Ankle aci patient handout aug 2011

POSTOPERATIVE PHYSIOTHERAPY ADVICE FOLLOWING CARTILAGE CELL IMPLANTATION OF THE ANKLE A patient’s guide

The Foot and Ankle unit at the Royal National Orthopaedic Hospital is made up of a multi-disciplinary team. The team consists of three specialised orthopaedic foot and ankle consultant surgeons (Mr Singh, Mr Cullen and Mr Goldberg), specialist doctors in training, a physician assistant, a clinical nurse specialist, orthotists, physiotherapists and occupational therapists. All team members are specialised in foot and ankle care and work together to provide and deliver a quality service.

Introduction Cartilage is the ‘coating’ covering the end of a bone. It allows smooth, friction-free movement and protects the bone underneath.

Cartilage can be damaged as a result of trauma or abnormal wear. This area of damage, called a defect, can be treated by a surgical technique called autologous chondrocyte implantation (ACI) or matrix-assisted ACI (MACI).

In both cases patients will usually have failed to respond to an initial arthroscopic debridement. This is because cartilage transplantation techniques are invasive and expensive and are only currently used as part of formalised audit or a clinical trial.

The operation The operation is a two-stage procedure. First, keyhole surgery is performed to look at the defect. Cartilage cells are taken either from the defect itself, or from a healthy area in the knee or ankle. The cartilage cells are then treated in a laboratory for 3-4 weeks where they multiply.

A second operation is performed several weeks later. The technique(s) used will vary depending on the location and size of the defect. The cartilage cells are placed into the defect, either by fixing a patch over the defect and injecting the cells underneath (ACI), by growing the cells on a membrane in the laboratory and fixing this directly over the defect (MACI) or by mixing the cells with fibrin glue and injecting them straight into the defect (Chondron).

In some cases the second operation is keyhole, but in many cases it is difficult to gain access to the joint and instead a controlled ‘break’ in the ankle bone called an osteotomy is used.

This is then held in place with screws or a plate.

The cells should eventually produce a form of cartilage very similar to the original cartilage. It can take several years until the cells fully mature.

Expected outcome The expected outcome following ACI surgery is: • • • • •

Improved function / mobility Decreased pain Decreased joint clicking/locking Return to full sporting activity Full recovery may take at least twelve months

Before the operation (pre-operatively) Before the operation, you will see a nurse to check you are medically well enough for surgery. It is important to mention any medicines that you are taking, either prescribed or non-prescribed, including over the counter medications, herbal remedies or aspirin, warfarin, hormone replacement therapy (HRT), the contraceptive pill or medication for high blood pressure.

Prior to admission for your surgery there are a number of issues that need to be considered; for example can someone help you carry out basic every day tasks such as prepare and shop for food? If you have stairs, how will you get up and down them? Do you have sturdy hand rails? If your toilet is downstairs, would it be easier to have your bed downstairs until you have sufficiently recovered to be able to safely negotiate the stairs?

The preadmission nurse will discuss these with you and if they have any concerns about you coping at home after your operation, they may refer you to a physiotherapist and/or an occupational therapist. The therapist will telephone you to discuss your needs and it may be necessary to attend for a more in-depth assessment. This will ensure that we plan for your discharge home safely and shorten your stay in hospital.

What to bring with you?

Please ensure that you have a flat sturdy shoe to wear on the un-operated foot following surgery.

If you use a walking stick or crutches please ensure you bring these with you too.

What to expect after the operation (post-operatively) When you arrive back on the ward from theatre your leg will be in a plaster cast from knee to toe. You will need to make sure that you do not get the plaster wet.

It is important that you keep your leg up for at least 55 minutes in every hour for the first 3 days after your operation. This helps to decrease swelling. It is then important that you continue to do this regularly over the next few weeks/months depending on how much swelling you have.

Walking If you have had an osteotomy you will be ‘non weight-bearing’ (putting no weight through the leg at all) for six weeks. You will be taught how to use a walking aid (e.g. crutches) to help keep the weight off your leg.

If you have had keyhole surgery you will be ‘non weight-bearing’ for two weeks. You will then be given an Aircast boot and will be allowed to ‘partially weight-bear (put approximately 50% of your weight through the leg). You will be taught how to use a walking aid (e.g. crutches) to do this.

After this time you will be allowed to put full weight through the leg, depending upon your pain, swelling and muscle control. Your physiotherapist will advise you when your muscles are strong enough for you to do this and stop using your walking aid.

Plaster of Paris / cast Immediately after the operation your ankle will be in a Plaster of Paris back slab for two weeks. This will then be exchanged for either a lightweight removable cast or an Aircast boot depending on your surgery. You will be able to take this cast off three times a day to do exercises as taught to you by your physiotherapist. Otherwise you should wear the cast at all times. You will be told exactly when to stop wearing the cast or boot but you will have to wear it for a minimum of six weeks.

Stairs Your will be taught how to go up and down stairs with your walking aid by a physiotherapist before you are discharged home. As you are not allowed to take any weight through the operated leg initially you will have to hop up and down the stairs. This can be quite difficult. If the physiotherapist feels it is unsafe for you to do the stairs you may have to sleep downstairs initially.

Depending on your surgery there may be some other restrictions in the first eight to twelve weeks. If so, these will be explained to you in detail.

You will usually remain in hospital for approximately 1-2 days after your operation.

Outpatient Review You will be seen regularly by the doctors and clinical nurse specialist in the foot and ankle clinic.

You will be usually start physiotherapy two to three weeks following your surgery, in order to reduce swelling, encourage movement and regain strength, balance and function.

Physiotherapy is an essential part of your treatment. Without this you have a higher risk of the surgery failing. You can choose to have your physiotherapy at RNOH or your local hospital.

Exercises to do once your Plaster of Paris is exchanged for a removable cast / boot You will be able to remove your cast or boot to do the following exercises:

Lying on your back or sitting.

Gently bend and straighten your ankles.

Repeat 20 times, three times per day.

Lying on your back with your legs straight.

Push your knees down firmly against the bed. Hold 5 secs – relax.

Repeat 20 times, three times per day.

Lying on your back with your legs straight.

Squeeze your bottom muscles. Hold 5 secs – relax.

Repeat 20 times, three times per day.

It is important that you carry out these exercises regularly every day to regain movement in your ankle and maintain the strength in your hips and knees.

Things to look out for •

Swelling – You should expect some swelling after your operation. You can help manage swelling by resting with your foot up. If swelling persists or worsens and you are concerned, seek advice from a member of the Foot and Ankle team or from your GP.

•

Infection – Any operation is at risk of infection. Fortunately it is not common in this type of surgery but a small number of patients do get a wound infection and these normally settle after a short course of antibiotics. In rare circumstances the infection may be more severe and require further surgery to remove infected tissue and administer a longer course of antibiotics.

• Blood clots - Deep vein thrombosis (DVT) or Pulmonary Embolus (PE) are rare but can occur. Please inform the team if you have had a DVT or PE in the past or if you have a family history of clotting disorders. You will be given an anti embolic stocking to wear on your other leg and blood thinning injections while your leg is in plaster.

•

Numbness or tingling - This can occur at the surgical site(s) if fine, hair-like nerves are cut or more major nerves are stretched. This is normally temporary; however patchy numbness or sensitised areas may be permanent. In rare circumstances the nerves can become hypersensitive, in a condition called Complex Regional Pain Syndrome. This can lead to severe pain as well as colour and temperature changes in the foot. If this happens your Consultant will discuss treatment with you.

•

Wound healing - If blood supply to the area is not so good, wounds may be slow to heal.

If this is the case more frequent wound dressings may be required to ensure that the wound does not become infected. This is usually organised by the Foot and Ankle Clinical Nurse Specialist but may be possible at your GP surgery.

•

Scarring - Any type of surgery will leave a scar. Occasionally this can cause pain and irritation. If this happens please discuss this with your Consultant. Some people are prone worse scarring than others. Please inform the team if you have had a previous scar that has been described as a ‘keloid’ or ‘hypertrophic’ scar.

REPORT SEVERE PAIN, MASSIVE SWELLING, CHEST PAIN, EXCESSIVE NUMBNESS OR PINS AND NEEDLES TO YOUR GP OR TO US AS SOON AS POSSIBLE

General Advice Please note exercises should be pain-free. If your ankle hurts or swells excessively then you may have done too much.

If you have followed the above advice and your symptoms are not resolving/are getting worse then seek medical attention from your GP or go to your local A&E if it is an emergency.

If you have any queries about your physiotherapy you can contact your local physiotherapist or our physiotherapy department at RNOH on 0208 909 5820.

Royal National Orthopaedic Hospital Trust, Brockley Hill, Stanmore.

Middlesex.

HA7 4LP Telephone:

020 8909 5152

foot.ankle@rnoh.nhs.uk

This document was produced by R.N.O.H .Foot and Ankle Team Surgeons: Mr Singh, Mr Cullen and Mr Goldberg.

Clinical Nurse Specialist: Karen Alligan Physiotherapists: Joanna Benfield and Emma Stewart Published : August 2011 Review date: August 2013