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.
Monday, October 17th, 2011
The following case is a 45 year old male with marked shoulder pain and disability secondary to a complete rotator cuff tear. The rotator cuff was repaired arthroscopically ( minimally invasive surgery) as an outpatient procedure.
Upon entering the shoulder there is noted to be a massive tear of the rotator cuff involving the entire supraspinatus and a part of the Infraspinatus tendon with marked medial retraction exposing the entire numeral head ( image 1,2,3).
The rotator cuff tendon and muscle is released to allow restored excursion of the muscle and tendon so that it can be mobilized to again cover the numeral head. The greater tuberosity is prepared for a tendon to bone repair by removing remaining soft tissue and a very thin layer of bone to allow for biological activity at the bone surface ( image 4).
Next suture anchors are driven into the bone (image 5,6). 2 rows of anchors are placed- called a double row repair-for improved strength and stability of the repair. The sutures from the medial row anchors are passed throughout the tendon. A total of 4 fiber tape sutures are passed- fiber tape is preferred on account of it’s geometry allowing a greater surface area of contact with the tendon and less chance that the suture will cut through the tissue (image 7). Next the fiber tape sutures are brought over the tendon and crisscrossed over each other followed by tensioning and securing the suture tape with multiple lateral row anchors. The effect is to create a “suture bridge” which compresses the tendon down onto the prepared surface of the greater tuberosity and restores a wide footprint of tendon which contacts the bone surface for healing. When the repair is completed the numeral head is no longer visible now covered by the rotator cuff repaired and secured onto the bone ( image 8,9,10).
Full restoration of motion, strength and pain relief (please click on link to watch video: Rotator Cuff Tear – Post Surgery).
Saturday, October 1st, 2011
A 43 year old male with complaints of disabling right knee pain. On clinical and radiographic examination he is noted to have a marked varus mal-alignment of his knee. An MRI examination found an extensively torn medial meniscus. He underwent an arthroscopic procedure of the knee and was found to have an extensively torn meniscus which was treated with a sub-total menisecromy. The articular cartilage however was found to be intact with no substantial degeneration. He continued to have disabling pain after the arthroscopic procedure and elected to undergo a surgical correction of the mal-alignment ( varus mal-alignment = bow-legs). The deformity was isolated at the proximal tibia and a preoperative plan of the correction was prepared using a plain radiographic examination calculating the correction required to shift the mechanical axis into the desired position (image 1) and eliminate the bow-leg deformity. The surgery performed was a high tibia opening wedge osteotomy. The intra-operative radiographs shows the surgical osteotomy, the correction , as well as the application of surgical fixation (image 2,3). Note how the pre-surgical plan is reproduced in the intra-operative radiographs. At 6 weeks the osteotomy is healed (image 4,5) and the patient is weight bearing.
Varus mal-alignment or bow legs as it is commonly referred to is a common predisposing condition to knee joint deterioration and concomitant symptoms of pain and disability. Corrective osteotomy is an effective way of mitigating or eliminating progressive deterioration of the joint and symptoms.
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Sunday, September 18th, 2011
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Tuesday, August 30th, 2011
This is a middle aged female that underwent a total knee replacement for a diagnosis of osteoarthritis. She had constant pain that limited her activities and prevented her from enjoying an active life.
The X-rays (images 1,2) show the preoperative condition of the knee and X-rays (images 3,4) show the implants after joint replacement. Noted the ideal balance and alignment of the implants. Proper implant alignment and balancing of the joint restores normal knee kinematics and is important for restoration of normal motion and function.
In images 5 and 6 the patient demonstrates her knee motion. Notice that she has full extension and can bend the knee to 125 degrees which is equal to the motion she has in her non-surgical knee and falls with the reference range for normal motion.
Image 7 shows surgical scar at 8 weeks post. Notice the relatively small size of the incision. Over time as this scar matures it will turn the color of the surrounding skin and will contract and become smaller.
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Thursday, June 30th, 2011
42 year old female that underwent a hip arthroscopy for treatment of osteochondromatosis. In image 1 are all of the loose bodies that were removed from the hip joint. There were over 10 loose bodies removed from the hip joint. Image 2,3 and 4 are arthroscopic views inside the joint from which the loose bodies were removed. Hip arthroscopy is an effective procedure for addressing a variety of hip conditions.
Tuesday, February 1st, 2011
This is a middle age gentleman that sustained an elbow (olecranon) fracture as a result of a fall. He underwent ORIF (open reduction and internal fixation). As a result of the surgery the fracture healed with no visible alteration in the anatomy of the bone or joint. He regained full motion of the elbow joint and a restoration of full function.
Image 1 – Following ORIF. Note the contoured fracture implant which exactly matches the contour of the skeletal anatomy. Also note the absence of any residual evidence of the prior displaced fracture. Image 2,3,4. Following successful rehabilitation with our Peak Performance therapists he regained full range of motion and full function of his elbow.
Friday, January 28th, 2011
This is a 56 year old female who suffered from advanced osteoarthritis of the right knee. Her X-rays showed bi-lateral degenerative changes; the right knee being more severe than the left.
Image 1 – Preoperative Xray Lateral View
Friday, January 28th, 2011
This gentleman was involved in a motorcycle accident. He sustained a severely comminuted fracture of his tibia plateau. You can see from the x-rays (1,2) and CT scan (3) that the knee joint was severely disrupted with near complete destruction of the articular surface of the tibia.
The procedure to reconstruct the joint was done in 3 stages. As you can see from the postsurgical x-rays (4,5) the joint surfaces were successfully reconstructed.
In the clinical photograph (6) you can also see by the multiple small incisions that the implants to reconstruct the joint were placed percutaneously (multiple small incisions). This method of placing the implants is technically demanding however the clinical results are much better in most cases since the soft tissues are not disrupted. The patient’s knee and leg was restored to an appearance of normal (7). He has returned to work and normal activities. I recently saw him in the office and he is now 10 years from the accident and surgery. He continues to do well at this time and has what he describes as manageable pain. His only recent treatment has been sodium hyaluronate injections which is a medicine used to lubricate the joint.
