Tag Archives: hip replacement

15 April 2024

Osteoarthritis of the hip joint (OATBS) is one of the most common and socially significant forms of joint damage. Along with cardiovascular diseases and diabetes mellitus, OA has acquired the role of one of the most frequent reasons for contacting doctors of different profiles. Only in St. Petersburg today osteoaryritis has been verified in more than 275 thousand people [1]. According to experts, OA will become one of the most common causes of disability by 2030. Currently, groups and societies for the study of OA (OARSI, ESCEO, etc.) have not created a unified approach to treatment [2]. The analysis of the cost-effectiveness of EP TBS showed that the replacement of TBS is cost-effective only in patients with end-stage OA [3]. One of the reasons for the unsatisfactory results of hip replacement (ETBS) is the wrong choice of surgery as a treatment method [4]. This circumstance is largely due to the fact that the issues of indications and contraindications for conducting ETBS still remain debatable. According to S.P. Mironov and G.P. Kotelnikov (2008), indications and contraindications to ETBS may vary depending on the severity of the pain syndrome, the severity of concomitant pathology and other causes [5]. In the literature of recent years, publications are increasingly appearing on the increase in the number of cases of unjustified ETBS, which raises the question of limiting indications for surgical methods of treatment. Specialists from the UK A. Moorhouse and G. Giddins (2018) emphasize that there are currently no objective criteria for indications for arthroplasty in osteoarthritis [6]. According to M.G. Gademan et al. (2016), in about 20-45% of cases, TBS arthroplasty is performed unreasonably [7]. According to M.M. Dowsey and J. Gunn (2014), out of all cases of hip and knee replacements performed, about a quarter of patients were unsuitable candidates for surgery [8]. Goal/ Aim The aim of the study was a pathomorphological study of the removed femoral heads and a retrospective determination of the validity of hip replacement. Materials and methods / Materials and methods In the clinic of Traumatology and Orthopedics of the I.I. Mechnikov NWSMU from 01.01.2022 to 12/25/2022 112 operations were performed on the replacement non-hip joint in patients with osteoarthritis. Materials from 30 patients aged 38 to 78 years (17 women, 13 men) were taken by random sampling for morphological examination. After the operation, fragments of the femoral head were fixed in a 10% buffered formalin solution during the day. Then, for subsequent histological examination, bone material was cut using a set of saws. The production of histological preparations was carried out according to the standard procedure for bone tissue, including the decalcification stage [9], which was carried out according to the scheme: the studied bone fragments were decalcified in an electrolyte decalcifying solution (Biovitrum, Russia) with a ratio of the volume of the object and the volume of the decalcifying liquid 1:50. for 8 hours, simultaneously checking the degree of decalcification using needles. After decalcification was completed, the samples were washed with tap water for 60 minutes. Histological wiring, filling, and microtomy with a slice thickness of 5 microns were carried out according to the standard procedure. The preparations were stained with review dyes (hematoxylin and eosin) and safranin O. For the production of plastinated histopograms of the head and the entire hip joint (autopsy material), the technique of epoxy plastination was used [10]. After freezing to minus 80 ° C, the preparations were sawn on a Kolbe K430 band saw (Germany) in the frontal and horizontal planes, with a cut thickness of 2 to 3 mm. Subsequently, the cuts were dehydrated in a mixture of acetone and hexane in a ratio of 3:2 at a temperature of -25 ° C for 3 weeks with a double change of solvent, and then degreased in the same solution at room temperature for two weeks with a single change of solvent. In the Biodur Plastination Kettle vacuum chamber (Germany), saws were impregnated in a mixture of ED-20 epoxy resin and THETA hardener in a ratio of 20:1 with a smooth pressure reduction to 2 kPa using a plate-rotary vacuum pump Hydromech AVPR-16D (Russia). Impregnation was completed after the release of intermediate solvent bubbles stopped. The saws were enclosed in flat chambers made of polymethylmethacrylate in a mixture of ED-20 epoxy resin with a THETA hardener in a ratio of 10:1. After the resin was completely solidified, the slices were removed from flat cameras and scanned on an Epson V33 office scanner at a resolution of 600 pixels per inch. According to the same technique, on cadaveric material obtained from 3 men aged 57 to 72 years and 2 women aged 69 and 76 years, who were diagnosed with osteoarthritis of the hip joint of the II and III degrees during their lifetime and died from causes unrelated to diseases of the musculoskeletal system, total pelvic saws were made through the hip joint at the level of the acetabulum in the frontal and horizontal planes. Results / Results The data concerning 112 patients who underwent primary total knee replacement in 2022 due to osteoarthritis in the Clinic of Traumatology and Orthopedics of the I.I.Mechnikov NWSMU (hereinafter referred to as the clinic) were analyzed. The average age of patients was stated at the level of 57.4±8.8 years (from 28 to 88 years). Information on the age and gender of 112 patients discharged after ETBS from the clinic is presented in Table 1. As follows from the data presented in Table 1, women predominated in all age groups. Male ratio:women accounted for 2:3. Male patients were 45 (4.2%); female — 67 (59.5%). At the same time, among young patients, the male—female ratio was 1:2 (2.7% and 6.2%, respectively). From the anamnesis, it was revealed that only 33 (29.5%) patients before the endoprosthetics were at least once on a course of inpatient conservative or minimally invasive surgical treatment for osteoarthritis of the hip joint. In most cases (79 cases — 70.5%), only outpatient treatment took place. In all 112 patients, an X-ray examination of the hip joint was performed before surgery. Magnetic resonance imaging was performed in 17 (15.2%) cases. After a standard examination before arthroplasty, 73 patients (65.2%) were diagnosed with osteoarthritis of the hip joint of the III st. In 39 cases (34.8%), osteoarthritis of the hip joint of stage II — III was detected. Local and general complications were verified during ETBS and in the early postoperative period after hip arthroplasty. In the overwhelming majority, the results of hip replacement with an implant were regarded as positive. At the same time, intraoperative and postoperative complications were noted in 12 (10.7%) patients. Local — 3 (2.7%) cases were noted among intraoperative complications. This is a fracture of the large trochanter, damage to nerve trunks, damage to the acetabulum (according to 1 observation — 0.9%). Postoperative complications were noted in 7 (6.3%) patients: 3 (2.7%) cases of lymphorrhea, 2 (1.8%) hematomas and 2 (1.8%) — superficial infection of the surgical intervention area. Cardiac disorders prevailed in the structure of general complications (4 cases — 3.4%). No deaths were recorded during the operation and in the early postoperative period. Out of 112 patients, 30 patients were randomly selected for postoperative pathomorphological examination. The femoral head was examined (Fig. 1). Table 1 / Table 1 Distribution of patients who underwent primary total ETBS due to osteoarthritis, taking into account their age and gender Number of patients, % / Number of patients, % Age groups, years / Age group, men / women / women / total abs.s.s.% 18-44 3 2,7 7 6,2 10 8,9 45-64 23 20,5 32 28,6 55 49,1 65 and more than 19 17.0 28 25.0 47 42.0 Total 45 40.2 67 59.8 112 100 Figure 1. Macroscopic view of the femoral heads removed during total hip replacement: On total frontal pelvic saws obtained during autopsy from individuals with a confirmed lifetime diagnosis of osteoarthritis (Fig. 2), a decrease in the number of bone beams acting as buttresses in the proximal epiphysis of the femur was clearly visible. There was a thinning of the subchondral bone plate on the articular surfaces, a decrease in the density of the spongy substance of the femoral head and acetabulum in combination with the formation of the formation of cystic formations (thin arrows), having the appearance of rounded enlightened areas. A significant decrease in the thickness of the compact substance on the upper surface of the femoral neck (thick arrow) deserved special attention. On the frontal saws of the femoral head and neck (Fig. 3), special attention is drawn to the osteophytes forming in the area of the head fossa. Figure 2. Frontal cutting of the hip joint, plastered with epoxy resin. Autopsy. Osteoarthritis II art . Explanations in the text Figure 3. Frontal cutting of the femoral head after ETBS, plastinated with epoxy resin. Osteoarthritis of the hip joint of the III art . The study of micro-preparations revealed cases of both the initial stages of osteoarthritis of the hip joint and osteoarthritis of the II and III stages. It can be noted that among the 30 morphological studies conducted, 3 (10%) patients had stage I of osteoarthritis of CS verified (Fig. 4a). In 9 (30%) cases, art. II OA was diagnosed. (Fig. 4 b), and 18 (60%) were diagnosed with stage III osteoatritis (Fig. 5). Figure 4. Histotopograms of femoral heads with various degrees of damage: a — I st.; b — the area of marginal osteophytes in the area of the fossa of the head (see Fig. 3); 1 — preserved layer of hyaline cartilage tissue; 2 — spongy substance of the femoral head; 3 — the fossa of the head; 4 — osteophytes. Color: safranin O. Magnification: A x40; B x 100 Figure 5. The surface of the femoral head, III art.: a — osteosclerosis of the subchondral bone; b — microcysts filled with fibrous connective tissue; 1 — bone surface devoid of hyaline cartilage; 2 — lamellar bone tissue; 3 — microcysts. Color: a — hematoxylin and eosin; b — safranin O. Magnification x 100 Characteristic pathomorphological signs of osteoarthritis of the hip joint of the II and III degrees can be considered uneven thinning of the subchondral bone plate on the articular surfaces, the formation of cysts (dotted arrows) in the spongy substance of the head with a size of 3 to 6 mm, as well as the formation of osteophytes (continuous arrows) along the edges of the articular surface. Similar bone growths were observed on the fossa of the femoral head and had the appearance of an "incoming wave". These osteophytes formed a narrow bone ring, squeezing the ligament of the femoral head. A decrease in the diameter of the blood vessels passing through it was noted. The severity of the above-mentioned pathomorphological signs of osteoarthritis was more pronounced in patients with clinically confirmed grade III disease. Discussion The use of a new method of morphological examination — epoxy plastination made it possible to detect at the mesoscopic level characteristic pathomorphological signs of osteoarthritis of the hip joint, which were difficult to detect during radiation diagnostic studies. Such signs can be considered thinning of the subchondral plate of the articular surfaces in combination with the formation of cystic structures up to 6 mm in size in the spongy substance of the femoral head. The formation of bone growths along the edge of the articular surfaces, according to the anamnesis, was accompanied by pain syndrome and had a direct connection with it. Osteophytes in the area of the femoral head fossa formed a bone ring that compressed the blood vessels of the ligament, as evidenced by a decrease in the diameter and density of the distribution of blood vessels in this area. It is obvious that a violation of the blood supply to the proximal part of the head with deforming osteoarthritis will contribute to bone ischemia and can be considered another pathogenetic factor in the development of osteoarthritis. The noted decrease in the number of bone beams in the head and neck of the femur, along with the thinning of the compact substance, explains the decrease in the strength of the neck, which often leads to the formation of fractures in elderly patients. Without a doubt, when deciding on hip replacement, orthopedic traumatologists were guided not only by the data of X-ray or tomographic research methods and the estimated stage of osteoarthritis The features of the clinical picture were also taken into account (the intensity of the pain syndrome, the effectiveness of conservative treatment, the duration of the disease), the nature of concomitant pathology, etc. However, attention is drawn to the fact that in most cases (79 (70.5%) of observations among 112) total hip replacement was actually the reason for the first inpatient treatment of the patient due to osteoarthritis of the hip joint. Hip replacement with an implant is not an organ-preserving intervention. During this operation, all components of the joint (articular surfaces, synovial membrane, articular bag) are removed and a prosthesis is installed (while the life of the implant is not unlimited). According to formal signs, this operation is comparable to the amputation of a limb segment and is actually crippling, with the only difference that the limb prosthesis can be replaced an unlimited number of times without harm to the patient, and the results of re-endoprosthetics are much worse than with the primary replacement of the joint with an endoprosthesis. In addition, ETBS, like any other operation, can be accompanied by intra- or postoperative complications up to a fatal outcome. Patients do not always follow the doctor's recommendations regarding movement restrictions in the operated joint and a special regime, which also leads to various kinds of complications. In addition, the indications for endoprosthetics are imperfect and are constantly being refined in the direction of their limitation. On the other hand, the healthcare structure of the Russian Federation does not provide for a system of medical examination of patients with osteoarthritis; inpatient treatment of such patients under compulsory medical insurance has the cheapest rates, and the interaction of therapists, orthopedists, rheumatologists, rehabilitologists and specialists in restorative medicine is not regulated by a strict algorithm. A similar situation is observed not only in Russia, but also in the United States, the European Union and Asia. Based on the morphological study data, it can be assumed that in 12 (40%) patients with stage I or II osteoarthritis, joint replacement was performed prematurely, without using the potential of conservative or minimally invasive surgical treatment of hip osteoarthritis. The presented results are an incentive to conduct a special scientific study devoted to the development of a strategy for the treatment of patients with osteoarthritis of the hip joint, including outpatient examination and treatment, inpatient conservative treatment, minimally invasive surgical techniques, hip replacement, as a last resort, and rehabilitation. Conclusions/ Summary In the Russian Federation, as well as all over the world, the number of publications devoted to the fact that hip replacement in osteoarthritis is often performed prematurely, while the potential of conservative and minimally invasive surgical techniques is not used. Among the patients hospitalized in the clinic for hip replacement, 33 (29.5%), i.e. only one in three at least once was on a course of inpatient conservative or minimally invasive surgical treatment for osteoarthritis of the hip joint. According to the morphological study, stage III osteoarthritis was confirmed in 18 (60%) patients. In the remaining 12 (40%) clinical cases that underwent arthroplasty, the I-II stage of osteoarthritis was verified. To form a strategy for the treatment of patients with osteoarthritis of the hip joint, it is necessary to develop an algorithm for interaction between specialists involving therapists, orthopedists, rheumatologists, rehabilitologists and specialists in restorative medicine of both outpatient and inpatient and sanatorium-resort units. Ethics of publication. The submitted article has not been published before, all borrowings are correct. Ethics of research. The research was approved by the Ethics Committee of the I.I. Mechnikov NWSMU and conducted in accordance with the ethical standards set out in the Helsinki Declaration. All patients received informational consent to conduct the study. Conflict of interest. The authors declare that there is no conflict of interest. Source of funding. The study had no sponsorship....

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