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ADVANCED SURGICAL OPTIONS
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General
Arthrodesis (Joint Fusion)
Arthrodesis (Joint Fusion) Book an Appointment Overview Joint fusion or arthrodesis is still a useful surgery in some conditions where the joint has been destroyed to the extent that it cannot be reconstructed and the replacement of the joint may not be available or involves higher risk. The common joints which get this arthrosed (fused) are ankle, big toe, mid foot and wrist. The aim of this surgery is to provide a painfree rigid joint in place of a painful and stiff joint. When to get Arthrodesis done? Osteoarthritis: Advanced stages of ankle arthritis with severe pain, limitation of mobility in a young and active patient. Secondary Arthritis: Arthritis secondary to deformity post injuries around the joint in young patients. What symptoms warrant surgery? Persistent pain Night pain Limited mobility due to pain Difficulty with activities of daily living due to stiffness and pain Risks Any surgery would involve certain risks, however the risks with arthrodesis are low. Fracture: During the surgery there is a small risk of fracture of the bones adjacent to the joint. Infection: Risk of infection is low with the advanced techniques and improvised theatre environment. Infection if picked up early, are likely to respond to antibiotics. In some instances it may need further washout or even removal of the implant. Nerve Damage: Rare, but can lead to numbness or weakness down the limb. In most patients, that recovers within 3 months. Clots in legs and lungs: To prevent clots (Deep vein thrombosis and pulmonary embolism), medications are given for first 45 days post-surgery. Stiffness: Stiffness of the joint is a rule post arthrodesis rather than an exception. Arthrodesis leads to stopping the movements at that particular joint. Hence the stress can increase on the joints above and below. Preparing for the surgery A good control of medical conditions such as diabetes and blood pressure is required. In addition to that a thorough check up by the physician and advice regarding the dosage of the medications and any alterations to that the days before and after the surgery needs to be taken. Stopping smoking is necessary as smoking affects the healing of the surgical wound and the bones. Arthrodesis surgery The surgery is either performed with injection in the back to numb the legs or alternatively under general anaesthesia where you are put to sleep for about the 1.5 hours of surgical time. The surgery is performed by clearing up the remaining cartilage in the joint and create the fresh edges of the bone which can fuse well and then fixed with either multiple screws or a nail. Post-Surgery Post-surgery you can expect to be in a plaster for 6 to 8 weeks till the bones fuse. Post that rehabilitation to help regain the muscle strength and joint mobility in the joints above and below are resumed. Once the bones have fused, the individual can resume heavy manual work as well.
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Elbow
Ac Joint Reconstruction
Ac Joint Reconstruction Book an Appointment Shoulder AC Joint Surgery Diagnosis The AC joint dislocation is easy to diagnose and identify. On clinical examination, the shoulder top appears prominent in comparison to the other side. X-ray. X-ray of both the shoulders (AP view), with weights held in the hands pulling the arm down helps in identifying this condition. The grade of injury needs to be determined as Grade 1 and 2 can be managed with conservative management. Higher grades of injury Grade 3 to 6 are usually treated with surgery. MRI Scan. MRI Scan helps in understanding the extent of injury to the ligaments holding the AC (Acromio-Clavicular) joint as well as the CC (Coraco-Clavicular) ligaments. This helps in determining the grade of injury. MRI Scan also helps in ruling out any other additional injuries to the shoulder joint Treatment AC Joint injuries Grade 1 and 2 will not affect the functioning of the arm. Hence a broad arm sling for 2 to 3 weeks till the pain and swelling settles down would be sufficient. One needs to be aware that the point of the shoulder may appear more prominent compared to the other side permanently. However, as function of the arm is not hampered. AC (Acromio-Clavicular) Reconstruction Surgery is recommended in people with Grade 3 to 6 AC joint injury. AC joint reconstruction surgery is a day care surgery. It is done either as a key hole (arthroscopy) or mini-open surgery. A tight rope with fiber-tape and small titanium buttons is used. A small hole is drilled through the clavicle (collar bone) and then through the coracoid (part of the scapula – shoulder bone). The button is passed through the bones and then flipped. It is then tightened to compress the AC joint back to place. The reduction of the joint back to place is confirmed by an x-ray imaging during surgery. AC Joint Rehabilitation Post-surgery a broad arm sling is needed for 2 to 3 weeks. Early mobilization of the arm is recommended. From the day 1, one needs to start moving the fingers, wrist and elbow. Once the surgery site pain improves, it is recommended to start moving the shoulder. Upto 6 weeks, overhead activities are to be avoided. Rehabilitation with physiotherapy is important to get the shoulder muscle strength back and the smooth movement of the muscles. Return to active sports is expected around 4 months post surgery.
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General
Achilles Tendinopathy Surgery
Achilles Tendinopathy Surgery Book an Appointment Fortunately majority of Achilles Tendinopathy problems can be resolved with simple fomentation and stretching exercises. In some who do not heal with exercise based treatment, a PRP injection can do the needful. In a small minority of people with achilles tendinopathy, none of these treatments work. In those, underlying reason for the same need to be understood so that appropriate arthroscopic surgical procedure can be undertaken. Diagnosis In patients with no respite with conservative management, an x-ray is necessary to understand the underlying pathology X-ray X-ray helps to understand about the bone spurs, Haglund deformity (Prominent heel bone rubbing the Achilles tendon) and the swelling around that area. MRI Scan: MRI Scan may not always be necessary. However, this can help us to understand the condition of the retrocalcaneal bursa (fluid filled pouch) with greater detail. Treatment Heat therapy followed by Foot and Achilles stretches twice a day for 4-6 weeks. If poor improvement PRP Injection to Achilles tendon. Achilles Tendinopathy Arthroscopic Surgery Achilles tendinopathy arthroscopic surgery is a day care surgery. In prone position, small cuts are made to insert the camera through. On either side of the achilles tendon camera on one side and the instruments through the other side are inserted. The prominent part of the Haglund deformity is shaved off using the bone burr. The ankle movements are performed and checked for the bone beak. Tendon debridement is performed and calcium deposits are removed. The thickened bursal tissue is debrided. The tendon is checked and adhesions are released using smooth PDS sutures taken through both sides of the tendon in the front and back of the tendon. Post this PRP injection may be used for healing of the tendon tissue. Achilles Tendinopathy Surgery Rehabilitation Post-surgery you can expect to be in a bulky dressing with Crepe bandage for 4 days. Early mobilization is recommended. You will be doing stretching exercises from second week. You will be allowed to start outdoor walking after 2 weeks post surgery. Jogging is typically started after 4 weeks post surgery. Return to most sporting activities is expected by 3 months.
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General
Achilles Tendon Repair Surgery
Achilles Tendon Repair Surgery Book an Appointment Partial Achilles tendon tears and tendon tears in patients with minimal displacement can be treated conservatively with walking boot and wedges. The number of wedges will have to be gradually reduced over a period of 6 to 12 weeks to get the foot plantigrade. However, the push off strength of the achilles tendon and calf muscle may not return to the pre-injury level. In people with acute tear of the muscle and in those with a large gap between the two ends of the torn achilles tendon, surgical treatment is appropriate. Surgical treatment may be percutaneous through small cuts in some. The technique permits mobilisation of the tendon and fixation in some, however there is a higher risk of nerve injuries in these. Diagnosis With good physical examination, the Achilles tendon tear can be identified easily due to the gap in the tendon. However, in partial tears and in tears higher up at the musculo-tendinous junction may be difficult to appreciate with the clinical examination. X-ray X-ray is often performed and is useful to rule out any bone injuries. However, Achilles tendon tear is not easy to appreciate on the X-ray. USG Scan: Ultrasound scan is often sufficient to understand the nature of Achilles tear and the gap. MRI Scan: MRI Scan helps in undertanding the nature of the tear, gap and the quality of the remaining stump of the tendon along with the condition of the surrounding tissues. Treatment First Aid for Achilles injuries involves the typical R.I.C.E therapy initially (Rest, Icepacks, Compression and Elevation). Partial Achilles Tear / Degenerative Achilles Tear (Acute) Partial Achilles tears and degenerative tears can be treated conservatively provided the patient is seeking medical attention in the initial few weeks post injury. A walking boot with wedges for 6 to 12 weeks is necessary. The results can be satisfactory provided the patient is not into active sports or high intensity activities. Achilles Tendon Surgery Achilles tendon surgery is a day care surgery. There are various ways of repairing the torn tendon. Percutaneous repair may suit some. End to End repair by using strong Fiberwires and Krakow technique in mid substance tear of the achilles. Speed-bridge technique is used when the Achilles tendon is avulsed from the calcaneus or when the distal stump of the tendon is not degenerative and not repairable. In this technique, we use bio suture anchors to fix the tendon to the bone. The bone bed of calcaneous is usually prepared by removing the osteophytes, making tiny holes in the calcaneus with K wires or even shaving a bit of bone to expose the cancellous bone so that the tendon can form strong connect with and grow into the bone. FHL Tendon transfer. In patients with poor degenerative distal stump of tendon and long gap to bridge, an FHL tendon transfer to the calcaeous and fixation by using bio-screw is undertaken. The remaining proximal stump of the Achilles tendon is attached to the the FHL so that these muscles will then work as one unit. Allograft Repair: In patients with no useful distal stump of tendon, Allograft is an excellent choice to bridge the gap. The repair to the done distally is done by Speedbridge technique and proximally by Krakow technique. Achilles Repair Surgery Rehabilitation Post-surgery you can expect to be in a walking boot with wedges initially. Early mobilisation is recommended. Depending on the type of repair you may need to use the walking boot for 4 to 8 weeks. Full mobility is expected by 6 to 8 weeks. To get back to running and other high impact activities usually around 6 to 8 months of time period is necessary.
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General
ACL Treatment Options
ACL Treatment Options Book an Appointment Non-surgical Treatment In people over the age of 55 with a sedentary life style may not need a surgery, but proper rehabilitation to optimise the muscle condition to minimise the risk of further deterioration and wear and tear of the knee joint. PRP Injection Partial tears of the ACL can be mended by Platelet Rich Plasma injections. Patient may typically need 1 to 3 injections at the intervals of 1 month each. 4 to 6 weeks post injection you will get examined clinically to reassess the effectiveness of the injection. Internal Bracing Technique Internal Bracing works well for patients with thin tendon grafts to augment the graft. Although Internal bracing alone has been heavily advertised, the long term outcomes of the internal bracing alone is not established. The tendon graft harvested from oneself will get incorporated into the body as the bone inter-digitations grow into tendon graft. With internal bracing long term wear and tear is expected to make it weak and non-functional. ACL Reconstruction Hamstring Grafts ACL Surgery using hamstring grafts is the commonest technique used worldwide as it gives reliable outcomes and the graft donor site problems are rare. The incision size is small and the hamstring strength returns to normal within 3 months. ACL Reconstruction BTB Graft ACL surgery using BTB (Bone-Tendon-Bone) graft from the front of the knee is another very useful technique for reconstruction. The advantage is that the bone to bone healing takes place more quickly and in an organised fashion. However the donor site pain, tenderness, longer incision makes it less popular option, however, in some this option is preferred on an individual basis. ACL Reconstruction Quads tendon Graft ACL surgery can be performed using the quads tendon above the patella (knee cap).The thick graft size makes it an attractive option, however the donor site pain and weakness remains for a longer duration in these patients. ACL Reconstruction Peroneal tendon Graft Peroneal tendon is an attractive option for the ACL surgery, however, the evidence for the long term efficacy of this tendon as a graft is still being evaluated. ACL Reconstruction Single Bundle The single bundle technique has been in use in most premier centres across the world. If is effective and technically sound to reproduce with proper training. ACL Reconstruction Double Bundle ACL reconstruction with two bundles does replicate the anatomy well, however the techniue is difficult to replicate and the outcomes reported have not been uniform across the fraternity. And with 2 tunnels, revisionsurgery if needed becomes more complicated. ACL Reconstruction – All-inside technique This technique is best used when the graft size is thin and getting longer graft is not possible. In this technique titanium buttons are used on both sides. The fixation with this provides secure support and avoids the problems due to liquification of the bio-composite screw. ACL Reconstruction – Tight Rope & BioComposite Screw Fixation This is the commonest way of fixing the graft in ACL reconstruction where a titanium button is used on the femoral (thigh bone) side and bio-composite screw on the tibial (leg bone) side. It provides secure fixation and good outcomes. ACL Reconstruction – Anatomical The femoral tunnel in the place where the ACL fibers are attached and in the same angle of pull is better as it provides better rotational stability. ACL Reconstruction – Non-Anatomical Some surgeons follow the trans-tibial tunnel technique to drill the femoral tunnel as well. However, this leads to poor rotational stability.
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Ankle
Ankle Ligament Surgery
Ankle Ligament Surgery Book an Appointment Majority of ankle ligaments heal naturally. However, some with recurrent injuries or non-healing ligaments will need a surgery to either repair or reconstruct the ligament. A vast majority of ankle ligament injuries are on the outer side (lateral) of the ankle. Inner side (medial) ligaments are more sturdy and injuries are less common. Diagnosis With good physical examination, the ATFL (anterior talo fibular ligament) and CFL (calcaneo fibular ligament) injury can be identified, however when the ankle is acutely swollen and painful, it may be difficult to examine. X-ray: X-ray is performed and is useful to rule out any bone injuries, however, ligaments are not visible on the X-ray. MRI Scan: MRI Scan is the gold standard investigation to identify the type and extent of the ATFL and CFL injury. In addition, it helps to assess the condition of the cartilage (smooth lining of the joint) in the ankle joint and other ligaments. These structures may be affected as well and need attention. Treatment First Aid for Ankle ligament injuries involves the typical R.I.C.E therapy for the first week. Rest: It is important to minimize walking around. Icepacks: Cold packs 3 to 4 times a day helps reduce the swelling Compression: Crepe bandage is sufficient to help with compression. Elevation: Keeping it elevated on a pillow when resting helps. Chronic Partial tear of ATFL and/or CFL Non-healing partial tears can be treated with PRP injection followed by plaster cast for 4 weeks. This has to be followed by foot stretches for 2 weeks post removal of the cast. This treatment can help heal majority of partial tears. In patients with no improvement with this treatment and in those with high grade 2 or grade 3 tears, surgery becomes necessary. Ankle Ligament Prehabilitation Ankle Prehab exercises can be started once the pain and swelling improve. These help in regaining the knee movements and keep the muscles in a good condition. Ankle ligament Surgery Ankle ligament surgery is a day care surgery. There are various ways of reconstructing the torn ligaments. ATFL and CFL Reconstruction - using autograft ATFL Reconstruction - Internal Brace using fibertape Anatomic repair using imbrication (overlapping) of the lateral ankle ligaments Anatomic repair using imbrication (overlapping) of the lateral ankle ligaments with reinforcement by extensor retinaculum (overlapping layer of tissue in the front of the ankle) The torn ligament is either repaired or replaced by your own spare piece of tissue. The surgical technique is decided based on the nature of the tear and the expertise available to repair it. Graft material can be obtained from cadaver source (another person). However own tissue is preferred and the healing and take up of the material is better. One of the hamstring muscles from the inner side of the thigh is used. The spare muscle tendon is harvested through small keyholes. Usually the graft is fixed using bio-composite or PEEK (high grade polymer) suture anchors. Ankle Ligament Surgery Rehabilitation Post-surgery you can expect to be either in a plaster cast or walking boot. Early mobilisation is recommended. Partial weight bearing up to 3 weeks is advised. You will start non weight bearing stretches by 3 weeks. For full mobility it may take up to 6 weeks. To get back to running and other high impact activities usually around 4 to 6 months of time period is necessary.
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Knee
Arthroscopy Knee
Arthroscopy Knee Book an Appointment Arthroscopy is a procedure done for the treatment of joint problems using small cuts through which camera and instruments are passed into the joint. Using the camera, the surgeon can see the joint and also treat various joint related problems. In addition to the camera, small thin instruments are passed into the joint and a vast array of surgical procedures such as cartilage repair, cartilage regeneration, ligament reconstruction, ligament repair, cyst removal can be done through this procedure. Knee Arthroscopic Procedures ACL Reconstruction Meniscal Repair Partial meniscectomy PCL Reconstruction LCL Reconstruction MCL Reconstruction MPFL Reconstruction Cartilage repair (abrasion chondroplasty) Cartilage regeneration Stem Cell Therapy Ganglion cyst excision Fat Pad Debridement Diagnostic arthroscopy Advantages There are several advantages to this procedure. Small incisions (Key-hole) About 5mm to 1 cm. Quick Recovery Less soft tissue injury Cosmetic Risks Risks are minimal in this procedure Infection Tissue injury Blood Clots Anaesthesia This procedure can be done under different modes of anaesthesia. General Anaesthesia Spinal Anaesthesia Nerve Block Local Anaesthesia Post-Operative Care Early mobility is preferred in most arthroscopic surgeries. However there will be restrictions to weight bearing in some depending upon the type of surgery performed. Post-operatively R.I.C.E therapy is advised to reduce the inflammation in the intial days. Exercise programs form an integral part of the rehabilitation. Physiotherapy plays a key role in complete recovery and return back to activities and sports.
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Shoulder
Arthroscopy Shoulder
Arthroscopy Shoulder Book an Appointment Arthroscopy is a procedure done for the treatment of joint problems using small cuts through which camera is passed into the joint. Using the camera, the surgeon can see the joint and also treat various joint related problems. In addition to camera, the small thin instruments are passed into the joint and a vast array of surgical procedures such as cartilage repair, cartilage regeneration, ligament reconstruction, ligament repair, cyst removal are done through this procedure. Shoulder Common procedures performed in the shoulder include Bankarts repair SLAP repair Rotator cuff repair Capsular Release for Frozen Shoulder Subacromal Decompression Posterior labral repair Biceps tenotomy Biceps tenodesis Superior capsular reconstruction (SCR) Stem Cell Therapy Cartilage regeneration Paralabral Cyst Removal Latarjet Procedure Loose body removal Diagnostic Arthroscopy Advantages There are several advantages to this procedure. Small incisions (Key hole) About 5mm to 1 cm. Quick Recovery Less soft tissue injury Cosmetic Risks Risks are minimal in this procedure Infection Tissue injury Blood Clots Anaesthesia This procedure can be done under different modes of anaesthesia. General Anaesthesia Spinal Anaesthesia Nerve Block Local Anaesthesia Post-Operative Care Early mobility is preferred in most arthroscopic surgeries. However there will be restrictions to active movements and lifting weight depending upon the type of surgery performed. Initially to reduce the inflammation R.I.C.E therapy is advised. Exercise programs form an integral part of the rehabilitation. Physiotherapy plays a key role in complete recovery and return back to activities and sports.
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Hip
Avascular Necrosis Hip Treatment
Avascular Necrosis Hip Treatment Book an Appointment Diagnosis Avascular necrosis of hip needs assessment of clinical symptoms and careful examination of the hips. X-ray X-rays can show the changes in the bone in AVN hip. However in early stages x-rays may appear completely normal. MRI Scan and CT Scan: These two are useful modalities to identify early stages of AVN Hip. Treatment Early stages (Stage I and II )AVN hip management includes medications. Medications are known to help to an extent but are usually not sufficient to salvage the problem. Medications prescribed depends on the patient’s condition and other medical issues. Medications routinely used to treat AVN are Osteoporosis medications. Eg: Alendronate Anti-cholesterol medications. Eg: Rosuvastatin Blood thinners. Eg: Ecosprin Surgery As the progression is inevitable in majority of patients, it is prudent to consider conservative bone and cartilage saving surgeries in the early stages of the AVN Hip. Core Decompression with Stem Cell Therapy This is the most advanced way of treating AVN hips as of now. It helps by reducing the pressure and regrowth of the blood vessels. The stem cells therapy help in regrowth of the bone. This procedure is done with small cuts of about 3 cm on the side of the hip. This surgery involves drilling a tunnel into the head of the femur (ball of the thigh bone), removal of the dead bone by curetting followed by injecting the stem cells into the head of the femur through the tunnel. This works well when performed in patients with AVN Hip stage I or II. Core Decompression with Bone Transplant This is considered to be a good alternative where the bone is of poor quality and needs additional support. However, this needs bone graft to be harvested from the lower leg. Hence, potential risk of graft harvest site pain are an issue. Secondly the risk of graft loosing vascularity needs to be considered. Hip Joint Replacement In patients with advanced hip necrosis with persistent pain and in patients with Stage III and IV AVN Hip, total hip replacement remains as a definitive treatment to achieve a pain free mobile hip.
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General
Bankarts Repair or Labral Repair
Bankarts Repair or Labral Repair Book an Appointment Diagnosis Shoulder instability. Repeated movement of the shoulder bone out of the socket (recurrent dislocations) is the cause of concern in patients usually belonging to the age group of 18 to 40. Apprehension sign where the patient experiences the scare of joint dislocation in certain angles of shoulder movement is noted. X-ray: Xray may reveal if there is a bony Bankarts, where a fragment of bone is lifted up from the front edge of the socket (Glenoid bone). Xray may also reveal a large dent in the back part of the upper portion of the shoulder bone (head of the humerus). However, in majority of patients with this problem, X-ray may not reveal any abnormalities. MRI Scan: With contrast is the gold standard investigation for identifying the extent of the tear of the lip (labrum), the dent (Hill Sach’s lesion) on the back side of the shoulder bone due to rubbing against the front of the socket. Treatment Acute dislocation of the shoulder joint needs immediate medical attention to reduce the shoulder joint back into place. Once the pain and inflammation reduces, it needs a prompt assessment regarding the risk of further dislocation. Bankarts repair or Labral repair In patients with risk of repeated dislocations, a key-hole surgery (arthroscopy) is undertaken to repair the lip (labrum) back to the edge of the socket bone where it is supposed to be attached. This procedure is done usually by using bio-composite suture anchors. If there is a large dent (Hill Sach’s lesion) on the back of the bone, then a procedure to attach the back capsule to the bone (Remplissage) is done. If a large bone fragment is lifted off from the front edge of the socket, it may need a procedure where a bone block (Latarjet) procedure may be required. Rehabilitation Post-surgery, for the first 3 weeks using a broad arm sling is recommended. Gentle passive stretches are started early. After 3 weeks, active movements are started. Return to non-contact sports by around 4 months and for contact sports by 6 months.
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General
Bunion Surgery
Bunion Surgery Book an Appointment Bunion Surgery Bunion Surgery is performed to correct the hallux valgus and other deformities of the toes and forefoot. Bunion is often a cosmetic deformity without any symptoms. Bunion are also one of the common causes of the foot pain. Bunion are more common in women. It is often associated with genetics and also wearing tight and pointed shoes. Bunions can also be the consequence of abnormal shape of the foot or arthritis. Indications Pain Pressure ulcers / painful corns Severe Deformity affecting effective mobilization Bankarts repair or Labral repair Severe Deformity affecting effective mobilization Disability in doing daily activities Deformity interfering in the sporting activities Severe deformity Secondary problems due to deformity such as ulceration between the toes due to perssure effect. Compliant to follow post-operative protocols Risks Risks of Bunion surgery are low however a small overall risk of adverse outcomes remains. Fracture: . During the surgery there is a small risk of fracture of the bone extending to the other side making the fragments unstable. However, the modern implants are strong enough to hold the bone fragments together and support well till the bone heals. Infection: . Risk of infection is low with the advanced techniques and improvised theatre environment. Infection if picked up early, are likely to respond to antibiotics. In some instances it may need further washout or even removal of the implant. Blood Vessel or Nerve Damage: . Rare, but can lead to numbness or weakness down the leg. In most patients, that recovers within 3 months. Stiffness: . Foot stiffness is common post-surgery and needs good physiotherapy support. Preparing for the surgery A good control of medical conditions such as diabetes and blood pressure is required. In addition to that a thorough check up by the physician and advice regarding the dosage of the medications and any alterations to that the days before and after the surgery needs to be taken. Stopping smoking is necessary as smoking affects the healing of the osteotomy and the surgical wound. Bunion Surgery The Hallux valgus surgery involves bone osteotomy as well as soft tissue procedures. This is either performed with injection in the back to numb the legs or alternatively under general anaesthesia where you are put to sleep for about the 1.5 hours of surgical time. Post-surgery you can expect to see a plaster slab around foot. The surgery involves removal of the enlarged portion of the bone, realign the bone, muscles, ligaments. To realign the bone creating the cuts in the bone in specific places and angles is required followed by realignment and fixation with small titanium screws. Post-Surgery Post-surgery you can expect to be in slab for first 2 weeks. You will need change of dressing 2-3 times. After 2 weeks you will be in a walker boot for upto 6 weeks. You will be walking with the support of a walker in the beginning. You need to be prepared to not put weight on the foot for first 2 weeks. Post that you need to be walking with partial weight for upto 6 weeks. After 2 weeks, you will start basic stretching exercises for the foot. For complete recovery you will need around 4 to 5 months.
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General
Carpal Tunnel Syndrome Management
Carpal Tunnel Syndrome Management Book an Appointment Carpal Tunnel is a 3 sided bone cave with one side being covered by the thick carpal tunnel ligament at the base of the palm in the wrist area. This tunnel contains 9 tendons and the median nerve. Increase in pressure in the tunnel affects the median nerve leading to pain, tingling and or weakness in the hand and fingers. Diagnosis Nerve Conduction Studies (NCS): . Nerve conduction study is an effective tool to diagnose and also understand the effect on both the sensory and motor (muscle) component of the medial nerve. Treatment Conservative Management Physiotherapy and carpal tunnel exercises may help resolve carpal tunnel symptoms in some. Steroid Injection Steroid injection can help allay the symptoms of the carpal tunnel syndrome. However, there is a risk of recurrence of the symptoms 3-4 months post injection. If it recurs, then surgery is the preferred option. Carpal Tunnel Release Surgery This can be performed as an open surgery or arthroscopic (keyhole) surgery. It is performed either under local anaethesia injection or under short general anaesthesia. The cut will be around 3 cm long. The transverse carpal ligament is released. Skin is closed and a bulky dressing is applied. Rehabilitation Finger movements are encouraged early. Post removal of stitches (around 10 to 14 days), gentle passive stretches of the wrist and active movements are started. By 4 weeks strengthening exercises are started. One can expect back to most of the regular activities by 6 weeks. The symptoms of carpal tunnel resolve slowly post-surgery over a period of 1 to 3 months. Pain relief occurs early by 2 to 3 weeks. Tingling resolves around 4 to 6 weeks. Muscle strength is the last one to return and takes around 2 to 3 months. In patients with the long standing carpal tunnel symptoms of more than a year, the symptom resolution occurs over a longer period of time and occasionally may remain incomplete.
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Shoulder
Frozen Shoulder Treatment
Frozen Shoulder Treatment Book an Appointment Frozen shoulder or adhesive capsulitis is a condition of shoulder in which the capsule has become very stiff and tight leading to pain and limitation of the motion. Diagnosis It is a clinical examination based diagnosis in most cases. X-ray: . X-ray in frozen shoulder is useful to rule out the osteoarthritis of the shoulder joint and fractures around the shoulder joint. MRI Scan: . MRI Scan shows certain signs such as thickening of Coraco-humeral ligament which is one of the reliable signs to confirm frozen shoulder. Treatment Pain management & Exercises Controlling the pain with short course of medication and / or physiotherapy can help in facilitating the frozen shoulder exercises which are vital to improve the range of movement and pain. Applying heat before exercises can help to stretch better. Steroid injection to the joint In patients with severe pain stopping them from doing the exercises, it can be a useful tool to help. However, post injection exercises still have to be done regularly to get the motion back. Manipulation under anaesthesia with steroid injection Manipulation under general anaesthesia will help to bring the range of motion back and injection helps the pain. Post this, exercises are still required, but it will be a lot easier to do the exercises to maintain the range of motion. Arthroscopic release of Anterior capsule In patients with persistent shoulder stiffness for prolonged period, an arthroscopic (keyhole) surgery to release the tight bands can help restore the range of motion.
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Elbow
Golfers Elbow Treatment
Golfers Elbow Treatment Book an Appointment Diagnosis Golfers Elbow or Medial Epicondylitis is easy to diagnose with clinical examination alone. However, an X-ray would help to rule out any underlying bone condition contributing to the problem. Treatment Exercise based treatment. Golfers Elbow responds well to simple stretching exercise based treatments. Home based or physiotherapy guided exercise regimes work well for majority of patients. Wearing an elbow band in addition, particularly for the hand work may help in preventing further irritation of the tennis elbow. Steroid Injection Steroid injection is a safe and effective treatment for the golfers elbow. However, there is a risk of recurrence with the injection alone. Post injection stretches can minimize the risk of recurrence. PRP (Platelet Rich Plasma) Injection PRP Injection is a safe and effective treatment for golfers elbow. The whole procedure of drawing blood, time to centrifuge and then injection is around 40 minutes of time in the out patients. For the PRP to be effective and average of 4 to 6 weeks of time is required. In some, more than one PRP injection may be required to cure the condition completely. Golfers Elbow Release Surgery In patients with no improvement with all other conservative measures, surgery is considered. This is performed either as an open surgery or arthroscopically (Keyhole). The incision for open surgery is around 3cm long. The tendon is released and debrided (the frail tissue removed). Small puncture holes are made in the bone underneath so that there is some bleeding to that area and healthy tissue can grow to that area. Rehabilitation Post-surgery, the bulky dressing is removed after 4 days. Early mobilization is allowed. Gentle passive stretches for the elbow are started as early as 2 weeks. Strengthening exercises are embarked upon after 4 weeks. One is expected to return to full activity by around 6 weeks post-surgery.
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General
Hamstring Repair Surgery
Hamstring Repair Surgery Book an Appointment While hamstring strain is a very common problem in sporting population, the proximal hamstring tear is an uncommon injury. Majority of them are likely to be partial tears, however a small number of them are complete tears with retraction of the proximal hamstrings. Often the tear would be due to avulsion of the periosteum of the bone along with the proximal hamstring muscle. Diagnosis With good physical examination, the bruising, gap in the hamstring tendon and free SLR without the restraint to passive stretch are indicative of the the proximal hamstring tear. X-ray: X-ray is performed and is useful to rule out any bone injuries. However, the hamstring muscle tear is not visible on the X-ray. MRI Scan: MRI Scan is the gold standard investigation to identify the type and extent of the hamstring tear. In addition, it helps to assess the retraction of the tendon. Treatment First Aid for proximal hamstring tear involves the typical R.I.C.E therapy for the first week. Rest. It is important to minimize walking around. Icepacks. Cold packs 3 to 4 times a day helps reduce the swelling Compression. Thigh compression band is sufficient to help with compression. Elevation. Keeping it elevated on a pillow when resting helps. Chronic Partial tear of Proximal Hamstrings Non-healing partial tears can be treated with PRP injection. In patients with no improvement with this treatment and in those with high grade 2 or grade 3 tears, surgery becomes necessary. Proximal Hamstring Repair Surgery Proximal hamstring needs fixation back to the ischial bone. Fiber-wires are used to stitch and pull the muscle tendon back to the bone. Bone is freshened up first to create the cancellous bone bed to help grow the tendon back to the bone Fixation is by using either PEEK (high grade polymer) or Bio Suture anchors inserted into the ischial bone. The fixation technique is called speed-bridge technique which helps compress the tendon to the bone. Hamstring repair Surgery Rehabilitation Rehabiliation starts immediately after the surgery. Post-surgery you can expect to be allowed to walk with a walker with short stride and bending the knee. You will be asked to keep the knee bent and not stretch and load to avoid strain on the repair. You can expect to walk comfortably outdoors by 6 weeks. By 3 -4 months light jogging is allowed. Around 6 months post surgery, you can expect to return to the sports on the ground or court.
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General
High Tibial Osteotomy or HTO
High Tibial Osteotomy or HTO Book an Appointment High Tibial (leg bone) Osteotomy or HTO and Distal Femoral (thigh bone) Osteotomy or DFO are the alignment correction procedures. These are valuable alternatives to Knee replacement in a selected group of patients. This is preferred approach in suitable patients for several reasons. As this does not lead to bone loss, at a later date even if the patient needs Knee replacement it will be primary knee replacement at that point of time. Indications Osteoarthritis. Advanced medial compartment knee arthritis with severe pain and / or limitation of mobility. Severe Angular Deformity predisposing to uni-compartmental osteoarthritis. Who is suitable for the HTO Surgery? Young (40 to 60 Years of age) and active patient Healthy otherwise Non- obese patient Persistent pain and disability affecting daily activities Single compartment of the knee involvement Compliant to follow post-operative protocols Risks Risks of HTO surgery are low however a small overall risk of adverse outcomes remains. Fracture: During the surgery there is a small risk of fracture of the bone extending to the other side making the fragments unstable. However, the modern implants are strong enough to hold the bone fragments together and support well till the bone heals. Infection: Risk of infection is low with the advanced techniques and improvised theatre environment. Infection if picked up early, are likely to respond to antibiotics. In some instances it may need further washout or even removal of the implant. Blood Vessel or Nerve Damage: Rare, but can lead to numbness or weakness down the leg. In most patients, that recovers within 3 months. Clots in legs and lungs: To prevent clots (Deep vein thrombosis and pulmonary embolism), medications are given for first 14 days post-surgery. Stiffness: Stiffness of the muscles is common post-surgery and needs good physiotherapy support. Preparing for the surgery A good control of medical conditions such as diabetes and blood pressure is required. In addition to that a thorough check up by the physician and advice regarding the dosage of the medications and any alterations to that the days before and after the surgery needs to be taken. Stopping smoking is necessary as smoking affects the healing of the surgical wound. HTO Surgery The surgery is either performed with injection in the back to numb the legs or alternatively under general anaesthesia where you are put to sleep for about the 1.5 hours of surgical time. Post-surgery you can expect to see a large dressing around your knee. The surgery involves making a cut in the bone either on the inner or outer side of the upper part of the leg bone (proximal tibia). Post that the bone is either opened up as a wedge or a wedge of bone is taken out and the rest of the bone is closed down (Open Wedge or Closed Wedge Osteotomy). Often a bone substitute or a bone graft is used to fill the gap. Then the bone is fixed with a plate and screws. This balances out the stress in the knee and hence relieves the pain in one compartment. Post-Surgery Post-surgery you can expect rehabilitation to start early. On the day 1 Physiotherapists will ask you to move your ankles and press your knee down. On day 2, you can expect to sit on the edge of bed also take a few steps with the help of walker and the physiotherapist. A stay of 2 to 3 days in hospital is expected. You can expect to walk comfortably without a walker support by 2 to 3 weeks.
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Knee
Knee Ganglion Cyst Excision
Knee Ganglion Cyst Excision Book an Appointment Diagnosis With good physical examination, the ACL or PCL ligament laxity can be identified in patients with ganglion cyst. Usually the laxity will be mild. X-ray: . X-ray is performed and is useful to rule out any bone injuries, however, ligaments are not visible on the X-ray. MRI Scan: . MRI Scan is the gold standard investigation to identify the type and extent of the ACL and PCL ligament condition. The fluid filled cyst stretching the ACL or PCL stretching the fibers of the ligament can be identified. Treatment Ganglion cysts of the knee remain so and can gradually expand, leading the symptoms of instability of the knee. Although strengthening the Quadriceps (thigh muscles) with eccentric exercises may help to minimise the signs of instability, the pain due to ganglion cyst often persists especially on doing squats and with cross legged sitting. Platelet Rich Plasma (PRP) Injection PRP injection to ACL can help improve the stability in these patients. As the ACL or PCL is usually overstretched and not torn, PRP injection can actually help in improving the stability of the ligament. Post PRP injection, a period of 4 to 6 weeks is needed for the injection to work. However, pain may persist inspite of the improved stability of the joint. Under those circumstances, surgery is warranted. Arthroscopic Ganglion cyst excision Arthroscopic (key hole)/procedure-surgery surgery is performed for this condition. The ganglion cyst is identified and the cyst wall is cleared with instruments. Post cyst removal, the ACL and PCL ligaments are assessed for stability. If they are overstretched then a PRP injection is also performed during the surgery. Post ganglion cyst excision rehabilitation Post-surgery, you are allowed to walk on the same day evening. Walking without any support is possible in most patients, but some may need the support of a walker for upto a week. Physiotherapy in the form of exercises to activate quadriceps (thigh muscles) and range of movement exercises are started on the day 1. Full return to sporting activity is usually delayed upto 6 weeks particularly if the ligament laxity was identified during surgery.
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Shoulder
Latarjet Procedure – Shoulder
Latarjet Procedure – Shoulder Book an Appointment Diagnosis Shoulder in/bone-joint-school/stability. Repeated movement of the shoulder bone out of the socket (recurrent dislocations) is the cause of concern in patients usually belonging to the age group of 18 to 40. Apprehension sign where the patient experiences the scare of joint dislocation in certain angles of shoulder movement is noted. X-ray: Xray may reveal if there is a bony Bankarts, where a fragment of bone is lifted up from the front edge of the socket (Glenoid bone). Xray may also reveal a large dent in the back part of the upper portion of the shoulder bone (head of the humerus). However, in majority of patients with this problem, X-ray may not reveal any abnormalities. MRI Scan: With contrast is the gold standard investigation for identifying the extent of the tear of the lip (labrum), the dent (Hill Sach’s lesion) on the back side of the shoulder bone due to rubbing against the front of the socket. Treatment Acute dislocation of the shoulder joint needs immediate medical attention to reduce the shoulder joint back into place. Once the pain and inflammation reduces, it needs a prompt assessment regarding the risk of further dislocation. Latarjet Procedure In patients with risk of repeated dislocations with ligament laxity or in patients with previous Bankarts repair (Labral repair) which has failed, the Latarjet procedure is undertaken. If a significant amount of glenoid (socket) bone loss is observed, then Latarjet procedure is indicated. Latarjet procedure entails detaching a part of the coracoid bone (a part of shoulder wing bone) and fashioning it to sit and fuse with the front portion of the glenoid (socket) bone. This will provide a mechanical block for the humerus head to jump out from its position. In addition, the muscles attached to coracoid bone work like a dynamic sling preventing dislocation. This is done either as a mini-open fracture or as an arthroscopic procedure. The Coracoid bone gets fixed to the glenoid bone by using titanium screws. Rehabilitation Post-surgery, for the first 6 weeks using a broad arm sling is recommended. Gentle passive stretches are started early. Upto 6 weeks external rotation and abduction movements need to be avoided. Return to non-contact sports by around 4 months and for contact sports by 6 months.
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About Our Surgical Procedures
Our orthopedic surgical procedures are designed to address a wide range of musculoskeletal conditions, from sports injuries to degenerative joint diseases. Our experienced surgeons utilize the latest techniques and technology to provide optimal outcomes for our patients.
When considering surgery, we believe in thoroughly educating our patients about their options, potential benefits, risks, and recovery expectations. Each procedure page provides detailed information to help you make informed decisions about your care.
Whether you require minimally invasive arthroscopic surgery or complex joint reconstruction, our team is committed to delivering personalized care and supporting you throughout your surgical journey.