Orthopaedic Follow Up

Orthopaedic Surgeon - Orthopaedic Follow Up 01/11/2024 It was a pleasure to review you today. Below is a letter detailing our consultation: _Review_: - The patient, a 45-year-old male, presented today for a follow-up regarding persistent right knee pain and instability, specifically exacerbated during weight-bearing activities and climbing stairs. He also reported a clicking sensation in the knee, which started approximately three months ago after a minor twisting injury during a football game. - The history of the presenting complaint indicates that the pain began insidiously after a football injury, initially mild but progressively worsened over the last three months. It is described as a dull ache, with occasional sharp, stabbing pains, particularly when pivoting or descending stairs. Aggravating factors include prolonged standing, walking on uneven surfaces, and sports activities. Alleviating factors include rest and over-the-counter anti-inflammatory medications, though relief is temporary. He denies any previous significant knee injuries or surgeries. Physiotherapy was initiated two months ago but has shown limited improvement in pain or stability. - Physiotherapy has been ongoing for eight weeks. The patient reports minimal progress in reducing pain or improving stability despite diligent adherence to his exercise programme. He feels his overall functional status has not significantly improved, and he continues to experience limitations in daily activities and sport. He finds the exercises challenging due to persistent pain. - Since the last visit, the patient reports a slight deterioration in his symptoms. The knee pain has become more constant, and the instability episodes are more frequent, impacting his ability to perform his work duties as a carpenter. His overall progress has been poor, and he expresses increasing frustration with his limited mobility. _Assessment & Investigations:_ - Vitals were stable today: Blood Pressure 128/78 mmHg, Heart Rate 72 bpm, Respiratory Rate 16 bpm, Temperature 36.8°C. - Physical examination of the right knee revealed mild swelling over the medial joint line and a positive anterior drawer test, indicating anterior cruciate ligament (ACL) laxity. There was tenderness to palpation along the medial meniscus. Range of motion was 0-130 degrees, with pain at extremes of flexion. Quadriceps strength was 4/5, and hamstring strength was 5/5. No gross deformity was observed, but a slight valgus alignment was noted during weight-bearing. McMurray's test was positive for medial meniscus pathology. - No surgical wound was present, as this is a pre-operative assessment. - Neurovascular examination of the right lower extremity was intact. Distal pulses (dorsalis pedis and posterior tibial) were palpable and strong, capillary refill was brisk (<2 seconds), and sensation was intact in all dermatomes. Motor function was normal in the foot and ankle, and the limb was warm to touch. - Recent investigations include an MRI of the right knee performed on 15/10/2024, which showed a complete tear of the anterior cruciate ligament (ACL), a complex tear of the medial meniscus, and mild chondromalacia of the patella. X-rays taken on 05/10/2024 revealed no acute fractures or significant arthritic changes. _Management plan_: 1. Right Knee Instability and Medial Meniscus Tear - Assessment, including the clinician's likely diagnosis and rationale based on subjective and objective findings. The likely diagnosis is a complete tear of the right ACL and a complex tear of the medial meniscus, supported by the patient's history of a twisting injury, persistent instability, positive anterior drawer and McMurray's tests, and confirmed by MRI findings. - Investigations planned, specifying any additional imaging, laboratory tests, or assessments needed for a definitive diagnosis or surgical planning. No further imaging or laboratory tests are immediately planned, as the MRI has provided sufficient detail for surgical planning. Pre-operative blood work and ECG will be arranged as standard protocol. - Non-surgical treatment options, including physiotherapy, casting or bracing, medications, lifestyle modifications, etc. Non-surgical options, including continued physiotherapy and bracing, have been discussed. However, given the complete ACL tear, persistent instability, and complex meniscal tear affecting his quality of life and occupational function, these options are unlikely to provide long-term resolution. - Surgical treatment options, detailing the type of surgery, the nature of the surgery, and any techniques mentioned. Surgical intervention is recommended, consisting of an arthroscopic right knee ACL reconstruction using a hamstring autograft, combined with an arthroscopic repair of the medial meniscus. The procedure will involve re-establishing ACL integrity and stabilising the knee joint, as well as preserving meniscal function. - Post-operative care plan, covering expected hospital stay, rehabilitation, physiotherapy, pain management, and follow-up appointments. The patient can expect a hospital stay of 1-2 days. Post-operative care will include strict physiotherapy protocols, gradual weight-bearing progression, and a comprehensive pain management regimen involving oral analgesics. A structured rehabilitation programme will be initiated immediately post-surgery, with regular follow-up appointments scheduled at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months. - Relevant referrals, e.g., to rheumatology, physiotherapy, pain management, etc. A referral to post-operative physiotherapy has been made, and the patient has been provided with contact details for the pain management team should it be required. - Counselling was provided to the patient regarding the diagnosis of ACL and meniscal tears, the surgical and non-surgical options available, the prognosis with and without surgery, and the critical importance of adherence to the post-operative rehabilitation plan for optimal recovery. The potential risks and benefits of surgery were thoroughly discussed. - The patient inquired about the recovery timeline and when he could return to playing football. He was advised that full return to contact sports typically takes 9-12 months, contingent on strict adherence to the rehabilitation protocol. He also asked about the success rate of the procedure, to which it was explained that ACL reconstruction with meniscal repair generally has a high success rate in restoring stability and function, but individual outcomes can vary. - Informed consent was obtained after a discussion of the nature of the treatment proposed, the nature of the condition, the treatment alternatives, the expected postoperative course, and material risks. The patient gave informed and signed consent for the discussed procedure. Kind regards,