Co leczymy?

Introduction

A shoulder dislocation is a fairly common injury, especially in certain sports. Most of the injuries are damage to the acromioclavicular joint (AC). The AC joint connects the shoulder blade and the collarbone. Shoulder dislocation and damage (dislocation) of the acromioclavicular joint are often confused with each other. These are completely different injuries. This guide will help you understand: what is the acromioclavicular joint (AC)? What happens when the joint is damaged (dislocated)? How is the AC joint damage treated?

Anatomy

How is the AC joint built and what is its function? The shoulder joint consists of three bones: scapula, humerus and collarbone. The part of the shoulder blade that forms the vault of the joint is called the acromion. The AC joint is the junction between the acromion and collarbone. The ligaments stabilize the connection. The ligaments are bands of the soft tissue that connect the bones. The acromioclavicular ligaments surround and stabilize the AC joint, forming the articular capsule. It is a waterproof bag that surrounds the joint, it is filled with joint fluid. Two other ligaments, the coracoclavicular ligaments, stabilize the collarbone by attaching to the coracoid process of the scapula. Damage to the AC joint can be mild to severe, depending on which ligaments have been stretched or torn. The mildest type of an injury is a minor damage (strain) of the acromioclavicular ligaments. It is the first degree injury, while the second degree injury is damage to the AC ligaments and the coracoclavicular ligaments. Complete rupture of the AC ligaments and the coracoclavicular ligaments is the third degree injury with a positive “piano key sign”.

Causes

How does the AC joint damage occur?

The most common cause of AC joint damage is a fall on the shoulder. When the limb hits the ground, the force of the impact moves the blade downwards. Because the collarbone is attached to the chest, it cannot move enough to follow the movement of the shoulder blade. As a result – the ligaments stabilizing the AC joint are damaged, displacing the collarbone.

Symptoms

The symptoms range from mild to severe pain of the AC joint in the event of complete dislocation. The second and third degree injury may cause swelling and bruising. In the third degree injury, the patient can experience the feeling of loose collarbone displacement (‘piano key sign’) and deformation of the AC joint.

Diagnosis

What examinations will be performed?

Your doctor will need to obtain the information about an injury and take detailed medical history. You will be asked questions about recent shoulder injuries. You will have to assess pain on a scale from one to ten. Diagnosis is usually preceded by a physical examination. The doctor can move the shoulder. It can be painful, but it is very important that your doctor finds the exact location of pain and identifies movements triggering pain. The doctor may order an X-ray to visualize damage to the joint and exclude collarbone fracture. Occasionally, an X-ray with loading of both hands is performed in order to confirm instability.

Treatment (What are treatment options?)

NON-SURGICAL TREATMENT

Treatment of the first and second degree injury is usually analgesic with a short period of rest using a sling. The rehabilitation program is prepared by a physiotherapist. Treatment of the third degree AC injury is somewhat controversial. Many studies have shown no difference between surgical and conservative treatment. Even with surgery, there is a possibility of persistent deformity of the area of an injury. A large proportion of patients after operation need another, additional surgery.

Research has revealed the condition of the AC joint after an injury. Many patients, regardless of whether they have undergone surgery or non-surgical treatment, will require surgery in the future. This is due to the fact that a damaged joint degenerates faster than an intact joint. It becomes deformed and painful over time. The process may take several years, but sometimes even one to two years.

SURGICAL TREATMENT

Some surgeons prefer to operate third degree AC joint injuries, especially in competitive hammer/discus/javelin athletes. Surgery is usually done through an incision over the AC joint. A surgeon sets the articular structures in the correct position (reposition). A screw or other type of fixation is used to stabilize the collarbone during the process of biological healing of the ligaments. Stabilization of the AC joint with a screw is based on joining the shoulder end of the collarbone with the coracoid process of the scapula. Some operators use tape to fix the clavicle with the coracoid process. Small holes are made in the collarbone and the coracoid process, tape is threaded through the structures and fixed, in some cases, ligaments are also repaired. If a screw is used, it is usually removed six to eight weeks after surgery.

In the Szpital Zakonu Bonifratrów, arthroscopy of the shoulder 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

REHABILITATION

Introduction

Hernia is a common condition in which organs of the body move to an area where they should not be physiologically. In inguinal hernia, the contents of the abdominal cavity (mainly preperitoneal fat, mesentery or the entire intestinal loops) are displaced into the inguinal canal. With large, long-developing hernias in men, the intestinal loops may move along the inguinal canal to the scrotum, causing it to significantly enlarge.

Causes

The causes of inguinal hernia can be divided into dependent and independent of the patient. The reasons beyond the patient’s control include genetic predisposition, the quality of collagen, the main component of the connective tissue which gives strength to the abdominal wall, the ratio of type I to type III collagen. Patient-dependent causes include chronically increased abdominal pressure due to, for instance, hard physical work, lifting weights or persistent coughing (hernias are more common in asthmatics). Sometimes, hernia develops in patients not burdened with the above risk factors.

Symptoms

A lump, prominence or bulge, that comes and goes and is located in the groin area, is often the first symptom of inguinal hernia. Additionally, hernia may be accompanied by pain or discomfort, such as burning, pulling or gentle pricking. Pain usually occurs with exertion, standing or walking for a long time. Incarceration, or a situation in which the contents of hernia become blocked in the canal and immobile, is a dangerous complication of inguinal hernia. It causes swelling, blood circulation disorders, and in the worst case, necrosis and perforation of the intestinal wall inside hernia. It is a life-threatening condition requiring emergency surgical intervention. This is why a surgery performed at an early stage of hernia development is the preferred method of treatment to prevent serious and dangerous complications.

Diagnosis

In order to diagnose inguinal hernia, it is necessary to take detailed medical history and perform a thorough physical examination. Sometimes, additional examinations, for example, ultrasound is needed.

Treatment

The treatment is based on a surgical reduction of hernia back into the abdominal cavity and strengthening the abdominal wall to prevent hernia from recurring. The strengthening is possible not only by suturing the defect, but also by implanting a special mesh that makes the wall stronger and reduces the possibility of recurrence. The mesh is made of a fully biocompatible material to avoid rejection by the patient’s body.

Type of operation

The procedure can be performed using the classic method (the so-called Lichtenstein repair) with a small, about 8 cm incision made in the groin – this place is very easy to hide under underwear – practically invisible. Laparoscopic surgery is an alternative method, which is a bit more technically complicated. It is the method of choice for patients who have previously undergone the Lichtenstein repair. Here, instead of a scar in the groin, the patient has 3 or 4 small (about 1 cm) incisions made on the abdominal integument through which laparoscopic instruments are inserted.

Postoperative period

In most cases, inguinal hernia surgery is a one-day procedure. This means that the patient is admitted to the Ward in the early morning, on the day of the procedure, operated on the same day, and discharged home in the evening. The patient leaves the hospital on his/her own, being practically fully functional. In some cases, there is a need to stay in the hospital for one night for observation.

The recovery period takes about a month. It is important to avoid strenuous exercises. Lifting heavy objects is also contraindicated. During this period, the patient is fully fit and, apart from avoiding heavy physical exertion, can perform normal daily activities.

In the Szpital Zakonu Bonifratrów, inguinal hernia operations are performed by doctors from the Department of General and Oncological Surgery.

Introduction

Cholecystolithiasis is one of the so-called “civilization diseases”, affecting about 20% of the adult population. The incidence of the disease increases with age, though recently there has been a marked increase in cholecystolithiasis among young people. The condition more often affects women. Predisposing factors may include lifestyle, improper diet, obesity, reproductive age and hormonal drugs.

The disease involves the production of hard stones around the so-called crystallization points in bile accumulated in the gallbladder. The structure is a kind of storehouse supplying bile to the lumen of the gastrointestinal tract as needed, mainly after abundant fatty meals. Over time, crystallization points in bile become larger and larger, reaching sizes up to several centimetres in diameter.

Symptoms

Initially, the disease is asymptomatic. The first symptoms of cholecystolithiasis usually include flatulence, a feeling of pressure under the right costal arch, the lack of appetite, discomfort, rarely, sharp stinging on the right side of the abdomen. Occasionally, a stone moves into the lumen of the gallbladder neck, obstructing the bile flow. This is dangerous to health and life, as it can lead to acute cholecystitis, perforation (rupture) of the wall and diffuse peritonitis, which is a life-threatening condition requiring an emergency intervention. In order to avoid this dangerous situation, most of the patients with the symptoms of cholecystolithiasis should undergo an elective surgery to remove the gallbladder. An elective surgery is safer than an emergency procedure, as it allows the patient to prepare for the operation which is performed at an appropriate time based on a previously agreed schedule, necessary examinations and consultations are also possible. Therefore, an elective removal of the gallbladder in patients with symptomatic cholecystolithiasis is the treatment of choice.

Diagnosis

In 95% of the cases, in addition to medical history and physical examination, an abdominal ultrasound is enough to diagnose cholecystolithiasis. The condition is often detected by chance during an ultrasound examination performed for other reasons. More specialized examinations, such as computed tomography and ERCP [Endoscopic Retrograde Cholangiopancreatography] are rarely necessary.

Treatment

The treatment is based on a surgical removal of the entire gallbladder. The procedure can be performed in two ways – by laparoscopic technique or classic method. Currently, practically all patients undergo a laparoscopic surgery as the technique of choice – it is less invasive, allows for faster convalescence, minimizes the risk of wound infection, healing is more efficient than after a conventional surgery. Virtually all gallbladder removal procedures performed in our hospital are laparoscopic.

Postoperative period

A laparoscopic removal of the gallbladder is carried out on the day of admission to the hospital. After the surgery, the patient spends one night in the hospital for observation. The next morning, the drain is removed, dressings are changed, and the patient is discharged home with further recommendations regarding the care of postoperative wound and an appropriate diet. After about 10 days, the patient reports to the Outpatient Clinic, where the general condition and the correct wound healing are assessed – then, the sutures are removed and the patient returns to full activity.

In the Szpital Zakonu Bonifratrów, gallbladder removal operations are performed by doctors from the Department of General and Oncological Surgery.