Partial Knee Resurfacing vs. Total Knee Replacement?

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What’s the difference between a partial knee resurfacing or replacement and a total knee replacement? Well, they are both designed to improve the pain and function of patients with arthritis that had damage the surface articular cartilage of their knees. The partial resurfacing or replacement only replaces the one specific area of the knee affected by the damage to the the articular cartilage. We divide the knee in to 3 main zones or areas that can be affected by arthritis. The patello-femoral joint or the joint involving the back of the patella or knee cap and the groove the knee cap normally runs in. This becomes worn in isolation often in patients who have had patellar instability that has not previously been treated or where they have had trauma involving this joint such as a fracture. By resurfacing the worn out joint surface with highly engineered and polished cobalt chrome on the groove and cross linked polyethylene on the back of the knee cap the knee then glides as it was intended and pain improves. The rest of the joint remains untouched as do the ligaments around and in the knee, and as a result recovery tends to be quicker than a total knee replacement and the risks of surgery less than a total knee replacement.

A similar situation occurs with the joints between the femur (thigh bone) and the tibia (shin bone). Arthritis often occurs here after injuries to the disc of cartilage called the meniscus. Osteoarthritis can develop with the associated pain. If this is again just involving one compartment of the knee, then it makes sense that we only resurface or replace that one small area rather than the whole knee. Partial medial and lateral knee resurfacing or replacement is a procedure that has a quicker recovery and less risk than a total knee replacement. As it retains your ligaments patients often report that it feel much more like their own knee.

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If you have arthritis that is more severe and affects all of the knee then it may be right to be offered a total knee replacement. This resurfaces or replaces the joint surface through out all three compartments of the knee and also the internal ligaments of the knee the anterior cruciate ligament or ACL and the posterior cruciate ligament or PCL.

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Contact us now to find out more about these options for your knee pain.

MPFL and Patellar Stabilisation Surgery

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Unstable knee caps or patellae is a very debilitating condition. There are many reasons this can happen. Some patients have normal knees and anatomy and have an injury that causes their patella to become dislocated. This can damage the medial patello-femoral ligament or MPFL. This can be thought of like a safety rope that protects your knee cap and prevents it from coming out of the trochlear groove where it should run. Once this structure is damaged the knee cap or patella can become chronically unstable and dislocate or sublux. This patellar instability can cause pain and can also cause damage to the articular cartilage. If cartilage is damaged and floats in the knee joint sometimes this can present as locking of the knee. This is an important symptom and something that needs dealt with quickly and may require surgery to reattach the damage cartilage to prevent osteoarthritis developing in the future.

Some patients however are born with abnormal anatomy of their knees and this can develop and cause patellar instability. There are multiple reasons. The trochlea or patellar groove can be too shallow and not capture the knee cap when bending and flexing the knee. The patella or kneecap can be high, called patella alta and this can make it more likely to become unstable and dislocate. Some patients have hyper laxity or ligaments or tendons that are more elastic than normal and therefore the extra freedom of movement often combined with other anatomical issues results in patellar instability and pain.

We can investigate your knees with xrays and MRI scans to see what abnormalities you might have and how best to resolve them to give you pain free and stable knee caps. This patellar stabilisation surgery ranges from physio and advice up to MPFL reconstruction, tibial tubercle osteotomy or trochleoplasty surgery. It is important when seeing someone for a consultation for patellar instability that they have the full range of skills and techniques to solve your problem. As a pure knee surgeon Mr. Frame has those skills and has spent time with the world expert Dr. David Dejour in Lyon France learning how to approach, diagnose and solve the complex issue that is patellar instability.

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If you have had problems in the past with patellar instability and this was not treated and you now have pain and osteoarthritis affecting your knee caps and you have been told you need a total knee replacement, it might be possible to simply have your kneecap and patellar groove resurfaced with a partial resurfacing of your patellofemoral joint. Get in touch now to have a consultation where we can help you will all aspects of your knee pain or problems.

ACL Repair = Faster Recovery!

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Mr Frame asked for advice about Premiership footballers ACL injuries and how they recover faster from the biggest Football Publication in the country FourFourTwo.

FourFourTwo – Zlatan Ibrahimovic ACL Injury

How did Zlatan recover from an ACL injury in seven months?

A new surgical technique could have helped Zlatan Ibrahimovic to recover from an ACL injury in just seven months

Alec Fenn

When Zlatan Ibrahimovic made his return from an ACL injury last weekend, he declared that ‘lions don’t recover like humans’. But a new surgical technique could be behind the striker’s miraculous seven-month recovery and is set to accelerate the rehabilitation of a host of other Premier League stars.

An ACL injury typically sidelines a player for nine months – but can take even longer depending on the severity of the injury. “The traditional way to repair the damaged knee involves removing part of a player’s hamstring and using that to create a new ACL,” says consultant orthopedic surgeon, Mark Frame. “It takes a long time for it to fuse to the bone and to restore strength in the hamstrings and quadriceps, because they’re inactive for so long during this process.”

However, knee surgeons are now able to use a different type of operation, which could get players back on the pitch faster. “Advances in keyhole surgery mean we can repair the existing ACL, using a technique known as an arthrex internal brace repair, rather than taking tissue from the hamstring,” says Frame. “We can also place it back in its original position, which reduces the amount of bone which needs removing and hardware implanting. A number of Premier League players have had this type of surgery and have returned quicker.”

Recommended story: Yannick Bolasie’s guide to ACL rehab

Frame also believes educating players from their teenage years on the risks of ACL injuries in the modern game can help to halt the 50% increase in ACL injuries in the Premier League in the last five years. “The ACL contains sensors which provide feedback to the brain, telling it how much stress it’s under and where it is positionally,” he adds.  “If the knee is cold, it won’t send this feedback effectively. Players need to know this from a young age, so they warm-up in the correct manner.”

For more expert insight on knee injuries, visit www.wessex-knee.com or follow @wessexkneedoc.

BBC Radio Solent….Ask the expert.

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Iplayer Radio link to Mr Frame on Ask the Experts

We had a great morning at BBC Radio Solent answering questions to all of the great listeners. Answering questions about partial and total Knee resurfacing, ACL repair surgery with the internal brace, patella instability and patellar stabilisation surgery including trochleoplasty, tibial tubercle osteotomy, MPFL reconstruction and durolane injections for Knee pin and osteoarthritis. Listen now for all the info.

BBC Radio Solent Interview – Ask the Experts!

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Mr Frame will be taking questions over the phone live on air tomorrow from 12.15pm.  It is an honour to be invited to be on Sasha Twining’s show where she has on the brightest and best experts in the UK and England on her ask the experts show segment. All topics welcome from partial knee resurfacing vs total knee replacement, ACL reconstruction vs the revolutionary ACL repair with the internal brace. We might also discuss trochleoplasty and patellar realignment and stabilisation surgery and what an MPFL reconstruction is and what the recovery is like. We will also discuss the epidemic of ACL injury in football today. Get listening and call if you have any burning questions!

ACL Injuries in Football? Why so many?

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all-inside-later.jpgIn the last 5 years in the premiership there has be an over 50% increase in the occurrence of devastating ACL injuries. Not the once career ending injury it once was with the advances in surgical repair and reconstruction, but still a season ending event with often very significant consequences both for the team and for players in the short and long terms. Even the best orthopaedic surgeon in England or even the best orthopaedic surgeon in the World don’t completely understand why!

There have been many studies done by the best knee surgeons to try and understand better why this seems to be and injury on the increase. There are many theories thrown around the changing rooms of clubs across the country. Some of them include the artificial surfaces players are now playing on, the boots and studs they use, the intensity of the fixtures and the demand on players, the warm up regimes and the overall fitness of players. The truth is we don’t currently know, and like most problems in life it is not just one factor but a combination.

Let’s look at each of the theories in turn, but first we need to understand what the ACL is and what its role is and then we can begin to understand how and why it gets injured.

The anterior cruciate ligament is a small structure that crosses the knee between the femur (thigh bone) with the tibia (shin bone). It is approximately 32mm in length and 8mm in diameter. Its main role is to resist the pivoting movement of the tibia on the femur when a player is changing direction. It is a very strong structure and can resist forces up to 250kgs. If the ACL becomes over stressed and torn it is not something that can repair itself and especially in footballers leads to significant problems and damage to other important structures within the knee. Pivoting and cutting maneuvers are fundamental to football and without a functioning ACL most are unable to return to their original level of play without surgery.

So now understanding the structure of the ligament and its role in the knee, how do the different theories hold up to scrutiny?

  1. New Playing Surfaces?

Many of the premiership clubs now use artificial turf as a surface for playing football. There are limited studies looking at the incidence of ACL injury in relation to the playing surface, however in the US where American Football is almost universally played on artificial turf there is a new study to show that these surfaces have a nearly 40% increased rate of ACL injury over traditional playing surfaces. These surfaces are unforgiving and very stable and predictable. This is part of their problem! By providing too much grip and no give or slide, players feet can often be fixed in a certain position and the change of direction movements they have, happen at their knee joints and stress the ACL beyond its capacity causing it to rupture. These surfaces are going to become more common and something that need to be investigated further. This leads on to the next most discussed possible reason for the increase in injury…the boots!

  1. The Boots?

The design and development of football boots and studs is something that has accelerated in the last few years. With the advertising revenues available from elite level football and being the brand of boots on the best players feet is an important goal for sports companies across the globe. In order to compete for this coveted position, millions of pounds have been invested in the design and research of football boots. There is no high-level research available to look at the types of studs and the correlation with ACL injury in particular. However, there are some eagle eye amateurs out there trying to look for links. One football fan site has correlated all the players over the past 24 months who have sustained an ACL injury and looked at what boots they wear, and if there are any trends. Interestingly there became a clear pattern with one manufactures boot type. This is not scientific or robust research and may simply be a coincidence, however it is an interesting observation and something if I was the manufacturer would take heed of and definitely warrants careful scrutiny. The current blade designs provide exceptional stability and may even provide too much, fixing the players foot rigidly in the playing surface allowing their body to pivot over their knee injuring their ACL. This maybe compounded by the hard-artificial surface discussed above.

  1. Demands and Fatigue?

The ACL is not a seatbelt for the knee, simply restraining the knee when we push things too far. It is a small brain filled with sensors that feedback where the knee is at any given moment in time. It works in combination with the other structures in and around the knee. The hamstring muscles at the back of the thigh and the powerful quads muscles at the front of the knee also help support and stop the knee moving beyond what it is capable of before injury. If players are fatigued and tired with busy match schedules it has been shown in studies that the normal protective feedback from the supporting muscles fails and the ACL can be over loaded in an abnormal fashion, putting players at risk of rupture. When this point is, is very player dependent and everyone’s thresholds are different. Understanding each player and their limitations is vitally important as well as making sure their overall level of fitness is as high as it can be giving them as much reserve as possible.

What can we do before it happens?

Further research is required to clarify the issue above, however FIFA has already instigated a plan to try and reduce the risk to players at all levels of the game through their 11+ Injury Prevention Program. This is an evidence based program developed and studied by the FIFA Medical Assessment and Research Centre (F-MARC).  This was developed in 2006 as a complete warm up program to help prevent injury in footballers. The aim being to make sure players recruit and use their muscles correctly and in a balanced fashion to help support and prevent injury. Studies have shown that implementing this program can reduce the rate of injury, including the risk of ACL.

What can we do if it does happen!

If you are in the unfortunate position of sustaining an ACL injury and you are a high-level athlete, like mentioned at the beginning of this article it is no longer the career ending injury it once was. Advances in arthroscopic surgery (keyhole) means that we can reconstruct the ligament using your own tissue to give your knee that feedback and stability it needs. The cutting edge of this surgery now includes striving to reconstruct the ACL back to the exact position that the original one once was in using minimally invasive techniques that reduce the amount of bone that needs removed and hardware that needs implanted, unlike traditional ACL reconstruction surgery (Arthrex All Inside, Arthrex, Ltd, Naples Florida). Research includes producing custom made 3D printed guides (Frame, M. (2017)Custom Anatomical 3d-Printed Patient-Specific Acl Femoral Tunnel Guide From Mri: A Proof Of Concept StudyBone Joint J, 99-B(SUPP 9)51Accessed September 12, 2017. Retrieved from the best knee surgeon in hampshire http://bjjprocs.boneandjoint.org.uk/content/99-B/SUPP_9/51. the best knee surgeon in england) from scans of the uninjured knee to help place the new ACL in position specific to each individual patient. The ability to treat patients early and rather than reconstruct their ligament, we can now aim to repair their original ACL and support it with an internal brace (Arthrex Internal Brace ACL repair, Arthrex, Ltd. Naples Florida) until it is healed allowing then to get back to their original elite level even quicker.