ou can watch and review all informative videos about the treatments recorded by Prof. Dr. Ömer Faruk Bilgen, M.D., Specialist of Orthopedics and Traumatology
Yeliz Cengiz (Presenter): Hello, good morning, welcome to Olay Health Show once again. Today, our we will dive into prosthesis surgeries and complications. Our guest is Prof. Dr. Ömer Faruk Bilgen, M.D. from Medicabil Hospital. He is a Specialist of Orthopedics and Traumatology Surgeries. Doctor Bilgen welcome to our show.
Prof. Dr. Ömer Faruk Bilgen, M.D.,: It’s nice to be here. Happy new years to you and our viewers.
Yeliz Cengiz (Presenter): How are you?
Prof. Dr. Ömer Faruk Bilgen, M.D.: Thank you very much.
Yeliz Cengiz (Presenter): We‘ve mentioned the prosthesis surgery but by the definition, what is prosthesis surgery? And who are eligible to have this operation?Prof. Dr. Ömer Faruk Bilgen, M.D.: We’ve talked about this subject in our previous shows together, but to remind one more time, we call the procedure through which an artificial joint is applied to the patients who have trouble in walking, experience pain in their knees or hips and whose activity in daily life is limited as prosthesis surgery. This is moving a device that can be placed in the patient’s body where the joints are located. Our goal is to raise our patient’s quality of life. We’ve addressed this issue before, but I think we’ve only talked about the positives. What a pleasant thing, let’s do prosthesis surgery on everyone, let them walk, let them have better lives, let their pain go away… But, of course this procedure has its problems too. Maybe we should mention them to some extent. It is important to raise consciousness of the patients who would have this operation or their loved ones. Because, being conscious is a very serious factor in determining the success of this procedure. Where should we have this operation? How the surgery will be performed? Are there any problems with that? What kind of problems we have with the patient’s own body? All of these questions should be answered. It
would be better if we address these issues, at least that’s what I thought.
Yeliz Cengiz (Presenter): First, I would like to touch on its definition. Let’s mention the innovations brought by the modern medicine in the prosthesis surgery field. For example, which innovative approaches do you take in your hospital? On which patients do you frequently apply this surgical method?
Prof. Dr. Ömer Faruk Bilgen, M.D.: Well, we apply this procedure on primarily patients with deformed joints, and we don’t have any age requirement here. When I say we don’t have any limit, I mean younger people, especially children have custom-made prostheses. What we talk about here is a process applied within the joints of the young, middle-aged and elder patients, a process about changing the joint itself., It has been concluded by a study conducted in USA that when performed on people whose lives have seriously been affected by this condition, this is an operation that provides more benefits than the by-pass surgery of the 20th century. This is a procedure that benefits the patient, I have been doing this for 25 years. Within the Orthopedics and Traumatology department of our University, we separated our branches many years ago. We talked about my Professors in our previous shows. He separated us and said everyone has their own branch of research. I have been engaged in prosthesis surgery, i.e. arthroplasty surgery for long time. Patient selection is a very important aspect of this profession. You should know, beforehand on whom are you operating, how do you operate on them, what type of benefits can they get out of this procedure; and you should be able explain these points to the patient before conducting the operation. These types of patients who have pain, experience difficulty in walking, are not able to complete daily activities, are eligible to get this operation, provided their age is also suitable. However, that does not mean that if a patient experience some kind of pain then they should immediately be operate on. The clinical and radiologic findings of the patient, as well as their daily activities should be taken into account when deciding to whether have this operation. To avoid confusion, you may experience pain in your joints, knees or hips, but the prosthesis surgery is the last resort option. It is an irreversible procedure. This is very important. Let’s consider knees; you have several options, including meniscus, adjustment, and other surgical methods. But, the prosthesis surgery may be performed only if every other option has already been exhausted. In other words, to operate on a patient who have not undergone the previous steps is a wrong practice. We should explain this point to the patients.
Yeliz Cengiz (Presenter): Doctor Bilgen, as you have pointed out, we are dealing with an inconvenience that has negative effects on people’s social lives. Olay Health Show viewers can recall this from our previous shows. We also addressed hip dislocations with you. We discussed this subject in detail. If you wish, let’s talk about congenital hip locations. Is prosthesis surgery available for this condition? You’ve mentioned that there is no age limit. Prof. Dr. Ömer Faruk Bilgen, M.D.: The subject of age goes like this; in the prosthesis surgery, the patient’s age is one of most important deciding factors. Sometimes we have patients aging 20, 23, or 30. They say “I have a complaint.” You examine them. Sometimes the issue may be related to psychological problems. By psychological problems, I mean that the patient does not want to have trouble in walking due to hip dislocation. They say that they do not like to walk like this on the street. When you are dealing with an unhappy patient, you should think thoroughly. You should consider, “How good I am as a surgeon?” This is very important; you should critically examine your abilities. This should not suggest that I am so good that I will never make a mistake and that there will never be an error in my work. Absolutely not. You should be able to explain the conditions to the patient in that kind of setting. However, if you detect the elements causing pain in your examination, if the patient’s immobility is suffering, if you identify the elements causing pain, cartilage reduction, osteoarthritis and deformities in the radiological scans, if such conditions are evidenced, and if the patient tells you about their suffering, then, you are left with no other option. They have pain, so surgical intervention is necessary. In terms of hip dislocations, to consider merely the potential discomfort associated with the pain in the hip area or the future inconveniences is not enough to justify the operation. Besides, the hip joint may very closely affect the waist and knee joints of a person. The joints located in that area may cause pain as the patient gets older by unsettling the waist and knee joints. That is one of the reasons why this surgery may be performed on younger patients. The benefits of performing this kind of operations on eligible patients, in a timely manner are; One – When you operate on a patient suffering from hip dislocation, you can enable them to walk with a posture that is as good as possible. Two – You can prevent development of future deformations in the waist and knee. You should explain these points to your patients in detail, because these are very important aspects. When we look at them in the general terms, we should first conduct our pre-examinations on the patients, in other words, we should identify who our patient is? They may have applied us, but what type of problems they have, do
they have extra conditions? How old are they? When evaluating extra conditions; they may have a heart condition, they have diabetes, they may have a rheumatic condition or they may have systematic lupus. These possibilities should be well-evaluated. Why? Because, let’s say you are performing a prosthesis surgery on a patient with diabetes. Let’s say you are performing a knee surgery. But, what about their veins? The deformations may vary per your patient’s age. For example, the problems, the potential complications in their bodies and the deformations caused by this condition differ from a patient who has had diabetes for 30 years to a patient who has been diagnosed just 3 or 5 years ago. If, as a surgeon, we are to operate on a patient, we must know their medical history and be able explain potential risks to the patient. For instance, when you get a patient’s knee scan, you may identify osteoarthrosis on their arteries. Now, we usually operate on most patients by using tourniquet. In the last 10 or 15 years, tourniquet usage has decreased. So, we cover the patient’s leg with a cuff to interrupt blood flow during the operation to ensure convenient, clean and blood-free surgery experience. Other methods have been developed in the field of anesthesia, such as the procedure called hypotensive anesthesia, which minimizes the anesthesia and enables a blood-free environment during the operation. Ultimately, if your approach does not consider their medical condition when working on a patient with diabetes, you will not be able to know how to deal with potential problems. So, we must explain this to the patient. For example, if you tighten the cuff on a sclerosed vein, you may cause distress on any point of the vein. You may have problems during the operation. Although, the probability is very low it may still happen, so we should pay attention. Since their tissues are deformed, and the condition has effects on their veins, the rate of infection is high in operations performed on patients with diabetes. With a normal rheumatic condition, the risk of infection is four or five times more likely when compared to the case of normal osteoarthritis. You should explain this risk to the patient, otherwise it would be unethical. The patient should also know what may happen.Yeliz Cengiz (Presenter): Sir, I beg your pardon, but when we hosted you a couple months ago, a viewer had sent an e-mail. Unfortunately, I was not able to ask that question since we had very short time left. I think it is relevant to our discussion now. Mr. Adnan Sönmez asks on behalf of his sister “My sister received hip dislocation treatment when she was one and a half years old and fully recovered. She is expecting now; is normal delivery appropriate for her condition? Or would you suggest cesarean section?
Prof. Dr. Ömer Faruk Bilgen, M.D.: Presumably, an operation on a patient who was one and a half years old at that time was conducted in such a way that does not deform the pelvis. Of course, it is possible to form an opinion on how the delivery should be performed if the patient’s current scan or a scan from the childhood, from an imaging procedure conducted during that time, is available. There are certain operations for hip dislocations performed during childhood that may contract the pelvis. If the procedure is performed on both sides, the pelvis must have contracted. In that case, the patient may have problems with normal delivery. So, cesarean section is suggested for this type of patients. However, if the pelvis has not contracted, the patient may proceed with normal delivery option. To be certain, an imaging scan should be examined first, otherwise we cannot be sure one hundred percent.
Yeliz Cengiz (Presenter): Thank you. Hopefully, your insight satisfies our viewer. Alright, sir. We’ll address the treatment methods according to these patient profiles. If you wish, let’s talk about the prosthesis surgery performed due to osteoarthritis. Prof. Dr. Ömer Faruk Bilgen, M.D.: Well, obviously we should mention rheumatoid arthritis, especially in patients with diabetes. The complications associated with this condition develop specifically to the patient. Generally, the patient’s weight and their smoking habits are problems on their own. In most cases, the patients with osteoarthritis should be well-prepared before the surgery. Usually, the issues such as infection risk or vascular occlusion are explained to patients in these terms. You may experience vascular occlusion and we may have problems after the operation. Let’s talk about infection first. There are certain factors associated with the patient themselves. If the patient has a focus of infection in any part of their body, including their teeth, gynecological condition, urinary tract or toenails, that may generate an infectious environment. These patients should be examined and any focus of infection that they may have should be identified before the surgery. Some patients apply to us being conscious of these aspects and say “I have an infection in my teeth, should I deal with that first?” You like that kind of approach when a conscious patients talks. When we say the infection rate is low around the world, everybody minimizes the risk, that’s why. That is what the struggle is for. If we were able to eliminate the infection rate, reduce it to 0%, what goodness that would be. But, it is not possible to do that in every single case. Some institutions around the world have started to publish those figures on an annual basis. Like, “this year we’ve had no infection, next year we might have some.”
When you publish your totals, it certainly shows something. In large institutions, this rate may have been reduced as low as 0%. However, if we look at it from the perspective of academic research, the infection rate is between 1% and 2%, or is 3% in some institutions. That is the acceptable limit. In other words, 3 cases of infection out of 100 operations… If your figures are higher, then, you certainly have some issue. What kind issue that might be? You are either unable to prepare your patients, or having problems with your surgeons or environmental factors. Such as? Your operating room conditions may not be sufficient. You may have not prepared your patients well enough in the operation room. You may have problems with your sterilization practices. One should consider this issue by taking into account all aspects. Sometimes, patients say “My body does not accept the prosthesis.” The only reason for that condition can be metal allergy. But, if the patient has an infection, the reasons may be related with the patient’s own medical condition, the factors specific to the patient, the problems specific to the patient, the problems specific to the surgical method, and the environmental factors, that is to say operation room conditions. What do we do? What kind of procedure are we performing? Are our tools sterilized? All of these are related. These surgeries should be performed in operation rooms equipped with laminar air flow systems. Otherwise, to assume “I should give antibiotics to the patient, that will prevent infection” or to claim “my infection rate is low” are not standard practices.
Yeliz Cengiz (Presenter): You’ve touched on a very important subject. I mean, you’ve also mentioned that this is operation that should be performed under appropriate operation room conditions by experienced hands and that this is an irreversible procedure. Doctor Bilgen, compared to that of Europe, what are your thoughts on the prosthesis surgery practices in our country?Prof. Dr. Ömer Faruk Bilgen, M.D.: You are asking tough questions no matter how you slice it. Our country is such a unique place that the spectrum here always shifts between two opposite edges. I mean, it is so hard to meet at the halfway. What is happening? I don’t want anybody to take this wrong way, but these operations must be performed by outstanding institutions. The Ministry of Health’s approach on this issue is very encouraging. That kind of approach will move us forward, especially in private hospitals. Of course it is great that the private hospitals are being monitored closely in this regard. On the other hand, we have public hospitals, as well. When talking about private hospitals, I am strictly discussing the part associated with my branch, which is arthroplasty and
prosthesis surgery. If you overlook certain things happening in public hospitals or other places, and restrict those things in another hospital, it will not be fair. There is no such thing. Every institution should be good. We should focus our efforts on developing all. We don’t have the luxury to say anybody “performs good surgeries or they perform bad ones.” It is up to their own abilities and educational background, we cannot criticize anybody on that. But, upgrading environmental factors is a mission for all of us. Whose mission is this? It is the mission of the surgeon. We should say “I will perform these operations only if you provide these conditions.” Otherwise, regardless of their identity, that is our patient, ultimately. It may not happen in one case, two cases or ten cases. But if it does happen for just one time, that is one hundred percent in the eyes of that patient. So, we should act with a sense of responsibility. These are issues that may be discussed in any kind of setting. When I say these things please do not take them in the wrong way. It is not that I am just a talking out of my head here; that is the truth.
Yeliz Cengiz (Presenter): Not at all! You are stating the truth, Doctor Bilgen. If you’ll excuse us, we’ll have a caller. Murat Akbulut from Bursa is on the line.
Murat Akbulut (Viewer): I’ve undergone two meniscus operations. The pain goes away for 6 or 7 months, but returns eventually. What may be the issue here?
Prof. Dr. Ömer Faruk Bilgen, M.D.: Let’s see, you’ve had meniscus surgery. What was the diagnosis on your meniscus, and if you don’t mind me to ask, how old are you Mr. Murat?
Murat Akbulut (Viewer): I am 36.
Prof. Dr. Ömer Faruk Bilgen, M.D.: Your age is appropriate for this kind of operation. If you were 50, we may have questioned the purpose of that operation. I don’t know what your doctor told you about the meniscus surgery. Was there any stitching? Was there any tissue removed? Did they look into these aspects? Those are the most important ones. If we assume that the intervention was the correct choice, usually, in my experience the most common cause of pain following such operations is lack of exercise with the operated knee. You’ve had an operation on your knee, is that correct?
Murat Akbulut (Viewer): The procedure was conducted with a camera. It was a closed-surgery. Prof. Dr. Ömer Faruk Bilgen, M.D.: Alright, you’ve had a closed-surgery on your knee. I asked that because
sometimes that operation is done on the hip, there are some tissues that have similar characteristics with the meniscus, which are also referred with the same name. So, it is lack of exercise which suggests inadequate strength in muscles. Because simply removing the deformation in that area, pathologically, is not enough for achieving full recovery in these types of treatments. The most important factor that facilitates full recovery is doing exercises properly. I don’t know whether my colleague has informed you on that aspect. Did they refer you to physiotherapy? Did you follow their advice? Sometimes, the physician tells them but patients do not observe the advice. Maybe, you didn’t follow the advice. Please consider this. Take a look at your exercises. Book another appointment with your doctor. Hopefully, they will help you if your condition has re-emerged.
Yeliz Cengiz (Presenter): Thank you and we send our get well soon wishes to Mr. Murat. Alright, Doctor Bilgen. I think we have addressed the pre-surgery preparation phase of the prosthesis surgery in great detail. How these surgical methods are being applied in terms of patient profiles? Our viewers, as you would appreciate, may be curious about this. We talked about Osteoma. I asked you a question about eliminating those tissues in our last show. Is amputation a requirement in this type of cases? And, to follow-up, what does the prosthesis application look like? What should we understand when we hear the term prosthesis surgery?Prof. Dr. Ömer Faruk Bilgen, M.D.: To repeat what I said in the beginning of the show, the prosthesis surgery is the last resort option for any joint. It is an irreversible procedure. The movements are generated by artificial joints consisting of metal, plastic or ceramic based materials. Let’s consider the knee. You open the knee. You cut deformed cartilages until you reach the bone. There is special cutting equipment for this procedure. Once you are done with cutting, what size of prosthesis will you use? It is just like your regular shoe size. What size will you use? You identify the size before the operation. You cut according to those dimensions, and then, you place the prosthesis. Then, the most important part comes. The prosthesis must be placed in a proper and neat way that is within the acceptable limits. After placing the prosthesis, you go over the knee as you do in a routine examination. If everything looks good, you close the tissues. The same procedure applies to the hip as well. But in hip surgeries, depending on the patient, the opening may be large or small. It depends on the weight or length of the patient. Similarly, we cut a portion of the spot where we move our joints more often and place the prosthesis within a bone. You also place prosthesis in
the bottom area. Afterwards, you stitch up the wound once you ensure that everything looks great by conducting a routine examination. Alright, what kind of complications may arise as you operate on the hip? You may have placed the prosthesis properly or improperly or there may have been some other issue. One of the most important challenges of hip operations is that the patient may suffer from hip dislocation post-surgery. If we look at the percentage of cases involving such complication, it ranges between 1% and 3 %, as it does in the post-surgery infection rate. Because this suggests that the operation you have performed has failed. You can re-adjust the hip. You can reduce it. But you will always have this question mark in the back of your head. Will anything happen? What is wrong? Has the patient done something wrong? Did I misplace the prosthesis? These questions will not leave your mind. That is why the prosthesis must be placed in the most appropriate and favorable conditions.
Yeliz Cengiz (Presenter): Doctor Bilgen, we have another call. Cevriye Sönmez from İstanbul is on the line.
Cevriye Sönmez (Viewer): I have question for the doctor. My husband needs knee prosthesis. But, he has vascular occlusion and diabetes. Cardiologists say that he is ineligible to have a surgery.
Prof. Dr. Ömer Faruk Bilgen, M.D.: Now, you are asking what to do, right? How old is your husband?
Cevriye Sönmez (Viewer): He is 76. He has trouble in walking, loses his balance and falls down.
Prof. Dr. Ömer Faruk Bilgen, M.D.: Alright, have they told you that he loses his balance and falls down due to a deformation in his knees? Or, does he have any condition with his cerebrovascular tissues, and has trouble in his blood travelling to his legs? Is this the reason for his imbalance? Have they made any distinction? Have they told you anything?
Cevriye Sönmez (Viewer): He has a condition with his cerebrovascular tissues. But, he falls down as he is unable to walk. He barely leaves the couch. Prof. Dr. Ömer Faruk Bilgen, M.D.: This is such difficult case. The operation can be performed in a blood-free environment without using tourniquet and tightening the leg. However, there is a scale created by our anesthesiology society. This consists of five groups. The patient may undergo the operation if he is classified under 3 or 2. But, if he is classified under 3 or 4, we should be extremely careful. If you decide to have this operation, the surgeon must be quick. Please don’t take this in the wrong way, I sincerely believe that there is a difference in the pace of completing the procedure between a young and an experienced surgeon. So, it would be beneficial to your case if you found an experienced surgeon. It would be beneficial to you if you followed their advice. It would be beneficial for you to hear the advices of cardiovascular surgeons or internal diseases specialists, who asserted that the patient is not eligible to have this operation. Sometimes you encounter problems when you have the surgery. You’ve mentioned vascular occlusion. If he has thrombus, and it affects the vena during the operation, it may move towards the lung and stay there. In that case, God forbids, we may lose the patient in two or three minutes. These are very important. So, please make your mind by considering the medical advices of the surgeons who will perform the operation. Ultimately, it is up to you to decide whether to have this surgery.
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