Orthopedic Treatment Options: Operative

Anterior Cruciate Ligament (ACL) Reconstruction

An Anterior Cruciate Ligament Reconstruction – ACL Reconstruction Surgery – is generally indicated when severe damage to one of the two main supporting ligaments of the knee joint, the anterior cruciate ligament, compromises the integrity of the knee joint and prevents active individuals and athletes alike from performing their activities.

ACL reconstruction is not a repair of the ACL, as a completely torn ACL cannot heal back together, but rather a reconstruction of the joint area and alternate support for that which relies on the ACL.

The procedure entails a graft that will be used as the replacement ACL. And while an ACL reconstruction can be performed using a number of different graft choices (Autografts, or live tissue, such as the patellar tendon or hamstring tendon graft choices and Allografts, cadaveric tissue) the graft is based on the level of activity and overall health of the patient and the preference of the orthopedic specialist.

Preferred graft choices for the active tend to be the living tissue of the patient, either a patellar tendon graft or a hamstring tendon graft. These grafts do not need to be revascularized and tend to adapt more quickly to the new location. Allografts are used less frequently but are occasionally considered for ACL revisions.

When an ACL tears, the tendon frequently appears frayed on the X-ray. Generally, the torn ends of the ACL are removed and the ligament is replaced with the strong, solid graft selection. In order to secure the graft in the position of the natural ACL, tunnels are made in the shin bone (tibia) and thigh bone (femur), and the graft is passed through these tunnels and the ligament is reconstructed.

Patellar Tendon Graft
The patellar tendon is located at the front of the knee and connects the kneecap (patella) to the shin bone (tibia). When a patellar tendon graft is taken, a central portion of the patellar tendon is removed along with a portion of bone at the sites of attachment on the kneecap and tibia.

This graft choice may be preferred as it closely mimics the natural ACL and allows for bone-to-bone healing. It may also, though, weaken the area of the kneecap from which it is taken.

Hamstring Tendon Graft
The hamstring muscles are the group of muscles located on the back of the thigh. As the graft of choice in an ACL surgery, the tendons of the Hamstring muscles are removed and "bundled" together to create a new ACL.

While the methods of affixing these grafts into place have improved over the years, the bone-to-bone healing is less secure than that which is created with the patellar tendon.

Allograft (Cadaver Tissue)
An allograft, cadaver tissue, is most commonly used in revision ACL surgeries and in those leading less active lifestyles. Studies continue to show that an allograft is not as strong as the patient's own living tissue (autograft). Though, the allograft proves sufficient for a portion of the population.

One of the greatest challenges with an allograft is the fact that it must be revascularized before it can become viable as a replacement ACL. There is also a small concern of disease transmission with donor tissue.

Postoperative
A comprehensive ACL protocol established to help patients work back to strength and flexibility is reviewed thoroughly with both the doctor and the rehabilitation team.

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Arthrodesis

Arthrodesis is a procedure that allows two bones coming together at a joint to fuse into a single bone. It is a fusing process employed when other stabilizing measures fail to stabilize the joint and relieve pain.

An alternative to joint replacement or joint arthroplasty, arthrodesis is often used in conditions of the ankle. Though it limits range of motion, it is effective in eliminating pain associated with painful joint degeneration and bone-on-bone contact.

By ensuring union of two adjoining bones and limiting range of motion, arthrodesis can eliminate the pain generated when articular surfaces void of a sufficient cartilage are allowed to rub directly against one another within the joint space.

Both total and limited arthrodesis was initially developed to decrease the pain of arthritis and required lengthy periods of immobilization, to ensure adequate fusion. Though, today internal fixation methods have eliminated the need for external immobilization following arthrodesis - allowing patients to more rapidly begin strengthening their affected limb and resume normal life function.

Today, new specialty plates and screw constructs in both limited and total arthrodesis, are producing more positive outcomes for trauma injuries, chronic joint instability and degeneration, avascular necrosis, tumor damage, and septic and rheumatoid arthritis.

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Arthroplasty

Total joint replacement is often referred to as total joint arthroplasty. Arthroplasty is a joint reconstruction procedure used to either reshape or replace damaged joints generally the result of osteoarthritis.

Joint arthroplasty restores joint function and relieves pain and inflammation. It is commonly used on hip and knee joints, in order to relieve the pain and disability associated with advanced osteoarthritis.

The two main types of arthroplastic procedures include joint resection and interpositional reconstruction. A joint resection entails removing a portion of the bone from the damaged and dysfunctional joint, in order to create additional space and improved range of motion.

Interpositional reconstruction is a procedure which reshapes the joint and uses a prosthetic to facilitate movement between the two bones that form the joint.

And total joint arthroplasty is the complete replacement of the joint with an artificial one, also known as total joint replacement.

A prosthesis, or artificial joint, may be made of plastic, metal, silicone and ceramic material - or created from body tissue such as skin, muscle or fascia. Artificial joints are generally cemented into place once soft tissue is temporarily moved aside and a space within the deteriorating joint is cleared. The type of joint will dictate the type of prosthesis to be used.

Recently, a growing number of "gender-specific" prostheses and implants have been created and proving effective in knee and hip replacements - where the musculoskeletal and physiological differences between men and women have shown to be most distinct.

Before any joint reconstruction procedure is complete, a series of tests are performed to ensure proper range of motion and correct movement.

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Lateral Epicondyle Release (Tennis Elbow Release)

A Lateral Epicondyle Release is a procedure used to address chronic lateral epicondylitis, or tennis elbow, that is not responsive to conservative treatment.

The procedure relieves the tension placed on the constricted extensor tendon compressed within the elbow joint.

An outpatient surgical procedure, a tennis elbow release utilizes an axillary block, numbing the arm and preparing for an incision made on the outside of the elbow over the lateral epicondyle. In order to ensure a clear view of the tendons, the surrounding soft tissue is gently moved aside. Any damaged tissue and existing bone spurs may be removed as the tendons are explored. Then, the extensor tendon is cut and separated where it connects to the lateral epicondyle, which allows removal of scar tissue. It may also be necessary to cut the tendon where it attaches to the bone, in order to remove a small portion of the bone and improve blood flow to the area.

Postoperative
While rehabilitative exercises begin once healing at the surgical site permits, complete home care and strengthening plan is reviewed before the patient leaves.

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Nerve Decompression

Nerve decompression is the surgical intervention for compressed nerve conditions nonresponsive to other conservative treatment. It helps relieve the pressure and release the area of compression.

An outpatient procedure, patients are first given either a general or regional anesthetic. The decision is made based on the location of the nerve. In some hand and arm nerve decompression procedures, an axillary block is used.

An incision is then made over the area of compression, and the soft tissue is gently moved aside in order to create an area of clear viewing and examine all areas contributing to the compression or pinching on the nerve. Once the area or areas are identified, compression is relieved. The manner in which compression is relieved depends on the source of the pinching or compression.

The skin is then sutured and rehabilitative exercises begin once the surgical site begins to heal.

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Resection arthroplasty is a "revision" procedure, which has also been called over the years a "salvage" procedure. It is frequently used when a total knee arthroplasty or a total hip arthroplasty procedure has developed complications (severe infection, deformity that hinders movement), which compromise the integrity and health of the new joint. It is also performed on ankle and shoulder joints affected by severe osteoarthritis.

A resection arthroplasty entails the removal of bone (and possibly failed implant) in and around the affected joint, allowing the space to fill with scar tissue. This procedure is most often performed in patients experiencing a severe infection that cannot be controlled. It may also be performed in patients affected with a severe physical condition and deformity that dramatically hinders normal movement.

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When severe elbow pain associated with an elbow instability condition , a surgical procedure known as Ulnar Nerve Transposition is performed in order to relieve the pressure that the condition places on the ulnar nerve, which travels down the arm and past the elbow.

The ulnar nerve is located beneath a layer of muscle at the front of the elbow, which keeps it protected from the bony groove of the elbow when the elbow is bent as well as from other injury.

In the procedure, the ulnar nerve repositioned slightly in order to relieve it from the compression that stress on the elbow is placing.

An incision is first carefully made along the back of the elbow is, preserving the integrity of the nerves in the area. Then, the bands of pressure which have been entrapping the ulnar nerve are identified and surgically released. The surrounding muscle is then lifted from the bone and a protected, uncompressed area is created for the nerve. Any existing scar tissue or other damage identified at this time are also addressed and the area is closed and sutured.

A patient-specific rehabilitation program is established and a path to recovery and return to activity are quickly begun. The sooner muscles are strengthened and range of motion is restored following an injury or surgical procedure, the faster the recovery.

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Today, the Ulnar Collateral Ligament Reconstruction procedure is most commonly known as the Tommy John Surgery, particularly among athletes. What was once a career-ending injury, before the professional Los Angeles Dodgers player, Tommy John, was successfully treated with a refined UCL Reconstruction procedure, is now just another sports injury from which athletes are quickly recovery.

The UCL Reconstruction, or Tommy John Surgery, repairs the damaged UCL and restores strength to the unstable elbow - resulting in a complete recovery for over 90 percent.

An outpatient procedure lasting only an hour, the goal of the Tommy John Surgery is to replace the torn UCL of the medial elbow with a tendon from the patient's forearm, hamstring or foot. Once it is confirmed that the tendon replacement is optimally positioned and functioning well in its new space, the area is closed with sutures.

A specific postoperative protocol is followed and a rehabilitation program is established for the rapid return to activity.

The UCL Reconstruction procedure is also used occasionally to treat medial epicondylitis (Golfer's Elbow) and lateral epicondylities (Tennis Elbow).

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