Privatklinik Bethanien in Switzerland attracts patients from all over the world. The hospital was founded more than 100 years ago and is proud of its exemplary reputation. It is a place which successfully draws upon traditional time-tested treatments, global inventions and the clinic’s own methods. The specialists at Privatklinik Bethanien are outstanding professionals experienced in the complex challenges of diagnostics and high-precision prosthetic surgery. One of the clinic’s most progressive areas is its orthopaedic department. Today we are talking to department heads Matthias Schmied, Urs Munzinger, Fabian von Knoch and Philipp Frey. They know all there is to know about the locomotive system – how to relieve joint problems and how to return patients to an active life after prosthetic work.
The knee is one of the most complex joints. It requires very delicate work – a watchmaker’s hand – to treat it. Our knees determine how easy or difficult our journey through life will be. Dr. Matthias Schmied told us how to efficiently treat a knee joint by non-surgical means and how new Swiss technologies help to improve the results of knee prosthesis.
– Dr. Schmied, what’s the most common diagnosis you give to your patients?
– Osteoarthritis, meaning degenerative changes. There are a wide range of causes, including age, activity, trauma, anatomic abnormalities, inflammatory conditions and other diseases.
– What should a patient do in this situation? What kinds of treatment can you recommend?
– First of all you should remain active if possible, and supplement your physical exercise with physiotherapy. The second step includes painkillers and injections – traditionally cortisone. Modern methods involve injections of autologous conditioned plasma. A patient’s blood is taken and processed. The healing elements are separated from the blood and are injected back into the joint. The advantage of this method is that the patient’s own healing potential is used. There is no risk of allergy. It is efficient in case of mild to moderate arthritis, sports injuries and inflammatory diseases affecting ligaments. If conservative treatment does not help, the next step is surgery. For early stage arthritis and a damaged meniscus, arthroscopy is a possible option as a minimally invasive procedure.
If joint preserving treatments fail and degenerative changes are too advanced, an artificial knee-joint is an excellent option. Patients spend a week in hospital and then they need to undergo rehabilitation. In a high percentage of cases we are very satisfied with the results. A new Swiss invention involves special surgical techniques to improve the stability of the artificial knee joint. The results are very promising and many patients are able to go back to taking part in sports.
– What are the most common knee operations?
– Knee-joint arthroscopy to address meniscal damage or to treat ruptured cruciate ligaments is very common. Another focus in our clinic is the treatment of arthritis. Patients with advanced degenerative changes are often given artificial knee joints. Revision of primary knee implants are increasing in number. Old or non-functional implants need thorough clinical examination and X-ray investigation to find the reason for the problem.
– What is the right time for surgery?
– This is a very important question. In the case of a damaged meniscus, it depends very much on the symptoms. Articular constrictions are mostly very painful and demand immediate surgical intervention. Sometimes the meniscus can be sutured, sometimes a part has to be removed. Degenerative lesions of a meniscus with moderate pain can be treated conservatively at first with the aim of leaving as much of the meniscus as possible to preserve its function. Concerning artificial knee joints the psychological strain is very important. If the patient is suffering and their quality of life is impaired one shouldn’t wait too long.
– Some people suffer from pain as a result of local cartilage damage. Are there options for repairing cartilage?
– Yes, we carry out a process known as microfracturing, or drilling of the afflicted area. Bone marrow cells can colonize the defect and form cartilage-like tissue. These cases demand post-operative partial weight-bearing and bracing of the knee.
– What sports are not recommended for people with knee problems?
– Generally speaking, any sport that results in pain should be avoided. Contact sports as well as stop-and-go movements are usually not good for damaged joints. Joint conserving activities include hiking, biking, swimming etc. If running is vital, choose soft paths and use cushioned running shoes.
It’s important to realize that moderate activity is good, even for arthritic joints. The joint surface is covered by cartilage and moving the joint helps to nourish this layer.
The hip joint has had a very important function since human beings evolved to stand on two legs and walk. This joint is subjected to extreme pressure, which is why it is one of the largest joints in our body. Dr. Urs Munzinger and Dr. Fabian von Knoch know what to do in order to ensure a long life for this joint.
– What makes it necessary to replace a hip joint with an artificial one? What preventative action can be taken? What aggravating factors can affect a hip replacement?
– Recent studies show that around 80% of cases of coxarthritis (arthritis of the hip joint) have mechanical causes going back to developmental disorders (in young people who are still growing). These create a deformation of the joint, which in turn leads to arthritis, usually at the age of around 50–60, sometimes earlier. It is called femoroacetabular impingement.
Other causes of painful coxarthritis can be inflammatory diseases such as polyarthritis, gout, or conditions affecting the circulation to the femoral head. Accidents involving fractures of the hip or hip socket can also lead to arthritis in the long term. One special situation that can occur is a condition known as hip dysplasia: the congenital misalignment of the hip or flattening of the hip socket. This condition is very rare and nowadays babies are checked for it with ultrasound scans and treated accordingly.
– Are there differences in the implants available? How do you choose the right joint for the patient?
– There are approximately 500 different models of artificial hip worldwide. The selection is made using scientific criteria, aiming to ensure good long-term performance (longevity should be at least 10 years). The trend everywhere is for uncemented hip arthroplasty. Cementing is only carried out in exceptional cases. The correct replacement hip must be adapted to the anatomical characteristics of each individual patient. Meticulous planning prior to surgery is key here, as is the experience of the surgeon in working with the relevant type of prosthesis.
– Are there any restrictions placed on the patient after the hip replacement? What do they need to be aware of regarding day-today activities, and sports as well?
– For the first four weeks the patient will need walking sticks, but they can place their full weight on the joint. For six weeks after surgery certain movements are not allowed; rotation in particular is limited in the initial period. Then, with good recovery, the hip can be used normally for everyday activities and sport. However, the range of movement is often a little limited compared to a healthy hip, so activities such as yoga will have to be adapted. Having said that, many patients go back to doing sports like tennis, skiing and cycling without restriction. The important thing, especially with sports, is that it is an activity that the patient did before.
We recommend returning to sports that were practised previously, albeit under professional supervision. You also have to make a distinction between sports involving an average level of activity and highperformance sports. Non-impact sports promote bone growth, reduce obesity and improve mental health.
Patients with uncemented hip replacements who actively participate in skiing, tennis or golf get better functionality and better coordination than less active patients. Very intense sporting activity can theoretically lead to a higher rate of wear, although modern artificial hips with a ceramic head and highly cross-linked polyethylene guarantee a very long service life without any measurable wear.
– How long does a replacement usually last?
– The life-span of a replacement hip these days is 20–30 years. The best results are achieved with an uncemented hip implant and a ceramic femoral head articulated against a special highly crosslinked polyethylene. Long-term studies have revealed practically no discernible wear in these cases.
– When would an artificial hip need replacing?
– An artificial hip needs replacing if an infection occurs. Early infection within the first three months is exceptionally rare (less than 0.5%). Occasionally a late infection may occur, where bacteria are dispersed through the bloodstream to the implant from a focus elsewhere (e.g. a tooth abscess), causing an acute infection of the joint.
Another reason for changing the prosthesis may be repeated coxofemoral luxation, i.e. dislocation of the hip joint. First, efforts are made to stabilize the joint by repositioning, but if that does not succeed, a more rigid model will have to be used. In rare cases, especially involving older models, abraded particles can lead to a painful loosening of the components of the joint. This requires surgery to replace the prosthesis. At any rate, for good measure the joint should first be aspirated to exclude the possibility of an infection being present.
Implant replacement operations are very time-consuming and post-operative care is complex. Surgeons need to be highly experienced and the medical team well-coordinated. Here for example we always have three specialist doctors at the operating table and work with an infectiologist during the follow-up treatment.
Even though the whole experience can be a difficult one for those involved – including the patient, of course – a positive outcome is achieved in almost every case. Competent and diligent care is important as well as the operation itself.
– Are there partial implants? When must a complete joint be replaced and when is a partial replacement sufficient?
– There is the possibility of replacing just the lower part of the hip joint on the femur without a new socket (in a process known as hemiarthroplasty). This type of partial replacement is occasionally used for older patients who have suffered a femoral neck fracture. In our opinion, however, a total hip arthroplasty, i.e. replacement of both the socket and the ball, is always the far better solution in these situations. It is important to restore the anatomic geometry and treat the soft tissue with care.
By contrast, partial prostheses are used on a regular basis in knee replacement surgery at the joint centre in Zurich. With partial knee implants it is possible to replace the medial, lateral and patellofemoral compartments separately whilst preserving all the tendons of the knee joint. Unlike a total knee replacement, this generally allows a more natural feeling in the knee and better functionality of the joint.
The shoulder joint has the widest range of motion of all joints in the human body – it enables us to move our arm through roughly 17,000 different positions and it helps us to carry out a wide variety of actions – everything from hugging to throwing! However, this huge mobility makes the shoulder prone to injuries. Dr. Philipp Frey tells us about typical problems and how to treat them.
– Dr. Frey, can you describe your typical patient?
– Shoulder problems are generally age-related. There are some young, competitive and athletic people with acute injuries or overuse-related problems due to sports activities or work-related wear. But the typical patient is middleaged and still very active, and sometimes .high-demand. in terms of sports and physical health. And there is a third group comprising an elderly population, sometimes with advanced degenerative changes or arthritis.
There are a lot of different conditions that can lead to a dysfunction of the shoulder joint and its movements. Among these are soft-tissue injuries like rotator cuff tears, degenerative joint disease, calcifications and arthritis, and even acute fractures, instability and dislocations.
– How do you treat those different kinds of patient-related requirements and injuries?
– The most important step is to obtain a detailed individual diagnosis straight away and to identify the factors causing pain, loss of strength and mobility or disabilities in everyday activities. In a predominant number of cases we go for an MRI or CT scan after a conclusive physical examination. Whenever possible I aim for anatomic restoration of the anatomy and shoulder function. By means of arthroscopic surgery via small skin incisions it is possible to reconstruct many kinds of injuries such as tendon-to-bone repair, impingement-related problems, stiffness and loss of motion or instability. For advanced degenerative changes such as shoulder arthrosis (degenerative joint disease) there are ultra-modern treatments involving prosthetic replacement of the joint, which produce excellent results.
– When would you make the decision in favour of prosthetic joint replacement?
– Shoulder prosthesis (arthroplasty, artificial joint replacement) is only used when anatomy-preserving treatments are no longer possible. There are two main groups: loss of cartilage and irreparable tears of the rotator cuff. However, it is important to determine the underlying cause of degenerative changes and choose an appropriate treatment schedule. It is also crucial to evaluate the individual risks properly. In some cases, we go for conservative treatment by injections with platelet-rich plasma (PRP or ACP) or steroids to combat inflammatory disease. But in many cases we can expect a very good and long-lasting restoration of shoulder function after prosthetic joint replacement. Patients can even go back to sports activities such as tennis or golf.
– Which types of shoulder arthroplasty do you use for your patients?
– There are two main groups of shoulder arthroplasty: anatomic and reversed. I usually go for the anatomic implant for patients with degenerative joint disease and intact rotator cuff tendons. In this case only the contact surfaces of the shoulder joint are changed by the implant.
But if the surrounding tendons of the rotator cuff are torn or defective and reconstructive surgery is no longer possible, we use the so-called reverse shoulder arthroplasty, which enables us to restore stability and a good range of motion to the shoulder joint again. The goal of both types of shoulder prosthesis is to restore a good and pain free shoulder function in each type of patient.
Much more important than the type of implant itself is careful surgical technique and accurate joint arthrolysis to rebalance the shoulder joint without damaging the important surrounding neurovascular structures. Sometimes this part of the operation takes up to an hour, but it is necessary – there is no room for error here.
– Dr. Frey, tell us about the recent developments and applications in shoulder arthroplasty.
– Many important replacements, renewals in techniques and implant designs have been developed in recent years. There has been a breakthrough in preoperative planning regarding the size and positioning of the implants, with 3D virtual analysis of the prosthetic components in the human body now possible. Planning software using computed tomography (CT) allows us to calculate and optimize the individual range of motion even before the operation, and patient-specific instruments are developed and produced for the operation. These tools can help the surgeon to position the implant to perfection and optimize the patient’s shoulder function after surgery.
– Please tell us something about postoperative care and rehabilitation.
– The most important thing is for the patient to understand what movements are available to them, so we teach them about that. A specialist needs to examine the patient to assess progress and the extent to which it is possible to load the joint. It should not be kept still, as then it will not only fail to regain mobility, but may lose it altogether.
Rehab after the operation is crucial. The patient needs to know which movements are allowed and which are not. This is the most important issue. We use continuous passive motion on a special shoulder chair and give instructions for easy-to-perform exercises – so we teach them about all that in person. Additional physical therapy may help achieve a good outcome, but ultimately individuals are responsible for their own regular shoulder rehab. They have to understand what it is all about and we help them to get an idea about that. Teaching and understanding is the road to success.
Doctor of Medicine, MD. Specialized in Orthopaedics and Traumatology. He studied medicine at the University of Zurich (Universit.tsspital, Zürich) and has been practicing since 2000. Dr. Schmied has worked in leading healthcare institutions in Switzerland, Germany and Scotland. Since 2016, he has run his own practice. Among others, he is a member of the International Society for Hip Arthroscopy (ISHA) and the Swiss Medical Association (Vereinigung der Schweizer .rztinnen und .rzte, FMH).
Doctor of Medicine. His specializations are orthopaedic surgery and locomotive system traumatology, and hip and knee replacement. He graduated as a medical doctor in 1971. From 1996–2009, he was head doctor at the Schulthess Clinic in Zurich. Since 1998, he has been visiting professor at Charles University in Prague. Since 2009, he has worked at the Orthopaedics Centre at Privatklinik Bethanien. He is a member of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), the International Society of Orthopaedic Surgery and Traumatology (SICOT) and the European Hip Society (EHS).
Fabian von Knoch
Doctor of Medicine, Associate Professor for Orthopaedic Surgery, and specialist for minimally invasive hip and knee replacement including complex revision surgery. He is a member of national and international orthopaedic expert groups including the Knee Expert Group of the Swiss Orthopaedic Society, the European Knee Society (EKS), and the European Knee Associates (EKA). Dr. von Knoch completed the renowned Harvard Arthroplasty Fellowship at the Massachusetts General Hospital in Boston (USA), and worked as consultant hip and knee surgeon at the Schulthess Clinic; since 2013 he has been in private practice at the Zurich Bone and Joint Centre at Private Hospital Bethanien in Zurich.
Doctor of Medicine, and an expert in orthopaedic surgery and shoulder and elbow joint traumatology. He qualified at the University Hospital of Zurich (Universit.tsspital Zürich). After his studies he completed a profound education in several Swiss orthopaedic centers, where he went through 3 years of training in surgery, followed by 7 years of special education in ortopaedics. Since 2013, he has run his own practice and has worked at Privatklinik Bethanien. He is a member of the Swiss Society of Orthopaedic Surgery and Traumatology (Schweizerische Gesellschaft für Orthop.die und Traumatologie, SGOT), Arthroscopy and Joint Surgery (Gesellschaft für Arthroskopie und Gelenkchirurgie, AGA) and the Zurich Society for Orthopaedics (Zürcher Gesellschaft für Orthop.die, ZGO).