Operative Orthopaedics
EBOT - European Board for Orthopaedics and Traumatology - Board Certified
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Meniscectomy
meniscus (plural menisci) is a special type of cartilage in the knee. There are two, one on the outside and one on the inside of the knee. They are shaped like the letter C (that is, a mirror image). The articular cartilage of the knee is not completely flat, and these unevennesses are leveled by the menisci and enable most of the body weight to be transferred over them, and not directly cartilage to cartilage. Most often, during a rotation movement in which the knee is flexed, followed by knee extension, the meniscus is pinched between the cartilages of the femur and tibia, and can rupture. Depending on the location of the injury, it can sometimes heal on its own. But if the symptoms last longer than a month after the injury, there is little chance. After the orthopedic examination, we orient ourselves on the possibility and location of the meniscus injury. Definitive confirmation of the working diagnosis is a high-quality Magnetic Resonance Imaging. In a small number of cases, a torn meniscus can heal itself so that it remains as it was before the injury. However, in most cases, the damaged part is removed using a camera through two small skin incisions. The goal is to preserve the greater part of the meniscus, since we know its essential role in the knee joint.
In cases where a large part of the meniscus has to be removed or even the entire one, in younger people there is a possibility of implanting an artificial meniscus or transplanting a meniscus from a donor.
normal meniscus
torn meniscus
arthroscopically removed part of the torn meniscus
Cartilage debridement and microfractures procedure
cartilaginous damage can be caused by a single trauma, frequent microtraumas or for an unknown reason (arthrosis). Seen under a microscope, cartilage is made of several layers. Each layer has its role. When the first layer that is in contact with joint fluid in the joint is damaged, other layers become visible. In these other layers, cartilage elements are organized in different directions. Most often, during operations, we see damaged cartilage that looks like grass, that is, like crab meat. Those threads that protrude into the joint, when moving, are caught between the joint bodies and constantly get further damaged. With a motorized instrument and a special electric instrument, it is possible to smooth out the unevenness of the cartilage and thus slow down the damage. In the extreme case, when the cartilage is missing completely on a smaller part of the joint, using the microfracture technique, it is possible to fill the existing defect with a special type of scar similar to cartilage. It is the same color and looks like real cartilage. A microscopic image shows the difference. It is a combination of cartilage and so-called scar tissue. fibrocartilage. With such a technique, holes are drilled in the bone with special chisels, and in this way the bone marrow located under the bone enters the defect. Bone marrow looks like thick blood. Over time, it fills the cartilage defect, which is visible on the control Magnetic Resonance Image.
Removal of free articular 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.
Synoviectomy
is a procedure by which part or all of the soft inner joint sheath is removed, which secretes joint fluid, which in turn lubricates and nourishes the cartilage. It is often part of every arthroscopy. There are situations when it is necessary to completely remove it. All this is possible through several 1 cm arthroscopic incisions.
Reconstruction of ligaments; - anterior and posterior cruciated ligament
the sports requirements of professional and recreational athletes are increasing today, the surface on which to train and play as well as sports shoes enable the athlete to change direction quickly and with minimal slippage (sometimes there is no slippage at all). The strong force generated by the athlete's muscles during such movements can damage the weakest part of the joint, namely the ligaments. Most often it is the anterior cruciate ligament. It is the main stabilizer of the knee. It enables the knee to be stable in all joint positions. In case of injury, most people have a subjective feeling and/or an objective finding of knee instability. This is especially evident in sports when the muscle forces in the joint are stronger than during normal walking. The reason for surgical reconstruction of this ligament is to stabilize the knee, which prevents unusual movements of the joint during activities that do not occur in a healthy knee. Such movements can damage the elements of the joint that are not yet damaged, eg. menisci, cartilage, other ligaments. Nowadays, most often by using one (out of three) tendons of the posterior thigh muscle, we anatomically reconstruct the ligament. This means that we place the tendon exactly where the ligament was damaged. We fix such a graft in the bone with different methods of attachment. The hospital stay is one day. Some operators recommend wearing a knee joint orthosis for a month, which protects the graft, and walking on forearm crutches 1.5 months after the operation. Postoperative rehabilitation begins immediately. Straight running is possible after 3 months, and return to contact professional sports is 6 to 9 months. The reason for the long rehabilitation is the so-called ligamentization. It is a process by which tendon tissue is gradually replaced by ligament tissue. During that time ligament is too weak to withstand intense professional sport activity.
Patellar instability (Yamamoto procedure, MPFL reconstruction, corrective osteotomy of the tibial tuberosity - Fulkerson)
although all knees are similar they are not the same. In fact, they can be quite different in the design of their elements, which can sometimes be reflected in the function. Then joint function is not ideal or it can be even bad. With the use of such a joint, injuries occur more and more often, even with minimal movements. Cartilage and menisci are damaged. With a careful inspection, we orientate ourselves on the elements that are not normal. It can be just one, several or even all of them. After analyzing special standing X-ray images of the lower extremities and Magnetic Resonance Images, we analyze each element in detail. We decide then to correct one, seeral or even all elements of the joint with surgery. In the simple case of the first dislocation of the patella, an MR scan is mandatory. The reason for this is often cartilage damage in one or two typical places. It is not possible to see this with an X-ray.
If the cartilage is damaged, it should be repaired. Or the damaged part must be removed. If, on the other hand, a part of the damaged cartilage is still attached to a part of the bone, then the fragment can be fixed in place with resorptive nails. Dislocations regularly tear or lengthen the MPFL-medial patellofemoral ligament. It is the main ligament that prevents dislocation in a normal knee. Of course, in the whole situation, the most important thing is to find the main reason for the injury and to assess the possibility of the injury occurring again. If we estimate that the risk of re-injury is small, we shorten the damaged ligament and reinforce it with stitches, the so-called operation according to Yamamoto. The operation is performed through the joint with an arthroscope so that no incisions are visible on the skin. Such operations are most often performed in childhood or puberty. Later or after multiple dislocations alone or in combination with other operations, MPFL reconstruction is performed. Using one (out of three) tendons of the muscles of the back of the upper leg, the damaged ligament is reconstructed. The graft is attached to the patella and femur at its natural attachment using bioresorbable screws.
Treatment of 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 weight. Depending on the degree of the disease (assessed by analysis of Magnetic Resonance Images), treatment can be conservative. Relief can achieved 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 can slip out of the socket like a plug and become a free articular body. Then it is necessary to remove the free articular body, and in the bed where it used to be, drill the so-called bone. microfractures. 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. If a significantly larger area of the bone is affected, the disease is called avascular necrosis. In the initial stage (assessed by Magnetic Resonance), the treatment is conservative, while in case of failure of conservative treatment, surgery will bring success. Occasionally, the progression of bone damage and associated cartilage is rapid, and the final treatment is total knee replacement.
Stabilization of unstable cartilage with resorbable pins
In the case when only part of the cartilage is separated from the bone, then it is not possible to reattach that cartilage to the suchondral bone. If a part of the bone has separated along with the cartilage, then it is possible to attach the separated part with special nails that dissolve over time, so they do not need to be removed after the bone and cartilage have healed in their place.
Corrective femur and tibia osteotomies
A normal knee in a standing position has the appearance of the letter X. The arms of this letter should not be at a large angle (there is normal), just as the knee should not have the shape of the letter O. In cases where the deformity is visible and accentuated, due to the improper distribution of the pressure of the body weight in in the knee, there is a stronger use of the outer or inner part of the knee (instead on both). While the opposite part of the knee almost completely does not participate in weight transfer. For this reason, damage and faster wearing of the cartilage of the pressed side occurs over time. In case the cartilage is damaged but still exists, it is possible to move the so-called the center of gravity (axis of the middle of the joint) to normal or even a little on the healthy side. In this way, we slow down further damage to the joint. Apart from patients with complaints and damaged cartilage, some patients do not want to have heavily accentuated X or O knees. This is the domain of aesthetic orthopedics and at the same time it is the prevention of certain future cartilage damage.
The problem can be solved in the lower part of the femur, the upper part of the lower leg or less often at both levels. Everything depends on the place where the deformity originated and whether the problem can be solved with one procedure. Most often the so-called opening osteotomy, an operation in which the bone is cut almost to the end at a precise location. Then a special plate with a wedge is inserted into the opening. The size of that wedge corresponds to the degree of axle correction, i.e. the center of gravity shift. The plate is attached to the bone with screws. Followed by rehabilitation and walking with forearm crutches for 1.5 months.
condition after corrective lower leg osteotomy in varus - O - knee
Total and partial knee replacement (patellofemoral and femorotibial)
The knee is a complex joint. Although it is one, we can imagine it as three joints connected to each other. Damage can be found only in one part, two or in all three. When the entire knee is damaged (cartilage), meaning two or all three elements, today we recommend a total knee replacement. In this operation, instead of the damaged cartilage, metal coverings are installed on the upper and lower leg bones, and a special type of plastic is inserted in between to replace the cartilage. The prosthesis is attached to the bones with bone cement, which increases the contact surface between the bone and the prosthesis 300 times. The advantage of such prostheses is that the patient can walk with full weight bearing on the leg the next day. Crutches are only for balance. On the third day, our patients usually walk up the stairs, and on the fourth day, the patient goes to the Rehab center for inpatient rehabilitation or at home for outpatient treatment. Different types of prostheses from different manufacturers enable different degrees of knee flexion. There are prostheses that enable kneeling with full flexion.
About 120 degrees of flexion is required for normal functioning, walking on a level surface, up and down stairs, and sitting down and getting up from a chair.
Jumper's knee
there are places in the human body where extremely large muscle forces are directed via tendons (ligaments) to a relatively small bone surface. In these tendons there are places with a slightly smaller supply of blood vessels than in the rest of the tendon. In people who intensively use such strong muscles, there may be damage to the that place on the tendon. Inflammation occurs acutely. The role of inflammation is to repair damage. Repair can be with the same tissue as a tendon or with scar tissue. Often the inflammatory phase passes without symptoms, especially in top athletes. With long-term frequent microtraumas, the body gives up on inflammation and repair. Degeneration follows. It is the replacement of the original tendon tissue with scar tissue that is often filled with nerve endings that are the cause of pain. Since there is no more inflammation, anti-inflammatory drugs and anti-inflammatory Physical therapy procedures have no effect. So, in case of failure of repeated administration of anti-inflammatory drugs by injection, it is possible to continue treatment with PRP, tendo PRP, and stem cells. In the event that a newly formed blood vessel (neovascularization) is found in the painful area of the tendon by Doppler ultrasound examination, the treatment will most likely be surgical. In this operation, under the control of the arthroscope, all damage (degeneration) visible on the tendon is removed. Regardless of the type of treatment, 30% of top athletes give up that level of activity 3 years after diagnosis.
Mb. Osgood-Schlatter
in children's bones there is a special cartilage called the growth zone from which the child's bone grows in length. These zones are visible on X-ray images. After puberty they are no longer present. In children who play intensive sports where running and jumping is predominate, such a growth zone on the upper part of the lower leg bone can be damaged at the where the patellar ligament attachment , which is the end of the strongest muscle of the upper leg. That growth zone is extremely thin at that point and is susceptible to injuries from strong pulling forces of the muscles. The most common cause of injury is excessive tension of strong muscles. Children's bones grow faster than muscles, and in children who play sports, such strong muscles pull on a relatively weak growth zone. If the condition lasts longer, typical protrusions may appear on it. They are later painless, but sometimes they can start to hurt again. The condition is treated with regular and frequent stretching of the upper leg muscles, physical rehabilitation procedures to reduce inflammation and pain, and possibly given PRP.
Rarely there is possibility of operative treatment.
Fractures of the patella, the lower part of the femur, the upper part of the lower leg
For osteosynthesis, low-profile implants and screws are used whose heads do not protrude above the plate surface. Such screws have the ability to lock into the plate itself, which achieves exceptional structural stability. On the lower extremities, the osteosynthetic material must be removed after the bone has healed.
Osteochondroma - tumor-like lesion (benign)
Occasionally, in childhood or later, patients notice a painless growth under the muscles above the level of the knee. Tumor - like formation grows gradually like a child. After puberty, the formation generally stops growing. Discomfort can occur due to pressure on the muscle or the surface. An X-ray image confirms the diagnosis, and magnetic resonance imaging shows the formation in its entirety better because the X-ray image does not show the cartilage cap. So formation is larger than seen on the X-ray image. It is a benign formation similar to tumors, which consists of normal bone and a cartilage cap, but this tissue has grown in the wrong place. If and when the formation begins to , annoy it can be entirely surgically removed , and the diagnosis is additionally confirmed by pathohistological analysis (microscopic diagnosis). Extremely rarely, the formation can become malignant, and suspicion can be aroused by the rapid growth of the formation after the end of puberty.
