A ligament is a strong fibrous tissue that attaches one bone to another.

The anterior and posterior cruciate ligaments form an “X” in the centre of the knee joint. The posterior cruciate ligament (PCL) being the larger of the 2 and situated behind the anterior cruciate ligament (ACL).

PCL- Looking from the Back of the Knee

What is the Function of the PCL?

The PCL resists backwards motion of the lower leg. Unlike the ACL, which is mainly functional during certain high risk athletic activities, the PCL is important and is functioning almost all the time even during simple walking.

How Does One Injure the PCL?

A PCL tear occur when a direct blow to the front of the knee or leg just below the knee (tibia) creates a large sudden force directed backwards. This puts a significant amount of stress on the PCL. The stress in the ligament is even higher when the knee is flexed (bent) closed to 90°. The posterior cruciate ligament then stretches to the point of mechanical failure which is considered a tear.

This can happen when someone is tackled in football below the knee from the front or when someone in any sport lands forcefully directly onto their knee with their knee simultaneously bent.

The PCL can also tear in this manner when in a head-on motor vehicle collision the vehicle’s dashboard strikes directly against the knee.

Sometimes the PCL can be stretched and subsequently torn by forceful hyperextension (bending backwards beyond straight) occurring to the athlete’s knee. This may occur when, in football, a player is hit on the legs just below the knee from the front and their knee hyperextends because their foot is firmly planted in the playing surface. This mechanism, especially when the knee twists during the injury, can lead to tearing of other important knee structures beyond simply the PCL.

What are the Symptoms of PCL Tear?

Signs and symptoms of a posterior cruciate ligament injury may include:

•     Mild to moderate pain in the knee
•     Rapid onset of knee swelling and tenderness (within three hours of the injury)
•     Pain with kneeling or squatting
•     A slight limp or difficulty walking
•     Feeling of instability or looseness in the knee, or the knee gives way during activities
•     Pain with running, slowing down, or walking up or down stairs or ramps
•     Sometimes the patient may have little or no complaints until much later

When Does It Become More Serious?

It is more serious when the PCL tear is associated with other knee ligament tears.  It can be combined with an ACL tear, medial collateral ligament (MCL) or more commonly a lateral collateral ligament (LCL) or posterolateral corner of the knee injuries.

These knees tend to be more unstable and problematic compared to an isolated mild PCL tear.

How to Diagnose PCL Tear?

The best way to diagnose a PCL tear is to examine the knee for posterior sag at 90 degrees of knee flexion with the patient lying on the examination couch. The loss of the usual medial tibial plateau anterior step-off will imply the presence of a posterior tibial sag from a PCL tear.

A posterior drawer test can also be done.

This is the left knee of a patient.  Notice that there is no posterior laxity on posterior drawer  test.

This is the right knee of the same patient.  Notice the posterior sag of the tibia on posterior drawer test.

This implied a PCL tear in this patient’s right knee.

What are the Useful Investigations?

A knee x-ray should be done. This is to exclude a bony avulsion of the PCL off the tibial bone insertion. This can be treated with open reduction and internal fixation using screws.

I find the stress views of the knee in the lateral position with the knee at 90 degrees of flexion useful. I will request that each knee be subjected to an anterior and posterior drawer at the time of the x-rays. The knee with the PCL tear will show increased posterior translation of the tibial with respect to the femur.

Note the increased posterior sag in the left knee compared to the right knee during posterior drawer test:

PCL Stress Lateral Views

How to Classify the Severity of PCL Tears?

A PCL tear can be classifed as either an isolated PCL tear, where only the PCL is injured, or as a combined ligament injury. A combined ligament injury would involve a tear of the PCL and at least one other injured ligament. A common example would be a PCL and lateral-sided ligament injury.

Injuries to the PCL can also be graded as I, II or III.

Grade I and II injuries are partial PCL tears. Grade I refers to only a few mm of sag of the tibia backwards while Grade II injuries refer to sagging of the tibia to the level flush with the end of the thigh bone (femur). This roughly corresponds to 1 cm of backwards sag.

A grade III injury signifies a complete rupture and the tibia sags backwards even further. It is likely that when a grade III injury occurs, there are other ligaments torn along with the PCL. It is important to scrutinize the type of PCL injury an athlete sustains because there are significant treatment implications, especially for a Grade III or combined ligament injury.

How to Decide on Treatment?

A partial PCL tear, grade I and II, are typically treated non-operatively with a long course of intensive physical therapy to strengthen the surrounding muscles controlling the knee.

Complete PCL tears often require surgical treatment to regain knee stability.

When the PCL pulls off a small piece of bone from the back of the lower leg (tibial avulsion), the PCL may be surgically repaired. If the bone fragment is large enough a screw can be place to secure the piece of avulsed bone back to where it was originally.

However in the majority of PCL injuries, the ligament tears in the middle of the structure. In this case, the PCL must be reconstructed which refers to replacing the entire ligament with what is known as a graft.

PCL Reconstruction

I perform both single bundle and double bundle PCL reconstructions.

My graft of choice can be either autogenous hamstrings or allografts (usually tibialis anterior tendons).

Example of a PCL Single Bundle Reconstruction using Hamstring Grafts

The hamstring grafts are harvested from the patient through a small 3cm oblique incison along the medial aspect of his proximal shin bone.

The hamstring grafts are then prepared as shown.

Preparing the Hamstring grafts

Stitching the Hamstring grafts

Grafts looped over endobutton and pre-tensioned

This is a video of the surgical procedure.

For more information on PCL injuries and the treatments, please contact us at 683 666 36 or email hcchang@ortho.com.sg

Do visit us at www.ortho.com.sg

A bony growth that appears at the back of the heel bone can occur. This growth is called an exostosis (a benign cartilaginous growth) and is known as Haglund’s deformity.

This bony prominence can rub against the overlying Achilles tendon and causes pain in the tendon.  A small sac (called bursa) that lies between the bone and the Achilles tendon usually becomes inflamed and swollen.  This is called retrocalcaneal bursitis.

Haglund's Bony Protruberance Causing Bursitis and Achilles Tendon Pain

The syndrome is caused by repetitive impingement of the bursa between the ventral aspect of the Achilles tendon and the posterosuperior calcaneal prominence. Typically, patients have pain when they start to walk after a period of rest.

Haglund’s deformity can occur in one or both feet. The signs and symptoms include:

•     A noticeable bump on the back of heel
•     Pain in the area where the Achilles tendon attaches to the heel.
•     Swelling in the back of the heel.
•     Redness near the inflamed tissue.

Haglund’s disease is characterized by pain and tenderness at the posterolateral aspect of the calcaneus where a  calcaneal prominence can be palpated. This entity also is known as ‘‘pump-bump.’’ A distinction between Haglund’s disease and other pathologic conditions, such as a superficial Achilles bursitis, must be made.

Haglund’s syndrome involves a painful swelling of an inflamed retrocalcaneal bursa, sometimes combined with insertional tendinopathy of the Achilles tendon.

What Causes This?

High arches (pes cavus) can contribute to Haglund’s deformity. The Achilles tendon attaches to the back of the heel bone, and in a person with high arches, the heel bone is tilted backward into the Achilles tendon. This causes the uppermost portion of the back of the heel bone to rub against the tendon. Eventually, due to this constant irritation, a bony protrusion develops and the bursa becomes inflamed. It is the inflamed bursa that produces the redness and swelling associated with Haglund’s deformity.

A tight Achilles tendon can also play a role in Haglund’s deformity, causing pain by compressing the tender and inflamed bursa. In contrast, a tendon that is more flexible results in less pressure against the painful bursa.

Another possible contributor to Haglund’s deformity is a tendency to walk on the outside of the heel (varus heel). This tendency, which produces wear on the outer edge of the sole of the shoe, causes the heel to rotate inward, resulting in a grinding of the heel bone against the tendon. The tendon protects itself by forming a bursa, which eventually becomes inflamed and tender.

This is a person who is an avid runner.  He has pain in both heels from Haglund’s deformity.   The right heel was operated on with an open technique.  The Haglund’s exostosis was removed surgically with improvement of his right heel pain.   His left heel was now giving him pain when running.

Diagnosis

There is usually pain in the Achilles tendon insertion into the calcaneus (heel bone) posteriorly.

The Achilles tendon can be thickened (swollen) and tight.

There is pain in the retrocalcaneal bursa (see the 1st picture in this article).

I usually check for high arch of the foot as well as look at the heel from the back with the patient standing to make sure that there is no heel varus (the heel points inwards when standing).  These physical signs usually point to poorer results with treatment.

An X-ray of the heel can be done to look for any Haglund’s exostosis or deformity.

An MRI scan can be done.  This is useful to diagnose Achilles tendinosis (which is related to the Haglund’s bump), swelling of the sac between the Haglund’s bump and  Achilles tendon (retrocalcaneal bursitis).

MRI of Haglund's with Retrocalcaneal Bursitis | HC Chang

Non-Surgical Treatment

Non-surgical treatment of Haglund’s deformity is aimed at reducing the inflammation of the bursa. While these approaches can resolve the bursitis, they will not shrink the bony protrusion. Non-surgical treatment can include one or more of the following:

•     Medication. Anti-inflammatory medications may help reduce the pain and inflammation. Some patients also find that a topical pain reliever, which is applied directly to the inflamed area, is beneficial.

•     Ice. To reduce swelling, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.

•     Exercises. Stretching exercises help relieve tension from the Achilles tendon. These exercises are especially important for the patient who has a tight heel cord.

•     Heel lifts. Patients with high arches may find that heel lifts placed inside the shoe decrease the pressure on the heel.

•     Heel pads. Placing pads inside the shoe cushions the heel and may help reduce irritation when walking.

•     Shoe modification. Wearing shoes that are backless or have soft backs will avoid or minimize irritation.

•     Physical therapy. Inflammation is sometimes reduced with certain forms of physical therapy, such as ultrasound therapy.

•     Orthotic devices. These custom arch supports are helpful because they control the motion in the foot, which can aggravate symptoms.

•     Immobilization. In some cases, casting may be necessary to reduce symptoms.

Surgical Treatment

If non-surgical treatment fails to provide adequate pain relief, surgery may be needed.

Operative treatment consists of removal of the inflamed bursa and resection of the bony prominence. This can be done by the traditional open surgical technique with a 3 to 4cm scar or a minimally invasive endoscopic technique using 2 small stab incisions.

I perform a minimally invasive procedure to remove the Haglund’s bony prominence. This procedure is called Endoscopic Calcaneoplasty.

Endoscopic Calcaneoplasty

The operation is performed under general or regional anesthesia with the patient in a prone position.

The patient is in a prone position. The opposite leg is held away from the surgical field.

I use the fluoroscope (x-rays) to localise the position of the Haglund’s exostosis.

Fluroscopic Localisation of Haglund's

A small vertical incision is made through the skin at the level of the superior aspect of the calcaneus. The  retrocalcaneal space is penetrated by a blunt trocar. A 4.5-mm arthroscope is introduced into the retrocalcaneal space.

Dr HC Chang perforrming Endoscopic Calcaneoplasty

Under direct vision a spinal needle is introduced just medial to the Achilles tendon, again at the level of the superior aspect of the calcaneus, to locate the medial portal. After making a vertical stab incision, the 3.5-mm full radius
resector is placed and visualized by the arthroscope. The inflamed retrocalcaneal bursa is removed to provide a better view.

The superior surface of the calcaneus is visualized, and its fibrous layer and periosteum is stripped off using a radiofrequency wand.

Using radiofrequency wand to clear soft tissue

The Haglund’s exostosis is exposed.

Haglund's exostosis with foot in neutral position

When the foot is brought into full dorsiflexion, the impingement site is determined.

Haglund's exostosis impinging the Achilles tendon with foot in dorsiflexion

A 4.0mm hooded arthroscopic burr is used to remove the Haglund’s exostosis. All of the time the opening of the burr is facing the bone. The foot is placed in full plantarflexion and the posterior superior bone rim can be removed.

Burring away the Haglund's exostosis

Upon completion of the procedure, the exostosis should be flattened and the insertion of the Achilles tendon into the heel bone should be clearly seen.

Completion of Removal of Haglund's exostosis

View from lateral portal showing the Achilles tendon insertion

An intra-operative fluroscopy (x-rays) is taken to confirm complete removal of the Haglund’s protruberance.

Pre and Post Endoscopic Calcaneoplasty

This is the surgical scar after skin closure:

Surgical Wounds in Endoscopic Calcaneoplasty

Post-Surgical Recovery

The patient is allowed to walk with the help of crutches and avoid bearing weight in his operated foot for the next 3 weeks.

The operated foot should be elevated for at least 3 to 5 days.

The surgical wound should heal in 14 days after surgery and the stitches are removed.

The patient can start putting more weight on the operated foot from 3rd week onwards.

He can resume running in 3 months’ time.

The success rate of this procedure has been quoted to be 90%.

For more information on the treatment of heel pain, please contact us at +65-683 666 36 or email hcchang@ortho.com.sg

Do visit our website at www.ortho.com.sg

What Is Mucoid Degeneration of the ACL?

This is basically an MRI diagnosis of expansion and increased signal of an intact ACL in a person with knee pain which is worse on knee flexion/bending.

Presentation

Patients usually present with nonspecific posterior knee pain with restriction of flexion. There is usually no restriction of knee extension, no complaints of instability, no major trauma episode preceding the symptoms. It affects people of all age group but more commonly in the middle-aged patients, between 35 and 52 years old.

Mucoid Degeneration of ACL

What is the Cause?

The cause of mucoid degeneration of the ACL remains unknown. Two theories are generally accepted. One theory is that this lesion may simply represent a continuum of senescent degeneration (aging) of the ligament. I do not really subscribe to this theory as there have been reports of such cases in young people as well.  The second theory considers that congenitally displaced synovial tissue maybe the cause of cystic lesions within mucinous degeneration.  The truth is no one really knows why or how it occurs.

The lesion may look like an elongated cyst along the long axis of the ACL, or as an enlarged ACL. Discrete intraosseous ganglia are observed in 3/4 of the cases with mucoid degeneration of the ACL. These ganglia consist of myxoid material.

The MR-findings of mucoid degeneration of the ACL include:

• an ill-defined ACL
• an increased ligamentous girth
• a normal orientation of the ligament and an increased signal intensity on all sequences interspersed among visible intact ACL fibers (“celery stalk” appearance).

What is the Treatment?

Arthroscopic surgery is a great option to allow partial excision of the degenerate lesions of the ACL resulting in immediate pain relief and improvement of the range of motion without any symptoms of instability. The significant pain relief is being attributed to the decreased volume and tension in the ACL.

Mucoid degeneration of the ACL should be considered when an apparently thickened and ill-defined ACL with increased signal intensity on all sequences is identified in a patient with a clinically intact ACL.

Any Other Problems?

There has been reports of secondary instability of the knee after this surgery as the anterior cruciate ligament can be weakened to the state that it ruptures or is no longer functional.

There is also a risk of recurrence of the mucoid degeneration over time.

For more information, please contact us at +65-683 666 36 or email hcchang@ortho.com.sg

Do visit us at www.ortho.com.sg

The medial meniscus or inner shock absorber of the knee has attachment in the front (anterior horn) and the back (posterior horn).

The posterior horn or root can tear as a result of degeneration or trauma.

This typical presentation include:

1. Sudden onset of severe  knee pain.
2. Does not improve with pain killers.
3. May be associated with a sudden “pop” when walking followed by the onset of pain.
4. Typically in people older than 55.
5. Knee swelling within the next 1 day.
6. Pain is felt at the back of the knee.
7. Pain on bending the knee or squatting. Most patients cannot squat due to this pain.

The physical examination may show some swelling in the knee joint. Typically these knees already have some pre-existing degeneration or osteoarthritis.

There is usually pain on pressing of the inner and posterior aspect of the joint line of the knee.  The patient may not be able to squat down.

X-rays may show some osteoarthritis which was probably pre-existing.

MRI scan may sometimes show a root tear.  One need to actively look for a posterior horn root tear on MRI scan if this diagnosis is suspected.

This is a video showing a 59 year old woman who has pre-existing mild knee pain which suddenly worsened severely about 2 weeks ago.  She does not remember any trauma or injury.  She does Yoga as a form of exercise.

She was not able to walk properly due to pain in her right knee.

There was some fluid in her right knee on examination.  Tenderness (pain) was found along the posteromedial aspect of her right knee.

X-rays showed mild osteoarthritic changes.

MRI scan showed a possible posterior horn root tear.

Posterior Horn Medial Meniscus Root Tear

Arthroscopy of her right knee was done.  It showed an incomplete tear of the posterior root of the medial meniscus. The tear was cleaned up with an arthroscopic shaver and the posterior horn was the medial meniscus was secured to the capsule using a Fast-Fix meniscus repair device.

The patient’s right knee pain improved significantly after this surgery.  She was able to walk the very next day.

For more information on knee pain and meniscus tears, please contact us at 683 666 36 or email hcchang@ortho.com.sg

Do visit our website at www.ortho.com.sg

A SLAP tear is a cause of shoulder pain.

The the long head of your biceps tendon goes inside the shoulder joint and  joins with the glenoid labrum (shoulder cartilage) in the top of the shoulder.

A SLAP tear refers to a tear or avulsion of this attachment of the long head of biceps tendon’s anchorage into the upper portion of the glenoid labrum.

SLAP tear stands for Superior Labrum Anterior Posterior lesion.

Common reasons for a SLAP tear include:

1. Fall onto an outstretched hand
2. Repetitive overhead actions (throwing)
3. Lifting a heavy object

Symptoms of a SLAP tear may include:

1. Painful popping, clicking, or catching in the shoulder.
2. Pain when you move your arm over your head or reach back.
3. Pain when you throw a ball.
4. An ache often described as being deep inside the shoulder.

4 different types of SLAP tears have been described.  The commonest type that I see and treat is the Type 2 tear.

This is an arthroscopic picture of a Type 2 SLAP tear:

The symptoms of a SLAP tear include:

1. Painful popping, clicking, or catching in the shoulder.
2. Pain when you move your arm over your head or reach for the back.
3. Pain when you throw a ball.
4. An ache often described as being deep inside the shoulder (often difficult to pin-point).

Diagnosis of SLAP tear includes:

• Clinical examination.  I have found the O’Brien’s test to be useful in my clinical practice. This is a picture of how this test is done:

• MRI scan can usually show the tear.

SLAP tears rarely heal well without surgery in my experience.  The treatment is arthroscopic (keyhole) surgery to the shoulder to repair the tear back to the glenoid attachment.

This picture shows a type 2 SLAP tear being examined during arthroscopy of the right shoulder.

This is a picture of the SLAP tear after it has been surgically repaired through key-hole surgery.

For more information on SLAP tear of the shoulder or if you need advice on shoulder pain problems, please contact Dr HC Chang at 683-666-36 or email hcchang@ortho.com.sg

Do visit our website at www.ortho.com.sg

PVNS Knee

What is PVNS?

Pigmented villonodular synovitis (called PVNS for short) is a joint problem that usually affects the knee. It can also occur in the shoulder, ankle, elbow, hip, hand or foot.

When you have PVNS, the lining of a joint becomes swollen and grows. This growth harms the bone around the joint. The lining also makes extra fluid that can cause swelling and make the joint hurt.

Who Gets PVNS?

PVNS is not common. It usually affects people 20 to 45 years old, but it can also occur in children and people over 65 years old. Both men and women can suffer from this problem.

We do not know what causes PVNS. Some people with PVNS remember that they hurt their joint at some time in the past.

For unknown reasons, some or all of the synovial lining tissue of a joint occasionally undergoes a change and becomes diseased, wherein the joint lining tissue becomes thick and overgrown and accumulates a rust-colored, iron pigment known as hemosiderin. Strange, foamy cells and large (so-called “giant”) cells with many nuclei also appear. The overgrowth of the joint lining tissue can occur diffusely throughout a joint by way of a generalized thickening of the entire lining membrane, or a localised area of synovial membrane can overgrow and form a discrete nodule (tissue mass) that remains attached to the rest of the internal joint lining by way of a stalk. While this disease process does involve abnormal tissue growth, it is uniformly benign and has not been known to metastasize as do malignant growths. PVNS can be considered a benign, “neoplastic” (tumor growth) process, with some varieties being more aggressive in their growth and thus harder to treat, and other varieties being less aggressive in their growth and thus easier to treat.

What Are the Symptoms?

The common symptoms are swelling of the affected joint. As the knee joint is the most commonly affected joint in PVNS, the person may have swelling of the knee joint.

Swollen knee from PVNS

It can also cause pain due to erosion of the articular cartilage of the joint by the locally aggressive tumour.

pvns knee x-ray with erosion of patella

Sometimes the person with PVNS may present with acute swelling and pain in the knee. There may be a history of pain after getting up from a squatting position. The knee joint may become locked due to the tumour blocking knee extension.

How t0 Diagnose PVNS?

PVNS can look like arthritis and some other conditions.

After a physical exam, x-rays of the joint that hurts may be useful.

Soft tissue swelling seen on X-rays

Your doctor may also want to draw some fluid from the joint and test it.

pvns knee aspirate

Another test, magnetic resonance imaging (also called MRI), takes a “picture” of the joint.

Note the Nodular Tumours in front and behind the knee

What is the Treatment?

The best way to treat PVNS is to remove the lining of the joint. This can be done with regular surgery (sometimes called “open” surgery) or with arthroscopy. In arthroscopy, the doctor makes a tiny cut in the skin over your joint. Then a thin tube is put into the joint to remove the lining.

Even with treatment, PVNS comes back about half of the time. If the pain comes back again and again, radiation therapy may help. Sometimes, the joint may need to be replaced.

This is a video of a patient who presented with acute knee locking (inability to straighten the knee) after getting up from a squatting position. MRI showed nodular PVNS in the right knee.

Arthroscopic resection of the PVNS tumour together with thorough arthroscopic synovectomy was performed.

This is the picture of the tumours that were removed:

PVNS Tumours removed from the Knee

Summary

Treatment of PVNS is surgical excision.

For more information on PVNS, please contact us at 683 666 36 or email hcchang@ortho.com.sg

Visit us at www.ortho.com.sg

It can affect someone who does a lot of free-style swimming, tennis serves, badminton smashes etc.

The best x-rays to diagnose the bony spur include the AP and Supraspinatus outlet view.

This is an AP view of a right shoulder with shoulder impingement syndrome:

Anteroinferior Acromial Spur of the Shoulder

This is the Supraspinatus outlet view X-ray of a right shoulder showing a large bony spur. This is a typical Bigliani type 3 acromion with a hook.

Subacromial Impingement by Type 3 Spur

A high degree of suspicion for rotator cuff tendon tear should be borne in mind if the patient has a lot of rest pain, night pain or weakness of the affected shoulder.

This is the MRI scan of the right shoulder of this patient with shoulder impingement syndrome. 

The MRI shows a full thickness tear of the supraspinatus tendon. 

Full thickness Tear of Supraspinatus Cuff Tendon

In those with rotator cuff tendon tear of a longer duration, the muscle belly may undergo disuse atrophy (wasting).

This MRI shows the supraspinatus muscle atrophy.

Supraspinatus Muscle Atrophy

The treatment for this patient will include:

1. Arthroscopic removal of the bony spur i.e. arthroscopic subacromial decompression.
2. Arthroscopic repair of the shoulder tendon.

For more information on shoulder pain, please contact us at 683 666 36 or email us at hcchang@ortho.com.sg

Do visit our website at www.ortho.com.sg

Platelet-Rich Plasma (PRP) therapy is an innovative treatment that uses the body’s own cells to relieve pain and promote accelerated, long-lasting healing of certain musculoskeletal conditions.
Type of Injuries where PRP Can Help

Although PRP therapy has been used safely in dentistry for over twenty years, recent
advancements have revolutionized the field of orthopedic sports medicine throughout
North America and Europe. By using the body’s own blood cells, PRP therapy naturally
stimulates and accelerates soft tissue healing and regeneration in certain soft tissue
injuries and conditions, including:

1. Osteoarthritis of the knee, shoulder, hip and spine
2. Rotator cuff tears
3. Anterior cruciate ligament (ACL) injuries
4. Tennis elbow
5. Ankle sprains
6. Tendonitis
7. Ligament sprains
8. Chronic plantar fasciitis

The body’s first response to any soft tissue injury is to deliver platelets, which play an
instrumental role in the normal healing process by secreting growth factors and
attracting stem cells–critical components of the healing cascade.

PRP therapy magnifies the body’s own healing and reparative efforts by delivering a much higher concentration of platelets through a single injection than the body would otherwise produce. This higher concentration of platelets helps accelerate the healing of tendons and ligaments, which translates to a quicker recovery for the occasional athlete as well as for the professional one.
Persons who develop tendonitis from everyday activities have also benefited from this technique.
Preliminary studies have demonstrated that PRP therapy is associated with a reduction in pain and faster healing, and has decreased risks and costs as compared to surgical alternatives. In addition, because a patient’s own blood is used, there is no risk of a transmissible infection and a very low risk of allergic reaction.
How PRP works
PRP injections are brief outpatient procedures that involve obtaining a small sample of
your blood, which is drawn similar to a lab test sample.

We use the REGENLab’s system.

The blood is then spun at high speeds in a centrifuge, which separates the desired platelets from the other blood
components.

The concentrated platelet-rich plasma is then injected into and around the site of injury, which appears to jumpstart the body’s instincts to repair muscle, bone and other tissue.

The entire procedure, including preparation and recovery time, takes approximately 30 minutes. Most patients can expect to return to their jobs or usual activities right after the procedure, although some patients do report increased pain in the treatment area over the following week due to the accelerated healing process.

Panadol can be taken to minimize or eliminate this discomfort. We discourage the use of nonsteroidal anti-inflammatory medications (NSAIDs), such as aspirin, ibuprofen-containing products, as they may adversely affect the treatment outcome.

Up to three injections may be administered within a 6-month period, and the injections
are typically performed two to three weeks apart. However, significant or even complete relief may be achieved after the first or second injection.

Currently, many insurance companies do not cover PRP Therapy, as it is still
considered by most to be “experimental”; however, researchers are optimistic that larger
studies of its use in the treatment of joints, spine, bones and tendons will convince
insurance companies to pay for this treatment.

In fact, many physicians and researchers believe that PRP Therapy may become part of the standard treatment protocol for many musculoskeletal conditions before surgical treatment is warranted.

What Are the Evidences?

Treatment of chronic elbow tendinosis with buffered platelet-rich plasma.
Mishra A, Pavelko T.  Am J Sports Med. 2006 Nov;34(11):1774-8.

This is the first study supporting the use of PRP for chronic tendon problems.  93% reduction in pain at average 2 year follow up.

Treatment of tendon and muscle using platelet-rich plasma.  Mishra A, Woodall J Jr, Vieira A.Treatment of Tendon and Muscle  Clin Sports Med. 2009 Jan;28(1):113-25.

This is a review article that includes basic science, animal and human data including a reference to Dr. Gosens’ work showing PRP improves patient pain and function when compared to cortisone in a 100 patient double-blind prospective randomized trial.

Platelet-rich plasma enhances the initial mobilization of circulation-derived cells for tendon healing.
Kajikawa Y, Morihara T, Sakamoto H, Matsuda K, Oshima Y, Yoshida A, Nagae M, Arai Y, Kawata M, Kubo T.   J Cell Physiol. 2008 Jun;215(3):837-45.

This study confirms PRP can help attract cells that contribute to a healing process in a tendon.

Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices.
Sánchez M, Anitua E, Azofra J, Andía I, Padilla S, Mujika I. Am J Sports Med. 2007 Feb;35(2):245-51.

This study showed PRP may accelerate healing from Achilles Tendon repair surgery.

Can platelet-rich plasma enhance tendon repair? A cell culture study.
de Mos M, van der Windt AE, Jahr H, van Schie HT, Weinans H, Verhaar JA, van Osch GJ. Am J Sports Med. 2008 Jun;36(6):1171-8.

This study confirms PRP enhances tenocyte proliferation and collagen production.

Cellular effects of platelet rich plasma: a study on HL-60 macrophage-like cells.  Woodall J Jr, Tucci M, Mishra A, Benghuzzi H.  Biomed Sci Instrum. 2007;43:266-71

This study found PRP initially inhibits the inflammatory Macrophage cell.  This helps explain why PRP may be useful for tissue healing.

Any Level I Evidence? (Level I evidence is the most reliable evidence in Scientific studies)

Level One Two Year Follow Up Paper Supports Use of Platelet Rich Plasma for Tennis Elbow

Dr. Taco Gosens and his team from the Netherlands have just published in the American Journal of Sports Medicine the best paper to date on the use of PRP for tennis elbow.  Using the Biomet GPS device to create platelet rich plasma (Type 1A PRP in Mishra’s classification system of PRP), they found PRP patients were successfully treated more often than patients treated with corticosteroid injections at two year follow up.  This was highly statistically significant at a p value of < 0.0001.

This paper confirms that a specific type of PRP is better than the often used cortisone injection for chronic lateral epicondylar tendinopathy.  This team of researchers also needs to be congratulated on finishing this important work.

For more information on PRP therapy, please contact us at 683 666 36 or email hcchang@ortho.com.sg

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One possible diagnosis to keep in mind is that of calcium crystal deposition into the tendons of the shoulder.  We doctors call it “Calcific tendonitis of the Shoulder“.

The pain is commonly described as severe, sharp in nature and disturbs sleep.

Painter first described calcification in the shoulder in 1907. Codman established that the calcification was within the tendons of the rotator cuff. Calcifying tendinitis of the shoulder is characterized by the presence of macroscopic deposits of hydroxyapatite (a crystalline calcium phosphate) in any tendon of the rotator cuff.

How To Make The Correct Diagnosis?

The best way to make a diagnosis is to order some radiological tests.

A plain x-ray of the shoulder joint can show calcification of the tendons around the shoulder.

An ultrasound scan can also show calcium deposits in the rotator cuff tendon.

MRI scan when used to look for other problems in the shoulder, e.g. tendon tears, can also show the calcium deposits inside the tendons.

Calcific tendonitis of the Subscapularis tendon (arrow)

Why Is Calcium Deposited There?

Calcific tendonitis is due  to a build-up of calcium in the rotator cuff tendons, and is often aggravated by an existing condition, such as Impingement or overuse tendonitis in the shoulder.

The cause of this condition is UNKNOWN.  It usually occurs in people aged 30 to 40 years, and can occur in both shoulders in about 15% of people.

When calcium builds up in the area, pain results from acute inflammation.  Calcium is deposited in the rotator cuff, between the humerus and acromion inhibiting the normal, friction-free movement of the joint. Impingement or tendonitis, which reduce the mobility of the joint leads to degenerative change and Calcium deposition.

Why Does It Cause Pain?

When calcium builds up in the tendon, it can cause a build up of pressure in the tendon, as well causing a chemical irritation. This leads to pain. The pain can be extremely intense. It is one of the worst pains in the shoulder and can be very acute in it’s presentation.

The calcium in the tendon makes the tendon swollen and this reduces the space between the rotator cuff and the acromion, as well as affecting the normal function of the rotator cuff. This can lead to impingement of the subacromial space between the acromion and the calcium deposit in the rotator cuff when lifting the arm overhead.

Three Stages of this Condition has been Described

• Precalcification Stage
  Patients usually do not have any symptoms in this stage. At this point in time, the site where the calcifications tend to develop undergo cellular changes that predispose the tissues to developing calcium deposits.
• Calcific Stage
  During this stage, the calcium is excreted from cells and then coalesces into calcium deposits. When seen, the calcium looks chalky, it is not a solid piece of bone. Once the calcification has formed, a so-called resting phase begins, this is not a painful period and may last a varied length of time. After the resting phase, a resorptive phase begins–this is the most painful phase of calcific tendonitis. During this resorptive phase, the calcium deposit looks something like toothpaste. 
• Postcalcific Stage
  This is usually a painless stage as the calcium deposit disappears and is replaced by more normal appearing rotator cuff tendon.

In over 90 percent of cases, the deposits disappear spontaneously,  but this may take 12 to 18 months.

What is the Treatment?

Treatment of calcific tendinitis involves:

1.        Painkillers and anti-inflammatory medications

2.        Physiotherapy – keeps your shoulder muscles strong and flexible and reduce the irritation

3.        Cortisone steroid injections – reduces inflammation and control the pain

4.        Ultrasound guided aspiration of calcium – this can only work if the calcium is not solid yet

5.        Arthroscopic excision – removal of the calcium from the tendon using keyhole surgery

This is a video which explains what this condition is and how it is treated arthroscopically.  Credits to Dr Terry Hammond for the excellent educational video:

For more information on shoulder pain and treatment, please call us at +65-683 666 36 or email us at hcchang@ortho.com.sg

Do visit us at www.ortho.com.sg

The indications, contraindications and biopsy of the cartilage were previously discussed. You can click on this link to read the article. Click Here.

In this article, I will explain how the cultured cartilage cells are implanted into the knee cartilage defect.

A small cut is made in the knee to allow access into the knee joint so as to expose the cartilage defect.

A small ring curette is used to debride the cartilage defect in order to expose the subchondral bone and to achieve a vertical stable cartilage rim.

Full Thickness Cartilage Defect of the Knee

Next, a sterile aluminium foil is used to template the size of the cartilage defect.

Using a scissors, the template is cut to the size of the defect.

This is next placed onto the MACI cartilage implant and the cartilage implant is cut according to the size of the aluminium foil template.

The MACI implant which has been cut to the size of the cartilage defect is then glued onto the defect using tissel glue.

The final product is as shown:

After Implantation of the Cartilage Cells | HC Chang

The wound is closed up and the knee is braced from 0 to 30 degrees.

The patient needs to follow a strict rehabilitation protocol.

For more information on cartilage repair and use of MACI technique for cartilage injuries, please contact us at +65-683 666 36 or email hcchang@ortho.com.sg

Do visit our website at www.ortho.com.sg