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Frequently asked questions

Total Hip Replacement (THR)

What type of Total hip replacement prosthesis is the best?

There are so many different makes of hip prostheses which can be classified into either cemented and uncemented prosthesis with hard on soft and hard on hard articulations. There is also bone conserving metal on metal (resurfacing) prosthesis. Generally, younger patients have better bone quality and will demand longer survival from their prosthesis. There are very specific indications for a different prosthesis in different patients. These days the Swedish, Norwegian, British, American, Australian, New Zealand and recently SA national joint registers provide us with data on any prosthesis. These registers can give important information on different prosthesis longevity, complications and surgeons results. It is for that reason that Dr Morkel support joint registers and all his procedures and prosthesis are documented on the SA National Joint Register.

What type of articulations is the best?

Each of the different articulations has its pros and cons. Modern cross-linking techniques of high-density polyethene HDPE (plastic) and Vit E treatment promises extended survival of plastic acetabular liners/prosthesis. In laboratory studies, ceramic femoral head prostheses seem to promise better longevity than metal (cobalt chrome). There will always be particles released in plastic ceramic or cobalt chrome articulations, but these stay contained in the hip.

Is metal on metal articulations safe?

20 years ago when the resurfacing prosthesis was designed in the UK, it seemed to promise a stable large head articulation and bone preservation that promised to be the solution orthopaedic surgeons and patients were looking for.
In many cases, these resurfacing hip procedures did very well, but when the acetabular prosthesis alignment was not accurate, it led to foreign body reactions and early revision procedures for the patients. The different designs from other companies in resurfacing prosthesis that followed the original designs, could also not deliver the same result. Excellent medium-term results have been achieved by experienced surgeons with the original prosthesis. If a male patient considers a resurfacing prosthesis, it is essential to find an experienced orthopaedic surgeon in the procedure and to have the original design implanted. Females and patients with sensitivity to metal must not consider it as an option. Metal on metal articulations carries a risk of elevated cobalt and chrome ions in the blood and possible long term issues for patients. There is also a very small percentage of patients with allergies to chrome and nickel that develop allergic reactions to these ions in the body.

What is the best replacement for me?

It depends on your age, demands and bone morphology. The best is to choose an orthopaedic surgeon who you trust, who does a reasonable amount of total hip replacements and is available if there are any post-surgery hiccups. Allow Dr Morkel to choose the prosthesis after all the pros and cons have been discussed.

What is the best surgical approach for a total hip replacement?

Each of the different approaches has its pro and cons. The alignment and soft tissue tension determines the long term survival of the prosthesis and is much more important than the promise of returning to sport a few days quicker. It is best that the surgeon is comfortable with the approach that gives him or her the best ability to align the prosthesis and achieve the necessary exposure to implant the prosthesis with the necessary care to detail for the best long term outcome.

Minimally invasive hip surgery - a fad or a must have?

The length of the surgical scar is less important than the alignment and tissue tension in determining long term outcomes. Total hip replacements, although a very successful procedure, still carry risk and often specialised observation in the immediate post-operative period, can prevent complications. While the cosmetic appearance is important, it should not be more important than the patient's health or long term outcomes.

How long after the total hip replacement can I drive a motor vehicle?

This will depend on the approach that Dr Morkel uses, but a general rule is that 4-6 weeks after a total hip replacement should be a safe period to return to driving.

How can I prevent dislocation after a hip replacement?

Soft tissue healing in the immediate few weeks post-surgery is important to ensure the longevity of the hip arthroplasty. The physiotherapist will instruct patients how to navigate and mobilize sufficiently for enhanced recovery safely. Keeping to 4 basic principles: not to cross legs, not bend legs up beyond 90 degrees, not sit on sofas or in low chairs and not to sleep on the side should aid the results.

What about prophylactic antibiotics for surgical procedures or dental procedures post hip replacement?

Total hip replacement implants are large prosthesis, and there can be an increased risk with systemic bacterial infections. Small surgical procedures and localised infections are most probably not an extremely high risk, but taking amoxicillin as prophylactic antibiotic also should not lead to complications. General principles of early detection of systemic infections and balanced lifestyle supporting a vibrant immune system should be enough to ensure the longevity of the prosthesis.

Which sports are safe after hip arthroplasty?

All low impact sports that the patient participated in before the total hip replacement should be safe. Low impact sports include; tennis, golf, cycling, lawn bowls, alpine skiing, hockey, social squash, hiking and body boarding. Contact sports and high impact sports will not be possible. High impact sports include long distance running, rugby and extreme sports like kiteboarding, wakeboarding, surfing and bungee jumping. If someone is skilled at certain sports like alpine skiing or water skiing, for instance, it will be a safe sport to return to, but not to start as a new sport after the joint replacement.

Hip Arthroscopy

Can osteoarthritis of the hip be treated by arthroscopy?

Can osteoarthritis of the hip be treated by arthroscopy? Once the chondral cartilage has begun to deteriorate, the results of arthroscopic surgery aren't good. MRI scans can help determine the amount of chondral damage prior to surgery to see if this approach may work or not. If the joint space on x-rays is narrowed to less than 3 mm, the arthroscopic technique is not favourable

Can osteochondral cysts in the hip be treated with arthroscopy?

Because the results of curettage and bone grafting of osteochondral cysts in the hip using arthroscopic techniques aren't good, Dr Morkel would advise against it.

What are cam and pincer lesions?

In some cases, the femoral head, which is the ball of the hip joint, can develop an extra bone. This extra bone creates an abnormal ball for the hip joint, looking like a pistol grip. This is called a cam lesion, which can limit the range of motion of the hip joint. In some cases, the acetabulum, the socket into which the ball fits to make the hip joint, can develop a bony rim which is called a pincer lesion. This can become impinged and limit the range of motion of the hip joint. As long as the chondral cartilage is still unaffected, these bony protuberances can be safely removed by Dr Morkel to improve range of motion and enhance activities of daily living.

Anterior Cruciate Ligament Injuries

Does an ACL rupture require ACL reconstruction surgery?

For some patients, an isolated ACL rupture can be treated conservatively without the need for surgery. It will, however, mean that an adjustment will need to be made in sports participation and diligent conditioning of the stabilisers of the knee. In cases where there is associated injuries such as an MCL, PCL, posterolateral corner and meniscus injury, then the ACL would need to be reconstructed surgically. An untreated ACL injury in a growing child is also associated with long-term problems in the knee joint and should thus be operated on.

Can ACL injuries be prevented?

There is certainly a higher incidence of ACL injuries with female athletes and certain sports, for instance, netball and female soccer. A specific injury prevention program focusing on core stability, prevention of valgus knee movement on jumps and generalised hamstring conditioning/centralisation can prevent ACL injuries. Hamstring fatigue and loss of footing or too much grip of the shoes on the playing surface are all factors that can lead to an ACL injury. Wearing the correct shoe for each surface is also important. All young female athletes that participate in high-risk sports, like netball in female soccer, should follow an ACL injury prevention program.

How is an ACL injury diagnosed?

There is usually a definite injury, forcing the athlete not to finish the match or training session. Often this injury is slipped of the foot or twist of the knee whilst changing direction. The knee swells up acutely in isolated ACL injuries. The swelling can subside quite quickly, but the knee will tend to buckle as soon as athlete returns to running. ACL is injuries also happen during high velocity injuries in extreme sports and motor vehicle accidents. There are 3 clinical tests, anterior drawer, Lachmann and pivot shift tests that helps with the diagnosis. Sometimes these clinical test can be difficult in very muscular patients or when the knee is still too painful. X-rays can have subtle bony injuries that are associated with ACL injuries (avulsion fracture or Second fractures) but the gold standard special investigation to diagnose ACL, and associated injuries, is the MRI scan

How is an ACL injury diagnosed?

Usually an ACL injury will be painful enough for the athlete/person to see a doctor. It is often caused by a slip of the foot or twist of the knee whilst changing direction. An ACL injury will cause the knee to swell significantly and while the swelling can subside quite quickly, the knee will tend to buckle as soon as the person returns to running. ACL injuries can also occur due to high-velocity injuries in extreme sports or motor vehicle accidents. To diagnose an ACL injury, Dr Morkel may use three clinical tests: the anterior drawer, Lachmann and the pivot shift test. When necessary, x-rays can also help diagnose any subtle bony injuries that are associated with ACL injuries (like avulsion fractures or second fractures). In most cases, the gold standard special investigation to diagnose an ACL injury is an MRI scan.

When is the right time for ACL reconstruction?

In most cases an isolated ACL ligament reconstruction can be staged, as long as the mobility of the knee is fine and the quadriceps and hamstring strength is maintained. There are special cases where earlier reconstructions will give better results, but when this is the case, Dr Morkel will discuss this with you. ACL ligament reconstructions, in combination with medial collateral ligament (MCL) reconstructions, also lead to better results. When there is an associated meniscus tear during the injury, the ACL needs to be reconstructed in addition to the repair of the meniscus. Usually, athletes fair better with an early ACL reconstruction, as long as the growth plates are respected. In a very young patient with an ACL ligament injury, special care needs to be taken with bony drill holes to prevent early growth plate closure and stunted growth of the bone.

Which graft option is the best?

Excellent results can be achieved with all 3 different autograft options (hamstrings, patellar tendon and quadriceps tendon). When choosing which of the three to use as a graft, the morbidity of the donor site plays a key role in Dr Morkel's decision. Each graft has its pros and cons. Patellar tendon graft harvesting as a reported a higher incidence of knee pain in the long run. Hamstring tendon harvesting, although strength returns to 100% within a year, has a higher incidence of hamstring spasms. Quadriceps tendon harvesting seems to have fewer complications. The contact sportsman and high demand patient certainly require a lower recurrence rate and low donor site complications incidence. When is extra-articular, augmentation procedures indicated? Extra-articular augmentation procedures are indicated for revision ACL reconstructions, medial meniscus repairs, severe rotational instability and severe anterior drawer tests, smokers and professional contact athletes. Will I wear a brace after the operation? A brace is only indicated when there is an associated injury, for instance, meniscus repair, collateral ligament injuries or PCL reconstruction in addition to the ACL reconstruction. What is the role of physiotherapy and biokinetics in ACL injuries? Physiotherapists play an important role in ensuring a full range of motion with an exercise program to begun prior to surgery to protect the knee, as well as 4 weeks after surgery. Biokinetics is also important from 5 weeks to 1 year after surgery to ensure the athlete can return to his or her chosen sport.

Knee Arthroscopy

Will I need crutches after knee arthroscopy?

In most cases, patients do not need crutches. In some special cases where micro-fracturing or fixation of the osteochondral lesion was indicated, the patient will be supplied with crutches for partial weight-bearing mobilisation.

What happens if I am the one patient to suffer an infection?

Infections are rare, but if that happens, then, the patient will have to undergo another arthroscopic procedure. In this case, the knee will be irrigated, and intravenous antibiotics are given. Most cases a drain will be placed which can be removed 2-3 days.

How can deep vein thrombosis (DVT) be prevented?

Prevention is better than cure. Early mobilisation, decreased waiting period before the surgery in the hospital, general anaesthetic and surgery time as short as possible, good hydration and foot exercises are all part of prevention. In high-risk cases trombo-prophylaxis medication (blood thinning injections or tablets) will be used.

What if I am on Warfarin, Disprin (Ecotrin) or Plavix medication?

Warfarin, Plavix, Disprin or Ecotrin needs to be stopped at least 5 days before the procedure. Your cardiologist will be contacted by Dr Morkel to discuss your particular case prior to surgery, for your safety.

What is bone marrow oedema pattern?

Bone marrow oedema is swelling/water that can be seen in an MRI in a patient's bone. It can be spontaneous with no known cause or caused by trauma, osteoarthritis, infection and even arthroscopy. It is quite often very painful, especially night pain. The treatment includes analgesics, decreasing load on that particular bone with the help of crutches or unloader brace and the adjustment of activities

What can be expected after a torn meniscus is removed?

The meniscus plays an important role in protecting the chondral knee cartilage from wear. As an orthopaedic surgeon, Dr Morkel is well aware of this and will try to keep as much of the meniscus intact and try to repair a torn meniscus if possible. If a repair is not possible, then the unstable unrepairable flap of the meniscus will be removed. It is obvious that the smaller the removed meniscus is, the lesser the effects on the chondral cartilage. In certain cases, a very large part of the meniscus is removed. Although meniscus transplants are possible, the outcomes and recovery process aren't favourable. The long term results with a partial meniscectomy with no other underlying pathology/instability are decent, with only 25% reoperation rate at 25 years .

Total Knee Replacement (TKR)

Can both knees be replaced simultaneously?

If fit and healthy, patients can safely undergo knee replacements for both knees, simultaneously. The advantage of this would be that you won't need to take more time off from work. You will also only undergo surgery once meaning the anaesthetic and theatre costs will be reduced by half. In some cases, medical aids will have a cap on the prosthesis benefits, and that will preclude bilateral procedures. In elderly patients or patients with underlying medical conditions, there is a higher risk of complications, and thus Dr Morkel will advise that the replacements are done separately.

What will my limitations be after a total knee replacement?

Only a small percentage of patients will be able to do a full squat post knee replacement. After a total knee replacement, you will not be able to participate in high impact sports like jogging, jumping, squash, snowboarding, kiteboarding, wakeboarding and surfing. Patients that are skilled in Alpine skiing, tennis, body boarding and windsurfing will be able to their previous sports as social participants and should only compete at a lower level.

How long after the knee replacement can I drive?

This will depend on Dr Morkel's approach and the condition of the soft tissue, but a general rule is that 4-6 weeks after a total knee replacement should be a safe period to return to driving.

Are minimally invasive procedures a fad or a must have?

Whether or not you will have a scar is not the important part – what is important is that the alignment and tissue tension is at its best to allow for long term outcomes. And while a total knee replacement is a very successful procedure, it still carries a risk for complications which may require follow up surgery. While the cosmetic appearance of the scar is important, it should not be more important than the patient's health or long term outcomes.

What is the best type of knee replacement for me?

It depends on your age, demands and bone morphology. Dr Morkel will be able to choose the most suitable option as he has done a reasonable amount of total knee replacements through his career. He will choose the prosthesis after all the pros and cons have been discussed with you.

What is Computerised Assisted Surgery (CAS), Robotic and Patient Specific Instrumentation (PSI)

There was a time in the evolution of total knee replacements when the correct anatomical alignment of the prosthesis was thought to increase the longevity of the prosthesis. CAS, Robotic-assisted and PSI were developed to improve the alignment of the implanted prosthesis. Both these 2 technologies are available, but improved implant materials (cross-linked high-density polyethene) and instrumentation have made them less crucial for better surgical outcomes. CAS leads to the added cost, longer theatre time and increased risk for complications. PSI can decrease the theatre time, but MRI or CT scans need to be done prior to surgery, which then adds to the cost. There are still very specific indications for this technology in patients with previous implants for femoral or tibial fractures or serious malalignment caused by previous fractures. Unless you want this added, Dr Morkel will only suggest it if necessary.

When is the right time for a total knee replacement?

Once all underlying causes for cartilage wear, inflammatory causes, metabolic (gout), instability and alignment have been treated, and all other non-surgical options have been exhausted, a knee replacement may be suggested. The decision is ultimately up to you as the patient. Whether it will be a total or partial knee replacement will be decided by Dr Morkel once he sees the internal condition of the knee joint.

Posterior Cruciate Ligament (PCL) Reconstruction

When is a PCL reconstruction necessary?

Most PCL injuries can be treated conservatively, only PCL injuries that are accompanied by injuries to the MCL, ACL, posterolateral corner or meniscus will require a PCL reconstruction.

How is a PCL injury diagnosed?

Because the PCL is located inside the knee joint, it can be difficult to diagnose. It can be very swollen and painful, but Dr Morkel will still do a posterior drawer test to diagnose you. This is done by pushing the shinbone or tibia back while the knee is bent 90 degrees. If the tibia moves more than 5mm backwards, a PCL injury can be diagnosed as third grade. Other diagnostic tests may include an x-ray. MRI and arthroscopy.

When is the right time for PCL reconstruction?

In most cases, as long as the as long as the mobility and strength of the muscles are intact, a PCL reconstruction can be staged. In some cases, like when a medial collateral ligament (MCL) is injured in addition to the PCL, better results are obtained when reconstruction surgery is done early.

Which graft option is the best?

There are 3 different autograft options for a tendon graft: the hamstring, patellar or quadriceps tendon. Which of the three is chosen will depend on Dr Morkel as each comes with its own pros and cons.

Will I need a brace after the surgery?

A special brace for the knee joint will be needed for 4 weeks after surgery. The brace will be worn with the knee in extension (straight position).

Why would I need physiotherapy and biokinetics for the rehabilitation of a PCL injury?

A special brace is locked for 4 weeks in extension and wear unlocked for another 2 weeks in most cases.

What is the role of physiotherapy and biokinetics in ACL injuries?

With the help of physiotherapy, you can ensure a full range of motion of the knee joint after a PCL injury. An exercise program will be provided by your physiotherapist to help you protect the knee before your PCL reconstruction surgery. After surgery, approximately 6 weeks later, you will do more physiotherapy to strengthen the newly reconstructed ligament. Biokinetics plays an important role for athletes wanting to return to their sport after PCL reconstruction and should be begun from 5 weeks up to a year after surgery.

What are possible complications with a PCL reconstruction?

The incidence of complications with soft tissue arthroscopic knee procedures are generally low but may include deep vein thrombosis, infections, bone marrow oedema and complex region pain syndrome. Specific complications of ligament reconstructions include recurrence of instability and post-operative knee stiffness. Intra-operative X-rays are done to prevent vascular injuries.