ONE is on the Leading Edge of Bio-Orthopaedics
As the region’s largest Orthopedic practice, Ortho NorthEast is committed to providing the most comprehensive treatment options. The new Cartilage Restoration Center (CRC) is an exclusive Center of Excellence that provides alternatives to joint replacement surgery. ONE physicians are skilled in a wide range of procedures that offer relief to those who have an injury or joint deterioration that causes pain, swelling, loss of motion and other symptoms. Cartilage restoration therapy is considered ideal for patients under the age of 50 who are seeking to delay or avoid joint replacement and maintain active lifestyles.
The Cartilage Restoration Center combines leading cartilage repair techniques in a subspecialty that includes all major joints: knee, hip, shoulder, elbow and ankle. Procedures currently offered include:
- Microfracture surgery — a minimally invasive procedure that encourages the growth of new cartilage
- OATS (Osteoarticular autograft transfer system) — a transfer of healthy hyaline cartilage to the site of damaged articular cartilage (Patient’s own cartilage)
- Osteoarticular allograft — replaces damaged cartilage and encourages new cartilage growth (donor cartilage)
- Cartilage transplant — replaces cartilage defects with new cartilage cells to help restore normal joint function
- Meniscus transplant — replaces the damaged meniscus “cushion” of cartilage with donor cartilage
- Viscosupplementation — an injection of a thick fluid to help cushion the joint, provide lubrication and encourage cartilage growth
To learn more about the Cartilage Restoration Center or to consult with an ONE physician, contact us to arrange an appointment.
Cartilage Restoration Center Testimonials
Joe Cockrell: “The pain was only getting worse.”
Most of us take for granted being able to take a few simple steps without pain. Not Joe Cockrell. As he approached his mid-50s, he suffered from knee pain that was growing progressively worse. “The pain in my knee was so bad, I could barely walk,” said Joe. “I realized I was missing out on everything.”
Joe was referred to Dr. Brett Gemlick at Ortho NorthEast. “Dr. Gemlick explained that the cartilage in my knee was damaged from years of wear and tear and that the cartilage would not grow back on its own. I realized the pain was only going to get worse.”
Dr. Gemlick determined that Joe was a good candidate for an advanced cartilage restoration procedure known as microfracture surgery. In microfracture surgery, the surgeon makes very small holes in the bone near the damaged cartilage. The holes release bone marrow cells that form a clot and trigger the production of new cartilage.
According to Joe, the pain in his knee improved immediately following the procedure. And today? “It feels great — my knee is totally pain-free,” said Joe. “I’m even back to being an assistant coach of a youth football league.”
Joe realizes that many people who suffer from knee pain put off seeing an orthopaedic specialist. “I tell them the pain isn’t going to get better on its own,” he says. “For me, the first step to getting better was getting to Dr. Gemlick.”
Matthew Dawson: “Active all day.”
Two years ago, 21-year-old Matthew Dawson learned first-hand what can happen when your upper and lower leg twist in opposite directions. “I was running around with friends when my foot got caught and my body kept moving,” said Matt. “I knew right away my knee was badly hurt, and as it turned out, I tore much of the soft tissue, damaged the cartilage and fractured my knee cap.”
Matt saw Dr. Brett Gemlick at Ortho NorthEast and was scheduled for cartilage fixation surgery three days later. According to Dr. Gemlick, the extent of Matt’s cartilage detachment was very serious and put him in danger of developing arthritis in his knee.
“Dr. Gemlick fixed a hole in my knee cartilage that was as big as a half-dollar,” said Matt. During the procedure, Dr. Gemlick attached the cartilage using advanced bio-absorbable pins and screws that are designed to resorb into the body within 8-12 months.
After being on crutches for a month, Matt began three months of physical therapy. “By the second month of rehab, I began to regain mobility and the pain was much better,” said Matt. These days, Matt is on his feet and active all day at his job. He knows that until recently, people with his injury would likely have faced a lifetime of knee problems. Thanks to ONE’s advanced Cartilage Restoration Center, Matt has made a full recovery.
Arthroscopy is a surgical procedure used to diagnose and treat joint conditions or injuries. This procedure allows the surgeon to look directly inside the joint through the use of an arthroscope, a small illuminated fiber optic camera. The pictures captured by the camera are magnified and displayed on a television monitor, allowing the surgeon to determine injuries, diagnose disease and even perform repairs. The joints most frequently examined through arthroscopy are the knee, shoulder, hip, ankle, elbow, shoulder and wrist.
How is arthroscopy performed?
Arthroscopy is performed through very small incisions called portals. One incision is made for insertion of the camera and several others may be made for additional instruments or to look at various areas of the joint. The joint is filled with fluid causing it distend giving the surgeon more room to work
Special surgical instruments are commonly used to trim tissue, remove debris or “loose bodies,” smooth rough surfaces, and to stitch or staple ligaments or cartilage (shown at right). Because of technological advances, even procedures such as anterior cruciate ligament (ACL) reconstruction can be performed arthroscopically.
After a complete orthopedic examination and possibly diagnostic tests, your physician may recommend arthroscopy as a more precise way to diagnose your condition, or to repair a problem. Your doctor will discuss whether your procedure will be performed on an outpatient basis or if a hospital stay will be required; fully explain the procedure; discuss anesthesia options; and explain the risks and benefits of surgery.
After surgery, you will be monitored as your anesthesia wears off. As your recovery progresses, you will be given instructions on care of your incisions, pain medication, exercises, and other instructions to help speed your recovery.
Although arthroscopic surgery is less invasive than other types of “open” procedures, it will take several weeks for the joint to recover. Many patients can resume daily activities and return to work or school within a few days.
The anterior cruciate ligament (ACL) stabilizes the knee to prevent unwanted movement of the bones that meet to form the knee. ACL injuries occur most often during athletic activities. When the ACL is injured, it may require surgical repair to restore the knee’s stability and normal function. ACL reconstruction has become a safe and common knee procedure. Today, ACL injuries are no longer devastating to knee function. New technologies and surgical techniques combined with aggressive postoperative care and therapy allow a full return to normal activity.
The Knee Joint
The knee, which is the largest joint in the body, is considered a “hinged” joint since it is designed to allow the knee to flex (bend) and extend (straighten). The knee is formed by the femur (thigh bone), tibia (shin bone) and patella (kneecap). Each bone is covered with a layer of smooth cartilage, called articular cartilage.
The knee maintains its stability through a series of ligaments that act like rubber bands to allow motion while maintaining proper orientation of the bones. Both the anterior cruciate ligament, or ACL, and the posterior cruciate ligament (PCL) stabilize the knee. The ACL and PCL cross each other in the center of the knee. The ACL is tightest when the leg is straight, and the PCL is tightest when the leg is flexed. The ACL, which runs from the front of the tibia to the back of the femur, prevents the tibia from gliding forward. The PCL prevents the tibia from gliding backward.
If you have suffered an ACL injury, treatment depends on many factors, including your lifestyle. Your expectations for knee function or performance may play a role in determining whether reconstruction is needed. For example, an active person may require surgical treatment to obtain the knee stability needed to continue their activities.
With an ACL tear, your knee will be unstable. This instability will cause your knee to “give out,” which will significantly influence knee function. If therapy and the use of a special ACL brace do not improve the stability of the joint, your physician may recommend surgical reconstruction. The physician will also consider whether there are additional knee injuries which make surgery necessary, such as a meniscal tear.
If surgery is required, the amount of time between your injury and when the reconstruction is performed will be decided by your surgeon. Your doctor will discuss whether your procedure will be performed on an outpatient basis or if a hospital stay will be required; fully explain the procedure; discuss anesthesia options; and explain the risks and benefits of surgery.
Physical therapy will be started before your surgery. This will help you learn the exercises you will need to perform during the initial phases of recovery after surgery. Physical therapy will focus on the following goals:
- establishing a full range of motion (bending and straightening)
- reducing swelling in your knee
- strengthening the musculature surrounding your knee
During surgery, your surgeon will examine your knees to compare the stability of your injured knee to the other knee. After this examination, your injured knee will be evaluated with the help of an arthroscope. The arthroscope is a tiny illuminated fiberoptic camera that is inserted into your knee through very small incisions, allowing the surgeon to see the interior of your knee on a video monitor.
If ACL reconstruction is indicated, the surgeon will use the arthroscope to perform this procedure through very small incisions. Reconstruction usually involves replacing the damaged ligament with a tendon graft. The graft is usually obtained from the central third of your patellar tendon, or from a portion of your hamstring tendons. The graft will be placed in your knee in the exact location of your natural ACL.
After the arthroscopic evaluation, two small tunnels will be made. The first tunnel is placed through the tibia, and the second will be in your femur. This prepares your knee for graft placement. The graft is pulled into place through the tunnels in the exact position of your ACL. After the graft has been inserted into the new tunnels, it is fixed in place. This will secure the graft until complete healing can take place.
After your surgery, you will awaken in the Post-Anesthesia Recovery Room where you will stay until you recover from the anesthesia, are breathing well, and your blood pressure and pulse are stable. It is normal to feel pain and discomfort after surgery. Pain medication and anti-inflammatory medication will be given to you after your surgery to ease your discomfort and swelling.
Your knee will be in a post-operative leg brace or knee immobilizer to limit motion. A cold pack, fluid-filled wrap or a continuous circulating cold therapy device will be placed around your knee to provide compression and cooling and control your inflammation, pain and swelling. Special hose or stockings will cover your injured leg to prevent blood clots. Your surgeon will tell you how long the hose should remain on your leg, usually from 10 to 14 days.
In some cases, your surgeon may recommend the use of a Continuous Passive Motion (CPM) machine. The CPM machine will establish your knee motion in the days following surgery. You will be instructed on how to use the machine. It is likely that you will also be directed to use a cooling system on your knee for approximately 30 minutes each hour. You will be instructed to keep your knee elevated above your heart as much as possible.
Crutches will be provided and will be needed for the first 10 to 14 days. You may put weight on your knee when it is comfortable for you. Expect to feel weak for a few days after surgery.
On the day after surgery, you may change all of your surgical dressings except for the steri-strips. The steri-strips are tape strips that are placed directly on the incision. You can expect some bleeding from your incision, which should stop in 24 to 48 hours. Be sure to keep your wounds clean and dry for 10 to 14 days.
A specific exercise program recommended by your doctor should be started the day after surgery. The exercises are designed to reestablish range of motion and strength after ACL reconstruction.
After your ACL reconstruction and rehabilitation program, you can expect to return to an active lifestyle. Some surgeons may recommend a functional knee brace for a period of time after surgery and possibly for extended use during sports-related activities. Your physician will track your progress and make recommendations during a follow-up appointment.
When pain, stiffness, knee swelling and limitation of motion in your knee keep you from your daily activities, you may need total knee replacement. (The most frequent source of debilitating pain is arthritis.) The development of total knee replacement began more than 30 years ago. Today, more than 200,000 people in the United States annually undergo knee replacement surgery as a means of diminishing pain and stiffness and restoring mobility.
The Knee Joint
The knee is the largest joint in the body. It is commonly referred to as a “hinge” joint because it allows the knee to flex and extend. While hinges can only bend and straighten, the knee has the additional ability to rotate (turn) the femur (thigh bone) and the patella (knee cap). Each bone end is covered with a layer of smooth shiny cartilage that cushions and protects while allowing near frictionless movement. Cartilage, which contains no nerve endings or blood supply, receives nutrients from the fluid contained within the joint. Surrounding the knee structure is the synovial lining, which produces this moisturizing lubricant. If damaged, the cartilage is not capable of repairing itself.
Tough fibers, called ligaments, link the bones of the knee joint and hold them in place; adding stability and elasticity for movement. Muscles and tendons also play an important role in keeping the knee joint stable and mobile.
Your Knee Evaluation
An orthopedic surgeon specializes in problems affecting bones and joints. Your knee evaluation will begin with a detailed questionnaire. Your medical history is very important in determining whether surgery is necessary and medically safe. It helps the surgeon understand your pain, limitations in activity and the progression of your knee problem.
After your history is taken, a physical exam is performed. The range of motion of your knee is measured, your legs are evaluated for variances such as bowlegs or knock-knees, and your muscle strength is analyzed. The surgeon will observe how you walk, sit, bend and move.
X-rays are taken of your knee joint. Bring any X-rays that may have been taken of your knee in the past. These X-rays will help your surgeon plan the surgery and evaluate the fit of your new knee prosthesis.
A small amount of fluid may be taken from your knee joint to check for infection.
After your initial orthopaedic evaluation, the surgeon will discuss all possible alternatives to surgery. If the X-rays show severe joint damage and no other means of treatment has provided relief, total knee replacement may be recommended.
Total Knee Replacement
Total knee replacement or “arthroplasty” is the relining of the joint (bone end surfaces) with artificial parts called prostheses.
There are three components used in the artificial knee. The femoral (thigh) component is made of metal and covers the end of the thigh bone. It may be cemented to the bone or, for some prostheses, inserted without cement for tissues to grow into the porous coating of the device (biological fixation). The tibial (shin bone) component, made of metal and polyethylene (medical-grade plastic), covers the top end of the tibia.
The metal forms the base of this component, while the polyethylene is attached to the top of the metal to serve as a cushion and smooth gliding surface between the metal of the femoral and tibial components. The tibial component may be secured to the bone with bone cement or, for some porous coated prostheses, biologically fixed by tissue ingrowth.
The third component, the patella or knee cap, may be all polyethylene or a combination of metal and polyethylene. Depending on the prosthesis used, this part may be fixed with or without cement.
The total knee replacement is inserted through an incision that runs three or four inches above the knee down along the inside of the kneecap to several inches below the knee. The new components are stabilized by your ligaments and muscles, just as your natural knee was.
You may be asked to see your family physician or an internal medicine doctor for a more thorough medical evaluation. To prepare yourself for surgery, you may be asked to do a number of things. You may be asked to lose weight if you are overweight. If you smoke, it is important for you to stop two weeks prior to surgery. If you are taking aspirin or certain arthritis medications, inform your surgeon; you may need to stop taking these two weeks before surgery. If you take estrogen (i.e. Premarin), your surgeon will probably advise you to stop taking it one month prior to surgery. Your doctor may want you to donate your own blood ahead of time for a possible transfusion during surgery.
You will probably be admitted to the hospital the morning of surgery. You cannot eat or drink anything after midnight the day of surgery.
In order to receive medications and blood transfusions during surgery, an intravenous (IV) line will be started. The anesthesiologist will speak to you before surgery and discuss the type of anesthetic to be used.
What To Expect After Surgery
You will awaken after your surgery in the Post-Anesthesia Recovery Room. You will remain there until you have recovered from the anesthesia, are breathing well, and your blood pressure and pulse are stable. You may feel as though you only left your room for a few minutes. If you experience pain, medication will be available.
You may have a tube or drain coming through the surgical dressing that is attached to a drainage apparatus. This system provides gentle, continuous suction to remove any blood that accumulates in the surgical area. The drain will probably be removed several days after surgery. The dressing will also be changed and a smaller one applied.
An “immobilizer” (a cloth support with stays) will fit around this dressing and will hold your leg straight. An alternative to immobilization after surgery is the use of a “Continuous Passive Motion” (CPM) machine. Your leg is held softly in a cradle. The knee is then gently and slowly bent and straightened.
Your leg will be supported and elevated on one or two pillows to help your circulation and stretch the muscles behind your leg. You will be asked to move your ankle to promote circulation and prevent stiffness in your ankle joint. The immobilizer may be used the first 48 hours after surgery, then removed. The CPM machine may be used the next 48 hours or longer, if needed, even after you leave the hospital.
The nurse will assist you in turning on your side, if you wish. You may adjust the head of the bed to any level you desire. The knee adjustment on the bed should not be used. Your knee should remain straight unless you are performing knee exercises.
An IV may remain in your arm for several days to administer antibiotics or other medications you may need. This helps prevent infection and gives you proper nourishment until you are eating and drinking comfortably. You will begin regular fluid and food intake under the direction and advice of your surgeon.
To prevent problems in your lungs, you may receive an incentive spirometer after surgery to encourage you to cough and breathe deeply. This is used every hour while you are awake.
It is normal to feel pain and discomfort after surgery. Inform the nurse of your pain, and medication will be ordered.
A knee rehabilitation program, which begins 24 hours after surgery, will be ordered and supervised by your surgeon. Isometric exercises (tightening muscles without moving the joint) will begin while you are still in bed.
You will be instructed to do these exercises a number of times per day while awake. You will be encouraged by the physical therapist to move your ankle and other joints so that you will remain strong. These exercises will help you regain strength and mobility.
The day after surgery, you will probably begin walking and exercising your knee joint. The exercises will probably be done twice daily. Initially, the physical therapist will assist you in getting out of bed and standing at the bedside with a walker. For your entire hospital stay, you will walk with a walker or crutches under the supervision of a therapist. Your walking distance will gradually increase. When you are strong enough, you will be able to walk without the support of the immobilizer.
Through progressive daily exercises, you may achieve about a 90-degree bend in the knee joint by the time you leave the hospital. Bending your knee during the exercises may be painful. Pain medication taken before therapy will make the exercises more comfortable. Ice packs, hot packs and other treatments may be used to assist you in bending your knee.
Preparing To Go Home
The usual hospital stay for knee joint replacement is usually three to five days. Depending on your progress, you will probably gain independence within one week after surgery. To accommodate sitting, there will be an elevated chair and commode available for your use. An elevated toilet seat will be ordered for you to take home. At home, you will need a firm chair with arms.
Just prior to your discharge, you will receive instructions for your at-home recovery. Until you see the surgeon for your follow-up visit, you must take certain activity precautions. It is important for you to adhere to your surgeon’s directions and follow proper positioning techniques throughout your rehabilitation. Arrangements will be made for someone to remove the sutures or skin clips about 10 days after surgery.
It is normal for you to have some discomfort. You will probably receive a prescription for pain medication before you go home. If a refill is needed, please call your surgeon’s nurse at least five days before you run out of pills.
Look for any changes around your incision. Contact your surgeon if you develop any of the following:
- Drainage and/or foul odor coming from the incision.
- Fever (temperature about 101 degrees F or 38 degrees C) for two days.
- Increased swelling, tenderness, redness and/or pain.
Take time to adjust to your home environment. It is normal to feel frustrated, but these frustrations will soon pass. It is okay to take it easy.
Depending upon the physical demands of your job, you normally can resume work when authorized by your surgeon.
You usually may begin driving once you are able to bear full weight on your knee. Be sure you are comfortable with your strength. Be sure to practice driving in a safe area. Once you are comfortable with your mobility, you generally may drive anywhere.
Sexual intercourse may be resumed at any time as long as all knee precautions are kept in mind.
We encourage you to be active in order to control your weight and muscle tone. It is generally three to four months before you can resume low-impact aerobic activity such as walking, golfing, bowling and swimming. Jogging, high-impact aerobics and contact sports are never allowed. Your new knee is artificial and although it is made of very durable materials, it is subject to wear and tear.
Since your rehabilitation is an individual one, please seek advice on future activities from your surgeon.
You may be seen six weeks, five months and twelve months after your surgery. It may be requested that you see your surgeon once a year after the first year, even if you are not having any problems.
Any infection must be promptly treated with proper antibiotics because infection can spread from one area of the body to another through the blood stream. Every effort must be made to prevent infection in your artificial joint. You should always tell your dentist or physician that you have an artificial joint. If you are to have dental work performed, please call your surgeon prior to having this work done. Your surgeon will most likely prescribe an antibiotic for you. Antibiotics must be used before and after any medical or dental procedure. This precaution must be taken for the rest of your life.