Do you need bunion surgery

Do you need bunion surgery?

Article Featured on AAOS

Most people with bunions find pain relief with simple treatments to reduce pressure on the big toe, such as wearing wider shoes or using pads in their shoes. However, if these measures do not relieve your symptoms, your doctor may recommend bunion surgery.

There are different types of surgeries to correct a bunion. Bringing the big toe back to its correct position may involve realigning bone, ligaments, tendons, and nerves.

Are You a Candidate for Surgery?

In general, if your bunion is not painful, you do not need surgery. Although bunions often get bigger over time, doctors do not recommend surgery to prevent bunions from worsening. Many people can slow the progression of a bunion with proper shoes and other preventive care, and the bunion never causes pain or other problems.

It is also important to note that bunion surgery should not be done for cosmetic reasons. After surgery, it is possible for ongoing pain to develop in the affected toe — even though there was no bunion pain prior to surgery.

Good candidates for bunion surgery commonly have:

  • Significant foot pain that limits their everyday activities, including walking and wearing reasonable shoes. They may find it hard to walk more than a few blocks (even in athletic shoes) without significant pain.
  • Chronic big toe inflammation and swelling that does not improve with rest or medications
  • Toe deformity—a drifting in of the big toe toward the smaller toes, creating the potential for the toes to cross over each other.

Photo and x-ray of foot deformed by a bunion

(Left) A bunion that has progressed to deformity with the big toe crossing over the second toe. (Right) An x-ray of the same bunion shows how far out of alignment the bones are.

Reproduced from Wagner E, Ortiz C: Proximal Oblique Sliding Closing-wedge Osteotomy for Wide-angle Hallux Valgus. Orthopaedic Knowledge Online Journal: Vol 12, No 4, 4/1/2014; Accessed December 4, 2015.

  • Toe stiffness—the inability to bend and straighten the big toe
  • Failure to obtain pain relief with changes in footwear
  • Failure to obtain pain relief from nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen. The effectiveness of NSAIDs in controlling toe pain varies greatly from person to person.

Deciding to Have Bunion Surgery

After bunion surgery, most patients have less foot pain and are better able to participate in everyday activities.

As you explore bunion surgery be aware that so-called “simple” or “minimal” surgical procedures are often inadequate “quick fixes” that can do more harm than good. Although many bunion procedures are done on a same-day basis with no hospital stay, a long recovery period is common. It often takes up to 6 months for full recovery, with follow-up visits to your doctor sometimes necessary for up to a year.

It is very important to have realistic expectations about bunion surgery. For example, bunion surgery may not allow you to wear a smaller shoe size or narrow, pointed shoes. In fact, you may need to restrict the types of shoes you wear for the rest of your life.

As you consider bunion surgery, do not hesitate to ask your doctor questions about the operation and your recovery. Some examples of helpful questions to ask include:

  • What are the benefits and risks of this surgery?
  • What are the possible complications and how likely are they to occur?
  • How much pain will there be and how will it be managed?

Be sure to write down your doctor’s answers so you can remember them at a later time. It is important to understand both the potential benefits and limitations of bunion surgery.

Surgical Procedures

In general, the common goals of most bunion surgeries include:

  • Realigning the metatarsophalangeal (MTP) joint at the base of the big toe
  • Relieving pain
  • Correcting the deformity of the bones making up the toe and foot

Because bunions vary in shape and size, there are different surgical procedures performed to correct them. In most cases, bunion surgery includes correcting the alignment of the bone and repairing the soft tissues around the big toe.

Your doctor will talk with you about the type of surgery that will best correct your bunion.

Repairing the Tendons and Ligaments Around the Big Toe

In some cases, the soft tissues around the big toe may be too tight on one side and too loose on the other. This creates an imbalance that causes the big toe to drift toward the other toes.

Surgery can shorten the loose tissues and lengthen the tight ones. This is rarely done without some type of alignment of the bone, called an osteotomy. In the majority of cases, soft tissue correction is just one portion of the entire bunion corrective procedure.

Osteotomy

In an osteotomy, your doctor makes small cuts in the bones to realign the joint. After cutting the bone, your doctor fixes this new break with pins, screws, or plates. The bones are now straighter, and the joint is balanced.

Osteotomies may be performed in different places along the bone to correct the deformity. In some cases, in addition to cutting the bone, a small wedge of bone is removed to provide enough correction to straighten the toe.

As discussed above, osteotomies are normally performed in combination with soft tissue procedures, as both are often necessary to maintain the big toe alignment.

Foot x-rays showing a bunion corrected with osteotomy

X-rays taken from the top and the side of the foot show a bunion corrected with osteotomy.

Arthrodesis

In this procedure, your doctor removes the arthritic joint surfaces, then inserts screws, wires, or plates to hold the surfaces together until the bones heal. Arthrodesis is commonly used for patients who have severe bunions or severe arthritis, and for patients who have had previous unsuccessful bunion surgery.

X-rays of an arthritic foot before and after arthrodesis

The x-ray on the left shows severe arthritis of the MTP joint. After arthrodesis (shown on the right), the entire foot is realigned. An advantage of arthrodesis is that no additional procedures are necessary to correct the bunion.

Exostectomy

In this procedure, your doctor removes the bump from your toe joint. Exostectomy alone is seldom used to treat bunions because it does not realign the joint. Even when combined with soft tissue procedures, exostectomy rarely corrects the cause of the bunion.

Exostectomy is most often performed as one part of an entire corrective surgery that includes osteotomy, as well as soft-tissue procedures. If a doctor performs exostectomy without osteotomy, however, the bunion deformity often returns.

X-rays of a bunion before and after exostectomy

The x-ray on the left shows a mild bunion bump before exostectomy. After the procedure (right), the bump has been shaved but the toe deformity remains and is actually worse; the big toe drifts closer to the other toes and the metatarsal bone sticks out further.

Resection Arthroplasty

In this procedure, your doctor removes the damaged portion of the joint. This increases the space between the bones and creates a flexible “scar” joint. Resection arthroplasty is used mainly for patients who are elderly, have had previous unsuccessful bunion surgery, or have severe arthritis not amenable to an arthrodesis (see above). Because this procedure can change the push off power of the big toe, it is not often recommended.

X-ray of a failed resection arthroplasty and photo of a shortened big toe

This x-ray shows a failed resection arthroplasty. Although the damaged bone of the MTP joint was removed, scar tissue did not fill the space between the bones. The bone edges are still in contact. The photograph shows that without the needed scar tissue, the big toe is shortened. This makes it more difficult to push off while walking.

Preparing for Surgery

Medical Evaluation

Before your surgery, you may be asked to visit your family doctor for a complete physical examination. He or she will assess your health and identify any problems that could interfere with your surgery. If you have a heart or lung condition or a chronic illness you will need a preoperative medical clearance from your family doctor.

Medications

Tell your doctor about any medications you are taking. He or she will tell you which medications you can continue taking and which you should stop taking before surgery.

Tests

You may require several preoperative tests, including blood counts, a cardiogram, and a chest x-ray. You may also need to provide a urine sample.

To help plan your procedure, your doctor may order special foot x-rays. These x-rays should be taken in a standing, weight bearing position to ensure your doctor can clearly see the deformity in the foot. These x-rays assist your doctor in making decisions about where along the bone to perform an osteotomy in order to provide enough corrective power to straighten the toe.

Your Surgery

In planning your surgery, your doctor will consider several things, including how severe your bunion is, your age, your general health and activity level, and any other medical issues that may affect your recovery.

Almost all bunion surgery is done on an outpatient basis. You will most likely be asked to arrive at the hospital or surgical center 1 or 2 hours before your surgery.

Anesthesia

After admission, you will be evaluated by a member of the anesthesia team. Most bunion surgery is performed with anesthesia that numbs the area for surgery but does not put you to sleep.

  • Local anesthesia. An ankle block numbs just your foot.
  • Regional anesthesia. A popliteal block works for a longer period of time compared to an ankle block and numbs more of the leg. The numbing medicine is injected behind the knee.
  • Spinal anesthesia. This injection will numb your body below your waist.
  • General anesthesia. This form of anesthesia will put you to sleep.

The anesthesiologist will stay with you throughout the procedure to administer other medications, if necessary, and to make sure you are comfortable.

Procedure

Depending upon your bunion and the procedures you need, your doctor will make an incision along the inside of your big toe joint or on top of the joint. In some cases, more than one incision is needed to correct the bunion deformity.

Surgical photo of an osteotomy

This surgical photograph shows a saw cutting the bone to perform an osteotomy.

The surgical time varies depending on how much of your foot is malaligned. Surgery will take longer if your deformity is greater or if more than one osteotomy is required. Every bunion correction is a little bit different, and there is no reason to be concerned if your surgery takes more time.

Afterward, you will be moved to the recovery room. You will be ready to go home in an hour or two. Be sure to have someone with you to drive you home.

Photo and x-ray of a foot after osteotomy for a bunion

(Left) The bunion that was shown at the beginning of this article as it appeared immediately after surgery. (Right) An x-ray showing the bones in alignment after surgery. Osteotomies were performed on both bones; screws and plates hold the bones in place. Reproduced from Wagner E, Ortiz C: Proximal Oblique Sliding Closing-wedge Osteotomy for Wide-angle Hallux Valgus. Orthopaedic Knowledge Online Journal: Vol 12, No 4, 4/1/2014; Accessed December 4, 2015.

Complications

As with any surgical procedure, there are risks associated with bunion surgery. These occur infrequently and are usually treatable — although, in some cases, they may limit or extend your full recovery. Before your surgery, your doctor will discuss each of the risks with you and take specific measures to avoid complications.

The possible risks and complications of bunion surgery include:

  • Infection
  • Nerve injury
  • Failure to relieve pain
  • Failure of the bone to fully heal
  • Stiffness of the big toe joint
  • Recurrence of the bunion

Recovery at Home

The success of your surgery will depend in large part on how well you follow your doctor’s instructions at home during the first few weeks after surgery. You will see your doctor regularly for several months — occasionally up to a year — to make sure your foot heals properly.

Dressing Care

You will be discharged from the hospital with bandages holding your toe in its corrected position.

Because keeping your toe in position is essential for successful healing, it is very important to follow your doctor’s directions about dressing care. Do not disturb or change the dressing without talking to your doctor. Interfering with proper healing could cause a recurrence of the bunion.

Dressing applied to foot after osteotomy

Legend: Your doctor will apply your dressing in a specific way to keep the bones in correct position.

Reproduced from Hirose CB, Coughlin MJ: Proximal and Distal First Metatarsal Osteotomies for Hallux Valgus, in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 535-539.

Be sure to keep your wound and dressing dry. When you are showering or bathing, cover your foot with a plastic bag.

Your sutures will be removed about 2 weeks after surgery, but your foot will require continued support from dressings or a brace for 6 to 12 weeks.

Medications

Your doctor will prescribe pain medication to relieve surgical discomfort. The most effective medications for providing postsurgical pain relief are opioids. These medications are narcotics, however, and can be addictive. It is important to use opioids only as directed by your doctor.

As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

In addition to pain medicine, your doctor may prescribe antibiotics to help prevent infection in your wound for several days after surgery.

Swelling

Keep your foot elevated as much as possible for the first few days after surgery, and apply ice as recommended by your doctor to relieve swelling and pain. Never apply ice directly on your skin. It is common to have some swelling in your foot from 6 months to a year after bunion surgery.

Bearing Weight

Your doctor will give you strict instructions about whether and when you can put weight on your foot. Depending upon the type of procedure you have, if you put weight on your foot too early or without proper support, the bones can shift and the bunion correction will be lost.

Some bunion procedures allow you to walk on your foot right after the surgery. In these cases, patients must use a special surgical shoe to protect the bunion correction.

Many bunion surgeries require a period of no weightbearing to ensure bone healing. Your doctor will apply dressings, a brace, or a cast to maintain the correct bone position. Crutches are usually used to avoid putting any weight on the foot. A newer device called a knee walker is a good alternative to crutches. It has four wheels and functions like a scooter. Instead of standing, you place the knee of your affected foot on a padded cushion and push yourself along using your healthy foot.

In addition to no weightbearing, driving may be restricted until the bones have healed properly — particularly if the surgery was performed on your right foot.

No matter what type of bunion surgery you have, it is very important to follow your doctor’s instructions about weightbearing. Do not put weight on your foot or stop using supportive devices until your doctor gives approval.

Physical Therapy and Exercise

Specific exercises will help restore your foot’s strength and range of motion after surgery. Your doctor or physical therapist may recommend exercises using a surgical band to strengthen your ankle or using marbles to restore motion in your toes.

Marble pick-up exercise for foot

Specific exercises such as the marble pick up exercise will help restore full motion to your foot.

Reproduced from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Always start these exercises slowly and follow instructions from your doctor or physical therapist regarding repetitions.

Shoe Wear

It will take several months for your bones to fully heal. When you have completed the initial rehabilitation period, your doctor will advise you on shoewear. Athletic shoes or soft leather oxford type shoes will best protect the bunion correction until the bones have completely healed.

To help prevent your bunion from recurring, do not wear fashion shoes until your doctor allows it. Be aware that your doctor may recommend that you never return to wearing high-heeled shoes.

Avoiding Complications

Though uncommon, complications can occur following bunion surgery. During your recovery at home, contact your doctor if:

  • Your dressing loosens, comes off, or gets wet.
  • Your dressing is moistened with blood or drainage.
  • You develop side effects from postoperative medications.

Also, call your doctor immediately if you notice any of the following warning signs of infection:

  • Persistent fever
  • Shaking chills
  • Persistent warmth or redness around the dressing
  • Increased or persistent pain, especially a “sunburn” type pain
  • Significant swelling in the calf above the treated foot, especially if there is a “charley horse” pain behind the knee, or if your develop shortness of breath.

Outcomes

The majority of patients who undergo bunion surgery experience a reduction of foot pain, along with improvement in the alignment of their big toe. The length of your recovery will depend upon the surgical procedures that were performed, and how well you follow your doctor’s instructions.

Because a main cause of bunion deformity is a tight-fitting shoe, returning to that type of shoe can cause your bunion to return. Always follow your doctor’s recommendations for proper shoe fit.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

Does an ACL Injury Require Surgery

Does an ACL Injury Require Surgery

The following article provides in-depth information about treatment for anterior cruciate ligament injuries. The general article, Anterior Cruciate Ligament (ACL) Injuries, provides a good introduction to the topic and is recommended reading prior to this article.

The information that follows includes the details of anterior cruciate ligament (ACL) anatomy and the pathophysiology of an ACL tear, treatment options for ACL injuries along with a description of ACL surgical techniques and rehabilitation, potential complications, and outcomes. The information is intended to assist the patient in making the best-informed decision possible regarding the management of ACL injury.

Anatomy

normal knee anatomy

Normal knee anatomy.  The knee is made up of four main things: bones, cartilage, ligaments, and tendons.

The bone structure of the knee joint is formed by the femur, the tibia, and the patella. The ACL is one of the four main ligaments within the knee that connect the femur to the tibia.

The knee is essentially a hinged joint that is held together by the medial collateral (MCL), lateral collateral (LCL), anterior cruciate (ACL) and posterior cruciate (PCL) ligaments. The ACL runs diagonally in the middle of the knee, preventing the tibia from sliding out in front of the femur, as well as providing rotational stability to the knee.

The weight-bearing surface of the knee is covered by a layer of articular cartilage. On either side of the joint, between the cartilage surfaces of the femur and tibia, are the medial meniscus and lateral meniscus. The menisci act as shock absorbers and work with the cartilage to reduce the stresses between the tibia and the femur.

Description

ACL tear

The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee.  In general, the incidence of ACL injury is higher in people who participate in high-risk sports, such as basketball, football, skiing, and soccer.

Approximately half of ACL injuries occur in combination with damage to the meniscus, articular cartilage, or other ligaments. Additionally, patients may have bruises of the bone beneath the cartilage surface. These may be seen on a magnetic resonance imaging (MRI) scan and may indicate injury to the overlying articular cartilage.

arthroscopic images of normal ACL and ACL tear

(Left) Arthroscopic picture of the normal ACL. (Right) Arthroscopic picture of torn ACL [yellow star].

Cause

It is estimated that the majority of  ACL injuries occur through non-contact mechanisms, while a smaller percent result from direct contact with another player or object.

The mechanism of injury is often associated with deceleration coupled with cutting, pivoting or sidestepping maneuvers, awkward landings or “out of control” play.

Several studies have shown that female athletes have a higher incidence of ACL injury than male athletes in certain sports. It has been proposed that this is due to differences in physical conditioning, muscular strength, and neuromuscular control. Other hypothesized causes of this gender-related difference in ACL injury rates include pelvis and lower extremity (leg) alignment, increased ligamentous laxity, and the effects of estrogen on ligament properties.

Doctor Examination

Immediately after the injury, patients usually experience pain and swelling and the knee feels unstable. Within a few hours after a new ACL injury, patients often have a large amount of knee swelling, a loss of full range of motion, pain or tenderness along the joint line and discomfort while walking.

When a patient with an ACL injury is initially seen for evaluation in the clinic, the doctor may order x-rays to look for any possible fractures. He or she may also order a magnetic resonance imaging (MRI) scan to evaluate the ACL and to check for evidence of injury to other knee ligaments, meniscus cartilage, or articular cartilage.

MRI of ACL tear

An MRI of a complete ACL tear. The ACL fibers have been disrupted and the ACL appears wavy in appearance [yellow arrow].

In addition to performing special tests for identifying meniscus tears and injury to other ligaments of the knee, the physician will often perform the Lachman’s test to see if the ACL is intact.

If the ACL is torn, the examiner will feel increased forward (upward or anterior) movement of the tibia in relation to the femur (especially when compared to the normal leg) and a soft, mushy endpoint (because the ACL is torn) when this movement ends.

Natural History

What happens naturally with an ACL injury without surgical intervention varies from patient to patient and depends on the patient’s activity level, degree of injury and instability symptoms.

The prognosis for a partially torn ACL is often favorable, with the recovery and rehabilitation period usually at least 3 months. However, some patients with partial ACL tears may still have instability symptoms. Close clinical follow-up and a complete course of physical therapy helps identify those patients with unstable knees due to partial ACL tears.

Complete ACL ruptures have a much less favorable outcome without surgical intervention. After a complete ACL tear, some patients are unable to participate in cutting or pivoting-type sports, while others have instability during even normal activities, such as walking. There are some rare individuals who can participate in sports without any symptoms of instability. This variability is related to the severity of the original knee injury, as well as the physical demands of the patient.

About half of ACL injuries occur in combination with damage to the meniscus, articular cartilage or other ligaments. Secondary damage may occur in patients who have repeated episodes of instability due to ACL injury. With chronic instability, a large majority of patients will have meniscus damage when reassessed 10 or more years after the initial injury. Similarly, the prevalence of articular cartilage lesions increases in patients who have a 10-year-old ACL deficiency.

Nonsurgical Treatment

In nonsurgical treatment, progressive physical therapy and rehabilitation can restore the knee to a condition close to its pre-injury state and educate the patient on how to prevent instability. This may be supplemented with the use of a hinged knee brace. However, many people who choose not to have surgery may experience secondary injury to the knee due to repetitive instability episodes.

Surgical treatment is usually advised in dealing with combined injuries (ACL tears in combination with other injuries in the knee). However, deciding against surgery is reasonable for select patients. Nonsurgical management of isolated ACL tears is likely to be successful or may be indicated in patients:

  • With partial tears and no instability symptoms
  • With complete tears and no symptoms of knee instability during low-demand sports who are willing to give up high-demand sports
  • Who do light manual work or live sedentary lifestyles
  • Whose growth plates are still open (children)

Surgical Treatment

ACL tears are not usually repaired using suture to sew it back together, because repaired ACLs have generally been shown to fail over time. Therefore, the torn ACL is generally replaced by a substitute graft made of tendon.

  • Patellar tendon autograft (autograft comes from the patient)
  • Hamstring tendon autograft
  • Quadriceps tendon autograft
  • Allograft (taken from a cadaver) patellar tendon, Achilles tendon, semitendinosus, gracilis, or posterior tibialis tendon

Patient Considerations

Active adult patients involved in sports or jobs that require pivoting, turning or hard-cutting as well as heavy manual work are encouraged to consider surgical treatment. This includes older patients who have previously been excluded from consideration for ACL surgery. Activity, not age, should determine if surgical intervention should be considered.

In young children or adolescents with ACL tears, early ACL reconstruction creates a possible risk of growth plate injury, leading to bone growth problems. The surgeon can delay ACL surgery until the child is closer to skeletal maturity or the surgeon may modify the ACL surgery technique to decrease the risk of growth plate injury.

A patient with a torn ACL and significant functional instability has a high risk of developing secondary knee damage and should therefore consider ACL reconstruction.

It is common to see ACL injuries combined with damage to the menisci, articular cartilage, collateral ligaments, joint capsule, or a combination of the above. The “unhappy triad,” frequently seen in football players and skiers, consists of injuries to the ACL, the MCL, and the medial meniscus.

In cases of combined injuries, surgical treatment may be warranted and generally produces better outcomes. As many as half of meniscus tears may be repairable and may heal better if the repair is done in combination with the ACL reconstruction.

Surgical Choices

Patellar tendon autograft prepared for ACL reconstruction

Patellar tendon autograft prepared for ACL reconstruction.

Patellar tendon autograft. The middle third of the patellar tendon of the patient, along with a bone plug from the shin and the kneecap is used in the patellar tendon autograft. Occasionally referred to by some surgeons as the “gold standard” for ACL reconstruction, it is often recommended for high-demand athletes and patients whose jobs do not require a significant amount of kneeling.

In studies comparing outcomes of patellar tendon and hamstring autograft ACL reconstruction, the rate of graft failure was lower in the patellar tendon group. In addition, most studies show equal or better outcomes in terms of postoperative tests for knee laxity (Lachman’s, anterior drawer and instrumented tests) when this graft is compared to others. However, patellar tendon autografts have a greater incidence of postoperative patellofemoral pain (pain behind the kneecap) complaints and other problems.

The pitfalls of the patellar tendon autograft are:

  • Postoperative pain behind the kneecap
  • Pain with kneeling
  • Slightly increased risk of postoperative stiffness
  • Low risk of patella fracture

Hamstring tendon autograft. The semitendinosus hamstring tendon on the inner side of the knee is used in creating the hamstring tendon autograft for ACL reconstruction. Some surgeons use an additional tendon, the gracilis, which is attached below the knee in the same area. This creates a two- or four-strand tendon graft. Hamstring graft proponents claim there are fewer problems associated with harvesting of the graft compared to the patellar tendon autograft including:

  • Fewer problems with anterior knee pain or kneecap pain after surgery
  • Less postoperative stiffness problems
  • Smaller incision
  • Faster recovery

Hamstring tendon autograft prepared for ACL reconstruction

Hamstring tendon autograft prepared for ACL reconstruction.

The graft function may be limited by the strength and type of fixation in the bone tunnels, as the graft does not have bone plugs. There have been conflicting results in research studies as to whether hamstring grafts are slightly more susceptible to graft elongation (stretching), which may lead to increased laxity during objective testing. Recently, some studies have demonstrated decreased hamstring strength in patients after surgery.

There are some indications that patients who have intrinsic ligamentous laxity and knee hyperextension of 10 degrees or more may have increased risk of postoperative hamstring graft laxity on clinical exam. Therefore, some clinicians recommend the use of patellar tendon autografts in these hypermobile patients.

Additionally, since the medial hamstrings often provide dynamic support against valgus stress and instability, some surgeons feel that chronic or residual medial collateral ligament laxity (grade 2 or more) at the time of ACL reconstruction may be a contraindication for use of the patient’s own semitendinosus and gracilis tendons as an ACL graft.

Quadriceps tendon autograft. The quadriceps tendon autograft is often used for patients who have already failed ACL reconstruction. The middle third of the patient’s quadriceps tendon and a bone plug from the upper end of the knee cap are used. This yields a larger graft for taller and heavier patients. Because there is a bone plug on one side only, the fixation is not as solid as for the patellar tendon graft. There is a high association with postoperative anterior knee pain and a low risk of patella fracture. Patients may find the incision is not cosmetically appealing.

Allografts. Allografts are grafts taken from cadavers and are becoming increasingly popular. These grafts are also used for patients who have failed ACL reconstruction before and in surgery to repair or reconstruct more than one knee ligament. Advantages of using allograft tissue include elimination of pain caused by obtaining the graft from the patient, decreased surgery time and smaller incisions. The patellar tendon allograft allows for strong bony fixation in the tibial and femoral bone tunnels with screws.

However, allografts are associated with a risk of infection, including viral transmission (HIV and Hepatitis C), despite careful screening and processing. Several deaths linked to bacterial infection from allograft tissue (due to improper procurement and sterilization techniques) have led to improvements in allograft tissue testing and processing techniques. There have also been conflicting results in research studies as to whether allografts are slightly more susceptible to graft elongation (stretching), which may lead to increased laxity during testing.

Some published literature may point to a higher failure rate with the use of allografts for ACL reconstruction. Higher failure rates for allografts have been reported in young, active patients returning to high-demand sporting activities after ACL reconstruction, compared with autografts.

The reason for this higher failure rate is unclear. It could be due to graft material properties (sterilization processes used, graft donor age, storage of the graft). It could possibly be due to an ill-advised earlier return to sport by the athlete because of a faster perceived physiologic recovery, when the graft is not biologically ready to be loaded and stressed during sporting activities. Further research in this area is indicated and is ongoing.

Surgical Procedure

Before any surgical treatment, the patient is usually sent to physical therapy. Patients who have a stiff, swollen knee lacking full range of motion at the time of ACL surgery may have significant problems regaining motion after surgery. It usually takes three or more weeks from the time of injury to achieve full range of motion. It is also recommended that some ligament injuries be braced and allowed to heal prior to ACL surgery.

The patient, the surgeon, and the anesthesiologist select the anesthesia used for surgery. Patients may benefit from an anesthetic block of the nerves of the leg to decrease postoperative pain.

The surgery usually begins with an examination of the patient’s knee while the patient is relaxed due the effects of anesthesia. This final examination is used to verify that the ACL is torn and also to check for looseness of other knee ligaments that may need to be repaired during surgery or addressed postoperatively.

If the physical exam strongly suggests the ACL is torn, the selected tendon is harvested (for an autograft) or thawed (for an allograft) and the graft is prepared to the correct size for the patient.

Passage of patellar tendon graft during ACL reconstruction

Passage of patellar tendon graft into tibial tunnel of knee.

After the graft has been prepared, the surgeon places an arthroscope into the joint. Small (one-centimeter) incisions called portals are made in the front of the knee to insert the arthroscope and instruments and the surgeon examines the condition of the knee. Meniscus and cartilage injuries are trimmed or repaired and the torn ACL stump is then removed.

post-operative x-ray of ACL reconstruction

Post-operative X-ray after ACL patellar tendon reconstruction (with picture of graft superimposed) shows graft position and bone plugs fixation with metal interference screws.

In the most common ACL reconstruction technique, bone tunnels are drilled into the tibia and the femur to place the ACL graft in almost the same position as the torn ACL. A long needle is then passed through the tunnel of the tibia, up through the femoral tunnel, and then out through the skin of the thigh. The sutures of the graft are placed through the eye of the needle and the graft is pulled into position up through the tibial tunnel and then up into the femoral tunnel. The graft is held under tension as it is fixed in place using interference screws, spiked washers, posts, or staples. The devices used to hold the graft in place are generally not removed.

Variations on this surgical technique include the “two-incision,” “over-the-top,” and “double-bundle” types of ACL reconstructions, which may be used because of the preference of the surgeon or special circumstances (revision ACL reconstruction, open growth plates).

Before the surgery is complete, the surgeon will probe the graft to make sure it has good tension, verify that the knee has full range of motion and perform tests such as the Lachman’s test to assess graft stability. The skin is closed and dressings (and perhaps a postoperative brace and cold therapy device, depending on surgeon preference) are applied. The patient will usually go home on the same day of the surgery.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.

Rehabilitation

Physical therapy is a crucial part of successful ACL surgery, with exercises beginning immediately after the surgery. Much of the success of ACL reconstructive surgery depends on the patient’s dedication to rigorous physical therapy. With new surgical techniques and stronger graft fixation, current physical therapy uses an accelerated course of rehabilitation.

Postoperative Course. In the first 10 to 14 days after surgery, the wound is kept clean and dry, and early emphasis is placed on regaining the ability to fully straighten the knee and restore quadriceps control.

The knee is iced regularly to reduce swelling and pain. The surgeon may dictate the use of a postoperative brace and the use of a machine to move the knee through its range of motion. Weight-bearing status (use of crutches to keep some or all of the patient’s weight off of the surgical leg) is also determined by physician preference, as well as other injuries addressed at the time of surgery.

Rehabilitation. The goals for rehabilitation of ACL reconstruction include reducing knee swelling, maintaining mobility of the kneecap to prevent anterior knee pain problems, regaining full range of motion of the knee, as well as strengthening the quadriceps and hamstring muscles.

The patient may return to sports when there is no longer pain or swelling, when full knee range of motion has been achieved, and when muscle strength, endurance and functional use of the leg have been fully restored.

The patient’s sense of balance and control of the leg must also be restored through exercises designed to improve neuromuscular control. This usually takes 4 to 6 months. The use of a functional brace when returning to sports is ideally not needed after a successful ACL reconstruction, but some patients may feel a greater sense of security by wearing one.

Surgical Complications

Infection. The incidence of infection after arthroscopic ACL reconstruction is very low.  There have also been reported deaths linked to bacterial infection from allograft tissue due to improper procurement and sterilization techniques.

Viral transmission. Allografts specifically are associated with risk of viral transmission, including HIV and Hepatitis C, despite careful screening and processing. The chance of obtaining a bone allograft from an HIV-infected donor is calculated to be less than 1 in a million.

Bleeding, numbness. Rare risks include bleeding from acute injury to the popliteal artery, and weakness or paralysis of the leg or foot. It is not uncommon to have numbness of the outer part of the upper leg next to the incision, which may be temporary or permanent.

Blood clot. Although rare, blood clot in the veins of the calf or thigh is a potentially life-threatening complication. A blood clot may break off in the bloodstream and travel to the lungs, causing pulmonary embolism or to the brain, causing stroke.

Instability. Recurrent instability due to rupture or stretching of the reconstructed ligament or poor surgical technique is possible.

Stiffness. Knee stiffness or loss of motion has been reported by some patients after surgery.

Extensor mechanism failure. Rupture of the patellar tendon (patellar tendon autograft) or patella fracture (patellar tendon or quadriceps tendon autografts) may occur due to weakening at the site of graft harvest.

Growth plate injury. In young children or adolescents with ACL tears, early ACL reconstruction creates a possible risk of growth plate injury, leading to bone growth problems. The ACL surgery can be delayed until the child is closer to reaching skeletal maturity. Alternatively, the surgeon may be able to modify the technique of ACL reconstruction to decrease the risk of growth plate injury.

Kneecap pain. Postoperative anterior knee pain is especially common after patellar tendon autograft ACL reconstruction. The incidence of pain behind the kneecap varies greatly  in studies, whereas the incidence of kneeling pain is often higher after patellar tendon autograft ACL reconstruction.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

An Experts Guide to Avoiding Back Pain

Deciding whether to have spine surgery

By Alan S. Hilibrand, MD | Featured on AAOS

Orthopaedic surgeons encourage “shared decision-making” when it comes to treating patients, because the doctor and patient each provide information needed to make a decision about surgery.

Read more

Knee Replacement Surgery for Arthritis

What Can I Do After Knee Replacement Surgery? When to Return to Normal Activity

Article Featured on AAOS

After having a knee replacement, you may expect your lifestyle to be a lot like it was before surgery— but without the pain. In many ways, you are right, but returning to your everyday activities takes time. Being an active participant in the healing process can help you get there sooner and ensure a more successful outcome.

Even though you will be able to resume most activities, you may want to avoid doing things that place excessive stress on your “new” knee, such as participating in high-impact sports like jogging. The suggestions here will help you enjoy your new knee while you safely resume your daily activities.

Hospital Discharge

Your hospital stay will typically last from 1 to 4 days, depending on the speed of your recovery. If your knee replacement is performed on an outpatient basis, you will go home on the same day as surgery.

Before you are discharged from the hospital, you will need to accomplish several goals, such as:

  • Getting in and out of bed by yourself.
  • Having acceptable pain control.
  • Being able to eat, drink, and use the bathroom.
  • Walking with an assistive device (a cane, walker, or crutches) on a level surface and being able to climb up and down two or three stairs.
  • Being able to perform the prescribed home exercises.
  • Understanding any knee precautions you may have been given to prevent injury and ensure proper healing.

If you are not able to accomplish these goals, it may be unsafe for you to go directly home after discharge. If this is the case, you may be temporarily transferred to a rehabilitation or skilled nursing center.

When you are discharged, your healthcare team will provide you with information to support your recovery at home. Although the complication rate after total knee replacement is low, when complications occur they can prolong or limit full recovery. Hospital staff will discuss possible complications, and review with you the warning signs of an infection or a blood clot.

Warning Signs of Infection

  • Persistent fever (higher than 100 degrees)
  • Shaking chills
  • Increasing redness, tenderness or swelling of your wound
  • Drainage of your wound
  • Increasing pain with both activity and rest

Warning Signs of a Blood Clot

  • Pain in your leg or calf unrelated to your incision
  • Tenderness or redness above or below your knee
  • Increasing swelling of your calf, ankle or foot

In very rare cases, a blood clot may travel to your lungs and become life-threatening. Signs that a blood clot has traveled to your lungs include:

  • Shortness of breath
  • Sudden onset of chest pain
  • Localized chest pain with coughing

Notify your doctor if you develop any of the above signs.

Recovery at Home

You will need some help at home for several days to several weeks after discharge. Before your surgery, arrange for a friend, family member or caregiver to provide help at home.

Preparing Your Home

The following tips can make your homecoming more comfortable, and can be addressed before your surgery:

  • Rearrange furniture so you can maneuver with a cane, walker, or crutches. You may temporarily change rooms (make the living room your bedroom, for example) to avoid using the stairs.
Home recovery center

Prepare a “recovery center” by placing items that you use frequently within easy reach.

  • Remove any throw rugs or area rugs that could cause you to slip. Securely fasten electrical cords around the perimeter of the room.
  • Get a good chair—one that is firm with a higher-than-average seat and has a footstool for intermittent leg elevation.
  • Install a shower chair, gripping bar, and raised toilet seat in the bathroom.
  • Use assistive devices such as a long-handled shoehorn, a long-handled sponge, and a grabbing tool or reacher to avoid bending over too far.

Wound Care

During your recovery at home, follow these guidelines to take care of your wound and prevent infection:

  • Keep the wound area clean and dry. A dressing will be applied in the hospital and should be changed as often as directed by your doctor. Ask for instructions on how to change the dressing before you leave the hospital.
  • Follow your doctor’s instructions on how long to wait before you shower or bathe.
  • Notify your doctor immediately if the wound appears red or begins to drain. This could be a sign of infection.

Swelling

You may have moderate to severe swelling in the first few days or weeks after surgery. You may have mild to moderate swelling for about 3 to 6 months after surgery. To reduce swelling, elevate your leg slightly and apply ice. Wearing compression stockings may also help reduce swelling. Notify your doctor if you experience new or severe swelling, since this may be the warning sign of a blood clot.

Medication

Take all medications as directed by your doctor. Home medications may include opioid and non-opioid pain pills, oral or injectable blood thinners, stool softeners, and anti-nausea medications.

Be sure to talk to your doctor about all your medications—even over-the-counter drugs, supplements and vitamins. Your doctor will tell you which over-the-counter medicines are safe to take while using prescription pain medication.

It is especially important to prevent any bacterial infections from developing in your artificial joint. Some patients with special circumstances may be required to take antibiotics prior to dental work to help prevent infection. Ask your doctor if you should take antibiotics before dental work. You may also wish to carry a medical alert card so that, if an emergency arises, medical personnel will know that you have an artificial joint.

Diet

By the time you go home from the hospital, you should be eating a normal diet. Your doctor may recommend that you take iron and vitamin supplements. You may also be advised to avoid supplements that include vitamin K and foods rich in vitamin K if you taking the blood thinner medication warfarin (Coumadin). Foods rich in vitamin K include broccoli, cauliflower, brussel sprouts, liver, green beans, garbanzo beans, lentils, soybeans, soybean oil, spinach, kale, lettuce, turnip greens, cabbage, and onions.

Continue to drink plenty of fluids and avoid alcohol. You should continue to watch your weight to avoid putting more stress on the joint.

Resuming Normal Activities

Once you get home, you should stay active. The key is to not do too much, too soon. While you can expect some good days and some bad days, you should notice a gradual improvement over time. Generally, the following guidelines will apply:

Driving

In most cases, it is safe to resume driving when you are no longer taking opioid pain medication, and when your strength and reflexes have returned to a more normal state. Your doctor will help you determine when it is safe to resume driving.

Sexual Activity

Please consult your doctor about how soon you can safely resume sexual activity. Depending on your condition, you may be able to resume sexual activity within several weeks after surgery.

Sleeping Positions

You can safely sleep on your back, on either side, or on your stomach.

Return to Work

Depending on the type of activities you do on the job and the speed of your recovery, it may take from several days to several weeks before you are able to return to work. Your doctor will advise you when it is safe to resume your normal work activities.

Sports and Exercise

Continue to do the exercises prescribed by your physical therapist for at least 2 months after surgery. In some cases, your doctor may recommend riding a stationary bicycle to help maintain muscle tone and keep your knee flexible. When riding, try to achieve the maximum degree of bending and straightening possible.

As soon as your doctor gives you the go-ahead, you can return to many of the sports activities you enjoyed before your knee replacement.

  • Walk as much as you would like, but remember that walking is no substitute for the exercises prescribed by your doctor and physical therapist.
  • Swimming is an excellent low-impact activity after a total knee replacement; you can begin swimming as soon as the wound is sufficiently healed. Your doctor will let you know when you can begin.
  • In general, lower impact fitness activities such as golfing, bicycling, and light tennis will help increase the longevity of your knee and are preferable over high-impact activities such as jogging, racquetball and skiing.

Air Travel

Pressure changes and immobility may cause your operated leg to swell, especially if it is just healing. Ask your doctor before you travel on an airplane. When going through security, be aware that the sensitivity of metal detectors varies and your artificial joint may cause an alarm. Tell the screener about your artificial joint before going through the metal detector.


New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.

4 Tips For Senior Citizens Recovering From Knee Surgery

4 Tips For Senior Citizens Recovering From Knee Surgery

BY JOAN TIMPSON | Article Featured on Sunrise Care

As senior citizens age, their bodies become increasingly vulnerable to conditions that decrease mobility and cause chronic pain. One of the most commonly experienced diseases that impacts the joints and muscles of older adults is osteoarthritis, which affects approximately 8.75 million people, according to Arthritis Research UK. As a result of osteoarthritis and other forms of arthritis, many senior citizens turn to knee replacements for relief from pain and to regain mobility.

Read more

What is Knee Arthroscopy? Benefits, Preparation, and Recovery

What is Knee Arthroscopy? Benefits, Preparation, and Recovery

By Jon Johnson | Featured on Medical News Today

Knee arthroscopy is a procedure that involves a surgeon investigating and correcting problems with a small tool called an arthroscope. It is a less invasive method of surgery used to both diagnose and treat issues in the joints. The arthroscope has a camera attached, and this allows doctors to inspect the joint for damage. The procedure requires very small cuts in the skin, which gives arthroscopy some advantages over more invasive surgeries.

Knee arthroscopy surgery has risen to popularity because it usually requires shorter recovery times. The procedure typically takes less than 1 hour, and serious complications are uncommon.

In this article, learn more about what to expect from knee arthroscopy.

Uses and benefits

Knee arthroscopy is less invasive than open forms of surgery. A surgeon can diagnose issues and operate using a very small tool, an arthroscope, which they pass through an incision in the skin.

Knee arthroscopy surgery may be helpful in diagnosing a range of problems, including:

  • persistent joint pain and stiffness
  • damaged cartilage
  • floating fragments of bone or cartilage
  • a buildup of fluid, which must be drained

In most of these cases, arthroscopy is all that is needed. People may choose it instead of other surgical procedures because arthroscopy often involves:

  • less tissue damage
  • a faster healing time
  • fewer stitches
  • less pain after the procedure
  • a lower risk of infection, because smaller incisions are made

However, arthroscopy may not be for everyone. There is little evidence that people with degenerative diseases or osteoarthritis can benefit from knee arthroscopy.

How to prepare

Many doctors will recommend a tailored preparation plan, which may include gentle exercises.

It is important for a person taking any prescription or over-the-counter (OTC) medications to discuss them with the doctor. An individual may need to stop taking some medications ahead of the surgery. This may even include common OTC medications, such as ibuprofen (Advil).

A person may need to stop eating up to 12 hours before the procedure, especially if they will be general anesthesia. A doctor should provide plenty of information about what a person is allowed to eat or drink. Some doctors prescribe pain medication in advance. A person should fill this prescription before the surgery so that they will be prepared for recovery.

Procedure

The type of anesthetic used to numb pain will depend on the extent of the arthroscopy. A doctor may inject a local anesthetic to numb the affected knee only. If both knees are affected, the doctor may use a regional anesthetic to numb the person from the waist down.

In some cases, doctors will use a general anesthetic. In this case, the person will be completely asleep during the procedure. If the person is awake, they may be allowed to watch the procedure on a monitor. This is entirely optional, and some people may not be comfortable viewing this.

The procedure starts with a few small cuts in the knee. Surgeons use a pump to push saline solution into the area. This will expand the knee, making it easier for the doctors to see their work. After the knee is expanded, the surgeons insert the arthroscope. The attached camera allows the surgeons to explore the area and identify any problems. They may confirm earlier diagnoses, and they may take pictures.

If the problem can be fixed with arthroscopy, the surgeons will insert small tools through the arthroscope and use them to correct the issue. After the problem is fixed, the surgeons will remove the tools, use the pump to drain the saline from the knee, and stitch up the incisions. In many cases, the procedure takes less than 1 hour.

Questions to Ask Before You Have Anesthesia

Questions to Ask Before You Have Anesthesia

Article Featured on US News

HAVING A MAJOR SURGICAL procedure can be a scary proposition. First, there’s the fear connected to the issue itself that prompted the surgery. Then, you may also have some concerns about how the procedure will go. Part of this fear often revolves around how you’ll react to anesthesia – powerful medications that block pain.

Dr. Karen Sibert, director of communications and associate clinical professor in the department of Anesthesiology & Perioperative Medicine at UCLA Health in Los Angeles, says that “anesthesia is what enables you to tolerate surgery. Modern surgery really couldn’t develop until anesthesia developed. Before the onset of anesthesia, surgical procedures were short and done as fast as possible for humanitarian reasons.” In the mid-1800s, a gas called ether was first used to anesthetize a patient during surgery. Since then, other drugs have been developed that also work to block pain and desensitize patients to nerve signaling in the body to enable procedures that otherwise would be far too painful to conduct.

Dr. Mary Dale Peterson, president-elect of the American Society of Anesthesiologists and executive vice president and chief operating officer of Driscoll Health System in Corpus Christi, Texas, says the word “anesthesia” comes from the Greek word meaning “without sensation. Anesthesia is either a loss of feeling or awareness,” such as you’d want to have if a surgeon were about to cut into your body to conduct a needed medical procedure.

Here are questions to ask if you’re about to have anesthesia:

  1. What type of anesthesia will be used?
  2. What are the risks of anesthesia?
  3. How can I best prepare for this procedure?
  4. What should I expect after the procedure?

1. What Type of Anesthesia Will Be Used?

Anesthesia can be divided into three major types:

  • Local. This type of anesthetic numbs a specific area of the body, such as what you’d receive when having a cavity filled by a dentist. Peterson says it leaves the patient wide awake and aware of what’s going on, or only mildly sedated.
  • Regional. These anesthetics block pain in an area of the body, such as an arm or leg. Epidurals – injections of pain-blocking medication directly into the spinal column that block pain from the waist down – are commonly used to alleviate labor pains without putting the mother completely to sleep. That way, she can participate in the birth of her child without feeling the pain that typically comes with that experience. Regional anesthetics may also be used for a variety of orthopedic surgeries on the lower extremities, such as reconstructing ligaments in the knee and sometimes in brain surgery, where the patient needs to be awake to respond to cues from the surgeon to help guide where incisions should be made.
  • General. General anesthesia is what most people probably think of when they hear the word “anesthesia.” These drugs make you unconscious and are usually delivered as a gas through a face mask. The National Institutes of Health reports that when given this type of anesthetic, “you do not feel any pain, and you do not remember the procedure afterwards.” It’s commonly used for larger or more complex procedures such as organ transplants or lung or heart surgery.

The type of anesthetic used will depend on the location of the surgery and the type of procedure.

2. What Are the Risks of Anesthesia?

Being sedated or made unconscious is not a risk-free enterprise, and anesthesiologists are highly-trained specialist physicians who know how to react in the dynamic environment of the operating room to keep you safe. “Every patient is a little bit different in how they react to or metabolize drugs,” Peterson says, a situation that can also be influenced by other medications the patient may be taking and disease states or other health issues. “All of these can change how those (anesthetic) drugs work on the body.”

With general anesthesia, “there’s a loss of consciousness and there’s a loss of ability for the patient to maintain their airway or breathe on their own,” which can be a challenge depending on the patient and the particular situation. “For a lot of major operations, a breathing tube will be fit in, and we’ll put the patient on a breathing machine to assist with that.” In addition, some anesthetic medications depress the heart or blood pressure, which means the anesthesiologist will have to counteract those effects with other medications to support the patient.

“In addition, you’ve got the insult of surgery and blood loss” that the anesthesiologist works to counteract with blood transfusions and other techniques and medications to stabilize the patent and allow the surgery to continue, Peterson says, adding that one reason why she loves the field is because “you’re bridging two different worlds. You’re bridging the surgical world and the internal medicine world. You’ve got to know about all those diseases and how they impact the patient, but you also have to know about the surgery, even though you’re not the person performing it.”

During a procedure, Sibert says the anesthesiologist is tasked with taking “care of the heart, the lungs, the brain, the circulation, the kidney function, you name it. We’re the internal medicine physician or pediatric physician for everything else that’s going on with that patient during the procedure.” Being able to do this all safely “requires a great deal of general medical knowledge in addition to what drugs to use to sedate or anesthetize someone and wake them up in the end. We’re also responsible for intraoperative fluid management, transfusions, ventilator management – all kinds of things that people never really think about,” Sibert says.

To make all this happen, the anesthesiologist has sophisticated equipment that monitors the patient’s status. “It’s sort of like a cockpit. We have a ventilator and infusion pumps and machines that deliver the anesthesia gasses. All the vital sign monitors are right there,” Sibert says.

Peterson also uses a flight analogy when describing what anesthesiologists do. “There’s a lot that anesthesiologists and pilots have in common. We have our take-offs – that’s what we call induction or getting the patient to sleep. That’s a very critical time. And we have landings, or waking them up, which is another really critical time. In between, it depends on the surgery and how everything is going.” Some surgeries are turbulence-free while others make for a bumpier ride where the anesthesiologist has to make a lot of adjustments on the fly. “It’s kind of like an airplane pilot – sometimes they’re on auto-pilot and other times they have to have all that experience and training to get the plane through.”

While having anesthesia may confer some risks to the patient, Peterson says anesthesiologists have “led medicine in that we have made anesthesia much safer and we’re operating on much sicker and younger patients” now than they once were able to because of how precisely they can regulate most people’s response to anesthesia. She says pediatric anesthesiologists can now safely anesthetize infants weighing less than a pound. At the other end of the spectrum, more elderly adults aged 90 and older are able to safely undergo surgery because of advances in anesthesiology the past few decades.

3. How Can I Best Prepare for This Procedure?

“Patients do need to take some ownership of their own health,” Sibert says, and “if they are in rough shape to begin with, they’re going to have a tough time getting through surgery.” This means that you may need to take some time prior to a surgical procedure to improve your health. Optimizing blood pressure, addressing anemia (low iron levels), reducing obesity or getting your diabetes under control before a procedure may result in a safer experience. “There isn’t always time to do that, but those things really help. The better shape patients are when they go into surgery, the better shape they’ll be in coming out of surgery.” Eating right, exercising and getting good sleep prior to surgery are also important to improving your outcome.

If you’re a smoker, you should try to lay off the habit for a period of time prior to surgery. “We know that patients do better not only from the anesthesia, but also healing from surgery, if they stop smoking. Even if it’s just for a few days before surgery, it can still make a difference in their recovery and risk,” Peterson says. No doubt, this is a tall order, but smoking cessation efforts prior to surgery have been shown to help.

Generally speaking, you shouldn’t have any food in your stomach when you head into a procedure that involves anesthesia, as that can make you sick. Your doctor will also outline any other specific requirements you need to follow prior to surgery. Follow these directions to the letter; there are many medications that can negatively interact with anesthetic medications or alter the effects of these powerful drugs. Because of this, Peterson says “all patients should be very open and honest with the anesthesiologist and give them a good health history, including things that are sensitive topics,” such as illicit drug use and pregnancy. “Even herbal supplements can affect how some of the drugs work,” Peterson says. Anesthesiologists aren’t there to judge you or your lifestyle choices, they just want to keep you safe.

In addition, “patients need to be really honest with us about what they’ve had done in the past,” Sibert says, including things like plastic surgeries that might not seem related to the current procedure. “Sometimes people who’ve had plastic surgery, their eyes don’t close completely and that puts them at risk for eye damage.” Alternatively, patients who’ve had chin implants pose a specific challenge. “It’s difficult to put breathing tubes into patients with very receding chins,” and a cosmetic augmentation of the chin might hide that aspect of a patient’s physiology. Therefore, “we really need to know anything you’ve ever had in terms of surgery, what health problems you’ve had, what medications you’re taking. And just because you have a health problem that seems to be under control doesn’t mean we don’t need to know about it.” The bottom line is, don’t lie to your surgeon or anesthesiologist about anything you may be taking and other procedures you’ve had. That information is critical to ensuring a safe outcome of the procedure you’re about to have.

Prior to your procedure, you should also ask lots of questions and make sure you understand what’s going to happen and what to expect. “If you don’t understand, you need to ask questions,” Peterson says. She says it’s always helpful to bring a friend or family member to support you, as “you might not be thinking clearly right after anesthesia, and if you’re having day surgery, you need someone to drive you home,” as the drugs can have a lingering sedative effect that makes driving a car dangerous.

In addition, “I also think that patients deserve to know who’s going to be taking care of them in the operating room,” so for that reason, she recommends asking for a meeting with the anesthesiologist. “I think it’s a perfectly legitimate thing to ask, ‘are you a physician anesthesiologist? Is there anyone else on the team who’s going to be taking care of me in the operating room?’ Sometimes a care team approach is used, and I think everybody should be open and honest” about who will be playing which roles while you’re unconscious. Most hospitals have some protocol for the anesthesiologist to review the patient’s history and meet with them ahead of time and to make themselves available to answer any questions, and that’s your time to ask whatever questions you may have. “Even though we may not meet you for a very long time, it’s an important relationship to establish,” Peterson says.

4. What Should I Expect After the Procedure?

Anesthesia is great in that it prevents you from feeling any pain while the procedure is ongoing, but once that medical support ends, pain can become an issue for many people. “It’s very important for us these days to make sure that expectations about pain relief afterward are realistic,” Sibert says, noting that post-operative pain management has been implicated as a contributing factor to the current opioid epidemic. Talk to your doctor prior to the procedure about how post-operative pain will be managed, and if a narcotic is recommended, consider whether that’s something you’re comfortable with. If not, find out what alternatives to opioids are available. Sibert says there are lots of ways to control pain with a variety of non-narcotic pain killers, “but we do need patients to meet us halfway and not have unrealistic expectations of having zero pain after major surgery. Unfortunately, it just isn’t like that.”

Similarly, taking an active role in your own recovery is important, as following your doctor’s orders on physical therapy and any other rehabilitative methods you’re prescribed will often take some work on your part.

11 Things Your Orthopedic Specialist Wants You to Know

Original Article By healthgrades.com

Insights from the Bone and Joint Experts

Whether you have ongoing backaches or sustain Read more

After Years of Paralysis, A Man Walks the Length of a Football Field

Original Article By Emily Willingham | Scientific Journal

An electrical stimulation device combined with intensive rehabilitation restores walking ability to a spinal cord injury patient

Read more

What is joint replacement surgery?

Original Article: National Institute of Arthritis and Musculoskeletal and Skin Diseases


What is joint replacement surgery?

Joint replacement surgery removes damaged or diseased parts of a joint and replaces them with new, man-made parts.

Replacing a joint can reduce pain and help you move and feel better. Hips and knees are replaced most often. Other joints that can be replaced include the shoulders, fingers, ankles, and elbows.

Points To Remember About Joint Replacement Surgery

  • Joint replacement surgery removes damaged or diseased parts of a joint and replaces them with new, man-made parts.
  • The goals of joint replacement surgery are to relieve pain, help the joint work better, and improve walking and other movements.
  • Risks of problems after joint replacement surgery are much lower than they used to be.
  • An exercise program can reduce joint pain and stiffness.
  • Wearing away of the joint surface may become a problem after 15 to 20 years.

Why may joint replacement surgery be needed?

Joints may need to be replaced when they are damaged from:

  • Arthritis
  • Years of use
  • Disease

Your doctor will likely first suggest other treatments to reduce pain and help you move better, such as:

  • Walking aids, such as a cane or walker
  • An exercise program
  • Physical therapy
  • Medications

Sometimes the pain remains and makes daily activities hard to do. In this case, your doctor may order an x-ray to look at the joint. If the x-ray shows damage and your joint hurts, you may need a joint replacement.


What happens during joint replacement surgery?

During joint replacement your doctors will:

An illustration showing a hip prosthesis that is used in hip replacement surgery.
Hip Replacement Location
  • Give you medicine so you won’t feel pain. The medicine may block the pain only in one part of the body, or it may put your whole body to sleep.
  • Replace the damaged joint with a new man-made joint.
  • Move you to a recovery room until you are fully awake or the numbness goes away.


What can I expect after joint replacement surgery?

With knee or hip surgery, you will probably need to stay in the hospital for a few days. If you are elderly or have additional disabilities, you may then need to spend several weeks in an intermediate-care facility before going home. You and your team of doctors will determine how long you stay in the hospital.

After hip or knee replacement, you will often stand or begin walking the day of surgery. At first, you will walk with a walker or crutches. You may have some temporary pain in the new joint because your muscles are weak from not being used. Also, your body is healing. The pain can be helped with medicines and should end in a few weeks or months.

Physical therapy can begin the day after surgery to help strengthen the muscles around the new joint and help you regain motion in the joint. If you have your shoulder joint replaced, you can usually begin exercising the same day of your surgery! A physical therapist will help you with gentle, range-of-motion exercises. Before you leave the hospital, your therapist will show you how to use a pulley device to help bend and extend your arm.


What are the complications of joint replacement surgery?

Complications after joint replacement surgery are much lower than they used to be. When problems do occur, most are treatable. Problems could include:

  • Infection.
  • Blood clots.
  • Loosening of the joint.
  • Ball of the new joint comes out of its socket.
  • Wear on joint replacements.
  • Nerve and blood vessel injury.

New Mexico Orthopaedics is a multi-disciplinary orthopaedic clinic located in Albuquerque New Mexico. We have multiple physical therapy clinics located throughout the Albuquerque metro area.

New Mexico Orthopaedics offers a full spectrum of services related to orthopaedic care and our expertise ranges from acute conditions such as sports injuries and fractures to prolonged, chronic care diagnoses, including total joint replacement and spinal disorders.

Because our team of highly-trained physicians specialize in various aspects of the musculoskeletal system, our practice has the capacity to treat any orthopaedic condition, and offer related support services, such as physical therapy, WorkLink and much more.

If you need orthopedic care in Albuquerque New Mexico contact New Mexico Orthopaedics at 505-724-4300.