Dr Wolfgang Zinser, former Head of Department (Germany), is a highly respected specialist in orthopedics and traumatology, specializing in orthopedic and trauma-related issues and clinical conditions. His international expertise extends in particular to joint-preserving hip surgery, hip arthroscopy including labrum and cartilage reconstruction, pelvic corrections for hip dysplasia using minimally invasive PAO (periacetabular osteotomy), and corrective osteotomies of the femur (thigh bone).
With over 2,000 cartilage cell transplantation procedures on the knee, hip and ankle to his name, he is one of the most experienced orthopedic surgeons in the world. At his modern practice, the OrthoExpert Clinic, Dr Zinser offers comprehensive diagnostics and treatment of the highest scientific standard in accordance with current guidelines. He performs surgical procedures at the well-equipped Graz Ragnitz Private Clinic, where patients can enjoy first-class inpatient care. His primary goal is to provide his patients with holistic care that enables a rapid return to their normal activities, and he specializes in preserving joints wherever possible.
For two decades, he has been active nationally and internationally as a trainer, speaker and advisor to both patients and colleagues in the field of joint and cartilage regeneration. Dr Zinser was Chief Physician at St. Vinzenz Hospital in Dinslaken from April 2007 to January 2022, where he treated around 1,000 patients annually with joint-preserving surgery. Since 1 July 2022, Dr Zinser has made Styria in Austria his professional and personal home and has founded a center for joint-preserving orthopedics. As President of the Society for Cartilage Regeneration and Joint Preservation (QKG), he ensures his patients receive the best possible treatment thanks to his extensive experience and expertise in orthopedics and sports medicine.
Dr Zinser has a personal sporting background as a former national team athlete in the triple jump, which gives him a special understanding of the needs and problems of injured athletes. In addition to his surgical specialities, he offers a wide range of modern conservative therapies, including hyaluronic acid injections, PRP (Platelet-Rich Plasma) injections and cartilage-protecting physiotherapy. The editorial team at Leading Medicine Guide had the opportunity to speak with PD Dr Zinser about hip joint-preserving treatments to explore the various options.
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The significance of hip joint-preserving treatment lies in the possibility of maintaining or restoring natural joint function without having to replace the joint with an endoprosthesis (artificial hip joint). Joint-preserving conservative and non-surgical measures are of great importance for suitable patients, as they can help to alleviate pain and restrict mobility in patients with hip problems. These include conservative therapies such as physiotherapy, weight management, and drug therapies that modulate the joint environment, as well as pain management. These approaches aim to strengthen the muscles, stabilize the joints and reduce inflammation.
“If a patient suffers from pain and restricted mobility in the hip, targeted physiotherapy is often a good way to exercise the hip joint. The World Health Organization recommends 150 minutes of exercise per week. This is because even non-specific muscle exertion leads to the release of substances that have an anti-inflammatory effect, particularly when it comes to exercises designed to relieve pressure on the joints. Wearing orthoses also helps to relieve pressure, particularly for people with knock-knees or bow-legs,” begins Dr Zinser in our conversation. Furthermore, non-invasive treatments such as injections of hyaluronic acid or platelet-rich plasma (PRP), which is derived from the patient’s own blood, play an important role. PRP has increasingly replaced repeated cortisone injections, as PRP has similar effects to cortisone on the joint but does not have the negative side effects of cortisone. A combination of hyaluronic acid and PRP is increasingly being used, which further improves treatment outcomes. These therapies can improve joint function and provide temporary pain relief. Such therapies are particularly important in the early stages of joint wear, osteoarthritis or other degenerative joint diseases.
“Dietary supplements, and so-called ‘slow-acting drugs for osteoarthritis’ (SYSADOAs), containing vitamin D, chondroitin, glucosamine and antioxidants, also support cartilage and bone metabolism and can help improve the joint environment. In this context, I often recommend combination preparations, such as those from the Orthomol brand, which manufactures and distributes a wide range of dietary supplements and vitamin preparations. These products are designed to integrate additional vitamins, minerals and other nutrients into people’s diets to compensate for any deficiencies or support specific health goals. Furthermore, certain amino acids and proteins play an important role. “The products on the market are available in various forms and compositions, including multivitamin preparations, protein supplements, preparations to strengthen the immune system, dietary supplements for athletes and other specialized formulations,” recommends Dr Zinser.
“Treatment using platelet-rich plasma (PRP) injections is very effective. For this, blood is drawn from the patient and then centrifuged to extract the plasma and concentrated platelets, which have anti-inflammatory and healing effects. These are combined, for example, with special hyaluronic acid at the joints and reinjected into the patient. Stem cell therapy is also an option, although current studies have not yet demonstrated its superior efficacy compared to PRP. In this procedure, precursor stem cells are extracted from human adipose tissue and processed, before being injected into the joint. “Clinical experience shows that this therapy, in combination with arthroscopic joint lavage and ‘joint cleaning’, demonstrates greater efficacy,” explains Dr Zinser.
Overall, joint-preserving conservative treatment of the hip is a holistic approach aimed at maintaining patients’ mobility and quality of life and minimizing pain without requiring invasive procedures. The selection of appropriate measures is made in close consultation between the patient and the orthopedic surgeon to take individual needs and goals into account.
Hip arthroscopy plays a crucial role in preserving the hip joints, particularly for patients with certain hip conditions. This minimally invasive procedure enables orthopedic surgeons who have mastered this difficult surgical technique to examine, diagnose and treat the hip joint through tiny incisions.
Therapeutic hip arthroscopy is used when clinical examination and careful analysis of the necessary specialist X-ray and MRI images reveal causes of pain that can be effectively treated by hip arthroscopy. It is particularly useful in the treatment of damage to the labrum (joint rim) or joint cartilage, and especially in cases of so-called hip impingement. During the procedure, orthopedic surgeons can correct hip deformities that lead to premature wear and tear, repair or remove damaged tissue, and alleviate inflammation, thereby enabling a lasting improvement in joint function. Today, hip arthroscopy allows various hip joint conditions to be treated very successfully using minimally invasive techniques, whereas just a few years ago these required major open surgery. In particular, deformities and changes in the hip that, if left untreated, can lead to premature osteoarthritis (joint wear and tear) must be detected in good time and treated surgically so that the patient’s own joint can be preserved to withstand long-term stress. This is particularly important for younger patients who still have many years ahead of them with their hip joint.
Hip arthroscopy is a minimally invasive surgical procedure in which an arthroscope (a type of thin, rigid tubular instrument with a camera and light source) is inserted into the hip joint to carry out a detailed examination and, if necessary, repair or treatment using special additional instruments.
Compared to traditional open hip surgery, the recovery time after hip arthroscopy is usually much shorter. Patients can regain mobility more quickly and resume their normal activities. “Hip arthroscopy is often the preferred option for younger patients suffering from hip conditions such as labral tears, femoroacetabular impingement (FAI) or synovitis. Athletes with hip injuries or problems have also been shown to benefit significantly and long-term from hip arthroscopy, as it can restore joint function and maintain sporting performance. Athletes involved in football, ice hockey or martial arts are particularly affected and should be treated at an early stage,” says Dr Zinser. The earlier hip problems are diagnosed, the better the prospects of success for hip arthroscopy. It can help to prevent or slow down joint wear and tear and halt the progression of the condition.
Periazetabular osteotomy (PAO) is a surgical procedure used in orthopedic surgery to preserve the hip joint in cases of hip dysplasia.
“This operation is particularly important and necessary if the patient suffers from hip dysplasia, a malformation of the hip joint in which the hip socket does not adequately cover the femoral head. This leads to uneven, excessive strain on the joint and premature joint wear. In the past, hip joint malformations were more common. Thanks to the use of early detection in infancy via pediatric ultrasound, developed by Prof. Reinhard Graf (Austria), and appropriate therapy, e.g. abduction trousers, the incidence has fallen to around 1 in 5 in many European countries. “The downside today, however, is that as a result, many doctors have forgotten how to recognize and treat dysplasia,” explains Dr Zinser.
The PAO procedure involves several steps. First, the patient is prepared and anesthetized under general anesthesia. The surgeon makes an incision in the groin area to access the hip joint. This is followed by the osteotomy, during which the surgeon separates the acetabulum from the pelvic bone and repositions it to correct the anatomy of the hip joint. This allows for better weight distribution and protects the articular cartilage. The repositioned bone fragments are then fixed in the correct position using screws. Once fixed, the wound is closed. “Personally, I operate using the minimally invasive method developed by the Danish surgeon Kjeld Soballe, in which the hip socket is gently rotated into the correct position and secured with screws following an incision of approximately 8 cm, without detaching any muscles or tendons. This means the patient is back on their feet much sooner and has a good chance of never needing a prosthesis. However, patients must come in at an early stage. Because once the cartilage has been damaged or even destroyed, the operation does not last as long as usual!” explains Dr Zinser.
Cartilage regeneration in the knee, hip and ankle joints involves various methods and technologies aimed at repairing damaged cartilage and improving joint function.
“It is important to know that joint cartilage consists of 80% water, has no blood vessels or nerves, and is nourished solely by synovial fluid. Cartilage cells make up only 4–8% of the cartilage. Localized, limited cartilage damage in the knee is often the result of an accident or misalignment (e.g. bow legs/knock-knees). In the hip joint, localized cartilage damage is often the result of impingement. Impingement, also known as femoroacetabular impingement (FAI), is a condition in which abnormal contactor collisions between the bony structures of the femoral head (femur) and the hip socket (acetabulum). These unnatural collisions can lead to damage to the surrounding structures, including the articular cartilage. Impingement can occur in various forms, including ‘cam impingement’ and ‘pincer impingement’. In the case of cam impingement, the femoral head is not round, but rather flattened or even excessively protruding, causing it to rub irregularly against the hip joint. This repeated contact can place excessive strain on the articular cartilage and lead to cartilage damage over time. Pincer impingement, on the other hand, is characterized by increased coverage of the femoral head by the hip socket or an excessive protrusion of the hip socket (acetabulum), which can also lead to wear and tear of the joint cartilage at the rim of the socket and damage to the joint lip (labrum)”, explains Dr Zinser.
Cartilage can be regenerated in various ways.
“In matrix-associated bone marrow stimulation (mBMS), a membrane, e.g. made of a collagen or hyaluronic acid mesh, is inserted into the damaged area along with blood from the bone marrow (which may contain stem cells). This promotes cartilage regeneration and can be effective for medium-sized defects (a defect size of 1.5–3 cm²). For defect sizes of 2.5–3 cm² or larger, matrix-associated autologous cartilage cell transplantation (mACI) is considered the international gold standard and the most promising long-term treatment of choice. This is an orthopedic procedure for treating cartilage damage in joints, particularly in the knee and hip. In this technique, small pieces of healthy cartilage are taken from a healthy area of the affected joint and sent to a certified laboratory. There, the cartilage cells are isolated from the cartilage fragments and subsequently cultured over a period of 3–6 weeks. These cultured cartilage cells are then transplanted into the damaged area of the cartilage during a second operation. It is important for the patient to subsequently undergo daily exercise therapy using a motorised splint. Only in this way can the cells then form pressure-relieving cartilage. Unfortunately, this highly successful method, which has been tried and tested for 25 years, is used far too rarely due to misguided health policy incentives. “We were recently able to demonstrate in a large study that, if applied correctly and in a timely manner, this could prevent approximately 21% of knee replacements,” says Dr Zinser on modern cartilage therapies.
Advances in regenerative medicine are exploring the use of stem cells and growth factors to promote cartilage regeneration. This is a promising but still experimental field.
Recovery and rehabilitation play a crucial role in the context of joint preservation for the hip and knee. Following surgery or other joint-preserving measures, it is crucial to achieve the best possible outcomes, and this is where rehabilitation comes into play.
Restoring joint function is a key goal of rehabilitation. This involves the gradual restoration of normal range of motion and stability in the affected joint. “The muscles surrounding the joint play a crucial role in supporting and relieving the joint. That is why targeted exercises to strengthen the muscles are of great importance. I recommend what is known as assessment- and phase-based physiotherapy. In this approach, certain objective parameters are recorded at regular intervals, such as muscle circumference, skin temperature, joint swelling, strength… Once the parameters reach the desired range, the patient moves on to the next phase of exercise. As the load must be restricted at the start following cartilage therapy to protect the regenerating cartilage, we use what is known as blood flow restriction training for some exercises. This involves tying off the thigh, thereby reducing blood flow to the thigh during the exercise, which is performed with very low loads and weights. However, due to the reduced blood flow, the muscle responds with the same growth response as if heavy weights were being used. Electrical muscle stimulation is also used for muscle building and faster recovery of muscle function,” explains Dr Zinser.
According to current scientific knowledge, the long-term success and quality of life for patients who opt for joint preservation in the hip and knee are very promising. The aim of joint preservation is to maintain the natural joints for as long as possible. This is particularly important for younger patients with high expectations regarding mobility and quality of life.
Although joint replacement surgery is successful in many cases for older patients when correctly indicated, it is nevertheless associated with certain risks and the limited durability of the implants. By preserving the joints for as long as possible, joint replacement surgery—with its associated risks—and, above all, revision surgery—which carries significantly higher risks—can be avoided or significantly postponed. This has a direct impact on the quality of life of a population with a high life expectancy and an expectation of mobility well into old age, as pain can significantly impair daily life and participation in activities.
“One of the key components of joint preservation is maintaining mobility. Good mobility enables people to retain their independence and quality of life, as they can manage everyday tasks and take part in activities. Furthermore, joint preservation can improve joint function and activity levels. This may include the ability to participate in sports and leisure activities, which significantly enhances quality of life. Knowledge and skills regarding joint preservation are not yet where they should be. Therefore, here at the OrthoExpert practice and within the professional association QKG (Society for Cartilage Regeneration and Joint Preservation, www.qkg-ev.de), of which I am the Chair, we offer training courses and workshops so that many colleagues can learn these therapeutic methods. Our core message is: Joint-preserving surgery is effective. We must not forget that cartilage damage is a ticking time bomb. After all, cartilage does not hurt because of the lack of nerves in the tissue. But untreated cartilage damage often leads to osteoarthritis, which is simply incurable. This is why early detection is so important, as timely treatment – at the latest within three years of the cartilage damage occurring – can halt or delay the onset of premature osteoarthritis – the sooner, the better! The complications associated with cartilage therapy are very low. And if it doesn’t succeed the first time, I can repeat the procedure and the joint is still preserved. This does not apply to the insertion of artificial joints; there is no going back! “We are therefore trying, in various forums – among specialist colleagues, in health policy discussions and with patients – to raise awareness of the importance of joint preservation,” argues Dr Zinser, bringing our conversation to a close.
Dr Zinser – thank you very much for this focused insight into joint-preserving therapies!
