Dr Majed Issa

TOTAL HIP REPLACEMENT

admin — Tue, 06 Feb 2024 15:34:30 +0000

Total hip replacement or THR is one of the most commonly performed surgeries in France, with about 130,000 primary procedures performed each year.

The two main indications for such surgery are displaced femoral neck fractures and hip osteoarthritis (coxarthrosis), which generally occurs after the age of 60.

In younger patients, several other pathologies can lead to such surgery: dysplasia, rheumatoid arthritis, avascular necrosis, advanced femoroacetabular impingement, etc.

In the case of hip osteoarthritis, the eroded and dried-out cartilage can no longer ensure frictionless sliding of the joint surfaces. The contact of the bare bones during joint movement becomes increasingly painful and stiffening.

DEFINITION OF A THR:

Joint replacement with a prosthesis involves the excision of damaged joint surfaces and the installation of new, smooth, and painless artificial surfaces, accurately replicating the morphology and mobility of a native hip.

Preparation for the surgery:

Preparation of the general medical condition is essential before the surgery, including:

A cardiological assessment: Your cardiologist must evaluate your cardiac condition and certify the absence of contraindications to surgery.
A dental check-up: Your dentist must certify the absence of a dental infection.
If you are diabetic, your diabetes must be well-controlled. Poorly managed diabetes increases the risk of infection and healing problems.
Verification of the absence of latent infection in your body, notably urinary tract infection.
A general blood test.

This will be followed by a consultation with the anesthesiologist, who will analyze all these elements and propose the type of anesthesia according to your needs: General anesthesia (you are completely asleep throughout the surgery) or spinal anesthesia (injection in the back similar to an epidural, only the lower body is anesthetized). Each anesthesia method has its advantages.

If you prefer not to see, hear, or feel anything, general anesthesia is ideal for you. If you are apprehensive about falling asleep and prefer to maintain a sense of “control” over the situation, you can request spinal anesthesia. Hip replacement cannot be performed under pure local anesthesia.

Surgical planning:

We perform a digital planning or use templates for the prosthesis beforehand. This involves determining in advance the sizes and shapes of implants that match the patient’s anatomy and allowing for a faithful reproduction of the movements and anatomy of the native joint (range of motion, length of the lower limb, appropriate tension of tissues, especially the muscular sling of the gluteals).

In cases where the femoral or acetabular anatomy is unusual, it is necessary to perform a 3D planning of the prosthesis.

Moreover, we have the possibility to simulate the range of motion of the planned prosthesis, and to adjust precisely the position of each implant in the three planes of space to optimize this range to the maximum and avoid potential mechanical conflicts. 3D printing has also been helpful in planning certain difficult cases of hip dysplasia or revision THR.

The surgery:

The surgery typically lasts one hour. This duration can vary depending on the complexity of the case.

You are laid on your back on a specialized table that allows for the mobilization of the operated hip in all planes of space.

The surgical approach:

Several surgical approaches are available for performing a Total Hip Replacement (THR). Statistically, the most commonly used approach in France is the posterior approach (Moore’s approach), which requires cutting through the gluteus maximus muscle and some of the pelvitrochanteric muscles to access the joint. It provides easy access to the joint and allows for extension to the femoral diaphysis if needed, but it has a slightly higher dislocation rate and a slightly longer functional recovery than other approaches.

We have chosen to use Moore’s posterior approach only for difficult prosthesis changes (difficult THR revisions) and situations where a mini-invasive anterior approach would be contraindicated. Indeed, we perform the majority of our hip prostheses through a mini-invasive anterior approach.

This approach was described by the German C. Hueter and then developed by R. Judet, M. Siguier, and E. Letournel in France (three pioneers of orthopedic surgery in the world). It allows access to the hip without cutting through muscles. The skin incision is on average 10cm and is located at the front of the proximal thigh.

For such surgery, this is considered a small incision. But what truly makes the anterior approach “mini-invasive” is the preservation of deep structures, especially the muscles. At each depth level, muscles are successively pushed aside to reach the anterior face of the hip joint.

Once the joint procedure is completed and the prosthesis placed, the retractors are removed, and the muscles naturally return to their anatomical position. There is no need for muscle suturing.

Postoperative follow-up:

Once the surgery is completed, you are transferred to the recovery room, where you gradually wake up from the anesthesia under the watchful eyes of the nursing staff. A control X-ray is systematically requested and shown to the surgeon to verify the position of the implants once again.

You stay in the recovery room for an average of one to three hours, then a porter takes you back to your room. I visit you with the nurses at the end of the day to give you post-operative instructions, but also to help you walk.

The quick and relatively painless recovery is one of the main advantages of the mini-invasive anterior approach, and the majority of our patients manage to stand up and take a few steps in the corridor on the evening of the surgery. Even though they are allowed full weight-bearing on both legs, I strongly recommend my patients walk with two crutches for at least two weeks. This serves as protection against false movements and slips while they regain perfect control of all movements.

The next morning, a physiotherapist visits you. They help you walk, teach you how to use crutches, and have you practice a few stair steps. If you are comfortable enough walking and your control blood test is good, discharge can be authorized. The majority of our patients manage to return home the day after the surgery. Post-operative pain is generally well controlled by the prescribed medication and significantly diminishes starting from the 2nd week.

A daily injection of anticoagulants for 4 to 6 weeks reduces the risk of post-operative thrombophlebitis. Rehabilitation during the first two months following a THR is quite straightforward: You should walk, at your own pace, gradually increasing the distance and frequency each day, to gradually get your muscles, which have suffered for years from arthritic disease, back in shape.

If needed, exercises and rehabilitation sessions will follow with a physiotherapist, beyond the first two months.

Prothèse totale de la hanche gauche. La prothèse est fabriquée à partir d'un alliage de Chrome-Cobalt ou de Titane

La mobilité du patient est radicalement améliorée!

Parfois l'articulation est tellement détruite par l'arthrose qu'une reconstruction osseuse est nécessaire.

Radiographie après reconstruction du cotyle pour restituer le centre de rotation de l'articulation

Here is a photo of a scar from an anterior approach, it averages 10cm in length.

L’article TOTAL HIP REPLACEMENT est apparu en premier sur Dr Majed Issa.

THE FEMORAL NECK FRACTURE

admin — Tue, 06 Feb 2024 15:13:16 +0000

The femoral neck fracture is one of the most common fractures in trauma surgery. Each year, most often due to a simple fall, more than 80,000 people, a majority of whom are women over 70 years old, fall victim to it. The treatment for these fractures is surgical in almost all cases.

The femur forms the skeleton of the thigh; its upper end, the femoral head, which is spherical in shape, articulates with the pelvis. It is connected to the body of the femur, the diaphysis, by the femoral neck. This neck is shaped like a very strong flying buttress but works in cantilever and bears the entire weight of the body while standing, walking, and in all acts performed while bearing weight on the lower limb.

The risk of fracture increases with age:

The femoral neck fracture can affect adults of any age following a violent accident (scooter, motorcycle, car, sports, etc.), or at lower velocity among the elderly (20 to 30 times more than in young adults).

Indeed, the femoral neck, like other parts of the skeleton, becomes more fragile with age due to decreased bone density. In severe cases, this is referred to as osteoporosis. This is exacerbated by sedentary lifestyle or certain treatments (e.g., long-term high-dose cortisone), and affects women twice as much after menopause as it does men.

In the elderly, the risk of falling and therefore of fracture can be increased by a multitude of medical and non-medical factors:

Visual disorders (AMD, loss of visual acuity, etc.)
Balance disorders (inner ear problems, vertigo, etc.)
Loss of muscle strength (sarcopenia)
Neurological disorders (consequences of stroke, tumors, etc.)
Certain medications (opioid derivatives, tranquilizers, antihypertensives, etc.)
Insufficient fall prevention: wet floors, poorly lit rooms, carpet edges, etc.

Two types of fractures:

There are two main types of femoral neck fractures according to their location:

➜ “True cervical” fractures that affect the neck itself (1/3 of fractures)

➜ Pertrochanteric fractures (2/3 of femoral neck fractures) located at the junction between the neck and the diaphysis.

An emergency situation:

In most cases, the patient has total functional impotence: they are unable to get up or walk. They experience very severe pain at the hip level (groin fold, buttocks). Most often, there is a shortening and external rotation of the lower limb.

Emergency hospitalization is necessary to confirm the diagnosis with radiographs, sometimes a CT scan if needed.

In the case of some true cervical fractures where the neck is embedded in the femoral head without detaching, the pain is less, which can be misleading. Therefore, in the slightest suspicion of a femoral neck fracture, the patient is immobilized in principle, until a precise radiological diagnosis is obtained, to avoid worsening an initially good prognosis fracture.

Two types of surgery:

Surgery is almost always performed after a femoral neck fracture, except in cases of major contraindications in some patients whose health is very deteriorated (less than 1 case out of 100).

The surgery must be carried out very quickly after the accident to give the patient the best chances of recovery and to limit the medical risks associated with prolonged bed rest (urinary infection, pneumonia, bedsores, etc.).

Displaced true cervical fractures

Pertrochanteric fractures

➜ In displaced true cervical fractures, the microvessels supplying blood to the femoral head have likely been ruptured at the time of the fracture. The risks of necrosis of the head (death of bone cells) or non-union (called pseudarthrosis) are significant.

In elderly subjects, we prefer to solve the problem once and for all, and therefore often opt for prosthetic replacement of the joint (intermediate or total hip prosthesis).

In the specific case of very young patients or in cases of non-displaced true cervical fractures, osteosynthesis with percutaneous screws or intramedullary nailing is worth attempting, in the hope of sufficient restoration of blood supply and thus a "revitalization" of the native femoral head after the fracture.

➜ In pertrochanteric fractures, the microvessels ensuring blood supply to the femoral head have probably not been affected by the fracture. The fracture is distant from their anatomical emergence point.

Therefore, these fractures are most often reduced and stabilized by osteosynthesis (intramedullary nail or screw-plate).

Displaced true cervical fractures

Pertrochanteric fractures

➜ In displaced true cervical fractures, the microvessels irrigating the femoral head have likely been ruptured at the time of the fracture. The risks of head necrosis (death of bone cells) or non-union (called pseudarthrosis) are significant.

In elderly subjects, we prefer to solve the problem once and for all, and therefore often opt for prosthetic replacement of the joint (either a hemiarthroplasty or total hip prosthesis).

In the specific case of very young patients or in cases of non-displaced true cervical fractures, osteosynthesis with percutaneous screws or an intramedullary nail is worth attempting, in the hope of sufficient restoration of blood supply and thus a "revitalization" of the native femoral head after the fracture.

➜ In pertrochanteric fractures, the microvessels ensuring the blood supply to the femoral head have probably not been affected by the fracture. The fracture is distant from their anatomical emergence point.

Therefore, these fractures are most often reduced and stabilized by osteosynthesis (intramedullary nail or screw-plate).

Prothèse partielle ou intermédiaire: Seul le versant fémoral est remplacé

Prothèse totale: Le versant fémoral et cotyloidien sont remplacés

Vissage percutané d'une fracture non déplacée du col fémoral

Ostéosynthèse d'une fracture per-trochantérienne par clou gamma

The primary goal of surgery in elderly patients is to enable them to stand and walk as soon as possible with full support.

Early complications: (surgical site infection, pulmonary embolism, etc.) are rare but can be serious.

Late complications: nonunion (lack of fracture healing), avascular necrosis of the femoral head, and prosthesis loosening often require re-intervention.

The most serious complication of femoral neck fractures in old age is the progressive post-operative deterioration of the general condition with decompensation of preexisting diseases.

In rare cases where the patient cannot undergo surgery for medical reasons, a non-surgical treatment can be performed (continuous traction of the fractured limb until consolidation) but the complications related to bed rest in an already very fragile patient are often very serious.

After the surgery:

Rehabilitation is essential after the surgery. Its duration varies according to the patient’s age and their ability to recover. It starts the day after the operation in the orthopedic and trauma surgery department and primarily consists of getting the patient to walk and gently maintaining their joint mobility.

Rehabilitation is often lengthy for elderly patients who must not only relearn to walk but also regain their independence in daily life activities (sitting, lying down, getting out of bed, bathing, etc.). Hence, the need for appropriate care after the hospital stay: either by a physiotherapist at home in the best cases, or more often, in a convalescence center or a functional rehabilitation service.

Bone consolidation of the fracture is generally achieved within six to eight weeks, justifying prolonged use of canes. In the case of a prosthesis, the hip can be immediately loaded, allowing for a quicker recovery.

Ultimately, the patient will be able to walk again, preferably with a walker (or crutches) to avoid another fall.

It’s important to know that even in the absence of complications, a femoral neck fracture often results in some partial loss of independence in elderly patients.

After 80-85 years, and for patients living alone, the femoral neck fracture is one of the most frequent reasons for admission into a nursing home.

On the other hand, a young adult, quickly autonomous with their crutches, will return home after a short hospital stay and will regain their functional abilities once the fracture has consolidated.

Here are some prevention tips:

In addition to adapting one’s home to eliminate objects on the floor that could cause a fall, the first piece of advice is to stay active. It is strongly recommended to walk every day, which helps to strengthen bone density and maintain good muscle quality.

For the same reason, it is important to have a good nutritional balance with sufficient intake of proteins and calcium. After menopause, women should also monitor their bone mineralization with exams and, in case of mineral deficiency, take appropriate supplementation.

To learn more about the care of elderly patients suffering from a hip fracture, you can consult the article published by the Haute Autorité de Santé by clicking on the following link:

(https://www.has-sante.fr/portail/jcms/c_2803118/fr/fracture-de-la-hanche-optimiser-la-prise-en-charge-des-patients-ages)

Adapted from the information sheet of SOFCOT (French Society of Orthopedic and Traumatological Surgery)

L’article THE FEMORAL NECK FRACTURE est apparu en premier sur Dr Majed Issa.

HIP ARTHROSCOPY

admin — Tue, 06 Feb 2024 14:37:07 +0000

Hip arthroscopy is a recent technique, developing rapidly over the past fifteen years, allowing for the repair of the joint when it is not yet too damaged. Thus, it is part of the treatments that preserve the native hip.

Indeed, we are increasingly realizing that at least 40% of hip osteoarthritis could be due to untreated old lesions or small anatomical defects leading to the slow and progressive destruction of the joint.

Hip-preserving surgery, notably arthroscopy, allows for the repair of these lesions and anatomical defects in patients before the joint damage becomes irreversible and hip replacement becomes the only remaining solution.

Arthroscopy involves the insertion of a camera and thin instruments into the joint to perform a surgical intervention without tissue destruction. There is no muscle cutting, and the scars are pinpoint.

This process, therefore, allows for a quicker recovery, which is why arthroscopies are most often performed on an outpatient basis.

What pathologies can be treated with hip arthroscopy?

1) Femoroacetabular Impingement (FAI):

This is a dynamic pathology, characterized by the abnormal contact of the femoral neck against the rim of the acetabulum during hip flexion and rotation. The labrum and the cartilage on this rim are repeatedly crushed, leading to their fissuring.

This contact can originate either from the presence of a bone bump on the femoral neck (cam effect), or from a too prominent acetabular rim (pincer or clamp effect). The combination of both deformities is common, referred to as a mixed impingement.

Certain sports requiring large ranges of motion are particularly prone to impingements, such as combat sports, classical dance, ballet, etc. Some professions are also predisposed, especially those requiring squatting on the ground (e.g., tilers, mechanics), or extreme prolonged or repetitive hip flexion (e.g., taxi drivers).

The procedure involves shaving the bone areas causing the impingement, at the level of the femur and/or the acetabulum, using a motorized arthroscopic burr. It is often also necessary to repair sequela lesions of the impingement, such as tears of the labrum or cartilage.

2) Labral lesions

The labrum is an elastic joint attached to the periphery of the acetabulum, which ensures the tightness and stability of the hip. It has the same consistency as a meniscus in the knee, somewhat like soft rubber.

Its lesion is sometimes isolated but most often secondary to other pathologies, such as femoroacetabular impingement or hip instability. This lesion is often the cause of pain.

During an arthroscopy, the main objective is to save the labrum by performing a suture: Harpoons inserted into the bone (anchors) allow it to be reattached to the rim of the acetabulum.

Parts of the labrum that are too frayed and not amenable to suturing are debrided, trying to preserve as much labral tissue as possible.

3) Cartilage lesions

Like labral lesions, they are most often secondary to femoroacetabular impingement or hip instability. When these lesions are in their early stages, they can benefit from treatment under arthroscopy.

The possible technical procedures vary according to the indications: bone microfracture, cartilage grafting, mosaicplasty, etc.

4) Synovial pathologies

The synovial membrane lines the inner surface of all joints. It produces a lubricating fluid called synovial fluid and plays a significant biochemical and immunological role.

Certain synovial pathologies can lead to the destruction of the hip cartilage.

The most common are synovial chondromatosis (formation of cartilage "flakes" in the joint cavity) and pigmented villonodular synovitis (thickening of the synovial membrane in the form of villi and nodules). These are benign tumor pathologies in both cases, but the accompanying inflammation can be very painful and resistant to non-surgical treatment, hence the need for intervention.

Arthroscopy allows for visual diagnostic confirmation and intra-articular biopsies, as well as treatment by debridement (partial or complete depending on the pathology) of the synovial membrane.

It also allows for the removal of cartilage "flakes" from the joint cavity.

5) Hip tendinitis and tendinopathy

It's the inflammation of one or more tendons around the hip that causes your pain and discomfort. It can be a simple inflammation, or more significant lesions such as a tear or rupture of the tendon. This is then referred to as tendinopathy.

Most often, it involves the tendons of the gluteus medius, gluteus minimus, or iliopsoas.

As with the rotator cuff in the shoulder, debridement with repair of the damaged tendon can be performed either openly or by arthroscopy, depending on the type, extent, and location of the lesion. Anchors can be used if necessary to reattach the tendon to its bony insertion.

6) Hip microinstability

It involves excessive laxity of your joint, or a shallow acetabulum, leading to insufficient coverage of the femoral head, which can result in lesions of the labrum and/or cartilage.

The treatment addresses the articular capsule, which contains the ligaments stabilizing the hip and can be tightened. This procedure is known as capsular plication.

In severe cases where there is a significant coverage defect of the femoral head in a very young patient, a hip impingement surgery can be performed. This involves grafting a small bone block onto the roof of the acetabulum to increase its coverage.

Is there an alternative to surgery?

In most cases, the medical treatment of hip pain is a mandatory step.

We have a multitude of “small means” to try to control the symptoms without surgery: Avoiding traumatic movements or extreme positions, injections, PRP injections, anti-inflammatories, and painkillers, etc.

Well-conducted physical therapy can be of decisive utility: through specific work to correct certain movements, and by primarily strengthening the muscle groups that separate the bones in conflict, it can improve symptoms and avoid surgery.

If the well-followed medical treatment proves insufficient and the impact of symptoms on your physical and sports activities is significant, performing a hip arthroscopy becomes necessary.

Your surgery:

In the month preceding the surgery, you will have a consultation with the anesthetist, who will analyze all your medical data and will propose the type of anesthesia accordingly: general anesthesia (you are completely asleep throughout the surgery) or spinal anesthesia (injection in the back similar to an epidural, only the lower body is anesthetized). You will be able to share your preferences. Each anesthesia method has its advantages. If you do not want to see, hear, or feel anything, general anesthesia is ideal for you.

If you are apprehensive about falling asleep and prefer to keep a sense of “control” over the situation, you can request spinal anesthesia. Hip arthroscopy cannot be performed under pure local anesthesia.

During the surgery, you are laid on your back on a special table, called an orthopedic table. It allows us to position and hold the legs and therefore the hip. Hip arthroscopy is most often performed under radiological control using a mobile radiographic arch.

In most cases, the surgery is carried out on an outpatient basis. I will come to see you in your room at the end of the day before your discharge and will give you post-operative instructions, as well as prescriptions (dressings, painkillers, physiotherapy, etc.). You will probably have to walk with crutches for a few weeks, with or without bearing weight on the operated side, depending on your case. A daily injection of anticoagulant is necessary to avoid the risk of thrombosis. In some cases, a high-dose anti-inflammatory treatment is prescribed for a short period to prevent the formation of post-operative tissue calcifications.

We will meet regularly for follow-up consultations, and we will plan together the stages of rehabilitation, as well as the gradual resumption of regular activities, especially sports, work, and driving.

The final result of the surgery can only be evaluated after 6 months and sometimes up to 1 to 2 years. Do not forget that your joint has been ill for several months, if not years. Your muscles have weakened in parallel. With regular and well-measured efforts, without going too fast or too strong, you will experience constant progress, sometimes punctuated by small setbacks that should not worry or discourage you!

L’article HIP ARTHROSCOPY est apparu en premier sur Dr Majed Issa.

PATELLAR INSTABILITY SURGERY

admin — Tue, 06 Feb 2024 13:49:03 +0000

WHAT IS IT?

The medial patellofemoral ligament (or MPFL) is a ligament that attaches to the inner edge of the patella and the inner femoral condyle on the inner side of the femur. It stabilizes the patella by preventing it from dislocating outward during knee flexion.

After an episode of patellar dislocation, the MPFL is systematically torn. It is possible to reconstruct it to stabilize the patella and prevent the occurrence of new dislocations: this is the MPFL reconstruction.

In agreement with your surgeon and based on the benefit-risk balance, MPFL reconstruction was proposed to you. The surgeon has explained the other alternatives. It goes without saying that your surgeon may, if necessary and depending on the findings during surgery or a difficulty encountered, proceed with another technique deemed by him more beneficial to your specific case.

BEFORE THE TREATMENT:

An imaging assessment will be carried out by your surgeon to look for factors predisposing to patellar dislocation. This generally involves standard radiographs and a CT scan and/or MRI of the knee.

WHAT TREATMENT?

The surgical procedure is performed under general or regional anesthesia. A vertical incision of a few centimeters is made on the upper and inner side of the tibia. A hamstring tendon is harvested from the inner side of the tibia (semitendinosus or gracilis tendon).

The actual reconstruction of the MPFL requires one or two other incisions at the inner edge of the patella and the inner side of the femur. Tunnels may be created to pass the graft according to the technique used.

The new ligament is positioned and fixed to the femur and patella by various means (suture, staple, screw, anchor…). At the end of the procedure, the surgeon tests the patella, which should be stable and not dislocate outward.

AND AFTER?

The procedure is performed on an outpatient basis. Weight-bearing on the operated limb is allowed from the first day with crutches and a removable brace in extension. Rehabilitation starts immediately.

Flexion may be limited during the first few weeks. A preventive anticoagulant treatment for thrombosis may sometimes be prescribed.

EXPECTED RESULTS

MPFL reconstruction is a straightforward surgical procedure. It is very effective for patellar dislocation. It can often be combined with other treatments for dislocation (tibial tuberosity osteotomy, vastus medialis plasty, lateral retinacular release, trochleoplasty, etc.).

L’article PATELLAR INSTABILITY SURGERY est apparu en premier sur Dr Majed Issa.

MENISCAL LESIONS

admin — Tue, 06 Feb 2024 13:42:52 +0000

The menisci are two crescent-shaped structures interposed between the femur and the tibia, serving both as stabilizers and shock absorbers for the knee joint.

Thus, they protect the cartilage from excessive pressure and hence wear. They have a fairly hard elastic consistency, like rubber.

The menisci can either crack or tear following a trauma or wear down gradually over time. In both cases, a more or less significant fragment can detach and sometimes become lodged between the femur and the tibia.

ACUTE TRAUMATIC OR DEGENERATIVE LESION?

In young patients, meniscal lesions generally occur suddenly. It is often due to a pivoting movement, quickly standing up from a squatting or sitting position, a sudden acceleration/deceleration, lifting a very heavy object, landing from a jump, etc.

A sharp pain is felt, sometimes accompanied by a locking with the inability to extend and/or bend the knee completely. A more or less abundant effusion can follow within a few minutes to a few days. Degenerative meniscal lesions, on the other hand, are rather the result of progressive wear of the meniscal tissue over several months or years, with excessive mechanical stresses repeated over time.

We most often encounter them in patients over 40 years old who have quite physical sports and/or professional activities: Footballers, hikers, bricklayers, nursery assistants, etc. Certain factors can promote this meniscal degeneration, such as genu varum (“Lucky Luke” knees) and being overweight. The pains are quite chronic, fluctuating, progressively setting in, and accompanied by also fluctuating effusion.

It involves the medial meniscus in the majority of cases.

The typical image on MRI is a “horizontal tearing” of the meniscus, sometimes accompanied by small meniscal cysts. This can constitute the warning signs of arthritis of the joint.

PRINCIPLES OF TREATMENT:

While surgical resection of the entire damaged meniscus may relieve symptoms quickly and for several months, it would significantly increase the risks of osteoarthritic degeneration of the knee. We are therefore currently aiming to preserve the meniscus as much as possible. We first opt for a meniscal suture whenever the chances of healing are good.

When it comes to a non-suturable tear (significant damage, old rupture, lesion in a non-vascularized zone, etc.), we perform a meticulous excision of the damaged part only (partial meniscectomy).

In the case of a “degenerative horizontal tear,” non-surgical treatment is prioritized, since the wear generally affects the entire meniscus: Joint hygiene measures, physiotherapy, crutches, hyaluronic acid injections, PRP injections, etc.

THE SURGERY:

In the vast majority of cases, the surgery is performed by arthroscopy: through two skin punctures of less than one cm, a camera (the arthroscope) and 4mm instruments are inserted into the knee to perform the surgical procedure.

The surgery is most often carried out on an outpatient basis.

Depending on your preferences and especially your medical history, the surgery is done under general anesthesia or spinal anesthesia.

Skin closure is performed using 2 sutures.

POSTOPERATIVE FOLLOW-UP:

You leave the same evening of the surgery with a dressing, a knee brace, and crutches. If it is a meniscal suture, you are not allowed to bear weight on the operated side for 6 weeks, the time necessary for the healing of the sutured meniscal lesion.

If it is a meniscectomy, you can bear weight normally from the first day. Crutches are then kept only for a few days, the time it takes to resume normal walking. In all cases, you will need to rest your knee for the 3 months following the surgery, avoiding mechanically demanding activities.

Physiotherapy sessions may be prescribed depending on the case to maintain your muscles and recover joint flexibility.

Thanks to arthroscopy and the outpatient mode, complications from meniscal surgeries have become even rarer (in the order of less than 1 case per 1,000). In case of healing failure after meniscal suture (about 20% of cases), a second surgery may be necessary to remove the part that has not healed.

L’article MENISCAL LESIONS est apparu en premier sur Dr Majed Issa.

CARTILAGE GRAFT

admin — Tue, 06 Feb 2024 13:02:20 +0000

CARTILAGE GRAFT: WHAT IS IT?

Cartilage covers the bone surfaces in joints. It does not regenerate, or does so very minimally. Its disappearance can cause pain and lead to osteoarthritis in the long term. In cases of limited substance loss, it is possible to fill in the gap with your own cartilage. This is harvested from a healthy area along with the corresponding bone portion in the form of a small cylinder. It is then grafted to fill in the substance loss.

In agreement with your surgeon and according to the benefit-risk balance, a cartilage graft through mosaicplasty has been proposed to you. The surgeon has explained the other alternatives. It goes without saying that your surgeon may, if necessary based on preoperative findings or a difficulty encountered, proceed with another technique deemed by him more beneficial to your specific case.

BEFORE THE TREATMENT:

The diagnosis is refined using various examinations such as MRI and/or arthroscopy. These tests allow the visualization of the loss of cartilaginous substance and the determination of its size. The mosaicplasty technique is often proposed for lesions larger than 1cm².

WHAT TREATMENT?

The surgery is performed under general or regional anesthesia with a tourniquet placed at the root of the thigh. The incision is centered on the cartilaginous lesion and can vary in size depending on the case. The lesion is then visualized and measured.

The harvesting of one or more osteochondral cylinders is carried out on the periphery of the joint. This graft, which includes a bony part and a cartilaginous part, is then placed at the site of the substance loss. Depending on the size of the lesion, several grafts may be harvested and grafted.

AND AFTER?

After the first surgery, you will be prescribed a short-term work stoppage, as well as a few physiotherapy sessions. Full weight-bearing will be allowed immediately. The follow-up is similar to that of a simple arthroscopy.

After the second surgery, your knee will be immobilized in a removable brace in extension between physiotherapy sessions for a duration that will be specified by your surgeon. Weight-bearing will be prohibited for several weeks to several months to protect the cartilage graft. An anticoagulant treatment will be prescribed for the non-weight-bearing period.

Driving will be possible as soon as full weight-bearing is resumed. The return to sports will be delayed for several months (up to 1 year depending on the lesions). A work stoppage of several months will be prescribed depending on your profession.

EXPECTED RESULTS?

The mosaicplasty graft technique is a method used to treat medium-sized lesions. The expected result is an improvement or even disappearance of pain or cracking sounds. Do not hesitate to ask your surgeon for more details.

IN SUMMARY:

Knee cartilage grafting by mosaicplasty technique is a procedure indicated for cartilaginous lesions. It is performed in one stage. There are few complications, but the postoperative follow-up is demanding. Recovery after surgery requires several months. The resumption of sports should be gradual and carried out under medical supervision, respecting the time limits given by your surgeon.

L’article CARTILAGE GRAFT est apparu en premier sur Dr Majed Issa.

KNEE OSTEOTOMIES

admin — Tue, 06 Feb 2024 12:32:05 +0000

Tibial or femoral osteotomy at the knee is a so-called “conservative” surgical technique used in the treatment of early to moderate knee osteoarthritis, in contrast to non-conservative techniques such as knee prostheses.

Internal knee osteoarthritis is favored by an anomaly in the axis of the lower limb (genu varum, like “Lucky Luke”). When there is an axis defect, the stresses are poorly distributed, and the body weight applies more on the inside, accelerating wear.

Conversely, X-shaped knees (genu valgum) promote wear on the external compartment of the knee. When the osteoarthritis is not too severe yet, it is possible to propose to slow down or even stop its progression by straightening the osseous axis of the knee. The diagnosis of osteoarthritis is confirmed by clinical examination, radiography, MRI, and sometimes arthroscopy.

The mechanical axis of the limb is measured to determine the exact angle of correction needed.

THE SURGERY:

The surgery is performed under general anesthesia or spinal anesthesia, depending on your preferences and especially your medical history.

The scar is vertical and averages 8cm in length. A partial cut is made in the bone (osteotomy). An instrument gently spreads the bone edges by a few millimeters, according to the planned correction (8 to 12mm at maximum).

A wedge made of bone graft is inserted into the created space, and a titanium plate that conforms to the anatomical shape of the bone is used to secure the correction.

Une entaille osseuse et réalisée, puis ouverte de quelques millimètres à l'aide d'instruments précis

La correction osseuse est mesurée au millimètre près, puis est fixée avec une plaque et vis en titane

L'espace créé est comblé avec de la greffe osseuse pour une consolidation plus rapide

Aspect de la cicatrice à 3 semaines post-opératoires

POSTOPERATIVE FOLLOW-UP:

The surgery is generally performed on an outpatient basis. A physiotherapist comes to see you before discharge to get you standing and to give you practical advice on using crutches. Weight-bearing on the operated limb is prohibited for 6 weeks, the time needed for the osteotomy to consolidate.

During this time, you will be able to move around with crutches, and you will need to have regular sessions (with a physiotherapist and at home) of knee mobilization in flexion/extension, to maintain joint flexibility and prevent muscle atrophy.

An anticoagulant treatment will also be prescribed for 6 weeks.

The consolidation of the osteotomy will be monitored in consultation with regular radiographs. Driving is possible as soon as full weight-bearing is resumed.

EXPECTED RESULTS:

It is very important to understand clearly that a knee osteotomy does not repair the osteoarthritis that already exists in your knee.

Its purpose is to modify a predisposing factor to osteoarthritis, the poor anatomical alignment, in order to preserve what healthy cartilage you have left.

It involves an extra-articular bone procedure, meaning that your surgeon does not touch the inside of your joint.

As a result, you will probably continue to experience the pains associated with osteoarthritis after the osteotomy, sometimes for more than a year, but these will gradually decrease since the pressure on the arthritic compartment is now reduced.

It is therefore appropriate to act seriously and effectively on all the other predisposing factors to osteoarthritis: Excess weight, demanding activities and sports, lifting heavy objects, sedentary lifestyle, etc.

L’article KNEE OSTEOTOMIES est apparu en premier sur Dr Majed Issa.

RUPTURE OF THE KNEE’S CRUCIATE LIGAMENTS

admin — Tue, 06 Feb 2024 12:17:27 +0000

At the center of the knee joint, two powerful ligaments stabilize the joint in rotational movements and anterior or posterior translations. These are the cruciate ligaments (anterior and posterior), which constitute what is called the central pivot. It’s like two very tight, inelastic ropes that bathe in the joint fluid (synovial fluid).

The rupture of the cruciate ligaments is a common accident, especially with the practice of contact sports or pivot sports like football, skiing, martial arts, etc. Acutely, the rupture of a cruciate ligament is accompanied by bleeding and swelling of the joint cavity, as well as partial or total functional impairment.

In fact, it is mainly the associated traumatic lesions that cause pain: Bone contusions or fissures, sprains of the extra-articular ligaments, meniscal tear, cartilage lesion, etc. The cruciate ligament itself is little, if at all, painful, once the initial trauma has cooled down. But the absence of pain can be misleading. The knee has not returned to normal.

Indeed, unlike the extra-articular ligaments, a cruciate ligament ruptured in full substance does not have the capacity to heal by itself. Its absence leads to millimetric anteroposterior and rotational instability, which is responsible in the medium and long term for progressive wear of the joint.

Patients often experience giving way, a lack of confidence in their knee, especially if they practice pivot sports, contact sports, or those with strong accelerations/decelerations. With a ruptured cruciate ligament, the increased risk of long-term knee osteoarthritis is estimated at 40%, according to scientific publications.

In an active, athletic patient of a young physiological age, the reconstruction of the cruciate ligament is indispensable to restabilize the knee and prevent as much as possible the arthrosic evolution over time.

At the other extreme, in a sedentary patient of an advanced physiological age, or already showing signs of osteoarthritis beforehand, the reconstruction of the cruciate ligament may not necessarily have enough advantages to justify surgery.

PREPARATION FOR THE SURGERY:

The immediate aftermath of a trauma with cruciate ligament rupture is consistently marked by varying degrees of stiffness, weakening, and muscular atrophy, particularly of the quadriceps.

It is essential to regain good joint flexibility and good muscular tone before surgery: The quality of the postoperative result and the speed of recovery depend on it.

Therefore, physiotherapy sessions are prescribed preoperatively, to properly prepare for the surgery.

THE SURGERY:

Cruciate ligament reconstruction, also known as ligamentoplasty, lasts 1 hour and can be performed under general anesthesia or spinal anesthesia (injection in the back, only the lower body is numbed). It is most often carried out on an outpatient basis.

The surgery is performed by arthroscopy: Through two small skin incisions of 5mm at the front of the knee, a 4mm camera and multiple instruments are inserted into the joint cavity to perform the procedure. There is no need for a large surgical opening.

To reconstruct a new cruciate ligament, a portion of a tendon from the lower limb is harvested: This involves either the hamstring tendons (DT4 and DI-DT technique) or the patellar tendon (KJ or Kenneth Jones technique), more rarely the quadriceps tendon.

We have chosen to preferentially perform the DT4 technique. As its name suggests, it involves harvesting a single hamstring tendon, the semitendinosus (DT), through a 3cm incision in the proximal leg, which is folded in four to serve as a new cruciate ligament.

The graft is inserted into the knee through the same arthroscopic openings, then fixed in a tibial bone slot on one side, and a femoral bone slot on the other. The tension of the graft is adjusted as needed using a well-perfected system of cords.

This is the least invasive technique available to date, which therefore allows for a less painful and faster recovery: Only one hamstring tendon is harvested (compared to DI-DT), no morbidity at the harvest site (compared to KJ sometimes), no drilling of bone tunnels (compared to DI-DT and KJ).

POSTOPERATIVE FOLLOW-UP:

After the surgery, you are taken to the recovery room where you stay on average for 2 hours.

A postoperative control radiograph is systematically performed before you are taken back to your room.

On the evening of the surgery, a physiotherapist comes to see you, gives you some instructions, and then helps you get up and walk, with the protection of a brace and crutches.

You are allowed full weight-bearing on the operated leg after a standard ligamentoplasty. If a meniscal suture has to be performed at the same time, the resumption of weight-bearing is delayed for 4 to 6 weeks to wait for the meniscal healing.

Physiotherapy starts two to three days after the surgery, according to a specific protocol and schedule. It lasts at least 6 months and typically 1 year, ending with a step of getting back to sports.

The healing of the ligamentoplasty graft in the bone is estimated at 1 year. During this period, sports and activities with pivoting or contact such as martial arts, football, tennis among others are prohibited, at the risk of rupturing or stretching the new ligament.

We meet regularly in postoperative follow-up consultation, and we plan together each activity that you wish to resume.

L’article RUPTURE OF THE KNEE’S CRUCIATE LIGAMENTS est apparu en premier sur Dr Majed Issa.

KNEE REPLACEMENT

admin — Tue, 06 Feb 2024 12:13:11 +0000

Knee osteoarthritis is a common disease affecting more than one in four people after the age of 65. It leads to a progressive destruction of the knee’s articular cartilage.

The wear of the cartilage is accompanied by a degradation of the menisci, muscles, and synovial inflammation.

It is a global affliction of the joint that becomes painful and starts to stiffen. In some cases, it is no longer possible to fully extend the knee (flexum).

Among the predisposing factors, we can notably mention:

A misalignment of the knees: “Lucky Luke” knees (genu varum) or X-shaped knees (genu valgum).
Genetic factor.
Sequels of old traumas to the bones, cartilage, menisci, or ligaments.
Overweight.
The practice of intensive sports or very physical professional activity.
Inflammatory rheumatism can lead to the destruction of the knee cartilage.

The progression of osteoarthritic disease generally occurs through flares of pain and effusions, lasting a few days to a few weeks, separated by periods of calm of varying lengths.

WHAT ARE THE OPTIONS?

There is no medical treatment available to date that can prevent osteoarthritis or regenerate eroded cartilage. That said, the body often adapts in quite a surprising way to joint wear, sometimes for long durations.

The progression of osteoarthritis can be slowed down by avoiding sports and activities that mechanically stress the knee, and by reducing overweight.

Physiotherapy sessions focusing on muscle strengthening, injections of corticosteroids, hyaluronic acid, or PRP (Platelet-Rich Plasma) can be very beneficial.

These medical measures, when well conducted, can spare the patient from surgery.

But if the pain starts to heavily affect the patient’s daily life and becomes difficult to control with non-surgical means, the surgical option of knee replacement is discussed: It involves freshening the damaged joint surfaces, and “dressing” them with prosthetic parts, thus avoiding painful bone friction.

Contrary to a widely held misconception among the general population, there is no massive bone resection with knee replacement. It is a matter of dressing or “resurfacing” the two damaged joint edges, while preserving as much as possible the other native anatomical structures.

In some cases, the wear is significant but localized to a single compartment of the knee. In such cases, only that compartment can be resurfaced with a partial prosthesis (unicompartmental).

THE SURGERY:

A radiographic assessment is systematically prescribed for you, in order to plan the ideal sizes and positions of the prosthetic implants and to replicate the alignment of the native knee.

Sometimes a CT scan or an MRI is requested to look for a rotational abnormality of the limb or to allow for the manufacture of custom tools specific to your knee, or even to make a tailor-made prosthesis.

A blood test, a urine exam, a cardiology consultation, and a dental assessment are necessary for the medical preparation for the surgery.

The surgery can be performed under general anesthesia or spinal anesthesia, depending on your preferences and especially your medical history. You will be able to discuss this in detail with the anesthetist during the anesthesia consultation.

The surgery generally lasts between 1 to 1.5 hours.

The prosthesis consists of a femoral piece and a tibial piece made of a Chrome-Cobalt alloy, each a few millimeters thick, replicating the native anatomy of the knee. They are fixed to the bone with a medical cement (rapid-setting resin). A polyethylene piece (a very resistant polymer) is placed between the femur and the tibia, ensuring smooth mobility.

At the end of the surgery, a rather thick and slightly compressive dressing is applied. A drain is sometimes used to prevent the formation of a hematoma in the joint. You will stay in the recovery room for an average of two or three hours, where cold packs will be applied to the knee.

A control radiography is performed, then you are taken back to your room. A meal will be served to you there.

POSTOPERATIVE FOLLOW-UP:

Hospitalization after knee replacement surgery generally lasts 3 to 4 nights.

From the next morning, a physiotherapist comes to see you to start mobilizing the knee in flexion/extension, and to have you walk with the aid of a walker or crutches. The physiotherapist will even try to have you climb up and down a few steps before you leave.

The nurses change the dressing every 2 days, which will now be a very thin adhesive dressing. It must remain perfectly clean and dry until the wound is completely healed (2 to 3 weeks). A daily anticoagulant injection is essential to ward off the risk of thrombosis.

You will be able to cover increasingly longer distances. You can dispense with the crutches as soon as you feel stable enough.

Due to the poor function of your knee before the operation, your muscles have likely weakened over several months or even years. Therefore, they will need time to regain their strength and flexibility. It is not uncommon for the knee to remain sensitive and easily fatigued during prolonged efforts or squatting.

This should not discourage you.

The time for healing, for your skeleton to adapt to your prosthesis, and for the recovery of your flexibility and strength is long. Progress will be steady, and it often takes nearly a year to achieve a “forgotten knee.”

To get there more surely and more quickly, you will be asked to do very regular sessions of knee mobilization in flexion/extension yourself, from the day after your surgery, wherever you are, in bed, sitting on your sofa, or outside, without forcing through pain.

You should not rely solely on the time spent with the physiotherapist. You remain the main actor in your recovery.

L’article KNEE REPLACEMENT est apparu en premier sur Dr Majed Issa.

SHOULDER INSTABILITY

admin — Tue, 06 Feb 2024 11:42:36 +0000

Shoulder instability is a condition where the upper arm bone (humerus) does not stay properly centered in the shoulder socket (glenoid), leading to a partial or complete dislocation. This can cause pain, weakness, and difficulty moving the shoulder. Whether caused by injury, repetitive motion, or naturally loose joints, shoulder instability can significantly affect your daily life. This guide will help you understand the causes, how doctors diagnose it, and the treatment options available.

What Causes Shoulder Instability?

Several factors can lead to shoulder instability, and it’s important to understand what might have caused yours:

1. Traumatic Injury: A fall, a direct blow to the shoulder, or an accident can force the shoulder out of place. This kind of injury often tears the labrum (a ring of cartilage around the socket) or damages the bone. If you’ve dislocated your shoulder in an accident, this is likely the cause.
2. Repetitive Strain: Some activities, especially sports that involve a lot of overhead motions like swimming, baseball, or volleyball, can cause wear and tear over time. These repetitive movements can stretch the ligaments (the bands of tissue that hold the bones together), making the shoulder unstable.
3. Loose Joints (Congenital Laxity): Some people are born with naturally loose or flexible joints, a condition known as hypermobility. This can make the shoulder more prone to slipping out of place, even with minor movements or activities.
4. Previous Surgeries: If you’ve had surgery on your shoulder before, especially for rotator cuff problems or other issues, it might have changed the way your shoulder works. Sometimes, this can lead to instability afterward.

How Is Shoulder
Instability Diagnosed?

Diagnosing shoulder instability involves several steps, starting with a
conversation with your doctor about your symptoms and how the problem started.
This is followed by a physical examination and various imaging tests to get a
clear picture of what’s going on inside your shoulder.

1. Talking with Your Doctor and Physical Examination:

Your doctor will ask about any injuries you’ve had, what activities you do, and
what kind of symptoms you’re experiencing. Do you feel like your shoulder might
slip out of place? Is there pain or weakness? Understanding your history is the
first step.

During the physical exam, your doctor will move your shoulder in different
directions and perform specific tests. These might include:

– Apprehension Test: Your doctor will gently move your arm into a position
where the shoulder could dislocate, checking if you feel any discomfort or fear
of dislocation.
– Relocation Test: This follows the apprehension test and involves applying
gentle pressure to see if it reduces the feeling of instability.
– Sulcus Sign: This test checks for a gap under your shoulder joint, which can
indicate that the shoulder is too loose.

2. Imaging Studies:

After the physical exam, your doctor will likely recommend some imaging tests
to look inside your shoulder. These tests are crucial for understanding the
extent of the injury and planning the best treatment.

– X-rays: This is usually the first test done. X-rays help show if there’s any
damage to the bones, like fractures or changes in the shape of the shoulder
socket.

– MRI (Magnetic Resonance Imaging): An MRI provides detailed images of the soft
tissues in your shoulder, including the labrum, ligaments, and muscles. This
test is very useful for detecting tears in the labrum or rotator cuff.

– CT (Computed Tomography): If there’s a concern about bone loss or damage to
the shape of the bones, a CT scan might be used. This test gives a 3D view of
the shoulder, which is helpful for planning surgery if needed.

– Arthroscanner (MR Arthrography): The arthroscanner is a special type of MRI
that involves injecting a contrast dye into your shoulder joint before taking
the images. This dye helps to highlight any tears or other problems inside the
joint. The arthroscanner is particularly useful for seeing small tears in the
labrum or ligaments that might not show up on a regular MRI. It gives doctors a
very clear picture of the joint, which is important for making an accurate
diagnosis and deciding on the best treatment approach.

What Are the
Treatment Options?

Treatment for shoulder instability depends on how severe the problem is, what
caused it, and your overall health and activity level. Some people can manage
the condition with physical therapy and lifestyle changes, while others may
need surgery.

1. Non-Surgical Treatments:

– Physical Therapy: The main treatment for shoulder instability is physical
therapy. A therapist will guide you through exercises to strengthen the muscles
around your shoulder, particularly the rotator cuff and the muscles that
stabilize the shoulder blade (scapula). Stronger muscles help keep the shoulder
in place and reduce the chance of dislocation.

– Activity Changes: Depending on what’s causing your shoulder instability, you
might need to adjust your activities. If you’re an athlete, this could mean
modifying how you play your sport to avoid positions that put your shoulder at
risk.

– Bracing: Sometimes, wearing a shoulder brace during activities can provide
extra support. This can be particularly helpful if your shoulder tends to
dislocate during specific movements.

2. Surgical Treatments:

If physical therapy and other non-surgical treatments don’t work, or if your
shoulder instability is severe, surgery might be necessary. Several surgical
options can help stabilize your shoulder:

– Arthroscopic Bankart Repair: This is a common surgery for repairing a torn
labrum (the cartilage that surrounds the socket). During the procedure, the
surgeon reattaches the torn labrum to the socket, restoring stability to the
joint.

– Latarjet Procedure: If there’s significant bone loss in the shoulder socket,
the Latarjet procedure might be recommended. This surgery involves transferring
a piece of bone from another part of your shoulder to the socket to provide
extra support and prevent future dislocations.

– Capsular Shift or Plication: For people with loose joints or multidirectional
instability (where the shoulder can slip in multiple directions), surgery might
focus on tightening the joint capsule (the tissue that surrounds the joint) to
limit excessive movement.

– Rotator Cuff Repair: If your shoulder instability is related to a rotator
cuff tear, surgery may be needed to repair the tear. Fixing the rotator cuff
can help restore the shoulder’s stability and function.

Recovery After Surgery:

After surgery, you’ll need to keep your shoulder in a sling for a few weeks to
protect it while it heals. Physical therapy will then be a key part of your
recovery. Your therapist will help you regain movement and strength in your
shoulder. Full recovery can take several months, but with proper
rehabilitation, most people regain good function and return to their normal
activities.

L’article SHOULDER INSTABILITY est apparu en premier sur Dr Majed Issa.