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After hip replacement, your temperature rises. Complications after hip replacement in the elderly

Modern production methods make it possible to produce high-quality endoprostheses with a long service life. If you take good care of your health, they will serve the patient for decades.

An important point is the patient’s refusal to cooperate with the doctors. In young patients, dislocation of the endoprosthesis occurs no more often than 1.2%, while in older people the percentage is higher – 7.5.

Also absolute contraindications include the inability to move independently and polyallergies. Relative contraindications include cancer, liver failure, osteopathy (hormonal), obesity (III degree).

deforming coxarthrosis degree III;
An important part of it is the friction unit. It consists of two parts - an insert (articular cavity) and the head of the endoprosthesis on a stem, which is fixed in the femur. The durability of the prosthesis depends on the material from which the friction unit is made.
The hip joints are the largest and most heavily loaded in our body. They experience constant stress and are therefore at risk. A sign of incipient problems is pain in the hip joints. It can occur for various reasons (dislocation, fall, illness).
It will be easier for the patient after the operation if he can, while sitting in a chair, put his leg on a small bench;
It is very important that the patient is of normal weight before surgery. This can significantly ease the postoperative period, reduce the load on the joint, and minimize complications. If physical activity due to pain in the hip joint is impossible, then a diet aimed at reducing weight to normal levels is indicated.

Hip replacement, the price of which depends on the material of the prosthesis, is performed under general or spinal anesthesia.

Weakness of the joint, which may be accompanied by pain in it. Elimination of this complication is only surgical.

Hip replacement (endoprosthetics) is an operation that results in the complete replacement of diseased cartilage and bones with artificial prostheses consisting of a concave cup and a spherical head. The main goal of this surgical intervention is to reduce pain caused by various joint diseases.
Patients are not recommended to bend their leg at an angle of more than 90° or turn it inward after installation of the implant. Dislocation of the artificial head of the joint can also occur due to a fall. The symptoms are similar to a dislocated healthy joint. This is a sharp pain, swelling, forced position of the operated leg and its shortening. If the patient does not see a doctor after a dislocation, the temperature may rise due to the onset of inflammation.
The patient is hospitalized two days before the scheduled date of the operation. At this time, all necessary procedures are carried out with the patient, and, if necessary, maintenance therapy is prescribed or adjusted. Progress of the operation:
post-traumatic coxarthrosis (serious damage to the acetabulum);
Hip replacement is a complex operation (although its duration is short). Therefore, the initial examination, selection of the optimal endoprosthesis and postoperative rehabilitation are very important (the use of NSAIDs is mandatory to prevent severe pain).
The main reason when joint replacement is indicated is coxarthrosis.

you can make a list of items that should always be within the reach of the patient: mobile phone, glasses, book, telephone directory, necessary medications, water, TV remote control;

Some patients feel calmer if they know that the ideal blood is available for transfusion. And sometimes the surgeon may insist on this. To do this, a reserve of your own blood is created in advance. If for some reason this is not possible, then you can find a donor in advance from among your close friends and relatives. The blood is examined for all kinds of infections and then frozen. In this form, blood can be safely stored for about a month.

Complications after endoprosthetics are possible, but they occur much less frequently than after other treatment methods. In this case, motor activity begins to be restored the very next day after the operation, and after the end of the rehabilitation period the patient can walk independently, even without the help of crutches.
But the main danger of this method is the high probability that the bones will not heal.
Hip replacement can lead to thrombosis. If movement on the operated leg decreases, blood stagnation in the veins may develop. To prevent this, the patient is not allowed to lie down for a long time and is prescribed anticoagulants.
When is endoprosthetics performed?
Hip replacement significantly improves the patient's quality of life, but an artificial joint head cannot replace a real one.

Preparation for endoprosthetics involves performing spinal anesthesia, cutting the skin over the operated joint, cutting soft tissues and the joint capsule. After this, the surgeon gains access to the destroyed joint.

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Femoral neck fracture in the elderly, endoprosthetics at the FCS clinic

tumor in the area of the femoral neck or its head.

Surgical treatment

The decision to undergo surgery is made by the doctor and the patient. It is important to explain to the patient that refusal to undergo surgery will result in disability and, in some cases, complete immobility. The patient should be aware that complications are possible after hip replacement:

Abrasion of the articular head leads to severe pain, which is not relieved even by non-steroidal anti-inflammatory drugs. If energetic and temperamental animals live in the house, then it is better to temporarily remove them from the house to avoid the patient falling.

You definitely need to get your teeth in order. A tooth affected by caries is a potential source of infection, which can lead to postoperative complications. The doctor prescribes the first simple exercises the next day after endoprosthetics; subsequently, the set of exercises expands and their intensity increases. For 10 days, patients are in the hospital, under constant supervision, after which they can be discharged for further rehabilitation at home.

Hip replacement

Today, surgical treatment is the most rational way to restore the patient’s ability to work. There are two surgical options:

Ossification is the impregnation of the tissues surrounding the joint with calcium salts. This factor can lead to limited joint mobility.

Hip replacement is performed for the following diseases:
To avoid dislocation, the patient must be very careful, not make sudden movements, and monitor the appearance of warning symptoms. A systematic visit to the doctor is necessary.

Next comes the stage of dislocation (twisting) of the femoral head from the acetabulum. A template is installed and the proximal femur is cut. After this, the sawed-off head of the joint is removed, the acetabulum is processed with cutters (prepared for installation of the acetabular component of the endoprosthesis). The acetabular component is fixed either with cement or with screws. Then the liner is installed.

For a fracture of the femoral neck and aseptic necrosis of the head (III–IV degree), surgery is also necessary.

danger of blood clots in damaged vessels;

Rehabilitation

An artificial mechanism that is installed in the human body for one reason or another is called an endoprosthesis. Endoprosthetics is a complex operation to remove part of the destroyed bone and replace it with an implant. The service life of a modern endoprosthesis is long (on average 15–20 years). At the end of this period, the artificial joint is replaced with a new one (re-endoprosthesis surgery is performed).

The preparation of the bathroom and toilet for a person after joint replacement surgery deserves special attention. It is imperative to provide the bathroom and toilet with grab bars. It would be a good idea to purchase a chair in advance on which the patient will take a shower. It must be sustainable. In addition, you need to take measures to prevent this chair from slipping. Soap, shampoo and everything else you might need in the bathroom should be within reach while sitting on a chair. The toilet will have to be raised so that the knees of the person sitting are higher than the hip joint.

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The surgeon must be informed about all medications taken. This also applies to medicinal herbs.

Indications for hip replacement

Call us:

Osteoarthritis of the hip joint

1. Osteosynthesis, or reposition.

Femoral neck fracture

Displacement of the prosthesis. May occur during certain movements. To avoid this complication, patients should not cross their legs or bend their hip joints more than 80 degrees.

Arthritis

Arthrosis.

The dislocation is reduced under anesthesia (intravenous or spinal). After this, the limb is fixed. If the dislocation cannot be corrected, they resort to surgery.

Preparation for prosthetics

The hip joint endoprosthesis is installed in the femur. To do this, the bone marrow canal is opened. Next, it is prepared for implantation using osteoprofilers. The femoral part of the endoprosthesis is installed into the prepared hole. The head is installed in the acetabulum.

After clarifying the medical history and conducting an examination, chronic diseases are identified. Absolute contraindications for endoprosthetics are systemic diseases:

large blood loss during and after surgery;

When performing hip replacement surgeries, two types of anesthesia are used.

Some medications will need to be stopped in advance.Some injuries and their consequences, as well as some diseases, lead to the fact that the only chance for a full life is a hip replacement.

With this method, femoral bone fragments are compared in such a way as to ensure their maximum contact, and then fixed with metal screws. Such operations can extremely rarely be recommended for older people, primarily due to the low likelihood of bone fusion.

How to prepare your home for the post-op period

Change in the length of the operated leg. This complication occurs as a result of relaxation of the muscles surrounding the joint. This problem can be solved by performing special physical exercises.

Femoral neck fracture.
The service life of modern endoprostheses is more than 20 years. Many patients live up to 30 years after surgery without any problems and do not show any complaints. However, sooner or later re-endoprosthetics will be required - this is the replacement of a worn-out implant with a new one.
The surgeon checks how the limb will function (moves it in different directions). If everything is normal, first the soft tissues are sutured, then the sutures are applied to the skin. A drainage tube is installed to drain possible blood. The duration of the operation is no more than two hours, depending on the degree of destruction of the hip bone.
Cardiovascular and bronchopulmonary (in the acute stage);
infection at the site of installation of the prosthesis (the patient has a fever, pain is felt in the area of the operated joint, the skin is hyperemic);
The endoprosthesis can be made of titanium and steel alloys (stainless), ceramics and high-strength plastics. The peculiarity of these materials is their strength and, at the same time, ease of processing. It is quite difficult to make a high-quality endoprosthesis, so there is control at every stage of production. All products have their own quality certificate.
The medicine in a gaseous state enters the lungs through a special mask. After the patient has fallen asleep, a tube is inserted into his airway for artificial ventilation. Using various sensors, the anesthesiologist monitors the patient’s condition throughout the entire operation.
As part of the overall health of the body, it is very advisable to stop smoking before hip replacement surgery. This measure will also help prevent complications.

Hip replacement is indicated for certain types of injuries and diseases of the bones and joints.

Anesthesia during surgery

2. Endoprosthetics.

General

Hip replacement surgery

Regional

Polyarthritis.

The operation is more complex than primary endoprosthetics, since it is necessary to remove the old prosthesis, clean out the acetabulum and the canal in the hip bone.

The postoperative period is long. The patient can begin to move within the first day. On the second day, light gymnastics in a sitting position is allowed. You can walk with the help of a walker already on the third day. The stitches are removed after about two weeks. All this time, the patient receives full treatment with antibiotics and painkillers. Additionally, symptomatic treatment may be prescribed for mental disorders and problems with the nervous system;

risk of developing pneumonia;

The artificial joint can be fixed with cement based on acrylic resin and an alloy of chromium or cobalt, or installed without it.

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Hip replacement or endoprosthesis: preparation for surgery

There are two types of regional anesthesia: spinal, epidural, or a combination of both. During the operation, the patient is asleep, but he wakes up immediately after the operation, without feeling pain.

First of all, it is necessary that someone is constantly with the patient after the operation. In addition, you will have to adapt your home in such a way as to make the patient’s life as easy as possible:

This disease is a consequence of damage to the cartilage tissue of the joint. Most often, cartilage wears out with age, so this condition is common in older people. Less commonly, arthrosis develops as a result of injury.

What is endoprosthetics

In this case, damaged bone and joint fragments are replaced with implants, ensuring complete restoration of mobility. The method is highly effective and allows you to return to physical activity as quickly as possible.

Types and materials of endoprostheses

Basically, endoprosthetics is carried out according to the general scheme:

Disturbance of the blood supply to the hip joint.

The new acetabular liner will be larger, as will the head of the implant.

When lying on the bed, it is important to keep a thick pad between your legs. It helps maintain the correct position of the operated leg. After the sutures are removed, the patient is discharged. For the next 2 months after surgery, it is recommended to limit the weight on your leg. You need to walk, but with the use of crutches or a walker.

long-term infection in the area of the damaged joint (3 months or more);
dislocation of the endoprosthesis (treatment period increases);

Hip replacement is divided into two types:

The type of anesthesia is discussed with the patient in advance. The anesthesiologist studies the medical history, talks with the patient before the operation, explains to him the principle of action and possible side effects of different types of anesthesia, after which, having all the necessary information, the patient decides on the method of pain relief during joint replacement surgery.

all items needed in everyday life should be placed at arm's length;

In old age, such a fracture may no longer heal. In this case, joint replacement is not only the ability to walk, but also, in principle, to live.

How is the treatment carried out?

Surgery to replace damaged areas with endoprostheses is the most reliable method of treating a hip fracture, especially in older people, and in some cases, such as significant displacement of fragments or a complex fracture, it is the only option to restore mobility.

An incision is made on the lateral or frontal surface of the thigh.
Necrosis of the femoral head, which may be caused by taking certain medications or performing certain surgical interventions (for example, kidney transplantation).
Reendoprosthetics may also be required in case of accidental injuries to a previously operated hip. Therefore, it is very important to take care to ensure that the implant lasts as long as possible. Preparation for re-endoprosthetics is no different from primary prosthetics. It is shorter in time, since the attending physician already has a complete medical history.
Hip replacement can be complicated by dislocation. There are several reasons - the structural features of the artificial articular head, the human factor (the patient himself is to blame), the surgeon’s mistake due to lack of experience (in particular, performing the operation from behind). At risk are:
acute vascular diseases of the extremities;
looseness (of the leg or head), resulting in a paraprosthetic fracture.

replacement of the articular head;

Indications

You can’t eat anything 12 hours before surgery, and you can’t drink anything 7 hours before surgery. You will be able to eat for the first time after the operation in the evening of the same day.

if the house has more than one floor, then you need to make sure that everything necessary for a person after surgery is located on the ground floor;
Inflammation in the joint can lead to irreversible consequences. Sometimes complete joint replacement is the only possible way to restore mobility to the patient.
Endoprosthetics can be:
Cartilage tissue or affected bone is removed.

However, hip replacement is not performed immediately after diagnosis. Surgical intervention is performed only when pain in the joints becomes permanent, contributes to the deterioration of the simplest functions (walking, climbing stairs, etc.) and is not relieved with the help of strong painkillers.

Contraindications

Joint operations help desperate patients experiencing constant severe pain to be able to move independently, even with a crutch or cane.

patients with hip fracture and dysplasia;
a source of infection in the body (including caries, tonsillitis, sinusitis);
Immediately after surgery, the patient may develop a fever. This is the body's reaction to surgery. Therefore, taking antibiotics for 10 days after surgery is mandatory.
replacement of cartilage tissue (with undestroyed bone).
Sometimes the patient may experience nausea due to anesthesia. There is no need to endure it; it is better to seek help, and the doctor will prescribe a medicine to relieve nausea.
it is better to free up as much space as possible from unnecessary furniture and other objects in order to ensure that the patient on crutches can move freely around the room and between them;
Hip replacement in most cases allows the patient to have an absolutely normal, fulfilling life.

unipolar, when only the neck and head of the femur are replaced;

Operation

Implantation of the cavity coupling is performed.

Are there any risks with this operation?
The preparation takes a little time. You need to undergo a full examination, based on the results of which the doctor will make a diagnosis and recommend treatment. The conservative method often does not pay off, since a damaged joint cannot be restored with medication or other non-surgical methods, and the pain intensifies over time.
have undergone previous surgical interventions;
young age (when the skeleton is in the growth stage);
Endoprosthetics has become popular due to frequent injuries to the hip joints. Installation of implants helps patients lead an active lifestyle, take care of themselves, and work. Hip replacement is indicated for the following diseases:
The second option is a priority for young active people. It leaves the bone intact, thereby maximizing the preservation of all motor functions of the joint. This operation is much simpler than with the installation of a full-fledged implant; in the postoperative period the patient feels almost no pain. There is also an endoprosthesis with a shortened leg. It allows you to save more of the patient's femur, while holding as firmly as a standard one.

Symptoms of endoprosthesis dislocation

It is very important to trust the surgeon and anesthesiologist. With proper preparation and rehabilitation after surgery, the patient does not face complications. A positive attitude and support from loved ones before surgery and in the postoperative period can work wonders.

you need to purchase in advance a good, durable chair in which the patient sits so that the knees are below the hip joint, which will allow him to stand up easily;
In order to avoid complications, you need to carefully prepare for joint replacement surgery. Before the operation, it is necessary to undergo a complete examination of the body. All chronic diseases are taken into account. A course of treatment is prescribed so that the patient is as healthy as possible by the time of surgery. The condition must be corrected in the case of arterial hypertension, diabetes mellitus, and blood clotting disorders. A suitable anesthesia is selected.
Bipolar or total, if the acetabulum of the pelvic bone is also replaced.

The hip hinge is replaced with an artificial prosthesis that is attached to the hip bone.

Like any other surgical intervention, endoprosthetics has possible complications:

The doctor must explain to the patient that joint replacement will help get rid of pain and give the opportunity to live a full life.

Patients with joint hypermobility.

absence of the medullary canal of the hip bone (if hip replacement surgery is performed).

Reendoprosthetics

one- and two-sided deforming arthrosis (II–III degree);

For each patient, the endoprosthesis is selected individually.

the house needs to be inspected as if a small child lived there, and wires, sharp corners, slippery surfaces, thresholds in doorways must be removed, and good lighting of the entire house, including corridors, must be made;

Advantages of endoprosthetics

To facilitate the postoperative period, the patient is prescribed special exercises. It is important to have strong arms and developed torso muscles. It will be difficult to learn to walk with crutches after surgery. It is better to master this skill in advance.

Implants are attached using a cementless or cement method. The first method is more suitable for young patients, since in this case prostheses with a porous structure are used, which are connected to the bones without additional fixators.

A suture is placed at the incision site.

Penetration of infection into the surgical wound or into the place where an artificial prosthesis was installed. This may manifest as redness, swelling and pain at the surgical site. To prevent such complications, antibiotics are prescribed.

However, this does not mean that endoprosthesis replacement is contraindicated in older people. Most patients are allowed to undergo it; in addition, it is older people who most often need joint replacement.

The specialist must take into account the state of the body and take measures necessary to ensure that the recovery period is successful.

Dislocations and subluxations of the prosthesis

Such consequences are detected in the first year after installation of the prosthesis. This is the most common complication in which the femur is displaced in relation to the acetabulum. Because of this, it ceases to function as a single whole. Provoking factors are considered:

increased physical activity;
incorrect selection of implant;
falls and blows.

The risk group includes people who have suffered a hip fracture or have congenital hypoplasia of the hip joint, neuromuscular diseases and obesity. Complications often occur in patients who have had surgery on a natural joint.

Treatment of dislocation is carried out using the open or closed method. If you consult a doctor in a timely manner, it is possible to straighten the head of the endoprosthesis without making an incision in the skin. In advanced cases, repeat joint replacement is prescribed.

Infection of the prosthesis

This is the second most common complication. It is characterized by the development of active purulent-inflammatory processes of a bacterial nature in the area of the implanted implant. Pathogenic microorganisms penetrate through non-sterile instruments.

Bacteria travel through the circulatory system from any chronic source of infection in the body. These include:

carious teeth;
inflamed joints;
diseases of the genitourinary system.

Poor healing, which often results in fistula formation, is observed in diabetes mellitus. This contributes to the rapid proliferation of bacteria and suppuration of the wound.

With the development of this complication, the patient develops signs of intoxication of the body:

elevated temperature;
chills;
pain in muscles and joints.

Suppuration negatively affects the strength of the prosthesis and contributes to its loosening.

Infection after prosthetics is difficult to treat; it is assumed that the implant is removed and reinstalled after completion of antibacterial therapy.

An antibiotic is prescribed only after determining the type of bacteria. The wound is regularly treated with antiseptic solutions.

Other complications

Pulmonary embolism 1 blockage of the lumen of a vessel by a detached thrombus. Its formation is promoted by stagnation of blood in the deep veins of the thigh due to poor circulation. Thrombosis most often occurs in the absence of rehabilitation and drug therapy, as well as with prolonged immobilization. Blockage of the pulmonary artery can be fatal, so the patient is immediately taken to the intensive care unit, where thrombolytics and anticoagulants are administered.

Periprosthetic fracture is a violation of the integrity of the bone in the places where the prosthesis is fixed, occurring at any time after surgery. The occurrence of this complication is facilitated by a decrease in tissue density or improper drilling of the bone canal before installation of the implant. Treatment consists of repeated surgery, called. The leg of the prosthesis is replaced with a part of a more suitable size and configuration.

Neuropathy develops when the peroneal roots, which are part of the greater sciatic nerve, are affected. This condition can be caused by the rapid growth of a hematoma or tissue damage during bone preparation and implant installation. Knee and hip pain can be treated with surgery or physical therapy.

The intensive development of hip arthroplasty, along with the high rehabilitation potential of this operation, is accompanied by an increase in the number of cases of deep infection in the surgical area, amounting, according to domestic and foreign authors, from 0.3% to 1% in primary arthroplasty, and 40% and more - during revision. Treatment of infectious complications after this type of operation is a long process, requiring the use of expensive medications and materials.

Treatment issues for patients who have developed infectious process after hip replacement, continue to be a hot topic for discussion among specialists. It was once considered completely unacceptable to implant an endoprosthesis into an infected area. However, evolving understanding of the pathophysiology of implant-associated infection, as well as advances in surgical technique, have made successful arthroplasty possible in this setting.

Most surgeons agree that removal of endoprosthetic components and careful debridement of the wound are an important initial stage of patient treatment. However, there is still no consensus on techniques that can restore the functional state of the joint without pain and with minimal risk of recurrent infection.

Classification

Using an effective classification system is important when comparing treatment results and determining the most appropriate treatment option.

With all the variety of proposed classification systems, the absence of an international system of criteria for constructing a diagnosis and subsequent treatment of paraendoprosthetic infection indicates that the treatment of infectious complications after endoprosthetics is rather poorly standardized.

The most common classification of deep infection after total hip arthroplasty according to M.V. Coventry - R.H, Fitzgerald, the main criterion of which is the time of manifestation of the infection (the time interval between the operation and the first manifestation of the infectious process). Based on this criterion, the authors identified three main clinical types of deep infection. In 1996, D.T. Tsukayama et al added type IV to this classification, defined as a positive intraoperative culture. This type of paraendoprosthetic infection refers to asymptomatic bacterial colonization of the surface of the endoprosthesis, which manifests itself in the form of positive intraoperative cultures of two or more samples with isolation of the same pathogenic organism.

Classification of deep infection after total hip arthroplasty (Coventry-Fitzgerald-Tsukayama)

Depending on the type of infection, the authors recommended certain treatment tactics. Thus, in type I infection, revision with necrectomy, replacement of the polyethylene liner and preservation of the remaining components of the endoprosthesis is considered justified. The authors believe that in case of type II infection, during a revision with mandatory necrectomy, removal of the endoprosthesis is required, and in patients with type III paraendoprosthetic infection, an attempt can be made to preserve it. In turn, if a positive intraoperative culture is diagnosed, treatment can be conservative: suppressive parenteral antibiotic therapy for six weeks.

Features of the pathogenesis of paraendoprosthetic infection

Paraendoprosthetic infection is a special case of implant-associated infection and, regardless of the route of penetration of the pathogen, the time of development and the severity of clinical manifestations, it is specific to endoprosthetics. In this case, the leading role in the development of the infectious process is given to microorganisms and their ability to colonize biogenic and abiogenic surfaces.

Microorganisms can exist in several phenotypic states: adherent - biofilm form of bacteria (biofilm), free-living - planktonic form (in solution in suspension), latent - spore.

The basis of the pathogenicity of microbes that cause paraendoprosthetic infections is their ability to form special biofilms (biofilms) on the surfaces of implants. Understanding this fact is extremely important for determining rational treatment tactics.

There are two alternative mechanisms for bacterial colonization of the implant. The first is through direct nonspecific interaction between the bacterium and an artificial surface not covered with host proteins due to the forces of the electrostatic field, surface tension forces, Waan der Wiels forces, hydrophobicity and hydrogen bonds. It has been shown that there is selective adhesion of microbes to the implant depending on the material from which it is made. Adhesion of St. strains epidermidis occurs better in the polymer parts of the endoprosthesis, and strains of St. aureus - to metal.

In the second mechanism, the material from which the implant is made is coated with host proteins, which act as receptors and ligands that bind the foreign body and microorganism together. It should be noted that all implants undergo so-called physiological changes, as a result of which the implant is almost instantly coated with plasma proteins, mainly albumin.

After the adhesion of bacteria and the formation of a monolayer, the formation of microcolonies occurs, enclosed in an extracellular polysaccharide matrix (EPM) or glycocalyx (EPM is created by the bacteria themselves). Thus, a bacterial biofilm is formed. EPM protects bacteria from the immune system, stimulates monocytes to create prostaglandin E, which suppresses T-lymphocyte proliferation, B-lymphocyte blastogenesis, immunoglobulin production and chemotaxis. Studies of bacterial biofilms show that they have a complex three-dimensional structure, much like the organization of a multicellular organism. In this case, the main structural unit of the biofilm is a microcolony consisting of bacterial cells (15%) enclosed in an EPM (85%).

During the formation of a biofilm, adhesion of aerobic microorganisms first occurs, and as it matures, conditions are created in the deep layers for the development of anaerobic microorganisms. Periodically, upon reaching a certain size or under the influence of external forces, individual fragments of the biofilm are torn off with their subsequent dissemination to other places.

In the light of new knowledge about the pathogenesis of implant-associated infection, the high resistance of adherent bacteria to antibacterial drugs, the futility of conservative tactics, as well as revision interventions with preservation of the endoprosthesis in patients with para-endoprosthetic infection type II-III, become clear.

Diagnosis of paraendoprosthetic infection

Identification of any infectious process involves the interpretation of a set of procedures, including clinical, laboratory and instrumental studies.

Diagnosis of paraendoprosthetic infection is not difficult if classic clinical symptoms of inflammation are present (limited swelling, local tenderness, local fever, skin hyperemia, dysfunction) in combination with a systemic inflammatory response syndrome, characterized by the presence of at least two of the four clinical signs: temperature above 38°C or below 36°C; heart rate over 90 beats per minute; respiratory rate over 20 breaths per minute; the number of leukocytes is above 12x10 or below 4x10, or the number of immature forms exceeds 10%.

However, significant changes in the immunobiological reactivity of the population, caused by both the allergenic influence of many environmental factors and the widespread use of various therapeutic and preventive measures (vaccines, blood transfusions and blood substitutes, medications, etc.), have led to the fact that blurred clinical picture of the infectious process, making timely diagnosis difficult.

From a practical point of view, for the diagnosis of peri-endoprosthetic infection, it seems most rational to use the standard case definitions for surgical site infection (SSI), developed in the USA by the Centers for Disease Control and Prevention (CDC) for the National Nosocomial Infection Surveillance (NNIS) program. The CDC criteria are not only the de facto national standard in the United States, but are also used virtually unchanged in many countries around the world, providing, in particular, the possibility of comparing data at the international level.

Based on these criteria, SSIs are divided into two groups: surgical incision (surgical wound) infections and organ/cavity infections. Incision SSIs, in turn, are divided into superficial (only the skin and subcutaneous tissues are involved in the pathological process) and deep infections.

Criteria for superficial SSI

Infection occurs up to 30 days after surgery and is localized within the skin and subcutaneous tissues in the incision area. The criterion for diagnosis is at least one of the following signs:

purulent discharge from a superficial incision with or without laboratory confirmation;
isolation of microorganisms from fluid or tissue obtained aseptically from the area of a superficial incision;
presence of symptoms of infection: pain or tenderness, limited swelling, redness, local fever, unless culture from the wound gives negative results.
The diagnosis of superficial incision SSI was made by a surgeon or other attending physician.

Suture abscess is not registered as an SSI (minimal inflammation or discharge limited to points of penetration of the suture material).

Criteria for deep SSI

Infection occurs up to 30 days after surgery if there is no implant or no later than one year if there is one. There is reason to believe that the infection is associated with this surgical procedure and is localized in the deep soft tissues (for example, fascial and muscle layers) in the incision area. The criterion for diagnosis is at least one of the following signs:

purulent discharge from the depth of the incision, but not from the organ/cavity in the surgical area;
spontaneous wound dehiscence or intentional opening by the surgeon with the following signs: fever (> 37.5°C), localized tenderness, unless wound culture is negative;
upon direct examination, during reoperation, histopathological or radiological examination, an abscess or other signs of infection were detected in the area of the deep incision;
The diagnosis of deep incision SSI was made by a surgeon or other attending physician.

Infection involving both deep and superficial incisions is reported as deep incision SSI.

Laboratory research

Number of leukocytes in peripheral blood

An increase in the number of neutrophils during manual counting of certain types of leukocytes, especially when a shift in the leukocyte formula to the left and lymphocytopenia is detected, means the presence of an infectious infection. However, in the chronic course of paraendoprosthetic infection, this form of diagnosis is uninformative and does not have much practical significance. The sensitivity of this parameter is 20%, specificity is 96%. At the same time, the level of predictability of positive results is 50%, and of negative ones - 85%.

Erythrocyte sedimentation rate (ESR)

The ESR test is a measurement of the physiological response of red blood cells to agglutination when stimulated by protein reagents in the acute phase. Typically, this method is used in orthopedics when diagnosing an infectious lesion and subsequently monitoring it. Previously, an ESR value of 35 mm/hour was used as a differential threshold criterion between aseptic and septic loosening of the endoprosthesis, with a sensitivity of 98% and a specificity of 82%.

It should be taken into account that other factors may also influence an increase in ESR levels (concomitant infectious diseases, collagen vascular lesions, anemia, recent surgery, a number of certain malignant diseases, etc.). Therefore, a normal ESR level can be used as evidence of the absence of an infectious lesion, while its increase is not an accurate indicator of excluding the presence of infection.

However, the ESR test may also be useful in determining chronic infection after repeat arthroplasty. If the ESR level is more than 30 mm/hour six months after a two-stage procedure to replace a total endoprosthesis, the presence of a chronic infection can be assumed with an accuracy of 62%.

C-reactive protein (CRP)

CRP belongs to the acute phase proteins and is present in the blood serum of patients with injuries and diseases of the musculoskeletal system, which are accompanied by acute inflammation, destruction and necrosis, and is not a specific test for patients who have undergone joint replacement. As a screening test for a patient who has developed a peri-endoprosthetic infection, the CRP test is a very valuable tool, since it is not technically difficult and does not require large financial costs. The level of CRP decreases soon after the infectious process is stopped, which, in turn, does not occur with ESR. Elevated ESR levels may persist for up to a year after successful surgery before returning to normal levels, while CRP levels return to normal within three weeks of surgery. According to various authors, the sensitivity of this indicator reaches 96%, and the specificity - 92%.

Microbiological studies

Bacteriological research includes identification of the pathogen (qualitative composition of the microflora), determination of its sensitivity to antibacterial drugs, as well as quantitative characteristics (number of microbial bodies in tissues or wound contents).

A valuable diagnostic technique that allows you to quickly get an idea of the likely ethology of the infectious process is microscopy with Gram staining of the resulting material. This study is characterized by low sensitivity (about 19%), but fairly high specificity (about 98%). Wound discharge in the presence of fistulas and wound defects, contents obtained during joint aspiration, tissue samples surrounding the endoprosthesis, and prosthetic material are subject to study. The success of isolating a pure culture largely depends on the order of collection, transportation, inoculation of the material on nutrient media, as well as on the type of infectious process. In patients whose surgical treatment included implants, microbiological testing provides a low degree of infection detection. The main material for research is discharge from wound defects, fistulas and contents obtained during joint aspiration. Since in implant-associated infections the bacteria are predominantly in the form of adhesive biofilms, they are extremely difficult to detect in the synovial fluid.

In addition to standard bacteriological examination of tissue culture samples, modern methods of analysis at the molecular biological level have been developed. Thus, the use of polymerase chain reaction (PCR) will determine the presence of bacterial deoxyribonucleic acid or ribonucleic acid in tissues. A culture sample is placed in a special environment in which it undergoes a development cycle for the purpose of exposure and polymerization of deoxyribonucleic acid chains (consecutive passage of 30 - 40 cycles is required). By comparing the obtained deoxyribonucleic acid sequences with a number of standard sequences, the microorganism that caused the infectious process can be identified. Although the PCR method is highly sensitive, it has little specificity. This explains the possibility of obtaining false-positive responses and the difficulty in differentiating a stopped infectious process from a clinically active infection.

Instrumental studies

X-ray diffraction

There are very few specific radiological signs that can be used to identify an infection, and none of them are pathognomonic for periprosthetic infection. There are two radiological signs that, although they do not make it possible to diagnose the presence of an infectious process, do suggest its existence: periosteal reaction and osteolysis. The rapid appearance of these signs after a successful operation, in the absence of visible reasons for this, should increase suspicions about a possible infectious lesion. In this case, X-ray control is mandatory, since only by comparison with previous radiographs of good quality can one judge the real state of affairs.

In case of fistulous forms of paraendoprosthetic infection, a mandatory research method is x-ray fistulography, which makes it possible to clarify the location of the fistulous tracts, the localization of purulent leaks and their connection with foci of destruction in the bones. Based on contrast X-ray fistulography, differential diagnosis of superficial and deep forms of paraendoprosthetic infection can be carried out.

X-ray fistulography of the left hip joint and left thigh of patient P., 39 years old. Diagnosis: paraendoprosthetic infection type III; fistula in the lower third of the thigh, the postoperative scar is intact, without signs of inflammation.

Magnetic resonance examination

Magnetic resonance imaging studies are regarded as additional and are used when examining patients with paraendoprosthetic infection, usually for the purpose of diagnosing intrapelvic abscesses, clarifying their size and extent of spread within the pelvis. The results of such studies help with preoperative planning and increase hopes for a favorable outcome during repeated replacement of the endoprosthesis.

Radioisotope scanning

Radioisotope scanning using various radiopharmaceuticals (Tc-99m, In-111, Ga-67) is characterized by low information content, high cost and labor-intensive research. Currently, it does not play an important role in diagnosing an infectious process in the area of the operated joint.

Ultrasound echography (ultrasound)

Ultrasound is effective as a screening method, especially in cases where infection is highly likely and conventional femoral aspiration is negative. In such situations, ultrasound helps to determine the location of the infected hematoma or abscess and, upon repeated puncture, obtain the necessary samples of the pathological contents.

Ultrasound of the right hip joint, patient B., 81 years old. Diagnosis: paraendoprosthetic infection type II. Ultrasound signs of moderate effusion in the projection of the neck of the right hip joint, limited by the pseudocapsule, V up to 23 cm 3.

Aortoangcography

This study is complementary, but can be extremely important in preoperative planning in patients with defects of the acetabular floor and migration of the acetabular component of the endoprosthesis into the pelvic cavity. The results of such studies help to avoid serious complications during surgery.

Aortography of patient 3., 79 years old. Diagnosis: paraendoprosthetic infection type III; instability, separation of the components of the total endoprosthesis of the left hip joint, defect of the floor of the acetabulum, migration of the acetabular component of the endoprosthesis into the pelvic cavity.

General principles of treatment of patients with paraendoprosthetic infection

Surgical treatment of patients with paraendoprosthetic infection generally reflects advances in the field of endoprosthetics.

In the past, treatment tactics were largely the same for all patients and largely depended on the surgeon's point of view and experience.

However, today there is a fairly wide choice of treatment options that take into account the general condition of the patient, the reaction of his body to the development of the pathological process, the time of manifestation of the infection, the stability of fixation of the components of the endoprosthesis, the prevalence of the infectious lesion, the nature of the microbial pathogen, its sensitivity to antimicrobial drugs, the condition of the bones and soft tissues in the area of the operated joint.

Surgical treatment options for paraendoprosthetic infection

When determining surgical tactics in the case of an established fact of paraendoprosthetic infection, the main thing is to decide on the possibility of preserving or reinstalling the endoprosthesis. From this position, it is advisable to distinguish four main groups of surgical interventions:

I - revision with preservation of the endoprosthesis;
II - with one-stage, two-stage or three-stage endoprosthetics.
III - other procedures: revision with removal of the endoprosthesis and resection arthroplasty; with removal of the endoprosthesis and the use of VCT; removal of the endoprosthesis and non-free musculoskeletal or muscle plastic surgery.
IV - disarticulation.

Technique for revision of the artificial hip joint area

Regardless of the period of development of infection after hip replacement, when deciding on surgical treatment, it is necessary to adhere to the following principles of revision of the artificial hip joint area: optimal access, visual assessment of pathological changes in soft tissues and bone, revision of the components of the endoprosthesis (which cannot be fully performed without dislocating the artificial joint), determining indications for retaining or removing components or the entire endoprosthesis, methods for removing bone cement, drainage and closure of the surgical wound.

Access is through the old postoperative scar. First, a dye (an alcohol solution of brilliant green in combination with hydrogen peroxide) is injected into the fistula (or wound defect) using a catheter connected to a syringe. In cases where there are no fistulas, it is possible to inject a dye solution during puncture of a purulent focus. After injection of the dye, passive movements are performed in the hip joint, which improves staining of the tissue deep in the wound.

The wound is inspected, focusing on the spread of the dye solution. Visual assessment of soft tissues includes studying the severity of swelling of the latter, changes in their color and consistency, the absence or presence of soft tissue detachment and its extent. The nature, color, smell and volume of liquid pathological contents of the surgical wound are assessed. Samples of pathological contents are taken for bacteriological examination.

If the cause of suppuration is ligatures, the latter are excised along with the surrounding tissues. In these cases (in the absence of dye flow into the area of the artificial joint), revision of the endoprosthesis is not advisable.

For isolated epifascial hematomas and abscesses, after evacuation of blood or pus and excision of the edges of the wound, a puncture of the area of the artificial hip joint is performed in order to exclude non-draining hematomas or reactive inflammatory exudate. If they are detected, a full inspection of the wound is carried out to its full depth.

After exposure of the endoprosthesis, the stability of the artificial joint components is assessed. The stability of the acetabular component and polyethylene liner is assessed using compression, traction and rotation forces. The strength of the component's fit in the acetabulum is determined by the pressure on the edge of the metal frame of the prosthesis cup. In the absence of mobility of the cup and (or) release of fluid (dye solution, pus) from under it, the acetabular component of the prosthesis is considered stable.

The next step is to dislocate the head of the endoprosthesis, and determine the stability of the femoral component by applying strong pressure on it from different sides, while performing rotational and traction movements. In the absence of pathological mobility of the endoprosthesis leg, or the release of fluid (dye solution, pus) from the medullary space of the femur, the component is considered stable.

After monitoring the stability of the endoprosthesis components, a re-examination of the wound is carried out in order to identify possible purulent leaks, an assessment of the condition of the bone structures, a thorough necrectomy, excision of the edges of the surgical wound with re-treatment of the wound with antiseptic solutions and mandatory vacuuming. The next stage involves replacing the polyethylene liner, repositioning the head of the endoprosthesis and re-treating the wound with antiseptic solutions with mandatory vacuuming.

Wound drainage is carried out in accordance with the depth, localization and extent of the infectious process, as well as taking into account possible paths of spread of pathological contents. For drainage, perforated polyvinyl chloride tubes of various diameters are used. The free ends of the drains are removed through separate punctures of the soft tissues and fixed to the skin with separate interrupted sutures. An aseptic bandage with an antiseptic solution is applied to the wound.

Revision with preservation of endoprosthesis components

Postoperative hematoma plays a large role in the development of early local infectious complications. Bleeding of soft tissues and exposed bone surface in the first 1 - 2 days after surgery is observed in all patients. The incidence of hematomas after total arthroplasty is, according to various authors, from 0.8 to 4.1%. Such significant fluctuations are explained, first of all, by differences in attitudes towards this complication and underestimation of its danger. K.W. Zilkens et al believe that about 20% of hematomas become infected. The main method of preventing hematomas is careful handling of tissues, careful suturing and adequate drainage of the postoperative wound, and effective hemostasis.

Patients with an infected postoperative hematoma or late hematogenous infection are traditionally treated with open debridement and prosthesis retention and parenteral antimicrobial therapy without removal of endoprosthetic components.

According to various authors, the degree of success from this type of surgical intervention varies from 35 to 70%, with favorable outcomes in most cases observed during the revision on average within the first 7 days, and unfavorable ones - 23 days.

Performing a revision while preserving the endoprosthesis is justified in case of type I paraendoprosthetic infection. Patients for whom this treatment method is indicated must meet the following criteria: 1) the manifestation of infection should not exceed 14 - 28 days; 2) absence of signs of sepsis; 3) limited local manifestations of infection (infected hematoma); 4) stable fixation of endoprosthesis components; 5) established etiological diagnosis; 6) highly sensitive microbial flora; 7) the possibility of long-term antimicrobial therapy.

Therapeutic tactics during revision while preserving the components of the endoprosthesis

replacement of the polyethylene liner, endoprosthesis head.

Parenteral antibacterial therapy: 3-week course (inpatient).

Suppressive oral antibiotic therapy: 4-6 week course (outpatient).

Control: clinical blood test, C-reactive protein, fibrinogen - at least once a month during the first year after surgery, subsequently - as indicated.

Clinical example. Patient S., 64 years old. Diagnosis: right-sided coxarthrosis. Condition after total endoprosthesis of the right hip joint in 1998. Aseptic instability of the acetabular component of the total endoprosthesis of the right hip joint. In 2004, re-endoprosthetics of the right hip joint was performed (replacement of the acetabular component). Removal of drainages - on the second day after surgery. Spontaneous evacuation of a hematoma was noted from the wound defect at the site of removed drainage in the area of the right thigh. Based on the results of a bacteriological study of the discharge, the growth of Staphylococcus aureus with a wide spectrum of sensitivity to antibacterial drugs was revealed. Diagnosis: type I paraendoprosthetic infection. The patient underwent revision, sanitation, and drainage of the infectious focus in the area of the right hip joint and right thigh, preserving the components of the endoprosthesis. Within 3 years after the revision, no recurrence of the infectious process was noted.

Patient S., 64 years old. Diagnosis: paraendoprosthetic infection type I: a — radiographs of the right hip joint before re-endoprosthetics, b — X-ray fistulography on the 14th day after re-endoprosthetics of the right hip joint; c - after performing the audit; d — wound defect at the site of remote drainage; d — stage of operation (extensive subfascial hematoma); f, g — the result of surgical treatment on the 16th day after the revision with preservation of the components of the endoprosthesis.

Reasons for unsatisfactory outcomes of revisions with preservation of the endoprosthesis:

lack of early radical comprehensive treatment of suppurating postoperative hematomas;
refusal to dislocate the endoprosthesis during revision;
refusal to replace polyethylene inserts (replacement of the endoprosthesis head);
audit for an unidentified microbial agent;
preservation of the endoprosthesis in case of widespread purulent process in the tissues;
an attempt to preserve the endoprosthesis during repeated revision in case of recurrence of the infectious process;
refusal to carry out suppressive antibiotic therapy in the postoperative period.

Although in recent years there has been some success in treating patients with paraendoprosthetic infection by surgical debridement without removing the endoprosthesis, the general consensus is that this method is ineffective, especially in the treatment of patients with type III paraendoprosthetic infection, and leads to a favorable outcome only under a certain set of conditions.

Revision with one-stage re-endoprosthetics

In 1970 H.W. Buchholz proposed a new treatment for periprosthetic infection: a one-stage prosthetic replacement procedure using antibiotic-loaded polymethyl methacrylate bone cement. In 1981, he published his data on the results of primary re-endoprosthesis on the example of 583 patients with this type of pathology. The success rate for this procedure was 77%. However, a number of researchers advocate a more cautious use of this treatment method, citing data on recurrence of the infectious process in 42% of cases.

General criteria for the possibility of performing one-stage revision arthroplasty:

absence of general manifestations of intoxication; limited local manifestations of infection;
a sufficient amount of healthy bone tissue;
established etiological diagnosis; highly sensitive gram-positive microbial flora;
the possibility of suppressive antimicrobial therapy;
both stability and instability of endoprosthetic components.

Clinical example. Patient M, 23 years old, diagnosed with juvenile rheumatoid arthritis, activity I, viscero-articular form; bilateral coxarthrosis; pain syndrome; combined contracture. In 2004, surgical intervention was performed: total endoprosthetics of the right hip joint, spinotomy, adductorotomy. In the postoperative period, fibril fever was noted, laboratory tests showed moderate leukocytosis, and ESR was 50 mm/h. A bacteriological examination of a puncture from the right hip joint revealed the growth of Escherichia coli. The patient was transferred to the purulent surgery department with a diagnosis of paraendoprosthetic infection) type. The patient underwent revision, sanitation, drainage of the infectious focus in the area of the right hip joint, and re-endoprosthetics of the right hip joint. Over the period of 1 year and 6 months after the revision, no recurrence of the infectious process was noted; total endoprosthetics of the left hip joint was performed.

Patient M., 23 years old. Diagnosis: paraendoprosthetic infection type I. X-rays of the right hip joint: a - before endoprosthetics, b - after endoprosthetics and diagnosis of infection, c - after revision and repeated one-stage endoprosthetics.; d - f; image of the postoperative wound before the revision; d, g, h, i - stages of the operation; j - a well-developed postoperative scar 1.5 years after the revision with one-stage repeat arthroplasty.

Undoubtedly, one-stage replacement of an endoprosthesis is attractive, as it can potentially reduce patient morbidity, reduce the cost of treatment and avoid technical difficulties during reoperation. Currently, one-stage repeated replacement of the endoprosthesis plays a limited role in the treatment of patients with paraendoprosthetic infection and is used only in the presence of a number of certain conditions. This type of treatment can be used to treat older patients who need a quick cure and who cannot tolerate a second operation if re-implantation is performed in two stages.

Revision with two-stage re-endoprosthetics

Two-stage revision arthroplasty, according to most surgeons, is the preferred form of treatment for patients with paraendoprosthetic infection. The probability of a successful outcome when using this technique varies from 60 to 95%.

A two-stage revision includes removal of the endoprosthesis, careful surgical debridement of the source of infection, then an interim period with a course of suppressive antibiotic therapy for 2-8 weeks and installation of a new endoprosthesis during a second operation.

One of the most difficult moments when carrying out a two-stage replacement of an endoprosthesis is the exact choice of when to perform the second stage. Ideally, joint reconstruction should not be performed in the presence of an unresolved infectious process. However, most of the data used to determine the optimal duration of the staging phase is empirical. The duration of stage II ranges from 4 weeks to one or more years. Therefore, when making a decision, a clinical assessment of the course of the postoperative period plays a significant role.

If peripheral blood tests (ESR, CRP, fibrinogen) are performed monthly, their results can be very useful in determining the timing of final surgery. If the postoperative wound has healed without any signs of inflammation, and the above indicators have returned to normal during the intermediate stage of treatment, it is necessary to carry out the second stage of surgical treatment.

At the final stage of the first operation, it is possible to use various types of spacers using bone cement impregnated with antibiotics (ALBC-Artibiotic-Loadet Bone Cement).

The following spacer models are currently used:

block-shaped spacers, made entirely of ALBC, serve mainly to fill the dead space in the acetabulum;
medullary spacers, which are a monolithic ALBC rod inserted into the medullary canal of the femur;
articulated spacers (PROSTALAC), which exactly follow the shape of the endoprosthesis components, are made of ALBC.

The main disadvantage of the trochlear and medullary spacers is the proximal displacement of the femur.

X-ray of the right hip joint of patient P., 48 years old. Diagnosis: paraendoprosthetic infection type I, deep form, recurrent course. Condition after installation of a combined trochlear-medullary spacer. Proximal femoral displacement.

A pre-selected new femoral component of the endoprosthesis or a recently removed one can be used as a spacer. The latter undergoes sterilization during the operation. The acetabular component is specially manufactured from ALBC.

General criteria for the possibility of performing two-stage revision arthroplasty:

widespread damage to surrounding tissues, regardless of the stability of the endoprosthesis components;
failure of a previous attempt to maintain a stable endoprosthesis;
stable endoprosthesis in the presence of gram-negative or multiresistant microbial flora;
the possibility of suppressive antimicrobial therapy.

Therapeutic tactics during two-stage repeat arthroplasty

Stage I - revision:

thorough surgical treatment of the wound;
removal of all components of the endoprosthesis, cement;
installation of an articulating spacer with
ALBC;
parenteral antibacterial therapy (three-week course).

Interim period: outpatient observation, suppressive oral antibiotic therapy (8-week course).

Stage II - re-endoprosthetics, parenteral antibacterial therapy (two-week course).

Outpatient period: suppressive oral antibiotic therapy (8-week course).

Clinical example of two-stage revision arthroplasty using a combined trochlear-medullary spacer.

Patient T., 59 years old. In 2005, total arthroplasty of the right hip joint was performed for a pseudarthrosis of the right femoral neck. The postoperative period was uneventful. 6 months after surgery, type II paraendoprosthetic infection was diagnosed. In the department of purulent surgery, an operation was performed: removal of the total endoprosthesis, revision, sanitation, drainage of the purulent focus of the right hip joint with the installation of a combined trochlear-medullary spacer. Skeletal traction for 4 weeks. The postoperative period was uneventful. Three months after the revision, re-endoprosthetics of the right hip joint was performed. The postoperative period was uneventful. At long-term follow-up, there are no signs of recurrence of the infectious process.

Patient T., 58 years old. Diagnosis: paraendoprosthetic infection type II.: a, b — x-ray fistulography of the right hip joint; c — condition after installation of a combined trochlear-medullary spacer; d — stage of the operation, extensive infection in the area of the artificial joint; d — skeletal traction in the early postoperative period; e — radiograph after installation of a permanent endoprosthesis; g - a well-established postoperative scar 6 months after the revision with two-stage repeat endoprosthetics; h, i - clinical result after the second stage of surgical treatment.

Clinical example of two-stage revision arthroplasty using an articulated spacer.

Patient T., 56 years old, was operated on in 2004 for right-sided coxarthrosis. Total endoprosthetics of the right hip joint was performed. The postoperative period was uneventful. 9 months after surgery, type II paraendoprosthetic infection was diagnosed. In the department of purulent surgery, an operation was performed: removal of the total endoprosthesis, revision, sanitation, drainage of the purulent focus of the right hip joint with the installation of an articulated (articulating) spacer. The postoperative period is without complications. Three months after the revision, re-endoprosthetics of the right hip joint was performed. The postoperative period is uneventful. During follow-up for 14 months, no signs of recurrence of the infectious process were detected.

Patient T., 56 years old. Diagnosis: paraendoprosthetic infection type II: a — radiographs of the right hip joint before total arthroplasty; b, c — reitgenofistulography; d, e, f - stages of the operation; g — radiographs after installation of the articulated spacer; h — after installation of a permanent endoprosthesis; and - clinical result 3 months after the first stage; j - 14 months after completion of the second stage of treatment.

Revision with three-stage revision arthroplasty

It is not uncommon for a surgeon to be faced with significant bone loss in either the proximal femur or the acetabulum. Bone grafting, which has been successfully used for aseptic re-replacement of total endoprosthesis, should not be used if there is an infection in the area of the upcoming operation. In rare cases, the patient may undergo an endoprosthesis replacement in three stages. This type of treatment involves removal of the endoprosthetic components and careful debridement of the lesion, followed by the first intermediate stage of treatment using parenteral antimicrobial therapy. In the absence of signs of an infectious process, bone grafting is performed at the second surgical stage. After the second intermediate stage of treatment using parenteral antimicrobial therapy, the third, final stage of surgical treatment is performed - installation of a permanent endoprosthesis. Since this method of treatment is used to a limited extent, there is currently no accurate data on the percentage of favorable outcomes.

In recent years, reports have appeared in the foreign scientific literature about the successful treatment of this pathology using two-stage repeat arthroplasty. Here is one of our own similar clinical observations.

Clinical example.

Patient K., 45 years old. In 1989, surgery was performed for post-traumatic right-sided coxarthrosis. Subsequently, repeated endoprosthetics were performed due to instability of the components of the total endoprosthesis. Bone deficiency according to the AAOS system: acetabulum - class Ill, femur - class III. In 2004, re-endoprosthetics was performed due to instability of the acetabular component of the endoprosthesis. In the early postoperative period, type I paraendoprosthetic infection was diagnosed. In the department of purulent surgery, an operation was performed: removal of the total endoprosthesis, revision, sanitation, drainage of the purulent focus of the right hip joint with the installation of an articulated (articulating) spacer. The postoperative period is without complications. Three months after the revision, re-endoprosthetics of the right hip joint, bone auto- and alloplasty were performed. The postoperative period was uneventful. During follow-up for 1 year, no signs of recurrence of the infectious process were detected.

Patient K., 45 years old. Diagnosis: paraendoprosthetic infection type I: a — radiograph of the right hip joint before re-endoprosthetics, b — after re-endoprosthesis, c — after installation of an articulated spacer; d, e, f — stages of the operation to install a permanent total endoprosthesis with bone auto- and alloplasty; g - radiograph of the right hip joint 1 year after the second stage of surgical treatment: h, i - clinical result after completion of the second stage of treatment.

Other surgical procedures

Absolute indications for removal of the endoprosthesis:

sepsis;
multiple unsuccessful attempts to preserve the endoprosthesis through surgery, including options for one- and two-stage endoprosthesis;
the impossibility of subsequent re-endoprosthetics surgery in persons with severe concomitant pathology or polyallergy to antimicrobial drugs;
instability of the endoprosthesis components and the patient’s categorical refusal to undergo re-endoprosthetics.

If there are absolute indications for removal of the endoprosthesis and it is impossible for one reason or another to carry out re-endoprosthesis at the final stage of surgery aimed at sanitizing the infectious focus (the exception is “patients with sepsis”), the method of choice, along with resection arthroplasty, is to perform operations aimed at to preserve the weight-bearing ability of the lower limb. The staff of our institute have proposed and implemented: the formation of a support for the proximal end of the femur on the greater trochanter after its oblique or transverse osteotomy and subsequent medialization; or onto a demineralized bone graft.

Hip disarticulation may be necessary when there is a chronic, recurrent infection that poses an immediate threat to the patient's life, or when there is severe loss of limb function.

In some cases, with chronic recurrent infection that persists after removal of the total endoprosthesis in patients with significant residual bone-soft tissue cavities, it becomes necessary to resort to plastic surgery with a non-free island muscle flap.

Method of non-free plastic surgery using an island muscle flap from the lateral thigh muscle

Contraindications:

sepsis;
acute phase of the infectious process; pathological processes preceding injury and (or) previously performed surgical interventions in the recipient area, making it impossible to isolate the vascular axial bundle and (or) muscle flap;
decompensation of the function of vital organs and systems due to concomitant pathology.

Operation technique. Before the start of surgery, a projection of the intermuscular space between the rectus and vastus lateralis muscles is marked on the skin of the thigh. This projection practically coincides with the straight line drawn between the superior anterior iliac spine and the outer edge of the patella. Then the boundaries within which the blood supplying the flap are located are determined and marked on the skin. An incision is made with excision of the old postoperative scar with preliminary staining of the fistula tracts with a solution of brilliant green. According to generally accepted methods, an inspection and sanitation of the purulent focus is carried out with the obligatory removal of the components of the endoprosthesis, bone cement and all affected tissues. The wound is washed generously with antiseptic solutions. The sizes of the bone and soft tissue cavities formed during the operation are determined, and the optimal sizes of the muscle flap are calculated.

The surgical incision is extended distally. The mobilization of the skin-subcutaneous flap is performed to the intended projection of the intermuscular space. They enter the gap, pushing the muscles apart with hooks. Within the intended area, vessels supplying the vastus lateralis muscle are found. Plate hooks retract the rectus femoris muscle medially. Next, the vascular pedicle of the flap is isolated - the descending branches of the lateral femoral circumflex artery and vein in the proximal direction for 10-15 cm up to the main trunks of the lateral femoral circumflex vascular bundle. In this case, all muscle branches extending from the indicated vascular pedicle to the vastus intermedius muscle are ligated and crossed. An island muscle flap is formed with dimensions corresponding to the reconstruction tasks. Then the selected tissue complex is passed over the proximal femur and placed into the formed cavity in the area of the acetabulum. The muscle flap is sutured to the edges of the defect.

The surgical wound is drained with perforated polyvinyl chloride tubes and sutured in layers.


	.

Clinical example.

Patient Sh., 65 years old. In 2000, total endoprosthetics of the left hip joint was performed for left-sided coxarthrosis. In the postoperative period, a paraendoprosthetic infection of type I was diagnosed, and the infectious focus was revised while preserving the endoprosthesis of the left hip joint. 3 months after the revision, a recurrence of infection developed. Subsequent conservative and surgical measures, including removal of the total endoprosthesis of the left hip joint, did not lead to relief of the infection. In 2003, a revision with non-free plastic surgery with an island muscle flap from the lateral thigh muscle was performed. The postoperative period is uneventful. During follow-up for 4 years, no signs of recurrence of the infectious process were detected.

Patient Sh, 65 years old. Diagnosis: paraendoprosthetic infection type I, recurrent course: a, b — X-ray fistulography of the left hip joint before the revision, c — after removal of the total endoprosthesis; d, e, f, g — stages of revision using non-free plastic surgery with an island muscle flap from the lateral thigh muscle; h — radiograph of the left hip joint 4 years after revision with non-free muscle plasty; and, j - clinical result.

Currently, there is a continuing trend towards both an increase in the number of hip replacement operations and an increase in various types of complications of these operations. As a result, the burden on the healthcare system increases. It is important to find ways to reduce the cost of treating these complications while maintaining and improving the quality of care provided. Data from many studies on the results of treatment of patients with paraendoprosthetic infection are difficult to analyze, since patients were implanted with various types of endoprostheses, both with and without the use of polymethyl methacrylate. There are no reliable statistical data on the number of revision procedures or the number of relapses of the infectious process preceding a two-stage replacement of the endoprosthesis; the nature of the concomitant pathology is not taken into account; different treatment methods are often used.

However, two-stage reimplantation demonstrates the highest infection clearance rate and is considered the “gold standard” for the treatment of patients with periprosthetic infection. Our experience with the use of articulating spacers has shown the advantages of this method of treatment, since, along with sanitation and the creation of a depot of antibiotics, it ensures the preservation of leg length, movements in the hip joint, and even some ability to support the limb.

Thus, modern developments in medicine make it possible not only to preserve implants in conditions of a local infectious process, but, if necessary, to perform staged reconstructive operations in parallel with stopping the infectious process. Due to the high complexity of re-endoprosthetics, this type of operation should be performed only in specialized orthopedic centers with a trained operating team, appropriate equipment and instruments.

R.M. Tikhilov, V.M. Shapovalov
RNIITO im. R.R. Vredena, St. Petersburg

The most complete answers to questions on the topic: “temperature after hip replacement.”

Hip replacement often causes hyperthermia, or an increase in a complex indicator of the body's thermal state. In addition, after this type of surgical intervention, patients often complain of excessive heat concentration on the skin, which is located in the area of the implanted prosthetic device.

Photo after surgery.

If a hip joint endoprosthesis is installed, can elevated general and local temperatures be considered normal? What values indicate the development of unfavorable pathogenesis; How long can low-grade fever last? These are just some of the questions on this topic that many people who have undergone hip replacement surgery ask. Well, let's look in detail at a rather serious matter.

To begin with, it would be advisable to do a little research. We will talk about surgical procedures associated with hip replacement, since it is after them that signs of fever are most often observed. Then we will give answers to all the exciting questions regarding the temperature after hip replacement, which goes beyond normal numbers.

Surgical trauma is stress for the body

Any surgical intervention, even the most minimally invasive, is to a certain extent stress for the entire human biological system. And in this case we are not talking about an operation through small punctures, here soft tissue structures are dissected for a long time (length from 10 to 20 cm) and deeply, followed by their moving apart, opening the deformed bone joint. Moreover, the “native” joint is cut off from the articular bones, and a fragment of the femoral neck is captured.

perforation of the femur to create a channel that is optimal in width, depth, and angle of inclination in order to insert the leg of a hip joint prosthesis into it;
removing the top layer of the acetabulum, grinding and grinding this part of the pelvic bone;
formation of anchor holes in the walls of the prepared acetabulum using a special medical drill.

The next stage of surgery is immersion into the bone and fixation of, in fact, the most artificial analogue of the joint. For these purposes, the technique of dense driving, the method of cement planting or combined fixation is used. After checking the functionality of the hip joint endoprosthesis, internal disinfection is carried out, drainage tubes are installed and the wound is sutured.

Intraoperative manipulations cause injury to both anatomical structures and the entire body. Due to operational aggression, the following arises:

reactive inflammation of areas within the surgical field;
excessive loss of water in the body due to the release of wound effusion;
decreased movement of biological fluid in the bloodstream;
absorption into the blood of decay products, which are always formed when tissue is damaged.

Thus, increased local and general temperature after hip replacement is a completely adequate reaction of the body to sudden structural changes. Temperature deviations in the early postoperative stage towards an increase are regarded not as a pathology, but as a result of increased work of the immune system, which is normal from a physiological point of view. Immune mechanisms are activated to regulate disrupted vital processes, protect injured tissues from the potential danger of infection, and initiate active regeneration mechanisms. Note that there may not be any febrile symptoms immediately after surgery; it all depends on the individual characteristics of a particular organism.

An increase in temperature to 37.5 degrees immediately on the first or second day after arthroplasty is considered normal. The temperature persists (37-37.5 degrees) or “jumps” from normal to subfebrile values with positive recovery during the first week, usually up to 3-5 days. Maximum it can bother you for 10 days.

The main cause of low-grade fever in the early stages is inflammation of the wound. As soon as the incision is completely healed and the stitches are removed, which happens after about 1.5 weeks, thermoregulation should finally return to normal.

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Temperature as a sign of complications

If hyperthermia persists after 10 days or increases, or suddenly appears on the 3rd day or later, accompanied by pain and swelling, you need to urgently sound the alarm. A visit to the doctor cannot be put off for a day! Since there is a huge probability of the development of unfavorable processes, in other words, complications. Common provoking factors for a sharp increase or persistent persistence of high temperature include:

violation of the integrity and stability of the hip joint prosthesis (dislocation, subluxation, fracture, loosening);
fracture of the femur as a result of unprofessional development of the canal or reduced bone density;
inflammation of the suture line and nearby skin due to poor quality suture material or poor wound care;
penetration of non-infectious pathogenesis into the superficial and deep layers of soft tissue, as well as bone structures to which the prosthesis is attached;
the presence of necrotic processes in areas affected by surgery;
an inflammatory focus in the lungs, or, more simply, developed pneumonia;
the formation of thrombotic formations in the deep veins of the operated lower limb (phlebothrombosis).

Arrows indicate areas of infection

In isolated cases, after hip replacement, an elevated temperature may indicate rejection of the endoprosthesis. The body's rejection of a foreign body may be caused by biological incompatibility, an allergy to the materials of the analogue joint, or a reaction to bone cement. The modern generation endoprosthesis is an anatomical copy of the hip joint; it is made of hypoallergenic, non-toxic and biocompatible nanomaterials, more than 99%. Therefore, such a crisis is an unlikely phenomenon, although it cannot be completely ruled out.

Discharge from the seam.

As for the cement used for fixation purposes, its properties are as close as possible to natural bone structures. However, an allergic response, accompanied by fever, is possible in a very limited number of people if there is hypersensitivity to the composition of the biocement used.

Precautions

In order to prevent them from the first days, they begin to use the necessary preventive measures, namely:

prescribing or intramuscular administration of an antibiotic with a broad spectrum of antibacterial action;
carrying out anti-inflammatory physiotherapeutic procedures that relieve swelling and pain, as well as improve tissue trophism, damage healing, lymphatic drainage and blood circulation;
inclusion of a complex of early therapeutic and restorative physical education, where an important role is given to breathing exercises aimed at eliminating pulmonary hypoventilation;
the use of blood thinners to prevent the formation of blood clots in the vessels of the legs.

But control over thermoregulation should be carried out even after discharge from the clinic, thanks to which the source of poor health can be diagnosed in time. Thereby preventing the progression of unsafe complications, which may serve as a motive for repeat (revision) surgery. For example, in case of advanced infection, revision prosthetics means removal of the artificial hip joint, while a new endoprosthesis cannot always be installed immediately. Such harsh prospects will not please anyone, that’s for sure. Therefore, it is easier to be alert and promptly alert the doctor about emerging problems than to undergo difficult drug and surgical treatment in the near future (during the first year).

It is important to warn that not only the complex temperature, but also the local one should be alarming. Monitor the condition of the skin around the wound! If it becomes hot and swollen to the touch, you feel pain when touched or at rest, you notice serous discharge from the surgical wound - all these symptoms should cause alarm and serve as an absolute reason for an immediate medical examination.

Fever and related symptoms

In the pathological process after hip replacement, a number of other symptoms are added to the temperature. Almost always, the ill-fated hyperthermia occurs in combination with various manifestations, where pain is one of its frequent companions. It is worth noting that the more severe the clinical picture, the higher the temperature and the more intense the pain. Let us remind you that values more than 37.6 ° are a cause for concern, no matter at what stage they are recorded.

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The following symptoms indicate pneumonia, which is observed mainly in the initial postoperative stage:

fever and chills;
headache;
loss of strength;
dyspnea;
obsessive cough;
lack of air;
pain behind the sternum when trying to take a deep breath.

The criticality of the situation in the late rehabilitation period is indicated by temperature if it:

rises daily for a long time above the physiological norm (> 37 °);
increases periodically for reasons unknown to humans;
appeared some time after a hip injury or unsuccessful movement;
appeared against the background or after an infectious disease, and it does not matter what the etiology of the pathogen is and what part of the body it attacked.

Warning signs of serious inflammation that may precede and accompany fever include the following:

increasing redness in the area of the access performed;
increased swelling of the skin in the area where the hip joint prosthesis is located;
leakage of purulent contents, exudative or bloody fluid from the wound;
formation of subcutaneous hematoma, compactions;
an increase in pain during physical activity or the constant presence of pain, including in an immobilized state;
hot skin at the implant site;
the appearance of tachycardia and increased blood pressure.

Why the temperature has worsened, only a specialist will give a reliable answer after a thorough examination of the area of hip replacement, studying the results of X-rays and laboratory tests. The patient can only guess this or that problem on his own, but nothing more. To refute or confirm suspicions, you need competent, qualified help. So don’t hesitate or waste your time, go to the hospital immediately! By delaying a visit to the doctor, you will not achieve anything good, but will only further aggravate the pathogenesis.

Attention! Simply taking antipyretic medications is not an option, as every sane person should understand. By lowering the temperature, you only relieve the fever for a while, but the root of the problem remains with you. Moreover, it grows progressively, and every day leaves you less and less chances to recover quickly and easily, to save the endoprosthesis without resorting to surgical intervention again.

Inflated thermometry results definitely should not be ignored. And if in the first 10 days we can talk about them as a normal reaction on the part of the body, which has received stress from undergoing complex surgery on the musculoskeletal system, then in the following days they are regarded as a clear deviation.

The temperature from the 1st day after hip replacement to the 10th day inclusive should not exceed 37.5 (if higher, this is a signal for action); at the end of the ten-day period it should completely stabilize.
An early temperature reaction within established limits, as a rule, has nothing to do with infection; it can be safely called a typical inflammatory response of non-infectious origin. There is no reason to worry.
If thermometric indicators have not returned to normal within 4 weeks, you need to urgently take action, first of all, contact your attending surgeon.
Weeks and months after the operation, the thermometer showed more than 37°, 38°? Contact a specialist urgently! Abnormal numbers are already associated with infectious-inflammatory pathogenesis.

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The patient’s own well-being depends on the patient’s responsibility and vigilance. To avoid encountering difficulties of this kind, you should:

adhere to all medical recommendations;
Impeccably follow the individual rehabilitation program;
engage in physical activity within strictly permitted limits;
carry out prevention of all chronic pathologies;
strengthen immunity;
treat acute diseases in a timely manner;
undergo mandatory scheduled examinations;
be under the supervision of a rehabilitation specialist, orthopedic surgeon, and exercise therapy instructor during rehabilitation;
If you feel unwell, contact your doctor the same day.

Hip arthroplasty is the replacement of a damaged element of the joint. For this purpose, special implants are used. Endoprostheses may be required for a variety of reasons (injuries and diseases of the hip joint). After hip replacement, certain recommendations must be followed.

Surgery to replace a worn joint

Reasons for prosthetics

The most common reasons why endoprostheses may be required are:

Advanced and severe stages of rheumatoid arthritis.
Injuries to the femoral neck (most often fractures).
Development of hip dysplasia.
The presence of aseptic necrosis of the head, which is called avascular necrosis.
Severe stages of coxarthrosis.

The need for an endoprosthesis may arise due to post-traumatic consequences (for example, arthrosis).

The life of a patient after endoprosthetics, as a rule, changes: a number of recommendations appear that the patient must strictly follow. After endoprosthetics, some restrictions arise, the patient needs special therapeutic exercises.

At first, the patient is forced to walk on crutches. How long will it take to recover?

The postoperative period and complete recovery depend on the patient’s age, his general condition and many other factors. In order to avoid complications after hip replacement, it is necessary to follow all the recommendations of the attending physician.

Exercises after hip reconstruction surgery should be performed strictly under the supervision of a qualified specialist. Living with a new regime will speed up the recovery process. The patient will be able to walk without the help of crutches much faster.

Pain after endoprosthetics, as a rule, is pronounced. Under no circumstances should you take any measures on your own, otherwise serious complications may arise.

What does a joint prosthesis consist of?

). Each individual element has its own dimensions. The surgeon must select and install the size that is ideal for the patient.

The types of fixation of hip joint endoprostheses have the following differences:

Cement fixation.
Cementless fixation.
Hybrid type of prosthesis fixation.

Full name:

Complications of hip replacement

Slobodskoy A.B., Osintsev E.Yu., Lezhnev A.G. (Saratov Regional Clinical Hospital)

"Bulletin of Traumatology and Orthopedics", 2011, No. 3

An increase in the number of endoprosthetics of large joints, and primarily the hip, is noted in most countries of the world, including Russia (9, 11). Despite the improvement in the quality of the implants used, the improvement of endoprosthetics technologies, as well as the accumulation of practical experience among surgeons, the percentage of complications and unsatisfactory outcomes of arthroplasty remains quite high. Thus, according to a number of authors, dislocations of the head of the endoprosthesis occur in 0.4 - 17.5% of cases (2, 3, 4, 14, 15), purulent-inflammatory complications in 1.5 - 6.0% (7, 8, 10, 13, 15, 18), periprosthetic fractures in 0.9% - 2.8% (1, 15, 18, 19), postoperative neuritis in 0.6 - 2.2% (1, 16, 17 ), thromboembolic complications in 9.3 - 20.7% (5, 6, 18). It has been proven that these same complications after previous operations on the joint (osteotomies, osteosynthesis, etc.), as well as after revision arthroplasty, increase significantly (12, 16). Thus, studying the causes and developing ways to prevent the most common complications of hip replacement have been and remain pressing issues in traumatology and orthopedics.

Purpose of the study

To study the nature and frequency of complications of hip replacement, determine their possible causes and ways of prevention.

Materials and methods

In the period from 1996 to the present, 1399 patients were under our supervision, who underwent 1603 operations of primary hip arthroplasty. 102 patients were operated on on 2 sides. There were 584 men treated, 815 women. The age of the patients ranged from 18 to 94 years. Of these, 20 are under 25 years of age; from 26 to 40 years old – 212; from 41 to 60 years 483; and over 60 years old 684 patients. As implants for hip replacement, the ESI endoprosthesis (Russia) was used in 926 cases, Zimmer (USA) in 555, De Pue (USA) - 98, Seraver (France) - 18, Mathis (Switzerland) - 6. Cementless fixation of components endoprosthesis was used in 674 operations, hybrid in 612 and fully cemented in 317 cases. Revision hip arthroplasty operations were performed in 111 cases in 106 patients. In 5 cases, the revision was performed on 2 sides. The ratio of primary and revision endoprosthetics operations was 1:14. There were 49 men, 57 women. The age of the patients ranged from 42 to 81 years. 19 oncological hip joint endoprostheses were implanted. Reinforcing structures (Müller rings, Bursch-Schneider rings) were used in 22 operations. 267 operations were performed for dysplastic coxarthrosis and other complex cases.

Research results

We analyzed postoperative complications: by age group, depending on the indications for primary arthroplasty, in groups of patients with concomitant pathology (diabetes mellitus, rheumatoid arthritis), with primary and revision arthroplasty, with uncomplicated primary arthroplasty and arthroplasty in complex cases, with endoprosthetics with domestic and imported implants.

The nature and frequency of complications of hip arthroplasty (in the numerator - absolute numbers, in the denominator - percentages):

From the analysis of the table it can be seen that in 1603 operations, 69 complications of various types were diagnosed, which amounted to 4.30±0.92%. The most common were dislocations of the head of the endoprosthesis - 31 cases (1.93±0.44%) and complications of a purulent-inflammatory nature - 22 cases (1.37±0.44%). Other complications of hip replacement (periprosthetic fractures, postoperative neuritis, body parts) were isolated and were observed in less than 0.5%.

The nature and frequency of complications of hip arthroplasty depending on the age of patients (in the numerator - absolute numbers, in the denominator - percentages):

As can be seen from the table, there is a direct pattern of increase in the number of complications with age. Thus, purulent-inflammatory complications in patients under 25 years of age were not observed at all; between the ages of 26 and 40 years they occurred in 3 patients (0.18%), between the ages of 41 and 60 years in 6 (0.18). 37%), and over 60 years old in 13 (0.81%). Dislocations of the endoprosthesis head in the postoperative period were also observed more often in older patients. Thus, in groups of patients under 60 years of age they were diagnosed in 9 cases (0.54%), and in the group over 60 years of age in 22 cases (1.37%). Periprosthetic fractures occurred in three patients (0.18%) over 60 years of age. Neuritis of the peroneal nerve complicated the course of the postoperative period in 1 patient (0.06%) aged 35 years, 3 patients (0.18%) in the age group from 41 to 60 years and in 4 patients (0.24%) over 60 years old . Pulmonary embolism occurred in one patient aged 57 years and in 4 patients (0.24%) over 60 years of age, of which three were fatal.

The total number of complications in the group of patients under 25 years old was 1 (0.06%), in the group of patients from 26 to 40 years old - 8 (0.48%), in the age group from 41 to 60 years old - 14 (0.87% ) and in the older age group (over 60 years) – in 46 patients (2.87%).

The nature and frequency of complications of hip arthroplasty depending on the etiology (in the numerator - absolute numbers, in the denominator - percentages):

Nosological forms Character Complications	Idiopathic coc-arthrosis	Dys-plastic coxar-troz	Aseptic necrosis of the head	Acute prox injury. thigh department bones	Consequences of prox injury. thigh department bones	Inspections, complex endo-prosthetics.	TOTAL
Purulent - inflammatory	1/0,06	3/0,18	2/0,12	4/0,24	4/0,24	8/0,48	22/1,37
Dislocations of the head of the endoprosthesis	2/0,12	4/0,24	2/0,12	6/0,36	8/0,48	9/0,54	31/1,93
Periprosthetic fractures	-	1/0,06	-	-	1/0,06	1/0,06	3/0,18
Postoperative neuritis	-	-	-	4/0,24	2/0,12	2/0,12	8/0,48
TELA	-	-	-	2/0,12	-	3/0,18	5/0,30
TOTAL	3/0,18	8/0,48	4/0,24	16/0,99	15/0,93	23/1,43	69/4,35

From the analysis of the table, the following conclusions can be drawn. A greater number of complications of hip arthroplasty were noted in groups of patients who underwent revision arthroplasty and arthroplasty in complex cases. Thus, in this group, purulent-inflammatory changes occurred in 8 patients (0.48%), dislocations of the head of the endoprosthesis in 9 patients (0.54%), and in total complications were diagnosed in 23 patients (1.43%). Complications occurred somewhat less frequently in patients with acute trauma to the proximal femur - 16 patients (0.99%) and with consequences of trauma to the proximal femur - 15 patients (0.93%). Thus, purulent-inflammatory complications were noted in 8 patients (4 in each group), 0.24% in each group. Dislocations of the head of the endoprosthesis in these groups occurred in 6 patients (0.48%) and 8 patients (0.54%), respectively. Among patients operated on for diseases of the hip joint, the largest number of complications was noted in the group of patients with dysplastic coxarthrosis - 8 patients (0.48%). In patients with idiopathic coxarthrosis and aseptic necrosis of the femoral head, the number of complications was 2–2.5 times less than in dysplastic coxarthrosis.

The nature and frequency of complications of hip arthroplasty depending on concomitant pathology (in the numerator - absolute numbers, in the denominator - percentages):

Diseases Character Complications	Diabetes mellitus	Systemic diseases	Other diseases and without accompanying ones. pathology	TOTAL
Purulent - inflammatory	7 /0,44*	11 /0,67*	4 /0,24	22/1,37
Dislocations of the head of the endoprosthesis	2 /0,12	1 /0,06	28 /1,75	31/1,93
Periprosthetic fractures	-	1 /0,06	2 /0,12	3/0,18
Postoperative neuritis	1 /0,06	3 /0,18	4 /0,24	8/0,48
TELA	1 /0,06	1 /0,06	3 /0,18	5/0,30
TOTAL	11 / 0,67	17 /1,06	41 /2,56	69/4,35

* a total of 72 patients with diabetes mellitus were operated on, and 83 patients with systemic diseases, thus, in the group of patients with diabetes mellitus there were 9.7% purulent-inflammatory complications, and in case of systemic diseases - 13.2%

Analyzing the number and nature of complications in patients with various concomitant pathologies, it should be noted that here a dependence is possible only in the group of purulent-inflammatory complications. The remaining complications considered in most cases do not depend on changes in the body associated with concomitant diseases. Thus, the greatest number of complications of a purulent-inflammatory nature was observed in patients with systemic diseases. They were diagnosed in 11 patients of this group. (0.67%) These complications were observed somewhat less frequently in various forms of diabetes mellitus - 7 patients (0.44%). And in patients with other diseases or without concomitant pathology, they were noted only in 4 cases (0.24%). No pattern was found in the development of non-inflammatory complications with concomitant pathology.

The nature and frequency of complications of hip arthroplasty depending on implant manufacturers:

Manufacturer Character Complications	Domestic producers	Imported manufacturers	TOTAL
Purulent - inflammatory	12 /0,75	10 /0,62	22/1,37
Dislocations of the head of the endoprosthesis	15 /0,94	16 /0,99	31/1,93
Periprosthetic fractures	2 /0,12	1 /0,06	3/0,18
Postoperative neuritis	4 /0,24	4 /0,24	8/0,48
TELA	3 /0,18	2 /0,12	5/0,30
TOTAL	36 /2,24	33 /2,11	69/4,35

Analyzing the data, it can be noted that both in quantitative and qualitative terms, the complications that developed after hip replacement with implants from different manufacturers do not differ. The differences in the presented groups are not statistically significant. However, it would not be objective to draw conclusions about the quality of certain implants only based on postoperative complications. Therefore, we carried out an analysis based on the duration of the “life of joints”, i.e. on the timing of development of aseptic instability when using endoprostheses from various manufacturers. Time frame for the development of aseptic instability of components after hip replacement (in the numerator - absolute numbers, in the denominator - percentages):

As can be seen from the table, the number of cases of aseptic loosening of hip joint endoprosthesis components, as well as the timing of its development in domestic and foreign manufacturers, is almost the same; the existing differences are statistically insignificant.

Discussion of the research results

Having examined the data on the nature of complications after hip replacement and their frequency depending on age, indication for surgery, concomitant pathology, as well as the implants used, a number of patterns are noted.

The increase in complications with age is primarily due to the fact that in older people the number and severity of concomitant diseases increases and resistance to infection decreases. In addition, in elderly patients, reparative and restorative functions are weakened, the tone of the muscular-ligamentous apparatus decreases, osteoporosis increases, and the risk of bone fractures increases. All this explains the significant increase in the number of purulent-inflammatory complications, as well as dislocations of the femoral head by 2–4 times. Thromboembolic complications, including those leading to a fatal outcome, were diagnosed only in patients over 60 years of age.

A clear pattern in the development of certain complications can be traced depending on the indications for hip replacement. Thus, with revision endoprosthetics and endoprosthetics in complex cases, the number of complications of a purulent-inflammatory nature, as well as dislocations of the head of the endoprosthesis, is 2.5 - 3 times higher, and with dysplastic coxarthrosis, it is 1.5 - 2 times higher than with endoprosthetics for idiopathic coxarthrosis and aseptic necrosis of the femoral head. In acute trauma of the proximal femur and in patients with the consequences of this injury, the number of purulent-inflammatory complications and dislocations of the endoprosthesis head was 1.5 - 2.5 times higher than the similar indicators of those operated on for degenerative diseases of the hip joint. It is characteristic to note that complications such as pulmonary embolism and postoperative neuritis were noted only after revision arthroplasty, arthroplasty in complex cases and for injuries of the proximal femur. The above pattern is quite understandable. Operations of revision endoprosthetics, operations after previously performed osteotomies, osteosynthesis, failed arthrodeses and others, which are classified as endoprosthetics in complex (or special) cases, are carried out under completely different conditions than conventional primary endoprosthetics. These operations are characterized by gross violations of the normal anatomy of the hip joint. They develop due to the presence of a rough cicatricial adhesive process in the wound, the presence of bone tissue defects in the area of the acetabulum and proximal femur, and deformation of various parts of the bones that make up the hip joint. The anatomical features of dysplastic coxarthrosis are well known. Deficiency of bone mass, deformation of the acetabulum, head, neck, proximal femur, pathology of the musculo-ligamentous apparatus of the hip joint determine the operation in much more difficult conditions than with uncomplicated endoprosthetics, increasing its time and blood loss. The increase in the number of almost all complications in acute trauma and its consequences is explained by the predominant impact of this pathology on people in the older age group, an increase in the number of concomitant diseases, and the progression of osteoporosis.

Complications of a purulent-inflammatory nature after hip replacement with systemic diseases and diabetes mellitus were observed 1.5 - 2.5 times more often than with other concomitant pathology or without it at all. It is known that both in diabetes mellitus and in many systemic diseases (rheumatoid arthritis, systemic lupus erythematosus, nonspecific arthritis, etc.) disturbances of homeostasis of varying severity are observed. Disorders of microcirculation, innervation, ischemic changes in tissues, as well as changes in carbohydrate, protein, and fat metabolism cause a decrease in specific and nonspecific immunity, and disturbances in the regenerative function of tissues. Thus, the increase in the number of complications due to diabetes mellitus and systemic diseases is quite natural. There were no changes in the number of non-inflammatory complications of hip replacement, either increasing or decreasing, depending on the concomitant pathology.

An important criterion used to analyze the incidence of complications after hip replacement is the quality of the implant used. It is a well-known opinion, both at the everyday level and among many traumatologists and orthopedists, that imported hip joint endoprostheses are better, domestic ones are worse. This opinion is not confirmed by any objective criteria other than subjective assessment. In this regard, we conducted an analysis both by individual groups of complications, as well as by their number in patients who were implanted with endoprostheses from various manufacturers. From domestic manufacturers, endoprostheses from ESI (Moscow) were used - 926 operations, from Zimmer (USA) - 555, De Pue (USA) - 98, Seraver (France) - 18, Mathis (Switzerland) - 6. It was established that the total number of complications when using domestic implants there were 36 cases, and imported ones – 33, respectively 2.24% and 2.11%. Complications of a purulent-inflammatory nature were diagnosed in 0.75% when using domestic endoprostheses and in 0.62% when using imported ones. Dislocations of the head of the endoprosthesis occurred in 0.94 and 0.99%%, respectively, periprosthetic fractures in 0.12 and 0.06%%, postoperative neuritis developed in 4 patients in each group (0.24%) and pulmonary embolism complicated the postoperative course. period in 3 patients in group 1 (0.18%) and in 2 patients in group 2 (0.12%). Analyzing the timing and frequency of development of aseptic instability of endoprosthetic components, it can be noted that in the early stages after surgery (up to 3 years), this complication was observed in isolated cases - in 2 patients with endoprosthesis replacement according to ESI and in 1 patient according to Zimmer. In the period from 3 to 5 years, joint instability was not observed at all. In the period from 5 to 8 years after surgery, approximately the same number of cases of aseptic loosening of joint components was observed, in both groups - 2 - 3 patients (0.18%). And after 10 years from the moment of surgery, aseptic loosening of the joints was noted in 6 patients who were implanted with domestic endoprostheses (0.36%) and the same number after arthroplasty with imported implants. Thus, assessing the number of complications and aseptic loosening of hip joint endoprostheses from domestic and foreign manufacturers, it can be noted that there are no statistically significant differences in both quantitative and qualitative terms.

Thus, the problem of complications after various types of hip arthroplasty remains not only relevant, its significance increases every year, with a progressive increase in the number of endoprosthetics operations. The group of risk factors for the development of complications of various types includes the advanced age of patients, severe concomitant pathology (diabetes mellitus, rheumatoid arthritis and other systemic diseases), acute injury of the proximal femur, operations for dysplastic coxarthrosis, revision and complex hip replacement. In these cases, the risk of complications increases by 1.5 - 3.5 times. A history of a purulent-inflammatory process in the area of the hip joint, as well as each repeated surgery on the hip joint, increases the risk of complications in the postoperative period significantly. We did not note any differences in the number of complications or the timing of development of aseptic instability depending on the manufacturers of the implants used.

Conclusions:

During hip replacement, complications of various types occur in 4.3% of cases. Including purulent-inflammatory ones - in 1.37%, dislocations of the head of the endoprosthesis in 1.93%, periprosthetic fractures in 0.19%, postoperative neuritis in 0.49% and pulmonary embolism in 0.31% of cases.
Risk factors for the development of complications of endoprosthetics include the advanced age of patients, severe concomitant pathology (diabetes mellitus, rheumatoid arthritis and other systemic diseases), acute injury of the proximal femur, operations for dysplastic coxarthrosis, revision and complex hip replacement, purulent inflammatory processes in history of the hip joint.
There is a clear pattern between the increase in the complexity of the operation, the performance of each subsequent operation on the joint and the increase in the number of complications, especially purulent-inflammatory in nature and dislocations of the head of the endoprosthesis.
There was no dependence of the number of complications and timing of development of aseptic instability depending on the manufacturer of endoprostheses.