Winter is knocking on the door, and it increases the risk of injuries, while training or walking. Which are the most common problems and how to deal with them? “Standard” asked Dr. Dinko Hubenov who works at Medical Center ” Sveta Bogorodica ” in Sofia. He is the first specialist in our country to introduce the method of treatment with growth factors in athletes.

– Dr Hubenov, which is the most significant and severe trauma in winter?
– The knee injury, and in particular – the tear of the ACL (PKV). Mistakes still occur , both in diagnosis, and the behavior and treatment after the injury. Most often after a torsional trauma of the knee ,especially when it happens for the first time ,the ACL gets torn. In only 20-25% of cases there might be some additional damage.
I won’t mention the common mistakes made by some doctors after this type of injury – operations which are completely unnecessary, or immobilization of the joint for a long time. I will try to give you an algorithm for a proper behavior in these cases. When such trauma occurs, the most important thing is the primary exam. An X-ray is obligatory to exclude broken bones and joint elements. If there is no bone damage and the knee is very swollen, the doctor must evacuate the liquid from it. He also must examine the collateral ligaments of the knee. It’s not a hard thing to do. If these ligaments are damaged too , it is necessary to evaluate the degree of instability. Depending on that, the knee might be immobilized with a suitable splint or operated urgently in order to sew in the torn ligament. We have a device called TELOS, which gives a fair view of the lateral stability.
Most often, LCM is slightly swollen and stretched .It does not require a special intervention. The patients are sent home and advised what kind of drugs to take and to put ice on the damaged knee several times a day. After about 6-7 days the pain and swelling decrease about 80%. A secondary examination must be made, to evaluate the stability of the knee. Sometimes it might be necessary to make a MRI examination. I want to warn the patients that in the treatment of the knee injury there is no emergency condition, requiring surgery at all costs. Here I exclude bone fractures and complete rupture of one or both collateral ligaments. All other injuries must be treated in planned order. After restoring the range of motion and the acute period is passed, a reconstructive operation of the torn anterior cruciate ligament has to be done. Experience shows that the most appropriate period to do that is about 1.5 months after the trauma. Preoperative rehabilitation quickly and easily prepares the damaged joint for the operation.

– What is your approach to these kinds of injury?
– At MC “Sveta Bogorodica-Vazvestitelka” (which is made by model of a clinic in the Austrian Alps), we introduced an integrated approach based on our vast experience – more than 2800 reconstructive LCA operations. We have a super modern diagnostic and operating equipment and a unique physiotherapy and rehabilitation center.

– Why is it unique?
– Unique, because we were able to combine the vast experience of our therapists, gained by treating our national athletes for 20-25years, with the full set of physiotherapy equipment of the best company specialized in production of sports equipment and tools “Don Joy” – all of them are “Intelect” series. This equipment has a huge software library concerning various types of conditions, and all its parameters are set automatically.

– What is different in your approach?
– Everything that concerns diagnosis, treatment and rehabilitation is performed in one place by the same team. Every operation we make is recorded and a copy of it is given to the patient. 90% of our patients don’t need to use crutches .They don’t need to use the splints to immobilize the knee for more than 5 days. The patients can walk properly after 6-7 days . The active rehabilitation starts after removing the stitches, on the 10-12th day. Almost full range of motion is achieved in the gym about 20-25 days after the operation. In this period we put intraarticular injection with growth factors in the knee. It accelerates the bone and tissue healing. Most patients can start work about 30-35 days after the surgery. Full recovery , which allows sports practice depends on the individual characteristics of the patient and takes from 5 to 10-11 months.

– Why is the treatment of this injury so important?
– These injuries affect mostly young people and if our approach is not serious enough, it leads to serious damage that can cause invalidity. If this happens to a 20 years old person, what can he expect next? Artificial joint is not an option.

– This is just one of the sports injuries. How do you proceed with others?
– This is the most frequent serious sports trauma. In lighter injuries – such as sprains, muscle tears, strains, direct clashes we provide treatment with growth factors. In most of the acute trauma cases we put plasma injection in the affected area. It is extracted from your own blood. These injections cause reaction of selfhealling, which quickly decrease the inflammation symptoms and provide good and proper recovery.

– Does it help only in acute injuries?
– No, they help also in chronic diseases such as overload, problems with the Achilles tendon , cartilage damage and others. Lately, in some complicated cases, we combine the therapy of growth factors by introducing them from the outside, and help their release from the inside of the body.

– How do you do it?
– The procedure became possible after we bought a device for SHOKOWAVE therapy. It provides a precisely measured ultrasonic hit. It is something like breaking the kidney stones. These ultrasonic hits transform the chronic process to acute. Once it is done a release of growth factors occurs from inside of the body. We combine and reinforce this effect by using the plasma injections from outside to inside. So far, the results of the therapy are very encouraging. Yet our experience does not give us the right to make scientific conclusions. A month ago we made a presentation based on our overall experience at the Fifth Congress of Balkan arthroscopic surgery and sports injury association, under the aegis of the European Association of Knee Surgery and Sports Medicine. It caused a serious scientific interest. We called the therapy “The biophysiological method of treatment of the XXI century”.

– You mentioned the cartilage damages. They are “the plague” of the generation over ’50. What can you tell us about it?
– For a very long time I’ve tried to reach the people with such problems, but the incorrect practice implanted over the years, is enshrined firmly in the life of the bulgarian people. When they start seeking competent medical help, unfortunately, it is too late! The most common story begins with an incident preceding the pain in the knee for more than two months. People go to the doctor, he recommands an X-ray. The conclusion in people over 50 is “initial gonarthrosis”(Degree of degeneration of the joint, which many interpret as spikes in the knee). It happens in 90% of cases.
This makes people passive and disillusioned , and they usually proceed to Spa treatment. It often leads to increase of the pain. From that point on people are determined to more aggressive action. To be more specific -injections. Please do not allow treatment with cortisone when the reason for the pain is not clear. It dramatically weakens the strength of the connective tissue and the cartilage. Very often some doctors place 2-3 injections In very short period of time. This is wrong. This is the beginning of the end. After about a month , dew to overload , pain occurs in the other leg. When this pain increase to the point of inability to walk, it is too late. Injections are very good, but only when placed on the right indication. Artificial joint is an alternative with an open end.

– So what would you suggest?
– No cortisone in the early stages of the complaint. When the knee pain persist for more than 3-4 months, especially after some kind of accident, a MRI must be made. In 70% of cases, it appears that there is rupture of one or both meniscus – external or internal. This is a source of inflammation, leading for a few months to severe osteoarthrosis and joint destruction. Cortisone injections increase this process. When the meniscus is injured it requires surgery. I doubt there to be any more colleagues who think differently. It’s a matter of one day surgery. The procedure of meniscus repair takes no more than 20 minutes. In most cases, physical therapy and rehabilitation begin the next day. In patients who’s knees are hardly damaged but still hopefull, we provide a kind of cleaning of the joint under athroscopic control. When mechanical irritants are removed and the damage they made decreased we can proceed to treatment with growth factors. In the major part of this group of patients ,during the operation we make microfractures or different types of chondroplasty. After that kind of treatment we can use injections with different types of hyaluronic acid, but let’s not forget that they have a preventive rather than healing effect. We think the effect of the treatment with PRP is better than hyaluronic acid, but in some cases it still is a valuable assistant.