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Arthroscopy

 

Common Disorders we treat 

  • ACL Injury
  • Meniscus Injuries
  • PCL Injury
  • Multi ligament injury
  • Articular Cartilage lesions
  • Patellar Instability

 

Services we offer

  • ACL reconstruction
  • Revision ACL reconstruction
  • Meniscus surgery
  • PCL Reconstruction
  • Multi-ligament Reconstruction
  • Cartilage restoration
  • Patella (MPFL) Realignment
  • Tibial/ Femoral Osteotomy
  • Arthroscopic Loose Body Removal


ACL Injury

Anterior Cruciate Ligament

ACL is an important soft tissue structure inside the knee joint. It is a thick cord-like structure. Its function is to stabilise the knee joint by connecting between thigh bone (femur) and leg bone (tibia).
ACL is frequently torn by twisting injury to the knee during sports activity and by being hit onto knee from falls.

Symptoms of torn ACL includes popping sensation at the time of injury, pain and swelling of knee, difficulty in moving the injured knee and difficulty in walking.

ACL injuries are diagnosed based on the history, examination of the knee and imaging tests (X-ray and MRI)

Managing ACL injuries

A completely torn ACL cannot heal on its own. Complete ACL tears are treated through key-hole surgery (Arthroscopy) via small incisions using a combination of fibre optics and small instruments. In ACL reconstruction surgery, the torn ligament is replaced with a tissue graft, which will mimic the natural ACL. Treatment without surgery may be recommended in older or more sedentary patients.

Partial ACL tears

Partial ACL tears can heal with time. However, some patients with partial ACL tears may still have instability symptoms and needs surgical treatment.

Meniscus Injuries

Meniscus is a pad of fibrocartilage that acts as a cushion within the knee joint. There are two separate meniscus in the knee – one in the inner half of the knee (the medial meniscus) and other in the outer half of the knee (the lateral meniscus). They serve as shock absorbers between the ends of the bones to protect the surface of the articular cartilage. Without a functioning meniscus, the articular cartilage is exposed to increased pressure and tends to wear earlier, leading to osteoarthritis.

Meniscus injury is common, especially among people who play sports. A sudden twist, turn or collision can tear a meniscus. The Main symptom of this condition is the Knee pain, especially at the side of the knee joint.
This condition may be diagnosed based on your symptoms and a physical exam. MRI knee joint helps to confirm the diagnosis.
Acute injuries are managed with Rest, Ice application, medications and physical therapy. If these treatments don’t work or if the injury is severe, surgery might be necessary.

PCL Injury

The posterior cruciate ligament (PCL) is one of the less commonly injured ligaments of the knee. The PCL is located near the back of the knee joint. It attaches to the back of the femur (thighbone) and the back of the tibia (shinbone) behind the ACL.

The PCL is the primary stabilizer of the knee and the main controller of how far backward the tibia moves under the femur. If the tibia moves too far back, the PCL can rupture.

PCL injuries can occur with low-energy and high-energy injuries. The most common way for the PCL alone to be injured is from a direct blow to the front of the knee while the knee is bent.

Sometimes the PCL is injured during an automobile accident. This can happen if a person slides forward during a sudden stop or impact and the knee hits the dashboard just below the kneecap.

The symptoms following a tear of the PCL can vary. Most patients with a PCL injury sense a feeling of stiffness and some swelling.

Some patients may also have a feeling of insecurity and giving way of the knee, especially when trying to change direction on the knee.

The history and physical examination are probably the most important tool in diagnosing a ruptured or deficient PCL. The magnetic resonance imaging (MRI) scan is more accurate test. Initial treatment for a PCL injury focuses on decreasing pain and swelling in the knee. Rest and mild pain medications help decrease these symptoms. You may need to use a long-leg brace and crutches at first to limit pain.

Less severe PCL tears are usually treated with a progressive rehabilitation program. If the PCL alone is injured, nonsurgical treatment may be all that is necessary. When other structures in the knee are injured, patients generally do better having surgery within a few weeks after the injury. Long-term studies show that without reconstructive surgery, over time, knee instability and joint degeneration develop.

Multi ligament injury

The 4 ligaments in and around the knee which are the main reasons for the stability are ACL, PCL, MCL and LCL - (ACL- Anterior Cruciate ligament, PCL- Posterior Cruciate Ligament, MCL- Medial collateral ligament, LCL- Lateral collateral Ligament). Normal tension within the ligament prevents abnormal movements within the knee joint When two or more major ligaments of the knee are injured, it is termed as multi-ligamentous injury.

Such type of injury occurs as result of high velocity trauma like Road Traffic Accidents. X-rays of the knee are done to rule out fractures and to check the knee alignment/ knee dislocation.
MRI of the knee is done to assess the number of the ligaments that have been damaged & also other associated injuries like meniscus/cartilage injuries. Treatment for multi-ligament injury is always surgical reconstruction.

Articular Cartilage lesions

An articular cartilage injury is damage to the cartilage that lines the surface of joints (articular cartilage). The cartilage is smooth, white tissue that covers the ends of bones where they meet at a joint. This cartilage allows smooth movement of the joint. It also acts as a thin cushion between the bones of the joint. Injuries to joint cartilage can cause pain and decrease range of movement.

Articular cartilage damage can occur from a recent (acute) injury or from wear and tear that takes place over time. The knee joint is the most common area for this type of injury.

Symptoms of this condition include:

  • Pain and swelling in the joint.
  • Giving way or locking of the joint.
  • Stiffness and decreased range of motion of the joint.
  • A crackling or clicking sound within the joint when it moves

This condition may be diagnosed based on your symptoms, your history of injury, and a physical exam. You may also have tests, such as:

  • MRI.
  • A procedure in which a thin scope is used to check inside the joint (arthroscopy).
  • X-rays may show a defect in the bone due to damage to cartilage and are used to help rule out other conditions that may be similar to an articular cartilage injury.

Treatment depends on the severity of the injury and the joint that is involved. Treatment options include:

  • Surgery. This may involve any of the following:
    • Drilling holes through the cartilage into the bone underneath it to improve blood flow.
    • Removing torn or damaged cartilage.
    • Replacing cartilage with a type of cartilage graft.
    • Replacing the entire joint.

Patellar Instability

The kneecap (patella) is located in a groove in front of the lower end of the thighbone (femur). This groove is called the patellofemoral groove. A patellar dislocation occurs when your patella slips all the way out of the groove.

This condition may be caused by:

  • Sports injuries.
  • Twisting the knee when the foot is planted.

The patellar dislocation results in the rupture of a ligament on the inner side of the knee called the MPFL(medial patellofemoral ligament) that keeps the kneecap in center of knee. Deficient MPFL can lead to recurrence of the dislocation even with trivial trauma. Less common factors such as altered limb alignment, flattening of the grove underlying the patella(trochlea dysplasia), Patella alta (relatively higher position of the patella) can also cause recurrence.

MRI scan with or without CT are essential for assessing the abnormalities in recurrent patella dislocation.
In general, the initial treatment of most patellar dislocations is nonoperative with a dedicated rehabilitation program.
In those patients who have recurrent dislocations, the recommended treatment is surgery to stabilise the knee to the center of knee.

Services we offer

  • ACL reconstruction
  • Revision ACL reconstruction
  • Meniscus surgery
  • PCL Reconstruction
  • Multi-ligament Reconstruction
  • Cartilage restoration
  • Patella (MPFL) Realignment
  • Tibial/ Femoral Osteotomy
  • Arthroscopic Loose Body Removal

ACL reconstruction

A ligament is a strong, cord-like band of tissue that connects one bone to another bone. The anterior cruciate ligament (ACL) connects one of the lower leg bones (tibia) to the upper leg bone (femur).

A completely torn ACL cannot heal on its own. In athletes and other people of any age who wish to continue doing physically demanding activity, ACL reconstruction surgery is needed. ACL reconstruction is a surgery to replace a torn ACL.
It is performed through key-holes (Arthroscopy) via small incisions using a combination of fibre optics and small instruments. In ACL reconstruction surgery, the torn ligament is replaced with a tissue graft, which will mimic the natural ACL. A portion of patient’s own tendon (patellar, hamstring, or quadriceps) is used to make a new ACL. A tunnel is drilled into both the tibia and femur. The graft is threaded across the knee and secured in place by using screws, buttons, staples or sutures. This restores the stability to the knee joint.

Revision ACL reconstruction

A revision ACL reconstruction is a second surgery needed to replace the deficient ACL graft. ACL revision surgery is a more challenging operation than a primary reconstruction.

The main reasons a patient might need a revision ACL reconstruction include:

  • A re-tear of the ACL
  • Problems arising from the previous surgery
  • Failure of the reconstructed ligament to heal properly

Revision ACL reconstruction surgery is recommended when there is recurrent instability feeling of the knee, even after focussed rehabilitation and physiotherapy. Some patients may require a two stage revision surgery, in which Bone grafting is done during the first surgery to fill up the previous surgery tunnels in the bones. New ACL ligament is reconstructed using one of the options: the patellar tendon, quadriceps tendon, hamstring tendon, peroneus longus tendon or tendon from the opposite side knee.

Meniscus surgery

Meniscus is operated arthroscopically using small incisions (key-hole surgery) using an Arthroscope, which is a thin tube with light and video camera at its end.

Two types of Meniscus Surgery:
  • Meniscus Repair – The Torn meniscus portions are stitched together using special instruments and meniscus is allowed to heal.
  • Partial Meniscectomy – The damaged meniscal tissue is trimmed and removed leaving the healthy meniscus in place.
Recovery after the Meniscus Surgery
  • The recovery time depends on the type of surgery performed.
  • Full recovery from Meniscus repair takes between six weeks to twelve weeks.
  • After Partial Meniscectomy, the recovery is much quicker.

PCL Reconstruction

The PCL is a band of tissue that connects the femur to the tibia and stabilises the knee joint from backward translation.

Isolated PCL injuries of mild grade (grade 1 and 2) can be managed without surgery by Physical therapy and brace.

Significant laxity (grade 3 laxity) & posterior sag or associated injury to other structures like the posterolateral corner (PLC) warrants Surgery – PCL reconstruction. In this Surgery, torn PCL ligament is replaced using a piece of tendon or ligament (autograft). The surgery is performed through key hole incisions (Arthroscopy).

Multi-ligament Reconstruction

Multi-ligament injury of the knee means two or more major ligaments in and around the knee is torn. These injuries always require surgery in the form of arthroscopic and open ligament reconstruction.

The reconstruction requires autografts (patient’s own) harvested from the same or opposite knee or allografts (tissue bank).

Generally a waiting period of 10-14 days is required for the soft tissue swelling to subside before surgery. Surgery can be done in single stage or in two stages, depending upon the severity of the injury.

Cartilage restoration

An articular cartilage injury is damage to the cartilage that lines the surface of joints (articular cartilage). The cartilage is smooth, white tissue that covers the ends of bones where they meet at a joint.

Articular cartilage damage can occur from a recent (acute) injury or from wear and tear that takes place over time. The knee joint is the most common area for this type of injury.

Initial treatment involves rest and analgesics for the relief of pain with supervised physiotherapy. Since the cartilage injuries have very poor healing capacity treatment and prognosis depends on the size of the defect.

1. Smaller Defects :

Defects smaller than 2 cm have the best prognosis. Treatment of such defects include arthroscopic surgery involving drilling and causing microfractures(creating small holes). This procedure stimulates healing response by marrow cells that produce cartilage at the area of the defect almost similar to the native cartilage.

2. Larger defects:

For slightly larger defects, it may be necessary to transplant cartilage from other areas of the knee called mosaicplasty/OATS- Osteochondral autograft transfer.

3. Larger defects:

For very large defects, it is necessary to harvest the patients cartilage cells in the 1st stage operation which are then cultured followed by implantation of these cells about 3 weeks later. This procedure is called autologous chondrocyte implantation(ACI).

Patella (MPFL) Realignment

Patellar instability surgery is a procedure to restrain the kneecap (patella) in its groove (patella femoral groove).

This surgery may involve a combination of procedures:

  • Reconstruction of the MPFL ligament using autograft. This is done arthroscopically using key-hole incisions.
  • Release of tight tissues on the outer side of your knee.
  • Moving the area where your patellar tendon attaches to your shin bone (tibial tubercle transfer).

Tibial Osteotomy

The knee is divided into two halves, or compartments. The medial compartment is the inside half of the knee and the lateral compartment is the outside half of the knee.

The Wear and tear of the articular cartilage (osteoarthritis) sometimes affects one half of the knee far more than the other. In such cases, surgery to realign the lower leg shifts the pressure to the healthier half of the knee. This procedure intends to increase the life span of the joint and prolong the time before a knee replacement surgery becomes necessary.

The procedure involves a cut through the upper part of the tibial bone (Osteotomy). After the bone is cut, the two sides of the tibia are separated to form a wedge-shaped opening. This opening is then filled with bone graft and the bone is stabilised using special plates. This procedure changes the overall axis of the lower leg and shifts the load onto the healthier side within the knee joint.

 

 

Dr. Manuj Wadhwa
Years Of - Experience 20 +

Dr. Manuj Wadhwa

Chairman & Executive Director Elite Institutes of Orthopedics & Joint Replacement
  • Ivy Hospitals, Punjab
  • Ojas Hospitals, Panchkula
Awards Wining Doctor
  • 2 Times World Book of Records
  • 7 Times Limca Book of Records
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