Knee Arthroscopy- ACL Reconstruction Knee arthroscopy, keyhole surgery, is a technique used to inspect the inside of the joint cavity to diagnose and assess damage and, where possible, to treat this damage. Arthroscopic knee surgery involves putting a small telescope and special instruments into the knee, with the ability to photograph and video the operation. Arthroscopic knee surgery is used to treat any number of conditions that occur within the knee from simple cartilage tears to removal of loose bodies, meniscal surgeries and anterior/ posterior cruciate ligament reconstructions. At the same time all of the other structures within the knee can be clearly viewed and probed. The four main ligaments in the knee connect the Femur (thighbone) to the Tibia (shinbone) and include the following: • ANTERIOR CRUCIATE LIGAMENT (ACL): The Ligament located in the center of the knee, which controls rotation and forward movement of the Tibia. • POSTERIOR CRUCIATE LIGAMENT (PCL): The Ligament located in the center of the knee, which controls backward movement of the Tibia. • MEDIAL COLLATERAL LIGAMENT (MCL): The Ligament that gives stability to the inner knee. • LATERAL COLLATERAL LIGAMENT (LCL): The Ligament that gives stability to the outer knee. WHAT IS DONE? The entire procedure is done with the help of 2-3 small keyhole sized incisions from which the instruments and the small laser/telescopic camera is inserted and the procedure is visualized on a high definition screen. Arthroscopic ACL/PCL reconstruction: The torn portion of the anterior cruciate ligament or the Posterior cruciate Ligament is removed. A new ligament graft is taken from the extra tendon of hamstrings group of muscles and after preparation is inserted into the Femoral (upper bone) and the Tibial(lower bone) tunnel. Arthroscopic MCL/LCL repair with augmentation: The torn portions of the ligament are repaired with sutures. In order to further strengthen the repaired ligaments, an augmentation (extra support) is done with additional grafts obtained from the extra tendons of Hamstring (knee) or Peronei (ankle) group of muscles. PRE-OPERATIVE STEPS Though the procedure is a very minor procedure, every effort is made to assess the patient prior to surgery in order to ensure safety of the patient for the elective procedure. 1. After admission, routine blood work-up will be done prior to surgery. Depending on the age of the patient and other premorbid conditions, other investigations such as Echocardiography may be performed. 2. All the investigations prior to surgery are performed in order to ensure that the surgical procedure can be safely tolerated by the patient, since it is an elective procedure. If any risk is involved, the patient/ attendants will be informed so. 3. X-rays and MRI may be done depending on the surgeon’s choice and the surgical indication for the procedure. 4. Surgical consent will be explained to the patient detailing the procedure as well as the risks involved, if any. INTRA-OPERATIVE STEPS ACL/PCL Reconstruction Procedure for the reconstruction of ACL and PCL is almost the same except the position of the femoral and tibial tunnels are different. An ACL injury is about 100 times more common than a PCL injury. Here we are describing the steps for an ACL reconstruction. 1. The inflow cannula, which brings the fluid into the joint so that the knee may be visualized, is seen in this picture. The patella is at the top of the screen and the trochlear groove of the femur at the bottom. The width of the tube is approximately 4 mm (1 inch = 25.4 mm). 2. The apparently normal meniscus is viewed. The femur is above the meniscal cartilage and the tibia is below it. A probe is inserted to inspect the meniscal cartilage. 3. The normal ACL is a taut rope-like structure which goes from the femur to the tibia. Probing of this ACL indicates that it is lax and frayed. This indicates a functionally incompetent ACL (torn ACL). 4. To reconstruct the ACL, it is necessary to remove all of the existing damaged ACL. This is done with a motorized device which is called a shaver. 5. At this point, attention is directed to the hamstring tendon. Incisions are made at the inner aspect the upper 1/3 leg. Each incision is approximately 1.5 inches in length. 6. After making the skin incisions, the tendon is identified, and is harvested with a tendon stripper. Harvesting is completed. 8. The graft then has sutures placed through the bone blocks. 7. Attention is then directed to the arthroscopic part of the procedure. The tibial drill guide is positioned on the tibia. 8. The guide wire is then drilled into the tibia, exiting inside the joint. 9. The tibial drill hole is placed. 10. The endoscopic femoral drill guide is then passed. 11. The guide is then positioned on the back of the femur. 12. The femoral guide wire is then placed, the femoral guide is removed and the femoral drill is used to place a hole in the femur. 13. The graft is then placed through the tibia, through the knee joint, and into the femoral drill hole. 14. For the graft to heal, blood vessels must grow into the reconstructed ACL. To hold the graft in place, a endobutton attached to the graft is inserted through the femoral drill hole. This particular screw is a bioabsorbable screw. 15. A second screw is inserted into the tibia to hold that part of the reconstruction in place. Following this, the reconstructed ACL is inspected. Unlike the picture of the torn ACL, the reconstructed ACL is a rigid rope-like structure that provides stability to the joint. 16. At this point the procedure is finished, the incisions are closed, and the surgical procedure is completed. POST-OPERATIVE MANAGEMENT/ REHABILITATION ACL Reconstruction Rehabilitation is a vital part of your ACL recovery and is essential to getting back to regular physical activity. Your program can last anywhere from two to six months or longer. Your doctor will help you find a program that is suited to your recovery goals. Weeks 1 - 2 • Ice/elevation every 2 hours for 15 minutes to minimize edema and promote healing (please refer to Icing handout). • Full weight bearing is allowed immediately after surgery. Though some surgeons may prefer not to allow weight bearing for up to 6 weeks after surgery. • ROM knee brace needs to be worn for support. • Dressing will be done on day 4 after the surgery. Exercises • The patient should be seated at the edge of bed and asked to hang the knee for flexion; lift for knee extension. • Quad sets/straight leg raises, hip abduction, calf presses, glut sets, and core exercises. • Upper body conditioning, non-operated leg stationary cycling. Goals • Knee Range of motion: 0-90 degrees. • Good quality gait with least amount of Assistive Device. Weeks 2 - 4 • Suture removal on day 14. • Walking for exercise for 15-20 minutes if no limp or swelling present. Manual • Extensive patellar mobilization. • No direct scar mobilization x 4weeks. Exercises Range of motion and functional strengthening exercises: • Squats/Leg Press, Bridges/Hamstring Curls. • 2” step up/down, intense core training. • Aerobic exercises as tolerated (bilateral stationary bike, Elliptical, arm bike). Goals • Active range of motion equal extension to uninvolved side and flexion to 120 degrees. No edema. Full weight-bearing; normal gait without assistive device. Single leg balance 60 seconds on level surface. Weeks 4 - 6 • Review with the doctor at 4 weeks. • Walk up to 1 hour for exercise. Manual • Continue with soft tissue mobilization. Apply direct scar tissue mobilization; can use instruments/tools. Exercises • Emphasize self-stretching to both lower extremities. • Increase intensity of resistance exercises (i.e. standing resisted squats, lunges, etc.). • Introduce eccentric exercises (4-6” steps). • Increase single leg strength, challenge proprioceptive training. Goals • Full Range Of Motion equal to uninvolved leg. • Perform 4 inch step down. • Bike with minimal resistance for 20-30 minutes (in saddle), walking for 30 minutes, Elliptical, water-walking. Weeks 6 - 10 Manual • Soft tissue mobilization and joint mobilization as needed. Exercises • Add lateral training exercises (lateral step ups, lunges, step overs). • Initiate tri-planar activities with the exception of closed-chain rotation (pivots). • No cutting or pivoting. Goals • Activities should be pain-free: • Able to descend stairs, double leg squat hold for >1 minute. • Bike >30 minutes with moderate resistance, Elliptical with interval training. Weeks 10 - 16 • Doctor visit at 3 months. • Incorporate bilateral, low level jumping exercises. • Continue to increase strength, endurance, and add sport specific training drills. Weeks 16+ • Doctor visit at 6 months. • Implementation of jump training, agility training. • After 6 months add lateral plyometric type drills, agility ladder Goals • Initiate sagittal plane plyometrics, work towards single leg plyometrics. Clearance by surgeon before returning to full athletics.

Shoulder Arthroscopy- Frozen Shoulder Release Frozen shoulder, also called adhesive capsulitis is a condition characterized by pain and loss of motion in shoulder joint. Frozen shoulder release is extremely useful in cases of frozen shoulder that do not respond to therapy and rehabilitation. The aim of the surgery is to decrease pain, reduce the recovery time and help to gain full range of movement. Arthroscopic capsular release and manipulation under anesthesia (MUA) are the surgical procedures performed to treat the frozen shoulder. PRE-OPERATIVE STEPS Every effort is made to assess the patient prior to surgery in order to ensure safety of the patient for the elective procedure. 1. After admission, routine blood work-up will be done prior to surgery. Depending on the age of the patient and other premorbid conditions, other investigations such as Echocardiography may be performed. 2. All the investigations prior to surgery are performed in order to ensure that the surgical procedure can be safely tolerated by the patient, since shoulder arthroscopy is an elective procedure. If any risk is involved, the patient/ attendants will be informed so. 3. Blood transfusion though rarely required, may be done depending on the reports. 4. X-rays and/or MRI may be done depending on the surgeon’s choice and the surgical indication. 5. Surgical consent will be explained to the patient detailing the procedure as well as the risks involved, if any. INTRA-OPERATIVE STEPS A manipulation under anesthesia (MUA) is most commonly indicated in patients with simple frozen shoulder. This procedure is performed with the patient sedated under anesthesia. Your surgeon moves the shoulder through a range of motion which causes the capsule and scar tissue to stretch or tear. Thus the tight capsule is released allowing increased range of motion. The procedure involves freeing the shoulder by manipulation and does not involve any incisions. Arthroscopic capsular release is a keyhole surgery that involves the release of the tight, constricted capsule. It is an effective treatment for most people with stiff shoulder after injury, trauma, or fracture, and diabetes. 1. During the procedure 2 to 3 small incision holes are made in the shoulder in the front and the back. 2. The thickened, swollen abnormal capsule tissue is cut and removed using a special radiofrequency thermal probe with adequate precautions to not damage the normal tissue. 3. Once adequate capsular release is achieved, wound is closed and dressing applied. 4. Once again the shoulder movements are checked to ensure adequate shoulder release. POST-OPERATIVE MANAGEMENT Following Capsular release, immediate rehabilitation is necessary to prevent the recurrence of Frozen Shoulder. The aim of the rehabilitation is to reduce pain and to restore full range of motion. • Pain medications are recommended to control pain • Following these procedures, though much easier than the pre-operative phase, aggressive regular exercises need to be done in order to maintain full range of motion for 1 week- 1 month. • If you feel comfortable and have good range of movement, you can begin driving 1 week after your surgery. • Returning to work depends on the nature of your work. If you are in a sedentary job you may be able to return as early as 1 week after surgery • But if your job requires heavy lifting or using your arm at shoulder height, it may take longer time to return to your work. • Full range of motion is achieved at 4 – 6 weeks once the swelling is reduced.

INTRODUCTION A revision knee replacement surgery is a procedure that is performed to replace a knee implant that is no longer functioning properly. Most knee replacements last several decades, some longer. However, there are also times when a knee replacement needs to be redone after years or even just months. Understanding why a knee replacement has worn out is critical to performing a successful revision knee replacement. The average knee replacement lasts more than two decades, and there are reports of implants lasting longer, and new materials and surgical techniques are hoped to provide even longer-lasting knee replacements. That said, there are times when knee replacements may last a very short time, even in otherwise healthy patients. A small percentage of patients (around 1-2%) end up requiring a knee replacement revised within a few years of their initial surgery. Revision replacements are performed for a number of reasons. Some of the more common include: Loosening of the implant Infection of the joint Instability of the knee Malalignment of the components Many people ultimately have a revision knee replacement because the problem is causing significant pain. While pain can be a problem in itself, a revision knee replacement surgery should not be performed without understanding why the pain is occurring. Performing this type of surgery for pain without an identified cause is unlikely to yield good results. Instead, the cause of the problem with the knee replacement needs to be precisely understood, and there needs to be a plan to address that problem with the implant. An operation without a clear plan to address the problem is unlikely to be helpful. Complexity in revision surgeries Revision replacement is difficult for several reasons. First, when someone has had surgery, scar tissue develops, and soft tissues become less identifiable. Performing the second surgery is always more difficult. Second, when performing a knee replacement, bone is removed. When performing a revision knee, often more bone has to be removed, and some may be lost as a result of the problem with the implant. Maintaining adequate bone to support the new implant can be a challenge. Finally, obtaining a knee that is flexible enough to allow for motion, yet stable enough to keep you steady, is also more difficult in revision situations. PRE-OPERATIVE PHASE Your surgeon will send you for routine blood tests to rule out infection, CT scan to look closer at the anatomy, and bone scans to help to determine if a component is loose. X-rays and/or MRI will be considered. Aspiration of the knee joint is occasionally done to diagnose or rule out infection Patient will be asked to undertake a general medical check-up with a physician Patient should have any other medical, surgical or dental problems attended to prior to the surgery in order to prevent a risk of infection. Cease aspirin or anti-inflammatory medications 10 days prior to surgery as they can cause bleeding. Any antiplatelet drugs / blood thinners such as clopidogrel, warfarin will be stopped 3-7 days prior to the date of surgery. Surgical consent will be explained to the patient detailing the procedure as well as the risks involved, if any. Blood transfusion, if required will be informed and done. Day of surgery You will meet the nurses and answer some questions for the hospital records You will meet your anesthetist, who will ask you a few questions and assess the risk factors for surgery. You will be given hospital clothes to change into and have a shower prior to surgery The operation site will be shaved and cleaned Approximately 45 minutes prior to surgery, you will be transferred to the operating room After explanation of the procedure, you will be asked to sign the consent for surgery. Occasionally, a high risk consent for surgery may be requested depending on the blood reports and clinical examination. SURGICAL PROCEDURE Each knee is individual and knee replacements take this into account by having different sizes for your knee. If there is more than the usual amount of bone loss, sometimes extra pieces of metal or bone are added. Surgery is performed under sterile conditions in the operating room under spinal or general anesthesia. You will be on your back and a tourniquet will be applied to your upper thigh to reduce blood loss. Surgery takes approximately two hours. The patient is positioned on the operating table and the leg prepped and draped. A tourniquet is applied to the upper thigh and the leg is prepared for the surgery with a sterilizing solution. An incision around 7cm is made to expose the knee joint. Old/ damaged components of the implants are removed. The bone ends of the femur and tibia are prepared using a saw or a burr to freshen the bone. Trial components are then inserted to make sure they fit properly. The real components (Femoral & Tibial) are then put into place with or without cement. The knee is then carefully closed and drains usually inserted, and the knee dressed and bandaged. POST- OPERATIVE MANAGEMENT When you wake up you will be in the recovery room with intravenous drips in your arm, a tube (catheter) in your bladder may be inserted, and a number of other monitors to check your vitals. Once stable, you will be taken to the ward. The postop protocol is surgeon dependent, but in general your drain will come out at 24 hours and you will sit out of bed and start moving your knee and walking on it within a day or two of surgery. The dressing will be reduced usually on the second postop day to make movement easier. Your rehabilitation and mobilization will be supervised by a physical therapist. To avoid lung congestion, it is important to breathe deeply and cough up any phlegm you may have. Your surgeon will use one or more measures to minimize blood clots in your legs, such as inflatable leg coverings, stockings, and injections to thin the blood clots or DVT’s. A lot of the long-term results of knee replacements depend on how much work you put into it following your operation. Usually you will be in hospital for 3-5 days and then either go home or to a rehabilitation facility depending on your needs. You will need physical therapy on your knee following surgery. You will be discharged on a walker or crutches and usually progress to a cane at six weeks. Your sutures will be removed at approximately 12-15 days. Bending your knee is variable, but by 6 weeks it should bend to 90 degrees. The goal is to get 110-115 degrees of movement. Once the wound is healed, you may shower. You can drive at about 6 weeks, once you have regained control of your leg. You should be walking reasonably comfortably by 6 weeks. More physical activities, such as sports may take 3 months to be able to do comfortably. You will usually have a 6-week checkup with your surgeon who will assess your progress. You should continue to see your surgeon for the rest of your life to check your knee and take X-rays. This is important as sometimes your knee can feel excellent but there can be a problem only recognized on X-ray. You are always at risk of infections especially with any dental work or other surgical procedures where germs (bacteria) can get into the blood stream and find their way to your knee. If you ever have any unexplained pain, swelling, redness or if you feel unwell you should see your doctor as soon as possible. A Revision Knee replacement is a complex procedure and requires a highly skilled surgeon with adequate expertise. Our Consultant in chief, Dr Vikas Jain is one of the few surgeons in the region who is trained from Europe and has adequate surgical experience in such complex revision procedures.

Shoulder Arthroscopy- Dislocation Bankarts Repair Surgery To better understand what shoulder dislocation is, an overview of the shoulder is needed. The humeral head (ball of the shoulder joint) is centered in the glenoid (the socket of the joint), which stabilizes the shoulder. If the shoulder becomes dislocated, it can tear the glenoid labrum and ligaments that help reinforce its structure. Bankarts repair surgery is a minimally invasive surgery to repair instability and restore function of dislocated shoulders. The goal of Bankart repair surgery is to re-attach the torn labrum and ligaments to the tip of glenoid from which they were detached. Symptoms of Bankart tear or lesions are: • Severe shoulder pain • Shoulder dislocation, single or multiple episode. • Repeated instances where the shoulders give out during activity • Sensation of the shoulder feeling loose, slipping out of the joint or “hanging there” PRE-OPERATIVE STEPS Every effort is made to assess the patient prior to surgery in order to ensure safety of the patient for the elective procedure. 1. After admission, routine blood work-up will be done prior to surgery. Depending on the age of the patient and other premorbid conditions, other investigations such as Echocardiography may be performed in elderly patients. 2. All the investigations prior to surgery are performed in order to ensure that the surgical procedure can be safely tolerated by the patient, since shoulder arthroscopy is an elective procedure. If any risk is involved, the patient/ attendants will be informed so. 3. Blood transfusion though rarely required, may be done depending on the reports. 4. X-rays and/or MRI may be done depending on the surgeon’s choice and the surgical indication. 5. Surgical consent will be explained to the patient detailing the procedure as well as the risks involved, if any. INTRA OPERATIVE STEPS 1. After anesthesia induction and patient positioning your surgeon will make two small incisions in the front and one small incision in the back of the shoulder. 2. The surgery is considered minimally invasive thanks to the small incisions resulting in less discomfort and shorter recovery time. 3. The surgery is performed using a small fiberoptic camera (an arthroscope) and other small instruments. 4. The labrum tissue which is attached due to fibrosis at abnormal position (after shoulder dislocation) is released from the underlying glenoid. 5. Small holes are drilled near the detached labrum, once it has been cleared of loose particles. 6. The surgeon will then attach sutures to the released labrum and pull them tightly across the anchors so the labrum can be reattached to the glenoid. 7. Once the ligaments are firmly in place, the incisions are then closed with small bandages and the surgery is complete. POST OPERATIVE STEPS The first few days following surgery may be painful, but is typically managed by minimal amounts of pain medication. Seven to 10 days after the surgery, patients should have a follow-up with their surgeon.. Physical therapy helps to improve physical strength, range of motion, and assists with normal activities of daily living. 1. After surgery the arm is placed in a sling immobilizer. The sling is worn for at least the first two weeks after the operation. It should be removed when bathing/showering, or to do exercises. The sling is worn to sleep, and when in big crowds for at least four weeks after surgery. 2. Physical therapy should begin 7 to 10 days after surgery. Your surgeon will guide you through the exercises required after the surgery. The exercises are necessary to strengthen the muscles around the shoulder joint. 3. 1-2 week: passive shoulder motion and passive/active elbow motion 4. 2-8 weeks: active-assisted range of motion 5. 8-12 weeks: isometric rotator cuff strengthening 6. 3-6 months: sports- and work-related exercises 7. Return to sport: conditioning at 12 weeks but full return to contact sports at 6 months For the first four to six weeks following surgery, the focus should be on rehabilitation and regaining as much range of motion as possible (keeping surgical repair in mind). Depending on the progress of the patient, the next four to six weeks the focus will be on increasing the strength of the shoulder. As the strength of the shoulder improves any pain should decrease. Patients should visit their physical therapist six-eight times over a period of 12 weeks. Depending on the recovery, a patient can return to normal activity within a short period.