Cartilage Repair Knee Specialist Surgeon Tim Spalding - General

General

General (155)

Conference presentations by Mr Spalding

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Conference presentations at South African Orthopaedic Association meeting September 2017


Meniscal allograft: Why when and how. Tim Spalding      
 



Prophylactic Meniscal allografting. Early suggestions  from RCT.  T Spalding    
   



Udpate on cartilage repair ACI/MACI. T Spalding        


Update on use of Allografts for articular cartilage. T Spalding    
   

Combining treatments for complex knee problems: Osteotomy, stability, meniscus, cartilage    
   
       

 

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Medial Patello-Femoral Ligament (MPFL) Reconstruction

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This page is intended to help you understand the operation and the recovery following the surgical procedure to stabilise your kneecap (patella)

It is not intended to be a comprehensive guide, and you should discuss any further queries that you may have with your consultant surgeon.   

 What is the medial patellofemoral ligament?

The knee cap (patella) is designed to help the muscles on the front of your thigh to straighten your leg.  As you bend and straighten your leg, the patella glides in a groove at the end of your thigh bone (femur) known as the trochlear groove of the femur.  Sometimes this groove may not be very deep and this can contribute to instability of the patella and a feeling that it may slide out of the groove (dislocate) when the knee moves.  Stability of the patella can also be affected by the alignment of your leg so that patients who are knock-kneed (valgus alignment) have a higher chance of developing patella instability.  This instability may also be caused by an injury that dislocates the patella. 

To aid stability of the patella there are a number of soft-tissues that attach to it.  These structures can weaken over time particularly if there is little stability provided by a flat trochlear groove.  This may lead to recurrent partial dislocations (subluxations) or complete dislocations.  This is painful and causes scuffing (wear) to the under-surface of the patella and may lead to the development of osteoarthritis.  

Of the soft tissue structures that stabilise the knee, the medial patellofemoral ligament (MPFL) is the most important.  It is a thin strip of tough tissue that attaches from the inside edge of your patella to the inner side of the lower end of your femur, to anchor and prevent the patella from sliding out of its groove. 

If your patella feels unstable or is regularly dislocating this can often be improved by strengthening the muscles around the knee using physiotherapy.  If this does not provide much improvement then surgical reconstruction of the MPFL may improve the situation.     

 

Surgical reconstruction of the MPFL

Surgical reconstruction of the MPFL is carried out under a general anaesthetic. It is a minimally invasive procedure and will require only a few small incisions on the front and side of your knee.  A small camera will be used to look inside your knee and to repair any other damage that may be found in the joint.

One of your hamstring tendons will be used, harvested through one of the small incisions that have been made.  The new ligament is secured by passing it through a small tunnel made on the inner edge of the patella and then fixing it to a short tunnel in the inner side of the femur.  Great care is taken not to under or over tighten the ligament so that it can effectively carry out its new job. 

 

Intended benefits of the surgery:

The aim of the procedure is to prevent the feeling of instability (giving way) and the recurrent dislocations that occur when the MPFL is disrupted.  This is usually an extremely successful operation with high levels of satisfaction for those who undergo this surgery.

 

Some of the identified risks with this type of surgery:

Some risks associated with this procedure are:

  • The operation may not to work patients may develop recurrent instability, The risk of this is 5-10%.
  • There will be some bleeding + swelling after the procedure but it is extremely rare for this to cause a serious problem.
  • There is a very small risk of a blood clot forming in the legs (deep venous thrombosis) which may require treatment with medicines to thin the blood (less than 1 in 200 cases). Even more rarely, one of these clots may travel to the lungs (pulmonary embolism) which may be serious.
  • Post-operative infection is very rare but could cause further damage to your knee. Very occasionally further surgery to wash the knee out is required.
  • Patients are often left with an area of numbness over the inner aspect of their knee. This isn’t often troublesome and usually reduces with time.  It can occasionally be permanent.
  • Fixing the MPFL and preventing further instability of the patella does not necessarily protect you from developing osteoarthritis in the future. This is due mainly to any damage that has already been done.
  • A small proportion of patients are left with persistent pain at the front of their knee after any knee operation.
  • Failure of the wound to heal is extremely rare. Certain individuals are at a higher risk of this (e.g. those with diabetes or peripheral vascular disease).  If you are at risk, this will be discussed with you prior to the operation. 

N.B. Many of the above complications apply to all forms of knee surgery

 

What are the alternatives to an MPFL reconstruction?

The main alternative is to do nothing at all and to continue with the physiotherapy and exercises that you are already doing.  If no improvement has been noticed it is unlikely that any further improvement is going to occur.  You may be happy just to accept the problem and not go through with any surgery.

If it is found that you have a shallow trochlear groove in which the patella glides, an operation that may help you is a Trochleoplasty.  This bigger operation involves lifting the articular surface of the groove and then hollowing out the groove to make it deeper.  The articular surface is then replaced and patella stability is improved as the groove is deeper.  This procedure is only required if your trochlear groove is completely absent.  

 

 

Follow up procedure and hospital stay

The majority of people undergoing MPFL reconstruction will have to spend just one night in hospital.  Rarely, a person may need to be kept in hospital if a complication has occurred.

You should be able to resume driving in 4 weeks and it is expected that you can return to sporting activities from 4-6 months. 

Follow-up appointments should be arranged for 4-6 weeks post op and then at 3 months and 6 months

If you have any further queries or concerns after your operation then please contact Nicki on 01926 772731

If you experience any excessive pain, swelling, or discharge then please contact either the hospital or your own GP immediately.

 

Post-operative rehabilitation

Day of operation / Day 1

  • Return from surgery with a wool / crepe dressing. This dressing will be changed to a Tubigrip before you leave hospital the next day.
  • You will be encouraged to practice full active extension of your operated leg.
  • Your physiotherapist will show you static quadriceps exercises, proceeding on to straight leg raises (you may need to help lift your leg with a towel/belt so that your knee is kept straight when lifting your leg).
  • You will be encouraged to mobilise so that you are full weight bearing - in full extension with crutches (you may have a brace only if you have poor quadriceps control).

Week 1

Goals

  • Diminish swelling / inflammation.
  • Regain active quadriceps / VMO control.
  • Maintain full knee extension / hyperextension.
  • At least 45° knee flexion.
  • Patient education regarding rehabilitation process

Week 2: Wound check and Suture (stitch) removal by nurse

Weeks 2 - 4

Goals

  • Control swelling / inflammation.
  • Gradual increase in range of movement (within limits of pain).
  • At least 90° knee flexion by end of week 2.
  • At least 120° knee flexion by end of week 4.
  • Quadriceps strengthening (especially VMO).

 

Week 4: begin to drive short distances if able to perform an emergency stop safely.

Week 4: Return to sedentary job.

Weeks 5 - 6

Goals

  • Full flexion.
  • Good activation of quadriceps and straight leg raise with no lag (knee bend).
  • Can start swimming ( not breaststroke until 10-12 weeks post operatively).
  • Can return to work in a physical job if able to carry out light duties with limited walking.

Week 6: Clinic review Ensure appropriate progress.

Weeks 7 - 12

Goals

  • Increase quadriceps and VMO control for restoration of proper patella tracking.
  • Improve muscular strength / control / endurance without exacerbation of symptoms.
  • No altered walking pattern.
  • Functional exercise.
  • Begin kneeling.
  • Able to return to gym (with guidance from physiotherapist).
  • Can start breaststroke when swimming.

Week 12 clinic review: check of progress.

Weeks 12 - 16

  • Goals
  • Knee extension strength at least 70% other knee.
  • Work towards achieving maximum strength and endurance of leg musculature.
  • Functional activity drills.
  • Good active patella control with no evidence of lateral tracking or instability.

Weeks 16+

Goals

  • Full pain free range of movement.
  • Continued improvement in quadriceps strength (80% or greater of contra lateral leg).
  • Improve functional strength and balance reactions.
  • Maximise confidence in returning to appropriate activity level.
  • Functional return to work / sport. ** Return to sports dictated by particular sport, ability, fitness and confidence – minimum 4 months (with guidance from physiotherapist and surgeon)

 

Tim Spalding 2018

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Guide to local area

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Here is a guide to the local best places in and around Leamington Spa.

Please check out the places or call Nicki for advice

Tourist type places to visit and see Warwick Castle: Largest working Castle in England: https://www.warwick-castle.com/
Stratford: Shakespeare birthplace and great theatre: https://www.visitstratforduponavon.co.uk/

Good pubs and eating
Fat pug pub: https://www.thefatpug.com/ Royal Pug pub: https://www.theroyalpug.com/
Fox and Vivian: http://www.foxandvivian.com/
Saxon Mill (on the river with a weir): https://www.saxonmill.co.uk/
Any pub from the Lovely Pubs group, as these are the best eating place just outside the town of Leamington: http://www.lovelypubs.co.uk/
Coffee Architects: http://www.coffeearchitects.com/
Swirls for the best Gelato: http://www.royal-leamington-spa.co.uk/swirls/

Hotels and accommodation
Premier Inn Chesford Grange with pool: https://www.qhotels.co.uk/our-locations/chesford-grange/
Mallory Court and Spa: https://www.mallory.co.uk/
Episode Hotel: http://www.episodehotels.co.uk/hotel-overview.html

Top Shopping
Status Menswear (mention my name): https://www.statusmenswear.com/

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Episurf Partial Resurfacing Procedure

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Episurf Partial Resurfacing

Episurf is a specialist company who have pioneered a customised metal implant for partial resurfacing of the knee

See the website EPISURF: for further information and indications

Mr Spalding is on the medical advisory board for the company Episurf and has produced a surgical technique video.

EPISURF Post Operative Rehabilitation

rehabilitation (n.) recovery, improvement The action of restoring someone to health or normal life through training and therapy after illness. Commonly referred to in its shortened version, “rehab”.

Episurf produce the Episealer®: a product designed for patients who have a cartilage lesion with an underlying bone defect. In young patients these defects are often treated ‘biologically’. Once this window of opportunity has passed and lasting biologic treatments are no longer an option, Episurf produce an innovative treatment option. Episurf have developed technology that allows your surgeon to customise a solution, tailor-made for every patient, targeting only the damaged cartilage. The implant is designed to stop or delay the need for joint replacement and restore your normal function, whilst reducing your pain.

To ensure a perfect fit, the implant is customised based on your anatomy and the area of damaged cartilage, using details obtained from specialised MRI scans.

The implant is manufactured using cobalt chrome alloy. The underside is sprayed with a layer of pure titanium and a top coat of hydroxyapatite on the underside. Once in contact with bone, these specialised materials enable your body to grow onto the implant to keep it firmly in place. The top surface of the implant is polished to an ultra-smooth finish to ensure a smooth articulation in your knee.

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  • Attachment - EPISURF Ppst Operative Rehabilitation download

Further Information

  • Episurf Medical AB
    Karlavägen 60
    114 49 Stockholm
    Sweden

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Osteo-Chondral Allograft

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Knee Reconstruction using Osteochondral Allografts

Allografting or, to give its full name, ‘fresh osteochondral allograft transplantation (OCA)’ is an operation in which a damaged or diseased area of a joint is reconstructed using a bone and articular cartilage transplant. The cartilage cells can survive the transplantation only if the tissue is ‘fresh’, which means it has not been exposed to radiation or prolonged freezing.

OCA was pioneered at the beginning of the 20th century, and has had a long and successful history. It is becoming increasingly popular as a treatment for large injuries caused by trauma, osteochondritis dissecans (growth abnormality of bone and joint), and bone death (osteonecrosis) resulting from lack of blood flow to the bone supporting the joint cartilage.

The scientific basis of OCA is the transplantation of fully developed or mature hyaline (joint) cartilage containing living cartilage cells (‘chondrocytes’) that survive the transplant and support the production of the cartilage matrix indefinitely. Theoretically, this maintains the tissue balance (‘homeostasis’) of the joint cartilage. Studies have shown chondrocytes living as long as 29 years after transplant. The graft often includes a portion of bone to help restore missing bone.

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  • Attachment -  Department of Trauma & Orthopaedics : Knee Reconstruction using Osteochondral Allografts download
  • Authors: Consultant Surgeons Mr Tim Spalding, Mr Pete Thompson, Mr Andy Metcalfe, UHCW NHS Trust
  • Contact email: via Desdimina Rai, Secretary to Mr Tim Spalding, Consultant Orthopaedic Surgeon.
  • Tel: 024 7696 5098, Email This email address is being protected from spambots. You need JavaScript enabled to view it.

The Trust has access to interpreting and translation services. If you need this information in another language or format please contact and we will do our best to meet your needs. The Trust operates a smoke free policy

    Document History
  • Author Mr Tim Spalding, Mr Pete Thompson, Mr Andy Metcalfe
  • Department Trauma & Orthopaedics
  • Contact Tel No 024 7696 5098
  • Published December 2017
  • Review December 2019
  • Version 1
  • Reference No HIC/LFT/2192/17

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  • Attachment - Osteochondral Grafting post operative rehabilitation download
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CartiOne Articular Cartilage Repair

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CartiOne Articular Cartilage Repair : POST-OPERATIVE REHABILITATION

cartione logo

Femoral and Tibial Defects

 

Week 1

Week 2-6

After week 6

Weight bearing

Non- weight bearing

Non- weight bearing

Gently commence weight bearing to achieve full weight bearing over 2 weeks

Mobilisation

TROM

First 48h 0

After 48h 0-60

 

TROM

Week 2 0-60

Week 3-4 0-90

Week 5-6 0-120

Free movement

(as pain allows)

 

 

Walking, sport

Gentle mobilisation

Swimming

After 8 weeks:static bike without resistance

After 6 months:Light jogging

After 12 months:Skiing

After 12-18 months: contact sports

Patella and trochlear defects

 

Week 1

Week 2-6

After week 6

Weight bearing

Non- weight

bearing

Non- weight

bearing

Gently commence weight bearing to achieve full weight bearing over 2 weeks

Mobilisation

TROM

First 48h 0

After 48h 0-30

 

TROM

Week 2 0-30

Week 3-4 0-60

Week 5-6 0-90

Free movement

(as pain allows)

 

 

 

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Knee Replacement

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 Knee Replacement

( Click PDF to download by section)

Part 1: Information about knee replacement Knee Part 1 Download

•    What is Knee Replacement (metal and plastic resurfacing)
•    The normal knee and the types of replacements
•    Indications for surgery
•    Expectations and potential problems


Part 2: Information about the time in hospital knee part 2 download

•    Coming into hospital
•    Discharge planning
•    Your anaesthetic
•    Recovery after the operation
•    Going home plans


Part 3: Rehabilitation Physiotherapy exercises following surgeryknee part 3 download

•    Early bed exercises - the first set
•    The second set of exercises
•    Early Functional activities
•    The third set of exercises
•    Next functional activities
•    Advanced and home exercises - the fourth set
•    Further information and follow-up plans

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Knee Information - Useful Links

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Knee Information - Useful Links

 

Interesting Medical Articles in the Press

Videos and animations of operative procedures

Understanding knee surgery - excellent animations from understand.com 

Recent Open Access Publications for Mr Spalding

Recent Conferences with online access to Presentations

Various national and international conferences are recorded and the content is available on line - this usually requires registration.

  • Vail International Complex Knee Symposium, 2015. Presentations and surgical demonstrations online collection. 16 cadaveric demonstration and dissection videos and 40 lecture presentations from world renowned faculty. play the video
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PCL reconstruction

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POSTERIOR CRUCIATE LIGAMENT RECONSTRUCTION (PCL)

This information sheet provides information on the nature and purpose of the procedure in addition to an outline of the post-operative rehabilitation.

Purpose and description of the procedure

The PCL is the largest ligament in the knee and stops the shin bone (tibia) from moving too far backwards.

It is commonly injured by a blow to the front of the upper shin, such as during a fall onto the flexed knee. Hyperextension (over straightening) and hyperflexion (over bending too far) of the knee can also tear the PCL and it is often torn in high energy injuries dislocating the knee such as falling from a height or in RTA's. Not everyone who has a PCL injury will require surgery as milder or partial isolated tears (no other ligaments involved) can heal just with the aid of an appropriate brace and rehabilitation. When torn the problem symptom is a feeling of ‘looseness’ and a feeling of giving way.

Often a brace is recommended, holding the tibia forwards and controlling stability. This helps predict who would respond well to the operation. The knee can tolerate some looseness associated with a healed PCL ligament but it depends on the required sport and how the ligament heals.   

Download the full bookletdownload

 

Post-Op Posterior Cruciate Ligament bracing Protocol

  1. On day of surgery Lead Physio to measure patient and order Medi PCL dynamic brace
  2. At the end of operation patient is fitted with Medi PTS brace - PTS brace to be worn at all times including at night for the first 3 weeks - May remove brace for range of motion physio exercises and to wash leg
  3. At 3 weeks PTS brace to be changed to the Medi PCL dynamic brace as initial post-op swelling should have improved - Allow 0-90 degrees of flexion (this is the default setting of the PCL dynamic brace) - Wear PCL dynamic brace at all times including at night until 8 weeks
  4. At 6-8 weeks when reviewed in clinic remove the ‘90’ degree stop from the brace to allow full range of movement - Continue with dynamic brace at all times except physio exercises until 3 months post-op - May stop using brace at night after 3 months
  5. Continue dynamic brace when walking for 4-6 months post-op as decided by
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