SPORTS SURGERY
Participating in sport and exercise is good for us. It helps maintain our health, prevents chronic illness, and keeps us happy. However, such participation can sometimes lead to injuries affecting our joints and muscles, especially our knees, shoulders and back. Acute traumatic injuries occur due to falls, knocks and twists, while chronic overuse injuries arise from constant repetition of the same movement, such as when one is running or cycling.
Sports Medicine deals with the prevention, diagnosis and treatment of sport- or exercise-related injuries. At Orthopaedic and Hand Surgery Partners, we provide the entire spectrum of Sports Medicine services, ranging from detailed clinical assessment, radiological investigations (such as MRI and ultrasound scans), non-surgical treatment (including orthotics and physiotherapy) and surgical treatment (particularly minimally-invasive ‘key-hole’ procedures)
Meniscus Surgery
The knee joint is made up of the ends of the femur (thigh bone) and tibia (shin bone). The meniscus is a rubbery, C-shaped disc that cushions your knee. It also helps to protect the cartilage in the knee. Each knee has two menisci - one at the outer edge of the knee and one at the inner edge. The menisci function as shock absorbers in the knee and also help to maintain stability within the knee. Injuries to the meniscus can occur after acute traumatic injuries or chronic repetitive injuries. Meniscus injuries can result in pain, swelling and stiffness of the joint.
The diagnosis of a meniscus injury within the knee is made after a thorough clinical assessment of the knee. MRI scans are done to confirm the diagnosis and to look for concomitant knee injuries, such as ligament tears and cartilage injuries. Patients with small meniscus tears may be treated non-surgically with a course of rehabilitation. However, patients with large or displaced meniscal tears, who develop persistent pain, swelling and loss of joint function, are candidates for surgical treatment. Surgical treatment involves minimally invasive knee arthroscopy (or keyhole surgery) and includes the following options:
1. Meniscus repair (See Figures below): Given its important function within the knee, meniscus tears should be repaired as far as possible. The meniscus is repaired by placing fine sutures
within its substance to keep it together while it heals.
2. Partial meniscectomy: Sometimes the meniscus tear is so severe that it precludes a repair. In
this instance, the torn non-functional part of the meniscus is removed using specialized
instruments.
3. Meniscus transplant: In patients who develop pain in their knee because most or all of the
meniscus has been removed, meniscus tissue from a donor (allograft) may be transplanted into the knee to replace the deficient meniscus.
At the same time, concomitant ligament and cartilage injuries may need to be addressed. Such surgery is usually performed under general anaesthesia and takes about 1-2 hours. An overnight stay in hospital is usually required after the surgery and 4-6 weeks of crutch-assisted ambulation may be advised.
The rehabilitation process after the surgery is generally supervised by a physiotherapist, and consists of progressive knee range of motion exercises, muscle strengthening exercises, and sport-specific drills. The whole rehabilitation process may last to 4-6 months following the procedure. The success rate of meniscus surgery has been reported to be about 80-90%. The complications of this procedure include infection, meniscus retears and future osteoarthritis (if meniscectomy is performed).
ACL Reconstruction
ACL is an acronym for the ‘anterior cruciate ligament’. It is an important ligament that is found in the centre of the knee, and it helps to maintain knee stability by preventing forward and twisting movements of the tibia (or shin bone) relative to the femur (or thigh bone). Injuries to the ACL are common. They usually occur due to twisting, non-contact injuries during sporting activities such as soccer, basketball or netball.
The risk factors for ACL injuries include female gender and familial predisposition. The diagnosis of an ACL injury is made after a thorough clinical assessment of the knee. MRI scans are done to confirm the diagnosis and to look for concomitant knee injuries, such as meniscal tears and cartilage injuries.
Some patients with isolated tears of the ACL may be treated non-surgically with a course of rehabilitation. However, patients with symptoms of recurrent knee instability, those with concomitant repairable meniscal tears, and individuals who are keen to return to competitive pivoting sports (such as soccer, basketball or netball) are candidates for surgical treatment.
Surgical treatment involves ACL reconstruction. This surgery is usually performed under general
anaesthesia, using minimally invasive arthroscopic (keyhole) techniques. The surgery essentially involves replacing the torn ACL with a new ACL graft. Bone tunnels are drilled in the femur and tibia within the knee, and a new ACL graft is secured within these tunnels. This new graft may be obtained from patient himself (autograft) or from a donor (allograft). At the same time, concomitant injuries to the menisci or cartilage may be repaired. An overnight stay in hospital is usually required after ACL reconstruction and 2-4 weeks of crutch-assisted ambulation may be advised.
The rehabilitation process after the surgery is supervised by a physiotherapist, and consists of progressive knee range of motion exercises, muscle strengthening exercises, and sport-specific drills. The whole rehabilitation process may last 9-12 months following the ACL reconstruction procedure. The success rate of ACL reconstruction surgery has been reported to be about 90%. The complications of this procedure include ACL graft injury, knee stiffness and infection.
ACL Revision
Anterior cruciate ligament (or ACL) reconstruction is a safe and effective procedure. However, in about 5-10% of cases, the ACL graft may tear or fail. Higher rates of graft tears of up to 30% have been reported in young patients, who are involved in competitive sport. The risk factors for graft failure include reinjury, technical issues arising from the initial surgery and associated injuries which compromise knee stability.
The diagnosis of a torn or failed ACL graft is made after a thorough clinical assessment of the knee. MRI scans are done to confirm the diagnosis and to look for concomitant knee injuries. CT scans may also be needed to assess the positions of the bone tunnels used in the previous ACL reconstruction and to look for possible excessive enlargement of these tunnels.
In patients who have symptoms of knee instability due to a torn or failed ACL graft, revision surgery is needed to improve knee stability. The surgery involves drilling new bone tunnels in the knee and securing a new ACL graft within these tunnels. This new graft may be obtained from patient himself (autograft) or from a donor (allograft). At the same time, an extra-articular lateral tenodesis may be added to enhance the stability of the knee. This involves using part of the iliotibial band to secure and improve the rotational stability of the knee. An overnight stay in hospital is usually required after revision ACL reconstruction and 2-4 weeks of crutch-assisted ambulation may be advised.
Revision ACL reconstruction is a technically demanding procedure and should be carried out by surgeons who are trained and experienced. It is often carried out in one stage, although in a few patients, the surgery may need to be divided into two stages. In the first stage, bone grafting of the old tunnels is done, especially if there is significant widening of these tunnels, as they may compromise graft fixation. The second stage of the procedure is carried out several months later, once the bone grafts have healed and completely filled up the widened spaces within the old tunnels. In the second stage, new bone tunnels are created and a new ACL graft is secured within these tunnels.
The rehabilitation process after revision ACL reconstruction is often slower and longer compared to that following primary ACL reconstruction. It may last up to 12-18 months following the revision procedure. The success rate of revision ACL reconstruction has been reported to be approximately 75%. The complications of this procedure include infection, knee stiffness and recurrent graft failure.