Operative Orthopaedics
EBOT - European Board for Orthopaedics and Traumatology - Board Certified
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Arthroscopic cartilage and bone debridement
is a surgical technique used to clean bone and cartilage damage before it has completely disappeared.
Free joint bodies
removal of free articular bodies, in some patients parts of cartilage or bone with cartilage separate from their bed and float in the joint. Over time, they can get caught between the articular bodies and cause additional damage. They can be removed with an arthroscopic approach.
Osteochondritis dissecans - avascular necrosis
is a sharply delimited area of bone below the articular cartilage that has remained without circulation.
The living cells that make up the bones disappear, and only the mineral structure of the bone remains. Without living cells, the bone becomes too soft to bear the load. Depending on the degree of the disease (estimated by Magnetic Resonance Imaging analysis), treatment can be conservative by walking with forearm crutches and Physical therapy. Over a period of time, circulation and living cells in the bone are restored and healing occurs. In the case of a higher degree of the disease, the damaged bone begins to separate from the healthy one. In this case, it is possible to clean the bone bed of the scar with an arthroscopic operation, to introduce new circulation using the technique of drilling holes in the bone, and to attach the diseased bone and its cartilage to the healthy bone with special bioresorbable nails. In the final stage, the articular cartilage is damaged, and the bone and cartilage like a plug can slip out of the socket and become a free joint body. Then it is necessary to remove the free articular body, and in the bed where it used to be, drill the bone so called microfractures procedure. In this way, the bone marrow from the surrounding bone fills the bed, and over time turns into a scar that looks like healthy cartilage. Its composition is a combination of cartilage and scar tissue.
osteochondritis dissecans ankle - magnetic resonance imaging
cartilage damage in osteochondritis dissecans of the ankle
arthroscopically debrided cartilage damage
microfracture procedure of the subchondral bone
Microfracture procedure
are a surgical technique by which bone marrow is brought to the area of damage by drilling the bone with special instruments in a limited area with complete lack of cartilage. In this way, the bone marrow from the surrounding bone fills the bed, and over time turns into a scar that looks like healthy cartilage. Its composition is a combination of cartilage and scar tissue.
Anterior / posterior impingement of the ankle - impingement syndrome
Problems with anterior or posterior ankle impingement syndrome - impingement syndrome occur when, due to congenital or subsequent protrusions on the edges of the ankle joint, during maximum dorsal or plantar flexion (extreme movements in the joint), there is an impingement between these parts of the bone. Pain appears, initially only in those extreme movements, later also at rest. The diagnosis is confirmed by an X-ray in the extreme movements of the joint, where the contact between the two bones is visible. Magnetic resonance images also show soft tissue contact (cartilage, articular sockets), which is not visible on X-ray. The treatment is arthroscopic removal of the parts of the bone on both sides of the joint. The operation is performed through two 1 cm incisions. The patient goes home the same day. Recovery is very fast since the cause of the pain has been removed.
Anterior ankle impingement and arthrosis X-ray
Posterior ankle impingement X-ray
Ligament reconstructions after rupture - ankle instability
In orthopedic examination after an ankle and foot injury, we first analyze the mechanism of the injury based on the information provided by the patient, after which we make a working diagnosis by carefully testing all possible damages (not only those that are visible at first glance). Confirmation of this diagnosis is followed by ultrasound, X-ray or MR imaging, depending on the need. A common ankle sprain injury is not adequately diagnosed or treated. The doctor should describe all the tests he performed, and in this way serious injuries would be avoided. For example rupture of the Achilles tendon, pain, and swelling are presented with a similar mechanism of injury and appearance on examination. But if the doctor does not examine the tendon in detail, the injury may be overlooked. Most often, however, it is about injuries to the ligaments that are the stabilizers of the ankle joint. These are the anterior talofibular ligament, calcaneofibular, anterior syndesmosis and deltoid ligament. Each of them can be injured alone or in combination with another. Each should be separately tested and described in the findings. In ankle sprains, the anterior talofibular ligament is often stretched. It is manifested by pain, while other tests are negative.
It can be associated with stretching of the anterior syndesmosis (the ligament that holds both lower leg bones together, the so-called articular fork). With diagnostic imaging, we can find associated injuries to the bone or other elements of the joint. Such a sprain of the first degree is treated by immobilization. A second-degree injury is characterized by a partial rupture of the ligament. The diagnosis is made by US or MR imaging. The treatment is also conservative with immobilization. Regardless of the treatment, up to 20% of patients have complaints up to a year after the injury. The third degree is often not diagnosed in time. What can mislead the patient is that in the case of a complete rupture of the ligament, the pain lasts less than in the first two stages. The reason for this is that there is no more painful stretching of the ligament. With a careful examination, the doctor will notice instability in the joint. If the joint is unstable, walking is difficult and the frequency of repeating the same injuries is high. An unstable joint leads to damage to the joint cartilage. Arthroscopic non-anatomical reconstruction is recommended as the first operation. This means that instead of the torn ligament, surrounding tissues are used to stabilize the joint. If the doctor judges that the instability is great or the previous operation did not give an adequate result, an anatomical reconstruction of the ligaments will be performed. This means that one tendon (out of three) of the muscles of the back of the thigh, as a graft (new ligament), will be placed exactly at the place of the injured ligament. Such a ligament is attached to the bone with special screws and anchors.
Arthrodesis (fusion) of the joint in advanced arthrosis
although all the weight of the body is transferred over this relatively small joint compared to the knee and hip, complete damage to the cartilage (arthrosis) is rare. In the case where the cartilage has completely disappeared and the pain prevents movement, it is possible to achieve pain-free walking by surgically immobilizing the joint. The operation is performed arthroscopically, where the remaining damaged cartilage is cleaned through several small incisions, the tibia and ankle bones are prepared so that they come into contact and can heal together over time. Everything is attached with up to 3 screws. The stiff joint becomes painless, and if the operation is done in time, the numerous remaining joints of the foot will gradually take over the function and enable orderly walking. Walking in high heels is also possible.
Achilles tendon rupture
is an injury that comes without notice. Patients usually never have any previous complaints or pain. Regardless, the injury occurs on the basis of long-term microdamages. During sports activities, the patient feels severe pain, and it is often heard that something has broken. He usually thinks he got hit by a teammate. It cannot continue the activity. But sometimes can move foot because of remaining small plantar muscle/ tendon Swelling occurs very quickly. What can deceive the patient is the rapid cessation of pain, and sometimes they do not decide to seek medical help. On the other hand, with a careless examination, it is possible to overlook the injury and mistake it for a sprained ankle. After a certain time, the pain disappears completely, but the patient notices that it is difficult to walk and that he cannot stand on his toes. With surgical treatment, it is possible to restore the function of the tendon in both cases. However, with late-recognized ruptures, surgical treatment can be more complex with possible postoperative complications. In the end, function is always restored, except that the treatment may be longer.
Haglund's heel
even though all heels in people are similar, they are not the same. Some people have a square upper end of the heel bone as opposed to a rounded one. The Achilles tendon attaches in the lower third of the heel bone. In people with a square end of the heel bone, the sharp edge of the bone protrudes and scrapes the tendon. This creates inflammation and pain and the possibility of tendon rupture. On the skin of the back of the heel, there are visible bumps, redness and soreness on pressure. Women who wear high heels usually do not have any problems because in this position the tendon moves away from the bone. Most often, patients with complaints are men, especially athletes. It is possible to remove the bony protrusion through a mini incision or arthroscopically. In the case of severe damage to the tendon, it is necessary to examine the tendon using a mini-open approach, remove the diseased parts, and strengthen the tendon with particularly strong stitches that are attached to the heel bone with special anchors. They can be made of metal (titanium) or of bioresorbable materials (they dissolve over time).
Tendinopathy
long-term microdamages to the tendons of the foot or ankle lead to degeneration. This means that the tendon tissue has been replaced by a scar. Occasionally, scar tissue is replaced by calcification. Often this scar is filled with nerves and this is the reason for the pain. Since there is no inflammation, conservative treatment often has no effect. One can always try PRP treatment. If the symptoms persist, it is necessary to surgically remove the cause of the pain. It is possible to perform the operation using an endoscope or a mini incision.
Heel spur - plantar fascitis
the longitudinal arch of the foot is held in tension by the plantar fascia, which is a type of ligament that extends from the heel bone to the toes. Over the course of life, this longitudinal arch may drop and the plantar fascia stretches where it attaches to the heel bone. The inflammation of that grip is painful. Over time, the tension of the fascia can pull out a part of the bone, which is then called the heel spur. It is visible on the lateral X-ray, while in reality it looks like a duck's beak when viewed from above. So it's not a thorn that pricks something, but a painful inflammation of the fascia. Treatment is mostly conservative. High-quality orthopedic insoles raise the longitudinal arch, and Physical therapy treatment reduces inflammation. It is also possible to give long-acting anti-inflammatory injections or treatment with PRP. A common mistake is to start treatment with Physical therapy without addressing the cause, which is a lowered transverse arch of the foot.
Flat feet of children and adults
all young children have an apparently lowered longitudinal arch of the foot when looking at the imprint. The arch actually exists, but due to the abundant fat pad on the foot, it is not visible. Later the pad shrinks and the arch becomes noticeable. If the child has a lowered arch, it forms when raised on the toes. Then it is about the so-called flexible flat arch of the foot. It is often associated with the displacement of the heel bone outwards, the so-called valgus. The foot position is corrected with adequate orthopedic insoles. However, not all children have flat feet, nor do they all need orthopedic insoles. The key is a good orthopedic examination of the whole child, not just the feet. It is necessary to examine all bones and joints, the spine as well as the length of the leg, which, if different, can be corrected with insoles. Examining only the feet and taking different types of imprint (indigo paper, impression sponge, plaster cast, computerized board) does not provide this important information.
Morton's neuroma
a normal foot has a longitudinal and a transverse arch. Walking on flat surfaces in footwear that restricts movement can cause the transverse arch to drop. This means that the three middle bones that continue into the toes will come into contact with the ground when walking, and body weight will be transferred through them. The nerves that continue to the fingers pass under that arch, under and between the bones. In a normal foot, they are never pressed. With a lowered arch of the foot, the nerves can be pressed between the bones and the substrate. Most often it happens in the area on the foot above the 3rd and 4th toes. The reason for this is the natural thickening of the junction of the two nerves. First, you can try to raise the transverse arch with adequate orthopedic insoles. If the complaints are still present, that part of the nerve is surgically removed. In the beginning, the patient feels reduced sensation between the 3rd and 4th toes, while later the patient does not notice a difference in sensation compared to the pre-surgery situation.
MR - Morton's neurina between the 3rd and 4th metatarsal bones
Metatarsalgia - pain in the front part of the foot
During normal walking, the body weight transfer mostly goes through the heel, then the first joint between the big toe and the rest of the foot (1st metatarsophalangeal joint) and finally through such a joint from the little toe (5th metatarsophalangeal joint). Between the heel and the first joint there is a longitudinal arch, and between the first and fifth there is a transverse arch. As a result of walking on flat ground, the weakening of the muscles and ligaments of the foot gradually leads to a lowering of the transverse arch. At the same time, there is atrophy (disappearance) of the fatty tissue pads under the bones of the front part of the foot as well as the skin. Then calluses appear. Most often under the head of the 2nd metatarsal bone, especially in people with the Greek type of foot (second toe longer than the big toe). Over time, these calluses can start to hurt. Sometimes pain in the front part of the foot occurs without visible calluses. Treatment is initially conservative. Adequate orthopedic insoles will raise the lowered transverse arch of the foot. After that, various physical therapy procedures can reduce the pain. If there is no satisfactory reduction of pain after conservative treatment, surgical treatment should be applied. most often it is a shortening of the 2nd metatarsal bone. The goal of the operation is to equalize the length of the 1st and 2nd metatarsal bones (bones in the continuation of the big toe and the second toe). Immediately after the operation, the patient can walk in a postoperative shoe with support only on the heel and with forearm crutches.
Ankle and foot bone fractures (Jones fracture, avulsion of the base of the 5th metatarsal bone...)
Most nondisplaced fractures can be treated conservatively with immobilization. And yet such treatment is not without consequences. Namely, during immobilization, only the broken bone heals, while other elements of the joint, cartilage, tendons, muscles weaken due to lack of use. Rehabilitation occurs only after the repair of the fracture and after removing the immobilization. Sometimes such rehabilitation is extremely long. Unlike surgical treatment, when rehabilitation begins on the first post-operative day.
An example of such a fracture is the so-called Jones reception of the fifth metatarsal bone. Most often occurs in athletes who run a lot. It is about the so-called stress fracture or fatigue fracture in which the bone breaks after undergoing a certain number of bending cycles without the damage from previous training having been repaired. Such fractures are treated conservatively for an extremely long time with an uncertain result. In this case, it is better to stabilize the fragments with a screw. Stress fractures take a long time to heal since the bone is not only damaged at the fracture site but in the wider area around it. This area can be seen on the magnetic resonance imaging as bone edema.
a bone fracture close to the surface of the skin is visible on ultrasound
Jones fracture - osteosynthesis with screw and plate X-ray
Fibular malleolus fracture
Osteosynthesis of fibular malleolus fracture with plate and screws, transfixation screw
Sudek's dystrophy - Complex Regional Pain Syndrome
In rare patients who are treated conservatively or surgically for an ankle injury (sprain, fracture), the initial pain caused by the injury does not stop during and after the treatment. Aggravation is also possible. The pain is present even after the repair of the damage (ligaments and bones healed in normal time). In this case, the doctor must suspect the development of Sudek's dystrophy (the older name), i.e. regional pain syndrome. The disease is not reserved only for the ankles, but can occur on other parts of the body, for example the wrist and hand. X-ray diagnostics as well as ultrasound do not show any change. Until the use of Magnetic Resonance Imaging, which shows patchy diffuse edema of the bone, the diagnosis was rarely made, which confused patients, doctors and employers. Although the disease goes through several stages, there are generally no visible changes on the outside of the ankle and foot. Treatment is long-term Physical therapy with adequate analgesia. High doses of vitamin C are also mentioned. It is a brain disorder in which the brain behaves as if the damage (trauma) has just occurred, but in reality it was significantly earlier and all the damage has already been repaired.
