Co leczymy?

Introduction

Internal carotid artery stenosis is a chronic disease with the progressive course and serious complications. It is associated with a gradual reduction of the lumen of the main artery that supplies blood to the brain. The course of the disease may be asymptomatic or symptomatic. Stroke is the most dangerous complication. Central nervous system ischemia is usually sudden and has a rapid course. It often results in permanent disability.  

Causes

In over 90% of cases, stenosis is caused by obliterative atheromatosis. Less common causes include radiation therapy, vasculitis, delamination or fibromuscular dysplasia. The main risk factors for atherosclerosis are smoking, lipid metabolism disorders (hypercholesterolaemia), hypertension and diabetes.

Symptoms

Symptomatic carotid artery stenosis causes a neurological defect, transient ischemic attack (TIA) or stroke within the recent 6 months. The symptoms include paresis, paralysis, sensory disturbances on the side opposite to stenosis, as well as speech disorders if the artery on the side of the dominant hemisphere is narrowed. Visual disturbance occurs on the side of stenosis.

Diagnosis

Sometimes, murmur can be heard over the carotid artery in the area of the mandibular angle. It appears with the narrowing of more than 50% of the lumen. Usually, no sound is heard with the stenosis > 90% or occlusion. Colour Doppler ultrasound is used to confirm the diagnosis and determine the degree of stenosis. In some cases, it is helpful to extend imaging diagnostics to include computed tomography angiography and magnetic resonance imaging.

Treatment

Conservative treatment is based on the elimination of risk factors (giving up smoking, treatment of hyperlipidemia, hypertension and diabetes) and the use of antiplatelet drugs. Symptomatic patients and those with artery stenosis of at least 70% are eligible for invasive treatment. Classic surgery involves a removal of the atherosclerotic plaque (endaterectomy) and widening of the internal carotid artery (using a vascular patch). An alternative is minimally invasive treatment based on vascular stent implantation. The choice of the treatment method generally depends on the experience of a centre.

Type of operation

During the endovascular procedure, an atherosclerotic lesion is forced using various catheters. Because the procedure can be complicated by stroke, stent implantation is preceded by insertion of the neuroprotection system. The system resembles a basket to catch the potential embolic material travelling with the bloodstream to the brain. After unfolding the stent and compressing it with a balloon, the system is folded and removed outside. The procedure is performed under local anaesthesia from the inguinal access.

Postoperative period

As a rule, patients are discharged home on the second day after the surgery with the recommendations to take medications, change lifestyle and report for a check-up at the Regional Outpatient Clinic of Vascular Diseases.

In the Szpital Zakonu Bonifratrów, endovascular procedures are performed by doctors from the  Regional Department of Vascular Surgery and Angiology.

Rehabilitation in inoperable cases

Unless the doctor decides on the need for surgery, movement exercises should begin as pain subsides and be followed by muscle-strengthening exercises. Initially, the exercises are performed with the limb placed below the level of the shoulder. The program includes strengthening exercises for the rotator cuff tendons and the muscles of the shoulder girdle. Pain usually goes away within three weeks. In the second degree injuries, full recovery may take up to six weeks, and up to 12 weeks in the third degree injuries.

Postoperative rehabilitation

Your doctor may recommend wearing a sling/vest for several days after the procedure. A physical therapist or therapist will prepare the rehabilitation program. The first treatments are aimed at reducing pain and swelling. Applying ice packs and electrical stimulation can be helpful. A therapist may also use massage and other types of manual therapies to reduce muscle spasm and pain. Four weeks after the operation, the range of motion exercises begin, i.e. passive exercises. The shoulder is mobilized by the therapist, you can learn the exercises and practice on your own at home.

Active exercises are introduced six to eight weeks after surgery, giving the ligaments time to heal. These exercises allow the patient to move the shoulder joint using own muscle strength. You can start off with easy isometric exercises which activate the muscles without overloading the AC joint which is in the phase of healing.

After three months, more intensive rehabilitation program begins. The exercises focus on improving the endurance and control of the rotator cuff muscles and the muscles of the shoulder girdle. A therapist will help to strengthen the muscles that correctly center the head of the humerus in the socket. This will improve shoulder mobility.

Rehabilitation after surgical treatment of shoulder injuries may take some time. It requires patience and discipline, you should follow your individual therapeutic program. Some exercises are programmed in the same way as daily activities and your favorite sports. A therapist will help you to find the best way to perform tasks/exercises in order to avoid overloading. A therapist will teach you ways to avoid injuries in the future.

In the Szpital Zakonu Bonifratrów, physiotherapy is performed by a team of specialists:

Rafał Trąbka, PhD

Łukasz Gregulski, MSc

Introduction

Arthroscopy of the shoulder is an operation to heal damage to the shoulder joint. The most common indications for surgery are:

• acromioplasty (release and removal of adhesions from the subacromial space),
• labrum reinsertions with shoulder instability,
• reconstruction of the rotator cuff tendons,
• removal of free bodies from the shoulder,
• excision of degenerative changes.

An orthopedist can perform several procedures during one surgery. With an increase in the number of repaired structures, the rehabilitation time to full recovery is extended.

Is rehabilitation after arthroscopy of the shoulder joint necessary?

Rehabilitation after surgery is an essential element of returning to full fitness. After arthroscopy, correct mobility and stability of the shoulder as well as the scapulohumeral rhythm can be regained only with well-conducted physiotherapy. Abandoning rehabilitation usually leads to capsular and muscular contractures, and thus limitation of mobility and pain.

When to start rehabilitation?

Rehabilitation can be started the next day after the surgery. During the first visit, a physiotherapist will thoroughly explain what activities should be avoided. Depending on the structures repaired, the initial stage of rehabilitation will focus on pain control and passive exercises guided by a therapist, indirect work and taping. At this time, adjacent joints of the upper limb are exercised, a physiotherapist orders the first home non-weight bearing exercises. The worst approach is to immobilize the shoulder in a sling for a few weeks!

How long does rehabilitation take?

The duration of rehabilitation depends on the type and method of arthroscopic treatment. The minimum recovery time for minor shoulder arthroscopy is about 6 weeks. With complex treatments, such as reconstruction of the rotator cuff, this time can be up to 6 months. Despite the same type of surgery, each shoulder will behave differently, and therefore the rehabilitation time is very individual. Hence, the recovery period may be different for each patient.

How to prepare for the procedure?

Before the procedure, it is good to acquire basic rehabilitation equipment, such as a ball and an elastic band. You will need this equipment to continue rehabilitation at home, which is a necessary element for a speedy recovery. You should also buy cooling gel compresses, which are especially useful in the initial phase of rehabilitation. The last element is an orthosis or a shoulder sling. The orthopedic equipment is helpful when sleeping and will keep the shoulder safe when traveling.

The main goals of rehabilitation:

1. Reducing pain and swelling after the procedure,
2. Achieving full mobility of the shoulder joint and restoring the scapulohumeral rhythm,
3. Regaining stability of the shoulder joint,
4. Improving strength of the upper limb in order to perform everyday activities,
5. Dexterity training with the elements allowing to return to favorite sports.

In the Szpital Zakonu Bonifratrów, physiotherapy is performed by a team of specialists:

Rafał Trąbka, PhD

Łukasz Gregulski, MSc

Introduction

Platelet-Rich Plasma (PRP) injection is a medical procedure used for a wide range of musculoskeletal problems. PRP is a blood sample formulated to obtain a high concentration of platelets. The treatment improves the body’s natural ability to self-cure. It is applied to fasten healing and shorten the recovery time after acute and chronic soft tissue problems. The treatment technique has been relatively recently used to treat musculoskeletal problems, but due to its very good results, it is rapidly gaining popularity. PRP is successfully used to treat tennis elbow, golfer’s elbow, plantar fasciitis, Achilles tendinopathy and others.

Platelets are blood components whose main function is to participate in the process of blood clotting, e.g. after an injury. In addition to clotting factors, platelets release the so-called growth factors to start the natural process of healing. Injection of PRP at the site of musculoskeletal system damage stimulates and speeds up the natural processes of healing. This is especially important in the areas of poor blood supply (for example, tendons), because the procedure enables more effective delivery of the substances necessary for self-healing. Other treatments for chronic tendon problems do not necessarily improve the healing capacity of the tendon in the same way as PRP. In addition, PRP injections are devoid of many potential side effects of steroid injections or the long-term use of non-steroidal anti-inflammatory drugs (NSAIDs).

Course

Platelet-rich plasma treatment is divided into two steps: preparing platelet-rich plasma for injection, and injecting the preparation into the desired area. First, blood is collected and placed in a machine called a centrifuge. A centrifuge separates blood into layers, making it possible to collect the layer containing PRP. After the blood is collected and properly treated, PRP is ready. The preparation can be injected up to 30 minutes later. A doctor can use an ultrasound probe to place the needle directly in the desired area. General anaesthesia is not necessary.

What can go wrong?

There have been very few reports on complications and side effects of the procedure. Whenever an injection is given, there is a risk of an infection. A small number of patients reported pain, redness and swelling at the injection site, but these symptoms did not last long. Because the material injected during the procedure is mostly the patient’s blood content, there is no fear of transmission of bacteria or viruses (e.g. HIV). With other types of injection therapy, scarring and calcification may appear at the site of injection. This has not yet been reported with PRP injections, but it is theoretically possible. Allergic reactions are also likely but rare and are associated with the administration of a local aesthetic. The most dangerous complication is when a needle penetrates a blood vessel or a nerve, but with ultrasound visualization the risk of this complication is very small.

What happens after the procedure?

Immediately after the procedure, the patient is monitored. There may be some discomfort at the site of injection lasting from a few days to a week. The patient may feel even worse than before the surgery. This is because a local inflammatory response has just been triggered. However, worsening of the condition usually does not last long. After returning home, ice can be applied at the site of injection, you can raise your leg or arm, and reduce the activity to a comfortable level. Recommendations to limit activity vary depending on the area being treated. It is not recommended to use anti-inflammatory drugs (one week before the procedure and about 4 weeks after) because they may reduce the positive effect of the treatment.

The most surprising is the speed of recovery after the administration of platelet-rich plasma. This time is influenced by many factors, also independent of the patient and doctor. Sometimes, PRP allows to recover in half the time, without side effects, such as scars and adhesions.

In the Szpital Zakonu Bonifratrów, PRP is introduced by a team of specialists in orthopaedics and traumatology:

Stanisław Szymanik, MD – Head of the Diagnostic and Treatment Department

Michał Latos, MD

Michał Starmach, MD

MENISCUS

There are two menisci in the knee – lateral and medial. They are flexible “C”-shaped structures located between the articular surfaces of the tibia and the thigh. Their main role is to absorb stresses to which the knee is exposed during physical activity. They also help to keep the movements of the joint smooth and stable.

CARTILAGE

The ends of the femur, tibia and the articular surface of the patella are covered with the so-called hyaline cartilage – smooth and elastic tissue. It minimizes friction during movement and provides cushioning, which makes the movements in the joint painless.

Causes

Both the above structures can be damaged. The condition can be acute or chronic. The first appears suddenly, e.g. after an injury during physical activity. The second is the result of long-term overloads or changes in the structure of the tissues, e.g. prolonged process of destroying the structures due to osteoarthritis.

Symptoms

Injuries of the meniscus can be painful, e.g. when bending or straightening the knee. Sometimes there are mechanical symptoms, such as the feeling of clicking, shooting in the knee until joint mobility becomes blocked. These symptoms can be accompanied by joint swelling.

Damage to the articular cartilage can give similar symptoms, especially pain, which depends on damage to other joint structures.

Diagnosis

The initial diagnosis is often made after taking medical history and performing a clinical examination of the joint, it is confirmed by a diagnostic examination – magnetic resonance imaging of the knee.

Treatment

The treatment of damage to the articular cartilage and menisci depends on the form (acute vs. chronic), the extent of the disease and injuries of other structures of the knee. Minor damage can be treated conservatively – after the acute symptoms subside, rehabilitation is implemented. With larger damage, surgery is sometimes necessary.

Type of operation

The operation is performed by arthroscopy. Usually, two incisions are made – arthroscopic portals are located on the frontal surface of the knee. During the operation, an orthopedist confirms the preliminary diagnosis and examines all the structures for other damage. After a thorough intraoperative assessment, the doctor proceeds to the next stage of the operation.

Meniscal injuries are treated either by suturing the damaged fragment or removing the structure. A decision is influenced by many factors, especially the extent and location of damage. Meniscus transplants can also be applied – this method is still new, though high hopes are held for this procedure.

The treatment of cartilage also depends on the extensiveness of damage – the final decision is always intraoperative, and requires careful evaluation of the joint. The treatment options include “debridement” or “cleaning” of the damaged fragment, “microfracturations” or stimulation of the tissue at the site of damage to form a functional “scar”. There are also possibilities of cartilage transplantation or filling defects with biological matrices.

Postoperative period

In most cases, the day after surgery, drains are removed and the patient gets out of bed with the help of elbow crutches. Post-operative management depends on the treatment method. The limb usually does not require immobilization, quite the contrary, quick returning to full functionality is crucial for the patient to regain fitness. If everything is fine, the patient is discharged from the hospital. Rehabilitation should begin as soon as possible.

In the Szpital Zakonu Bonifratrów, arthroscopy of damaged meniscus/cartilage is performed by a team of specialists in orthopedics and traumatology:

Stanisław Szymanik, MD – Head of the Diagnostic and Treatment Department

Michał Latos, MD

Michał Starmach, MD

REHABILITACJA