Surgical Techniques

          ACL Reconstruction


When a severe twisting of the knee occurs, one or both of these ligaments (ACL and PCL) may become stretched, or even torn. This twisting of the knee may be related to a contact injury (such as might occur in football), or even a non-contact injury. Some patients report of hearing a “pop” or “snap” when the injury occurred. Following the injury, the injured knee joint may swell and feel like it may “give way” when weight is applied.
A tear in the anterior cruciate ligament (ACL) is one of the most common knee injuries that may occur to a recreational, amateur, or professional athlete. This injury may result from twisting the knee too far in one direction, or by a sudden and forceful change in direction as may occur during football, soccer, skiing, basketball, racquetball, or tennis. Frequently, the injury occurs in those sports that require the foot to be planted in one spot, and the body to suddenly change direction or make a lateral movement.

This anterior cruciate ligament is a thick fibrous band that connects the femur (the thigh bone) with the tibia (shin bone). If the ACL is completely torn, the knee becomes unstable. Because long-term instability may lead to early arthritis of the knee, a proper diagnosis is necessary to obtain the best possible outcome. By recognizing the instability and reconstructing the ACL, the chance of degenerative changes in the joint are reduced. A small percentage of people may be able to function with a torn ACL; however, this usually requires modification of activity.

Reconstruction of the knee joint following complete ACL rupturing, may require surgery to replace the stabilizing effect of the original ACL.


During surgery, a bone and soft tissue graft is taken (or harvested) from the anterior knee. A small portion of bone is taken from both the patella (knee cap) and tibia (shin bone). The drawing on the left depicts the location of this graft site. The bone grafts are connected to each other by a piece of strong patellar tendon. This graft with its three components will now serve as the new ACL ligament.












       



                   
                          
      







During surgery the one-piece bone and tendon graft (as seen on the left) will be surgically anchored inside of the knee joint in a location similar to the patient's original anterior cruciate ligament. This will help insure that the knee joint will have stability postoperatively.  During surgery the bone tunnels (holes) within the tibia and femur are created arthroscopically with small skin incisions, creating bone pathways for the insertion of the new tendon graft.

Prior to placement of the ACL tendon graft, it is prepared by attaching a metallic Endobutton to the graft's proximal end. This button will be inserted into the femur providing a secure proximal attachment to the ACL graft.  Additionally, a strong tensioning suture is attached to the graft's distal end. During surgery, this suture is used to apply the appropriate amount of tension to the graft within the knee.

The tendon graft itself is positioned by arthroscopic technique, providing a secure reconstruction both in the femur (with Endobutton stabilization) and in the tibia (with interference screw fixation). By using arthroscopic technique, Dr. Ahlfeld is able to surgically reconstruct the ACL with minimal skin incisions.  The small Endobutton allows the ACL graft to be inserted and held securely within the femur.

Following the graft placement into the femur, the graft is tensioned at the tibia below the knee joint. A single absorbable interference screw is inserted into the tibial drill hole securing the bone segment to the cancellous bone within the tibia. A close-up view of one type of this "interference screw" is shown below.




The proper placement and alignment of this graft insures that the reconstructed knee will function as it did in its pre-injury condition. Care is taken to place the ligament graft into the correct anatomical position, so that optimal knee joint function and stability will be achieved. Once healed, and following rehabilitation, the graft's function will closely match that of the original ACL.

The original incision on the patellar tendon is closed with sutures. Recovery time for this type of surgery may take several months.

Because each injury and each patient's knee may be different, an individually tailored, post-operative rehabilitation program is designed to assure each patient of the best outcome.

Dr. Ahlfeld is a pioneer in this type of ACL reconstruction and has been using this technique successfully in athletes for many years.

If you should have a question or concern about anterior cruciate ligament (ACL) reconstruction, or any other knee problem, please call our office.               

                                          

 Fractures at the base of the Fifth Metatarsal in the Foot


Fractures of the base of the foot's fifth metatarsal bone are common fractures seen both in recreational and competitive athletes. This type of fracture is generally referred to as a “Jones Fracture,” named after Sir Robert Jones, who first described this fracture pattern in 1902.  The metatarsal bones are a group of 5 bones in the foot that contribute to the foot's normal arched shape. The fifth metatarsal is located on the little toe side (or lateral side) of the foot, and connects the small toe's proximal phalanx to the cuboid bone near the ankle joint. Strong ligaments attach the base of the fifth metatarsal to the cuboid bone and the fourth metatarsal bone. Because of these strong ligament attachments, Sir Robert Jones concluded that it was easier for an individual to break or fracture the fifth metatarsal, than to dislocate it.

There are three patterns of Jones fractures, according to the actual location of the fracture on the bone. Fractures in Zone I are typically avulsion type fractures, wherein a small fragment of bone is broken off the proximal end of the bone. Zone II fractures involve an area of the bone a little more distal (or toward the toes), and most typically appear as horizontal or transverse fractures. Zone III fractures usually occur in the shaft of the metatarsal bone.




Fractures to the fifth metatarsal base are thought to occur in different ways. The “acute” type of fracture, meaning a sudden, severe fracture, or one with a rapid onset, happens all at once from one single, forceful incident. Such a fracture might occur when excessive forces are applied to the lateral slide (small toe side), or lateral ball of the foot.

A “chronic” fracture represents those fractures that occur due to bone stress or bone fatigue. These stresses on the metatarsal bone occur over time from repetitive forces to the lateral foot area. These types of fractures do not happen all at once from one single injury, but may be a result of weeks or even months of traumatic stress. X-rays of these fractures usually show evidence of a pre-existing stress reaction in this area.

Some of the more minor fractures that are stable, and not displaced, may be successfully treated with bracing or casting. At times, however, these fractures may require surgery to fix (or reduce) the fracture. This surgery may include the placing of an intramedullary screw (much like a long wood screw) into the bone’s shaft. This procedure stabilizes the fractured bone, and holds it securely in place while healing occurs. This internal fixation technique frequently enhances bone healing, and allows for an earlier return to athletic activities.  Intramedullary screw are placed into the shaft of the metatarsal to fix (or reduce) the fracture. The final x-ray shows complete bone healing with new bone formation at the site of the original fracture.

        





 Knee Arthroscopy


Knee joint arthroscopy is performed with a surgical arthroscope that allows the surgeon to indirectly view the knee's anatomy on a television monitor. 
Torn or ragged tissue can be easily trimmed and removed, and other structures can be viewed to verify that they are intact.  Three to four small, half-inch incisions allow the arthroscopic camera and other instruments to be inserted into the knee joint.  The arthroscope's small video camera allows the surgeon and assistants to access the status of the knee's anatomy, including both cruciate ligaments, the lateral and medial meniscus, and other soft tissue structures.

Recovery time from arthroscopic surgery is much shorter than it is for conventional or open surgery. Because the incisions for this minimally invasive surgery are much smaller, patients experience less post-operative discomfort, and are able to return to their daily activities in a much shortened time period. 

Link to video of this procedure
                                              




 Arthroscopic Rotator Cuff Repair

A rotator cuff repair is necessary when the tissue of at least one of the rotator cuff muscles is fully torn, requiring the tendon of the muscle to be reattached to the head of the humerus. Arthroscopic repairs typically result in quicker healing and faster recovery times when compared to alternative repairs. 

Click to see a video illustration of this procedure

                                                                                                                                                        



                                  Arthroscopic Shoulder Labrum Repair

                           

The cartilage that cushions the shoulder socket is also known as the labrum.  This tissue can tear from compression, twisting and often overuse injuries of the shoulder.  Small tear can be debrided away similar to a knee arthroscopy, however larger tears need to be anchored back to the glenoid to assure proper attachment and full function.

                         Click to see video illustration of this procedure 



 Unicompartmental Knee Arthoplasty
       (Partial Knee Replacement)

A partial knee replacement is used to treat moderate to severe arthritis of the knee.  This procedure replaces the medial components of the femur and tibia, allowing a patient to keep existing lateral bone that may not need to be replaced.

    Click to learn more about this procedure   
                             
 
 
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