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Web Dr. Lisandro Carbo, especialista en Artroposcopia y Prótesis de Rodilla Doctor specializing in Arthroscopy and Knee Prosthesis Areas of Expertise Total knee arthroplasty Robotic surgery Meniscal injuries

Practice Locations SG Medical Office Tel: +54 911 6645 2564 Avda. Coronel Díaz 2760 PB ¨B¨ CABA Reception Hours Monday 10am - 12pm Thursday 11am-3pm Italian Hospital of Buenos Aires Tel: +54 11 4959 0200 int: 8267 (leave voicemail) Potosí 4247 ¨PB¨ CABA Contact

Revision Total Knee Replacement (TKR) HeRTR Revision surgery is a highly specialized operation to replace worn, loose, infected or failed primary (first time) implants, and in extreme cases, up to multiple revision total knee replacements. Dr. Lisandro Carbó has extensive experience and a special interest in the field of complex revision surgery, and is a regular guest speaker at national and international medical conferences on topics related to surgical techniques and strategies. He has specialized in revision knee replacement surgical techniques, and works closely with radiologists specializing in the musculoskeletal system and orthopedic microbiologists for the treatment of this very complex condition. He also gained experience in reconstructive surgery of the knee and extremities in important treatment centers such as the Endo-Klinik in Hamburg, Germany (a world-renowned center for knee revisions for mechanical failure and infections). Typical symptoms of a “worn out” RTR are pain, edema, mechanical weakness, and discomfort when getting up from a chair or starting to walk. X-rays are used to see how the primary implant is failing, often as a result of wear of the polyethylene (artificial plastic joint surface), surgical detachment of the knee replacement, or infection of the original joint. In difficult cases, additional blood tests, scans and sometimes computed tomography (CT) will be used to plan the surgery in detail before the procedure. Each case is different but, in general, larger knee prostheses (implants) are used with additional stems (to reconstruct the joint and improve ligamentous instability) and other innovative elements such as the use of transplants with bone or ligament grafts from cadaveric donors to massive bone loss; It is also extremely useful to use porous trabecular metal augmentations or femoral and tibial metaphyseal fixation cones to replace bone defects, which guarantee that the prosthesis is completely “fixed” or cemented with good potential for long-term use. After knee revision surgery, recovery is a little slower than in primary surgery since the intervention can affect soft tissues, muscle and bone more. However, the benefits for the patient will be significant as they improve pain, edema, and mechanical stability of the knee. Surgeons use different designs and types of implants depending on the individual circumstances of each case, and for Dr. Carbó it is important to describe the expectations and specific process that each patient must follow prior to surgery.

Partial knee arthroplasty (Unicompartmental) The knee joint is formed by the union of three bones: the femur (thigh bone), the tibia (leg bone), and the kneecap. The knee has three main compartments: the medial compartment (located internally), the lateral compartment (located externally), and the anterior or patellofemoral compartment (between the kneecap and the femur). When two or more compartments of the knee are severely compromised, total knee replacement (TKR) surgery uses implants that are placed in the bones of the knee. There are patients who will only have one of these three compartments, usually the medial compartment. In the latter there is an arthroplasty that reconstructs only the internal compartment (partial knee arthroplasty). The entire replaced knee may feel strange or feel heavy and not move like the original knee. This can lead to patient dissatisfaction and decreased “quality of life” post-surgery. Recently, innovative changes in the understanding of the biomechanics and function of the knee joint, coupled with novel advances in the design of surgical implants, allow surgeons to replace only the parts of the knee affected by the wear process. By replacing only the damaged parts, and leaving the unaffected parts intact, we hope to achieve a more natural and functional feel in the knees undergoing partial resurfacing arthroplasty, which will allow the patient to participate more actively in recreational activities, while treating arthritis and improving pain and edema. This allows the healthy parts of the knee and native ligaments to work normally, achieving more natural movement and sensation in the knee undergoing partial resurfacing.

Robotic surgery Therobot-assisted knee arthroplasty It is an innovative approach in the field of orthopedic surgery. It is used to treat patients with severe knee problems, such as advanced arthritis or joint damage. In this procedure, the damaged knee joint is replaced with an artificial prosthesis. The distinguishing feature is the collaboration between the surgeon and a highly advanced robotic system. This method begins with 3D images of the patient's knee, allowing for highly personalized surgical planning. During surgery, the robot assists the surgeon in real time, guiding and improving precision in the placement of the prosthesis. This can result in benefits such as more precise alignment of the prosthesis, smaller incisions, and potentially faster recovery. Key advantages of robotic-assisted knee arthroplasty include: Improved Accuracy: Robots can achieve a millimeter level of precision, improving prosthetic alignment and therefore long-term function of the knee. Personalization: 3D image-based planning allows for a personalized surgical approach, tailored to the patient's specific needs. Minimal Invasion: The robot's precision may allow for smaller incisions, decreasing damage to surrounding tissues and potentially speeding recovery. Improved Results: Precise placement of the prosthesis can lead to increased durability of the artificial joint and improved knee function. Surgeon-Robot Collaboration: Although the robot assists in the surgery, the surgeon's experience and judgment remain essential to the success of the procedure. In summary, robotic-assisted knee arthroplasty represents an exciting advancement in orthopedic surgery, improving precision and outcomes for patients in need of a new knee joint. Ver más

Meniscal Injury A meniscal injury is an injury that affects the menisci, which are two "C"-shaped structures located in the knee, which act as shock absorbers and stabilizers between the femur (thigh bone) and tibia (leg bone). . These injuries can occur due to sharp turns or sudden movements of the knee, and are common in athletes and people who engage in intense physical activities. Meniscal degenerative injuries are also very common, meaning they occur due to the use of the knee over the years. Injuries may occur to the internal meniscus (most frequently), the external meniscus, or both. And they may be associated with other concomitant injuries such as injury to the anterior cruciate ligament or collateral ligaments. Symptoms of a meniscal injury can vary depending on the severity of the injury, but generally include: Pain in the knee, especially when performing specific movements. Swelling and tenderness in the knee. Feeling of locking of the knee. Difficulty bending or straightening the affected leg completely. Diagnosis of a meniscal injury usually involves a specific physical examination along with evaluation of the patient's medical history and symptoms. In addition, imaging studies, such as MRIs or x-rays, may be performed to confirm the presence of the injury, evaluate its severity and therapeutic possibilities. Treatment for a meniscal injury may vary depending on the severity of the injury and the patient's activity. Treatment options include: Rest and physical therapy: For minor injuries, rest and physical therapy may be enough to reduce pain and improve knee function. Medications: Pain relievers and nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed to relieve pain and reduce inflammation. Infiltrations: In some cases, corticosteroid injections may be given into the knee to reduce inflammation and pain. Surgery: For more serious injuries or if conservative treatments are not effective, arthroscopic surgery may be necessary to repair or remove part of the injured meniscus. Recovery after a meniscal injury can take several weeks, depending on the severity of the injury and the type of treatment received. Patients typically undergo a rehabilitation program after surgery to regain knee strength and function. It is important to follow the recommendations of the medical team after surgery and the physical therapist during the recovery process to ensure a successful recovery and prevent future meniscal injuries.

knee arthroscopy Arthroscopy is a minimally invasive procedure that allows the surgeon to look at the joint surfaces (smooth articular cartilage), menisci (“sports” or “shock absorber” cartilage), and the main ligaments of the knee (cruciate), and treat and debride (smoothe ) damaged structures. Before surgery you will meet with Dr. Carbó to discuss the operation and listen to and answer any questions that may arise. You will receive a detailed description of the operation based on your symptoms and the results of the images, you will sign the consent for the operation, and the knee to be operated on will be marked. During surgery, digital photographs are taken that will help explain the intraoperative findings and the intervention performed. You will receive a copy of it for your personal medical history. For arthroscopy, a camera is inserted through 2 or 3 very small incisions. The operation is performed under general anesthesia. This is normally an outpatient procedure lasting between 20 and 30 minutes, although occasionally an overnight stay may be recommended, especially if the surgery includes any additional procedures (for example microfracture of seriously damaged cartilage). This surgical technique allows us to treat the following pathologies: Synovial tissue resection Osteochondral lesions, such as detachment of circumscribed lesions or removal of free intra-articular fragments Meniscal injuries, either partial meniscectomies (that is, only the damaged region of the meniscus is removed) or meniscal sutures. Ligament injuries, such as anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) reconstruction.

Patellofemoral replacement Resurfacing surgery replaces areas of damaged or osteoarthritic cartilage on the back of the kneecap and the corresponding groove in the thigh bone with which it articulates (femoral trochlea). A substantial proportion of the Argentine population is born with alterations in the alignment of the patella as a result of an inherited “design” difference and its patellofemoral tracking is deficient. This condition runs in families and its result is the early development of patellofemoral arthritis in the 3rd and 4th decades of life – while the rest of the joint remains unscathed by wear and tear. Patients typically complain of “pain” in the front of the knee behind the kneecap, crepitus or “noisy” joints, and problems going up and down stairs, kneeling, knee stiffness when sitting, driving, and standing. squatting. Edema usually appears in the knee in relation to physical activity and in the final stages of the condition, the pain begins to wake the patient at night, causing a marked reduction in the levels of sports activity and daily life. Dr. Lisandro Carbó is a specialist in knee surgery, and is trained not to touch the uninjured areas of the knee and only approach the patellofemoral joint with surface arthroplasty. This partial resurfacing arthroplasty is performed under general anesthesia using a minimally invasive surgical technique and allows for a much faster return to activity, with a short hospital stay and less pain than traditional total knee replacement techniques. The benefit of partial knee arthroplasty means that more “natural” joint and ligament structures are retained and patients report that the knee “feels normal” with the added benefit of a significant reduction in pain.

cartilage transplant Healthy (hyaline) articular cartilage is essential for proper knee function, allowing virtually frictionless movement. Articular cartilage is capable of absorbing tensions and forces equivalent to up to 8 times body weight. Articular cartilage defects have very little self-repair potential because the cartilage contains very few “living” cells and blood flow is relatively poor. Even a small defect in the articular cartilage of the knee can generate considerable pain, blockage, edema and other symptoms that limit activity and often precipitate degenerative osteoarthritis (DO). Traditional surgical techniques that aim to fill the articular cartilage defect (such as microfractures or debridement) only form scar tissue (fibrocartilage) whose structure is different from that of the original hyaline articular cartilage. Fibrocartilage is much less resistant to large mechanical stresses in the knee than the original hyaline (articular) cartilage and is usually destroyed within 3 years, causing greater damage to the joint, precipitating the onset of degenerative osteoarthritis of the knee, and the need for an earlier knee arthroplasty. Cartilage transplantation or autologous chondrocyte implantation (ICA) has been developed to fill such traumatic defects with durable and stable hyaline-like cartilage instead of scar tissue (fibrocartilage). In this way, the possibility of much superior clinical results with reduced pain and greater longevity of the knee is offered. Brittberg in 1994 initially described the ICA technique, in which through arthroscopy (minimally invasive surgery) a small biopsy of live cartilage is obtained from the edge of the knee. The few thousand chondrocytes (live cartilage cells) contained in the biopsy are cultured and multiplied (usually between 4 and 8 million live cells are obtained) to be used as a replacement in the knee in a second mini-incision operation, under a synthetic patch (absorbable collagen) that is sutured and glued to the cartilage defect, creating a waterproof seal over the transplanted living cartilage cells that, over 6 – 12 months, produce new cartilage in the knee. Currently there are commercial systems with which transplants can be performed with larger grafts. Current therapeutic options to treat this problem include: Debridement . It consists of the extraction of unstable chondral fragments, osteophytes, excess synovial membrane, degenerated menisci and torn ligaments. Although debridement has been found to provide relief of pain and improvement of symptoms, symptoms can be expected to return over time.[1] . Current research has shown that the best candidates for debridement and lavage are those who suffer from mechanical symptoms (a catching or locking sensation when trying to bend or straighten the knee), which may be caused by a meniscus tear or loose body.[2] . Perforations (Microfractures) : Through arthroscopy, perforations are made in the chondral defect in order to release biological modulators into the microenvironment that stimulate the generation of fibrocartilage. Abrasion: The goal is to debride the boundaries of the articular cartilage defect to support a uniformly contoured edge of fresh collagen, capable of adhering to a fibrin clot. The subchondral bone then breaks and allows blood to perfuse for the formation of a fibrin clot. Autologous osteochondral transplant (Mosaicoplasty - OATS): It is a procedure in which the arthroscope is used. Cylinders of 5 to 12mm in diameter and 15 to 20mm in length are used, which are taken from areas that do not receive load from the joints to treat small and medium-sized defects. Osteochondral transplant with bank graft (Alogenic): Cadaveric graft is used. This technique exposes the cartilage defect through a small arthrotomy that places a “plug” of osteochondral allograft around the contour of the defect. It is indicated in medium and large cartilage defects. Autologous chondrocyte implantation: It is distinguished by using bioengineering techniques to create hyaline cartilage tissue, such as autologous chondrocyte implantation (ICA) or mesenchymal stem cell implantation (MSC). To date, there are few clinical reports in humans on these implants, but no significant results have been found when comparing them with ICA.

Osteotomy Osteotomy aims to restore the correct mechanical or offloading alignment of the knee, as well as its natural structure. It is used to treat symptoms such as pain, inflammation and instability caused by cartilage wear due to poor alignment of the limb. It is generally used in younger patients and athletes, considered too young for a total or partial knee replacement. It is a surgery which allows the surgeon to precisely plan the amount of correction to be applied through detailed preoperative radiographs (XRs) of the leg, from hip to ankle, in standing position. These x-rays allow you to plan the operation on the computer in great detail and predict the outcome of the surgery in advance. The surgeon plans precise surgical correction of the proximal tibia (shin) or occasionally, the distal femur (thigh bone), depending on the specific problem and preoperative natural alignment. During the procedure, using a saw, the surgeon makes a small surgical cut in the bone (osteotomy) at the precise location and angle, allowing it to be moved before fixing it in the chosen position with locking plates and state-of-the-art titanium screws. . During the first 6 postoperative weeks, the patient can do partial unloading as the bone begins to heal and the leg recovers from surgery. The result of the surgery and the best alignment achieved are evaluated radiographically at regular intervals over the following 6 months. By improving mechanical or unloading alignment, the surgeon aims to improve pain, edema and instability, and delay the appearance of degenerative osteoarthritis by protecting the remaining or repaired cartilage of the knee.

Total knee replacement TKR continues to be a surgical solution that provides excellent quality of life in the treatment of a joint severely affected by degenerative osteoarthritis (wear of the articular cartilage) or inflammatory rheumatoid arthritis. It is generally used when other less invasive procedures do not relieve symptoms of pain, inflammation, or mechanical locking of the knee. Total knee replacement will only be recommended when appropriate pain medications, activity modification, and other surgical solutions (such as injections) have not satisfactorily relieved symptoms. Prosthetic designs and technology applied to surgery Building on recent research into normal knee motion, teams of engineers and surgeons have designed knee prostheses that allow for more biomechanically physiological motion. Among these are prosthesesmedial pivot or designs that use an insertultracongruent or anterior stabilized . Both are used in most joint replacement centers around the world, with excellent survival rates (greater than 15 years) and patient satisfaction. Technological advancement brings with it new tools (such as artificial intelligence and augmented reality) so that the surgeon can obtain data within the surgery and make the latter much more precise. This is how the use of computerized systems that assist in surgery increases year after year. Currently at the Italian Hospital of Buenos Aires, Dr Carbó uses the equipment called ROSA (Zimmer Biomet), from its acronym “Robotic Surgical Assistant” to perform joint replacement surgeries.