Dr. Valentin Stoyanov is a specialist in orthopedics and traumatology. He has realized one invention and eight rationalizations in the field of surgery of large joints, recognized by INRA
Since 1982, he has been working mainly in endoprosthetics of large joints: hip, knee, shoulder. In recent years, he has turned his attention to operative methods for absolute equalization of the length of the lower limbs after hip arthroplasty. There are patented methods for reoperation in case of fracture of the femoral stem and in case of luxation of the endoprosthesis.
He graduated in orthopedics and traumatology at the Higher Medical Institute in Varna in 1979. He worked in the District Hospital, Razgrad, in the Clinic for Endoprosthesis of large joints at the Institute of Orthopedics and Traumatology.
From 1991 until now he has been practicing at the Orthopedics and Traumatology Clinic at the University Hospital "St. Anna" in Sofia.
Falling carries the risk of sprains and fractures, especially in older people whose bone density is weaker. It is known that this type of trauma poses a high risk to their lives. In most of these cases of fractures, arthroplasty is required. Many of the patients requiring and undergoing hip replacement are between the ages of 60 and 80. In recent years, orthopedic surgeons have created and developed new minimally invasive surgical techniques for placing hip implants through small incisions. The goal is to achieve a faster and painless recovery.
When endoprosthesis placement is necessary and in which cases reprosthetics are necessary - we talk with Dr. Valentin Stoyanov, orthopedist and traumatologist.
Dr. Stoyanov, have the cases of patients with endoprosthesis increased in recent years?
- In recent years, the cases of endoprosthetic patients have increased significantly, but I do not think that the diseases are more. The rate of arthroplasty has not changed significantly, but as in other areas of medicine and in orthopedics, a fairly large step forward has been made in the last 10 years. This is specifically related to the opening of Bulgaria to the world and the introduction of endoprostheses, which are produced by elite global companies.
How long have you been doing arthroplasty?
- I started doing endoprosthetics in the first Bulgarian clinic in Etropole, under the great professor Genchev, in 1982. Without exaggerating, at that time there were about 20 people in Bulgaria who were doing endoprosthetics.
Companies that deal with the sale of prostheses in Bulgaria have also started investing in the training of doctors in their specialized centers. And now the number of endoprosthetics specialists has increased a lot. In practice, regional hospitals are units where such surgery is not performed.
What are the main diseases that lead to the need for arthroplasty?
- One large group are degenerative joint diseases, mainly of the large joints, especially coxarthrosis and gonarthrosis. Out of 5,000 endoprostheses per year, about 4,000 are hip and the rest knee.
Systemic diseases, such as rheumatoid arthritis, Bekhterev's disease, also lead to endoprosthetics.
Another large group is femoral neck fractures. In elderly people, in the more severe cases of fracture, it goes straight to placing an artificial joint.
Which joints are replaced most often?
- Large joints are mainly prosthetics. Of course, it may be necessary to replace the shoulder joint as well, as the main indication in this case is fractures. The reason is that these fractures, which even if we manage to repair, heal with such adhesions that the hand has no mobility. Therefore, in case of certain types of severe fractures, one goes straight to endoprosthetics.
Are fractures the most common reason for prosthetic fitting?
- The most common cause is a fracture, less often - in tumors and in degenerative arthrosis of the shoulder joint.
Is it possible to avoid endoprosthesis with previous appropriate treatment?
- This is an important question for patients. The arthrosis process takes place in several stages - there is primary and secondary arthrosis, but the disease, unfortunately, always progresses. In some forms, it progresses more quickly, even within a year. I have a colleague with whom we work together. In one year, it got to the point where she couldn't walk, even though we caught her arthrosis in a very early form. I operated on her and now she is coming to work. In one year, in the absence of any pain before, primary coxarthrosis appeared and an endoprosthesis was needed.
There are others in whom the disease develops for a long time. For example, with dysplastic coxarthrosis (dysplasia means underdevelopment of the joint). It is a congenital disease. Women suffer from it more often, in a ratio of 9:1 compared to men. It is not uncommon for people to live without complaints, but at one age - fourth or fifth decade - secondary arthrosis appears. The disease has a very long evolution. The pain starts somewhere around 30-40 years old - it depends on the degree of underdevelopment of the joint. But it can manifest itself even at the age of 60-70, in order to reach endoprosthetics.
What are the main symptoms of degenerative diseases?
- In coxarthrosis, there are basically three symptoms, three profiles. The first is pain. She is different. It doesn't have to be strong, it can be weaker, even if there is no pain. - When does the pain appear? - Upon exertion. While in the more advanced stages, the pain manifests itself with the first step in the morning.
As the disease progresses, night pain appears. This indicates that the degeneration in coxarthrosis is quite advanced. It is due to venous blood retention and increased intra-osseous pressure.
Another group of symptoms is limitation of movements, mainly in external rotation, in the opening of the leg. They are also expressed to varying degrees. For example, in women with bilateral coxarthrosis, movement is restricted to such an extent that the patient cannot even wash herself - both legs are facing each other.
The legs can also stand bent, turned outwards - these are already the last, heaviest forms.
And the third group of symptoms, this is a decrease in bearing capacity. Various deformities also develop, such as shortening of the hip joint, muscle weakness begins. In the more advanced forms, through the trousers it is seen that the leg is weaker. These are the three main symptoms.
What does the treatment achieve?
- Treatment aims to eliminate these symptoms. When the range of motion is restored to 80%, together with the elimination of pain and the ability to support the limb, the treatment is considered successful.
Is this the purpose of arthroplasty?
- Endoprosthesis is a reparative (restorative) surgery - it improves the quality of life. When a fracture of the neck of the hip joint occurs during a fall, displacement, the patient feels pain and becomes unable to move - he cannot lift his heel off the ground, although he can bend the leg at the knee. This leg has no support and the patient is unable to walk, even standing up with assistance. This happens more often in older people who have serious co-morbidities. When the patient is bedridden, these diseases worsen - bronchopneumonia, inflammatory diseases, diseases of the excretory system and often lead to death. A great German traumatologist many years ago said regarding fractures of the femoral neck: "A man is born from his mother's reproductive organs, but not infrequently passes through the femoral neck!" Therefore, over the years, the decision has been reached for rapid endoprosthetics for fractures and displaced fractures of the femoral neck. After endoprosthesis, the very next day the patient can sit, stand upright, with no or minimal pain, and move.
And when is re-prosthetics necessary?
- Reprosthetics are required in several types of complications.
For a hip prosthesis to function painlessly, there must be a strong connection between the implant (prosthesis) and the bone. Because the most common complication is the so-called loosening - the endoprosthesis begins to move relative to the bone. Although the mobility is only fractions of a millimeter, it is very painful for the patient. Therefore it needs to be replaced.
Is the entire endoprosthesis replaced?
- No. The endoprosthesis consists of three parts. A femoral component that fits into the femoral canal, the acetabular capsule where the femoral head fits, and a femoral component that a cap sits on. That's where the movement takes place - the head rotates in the capsule. It is immovable, the femur is immovable, the head is also immovable in relation to the femur. The movement is between the cap and the acetabular capsule. When there is mobility between the femoral stem and the femur, we say that the femoral stem is loose. It alone and the acetabular capsule can loosen. And it is these parts that are replaced.
What are the most common complications requiring replacement?
- The larger group of complications is luxation of the prosthesis, when the cap comes out of the acetabular capsule. Whenever this happens, there is some minor or major error in placement of the endoprosthesis. A variety of reasons can be cited - that the patient had crossed his legs, that the rehabilitator did not move him properly, and many other things, but the reason is a mistake in the placement. When we exclude, of course, cases of severe falls. A he althy hip joint can also break in severe trauma. This can also happen with a hip replacement. When there is no such severe trauma, there is always a placement error.
And can the prosthesis itself break?
- The endoprosthesis itself can also break. Fortunately, in recent years this has become a case study - it is extremely rare. Even the young doctors who are studying now will not see such a fracture.
Is there another reason for reprosthetics?
- We come to the third reason - infection of the endoprosthesis This, fortunately (for both patients and us), happens rarely - in about 2-3% of cases. I say: -about", because unfortunately, we do not have good statistics in Bulgaria. In Western clinics, this figure is less than 1%.
Looseness, breakage, no matter how unpleasant they are, can be successfully treated in experienced hands. And the infection is extremely difficult to treat - regardless of the skill of the doctor, regardless of which hospital it is treated in, regardless of the antibiotics and various antiseptics that are applied, half of the infections end with the removal of the prosthesis.
And then what is done?
- At first the person walks with two crutches, then with one - it depends on the age, on the presence of other diseases… But this is the most unpleasant complication.
The endoprosthesis of the large joints - hips and knees - is a serious operation. The fact that there are already many experienced specialists, or rather teams, does not turn it into some small operation. Before its implementation, the patient is mainly examined because he must be in good general condition (I am talking about arthrosis). A blood transfusion is often necessary (in almost half of the cases), and prophylaxis is carried out.
In which cases is prophylaxis required?
- The criteria for prevention are different. Patients should know that it is necessary to do one with antibiotics - once or for three days.
What other complications should be prevented?
- Another unpleasant complication that is also prevented is phlebothrombosis and embolism. It is not only a priority in performing cardiac operations, but also in all major operations of the musculoskeletal system. Even without conducting an operation - for fractures treated with plaster, such prevention should also be done. It is carried out by means of high molecular weight nivalins. More than 10 years ago, drugs that are taken orally and block clotting factors also appeared on the market. They help us protect the patient from these very unpleasant and dangerous complications.
Phlebothrombosis and embolism can occur in a very mild form, but it can also develop severe and lead to a fatal outcome. Fortunately, with the introduction of these dosage forms, this complication has been reduced to a very low rate.
When should the prevention of these two complications be carried out?
- It is prevented even in the hospital, and then continues at home - it may take a month, but if there are other accompanying diseases of the bone system - up to two or three months.
Bulgarian dentures are of good quality
“Bulgarian prostheses for beautiful. Technological errors that previously led to broken prostheses have long since been overcome. But they have the following drawback: they have not undergone any technological improvements and improvements for 20 years. While in Europe and the USA they have serious advances in technology. New materials, new instrumentation, new biomechanical improvements are released every year, and Bulgarian prostheses remain at the level of 20 years ago
My 8 rationalizations are mainly in the centralization of the joint, in the extraction of a broken femoral stem - a very elegant method. I have also made improvements in the area of hip dislocations that are constantly shifting and coming out. This method solves this constantly recurring endoprosthesis problem.
The problem of equalizing the length of the limbs after endoprosthesis is also important," explained the surgeon.
Rehabilitation after surgery is very important
“Rehabilitation is very important. It should start in the hospital, continue at home, and then in a spa. In order to achieve a good result, there must be a very close interaction between the surgeon and the rehabilitator. I have already mentioned that in the case of degenerative diseases and fractures, the muscles weaken. Therefore, even if the operation is done perfectly, it cannot restore the muscles. Endoprosthesis relieves pain, makes the joint resilient, restores volume, but cannot restore movement without the help of a rehabilitator, and that too in a specialized facility.
Even the most expensive and beautiful prosthesis, placed perfectly, cannot move on its own. The range of motion must then be restored through rehabilitation," said Dr. Stoyanov.
