Operative Orthopaedics
EBOT - European Board for Orthopaedics and Traumatology - Board Certified
Certified by the European Board for Orthopaedics and Traumatology
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Joint preservation techniques;
are surgical methods by which we try to completely eliminate or at least postpone for a certain time total hip replacement (replacement of the diseased hip with an artificial joint) - arthroscopic and minimally invasive techniques
Femoroacetabular impingement - removal of CAM and pincer lesion, suture and labrum reconstruction
is a disorder of the shape of the hip joint, only the cup, only the head of the femur or in combination. Due to the unfavorable position and/or bony protrusions, during movements in the hip joint there is a impingement. In the initial phase only of the soft tissue (labrum - a special cartilaginous ring around the joint and cartilage) parts of the hip, and in the later phases, of bone on bone impingement. Symptoms do not have to be present in every patient. These are patients of a younger age, and if they play sports, especially in which the leg is raised above the level of the hip or deep squats, the problems start already in their 20s. If the disease is suspected, it is possible to confirm the disease with a simple clinical examination. In addition, an X-ray of the pelvis and hips reveals the cause of the problem. On these images, bony protrusions and a different orientation of the cup are visible. In this case, it is necessary to additionally perform an arthrography examination with Magnetic Resonance. It is a scan that takes images of the hip joints after a special contrast has been injected into them. This is given by injection under the control of an ultrasound or X-ray device. The reason for applying contrast is to precisely diagnose damage to the soft tissues of the hip (labrum and cartilage), which are not clearly visible in the examination without contrast. After we receive high-quality images and precise confirmation of the joint elements, we move on to the creation of a detailed operation plan that includes the repair of damaged joint elements, if possible, and/or the removal of damage to those elements while also removing the cause of the damage (changing the shape of the joint elements). It is possible to remove the damaged cartilage and labrum, or repair, suture the labrum, attach cartilage lesions with resorbable nails or a microfracture procedure, which creates cartilage-like tissue at the point of deficiency. It is also crucial to remove the bony protrusions that led to the initial damage.
On the right (on the left hip in the image) X-ray visible CAM lesion as part of FAI
FAI on MR image of right hip, left hip affected by arthrosis caused by untreated the FAI
Decompression of the femoral head and neck in avascular necrosis
in this condition, most often, for an unknown reason, the bone under the cartilage of the femoral head remains without circulation. Since bone is made up of living cells and non-living mineral material, the living cells disappear and the remaining bone is not strong enough to support the bodyweight. In the initial stage, only pain is present. The changes then cannot yet be seen on X-rays. Magnetic Resonance Imaging shows the so-called bone edema. These are microscopic fractures of bone. It is important to do an MR imaging because bone changes can be seen much earlier than on X-rays (where damage is visible in the later stages of disease development). Depending on the degree of the disease, which we estimate from the MR images, we start the treatment. For lower degrees, conservative treatment begins, relieving the joint by walking with forearm crutches and Physical therapy. In the later stages, when it is clear that the organism is no longer trying to repair the damage by itself, it is possible to reduce the pressure in the damaged bone by drilling holes in the bone (decompression) and bring new circulation. Additionally, PRP or stem cells can be placed through such channels. The procedure itself is designed so that the damaged bone is exposed to its own PRP and stem cells. Specially prepared device (from your own blood, abdominal fat or bone marrow from the pelvis) contain a higher concentration of active substances and living cells. In case of total damage to the joint or pain intensity not reduced by simpler procedures, it is necessary to perform a total hip replacement, regardless of the age of the patient.
Arthroscopic fenestration of the fascia lata in chronic trochanteritis
relatively common disease, but unfortunately rarely diagnosed. It is a case of severe pain on the side of the hip, which makes it difficult to walk, sit, and lie on that side. In the initial phase of the disease, the pain is localized, while later it spreads to the surroundings, so the patient and the doctor often treat the hip joint or the painful lower back, of course without success. We suspect the disease with a simple clinical examination. With an ultrasound examination, we visualize changes in the attachment of muscles to the bone, effusion in the bursa (mucous sac) and thickening of the fascia lata (a type of ligament that scrapes on the attachment of muscles and bones during movement and causes inflammation). By administering a long-acting anti-inflammatory drug with a short-acting anesthetic to the painful area, the pain is immediately relieved. This is the final confirmation of the correctness of the diagnosis as well as the precision of the place where the drugs were administered. The pain will soon reappear as the anesthetic wears off. After a few days, the corticosteroid preparation will begin to work. Such an injection can be repeated one more time. In case of failure of such conservative treatment, it is necessary to make an opening, a window on the fascia lata, through two small holes in the skin using a camera (endoscope). On both sides of such an opening, a lot of ligament remains preserved, which continues to perform its function, while the large rotator cuff (protrusion of the hip to which the strong muscles of the pelvis are attached) turns inside this opening and no longer scrapes on the ligament.
In the middle, the large trochanter and the cleaned inflammatory bursa
From the side, parts of the longitudinally cut fascia latae are visible
Snapping hip - coxa saltans - snapping hip
it is one of the rarer problems seen in the orthopedic outpatient clinic. If there is no pain, the patient complains of visible and often audible skipping in the hip area. Sometimes the snapping can be painful. First of all, it is necessary to accurately diagnose the cause of the snapping. Most often, the cause is outside the joint itself, and it is caused by the fascia lata jumping over the greater trochanter (protrusion of the bone at the beginning of the upper leg). Another cause is the jumping of the tendon of the ileopsoas muscle over the head of the femur. The last cause of snapping in the hip is intra-articular pathology, most often free joint bodies or damage to the labrum (cartilaginous ring around the joint cup). Depending on the cause, surgical treatment is different and in most cases arthroscopic.
Stress reaction or stress fracture of the femoral neck
Top professional athletes or non-professional athletes (athletes who train intensively but do not live from sports) who run for a long time during training or sports may experience pain in the groin. After Magnetic Resonance Images diagnostics in the area of the neck of the femur, the so-called bone edema. It is a fracture of bone beds on a microscopic level. The change is significantly smaller than can be diagnosed with an X-ray. Nowadays, treatment starts significantly earlier and conservatively.
It is necessary to walk with no weight bearing on diseased leg using forearm crutches and Physical therapy. After 6 or more weeks, a follow-up MRI can be done, which should show a decrease or disappearance of edema. Before the discovery of Magnetic Resonance Imaging, the diagnosis was made by bone scintigraphy (a test in which radioisotopes given intravenously accumulate at the site of bone damage) and X-ray imaging. Back then, the diagnosis of stress fractures was more common because it was visible on an X-ray, while today we detect the disease before the fracture itself. In the case of an unsatisfactory effect of conservative therapy, a threatening fracture or an already existing fracture, the treatment must be carried out surgically, by strengthening the bone by placing screws (osteosynthesis).
Joint replacement techniques:
partial and total (cementless and cemented)
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for partial hip replacement, there are in principle only two surgical indications after a femoral neck fracture, the first in the case when the patient is not expected to live longer than 6 months (which is extremely difficult to estimate) or when the patient has never walked due to the underlying disease . The reason for the operation is painless movement in the joint when moving in bed. Partial hip replacement can be cemented or cementless. Installing a high-quality partial prosthesis is more difficult than a total prosthesis, since in the case of a partial prosthesis, the head of the endoprothesis must be adapted to the existing anatomy of the hip socket. When installing a total, it is possible to completely change the existing anatomy. The reason for this is the situation in which the anatomy was never in order or it changed a lot during some disease. In this case, we place the endoprosthesis in the ideal position. Most often, however, in cases where only the cartilage is damaged, and the anatomy of the hip is normal, we respect the natural position of the hip.
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total hip replacements are used in cases where the hip joint is so destroyed by some disease (most often arthrosis) that it can no longer perform its function properly. The most common reason for surgery is pain in the joint, which significantly impairs the quality of life and cannot be controlled with painkillers, Physical therapy and walking with crutches. Another reason is the limitation of movement along the joint (with or without pain). Patients who, regardless of the advanced degree of joint damage, do not have severe pain tend to tolerate this condition for a long time. But we have to explain to such patients that the damage can progress so much that the operation would be extremely difficult, as well as the post-operative rehabilitation. Years of life are not the decisive factor for the indication of surgery, but the previously mentioned quality of life. After the installation of a total cementless or cemented hip endoprosthesis, the day after the operation the patient starts walking with forearm crutches or a walker under the control of a Physiotherapist, and on the third postoperative day the patient walks down and up the stairs. On the fourth day, he goes home where he continues outpatient rehabilitation or to the stationary rehab center for inpatient rehabilitation. Upon returning from such center, the crutches are discared and the patient walks independently and returns to the state before the onset of ailments. The essential difference between cementless and cemented prostheses is in the so-called primary and secondary stability. At the end of the operation, both types of prostheses must be stable. In case of cementless prostheses, the primary stability is provided by the elasticity of the bone. Namely, both elements of the prosthesis, the cup and the stem (the part that is placed in the initial part of the thigh bone) are pressed into the bone as a wedge (the so-called press fit technique), where the diameter of the prosthesis is 1 mm larger than the bed in the bone. The elasticity of the bone then holds the prosthesis. However, this stability is not sufficient for walking with full load, but by partial weihtbearin with cruthes in necessary for the next 1.5 months, the bone gradually grows into the rough surface of the endoprosthesis (it is coated with the mineral hydroxyapatite). After that, the so-called secondary stability occurs. In the event that the patient's bone is not elastic enough, and could break when placing a cementless prosthesis, we decide on a cemented one. These prostheses are different in design from the previous ones, they are generally narrower and generally do not touch the bone directly with any of their parts. In order for such a prosthesis to be stable in the bone bed, the so-called bone cement. It is a special type of plastic mass that is made during surgery from a solid substance (powder) and a liquid part. An endoprosthesis is pressed into this still liquid elastic mass. During the operation, the plastic polymerizes (hardens) and the prosthesis is fixed in the bone. Primary and secondary occur at the same time, and after the installation of such a prosthesis, support with the full weight of the body is allowed. This is the most common reason why older patients with osteoporotic bones opt for such a prosthesis. In principle, there is no reason why such prostheses should not be placed on younger people, which is also the attitude of some countries of the European Union.
total hip replacement and hip arthrosis
Osteosynthesis in pertrochanteric (intertrochanteric) fractures of the femur:
DHS (dynamic hip screw)
gamma nail (PFN - proximal femoral nail)
They are modern implants that are used with a minimally invasive approach in the case when proper healing of the broken bone of the initial part of the upper leg is expected. After the installation of such implants (usually in elderly patients), it is possible to immediately put a full load on the operated leg when walking with forearm crutches or a walker.