Federal Scientific Clinical Center of Miners’ Health Protection, 

Leninsk-Kuznetsky, Russia

 

Demographic changes taking place all over the world result in both increasing amount of operations for joint replacement and increasing number of failed implants after complications. At the present time the rate of primary and revision prosthetics significantly exceeds the previous predictions [1, 3, 4, 7, 12, 17].

Within the last years the Russian market of endoprosthetic devices is characterized with significant increase in choice of implants from the leading western and domestic companies, as well as with significant improvement in quality of the products in concordance with the European and international ISO standards etc. [5, 6, 18]. The implants for endoprosthetics are made of high quality modern materials; however, they differ in terms of constructive features, design and application technology [11, 16]. Despite of persistent universalization of prosthetic devices, many issues are not solved yet, particularly, optimal choice of an implant for the specific patient with consideration of individual features of pathology and the anatomic situation, low traumatic surgical approaches, postsurgical management, prevention and treating complications [9, 10, 14, 15].

Objective – to estimate short term results of treatment in patients after primary total hip joint endoprosthetics with use of low invasive surgical approaches and appropriate drug therapy.

 

MATERIALS AND METHODS

The follow-up covered 1,012 patients including 445 men (44 %) and 567 women (56 %) with different pathologies of the hip joint who were treated in the department of traumatology and orthopedics #2 in Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, in 2008-2014. The mean age was 56.6.

The inclusion criteria were available informed consent approved and reviewed by the ethical committee of Clinical Center of Miners’ Health Protection in concordance with Helsinki Declaration – Ethical Principles for Medical Research Involving Human Subjects (2000) and the Rules for Clinical Practice in Russian Federation (The order by the Russian Ministry of Health, 19.06.2003, #266).

There were 1,093 operations of primary total endoprosthetics for the hip joint including 81 patients with replaced right and left joints. All patients were taken to the surgery room the next day after admission to the department.

Implantation was performed with devices from DePuy, Sanatmetal, Stryker, Zimmer, ESI, Âiomed, Plus Orthopedics, Aesculap, Wrigth.

The choice of the technique for implant fixation depended on the patient’s age, degree of osteoporosis estimated with the cortical index according to Barnet and Nordin, and, during operation, with bone tissue structure, changes in the acetabulum and the proximal femur, time from injury moment, degree of joint contracture, degree of dysplasia and some other factors [2].

The excessive mass of the body (the index of not less than degree 3), compensated somatic diseases, age characteristics, contractures and ankyloses in the joints were not the criteria for exclusion.

Cementless fixation of implants was used in 864 cases (79 %), cement fixation – in 98 (9 %), mixed fixation – in 131 cases (12 %). The friction pairs in the offered systems were metal-metal, ceramics-metal, metal-polyethylene.

The tactics of surgical treatment included use of our modified minimally invasive approach according to Watson-Jones (MIS AL). The size of skin incision did not exceed 9-10 cm that favored atraumatic preparation of soft tissues, decreasing blood loss to 100 ml, early restoration of joint function. Before closing the surgical wound we performed layer infiltrative introduction of the drugs of mixed-type effect consisting in local and systemic analgesia, neuromodulation and immune stimulation [13].

For preventing bacteriemia all patients received intravenous administration of two grams of antibiotics of the fourth generation according to AAOS protocol 60 minutes before surgery (Antibiotics for Patients with Joint Replacement, 2009).

The patients were mobilized within 24 hours after surgery (walking frame and crutches). The dosed load was allowed to the operated extremity and it depended on individual level of rehabilitation and intensity of pain syndrome.

The clinical estimation of the outcomes was realized with Harris Evaluation System of the Hip [8]. This technique allows estimating results of hip joint arthroplasty. This system supposes estimation of 4 categories: pain, function, deformation, range of motions. Each category requires the specific amount of points. The maximal score is 100. The score from 90 to 100 is considered as excellent function of the joint, 80-90 – as good, 70-79 – as satisfactory and <70 – as non-satisfactory.

 

RESULTS AND DISCUSSION

The table 1 shows the indications for surgery and the number of procedures.

According to the table one can see that the patients with posttraumatic coxarthrosis in the proximal femur received 92 operations of primary endoprosthetics for the hip joint (8.4 % from the total number of operations) (Fig. 1). The feature of these operations was replacement of acetabular defect to automass from the resected and blenderized head of the femur. The fixation of the bearer ring to the pelvic bone was performed with Bursh-Schneider, the prosthetic cup was fixed with use of bone cement for saving the rotation center [14].

For hip joint diseases 1,001 operations of primary endoprosthetics (91.6 %) were performed including 632 operations for idiopathic coxarthrosis (Fig. 2), 201operations for aseptic necrosis of the femoral head (Fig. 3) and 134 operations for dysplastic coxarthrosis. We could observe dysplasia of different degrees – from insignificant underdevelopment of the iliac and ischial sectors to significant underdevelopment with substantial changes in anatomy of the pelvis and the proximal femoral bone. All cases were associated with developed persistent postural disbalance in view of pathologic gait beyond the pelvic region (Fig. 4).                                       

 The postsurgical complications included dislocations of endoprosthesis head, periprosthetic fractures, complications of purulent inflammatory pattern, neuropathy, thromboembolic complications (table 2).          

The analysis of characteristics of the complications after primary endoprosthetics showed the purulent inflammatory complications in 10 patients (0.9 %) with necessity of endoprosthesis removal in 5 cases. All purulent inflammatory complications were noted within the period from hospital discharge to 6 months after surgery and were common for the patients with burdened anamnesis: diabetes mellitus, systemic diseases that hinder surgery for the hip joint.

14 patients (1.3 %) had dislocations of endoprosthesis head as result of disorders in motor conditions in early postsurgical period. In 13 cases the dislocations were reduced with conservative techniques, in 1 case – with surgical treatment; it did not influence on the outcomes of treatment.        

Periprosthetic fractures were in 6 patients: 2 patients with prolapse of the cup into the pelvic cavity and its dislocation; 4 cases with femoral bone fractures resulting in recurrent osteosynthesis for an injured segment and reendoprosthetics (Fig. 5).

Within postsurgical period femoral artery thrombosis was in 1 case, thrombophlebitis and thrombosis in the veins of the lower extremities – in 103 cases including 11 cases with registered embolia-associated states that required surgical interventions for the vessels. The high rates of identified cases of thrombophlebitis and thrombosis were conditioned by total DS control in postsurgical management.     

11 cases were associated with hydrocyanic and alcohol delirium, 4 cases – with contact dermatitis. The patients received conservative treatment resulting in the positive outcomes.

The clinical estimation of the treatment outcomes with use of Harris Evaluation System of the Hip is presented in the table 3.

The analysis of the clinical functional results of primary endoprosthetics in the patients with hip joint pathology after surgical treatment showed that the excellent and good results were achieved in 8.5 % and 68.4 % correspondingly, satisfactory – in 18.9 % and unsatisfactory – in 4.2 %. Treatment of idiopathic coxarthrosis showed excellent, good and satisfactory results in 97.2 %, dysplastic coxarthrosis – in 94.2 %, aseptic necrosis of the femoral head – in 91.9 %, in posttraumatic coxarthrosis – in 98.2 %, in rheumatoid arthritis – in 94.4 %.

Therefore, basing on the analysis of the short term results in the patients after primary endoprosthetics for the hip joint, we can acknowledge the high rate of excellent and good functional results of treatment of degenerative and posttraumatic diseases of the hip joint and these results depend on appropriate usage of minimally invasive surgical approach, optimal way for fixation of endoprosthesis, intrasurgical infiltration of the surgical wound with drugs of mixed effect and activation of patients within 24 hours after surgery.