staff will contact you about what time to arrive for surgery. You may not eat or drink anything after midnight before your surgery.
How long will I be in the hospital?
Almost all patients are able to have surgery and go home the same day.
What happens the day of surgery?
The day before surgery you will be told what time to report to the hospital. You will be admitted and taken to a pre-operative holding area where you are prepared for surgery. You will be asked several times which extremity I am operating on, this question is asked many times on purpose.
After the operation, you will be taken to the recovery room to be monitored. Once the effects of anesthesia have worn off and your pain is under control, you will be given your post-operative instructions and a prescription for pain medication. Please be aware that the process of getting checked in, prepared for surgery, undergoing the operation, and recovering from the anesthesia takes the majority of the day. I would recommend that you and your family members bring some reading material to help make the process easier.
How should I care for my shoulder after surgery?
Prior to your discharge, you will be given specific instructions on how to care for your shoulder. In general you can expect the following:
Diet:
Resume your regular diet as soon as tolerated. It is best to start with clear liquids before advancing to solid food.
Medication:
You will be given a prescription for pain medication before you go home. Advil or aleve can also be used.
Sling: You will have a sling, which you will use for the first 2 to 4 weeks. You can remove the sling for showering and performing your home exercise program.
Ice: You should apply ice over the dressing for 30 minutes every 1 to 2 hours for several days. Sometimes we use a device called a Polar Care Cold Therapy Unit to help administer ice to your shoulder. Often insurance companies do approve this. If you want one, there is a cost. Do not use heat the first week after surgery.
Suture Removal:
Sometimes absorbable sutures are used, they do not need to be removed. Occasionally, there are non-absorbable sutures, and they will be removed on your first post-operative visit.
Follow-up office visit:
You will be instructed on when to follow-up in the office. This is usually 2 weeks after surgery.
Exercise:
You will be instructed prior to your surgery on exercise to begin the day after your surgery.
Return to school or work:
You can return to school or work when your pain is under control, and you can perform the needed daily activities. If you need to use the arm to return, you may be out of work or school for a longer period of time.
What will rehabilitation involve?
The rehabilitation is based on several goals: 1) allowing the tissue to heal; 2) regaining your range of motion; 3) regaining strength; 4) return to full duty at work, or return to sports. You will attend PT 2-3 days per week.
When can I return to sports?
In general, you will be allowed to return to sports in 4 – 6 months after surgery. You must have good motion, strength, and control of your shoulder and arm. How quickly you return to sports depends on several factors, including: 1) your own rate of healing; 2) the damage found at surgery; 3) if you have any complications (like stiffness); 4) how well you follow the post-operative instructions; 5) how hard you work in rehabilitation.
When can I return to full duty at work?
You may return back to work in a matter of days, but on limited duty. In general I keep people on clerical duties for 6 weeks after the surgery, which means no lifting with your operated arm. This is to protect the repair. In the second month I allow you to perform light duty meaning lifting no more than 10 pounds. People generally get back to performing full duty at work from 3 to 4 months, depending on the type of work.
What is the success rate?
The success rate for a Labral repair ranges from 85 to 95%. The goal is to achieve a shoulder with no pain for lifting, throwing, or overhead activity.
What is the rotator cuff?
The rotator cuff is made up of four muscles and their tendons. The muscles attach at the shoulder blade (scapula) and extend out to form a cuff around the shoulder joint and insert at the upper portion of the arm (humerus). These four muscles are the supraspinatus, subscapularis, infraspinatus, and teres minor. These four muscles help to elevate and rotate the arm. In addition, these muscles help to stabilize the ball of the shoulder joint (humeral head) in the shallow socket of the shoulder blade (glenoid). The rotator cuff works especially hard to stabilize the shoulder when the arm is in the overhead position. This is why overhead activities can cause pain in someone with a rotator cuff injury.
What is a rotator cuff injury?
Most rotator cuff injuries are an inflammation of the tendon called tendonitis. The tendon gets overworked or sometimes gets pinched between the bones of the shoulder and becomes inflamed. This term is “impingement syndrome”. In addition, there is a bursa which lies between the rotator cuff and the bone of the scapula (acromion). This bursa is a fluid filled sac that reduces the friction between the tendon and the acromion. Sometimes this subacromial bursa becomes inflamed along with the tendon, a condition called “bursitis”.
Sometimes the tendonitis will progress to the point that the tendon becomes frayed or torn. Tears of the rotator cuff can be partial thickness tears only go part way through the tendon. Full thickness tears extend all the way through the tendon, and the tendon is detached from the bone. Once a rotator cuff tear has occurred they do not heal.
How is the rotator cuff injured?
Most commonly, the rotator cuff tendons wear and weaken with use until they eventually tear. In addition, in a tendon that already has some “wear and tear” a small amount of trauma, such as a pulling or lifting injury, can lead to a full thickness tear. Occasionally, there is a severe traumatic injury that also may cause the tear, such as an accident or fall. Rotator cuff tears occur most commonly in patients age 50 and older, and in people who play sports or perform a lot of overhead work.
How do I know my rotator cuff is injured?
Injuries to the rotator cuff most typically cause pain, especially with overhead activities. In addition, rotator cuff injuries or tears cause shoulder pain at night and lead to difficulty sleeping. Most patients that have a rotator cuff injury will complain of pain on the lateral or side of the shoulder. With large rotator cuff tears you may notice weakness in doing overhead activities. You may also have pain with activities of daily living, such as dressing, bathing, and reaching outward.
Do I need x-rays, a MRI, or any other test?
A set of x-rays is usually ordered to evaluate the bones around the shoulder. The bone above the rotator cuff, called the acromion, can be hooked, or have a bone spur, which leads to pinching and irritation of the rotator cuff. The x-rays are also used to evaluate for arthritis of the shoulder joint (glenohumeral joint), and acromio-clavicular joint (AC joint). An MRI may be ordered if a rotator cuff tear is suspected, or if the patient is not improving with conservative treatment.
Is there other damage to the shoulder when the rotator cuff is injured?
There is frequently other damage to the shoulder that can occur with rotator cuff injuries. The biceps tendon, which runs from the muscle in the front of the arm to the top of the shoulder joint, can become frayed or torn. You can also tear the labrum is a fibrous ring of tissue that surrounds the shoulder socket. In addition, the acromioclavicular joint, the joint on top of the shoulder, can become damaged or arthritic. Arthritis of the acromioclavicular joint commonly occurs along with rotator cuff injuries or tears.
What are the treatment options for rotator cuff injuries?
Many patients with a minor rotator cuff injury improve with conservative treatment. The treatment includes exercises, use of anti-inflammatory medications (NSAIDs), and possibly an injection of steroid (cortisone injection). The exercises may be a program you can do at home, or more commonly a formal physical therapy program. A cortisone injection is commonly used. Some patients get better with these treatments and do not need surgery. However, often the tear does not heal and may get bigger or if patients have an acute rotator cuff tear, surgery may be necessary.
How are rotator cuff injuries treated with surgery?
The surgery for rotator cuff injuries depends on the extent of the problem. Some rotator cuff tears can be repaired arthroscopically. The arthroscope is a fiber optic instrument (narrower than a pen) which is put into the joint through small incisions. A camera is attached to the arthroscope which allows me to fully evaluate the entire shoulder joint, including the ligaments, the rotator cuff, the labrum, and the cartilage surfaces. Small instruments ranging from 3-5 millimeters in size are inserted through additional incisions so that I can feel the joint structures for any damage, diagnose the injury, and then repair, reconstruct, or remove the damaged tissue. For cases involving bad tendonitis or partial thickness rotator cuff injuries the entire procedure is done with the arthroscope. The under side of the acromion is shaved down (an acromioplasty or decompression) which allows the rotator cuff to glide better, and not get pinched. If the rotator cuff is frayed, it is cleaned up (debrided).
For cases involving full thickness tears of the rotator cuff, the tear can sometimes be repaired completely arthroscopically. The bone is prepared for the tendon to be reattached, and then metal anchors (titanium suture anchors) are placed in the bone which contain sutures. These sutures are then weaved through the tendon, and the tendon is mobilized back to its bony attachment. These metal anchors are deep in the bone and do not need to be removed.
If the tear is large or longstanding, the surgery in rare cases needs to be performed with an open incision. This incision is placed in the area of the rotator cuff on the side of the shoulder, and the repair is performed with suture anchors and bone tunnels. This is called a “belts and suspenders” repair, which is the strongest repair that can be performed. This is called a “mini-open” rotator cuff repair.
What if I have pain or arthritis of my acromioclavicular (AC) joint?
Pain directly on top of the shoulder in the acromioclavicular (AC) joint can be treated with surgery. The surgery is to remove a small portion of the end of the clavicle bone, to eliminate rubbing between the bones. This then eliminates the pain. This procedure can be performed with the arthroscope or through a small 1 inch incision. There is no significant problem with arm strength when the end of the clavicle is removed.
What are some of the possible complications?
While complications are not common, all surgery has associated risk. Possible complications include stiffness of the shoulder after surgery or recurrent pain. Other complications include an infection, bleeding, nerve damage, or problems with the anesthesia.
What do I need to do to prepare for surgery?
Our staff will help to set up the surgery through your insurance company and will instruct you on any paperwork that may be necessary. If you are over the age of 50, or have significant health conditions you may require an EKG and chest x-ray. You may also need to see your internist or family doctor to obtain a Letter of Medical Clearance. The day before the surgery, a member of the hospital or surgery center staff will contact you about what time to arrive for surgery. You may not eat or drink anything after midnight before your surgery.
How long will I be in the hospital?
Almost all patients are able to have surgery and go home the same day.
What happens the day of surgery?
The day before surgery you will be told what time to report to the hospital. You will be admitted and taken to a pre-operative holding area where you are prepared for surgery. You will be asked several times which extremity I am operating on, this question is asked many times on purpose.
After the operation, you will be taken to the recovery room to be monitored. Once the effects of anesthesia have worn off and your pain is under control, you will be given your post-operative instructions and a prescription for pain medication. Please be aware that the process of getting checked in, prepared for surgery, undergoing the operation, and recovering from the anesthesia takes the majority of the day. I would recommend that you and your family members bring some reading material to help make the process easier.
How should I care for my shoulder after surgery?
Prior to your discharge, you will be given specific instructions on how to care for your shoulder. In general you can expect the following:
Diet:
Resume your regular diet as soon as tolerated. It is best to start with clear liquids before advancing to solid food.
Medication:
You will be given a prescription for pain medication before you go home.
Sling:
You will have a sling, which you will use for the first 2 to 4 weeks. You can remove the sling for showering, performing your home exercise program.
Ice:
You should apply ice over the dressing for 30 minutes every 1 to 2 hours for several days. Do not use heat the first week after surgery. You may be given a cold therapy unit the day of surgery.
Suture Removal:
Absorbable sutures do not need to be removed. There may be non-absorbable suture, and it will be removed on your first post-operative visit.
Follow-up office visit:
You will be instructed on when to follow-up in the office. This is usually 2 weeks after surgery.
Exercise:
You will be instructed prior to your surgery on exercise to begin the day after your surgery. You will start formal physical therapy anywhere from 2 days to 2 weeks post op.
Return to school or work:
You can return to school or work when your pain is under control, and you can manage your daily activities. If you need to use the arm to return, you may be out of work or school for a longer period of time.
What will rehabilitation involve?
The rehabilitation is based on several goals: 1) allowing the tissue to heal; 2) regaining your range of motion; 3) regaining strength; 4) return to full duty at work, or return to sports.
When can I return to sports?
In general, you will be allowed to return to sports in 4 – 6 months after surgery. You must have good motion, strength, and control of your shoulder and arm. How quickly you return to sports depends on several factors, including: 1) your own rate of healing; 2)
the damage found at surgery; 3) if you have any complications (like stiffness); 4) how well you follow the post-operative instructions; 5) how hard you work in rehabilitation.
When can I return to full duty at work?
In general I keep people on clerical duties for 3 months after the surgery, which means no lifting with your operated arm. This is to protect the repair. In the 3rd and 4th month I allow you to perform light duty meaning lifting no more than 10 pounds. People generally get back to performing full duty at work from 4 to 6 months.
What is the success rate?
The success rate for a rotator cuff repair ranges from 85 to 95% for attaining pain relief. If weakness is a significant problem, the results for regaining strength can be more variable.
Shoulder replacement surgery is a less common surgical intervention than hip and knee, but is also tremendously successful and scores high satisfaction rates. Like hip and knee replacement, it is an option for those who have failed conservative treatment and have an ongoing pain pattern that affects activities of daily living. The operation resurfaces both the ball (humeral head) and socket (gleniod) with metal and plastic implants. For further education and illustrations click on the link above.
KNEE
If you suffer from arthritis in one or both of your knees, you have many options to control arthritic associated pain and stiffness. Treatments include exercise, weight control, physical therapy, medication, injections, bracing and arthroscopy. When these conservative therapies fail you may become a candidate for total knee replacement. Partial or total knee replacement can relieve pain associated with arthritis as well as increase mobility improving overall quality of life. This operation resurfaces the damaged articular surface of the knee joint with metal and plastic implants. For further education and illustrations click on the link above.
Partial Knee Replacements
Partial knee replacement or unicompartmental knee replacement is an advancement in replacement technique. Those individuals with focal arthritis limited to one area of the knee may be a candidate for this procedure provided they have exhausted conservative treatments. As the name implies it replaces only part of the knee. There are three areas that can be resurfaced with metal and plastic implants. They are the patellofemoral joint (knee cap), medial compartment and lateral compartment. The medial compartment is most common. This procedure allows for a smaller incision, less blood loss, shorter hospital stay and quicker return to more normal activities.
Patello-Femoral Joint Anatomy
Joint is the generic name for the places in the body where two or more bones are joined together. They are also the places where the skeletal structure moves or articulates. Articular cartilage covers or encapsulates these bony surfaces. Several of the major joint systems are weight bearing. This combination of functions (movement, bone connection and weight-bearing) makes the joints some of the most susceptible areas in the body for injury and chronic pain.
Patello-Femoral Cartilage Damage
Articular cartilage is a thin, whitish, glistening layer of protective tissue that covers the joint surfaces of bones. Articular cartilage is composed of hyaline cartilage cells, which have many unique properties that allow it to function effectively as a smooth and lubricious load-bearing surface. Small defects in the articular surface can cause pain and restrict range of motion. When traumatized or injured, new hyaline cartilage cells do not replace damaged hyaline cartilage cells. Several joint diseases (e.g. rheumatoid arthritis) are complex inflammatory disease processes that slowly deteriorate the overall joint surface and often affect multiple joints at the same time. Arthrosurface’s technology is not intended to treat these systemic joint diseases.
A different type of joint disease is the result of injury to a relatively small, localized area of the articular surface. These injuries create defects in the articular surface. These injuries or defects can be caused by either acute or repetitive trauma, as when one bony surface strikes against the opposing bony surface. The trauma may have occurred from athletics, a fall, car crash or other high-energy event or impact. These defects may also be caused by chronic conditions that cause the joints to load disproportionately on one side or area. These joint surfaces appear largely normal but have one or more localized lesions or defects. These defects range from a softening of the articular cartilage to complete loss of articular cartilage thus exposing the underlying bone.
Orthopedic surgeons classify the severity of the defect by assigning a grade from one to four, four being the most serious. A severe lesion (grade IV) looks like a hole or deep pockmark in an otherwise smooth, shiny articular surface. The severity (depth, size and location) of the lesion will often determine whether and what type of surgical intervention may be employed. Grade IV lesions, in particular, are defined as full-thickness defects where the underlying bone is exposed. Many physicians also believe that smaller lesions deteriorate over time and, therefore, Grade III lesions are likely to become Grade IV lesions.
Patello-Femoral – Existing Treatments
Microfacture/Microdrilling Technique
This technique is very similar to abrasion arthroplasty except that the bleeding is initiated by impacting awls, picks or drilling directly into the bone within the lesion.
Articular defects that are larger than 15mm in diameter are generally believed to require a more aggressive intervention and are typically treated using one of the following approaches, most of which are performed as open surgery:
Autografts
MosaicPlasty (OATS)
This technique was popularized in the mid-1990s. In MosaicPlasty, a series of dowel cutting instruments are used to harvest one or more cylindrical plugs or grafts of articular cartilage and bone from the surrounding healthy tissue. These tube-like grafts are then implanted into the defect site. A series of these plugs placed in close proximity to one another is used to establish a new grafted hyaline cartilage surface. A limited number of surgical institutions are performing this procedure as it is technically very challenging. Outcomes for these patients have been reported as variable based on surgeon expertise, and patient selection. In addition, pain relief has been found to be inconsistent. A lengthy post-operative regime of non-weight bearing (up to 2-6 months) and continuous passive motion has also been identified as a major contributor to the success of this procedure.
Autologous Cell Transplantation
ACI (Carticel®)
ACI is a therapeutic treatment whereby healthy hyaline cartilage cells are harvested from the patient, the cell counts are increased in vitro (outside the body) via some type of bioreactor expansion technique, and then those cells are injected back into the defect. This technique is still considered somewhat experimental.
Total Knee Replacement
For patients with large articular defects a procedure known as “total knee replacement” is often required. This procedure requires the removal of substantial amounts of bone followed by the implantation of a prosthetic device. Patients who undergo TKR often describe a restoration of lifestyle/activity that is profound; however, rehabilitation periods following this procedure are several months or even longer.
While the useful life of a TKR is generally claimed to be up to 20 years, clinical evidence indicates that complications can begin to arise at approximately 8 – 10 years. Each successive TKR (commonly referred to as a “revision”) has been shown to have a shorter useful life than the previous implant. With each revision, the amount of remaining good quality bone stock into which the implants are anchored becomes an issue. Bone loss as a result of tissue reaction, implant loosening, implant preparation, etc., can lead to great challenges in restoring a solid anchoring site for the implant. As the revision or replacement of these devices can lead to increased morbidity (complications) and result in a very difficult rehabilitation for older patients, efforts are made to forgo the TKR procedure for as long as possible. Therefore, there is a reluctance to use TKR in patients under 60 years of age. Similar concerns and issues are prevalent in total hip replacement procedures as well.
Resurfacing Arthroplasty
Resurfacing arthroplasty is the replacement of only the articular surface of a joint which means that only the damaged portion of the joint is resurfaced. Therefore a smaller amount of diseased tissue is being removed when compared to a total joint.
The HemiCAP® implant is a rounded, cap-like implant made from a cobalt chrome alloy with a central post on the implanted, or bone side. Cobalt chrome is a material that has been used in total joint reconstruction devices for over two decades. This material has proven to provide a safe, effective and strong weight-bearing surface in joints. The HemiCAP® system precisely aligns the surface of the implant to the contours of the patient’s articular cartilage surface, thus filling the defect and restores a smooth and continuous articulating surface.
Arthrosurface believes that the HemiCAP® implant will offer the following clinical benefits:
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The McKeever Patellar Resurfacing Prosthesis (Howmedica®), has been used in the treatment of grade III and grade IV degenerative changes in the patellofemoral joint. This anatomically shaped polished metallic patellar device was designed to maximize the area of contact with the opposed femoral articular cartilage, and differed from other non-anatomic dome-shaped designs of that time. In a series completed from 1972 to 1985, with an average of 8.1 years follow-up, excellent results were obtained in 81% of the cases. Further, no progressive degenerative changes in the opposed femoral articular cartilage associated with the prosthetic were identified over the prolonged follow-up evaluation of up to 16 years.
Patello-Femoral – Product Overview
The Arthrosurface® HemiCAP® system is a surgical method for the treatment of localized cartilage lesions and defects in the major joints. This system is comprised of three elements; a three-dimensional mapping technology, a set of instruments to map and prepare the damaged area and a cobalt-chrome and titanium implant placed opposite to a polyethylene implant. The system precisely aligns the surface of the implant to the contours of the patient’s articular cartilage surface, thus filling the defect and restoring a smooth and continuous articular surface. The HemiCAP® system has been developed so that it can be utilized via minimal access surgical techniques.
There are 2 systems that comprise the Patello-Femoral Line. The first is the Classic Focal HemiCAP which is used for isolated and well contained lesions of the trochlea groove and the patella. The second system is called the WAVE and is used for those patients that have more diffuse or extensive damage to their PF joint. Both systems use the same proven intraoperative mapping technology of all HemiCAP systems.
The HemiCAP® Instrument Set enables the surgeon to accurately place the implant and precisely map the curves of the articular surface, in real-time, under direct or arthroscopic visualization, with no angle-induced errors or magnification errors that might exist with MRI, or X-ray imaging techniques.
The HemiCAP® system is intended to provide an effective interim means for managing pain and disability in the middle-aged patient until a total joint replacement treatment option becomes more necessary, and is part of a clinical treatment strategy to help avoid early-age-revision scenarios. The prosthetic may also provide a treatment option for the older patient who may not tolerate the morbidity of a total joint replacement procedure.
The HemiCAP® implants and instruments are designed to remove a minimal amount of bone stock, preserve functional structures and tissues, and allow for an uncomplicated removal in the event of revision.
What is a total knee replacement?
A knee replacement involves removing a thin layer of bone from the damaged surface of the femur (thigh bone), using special instruments which remove the correct thickness of bone. The removed bone is then replaced by a thin layer of metal, approximately the same dimensions and thickness as the bone which was removed.
In a similar fashion the upper end of the tibia (shin bone) is removed and is replaced with a metal plate. In between the metal place on the femur and the metal place on the tibia is a thin wafer of plastic which acts as the new cartilage. The back part of the kneecap (patella) is also resurfaced with a thin layer of plastic to get rid of the arthritis in this area.
After the knee has been replaced, the metal covering the end of the femur rubs against the plastic covering the metal on the end of the tibia, preventing bone from rubbing on bone and giving relief of pain. The plastic is a high density polyethylene material which has a very low wear-rate and very low frictional resistance when rubbing against a highly polished metal surface.
What are some of the possible complications of surgery?
While complications are not common, all surgery has associated risks. Possible complications include stiffness of the knee after surgery or continued pain. Other complications include infection, bleeding, nerve injury, blood clots, or problems with anesthesia or underlying medical conditions. In the hospital, we usually have a medical doctor follow patients for their medical conditions and we take every precaution against blood clots and infection.
What kind of anesthesia is used?
Total knee replacement is usually performed with general anesthesia (going to sleep), but sometimes it may be performed with regional anesthesia (spinal or epidural block). The type of anesthesia will depend on your choice, as well as what the anesthesiologist best recommends for you. I recommend that you undergo a continuous femoral nerve block, which is performed by anesthesia before your surgery. This is an excellent tool to minimize pain in a patient’s knee for the first 2-3 days. The difference has been amazing, in that a lot of patients are not using much oral medication for the first several days and are much more relaxed and are improved during physical therapy.
What do I need to do to prepare for surgery?
My staff will help to set up the surgery through your insurance company and will instruct you on any paperwork that may be necessary. If you are over the age of 50, or have significant health conditions, you may require an EKG and a chest x-ray. You may also need to see your internist or family doctor to obtain a letter of medical clearance.
The day before surgery a member of the hospital will contact you about what time to arrive for your surgery. You may not eat or drink anything after midnight before the surgery.
How long will I be in the hospital?
Hospitalization is usually a 3 to 4 day length. Sometimes patients get out sooner, but rarely do patients spend any time longer than 4 days. Sometimes patients are not able to go home but are required to go to a rehab or skilled nursing facility to get added physical therapy before they go home. This will be individualized while you are in the hospital and social services will help us coordinate this if it is a necessary option.
What happens the day of surgery?
The day before surgery you will be told what time to report to the hospital. You will be admitted and taken to a pre-operative holding area where you are prepared for surgery. You will be asked several times which extremity I am operating on. Please note that you are asked this question many times on purpose.
Please be aware that the process of getting checked in, prepared for surgery, undergoing the operation, and recovering from anesthesia takes the majority of the day. I would recommend that you and your family members bring along some reading material to make the process easier for all.
After your surgery, you will then be taken to the recovery room to be monitored. Once the effects of anesthesia have worn off and your pain is under good control, you will be transferred to your room in the hospital. All of the rooms at Des Peres Hospital are private rooms.
After your surgery you will have a drain in your joint as well as a Foley catheter in your bladder. The drains are usually removed the next day in all patients and the Foley catheter is removed the next day for men. In women, I usually leave the Foley catheter in for several days until a patient is able to get up better and get to the bathroom much easier.
How should I care for my knee after surgery?
During your hospitalization you will begin physical therapy the day after your surgery as well as a continuous passive motion (CPM) machine. During the hospitalization you will be helped with walking, you will be instructed on stair climbing and range of motion exercises. For the first day or two your knee might be in an immobilizer because of the use of the femoral nerve block. The femoral nerve block helps out with post-operative pain but may make your muscles weak for a day or two. To ensure that your knee does not give out, we may use a knee immobilizer while doing some of the physical therapy exercises while walking. You certainly do not need to have that on in bed or obviously when you are on the continuous passive motion machine.
After you are discharged from the hospital, you will have a continuous passive motion machine at home and will have a home physical therapist usually coming for three times a week for two to three weeks.
Medication:
You will be given a prescription for pain medication and an antibiotic. You will be instructed to take a regular aspirin daily to minimize the effects of blood clots.
Showering:
You may shower when you get home from the hospital. If you have a safe shower, you may go ahead and take your dressing off and enter the shower. I do not want you soaking the knee, but do not mind a little shower water coming down across your knee. After you get out of the shower you will be instructed to take a little bit of hydrogen peroxide on a clean washcloth and dab off the knee to clean it. You will then place a dressing on for that day. If you do not take a shower, we still want you to clean the incision off once a day with hydrogen peroxide.
Walker/Crutches:
You will be instructed on how to use an ambulatory device after your surgery while in the hospital. Most patients elect to use a walker and this will be supplied to you. You may put as much weight as you feel comfortable on your knee, but you certainly will advance your weight-bearing with the walker until you are able to switch to a cane. The time that people take to switch to a cane varies, but some people can do that after a week and are comfortable doing so.
Diet:
Your regular diet will be resumed in the hospital as tolerated.
Follow up:
A follow up appointment will be made at two weeks post-operatively, where we will remove the staples.
What will rehabilitation involve?
The rehabilitation is based on several goals: 1) allowing the tissues to heal; 2) regaining motion; 3) regaining strength; and 4) return to normal activities or activities that you have not been able to do for some time because of your arthritis. Most of the time patients will not need any formal physical therapy after the home physical therapy. However, if a patient is having trouble with motion, an outpatient physical therapy program may be recommended. A continuance of the exercises learned in the hospital and by the home physical therapy after discharge from the hospital can usually be performed by a patient to continue to obtain better range of motion and better strength.
When can I return to regular activities or work?
A return to a desired activity level certainly depends on how fast a patient may heal. In general, people may return to a sedentary type job at four weeks or so. Certainly more strenuous jobs will take longer and may be in the neighborhood of two to three months.
I want you to have good motion, strength, and control of your knee before returning to your job. How quickly you return depends on several factors including: 1) your rate of healing; 2) the presence of any complications; 3) how well you follow physical therapy and post-operative instructions; and 4) how hard you work in rehabilitation.
What is a tibial tubercle osteotomy?
An osteotomy is the movement of the insertion of the patella tendon by cutting through it and then re-securing it with two screws, in order for it to heal in this new location at the insertion of the patella tendon as it inserts into the top of the tibia (shin bone). This procedure is done for several reasons. One reason we perform this procedure is in patients who have instability of the patella (kneecap) to prevent it from dislocating. The other reason this procedure is performed is to correct significant maltracking that may be leading to significant arthritic changes behind the kneecap. By moving the bone, we can correct the malalignment of the kneecap in the groove of the femur (thigh bone) and eliminate symptoms of instability and decrease the symptoms of arthritis. Whereas the procedure is done to cure instability in patients who have an unstable kneecap, the procedure is performed to decrease symptoms of arthritis in patients who need this procedure. In other words, we cannot cure arthritis with a knee arthroscopy or with this procedure but can significantly eliminate the symptoms of pain by reducing the forces on the kneecap.
An arthroscopic procedure is performed with this procedure in order to inspect the inside of the joint.
What is arthroscopy?
The arthroscope is a fiber optic instrument (narrower than a pen) which is put into the knee joint through two small incisions. A camera is attached to the arthroscope and the image is viewed on a TV monitor. The arthroscope allows me to fully evaluate the entire knee joint, including the knee (patella), the cartilage surfaces, the meniscus, the ligaments (ACL & PCL), and the joint lining. Small instruments ranging from 3-5 millimeters in size are inserted through the incisions so that I can feel the joint structures for any damage, diagnose the injury, and then repair, reconstruct, or remove the damaged tissue. Before the development of arthroscopy, large incisions had to be made over the knee joint to treat or diagnose injuries. Today’s arthroscopic techniques allow more complete evaluations of the knee joint while accelerating the rehabilitation process.
What are some of the possible complications of surgery?
While complications are not common, all surgery has associated risks. Possible complications include stiffness of the knee after surgery or continued pain. The use of arthroscopic techniques attempts to limit these complications. Other complications include infection, bleeding, nerve damage, blood clots, or problems with the anesthesia. Although I have never seen it in my patients, there is a chance that the osteotomy will not heal. Certainly it is also possible that if a trauma or other unplanned event would happen after surgery, or if the restrictions are not followed closely, the osteotomy could be pulled away from the bone.
What kind of anesthesia is used?
Knee arthroscopy can be performed with general anesthesia (going to sleep), or regional anesthesia (spinal or epidural block). The type of anesthesia will depend on your choice. The anesthesiologist will discuss your options the morning of surgery. The anesthesiologist will also talk to you about getting a femoral nerve block. This is a very useful procedure to minimize pain for the first eighteen to thirty-six hours and I would strongly recommend that patients undergo this procedure.
What do I need to do to prepare for surgery?
Our staff will help to set up the surgery through your insurance company and will instruct you on any paperwork that may be necessary. If you are over the age of 50, or have significant health conditions you may require an EKG and chest x-ray. You may also need to see your internist or family doctor to obtain a Letter of Medical Clearance. The day before the surgery, a member of the hospital or surgery center staff will contact you about what time to arrive for surgery. You may not eat or drink anything after midnight before your surgery.
How long will I be in the hospital?
Knee arthroscopy is an outpatient procedure you will go home the same day.
What happens the day of surgery?
The day before surgery you will be told what time to report to the hospital or surgery center. You will be admitted and taken to a pre-operative holding area where you are prepared for surgery. You will be asked several times which extremity I am operating on. Please note that you are asked this question many times on purpose.
After the operation you will be taken to the recovery room to be monitored. Once the effects on anesthesia have worn off and your pain is under good control, you will be given your post-operative instructions and prescription for pain medication and released. Please be aware that the process of getting checked in, prepared for surgery, undergoing the operation, and recovering from anesthesia takes the majority of the day. I would recommend that you and your family members bring along some reading material to make the process easier for all.
How should I care for my knee after surgery?
Prior to your discharge, you will be given specific instructions on how to care for your knee. In general you can expect the following:
Medication:
You will be given a prescription for pain medication.
Showering:
You may not shower until you see me back on the third postoperative day.
Crutches:
You will be instructed how to use crutches before the surgery. You should bring a set of crutches with you to the surgery. How long you use crutches will depend on the type of surgery performed. Crutches are commonly used for several weeks until you get your muscle control back and until we feel comfortable with you allowing to put weight on it.
Brace:
A straight leg brace is placed on the day of surgery. This brace will remain on your knee until we see each other back on the third post-operative day. On that visit we will change your dressing and instruct you on how to start some early range of motion.
Diet:
Resume your regular diet as soon as tolerated. It is best to start with clear liquids before advancing to solid food.
Ice:
You should apply ice over the dressing for 20 -30 minutes every hour for several days. Do not use heat for the first 48-72 hours.
Suture removal:
Some stitches are absorbable and do not need to be removed. However, if there are stitches they will be removed on your first post-op visit.
Return to work or school:
You can return to school or work anywhere from 2 days to 2 weeks. If your job involves more extended walking or heavy activity, you may be out of work or school for a longer period of time.
What will rehabilitation involve?
The rehabilitation is based on several goals: 1) allowing the tissue to heal; 2) regaining motion; 3) regaining strength; and 4) return to sports or work activity. After lateral release, the rehabilitation generally occurs very rapidly. We will instruct you on a home physical therapy program on your first post-operative visit on Day 3. Simple exercises and range of motion will be given to you to perform on your own. Formal physical therapy usually does not start until about three weeks post-op, due to the fact that there is not much for them to do in the early going. After you start physical therapy, the emphasis will be on range of motion, improving your quadriceps muscle function, and restoring normal weightbearing and ambulation.
When can I return to sports or full duty at work?
How quickly you return depends on several factors, including: 1) your own rate of healing; 2) the damage found at surgery; 3) if you have any complications; 4) how well you follow the post-operative instructions; 5) how hard you work in rehabilitation. Obviously the type of work an individual does will determine how soon they go back to that type of activity. As far as full sports activity, it usually will take approximately four months.
What is arthroscopy?
The arthroscope is a fiber optic instrument (narrower than a pen) which is put into the knee joint through two small incisions. A camera is attached to the arthroscope and the image is viewed on a TV monitor. The arthroscope allows me to fully evaluate the entire knee joint, including the knee (patella), the cartilage surfaces, the meniscus, the ligaments (ACL & PCL), and the joint lining. Small instruments ranging from 3-5 millimeters in size are inserted through the incisions so that I can feel the joint structures for any damage, diagnose the injury, and then repair, reconstruct, or remove the damaged tissue. Before the development of arthroscopy, large incisions had to be made over the knee joint to treat or diagnose injuries. Today’s arthroscopic techniques allow more complete evaluations of the knee joint while accelerating the rehabilitation process.
What kinds of procedures can be performed with the arthroscope?
Arthroscopy allows the surgeon to view the inside of the knee joint and perform a variety of surgeries. In your case, the main reason for the arthroscopic procedure was to perform a lateral retinacular release. This is done to correct some mild maltracking as well as to unload this portion of the knee cap to relieve symptoms from compression and to relieve symptoms of potentially some arthritis. A lateral release is a knee arthroscopic procedure that may lend itself to having more swelling, so it is important to ice and follow the guidelines that we outline for you. This procedure takes a little longer to recover from in some people, but it will be well worth it once you make that recovery.
What are some of the possible complications of surgery?
While complications are not common, all surgery has associated risks. Possible complications include stiffness of the knee after surgery or continued pain. The use of arthroscopic techniques attempts to limit these complications. Other complications include infection, bleeding, nerve damage, blood clots, or problems with the anesthesia.
What kind of anesthesia is used?
Knee arthroscopy can be performed with general anesthesia (going to sleep), or regional anesthesia (spinal or epidural block). The type of anesthesia will depend on your choice. The anesthesiologist will discuss your options the morning of surgery.
What do I need to do to prepare for surgery?
Our staff will help to set up the surgery through your insurance company and will instruct you on any paperwork that may be necessary. If you are over the age of 50, or have significant health conditions you may require an EKG and chest x-ray. You may also need to see your internist or family doctor to obtain a Letter of Medical Clearance. The day before the surgery, a member of the hospital or surgery center staff will contact you about what time to arrive for surgery. You may not eat or drink anything after midnight before your surgery.
How long will I be in the hospital?
Knee arthroscopy is an outpatient procedure you will go home the same day.
What happens the day of surgery?
The day before surgery you will be told what time to report to the hospital or surgery center. You will be admitted and taken to a pre-operative holding area where you are prepared for surgery. You will be asked several times which extremity I am operating on. Please note that you are asked this question many times on purpose.
After the operation you will be taken to the recovery room to be monitored. Once the effects on anesthesia have worn off and your pain is under good control, you will be given your post-operative instructions and prescription for pain medication and released. Please be aware that the process of getting checked in, prepared for surgery, undergoing the operation, and recovering from anesthesia takes the majority of the day. I would recommend that you and your family members bring along some reading material to make the process easier for all.
How should I care for my knee after surgery?
Prior to your discharge, you will be given specific instructions on how to care for your knee. In general you can expect the following:
Medication:
You will be given a prescription for pain medication.
Showering:
You may shower the next day. You cannot take a bath until the wounds are completely sealed, usually 2-3 weeks after surgery.
Crutches:
You will be instructed how to use crutches before the surgery. You should bring a set of crutches with you to the surgery. How long you use crutches will depend on the type of surgery performed. Crutches are commonly only required for a couple of days.
Diet:
Resume your regular diet as soon as tolerated. It is best to start with clear liquids before advancing to solid food.
Ice:
You should apply ice over the dressing for 20 -30 minutes every hour for several days. Do not use heat for the first 48-72 hours.
Suture removal:
Some stitches are absorbable and do not need to be removed. However, if there are stitches they will be removed on your first post-op visit.
Return to work or school:
You can return to school or work anywhere from 2 days to 2 weeks. If your job involves more extended walking or heavy activity, you may be out of work or school for a longer period of time.
What will rehabilitation involve?
The rehabilitation is based on several goals: 1) allowing the tissue to heal; 2) regaining motion; 3) regaining strength; and 4) return to sports or work activity. After lateral release, the rehabilitation generally occurs very rapidly. Most patients can return to strenuous work in four to six weeks. However, you complete recovery may take 2-3 months to get all your strength back. The specific rehabilitation protocol will be reviewed with you after surgery. I send most patients to physical therapy after a lateral retinacular release.
The potential for swelling and the potential for muscle atrophy is a little higher in this situation, therefore it is best for a patient to see physical therapy before follow-up with me. After they see me in follow-up, they may or may not need to continue their formal physical therapy.
When can I return to sports or full duty at work?
Your return to your desired activity level will depend on the extent of damage and the procedure performed on your knee. In general, you will be allowed to return to sports in 4-8 weeks after surgery. You must have good motion, strength, and control of your knee. How quickly you return depends on several factors, including: 1) your own rate of healing; 2) the damage found at surgery; 3) if you have any complications; 4) how well you follow the post-operative instructions; 5) how hard you work in rehabilitation.
What is arthroscopy?
The arthroscope is a fiber optic instrument (narrower than a pen) which is put into the knee joint through two small incisions. A camera is attached to the arthroscope and the image is viewed on a TV monitor. The arthroscope allows me to fully evaluate the entire knee joint, including the knee (patella), the cartilage surfaces, the meniscus, the ligaments (ACL & PCL), and the joint lining. Small instruments ranging from 3-5 millimeters in size are inserted through the incisions so that I can feel the joint structures for any damage, diagnose the injury, and then repair, reconstruct, or remove the damaged tissue. Before the development of arthroscopy, large incisions had to be made over the knee joint to treat or diagnose injuries. Today’s arthroscopic techniques allow more complete evaluations of the knee joint while accelerating the rehabilitation process.
What kinds of procedures can be performed with the arthroscope?
Arthroscopy allows the surgeon to view the inside of the knee joint and perform a variety of surgeries. These surgeries include:
- Complete evaluation of the joint (diagnostic arthroscopy)
- Removal of damaged or torn cartilage (partial meniscectomy) – Most often done
- Repair of torn cartilage (meniscus repair) – The tear has to be in an area of good blood supply, so this is rare.
- Smoothing of damage to the cartilage surface in arthritis (chondroplasty)
- Realignment of patella in patellar mal-tracking (lateral release)
- Removal of joint lining (synovectomy)
- Replacement of articular cartilage (cartilage transplant)
What are some of the possible complications of surgery?
While complications are not common, all surgery has associated risks. Possible complications include stiffness of the knee after surgery or continued pain. The use of arthroscopic techniques attempts to limit these complications. Other complications include infection, bleeding, nerve damage, blood clots, or problems with the anesthesia. If a meniscus repair is performed, it is possible that the torn area will not heal. This would require a second surgery to remove the torn meniscus. Even though this is possible, it is better to attempt to repair a meniscus that may heal, in order to preserve the normal meniscus function.
What kind of anesthesia is used?
Knee arthroscopy can be performed with general anesthesia (going to sleep), or regional anesthesia (spinal or epidural block). The type of anesthesia will depend on your choice. The anesthesiologist will discuss your options the morning of surgery.
What do I need to do to prepare for surgery?
Our staff will help to set up the surgery through your insurance company and will instruct you on any paperwork that may be necessary. If you are over the age of 50, or have significant health conditions you may require an EKG and chest x-ray. You may also need to see your internist or family doctor to obtain a Letter of Medical Clearance. The day before the surgery, a member of the hospital or surgery center staff will contact you about what time to arrive for surgery. You may not eat or drink anything after midnight before your surgery.
How long will I be in the hospital?
Knee arthroscopy is an outpatient procedure you will go home the same day.
What happens the day of surgery?
The day before surgery you will be told what time to report to the hospital or surgery center. You will be admitted and taken to a pre-operative holding area where you are prepared for surgery. You will be asked several times which extremity I am operating on. Please note that you are asked this question many times on purpose.
After the operation you will be taken to the recovery room to be monitored. Once the effects on anesthesia have worn off and your pain is under good control, you will be given your post-operative instructions and prescription for pain medication and released. Please be aware that the process of getting checked in, prepared for surgery, undergoing the operation, and recovering from anesthesia takes the majority of the day. I would recommend that you and your family members bring along some reading material to make the process easier for all.
How should I care for my knee after surgery?
Prior to your discharge, you will be given specific instructions on how to care for your knee. In general you can expect the following:
Medication:
You will be given a prescription for pain medication.
Showering:
You may shower the next day. You cannot take a bath until the wounds are completely sealed, usually 2-3 weeks after surgery.
Crutches:
You will be instructed how to use crutches before the surgery. You should bring a set of crutches with you to the surgery. How long you use crutches will depend on the type of surgery performed. Crutches are commonly only required for a couple of days, unless you had a meniscus repair or cartilage procedure, in that case I will let you know how long you should stay on your crutches to protect the repair.
Brace:
If a meniscus repair is performed, you will receive a brace to restrict the motion of your knee. This is to protect the repair for the first 4-6 weeks, to allow the area to heal.
Diet:
Resume your regular diet as soon as tolerated. It is best to start with clear liquids before advancing to solid food.
Ice:
You should apply ice over the dressing for 20 -30 minutes every hour for several days. Do not use heat for the first 48-72 hours.
Suture removal:
Some stitches are absorbable and do not need to be removed. However, if there are stitches they will be removed on your first post-op visit.
Return to work or school:
You can return to school or work anywhere from 2 days to 2 weeks. If your job involves more extended walking or heavy activity, you may be out of work or school for a longer period of time.
What will rehabilitation involve?
The rehabilitation is based on several goals: 1) allowing the tissue to heal; 2) regaining motion; 3) regaining strength; and 4) return to sports or work activity. After partial meniscectomy, the rehabilitation generally occurs very rapidly. Most patients can return to strenuous work in four to six weeks. However, you complete recovery may take 2-3 months to get all your strength back. Following meniscus repair, you will be restricted from performing certain activities. The specific rehabilitation protocol will be reviewed with you after surgery. Most patients do not need formal physical therapy.
When can I return to sports or full duty at work?
Your return to your desired activity level will depend on the extent of damage and the procedure performed on your knee. In general, you will be allowed to return to sports in 4-8 weeks after surgery. You must have good motion, strength, and control of your knee. How quickly you return depends on several factors, including: 1) your own rate of healing; 2) the damage found at surgery; 3) if you have any complications; 4) how well you follow the post-operative instructions; 5) how hard you work in rehabilitation.
What is the anterior cruciate ligament?
The anterior cruciate ligament (ACL) is one of the most important ligaments in the knee joint. Unfortunately, it is also one of the most commonly injured. There are essentially four main ligaments to the knee joint – the anterior cruciate ligament, the posterior cruciate ligament, and a ligament on the inside part of the knee and a ligament on the outside part of the knee. The ACL is one of the two ligaments that is in the middle of the knee and is responsible for preventing the shin bone from moving forward on the thigh bone. Once the ACL is torn, the knee will have laxity demonstrated on the physical exam with a lot of “play” in the knee. Typically, this laxity then will lead to instability of the knee when patients are active. Some patients experience instability only when they play sports and some people experience it on a daily basis. The likelihood of a patient experiencing instability is very high, especially when they are young and they are active. The activity level though is the number one factor that determines whether a person will have instability or not. Some patients may avoid a lot of cutting and turning activities to prevent instability and sometimes choose to do this rather than have surgery to reconstruct the ACL.
What is an ACL reconstruction?
Once the ACL tears, it occurs in a way that makes it impossible to repair with sutures or other means. Usually the torn ACL is “stretched out like taffy” and then has two separate ends that cannot be repaired to each other. Therefore, a reconstructive procedure has to be done in order to duplicate the ACL’s characteristics. This is done through an arthroscopic-assisted procedure where we will use new tissue (usually a portion of the patella tendon or a portion of the hamstring tendons) to put reconstruct a new ACL. This new tissue is actually stronger than the native ACL. This tissue then has to go through a healing phase where the bone tunnels that we make for the procedure will heal in with bone and the new tissue will become a new ligament. This is the primary reason why the rehab and the length of recovery is so long. Incisions have to be made in order to harvest the tissue to use for the new ligament, but the remaining procedure is arthroscopic. I strive to use very small incisions in order to harvest the graft material for the new ligament, and therefore help with post-operative pain and also minimize significant scarring. Often there are other injuries involved with an anterior cruciate ligament tear, such as meniscus tears or cartilage injuries. During the arthroscopic component of this procedure, these injuries will be addressed as well.
What are some of the possible complications of surgery?
While complications are not common, all surgery has associated risks. Possible complications include stiffness of the knee after surgery or continued pain. The use of arthroscopic techniques attempts to limit these complications. Other complications include infection, bleeding, nerve damage, blood clots, or problems with the anesthesia. If a meniscus repair is performed, it is possible that the torn area will not heal. This would require a second surgery to remove the torn meniscus. Even though this is possible, it is better to attempt to repair a meniscus that may heal, in order to preserve the normal meniscus function.
What kind of anesthesia is used?
Knee arthroscopy can be performed with general anesthesia (going to sleep), or regional anesthesia (spinal or epidural block). The type of anesthesia will depend on your choice. The anesthesiologist will discuss your options the morning of surgery. The anesthesiologist will talk to you about a femoral nerve block. This is a numbing procedure to one of the main nerves that supplies sensation to the knee and is very helpful for pain control for the first 18 to 36 hours. I would highly recommend patients undergoing this and certainly I would choose to have this if I was to have this procedure.
What do I need to do to prepare for surgery?
Our staff will help to set up the surgery through your insurance company and will instruct you on any paperwork that may be necessary. If you are over the age of 50, or have significant health conditions you may require an EKG and chest x-ray. You may also need to see your internist or family doctor to obtain a Letter of Medical Clearance. The day before the surgery, a member of the hospital or surgery center staff will contact you about what time to arrive for surgery. You may not eat or drink anything after midnight before your surgery.
How long will I be in the hospital?
ACL reconstruction is almost always an outpatient procedure, where you will go home the same day.
What happens the day of surgery?
The day before surgery you will be told what time to report to the hospital or surgery center. You will be admitted and taken to a pre-operative holding area where you are prepared for surgery. You will be asked several times which extremity I am operating on. Please note that you are asked this question many times on purpose.
After the operation you will be taken to the recovery room to be monitored. Once the effects on anesthesia have worn off and your pain is under good control, you will be given your post-operative instructions and prescription for pain medication and released. Please be aware that the process of getting checked in, prepared for surgery, undergoing the operation, and recovering from anesthesia takes the majority of the day. I would recommend that you and your family members bring along some reading material to make the process easier for all.
How should I care for my knee after surgery?
Prior to your discharge, you will be given specific instructions on how to care for your knee. In general you can expect the following:
Medication:
You will be given a prescription for pain medication and an antibiotic. You also will be asked to take one regular Aspirin (325mg) a day. You may also supplement the pain medicine with Advil or Aleve.
Showering:
You may not shower until we see you back on post-operative Day 3. On that day your dressing will be changed, the brace protocol will be explained to you, and you may shower at that point. If you really need to take a shower prior to this, then you need to use a garbage bag to seal over the brace and the dressing and be very careful that you do not get it wet.
Crutches:
You will be instructed how to use crutches before the surgery. You should bring a set of crutches with you to the surgery. Crutches are usually used by patients for the first week. You may put weight on your knee as you feel comfortable, but typically people are using crutches in order to minimize some discomfort and until their leg becomes stable and their muscles start to return to function.
Brace:
We will put you in a brace after your ACL reconstructive procedure. The brace will remain locked in the 0 position or held straight until you see us back on post-operative Day 3. At that time we will reacquaint you with the brace and show you how you may start gentle range of motion. You usually have the brace locked when you are walking with or without crutches for the first week. You also need to wear it while you are sleeping for the first week.
Diet:
Resume your regular diet as soon as tolerated. It is best to start with clear liquids before advancing to solid food.
Ice:
You should apply ice over the dressing for 20 -30 minutes every hour for several days. If your insurance company approves the use of a cold therapy unit, then this will be part of your dressing. This is a very excellent tool to help minimize swelling and minimize discomfort. Unfortunately, most insurance companies do not pay for this and if you would like one we can arrange it but there is a nominal cost.
Suture removal:
Some stitches are absorbable and do not need to be removed. However, if there are stitches they will be removed on your first post-op visit.
Return to work or school:
You can return to school or work anywhere from 2 days to 2 weeks. If you return to work, it would be obviously in a sedentary type position because you would be using crutches and your brace would be on with your knee straight. If your job involves more extended walking or heavy activity, you may be out of work or school for a longer period of time.
What will rehabilitation involve?
The rehabilitation is based on several goals: 1) allowing the tissue to heal; 2) regaining motion; 3) regaining strength; and 4) return to sports or work activity. Formal physical therapy will begin typically on post-operative Day 4 or 5. We will get you involved with a therapist that is very good at recovering people from ACL reconstructions, but also is close to your home. I have a specific protocol that I will give the therapist to go over and help your knee come back to the best possible outcome. The emphasis on early rehabilitation is on range of motion followed by the strengthening.
When can I return to sports or full duty at work?
Your return to your desired activity level will depend on the extent of damage and the procedure performed on your knee. In general, even the most strenuous jobs usually can get back to full duty somewhere between 8 to 12 weeks. Certainly there would be caution with some cutting and pivoting activities. As far as sports is concerned, the return is of longer duration due to the fact that the knee needs to have excellent motion, strength, and the ACL reconstruction also needs to acquire increased strength. Approximately 90% of my patients get back to full sports activity in the 4 to 6 month window. However, there are a few that get back sooner and there are a few that may take longer. How quickly you return depends on several factors, including: 1) your own rate of healing; 2) the damage found at surgery; 3) if you have any complications; 4) how well you follow the post-operative instructions; 5) how hard you work in rehabilitation.
HIP
Hip replacement surgery is an option for those who have failed conservative treatment and are having ongoing hip and groin pain. Conservative options include exercise, weight loss, physical therapy, medication and injections. This operation resurfaces the damaged articular surface of the hip joint with metal and plastic implants improving pain and function. For further education and illustrations click on the link above.
What is a total hip replacement?
A hip replacement uses the combination of one surface gliding on another surface, to recreate the normal ball and socket of the normal joint. These artificial component are used in order to eliminate the arthritis one has in their hip joint, and re-establish the normal characteristics that we see in an undamaged hip joint. The acetabulum (socket) of the artificial hip is a metal cup. The femoral head (ball) is also made of metal and glides within this cup. Depending on the type of total hip that is performed, sometimes there is a plastic liner or sometimes it is metal-on-metal, rubbing against each other. The ball of the hip joint is secured to a metal stem which goes down into the femur (thigh bone).
The painful parts of the arthritic hip are thereby completely replaced with these surfaces. The surfaces that touch each other have a very low frictional resistance and a very low wear-rate against each other.
Most of the time a total hip replacement is done without the use of cement, because this is what is best for the implant.
What are some of the possible complications of surgery?
While complications are not common, all surgery has associated risks. Possible complications include stiffness of the hip after surgery or continued pain. Other complications include infection, bleeding, nerve injury, blood clots, or problems with anesthesia or underlying medical conditions. In the hospital, we usually have a medical doctor follow patients for their medical conditions and we take every precaution against blood clots and infection.
What kind of anesthesia is used?
Total hip replacement is usually performed with general anesthesia (going to sleep), but sometimes it may be performed with regional anesthesia (spinal or epidural block). The type of anesthesia will depend on your choice, as well as what the anesthesiologist best recommends for you.
What do I need to do to prepare for surgery?
My staff will help to set up the surgery through your insurance company and will instruct you on any paperwork that may be necessary. If you are over the age of 50, or have significant health conditions, you may require an EKG and a chest x-ray. You may also need to see your internist or family doctor to obtain a letter of medical clearance.
The day before surgery a member of the hospital will contact you about what time to arrive for your surgery. You may not eat or drink anything after midnight before the surgery.
How long will I be in the hospital?
Hospitalization is usually a 3 to 4 day length. Sometimes patients get out sooner, but rarely do patients spend any time longer than 4 days. Sometimes patients are not able to go home but are required to go to a rehab or skilled nursing facility to get added physical therapy before they go home. This will be individualized while you are in the hospital and social services will help us coordinate this if it is a necessary option.
What happens the day of surgery?
The day before surgery you will be told what time to report to the hospital. You will be admitted and taken to a pre-operative holding area where you are prepared for surgery. You will be asked several times which extremity I am operating on. Please note that you are asked this question many times on purpose.
Please be aware that the process of getting checked in, prepared for surgery, undergoing the operation, and recovering from anesthesia takes the majority of the day. I would recommend that you and your family members bring along some reading material to make the process easier for all.
After your surgery, you will then be taken to the recovery room to be monitored. Once the effects of anesthesia have worn off and your pain is under good control, you will be transferred to your room in the hospital. All of the rooms at Des Peres Hospital are private rooms.
After your surgery you will have a drain in your joint as well as a Foley catheter in your bladder. The drains are usually removed the next day in all patients and the Foley catheter is removed the next day for men. In women, I usually leave the Foley catheter in for several days until a patient is able to get up better and get to the bathroom much easier.
How should I care for my hip after surgery?
Physical therapy will begin on postoperative Day 1. The therapist will help you to get up out of your bed and into a chair. They will also help you with ambulation and will start you with the use of a walker to advance your weightbearing as you feel comfortable. Most often, patients use a walker while in the hospital and will switch to a cane at home in about a week as instructed by the home physical therapist. Simple exercises will be taught to you in the hospital regarding strengthening and range of motion exercises. While in the hospital, you will have a pillow between your legs to help with position and stability. When patients go home, I tell them to use just a regular bed pillow between their legs when sleeping.
Medication:
You will be given a prescription for pain medication as well as an antibiotic. We also will give you a prescription for a blood thinner, called Coumadin, to be taken for the first three weeks after surgery. This requires some blood test monitoring at home to ensure that we have you at the right level.
Showering:
You may shower when you get home from the hospital. If you have a safe shower, you may go ahead and take your dressing off and enter the shower. I do not want you soaking the hip, but do not mind a little shower water coming down across your hip. After you get out of the shower you will be instructed to take a little bit of hydrogen peroxide on a clean washcloth and dab the incision to clean it. You will then place a dressing on for that day. If you do not take a shower, we still want you to clean the incision off once a day with hydrogen peroxide.
Diet:
Your regular diet will be resumed in the hospital as tolerated.
Follow up:
A follow up appointment will be made at two weeks post-operatively, where we will remove the staples.
What will rehabilitation involve?
The rehabilitation is based on several goals: 1) allowing the tissues to heal; 2) regaining motion; 3) regaining strength; and 4) return to normal activities or activities that you have not been able to do for some time because of your arthritis. Most of the time patients will not need any formal physical therapy after the home physical therapy. However, if a patient is having trouble with motion, an outpatient physical therapy program may be recommended. A continuance of the exercises learned in the hospital and by the home physical therapy after discharge from the hospital can usually be performed by a patient to continue to obtain better range of motion and better strength.
When can I return to regular activities or work?
A return to a desired activity level certainly depends on how fast a patient may heal. In general, people may return to a sedentary type job at four weeks or so. Certainly more strenuous jobs will take longer and may be in the neighborhood of two to three months.
I want you to have good motion, strength, and control of your hip before returning to your job. How quickly you return depends on several factors including: 1) your rate of healing; 2) the presence of any complications; 3) how well you follow physical therapy and post-operative instructions; and 4) how hard you work in rehabilitation.