Townsville surgeon wants health providers enforce smoking laws

OLIVIA GRACE-CURRAN, Townsville Bulletin
March 20, 2018 12:00am

SMOKERS are being urged to consider others and heed signs discouraging smoking near public and private health facilities.

Smoking is prohibited within 5m of all public and private health facilities in Queensland.

A Townsville orthopaedic surgeon is hoping local health providers consider driving an initiative to enforce the $252.30 fine on those breaching the laws.

Dr Kaushik Hazratwala posted a response from the Townsville Hospital on Facebook after he complained about people smoking outside the hospital.

“The Townsville Hospital and Health Service remain committed to both the active promotion of the‘Quit smoking … for life’ campaign and the provision of program support to patients and staff who are ready to quit smoking,” a letter addressed to him read.

Dr Hazratwala said it was sad that the hospital was unable to enforce the no-smoking rule but he was disappointed at those people who were blatantly ignoring the signage.

“Patients and patrons alike simply ignore the signs and nothing can be done about it,” Dr Hazratwala wrote.

He believes society is not afraid of authority and smokers will only follow protocol when policies are correctly implemented at both public and private health facilities.

“It’s about the system and society being considerate of others when there is a law that says you’re not supposed to smoke, society is to blame,” Dr Hazratwala said.

Acting Townsville Hospital and Health Service chief executive Kieran Keyes said the hospital employed two security officers to conduct foot patrols of the hospital grounds

“A component of this work is educating the public about not smoking on hospital grounds,” Mr Keyes said.

The Townsville HHS strongly discouraged patients from smoking.

“The Townsville Hospital offers significant support to staff and patients to quit smoking. However, this is something that people need to be willing to do,” Mr Keyes said.

“For patients particularly, receiving care in the hospital can be extremely taxing and stressful and smoking can often be a familiar and learned coping mechanism.”

According to Queensland Health tobacco laws, a person caught smoking at a health facility and a person smoking on land within the 5m beyond the boundary of the health facility can be fined two penalty units or $252.30.

Failure of a person to stop smoking at a health facility or on land within 5m beyond the boundary of the health facility, when directed to do so by an authorised person, faces the same penalties.

“The Townsville HHS has not issued a fine for smoking at the Townsville Hospital with the focus being on education ahead of enforcement,” Mr Keyes said. Read More

 

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Computer Navigation is for the Outliers!!!!!!

Computer Navigation is for the Outliers!!!!!!

By Dr Kaushik Hazratwala, Orthopaedic Surgeon,

Director – Orthopaedic Research Institute of Qld

Director – Townsville Lower Limb Clinic

computer navigation in knee

Finally, after 15 yrs. this Korean group has proven that Computer Navigation will not improve patient outcome in all comers.  The proponents of conventional Knee replacements will rejoice in this publication and uncork expensive French champagne. Finally, their resistance to adopting Computer navigation has been vilified.

So why do we still have a 20% dissatisfaction rate in patient following a “successful” TKR.  Is it because some surgeons are poor technicians and are diluting the data for the super gifted surgeon. Or is it that 20% of the population undergoing TKR are just whingers.  Could it be that we as surgeons are not catering for that 20%?  God forbid it’s the later!!!!!!!

Let’s look at some published data on anatomical variation amongst the normal population. Belleman’s et al1 in 2013 found that approximately 20% of the population is outside the +/- 3° Hip Knee Ankle Alignment (HKA). These are asymptomatic patients whose knees are not Straight. Below is a graph form this paper demonstrating the spread of constitutional alignment.

Knee Replacement

Fig 1-  24.6% of the sampled population had a constitutional Varus of greater than 3° Varus, and 2.4% were greater than 3° valgus.

So why do we aim to align our knees to within +/-3°?   The answer lies in the fact that we cannot accurately vary the degree of resection within 1° of accuracy with conventional instruments. The margin of error that has led to older publication 2345  agreeing with the fact that knees have a higher failure rate if outside the 3° window of safety. Some of these studies included poorly designed prosthesis and notwithstanding the fact that these knees were implanted using the mechanical alignment technique and the fact they ended up outside the 3° widow was an error. These knees were then followed up to show inferior results and a higher failure rate.  Hardly surprising!!

Conventional technique works great for the 80% of the population utilizing the mechanical alignment technique and subsequent soft tissue release to balance the knee. If the same surgical technique is used using computer navigation one would have to be foolish to expect a different outcome. All the computer navigation does is help the surgeon hit the target +/-3° more precisely. Many papers have shown the superiority of CAS over conventional  instruments678.  Deep et el7 have performed a metaanalysis on this topic and found that the current literature does support the use of CAS and in the future assistive technologies will pave the way for superior outcomes.

 

I’m proposing a shift in the way we look at Knee replacement assistive technology. We currently have 3 basic forms of assistive technology, CAS, IDI (Image derived instrumentation) and Robotics. These technologies are not a prescription to perform a knee replacement but rather a guide and a tool to execute your pre-operative plan.

If you are able to predict the outliers and tailor your surgery to realign not only the bony anatomy but also restore the soft tissue envelope to its native alignment I would think that we might just see better outcomes. This change in mindset could lead to the drop in the 20% dissatisfaction rate.

I have no issue with the conventional instruments as long as the surgical algorithm allows the surgeon to vary the resection angle to the pre-operative templated angles. I have been thru this curve and have settled on navigation as the gold standard in the execution of a plan that is not necessarily +/-3°. Our research group (Orthopaedic Research Institute of Queensland) is currently looking at outcome data of bilateral patients who are constitutional outliers and have been either mechanically or alternately aligned. Both groups have been done using the CAS. The Game is not within +/-3° it is outside this range. The 80% good results in both groups dilute the 20% outlier poor result in the machine when compared to the alternately aligned outliers.

Therefore, let’s not rejoice in this paper – let’s be critical and let’s work towards dropping the dissatisfaction rate to whatever we can.

  1. Bellemans J, Colyn W, Vandenneucker H, Victor J. The Chitranjan Ranawat award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res. 2012;470(1):45-53. doi:10.1007/s11999-011-1936-5.
  2. Bonner TJ, Eardley WGP, Patterson P, Gregg PJ. The effect of postoperative mechanical axis alignment on the survival of primary total knee replacements after a follow-up of 15 years. J Bone Jt Surg Br. 2011;9393(9):1217-1222. doi:10.1302/0301-620X.93B9.
  3. Eckhoff DG, Bach JM, Spitzer VM, et al. Three-dimensional mechanics, kinematics, and morphology of the knee viewed in virtual reality. J Bone Joint Surg Am. 2005;87 Suppl 2(suppl_2):71-80. doi:10.2106/JBJS.E.00440.
  4. Parratte S, Pagnano MW, Trousdale RT, Berry DJ. Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements. J Bone Joint Surg Am. 2010;92(12):2143-2149. doi:10.2106/JBJS.J.00937.
  5. Lotke PA, Ecker ML. Influence of positioning of the prosthesis in total knee replacement. J Bone Joint Surg Am. 1977;59(1):77-79. http://www.ncbi.nlm.nih.gov/pubmed/833180. Accessed January 27, 2018.
  6. Todesca A, Garro L, Penna M, Bejui-Hugues J. Conventional versus computer-navigated TKA: a prospective randomized study. Knee Surgery, Sport Traumatol Arthrosc. 2017;25(6):1778-1783. doi:10.1007/s00167-016-4196-9.
  7. Deep K, Shankar S, Mahendra A. Computer assisted navigation in total knee and hip arthroplasty. doi:10.1051/sicotj/2017034.
  8. de Steiger RN, Liu Y-L, Graves SE. Computer Navigation for Total Knee Arthroplasty Reduces Revision Rate for Patients Less Than Sixty-five Years of Age. J Bone Jt Surgery-American Vol. 2015;97(8):635-642. doi:10.2106/JBJS.M.01496.
Dr Kaushik Hazratwala - orthopaedic surgeon

PLATELET RICH PLASMA (PRP) – LATEST EVIDENCE OR LACK OFF !!!

This is an abstract from the recently published review article in the American JBJS.
It summarises the current application of the use of PLATELET RICH PLASMA in clinical orthopaedics.
There is support for its use in knee Arthritis but there is not enough evidence for routine use in soft tissue injuries.
image1

“Platelet-rich plasma has shown great promise and potential to stimulate biologic activity in difficult-to-heal musculoskeletal tissue. However, the optimal formulation, method of administration, and dosing for different tissues have yet to be determined.

image3

Read: Alternate Alignment Technique for Total Knee Replacement

Within a given platelet-rich plasma preparation technique, there is a high degree of inter-subject and intra-subject variability in the composition of platelet-rich plasma produced. This likely contributes to the inconsistent results reported in the current platelet-rich plasma literature.

image4

Read: How old is too Young for Hip and knee arthroplasty

Current evidence best supports the use of platelet-rich plasma as a treatment for osteoarthritis of the knee. Evidence on the use of platelet-rich plasma as a treatment or adjunct for rotator cuff repair, lateral epicondylitis, hamstring injuries, anterior cruciate ligament (ACL) reconstruction, patellar tendinopathy, Achilles tendinopathy, and fractures is inconsistent or only available from low-powered studies. To our knowledge, no comparative studies examining platelet-rich plasma treatment for partial ulnar collateral ligament tears in the elbow currently exist.

Current evidence suggests that different platelet-rich plasma formulations are needed for different tissues and pathologies. Ultimately, improved understanding of the underlying structural and compositional deficiencies of the injured tissue will help to identify the biologic needs that can potentially be targeted with platelet-rich plasma.”

REFERENCE

Wang, Dean; Rodeo, Scott A, Platelet-Rich Plasma in Orthopaedic Surgery: A Critical Analysis Review
JBJS Reviews: September 2017 – Volume 5 – Issue 9 – p e7doi: 10.2106/JBJS.RVW.17.00024

 

Dr Kaushik Hazratwala - orthopaedic surgeon

Who is more likely to have anterior patella pain (knee cap)?

Who is more likely to have anterior patella pain (knee cap)?

The patella is located anterior (in front) of the femur in the femoral trochlear groove, and “tracks” along this groove depending on how the knee is bent. Patellar instability and pain can happen to anyone once the patella begins to move incorrectly. Most commonly, pain in the front of the knee occurs in:

Athletes involved in sports with repeated running or jumping
People employed in heavy manual labour required to climb up and down repeatedly
People who are overweight
Individuals with prior patella injuries (dislocation)
Females as they are predisposed to maltracking.
People with mal-alignment of the lower limbs
Patients with arthritis.

 

Alternate Alignment Technique for Total Knee Replacement

Alternate alignment is gaining popularity amongst orthopaedic surgeons. The alternate alignment principal for total knee is based on the gap balancing principal, allowing the medial and lateral soft tissue envelope to remain at their native lengths.12

It is an anatomical tibia 1st technique with subsequent femoral cuts to balance the knee within its native soft tissue envelope, Compared to mechanical alignment, use of the alternate alignment technique results in the femoral component being slightly valgus and the tibial component slightly varus, in most cases without affecting mean HKA alignment and leading to improved early functional outcomes.13

Cadaveric studies have shown alternate alignment in TKA reduces tibial forces and contact, although these studies were only performed on native rather than osteoarthritis knees.14

Howell et al.15 followed a cohort of kinematically aligned postoperative neutral and varus/valgus outliers and found no incidence of failures for any category after 31 months, with comparable functional scores for the three alignment categories.

The utility of specific postoperative target alignment categories for TKA patients was recently questioned by Rames et al.16, who found no significant benefit to functional outcomes regardless of whether patients were corrected to neutral, mild varus, severe varus or valgus mMPTA postoperatively. The authors highlight the contribution of factors other than coronal alignment toward implant survivorship, including ligament balancing and component rotation.

Unlike mechanical alignment, alternate alignment does not target a specific postoperative alignment category, instead restoring the joint line to its native alignment.

However, there is concern that, particularly for patients with severe preoperative varus or valgus alignment, this technique may increase the risk of catastrophic failure of the implants.2,9 Stan et al.17 demonstrated using finite element analysis, that knee balancing significantly reduces the contact pressure on the tibial polyethylene insert and improves prosthesis survival. The authors however caution that increasing tibial varus tilt beyond 3° may have a detrimental effect on pressure distribution across the tibial component. Further studies are therefore warranted to determine the suitability of alternative alignment for patients with constitutional varus or valgus deformity and to better understand the effect this has on risk of catastrophic failure of the tibial component.

I’m sharing intra operative Navigated resection and alignment parameters of my first 50 Alternate Aligned Knees. It shows that the Alternate alignment resection is very similar to the preoperatively templated Resection angles.

Alternate Alignment Technique for Total Knee Replacement

REFERENCES

 

  1. Green GV, Berend KR, Berend ME, Glisson R, Vail TP. The effects of varus tibial alignment on proximal tibial surface strain in total knee arthroplasty: The posteromedial hot spot. J Arthroplast 2002;17:1033-1039.
  2. Werner FW, Ayers DC, Maletsky LP, Rullkoetter PJ. The effect of valgus/varus malalignment on load distribution in total knee replacements. J Biomech 2005; 38:39-55.
  3. Bellemans J, Colyn W, Vandenneucker H, Victor J. The Chitranjan Ranawat Award: is neutral mechanical alignment normal for all patients? The concept of constitutional varus. Clin Orthop Relat Res. 2012;470(1):45-53. doi:10.1007/s11999-011-1936-5.
  4. Dunbar MJ, Richardson G, Robertsson O. I can’t get no satisfaction after my total knee replacement. Bone Joint J 2013;95-B(11 Supple A).
  5. Robertsson O, Dunbar M, Pehrsson T, Knutson K, Lidgren L. Patient satisfaction after knee arthroplasty: A report on 27,372 knees operated on between 1981 and 1995 in Sweden. Acta Orthop Scand. 2000;71(3):262-267. doi:10.1080/000164700317411852.
  6. Nam D, Nunley RM, Barrack RL. Patient dissatisfaction following total knee replacement: a growing concern? Bone Joint J 2014;96-B(11 Supple A):96-100. doi:10.1302/0301-620X.96B11.34152.
  7. Vandekerckhove PJ, Lanting B, Bellemans J, Victor J, MacDonald S. The current role of coronal plane alignment in Total Knee Arthroplasty in a preoperative varus aligned population: an evidence based review. Acta Orthops Belg. 2016;82:129-142.
  8. Bargren JH, Blaha JD, Freeman MA. Alignment in total knee arthroplasty: correlated biomechanical and clinical observations. Clin Orthop Relat Res 1983;173:178-183.
  9. Ritter MA, Davis KE, Davis P, et al. Preoperative malalignment increases risk of failure after total knee arthroplasty. J Bone Joint Surg Am 2013;95:126-131.
  10. Parratte S, Pagnano MW, Trousdale RT, Berry DJ. Effect of postoperative mechanical axis alignment on the fifteen-year survival of modern, cemented total knee replacements. J Bone Joint Surg Am 2010;92:2143-2149.
  11. Van Lommel L, Van Lommel J, Claes S, Bellemans J. Slight undercorrection following total knee arthroplasty results in superior clinical outcomes in varus knees. Knee Surg Sports Traumatol Arthrosc 2013;21:2325-2330.
  12. Howell SM, Papadopoulos S, Kuznik KT, Hull ML.Accurate alignment and high function after kinematically aligned TKA performed with generic instruments. Knee Surg Sports Traumatol Arthrosc 2013; 21:2271-2280.
  13. Dosset HG, Estrada NA, Swartz GJ, LeFevre GW, Kwasman BG. A randomised controlled trial of kinematical and mechanically aligned total knee replacements: two-year clinical results. Bone Joint J 2014;96-B:907-913.
  14. Roth JD, Howell SM, Hull ML. Kinematically aligned total knee arthroplasty limits high tibial forces, differences in tibial forces between compartments, and abnormal tibial contact kinematics during passive flexion. Knee Surg Sports Traumatol Arthrosc 2017; doi: 10.1007/s00167-017-4670-z
  15. Howell SM, Howel SJ, Kuznik KT, Cohen J, Hull ML. Does a kinematically aligned total knee arthroplasty restore function without failure regardless of alignment category? Clin Orthop Relat Res 2013;471:1000-7.

Dr Kaushik Hazratwala
Orthopaedic Surgeon
Townsville Lower Limb Clinic
http://www.tsvllc.com.au
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Issues to consider with health insurance in Australia

health insurance australia by dr kaushik hazratwala

Health insurance issues in Australia – Dr Kaushik Hazratwala

One of the most important components of hospital insurance is the cover for medical services expenses during hospital treatment.The cover provided by different funds delivers different outcomes for patients. There is essentially 3 types of Billing structure from your service Provider (Usually specialist in-hospital stay) Note- Health insurance does not cover outpatient service e.g. consult, blood, x rays etc.

1. Medicare only. – This usually applies to the public hospital and is usually used as an item number guide in the private sector.

2. No Gap/Known Gap- This usually applies to a specialist who has signed up with the health funds and will only charge a designated scheduled fee for a procedure. The Gap is set by your health fund and the specialist has to abide by this schedule.

3. AMA or Surgeon Preferred Fee- Australian Medical Association (AMA) publishes a schedule of fees for all items on the Medicare Benefits Schedule (Govt codes for all surgeries and procedures). This is set according to CPI indexation and cost of services provided. If your Doctor chooses to charge this fee or higher than your health fund may only pay up to medicare schedule fee only- leaving the patients significantly out of pocket (GAP)

Dr Kaushik Hazratwala explaining the insurance issues in Australia

There a few health funds that will pay the full AMA fee therefore significantly limiting your GAP fees. Usually, their premium will be slightly higher. The questions you need to ask is

1. Do you want to pay a low premium and pay an ‘Excess” later (GAP) If you want to have a Comprehensive cover ask your insurer if they cover up to AMA schedule of fee and compare the premiums and then make the decision? Below is a poster published by AMA outlining why the GAP is increasing. The Health funds base their schedule of fees on the MBS (Gov schedule) Happy to answer questions on PM if required.

Dr Kaushik Hazratwala - orthopaedic surgeon Dr Kaushik Hazratwala
Orthopaedic Surgeon
Townsville Lower Limb Clinic
http://www.tsvllc.com.au
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How old is too Young for Hip and knee arthroplasty

Knee Arthroplasty by Dr Kaushik Hazratwala

Knee Arthroplasty by Dr Kaushik Hazratwala

Nearly every day I consult I would see a patient in their 40’s or early 50’s with bone on bone arthritis of the knee and less commonly the hip.

Unfortunately, the easiest operation for me to perform on these patients is a total joint replacement (Arthroplasty). Why?- Because the surgery has predictable results including pain relief.

However, is this the morally, ethically and scientifically the right thing to do?

The answer is very complex. My longest consultations are with these patients. I need to spend a long time explaining to them what their options are.

1. Non Operative

  • Analgesia
  • Weight Loss (A medical issue in itself which has shown to increase the risk of developing osteoarthritis in these younger patients)
  • Activity Modification
  • Alternate therapy – Physio, acupuncture, massage therapy etc.

2. Operative

  • Salvage non-arthroplasty options e.g. HTO (realignment surgery) for the knee, which shifts the weight to the outside of the knee, thus preserving the inside of the knee for as long as possible.
  • Arthroscopy clean out (Research is now proving that this is not acceptable practice)
  • Minimally invasive bone preserving Arthroplasty e.g. UKR (half a knee replacement)

The last option is a Total Knee Replacement. (Replacement of all 3 compartments – inside, outside and the front of the knee)

So How Old is too young?

The youngest patient I have done knee replacement is 42 yrs. old. He was an electrician working on the windmills out west. He had a family and was the sole income earner. He came to see me with severe deformity (bent) knees, pain, swelling and stiffness. He had pain was able to deal with it (Bushy- she’ll be right mate). Functionally, he could not climb the ladder to get up the windmill and was feeling very unstable and could possibly fall over.

He was about to lose his livelihood. He was going to lose his house and family. In this case, we had no option but to proceed with total knee replacement surgery.

I also have an anecdote of patients in their 40’s to early 50’s whom I see with mild, early arthritis but want to run marathons, or are overweight or refuse to take analgesia. Essentially these patients need to optimise their function and make a few lifestyle changes to avoid Knee or Hip replacement surgery.

Why not replacement??

As I mentioned, I would love to perform hip and knee replacements all day, every day. I have some amazing state of the art equipment to utilise with and the results are terrific in the short to medium term. But what about the long-term? The need for further revision is required when the patient would be in their 60’s to 70’s, and there is only so much bone that can be removed before there are no options left.

Young for Hip and knee arthroplasty

A person in mid 60’s will be 75-80 years of age before his/her knee wears out. If you have followed my previous post – I have to resect some of your bone (not much with navigation technique) to replace it with metal and plastic.

Knee function by dr kaushik hazratwala

There are 2 issues here-

  1. I have taken some of your bone away
  2. I have put plastic (soft) material between chrome cobalt and titanium.

So as you move the knee and since you are young, you will move it a lot more than a 65-70-year-old. As you move the plastic undergoes a wear process and releases very minute plastic particles in the knee joint. These particles have nowhere to go. However, the body detects that there is something foreign in the knee joint floating around. It sends its soldiers, the white cells to fight this foreign enemy. Usually, this foreign enemy is either virus or bacteria and the usually this war is won by the body.

This time the enemy is non-biological. The white cells in an attempt to kill the plastic will ingest (engulf) it but are unable to kill it and it the process the white cell releases all the toxic enzymes as it dies into the knee joint. These enzymes really have no effect on the metal or the plastic but it now starts to dissolve the bone behind the knee replacement and so the knee comes loose and the patient starts developing pain again.

knee replacement specialist dr kaushik hazratwala

Knee replacement specialist Dr. Kaushik Hazratwala

This leads to revision knee replacement. The surgery is then repeated and the process starts all over again. If there is an active infection, sometimes this surgery takes place in two stages over a period of 6 – 12 months.

If you are 65, your knee may last 10-15yrs. If you are 45, it will last for 5-10 yrs. This is directly related to the activity level of a 45 year. old when compared to a 65-75-year-old.

At some stage, there won’t be enough native bone to fix the revision knee into. This is a catastrophic disaster. The only option is a Tumor Prosthesis, which is not ideal and not indicated for the young.

I hope I have given some food for thought for the young arthritis sufferers. Have a good think about your options. If your life is an absolute misery, and you are about to lose your livelihood because of your hip or knee pain, then replacement is an option for you as well. You must understand the consequences of your decision (In collaboration with your surgeon).

Dr Kaushik Hazratwala - orthopaedic surgeon Dr Kaushik Hazratwala
Orthopaedic Surgeon
Townsville Lower Limb Clinic
http://www.tsvllc.com.au
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Baker’s Cyst of The Knee

Baker's cyst of the knee by dr kaushik hazratwala

A Baker’s cyst is a fluid-filled cyst that causes a bulge and a feeling of tightness behind your knee. The pain can get worse when you fully flex or extend your knee or when you’re active.

knee replacement specialist dr kaushik hazratwala

Image courtesy – Mayo Foundation

Read: 5 Steps to Finding the Perfect Life after Knee Replacement

A Baker’s cyst is usually the result of a problem with your knee joint, such as arthritis or a cartilage tear. Both conditions can cause your knee to produce too much fluid, which can lead to a Baker’s cyst.

best knee surgeon in Townsville

Image courtesy – tabletsmanual.com

Read: Know all things about Knee Replacement Surgery Procedure.

It is very important to know that the Bakers Cyst is an effect of an underlying Condition. It is not the primary problem. So getting the cyst drained or removed without treating the underlying condition will just cause the Cyst to reappear.

total knee replacement specialist

Read: ACL rupture and associated structural injuries of the knee

Although a Baker’s cyst may cause swelling and make you uncomfortable, treating the probable underlying problem usually provides relief.

Lateral Hip Pain (Outer)

The most common reason for Lateral (outer) hip pain is Trochanteric Bursitis.

This is inflammation of the trochanteric bursa.

This bursa is at the top, outer side of the femur. It has the function of working as a shock absorber and as a lubricant for the movement of the muscles adjacent to it, especially the Ilio-Tibial Band (ITB). This is a strong sheet of tissue that runs from the Pelvis all the way past the knee to insert into the Tibia.

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Bilateral (2) Hip and Knee ReplacementsChronic Ankle Instability

The ITB can get tight over time or due to general deconditioning and poor gait. The ITB will cause friction over the Trochanteric Prominence causing the Bursa to get inflamed.

21462818_1898624860390175_2120111222177473042_n

Clinically this condition presents as pain and tenderness over the outer side of the Hip. There is often pain on walking up and down stairs and inability to sleep on that side.

5 Steps to Finding the Perfect Life after Knee Replacement

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Know all things about Knee Replacement Surgery Procedure.

This condition is more common in middle-aged women and is associated with a chronic and debilitating pain which does not respond to conservative treatment.

The mainstay of conservative,non-operative treatment consists of :
1. Weight Loss
2. ITB stretches
3. Core Strengthening
4. Gait retraining

This can be augmented with
1. Anti-inflammatory medication
2. Intra-bursal Steriod and Local Aneasthetic injection

If this treatment plan is followed there is an 80% success- however, can take 8-12mths for complete resolution.

If symptoms fail to resolve then surgical ITB release and Bursectomy is an option.

Chronic Ankle Instability

Chronic ankle instability is a condition characterized by a recurring giving way of the outer (lateral) side of the ankle. This condition often develops after repeated ankle sprains. Usually, the giving way occurs while walking or running on uneven surfaces or sloped surfaces.
Most people who suffer an ankle sprain will recover with Physio and retraining. A select small number go on to develop CAI.

The traditional surgical technique of Brostrum Reconstruction is the direct repair of the ruptured ligaments back onto the bone. This requires the patient to be in a cast for 6 weeks till the ligaments heal back on.

I am sharing a new surgical technique with the augmentation repair using a Gracilis Tendon graft to reconstruct the ATFL and CF ligament. This technique does not require casting and allows for the early mobilisation of the joint and return to activity.

We recently presented this paper as a poster presentation at a research meeting and I am sharing this technique below.
http://www.tsvllc.com.au
http://www.oriql.com.