FAI - Femoro Acetabular Impingement

The 2016 Warwick Agreement on femoroacetabular impingement (FAI) syndrome was convened to build an international, multidisciplinary consensus on the diagnosis and management of patients with FAI syndrome. 

So,
What is FAI syndrome?

FAI syndrome is a motion-related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findings. It represents symptomatic premature contact between the proximal femur and the acetabulum.

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http://bmjopensem.bmj.com/content/2/1/e000144

These data confirm that hip arthroscopy as part of a structured evidence-based multidisciplinary care pathway produces significant and continued symptomatic, functional and vocational improvements over a 12-month period in a military population exposed to high intensity, weight-bearing exercise in uncontrolled and unforgiving environments.

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AC joint (Acromio-clavicular) reconstruction - Patient information

AC joint usually gets disrupted by trauma, which can happen by a fall during sports. Though the milder grades ( identified by a simple x-ray) can be treated non-operatively, the severe disruptions will need operative reconstruction.

After due consultation and preperation, the patient is taken to the operating theatre. After Anaesthesia, the position is beach-chair and the skin incision goes down from the collar-bone to a bony prominence called the coracoid process. The skin and the tissues are carefully prepared. The bony ends are prepared too. Two holes are drilled at the end of the collar bone, and a hamstring graft is threaded around the coracoid process into the drill holes, in a figure-of- eight(8) fashion. The AC joint is reduced, and the graft is tied securely with the help of sutures. The wound is closed carefully.

After the surgery, the arm is kept in a sling and shoulder gradually mobilised and strengthened.

Key-hole surgery (Arthroscopy) for Biceps tenotomy and Tenodisis. What does it involve ?

The long head of the Biceps tendon, at the shoulder end, can be a source of pain. It may be due to inflammation, wear and tear, SLAP leisons, and tendon instability. Once identified, it may be be treated with non-operative options like physiotherapy, injections around the tendon, within the joint, addressing other causes, etc. Patients who are not responding may be offered  tenotomy/tenodesis. Tenotomy is a complete transection of the tendon, whereas tenodesis involves transection and further securing of the tendon lower down to the bone or soft-tissues. Again this maybe done completely Arthroscopically (takes longer, as it is technically demanding) or with a mini- incision (open) to aid the tenodesis.

Patients presenting with such symptoms for the first time to our clinic, are ususally given a thorough clinical assesment and appropriate investigations like x-rays or MRI scans may be requested. After diagnosis, a physiotherapy protocol is initially recommended for most patients. Patient's who fail the above protocol are recommended for surgery.

Pre-Operative assesment

This involves being assesed by a Physician / Anaesthetist to decide on fitness for surgery and the type of anaesthesia. Appropriate blood tests, X-rays and Scans may be requested. This is usually a General Anaesthesia with  a nerve block for post-operative pain releif, if necessary.

Admission

This maybe done as a day-care or an over-night(s) admission procedure, depending on other co-morbidities (illnesses) and insurance provisions.

Procedure

Inside the operating theatre, our Anaesthetisit will give the General Anaesthesia, and a block sometimes, for post-operative pain relief.

Position

This is usually done with the patient in the beach-chair position (semi-sitting), especially if a tenodesis is contemplated, as it provides necessary access to the front of the arm, if a mini-open incision is used. If a beach-chair position is used, mechanical compression stockings may be used, to facilitate blood flow from the legs.

Arthroscopic Procedure

After Anaesthesia, the area is prepared by cleaning thoroughly with anti-septics (e.g. Chlorhexidine), and draped with sterile sheets to maintain sterility during the procedure. Antibiotics also may be administered.

A small (less than a cm) stab incision called a portal (key-hole size), is made at the back of the shoulder to facilitate entry into the joint. A cannula (conduit) is inserted to keep the portal open. A tiny camera (Arthroscope), with a light source and water inflow are used to visualise the joint. The landmarks inside the shoulder joint are duly noted, and the integrity of structures may be probed with a tiny probe through another portal made from the front of the joint.

The Biceps tendon is probed and evaluated for inflammation, damage and stability. It is even pulled into the joint to asses the tubercular portion as well. A decision is made as to whether a tenotomy or tenodesis is appropriate for the patient.  In general both provide equally good results.There a pros and cons for both depending on the age, associated damage, type of sport, requirement of the individual etc.

In a tenotomy, the tendon is divided at its attachment, and the retraction from the joint is confirmed. Whereas with a tenodesis, the cut end is either secured closer to the joint or further down the Humerus (arm bone), with a mini-open incision. A tenodesis screw may be employed, or bony anchors maybe used.

After the Procedure, the patient may find himself or herself, in the Recovery Room, which is a specially equipped and staffed room for recovering patients from Anaesthesia. They may notice that their arm is supported in a sling, to protect them from moving their operated shoulder. And after recovery, they will be shifted to the ward. Usually, if it was a planned day-case procedure they may be discharged on the same evening, if not the following day.

After discharge, the patient is asked to return to the clinic for regular dressing changes till, sutures are removed.

Re-habilitation involves a couple of weeks of immobilisation in the sling, followed by gradual mobilisation to obtain a good range of motion. The special Re-habilitation protocol is individualised according to patient's needs. It is often a fine balance between delaying it just enough to let it heal un-disturbed and starting it early enough, to minimise stiffness. After due re-habilitation, sports specific exercises are instituted, for sportspersons who are intending to get back to play.

Key-hole surgery / Arthroscopy for a SLAP leison in the shoulder. What does it involve ? - patient information.

A SLAP is an acronym for an injury at the Biceps tendon-labrum complex. The area where the biceps tendon attaches to cartilage rim (labrum) surrounding the Glenoid. The injury is commonly seen in throwing sports, but a sudden eccentric load on the biceps tendon may also lead to its traumatic tear. Other instances maybe due degeneration (wear and tear)

Patients presenting with such symptoms for the first time to our clinic, are ususally given a thorough clinical assesment and appropriate investigations like x-rays or MRI scans may be requested. After diagnosis, a physiotherapy protocol is initially recommended for most patients. Patient's who fail the above protocol are recommended for surgery.

Pre-Operative assesment

This involves being assesed by a Physician / Anaesthetist to decide on fitness for surgery and the type of anaesthesia. Appropriate blood tests, X-rays and Scans may be requested. This is usually a General Anaesthesia with  a nerve block for post-operative pain releif, if necessary.

Admission

This maybe done as a day-care or an over-night(s) admission procedure, depending on other co-morbidities (illnesses) and insurance provisions.

Procedure

Inside the operating theatre, our Anaesthetisit will give the General Anaesthesia, and a block sometimes, for post-operative pain relief.

Position

This is usually done with the patient in the lateral position (lying-by-the-side) or sometimes by the beach-chair position (semi-sitting). With the former position, the arm is suspended by a simple pulley traction system. to facilitate the procedure. If a beach-chair position is used, mechanical compression stockings may be used, to facilitate blood flow from the legs.

Arthroscopic Procedure

After Anaesthesia, the area is prepared by cleaning thoroughly with anti-septics (e.g. Chlorhexidine), and draped with sterile sheets to maintain sterility during the procedure. Antibiotics also may be administered.

A small (less than a cm) stab incision called a portal (key-hole size), is made at the back of the shoulder to facilitate entry into the joint. A cannula (conduit) is inserted to keep the portal open. A tiny camera (Arthroscope), with a light source and water inflow are used to visualise the joint. The landmarks inside the shoulder joint are duly noted, and the integrity of structures may be probed with a tiny probe through another portal made from the front of the joint.

The presense of a SLAP leison is confirmed by probing the tear. It is carefully assesed along with that of the Biceps attachment, noting the extent of damage. Certain bucket-handle type tears are trimmed, but if there is disruption of the tendon-biceps complex, it has to re-attached to the bony rim. In elderly individuals with an associated wear and tear of the rotator-cuff, it may be preferable to cut the biceps tendon (tenotomy/tenodesis) than repair the SLAP leison. So, the initial assesment is crucial for confirmation of the problem, as well as to determine appropriate surgery.

When a decision, is made to repair the leison, one or two additional portals are made. Two specialised anchor sutures are inserted on either side of the biceps tendon attachment, and using specialised techniques, threaded through the labrum, and the whole complex is secured back to the rim.

After the Procedure, the patient may find himself or herself, in the Recovery Room, which is a specially equipped and staffed room for recovering patients from Anaesthesia. They may notice that their arm is supported in a sling, to protect them from moving their operated shoulder. And after recovery, they will be shifted to the ward. Usually, if it was a planned day-case procedure they may be discharged on the same evening, if not the following day.

After discharge, the patient is asked to return to the clinic for regular dressing changes till, sutures are removed.

Re-habilitation involves six weeks of immobilisation in the sling, followed by gradual mobilisation to obtain a good range of motion. The special Re-habilitation protocol is individualised according to patient's needs. It is often a fine balance between delaying it just enough to let it heal un-disturbed and starting it early enough, to minimise stiffness. After due re-habilitation, sports specific exercises are instituted, for sportspersons who are intending to get back to play.

Key-hole surgery (Arthroscopy) for Rotator cuff tear. What does it involve ?

Arthroscopic Rotator-cuff Repair   -  Patient Information.

Rotator-cuff is a cuff of muscle-tendon tissue that envelops the shoulder joint, to aid its stability and movement. Patients may suffer from a tear for a variety of reasons, it may be partial or complete. Patients with pain and weakness from a complete tear inspite of non-surgical treatment, are usually recommended this procedure. Some partial tears, will also benefit from the procedure.

Patients presenting with such symptoms for the first time to our clinic, are ususally given a thorough clinical assesment and appropriate investigations like x-rays or MRI scans may be requested. After diagnosis, a physiotherapy protocol is initially recommended for most patients. Patient's who fail the above protocol are recommended for surgery.

Pre-Operative assesment

This involves being assesed by a Physician / Anaesthetist to decide on fitness for surgery and the type of anaesthesia. Appropriate blood tests, X-rays and Scans may be requested. This is usually a General Anaesthesia with  a nerve block for post-operative pain releif, if necessary.

Admission

This maybe done as a day-care or an over-night(s) admission procedure, depending on other co-morbidities (illnesses) and insurance provisions.

Procedure

Inside the operating theatre, our Anaesthetisit will give the General Anaesthesia, and a block sometimes, for post-operative pain relief.

Position

This is usually done with the patient in the lateral position (lying-by-the-side) or sometimes by the beach-chair position (semi-sitting). With the former position, the arm is suspended by a simple pulley traction system. to facilitate the procedure. If a beach-chair position is used, mechanical compression stockings may be used, to facilitate blood flow from the legs.

Arthroscopic Procedure

After Anaesthesia, the area is prepared by cleaning thoroughly with anti-septics (e.g. Chlorhexidine), and draped with sterile sheets to maintain sterility during the procedure. Antibiotics also may be administered.

A small (less than a cm) stab incision called a portal (key-hole size), is made at the back of the shoulder to facilitate entry into the joint. A cannula (conduit) is inserted to keep the portal open. A tiny camera (Arthroscope), with a light source and water inflow are used to visualise the joint. The landmarks inside the shoulder joint are duly noted, and the integrity of structures may be probed with a tiny probe through another portal made from the front of the joint.

In a patient with a Rotator-cuff tear, the tear may be noted from inside the joint. Some times there may be an associated wear of the biceps tendon too, which maybe probed and assesed. Then the scope is directed slightly upward into the space above the shoulder joint, called the sub-acromial space. From here you can actually look down upon the Rotator cuff. But there is a thick bursa, which is cleared with the help of a thin mechanised shaver. Part of the Acromion process (shoulder tip) is also shaved to decrease impingement on the cuff. Once a clear view of the tear is obtained, it is probed to asses its type and extent. Types like U or L have been described depending on the shape of the tear. This helps in the design of the repair too.  Now two additional portals are made to help in the repair. The bed of bone, on the head of the Humerus bone, where the cuff has to be attached is prepared. Anchors are inserted. The sutures are threaded into the Rotator-cuff, using specialised instruments, and the cuff is tied down securely onto the bone. The number of anchors used depends on the type of the tear. Thus attempting to re-create a pre-tear anatomical environment for the shoulder. The whole procedure is completed with the aid of special tiny instruments through tiny skin incisions called portals. These incisions are closed with sutures, at the end of the procedure, and dressings applied on top.

After the Procedure, the patient may find himself or herself, in the Recovery Room, which is a specially equipped and staffed room for recovering patients from Anaesthesia. They may notice that their arm is supported in a sling, to protect them from moving their operated shoulder. And after recovery, they will be shifted to the ward. Usually, if it was a planned day-case procedure they may be discharged on the same evening, if not the following day.

After discharge, the patient is asked to return to the clinic for regular dressing changes till, sutures are removed.

Re-habilitation involves six weeks of immobilisation in the sling, followed by gradual mobilisation to obtain a good range of motion. The special Re-habilitation protocol is individualised according to patient's needs. It is often a fine balance between delaying it just enough to let it heal un-disturbed and starting it early enough, to minimise stiffness. After due re-habilitation, sports specific exercises are instituted, for sportspersons who are intending to get back to play.

Arthroscopic Bankart Repair / Key-hole surgery for Shoulder dislocation. What does it involve ?

Key-hole surgery for Shoulder dislocation. What does it involve ?

Arthroscopic Bankart Repair for shoulder dislocation / instability

Patients with recurrent shoulder dislocation, and sportspersons with instability inspite of non-surgical treatment, are usually recommended this procedure.

Patients presenting with such symptoms for the first time to our clinic, are ususally given a thorough clinical assesment and appropriate investigations like x-rays or MRI scans may be requested. After diagnosis, a physiotherapy protocol is initially recommended for most patients. Patient's who fail the above protocol are recommended for surgery.

Pre-Operative assesment

This involves being assesed by a Physician / Anaesthetist to decide on fitness for surgery and the type of anaesthesia. Appropriate blood tests, X-rays and Scans may be requested. This is usually a General Anaesthesia with  a nerve block for post-operative pain releif, if necessary.

Admission

This maybe done as a day-care or an over-night(s) admission procedure, depending on other co-morbidities (illnesses) and insurance provisions.

Procedure

Inside the operating theatre, our Anaesthetisit will give the General Anaesthesia, and a block sometimes, for post-operative pain relief.

Position

This is usually done with the patient in the lateral position (lying-by-the-side) or sometimes by the beach-chair position (semi-sitting). With the former position, the arm is suspended by a simple pulley traction system. to facilitate the procedure. If a beach-chair position is used, mechanical compression stockings may be used, to facilitate blood flow from the legs.

Arthroscopic Procedure

After Anaesthesia, the area is prepared by cleaning thoroughly with anti-septics (e.g. Chlorhexidine), and draped with sterile sheets to maintain sterility during the procedure. Antibiotics also may be administered.

A small (less than a cm) stab incision called a portal (key-hole size), is made at the back of the shoulder to facilitate entry into the joint. A cannula (conduit) is inserted to keep the portal open. A tiny camera (Arthroscope), with a light source and water inflow are used to visualise the joint. The landmarks inside the shoulder joint are duly noted, and the integrity of structures may be probed with a tiny probe through another portal made from the front of the joint.

In a dislocation of the shoulder, the labrum, which is a circumferential rim of around the shoulder joint, is usually  found to be disrupted. It's location is probed and extent of disruption, determined. This leison, when it is at the front of the shoulder is called as the Bankart's leison. The bed of bone where it was meant to have been attached is also prepared. Now special anchors (metal or bio-absorbable) with sutures are inserted at the specific sites of prepared bone using very special instruments. Additional portals, with or without cannulae, may also be made, to facilitate this part of the procedure. Once an adequate number of anchors, usually two or three, are inserted the next stage is to deftly thread the suture material through the labrum and capsule and tie them snugly to the bone (Glenoid) rim. Thus attempting to re-create a pre-tear anatomical environment for the shoulder. The whole procedure is completed with the aid of special tiny instruments through tiny skin incisions called portals. These incisions are closed with sutures, at the end of the procedure, and dressings applied on top.

After the Procedure, the patient may find himself or herself, in the Recovery Room, which is a specially equipped and staffed room for recovering patients from Anaesthesia. They may notice that their arm is supported in a sling, to protect them from moving their operated shoulder. And after recovery, they will be shifted to the ward. Usually, if it was a planned day-case procedure they may be discharged on the same evening, if not the following day.

After discharge, the patient is asked to return to the clinic for regular dressing changes till, sutures are removed.

Re-habilitation involves six weeks of immobilisation in the sling, followed by gradual mobilisation to obtain a good range of motion. The special Re-habilitation protocol is individualised according to patient's needs. It is often a fine balance between delaying it just enough to let it heal un-disturbed and starting it early enough, to minimise stiffness. After due re-habilitation, sports specific exercises are instituted, for sportspersons who are intending to get back to play.

Throwing Shoulder Injuries

While a throw maybe artificially divided into  various phases like wind up, cocking, acceleration, degeneration and ball release, and follow through, the forces acting through the phases a are real and so are the injuries that can happen.

The throwing motion puts a lot of stress on the shoulder and the injuries that these athletes ( javelin throwers, baseball pitchers, cricket ball throwers) sustain may be different to those who are not involved in overhead sports. The forces generated in the shoulder can be enormous and cause over use injuries to the cuff and labral tissues. In the kids it may lead to inflammation and separation of the growth plate.

Anterior impingement injuries occur due to the cuff and biceps tendon getting pinched under the acromion and coraco acromial arch. Posterior tension injuries occur during the deceleration phase of throwing where the posterior muscles are countering the excessive anterior force.  The posterior cuff muscles may fail under tension. The tears usually occur on the underside of the cuff. Avulsion injuries to the labrum when it is pulled eccentrically by the biceps Contraction during the deceleration phase of ball release. Repeated throwing also puts a lot of stress on the anterior labrum, capsule and glenoid, leading to anterior instability in the end.

Instability, ususally anterior, is usually diagnosed clinically, with MRI confirming the findings. Strengthening around the shoulder is initiated, failure of which may warrant a shoulder Arthroscopy and repair of the detached labrum.

Throwers can sustain injuries to the Biceps tendon too, Especially due to its eccentric contraction during the follow through phase. This may be treated conservatively with appropriate rest and strenghtening. Failing which an Arthroscopy may be indicated for a simple debridement or a tenotomy with tenodesis

Rotator cuff problems can be due to impingement, instability or due to tensile failure of the cuff, in the throwers. Instability and tensile failure seem to cause under surface partial tears, which may be treated with physio and rehabilitation initially, by stretching the posterior capsule and strengthening the Rotator Cuff. Failure to improve will lead to arthroscopic debridement, and perhaps repair. If underlying Instability is a cause that has to be addressed, just like a subacromial decompression that may be necessary to address a sub acromial impingement.

Other issues that one might encounter while treating throwing athletes with shoulder pain are wear and tear of cartilage (osteochondritis dissecans), nerve (supra-scapular nerve) and artery (quadrilateral space) entrapments, Acromia-clavicular joint degeneration, Bony growth (Thrower's exostosis) and growth plate injuries (little league shoulder) in kids.

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