Clinical Interests

• Arthroscopic (key hole) Surgery
  Including Anterior and Posterior cruciate ligament reconstruction using Bone Patellar Tendon bone and Hamstring Quadruple grafts
• Arthroscopic debridement of the knee and micro fracture
• Total Knee Joint Replacements
• Total Hip Joint Replacements
• Unicompartmental Knee Replacements
• Autologous Chondrocyte Implantation
• Trauma Surgery (treatment of fractures and dislocations)

Anterior Cruciate Ligament Injuries – Treatment and Rehabilitation

Over the past decade, there has been an increase in interest and participation in sports.  Concomitant with this, there has been an increase in sports related injuries, particularly to the lower limbs.  Of specifically ligamentous injuries to the knee, rupture of the Anterior Cruciate Ligament (ACL) has been the commonest, and has the greatest potential to cause both short term and long term disability. 

Functional Anatomy

The ACL is well recognised as a key structure in providing stability in the knee
 
The ACL is a broad ligament joining the anterior tibial plateau to the posterior femoral intercondylar notch.  The tibial attachment is to a facet, in front of, and lateral to the anterior tibial spine.  The femoral attachment is high on the posterior aspect of the lateral wall of the intercondylar notch.

It is composed of multiple non parallel fibres, which though not anatomically separate, act as three functionally distinct bundles i.e. anteromedial, posterolateral and intermediate. 

The ACLs main function is to keep the knee stable during rotational movements like twisting, turning or side stepping activities.

The ACL also provides important functions to the muscles around the knee (proprioception) which are involved in protecting the knee during activities. 

Causes of ACL Rupture and Rationale for Treatment

The most common cause of ACL rupture is a traumatic force being applied to the knee in a twisting moment.  This can occur with either a direct or an indirect force.  In my practice, about half of the cases of ACL rupture occur without contact, i.e. while side-stepping, pivoting or landing from a jump.  The other half are associated with some type of contact, whether it be on the football field, on the snow fields or in a motor vehicle accident.  

Rupture of the ACL causes significant short term and long term disability.  After each episode of ACL instability there is subluxation of the tibia on the femur.  This can lead to meniscal tears and articular cartilage damage and eventually resulting in osteoarthritis

History and Diagnosis

The classic story of a patient cutting, side-stepping or landing from a jump, and the knee giving way, followed by immediate pain and swelling should alert the surgeon to the most likely diagnosis of ACL rupture.  In my practice a “snap” or “pop” was noted by 60% of the patients.  Rapid intra-articular swelling following injury is nearly always due to hemarthrosis. 

Management of ruptured ACL

Operation is not required for all ACL injuries.

A small number of patients with lower physical activity levels and who do not participate in twisting activities can be treated conservatively with a well supervised physiotherapy programme. 

ACL Reconstruction

Anterior cruciate ligament (ACL) reconstruction can be done with several different graft choices.  These include patellar tendon, hamstring tendon, and donor tissue (allograft).  Each of these choices has advantages and disadvantages. 

ACL reconstruction is not an ACL repair.  A repair implies that you can fix something that is broken.  If an ACL is completely torn, it will not heal back together, even if the torn ends are sewn together.  In actuality, the tendon almost always appears frayed when visualized after an ACL tear.  What does work well, is to remove the torn ends of the ACL and replace the ligament with a different structure (a graft).  To secure the graft into the position of the normal ACL, tunnels are made in the shin bone (tibia) and thigh bone (femur) and the graft is passed through these tunnels to reconstruct the ligament. 

ACL reconstruction is usually performed using arthroscopic (key hole) surgery.  There is however either a 3” incision in front of the knee (patellar tendon graft) or a 1.5” incision just below the knee (hamstring graft)

Complications include infection, nerve damage, (a numb patch of skin, quite common over a small area, but rarely a problem), stiffness (uncommon) and failure of the draft due to re-injury or unexplained failure. 

Rehabilitation

The major goals of rehabilitation following ACL surgery are:

• Restoration of joint anatomy
• Provision of static and dynamic stability
• Maintenance of the aerobic conditioning and psychological well being; and
• Early return to work and sport

These have required the development of an intensive rehabilitation program in which the patient has to take an active involvement.

An elite athlete who has had a technically well performed early reconstruction of the anterior cruciate ligament followed by an adequate and successful rehabilitation program, should be able to return to the field of his chosen sport between six and nine months. 

Total Knee Replacement (T.K.R)

TKR is a procedure done to replace worn out cartilage of the knee with a metal or plastic implant.

I currently use a (RPF) knee replacement design that allows rotation of the leg and also deep flexion in the knee.  Theoretically, by acting more like a normal knee.  There will be less wear on the implant and consequently the plastic part of the knee replacement may last longer. 

Freedom from pain is the starting point but for most this is not enough.  Patients want to enjoy a full and active life, playing a game of bowls, going sailing or just gardening. All of these normal activities put the knee into deep flexion which is offered by the R.P.F knee replacement.  (rotating platform high flexion knee)