scott-faucett_logo Our new practice location has moved to below address

The Orthopaedic Center, P.A.
2112 F Street NW, Suite 305
Washington D.C. 20037

Phone: (202) 770-1447
Appointments: (202) 912-8480
Fax: (202) 912-8484

Click here for more information

X

Cartilage Procedures

Microfracture

Introduction

Microfracture is a surgical procedure performed to promote the healing of damaged cartilage with the use of stem cells (progenitor cells of the body). It is considered the best procedure to treat cartilage injuries less than ½ inch or 15 mm. Microfracture is widely used to treat hip and knee injuries, but can also be performed to treat articular cartilage (tissue cushioning two bones) of the ankle joint, damaged due to an ankle sprain or break, which can lead to snapping and locking of the ankle joint, loss of motion and deep ankle pain.

Indications

Microfracture may be indicated for the following:

  • Ankle sprains or fractures
  • Osteochondral lesion of the talus (injury to the cartilaginous layer on the ankle bone)
  • Young patients who have a single injury and healthy subchondral bone (bone underlying the articular cartilage)

Procedure

The microfracture technique is usually performed as an arthroscopic procedure (arthroscope or instrument consisting of a small camera to view the area of injury) under local, spinal or general anesthesia. Three small incisions are made to insert the arthroscope and other instruments. Any loose or unstable cartilage is removed. Your surgeon will insert a sharp tool known as an awl to make several holes on the surface of the ankle joint. These holes penetrate into the subchondral bone and open up new blood supply to the area. This new blood supply from within the bone marrow, supplies the damaged joint surface with new stem cells to form fibrocartilage which fills the damaged area and promotes the formation of new tissue. The incisions will then be covered.

Postoperative Care

Following the procedure, rehabilitation is critical for the success of the surgery. Your physical therapist will teach you exercises during the rehabilitation program to regain muscle strength, promote healing and gain normal range of motion of the ankle joint.

You can apply ice or ice packs over the ankle to reduce swelling. Whenever possible, elevate your leg higher than the level of your chest to minimize swelling. Your dressing will be removed in 3 days. You can get the incisions wet in the shower, but avoid submerging the wound in the pool or tub. A splint may be applied for the first 3 days after the surgery and you will have to use crutches regularly for the first 4 weeks to avoid bearing weight on the operated foot.

You may be prescribed medication for relieving pain. Avoid driving until you have been advised to do so by your doctor. Consult your doctor immediately if you experience fever, shortness of breath, sudden pain, or other unexpected symptoms.

Risks and Complications

As with any procedure, microfracture involves some of the following risks and complications:

  • Bleeding
  • Infections
  • Blood clots

The newly formed cartilage is not as strong as the body’s original cartilage and thus there is a risk of its breakage overtime.

Cartilage Grafting

Cartilage grafting is a surgical procedure that replaces damaged cartilage with healthy cartilage from a non‐weight bearing joint. Cartilage grafting is performed to correct joint deformities and restore the weight‐bearing capability of the affected joint.

Cartilage grafting is indicated in patients with articular cartilage damage in the knee to restore normal functioning of the joint.

Articular or hyaline cartilage is the tissue lining the surface of the two bones in the knee joint. Cartilage helps the bones move smoothly against each other and can withstand the pressure of activities such as running and jumping. Articular cartilage does not have a direct blood supply so it has less capacity to repair itself. Once the cartilage is torn it will not heal easily and can lead to degeneration of the articular surface, also called osteoarthritis.

The damage in articular cartilage can affect people of all ages. It can be damaged either by trauma such as accidents, mechanical injury such as a fall, or from degenerative joint

disease (osteoarthritis) occurring in older people.

Patients with articular cartilage damage experience symptoms such as joint pain, swelling, stiffness, and a decrease in range of motion of the knee.

Grafting methods

Cartilage grafting can be performed using various techniques depending on your particular situation and your surgeon’s preference.

Periosteal Grafting

This technique is performed in patients with large areas of cartilage damage in the knee. Periosteal grafts are taken from tissues lining the outer surface of bones in a non-weight bearing area of the joint. In this procedure, the damaged cartilage is removed and multiples holes are created in the bone to stimulate bleeding. The periosteal grafts are then attached to the subchondral bone with the help of sutures and glue. The periosteum cells provide growth factors to produce cartilage in the damaged area.

Perichondral Grafting

Perichondral grafting technique is similar to periosteal grafting but the graft is harvested from the lower part of the rib along with its chondrogenic layer. The procedure can be performed using minimally invasive technique or open surgery.

Once harvested, the perichondral grafts are fixed to the subchondral bone with the help of fibrin glue. This method also helps in regeneration of cartilage in the damaged area.

Osteochondral Autograft or Mosaicplasty

This grafting technique is indicated in patients whose articular cartilage damage is less than 2 cm in diameter. In this procedure, the hyaline cartilage is harvested from a non-weight bearing joint of the same individual (autograft) and transplanted in a mosaic pattern to the damaged area. The cells in the articular cartilage grow in the damaged area to promote healing. This procedure can be carried out arthroscopically or through open surgery.

Osteochondral Allograft

This procedure is similar to osteochondral autograft but the graft is harvested from a donor (allograft) and transplanted to the damaged area. The graft is held to the damaged area with the help of two metal screws or pins. The main disadvantage of this method is limited availability of donor grafts. The allografts that are harvested are larger than the autografts but can be shaped to fit the area of defect. This procedure is not recommended for patients with osteoarthritis.

Articular Cartilage Paste Grafting

In this technique, multiple holes are created in the bone to induce bleeding. The articular cartilage graft is harvested from the patient’s intercondylar notch at the center of the knee. The graft is ground with subchondral bone to make a paste which is transplanted to the damaged area. This method helps in regrowth of cartilage and provides better pain relief compared to all other grafting procedures.

Autologous Chondrocyte Implantation (ACI)

ACI is commonly performed in patients with large cartilage defects. In this procedure, healthy cartilage cells are harvested arthroscopically from a non‐weight bearing part of the joint and grown in a laboratory for about 4 to 6 weeks.

The periosteal graft is harvested from the thick tissue of the tibia or shin bone using an arthroscope through a tiny incision. The next part of the surgery is done through a laser, open incision. Your surgeon sews the graft over the damaged cartilage and the cultured cartilage cells from the lab are injected under the graft to allow new bone cells to grow. The cultured cartilage cells will repair and replace the damaged cartilage.

The advantage of this procedure is that the harvested cells are taken from the patient’s own body (autograft) lessening any risk of transplant rejection.

Postoperative Care

After cartilage grafting surgery your doctor will recommend certain measures for you to follow to promote healing and return to normal function:

Wearing a knee brace – A knee brace is applied to immobilize the knee joint and promote healing.

Participating in Rehabilitation – Physiotherapists will instruct you in performing various exercises to strengthen your leg muscles and restore movement to the operated joint.

Risks and Complications

As with any surgery, cartilage grafting is associated with certain risks and complications.

  • Graft delamination – Detachment of the grafts from the subchondral bone and the surrounding cartilage.
  • Allergic response, transfer of disease and infection, and graft rejection in allograft transplants
  • Injury to healthy cartilage

Some of the risks related to any knee surgery can include:

  • Postoperative bleeding
  • Deep vein thrombosis
  • Infection
  • Stiffness
  • Numbness around the incisions
  • Injury to vessels or nerves

It is important to understand that cartilage restoration can improve symptoms in the short to medium term but more definitive surgery may be required in the future.

Autologous Chondrocyte Implantation (ACI)

Articular or hyaline cartilage is the tissue lining the surface of the two bones in the knee joint. Cartilage helps the bones move smoothly against each other and can withstand the pressure of activities such as running and jumping. Articular cartilage does not have a direct blood supply so it has less capacity to repair itself. Once the cartilage is torn it will not heal easily and can lead to degeneration of the articular surface, also called osteoarthritis.

The damage in articular cartilage can affect people of all ages. It can be damaged either by trauma such as accidents, mechanical injury such as a fall, or from degenerative joint disease (osteoarthritis) occurring in older people.

Patients with articular cartilage damage experience symptoms such as joint pain, swelling, stiffness, and a decrease in range of motion of the knee.

ACI is commonly performed in patients with large cartilage defects. In this procedure, healthy cartilage cells are harvested arthroscopically from a non‐weight bearing part of the joint and grown in a laboratory for about 4 to 6 weeks.

The periosteal graft is harvested from the thick tissue of the tibia or shin bone using an arthroscope through a tiny incision. The next part of the surgery is done through a laser, open incision. Your surgeon sews the graft over the damaged cartilage and the cultured cartilage cells from the lab are injected under the graft to allow new bone cells to grow. The cultured cartilage cells will repair and replace the damaged cartilage.
The advantage of this procedure is that the harvested cells are taken from the patient’s own body (autograft) lessening any risk of transplant rejection.

Cartilage Transplantation

Articular or hyaline cartilage is the tissue lining the surface of the two bones in the knee joint. Cartilage helps the bones move smoothly against each other and can withstand the pressure of activities such as running and jumping. Articular cartilage does not have a direct blood supply so it has less capacity to repair itself. Once the cartilage is torn it will not heal easily and can lead to degeneration of the articular surface, also called osteoarthritis.

The damage in articular cartilage can affect people of all ages. It can be damaged either by trauma such as accidents, mechanical injury such as a fall, or from degenerative joint disease (osteoarthritis) occurring in older people.

Patients with articular cartilage damage experience symptoms such as joint pain, swelling, stiffness, and a decrease in range of motion of the knee.

Cartilage transplantation is a surgical procedure to replace the damaged cartilage with healthy cartilage taken from a donor or from the same patient harvested at the site that takes less weight of the body.

  • Osteochondral Autograft Transplantation: In this procedure, plugs of cartilage is taken from the non-weight bearing areas of knee, from the same individual and transferred to the damaged areas of the joint. This method is used to treat smaller cartilage defects since the graft which is taken from the same individual will be limited.
  • Osteochondral Allograft Transplantation: In this procedure healthy cartilage tissue or a graft is taken from a donor from the bone bank and transplanted to the area of cartilage defect.

Ligament Reconstruction

ACL

Anterior Cruciate Ligament (ACL) Tears

The anterior cruciate ligament, or ACL, is one of the major ligaments of the knee that is located in the middle of the knee and runs from the femur (thigh bone) to the tibia (shin bone). It prevents the tibia from sliding out in front of the femur. Together with posterior cruciate ligament (PCL) it provides rotational stability to the knee.

An ACL injury is a sports related injury that occur when the knee is forcefully twisted or hyperextended. An ACL tear usually occurs with an abrupt directional change with the foot fixed on the ground or when the deceleration force crosses the knee. Changing direction rapidly, stopping suddenly, slowing down while running, landing from a jump incorrectly, and direct contact or collision, such as a football tackle can also cause injury to the ACL.

When you injure your ACL, you might hear a “popping” sound and you may feel as though the knee has given out. Within the first two hours after injury, your knee will swell and you may have a buckling sensation in the knee during twisting movements.

Diagnosis of an ACL tear is made by knowing your symptoms, medical history, performing a physical examination of the knee, and performing other diagnostic tests such as X-rays, MRI scans, stress tests of the ligament, and arthroscopy.

Treatment options include both non-surgical and surgical methods. If the overall stability of the knee is intact, your doctor may recommend nonsurgical methods. Non-surgical treatment consists of rest, ice, compression, and elevation (RICE protocol); all assist in controlling pain and swelling. Physical therapy may be recommended to improve knee motion and strength. A knee brace may be needed to help immobilize your knee.

Young athletes involved in pivoting sports will most likely require surgery to safely return to sports. The usual surgery for an ACL tear is an ACL reconstruction which tightens your knee and restores its stability. Surgery to reconstruct an ACL is done with an arthroscope using small incisions. Your doctor will replace the torn ligament with a tissue graft that can be obtained from your knee (patellar tendon) or hamstring muscle. Following ACL reconstruction, a rehabilitation program is started to help you to resume a wider range of activities.

PCL

Posterior Cruciate Ligament Injuries

Posterior cruciate ligament (PCL), one of four major ligaments of the knee is situated at the back of the knee. It connects the thighbone (femur) to the shinbone (tibia). The PCL limits the backward motion of the shinbone.

PCL injuries are very rare and are difficult to detect than other knee ligament injuries. Cartilage injuries, bone bruises, and ligament injuries often occur in combination with PCL injuries. Injuries to the PCL can be graded as I, II or III depending on the severity of injury. In grade I the ligament is mildly damaged and slightly stretched, but the knee joint is stable. In grade II there is partial tear of the ligament. In grade III there is complete tear of the ligament and the ligament is divided into two halves making the knee joint unstable.

The PCL is usually injured by a direct impact, such as in an automobile accident when the bent knee forcefully strikes the dashboard. In sports, it can occur when an athlete falls to the ground with a bent knee. Twisting injury or overextending the knee can cause the PCL to tear.

Patients with PCL injuries usually experience knee pain and swelling immediately after the injury. There may also be instability in the knee joint, knee stiffness that causes limping, and difficulty in walking.

Diagnosis of a PCL tear is made on the basis of your symptoms, medical history, and by performing a physical examination of the knee. Other diagnostic tests such as X-rays and MRI scan may be ordered. X-rays are useful to rule out avulsion fractures wherein the PCL tears off a piece of bone along with it. An MRI scan is done to help view the images of soft tissues better.

Treatment options may include non-surgical and surgical treatment. Non-surgical treatment consists of rest, ice, compression, and elevation (RICE protocol); all assist in controlling pain and swelling. Physical therapy may be recommended to improve knee motion and strength. A knee brace may be needed to help immobilize your knee. Crutches may be recommended to protect your knee and avoid bearing weight on your leg.

Generally, surgery is considered in patients with dislocated knee and several torn ligaments including the PCL. Surgery involves reconstructing the torn ligament using a tissue graft which is taken from another part of your body, or a cadaver (another human donor). Surgery is usually carried out with an arthroscope using small incisions. The major advantages of this technique include minimal postoperative pain, short hospital stay, and a fast recovery. Following PCL reconstruction, a rehabilitation program will be started that helps you resume a wider range of activities. Usually, a complete recovery may take about 6 to 12 months.

(MCL)

Medial Collateral Ligament

Medial collateral ligament (MCL) is one of four major ligaments of the knee that connects the femur (thigh bone) to the tibia (shin bone) and is present on the inside of the knee joint. This ligament helps stabilize the knee. An injury to the MCL may occur as a result of direct impact to the knee. An MCL injury can result in a minor stretch (sprain) or a partial or complete tear of the ligament. The most common symptoms following an MCL injury include pain, swelling, and joint instability.

Diagnosis

An MCL injury can be diagnosed with a thorough physical examination of the knee and diagnostic tests such as X-rays, MRI scans, and arthroscopy. X-rays may help rule out any fractures. In addition, your doctor will perform a valgus stress test to check for stability of the MCL. In this test, the knee is bent approximately 30° and pressure is applied on the outside surface of the knee. Excessive pain or laxity is indicative of medial collateral ligament injury.

Management

If the overall stability of the knee is intact, your doctor will recommend non-surgical methods including ice, physical therapy, and bracing. Surgical reconstruction is rarely recommended for MCL tears but may be necessary in patients failing to heal properly with residual knee instability. These cases are often associated with other ligament injuries. If surgery is required, a ligament repair may be performed, with or without reconstruction with a tendon graft, depending on the location and severity of the injury.

Indications and Contraindications

Medial collateral ligament reconstruction is indicated in patients with chronic MCL instability despite appropriate nonsurgical treatment.

Medial collateral ligament reconstruction is contraindicated in patients with degenerative changes in the medial or lateral compartment, active infection, ligament instability, or presence of chronic diseases that can hamper surgical management or compliance to postoperative rehabilitation instructions.

Procedure

The procedure is performed under general anesthesia. Arthroscopic examination of the knee may be performed to rule out any associated injuries including anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) tears.

The surgical procedure for medial collateral ligament reconstruction involves the following steps:

  • Your surgeon will make an incision over the medial femoral condyle.
  • Care is taken to move muscles, tendons and nerves out of the way.
  • The donor tendon is usually harvested from the Achilles tendon.
  • The soft tissue around the femur is debrided to assist the insertion of the Achilles bone plug.
  • For placing the graft, a tunnel is created from a guide pin to the anatomic insertion of the MCL on the tibia, using the index finger and surgical scissors.
  • The Achilles tendon allograft is inserted in the femoral tunnel and fixed using screws.
  • The MCL graft is made taut, with the knee at 20° flexion under varus stress, and fixed to the tibia with a screw and a spiked washer.
  • The incision is closed with sutures and covered with sterile dressings.

Postoperative Care

In the first two weeks after the surgery, toe-touch and weight-bearing is allowed with the knee brace locked in full extension. After 2 weeks 0° to 30° of motion is allowed at the knee. At 4 weeks, knee flexion is allowed from 60° to 90° of motion and full weight bearing is permitted. At 6 weeks, the brace is removed and you are allowed to perform full range of motion. Crutches are often required until you regain your normal strength.

Risks and Complications

Knee stiffness and residual instability are the most common complications associated with MCL reconstruction. The other possible complications include:

  • Numbness
  • Infection
  • Blood clots (Deep vein thrombosis)
  • Nerve and blood vessel damage
  • Failure of the graft
  • Loosening of the graft
  • Decreased range of motion

LCL

LCL reconstruction

Lateral collateral ligament (LCL) is a thin set of tissues present on the outer side of the knee, connecting the thighbone (femur) to the fibula (side bone of lower leg). It provides stability as well as limits the sidewise rotation of the knee. Tear or injury of LCL may cause instability of the knee that can be either reconstructed or repaired to regain the strength and movement of the knee.

The knee is the largest joint of the body and is stabilized by a set of ligaments. In the knee there are four primary ligaments viz. anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL) and lateral collateral ligament (LCL).

Lateral collateral ligament (LCL) may tear due to trauma, sports injuries, or direct blow on the knee. Torn LCL may result in pain, swelling and even instability of the knee. LCL injuries and torn LCL can be diagnosed through physical examination and by employing imaging techniques such as X-rays or MRI scan.

The treatment of the torn LCL include non-surgical interventions such as rest, ice, elevation, bracing and physical therapy to help reduce swelling, and regain activity as well as strength and flexibility of the knee. Surgery is recommended if non-surgical interventions fail to provide much relief. Surgical interventions include repair and reconstruction of the torn ligament. Based on the severity and location of the injury, repair or reconstruction of the LCL is recommended. In case the ligament is torn from the upper or lower ends of attachment, then repair of the LCL is done with sutures or staples. If the ligament is torn in the middle or if the injury is older than 3 weeks, LCL reconstruction is recommended.

Procedure

LCL reconstruction involves replacement of the torn ligament with healthy strong tissue or graft. The tissue or graft can be taken either from the tissue bank (called allograft) or from the patient’s body (called autograft). The type of graft used, depends upon the condition of the patient and choice of your surgeon. Hamstring tendons are commonly used as autograft, as removal of such tendons does not affect the strength of the legs and effectively stabilizes the knee. A small incision is made on the lateral side of the knee to perform the LCL reconstruction. The procedure is done through an open incision and not arthroscopically. The thighbone and fibula bones are drilled precisely and accurately with specialized instruments to form tunnels. The ends of the tendon graft are passed through tunnels and are fixed by using screws, metal staples or large sutures. The knee undergone LCL reconstruction surgery is braced for 6-8 weeks.

Post-operative care

The common post-operative instructions for LCL reconstruction are:

  • Use crutches to avoid weight on the knee for at least 6 weeks
  • Use ice and the prescribed medications to reduce swelling
  • Avoid lifting heavy weight or vigorous exercise
  • Follow the specific instruction given by your surgeon
  • Follow rehabilitation programs or physical therapy to regain the motion and strength of the knee

Risks and complications

Some of the possible risks and complication associated with LCL reconstruction include:

  • Chronic pain
  • Knee weakness
  • Knee instability
  • Peroneal nerve injury

PLC (Postero-lateral Corner)

Coming soon

ALL (Anterolateral Ligament)

Coming soon

Patellar Ligament Surgery (Dislocating Patella)

Patella is the small piece of bone in front of the knee that slides up and down the femoral groove (groove in the femur bone) during bending and stretching movements. The ligaments on the inner and outer sides of patella hold it in the femoral groove and avoid dislocation of patella from the groove. Patellar (knee cap) instability results from one or more dislocations or partial dislocations (subluxations). Patellar dislocation is a condition that occurs when the kneecap or the patella completely shifts out of the groove towards the outside of the knee joint.
Normally, the kneecap fits in the groove, but uneven groove can cause the kneecap to slide off resulting in partial or complete dislocation of the kneecap.

Any damage to these ligaments may cause patella to slip out of the groove either partially (subluxation) or completely (dislocation). This misalignment can damage the underlying soft structures such as muscles and ligaments that hold the knee cap in place. Once damaged, these soft structures are unable to keep the patella (knee cap) in position. Repeated subluxation or dislocation makes the knee unstable and the condition is called as knee instability.

Patients with knee instability experience different signs and symptoms such as:

  • Pain, especially when standing up from a sitting position
  • Feeling of unsteadiness or tendency of the knee to “give way” or “buckle”
  • Recurrent subluxation
  • Recurrent Dislocation
  • Severe pain, swelling and bruising of the knee immediately following subluxation or dislocation
  • Visible deformity and loss of function of the knee often occurs after subluxation or dislocation
  • Sensation changes such as numbness or even partial paralysis can occur below the dislocation as a result of pressure on nerves and blood vessels

Various factors and conditions may cause patellar instability. Often a combination of factors can cause this abnormal tracking and include the following:

Anatomical defect: Flat feet or fallen arches and congenital abnormalities in the shape of the patella bone can cause misalignment of the knee joint.

Abnormal “Q” Angle: The “Q” angle is a medical term used to describe the angle between the hips and knees. The higher the “Q” angle, such as in patients with Knock Knees, the more the quadriceps pull on the patella causing misalignment.

Patellofemoral Arthritis: Patellar misalignment causes uneven wear and tear and can eventually lead to arthritic changes to the joint.

Improper Muscle Balance:
Quadriceps, the anterior thigh muscles, function to help hold the kneecap in place during movement. Weak thigh muscles can lead to abnormal tracking of the patella, causing it subluxate or dislocate.

Your surgeon diagnoses the condition by collecting your medical history and physical findings. He may also order certain tests such as X-rays, MRI or CT scans to confirm the diagnosis.

Treatment for instability depends on the severity of condition and based on the diagnostic reports. Initially your surgeon may recommend conservative treatments such as physical therapy, use of braces and orthotics. Pain relieving medications may be prescribed for symptomatic relief. However when these conservative treatments yield unsatisfactory response surgical correction may be recommended.

Considering the type and severity of injury surgeon decides on the surgical correction. A lateral retinacular release may be performed where your surgeon releases, or cuts, the tight ligaments on the lateral side (outside) of the patella enabling the patella to slide more easily in the femoral groove.

Your surgeon may also perform a procedure to realign the quadriceps mechanism by tightening the tendons on the inside or medial side of the knee.

If the misalignment is severe tibial tubercle transfer (TTT) will be performed. This procedure involves the surgeon removing a section of bone where the patellar tendon attaches on the tibia. The bony section is then shifted and properly realigned with the patella and reattached to the tibia with two screws.

Following the surgery rehabilitation program may be recommended for better outcomes and quicker recovery.

Tendon Repairs/Reconstruction

Patellar Tendon Repair/Reconstruction

Patella tendon rupture is the rupture of the tendon that connects the patella (knee cap) to the top portion of the tibia (shin bone). The patellar tendon works together with the quadriceps muscle and the quadriceps tendon to allow your knee to straighten out.

Patellar tendon tear most commonly occurs in middle-aged people who participate in sports which involve jumping and running. Patellar tendon can be ruptured by several reasons such as by fall, direct blow to the knee, or landing on the foot awkwardly from a jump. Other causes include patellar tendonitis (inflammation of patellar tendon), diseases such as rheumatoid arthritis, diabetes mellitus, infection, and chronic renal failure. Use of medications such as steroids can cause increased muscle and tendon weakness.

When the patellar tendon tears, the patella may lose its anchoring support to the tibia as a result when the quadriceps muscle contracts the patella may move up into the thigh. You are unable to straighten your knee and upon standing the knee buckles upon itself. In addition to this you may have pain, swelling, tenderness, a tearing or popping sensation, bruising, and cramping.

Patellar tendon tear can be a partial or a complete tear. In partial tear, some of the fibers in the tendon are torn, but the soft tissue is not damaged. In complete tear, the soft tissues are disrupted into two pieces.
To identify a patellar tendon tear your doctor will ask about your medical history and perform a physical examination of your knee. Some imaging tests, such as an X-ray or magnetic resonance imaging (MRI) scan may be ordered to confirm the diagnosis. X-ray of the knee is taken to know the position of the kneecap and MRI scan to know the extent and location of the tear.

Patellar tendon rupture can be treated by non-surgical and surgical methods. Non-surgical treatment involves use of braces or splints to immobilize the knee. Physical therapy may be recommended to restore the strength and increase range of motion of the knee.

Surgery is performed on an outpatient basis and not arthroscopically since the tendon is present outside the joint. The goal of the surgery is to reattach the torn tendon to knee cap and to restore the normal function in the affected leg. The procedure is performed under regional or general anesthesia and an incision is made on the front of the knee to expose the tendon rupture. Holes are made in the patella and strong sutures are tied to the tendon and then threaded through these holes. These sutures are tied in place to pull the torn edge of the tendon back to its normal position on the kneecap.

Severe damage can make the patellar tendon very short, and in such cases reattachment will be difficult. Your surgeon may attach a tissue taken from a donor (allograft) to lengthen the tendon.

Complications after the repair include weakness and loss of motion. In some cases, the tendon which re-attached may detach from the knee cap or re-tears may also occur. Other complications such as infection and blood clot may be observed.

Following surgery a brace may be needed to protect the healing tendon. Complete healing of the tendon will take about 6 months.

Quadriceps Tendon Repair/Reconstruction

Quadriceps tendon is a thick tissue located at the top of the kneecap. The quadriceps tendon works together with the quadriceps muscles to allow us to straighten our leg. The quadriceps muscles are the muscles located in front of the thigh.

Quadriceps tendon rupture most commonly occurs in middle-aged people who participate in sports which involve jumping and running. Quadriceps tear occur by fall, direct blow to the leg and when you land on your leg awkwardly from a jump. Other causes include tendonitis (inflammation of quadriceps tendon), diseases such as rheumatoid arthritis, diabetes mellitus, infection, and chronic renal failure which weakens the quadriceps tendon. Use of medications such as steroids and some antibiotics also weakens the quadriceps tendon.

When the quadriceps tendon tear, the patella may lose its anchoring support in the thigh as a result the patella moves towards the foot. You will be unable to straighten your knee and upon standing the knee buckles upon itself.
To identify a quadriceps tendon tear your doctor will ask about your medical history and perform a physical examination of your knee. Some imaging tests, such as an X-ray or MRI scan may be ordered to confirm the diagnosis. X-ray of the knee is taken to know the position of the kneecap and MRI scan to know the extent and location of the tear.

Quadriceps tendon tear can be treated by non-surgical and surgical methods. Non-surgical treatment involves use of knee braces to immobilize the knee. Crutches may be needed to prevent the joint from bearing weight. Physical therapy may be recommended to restore the strength and increase range of motion of the knee.

Surgery is performed on an outpatient basis cannot be repaired arthroscopically since the tendon is outside the joint .the goal of the surgery is to re-attach the torn tendon to knee cap and to restore the normal function of the knee. Sutures are placed in the torn tendon which is then passed through the holes drilled in the knee cap. The sutures are tied at the bottom of the knee cap to pull the torn edge of the tendon back to its normal position.
Surgical complications include weakness and loss of motion. In some cases, the tendon which re-attached may detach from the knee cap or re-tears may also occur. Other complications such as pain, infection and blood clot may be observed.

Following surgery a brace may be needed to protect the healing tendon. Complete healing of the tendon will take about 4 months.

Patella (Knee Cap) Surgeries

Patella (knee cap) is a protective bone attached to the quadriceps muscles of the thigh by quadriceps tendon. Patella attaches with the femur bone and forms a patellofemoral joint. Patella is protected by a ligament which secures the kneecap from gliding out and is called as medial patellofemoral ligament (MPFL).

Dislocation of the patella occurs when the patella moves out of the patellofemoral groove, (called as trochlea) onto a bony head of the femur. If the knee cap partially comes out of the groove, it is called as subluxation and if the kneecap completely comes out, it is called as dislocation (luxation). Patella dislocation is commonly observed in young athletes between 15 and 20 years and commonly affects women because of the wider pelvis creates lateral pull on the patella.

Some of the causes for patellar dislocation include direct blow or trauma, twisting of the knee while changing the direction, muscle contraction, and congenital defects. It also occurs when the MPFL is torn.

The common symptoms include pain, tenderness, swelling around the knee joint, restricted movement of the knee, numbness below the knee, and discoloration of the area where the injury has occurred.

Your doctor will examine your knee and suggests diagnostic tests such as X-ray, CT scan, and MRI scan to confirm condition and provide treatment.

There are non-surgical and surgical ways of treating patellofemoral dislocation.
Non-surgical or conservative treatment includes:

  • PRICE (protection, rest, ice, compression, and elevation)
  • Nonsteroidal anti-inflammatory drugs and analgesics to treat pain and swelling
  • Braces or casts which will immobilize the knee and allows the MPF ligament to heal
  • Footwear to control gait while walking or running and also decreases the pressure on the kneecap.
  • Physical therapy is recommended which helps to control pain and swelling, prevent formation of scar of soft tissue, and also helps in collagen formation. Physiotherapist will extend your knee and applies direct lateral to medial pressure to the knee which helps in relocation. It includes straightening and strengthening exercises of the hip muscles and other exercises which will improve range of motion

Surgical treatment is recommended for those individuals who have recurrent patella dislocation. Some of the surgical options include:

  • Lateral-release – It is done to loosen or release the tight lateral ligaments that pull the kneecap from its groove which increases pressure on the cartilage and causes dislocation. In this procedure, the ligaments that tightly hold the kneecap are cut using an arthroscope
  • Medial patellofemoral ligament reconstruction – In this procedure, the torn MPF ligament is removed and reconstructed using grafting technique. Grafts are usually harvested from the hamstring tendons, located at the back of the knee and are fixed to the patella tendon using screws. The grafts are either taken from the same individuals (auto graft) or from a donor (allograft). This procedure is also performed using an arthroscope
  • Tibia tubercle realignment or transfer – Tibia tubercle is a bony attachment below the patella tendon which sits on the tibia. In this procedure the tibia tubercle is moved towards the center which is then held by two screws. The screws hold the bone in place and allow faster healing and prevent the patella to slide out of the groove. This procedure is also performed using an arthroscope

After the surgery, your doctor will suggest you to use crutches for few weeks, prescribe medications to control pain and swelling, and recommend physical therapy which will help you to return to your sports activities at the earliest.

Meniscus Procedures

Meniscus Transplantation

Meniscus tear is the commonest knee injury in athletes, especially those involved in contact sports. A suddenly bend or twist in your knee cause the meniscus to tear. This is a traumatic meniscus tear. Elderly people are more prone to degenerative meniscal tears as the cartilage wears out and weakens with age. The two wedge-shape cartilage pieces present between the thighbone and the shinbone are called meniscus. They stabilize the knee joint and act as “shock absorbers”.

Torn meniscus causes pain, swelling, stiffness, catching or locking sensation in your knee making you unable to move your knee through its complete range of motion. Your orthopedic surgeon will examine your knee, evaluate your symptoms, and medical history before suggesting a treatment plan. The treatment depends on the type, size and location of tear as well your age and activity level. If the tear is small with damage in only the outer edge of the meniscus, nonsurgical treatment may be sufficient. However, if the symptoms do not resolve with nonsurgical treatment, surgical treatment may be recommended.

The surgical treatment options include meniscus removal (meniscectomy), meniscus repair, and meniscus transplantation.

Meniscus transplantation involves replacement of a torn cartilage with the cartilage obtained from a donor or a cultured patch obtained from laboratory. It is considered as a treatment option to relieve knee pain in patients who have undergone meniscectomy.

Meniscectomy

Meniscectomy is a surgical procedure indicated in individuals with torn meniscus where the conservative treatments are a failure to relieve the pain and other symptoms. Meniscectomy is recommended based on the ability of meniscus to heal, patient’s age, health status and activity level.

Meniscus is the C-shaped two pieces of cartilage located between thighbone and shin bone that act as shock absorbers and cushion the joints. Meniscus distributes the body weight uniformly across the joint and avoids the pressure on any one part of the joint and development of arthritis. Being the weight bearing part, meniscus is prone to wear and tear and meniscal tear is one of the common knee injuries. Meniscal tear may be developed by people of all ages and is more common in individuals who play contact sports.

On the pattern of tear, meniscal tear may be of different types such as longitudinal, parrot-beak, flap, bucket handle, and mixed/complex tear. Sudden twist, squat, or tackle may be the cause for meniscal tear in adults and ageing may cause the tear in elderly individuals. Meniscal tear may cause severe pain, stiffness and swelling, catching or locking of the knee, and may limit the movement. Meniscal tear is often diagnosed with the presenting symptoms and imaging techniques such as X-rays or magnetic resonance imaging scan.

Conservative treatments for meniscal tear include R.I.C.E (Rest, Ice, Compression, and Elevation) and use of nonsteroidal anti-inflammatory medications. Surgery is recommended in severe cases and may be performed using arthroscopic technique. Depending on the extent of tear, your surgeon will decide on whether to perform total meniscectomy (complete removal of torn meniscus) or partial meniscectomy (unstable meniscal fragments are removed and intact tissue is left in place and the edges are smoothened. Your surgeon may also order for rehabilitation program following the surgery for better and quicker recovery.

Arthroscopic Meniscectomy

The arthroscope is a small fiber-optic viewing instrument made up of a tiny lens, light source and video camera. The surgical instruments used in arthroscopic surgery are very small (only 3 or 4 mm in diameter), but appear much larger when viewed through an arthroscope.

The television camera attached to the arthroscope displays the image of the joint on a television screen, allowing the surgeon to look throughout the knee at cartilage and ligaments, and under the kneecap.

Then the surgeon makes two small incisions (about 1/4 of an inch), around the knee joint area. Each incision is called a portal. In one portal, the arthroscope is inserted to view the knee joint. Along with the arthroscope, a sterile solution is pumped into the joint which expands the viewing area, giving the surgeon a clear view and room to work. The other portal is used for the insertion of tiny surgical instruments.

With the images from the arthroscope as a guide, your surgeon can look at the menisci and confirm the type, location, and extent of the tear. Once your surgeon has located the meniscal tear, surgical scissors and shavers are inserted into the portals to remove the torn menisci. In total meniscectomy entire menisci is removed and in partial meniscectomy only the torn part of the tissue is removed leaving the intact tissue in place with edges smoothed.

^ Back to Top
aossm northwestein aoa isha aaos us-ski-snowboarding-sports-medicine us-ski-snowboarding-sports-medicine

X