We at Orthopedica have developed a methodology to prepare yourself at the best by the moment you are to get the surgical procedure with less hospital stay, better immediate post-op period and early deambulation (Within hours ) .
Immune system is critical when talking about surgical trauma stress presented at the moment of even days before of the surgical procedure itself.
Your whole body is stimulated or modulated to get the best scenario when facing a total joint replacement like the knee replacement.
Two weeks before the actual operation you will have a special treatment to enhance your immune system to fight infections and help your body heal better . We do address the potential complications like Deep Vein Thrombosis with preventive measures like Pneumatic pumps that keep the blood flow active avoiding Edema and swelling of the limb and oral anticoagulant of last generation like Xarelto® (Ribaroxavan from Bayer) that are safe and easy to take just like swallowing a pill .
These two measures assure the avoidance of this major complication and help the patient get sooner to their daily life activities .
Usually Total Replacement like the knee Joint, make the patient stay at hospital from three to five nights . Based on our scientific performance and experience, we can dismiss a patient form six to 36 hours, normally without having a blood transfusion (Exceptions apply depending on the clinical case, we do normally avoid transfusion in 95% of the cases) . Pain is modulated before the operation with other measures, the patient can start exercises from within hours of the actual procedure with better chances of starting the aided gait very early.
Our preferences in Knee Implants are based in quality and performance. We do recommend and use Johnson & Johnson PFC, Smith & Nephew's Oxinum and Biomet's Maxim.

Visit American Academy of Orthopedic Surgeons AAOS for a thorough description on total knee replacement

About the Anterior Cruciate Ligament (ACL) injuries
Anterior cruciate ligament (ACL) injuries are injuries to a ligament that connects the upper leg bone (femur) with the lower leg bone (tibia). An ACL injury may result in the knee occasionally buckling or giving out. This is the main references on symptoms from patients all over the world when questioned about what they feel about their knees with a torn ACL.
ACL injury can be a partial or complete tear of the ligament, a separation of the ligament from the upper or lower leg bone (avulsion), or a separation of the ligament and part of the bone from the rest of the bone (avulsion fracture). Other parts of the knee can be injured at the same time, including the pads that cushion the knee joints (menisci), another knee ligament, or the tissue that covers the ends of bones (cartilage).



What is the Anterior Cruciate LIgament (ACL)...?

The anterior cruciate ligament is considered by many authors the main ligament in the knee due to its complex role in the joint bio mechanics.
This ligaments is exposed to high tension forces and from time to time, these forces extend the ligament natural resistance stretching tolerance and tears apart .

When this ligament is torn, there are several events that happens, and one of the main symptoms that patients report is instability or the sensation that the knee become loose and out of control in episodes called “Give away” .

How do an ACL get stretched beyond its resistance and gets torn..?

If we analyze how our body is composed of complicated and elaborated mechanic leverage around the knee we wouldn’t be surprised that the very same long arm leverage that act in our behalf, suddenly become against Us when pushed to their limit.
We do not need a great impulse or a force generated when playing Football or basket ball games . Sometimes it is just needed a false step, a wrong twist when the foot is planted and locked against the floor to trigger our own weight and inertia against Us.
The blocked foot against the floor, sticks to the surface meanwhile the Femur continues it’s internal rotation over the tibial joint surface to the point that the tibia cannot follow through, then comes the ACL body stretching to the point of rupture.

What are the symptoms, when to think I’ve got a torn ACL

Usually it is not very complicated as a patient to think directly in a torn ligament when the following happens :

• You have just twisted your leg during a football rehearsal, a competition game or just simply during your daily jogging session .

• After and audible “POP” and sudden pain, the knee joint swells within the first half an hour after the event.This is due to the tear of the ligament artery that in minutes floods the joint cavity with blood sometimes to the point of stretching the capsule and producing an excruciate pain that only alleviates when the blood is evacuated and the joint pressure drops .

• As a resultant of the loss of an important stabilizing structure within the knee joint, a secondary loosening in stability follows. Instability means the reduced capacity of maintaining the congruency of the joint in all the phases of the natural movement along the whole range of motion. A subjective sensation of insecureness, lack of confidence when changing direction when walking, specially if there is an uneven ground, or feeling that your knee is “Giving away” in certain movements that you surely will try to avoid.

What is the solution for a torn ACL..?

When we are dealing with a mechanical based problem, it is usually a mechanical answer the one is needed . Although just in US, there are about 300,000 ACL surgical reconstruction over one year period, not all patients are good candidates for an ACL reconstruction.

You probably are if:

• More than an age dependent factor is the fact that you are an active person and that activities requires a stable and dependable knee joint, either because of your profession , like professional sports player, Police, Fireman, etc.,or your life activities preferences like outdoors, sporting, etc.

2)If you feel your life quality does get impaired to performs things you want to do, like, walking, jogging, playing with your kids or grand kids, or just name it, stepping off the car.


You probably are not if:

1)You are a sedentary person and consider you do not have any problem with your daily activities.

2)Your knee actually does not feels insecure and can perform the personal required standards of life, in few words, if you are really happy the way you are.


What happens if I need treatment, and ACL reconstruction and I do not get the operation..?

It is up to you whether you want to come back to sports or those activities that where impeded by your lack of ACL or you just want to live your life as it is.
Still, many improve after certain exercises routines in order to strengthen the leg muscles and perform some proprioceptive massage and limb motion .


How do we perform the ACl reconstruction at Orthopedica..?

It all start with a thorough physical evaluation, including imaging like regular X Rays Plates and Resonance imaging . Once the diagnosis is established we do proceed to prepare the patient from two main points; Immunological and on the healing biological process . The preparation period starts within a period of few weeks to few days.
The patients is advice to take some specific medication to prepare the body for a better blood circulation, a better Immune response and a better healing process.

The operation

We do operate at CIMA Hermosillo, a Joint Commission Accredited Hospital.
The anesthesia is provided by a certified anesthesiologist by means of a spinal block.
Antibiotic is given preoperatively in order to prevent infection. An arthroscopic exam of your joint is carried out to confirm the diagnosis and to assess the real visual status of the cartilage, meniscus and ligaments within the joint.
We take the semitendinous muscle tendon with a tendon striper and fold it to make a two bundle graft. Then we make a tunnel on tibia towards the center of the tibia spine, then make another tunnel up in the inner wall of the lateral side of the femur bone.
we pass the graft to be lodged in these tunnels and secure them with interferencial bioabsorbable screws driven in the Femur and tibial tunnel.
A number of procedures on cartilage or Meniscal tissue is done when needed.


The duration of the whole procedure typically is about one hour. After the compressive bandage is applied to the knee, the patient is sent to the recovery room and usually after two hours, is dismissed from the hospital.

Will there be pain once at home ..?

Pain medications are really handy in resolving and most important preventing the appearing of pain . When properly managed, pain can be not only treated successfully but prevented. In our experience, our patients do not refer pain by general means, nor swelling, only minor discomfort in some cases that can be easily controlled to a comfortable status .


What kind of pain killers will I take..?

There is a wide array of painkillers to provide that suites the specific needs of every patient. Usually in a typical situation, we prescribe : Tramadol mixed with Tylenol every six hours. Tramadol is an opioid that does is not an habit forming analgesic, therefore, this is a very safe medication. The only back draw can be a drowsiness sensations in some sensitive persons. Should this happens, we switch to Desketoprophen a new NSAID or Arcoxia 120 mgr . (Etoricoxib 120 mgr. Merck Sharp & Dome)

Preventing Deep Vein Thrombosis DVT

DVT events are serious complications can can be prevented with very simple measures. An assessment of every case potential risk is made. Should the patient present an elevated risk due to varicosities or other actual circumstances a modern and safe oral anticoagulant is provided, XARELTO © Bayer (Rivaroxaban) 10 mgr a day for ten to twenty days. Clinical studies confirm the efficacy and safeness of this new drug worldwide tested , specially in major orthopedic procedures such as Totla Knee Replacement and total Hip Replacement.

How about my rehabilitation program..?

This rehabilitation program will be created to suit your particular needs, but in general bases, this will be initiated the next day form the operation.
This program includes Range of Motion Exercising, strengthening of leg muscles and proprioception, the ability to recognize the position of a limb without actually seeing it. This ability is lost after a knee trauma and can successfully be recovered after the surgery to help improve your gait.

What about Sports..?

Once you are operated, we encourage the practice of some routines at Gym and Stationary bike to gain muscle strengthening, nevertheless, competitive sports will eventually com after six to nine months post op to allow the graft to be completely integrated to the bone tunnel.


More information from American Academy of Orthopedic Surgeons AAOS

Meniscal transplant is a salvage measure to try to reinstall an anatomic structure in the knee joint to help duplicate the protective function of this important tissue.
We at Orthopedica belong to the Mexican Meniscus Study group with a global experience of over 100 meniscus transplanted with an overall of 80% of satisfactory results in those patients whose meniscus had being ablated and that a number of symptoms were present such as pain due to the lack of meniscus and joint arthritis .
The meniscus were poorly understood as a vital structure and in many times their ablation was not justified on long term prognosis . Although many experimental procedures in tissue engineering is under way, meniscal transplant is now the golden standard to help restore the joint anatomy and physiology.
It is an arthroscopic outpatient procedure and with modern tissue bank safety standards we can expect that an infection transmission like HIV, Hepatitis, etc would be in the order of 1 in 6000,000, a very unlikely event .

Watch an actual meniscal transplant arthroscopic operation


Read more on meniscal transplant on American Academy of Orthopedic Surgeons AAOS

Dr. Pavlovich's technique , Meniscal repair with Radiofrequency pulses to enhance the meniscal healing process.
See interview with Knee heroes web page

Injury of the surface of the femur's cartilage.



Matrix Autologus Chncrocyte Implant MACI
Cartilage is a form of extracellular matrix secreted by specialized cells called chondrocytes. Articular cartilage covers the end of the femur, the top of the tibia, and the back of the patella. It serves as a shock absorber and is essentially frictionless, providing a smooth surface for the contact and movement of the bones of the knee joint. Meniscal cartilage is on the tibia and serves mostly as a shock absorber. Autologous Chondrocyte Implantation is used to repair defects to the articular cartilage.
Chondrocytes are one of the few cell types that can survive without being close to a blood supply. However, when the cartilage is damaged, the chondrocytes' distance from a blood supply means that they lack the ability to regenerate themselves, a process that requires an increased amount of nutrients and access through the blood stream to other cells and proteins that stimulate the regeneration.
 

When the cartilage is damaged what are the treatment options

There are certain procedures that can be done through arthroscopic surgery to relieve the patient's symptoms. The damaged area is usually first debrided, cleared of debris and dead cells, and the surface is smoothed. A number of techniques are also used to create scar tissue, including microfracture, drilling and abrasion arthroplasty. Like cartilage, scar tissue covers the joint surface, but unlike cartilage, scar tissue is not as durable or flexible. While these procedures will alleviate symptoms, it is a temporary repair and patients often experience a return of their symptoms. Patients then have the option of living with the pain, undergoing another arthroscopic procedure similar to the one that recently failed, or, in severe cases, receiving a total knee replacement.
Total knee replacement surgery is most common among people between 65 and 75 years old, although younger and older people are also eligible. For patients with knee injuries that would qualify for the ACI procedure, total knee replacement is often not needed. Also, for patients under the age of 50, total knee replacement is considered a poor treatment option because the artificial joint fails after about 10 to 15 years.
 

Am I eligible for a MACI....?

Patients eligible for treatment with ACI suffer "clinically significant, symptomatic defects of the femoral condyle (medial, lateral or trochlear) caused by acute or repetitive trauma".1 These patients usually have joint pain, swelling, catching or grinding. Patients with cartilage damage due to arthritis are not eligible. Arthritis is an autoimmune disease; thus if the immune system attacked and destroyed parts of the patient's cartilage previously, it will probably attack and destroy newly implanted chondrocytes as well.
MACI is generally applied to patients between the ages of 15 and 55, with little or no additional damage to the knee joint. These are patients who do not have enough knee damage to need a total knee replacement, but who are experiencing considerable pain that may be impairing their quality of life. Clinically appropriate patients are identified through traditional diagnostic methods, such as MRI and x-ray evaluation. Final decisions are made at the discretion of the orthopedic physician with the aid of an arthroscopic examination.

Knee surgery outcome is a measurable process and it is designed to evaluate the progress of different types of surgeries.
Should you want to evaluate your actual status expressed in numbers, you may go to these different links an answer the check boxes in each different scores for different procedures.

Lyshom and Tegner Score for anterior cruciate ligament


IKOOS International Knee and Osteoarthritis Outcome


Cincinnatti Modifyed Score