Dr Chintan Vadi

Patellar chondromalacia refers to pain around the front part of the knee.

Injuries, Ageing, or genetics may play a role in the roughening of the cartilage under the knee cap. In a healthy knee, the cartilage surfaces of the patella and trochlea are extremely smooth. When there is a fissuring in the cartilage, this efficient gliding surface no longer exists which leads to increased friction between two bones, which in turn leads to pain & swelling. Thus, chondromalacia occurs when the cartilage surface has broken down and early arthritis has formed.

Symptoms of patellar chondromalacia include:

• Active grinding of the knee with motion
• Anterior knee pain
• Swelling with activities

Treatment for Patellar Chondromalacia

The treatments can include rest, activity modification, physical therapy, stretching, bracing, injections, or arthroscopic surgery.

Physiotherapy and activity modification is the main line of treatment. Most of the patients get relief with rehabilitation. Surgery is rarely needed.

Arthroscopic surgery for patellar chondromalacia involves placing instruments into the knee to shave down any unstable cartilage flaps on the patella and the trochlear groove. In most circumstances, some surface cartilage will remain present. Physical therapy after surgery will work to strengthen the muscles around the knee and to make sure the patella does not scar in. It is also recommended to avoid any activities that can cause further cartilage wear, breakdown, and swelling in the knee. In general, except for a very high-level athlete, we recommend avoiding any high-impact activities, and squatting and lunging activities, to try slow down the rate of wear of the cartilage surface.

Arthritis in the knee is a debilitating condition that affects thousands of people every day.

Symptoms of knee arthritis include:

• Knee pain
• Swelling with or without activities
• Knee stiffness
• Crepitations/ clicking

Knee osteoarthritis is the most common form of arthritis in the knees. It is age related disease. It is a slow, progressive degenerative disease in which the joint cartilage gradually wears away. This injury is typically seen in middle-aged and older people, but can sometimes affect younger patients who have had fracture around the knee joint or had untreated torn meniscus,

Treatment of Knee Arthritis

Our treatment method for knee arthritis includes conservative trial in the form of life style modification, muscle strengthening exercises, certain joint preserving medicines and intra articular injections.

In Specific conditions, where a small portion of cartilage is involved while the rest of the join cartilage is normal, microfracture / osteochondral autograft transplants/Autologus chondrocyte implantation can be done.

For patients with advanced disease involving single compartment, depending on the age of the patient and their need, such patients can be successfully treated with High Tibial Osteotomy or Partial Knee Replacement.

For patient who have arthritis of more than one compartment of the knee joint, Total knee replacement may be needed.

What is High Tibial Osteotomy(HTO)?

A large percentage of adults suffer from knee arthritis. Arthritis may be the result of a degenerative condition, hereditary, or may have been caused by an earlier sports injury or accident to the knee area. Patients who experience osteoarthritis often strive for ways to improve knee function, limit pain, and for many, put off knee replacement surgery. One surgery to postpone knee replacement surgery and improve function is a knee osteotomy.

A knee osteotomy is a surgical procedure that Dr.Vadi performs on patients who have a single compartment of their knee affected by osteoarthritis. The significance of having the surgery is that for many patients, the procedure can offer years, and often a decade or more, of improvement and possibly continue to delay the need for knee replacement surgery. Osteotomies of the knee have been validated to be effective for decreasing pain and improving patient movement in most instances.

Many people who undergo a knee osteotomy will eventually need a total knee replacement. However, research studies have reported knee replacements are more successful in patients over 60 years of age. Therefore, patients in their 30’s, 40’s and 50’s are ideal candidates for knee osteotomies.

Description of Knee Osteotomy

During a knee osteotomy, Dr. Vadi will add a wedge of bone graft to the upper shinbone (tibia) or lower thighbone (femur). In essence, this helps shift a body’s weight off the damaged area of the knee joint onto the more normal cartilage area on the opposite side of the knee.

During an opening wedge osteotomy, Dr. Vadi may use hardware, such as screws and plates, to hold the bones of the knee to their new aligned position and add bone graft to help the osteotomy heal faster. Most patients who undergo a knee osteotomy will stay in the hospital for two days for pain control and to initiate physical therapy.

Post-Operative Protocol for Knee Osteomoty

Patients are generally sent to physical therapy immediately after surgery to work on swelling control, muscle reactivation, and knee motion. In general, patients are non-weight bearing on crutches for 8 weeks and progressively wean off crutches over the next month. This is achieved by slowly increasing weight bearing on the leg at ¼ body weight per week. Patients are only allowed to progress their rehabilitation program with weight bearing after review of x-rays. In general, most patients are able to wean off of crutches at 3 months after surgery. A low impact exercise program to include walking, cycling, and aquatic therapy is progressed at this time. Most patients note significant improvement of their function by 4-6 months after the knee osteotomy.

Description of ACL Injuries

The anterior cruciate ligament, or ACL, is one of four major ligaments that make up the knee. Ligaments are in place to stabilize the femur (thigh bone), which sits just above the tibia (shin bone).

The ACL is critical to maintaining knee stability. ACL injuries are very common among athletes of all ages and competitive levels. Approximately 10,00,000 ACL injuries are reported each year in the World. Football, Kabbadi are one of the common sports which put athlete at high risk of ACL injury. Also it is not uncommon in our part of the world to have a ACL tear following a Vehicular accident.

Symptoms of an ACL Injury:

• Patients with an ACL tear often report instability in the knee.
• Feeling as if the knee will “give out”, or pop out of place

In addition to role in providing stability, the ACL also provides protection for the menisci of the knee. When the knee continues to have instability episodes, it is not uncommon for the medial or lateral meniscus to tear. However, with the presence of a meniscal tear there is much higher risk of developing osteoarthritis. Because of this, Dr Vadi usually recommends ACL reconstruction for an ACL tear in young or otherwise active patients, in patients who have meniscal tears, and in almost all patients who report instability with twisting or turning activities.

Treatment:

Patients having Grade 1& 2 injury of the ACL will get better with the help of rest, ice application and physiotherapy.

Patient having Grade 3 injury(Complete tear) are candidates for surgery, as they have high chance of further injuries to cartilage and meniscus if left untreated. In last 5-10 years, the method of doing ACL Reconstruction has changed dramatically. Currently, Anatomical ACL reconstruction, where graft is placed in the center of the native ACL footprint is the method of choice.

Post operative Care:

It is absolutely essential that the patient follows a well-supervised physical therapy protocol following ACL reconstruction surgery. Reactivation of the quadriceps mechanism, edema control, patella mobilization, maintenance of full knee extension and regaining knee motion are absolutely essential to obtaining optimal post-operative outcomes.

Return to Sports/Running/Cutting/Pivoting usually takes 9-10 months after the surgery, as early return to sports is associated with high chances of Re-tear of the ACL graft.

Frequently Asked Questions

When to have ACL surgery after injury?

Athletes who have any difficulty with twisting, turning, or pivoting after an ACL tear should consider having their ACL reconstructed. This is because repeated twisting and turning mechanisms can damage both the cartilage in the joint and also the menisci. The medial meniscus is the most at risk to injury with an ACL tear because the medial meniscus takes over a lot of the function of the ACL when it is torn to prevent the knee from slipping forward. In addition, patients who may have a repairable meniscus tear at the time of their ACL tear should consider surgery to prevent the tear from becoming non-reparable. In general, most people who tear their menisci will be developing arthritis and having symptoms within 8-10 years after their ACL tear. Thus, one of the main reasons for the general public to consider having an ACL reconstruction is both to repair any meniscal tears which are repairable, and also to prevent meniscal tears from developing if their knee is unstable.

What is ACL reconstruction surgery?

ACL reconstruction surgery consists of replacing a torn ACL with another ligament or tendon.  This can be from one’s own body (an autograft) or from a donor (an allograft).  In an ACL  surgery, tunnels are reamed at the normal attachment site of the ACL on both the femur and tibia and the graft is secured either inside or outside these tunnels.  The type of graft from one’s own body and whether one should use a cadaver graft tissue or not can depend on multiple factors.  This can include the patient’s age, if they have hyperlaxity, where they participate in contact sports, and other factors.

How is an ACL reconstruction done?

An ACL reconstruction is done by replacing the torn ACL with tissue that is placed at the normal attachment sites of the native ACL.  This involves reaming a tunnel in the femur (posterior to the lateral intercondylar ridge) and also in the tibia (adjacent to the anterior horn of the lateral meniscus) and then securing the graft within those tunnels.  There are multiple ways to secure the graft, and this can include fixation within the tunnels with metal or bioabsorbable/plastic screws or through a loop and button placed on the outside of the tunnels.  In general, the fixation of the grafts is performed according to the way the surgeon was originally taught, with the gold standard being screws placed within the tunnels for patellar tendon grafts and looped sutures with cortical buttons or screws within tunnels for hamstring ACL reconstruction grafts.

When should an ACL be repaired?

The main time that  ACLs can be repaired is when an ACL is torn with a piece of bone, usually off the tibia, which is much more common than when torn off the femur.  In this circumstance, if there is not a lot of intrasubstance stretch within the torn ACL, the bony can be refixed at its normal attachment site and secured such that early motion can be started.  In those instances where the tissue is not strong enough to allow early motion, there is a much higher risk of stiffness if immobilization is required after surgery.

In terms of a repair of the ACL, there are perhaps 10% of patients who may have injury only to the attachment site on the femur or tibia and sutures can possibly be placed in to do a repair.  In those circumstances, research is still ongoing to try to improve outcomes because attempts at repairs in the literature previously have not shown good outcomes over time.  Thus, more research is necessary to define better techniques to perform ACL repairs in those circumstances.  It is important that these techniques be based upon good science and not on marketing by device companies because previous attempts at ACL repairs did not show failures until after two years after surgery.

How long is an ACL surgery recovery?

One of the most important things for preventing a retear of an ACL reconstruction is to ensure that the patient has gone through the proper recovery phase after surgery.  In the past, many surgeons tried to get their patients back to full activities by 5 or 6 months.  However, more recent data has suggested that waiting up to 9 months may be more advantageous in that the rate of retear goes down significantly after the 9- month timeframe for a return to activities after ACL surgery.  In general, it is important to make sure that an athlete has a full return of proprioception, strength, agility, and endurance to minimize their risk of reinjury.

When I can run after ACL surgery?

The ability to return to running after an ACL surgery is dependent upon many factors.  If the surgery is only the ACL, and there are no other ligaments or meniscus tears treated, and the cartilage surfaces are intact, then one has to go through a proper rehabilitation program first.  In general, we feel that an athlete has to wait a minimum of 4 months after their ACL reconstruction return to running.  In addition, they should have appropriate quadriceps strength.  Our main goal is to be able to have them perform a single-leg squat with no bending of the knee inwards (valgus collapse) during the single leg squat.  In these circumstances, if the patient has a good return of function, good motion, and does not have a valgus collapse when performing a single-leg squat, they are generally able to initiate a  return to their running program at about the 4-month timeframe.  This allows the quadriceps mechanism to be strong enough to prevent extra stress on the knee which can lead to knee swelling (effusions) and possibly damage the cartilage which would not be noticed until several years later.

What causes ACL reconstruction failure?

The number one cause of ACL reconstruction failure in all of the literature is improperly placed ACL grafts at the initial surgery.  This can cause extra stress on an ACL reconstruction graft which can lead to its failure.  In addition, a missed other ligament problem at th time of the ACL surgery, such as an MCL or a posterolateral corner injury, can also put significant stress on an ACL reconstruction graft, which can lead to its failure.  Other factors that can cause an ALC graft to fail can include the lack of the posterior horn of the medial meniscus.  This is because the posterior horn of the medial meniscus is the next structure that prevents the knee from sliding forward.  In patients who may not have their medial meniscus, the ACL graft generally tends to be looser than in patients who do have their medial meniscus.  Thus, in some patients, this can lead to the graft being overloaded and it can cause the ACL graft stretch out over time.

Other factors that can lead to ACL reconstruction failure are patients that have soft tissue grafts, such as hamstrings grafts, that have hyperlaxity.  These patients who have a significant increase of  heel height  (more than 4-5 cm) have a much higher risk of having these grafts stretch out versus a patellar tendon graft.  Other factors include patients with a large increase in their posterior tibial slope (sagittal plane tibial slope) which can cause an ACL graft to be overloaded and stretch out over time.

Description of a Meniscus Injury

A meniscus injury of the knee is common among both athletes and non-athletes. The knee joint has two menisci—one is on the inside of the knee, known as the medial meniscus, and the other is on the outside, known as the lateral meniscus. In the form of a C-shape, the meniscus is wedged between the femur (thigh bone) and tibial (shinbone) to help maintain balance and stability. In other words, the menisci help distribute the weight of the body appropriately across the knee joint. Without the meniscus, an uneven weight distribution would occur which would lead to overload of the cartilage surfaces.

A meniscus injury can occur by way of tears and strains, some of these injuries are mild and can be treated conservatively, while others are serious and will require surgical intervention. Typically, a torn meniscus is caused by twisting or turning quickly, often with the foot planted while the knee is bent. Meniscus injuries are most commonly seen in Skating, Football, Kabbadi.

When the meniscus is torn the patient may feel a “pop” in the knee. In most cases patients can still walk, and some athletes can continue playing with a torn meniscus. Gradually, the knee will become more stiff and swollen over the course of several hours to days.

Symptoms of a meniscus injury:

• Pain
• Stiffness and swelling
• Catching or locking of the knee
• Limited range of motion

Meniscus Anatomy

The menisci are made of fibrocartilage and act as shock absorbers for the joint. They have a blood supply on the outer third, with the inner portion of the meniscus not having any blood supply. In addition, the inner portion is much thinner than the thicker outer portion, which attaches to the joint lining. For this reason, tears of the inner portion of the meniscus, which does not have a blood supply, almost always have to be resected. In these circumstances, a partial meniscectomy is necessary to remove the torn portion of the meniscus that is causing pain. However, if meniscus tear is in outer third of the meniscus, this type of meniscus tear can be repaired as this area of meniscus is having good blood supply.

Treatment for Meniscus Injuries

The exact treatment method will depend on the size, location, and type of tear. The patient’s age, history of injury, and activity level will also determine the treatment method. The outside one-third of the meniscus has a rich blood supply, known as the “red zone”, this portion of the meniscus may heal on its own if the tear is small. The inner two-thirds of the meniscus has a lack of blood supply, known as the “white zone”. This portion of the meniscus cannot heal on its own.

For surgical treatment Dr. Vadi will use knee arthroscopy to either repair the meniscus or to trim out those portions which cannot be repaired.

Description of Partial Meniscectomy

The technique of partial meniscectomy is performed arthroscopically.  In these circumstances, the torn portion of the meniscus is resected with an attempt to try to preserve and sculpt as much of the remaining meniscus to both try and leave as much shock-absorbing capacity as possible, but also to try to minimize the chance of a re-tear.

The surgical technique involves making 2 small incisions on either side of the patellar tendon, with one being used for the arthroscopic camera and the second being used for the arthroscopic instruments.  The meniscus tear is trimmed down and “saucerized” in order to remove any edges which could catch in the joint and cause further pain, but at the same point in time trying to preserve as much meniscus as possible.

Description of Meniscus Repair

Dr Vadi will advise repair of a torn meniscus whenever the tear is present in the outer third of the meniscus. There are various techniques of repairing a torn meniscus.

For tears which are present near posterior horn, The Repair is performed using special disposable devices that have preloaded plastic implants.

For tears present in the body of the meniscus, Inside out method is used to repair the meniscus in which flexible needles are passed and knot is tied outside the capsule.

For tears present in anterior part of the meniscus, Outside-in method of repair is recommended. 

Following a meniscus repair, patient is asked to avoid weight bearing on the operated limb for 1 month. After 1 month, partial weight bearing is started and is recommended till 2 months after which full weight bearing is started.

The success rate of meniscus repair is 80-90 percent depending on the type of tear. when a meniscus repair fails, patient may need a surgery in the form of partial menisectomy. 

Posterior Cruciate Ligament Reconstruction

The posterior cruciate ligament, or PCL, is the strongest ligament of the knee. While the anterior cruciate ligament, or ACL is injured more often than the PCL and is more commonly discussed, a torn PCL accounts for more than 20% of reported knee injuries. A torn PCL is commonly missed and left undiagnosed.

The posterior cruciate ligament’s most important function is to prevent posterior translation of the knee at higher knee flexion angles. Thus, patients commonly complaining of problems with deceleration, problems going down stairs and inclines or general twisting, turning or pivoting activities.

PCL injuries are classified according to the amount of injury to the functional ligament:

• Grade 1 PCL Sprain: partial PCL tear
• Grade 2 PCL  Tear: near complete PCL tear
• Grade 3 PCL Tear: a complete PCL tear – the ligament is non-functional

PCL Reconstruction FAQ

How long does it take to recover from a sprained PCL?  How long does it take to recover from a PCL tear?

The time that it takes to recover from a PCL tear depends upon how severely the PCL is torn.  For a very minor sprain, which would be called a grade 1 PCL tear, athletes may be able to return back to competition within 2 or 3 weeks.  This usually requires that the swelling in the knee has resolved, strength is returning, and the athlete’s endurance and agility have returned back to normal.  For a grade 2 PCL tear, where there may be more instability of the knee, it may take up to 6 weeks for a sufficient recovery without surgery.  In these cases, the use of a dynamic PCL brace, such as the PCL rebound brace, may help to hold the knee in a more reduced position so when the PCL heals it is not loose.  For a grade 3 PCL tear, where a significant increase in posterior tibial translation occurs because of the PCL tear, it is becoming more widely accepted with improved PCL reconstruction techniques that these cases undergo surgery.  While some of these cases may respond well to a dynamic PCL brace holding their knee into a more reduced position, it is also important to recognize that patient reported outcomes after PCL reconstruction surgeries are much better when performed in the first few weeks after injury rather than waiting for 6 weeks or longer.  Thus, when one does have a grade 3 PCL tear and feels instability, surgical reconstruction would be indicated.  In these circumstances, it takes from between 9-12 months to completely heal after a PCL reconstruction.

Can a PCL injury heal on its own?

Unlike the ACL, the PCL does have an ability to heal.  The synovial membrane around the PCL allows for some healing to occur.  What is important to recognize is that in these circumstances, the effects of gravity can be bad on a PCL healing.  Thus, when one does have a severe PCL tear, one should consider either a cast or a dynamic PCL brace to hold the knee into a reduced position so that the PCL has the best chance of healing in a “tighter” rather than a loose position.

What is PCL reconstruction surgery?

PCL reconstruction surgery consists of replacing the torn PCL with one’s own tissues. The tissues used can be a hamstring tendon or a peroneus longus tendon or a Patella tendon with bone plug or a Quadricep tendon with / without bone plug. Dr Vadi will drill a socket in the center of the tibial and femoral foot print of PCL. The graft will be passed and fixed with the help of endobutton/ interference screws.

When to have PCL surgery?

Currently, it is recommended that almost all patients and athletes who sustain a grade 3 PCL tear should consider a reconstruction.  Patients with grade 2 PCL tears should consider reconstruction if they have trouble decelerating, going down inclines, going down hills, or if they start to develop pain in their kneecap joint or along the inside (medial joint line) of their knee.  Medium to long-term PCL tears often lead to patellofemoral and medial compartment arthritis, so pain in these locations should be carefully watched.  In general, one should have PCL stress x-rays to determine the grade of a PCL tear.  It is felt that PCL stress x-rays which show more than 8 mm of increased posterior tibial translation on the injured knee compared to the contralateral knee should consider surgery.  If it is less than 8 mm, it may indicate that the patient is guarding or that there is a partial PCL tear.  In these circumstances, a rehabilitation program would be indicated first followed by a repeat x-rays to make sure that the PCL is not completely torn at a later date (usually 2-3 weeks later).

What is PCL reconstruction recovery time?

The PCL takes longer to heal in, and thus requires more biologic healing time, than an ACL reconstruction.  This is because a PCL is larger and a larger graft is used to reconstruct the PCL.  Most PCL rehabilitation programs rely on a 6-week period of nonweightbearing, utilizing a dynamic PCL brace, followed by a program up to 6 months postoperatively whereby a patient/athlete avoids running, twisting, turning and pivoting.  At the 6-month point, if the PCL stress x-rays show good healing of the PCL reconstruction, patients can initiate a jogging program and start side- to-side activities if they have sufficient quadriceps strength and do not have any valgus collapse when they perform a single-leg squat.  In our hands, with our professional and Olympic athletes, they are generally able to return to full competition between 9 and 12 months postoperatively.  This totally depends upon whether there is solely an isolated PCL reconstruction or if there are other concurrent ligaments that are torn for the PCL.

What is a PCL reconstruction protocol?

A PCL reconstruction rehabilitation protocol needs to be individualized to the patient’s injury.  In general, PCL reconstructions undergo 6 weeks of non-weightbearing and perform motion exercises on their stomach with prone knee flexion.  This negates the effects of gravity and helps the PCL to heal without having to worry about stiffness.  At the 6-week point, patients initiate weightbearing and they wean off crutches when they can ambulate with a limp.  They generally work on straight-ahead (single-plane) activities until the 6-month point.  Thus, they are allowed to work on a stationary bike and graduate to the use of an elliptical machine to build up their quadriceps mechanism, but should allow the graft to heal sufficiently prior to doing higher level activities so the PCL graft does not stretch out with time.  During the first 6 months postoperatively, patients wear a dynamic PCL brace to ensure that the effects of gravity do not cause the graft to stretch out.  We have found that this dramatically improves the results of PCL reconstructions and feel it is essential to obtain the best outcomes.

Medial and Lateral collateral ligaments are present over the both the side of the knee joint. Their main function is to prevent side to side movement of the knee joint.

Grade 1 injury- Sprain of the ligament without actual tear.
Grade 2 injury – Partial tear of the ligament.
Grade 3 injury- Complete disruption of the ligament.

The treatment of collateral ligament tear is individualized according to the site of tear, how old is the injury, patient age. Generally speaking, the healing potential of Medial Collateral ligament is very high, thus it is allowed to heal on its own for 6 weeks and reassessed after 6 weeks. Complete tear of LCL/PLC do not heal and thus usually require operation to repair/augment/reconstruct them.

Patella is the bone that lies on the front of the knee (KNEE CAP). In Some patients after injury, the patella dislocates laterally and if at the time of first injury care is not taken, it is likely to occur again and again.

Such patients have apprehension over use of knee as their knee cap dislocates even without injury.

Generally speaking, if the patient has recurrent dislocation of patella, complete evaluation with thorough clinical examination,special X rays, CT scan for bony morphology and MRI assessing ligaments and cartilage is necessary. Once complete evaluation is done, only then the doctor can decide if surgery is indicated, and if the surgery is indicated whether only soft tissue procedure like MPFL reconstruction is needed or also Bony procedure like trochleoplasty/ Tibial Tuberosity Transfer is needed.

Rotator cuff is a group of 4 muscles aroung the shoulder joint. The muscles function in sync with each other and other major muscles around shoulder joint to bring about the movement of the shoulder joint. This muscle pass between the acromion and the head of the humerus and thus are at risk of tear due to less space available for their excursion.

If a rotator cuff tears, the patient will have pain, sleep disturbance, unable to carry out daily activities. The Rotator cuff in young age(Less then 40) is torn mostly due to trauma. In older age group, the rotator cuff can tear without injury and produce the above mentioned symptoms

In Late stage, due to incoordination between muscles due to rotator cuff tear, patient develops arthritis of the shoulder joint which a painful condition not amenable to minimal invasive treatment.

Whenever your doctor suspects rotator cuff tear, special X rays to rule out bone spurs and MRI is needed to confirm the diagnosis and also to know the quality o f the muscle to have a judgement about its repairability.

Treatment

• Partial Tear: when less than 50% of the thickness of the rotator cuff is damaged, conservative treatment is the main line of treatment. That includes Actvity modification, and rotator cuff strengthening exercises. Usually patient are better by 3 weeks and completely symptoms free by 3 months however it is of utmost important to continue the exercises so as to prevent recurrence of symptoms.
• Complete tears: When the rotator cuff is torn completely, it is best treated by Surgical repair. The repair is done with the help of suture anchors. Patient has to wear a sling for about 6 weeks. After 6 weeks rehabilitation is started which lasts for 4 -6 months.
• Cuff tear arthropathy/ Irreparable tear: If a patient comes late, the rotator cuff tear might not be possible to repair. Sometimes patient comes late with development of arthritis where repair is not indicated. In such scenario, the doctor will advise Reverse Shoulder Replacement.

Adhesive capsulitis is a condition where the shoulder joint becomes stiff. It is common in patients having Diabetes however it can also occur after immobilization of the shoulder joint.

It is a very painful condition and thus patient will not be able to move his shoulder joint which ultimately leads to stiffness.

Treatment is mainly physiotherapy in the form of capsular stretching exercises, scapular muscle strengthening, Joint mobilization, and rotator cuff strengthening exercises. This condition requires a long and dedicated rehab. If even after dedicated efforts of rehabilitation there is no improvement, then Arthroscopic capsular release is indicated. In this operation, the capsule of the joint is incised with the help of Shoulder arthroscopy and once satisfactory movement achieved, patient is put on rehab the very next day of operation. However this operation is very rarely needed if patient comes early and is following instructions given by the physiotherapist and the doctor. 

Shoulder is the most common joint in the body to dislocate. Due to its inherent design we have a great deal of mobility within the shoulder, which is directly at the cost of stability. Shoulder instability may present as repeated dislocation where in, patient has to go to a hospital to relocate the shoulder, often under sedation. Some times patients are able to relocate their shoulder themselves. Shoulder dislocation is a recurrent phenomenon. Commonly after the first dislocation there is a risk of 60%-80% recurrence. If the shoulder dislocates again there is more than 90% chance that it will re-dislocate. Each time the shoulder dislocates it peels off the attached ligament (Labrum) worsening the damage. Along with the ligament the cartilage of the joint on both sides (Glenoid & humerus) is damaged permanently. Cartilage damage cannot be repaired.

In modern day orthopaedics, the treatment of this condition has revolutionised the outcome of the patients. Arthroscopic repair enables the patient to go home the same day or next day of surgery and helps restore the range of motion fully with a early return to pre injury level.

It is prudent to get treated early to avoid long-term problems. Repeated shoulder dislocations can lead to nerve injury, which may not heal completely. Repeated peeling off cartilage will eventually lead to early arthritis which can be disabling and compromise daily essential activities.

In the past the surgery for recurrent dislocation was open surgery with long scar & mixed results. In modern era few hospitals are geared to treat this condition with Arthroscopic repair by name of Bankart repair. The keyhole surgery leaves three small scars. Patients go home the next day of surgery and usually resume light work in few days. Patients must avoid driving for 2 months after surgery. By three months most patients have achieved their full range of movement & strength.

Treatment of shoulder Dislocation largely depends on the condition of the bone of the socket. If the bone of the socket(glenoid) is adequate, the patient can be treated successfully with arthroscopic repair of the torn anterior labrum. Such patients usully resume their office work by 2 months and are back to their pre injury level by 3 months. If the bone of the socket joint is inadequate due to repeated dislocations, then such patients have to undergo open surgery to reconstruct the socket of the joint by means of coracoids transfer. This operation usually has inferior results then arthroscopic repair and is having alonger recovery time. That’s why it is prudent to get treated early if one has a recurrent shoulder dislocation.