Surgery is only contemplated and used as the last final resort. Most patients will improveand recover with a properly managed non-operative treatment protocol that is individualized to that specific person. If it does come to surgery, the most current up-to-date, minimally invasive procedures will be used if possible. Below are some of the more common procedures done

Specialties //

ARTHROSCOPIC KNEE MENISCUS (CARTILAGE) SURGERY

Meniscus

The meniscus is a circular shaped disc of cartilage tissue that function as a shock absorber between the bones of the knee. The meniscus is frequently damaged in twisting injuries or with repetitive impact over time. When the meniscus tears, a piece of cartilage can move in an abnormal way inside the joint causing pain, catching and swelling. Because cartilage has no blood supply, normal healing does not occur.

New techniques currently allow the meniscus to be repaired arthroscopically, using sutures or small dissolving tacks, eliminating the need for an incision in many cases.

In cases where the torn meniscus cannot be repaired, the smallest possible amount of tissue is removed, in order to preserve as much cushion for the joint as possible.

In rare cases, where a large portion of the meniscus has to be removed, current techniques allow transplantation of a new meniscus from a cadaver.

Surgery is done as an outpatient, using arthroscopic techniques. Immediate weight bearing is allowed using crutches for 48 hours. Range of motion and physical therapy are started immediately. Bandages are removed after 24 hours and band aids are applied. Stationary bicycling is allowed within a few days.

Results are 90-95% successful, with full return to sports at 4-6 weeks for most surgeries. Complex repairs and transplantations may take 6 months for full recovery.

Anterior Cruciate Ligament (ACL)

The anterior cruciate ligament (ACL) is an important stabilizing ligament of the knee. It is located deep inside the knee joint and provides almost 90% of the stability to forward force on the joint. Injuries to this ligament are very common in aggressive sports such as skiing and basketball . Injury to the ACL usually occurs with a sudden hyperextension or rotational force to the joint. The exact mechanism differs for different sports. Typically the injured athlete will hear or feel a “pop”, and will have sudden onset of pain, instability and swelling. If this scenario occurs, the athlete should not attempt to continue playing, and should seek medical attention. Because the ACL is such an important stabilizer of the knee, injury to the ligament makes it difficult to participate in aggressive twisting sports. It should be emphasized that certain sports can continue to be performed quite well without an ACL. These are “straight ahead” sports such as bicycling, roller rollerblading, light jogging and swimming. Twisting, cutting and jumping sports are not recommended however due to the risk of the knee giving way. The knee is designed to work as a hinge, moving in one plane. With a torn ACL, there is increased play in the joint allowing shearing forces across the cartilage surface, and leading to progressive tearing of the cartilage discs (menisci) and breakdown of the joint surface. Over time, this breakdown leads to degenerative arthritis.

Unfortunately, the ACL is injured with both high energy (car accidents) and low energy (field/court sports). Over the years surgical reconstruction of the ACL has become a very reliable operation. Newer reconstruction material are available in addition to the commonly used patella or hamstring tendons. The quadriceps tendon is thicker and stronger than either of those, and by reports, results in less pain in the front of the knee, commonly seen with those other grafts. This graft is commonly used in Europe and Australia, and I think this will be the graft of choice in the coming years in the U.S.

Treatment of ACL injuries has come a long way in the past ten years. Today athletes have greater than a 90% chance of returning to their pre-injury level of sports participation.

Conservative care is recommended for minor and partial tears of the ACL, or tears in which the knee is still within the accepted limits of stability (less than 3mm of laxity). Non surgical treatment is also recommended for the patient who is willing to modify their activity to non twisting less aggressive sports. In these athletes, we begin an immediate specialized rehabilitation program, and provide a custom fitted knee brace for use during sports activity.

Surgery for ACL injuries is extremely specialized and should only be performed by a surgeon who specializes in this type of injury. The techniques continue to change and only someone on the cutting edge can hope to stay up with all of the latest changes. Your surgeon should perform at least 50 of these operations a year.

The current state of the art recommendations:
The surgery should be entirely arthroscopic.
Associated surgeries such as meniscus repairs should be done arthroscopically.
Immediate weight bearing should be allowed following surgery.
Accelerated rehabilitation. (Motion begins immediately)

Suture Repair of the ACL
This is rarely the best choice for this injury, but is recommended in certain rare situations when the ligament is torn off its attachment site, but is still intact and not stretched out, or when it tears off with a fragment of bone. In most situations it has been proven in many scientific studies that repair is much less predictable of a good outcome than a full reconstruction.

Reconstruction
This means creating a new ligament out of a tendon from another location in the patient’s knee or using cadaver tissue. There are three popular choices for the choice of tissue:

Patella Tendon (Autograft)
This means taking a strip of the tendon from the front of the athlete’s own knee (autograft), and is the most popular choice for this surgery. This technique has been utilized for the longest period of time in the largest number of patients, and is considered the gold standard for ACL reconstruction. We have utilized this technique in hundreds of patients with superb results and recommend this as the best choice for the majority of athletes.

Advantages: Strong graft, with bone attachments at each end, which allows the graft to be fixed very solidly at the time of surgery and which allows healing to the body in the shortest period of time (bone to bone healing) of 4-6 weeks.

Disadvantages: Requires taking tissue from the body. This may cause donor site soreness in a small percentage of patients. To avoid this we utilize a unique method for harvesting the patella tendon graft. This method utilizes a round oscillating tool, which takes a circular graft and leaves the patella with a smooth defect. This makes the patella much less prone to any post surgical problems, and we have not found this to be a problem in many hundreds of patients.

Hamstrings
This is a newer method, that is gaining popularity. We recommend this technique for patients who for whatever reason are not a candidate for usage of the patella tendon.

Advantages: For some surgeons, this may result in a lower incidence of donor site discomfort. We have not found this to be the case.

Disadvantages: Hamstring tendons do not come with bone attachments, and it takes the body 12 weeks to heal the hamstring graft (3 times as long as the patella tendon). This means that in the early postoperative period the graft is at risk for injury for a longer period of time.

Allograft
This means using tissue from a cadaver. This is an attractive option for patients who want the least pain post surgery or in cases where multiple ligaments are injured and additional tissue is needed for surgery, or for revision cases where the patient’s own patella tendon has already been utilized.

Advantages: No need to take tissue from the patients already injured knee. May be a good idea in the older patient whose own tissue may be weaker than the usually young donor.

Disadvantages: There is approximately a 1/1,000,000 chance that a disease can be transmitted with a donor graft despite careful laboratory screening.

Patients are sent home with a knee brace for the first day. Range of motion is started as soon as the wound is checked. Early goals are to obtain range of motion and to reeducate the muscles. Weight bearing is begun immediately with crutches. The brace is utilized for three weeks or until the quadriceps are strong enough to support the limb. Crutches are discontinued after 1-2 weeks. Stationary bicycling is begun as soon as the patient can achieve 100 degrees of flexion and can get around on the pedal (usually 2 weeks). Outdoor bicycling and jogging are allowed at 3 months. Return to twisting cutting and jumping sports is delayed for 6 months since this is how long it takes for the graft to biologically heal. Prior to returning to sports, the patient is expected to have regained 90-95% of their muscular strength.

ACL reconstruction is a highly successful operation. 90-95% of patients can be expected to return to full sports participation with 6 months and with aggressive rehabilitation.

Rotator Cuff

The rotator cuff is a group of four muscles and their tendon attachments that surround the shoulder joint. These tendons attach to the ball of the shoulder (humeral head) and act as the inner “ball bearing” stabilizers of the joint. The rotator cuff needs to be functioning properly for the outer layer of large muscles to do their job. The muscles that comprise the rotator cuff are the supraspinatous, which elevates the shoulder, the subscapularis which internally rotates the shoulder, and the infraspinatous and teres minor which are the external rotators. The supraspinatous is the one most commonly involved in injury.

Pinching, or impingement of the rotator cuff can occur against the overlying bone called the acromion. This can occur due to a spur on the acromion, or a thickening or curvature of this bone which rubs against the tendon. This results in inflammation of the tendon (rotator cuff tendinitis) and its adjacent lubricating sac, the bursa (bursitis). If the impingement persists for extended periods, actual tearing of the rotator cuff tendons may occur. X-rays are usually necessary to confirm the presence of a special spur. Tearing of the tendon can best be detected with a special type of x-ray called an MRI (Magnetic Resonance Imaging).

Aching pain on the side of the upper arm is the most common complaint. Pain is often worse at night, and with any attempts at overhead activities. Throwing, tennis and weight lifting are particularly painful. There may be some clicking in the shoulder due to thickening of the inflamed bursa. Weakness suggests that the rotator cuff may be torn.

70% of patients will improve with non-surgical care. Initial treatment involves anti-inflammatory medication, ice, avoiding over shoulder reaching and lifting activities. In the very acute painful phase exercises are avoided. When pain subsides somewhat, rotator cuff exercises are begun. The primary goal of the exercises is to work the uninjured portion of the rotator cuff. This is accomplished by emphasizing internal and external rotation exercises using an elastic tubing. Scapula stabilizers are also strengthened. Deep tissue work by a physical therapist can help relieve associated spasm. Isolated strengthening of the most commonly injured supraspinatous tendon should be avoided. If there is no response to this treatment program, an injection of cortisone is provided. Cortisone is a strong anti-inflammatory medication that, when used appropriately and sparingly, is safe and can be dramatically beneficial.

If there is no response to conservative care for a minimum of three months, surgery is discussed. The purpose of the surgery is to remove the bone spur from the acromion. This surgery is performed arthroscopically using 3 small puncture holes in the shoulder. If the tendon is found to be torn, repair can now also be performed arthroscopically, avoiding an incision in most cases. All surgery is performed as an outpatient and typically takes one hour.

Facts and Myths: There have been many "regenerative" and "stem cell" clinics opening around the country. What's going on? Signaling Cells: The new research regarding Signaling Cells [stem cells] is becoming very exciting and may be appropriate for a very specific subset of patients. Despite reports and claims to the contrary, at least in the field of Orthopedic surgery, none of these products actually reproduce or stimulate actual cartilage growth. What we are able to is inject specific cells, whether from the blood/marrow or other areas that will signal anti-inflammatory and reparative processes. Compared to blood products, cells from adipose (fat) tissue appears to have greater and more consistent numbers of these signaling cells. With this in mind, in order to decrease pain and increase patient function this procedure is now available. Having waited for the procedure to be perfected I believe we are now ready to bring this to the mainstream in a safe and more economic fashion than currently available around NYC. We have recently completed a number of procedures where abdominal fat is removed, a sort of mini-liposuction performed, processed, and injected directly into the affected joint/area. This particular process, called Lipogems, is relatively easy to perform, and allow patients to return to work and light activities within a week. The early results are very promising with all patients who have have had knee procedures reporting significant pain relief.

LIPOGEMS® Treatment

LIPOGEMS® is a game changer in regenerative medicine that surpasses stem cell therapies. The FDA approved revolutionary treatment pertains to a non-expanded, micro-fractured autologous adipose tissue technology designed to harness the optimal healing properties of fat harvesting. It’s a sterile, single-use, closed-loop, disposable device that empowers your Bay Area LIPOGEMS® doctor to harvest, concentrate and transfer a patient’s fat for the reconstruction, replacement or repair of damaged tissue. LIPOGEMS® is effectively used for various orthopedic, neuromuscular, cardiovascular, and autoimmune conditions.

Isn’t Fat Bad For My Health?

Many have the common misconception that fat is harmful and something to avoid altogether, failing to realize how vital it is to the body’s operation. Fat is interestingly highly beneficial when injected into damaged tissue, or an arthritic joint. It’s a very dynamic and active biological tissue rich in the promising multipotent mesenchymal stem cells (MSCs), pericytes that are significant to overall growth, and cytokines that are crucial in sending other cells signals towards proper cell function.

Fat, however, tends to bury essential healing agents along with cytokines underneath its layers. Buried within the complex fat matrix, intact fat exhibits decreased healing potential. Though it can be dissolved into enzymes, FDA regulations prohibit this unless a special permission or research licenses exist, limiting its usefulness. This is where LIPOGEMS® comes in.

What Makes LIPOGEMS® So Unique?

LIPOGEMS® captures the complete healing potential of adipose tissue in an enzyme-free process. It’s not simply and merely another “stem cell” treatment. In fact, if pure stem cells are injected into a damaged area, most cells will become ineffective.

MSCs, together with the supporting cast of cells and proteins, pave the way to successful LIPOGEMS® treatments without the need for surgery. It promotes the natural regenerative process of tissues in a total healing microenvironment.

Carefully processed and then precisely injected by a LIPOGEMS® San Francisco expert, patients experience a life-changing treatment that merely takes over an hour to complete!

How The LIPOGEMS® Procedure Works

LIPOGEMS® treatments are virtually painless following a short process:

Your skin is numbed with local anesthesia.
A thin blunt-tip cannula is inserted and fat is infiltrated with a sterile saline and anesthetic mixture.
A harvesting cannula is inserted to aspirate the fat. As little as 50cc or approximately 4 tbsps can make a huge difference!
The harvested fat is processed using the revolutionary LIPOGEMS® device to reap the autologous tissue with powerful healing benefits.

Ankle Arthroscopy

Arthroscopy means ‘scoping of a joint’ in Latin, or the surgical treatment of a joint using a small fiber optic telescope-like device. Arthroscopic techniques allow less invasive surgery, with faster healing, less post operative pain and more rapid return to sports. Ankle arthroscopy is commonly performed in athletes to allow rapid return to sports.

A list of the most common indications for arthroscopy of the ankle follows:

Loose Bodies: Fragments of loose cartilage or bone are removed from the joint (common after multiple sprains).

OCD: Osteochondritis Dessicans-damaged bone and cartilage on the talus bone of the ankle are treated by drilling deep into the bone to encourage bleeding and in growth of healing cells.

Arthritis: Loose debris and inflammatory enzymes are washed free. Spurs are removed.

Fusion: In severe cases of arthritis, the joint can be fused arthroscopically

Impingement: Painful scar tissue that pinches in the front of the ankle is removed.

Fractures: In some cases, splinters of bone are removed from the joint after fractures