Introduction

Arthroscopic Surgery is a procedure that allows surgeons to see, diagnose, and treat problems inside a joint.  The procedure, also called an Arthroscopy, requires only small incisions and is guided by a miniature viewing instrument or scope.  Before arthroscopy existed, surgeons made large incisions that affected the surrounding joint structures and tissues.  They had to open the joint to view it and perform surgery.  The traditional surgery method carries a higher risk of infection and requires a longer time for recovery.  In contrast, arthroscopy is less invasive.  It has a decreased risk of infection and shorter recovery period.  Today, arthroscopic surgery is one of the most common orthopedic procedures.

Treatment

Arthroscopic Surgery uses an arthroscope, which is a very small surgical instrument; about the size of a pencil.  An arthroscope contains a lens and lighting system that allows a surgeon to view inside a joint. The surgeon only needs to make small incisions and the joint does not have to be opened up fully. The arthroscope can be attached to a miniature camera.  The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape.   
Initially, the arthroscope was designed as a diagnostic tool for planning traditional open joint surgeries.  A surgeon uses an arthroscope to diagnose joint conditions when physical examinations or imaging scans are not conclusive.  The diagnostic accuracy of arthroscopy is highly precise.  As the technology developed, special surgical instruments were created to use with the arthroscope. Now, it can be used to treat conditions as well.  Like the arthroscope, the thin surgical instruments are inserted into the joint through small incisions.  Some injuries or problems are treated with a combination of arthroscopic and open surgery.  
 
Conditions Treated with Arthroscopy
 
Although nearly all joints can be viewed with an arthroscope, it is used most frequently to treat six joints.  These include the knee, shoulder, elbow, ankle, hip and wrist.  Arthroscopy most commonly treats diseases and injuries that damage the bones, cartilage, ligaments, tendons, and muscles that make up a joint.
Bones are the hardest tissues in our body.  They support our body structure and meet to form joints.  Cartilage covers the ends of many of our bones. The cartilage forms a smooth surface and allows the bones to glide easily during motion.  Disease and injury can compromise the cartilage and joint structure and disrupt their functions.  
 
A condition called Chondromalacia can cause the cartilage to soften and deteriorate because of injury, disease, or “wear and tear.”  The curved cartilage in the knee joint, called a meniscus, is especially vulnerable to tears during injury.  An arthroscopic surgery can treat these conditions by shaving and smoothing out the cartilage.  It can also remove abnormal growths from bones, such as calcium deposits and bone spurs. 

Tendons are strong fibers that attach our muscles to our bones.  They are tissues that do not stretch easily and are susceptible to tears under repeated or traumatic stress.  Ligaments are strong tissues that connect our bones together and provide structural support.  The ligaments are lined with Synovial Membrane called Synovium.  The Synovium secretes a thick liquid called Synovial Fluid.  The Synovial Fluid acts as a cushion and lubricant between the joints, allowing us to perform smooth and painless motions.  Trauma and “wear and tear” from overuse can cause injury and inflammation to our tendons, ligaments, and Synovium.  
 
Tendons in the shoulder and ligaments in the knee are frequently torn or impinged from trauma and overuse.  An arthroscopy can repair tendons.  Many ligaments and tendons can be repaired arthroscopically.  Synovitis, a condition caused by an inflamed lining of a joint, can develop in the knee, shoulder, elbow, wrist, or ankle.  Arthroscopy can treat synovitis by removing scar tissue or the inflamed synovium.  A synovial biopsy, a tissue sample for examination, can be done via arthroscopy.
 
What to Expect
 
Arthroscopic surgery is usually performed as an outpatient procedure.  In some cases, an overnight stay in the hospital may be needed.  You may be sedated for the surgery or receive a local or regional anesthetic to numb the area, depending on the joint or suspected problem.  Before the surgery, your surgeon will elevate your limb and apply a tourniquet, an inflatable band.  This will reduce the blood flow to your joint during the procedure. 
 
Your surgeon will make one or more small incisions, about ¼” to ½” in length, near your joint.  Your surgeon will fill the joint space with a sterile saline (salt-water) solution.  Expansion of the space allows your surgeon to have a better view of your joint structures.  Your surgeon will insert the arthroscope and manipulate it to see your joint from different angles.  If you are having another surgical procedure, your surgeon may make additional small incisions and use other slender surgical instruments.  When your procedures are completed, your surgeon may inject your joint with medication to reduce pain and inflammation.  Because the incisions are so small, they will require just a few stitches 
 
Your recovery time will depend on the extent of your condition and the amount of surgery that you had.  Your surgeon will let you know what to expect.  Your surgeon may restrict your activity for a short period of time following your surgery.  It is common for people to return to work or school within a few days.  In some cases, rehabilitation is recommended to mobilize and strengthen the joint.  It usually takes a joint several weeks to fully recover.
 
Benefits of Arthroscopy 
 
An arthroscopy can be a short procedure.  In some cases, it may only take minutes for the actual surgery.  Because it is often a shorter procedure, a smaller amount of anesthesia is required and individuals need to be sedated for shorter amounts of time than with open joint surgery.  Most people have the procedure as an outpatient and return to their homes in just a few hours.
 
Overall, an arthroscopy requires a shorter length of time for recovery than open joint surgery.  It also has a reduced risk of infection and causes less pain because only small incisions are used and less surrounding tissue is affected or exposed.

Introduction

The Achilles tendon is the most powerful tendon in the human body.  Tendons are strong tissues that connect muscles to bone.  The Achilles tendon is located in the lower back part of the leg and works with the calf muscles to provide forceful foot movements.  Achilles tendon ruptures most commonly occur as a result of sports injuries from activities such as basketball, football, or tennis.  They can also result from a condition called Achilles tendonitis.  Individuals with Achilles tendonitis have weakened and inflamed tendons that are susceptible to injury.

Anatomy

The Achilles tendon is a large, strong fibrous cord that connects the calf muscles in the back of the leg to the back of the heel bone (calcaneus).  The Achilles tendon and the calf muscles work together to allow individuals to point the foot downward and to raise the heel upward.  People rely on it virtually every time they move their foot.  This motion enables individuals to walk, jump, stand on their toes, and climb stairs.  Individuals with Achilles tendon ruptures will most often not be able to perform such movements.

Causes

Achilles tendon ruptures most commonly occur in men between the ages of 30 and 50 years old that participate in sports.  Sports such as basketball, football, and tennis require quick forward and backward leg movements, jumping, and cutting that can create an imbalance of pressure on the leg and foot.  The Achilles tendon can rupture when the flexed foot sustains a sudden strong force and the calf muscles powerfully shorten.  Achilles tendon rupture can also result from tendons weakened over time by Achilles tendonitis (chronic inflammation of the tendon).

Symptoms

A loud “pop” may be heard when the Achilles tendon ruptures.  Most individuals feel a sudden painful “snap” in the back of the calf or lower leg followed by sharp severe pain.  Swelling and skin discoloration in the back of the calf will often develop because of bleeding beneath the skin.  Individuals are unable to point their feet downward or raise their heels upward making it difficult to walk, jump, stand on their toes, and climb stairs.

Diagnosis

In order to diagnose an Achilles tendon rupture, a physician will perform an examination and review the individual’s medical history.  The Thompson Test is the most reliable physical examination to confirm a suspected Achilles tendon rupture.  The test is simple to perform.  The individual lies face down with the leg straight.  The physician squeezes the calf muscles in the leg.  If the foot does not point, the Achilles tendon may have ruptured.  The foot will not be able to point because the tendon connecting the calf muscles at the heel is torn.  Some physicians may order medical imaging tests, such as ultrasound or Magnetic Resonance Imaging (MRI), to determine the location and type of tendon tear.  An ultrasound uses sound waves to create an image when a device is gently placed on the skin.  An MRI provides a very detailed view of body structures.  The MRI equipment focuses on the leg area while the individual remains very still.  In some cases, x-rays are ordered to assess if the leg or heel bone was injured when the Achilles tendon ruptured. 

Treatment

Each case of Achilles tendon rupture must be evaluated on an individual basis.  It is important for the individual and physician to discuss and determine which treatment options are most appropriate.  Treatment for Achilles tendon ruptures can be surgical or nonsurgical.

Surgery is not recommended for inactive individuals or those who are at high risk for complications or cannot tolerate surgery.  Treatment for these individuals includes approximately six weeks of casting to allow the tendons to heal, followed by physical therapy.  Physical Therapists focus on improving physical functioning by addressing muscle strength, flexibility, endurance, balance, and coordination.  This method can be effective, and it avoids the risks, such as infection, associated with surgery

Surgery

For individuals with active lifestyles and who want to return to strenuous recreational activities, physicians recommend surgery to reattach the torn Achilles tendon.  Surgery is generally very effective and the risk of complication is typically low.  The surgery will require anesthesia, but can also be performed on an out-patient basis.  The surgeon makes a three to four inch opening behind the ankle and reattaches the tendon ends to each other or to the bone.  The foot is placed in a pointed position in a splint or short leg cast.  The splint or cast is worn for four to six weeks.  The individual participates in physical therapy when the healing is complete.

Recovery

Individuals with surgical and non-surgical repair have good to excellent rates of returning to full activity levels with proper treatment and rehabilitation.  The length of time for healing is highly variable.  Generally, individuals with surgical repair can return to walking and swimming at six weeks, and gradually return to sports several months from the surgery.  They have a lower risk of repeated tendon rupture and a better chance of regaining full strength in the leg.  Individuals with non-surgical repair will often participate in rehabilitation for a longer period of time.  They have a higher risk of repeated tendon rupture and loss of strength.

Introduction

The anterior cruciate ligament (ACL)is one of the most commonly injured ligaments in the knee. Ligaments are strong non-elastic fibers that connect our bones together. The ACL crosses inside of the knee, connecting the thighbone to the leg. It provides stability to the knee joint.

ACL tears most commonly occur in very active people or athletes. The ACL can tear when people abruptly slow down from running, land from a jump, or change directions rapidly.  These types of actions are frequently performed during sports, such as football, basketball, skiing, and soccer. Athletes are especially at risk for ACL tears, although they may occur in active workers and the general population as well.

The ACL can tear completely or partially. It is unable to repair itself. When the ACL is injured, it is common to see other surrounding knee structures damaged as well. Some cases of ACL tears are treated with non-surgical methods. However, there are several surgical options that successfully restore knee strength and stability.

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Anatomy

The knee is structurally complex. Our knee is composed of three bones. The femur, or thighbone, sits on top of the tibia, the larger leg bone. The patella, or kneecap, glides in a groove on the end of the femur. 
 
Large muscle groups in the thigh give the knee strength and stability. The quadriceps muscles are a large group of muscles on the front of our thigh that straighten and rotate the leg. The hamstring muscles are located on the back of the thigh and bend or flex the knee.
 
Four ligaments connect our knee bones together. The ligaments are strong tissues that provide stability and allow motion. The ligaments enable our knee to have the flexibility to move in various directions while maintaining balance. The medial collateral ligament is located on the inner side of our knee. The lateral collateral ligament is at the outer side of our knee. These two ligaments help the joint to resist side to side stress and maintain positioning.
 
The anterior cruciate ligament and the posterior cruciate ligament cross inside of the knee joint. These two ligaments help to keep the joint aligned. They counteract excessive forward and backward forces and prohibit displacement of the bones. They also produce and control rotation of the tibia. We rotate our tibia when we turn our leg outward to push off the ground with our foot. We use this motion to push off from the side when skate, run, or move our body to get into a car.

Two cartilage disks, called menisci, are located on the end of the tibia. The cartilage forms a smooth surface and allows our bones to glide easily during motion. The menisci also act as shock absorbers when we walk or run. 
 
A smooth tissue capsule covers the bones in our knee joint. A thin synovial membrane lines the capsule. The synovium secretes a thick liquid called synovial fluid. The synovial fluid acts as a cushion and lubricant between the joints, allowing us to perform smooth and painless motions.

Proprioceptive nerve fibers are contained in the ligaments and joint capsule. The proprioceptive nerve endings send signals about body movements and positioning.  For instance, the proprioceptors in the knee send signals to let us know how far to bend our joint in order to place our foot  for a step. They plan and coordinate our leg movements whenever we move.

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Causes

The ACL can tear during strong twisting motions of the knee. The ACL can also tear if the knee is hyperextended or bent backwards. People frequently tear the ACL while pivoting, landing awkwardly from a jump, changing directions suddenly, or abruptly slowing down from running. ACL tears occur most frequently in young athletes.  Football, basketball, skiing, and soccer are sports associated with the highest injury rates. 

Researchers show that female athletes have a higher rate of ACL injury than males in certain sports. They suspect the greater angles in the female hip and leg alignment may make the knee more vulnerable to force. Additionally, female hormones can relax ligaments and make them less stable, making some women more susceptible to knee injury.

It is common for additional injuries to result when an ACL tear occurs. Surrounding structures, such as the meniscus, cartilage, and ligaments can be injured as well.  Some people may also experience bruised or broken bones. The ACL can tear during strong twisting motions of the knee. The ACL can also tear if the knee hyperextends or bends backwards. People frequently tear the ACL while pivoting, landing awkwardly from a jump, changing directions suddenly, or abruptly slowing down from running. 

ACL tears occur most frequently in young athletes. Football, basketball, skiing, and soccer are sports associated with the highest injury rates. 

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Symptoms

People usually experience pain, swelling, and knee instability immediately after the ACL tears. Your knee may buckle or give out on you. You may not be able to fully straighten your knee. You may have difficulty moving your knee and walking. Typically, within a few hours the swelling in the knee increases dramatically.

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Diagnosis

If you suspect you have torn your ACL, you should go to your doctor or an emergency room right away. A doctor can evaluate your knee by gathering your medical history, performing a physical examination, and viewing medical images. Your doctor will ask you about your symptoms and what happened if you were injured. Your doctor will examine your knee and your leg alignment. You will be asked to perform simple movements to help your doctor assess your muscle strength, joint motion, and stability.

Doctors typically perform the Lachman Test to determine if the ACL is intact. For this test, you will lie on your back and slightly bend your knees. Your doctor will place one hand on your thigh and attempt to pull your leg forward with the other hand. Your doctor will test both of your legs to compare the results. If you can move your leg three to five millimeters, the test is positive. 

The Pivot Shift Test is another test to determine if the ACL is functioning. For this test, you will straighten your leg. Your doctor will hold your leg while turning it and moving it toward your body. If your leg moves in and out of position, the test is positive for an ACL tear.

Your physician will order X-rays to see the condition of the bones in your knee and to identify fractures. Sometimes a fracture or soft tissue injury does not show up on an X-ray. In this case, your doctor may order a magnetic resonance imaging (MRI) scan. An MRI scan will provide a very detailed view of your knee structure. Like the X-ray, the MRI does not hurt and you need to remain very still while the images are taken.

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Treatment

Initially following an injury, your knee will be treated with rest, ice, compression, and elevation. You should rest your knee by not placing weight on it. You may use crutches to help you walk. Applying ice packs to your knee can help reduce pain and swelling.  You should apply ice immediately after injuring your knee. Your doctor will provide you with a continued icing schedule. Your doctor may provide over-the-counter or prescription pain medication. In some cases, a knee brace may be recommended to immobilize and support the knee. A knee immobilizer is used for only a short period of time. Elevating your knee at a level above your heart helps to reduce swelling.

Treatment for ACL tears is very individualized. Many factors need to be considered, such as your activity level, severity of injury, and degree of knee instability. Treatments may include physical therapy, surgery, or a combination of both. The most likely candidates for non-surgical treatments have partial ACL tears without knee instability, complete tears without knee instability, sedentary lifestyles or are willing to give up high-demand sports, or are children whose knees are still developing. 

Physical therapy and rehabilitation can help restore knee functioning for some individuals. Your physical therapist will help you strengthen your knee. Special emphasis is placed on exercising the quadriceps muscles on the front of the thigh and the hamstring muscles on the back of the thigh. Eventually, you will learn exercises to improve your balance and coordination. You may need to wear a knee brace during activities. Your therapists will educate you on how to prevent further injury.

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Surgery

Surgical treatment is most frequently recommended for individuals with ACL tears accompanied with other injuries. The most likely candidates for surgical treatment are active individuals in sports or jobs with heavy manual work that requires pivoting or pushing off with the knee. Surgery is also recommended for people with unstable knees or injuries combined with damage to the menisci, articular cartilage, joint capsule, or ligaments.

Prior to surgery, most people participate in physical therapy. Swelling can make the knee stiff. Immobility can cause the muscles and ligaments to shorten. Your physical therapist will help you stretch your knee to regain full movement. If your collateral ligaments are involved, you may need to wear a brace to allow them to heal prior to your surgery. These steps will help you prepare for a successful recovery after your surgery.

The goal of ACL repair is to reconstruct your knee joint to restore its function and stability, and prevent further injury. During surgery, your doctor will replace your damaged ACL with a healthy tendon, called a graft. There are several options for acquiring grafts. They may be taken from an area near your knee or from a donor cadaver.

A patellar tendon autograft uses the middle third of the patellar tendon and bone plugs from the shin and kneecap. This type of reconstruction is most often recommended for high-demand athletes and individuals that do not have to perform a lot of kneeling activities. This grafting procedure has been considered the “gold standard” for ACL repair.

A hamstring tendon autograft uses one or two tendons from the hamstring muscles at the inner side of the knee. The hamstring tendon autograft is most appropriate for lighter-weight individuals with a small patella bone and a history of pain. This method can be associated with a faster recovery. 

A quadriceps tendon autograft uses the middle third of the quadricep tendon and a bone plug from the upper end of the kneecap. The quadricep graft is large. It is most appropriate for taller and heavier individuals. It is also used for individuals with prior failed ACL reconstructions. Because it is a large graft, this method uses a larger incision.

Allografts are tendon grafts taken from cadavers. Allografts are most appropriate for older individuals that are moderately active or those with a history of pain. It is also used for individuals with prior failed ACL reconstructions, those attempting to return to sports more quickly, and those that need more than one ligament reconstructed.  Because the graft is not taken from the individual, this method is associated with less pain, smaller incisions, and a shorter surgery time.

Many ACL reconstructions are performed as outpatient procedures. You can be anesthetized for surgery or receive a nerve block to numb your knee and leg area.  After you have received your anesthesia and your leg is relaxed, your doctor will examine your knee by performing similar  tests that were done in your clinical examination. This provides your doctor with more information about your knee and helps to formulate the surgical plan.

Your surgeon will make one or more small incisions, about ¼” to ½” in length, near your joint. Your surgeon will fill the joint space with a sterile saline (salt-water) solution. Expansion of the space allows your surgeon to have a better view of your joint structures. Your surgeon will insert an arthroscope and will reposition it to see your joint from different angles.

An arthroscope is a very small surgical instrument. It is about the size of a pencil. An arthroscope contains a lens and lighting system that allows a surgeon to see inside of a joint. The surgeon only needs to make small incisions and the joint does not have to be opened up fully. The arthroscope is attached to a miniature camera. The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape.  

Your surgeon may make additional small incisions and use other slender surgical instruments if you are having your meniscus, cartilage, or ligaments repaired or removed. Your new graft will be attached using surgical hardware. Your surgeon will test the new graft and your knee function. Again, your doctor will examine your knee by performing similar muscle tests that were done in your clinical examination. This is to ensure that your knee is stable and has full range of motion. In addition to bandages, some surgeons apply a knee brace or a cold therapy device to help reduce swelling at the completion of your surgery.

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Recovery

You will most likely go home on the same day of your surgery. You will receive pain medication to make you feel as comfortable as possible. In some cases, ice is applied to the knee throughout the day to help to reduce pain and swelling. Your doctor may prescribe blood thinning medication and special support stockings. You should keep your leg elevated and move or pump your foot and ankle.

In some cases, doctors prescribe compression boots and a continuous passive motion (CPM) machine. Compression boots are inflatable leg coverings that are attached to a machine. They work to gently squeeze your legs to aid blood circulation. A CPM machine will move your leg in a cycling motion while you are in bed. The CPM machine is helpful to improve circulation, decrease swelling, and restore movement in your knee. 
 
Walking and knee movements are very important to your recovery. Exercising will begin immediately after your surgery. You will begin physical therapy soon after your surgery. Your first goals will include straightening your knee and strengthening your quadriceps muscles.  
 
At first, you will need to use a walker or crutches while standing and walking. Your doctor may also prescribe a knee brace for you to wear during activities. Your physical therapist will help you walk and show you how to go up and down stairs. You will also learn ways to exercise to further strengthen your quadriceps and hamstring muscles and regain balance and coordination. It can take up to four to six months to restore proprioception and coordinated leg movements.
 
An occupational therapist can show you ways to dress and bathe within your movement restrictions. Your therapists can also recommend durable medical equipment for your home, such as a raised toilet seat or a shower chair. The equipment may make it easier for you to take care of yourself as you heal and help to prevent further injury.

The success of your surgery will depend, in part, on how well you follow your home care instructions and participate in exercise during the weeks following your ACL reconstruction. You may need a little help from another person during the first few days at home. If you do not have family members or a friend nearby, talk to your physician about possible alternative arrangements. 
 
Recovery times differ depending on the severity of your injury, the type of procedure that you had, and your health at the time of your injury. Your doctor will let you know what to expect. Generally, you should be able to resume some of your regular activities in one to three weeks after your procedure and progress to full sporting activity in about six months. Overall, you should notice a steady improvement in your strength and endurance over the next six to twelve months. The majority of people are able to resume functional activities after ACL reconstruction.

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Prevention

It is important that you adhere to your exercise program and safety precautions when you return home. You should stay as active as possible. It is especially important to keep your quadriceps and hamstrings very strong. You should also continue to use the durable medical equipment as advised.

It is also important to avoid injuring your ACL again. Depending on your injury, your surgeon may provide you with temporary or permanent activity or lifting restrictions. In some cases, specialized knee braces may be recommended for specific activities.

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Introduction

Total ankle replacement surgery, or ankle arthroplasty, can improve ankle function and relieve severe pain caused by arthritis and other conditions. As more FDA-approved ankle implants have become available, ankle replacement has become the preferred alternative to ankle fusion. People with severe ankle pain from injuries or arthritis are ideal candidates for ankle replacement surgery.

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Anatomy

Your feet and ankles are extremely complex, including 26 bones, 33 joints, 107 ligaments, and 19 muscles. The ankle joint is where the leg and foot bones meet. The bones are coated with a smooth material called cartilage, and surrounded by strong ligaments. The cartilage minimizes friction as the bones glide on each other. The ligaments are bands of supportive tissue that provide stability and flexibility for range of motion, which is necessary for walking, running, and other activities.

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Causes

The need for ankle replacement is usually severe arthritis or injury. When cartilage is damaged because of injury or arthritis, the result is pain and swelling in the ankle area. According to the American Academy of Orthopedic Surgeons, about 2 million Americans visit the doctor for ankle pain caused by arthritis or fractures every year. Thousands of people suffer from disabling ankle arthritis, where the cartilage is worn away almost completely. Ankle injuries are common in sports or exercise, because of the added stress on the joint. A history of ankle fractures, osteoarthritis, rheumatoid arthritis, and even obesity can increase your risk for ankle replacement.

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Symptoms

Common symptoms of ankle arthritis or injury include pain, swelling, stiffness, and tenderness around the ankle. You may also notice weakness or instability when you try to put weight on the ankle or foot, making it difficult to stand or walk. In cases of arthritis, the symptoms usually get progressively worse over time. In cases of injury, the symptoms may appear immediately or within a few hours.

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Diagnosis

A physical examination of your ankle is the first step in diagnosis. The doctor will evaluate your range of motion and the amount of pain and swelling you are experiencing. Gentle pressure may be applied to pinpoint the source of your pain. An x-ray will be used to look for fractures, bone spurs, and damage to the cartilage. MRI or CAT scans are sometimes needed to gain more information on the condition of your ankle. Your primary doctor can do a basic evaluation, but a certified foot/ankle surgeon is the most qualified to diagnose these conditions.

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Treatment

If rest, heat/ice therapy, physical therapy, and anti-inflammatory medication do not improve your symptoms, consulting with an orthopedic surgeon who specializes in foot/ankle conditions is recommended. If the surgeon finds evidence of a poorly healed complex fracture or advanced (end-stage) arthritis, you may need ankle arthroscopy, ankle fusion, or a total ankle replacement.

Ankle arthroscopy can treat soft tissue injuries and minor arthritis, but severe ankle arthritis should be addressed by fusion or replacement. Ankle fusion will reduce the range of motion in your ankle, but for many cases of ankle arthritis, total ankle replacement is appropriate.

Ankle replacements have been around for decades, but early designs had limited success due to the complexity of the anatomy. Modern ankle replacements have made the surgery more successful. Orthopedic surgeons can match patients with an implant specifically designed to fit their ankle, which leads to better surgical outcomes and quality of life after ankle replacement surgery.

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Surgery

Total ankle replacement is also known as total ankle arthroplasty, or TAA. The procedure involves rebuilding the ankle joint with metal and plastic components. Additional surgery on tendons may also be done to improve the range of motion in your ankle. The surgery can sometimes be performed as an outpatient. Surgery is followed by post-operative rehabilitation.

You might be a candidate for ankle arthroplasty if you have osteoarthritis or rheumatoid arthritis that does not respond to conservative management; or if you need an ankle fusion but want to maintain full range of motion in your joint.

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Recovery

After surgery, you will work with a physical therapist to gradually strengthen and condition your ankle and return to your desired activity level. Most people make a full recovery within 6 to 12 months after surgery. Ankle replacement surgery enables you to achieve range of motion, increase function, and return to a more active lifestyle, with little or no pain. Thanks to improvements in modern ankle implants and techniques, ankle replacement surgery results have greatly improved.

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Introduction

Ankle Sprains are a very common injury that can happen to anyone.  Our ankles support our entire body weight and are vulnerable to instability.  Walking on an uneven surface or wearing the wrong shoes can cause a sudden loss of balance that makes the ankle twist.  If the ankle turns far enough, the ligaments that hold the bones together can overstretch or tear, resulting in a sprain.  A major sprain or several minor sprains can lead to permanent ankle instability.

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Anatomy

The bones in our leg and foot meet to form our ankle joint. The leg contains a large bone, called the Tibia and a small bone called the Fibula.  These bones rest on the Talus bone in the foot.  The Talus bone is supported by the Calcaneus bone, our heel.  Our heels bear 85% to 100% of our total body weight. 
 
Strong tissues, called ligaments, connect our leg and foot bones together.  One ligament, called the Lateral Collateral Ligament (LCL), is very susceptible to ankle sprains.  The LCL is located on the outer side of our ankle.  It contributes to balance and stability when we are standing or walking and moving.  The LCL also protects the ankle joint from abnormal movements, such as extreme ranges of motion, twisting, and rolling.
 
The LCL is composed of three separate bands commonly referred to as separate ligaments.  The Anterior Talofibular Ligament is the weakest and most commonly torn, followed by the Calcaneofibular Ligament.  The Posterior Talofibular Ligament is the strongest and is rarely injured.

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Causes

Our ankles are susceptible to instability, especially when walking on uneven surfaces, stepping down at an angle, playing sports, or when wearing certain shoes, such as high heels.  Everyone, even the fittest athlete, is vulnerable to a sudden loss of balance under these conditions.  Our ankles support our entire body weight.  When the foot is placed at an abnormal angle, the weight of our body places an abnormal amount of force on the ligaments causing them to stretch.  When a ligament is forced to stretch beyond its limit, it may overstretch, tear, or disconnect from the bone.

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Symptoms

You may lose your balance and fall if your foot is placed at a poor angle on the ground.  Some individuals may hear a “pop” noise when the injury takes place.  You will probably have difficulty putting weight on your foot or walking.  Pain is usually the first symptom of a Sprained Ankle.  Swelling, stiffness, and skin discoloration from bruising may occur right away or take a few hours to develop.

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Diagnosis

Your doctor can diagnose a Sprained Ankle by conducting a physical examination and asking you what happened to cause the injury.  Your doctor will move your ankle in various positions to determine which ligament was injured.  Your ankle may be X-rayed to make sure that you do not have a broken bone in your ankle or foot.  In severe cases, a Magnetic Resonance Imaging (MRI) scan may be ordered to view the ankle structures in more detail.  The X-ray and the MRI scan are painless and require that you remain very still while the images are taken.
 
Ankle Sprains are categorized by the amount of injury to the ligaments.  A Grade One sprain has minimal impairment.  The ligament has sustained slight stretching and some damage to the fibers.  A Grade Two sprain is characterized by partial tearing of the ligament.  The ankle joint is lax or looser than normal.  A Grade Three Spain describes a complete tear of the ligament.  The ankle joint is completely unstable.

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Treatment

The majority of Ankle Sprains heal with non-surgical treatment methods.  It is imperative that you seek evaluation and treatment for any ankle injury, as sometimes fractures are mistaken for sprains.  
 
The treatment of an Ankle Sprain depends on its Grade.  Grade One sprains are treated with the RICE method - Rest, Ice, Compression, and Elevation.  You should rest your ankle by not placing weight on it.  You may use crutches to help you walk.  Applying ice packs to your ankle can help keep the swelling down and reduce pain.  You should apply ice immediately after spraining your ankle.  Your doctor will provide you with a continued icing schedule.  Your doctor may recommend over-the-counter or prescription pain medication.  Compression bandages, such as elastic wraps, are helpful to immobilize and support the ankle.  You should also elevate your ankle at a level above your heart for 48 hours to help reduce swelling.
 
Care for Grade Two sprains includes applying the RICE method of treatment and in most cases your doctor will prescribe an ankle air cast or soft splint for positioning and stability.  As healing takes place, your doctor will gradually increase your activities.  Your doctor may recommend that you wear an ankle brace for stability as your healing continues.  
 
In addition to the primary care, your doctor may recommend a short leg cast or a cast-brace system for a Grade Three sprain.  The cast is typically worn for two or three weeks and followed by rehabilitation.  Rehabilitation is helpful to decrease pain and swelling and to increase movement, coordination, and strength.  Your doctor may recommend customized inserts called orthotics for your shoe or special shoes to help you maintain proper ankle positioning.
 
The recovery time is shorter for ankle sprains that do not require surgery.  Grade One sprains may heal in about six weeks.  Grade Two and Three Sprains may take several months to heal.  Grade Three Sprains usually involve a period of physical therapy to promote healing.

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Surgery

Ankle Sprains rarely require surgery; however, it is an option when non-surgical treatments and rehabilitation fail.  Your physician will evaluate each case of Ankle Sprain on an individual basis.  Your physician will discuss surgical options and help you determine the most appropriate choice for you. 
 
One type of surgery, termed Ligament Tightening, is performed to tighten the overstretched ligaments.  This usually involves the Anterior Talofibular Ligament (ATFL) and the Calcaneofibular Ligament (CFL).  The surgeon will make an opening over the ligaments and separate the ATFL and the CFL in half.  The ends of these two ligaments are surgically attached to the Fibula.  The surgeon will further reinforce the ligaments by also attaching the top edge of the Ankle Retinaculum.  The Ankle Retinaculum is a large band of connective tissue located at the front of the ankle.
 
If the ligaments are severely damaged or not appropriate for a Ligament Tightening procedure, the surgeon may perform a Tendon Graft.  For this procedure, the surgeon will use a portion of a nearby tendon for a tendon graft.  The tendon from the Peroneus Brevis muscle in the foot is most commonly used.  The tendon graft is surgically attached to the Fibula and the Talus, near the attachment sites of the original tendon. 
 
In some cases of chronic pain, an Arthroscopic Surgery may be performed to remove bone fragments, scar tissue, and damaged cartilage.  Arthroscopic surgery uses a small camera, called an arthroscope, to guide the surgery.  Only small incisions need to be made and the joint does not have to be opened up fully.  This can shorten the recovery time.

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Recovery

Depending on the grade of the injury and what surgical or non-surgical methods are applied to repair the ankle, will determine the rate of recovery.  
 
Grade 1 sprains should only experience slight limits to range of motion, and the recovery process is approximately six weeks.
 
Grade 2 sprains experience moderate impairment and recovery may take a few months.  
 
Grade 3 sprains have severe impairment and may take several months to fully recover.  Even after a full recovery, some patients find that swelling still might occur. In most cases, rehabilitation will help restore strength, mobility and range of motion.

Recovery from surgery differs and depends on the extent of your injury and the type of surgery that was performed.  Your physician will let you know what to expect.  Individuals usually wear a cast for up to 2 months following surgery.  Your doctor will instruct you to carefully increase the amount of weight that you put on your foot.  Rehabilitation following surgery is a slow process.  Individuals typically participate in physical therapy for two to three months.  Physical therapy helps to strengthen the ankle muscles and increase movement.  Success rates are high for both surgical procedures.  The majority of individuals achieve an excellent recovery in about six months.

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Prevention

Individuals that experience one ankle sprain are at an increased risk to experience another.  It may be helpful to wear shoes that provide extra ankle support and stability.  Shoes with low heels and flared heels may feel steadier.  In some cases, doctors recommend a heel wedge or prescribe an orthosis, a plastic brace, to help position the foot inside of the shoe.

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Introduction

When you need surgery to replace a damaged or diseased hip, some orthopedic surgeons have advanced training to perform anterior hip arthroplasty, also known as the direct anterior approach to hip replacement. This procedure is considered less invasive, as it spares the surrounding muscles that support the joint and minimizes scarring, pain, and down time. Patients can begin rehabilitation sooner and recover faster after having anterior hip replacement, compared to more traditional posterior hip replacement.

If you have suffered an injury due to a fall or have sudden onset of hip pain, seek medical attention immediately. If your pain is chronic, you should see a hip specialist for a complete evaluation of your symptoms.

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Anatomy

Your hip is a ball-and-socket joint, where the pelvis and thigh bones meet on the left and right sides of the body. The hip joints are surrounded by supportive tissues including muscle, ligaments, and tendons to provide stability while allowing for movement. The bones are covered with cartilage, which forms a smooth surface for bones to glide across when we move.

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Causes

There are several reasons for the need for hip replacement. Arthritis is one of the most common. Cartilage may deteriorate with age, leading to bone-on-bone rubbing. When this occurs in the hip, walking and other movements we take for granted can become extremely painful. Other forms of arthritis, such as rheumatoid arthritis and psoriatic arthritis, can lead to the need for hip replacement. Certain types of hip fracture are sometimes best treated with hip replacement.

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Symptoms

Pain, stiffness, or limited mobility are common symptoms of hip arthritis. Most often, the pain is felt in the groin, thigh, or in your knee. You may notice a feeling like your leg might give out when you take a step.

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Diagnosis

An evaluation of your hips begins with a comprehensive exam and X-rays. The X-ray will look for narrowing of the joints, bone spurs, and bone cysts that sometimes form in arthritic joints. In certain circumstances, your doctor may also order an MRI. 

During the exam, the doctor will ask about your symptoms and how long your hip has been bothering you. You will need to demonstrate some movements, such as walking, bending, or standing up. This will help the doctor pinpoint the areas that need to be further examined.

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Treatment

Unless you have an immediate need for surgery, the primary treatment will employ the most conservative, non-surgical options. Medication, rest, and exercises including physical therapy can be effective for treatment of hip arthritis and minor sprains and strains.

When conservative treatments fail to provide sufficient relief of your symptoms, you and your doctor may consider a surgical procedure to repair damage to the joint or replace the joint with an artificial implant (prosthetic hip). The extent of damage, your age, and activity level can help your surgeon decide if you are a candidate for surgery.

Many patients with severe hip damage caused by arthritis are candidates for anterior hip replacement surgery. Even large or obese patients can have a successful outcome with this muscle-sparing procedure. However, large size makes the operation more challenging.

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Surgery

Anterior hip arthroplasty is an advanced orthopedic procedure used to replace a damaged hip by making an incision on the front (anterior) side of the hip.

Traditionally, hip replacement surgery begins with an incision to the side or back of the hip area. With the anterior approach, having the incision on the front of the hip prevents any discomfort in the incision area when sitting down or lying on your side.

This approach also allows the surgeon to leave your muscles and ligaments intact while replacing the hip joint. This can decrease the chance of the joint popping out of place (dislocating). Lastly, a smaller incision is needed than would be for a posterior or side approach.

Many orthopedic surgeons prefer the anterior approach to hip replacement because of these advantages.

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Recovery

Compared to other approaches, the anterior hip arthroplasty is associated with shorter recovery times. This is because the surgical technique leaves the supportive tissues (muscles, ligaments, tendons) in place to support your hip immediately after the procedure.

Many people can begin post-operative rehabilitation right away and return to their normal activity level within weeks of surgery. Other approaches take longer because the muscles need additional time to heal.

Although the procedure is preferred over more traditional hip replacement, the anterior approach to hip surgery is not yet as widely performed. Advanced training in this technique is required for a successful outcome.

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Introduction

Arthritis is a common disease that causes joint pain, stiffness, immobility, and swelling.  Arthritis is actually a term for a group of over 100 diseases that affect the muscle and skeletal system, particularly the joints.  Arthritis alters the cartilage in joints.  Cartilage is a very tough, shock absorbing material that covers the ends of many of our bones.  The cartilage forms a smooth surface and allows the bones in our joints to glide easily during motion.  Arthritis can cause the cartilage to wear away.  Loss of the protective lining can cause painful bone on bone rubbing.  Arthritis can be quite painful and disabling.  While this may be tolerated with medications, therapy, other modalities, and lifestyle adjustments, there may come a time when surgical treatment