Orthopaedics & Joint Replacement Overview

1. Core Decompression of the Hip and Stem Cell Therapy

For young patients with early stages of osteonecrosis, core decompression is the preferred treatment. The procedure involves drilling being done into the dead bone tissue. Drilling has many benefits: it reduces swelling, allows better flow of blood, and inhibits further damage to the bones. The success of the procedure is dependent on how much of the bone has already suffered damage, which part of the bone has been damaged, the amount of weight, the stress the joint is subjected to, etc. An MRI done ahead of the surgery will tell the surgeon exactly which bone tissue needs removal. This removal will stimulate the production of healthy bone tissue.

The bone marrow that is present inside the bones contains stem cells. These stem cells can change into bone cells when they are injected into the body. This stem cell therapy is used along with core decompression for a better surgical outcome.

2. High Tibial Osteotomy

A high tibial osteotomy is typically recommended for younger patients suffering from arthritis of knee, to prevent the need for a total knee replacement. When only a part of the knee has suffered damage and not the entire knee, this procedure would be a good choice. During the procedure, a wedge is made in the upper part of the tibia. This helps to remove the weight from the damaged tissue and shift it to healthier tissue. This procedure serves to delay the need for a total knee replacement by at least 10 years.

An x-ray will be done before the surgery to ensure that osteotomy is the right choice and to determine the plan for the surgery. Performed under spinal anaesthesia, the surgery will last for around 2 hours. Hospitalization of two to three days may be required. Walking aids should be used after surgery so that the knee is protected from stress. Physiotherapy after surgery is a must and should be performed diligently for best results.

3. Osteochondral Autograft Transfer System (OATS)

The knee joints in our body are covered by cartilage. The purpose of the cartilage is to ensure that the joint movement is smooth and free from friction. Sometimes this cartilage can suffer injury because of high-impact activity. The patient will experience pain, inflammation, and inability to move the joint freely. To address this, healthy cartilage from the part of the knee that doesn’t bear much weight replaces the damaged cartilage. Performed as an arthroscopic surgery, it is minimally invasive. The surgeon removes the damaged cartilage and replaces it with the new one.

Before surgery, smoking should be avoided and the surgeon kept informed about all the drugs the patient is on. Talk to the surgeon about your doubts and get them clarified. The surgery will be done under spinal anaesthesia. The rehabilitation after surgery is very important and the surgeon and his team will guide the patient through it.

4. Bone Marrow Aspirate Concentrate (BMAC)

BMAC injections are helpful in providing pain relief from osteoarthritis. The injections contain stem cells that are harvested from the patient’s own bone marrow. When injected into the part that has been affected by osteoarthritis, the patient gets sufficient pain relief.

The procedure takes around an hour to an hour and a half and is performed under spinal anaesthesia. The stem cells are first harvested from the patient’s pelvis. It is processed and then injected back into the damaged area that is then covered in bandages. There may be some pain after the procedure. The doctor will guide the patient on managing it. It is to be noted that some painkillers are not allowed after this procedure. Pain relief after the procedure will take around 6 weeks. The pain relief will last for quite some time, and there usually is no need to repeat the procedure at short intervals. BMAC is not recommended for patients suffering from cancer, tuberculosis, radiotherapy, etc. The patient should communicate any condition they may be suffering from to the doctor so that the doctor can take an informed decision about giving the injection.

Knee

1. Anterior Cruciate Ligament Reconstruction

The anterior cruciate ligament is an important ligament in the knee that acts as a bridge between the bone of the thigh and the shin. The ligament traverses the knee in the middle and stabilizes it. When this ligament tears (which happens mostly during high-impact contact sports), the person will feel severe pain and buckling of the knee. In such cases, ACL reconstruction can be performed to replace the ligament with a tendon. The tendon is usually taken from patients same or from opposite leg.

Before surgery, physical therapy will commence with the goal of reducing inflammation. This is done to improve the outcome of surgery as a stiff, rigid knee may not benefit fully from the surgery. The procedure will be performed under spinal anaesthesia through very small openings or slits. After the procedure, the patient will have to use crutches with the knee being secured in a brace for protection. The doctor will help in pain management after surgery. Detailed post-operative care instructions will be given, which will have to be followed. Physiotherapy too will start. Recovery will take a few weeks.

2. Multi-ligamentous Injury Knee Reconstruction

In a multi-ligament knee injury, two or more of the knee ligaments suffer damage. Research has shown that treatment with surgery gives better outcome than any other non-invasive method. However, the surgery is a complicated one and needs detailed physical examination and imaging tests like x-ray and MRI. Sometimes, more than one surgery may be necessary. The surgery done arthroscopically is least invasive. The exact procedure will differ from patient to patient – for some patients, only one ligament may need repair, while for another all three might need reconstruction. Typically, grafts from the patient or a donor will be used for reconstruction.

After surgery, it is important to slowly mobilize the knee while keeping the reconstructed ligaments intact. Mobilizing the knee early will give the knee a better range of movement. Crutches and knee braces can be used. Depending on the patient’s progress, the doctor will take a call on when to walk without crutches. Knee strengthening and other physiotherapy exercises should be carried out for the next 4-6 months after surgery. The doctor will schedule reviews at regular intervals to monitor the patient’s progress.

3. Meniscectomy

The knee contains two menisci – one on the exterior edge of the knee and the other towards the interior. These menisci perform many vital functions:

• They help in smooth, friction-free movement of the knee.
• They help in distributing the body weight over the knee joint.
• They absorb shocks and sudden jerks.
• They provide stability to the knee joint.

Damage to the menisci may lead to the need for either a total or partial meniscectomy. Menisci injuries are quite common and minor tears will not need surgery. But if the menisci do not mend with conservative treatments or if the knee starts to lock, surgery is recommended. When a surgery is decided on, it is best to start knee-strengthening exercises before the surgery to improve surgical outcome. The surgery itself, done arthroscopically, will involve only three small cuts to repair the menisci. During surgery, the damaged parts of the menisci are removed. Patients are usually discharged on the same day. They can walk but will have to use crutches to prevent over-exerting the knee. Mild pain and inflammation in the knee are expected after surgery and are nothing to be concerned about. Pain medication will be given to manage it. It is important to do strengthening exercises at home after discharge.

4. Meniscal Repair

Meniscal repair is another surgery, also done arthroscopically, to repair torn menisci in the knee. Usually sustained during some kind of sporting activity, meniscal tears are accompanied by a popping sound. Walking after the tear might be possible but painful. Meniscal tears may also be caused by wear and tear, but this kind of tear usually subsides on its own without surgical intervention. Other symptoms that indicate meniscus tear are inflammation, limited movement of knee and a feeling of instability in the knee. Diagnosis involves the McMurray test and imaging tests to confirm diagnosis. If non-invasive treatments are ineffective, then surgical meniscal repair is performed.

During surgery, the torn menisci is sutured and then held in place. Physiotherapy will commence after surgery and complete recovery will take 4-6 weeks.

5. Root Repair

In a meniscus root tear, the part of the meniscus that attaches to the bone i.e. the root of the meniscus is damaged. The pain from a meniscus root tear is usually chronic; the tear itself can limit knee movement, make the knee unstable and increase the risk of osteoarthritis. The root tear can be of two types: traumatic and degenerative. A traumatic tear usually affects sportspeople and hence is more common in younger adults. A degenerative root tear is caused as a result of wear and tear; older adults are more prone to this. When the doctor is of the opinion that non-surgical treatments will not yield desired results, surgery is done arthroscopically.

During surgery, the roots of the meniscus are repaired and connected to the bone once again. Recovery after surgery will take around 4-6 weeks. During the recovery period, the patient will be advised to use crutches to minimize the load on the knees; physiotherapy will also commence.

6. Cyst Excision

A cyst in the knee, called a popliteal cyst or a Baker’s cyst, may develop in people suffering from arthritis. Usually found at the back of the knee, the cyst is in simple terms a sac of fluid. Surgery can be done to remove the cyst, but it is important to understand that the cyst may recur unless the underlying cause is treated.

The knee joint is covered in cartilage. The synovial membrane, which is the lining of the joint, produces a fluid to keep the joints moving smoothly. When an excess of this fluid is produced, the extra is contained in a sac at the back of the knee in the form of a cyst. This cyst can be felt when the back of the knee is touched. Other than arthritis, a knee injury may also be a cause of the cyst.

Treatment can be surgical or conservative. Only if the cyst is very painful, surgery is recommended. During surgery, the cyst is removed and any damage caused by the cyst to the lining of the joint is rectified. Treating the cause of the cyst is important to prevent its recurrence.

7. Cartilage Defect Treatment -OATS, BMAC

As the name suggests, a cartilage defect is a part of the cartilage that has been injured. The cause may be accidents, osteonecrosis or other knee conditions. Cartilage defects usually occur along with damage to knee ligaments like an ACL tear. The surgeon will always try to treat the defect non-invasively with physiotherapy, medication and injections. Only if this is not successful will other invasive procedures be considered. With a cartilage defect, the patient may experience pain and also a possibility of arthritic changes. Diagnosis is done with an MRI.

• Treatment with OATS – Osteochondral autograft transfer is preferred for younger adults especially, if the bone is also damaged. Here, healthy cartilage replaces the defective cartilage.
• Treatment with bone marrow aspirate concentrate (BMAC) – This procedure is carried out when the affected area is large. Stem cells from the bone marrow are harvested and injected back into the patient.

Shoulder

1. Bankart’s Repair

Like in all other joints, there is cartilage surrounding the shoulder socket as well. This cartilage, called the glenoid labrum, can suffer damage due to sporting injuries or other shoulder conditions. This tear to the cartilage is called Bankart’s tear and is quite a common condition. Shoulder pain is the symptom, and if left untreated, shoulder dislocation may become more frequent. Treatment starts with conservative methods; if the desired results are not obtained, the doctor will suggest the Bankart’s repair, which is done arthroscopically.

The surgery involves small incisions. During surgery, the cartilage and any torn ligaments are reconnected to the bone. The recovery duration after surgery will vary from patient to patient – it can be anywhere between 3-6 months. Physical therapy plays a very important role in strengthening the shoulder and restoring range of movement.

2. Latarjet Procedure

The shoulder has three bones which all join to create a ball and socket joint. The ball sits in the socket of the shoulder and is held in that position by various ligaments and tendons. When these ligaments and tendons are not able to keep the ball in the socket, shoulder dislocation takes place. Left untreated, repeated dislocations could damage the bone of the shoulder blade. A shoulder dislocation could manifest as severe shoulder pain, swelling, and inability to move the shoulder normally. The Latarjet procedure is recommended for such patients having recurrent dislocations, especially in those with a bony defect. Earlier the surgery was done as an open surgery, but now it can be done through arthroscopic means.

During the procedure, the coracoid from the shoulder blade replaces the damaged bone and thus prevents further dislocations from happening. The success rate of the procedure is good, and recovery will take around 3-6 months. The shoulder will be immobilized with the help of a sling during recovery. Physical therapy is important, and complete recovery can be achieved in around 6 months.

3. Rotator Cuff Repair

The rotator cuff in the shoulder is made of muscles and tendons. These muscles and tendons secure the ball of the shoulder in its socket. Thus, it is responsible for us being able to perform a number of functions like raising our hands up and being able to do activities like swimming, basketball, etc. Simply put, the ability to rotate our shoulder is attributed to the rotator cuff. A rotator cuff tear may happen due to overuse of the shoulder. Other causes include road traffic accidents, lifting big objects and a fall with your body weight being taken up by the arm.

To treat rotator cuff repair, earlier an open surgery had to be performed. But now, it is possible to do the procedure arthroscopically. The procedure differs depending on the kind of tear and is decided on by the surgeon. As in any procedure, rehabilitation plays an important role in recovery. Physiotherapy is started with mild exercises and will progress to exercises involving more movement. Recovery takes around 6 months. The results after surgery are encouraging with patients reporting pain-free shoulders with increased stability.

4. Neglected Rotator Cuff Tear Repair

A rotator cuff tear will not heal without treatment. Supply of blood is necessary for healing, and in its absence, the rotator cuff tear will worsen. The initial line of treatment is always conservative – in the form of physiotherapy. There are no medicines available to heal a torn rotator cuff; medicines are given only to alleviate pain. In physiotherapy, other muscles and tendons are strengthened to make up for the function of the torn rotator cuff. Unfortunately, there is always a chance of the rotator tear getting inflamed again.

When timely treatment is not given, the tear can get bigger, and the shoulder joint can become extremely unstable. This condition is called cuff tear arthropathy. Sometimes a condition called pseudo-paralysis may manifest where the range of shoulder movement is badly affected. Both are serious conditions that need aggressive treatment. For cuff tear arthropathy in senior citizens, a reverse shoulder replacement is recommended. If the patient is younger, then a muscle transfer (taking a muscle from the shoulder to do the function of the rotator cuff) or a superior reconstruction (introducing a graft from the thigh to aid in shoulder stability) can be done.

5. Subacromial Decompression

When the roof of the shoulder presses down on the rotator cuff, it results in a condition called shoulder impingement that is very painful. In most cases, it is a bone spur that presses the rotator cuff. This condition only aggravates with time. It starts as mild shoulder pain; the pain may be more when the hand is raised. Slowly the pain increases and lifting the hand overhead may not be possible at all. As with any treatment, surgery is the last option and is considered only when physiotherapy, medications, and corticosteroid injections do not give the desired results.

The surgical procedure is called subacromial decompression or acromioplasty. The surgery is done arthroscopically through small cuts. It involves removing the tissue and, in some cases, removing the bursa too if it is inflamed. The entire procedure is performed under general anaesthesia. Recovery typically happens within a month with the shoulder being immobilized in a sling. Once the sling is removed, physiotherapy will commence and complete recovery will take a year.

1. Pelvic – Acetabular Trauma

Pelvic-acetabular fractures are often very complicated and are usually caused by a road traffic accident. To treat these fractures, sometimes more than one surgery might be necessary. In patients suffering from osteoporosis, even a fall might cause this fracture.

Many bones make up the pelvis which, other than supporting the upper body, also protects the intestines and bladder. When one of the pelvic bones suffers a break, it is called a pelvic fracture. The joining point of the pelvis with the femur is called the acetabulum, which is a ball and socket joint. When the fracture is in the socket, it is called an acetabular fracture. An acetabular fracture is difficult to treat because of its position close to major organs and important blood vessels.

During surgery, the bones are positioned properly and then held by screws and plates, etc. Pain and complications after surgery will be treated by the surgeon and his team. The patient will be encouraged to not remain immobile as immobility may lead to complications. If many nerves are damaged, recovery may take from 6 months to more than a year.

2. Intraarticular & Comminuted Fractures

When a fracture occurs across a joint, it is called an intraarticular fracture. Such fractures are very complex as they involve bones inside the joints unlike fractures involving only bones that are relatively simpler to treat. The condition could be made more complex by bone fragments, which will slow down healing. Mostly caused by road traffic accidents, these fractures usually affect the wrist, the elbow, the shoulder, the hip, the knee and the ankle. The patient will experience immediate pain, inflammation and inability to move the affected part. Treatment starts with immobilizing the injured area. The surgeon will decide on open surgery or an arthroscopic procedure. During surgery, the bones will be repositioned and held in place by screws, wires, etc. The doctor will guide the patient on post-operative care and rehabilitation.

A comminuted fracture is one in which the bone has been broken at three or more places. It is further classified as open and closed. In an open comminuted fracture, the skin is cut, while in a closed comminuted fracture there is no visible injury to the skin. Sustained as a result of an accident or bad fall, diagnosis involves x-ray, CT, MRI, etc. Surgery involves repositioning the bones and holding them in place with rods, plates and screws, etc. Following surgery, immobilization with casts and pain management with medications will begin. In some cases, traction might also be needed. For an open fracture, the doctor will also take care to clean the wound to prevent infection.

3. Osteotomies and Realignment Surgeries for Malunion Fractures

A malunion happens when a fracture heals but with bones positioned improperly. The symptoms of a malunion are pain, rigidity of the part, limited movement, and in some cases the bone looks visibly deformed. It is necessary to treat a malunion as a failure to do so may cause arthritis, instability, and ultimately loss in functionality. Diagnosed with imaging tests, a malunion can be corrected through surgery. A procedure called osteotomy is done to realign the bone. During surgery, depending on individual conditions, the surgeon may shorten the bone and reposition it or may use a graft to fix the malunion. Surgery will be followed by physiotherapy to increase range of movement of affected part. This surgery can restore functionality of affected part and also prevent deterioration in bone health.

4. Bone Grafting & Revision Surgeries for Fracture Non-Unions

In normal circumstances, after surgery, the bones will heal with time and new tissue will form and reconnect. In some cases, however, even when a surgical procedure is carried out successfully, the fracture might not mend/join. This condition is called a non-union. The reasons for non-union vary from diabetes and hypothyroidism to lack of healthy food and old age. Another possible cause is the lack of blood supply needed for the fracture to heal.

The doctor may suggest a bone graft to treat a non-union. The graft could be taken from another part of the patient’s body or harvested from another individual or a synthetic graft. When the graft is introduced, it launches new bone cells and chemicals needed for healing to take place. In addition to a bone graft, metal plates and screws will be used to hold the bones in place.

1. Ankle Arthrodesis

Ankle arthrodesis is a surgery that involves fusing the bones of the ankle to overcome the effects of arthritis. The ankle has two joints:

• The tibiotalar joint that is the meeting of the shin bone with the foot bone.
• The subtalar joint formed when two of the tarsal bones in the foot meet.

Arthritis can lead to pain and swelling in the aforementioned joints. Ankle arthrodesis done to treat this can be performed either as an open surgery or arthroscopically. During surgery, the joints will be pressed together and then secured in that position using metal screws, nails, etc. Sometimes, a bone graft may be used to hasten healing. Post-surgery pain is expected. It will be managed with medication; keeping the foot raised will also help. The foot will be immobilized in a brace to prevent any movement. Complete recovery will take 3-6 months.

2. Lisfranc Fracture

A Lisfranc fracture sustained as a result of contact sports, fall, or road traffic accidents, involves the bones in the mid-section of the foot. The Lisfranc ligament is found in between two bones (medial cuneiform and second metatarsal) of the foot. These two bones meet to form the Lisfranc joint. Any of the aforementioned injuries can damage the bones and injure the ligament. Pain felt in the middle of the foot, inflammation and inability to exert weight on the foot are the symptoms of this condition. Diagnosed with a physical examination and imaging tests, your doctor might suggest surgery to correct it.

During surgery, the bones will be realigned and held in place with metal plates, screws, wires etc. Any ligament injury will also be attended to. Alternatively, the surgeon might also perform a fusion surgery. Here, the bones are fused together. Both procedures will need foot immobilization for a few weeks.

1. Club Foot

Club foot is a congenital condition in which the baby’s foot will be turned towards the inside and will also possibly face downwards. It mostly affects both the feet, but the new-born will be otherwise healthy. In club foot, the tendons of the foot will be shorter than usual. For severe club foot, surgery is done to correct it, and doctors recommend early surgery so that the baby’s walk is not affected. Parents however need not feel concerned that the baby will find club foot painful. Though it looks painful, club foot does not hurt the baby.

Club foot can be treated with casts and braces. A small surgery to the Achilles tendon might also be carried out. Wearing the brace properly according to the doctor’s instructions plays a very important role in recovery.

Alternatively, for severe club feet, surgery might be done to stretch the tendons and ligaments to position the foot properly. Here again, the use of casts and braces will be needed for best results.

2. Perthes Disease

Perthes disease is a rare condition that affects certain children. Here, the blood supply to the top of the thigh bone is impaired. When the bone does not get enough blood, the bone cells die (necrosis).

The thigh bone, or the femur, ends in a ball that fits into the socket of the pelvis. As a result of the reduction in blood supply to the bone, the top of the thigh bone (the ball) may weaken and ultimately collapse. The exact cause for this condition is unknown, though there is a probability that the condition might be genetic. Children in the age group of 4-10 years are the ones usually affected.

When the child is affected with Perthes disease, there will be a noticeable change in the way he/she walks and runs. Hip pain that increases with activity and a limp may be the other symptoms. Diagnosed with a physical examination (in which the doctor will check the child’s ability to move the legs) and an x-ray, the doctor may suggest treatment options depending on the individual child’s condition.

Non-surgical options include not stressing the legs too much with sporting activities, physiotherapy and using casts.

Surgery is recommended if the damage to the top of the thigh bone is bad. An osteotomy is usually performed wherein the bones are cut and realigned. They are made to fit well within the socket and held in position with metals screws, plates, etc. Post-operative care involves the use of crutches, casts, and rehabilitation exercises.

3. Slipped Capital Femoral Epiphysis

This is a condition that can manifest in adolescents. In adults, the thigh bone ends in a ball that fits into the socket of the acetabulum, thus forming the ball and socket joint. In children who are still growing, the head of the femur is called as the epiphysis. This epiphysis and the rest of the thigh bone are connected by a growth plate. In a slipped capital femoral epiphysis, this interconnecting growth plate is injured and the Epiphysis is displaced. Reasons for this may vary from obesity and hypothyroidism to endocrine problems. Boys are more susceptible to the condition compared to girls. Leg pain, reduced range of movement in the leg, change in walking style, etc. are the possible symptoms. It is usually diagnosed with a physical examination and an x-ray; in some cases an MRI may be required.

The condition is treated with surgery. A metal screw is used to join the femur head to the femoral bone. If the bones have been badly damaged, the surgeon may have to reposition the bones. After surgery, the use of crutches will be necessary to protect the leg till it heals.

4. Cubitus Varus/ Genu Valgus Deformities

Cubitus Varus Deformity

Cubitus varus, also known as gunstock deformity, is a condition in which when the arm is extended; the palm is facing front, and the arm is turned towards the body. Fracture malunions may result in this condition. Very rarely, it is present as a congenital defect. Sometimes, infections, tumours and bone cell death might also cause this condition. If the deformity does not cause any trouble, doctors may just decide to observe the condition. If the ulnar nerve is compressed, then surgery might be needed. The surgeon will perform an osteotomy to realign the elbow and treat the condition.

Genu Valgum Deformity

A genu valgum deformity is the opposite of a varus deformity i.e., the limb is turned away from the body at the knee. Knee pain may be a result of this deformity, and the uneven pressure distribution might result in arthritic changes in the knee. It can be corrected with surgery during which the bones are repositioned.

1. Limb Reconstruction Surgeries for Tumour Conditions

Tumours can be malignant or benign. They can either originate in the bone itself, or they may spread to the bone from the other parts of the body. Diagnosing a tumour will involve blood tests, x-ray, and possibly a biopsy. When the tumour is found to be benign, unless it is causing a problem, the doctor may decide to just observe it. If it is found to be pressing on a nerve or blood vessel, then surgery to remove it may be suggested.

For malignancy, surgery is suggested either before or after chemotherapy. The exact procedure will differ from patient to patient depending on their condition. Earlier, if the tumour had spread badly, then amputation was being done. Now with the development in medical technology, it is possible to carry out extensive reconstruction procedures to save the limb.

2. Minimally Invasive Plate Osteosynthesis (MIPO)

Due to road traffic accidents, fractures might happen at three or more places in the bones (comminuted fracture). Treating this (while being minimally invasive) is done with a procedure called minimally invasive plate osteosynthesis. In a comminuted fracture, along with the breakage in bone, bone fragments may also be present. This makes treatment all the more difficult. To avoid the disadvantages that are present in more conventional treatment methods, MIPO is done to reduce the possibility of infection as well as malunion and non-union. The other advantages of MIPO include:

• Reduction in the time taken for surgery
• Loss of blood is minimized
• Soft tissue harm is kept to a minimum
• Reduction in swelling
• Lesser recovery time

3. Debridement, Sequestrectomy, & Antibiotic Instillation

Debridement or sequestrectomy is done to accelerate healing in tissues in osteomyelitis. When a wound does not get better, removing the dead cells might start the healing process. Debridement reduces the possibility of infection and promotes growth of new, healthy cells. Debridement is done under anaesthesia, wherein the surgeon removes the dead tissue and (if need arises) puts a graft in place. When the procedure is done in conjunction with antibiotic instillation, the results are much better than when the procedure is done alone.