At Taos Orthopaedic Institute, we are genuinely concerned that our patients have a full understanding of their injury, treatment options, and the rehabilitation required for  recovery.  This handout is meant to complement the information you receive during your doctor’s visit.  We encourage you to read this and to ask questions.

Taos Orthopaedic Institute is a center of excellence for sports medicine.  Utilizing state-of-the-art diagnostic and treatment techniques, we offer a wide variety of conservative and surgical options for the patient with a torn anterior cruciate ligament.  Our sports medicine orthopaedic surgeons have specialty training and extensive experience in reconstruction of the anterior cruciate ligament.

What is the Anterior Cruciate Ligament (ACL)?

 The anterior cruciate ligament (ACL) is the central stabilizing ligament of the knee.  Running through the knee from the front of the tibia (shin bone) to the back of the femur (thigh bone) it assists proper movement of the joint and prevents abnormal slippage of the bones.  Abnormal slippage can create an unstable knee that “gives way” during activity.

How is the ACL injured?

While the ligament can be injured with a direct blow to the knee, it is more common to tear the ligament when pivoting or twisting on a planted food or by hyper extending the knee.

How do I know my ACL is torn?

 Usually, a tear to the ACL results in sudden pain, giving way of the knee, or a combination of both.  Many patient report having heard a “pop” when they injured their knee.   The knee usually swells within 1-3 hours of the injury.  A doctor can examine the knee and is usually able to identify any ligaments that are injured.  The knee will feel loose and/or you will have muscle guarding during the examination.

 Do I need x-rays, MRI’s or any other tests?

A set of x-rays is usually ordered to make sure that there are no broken bones in the knee.  MRI’s can be helpful, but are not always needed when the doctor knows what is wrong just from examining you.  MRI’s are obtained primarily to assess the extent of the damage to other structures including the menisci, joint surfaces and bone.

Is there usually other damage to the knee when the ACL is torn?

Other ligaments in the knee can be injured at the same time as the ACL.  These may need to be repaired, but many times  heal adequately without surgery.

The most common injury that occurs with the ACL tear is a meniscus tear.  Some meniscus tears can be repaired  and some can be trimmed back so that the torn edges are smooth. If the meniscus can be repaired, it is usually done at the time of the ACL surgery.

Another common injury that can occur with an ACL tear is damage to the cartilage on the joint surface.  Damage to these surfaces is very serious and in some cases is the worst part of the injury.  It may require more complex surgery which is usually done at the time of the ACL surgery.

Does a torn ACL have to be fixed with surgery?

The ACL cannot heal on its own, but not all tears of the ACL need to be fixed.  This depends on age and your activity level.  People under 40 years of age should have their ACL reconstructed to prevent arthritis.  People participating in activities where they plant their feet and twist or cut are susceptible to having an unstable knee and may be better off with surgery.  People with strenuous jobs may also need surgery.  People who are unwilling or unable to modify their activities and desire an unrestricted lifestyle are encouraged to consider the surgery to have the best chance of returning to their previous lifestyle.  Advances in arthroscopic surgery and an aggressive rehabilitation program contribute to an accelerated recovery for patients with ACL injuries.

On the other hand, people who lead a more sedentary lifestyle may be able to get by with exercise and a brace.  However, even someone with a sedentary lifestyle may experience giving way with simple activities such as climbing or descending stairs or stepping off a curb.  In these cases surgery is needed to restore normal every day activities and to prevent further damage to the knee.

If I don’t have my ACL fixed am I likely to hurt my knee again or get arthritis?

Even if the knee joint does not become unstable (give way) it will still be loose after an ACL injury.  This leads to damage in other supporting structures, such as the medial and lateral collateral ligaments and the cushion pads called meniscus cartilages.  In someone with a recent ACL injury, the risk of associated meniscus damage may be 30 to 40 percent.  In someone who has had an ACL injury that has been present for years and who may have buckling episodes, the risk of associated meniscus damage is 90 percent. ACL and meniscus injury may contribute to the early onset of arthritis in your knee.

How is the ACL fixed?

The ACL is reconstructed with arthroscopic techniques.  The arthroscope is a fiber optic instrument (narrower than a pen), which is put into the joint through small incisions.  A camera is attached to the arthroscope and the image is viewed on a TV monitor.  The arthroscope allows the surgeon to fully evaluate the entire knee joint.  Small instruments ranging from 3-9 millimeters in size are inserted through additional incisions so that the surgeon can feel the various joint structures, diagnose the injury, and then repair, reconstruct or remove the damaged structure.

In ACL reconstruction a replacement graft is precisely positioned in the joint at the site of the former ACL and then fixed to the thigh and lower leg bones with screws.  There are currently several options for replacement grafts and screws.  Choices for the type of replacement graft include autograft (using your own tissue), allograft (donor tissue) and synthetic (artificial) grafts.  Choices for the types of screws include inert metal screws and bio-absorbable screws.

Autografts can come from your patellar tendon, quadriceps tendon or the hamstring tendons.  The graft choice to be used is determined by you and your surgeon.  All of these graft options offer a strong graft, secure fixation and excellent long-term results.  The results show that people are able to return to their activities with few complications.  Since the graft comes from your own body there is no chance of infectious disease transmission or rejection.

Allografts are donor tissues taken from tissue banks.  They also are strong grafts with excellent long-term results.  Because the surgeon is not taking the tissue from your body, the surgical time and operative pain are less.  This allows for easier rehabilitation in the early post-operative stages. Although there is a risk of infectious disease, donor tissue is received only from a reliable tissue bank.  The tissue is rigorously screened and treated to prevent the spread of infectious disease.  The risk of contracting infectious disease from an allograft is very small (less than one in eight million).  Although rejection of the graft is possible, the risk of this is extremely low because the tissue is not living material.

Synthetic grafts are available for use in certain situations, but most are experimental and do not work as well as allografts and autografts.

Regardless of the graft material chosen, the most important aspect of surgery is that the ligament graft is placed and secured precisely.  Accurate graft placement is essential for a good result and secure graft placement permits early, more aggressive rehabilitation after surgery.

What are some of the possible complications?

While complications are not common, all surgery has associated risks.  Possible complications include excessive stiffness after the surgery or pain in the knee or under the kneecap.  Your rehabilitation after surgery is specifically designed to address these issues.  Other complications can arise from infection of the wounds, phlebitis, bleeding into the knee, and nerve injury.

What do I need to do to prepare for surgery?

Our staff will work with you to set up the surgery through your insurance company and will instruct you in matters that you will need to take care of concerning your insurance paperwork.

Prior to surgery you may be asked to perform some exercises at home or with a physical therapist to prepare for surgery.  These exercises prepare the knee by decreasing the swelling, increasing the motion and maximizing the strength of your leg.

What type of anesthesia is used?

General anesthesia is used.  An anesthetist is always present if there is a need for further sedation or pain control.   The morning of surgery, an anesthetist will discuss with you the various options and answer your questions.

Because our surgeons are extremely experienced, the operation can be performed rather quickly.  The shorter surgical time decreases the amount of anesthesia and limits side effects from the anesthesia.

How long will I be in the hospital?

Most people are able to have surgery and go home the same day. Occasionally, a night in the hospital is needed.  How long you stay will depend on several factors including your age, health status, other damage in the knee, and the side effects of anesthesia.

What happens the day of surgery?

 The day before surgery you will be told what time to report to the hospital the next day.  It is very important to arrive on time.  You will be admitted to the hospital and taken to a pre-operative area where you will be prepared for your surgery and then taken to the operating room.

Note:  You may not eat or drink anything after midnight the night before your surgery.  If you must take medicine then you will be permitted to do so with just a sip of water.

After the operation, you will be taken to the recovery room to be monitored.  Here the staff will check that the effects of the anesthesia are wearing off properly and they will provide you with medication for any pain you are having.  If you are going home the same day, you will be given specific instructions to follow at home and discharged after you have adequately recovered.  If you have to remain overnight, you will be taken to your room when you are ready.

How should I care for my knee after surgery?

Prior to your discharge from the hospital you will be given specific instructions on how to care for your knee.  It is important to follow these instructions.  In general, you can expect the following:

Diet:  Resume your regular diet as soon as possible.

Medication:  You will be given a prescription for pain medication and an anti-inflammatory medication.  Follow the directions from your pharmacy.

Bandage:    You will have an elastic bandage from your foot to your thigh.  There will be bulky dressings under the elastic wrap.  Keep these on for two to three days after your surgery as instructed.  Under these dressings you will have several small incisions with stitches.  You may cover these with bandages after you remove the original dressing.

Brace:     A post-operative brace is worn when walking for six weeks after surgery.  A sports brace is then provided and recommended for pivoting sports.

Bathing:     You will be able to shower within two to three days following surgery.  Do not soak your operated leg in a tub or whirlpool for at least three weeks after surgery.  The incisions are not fully closed and soaking the leg would increase the risk of infection.  Once you have showered you should put the brace back on prior to leaving the shower.

Ice:     Use ice over the knee.  It is best to apply ice for 20 minutes at a time, usually three to four times per day.  During the first two days after surgery, the heavy bandages may make it difficult for ice to penetrate.  Do not leave the ice directly on your skin for extended periods as this may cause frostbite.   DO NOT put heat on your knee.

Elevation:     Keeping your leg elevated above the level of your heart will help with swelling and discomfort.  DO NOT put a pillow directly under your knee as this encourages the knee to stay in a bent position.  Instead, place the pillow under the calf and foot.

 Continuous Passive Motion (CPM):     To prevent difficulty moving the knee after surgery, a CPM Machine gently promotes early postoperative motion.  This early movement of the knee also decreases swelling in the operated area.  In most cases, a CPM will be provided to you before you are released from the hospital.

Crutches:     Crutches are required for walking at first.  Most patients use crutches for the first 7-14 days.

 Follow-Up Office Visit:    You will be instructed to follow-up at our office one and one-half weeks after your surgery.  At this time, your stitches are removed, and your surgery is reviewed.  You will be instructed on making further follow-up appointments at this time.

Exercise:     You may be taught some exercises to do initially after surgery.  After 1-½ weeks you are given a prescription for formal rehabilitation to do with a physical therapist.

Return to work or school:     Most people are able to return to their jobs or school within 5-10 days.  The exception to this is for people who have strenuous jobs that require them to be on their feet a lot, lifting objects, climbing or driving.

Driving:     You should be able to drive within weeks after surgery.  However, you should be aware that there might be laws pertaining to use of your car in the early postoperative period.  If you are in a car accident and you knee is in a brace due to surgery, there may be legal implications.  Also, you should not drive while you are taking narcotic analgesics.

What will rehabilitation involve?     Rehabilitation begins the day after surgery.  As the tissues heal, you will be permitted to do more and more activities.  You will probably begin walking immediately after surgery with the postoperative brace. Your rehabilitation will be based on guidelines we have developed.  In general we use an accelerated protocol, which is based on several goals:  1) early motion 2) early weight bearing and 3) regaining control of the leg muscles as soon as possible.  Note that an accelerated program DOES NOT mean how soon you may return to activities.  You will start out with very specific exercises and will be permitted to do more as you recover.

Preliminary Exercises – Early Postoperative Period:  0-1 Week 

1. Isometrics:

     Tighten muscles in front and back of thigh.  Hold five seconds, relax.  Repeat 10 times

     an hour.

2. Straight Leg Raise:

Hip flexion – in brace, leg straight.  Raise leg off bed approximately 12 inches.  Hold

five seconds, relax.  Repeat 10 times.

Hip abduction – in brace, leg straight.  Lie on unoperated side, raise leg

approximately six inches off bed.  Hold five seconds, relax.  Repeat 10 times.

Hip adduction – in brace, leg straight.  Lie on operated side, raise leg approximately

six inches off bed.  Hold five seconds, relax.  Repeat 10 times.

Hip extension – in brace, leg straight.  Lie on stomach. Raise leg approximately

six inches off bed.  Hold five seconds, relax.  Repeat 10 times.

3. Range of Motion:

Begin passive range of motion using your unoperated leg to assist your operated leg.

Sit on edge of bed or chair.  Unlock the brace so that your knee can move freely.

Using unoperated leg to support your operated leg, lower the operated leg until the

knee bends to 90 degrees.  Use unoperated leg to straighten operated knee.  Repeat

10 times, four times a day.  Depending on the type of surgery you undergo, you might

not be able to start these motion exercises immediately after surgery.

4. Extension:

Place a pillow or folded towel under your heel (with nothing under the knee for

comfort).  Push the knee straight, 3 times a day for 20 minutes.

At Taos Orthopaedic Institute, we are genuinely concerned that our patients have a full understanding of their injury, treatment options, and the rehabilitation required for a full, speedy recovery.  This handout is meant to complement the information you receive during your doctor’s visit.  We encourage you to read this and feel free to ask any questions concerning your treatment.  Our goal is to help you make a fully informed decision about your knee.

Taos Orthopaedic Institute is a center of excellence for sports medicine and arthroscopy.  Utilizing state-of-the-art diagnostic and treatment techniques, the physicians offer a wide variety of conservative and surgical options for the patient with knee injuries.  Our orthopaedic surgeons have specialty training and extensive experience in the use of arthroscopic surgery to diagnose and treat the injured knee.

 Our treatment philosophy for all patients is the same as it is for the athletes under our care; we pledge to deliver the highest quality care using state-of-the-art diagnostic and treatment techniques.

What is arthroscopy?

The arthroscope is a fiber optic instrument, narrower than a pen.  It is placed into the knee through a tiny incision (portal).  A small camera attached to the arthroscope, allows the surgeon to view the knee structures on a television monitor.  Using additional portals (usually 1), small instruments ranging in size from 3-5 millimeters are inserted into the knee.  These instruments allow the surgeon to inspect and feel the joint structures, more accurately diagnose the injury, and then repair, reconstruct, or remove the damaged structures.

In the past, many orthopaedic injuries required complicated operations with large incisions, long hospital stays, and extensive physical therapy.  Today, many procedures are done entirely or in combination with the arthroscope, allowing for more accurate diagnosis, less invasive surgical intervention, and an accelerated rehabilitation process.  It must be kept in mind that not all surgery can be done through the arthroscope

What types of procedures can be done with arthroscopy?

Some of the more common arthroscopic procedures in the knee are partial menisectomy

(removal of torn cartilage) or meniscal repair, removal of loose fragments, smoothing of joint surfaces (chondroplasty), removal of inflamed joint lining (synovectomy), and lateral release of unbalanced kneecap (patella).

What is the difference between meniscal repair and partial menisectomy?

The meniscus is a cushion in the knee joint between the leg bone (tibia) and the thigh bone (femur).  It is commonly torn by twisting and bending activities in sports or even in routine daily activities.  Sometimes the tear is degenerative, meaning the damage is the result of worn-out tissue.

The location of the tear is an indication of whether the meniscus can be repaired or removed.   If the tear is in the outer third of the meniscus, there is usually an adequate blood supply so that it can be stitched together and healing will occur.  If the tear is located in the inner two-thirds of the meniscus, where most tears occur, the torn portion needs to be removed.  There is not an adequate blood supply in the inner two-thirds of the meniscus to permit adequate healing.

If the tear is removed, the patient can walk on the knee immediately.  If the tear is repaired, the meniscus requires six weeks to heal.  During the initial six weeks, the patient may bear weight on the knee, but must wear a brace to walk with the knee locked straight.

Don’t I need the meniscus?

If the meniscus is damaged it can cause further joint destruction, so it is better to remove the torn portion.  In the past, when the whole meniscus was removed, patients had good knee function for many years but eventually developed arthritis.  The arthroscopic procedure removes only part of the meniscus; normal knee functioning is expected unless pre-existing arthritis or chondromalacia (bad cartilage) is detected.

What are possible complications?

While complications are not common, all surgery has associated risks.  Possible complications include excessive stiffness after the surgery or pain in the knee or under the kneecap.  Your rehabilitation after surgery is specifically designed to address these issues.  Other complications, although rare, can arise from infection of the wounds, phlebitis, bleeding into the knee, or nerve injury.

What do I need to do to prepare for surgery?

Our staff will work with you to set up the surgery through your insurance company if you have health insurance.

Prior to surgery you may be asked to perform some exercises at home or with a physical therapist.  These exercises prepare the knee for surgery by decreasing swelling, increasing motion, and maximizing the strength of your leg.

What type of anesthesia is used?

Local, spinal, epidural, or general anesthesia can be used for arthroscopic surgery.  Except for when general anesthesia is used, the patient can stay awake and watch the procedure on the television monitor.  An anesthetist is always present if there is a need for further sedation or pain control.  Prior to surgery, an anesthetist will discuss with you the various options and answer your questions.  Because our surgeons are extremely experienced, the operation can be performed rather quickly.  The shorter amount of surgical time decreases the amount of anesthesia and limits the side effects of the anesthesia.

What happens the day of surgery?

The day before surgery you will be told what time to report to the hospital the next day.  It is very important to arrive on time.  You will be admitted to the hospital and taken to a pre-operative area where you will be prepared for your surgery and then taken to the operating room.

Note:  You may not eat or drink anything after midnight the night before your surgery.  If you must take medicine then you will be permitted  to do so with just a sip of water.

After the operation, you will be taken to the recovery room to be monitored.  Here the staff will check that the effects of the anesthesia are wearing off properly and they will provide you with medication for any pain you are having.  Most patients go home the same day.  You will be given specific instructions to follow at home and discharged after you have adequately recovered.

How should I care for my knee after surgery?

Prior to your discharge from the hospital you will be given specific instructions on how to care for your knee.  It is important to follow these instructions.  In general, you can expect the following.

Diet:  Resume your regular diet as soon as possible.

Medication:  You will be given a prescription for pain medication and an anti-inflammatory medication.  Follow the directions from your pharmacy.

Bandage:    You will have an elastic bandage from your foot to your thigh.  There will be bulky dressings under the elastic wrap.  Keep these on for two to three days after your surgery as instructed.  Under these dressings you will have several small incisions with stitches.  You may cover these with bandages after you remove the original dressing.

Bathing:     You will be able to shower within two to three days following surgery.  Do not soak your operated leg in a tub or whirlpool for at least three weeks after surgery.  The incisions are not fully closed and soaking the leg would increase the risk of infection.

Ice:     Use ice over the knee.  It is best to apply ice for 20 minutes at a time, usually three to four times per day.  During the first two days after surgery, the heavy bandages may make it difficult for ice to penetrate.  Do not apply ice directly to the skin for extended periods as this may cause frostbite.   DO NOT put heat on your knee.

Elevation:     Keeping your leg elevated above the level of your heart will help with swelling and discomfort.  DO NOT put a pillow directly under your knee as this encourages the knee to stay in a bent position.  Instead, place the pillow under the calf and foot. 

Crutches:     Crutches are required for walking at first.  Most patients use crutches for the first 2-3 days.

Follow-Up Office Visit:    You will be instructed to follow-up at our office one and one-half weeks after your surgery.  At this time, your stitches are removed, and your surgery is reviewed.  You will be instructed on making further follow-up appointments at this time.

Exercise:     You may be taught some exercises to do initially after surgery.  After 1-� weeks you may be given a prescription for formal rehabilitation to do with a physical therapist.

Return to work or school:     Most people are able to return to their jobs or school within 5-7 days.  The exception to this is for people who have strenuous jobs that require them to be on their feet a lot, lifting objects, climbing or driving.  It is very important to minimize activity (stay home and elevate your leg) for four days after surgery.  This will speed the ultimate recovery by preventing excessive post-operative inflammation.

Preliminary Exercises – Early Postoperative Period:  0-1 Week

1.  Isometrics:

     Tighten muscles in front and back of thigh.  Hold five seconds, relax.  Repeat 10 times an hour.

2.  Straight Leg Raise:

     Hip flexion – Leg straight.  Raise leg off bed approximately 12 inches.  Hold five seconds, relax.  Repeat 10 times. Hip abduction – Leg straight.  Lie on unoperated side, raise leg approximately six inches off bed.  Hold five seconds, relax.  Repeat 10 times.

Hip adduction – Leg straight.  Lie on operated side, raise leg approximately six inches off bed.  Hold five seconds, relax.  Repeat 10 times. Hip extension – Leg straight.  Lie on stomach. Raise leg approximately six inches off bed.  Hold five seconds, relax.  Repeat 10 times.

3.  Range of Motion:

     Begin passive range of motion using your unoperated leg to assist your operated leg. Sit on edge of bed or chair.  Using unoperated leg to support your operated leg, lower the operated leg until the knee bends to 90 degrees.  Use unoperated leg to straighten operated knee.  Repeat 10 times four times a day.  Depending on the type of surgery you undergo, you might not be able to start these motion exercises immediately after surgery.

4.   Extension:

      Place a pillow or folded towel under your heel (with nothing under the knee for comfort).  Push the knee straight, 3 times a day for 20 minutes.

If you suffer from knee pain, it’s possible you have arthritis. Knee arthritis is caused by the deterioration of the bone lining in the knee joint called cartilage.

The two most common types of knee arthritis are osteoarthritis and rheumatoid arthritis.  Other causes are trauma, avascular necrosis or loss of blood supply to the knee joint, and prior knee surgery.

Osteoarthritis

The most common type of knee arthritis is osteoarthritis which is wear and tear.

Osteoarthritis is a progressive, degenerative disease in which the cartilage of the knee slowly wears away. Cartilage serves as insulation between the bones of the joint, and when the cartilage of the knee joint wears away due to osteoarthritis, the resulting pain and inflammation can be debilitating.

Your chances of osteoarthritis of the knee increase with age; the condition most often affects middle-aged and older people. Osteoarthritis may first appear between the ages of 30 and 40, although symptoms may not be present in the early stages. By the age of 70, almost everyone will have some degree of this type of knee arthritis.

Causes
The question of what causes osteoarthritis of the knee has not been answered. Prior knee injuries seem to increase the likelihood of osteoarthritis, but many people with knee arthritis have never had a serious knee injury. Osteoarthritis is the most common form of arthritis, and many people have a genetic predisposition to this chronic disease.

Symptoms
The primary symptoms of osteoarthritis are pain in the knee as well as swelling and stiffness joint.

In the early stages of osteoarthritis the pain may be mainly associated with activity. As the cartilage wears away and the bones rub against each other, pain can become more severe and constant, interfering with regular daily activities and disrupting sleep.

Treatment
In the early stages of osteoarthritis, treatment may involve several techniques.

Behavioral and lifestyle changes including losing weight and changing routines to avoid painful situations can be very effective in relieving pain.

Pain medications such as Tylenol or non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen (Advil or Motrin) or Naproxen (Aleve) may also provide relief from pain.

Physical therapy may improve muscle strength and joint mobility, reducing the symptoms of osteoarthritis in the knee.

Bracing may correct malalignment.

Joint fluid therapy such as oral glucosamine or injection of hyaluronic acid (HA) may lubricate the knee and reduce the pain and swelling of the joint. A corticosteroid injection may also be used to reduce pain; in this procedure an anti-inflammatory agent is injected directly into the joint.

Arthroscopy or partial or total knee replacement surgery may be necessary as the disease progresses and daily functioning becomes more impaired.

Rheumatoid Arthritis

Unlike osteoarthritis, rheumatoid knee arthritis involves inflammation of the lining of the joint, known as the synovium. Though less common than osteoarthritis, rheumatoid arthritis is among the most debilitating of the over one hundred forms of arthritis. Rheumatoid arthritis usually develops in middle age, but may occur in the 20s and 30s.

Causes
The exact cause of rheumatoid arthritis is unknown. It’s possible that a virus or bacteria may trigger the disease in people with a genetic predisposition to rheumatoid arthritis. Many doctors think rheumatoid arthritis is an autoimmune disease in which the tissue of the joint’s lining is attacked by the body’s immune system. It’s also possible that rheumatoid arthritis is caused by severe stress. The disease sometimes occurs after a life-changing event such as divorce, loss of a job or a severe injury.

Symptoms
The primary symptoms of rheumatoid arthritis include pain and swelling in the joints and difficulty moving. Other symptoms may include loss of appetite, fever, loss of energy, anemia, and rheumatoid nodules (lumps of tissue under the skin).

Treatment
Treatment of rheumatoid arthritis usually involves medications such as NSAIDs, aspirin and analgesics. In severe cases, surgery may be indicated to replace the knee joint with an artificial joint.

Before deciding on knee surgery, Taos Orthopaedic Institute may try several knee surgery alternatives to relieve the pain and inflammation in your knee.

Knee Surgery Alternatives: Lifestyle Modification
The first alternative to knee surgery is lifestyle modification. This may include weight loss, avoiding activities such as running and twisting which can aggravate the knee injury, modifying exercise to no- and low-impact, and other changes in your daily routine to reduce stress on your knee.

Knee Surgery Alternatives: Exercise and Physical Therapy
Exercise and physical therapy may be prescribed to improve strength and flexibility. Exercises may include strengthening exercises such as riding a stationary bike, and stretching exercises such as flexing the ankle up and down, tightening and holding thigh muscles, sliding the heel forward on the floor, leg lifts, and knee extensions.

Exercise can strengthen your leg muscles and reduce your pain. If you really need knee surgery, this may not help, but many forms of knee pain can be mitigated by exercise.

Knee Surgery Alternatives: Pain Medications and Anti-inflammatory Medications
Arthritis pain is caused by inflammation in the knee as the bones rub against each other due to eroded cartilage. Reducing pain and inflammation of the tissue in the knee can provide temporary relief from pain and delay knee surgery.

For most patients, Tylenol is a safe pain medication. Anti-inflammatory medications (non-steroidal anti-inflammatory drugs or NSAIDs) such as Ibuprofen (Advil or Motrin) or Naproxen (Aleve) may also provide relief from pain and swelling. A corticosteroid injection may also be used to reduce pain; in this procedure a powerful anti-inflammatory agent is injected directly into the joint.

Knee Surgery Alternatives: Glucosamine/Chondroitin
A dietary supplement called glucosamine/chondroitin may improve the joint’s mobility and decrease pain from arthritis of the knee. Glucosamine and chondroitin sulfate can slow the deterioration of cartilage in the joint, reducing the pain of bone on bone. Both are naturally occurring molecules in the body. Glucosamine is thought to promote the growth of new cartilage and repair of damaged cartilage, while chondroitin is believed to promote water retention, improving the elasticity of cartilage, and also to inhibit cartilage-destroying enzymes.

Knee Surgery Alternatives: Joint Fluid Therapy
While medications and supplements can be helpful in reducing inflammation and pain and help you delay or avoid knee surgery, there are trade-offs. Drug therapies may have systemic side effects, and there is a limit to how much pain reduction can occur.

In a procedure called joint fluid therapy, a series of injections is made directly into the knee. This therapy is designed to reduce pain by improving lubrication in the knee, replacing the synovial fluid that lubricates the knee. Hyaluronate or hyaluronic acid (HA) is used for the treatment of osteoarthritis knee pain in patients who have failed to get adequate relief from simple painkillers or from exercise and physical therapy.

A solution made of highly purified, sodium hyaluronate is used in this procedure. HA is made from a natural chemical found in the body and is found in particularly high amounts in joint tissues and in the fluid (synovial fluid) that fills the joints.

The body’s own hyaluronan acts like a lubricant and shock absorber in synovial fluid of a healthy joint. Osteoarthritis reduces your synovial fluid’s ability to protect and lubricate your joint.

A physician administers an injection of HA solution into your knee once a week for 5 weeks (a total of 5 injections). This helps to re-lubricate your knee and reduce the pain of osteoarthritis, possibly delaying or helping you avoid knee surgery.  The series of 5 injections can last for 1 year and be repeated each year.

Bracing
A brace may be used to provide external stability to the knee joint. Braces are devices made of plastic, metal, leather and/or foam and are designed to stabilize a joint, reduce pain and inflammation, and strengthen the muscles of the knee. By putting pressure on the sides of the joint, the brace causes the joint to realign, which in turn decreases the contact between the two rough bone surfaces and reduces the pain while increasing mobility.

A total knee replacement involves cutting away the damaged bone of the knee joint and replacing it with a prosthesis. This ‘new joint’ prevents the bones from rubbing together and provides a smooth knee joint.

If you are considering knee surgery the following total knee replacement information might help you understand the procedure and implants better.

Your knees work hard during your daily routine, and arthritis of the knee or a knee injury can make it hard for you to perform normal tasks. If your injury or arthritis is severe, you may begin experience pain when you�re sitting down or trying to sleep.

Sometimes a total knee replacement is the only option for reducing pain and restoring a normal activity level. If Taos Orthopaedic Institute and you decide a total knee replacement is right for you, the following information will give you an understanding about what to expect.

Implant Components
In the total knee replacement procedure, each prosthesis is made up of parts. The tibial component has two elements and replaces the top of the shin bone or tibia. This prosthesis is made up of a metal tray attached directly to the bone and a plastic spacer that provides the bearing surface.

The femoral component replaces the bottom of the thigh bone or femur. This component also replaces the groove where the patella, or kneecap, sits.

The patellar component replaces the surface of the knee cap, which rubs against the femur. Patellar component problems are a most common cause of knee replacement complications.  For most patients, Taos Orthopaedic Institute uses a specially designed implant which eliminates the need for kneecap resurfacing.  This state-of-the-art technique eliminates this most common cause of mechanical failure of total knee replacement!

The Procedure
Before you are taken to the operating room you�ll be given medication to help you relax, and the anesthetist will talk with you about the medications he�ll be using. You may have an injection which will make your leg numb for many hours after the surgery and take away pain.  In the operating room, you will be placed under full anesthesia.

Once you are ‘under’, the surgeon will begin by making an incision in your leg to allow access to the knee joint. He’ll then expose the joint and place cutting jigs or templates on the end of the femur or thigh bone and the tibia or leg bone. These jigs allow the surgeon to cut the bone precisely so that the prosthesis fits exactly.

Now it’s time to place the prosthesis. This begins with the tibial prosthesis, which is cemented in place using special bone cement.  Next the metal component is cemented to the femur. The plastic spacer is then attached to the tibial tray. This will provide the weight-bearing surface of the leg.  If this component should wear out while the rest of the artificial knee is sound, it can be replaced. This is known as a revision. Finally, our state-of-the-art prosthesis and technique allow the patella to be spared while painful knee cap spurs are removed. The incision is closed, a drain is put in, and the post-operative bandaging is applied.

Returning Home
You will be discharged after three to five nights in the hospital when you can get out of bed on your own and walk with a walker or crutches.

At home you should begin ambulation with a support as tolerated. Keep your incision clean and dry and watch closely for any signs of infection.

You’ll continue your home exercise program and have home or outpatient physical therapy, where you will work on an advanced strengthening program and such exercises as stationary cycling, walking, and aquatic therapy.

Your long-term rehabilitation goals are a range of motion from 0 to at least 90 degrees of knee flexion, mild or no pain with walking or other functional activities, and independence in all activities of daily living.

Understanding Knee Replacement Alternative Bearing Material for Younger, Heavier or More Active Patients

OXINIUM is “Strong As An Ox!”

Not all implant devices are made of the same material. Due to significant advancements in technology, metallurgy and process, there is a revolutionary new material for implant devices that, quite literally, is “As Strong As An Ox!”

To date, cobalt chrome has been the material of choice for joint implants because of its strength and relative hardness. However, studies have shown that cobalt chrome implants roughen over time when implanted in your body. Every time a roughened replacement joint rubs against the plastic bearing surface, the plastic surface begins to wear out.

Laboratory studies have demonstrated that even a single scratch on the cobalt chrome surface can increase the rate of plastic wear by 10 times. Over time, the plastic surface wears out, and additional surgery is necessary to replace the worn implants. Recent studies have proven through controlled wear testing that a “scratched” or “roughened” cobalt chrome implant will dramatically increase the production of plastic wear debris, and substantially reduce the life span of an implant.

Oxinium or oxidized zirconium is the name of the material, and it is 4,900 times superior in terms of hardness, smoothness and resistance to scratching and abrasion compared to the cobalt chrome metal usually used for total knee replacement. Oxinium actually incorporates the best features of all available material options (ceramic and cobalt chrome) without the risks associated with either.

A younger, heavier or more active patient can expect an Oxinium replacement to be long-lasting and allow normal activities with less fear of undergoing a repeat replacement surgery.

Have you heard about MIS Total Knee Replacement?  Few have; soon all will.

As in the field of arthroscopic surgery where invasive procedures are now performed with minimally invasive techniques, Knee Replacement procedures can now be MIS.

While Total Knee Replacement is traditionally performed through a large, tendon-cutting incision, MIS can now be performed via a 4 to 5 inch tendon-sparing, mini-incision.  The result: less patient pain, shorter hospitalization and faster recovery and rehabilitation!

James H. Lubowitz, MD, has not only attended courses and visited leading surgeons who are developing MIS Total Knee technique.  Dr. Lubowitz is himself such a leading developer, a teacher, lecturer, designer, industry consultant and educational course Faculty member.  In addition, Taos Orthopaedic Institute and Holy Cross Hospital in Taos are national surgeon visitor sites for MIS instruction.

Mini-incision Total Knee Replacement has been performed in Taos since 2003. Dr. Lubowitz is one of the first surgeons in the nation and believed to be the first surgeon in New Mexico to routinely offer his patients the MIS Total Knee.

If you are considering knee surgery, the following partial knee replacement information may help you understand your alternatives.

Knee pain from arthritis can be particularly debilitating because we use our knees in almost all of our daily activities. If you are experiencing severe knee pain that interferes with your normal functioning, your doctor may recommend a partial knee replacement, also known as uni-compartmental knee replacement or UNI.

This procedure is less invasive than total knee replacement and may give relief to people suffering from arthritis of the knee or a knee injury. Partial knee replacement surgery replaces only the damaged area of your knee joint, may require only one day of hospitalization, and results in dramatically less recovery time when compared with total knee replacement surgery.

The knee can be divided into three compartments: the medial compartment, the lateral compartment, and the patello-femoral compartment. The uni-compartmental implant is designed to replace either the medial or lateral compartment.  The uni-compartmental knee replacement is a less invasive option for patients with knee arthritis that is isolated to either one compartment of the knee. This minimally invasive procedure provides several benefits to patients who have a moderately active lifestyle and are within normal weight ranges.

The procedure leaves a very small incision compared to a total knee replacement. There is no disruption of the muscles in the front of the knee which leads to more rapid rehabilitation. The procedure is often performed with no bone cuts and no cement. There is minimal blood loss in a partial knee replacement. The procedure causes less post-operative pain and requires greatly reduced hospitalization compared to a total knee replacement. There is also a reduced need for anesthesia and post-operative medication.

After the surgery, patients are able to walk and experience a faster rehabilitation and recovery. After achieving full recovery, most patients experience an increased range of motion when compared to total knee replacement.

In a small percentage of people, as with all major surgical procedures, knee replacement complications can occur. These risks include swelling, infection, bleeding, persistent pain, vascular and circulatory disorders, neurological symptoms, blood clots, anesthesia risks and even death in the rarest of cases. Your medical condition and general health contribute to the potential for complications.

The common complications of total knee surgery can now be largely avoided.  Each patient receives a thorough preoperative medical evaluation by an internist as well as routine pre-admission testing.

Below is a list of potential knee replacement complications and steps that we take at Taos Orthopaedic Institute and Holy Cross Hospital in Taos to prevent these complications.  In addition, we list steps that you, the patient, can take to prevent their occurrence.

Thrombophlebitis or Blood Clot
This condition is also known as deep vein thrombosis (DVT), and it occurs when the large veins of the leg form blood clots and, in some instances, become lodged in the capillaries of the lung and cause a pulmonary embolism (PE). While phlebitis (or inflammation of the leg veins) is not rare, the incidence of fatal pulmonary emboli (or blood clots to the lungs) has been almost totally eliminated. The following steps are taken to avoid knee replacement complications due to blood clots:

*  Foot and ankle exercises increase blood flow and enhance venous return in the lower leg after surgery

* Blood-thinning medication (anticoagulants) are prescribed after surgery

* Elastic wraps or support stockings (TED hose) are worn after surgery

* Continuous Passive Motion (CPM) machines and early mobilization, ambulation, and physical therapy are prescribed after surgery

* Plexipulse foot compression pumps increase blood flow and enhance venous return in the lower leg after surgery

IMPORTANT: If you develop swelling, redness, pain and/or tenderness in the calf muscle, chest pain, or shortness of breath, report these symptoms to your orthopaedic surgeon immediately.

Infection
Although great precaution is taken before, during, and after surgery, infections do occur in a small percentage of patients following knee replacement surgery. Thanks to our use of antibiotics, expeditious surgery, and a surgical team wearing sterile exhaust hood operating room space suits, the infection rate at our institution is below average.

In addition, steps our patients take to minimize this knee replacement complication include:

* Iodine showers before surgery

* Dental evaluation for abscess or infection before surgery

* Strict incision care guidelines after surgery

IMPORTANT: If you develop redness, swelling, tenderness, increased drainage, foul odor, persistent fever above 100.4 degrees orally, and increasing pain report these symptoms to your orthopaedic surgeon immediately.

Pneumonia
Because your lungs tend to become “lazy” as a result of the anesthesia, secretions may pool at the base of your lungs, which may lead to lung congestion or pneumonia. The following steps are taken to minimize this complication:

* Deep breathing exercises: Patients take deep breaths and cough out any secretions each hour after surgery while awake

* Incentive Spirometer: This simple device gives you visual feedback while you perform your deep breathing exercises. Your nurse or respiratory therapist will demonstrate proper technique. Patients take 10 deep breaths using the incentive spirometer each hour while awake

Knee Stiffness
In some cases, the mobility of your knee following surgery may be significantly restricted and you may develop a contracture in the joint that will cause stiffness during walking or other activities of daily living. The following steps must be taken to maximize your range of motion following surgery:

* Continuous Passive Motion (CPM) machines are prescribed after surgery to slowly and gently bend and straighten the knee while you rest

* Physical therapy begins on post-surgical Day #1 to begin range of motion exercises and walking

* Edema control to reduce swelling (ice, compression stocking, and elevation)

* Adequate pain control so you can tolerate the rehabilitation regime

Sometimes a knee replacement is the only option for reducing pain and restoring a normal activity level.  If Taos Orthopaedic Institute and you decide that knee surgery is right for you, here is an idea of what to expect during days leading up to, the day of, and the days after your surgery.

Preparing For Your Operation

 1.   Betadine (iodine) showers are advised twice daily for two weeks before surgery to lower the bacteria count of the skin.  You can obtain Betadine Skin Cleanser from most pharmacies without a prescription.

 2.     Multiple vitamins are advised, one daily for two weeks before surgery.

 3.     Discontinue aspirin and anti-inflammatory drugs (arthritis medications) two weeks before surgery.

 4.     There is a program known as auto transfusion for those who are able to give their own blood.  Your blood will be held for your own use and returned at the time of surgery.  Arrangements for this procedure can be made with our office.

 Additionally, patients participating in this program need to take supplemental iron tablets as well as a multivitamin.

 5.     A dentist must check your teeth for any abscess or infection prior to surgery.

 6.     A complete medical evaluation must be performed prior to surgery by your primary care physician.  You will also obtain the necessary preoperative studies such as a chest x-ray, blood counts and electrocardiogram.

 The Day of Surgery

 1.     Absolutely nothing should be taken by mouth to eat or drink after midnight on the night before surgery.  It is essential that your stomach be completely empty at the time of your operation.

 2.     Your knee will be shaved and scrubbed by an OR nurse prior to the operation to ensure cleanliness.

 3.  Antibiotic medications will be started just prior to surgery and continued after the operation intravenously.

 4.     You will be taken to the operating room approximately twenty minutes before the scheduled time of your surgery.  You will be asked to wear a hospital gown and to remove any jewelry as well as dentures or wigs.  Your valuables should be left at home or with your family.  If this is not possible, please leave them with the nursing staff who will arrange security.

 5.    You will receive preoperative medications by injection to help you relax and be more comfortable during preparations for your surgery.

 6.   You will be transported to the operating room on a stretcher or bed.  There you will be given medication by the Anesthetist to put you to sleep once you are in the room.  There are a wide variety of techniques used for anesthesia, all of which prevent pain during the surgical procedure.  If you wish, it is even possible to be awake during your surgery.

 AFTER SURGERY

 1.  You will be in the recovery room in your bed with your knee cushioned in a Continuous Passive Motion (C.P.M.) machine.  This cradle will help you with your physical therapy by slowly increasing the motion of your knee throughout your hospital stay.

 2.      Intravenous fluids and antibiotics are often given for the first two post-operative days.  You may eat and drink as you are able to tolerate liquids and food.

 3.      The nurses and physical therapist will show you how to move in bed and how to exercise your legs.

 4.      Several measures are taken to prevent blood clots.  Elastic stockings and foot compression pumps are worn and calf exercises are encouraged. A special medication will be administered to help prevent blood clots from forming. Early ambulation, mobilization and physical therapy (post-surgical Day #1) are also important to improve circulation and to prevent complications.

 5.     The surgical dressing is removed two days after surgery.  There may be small drainage tubes that are usually removed two days after surgery.

 6.     Exercises to strengthen the arms and legs and to encourage circulation are performed throughout the entire postoperative period.

 7.     Pain control is achieved by a variety of effective measures including pills, injections, PCA (patient controlled analgesia), and epidural analgesia.  PCA is given via an IV into the arm, and pain relief can be achieved by pressing a button to administer your own medication.  In addition, pain and sleeping medications are available and can be obtained simply by asking or notifying the nursing staff.  If the drug prescribed does not appear satisfactory, please notify the nursing or medical staff so that a substitute may be ordered.

 8.     Ambulation with a walker is started on the first postoperative day.  The physical therapist will help with walking and bending the knee twice a day.  Walking is performed with the assistance of the physical therapist and by the Nursing Staff. Your family can also assist you when you are strong enough.

 Preparation for Leaving the Hospital

Goals

The hospital time is primarily devoted to increasing your level of independence and bending your knee.  We prescribe daily physical therapy sessions to increase range of motion of your knee.  Stair climbing may be instructed as well as the basic activities of daily living.

Prior to being discharged from the hospital, you must be able to:

1.  Get in and out of bed yourself.

2.  Walk confidently in the hallway with a walker or crutches.

3.  Climb stairs.

4.  Be able to bathe and care for yourself.

5.  Understand all the dos and don’ts for being at home.

6.  You also must be able to bend your knee an acceptable amount.

If you are unable to achieve these goals in the hospital, these tasks can be accomplished by transferring you for additional treatment at an Inpatient Rehabilitation Center or in a Skilled Nursing Facility prior to your discharge to home.

When you go home, outpatient or home physical therapy services will be arranged. In special cases, a home nursing or health aide may be recommended. You may need someone to provide food and run errands.  Our Social Service Department will help you with the details of these arrangements.  Please ask our team (nurses, doctors, physical therapists, social service department, etc.) to help you to make these decisions.

Knee Condition and Mobility

Once you’ve had knee replacement surgery and completed rehab, your knee should have range of motion and strength sufficient for all your daily tasks such as walking and climbing stairs.

Thanks to your new knee, you will be able to do many of the activities you did before your knee surgery, but with little or no pain.  Most people with total knees can do recreational walking, swimming, golf, light hiking, recreational biking, ballroom dancing and stair climbing without difficulty. Usual activities such as housekeeping, gardening, driving, dancing, and sex are encouraged. Exercise is important on a regular basis

Maintain Your Ideal Weight

 Increased forces on your knee may lead to wear or loosening; your weight directly correlates with the amount of force on the knee joint.

Infectious Precautions

 Infectious precautions are important to prevent the artificial joint from infection. You must take antibiotic pills prior to any invasive procedure such as dental work or gastrointestinal studies.

Periodic Office Visits

 Patients receiving total knee replacement should see Taos Orthopaedic Institute periodically after surgery.  This varies depending on the individual.  This follow-up visit helps diagnose any potential complications which may arise and allows us to monitor the successful or poor outcomes of all total knee replacements.  (Please keep us informed of any changes in your status or address).

Activities to Avoid

Even though your activity level is likely to increase, a knee replacement surgery means that high-demand or high-impact activities must be avoided. You should definitely avoid running or jogging, contact sports, jumping sports, and high impact aerobics.

 You should also try to avoid vigorous hiking, aggressive skiing, singles tennis, repetitive lifting exceeding 50 pounds, and repetitive aerobic stair climbing.  The safest aerobic exercises are biking (stationary and traditional) or swimming because these place very little stress on the knee joint.

How Long Your Implant Should Last

The average total knee currently lasts 10-20 years before the components wear out. In some cases, worn components can be easily switched out for new ones, but revision surgery is always an experience doctors and patients want to avoid if at all possible.

 Fortunately, there have been significant advances in materials and designs that extend the life of total knee replacements.  Oxinium means 85% less wear for younger, heavier or more active patients with a goal of avoiding the need for revision surgery due to long term wear.

Before deciding on knee surgery, Taos Orthopaedic Institute may try several knee surgery alternatives to relieve the pain and inflammation in your knee.

Knee Surgery Alternatives: Lifestyle Modification
The first alternative to knee surgery is lifestyle modification. This may include weight loss, avoiding activities such as running and twisting which can aggravate the knee injury, modifying exercise to no- and low-impact, and other changes in your daily routine to reduce stress on your knee.

Knee Surgery Alternatives: Exercise and Physical Therapy
Exercise and physical therapy may be prescribed to improve strength and flexibility. Exercises may include strengthening exercises such as riding a stationary bike, and stretching exercises such as flexing the ankle up and down, tightening and holding thigh muscles, sliding the heel forward on the floor, leg lifts, and knee extensions.

Exercise can strengthen your leg muscles and reduce your pain. If you really need knee surgery, this may not help, but many forms of knee pain can be mitigated by exercise.

Knee Surgery Alternatives: Pain Medications and Anti-inflammatory Medications
Arthritis pain is caused by inflammation in the knee as the bones rub against each other due to eroded cartilage. Reducing pain and inflammation of the tissue in the knee can provide temporary relief from pain and delay knee surgery.

For most patients, Tylenol is a safe pain medication. Anti-inflammatory medications (non-steroidal anti-inflammatory drugs or NSAIDs) such as Ibuprofen (Advil or Motrin) or Naproxen (Aleve) may also provide relief from pain and swelling. A corticosteroid injection may also be used to reduce pain; in this procedure a powerful anti-inflammatory agent is injected directly into the joint.

Knee Surgery Alternatives: Glucosamine/Chondroitin
A dietary supplement called glucosamine/chondroitin may improve the joint’s mobility and decrease pain from arthritis of the knee. Glucosamine and chondroitin sulfate can slow the deterioration of cartilage in the joint, reducing the pain of bone on bone. Both are naturally occurring molecules in the body. Glucosamine is thought to promote the growth of new cartilage and repair of damaged cartilage, while chondroitin is believed to promote water retention, improving the elasticity of cartilage, and also to inhibit cartilage-destroying enzymes.

Knee Surgery Alternatives: Joint Fluid Therapy
While medications and supplements can be helpful in reducing inflammation and pain and help you delay or avoid knee surgery, there are trade-offs. Drug therapies may have systemic side effects, and there is a limit to how much pain reduction can occur.

In a procedure called joint fluid therapy, a series of injections is made directly into the knee. This therapy is designed to reduce pain by improving lubrication in the knee, replacing the synovial fluid that lubricates the knee. Hyaluronate or hyaluronic acid (HA) is used for the treatment of osteoarthritis knee pain in patients who have failed to get adequate relief from simple painkillers or from exercise and physical therapy.

A solution made of highly purified, sodium hyaluronate is used in this procedure. HA is made from a natural chemical found in the body and is found in particularly high amounts in joint tissues and in the fluid (synovial fluid) that fills the joints.

The body’s own hyaluronan acts like a lubricant and shock absorber in synovial fluid of a healthy joint. Osteoarthritis reduces your synovial fluids ability to protect and lubricate your joint.

A physician administers an injection of HA solution into your knee once a week for 5 weeks (a total of 5 injections). This helps to re-lubricate your knee and reduce the pain of osteoarthritis, possibly delaying or helping you avoid knee surgery.  The series of 5 injections can last for 1 year and be repeated each year.

Bracing
A brace may be used to provide external stability to the knee joint. Braces are devices made of plastic, metal, leather and/or foam and are designed to stabilize a joint, reduce pain and inflammation, and strengthen the muscles of the knee. By putting pressure on the sides of the joint, the brace causes the joint to realign, which in turn decreases the contact between the two rough bone surfaces and reduces the pain while increasing mobility.

WHAT IS THE ROTATOR CUFF ?

The rotator cuff is a series of four muscle-tendons that control motion of the shoulder joint. Tendons are like ropes which attach muscles to bones. Rotator cuff problems are common because of the anatomy of the shoulder. The rotator cuff tendon most commonly injured, the supraspinatus, lies between the humeral head (the ball at the top of the arm bone) and the acromion, (the bone that you can easily feel when you touch the top of the shoulder). Certain motions, especially overhead activities, can pinch or compress the rotator cuff between the humeral head and the acromion, sometimes referred to as “Impingement Syndrome”.

HOW IS THE ROTATOR CUFF TORN ?

Rotator cuff injuries can occur in several ways. A traumatic injury can occur from falling onto an outstretched hand, elbow or shoulder. A more gradual, degenerative or chronic process can also occur, resulting in gradual loss of motion, function and increasing pain. In some cases, there may be a pre-existing problem that can be made worse by an accident or fall. A bone spur underneath the acromion may also contribute to rotator cuff pathology.

WHAT ARE THE COMMON SYMPTOMS ?

The most common symptoms that patients note with rotator cuff problems are pain in the shoulder area that does not usually radiate below the elbow. Patients may also note pain that frequently worsens at night due to inflammation or swelling of the rotator cuff. Patients with severe disruption of the rotator cuff are unable to lift their arm above shoulder level (i.e., to comb one’s hair or reach behind one’s back). Less severe damage to the tendons will simply produce pain with overhead activities.

WHAT IS SPECIAL ABOUT OUR APPROACH AND TECHNIQUES ?

Our goal is always to reconstruct a repairable rotator cuff. We prefer to complete the procedure arthroscopically. This technique leaves a much smaller scar, thus reducing postoperative pain, avoids incision of an uninjured, healthy deltoid muscle, improves speed and comfort of rehabilitation and decreases the chance of infection.

HOW IS THE ROTATOR CUFF REPAIRED ?

A diagnostic arthroscopy is performed initially to assess the condition of the glenohumeral (ball & socket) joint (underneath the rotator cuff) and the extent of damage. The arthroscope is then placed in the subacromial space (on top of the rotator cuff) to first perform a bursectomy (removal of inflammatory tissue) and subacromial decompression (smoothing the acromial spur).

The rotator cuff tear is then assessed arthroscopically and a determination is made based on tear size, shape, scarring and tissue quality, whether an arthroscopic versus mini-open or open repair will be performed. A variety of different instruments, implants, sutures and techniques are employed to complete the repair.

WHAT KIND OF FUNCTION CAN I EXPECT FROM A ROTATOR CUFF REPAIR ?

The goal of rotator cuff repair is to restore strength, function and provide pain relief. The final result depends on many factors, including: the severity of the initial tendon injury (size of tear), the quality of the tissue, strength of the repair and finally, the motion and strength that is ultimately able to be achieved by the patient in rehabilitation.

These injuries vary in size from ½ inch (small tear) to three or four inches (massive tear). The outcome of surgery is related to the severity of the problem, the size of the tear and the condition of the muscles and tendons of the rotator cuff and the shoulder.

If the quality of the tendon tissue is poor, or the tear is very large, a partial repair or debridement is completed. In these cases of massive tears, full function and strength may not be able to be restored, but often pain relief can be achieved.

WHAT IS SPECIAL ABOUT OUR APPROACH AND TECHNIQUES ?

To re-emphasize, our goal is always to reconstruct a repairable rotator cuff. We prefer to complete the procedure arthroscopically. This technique leaves a much smaller scar, thus reducing postoperative pain, avoids incision of an uninjured, healthy deltoid muscle, improves speed and comfort of rehabilitation and decreases the chance of infection.

DO I NEED TO HAVE ANY TESTS PRIOR TO SURGERY ?

Depending on your overall medical condition, you may need specific tests and/or a medical evaluation by your primary care physician. Within two weeks of your surgery, you may need several medical tests. These are done on an outpatient basis. Some people require blood tests and urinalysis. A chest X-Ray and an EKG are required if you are over 50. In select cases, a MRI (magnetic resonance image) is useful to assess the soft tissue structures around the shoulder and may help in predicting the severity of injury and in preoperative planning.

You should STOP taking any medication 2 weeks prior to surgery that may cause excessive bleeding. These include: Aspirin, NSAIDs (Non-steroidals) like Ibuprofen, Naprosyn, and Daypro. Tylenol is okay to continue.

WHAT TYPE OF ANESTHESIA IS USED ?

A regional block to make the shoulder numb may often be combined with general anesthesia for most rotator cuff repairs. Prior to surgery you will meet a member of the Anesthesia Department who will explain your anesthesia alternatives and address questions that you may have concerning anesthesia. On the morning of surgery, a member of the Anesthesia Department will again review your anesthesia options with you.

WHAT HAPPENS THE DAY OF SURGERY ?

You will arrive at the hospital approximately one hour before your scheduled surgery. The surgery will take approximately two to three hours and you will be in the recovery room for one hour so that your recovery from the anesthesia can be monitored. You will then go home.

NOTE: YOU MAY NOT EAT OR DRINK ANYTHING BEGINNING AT MIDNIGHT THE NIGHT PRIOR TO THE SURGERY.
If you must take medicines daily you should do so with just a sip of water. This should be cleared by the operating surgeon or by the anesthesiologist prior to the day of surgery.

WHAT HAPPENS AFTER SURGERY ?

Following surgery, you will have a bandage over your incision and your arm will be placed in a sling so that the repaired tendons can heal (this takes 6 weeks). Ice and a prescription for medications will be provided for your comfort. You should keep a pillow under your elbow on the operated side while lying in bed. Also keep a pad in your armpit to avoid skin maceration from sweating. In addition, you will be provided with dressings to change over your shoulder wound after 2 days.

HOW DO I CARE FOR MY SHOULDER ?

Two days after you go home, the bandage may be removed. You will see an incision covered with suture. Remove the surgical dressing and replace it with the 4x4s and tegaderm dressings that were provided to you on discharge. You will then be able to shower. Remove the sling and keep your arm at your side while showering. To give your wound time to heal, please DO NOT SOAK or SUBMERGE your operated shoulder under water, i.e., in a tub or whirlpool.

After your surgery call the office to make a follow-up appointment for approximately seven to ten days following your surgery. At that time, the stitches will be removed and you will again be instructed in what activities you may do.

WHAT CAN I DO AFTER SURGERY ?

You will need to wear the sling for 6 weeks so that the tissues can heal. During this time, you are permitted to use your elbow, wrist and hand below shoulder level, i.e. to feed yourself, write or type on the computer. You MUST do the gentle PASSIVE ONLY range of motion exercises 5X a day, while lying flat, as instructed by your physician. It is suggested that you avoid driving during the time you wear the sling, for safety reasons and to prevent injury to the operated area.

Many people can return to a desk job within seven (7) days following surgery. Returning to a job that is more strenuous will require more time. You are not permitted to lift anything greater than one or two pounds for the first six weeks and NOTHING OVERHEAD.

WHEN CAN I EXPECT TO RETURN TO MY PREVIOUS LEVEL OF ACTIVITY?

For the first 6 weeks, you will be doing passive stretching motions with your shoulder. At six weeks following surgery, you will be permitted to begin more vigorous strengthening exercises as the tendon heals. It can take six months to a year, to recover the full strength of your arm. The end result depends on the size of the tear, the conditions of the tendon and the muscles at the time of the surgery and how much time and effort you can devote to your rehabilitation.

The shoulder has the most motion of any joint in the body.  Unfortunately, it is also the most susceptible to instability.  Dislocation of the shoulder joint, which occurs when the ball (head of the humerus bone) pops out of the socket (glenoid cup of the scapula bone), is common.  When the shoulder dislocates, the rim of soft tissue which surrounds the glenoid rips and tears. This rim, called the lip or labrum, is like a bumper which helps keep the ball in the cup. When the labrum is torn, dislocation can commonly recur (happen over and over again)

Disappointing Natural History

When a younger person dislocates their shoulder, the recurrence or re-dislocation rate may be as high as 90%. In addition, in those patients who don’t have recurrent dislocations, activities like sports or throwing must frequently be modified. Some patients even have difficulty sleeping comfortably. When a patient who is older than 40 years old suffers a shoulder dislocation, the rotator cuff (the main tendons and muscles which move the shoulder) may tear.  In either case, without repair, continued instability and disability may result.

 Shoulder Pain and the Throwing Athlete

Sometimes, the head of the humerus bone may only partially slide out of the socket.  This partial dislocation is known as a subluxation.  Repetitive overhead throwing, serving as in tennis or volleyball, weightlifting or swimming can cause the subtle instability resulting in subluxation. Accidents may also cause injuries to the labrum and result in subluxations. Patients may note pain or weakness and may not fully appreciate that the problem is their shoulder sliding out of the joint.

History

Patients commonly complain of symptoms of a loose shoulder joint. They may experience popping or grinding or pain in certain positions. Patients may feel afraid to use their arms in certain ways. Athletes may complain of a dead arm, weakness, pain or fatigue in their shoulder. Most patients who have had even one dislocation will tell you that it is extremely uncomfortable.

Treatment

The goal of shoulder stabilization is to restore stability, strength, function and provide pain relief. While non-operative treatment is preferred in most cases, surgery is recommended when non-operative management fails.  In addition, because of the high risk of recurrence, surgery is recommended for patients with dislocation who are less than 25 years old.  Surgery is also recommended for older patients who suffer a tear of the rotator cuff tendons.

Minimally Invasive Repair

Minimally invasive arthroscopic techniques are now used to perform repair of the torn shoulder labrum or rotator cuff. Taos Orthopaedic Institute Research Foundation’s Dan Guttmann, MD, is nationally recognized as a subspecialist in arthroscopic shoulder repair and is sought out as an instructor, teacher and lecturer so that he may share this expertise. With arthroscopic surgery, smaller scars, reduced pain, faster rehabilitation and lower rates of complications tip the balance in favor o

Anatomy

The shoulder is a combination of three bones: the humerus (upper arm bone), the clavicle (collarbone), and the scapula (shoulder blade). The ball-like head of the humerus fits into the cup-like end of the scapula known as the glenoid. This cup or glenoid is commonly referred to as the shoulder socket and is surrounded by a rim of soft tissue called the labrum. In order to maintain shoulder stability, the labrum acts like a bumper and is helped by the glenohumeral ligaments and capsule within the shoulder joint.

Definition

The head of the humerus may be forced out of the glenoid in a dislocation or can be forced partially out of the glenoid, which is known as a subluxation. Repeated dislocation or subluxation of the humerus out of the glenoid is known as instability. Instability is a weakening of the capsule and ligaments of the shoulder joint, which allows the ball to slip out of the socket, causing pain, frustration and doubt in the shoulder as a stable joint. Dislocations and some subluxations often happen from some sort of injury or trauma. Trauma often involves a high energy impact or may result from a fall onto an outstretched hand. Some patients may also have ‘loose’ shoulders that tend to sublux or even dislocate without trauma.

Repetitive overhead throwing can also cause subtle instability with secondary injury to the rotator cuff. Pain from instability can be from the unstable event or can be from overuse of the rotator cuff in an attempt to stabilize the loose shoulder. This is called instability-induced tendonitis, sometimes also called secondary impingement. Another type of instability is internal impingement, which is when the unstable shoulder rotates excessively (such as in a thrower). The rotator cuff bumps up against the glenoid, and it starts to tear the labrum (the tissue on the rim of the glenoid) and the posterior superior rotator cuff.

Both dislocations and subluxations can cause tears of the labrum, ligaments or capsule. They may also cause rotator cuff tears as well as fractures of the shoulder joint. When a traumatic dislocation occurs, and is associated with a tear of the labrum, it is often referred to as a, ‘Bankart lesion.’

Repeated dislocations may cause further tearing of these stabilizing structures and may cause the capsule to stretch out so much that the shoulder remains unstable.

The humerus may be forced out of the glenoid, (a dislocation), or overhead throwing sports may also injure the shoulder joint. Either may cause a Lesion, which stands for a tear in the Superior Labrum, Anterior to Posterior. In a SLAP Lesion, the labrum is torn from the front to the back. The superior labrum is the attachment for the biceps tendon, the strong muscle in the front of the arm. A sudden pull on this muscle can pull the superior labrum off of the bone.

History
Patients will commonly complain of symptoms of a loose shoulder joint. They may experience popping or grinding of the shoulder. There is often associated pain with certain positions of the arm. In patients who have a history of multiple dislocations, they may even re-dislocate while sleeping or getting dressed. Sometimes dislocations may be reduced by the patient themselves. This is often painful. More commonly, however, dislocations require a reduction in the emergency room supervised by a physician and require anesthesia. Most patients who have had even one dislocation will tell you that it is extremely uncomfortable.

A fall on an extended hand held close to the body presents the greatest risk of a SLAP lesion. Overhead sports, such as baseball, volleyball, swimming and weightlifting also increase the chance of the injury. A SLAP lesion may also occur as the result of an automobile accident. Additionally, those with above-average joint laxity, or looseness of the ligaments, stand at great risk of shoulder instability.

Treatment

After an initial dislocation is reduced, most patients are immobilized in a sling for a week or two and then started on a rehabilitation program. Some patients improve after immobilization followed by rehabilitation. One problem that affects younger patients more frequently is recurrence of dislocation. This means that patients will tend to re-dislocate, especially if they suffer their first dislocation between the ages of 15 and 25 years of age. For younger patients, the re-dislocation rate in the Orthopaedic literature ranges from 60-90%.

Patients older than 40 may suffer a rotator cuff tear with a dislocation rather than suffer  recurrence of dislocations.

Strong rotator cuff muscles remain the best defense against shoulder dislocation, subluxation, and, thus, instability. Exercises that build up these muscles around the shoulder should be done. Adequate warm-up before activity and avoidance of high-contact sports may help prevent a recurrence of instability.

When non-operative treatment fails, there are many different surgical options to stabilize the shoulder. These treatments include both open and arthroscopic techniques. Recent Orthopaedic literature has shown that arthroscopic techniques can be as successful as open surgery.

HOW IS THE SHOULDER STABILIZED ?

The affected shoulder is first examined under anesthesia and tested for instability and relative laxity. This is then compared to the unaffected shoulder. A diagnostic arthroscopy is performed initially to assess the condition of the glenohumeral joint (ball & socket) and evaluate the extent of damage.  The arthroscope is placed into the shoulder joint and the labral tear associated with a shoulder dislocation, often referred to as a ‘Bankart lesion’, is repaired. Often the capsule and associated ligaments are also torn or stretched out as well. In addition to the labral repair, the capsule and ligaments often need to be tightened up as well. If the shoulder instability is not secondary to a dislocation, but rather a subluxation, a labral tear may still be present. This is referred to as a SLAP tear and is associated with the Biceps tendon anchor or attachment. This anchor often requires stabilization.

The ability to stabilize the shoulder is assessed arthroscopically and a determination is made based on bone stock as well as tear pattern, size, shape, scarring and tissue quality, whether an arthroscopic versus open repair will be performed. A variety of different instruments, implants, sutures and techniques are employed to complete the repair.

WHAT KIND OF FUNCTION CAN I EXPECT FROM A SHOULDER STABILIZATION ?

The goal of shoulder stabilization is to restore stability, strength, function and provide pain relief. The final result depends on many factors, including: the severity of the initial injury (whether it is associated with a fracture of the ball and/or socket), the amount of times the shoulder has dislocated (this will affect how loose the shoulder structures become), the quality of the tissue (labrum, ligaments and capsule), the strength of the repair and finally, the motion and strength that is ultimately able to be achieved by the patient in rehabilitation.

These instability injuries vary from subtle subluxations to dislocations. The rotator cuff may also be affected secondarily.

WHAT IS SPECIAL ABOUT OUR APPROACH AND TECHNIQUES ?

Our goal is always to reconstruct and stabilize the shoulder joint. We prefer to complete the procedure arthroscopically.  This technique allows the surgeon to fully evaluate the shoulder joint and pathology associated with the shoulder instability. This arthroscopic procedure leaves a much smaller scar, thus reducing postoperative pain, avoids incision of an uninjured, healthy subscapularis muscle, improves speed and comfort of rehabilitation and decreases the chance of infection.

DO I NEED TO HAVE ANY TESTS PRIOR TO SURGERY?

Depending on your overall medical condition, you may need specific tests and/or a medical evaluation by your primary care physician.  Within two weeks of your surgery, you may need several medical tests.  These are done on an outpatient basis.  Some people require blood tests and urinalysis.  A chest X-Ray and an EKG are required if you are over 50.  If you have had a heart attack or significant heart disease a stress test may be required. In select cases, a MRI (magnetic resonance image) is useful to assess the soft tissue structures around the shoulder and may help in predicting the severity of injury and in preoperative planning.

You should STOP taking any medication 2 weeks prior to surgery that may cause excessive bleeding. These include: Aspirin, NSAIDs (Non-steroidals) like Ibuprofen, Naprosyn, and Daypro.  Tylenol is okay to continue.

WHAT TYPE OF ANESTHESIA IS USED?

A regional block to make the shoulder numb is often combined with general anesthesia for most shoulder repairs.  Prior to surgery you will meet a member of the Anesthesia Department who will explain your anesthesia alternatives and address questions that you may have concerning anesthesia.  On the morning of surgery, a member of the Anesthesia Department will again review your anesthesia options with you and your family.

WHAT HAPPENS THE DAY OF SURGERY?

You will arrive at the hospital approximately one hour before your scheduled surgery.  The surgery will take approximately two to three hours and you will be in the recovery room for one hour so that your recovery from the anesthesia can be monitored.  You will then go home.

NOTE: YOU MAY NOT EAT OR DRINK ANYTHING BEGINNING AT MIDNIGHT THE NIGHT PRIOR TO THE SURGERY.  If you must take medicines daily you should do so with just a sip of water. This should be cleared by the operating surgeon or by the anesthesiologist prior to the day of surgery.

WHAT HAPPENS AFTER SURGERY?

Following surgery, you will have a bandage over your incision and your arm will be placed in a sling or a brace so that the repaired tissues can heal (this takes 6 weeks).  Ice and a prescription for medications will be provided for your comfort. You should keep a pillow under your elbow on the operated side while lying in bed.  Also keep a pad in your armpit to avoid skin maceration from sweating.

HOW DO I CARE FOR MY SHOULDER?

Two days after you go home, the bandage may be removed.  You will see an incision covered with suture.  Remove the surgical dressing and replace it with the 4×4 gauze dressings and tape. You may later change this to bandaids or a tegaderm dressing. You will then be able to shower.  Remove the sling and keep your arm at your side while showering.  To give your wound time to heal, please DO NOT SOAK or SUBMERGE your operated shoulder under water, i.e., in a tub or whirlpool.

After your surgery call the office to make a follow-up appointment for approximately seven to ten days following your surgery.  At that time, the stitches will be removed and you will again be instructed in what activities you may do.

WHAT CAN I DO AFTER SURGERY?

YOU WILL NEED TO WEAR THE SLING FOR APPROXIMATELY 6 WEEKS so that the tissues can heal.  During this time, you are permitted to use your elbow, wrist and hand below shoulder level, i.e. to feed yourself, write or type on the computer.  You MUST do the gentle PASSIVE ONLY range of motion exercises 5X a day, while lying flat, as instructed by your physician.  It is suggested that you avoid driving during the time you wear the sling, for safety reasons and to prevent injury to the operated area.

Many people can return to a desk job within seven days following surgery.  Returning to a job that is more strenuous will require more time.  You are not permitted to lift anything greater than one or two pounds for the first six weeks and nothing overhead.

WHEN CAN I EXPECT TO RETURN TO MY PREVIOUS LEVEL OF ACTIVITY?

There are a rehabilitation protocols for the different types of shoulder stabilization. For the first 6 weeks, you will be doing passive motion with your shoulder. The key is allowing the tissues to heal properly while balancing the return of motion and strength.  The end result depends on the quality of the tissue and the repair, but also how much time and effort you can devote to your rehabilitation.