Monday, December 19th, 2011
This is a case of a fifty-something yo female who presented to us after sustaining a knee injury. Her xrays were normal (image 1,2). She underwent an arthroscopic procedure and was found to have a cartilage defect on the medial femoral condyle (image 3). A micro fracture procedure was performed.
1 year after the procedure she continued to have knee pain. A second look arthroscopy showed healing of the cartilage defect with fibrocartilage (image 4), however the quality of the tissue was poor and when stressed using a blunt probe cracked easily (image 5).
The reconstruction that was done was a resurfacing implant (Arthrosurface). This implant was used to reconstruct the medial femoral condyle by filling the cartilage defect as opposed to doing a more traditional procedure – total knee replacement (image 6,7).
One of the many advantages of this procedure is that the surface of the knee can be reconstructed with the removal of very little adjacent tissue during preparation of the bone. Also , the procedure is done through a minimally invasive exposure, is ambulatory and immediately weight bearing. Also, the kinematics of the knee are not changed as a result of the procedure and there are no anticipated limitation in regard to activities – run, jump, twist etc.
This is a wonderful reconstructive option for appropriately selected knees and a much better option then knee replacement for limited cartilage loss.
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Monday, December 19th, 2011
This was a twenty-something girl that sustained a fracture of her knee-tibia plateau- after sustaining a fall. She was seen in the ER after the accident and then came to us for treatment. A CT scan of the knee shows the depressed fracture of the lateral plateau in addition to fractures lines that separate the medial condyle from the main segment ( Images 1,23). The treatment was surgical and included open reduction of the fracture utilizing simultaneous radiographic and arthroscopic guidance to elevate the depressed segment and achieve an anatomic reduction of the fracture line inside the joint (image 4).
Following reduction of the fracture the fragments and bone graft were held in place using a peri-articular locking plate and screws (image 4,5). To minimize the length of the surgical scar the plate and screws was applied percutaneously. The plate was slid down the leg underneath the muscle through the incision at the knee and the screws were placed through tiny incisions in the skin and blunt dissection through the muscle.
This technique of plate application (MIPO) is an advanced technique for fracture surgery and has the advantages of improved cosmetic result (image 6) as well as less pain and a quicker recovery after surgery. This patient did very well after surgery and has returned to all of her activities without pain. She recovered quickly and regained full motion of her knee (image 7).
Tuesday, December 6th, 2011
This patient had a total knee replacement done on her left side by another surgeon (note the length of the incision highlighted with a purple marker- the incision extends from her mid thigh to well below the knee and measures over 10 inches in length). She then had a total knee replacement done on the right side by Dr Montalbano using a minimally invasive technique (note the length of Dr Montalbano’s incision which is just over the front of the knee and only 4 inches in length). This minimally invasive technique which does not require detachment of the muscle allows for not only a much more cosmetic result but a much faster recovery after surgery with much less discomfort.
Tuesday, December 6th, 2011
This is a woman who presented with severe persistent knee pain that had substantially reduced her functional abilities and dramatically reduced her quality of life.
Note on the preoperative X-ray (image 1,2) the arthritic changes including joint space loss and osteophyte formation (bone spurs). Following the surgery (image 3,4) x-rays show implants that have restored the joint with normal alignment Note the ultra-small incision size, in this patient 3.5 inches (image 5). The overall result is a satisfied patient.
Dr Montalbano uses a minimally invasive surgical technique to perform the procedure whereby the muscles around the knee are maintained. This is a special technique that is not utilized by many surgeons. The advantages of this technique include less post-surgical pain, a much faster and complete recovery after surgery.
Tuesday, December 6th, 2011
This is a 55 yo male who presented for treatment of severe osteoarthritis of the right and left (bilateral) knees. He had severe disabling symptoms which made even routine activities painful and difficult. He was also a very large framed muscular male with a physically demanding job. His right knee was the more severely affected and elected to have this done first.
Note the complete loss of space in the medial weight bearing compartment as well as the collapse and deformity of the proximal tibia cause which caused a substantial varus or ‘bow legged’ clinical deformity. His knee was restored with a total joint replacement. The implants were positioned ideally eliminating the bone deformity and restoring a balanced joint with anatomic alignment (image 2).
After surgery he recovered quickly and then underwent the exact same procedure on his left knee. Following bilateral staged total knee replacement his pain has resolved completely, normal alignment of his legs have been restored and he is very happy with the results of the procedures.
Tuesday, December 6th, 2011
This is a 49 yo male who suffered from medial uni compartmental osteoarthritis of the right knee. He had severe disabling pain from the knee that was not adequately reduced with nonsurgical management.
Note the reduced joint space ( space between the bones) in the medial compartment (right side of the radiograph) (image 1). Because of his young age and localized nature of his arthritis he was indicated for a partial knee replacement as opposed to a total knee replacement. The surgical procedure involved application of an implant that replaced only this isolated area of the knee (image2,3).
Following surgery he had complete resolution of his symptoms and demonstrates his ability to bend his knee having regained full range of motion (image 4). The benefit of partial knee replacement over total replacement is that it is a joint preservation procedure and much less invasive, is typically done on an outpatient basis, leaves 2/3rds of the knee natural and allows for a quicker recovery and a more natural feeling and functioning knee.
Tuesday, December 6th, 2011
This is a 56 year old female who suffered from advanced osteoarthritis of the right knee. Her X-rays showed severe bi-lateral degenerative changes.
Xray of the right knee shows severe degenerative arthritis: note the severe cartilage loss represented by bone on bone contact, complete joint space loss and also note the extensive osteophyte (extra bone) formation and deformity of the joint (image 1,2) Xrays after total knee replacement shows the joint spaces restored, the restoration of normal alignment with correction of the deformity.
Note the normalized joint alignment, the removal of the osteophytes and restoration of the space between the bones of the knee (image 3,4). After surgery she was extremely satisfied with the results of the surgery.
Monday, November 21st, 2011
This is a 34 year old man who was in an accident and sustained an injury to left knee. He suffered from a fracture of the tibia plateau, which was displaced enough to require surgical repair as well as a meniscal tear and ACL tear. He underwent an arthroscopic procedure for repair of both the meniscal and ACL tears, and also had three screws placed in the tibia in order to restore proper alignment to the tibia plateau. In the images below you can further observe the procedure.
In (image 1) you can observe the torn piece of meniscus, which is being resected (image 2). You can observe the repaired meniscus in (image 3), which now has its normal contour restored. Note where the metal probe is positioned; this is the area where the ACL which has been torn should insert (image 4).
In (image 5) you can observe the placement of the implanted screw (this is in the same area where the metal probe is place in the previous photo) preparing for the attachment of the new ACL. The ACL has been restored with the hamstring allograft (image 6).
(Image 7): Above is an x-ray taken after the placement of three screws which are used to stabilize and realign the fractured tibia plateau. You can only visualize two screws well, as the third is placed behind the top one.
Monday, October 17th, 2011
This is a 50s yo female who had a total knee replacement performed in Upstate NewYork. After the surgery she had a very difficult time regaining motion in her knee. She was taken back to the OR a second time without successful resolution of her condition. She presented to our office seeking another opinion. At that time she had a severe limitation of motion with the inability to extend her knee beyond 30 degrees or flex beyond 50 degrees. She complained of severe pain, stiffness and an inability to ambulate comfortably. A radiographic evaluation of her knee showed what appeared to be week fixed components in accceptanle coronal and saggital plane alignment ( image 1 ,2) , however there was felt to be internal rotation of the femoral component (image 3) with the patella sublimating lateral to the trochlea. To address her complaints ad at her request Dr Montalbano performed a revision arthroplasty. He removed both the femoral and tibial implants, excised scar tissue, widened and balanced the gaps ad corrected the mal- rotation of the femoral component ( image 4,5,6). She did very well during and after surgery and now has range of motion that is 0-100 degrees which is 5x more motion then what she had after the initial procedures and only 10 degrees less then what is the optimum result after primary total knee arthroplasty (image 7,8).
Monday, October 17th, 2011
This is a college football player that sustained an ACL tear while playing competitively. He underwent ACL reconstruction. The ACL (image 1) failed at it’s femoral attachment. The remainder of the torn ligament was derided(removed) from the intercondylar notch. Next the femoral tunnel is created to accept the ligament graft. The back wall of the femur is identified and a measurement is taken from the back wall to the anticipated center of the femoral tunnel (image 2). Next a guide pin is drilled into the bone using an aiming guide to target the tip of the pin to the planned center of the tunnel. At the end of this pin there is a cutting blade which deploys and is used to retro- ream the femoral tunnel (image 3). The advantage of retrograde drilling g of the femoral tunnel is that it allows ideal placement of the tunnel and also allows direct visualization of the back wall so that it will remain intact and not be compromised during drilling ( image 4,5). Next the footprint of the ACL on the tibial side is identified and the tip of a gidewire is drilled into the bone to center at this area. A tibial channel is then created in a similar fashion of the femoral tunnel using antegrade drilling. Once the bone channels are created the ligament graft can be passed into the tunnels and secured at both ends. I prefer hamstring- semitendinosus and gracilis graft – to other graft options for a variety of reasons. I typically will harvest from the patient using a small 1 inch incision and is the same incision I use to create the tibia tunnel and pass the graft. The hamstrings will regenerate over time. Compared to other graft options this technique offers many advantages with no disadvantages compared to others (patella tendon, quadriceps tendon, ITB etc). The graft is passed into the prepared tunnels and secured on each side using fixation implants ( tibial interference screw and femoral cortical button). Once the graft is secured it fully mimics the anatomy of the ACL that had been torn ( image 6,7). Return to sports is 3-6 months.
