Treating orthopaedic injuries and conditions

Dr Lai Choon hin Article -The Hip Preservation Replacement Revision

Q: With the current aging population, what are the common orthopedic surgeries of this age group? What prevention and aftercare advice can you give our readers?

With the aging population, we see more joint osteoarthritis and spine degenerative disease as well as osteoporotic fractures of the hip, spine and wrist. As a result more hips and knee replacements will be done together with treatment for osteoporotic fractures and spinal disease.

Preventive measure against degenerative joint disease would include avoidance of high impact activities such as running and substituting them with walking. Swimming and cycling. Squatting and stair climbing can be difficult for the elderly with osteoarthritis. Good nutrition, calcium, Vitamin D and glucosamine supplements are important to treat problems of osteoarthritis and osteoporosis.

Q: Do you see an increase in orthopedic surgeries in the youth, especially with National Service and the recent popularity in sports? What are the common injuries and how can these injuries be prevented?

National service has been around for a long time now. It is part of the Singaporean life. What we notice us that as more people, both young and old, participate in sports, there is an increase in the various types of soft tissue injuries of the knees and ankles such as torn menisci, ligamentous tears of the ankles and knees, shoulder dislocation and rotator cuff tears. Cartilage injuries of the joints are also common.

Such injuries can be lessened by having proper coaching and learning the correct techniques with proper sporting attire and warming up exercises.

Q: What is the most challenging surgery you have encountered?

In my 20 years of practice as a senior consultant orthopedic surgeon in TTSH and now in my own clinic at the AP Centre for Joint Reconstruction at Mount Elizabeth Novena Specialist Centre, I have done many types of surgery, from simple primary hip, knee,¬¬¬ shoulder, elbow and ankle replacement to complex revision hip and knee surgeries with massive bone loss and deformity. One of the most challenging surgeries that I have done is for a lady with severe Rheumatoid Arthritis involving all the joints in her body. This was int eh early 90’s when I had just returned after my 2 years of training in the Mayo Clinic as an Adult Reconstruction Fellow where I leaned from the dozen of hip and knee replacements . This unfortunate lady had been wheelchair bound for 3 years, with severe arthritis in her hands, wrist, elbows, hips and knees. Her right hop was dislocated and both knees were permanently fused at 90 degrees and partially dislocated as well. She was referred to me by her rheumatologist and her children wheeled her into my clinic and asked if I could make her walk again. At that time, it was like asking me to raise the dead as she had been seen by many other senior orthopedic surgeons who told her that is was not possible as her joint deformities were too severe and involved too many joints. Also her muscles were chronically weakened after being in a wheel chair for 3 years. I spent a long time with her, examining her carefully and evaluating all her joints, muscles power and rehabilitation potential. I also needed to assess her psychological makeup and determination to y the other knee 2 weeks later. This was followed walk again as well as her family support as it will be a long drawn out process with multiple complex surgeries. As no other surgeon in Singapore has experience to treat such a difficult patient, I wrote to my mentors from the Mayo Clinic and words of wisdom from my mentors, I started to operate on the right knee, followed by the other knee 2 weeks later. This was followed by months of intensive physiotherapy rehabilitation before processing with her right hop replacement. It was indeed a time of celebration and rejoicing with the patient and her family when she finally walking into my clinic after 2 knees and 1 hip replacement and months of physiotherapy exercises.

Q: What are the differences between private and public practices and how can the private practices add value to the sector in terms of orthopedic surgeries.

In the public institution like TTSH, we have a very heavy workload. I used to see about 35-45 patients per half day session which means we get about a minimum of 5 or less minutes to see each patient. So we had to delegate a lot of patient education and rehabilitation to others. On top of a heavy clinical work load, we have to perform many administrative duties, teach and do research.

In my own clinic, I have more time in the pre-operative evaluation, consoling and also supervise and teach my patients on the post-operative rehabilitation personally. I see my patients recover much faster and are more satisfied. I am able to practice the ‘patient first’ medicine which I have learned at the Mayo Clinic.

Q: Knee problems seem to be very common. When other treatments are not working, what are the surgeries that you would recommend?

This depends on the type of knee problems. If it is a sports injury in the middle age and younger ligaments reconstruction, joint stabilisation and meniscal and cartilage reconstructions.

In the older patients we have various types of joint replacements such as Unicompartmental arthroplasty and patellar femoral replacements beside total joint replacements. We also have various techniques to improve the precision of the surgery with the aid of computer navigation. Patient specific jigs manufactured based on MRI or CT scan measurements as well as using robotic systems such as the Robo-Doc. For total knee replacement and Makoplasty for Unicompartmental replacements.

Q: Are there any new developments in Hop, Knee, Shoulder and Elbow replacements that you could share> what are the diagnoses to look oout for and how can our readers advise their patients?

As said, we have the various robotic systems to do knee replacements. There systems allow for a more precise technique for surgery-based on CT or MRI scans of the lower limb and knee to measure the leg alignment, ligamentous balancing and rotation of the components to achieve a better functioning knee.

Q: We understand that you can specialize in revision surgery. Could you share more on that?

As with all fields of medicine, specialization and sub-specialization most for orthopedic surgery dividing it into adult reconstruction, Hand, Spine, Sports and Foot & Ankle surgery. The first subspecialty to evolve in Singapore is hand surgery which is a completely separate residency program in Singapore uinlike the US where Hand is still part of the orthopedic residency program and a post residency fellowship. I was the first Singaporean to be formerly trained in the sub-specialty of Adult Reconstruction at the Mayo Clinic. During my 2 years as an Adult Reconstruction Fellow at Mayo, I leaned and performed numerous types of hips, knee, shoulder and elbow replacement and revisions surgeries under supervision of the world renowned experts in Adult Reconstruction. After my intense training, I was able to put it to good use at TTSH, I had both the opportunity to do and to teach my residents how to perform revision surgery to failed joint replacements. Revisions surgeries are much more complex and difficult compared to primary joint replacement as we have to deal with massive bone loss, ligamentous, insufficiencies and often pre-existing infections. This extensive experience has stood me in good state to appreciate and anticipate all the possible complications preoperatively and take measure to prevent them during the revision surgery.

 

Click here to Download Original Article