Total Knee Replacement (TKR) – The Questions You Need To Ask Your Surgeon!

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One total knee replacement is not equal to the other. This surgery is complex and specialised and it is important to understand who and what is being done to you.

It surprises me how little some patients ask regarding something so important as surgery on your body. Many would scrutinise the details of their new car being ordered or who was doing building work on their home.

Here is an important checklist you NEED to ask any time you are thinking or are offered surgery:

  • Who is doing the surgery. 
    • Studies have shown the more a surgeon does of one procedure the better their outcomes. Also the more specialised they are the more of their practice is focused on that particular procedure. Working in a University hospital or tertiary referral centre where the regions most difficult cases get directed means those surgeons know how and have the resources to deal with any complication or problem that may occur. There is now a national focus on GIRFT – Getting It Right First Time. Surgery done well by the most appropriate person possible in the most appropriate place. With surgery moving at such a fast pace, it is difficult to be a ‘jack of all trades’. Choose your surgeon carefully. Make sure they are keeping up to date with new advances and that their surgical choices for you are evidence based.
  • What implant are they using and why?
    • Not all implants are the same. In the UK a national joint registry (http://www.njrcentre.org.uk/njrcentre/default.aspx) is kept of all the joint replacements and partial resurfacings implanted and how they are functioning and if they have been revised. The 2 top implanted total knee replacements are the Depuy J&J PFC and the Zimmer Nexgen TKR. These are well tried and tested implants with many years of follow up. Newer implants are available but their data is limited. Using newer implants without long term data always has some risk attached and should be made clear to patients prior to surgery. Make sure you ask?
  • Where is the Surgery going to take place?
    • Where the surgery takes place is vitally important. Every hospital has different resources and backup. If anything were to become more complicated does the hospital or surgeon have a plan B? Do they carry out complex revision surgery and have those implants available on the shelf just in case. Small units will often only have the basic first time knee replacements on hand, leaving the surgeon stranded if there was to be a problem. Also if there was a medical problem do they have the ability to treat you in a higher care setting such as ITU. Some small private hospitals and district generals do not have these resources on hand and would have to transfer your care to a central teaching hospital often many miles away. We always hope and anticipate things will go smoothly but planning for the problems makes things safer in the long term. Just make sure you find out what their plan B is in the event of problems?

If you need more info or advice don’t hesitate to contact us:

info@wessex-knee.com

 

Revision Knee Replacement

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If you have had a total knee replacement you will understand that they don’t last forever. Just like any bearing there will be some wear and tear between the surfaces. Technology has moved on and the types of material we use today for knee replacements both partial resurfacing and total knee replacements have improved. In total knee replacements and partial resurfacings  the most commonly used surfaces are highly engineered and polished cobalt chrome moving on high molecular weight polyethylene. There are some variation to those surfaces and in-particular if you have a nickel allergy or sensitivity we can use titanium instead of cobalt chrome with a special surface coating to aid the frictionless movement of the joint, or more recently we have used one of the worlds first all ceramic knee replacements from LIMA orthopaedics. This implant has no metal at all in its construction. The femur (thigh) component is made of zirconia one of the hardest materials in existence moving on highly cross-linked polyethylene.

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We anticipate from our joint registries that a total or partial knee resurfacing should last up to 20 years. If however you do require further surgery to change a well functioning knee replacement that has started to fail or have had some other problems with your knee replacement or resurfacing, then revision surgery may be required. This is highly complex and specialised surgery. The surgery requires very careful investigation and understanding as to what the problem is and why the implant has failed and how a revision or redo surgery can address those issues and provide you with an improvement in your symptoms. This will often require an MRI or CT scan, removing some fluid from the knee and testing for possible infection as a cause of the failure, nuclear medicine bone scan tests to identify if the previous implant is loose or well fixed.

Once a reason has been identified then moving on to surgery to address those problems can take place.

This surgery varies greatly from person to person and is very much a custom operation. The old implant must be removed , and in order to give you a functioning new joint, a much more complex implant is used to provide stability and longevity for the future.

The surgery will often take up to 2-3 hours to complete and the recovery and time in hospital is often a little longer than a first time knee replacement.

What has been identified in studies as one of the most important factors in a successful revision surgery is that it is done by someone who carries out this surgery regularly and has the resources available to them in a specialised centre to safely carryout this surgery. This is a regular surgery carried out by Mr Frame in University Hospital Southampton in Hampshire, which is a tertiary  referral centre for complex revision surgery.

Call us to find out more about revision surgery or if you have a painful or problematic partial or total knee replacement.

 

PRP Knee Injection (Platelet Rich Plasma)

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PRP or Platelet Rich Plasma injections involve taking your own blood or bone marrow and separating out all the different constituents. The aim is to produce a concentrated solution containing important building blocks to help accelerate healing and repair. It also contain stem cells, which are special cells that can transform in to almost any tissue type. There are some studies showing promising and exciting results. Treatment of tendinopathies has shown improvement in pain with injections of PRP. It is also useful in helping meniscal Repair and ACL Internal Brace Repair, bringing all the building block for healing in a concentrated form.

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PRP injections have also been studied for use in Osteoarthritis with some promising early results. We can talk you through whether your problem could be helped with PRP Injections.

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Keep an eye on our site for any new developments and for more info on PRP knee injections available in Southampton, Hampshire.

Total knee Replacement TKR

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Let’s go in to detail of what having a total Knee replacement means, and how the process of actually coming to hospital and having your surgery will work.

A partial replacement or resurfacing means we only deal with one specific worn out area of your Knee, a total knee replacement is a surgery that deals with all the surfaces in the Knee joint and is required when the arthritis is more advanced and cannot be dealt with using a partial knee resurfacing. A total knee replacement also replaces the anterior and posterior cruciate ligaments within the joint. We use only the safest and highly regarded joint replacements in the world. They are one of the best performing implants on the UK national Joint Registry.

When you arrive in to hospital you will be taken up to your room and checked in by one of the nursing staff. Mr Frame and the anaesthetic team will confirm what you are having done and answer any questions you might have. Then a mark will be drawn on to the Knee to be operated on to confirm and to be as safe as possible.

You will then be taken down to the theatre suite and further safety checks again will be made and you then go in to the anaesthetic room.

Once you are under anaesthetic be that a spinal or general we then apply a tourniquet to allow surgery to be blood free, and position the leg to help us carry out the surgery.

An incision is made and the old worn out joint surface is removed and shaped to allow us to inlay the new total knee replacement to match your original joint. This new titanium and cobalt chrome joint is cemented in place with PMMA (a special polymer glue). A gliding surface is the clipped in to the titanium part to allow almost frictionless movement. The joint is them washed with pulsed water jets and the knee closed with sutures. Mr Frame then closes the skin with absorbable sutures, glues the skin and places a special watertight transparent dressing. This keeps the wound sterile until healed.

You are then moved to recover to waken up under close one on one care. We then move you back up to your room. Keeping your pain controlled is very important and something we work hard to do.

You can begin moving, bending and walking as soon as a few hours after surgery.

An X-ray is taken the next day to confirm the position of the new total knee replacement implants. Once you are safe and pain controlled we get you up and home. To reduce your risk of deep vein thrombosis you have compression socks for 6 weeks and an oral anticoagulant for 2 weeks.

Physio will see you before you leave and as much as required on discharge.

At 2 weeks the wound is reviewed.

At 6 weeks we see you in clinic and most have a nicely healed wound, normal bend and are walking comfortably without aids.

Partial Knee Resurfacing

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Let’s go in to detail of what having a partial Knee resurfacing means, and how the process of actually coming to hospital and having your surgery will work.

A partial replacement or resurfacing means we only deal with one specific worn out area of your Knee. This can be the medial surfaces between the femur (thigh) and tibia (shin) or the lateral side. We can also just resurface the area of the joint between your patella (kneecap) and the femoral trochlea (femoral groove). Your ligaments all remain intact and the feedback from them make a resurfacing feel much more natural and much like your original Knee.

When you arrive in to hospital you will be taken up to your room and checked in by one of the nursing staff. Mr Frame and the anaesthetic team will confirm what you are having done and answer any questions you might have. Then a mark will be drawn on to the Knee to be operated on to confirm and to be as safe as possible.

You will then be taken down to the theatre suite and further safety checks again will be made and you then go in to the anaesthetic room.

Once you are under anaesthetic be that a spinal or general we then apply a tourniquet to allow surgery to be blood free, and position the leg to help us carry out the surgery.

An incision is made and the old worn out joint surface is removed and shaped to allow us to inlay the new partial resurfacing to match your original joint. This new titanium and cobalt chrome partial resurfacing joint is cemented in place with PMMA (a special polymer glue). A gliding surface is the clipped in to the titanium part to allow almost frictionless movement. The joint is them washed with pulsed water jets and the knee closed with sutures. Mr Frame then closes the skin with absorbable sutures, glues the skin and places a special watertight transparent dressing. This keeps the wound sterile until healed.

You are then moved to recover to waken up under close one on one care. We then move you back up to your room. Keeping your pain controlled is very important and something we work hard to do.

You can begin moving, bending and walking as soon as a few hours after surgery.

An X-ray is taken the next day to confirm the position of the new implants. Once you are safe and pain controlled we get you up and home. To reduce your risk of deep vein thrombosis you have compression socks for 6 weeks and an oral anticoagulant for 2 weeks.

Physio will see you before you leave and as much as required on discharge.

At 2 weeks the wound is reviewed.

At 6 weeks we see you in clinic and most have a nicely healed wound, normal bend and are walking comfortably without aids.

Making it easy for you to get the help you need – ACL, Patellar Instability, Partial Knee Resurfacing, Total Knee Replacement – Where & When can we see you?

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Finding time for yourself is not something we all do well. Looking after your health is important. Taking that first step to seeing someone about your knee pain is hard and we are trying to make it easier for you. We are based in Southampton, in Hampshire, only an hour and half from London. Mr Frame is a pure knee consultant who also does trauma surgery from his NHS practice in University Hospital Southampton. University Hospital Southampton is one of the largest Major Trauma Centres (MTCs) in England and is a tertiary referral centre for many complex conditions. We have many ways for you to make that first move to talk to us about your problem.

Most of the time surgery is not required and there are many options regarding physio and exercise that can get you back on track quickly.

We have clinics in the Spire Hospital Southampton in Chalybeate Close regularly every Monday afternoon and evening, but can be flexible and make arrangements for when bests suits you. The Spire Hospital in Southampton is a modern and efficient hospital with the latest technology and equipment to make your recovery and surgery as safe possible.  We also carry out clinics in the Nuffield Hospital Chandlers Ford. These are regularly on a Tuesday evening, but again we can work around your needs. For those based further west and in to the New Forrest, we are organising clinics to take place in Lymington to save you the need to travel in to Southampton.

We are always innovating and have established an even easier means to get in touch and get started with us. We now offer video consultations. This can take place over Apple Facetime, Google Hangouts or Skype. All are encrypted and secure for your safety.  This gives you the opportunity to get that help you need from the comfort of your own home or office. These video consultations are only £45.

Contact us to find out more and to book an appointment

Email: info@wessex-knee.com

Call: +44 (0)23 8076 4391

Having an ACL reconstruction or Internal Brace ACL Repair – What Will Actually Happen?

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So you may know what a ACL or anterior cruciate ligament is, and you may even have a rough idea of what the operation entails, but what will actually happen to you from coming in to the hospital in the morning to being discharged. It is a scary situation. Most people have never had an operation or been an inpatient before. So lets get started.

When you get added to the list for your surgery, we will contact you to arrange a date that is suitable for yourself. On that day you will need to be fasted which means nothing to pass your lips that is not water from midnight the night before (min 6 hours) Water is ok up to 2 hours before surgery, but its best to wait until the anaesthetist has seen you on the morning of surgery to let you know when you can drink water until.

You will be in the day surgery unit in an individual room to allow you to relax before surgery. The anaesthetic consultant will come in and have a chat regarding your health and any previous medical problems, or allergies that might change what we do for you.

The nursing staff will then ask you to get ready for theatre by giving you a hospital gown.

Mr Frame will then see you and have a chat to make sure you are happy with what is happening and that any questions regarding the surgery or after care is answered. He will then go through the consent process for theatre. This has already been covered in the clinic on booking you for your surgery, but we go through things again to refresh your memory and to address any concerns you have. The forms are then signed and an arrow is placed on the leg the surgery is taking place.

You will then when theatres are ready, walk you down to the theatre suite and in to the anaesthetic room, where you will be introduced to the rest of the team carrying out your surgery and the process for anaesthetic will take place. Normally with an ACL a general anaesthetic will be used. This is often supplemented to make you more comfortable post op with a nerve block. This is a small injection of some local anaesthetic around one of the small nerves in the leg just above the knee that numbs the knee itself for about 6-10 hours. This is often done with ultrasound guidance to help make sure it is as effective for you as possible.

Once you are comfortable and asleep, you are taken through in to the main operating room, where we place a tourniquet above to knee to make the surgery bloodless.

The surgery takes approx 40 minutes to an hour for an ACL reconstruction or an ACL repair.

If you are having an ACL reconstruction or and ACL repair, we examine your knee with you asleep and confirm the instability. We then do a further check to make sure you are you and we are doing the correct operation on the correct side and check all the equipment and the MRI scan are on large screens in theatre to help with the surgery.

Your leg is then placed in the correct position for surgery flexed at approx 90 degrees and held in position with supports.

The anaesthetic team then give you antibiotics to reduce your risk of infection.

We then clean and prepare the skin to make sure it is sterile. We use ChoraPreps which use chlorhexidine to sterilise. We then drape the area to maintain the sterile field.

 

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With an ACL reconstruction we first make a small incision to the top and inside part of the leg to take one of the hamstring tendons – semi-tendinosis. As we do the innovative Arthrex all inside technique we do not need to use the other hamstring tendons like the traditional ACL reconstruction techniques, reducing your pain and leaving your hamstrings stronger. This small tendon approx 250mm long is then fashioned in to the new ACL graft by folding it twice and quadrupling the stands. This ultimately ends up approximately 65mm long and 8.5mm in diameter, perfect for reconstructing your ACL. Tis is then placed in a small plastic tube that matches the size of the graft to compress it and make it perfectly uniform in size. These are called Arthrex Graft Tubes.

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Using small cuts at the front of the knee joint of only 4mm we can place a camera in to the knee joint and look at the articular surface of the knee and the meniscus and the damaged ACL. If we are doing an ACL repair using the Arthrex Internal Brace, we do not need to take any of your hamstrings. We would identify if the ACL is in good condition and has pulled off from the femoral side of the joint. If so and we can repair it we use a special instrument to pass two sutures through the ACL and then drill a small 4.5mm tunnel where the ACL was originally attached. these sutures are then passed through this bony tunnel. We then Drill another 4.5mm bony tunnel in the shin bone (tibial) side where the ACL originates from.

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Though this we can pass the internal brace and then pass it again through the femoral tunnel with the sutures holding the ACL back to where it was pulled off. We also make some small holes to allow stem cells in to the knee joint to help heal the ACL. The internal brace is like a seatbelt supporting the knee and providing stability as the original ACL heals back to where originally was. The Internal brace is then secured with an Arthrex Swivel lock which is a small peak (a type of special plastic) screw. The small holes we have made in the skin are then closed with absorbable sutures and the skin glued to make the wounds watertight and dressed with a transparent dressing to keep things as sterile as possible.

If we are carrying out an ACL reconstruction, the old ACL has to be trimmed away and we use a special small shaving device only 4.5mm in diameter. Once the ACL has been removed we then drill 2 small tunnels to accept the new graft. These tunnels are drilled using a special drill called a FlipCutter. this allows us to place the position of these tunnels as accurately as possible, and in the exact position of your original ACL so it functions as well as possible. This is called an all inside anatomical ACL reconstruction. once the tunnels are created we then pass the new ACL graft we created earlier from your hamstrings in through one of the small holes we used to put the camera in. The graft is then secured in the tunnels and tensioned after testing the movement of your knee through a full range of flexion and extension. The graft is secured using 2 small titanium buttons called a tightrope RT. These are very secure and strong and stronger than the traditional screw fixation.

 

The wounds are all then cleaned and closed with absorbable sutures, glue on the skin and clear dressings to keep things as clean and sterile as possible. We inject local anaesthetic in to the wounds to make things as pain free as possible.  The leg will then we wrapped in fluffy wool and a bandage. The tourniquet will be released. and you will be started to be woken up by the anaesthetic team and transferred to the recovery suite where you will be looked after on a 1 to 1 to keep you as safe as possible. Once you are awake and we are happy you are as pain free as possible we transfer you back to the ward in to your room.

The physio team will then introduce themselves and begin the rehab straight away. Teaching you haw to use crutches safely and mange the stairs. Normally you would be up and mobile very quickly. We would anticipate you getting away the same day from your surgery.

Physio will make arrangements for your rehab over the next 6-9 months back to sport.

You will have a wound review at 2 weeks.

We give you TED socks that you have to wear for 6 weeks to reduce your risk of getting a DVT (deep vein thrombosis).

We see you back in the clinic at 6 weeks, and at this point if you have had an ACL reconstruction you should have excellent range of motion, no pain and are feeling more stable and carrying out all your normal day to day activities. You often still have some swelling which is totally normal. It can take up to 3 months for the swelling to go down completely.

At 6 weeks for an ACL repair, you should be pain free with excellent range of motion, and minimal swelling, feeling very stable and getting back to your normal day to day activities.

At the 6 week appointment we take an X-Ray to confirm the position of the new ACL.

If at any point during this you need to contact us we are always available on info@wessex-knee.com or on the phone.

Thank you Arthrex for a great few days!

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We have just finished a great few (very cold and snowy!) days in Arthrex’s amazing Munich head office and their teaching labs. Taking people through some great techniques and picking up tips. We covered all aspects of soft tissue Knee surgery. From ACL Repair using the internal brace, the Arthrex swivelock screws, anterolateral ligament (ALL) reconstruction to supplement an ACL reconstruction, patellar instability surgery. We also demonstrated the all inside PCL and lateral ligament reconstruction.

We also found out that Arthrex are investing in a Mobile Lab for the UK to allow this incredible teaching to go to all corners of the UK.

Always a pleasure to teach and be taught especially at such an inspirational company. Well done everyone.

Arthrex Teaching Munich – ACL Repair and the all inside technique

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We have just landed in Munich Germany to teach at the amazing Arthrex Lab. More pictures tomorrow of the lab and some of the techniques we use to repair ACLs and reconstruct ACLs. We will also show you how we do the medial patellofemoral ligament reconstructions or MPFL for patellar instability. Hopefully to help prevent you going on to need total or partial knee resurfacing. Keep tuned in to see the best orthopaedic surgery techniques in Southampton, Hampshire or the south coast! If you have any questions make sure you email info@wessex-Knee.com.

Stop Arthritis and the need for partial Knee resurfacing – Meniscal Repair – Save Your Cartilage!

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If you have a twisting injury and develop a meniscal (cartilage) tear it is important that it is identified quickly as to what type of tear you have. We do this by examining the Knee and looking for symptoms such as locking or catching and pain. An MRI scan would then be ordered to see in detail where the tear is.

There are several different ways the little disc of cartilage can tear and this changes how we can deal with it.

The meniscus is very important to the function of your knee and also in protecting your articular surface of the joint. If you have surgery to remove the torn meniscus completely, evidence has shown this will almost inevitably lead to osteoarthritis. And increase your chances of having a partial Knee resurfacing or a total knee replacement.

If you have what we call a bucket handle tear where the meniscus has a circumferential tear and the meniscus has flipped like the handle of a bucket, the often jams the joint and you get intermittent locking. The longer this is left the more damage that is done. If dealt with early the meniscal tear can be reduced and if possible repaired with special sutures all done via a keyhole or arthroscopic surgery and give it the best possible chance of healing. We also do a small micro fracture procedure to release stem cells into the joint to bring all the building blocks needed to increase the healing potential.

Meniscal tears like these often occur when you injure your ACL or anterior cruciate ligament. It is even more important if you have a meniscal tear repaired in that circumstance that your ACL is also stabilised to protect your meniscal repair. This can be achieved with either an ACL reconstruction or ACL repair with the internal brace. Hopefully saving you own cartilage preventing the need for a partial knee resurfacing or total knee replacement.

Call us to find out more.