Revision hip arthroplasty. Revision knee arthroplasty
Today, hip arthroplasty has become a routine operation. Worldwide, millions of people live with artificial joints. As the number of implanted endoprostheses increases, as well as the duration of their operation, some artificial joints begin to wear out or become unusable. This requires an operation to replace the endoprosthesis, which is called revision arthroplasty.
While the technique of primary hip arthroplasty has long been standardized throughout the world, revision arthroplasty is a rather unpredictable operation that requires creativity and great professionalism from the surgeon.
In some cases, a failed artificial joint cannot be replaced. This can occur in case of infection of the endoprosthesis, with severe destruction bone tissue in the place of fixation of the endoprosthesis, as well as in the general serious condition of the patient. In this case, removal of the damaged endoprosthesis without installing a new one may be the best choice, since repeated endoprosthetics may fail or significantly aggravate the patient's health, and in rare cases lead to death. Removal of the endoprosthesis does not mean that the patient is doomed to bed rest for the rest of his life. Without a hip joint, you can move, but with difficulty, as the leg becomes shorter and the strength in it decreases.
Reasons for revision arthroplasty
The most common reasons for indications for revision arthroplasty are:
- instability of the connection of the endoprosthesis with the femur and pelvic bones
- endoprosthesis infection
- fracture of the bone to which the endoprosthesis component is fixed
- mechanical failure of the endoprosthesis
- wear of endoprosthesis parts
Preoperative period
Based on the questioning, physical examination and data from additional instrumental methods of examination, the surgeon carefully develops a plan for the upcoming operation. When assessing the need for an operation, the doctor takes into account many indications and contraindications. Before the operation, additional examinations are carried out to assess your general health, as well as the condition of the bones and soft tissues at the site of the proposed operation. During the operation, a blood transfusion may be required. Currently, it is considered that the safest method is to harvest the patient's own blood a few days or weeks before the upcoming operation (autodonation).
Endoprosthesis device
Before describing the operation of revision endoprosthetics, it is necessary to say a few words about the design of modern endoprostheses. Endoprostheses are divided into cement and cementless. Both types are widely used in revision arthroplasty. In some cases, a combination of cementless and cemented endoprosthetics is used: the femoral part of the endoprosthesis is fixed with cement, and the glenoid cavity is fixed with screws. The choice of one or another endoprosthetics technique is based on the analysis of such indicators as the patient's age, his lifestyle, and the experience of the surgeon.
All endoprostheses consist of two main parts. The acetabular component (the endoprosthesis cup) is installed in place of the glenoid cavity of the hip joint. This part of the endoprosthesis is made of metal with an insert made of biocompatible plastic, which is designed to improve the sliding of parts and additional shock absorption. A special cup can be used for revision arthroplasty. Such a choice is necessary in case of bone destruction near the installed endoprosthesis cup, as well as in severe local osteoporosis. The design of such a cup is designed so that the patient's weight is distributed over a larger area of the metal surface, which contributes to a more reliable attachment and reduces the risk of subsequent loosening of the reinforced endoprosthesis cup.
The femoral component of the endoprosthesis is designed to replace the head and neck of the femur and consists of the stem and head of the endoprosthesis. It is made of metal. Sometimes, the endoprosthesis head is made of ceramic. For revision arthroplasty, special femoral components can be used. They are necessary if the femoral canal into which the stem of the endoprosthesis is installed is severely destroyed or developed.
Components of cemented endoprostheses are fixed to the bones using a special methyl methacrylate cement. Cementless endoprostheses are fixed to the bones with special screws. Such endoprostheses have a rough surface, into the pores and depressions of which bone tissue grows over time, which contributes to additional fixation.
Operation
The technique of revision arthroplasty is very different from the initial installation of the endoprosthesis. One of the reasons for this is a significant loss of bone tissue around the primary implant. To fix the components of the endoprosthesis, it may be necessary to take a piece of the patient's own bone, for example, from the pelvic bone, and install it in place of the destroyed bone. When fixing the primary endoprosthesis with cement, before installing a new artificial joint, the remaining cement in the femoral canal and acetabular cavity must be removed. After preparing the bone surfaces of the articular cavity and femoral canal, the components of the new endoprosthesis are installed. At the end of the operation, a silicone tube (drainage) is installed to drain the wound contents. The wound is sutured in layers, after which an aseptic dressing is applied.
After operation
After the operation is over, you will be transferred to the recovery room. Your condition will be monitored by experienced medical staff. Within a few hours after the operation, oxygen is inhaled through nasal catheters or a transparent face mask. On the first day, monitoring of vital signs is carried out ( arterial pressure, pulse, electrocardiogram, blood oxygen saturation) using a special device. You will have to lie on your back, a special wedge-shaped spacer made of soft material will be located between the legs to prevent dislocation of the endoprosthesis head. To prevent the formation of blood clots, anti-thrombotic stockings will be put on your legs. In the first few days, a sufficient number of different injections are performed (painkillers and anti-inflammatory drugs, antibiotics, antithrombotic agents). To reduce risk pulmonary complications it is necessary to independently perform breathing exercises within 2-3 days after the operation, which consists in a series of deep breaths(8-10 times) every 2-3 hours.
You will be transferred to the ward of the department in the normal course of the postoperative period the next morning.
Postoperative rehabilitation
Your doctor, based on the results of the course of the postoperative period, the volume of surgical intervention, these radiographs, will determine your individual rehabilitation program. Since revision arthroplasty is a large traumatic operation, recovery after it can be quite slow. The date when a patient can start walking without crutches with a full load on the leg depends on many factors and is determined individually by your doctor. In some cases, the rehabilitation period can be delayed up to one year. After revision arthroplasty, it is necessary dispensary observation by an orthopedic surgeon, which consists in periodic preventive examinations and diagnostic tests.
This is a second operation to replace a failed artificial joint. The procedure is unscheduled, it may be required in case of loosening of the endoprosthesis elements, their wear or the development of infection.
Causes that can lead to a malfunction of the prosthesis
- Aseptic loosening of parts of the endoprosthesis;
- Mechanical wear of implant parts;
- Infection of tissues in the area of the implant.
The use is accompanied by large functional loads both on the materials of the artificial joint and on the places where they are connected with the patient's tissues. With constant friction, pressure, the so-called wear microparticles are formed, which begin to be actively absorbed by cells. immune system(macrophages) at the interface between the prosthesis and the bone. Over the years, microparticles accumulate in large quantities and in the area of the endoprosthesis develops chronic inflammation. This destroys the strength of the bond between the bone tissue and the components of the prosthesis. Fasteners no longer hold the prosthesis so tightly in the inflamed tissues, which leads to their loosening.
The loss of the strength of the connection of artificial materials with the bone is called aseptic loosening of the prosthesis components.
What measures are taken in case of aseptic loosening of the prosthesis
If there is aseptic inflammation in the bone surrounding the implant, it is necessary to take prompt measures:
- it is necessary to remove unstable elements of the prosthesis;
- you need to install new implant components, firmly fixing them to the bone.
Postponing the revision, untimely detection of aseptic loosening leads to even greater destruction of the bone thinned by inflammation. The structural components of the prosthesis, with their excessive mobility in the process of constant operation, are capable of forming large bone defects at the attachment sites. By itself, this situation cannot be corrected, sooner or later the patient is forced to resort to surgery, but:
- more massive implants are required;
- to close large defects in the bone will require the use of various types bone grafting which will significantly increase the time to return to normal mobility.
PHOTO 1. Aseptic instability of the components of the hip endoprosthesis.
The leg of the prosthesis is unstable, there is a thinning of the cortical bone. The orientation of the cement cup is broken, it is destabilized. The endoprosthesis head is dislocated.
PHOTO 2. After the primary prosthetics, after a few years, the instability of the implant developed. A massive defect in the bottom of the acetabulum was formed. The protrusion (falling through) of the cup is determined. After the removal of the components, massive bone defects formed. Revision endoprosthetics was performed with the installation of a reconstructive ring on screws, acetabular floor plasty, and installation of a revision stem.
PHOTO 3. A few years after the total cement prosthesis, aseptic instability of the endoprosthesis components developed. The patient suffered from severe pain syndrome. The clinic performed revision arthroplasty with a cementless endoprosthesis with a ceramic-ceramic friction unit.
Revision replacement of a hip endoprosthesis in the development of an infectious process
Infectious complication often cannot be eliminated without removal foreign body- implant. And in such a case, revision arthroplasty is required. During the operation, dead, non-viable tissues are removed. For the time of relief of acute inflammation, a temporary prosthesis (spacer) with antibiotics is installed. The spacer fills the voids, preventing shortening of the limb and retaining the ability to subsequently re-install a full-fledged hip prosthesis.
PHOTO 4. After the development of a deep infection of the hip endoprosthesis, the patient had a fistula for several years. The clinic performed the removal of the components of the endoprosthesis, sanitation of the hip joint area. A cement spacer with antibiotics was installed. After 6 months, the spacer was successfully replaced with a revision endoprosthesis.
Full title:
Revision hip arthroplasty
Slobodskoy A.B., Badak I.S., Voronin I.V., Dunaev A.G., Bystryakov P.A. GUZ Saratov regional clinical Hospital(Director of the hospital - Tyapkin I.A.)
Numerous publications of recent years convincingly prove the fact that today arthroplasty is the most effective method in the treatment of severe injuries and diseases of the hip joint (1, 4, 5, 7, 8, 9, 11). The number of primary endoprostheses is steadily increasing year by year. This is due to both an increase in the incidence of the hip joint and the number of injuries leading to arthroplasty (3, 6, 12, 14, 17). In proportion to the number of primary endoprostheses, the number of revision endoprostheses is also growing, which is due to a large number of reasons. Among the numerous criteria for assessing the quality of a particular implant, methods of surgical support, it is revision arthroplasty that is the most accurate and multifactorial assessment of any primary arthroplasty. It is this operation, as well as the timing of its implementation, that fairly objectively assess the quality of the primary construction, the “lifespan of the endoprosthesis”, possible defects in the primary operation, the correctness of the assessment of the primary diagnosis and comorbidity of the patient, as well as many other criteria (3, 6, 7 , 10, 13, 15, 16).
Purpose of the study.
To analyze the results of revision hip arthroplasty in the period from 1 to 6 years after the operation, to determine the features of surgical support after various types of primary operations in various anatomical situations.
Materials and methods.
In the period from 1996 to the present, under our supervision there were 1226 patients who underwent 1363 operations of primary hip arthroplasty. 137 patients were operated on from 2 sides. 511 men were treated, 715 women were treated. The age of the patients was from 18 to 94 years. Of these, under 25 years old - 18; from 26 to 40 years old - 158; from 41 years old to 60 years old 472; and older than 60 years 578 patients. As implants for primary hip arthroplasty, the ESI endoprosthesis (Russia) was used in 696 cases, Zimmer (USA) in 545, De Pue (USA) - 98, Seraver (France) - 18, Mathis (Switzerland) - 6. Cementless fixation endoprosthesis components were used in 582 operations, hybrid in 499 and fully cemented in 282 cases. In the same period, we performed 111 revision hip arthroplasty in 106 patients. In 5 cases, the revision was performed on 2 sides. The ratio of primary and revision arthroplasty operations was 1:12. Men 49, women 57. The age of patients is from 42 to 81 years. The time between primary and revision operations ranged from 2 months. up to 17 years old. Indications for revision arthroplasty and the number of operations performed are presented in Table. one
Tab. one
Reasons for Revisions of the Hip Endoprosthesis*
| № | Primary operation | Number of operations | % of total revisions |
| 1 | Instability of Sivash endoprostheses*, - incl. with broken leg |
63
12 |
56,8 |
| 2 | Instability of ESI endoprostheses, total instability |
8
5 2 1 |
7,2 |
| 3 | Instability of Zimmer endoprostheses, including acetabular component including femoral component total instability |
7
4 2 1 |
6,3 |
| 4 | Instability of endoprostheses Altimed*, including acetabular component including femoral component total instability |
5
3 - 2 |
4,5 |
| 5 | Instability of endoprostheses Biomet*, including acetabular component including femoral component total instability |
2
2 - - |
1,8 |
| 6 | De Pew endoprosthesis instability*, including acetabular component including femoral component total instability |
3
2 - 1 |
2,7 |
| 7 | Instability of endoprostheses of unknown manufacturers, incl. homemade* | 12 | 10,8 |
| 8 | Incorrect initial installation of the endoprosthesis components, which caused dislocations and impaired gait biomechanics | 11 | 9,9 |
| TOTAL | 111 | 100 |
* Operations in which primary arthroplasty was performed in other medical institutions are noted.
From the analysis of the table. Table 1 shows that the largest number of revisions of the hip joint was performed after primary arthroplasty according to Sivash (56.8% of operations). 10.8% of surgical interventions were performed due to the failure of endoprostheses of unknown manufacturers, and often “self-made”, unlicensed designs. In 9.9%, the reason for the revision was incorrect installation of the endoprosthesis components during the primary operation, which was manifested by pain, impaired walking biomechanics, and recurrent dislocations of the endoprosthesis head**.
The average terms for performing revision arthroplasty after primary hip arthroplasty, as well as the minimum and maximum terms of the "life of endoprostheses" are presented in Table. 2
Tab. 2
Terms of revision of the hip endoprosthesis
** this paper does not consider cases of endoprosthesis revisions associated with purulent complications
From the analysis of the table. Table 2 shows that the average terms of revision operations, as well as the minimum and maximum terms of the "life of the endoprosthesis" in primary endoprosthesis with modern implants from ESI, Zimmer, Biomet, DePew are quite long and range from 11.3 to 12.7 years. These terms are much lower when Sivash endoprostheses (3.7±2.9) and Altimed (1.5±0.8) are used in primary operations. The use of improvised designs from unknown manufacturers led to revisions within 1 year or earlier.
Features of revision interventions for various primary arthroplasty.
Revision after primary endoprosthetics according to Sivash.
When performing a revision operation, we used either the old approach or the anterior-external Harding approach, depending on the condition of the soft tissues and the severity of the cicatricial process. When examining the trochanteric region, it was found that in more than half of the cases, the key had migrated. The greater trochanter was in place and fused with the femur only in 8 cases (12.7% of the total number of revisions of Sivash endoprostheses). In all other cases, it lay freely on the outer surface in the region of the gluteus medius muscle, having a connection with the femur only through the scar tissue (Fig. 1). Depending on the specific anatomical situation, the greater trochanter was either synthesized to the revision stem or removed. It is advisable not to remove the key of the endoprosthesis immediately, since it is easier to remove the stem of the endoprosthesis with its help.
The removal of the Sivash endoprosthesis, which is one-piece, was started with a cup. It was characteristic that the cup of the joint, in almost all cases, was overgrown with powerful osteophytes and cicatricial adhesive tissue and was rather difficult to stand out. However, after the removal of the latter, it was freely removed from the acetabulum. We practically did not observe signs of osseointegration on the cup. On the contrary, in most cases, the acetabular component was covered with connective tissue membranes, granulation and scar tissues, which was evidence of its instability (Fig. 2). 
Thus, during the revision surgery, we observed that the cup of the Sivash endoprosthesis was, as it were, in the bone-scar shell, which did not provide its rigid fixation. Osseointegration with the walls of the acetabulum was minimal or non-existent. Sivash joint pedicle, thanks to round shape and the distal fixation system, was removed freely, often without special tools. Just like the acetabulum, the medullary canal was filled with fibrous, granulation and scar tissues, which were a “layer” between the pedicle of the joint and the inner surface of the medullary canal. We did not observe signs of osseointegration in the region of the endoprosthesis stem. In 19 cases (30.2% of the total number of revisions of Sivash endoprostheses), a fracture of the prosthesis leg in the “window” area was noted (Fig. 3). In these cases, the distal fragment was removed through additional longitudinal “cusps” in the femoral shaft.
In 11 patients, during the removal of Sivash endoprostheses in the area of the joint neck, an accumulation of fluid (up to 100-200 ml) was found, cloudy-gray, sometimes with a greenish tint, odorless. For such patients, we limited ourselves to the removal of endoprostheses and a course of antibiotic therapy. In bacteriological cultures, the liquid in all cases turned out to be sterile. We performed endoprosthesis replacement in these patients after 4–5 months. after the first operation.
In 52 patients previously operated on according to Sivash (82.5% of all those operated on according to this technique), thinning and, to varying degrees, defects in the walls of the acetabulum were noted during revision operations. Thus, bone defects (according to the W. Paprosky classification) of type 2 A were observed in 9 patients, 2 B - in 29, 2 C - in 11, 3 A - in 3. In these patients, different kinds plastic interventions on the acetabulum, Bursch-Schneider anti-protrusion rings and Muller support rings.
Revision after primary arthroplasty according to Altimed.
During revision arthroplasty of Altimed endoprostheses, we noted the following features. In all cases, the cementless threaded cup, after being freed from scar tissues and the liner removed, was unscrewed completely freely, without special tools. The polyethylene part of the acetabular component of the endoprosthesis with titanium coating, due to which the fusion with the bone was supposed to occur, lay freely in the acetabulum, without connection with the cup. We did not observe any signs of osseointegration in the region of the cup itself and the titanium-coated polyethylene part. The removal of the leg was performed with special instruments without any problems after the release of its proximal part from osteophytes and scar tissue. On the removed legs of Altimed, we did not observe integrated bone tissue in any case, even in the area of porous inserts in the proximal part. The bone marrow canal, after the removal of the pedicle, was a cavity filled with scar tissue, after the removal of which a sclerotic thinned non-bleeding bone tissue was exposed. In 3 cases, after the removal of Altimed endoprostheses, due to bone defects in the area of the acetabulum, Muller support rings were used. Some publications provide data on Altimed pedicle fractures after primary operations (2).
For the operation in 92 patients, cemented and cementless revision stems from ESI (Russia) and in 19 cases a Wagner SL revision hip stem from Zimmer (USA) were used. ESI revision legs of a tetrahedral shape, with a proximal fixation system. The shape of the stem allows you to tightly fill the bone marrow canal, compensate for defects in the proximal femur, and, if necessary, lengthen the leg. Technological holes in the metaepiphyseal region of the endoprosthesis allow synthesizing the greater trochanter or strengthening the joint using myofascioplasty.
Research results and discussion.
The data of clinical and radiological examination of 88 patients who underwent revision hip arthroplasty in the period from 1 to 5 years were analyzed. The analyzed group included 50 women and 38 men. Primary surgeries were performed for idiopathic coxarthrosis in 17 patients, dysplastic coxarthrosis in 28 patients, aseptic necrosis of the femoral head was treated in 19 patients, fractures of the head and neck of the femur in 14 patients, and false joints and ununited fractures of the femoral neck in 10. Sivash endoprostheses, ESI endoprostheses - 5, Zimmer - 6, Altimed - 4, De Pew - 2, Biomet - 2, unknown manufacturers - 10 were used in 59 operations of primary hip arthroplasty. Sivash's endoprostheses were self-made, from unknown grades of titanium or alloys. ESI revision endoprostheses were implanted in 79 patients, Zimmer cementless revision stems ZMR in 9.
To assess the statistical significance of the obtained data, methodological approaches based on the evaluation of the ?2 criterion were used, and the error probability of the Fisher criterion was calculated, which was significantly less than the specified value.
Clinical assessment The results of treatment were carried out according to the Harris evaluation scale (Table 3) for the hip joint (Harris W.H., 1969: Evaluation System of the Hip).
Tab. 3
Results of treatment of patients after revision hip arthroplasty (according to Harris)
Analyzing the clinical results of treatment of patients who underwent revision hip arthroplasty in the period from 1 to 5 years, it was found that excellent and good results in the above terms were noted in 75.0% of patients, and satisfactory in 18.2%. Unsatisfactory results occurred in 6 patients. Four of them - due to the development of deep suppuration in the area of the endoprosthesis and four - due to persistent pain in the postoperative period.
Complications.
Postoperative complications included purulent-inflammatory complications, postoperative dislocations of the endoprosthesis head, periprosthetic fractures, neuropathies, and thromboembolic complications (Table 4).
Tab. 4
Postoperative complications after revision hip arthroplasty
Analyzing the nature of complications after revision arthroplasty, it can be noted that the most common (4.5%) complications were of a purulent nature. In all cases, they developed in the late postoperative period (from 4 months to 3 years after surgery). Treatment purulent complications was carried out according to well-known methods and in 2 cases ended with the removal of the endoprosthesis. Dislocations of the endoprosthesis head were observed more often than after primary endoprosthesis replacement (4.5%). Of these, in 3 patients they occurred in the first days of the postoperative period, and in one case, dislocation occurred after 6 months. after surgery due to a violation of the patient's motor regimen. The dislocations that occurred in the early postoperative period were corrected conservatively, and the dislocation that occurred 6 months later was repaired openly. Two patients were diagnosed with neuropathies and non-severe forms of PLA, which were stopped by conservative measures and did not affect the outcome of treatment. A periprosthetic fracture of the femur occurred in a patient after revision arthroplasty 8 months later. after surgery and is associated with additional trauma. In this case, osteosynthesis was performed with a plate, screws and cerclage wire. Revisions of the endoprosthesis components were not performed. Additional immobilization was not required. The fracture consolidated at the usual time.
Clinical example 1.
Patient F., 68 years old, was admitted to the orthopedic department of SarOKKB on 12.05.2006. aseptic necrosis of the femoral heads, secondary coxarthrosis 2 tbsp. Instability of Sivash endoprostheses. Pain syndrome. On May 15, 2006, an operation was performed - total arthroplasty of the left hip joint with a cement ESI endoprosthesis; The postoperative period proceeded smoothly. The patient became active on the 2nd day after each operation. Extract on the 10th day after the 2nd operation. By this time, the patient was quite adapted to walking on crutches, including stairs. Homeostasis indicators at the time of discharge were satisfactory. The time of observation of the patient is 4 years (Fig. 4). Pain in the hip joints do not bother, the function is satisfactory. Walks without additional support. Harris score - 82 points. Satisfied with the results of the operation.
Clinical example 2.
Patient T., 64 years old, was admitted to the orthopedic department of SarOKKB on April 10, 2006. Diagnosis: condition after total hip arthroplasty according to Sivash (2004). about aseptic necrosis of the head of the right femur, secondary coxarthrosis 2 tbsp. Sivash endoprosthesis instability, pedicle fracture, pain syndrome. On April 12, 2006, an operation was performed - total revision arthroplasty of the left hip joint with a cemented ESI endoprosthesis. The postoperative period proceeded smoothly. The patient became active on the 2nd day after the operation. Discharge on the 12th day after the operation. By this time, the patient was adapted to walking on crutches, including stairs. Homeostasis indicators at the time of discharge were satisfactory. The time of observation of the patient is 4 years (Fig. 5). Pain in the operated joint does not bother, the function is quite satisfactory. Walks with a cane. Harris score - 80 points. Satisfied with the results of the operation.
Clinical example 3.
Patient K., aged 52, was admitted to the orthopedic department of SarOKKB on September 15, 2008. Diagnosis: condition after total arthroplasty of the left hip joint with an endoprosthesis of unknown design (2004), total instability of the endoprosthesis components. Deep suppuration in the area of the endoprosthesis (2005), removal of the metal structure. Defect of the proximal part of the left femur, defect of the roof and bottom of the left acetabulum. The purulent process did not recur for 3 years. On September 17, 2008, an operation was performed - total revision arthroplasty of the left hip joint with a cemented ESI endoprosthesis using a Muller support ring. The postoperative period proceeded smoothly. Discharge on the 10th day after the operation. By this time, the patient was adapted to walking on crutches, including stairs. Homeostasis indicators at the time of discharge were satisfactory. The observation time for the patient is 2 years (Fig. 6). Pain in the operated joint does not bother, the function is quite satisfactory. Walks with a cane. Harris score - 77 points. Satisfied with the results of the operation.
Conclusions:
- Revision hip arthroplasty, like any reoperation, is much more complicated and problematic than primary hip arthroplasty. Violations of normal topographic and anatomical relationships in the hip joint area, massive cicatricial adhesions, powerful osteophytes, against the background of bone mass deficiency in the acetabulum and proximal femur, significantly complicate both planning and the operation itself.
- Revision hip arthroplasty is a non-standard and purely individual operation in each specific case. When preparing for it, it is necessary to plan various options for its implementation, a possible transition from one of them to another, the use of a wide variety of materials and metal structures, and a high risk of intraoperative complications.
- The use of modern implants and other additional structures for revision hip arthroplasty, as well as a strictly individual selection of the latter, allows obtaining good functional and anatomical results for a long time.
The hip joint (HJ) is not only the largest and most heavily loaded joint in our ODS. It is literally vital, because with its inoperability it is impossible even to stand on your feet, and not just walk. Despite the complexity of hip arthroplasty, it is often prescribed precisely for vital signs. In this article, we'll look at:
- When is Hip Replacement Surgery Necessary?
- How is the operation and what are the contraindications to it
- What should be done so that after hip arthroplasty, a second operation is not needed as long as possible
- What is revision prosthetics
Hip arthroplasty: pros and cons
The structure of the hip joint
- The hip joint connects the femur and pelvic bones and has a hinged structure:
- In the pelvic bone there is an acetabulum, in which, with the help of ligaments and muscles, the spherical head of the femur is held and rotated.
- The head is connected to the thigh itself with the help of a neck at an angle of 125 - 145 ˚
- The surfaces of the head and cavity are covered with a cartilaginous layer, which is both strong and elastic
- The joint is closed by a capsule filled with synovial fluid.
- Uniform lubrication of the joint is provided by the acetabular lip - a hill along the edges of the acetabulum
Such a perfect structure provides greater mobility to the joint, the ability to perform extensor and rotational movements of a wide amplitude.
What can cause a joint replacement?
A number of diseases lead to the development of the resource of the hip joint:
When the contraindication is laziness
If you are tormented by pain in the hip joint and restrictions on your freedom of movement, but at the same time you are lazy, afraid exercise, then do not think that the operation will be an easy way out.
After hip arthroplasty, you will need an intensive rehabilitation program immediately on the second day without any self-pity.
As a rule, osteoarthritis develops faster precisely with musculo-ligamentous atrophy. If you fail to strengthen your muscles and ligaments even before the operation, preparing them for future rehabilitation, then it is hardly worth counting on the success of arthroplasty.
Contraindications - diseases of old age
The controversy of old age - the rehabilitation of the elderly must be even more active than in the young, and with an early full load in order to stimulate blood supply, healing and prevent complications
All this also does not fit into the usual scheme of recovery after complex surgical operations.
And another vicious circle… Yes, arthroplasty may be critical, but
- What to do if an elderly patient has contraindications - a whole bunch of serious diseases:
heart failure, diabetes, thrombophlebitis, etc..? - If he had a recent heart attack or stroke?
And this, unfortunately, is more the norm in old age than the exception ... - How will osteoporosis be tolerated with an endoprosthesis:
- Will there be further destruction? (often in older people, due to the head of the endoprosthesis, the edges of the acetabulum are destroyed)
- Will the prosthesis take root?
These contraindications can put an end to arthroplasty, and then they often hope for the formation of a false joint during fusion.
What is the solution for old people?
Thus, the replacement of the hip joint in old age raises more than enough questions.
The choice of material, the constructive form of the prosthesis leg is extremely important..
Intuition suggests that an elderly person needs a super prosthesis:
- Material - ceramics (polyethylene and metal emit harmful products friction)
- Anatomical in shape - adheres to the entire surface of the femur, and does not come into contact with it at three points
- Adjustable length
Unfortunately, it will be a very expensive prosthesis…
With a fracture of the femoral neck and preserved integrity of the pelvic bone, unipolar arthroplasty is usually used
However, if the acetabulum is destroyed, a total operation must be performed, which may require a modular cup with an overlay that is inserted into the gaps between the cup and the acetabulum.
Of course, this will further increase the price of the prosthesis and the operation.
The way out for the elderly is only in a well-thought-out system of state quotas that carry out arthroplasty for elderly patients not according to the cheapest option, but in accordance with their history and health indications
If not endoprosthetics, then what?
Often they don't even try to take our broken old people to the hospital, leaving them to die at home, consoling them with fairy tales about a false joint. This is motivated by:
- arthroplasty is not possible for some reason (mainly due to lack of money)
- the bones still won't heal
- and rehabilitation for a weak person, they say, is impossible
The video below suggests a treatment regimen if it is impossible to do endoprosthesis replacement, in which the doctor advises in no case to leave patients to their own devices, to perform an operation (reposition with fixation of the neck of the head), and after the operation to carry out intensive therapy with calcium and protein preparations.
Video: Hip fracture in old age
How to increase the life of your prosthesis
What will happen after - this question worries a patient who has undergone complex hip replacement.
It is believed that the service life of the prosthesis is 10 years.
However, in some cases it can fail much earlier:
- An unsuccessful type was selected that does not correspond to the anatomy of the patient
- If the prosthesis was not properly fitted
- The operation was performed in the presence of contraindications
- After the operation, contractures occurred that changed the natural angle of the hip
- The cement method was used
- The cheapest option is selected (for example, metal + metal)
Such a pair is undesirable, despite the high strength b:- due to the friction of metal surfaces, tiny metal particles are formed
- they, getting into the blood, cause all kinds of allergic and even autoimmune reactions, processes in the muscles, similar to tumors
To increase the service life of the prosthesis, you can use pairs of "ceramics - polyethylene" and "ceramics - ceramics"
Theoretically, the wear period of such pairs reaches 50 years, but the joint wears out not from friction alone, but from static and dynamic loads.
Ceramics is considered absolutely harmless, while polyethylene liners and cups emit harmful friction products - debris that accumulates in the bones and causes inflammation in them, which subsequently leads to loosening of the prosthesis.
Recently, to solve this problem, polyethylene parts have been impregnated with vitamin E.
Which is better - cement or cementless fastening?
A stronger connection of the endoprosthesis is cementless, since due to the porous outer surface of the artificial joint, the bone literally grows into it
But the cementless method, unfortunately, is not suitable for elderly patients with osteoporosis.:
With a cementless connection, the leg and cup are driven into the femur and pelvic bones: of course, with osteoporosis, this can finish off the unfortunate bones of the elderly.
Ways to improve fastening
- Improves the fastening of cups - the presence of holes in them and cloves:
- The holes are necessary so that the surgeon, when driving in the cup, can see the bottom of the cavity through the holes and make an accurate fit of the cup.
- The holes can also be used for additional fasteners.
- Cementless cup coatings - pressed beads, trabecular metal, wire
- The legs of the prosthesis to stimulate bone ingrowth with a cementless connection are coated with hydroxyapatite, titanium sputtering or subjected to abrasive sandblasting
- Also, arches, ribs and protrusions are sometimes made on the legs to improve fixation.
Legs and cups with cement connection are always polished, beautiful and shiny. This is necessary for better contact between the adhesive and the surface of the prosthesis.
However, as it has now become clear, a beautiful leg is not always firmly held.
Perfect leg:
- Individually tailored to the anatomical shape of the femoral canal
- Has a porous coating (for cementless connection)
This will probably last 100 years.
But in old age, the cement method of fastening is more often used.. And the design of the endoprosthesis looks something like this:
There are two options here:
- Unipolar prosthetics - when replacing only the femoral part of the joint
- Bipolar (total) prosthetics - when replacing the entire joint
Revision hip arthroplasty
After a hip arthroplasty, a second operation may be necessary after some time.
The following reasons can lead to it:
- Wear of the endoprosthesis, because of which it does not hold well and hangs out (the head can dislocate and come out of the acetabulum
- Fracture part of the prosthesis:
Most often, the neck of the leg breaks.
Many legs are not made in one piece, but with a removable neck:- this design does not require replacement of the entire stem during revision surgery
- but on the other hand, the prefabricated leg is less durable than the cast product
- Bone Breakdown:
This is the most unfavorable excuse for a second operation, as it leads not only to the manufacture of new prostheses, but also to further sawing of the bone and a decrease in its strength. After all, a bone graft may be needed in the near future
Surgery for revision hip arthroplasty is more than 50% more expensive than primary surgery.
Rehabilitation after hip arthroplasty
After hip arthroplasty, rehabilitation begins from the first day.
Recovery time depends on:
- Method of fastening the prosthesis
- The patient's condition and age
- Presence of pain and complications
Read more about the rehabilitation of the hip joint after arthroplasty in the next article.
In conclusion, a positive story in support of older people who have received a severe injury - a hip fracture and rehabilitation exercises.
Do not despair! There are no hopeless situations. At any age, you can and should overcome yourself.
Video: How to take the first step from complete stillness to movement
(78 ratings, average: 4,88 out of 5)The most complete answers to questions on the topic: "revision of the hip joint."
The purpose of the intervention: restoration of the supporting and motor function of the operated joint.
Requirements for surgeryEquipment requirements:- the presence of a separate operating room for endoprosthetics (preferably with laminar flow);
– availability of a full line of implants;
– the availability of specialized tools for the implant model to be installed;
– availability of medical power equipment (sagittal saw, drill);
– availability of equipment for coagulation hemostasis.
Requirements for additional equipment:– computer navigation system;
– pulse-lavage system.
Consumable requirements:- disposable underwear for the operating field and surgeons (preferably the use of "surgical suits");
– barrier film;
– disposable scalpel;
– suture material with atraumatic needles.
Medication requirements:- Presence of direct anticoagulants indirect action;
– antibacterial drugs wide spectrum of action;
- non-narcotic analgesics;
- narcotic analgesics;
- preparations for infusion4
– availability of a stock of blood products;
- presence of tranexanoic acid preparations;
- immunocorrectors.
Requirements for specialist operators:– a specialist operator must have at least 10 years of work experience in traumatology and at least 5 years of practical experience in the field of implantation of large joints;
– the presence of an operating team performing at least 100 implantations of endoprostheses of large joints per year;
– passing specialization in endoprosthetics at least 1 time in 1 year.
Requirements for patient preparation:- premedication is carried out immediately before the operation;
– preventive antibiotic therapy;
- cleansing enema;
– preparation of the surgical field on the day of surgery.
Conducting surgery
1. Revision hip arthroplasty: It is carried out, as a rule, in patients with instability of one of the components of the endoprosthesis.
After preparation of the surgical field, access to hip joint according to the method adopted in the clinic. After the revision of the hip joint, with obvious signs of aseptic instability of the endoprosthesis component, the bed is removed and processed (spherical cutters, rasps, rimmers, etc.). A revision installation of the component is performed, taking into account the tension of the gluteal muscles, correction of the length of the limb, selection, installation and reduction of the head of the endoprosthesis.
2. Revision total hip arthroplasty: It is carried out, as a rule, in patients with instability of the hip joint endoprosthesis.
After preparing the surgical field, as a rule, access to the hip joint is made according to the method adopted in the clinic. After isolating and removing the components of the hip joint, processing the acetabulum with spherical cutters, processing the femur with rimmers, rasps, the components of the endoprosthesis are installed, taking into account the tension of the gluteal muscles, correction of the length of the limb, selection, installation and reduction of the head of the endoprosthesis.
Assessment of motor function of the joint.
After the final toilet, postoperative layer-by-layer suturing of the wound according to the method adopted in the clinic.
3. Revision hip arthroplasty using revision systems: Preoperative planning - is carried out more carefully in patients with a gross deformity of the hip joint (for example, defects in the columns, the bottom of the acetabulum, i.e. deficiency of the bone tissue of the acetabulum; defect in the proximal femur).
After preparing the surgical field, access to the hip joint is made according to the method adopted in the clinic. The components of the endoprosthesis are removed.
Acetabular treatment: In the presence of an acetabular defect, it is necessary to evaluate the place of the intended installation of the cup. With a shortage of bone tissue, the impossibility of the initial installation of the bowl, there are several options for resolving the issue:
1 - processing with spherical cutters, installation of reinforcing or anti-protrusion rings with cement fixation of the endoprosthesis bowl;
2 – treatment of the bed for the endoprosthesis cup with medialization (iatrogenic cotyloplasty), fixation of the cup with a press-fit with additional fixation with screws, installation of a polyethylene component;
3 - processing with spherical cutters, installation of an anti-protrusion ring of the Octopus type with cementless fixation of the endoprosthesis bowl;
4 - processing of the bed for the cup of the endoprosthesis and the bed for the augment from nickel-titanium alloy or auto / allobone. Installation and fixation of the press-fit bowl with additional fixation with screws, installation and fixation of the augment or auto/allobone with screws, installation of the polyethylene component.
Thigh treatment: 1 - processing of the femur with rasps, rimmers, installation of the femoral component;
2 - in the presence of a defect in the proximal femur, in accordance with the classification of defects, the treatment tactics is determined (Classification of the American Association of Orthopedists for a bone defect in the proximal femur).
At grade 1, installation of standard femoral components, bone auto/alloplasty of bone tissue defects is possible, at grade 2, installation of revision systems of the femoral component, at grade 3, installation of oncological femoral components.
Installation and reduction of the endoprosthesis head.
Assessment of motor function of the joint.