KNEE & HIP SURGERY MANCHESTER, CHESHIRE

Lot of medical information is available on internet but theres no regulation about its validity. Some of the treatment options seen on internet may not be properly tested or trialled and could be seen bieng recommended and performed by individuals who may not be appropriately trained or experienced enough.

Knee conditions are best treated by knee specialists who have gained specialist training and experience in knee surgery like myself. Non surgical/surgical treatment options when presented, require a well considered,informed and weighted process of decision making in light of the pros/ cons and risk of complications against benefits to be expected, and that is where specially trained and experienced surgeons like myself can help in providing clarity to patients.

The information and advice given here is based on my own views based on my specialist training in orthopaedics including fellowship training in knee surgery from a prestigious and renowned centre , also encompassing the extensive experience I have gathered in general and specialist orthopaeics over a long period of time.
Management options and treatments need to be individualised based on various factors and that’s were the blend of experience and specialist training takes even more importance.

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INJECTION THERAPY

Patients may be suitable for injection in/around the knee to control their symptoms. The common injections used are steroids or viscosupplemenation which is a special type of a high quality lubricant. The severity and extent of wear and tear (arthritis) along with patient factors help in deciding the type of injection. This can be done as an out patient procedure for the knee but require Xrays for the hip joint and is done in the operation theatre.
In some conditions around the knee, a special injection like PRP or stem cells (special type of blood cells isolated from patients own blood) can be can be injected. This procedure is done in theatre, with either local and in some cases under general anaesthetic.

Knee Arthroscopy is done via two or three small stab incisions through which a camera and instruments are introduced in the knee.
The procedure is done as day surgery where patients go home walking same day. It usually requires a short general anaesthetic. Patients are asked to take it easy for the first two weeks allowing knee to settle from the operation. Quite a lot of procedures can be performed via key hole surgery (like meniscal surgery, smoothening of worn out surface in the knee lining, taking out floating loose bodies from the knee, micro fracture as explained below, meniscal debridement &repair,ligament shrinkage , release of tight areas around the knee cap to allow it to sit better on thigh bone, first part of cartilage regeneration procedures ,along with the assessment of the knee joint).
Key hole surgery can also be done with a knee replacement inside, in some cases for assessment, and also to take away any impingement that’s suspected to be the cause of a painful knee replacement.

MENISCAL SURGERY

Menisci are the spacer ‘shock absorber’ , ‘C’ shaped cartilages within the knee joint -one on the inner and one on outer side of the knee.These are there to absorb and share the load, and also to protect the lining of the joint. They can get damaged and torn which can either be trimmed or repaired depending on the type of the tear in light of patient factors.
In selected cases , patients with high level athletic activities could be consideredfor meniscal transplants.

CARTILAGE REGENERATION PRECEDURES

Articular cartilage (lining of a joint) doesn’t heal, regenerate or repair itself.
In young patients with damage to the lining , arthroplasty (knee replacement of different types) generally is not preferred choice due to their young age. There are however other procedures that can be considered, that carry potential to regenerate cartilage in localised areas of damage.
The procedures include microfracture – where micro holes in underlying bone are made in area of localised cartilage damageof knee. This allows bone marrow to seep out and cover the defect with a ‘super clot’ which will carry in it cells that may regenerate cartilage cells to plug the defect.
Other specialised techniques are where cartilage and bone cylinders taken from selected non weight bearing donor areas in knee joint are taken to cover the defect (osteochondral grafting), or cartilage cells grown in lab originally taken from the patient are placed on such defects,which can be deliveredon to the defect and then covered by different means, or are delivered set on a collagen membrane which can be placed and secured on the defect (ACI/MACI)as shown in picture below.

CUSTOMISED MINI KNEE REPLACEMENTS/RESURFACING

Patientswith only localised areas of symptomatic arthritis (wear and tear) who are unsuitable for other modalities of treatment of cartilage regeneration or where other such measures have failed ,and who have most of their knee unaffected may be suitable for this. The knee gets a MRI scan using special software whichis thenmapped in a 3D format.These images are then sent to a special facility abroad to have the customised implant made for that patient that would be specific to the patients knee contours and shape for that area of the localisedarthritis. By fitting this implant, the patient keeps most of his/her native knee with its inherent advantages.
I am one of the first few surgeons in the north west to have started performing this surgery .

REALIGNMENT PROCEDURES

Patient who develop arthritismainlyaffecting one compartment of the knee (inner or outer) may be considered for a realignment procedure to offload the area affected. Special type of Xrays/investigations are performed to note their existing alignment and axes (anatomical and mechanical), and then assessed to see if their lower extremity can be surgically realigned to change these axes to improve on their symptoms by offloading the weight bearing on worn out areas in their knee.. These corrections are generally done on the upper end of shin bone or the lower end of the thigh bone.The corrected bone is held with implants like plates and screws till the surgically created bone cut heals. The realignment is intended to control symptoms , and also to buy time before a knee replacement becomes inevitable. This procedure may be more useful especially in relatively younger patients who are not ready for a best knee replacement.

Sometimes realignment procedures may be necessary before best knee ligament surgery to prevent failure of soft tissue and ligament surgery.

Pre realignment XRAY

Post realignment XRAY showing offloading of the worn out areas in the knee

DIFFERENT TYPES OF KNEE REPLACEMENTS FOR ARTHRITIS

When conservative measures have been exhausted and the patient has reached a stage where a definitive option is to be considered – knee arthroplasty (replacement) can be considered. These are of different types depending on the areas affected which can be confirmed with the use of patient assessment,investigations like Xrays, MRI, and often key hole surgery may be necessary (arthroscopy).
Knee replacements could be partial (just the inner side – Medial unicompartmental knee replacement, outer side of knee – Lateralunicompartmental knee replacement or Knee cap area – Patello femoral knee replacement).
The area affected, symptoms and various patient related factors decide the type of knee replacement patient would be most suitable for.
The arthritic surface is excised from the end of the bones in a measured way and replaced with metal components which are cemented to the freshened surfaces of bone . A high quality plastic spacer is then clipped on to the top of shin bone component which forms the bearing surface with the end of the thigh bone metal component.
Partial knee replacements allow the rest of the unaffected native knee to be preserved with its advantages. The unaffected areas however may catch up with arthritis in coming years and there may be need of another surgery to convert this partial knee replacement to a total (Full) knee replacement.
I am alsotrained in performing ‘patient specific’ knee replacements – where part of equipment used in surgery is spesifically designed for that particular patient . This is based on specialised scans like CT or MRI. This technique has distinct advantages in situations where conventional techniques cannot be used , for example in patients with previous fractures and deformities.

DIFFERENT TYPES OF KNEE REPLACEMENT (ARTHROPLASTY)

PATIENT SPECIFIC INSTRUMENTATION AND KNEE REPLACEMENT

I follow principles of enhanced and functional recovery after joint replacement surgery and aim for patients to be discharged home Day 1-3 post surgery.

KNEE CAP INSTABILITY AND PAIN

Patients with symptoms of knee capinstability may be considered for surgery that stabilises the knee cap (patella). This can be either done by using a check rein to prevent abnormal movement of the knee cap that renders it to slip generally and more commonly outwards. This check rein can either be made using patients own tendons like hamstrings, or synthetic grafts which are hamstring sparing and also intended to enhance recovery and reduce post op pain and morbidity. Other operation to stabilise the knee cap may require moving the tibial tuberosity (the prominence of bone felt in front of the shin bone at the top end) into a better position which helps controlling the destabilising forces on the knee cap. Sometimes acombination of these procedures may be required. These conditions require a thorough assessment by a knee specialist withhelp from investigations like MRI, CT scans and often a camera operation to plan the best form of management.

The shin bone tuberosity may also be realigned in selected patients in a way that it takes the knee cap away from the thigh bone thus reducing pressure on the knee cap that could be causing pain .

MPLF (Check Rein) Reconstrction

Tibal Tuberosity Transfer

LIGAMENT RECONSTRUCTIONS

The knee is a complex joint and its stability depends on various factors like ligaments along with other contributors like muscles , bone and menisci etc. Different ligaments play different roles and they could be located either outside (MCL/LCL)or inside the knee joint (ACL/PCL). Acute injuries may render them suitable for repair but generally older injuries may need a new ligament to be reconstructed either using other donor tendons from the body like hamstring, part of patellar tendon or with the use of synthetic grafts.
Tendon reconstructions and soft tissue knee surgery require a structured and disciplined rehabilitation protocol delivered via specialist and experienced physios with whom I liaise personally. This allows for the new ligament and the knee joint to be retrained appropriately.
The use of bracing and orthotics may be needed in isolation or as an adjunct for patients with soft tissue knee injuries.
I perform Ligament surgery including ACL reconstruction using modern methods and advanced techniques aiming for high functional recovery.
I have co published a technique towards a modern method of ACL reconstruction.

X RAY AFTER ACL RECONSTRUCTION

HIP REPLACEMENT

I also perform Hip replacements.I am trained with the use of different types of hip replacement like cemented,uncemented or a combination (Hybrid). Based on patient factors and anatomy I use different options as the bearing surface in these artificial hips. These can be metal or ceramic heads (ball part of the hip replacement) and the acetabular (socketside) bearing surface can be either high quality hard wearing plastic or ceramic.

XRAY OF A LEFT SIDE TOTAL HIP REPLACEMENT

ENHANCED RECOVERY AFTER HIP AND KNEE REPLACEMENTS

I follow a specifically designed protocol for enhanced and functional recovery after joint replacement surgery. This process starts before surgery with appropriate patient education, fasting and hydration advise etc. Myself and my anaesthetist follow specialmeasures during and after surgery to allow for an enhanced , early recovery with quicker and functional rehabilitation that’s intended after a successful joint replacement.The aim is for patient to be discharge Day 1-3 post standard joint replacement.
I make every effort to apply principles of enhanced and functional recovery in management of all my patients.

REVISION SURGERY

Sometimes surgeries fail and that could be due to various factors.
Artificial joints are not designed to last for ever and they will eventually fail when patients outlive them. In failed surgeries – revision maybe required and should be performed by surgeons who are trained for this. These are major and complex surgeries and need specialists like me to do them. Each case needs to be considered and planned on its own merit and requires a thorough assessment, investigations, bespoke planning and execution.

Due to many people requiring knee replacements in present times, there has also been an increase seen in fractures around knee replacements from injuries. These are again major injuries and require complex surgery done by surgeons with specialist experience using special equipment to manage them. I perform such type of surgeries routinely in my practice and have experience with different type of solutions to these complex problems including stabilization, revising the knee replacement with the fracture using specialist implants, upto the replacement if needed of a part of the lower end of thigh bone or upper part of shin bone.

TRAUMA SURGERY

I perform trauma surgery routinely. Apart from general Orthopaedic trauma I have special interest in managing lower limb and knee trauma. I have extensive experience of managing trauma including working for many years at a busy major trauma centre in the country.
I have a special set up in place to deal with acute knee trauma where specialist investigations like Xrays ,Ultrasound, MRI scans etc can be organised very quickly and intervention planned on priority.
In injuries were surgery may or may not be indicated – either way I have excellent people in my team at different hospitals where Physiotherapists, occupational therapists and Orthotics can be organised quickly.

I have tried to briefly explain common knee problems with management options in simple terms for ease of understanding by lay people.