Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Achilles Tendonitis, Achilles Tear and Achilles Rupture in Singapore

Achilles tendonitis is a condition of irritation and inflammation of the large tendon in the back of the ankle. Achilles tendonitis is a common injury that tends to occur in recreational athletes. Overuse of the Achilles tendon can cause inflammation that can lead to pain and swelling. Achilles tendonitis is differentiated from another common Achilles tendon condition called Achilles tendinosis. Patients with Achilles tendinosis have chronic Achilles swelling and pain as a result of degenerative, microscopic tears within the tendon.

Causes of Achilles Tendonitis

The two most common causes of Achilles tendonitis are:

  • Lack of flexibility
  • Overpronation

Other factors associated with Achilles tendonitis are recent changes in footwear, and changes in exercise training schedules. Often long distance runners will have symptoms of Achilles tendonitis after increasing their mileage or increasing the amount of hill training they are doing.

As people age, tendons, like other tissues in the body, become less flexible, more rigid, and more susceptible to injury. Therefore, middle-age recreational athletes are most susceptible to Achilles tendonitis.

Symptoms of Achilles Tendonitis

The main complaint associated with Achilles tendonitis is pain behind the heel. The pain is often most prominent in an area about 2-4 centimeters above where the tendon attaches to the heel. In this location, called the watershed zone of the tendon, the blood supply to the tendon makes this area particularly susceptible. Patients with Achilles tendonitis usually experience the most significant pain after periods of inactivity. Therefore patients tend to experience pain after first walking in the morning and when getting up after sitting for long periods of time. Patients will also experience pain while participating in activities, such as when running or jumping. Achilles tendonitis pain associated with exercise is most significant when pushing off or jumping.

X-rays are usually normal in patients with Achilles tendonitis, but are performed to evaluate for other possible conditions. Occasionally, an MRI is needed to evaluate a patient for tears within the tendon. If there is a thought of surgical treatment an MRI may be helpful for preoperative evaluation and planning.

Treatment of Achilles Tendonitis

Treatment of Achilles tendonitis begins with resting the tendon to allow the inflammation to settle down. In more serious situations, adequate rest may require crutches or immobilization of the ankle. Learn more about different treatments for Achilles tendonitis, including ice, medications, injections, and surgery

Degenerative Spondylolisthesis in Singapore

Degenerative Spondylolisthesis in Singapore

Degenerative Spondylolisthesis in Singapore

Degenerative spondylolisthesis is Latin for “slipped vertebral body”, and it is diagnosed when one vertebra slips forward over the one below it.  This condition occurs as a consequence of the general aging process in which the bones, joints, and ligaments in the spine become weak and less able to hold the spinal column in alignment.

Degenerative spondylolisthesis is more common in people over age 50, and far more common in individuals older than 65.  It is also more common in females than males by a 3:1 margin.

A degenerative spondylolisthesis typically occurs at one of two levels of the lumbar spine:

  • The L4-L5 level of the lower spine (most common location)
  • The L3-L4 level.

Degenerate spondylolisthesis is relatively rare at other levels of the spine, but may occur at two levels or even three levels simultaneously.  While not as common as lumbar spondylolisthesis, cervical spondylolisthesis (in the neck) can occur.  When degenerative spondylolisthesis does occur in the neck, it is usually a secondary issue to arthritis in the facet joints.

This article reviews the underlying causes, diagnosis, symptoms, and full range of surgical and non-surgical treatment options for degenerative spondylolisthesis.

Degenerative Spondylolisthesis Causes

Every level of the spine is composed of a disc in the front and paired facet joints in the back. The disc acts as a shock absorber in between the vertebrae, whereas the paired facet joints restrain motion. They allow the spine to bend forwards (flexion) and backwards (extension) but do not allow for a lot of rotation.

As the facet joints age, they can become incompetent and allow too much flexion, allowing one vertebral body to slip forward on the other.

Degenerative Spondylolisthesis Diagnosis

Degenerative spondylolisthesis is diagnosed by a spine specialist through a 3-step process:

  • Medical History – primarily a review of the patient’s symptoms and what makes the symptoms better or worse.
  • Physical Examination – the patient is examined for physical symptoms, such as range of motion, flexibility, any muscle weakness or neurological symptoms.
  • Diagnostic Tests – if a spondylolisthesis is suspected after the medical history and physical exam, an X-ray may be done to confirm the diagnosis and/or rule out other possible causes of the patient’s symptoms.  Based on the results of the X-ray, further tests may be ordered, such as an MRI scan, to gain additional insights.

Unlike isthmic spondylolisthesis, the degree of the slip of a degenerative spondylolisthesis is typically graded as it is almost always a grade 1 or 2.

In cases of degenerative spondylolisthesis, the degenerated facet joints tend to increase in size, and enlarged facet joints then encroach upon the spinal canal that runs down the middle of the spinal column, causing lumbar spinal stenosis.

As the facet joints in the spine degenerate they often get larger, which can encroach upon the spinal canal that runs down the middle of the spinal column, resulting in spinal stenosis. The symptoms of a degenerative spondylolisthesis are very commonly the same as that of spinal stenosis.

The main symptoms of degenerative spondylolisthesis include:

  • Lower back pain and/or leg pain are the most typical symptoms of degenerative spondylolisthesis. Some patients do not have any back pain with degenerative spondylolisthesis and others have primarily back pain and no leg pain.
  • Patients often complain of sciatic pain, an aching in one or both legs, or a tired feeling down the legs when they stand for a prolonged period of time or try to walk any distance (called pseudoclaudication).
  • Generally, patients do not have a lot of pain while sitting, because in the sitting position the spinal canal is more open. In the upright position, the spinal canal gets smaller, accentuating the stenosis and pinching the nerve roots in the canal.
  • Patients typically have tight hamstring muscles (the muscles in the back of the thigh) decreased flexibility in the lower back, and difficulty or pain with extension (arching the back backwards).
  • The nerve root pinching can lead to weakness in the legs, but true nerve root damage is rare.

There is no spinal cord in the lumbar spine, so even for patients with severe pain, there is no danger of spinal cord damage. If the spinal stenosis becomes very severe, or if the patient also has a disc herniation, they can develop cauda equina syndrome where there is progressive nerve root damage and loss of bladder/bowel control. This clinical syndrome is very rare, but if it does occur it is a medical emergency.

While there is a wide range of non-surgical treatment options (such as pain medications, ice or heat application) that may help with some of the pain of a degenerative spondylolisthesis, there are essentially four categories of treatment options a patient will ultimately have to choose from.

Activity Modification

Patients can modify their activities so they spend more time sitting and less time standing or walking.   Activity modification generally includes:

  • A short period of rest (e.g. one to two days of bedrest or resting in a reclining chair)
  • Avoiding standing or walking for long periods
  • Avoiding active exercise
  • Avoiding activities that require bending backwards.

If activity modification substantially reduces the patient’s pain and symptoms, this is an acceptable way to manage the condition long term.  Simple self care can assist in this approach, such as application of cold packs and or heating pads and/or taking appropriate over-the-counter pain relievers, such as ibuprofen and/or acetaminophen, after walking or any strenuous activity.

For patients who want to be more active, stationary biking is a reasonable option, as activity in the sitting position should be tolerable.  Another option is pool therapy – physical therapy done while in a warm swimming pool – as the water provides support and buoyancy and the patient is allowed to exercise in a flexed forward position.

Many patients also benefit from controlled, gradual exercise and stretching as part of a physical therapy program to maintain and/or increase range of motion and flexibility, which in turn tends to alleviate pain as well as help the patient maintain their ability to function in everyday activities.

Manual Manipulation

Chiropractic manipulation provided by chiropractors, or manual manipulation provided by osteopaths, physiatrists or other appropriately trained health professionals, can help reduce pain by mobilizing painful joint dysfunction.

Epidural Injections

For patients with severe pain, especially leg pain, epidural steroid injections may be a reasonable treatment option.  The injections are effective in helping to curb pain and increase a patient’s function in up to 50% of cases.  If an epidural steroid injection does work to relieve the patient’s pain, it can be done up to three times per year. The length of time that the lumbar epidural injection can be effective is variable, as the pain relief can last one week or a year.

Surgery

Surgery for degenerative spondylolisthesis is rarely needed, and most patients can manage their symptoms with the above non-surgical options.  Surgery may be considered if the patient’s pain is disabling and they would likely be able to function better and be more active with less pain.  Surgery is also indicated if the patient is experiencing progressive neurologic deterioration.

The goals of surgery are to realign the affected segment of the spine to alleviate pressure on the nerve and provide stability to the area.

Surgery for a degenerative spondylolisthesis usually includes two parts, done together in one operation:

  • A decompression (also called a laminectomy)
  • A spine fusion with pedicle screw instrumentation

Decompression surgery (e.g. a laminectomy) alone is usually not advisable as the instability is still present and a subsequent fusion will be needed in up to 60% of patients. A 1991 randomized controlled study of fusion with and without pedicle screw instrumentation and found the fusion rates were much higher in the patients with instrumentation, but the clinical results were about the same1. However, when these same patients were followed up on 10 years later, the patients with a solid fusion ultimately fared significantly better than those that had not fused.

It is a difficult surgery to recover from as there is a lot of dissection. The hospital stay typically ranges from one to four days.  It can take up to a year to fully recover. Usually, most patients can start most of their activities after the fusion has had three months to heal. Once the bone is fused, then the more active the patient is the stronger the bone will become.

Potential Benefits of the Surgery

Spinal fusion surgery for a degenerative spondylolisthesis is generally quite successful, with upwards of 90% of patients improving their function and enjoying a substantial decrease in their pain.

Potential Risks and Complications

There are numerous risks and possible complications with surgery for degenerative spondylolisthesis and they are basically the same as for any fusion surgery. There are risks of non union (nonfusion, or arthrodesis), hardware failure, continued pain, adjacent segment degeneration, infection, bleeding, dural leak, nerve root damage and all the possible general anesthetic risks (e.g. blood clots, pulmonary emboli, pneumonia, heart attack or stroke). Most of these complications are rare, but increased risks can be seen in certain situations. Conditions that increase the risk of surgery include smoking (or any nicotine intake), obesity, multilevel fusions, osteoporosis (thinning of the bones), diabetes, rheumatoid arthritis, or prior failed back surgery.

Since degenerative spondylolisthesis is a condition that disproportionately affects individuals over age 60 or 65, the surgery does present some additional risk. Surgical risk is more directly related to the overall health of a patient and not his or her absolute age.  Particularly in patients who have multiple medical problems, surgery can be very risky. For some patients, even if non-surgical treatments have failed to alleviate their symptoms, surgery may present too much risk, and intermittent epidural injections combined with activity modification may be their best option.

After a fusion procedure, degeneration of the spinal segment adjacent to the fusion is possible. In an attempt to alleviate transferring extra stress to the next segment, there are many different devices currently being studied that hold the promise of being able to replace the function of the facet joint without having to include a fusion procedure. It is too early to determine whether or not the results of these newer technologies are better or worse than the standard fusion procedure.

Dr Kevin Yip on the Benefits of Platelet Rich Plasma (PRP)

Does science support PRP use in acute soft-tissue injuries?

Although platelet-rich plasma (PRP) has been used for many years in other medical specialties, it has only recently become popular in orthopaedic applications. Media reports of dramatic “cures” in high-profile athletes like Tiger Woods have helped fuel interest in PRP, resulting in a voluminous collection of publications. A recent literature search identified nearly 5,000 articles on PRP, more than a quarter of which were published within the last 5 years.

The use of the body’s own platelets to enhance healing is a seemingly simple concept that promised some very excellent results.

What is it?
PRP is most simply defined as “a volume of plasma that has a platelet count above the baseline of whole blood.” Current PRP preparations, however, can vary markedly in the following ways:

  • the amount of blood used and the efficacy of platelet recovery
  • the presence or absence of white or red blood cells
  • platelet activation with thrombin
  • the level of fibrin production

Some variations in PRP products may result from differing methods of preparation, but even when specific protocols are used, the platelet concentration of the final PRP can vary greatly among techniques and even within a single technique. In addition, platelet concentrations can vary from day to day in PRP produced from a single individual, depending on factors such as diet, general health, medications (eg, coagulants), and exercise.

“The final platelet (growth factor) concentration will be dependent upon the amount of whole blood used, the platelet recovery efficacy, and the final volume of plasma in which the platelets are suspended,” he explained.

The two basic steps in preparing PRP include an initial “soft” spin in a centrifugal separator to divide out plasma and platelets from red and white cells, followed by a “hard” spin that further concentrates the platelets into platelet-rich plasma (PRP) and platelet-poor plasma (PPP) components.

“Patients are seeing elite athletes, like Tiger Woods and Raphael Nadal, being treated with some form of PRP and are asking their orthopaedic surgeons to give them ‘what Tiger got.’

“All three major sports organizations—the National Football League (NFL), Major League Baseball, and the National Basketball Association—as well as the World Anti-Doping Agency, have declared that PRP is a reasonable treatment” .

PRP in soft-tissue injuries
PRP can help with acute Achilles tendon repair, rotator cuff repair, acute ligament injury, muscle injury, and meniscal repair.

A study on the Achilles tendon, for example, found that the operative management of tendons combined with the application of autologous platelet-rich growth factors may present new possibilities for enhanced healing and functional recovery.

X-Ray

X-Ray

X-Ray

What is X-Ray?

X-rays are a form of electromagnetic radiation, just like visible light. In a health care setting, a machines sends are individual x-ray particles, called photons. These particles pass through the body. A computer or special film is used to record the images that are created.

Structures that are dense (such as bone) will block most of the x-ray particles, and will appear white. Metal and contrast media (special dye used to highlight areas of the body) will also appear white. Structures containing air will be black, and muscle, fat, and fluid will appear as shades of gray.

How is the test performed?

The test is performed in a hospital radiology department or in the health care provider’s office by an x-ray technologist. The positioning of the patient, x-ray machine, and film depends on the type of study and area of interest. Multiple individual views may be requested.

Much like conventional photography, motion causes blurry images on radiographs, and thus, patients may be asked to hold their breath or not move during the brief exposure (about 1 second).

How to prepare for the test?

Inform the health care provider prior to the exam if you are pregnant, may be pregnant, or have an IUD inserted.

If abdominal studies are planned and you have had a barium contrast study (such as a barium enema, upper GI series, or barium swallow) or taken medications containing bismuth (such as Pepto-Bismol) in the last 4 days, the test may be delayed until the contrast has fully passed.

You will remove all jewelry and wear a hospital gown during the x-ray examination because metal and certain clothing can obscure the images and require repeat studies.

How the test will feel?

There is no discomfort from x-ray exposure. Patients may be asked to stay still in awkward positions for a short period of time.

The risk?

For most conventional x-rays, the risk of cancer or defects due to damaged ovarian cells or sperm cells is very low. Most experts feel that this low risk is largely outweighed by the benefits of information gained from appropriate imaging. X-rays are monitored and regulated to provide the minimum amount of radiation exposure needed to produce the image. Young children and fetuses are more sensitive to the risks of x-rays. Women should tell health care providers if they think they are pregnant.

Biopsy / Lump Removal

Biopsy / Lump Removal

Biopsy / Lump Removal

Definition

Biopsy is a diagnostic procedure in which a piece of tissue and/or cells are removed to be examined under a microscope by a pathologist.

Purpose

Biopsies are performed to determine the presence of cancer cells, establish tumor grading, and provide more information for treatment.

Precautions

Most biopsies should not be done on patients with blood clotting problems. If the patient has a low blood platelet count, a platelet transfusion can be given as a temporary relief measure, and a biopsy can then be performed. The physician should be notified of any bleeding problems—as well as any allergies, current medications, or pregnancy—well in advance.

Patients receiving IV sedation for a biopsy procedure will continue to feel drowsy for several hours, and should refrain from cooking, driving, or operating any equipment that requires careful attention. A ride home from the clinic should be arranged in advance.

Description

There are several different types of biopsies, and the decision on which one is most effective depends on where the tumor is located and the general health of the patient. Four common categories of biopsy are fine needle aspiration, core needle biopsy, excisional biopsy, and incisional biopsy.

Fine Needle Aspiration Biopsy

Fine needle aspiration biopsy, also known as suction biopsy or needle aspiration biopsy, involves applying negative pressure through the use of a syringe and hollow, hypodermic needle. This type of biopsy is often used as a diagnostic procedure on neck and thyroid masses. It results in the removal of tissue that is fragmented into cells, as opposed to one sample of undamaged tissue. Fine needle aspiration biopsy is a frequently performed procedure that results in minimum discomfort and is less costly than many other types of biopsy.

Core Needle Biopsy

Core needle biopsy, also known as wide-core needle biopsy or cutting core biopsy, involves the use of a large-bore needle and is the simplest method of pathologic diagnosis of cancer. It results in minimal disturbance of surrounding tissues and a solid, intact sample. Tumors located in the liver and breast are commonly biopsied with this technique.

Incisional Biopsy

This refers to the removal of part of the tumor from the larger tumor mass. An incisional biopsy is employed for tumors located deep within the body and after an initial needle biopsy has failed to supply enough tissue for diagnosis. Biopsies of this type are the preferred technique for diagnosing soft tissue cancers and osteosarcomas.

Excisional Biopsy

Also known as surgical biopsy, the excisional biopsy entails the surgical removal of the entire tumor mass and is a diagnostic technique that simultaneously serves as a treatment. For example, a lumpectomy removes the entire primary tumor mass associated with breast cancer. Excisional biopsy is also useful for diagnosing and removing surface tumors of the skin, such as those associated with squamous cell carcinoma, basal cell carcinoma, and malignant melanoma.

Preparation

Many biopsies can be performed in the doctor’s office or in the hospital on an outpatient basis. Most do not require much special preparation on the part the patient, but patients should ask their physician for special instructions. Prior to the procedure, most require the use of anesthesia. Prior to and during a biopsy, special imaging techniques may be employed to assist in locating the tumor and guidance of biopsy procedures using a needle. Such imaging techniques include computed tomography scan (CT guided biopsy), fluoroscopy, magnetic resonance imaging (MRI), nuclear medicine scan, and ultrasound (ultrasound guided biopsy). Patients who undergo imaging scans may be injected with or asked to drink a contrast agent (dye) prior to biopsy.

Fine Needle Aspiration Biopsy

Some routine blood work (blood counts, clotting profile) should be completed two weeks prior to biopsy.

Patients may be asked not to eat for a specified time before the procedure. Those taking blood thinners (anticoagulants) or aspirin should talk to their physicians about whether they should discontinue using them prior to biopsy.

Core Needle Biopsy

Women undergoing breast biopsy should not wear talcum powder, deodorant, lotion, or perfume under their arms or on their breasts on the day of the procedure (since these may cause image artifacts or other problems). A comfortable two-piece garment should be worn. Patients may be asked not to eat for a specified time before the procedure. Those taking blood thinners or aspirin should talk to their physicians about whether they should discontinue using them prior to core needle biopsy.

Incisional Biopsy

Patients should follow instructions provided by their doctor and give notification of any allergies. Those expecting general anesthesia should not eat or drink for at least 8 hours before an incisional biopsy. Patients should also bathe thoroughly before the procedure and allow time to rest afterward.

Excisional Biopsy

Patients may be asked to: sign a consent form allowing the physician to perform this test; refrain from eating or drinking for at least 8 hours prior to surgery; and arrange for a ride home from the hospital (most patients can go home on the same day as the surgery). Those taking insulin, aspirin, non-steroidal anti-inflammatory drugs, or any medicines that affect blood clotting should notify their doctor well before the procedure.

Aftercare

Fine Needle Aspiration Biopsy

After the biopsy, patients should be able to drive home, return to work, or perform any other routine activity. This biopsy does not affect medication schedules.

Core Needle Biopsy

Most patients can resume normal activities right after the biopsy. If there is excessive redness, pain, or drainage from the puncture site, patients should call their doctor immediately.

Incisional Biopsy

After recovering from anesthesia, the patient will be observed for a few hours before returning home. During this time, an analysis may come back from the lab and the doctor may explain the nature of the abnormality. This analysis is the result of only one test and will not be 100% accurate. In about two days, lab testing should be complete. Patients should call their doctor immediately if there is drainage from the wound or a fever develops.

Excisional Biopsy

Depending on the invasiveness of the procedure, the patient may receive varied instructions for aftercare. The incision site should be kept clean, dry, and free of lotion, medication, or ointments. The patient may be required to remain in a certain position until sufficient time has passed to warrant the release of the patient from medical care. For example, patients are required to remain on their right side for approximately four hours to allow for healing to occur after a liver punch biopsy. Some patients, however, may be able to return to normal activities on the same day. Those who develop a fever, or notice bleeding, drainage, strong pain, or redness and warmth at the biopsy site should contact their doctor immediately.

Risks

Although most biopsies end with success, there are a certain number of risks to keep in mind. For example, complications can arise if other organs are nicked during a biopsy using a long needle. As with any procedure, there is a slight risk of allergic reaction to anesthesia. To be well informed, patients should consult with their physician about the risks prior to undergoing the procedure.

Fine Needle Aspiration Biopsy

This biopsy poses no significant risks. Some minor bleeding may occur and some patients report a mild, dull, and throbbing sensation in the area of the biopsy, which usually subsides within 30 to 60 minutes. The risk of infection exists any time the skin is penetrated, but is extremely rare with this procedure. The error rate of diagnosis, however, is substantially higher than that of other biopsy procedures; major surgical resections should not be undertaken solely on the basis of the evidence of aspiration biopsy.

Core Needle Biopsy

A lumpy scar called a keloid may form in the area of puncture. Infection and bleeding may also occur at or under the biopsy site; however, this risk is uncommon. Core needle biopsy, like fine needle aspiration, only removes samples of a mass and not the entire area of concern. Therefore, it is possible that a more serious diagnosis may be missed by limiting the sampling of an abnormality.

Incisional Biopsy

A keloid may form in the incision area. In rare cases, infection and bleeding may occur.

Excisional Biopsy

Some patients may experience infection, bleeding, or bruising around the biopsy site. The physician should be consulted about any risks that may be related to a patient’s medical history.

Normal Results

The tissue sample obtained from the biopsy needs to be prepared for examination by a pathologist, and results usually are reported to the patient within a few days of the procedure. Normal (negative) results indicate that no malignancy is present.

Abnormal Results

Abnormal results indicate that a malignancy or other abnormality is present. In some cases, results are indeterminate and patients are subject to further diagnostic procedures.

Laceration Wounds & Cuts

Laceration Wound

Laceration Wound

What is a Laceration Wound?

A laceration is a wound that occurs when skin, tissue, and/or muscle is torn or cut open. Lacerations may be deep or shallow, long or short, and wide or narrow. Most lacerations are the result of the skin hitting an object, or an object hitting the skin with force. Laceration repair is the act of cleaning, preparing, and closing the wound.

Minor lacerations (shallow, small, not bleeding, and clean) may not require medical attention. Antibiotic ointment and a bandage may be all that is needed. However, most lacerations do require repair.

Cleaning and preparing a laceration for repair is crucial for preventing infection and reducing the appearance of scaring. Cleaning not only washes away dirt, but also removes the germs that could trigger infection. Cleaning is done in the same manner regardless of the technique that will be used for wound closure. Preparation is done to even out jagged edges so that scarring may be less noticeable. Preparation is done as needed.

Sutures (Stitches)

Sutures are used for wounds that are deep, bleeding, have jagged edges, or have fat or muscle exposed. Iodine is applied to the wound edges, and to the skin surrounding the wound. A surgical drape may be positioned over the wound, and taped to the skin so it does not move around (keeps the area sterile).

If a laceration is deep and underlying tissue or muscle is also lacerated, stitches may be needed under the skin before the wound can be closed. This will rejoin muscle and tissue layers. The stitches used under the skin are absorbed by the body, and do not need to be removed.

Types of Open Wound

  • Incisions or incised wounds, caused by a clean, sharp-edged object such as a knife, a razor or a glass splinter.
  • Lacerations, irregular tear-like wounds caused by some blunt trauma. Lacerations and incisions may appear linear (regular) or stellate (irregular). The term laceration is commonly misused in reference to incisions.
  • Abrasions (grazes), superficial wounds in which the topmost layer of the skin (the epidermis) is scraped off. Abrasions are often caused by a sliding fall onto a rough surface.
  • Puncture wounds, caused by an object puncturing the skin, such as a nail or needle.
  • Penetration wounds, caused by an object such as a knife entering and coming out from the skin .
  • Gunshot wounds, caused by a bullet or similar projectile driving into or through the body. There may be two wounds, one at the site of entry and one at the site of exit, generally referred to as a “through-and-through.”

Treatment for Wound

The treatment depends on the type, cause, and depth of the wound as well as whether other structure beyond the skin are involved. Treatment of recent lacerations involves examination, cleaning, and closing the wound. If the laceration occurred some time ago it may be allowed to heal by secondary intention due to the high rate of infection with immediate closure. Minor wounds like bruises will heal on their own with skin discoloration usually disappears in 1–2 weeks. Abrasions which are wounds with intact skin usually require no active treatment except keeping the area clean with soap and water. Puncture wounds may be prone to infection depending on the depth of penetration. The entry of puncture wound is left open to allow for bacteria or debris to be removed from inside.

Cleaning of Wound

For simple lacerations cleaning can be accomplished using a number of different solutions including tap water, sterile saline solution, or antiseptic solution. Infection rates may be lower with the use of tap water in regions where water quality is high. Evidence for the effectiveness of any cleaning of simple wound however is limited.

Most clean open wounds do not require any antibiotics unless the wound is contaminated or the bacterial cultures are positive. Excess use of antibiotics only leads to resistance and side effects. All open wounds should be cleaned at least twice a day with warm water and soap. Once the wound is cleaned, it should be covered with moist gauze. This should be followed by application of dry gauze and then the wound covered with a bandage. The purpose of a wet to dry dressing allows the bandage to adhere to dead tissue performing a mechanical debridement when removed.This allows new healthy skin to grow and prevents debris from collecting. When the wound is clean, it may be closed with a skin graft. No wound is ever closed if it is suspected to be infected

Closure of Wound

Incisions caused by a knife or a sharp object need to be thoroughly cleaned and the edges trimmed. If the wounds are fresh and less than 12 hours old, they can be closed with sutures or staples. Any wound which is more than 24 hours old should be suspected to be contaminated and not closed completely. Only the deeper tissues can be approximated and the skin should be left open. If closure of a wound is decided upon a number of techniques can be used. These include bandages, a cyanoacrylate glue, staples, and sutures. Absorbable sutures have the benefit over non absorbable sutures of not requiring removal. They are often preferred in children.

Spinal Decompression Surgery & Slip Disc

Spinal Decompression Surgery in Singapore

Spinal Decompression Surgery in Singapore

Microdiscectomy Spine Surgery?

In a microdiscectomy or microdecompression spine surgery, a small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to relieve neural impingement and provide more room for the nerve to heal.

A microdiscectomy is typically performed for a herniated lumbar disc and is actually more effective for treating leg pain (also known as radiculopathy) than lower back pain.

Impingement on the nerve root (compression) can cause substantial leg pain. While it may take weeks or months for the nerve root to fully heal and any numbness or weakness to get better, patients normally feel relief from leg pain almost immediately after a microdiscectomy spine surgery.

In general, if a patient’s leg pain due to a disc herniation is going to get better, it will do so in about six to twelve weeks. As long as the pain is tolerable and the patient can function adequately, it is usually advisable to postpone back surgery for a short period of time to see if the pain will resolve with non-surgical treatment alone.

If the leg pain does not get better with nonsurgical treatments, then a microdiscectomy surgery is a reasonable option to relieve pressure on the nerve root and speed the healing. Immediate spine surgery is only necessary in cases of bowel/bladder incontinence (cauda equina syndrome) or progressive neurological deficits. It may also be reasonable to consider back surgery acutely if the leg pain is severe.

A microdiscectomy is typically recommended for patients who have:

  • Experienced leg pain for at least six weeks
  • Not found sufficient pain relief with conservative treatment (such as oral steroids, NSAID’s, and physical therapy).

However, after three to six months, the results of the spine surgery are not quite as favorable, so it is not generally advisable to postpone microdiscectomy surgery for a prolonged period of time (more than three to six months).

How is a Microdiscectomy Spine Surgery Performed?

In a microdiscectomy spine surgery, a magnifying device is used to examine the disc and nerves. Using this it becomes possible to perform the surgery through a small incision of 1 or 1.5 inches. The incision is made in the lower back midline. The muscles of the back are moved out of the lamina of the spine. The membrane above the nerve roots is removed. Usually, a part of the inner facet joint is also removed to access the nerve root and remove pressure on the nerve. The nerve root is gently moved out of the way, and the disk is removed from beneath the nerve root. To complete the surgery, all the layers of incisions are closed with stitches or staples.

How to Prepare for the Surgery?

The patient should inform the doctor about any ailments, medical conditions and medication that the patient may be taking.

The patient should not smoke for several days before the surgery.

Two weeks prior to the surgery, the doctor may stop certain medication that the patient may be taking.

The patient is required to do some tests before the surgery. They may include the following:

  • MRI
  • CT scan
  • Myelogram

Recovery of the Surgery

  • The patient is encouraged to move around once the anesthesia wears off.
  • Pain medication may be prescribed by the doctor.
  • Sitting for more than 15-20 minutes may cause discomfort and should be avoided.
  • Some patient may need to undergo rehabilitation, which includes physical therapy.
  • Follow up visits may be scheduled by the doctor and the surgical stitches may be removed during these visits.

Risks of the Surgery

The risks involved in microdiscectomy spine surgery are rare. They include:

  • Injury to the nerve roots
  • Damage to the spinal structures
  • Infection
  • Blood clot
  • Risks of anesthesia
  • Bleeding
  • Leakage of cerebrospinal fluid
  • Bowel and bladder incontinence
  • No pain relief

After Care of the Surgery

  • Patients should avoid strenuous activities that cause pain.
  • Patients may walk to exercise for a few weeks after the surgery. This also reduces the risk of severe scar tissues.
  • Exercises like bicycling and swimming may be started 2 weeks after the surgery if the doctor permits.
  • Activities that involve bending and twisting of the waist should be avoided for 2 to 4 weeks after the surgery.
  • Patients with a sedentary job may return to work in one to two weeks after surgery. However, patients with strenuous jobs may need to avoid working for four to six weeks.
  • The incision area should be kept dry.
  • Patients should avoid taking baths and showers until the wound has healed, usually around 2 weeks after the surgery.

Microdiscectomy Success Rates

The success rate for microdiscectomy spine surgery is approximately 90% to 95%, although 5% to 10% of patients will develop a recurrent disc herniation at some point in the future.

A recurrent disc herniation may occur directly after back surgery or many years later, although they are most common in the first three months after surgery. If the disc does herniate again, generally a revision microdiscectomy will be just as successful as the first operation. However, after a recurrence, the patient is at higher risk of further recurrences (15% to 20% chance).

Total Hip Replacement in Singapore

Total Hip Replacement

Total Hip Replacement

What is Total Hip Replacement?

Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant. Hip replacement surgery can be performed as a total replacement or a hemi replacement. Such joint replacement orthopaedic surgery generally is conducted to relieve arthritis pain or fix severe physical joint damage as part of hip fracture treatment. A total hip replacement (total hip arthroplasty) consists of replacing both the acetabulum and the femoral head while hemiarthroplasty generally only replaces the femoral head. Hip replacement is currently the most successful and reliable orthopaedic operation with 97% of patients reporting improved outcome.

Who is a candidate for Total Hip Replacement?

Total hip replacements are performed most commonly because of progressively worsening severe arthritis in the hip joint. The most common type of arthritis leading to total hip replacement is degenerative arthritis (osteoarthritis) of the hip joint. This type of arthritis is generally seen with aging, congenital abnormality of the hip joint, or prior trauma to the hip joint. Other conditions leading to total hip replacement include bony fractures of the hip joint, rheumatoid arthritis, and death (aseptic necrosis) of the hip bone. Hip bone necrosis can be caused by fracture of the hip, drugs (such as prednisone and prednisolone), alcoholism, and diseases (such as systemic lupus erythematosus).

The progressively intense chronic pain together with impairment of daily function including walking, climbing stairs, and even arising from a sitting position, eventually become reasons to consider a total hip replacement. Because replaced hip joints can fail with time, whether and when to perform total hip replacement are not easy decisions, especially in younger patients. Replacement is generally considered after pain becomes so severe that it impedes normal function despite use of anti-inflammatory and/or pain medications. A total hip joint replacement is an elective procedure, which means that it is an option selected among other alternatives. It is a decision which is made with an understanding of the potential risks and benefits. A thorough understanding of both the procedure and anticipated outcome is an important part of the decision-making process.

What are total hip replacement complication?

The risks of total hip replacement include blood clots in the lower extremities that can travel to the lungs (pulmonary embolism). Severe cases of pulmonary embolism are rare but can cause respiratory failure and shock. Other problems include difficulty with urination, local skin or joint infection, fracture of the bone during and after surgery, scarring and limitation of motion of the hip, and loosening of the prosthesis which eventually leads to prosthesis failure. Because total hip joint replacement requires anesthesia, the usual risks of anesthesia apply and include heart arrhythmias, liver toxicity, and pneumonia.

What are preparation needed for the Surgery?

Total hip joint replacement can involve blood loss. Patients planning to undergo total hip replacement often will donate their own (autologous) blood to be banked for transfusion during the surgery. Should blood transfusion be required, the patient will have the advantage of having his or her own blood available, thus minimizing the risks related to blood transfusions. The preoperative evaluation generally includes a review of all medications being taken by the patient. Anti-inflammatory medications, including aspirin, are often discontinued one week prior to surgery because of the effect of these medications on platelet function and blood clotting. They may be reinstituted after surgery. Other preoperative evaluations include complete blood counts, electrolytes (potassium, sodium, chloride, bicarbonate), blood tests for kidney and liver functions, urinalysis, chest X-ray, EKG, and a physical examination. Your physician will determine which of these tests are required, based on your age and medical conditions. Any indications of infection, severe heart or lung disease, or active metabolic disturbances such as uncontrolled diabetes may postpone or defer total hip joint surgery.

What is the rehabilitation after hip replacement surgery?

Rehabilitation and physical therapy are started immediately following surgery and continue throughout hospitalization and at home for one year after surgery. On the first day after surgery, the physical therapist will meet with you in your hospital room for an assessment. On the second day, you will go to the Physical Therapy department by wheelchair for treatment. Your physical therapist will monitor the strength and flexibility in your leg and hip, as well as your ability to stand and sit. In addition, a physical therapist will provide goals and instructions for you to complete while in the hospital and at home.

Your doctor may determine that it is best for your recovery if you go to a rehabilitation center after discharge from the hospital. At the rehabilitation center, you will have concentrated time with a physical therapist and occupational therapist and will regain your strength, learn about all your exercises and the precautions that you’ll need to follow. Your length of stay at this facility is approximately five to 14 days. Your doctor’s physician assistant or nurse will discuss facilities available for your needs.

What is involved in the rehabilitation process?

After total hip joint replacement surgery, patients often start physical therapy immediately! On the first day after surgery, it is common to begin some minor physical therapy while sitting in a chair. Eventually, rehabilitation incorporates stepping, walking, and climbing. Initially, supportive devices such as a walker or crutches are used. Pain is monitored while exercise takes place. Some degree of discomfort is normal. It is often very gratifying for the patient to notice, even early on, substantial relief from the preoperative pain for which the total hip replacement was performed.

Physical therapy is extremely important in the overall outcome of any joint replacement surgery. The goals of physical therapy are to prevent contractures, improve patient education, and strengthen muscles around the hip joint through controlled exercises. Contractures result from scarring of the tissues around the joint. Contractures do not permit full range of motion and therefore impede mobility of the replaced joint. Patients are instructed not to strain the hip joint with heavy lifting or other unusual activities at home. Specific techniques of body posturing, sitting, and using an elevated toilet seat can be extremely helpful. Patients are instructed not to cross the operated lower extremity across the midline of the body (not crossing the leg over the other leg) because of the risk of dislocating the replaced joint. They are discouraged from bending at the waist and are instructed to use a pillow between the legs when lying on the nonoperated side in order to prevent the operated lower extremity from crossing over the midline. Patients are given home exercise programs to strengthen the muscles around the buttock and thigh. Most patients attend outpatient physical therapy for a period of time while incorporating home exercises regularly into their daily living.

Occupational therapists are also part of the rehabilitation process. These therapists review precautions with the patients related to everyday activities. They also educate the patients about the adaptive equipment that is available and the proper ways to do their “ADLs” or activities of daily living.

ORIF – Open Reduction Internal Fixation

ORIF - Open Reduction Internal Fixation

ORIF - Open Reduction Internal Fixation

What is ORIF Surgery?

An open reduction internal fixation (ORIF) refers to a surgical procedure to fix a severe bone fracture, or break. “Open reduction” means surgery is needed to realign the bone fracture into the normal position. “Internal fixation” refers to the steel rods, screws, or plates used to keep the bone fracture stable in order to heal the right way and to help prevent infection.

Open reduction internal fixation can also refer to the surgical repair of a joint, such as a hip or knee replacement.

The surgical procedure is performed by a doctor who specializes in orthopedics, which is a branch of medicine concerning the musculoskeletal structure of the body. Under general anesthesia, an incision is made at the site of the break or injury, and the fracture is carefully re-aligned or the joint replaced. The hardware is installed, and the incision is closed with staples or stitches. The steel rods, screws, or plates can be permanent, or temporary and removed when healing takes place.

Once the open reduction internal fixation is performed, a cast is usually applied. In the case of an ankle fracture, for instance, the first cast is a non-weight bearing cast, and crutches can be used to help keep weight off the healing bones. Later, when the healing has progressed, this cast will be replaced with one that can bear weight. Eventually, after a period of some weeks, the cast will be removed entirely.

Cons of Arthroscopy

Risks and complications can include bacterial colonization of the bone, infection, stiffness and loss of range of motion, non-union, malunion, damage to the muscles, nerve damage and palsy, arthritis, tendonitis, chronic pain associated with plates, screws, and pins, compartment syndrome, deformity, audible popping and snapping, and possible future surgeries to remove the hardware.

Recovery Rate & Process of ORIF Surgery

Recovery from a bone fracture after an open reduction internal fixation can be quite painful, and pain management becomes a concern. Commonly, acetaminophen with codeine is prescribed, as research has shown ibuprofen or other non-steroid anti-inflammatory drugs (NSAIDs) may slow down or inhibit the rate of healing. It is important to take the drugs as prescribed to help manage the pain cycle.

Physical therapy is also an important part of the recovery process after an open reduction internal fixation. Since the part of the body that has been injured is usually held still or immobilized for a long period of time, the muscles, tendons, and ligaments can become weak. Physical therapy helps to restore the strength, range of motion, and endurance of the affected area. It can also help with pain management. Physical therapy can consist of exercises, hot or cold packs, ultrasound, and nerve stimulation, or a combination of treatments.

ORIF Surgery Complications

Complications of ORIF can include infection, swelling, and movement of the installed hardware. The recovery process can take months, because bones grow slowly. Other factors that can affect recovery are the location and severity of the break, the age of the person, and the type of bone broken.

Arthroscopy in Singapore

Arthroscopy in Singapore

Arthroscopy in Singapore

What is Arthroscopy?

Arthroscopy is a surgical procedure orthopaedic surgeons use to visualize, diagnose, and treat problems inside a joint.

The word arthroscopy comes from two Greek words, “arthro” (joint) and “skopein” (to look). The term literally means “to look within the joint.”

In an arthroscopic examination, an orthopaedic surgeon makes a small incision in the patient’s skin and then inserts pencil-sized instruments that contain a small lens and lighting system to magnify and illuminate the structures inside the joint. Light is transmitted through fiber optics to the end of the arthroscope that is inserted into the joint.

Arthroscopy (also called arthroscopic surgery) is a minimally invasive surgical procedure in which an examination and sometimes treatment of damage of the interior of a joint is performed using an arthroscope, a type of endoscope that is inserted into the joint through a small incision. Arthroscopic procedures can be performed either to evaluate or to treat many orthopedic conditions including torn floating cartilage, torn surface cartilage, ACL reconstruction, and trimming damaged cartilage.

Benefit of Arthroscopy

The advantage of arthroscopy over traditional open surgery is that the joint does not have to be opened up fully. Instead, for knee arthroscopy for example, only two small incisions are made — one for the arthroscope and one for the surgical instruments to be used in the knee cavity to fully remove the knee cap. This reduces recovery time and may increase the rate of surgical success due to less trauma to the connective tissue. It is especially useful for professional athletes, who frequently injure knee joints and require fast healing time. There is also less scarring, because of the smaller incisions. Irrigation fluid is used to distend the joint and make a surgical space. Sometimes this fluid leaks into the surrounding soft tissue causing extravasation and edema.

The surgical instruments used are smaller than traditional instruments. Surgeons view the joint area on a video monitor, and can diagnose and repair torn joint tissue, such as ligaments and menisci or cartilage. It is technically possible to do an arthroscopic examination of almost every joint in the human body. The joints that are most commonly examined and treated by arthroscopy are the knee, shoulder, elbow, wrist, ankle, foot, and hip.

How is Arthroscopy Performed?

Arthroscopic surgery, although much easier in terms of recovery than “open” surgery, still requires the use of anesthetics and the special equipment in a hospital operating room or outpatient surgical suite. You will be given a general, spinal, or a local anesthetic, depending on the joint or suspected problem.

A small incision (about the size of a buttonhole) will be made to insert the arthroscope. Several other incisions may be made to see other parts of the joint or insert other instruments.

When indicated, corrective surgery is performed with specially designed instruments that are inserted into the joint through accessory incisions. Initially, arthroscopy was simply a diagnostic tool for planning standard open surgery. With development of better instrumentation and surgical techniques, many conditions can be treated arthroscopically.

Recovery Time after Arthroscopy

The small puncture wounds take several days to recover. The operative dressing can usually be removed the morning after surgery and adhesive strips can be applied to cover the small healing incisions.

Although the puncture wounds are small and pain in the joint that underwent arthroscopy is minimal, it takes several weeks for the joint to maximally recover. A specific activity and rehabilitation program may be suggested to speed your recovery time and protect future joint function.

It is not unusual for patients to go back to work or school or resume daily activities within a few days. Athletes and others who are in good physical condition may in some cases return to athletic activities within a few weeks. Remember, though, that people who have arthroscopy can have many different diagnoses and preexisting conditions, so each patient’s arthroscopic surgery is unique to that person. Recovery time will reflect that individuality.