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Rehabilitation and prevention of complications after total hip arthroplasty
Ruzibaev Dilmurod Ruzimetovic, Deputy of Chief doctor National Center of Rehabilitation and Prosthetics of Disabled E-mail: rdilmurod1979@mail.ru
Asilova Saodat Ubaevna, Professor of the department of traumatology and orthopedics in Medical academy of Tashkent E-mail: asilova_saodat@mail.ru
Nurimov Gayrat Kadamboyevich, Doctor Republican center for the social adaptataion of children
E-mail: nurimov@mail.ru
Rehabilitation and prevention of complications after total hip arthroplasty
Abstract: A comparative analysis of the structure and frequency of complications after total hip replacement (THR) and basic methods of prevention based on experience treating 303 patients with diseases and injuries of the hip joint.
It is proved that a comprehensive system of rehabilitation of patients, which includes preoperative preparation, prevention of complications, operation planning and original methods of treatment, diagnostics and physiotherapy, for each stage of treatment, up to the final physiological and social rehabilitation, provides a significant reduction in the number of complications, achieving optimal outcomes of treatment and functional outcomes.
Keywords: treatment, prevention, complications, arthroplasty, hip joint.
Introduction
The most effective method of medical and social rehabilitation of patients with degenerative-dystrophic diseases and injuries of the hip joint is a total hip replacement surgery [1; 3; 5; 6]. It has significant advantages over traditional interventions (corrective osteotomy, arthrodesis, osteosynthesis and others), and thus is becoming more common in practice [2; 4]. The number of operations is constantly increasing and there is reason to believe that it is now more than 1.5 million operations performed annually [8]. Despite improvements in implants and surgical technique, the number of complications arising during and after THR remains quite high. It is accepted to divide these complications into intraoperative, early and late postoperative types.
Frequent early complication is a dislocation of the femoral head, which occur in 0.3-11 % of cases and more commonly — after revision arthroplasty, as well as when using the posterior approach to the j oint [11]. In the first 3 months after surgery, they account for 70-90 % of the total number of dislocations and 0.5-3 % of the total number of operations [1].
In this regard, the study of the question of rehabilitation treatment and prevention of complications after THR is an important issue of reconstructive surgery.
Purpose
The purpose is to determine necessity of rehabilitation treatment and prevention of complications after THR and to determine the effectiveness of the complex developed methods of rehabilitation treatment for the prevention of early and late postoperative complications.
Materials and methods
The results of the study of 499 patients undergone surgical treatment of diseases of the hip joint were analyzed. The sample consisted of patients treated in trauma and orthopedic hospitals in Tashkent and regions of the Republic of Uzbekistan for 5 years from 2009 to 2013. Of these, 303 patients had THR and 196 patients underwent other reconstructive operations. More than a third of patients were of working age, significant share was represented by retirees, including the elderly (over 80 years). Most patients had underlying disease for 5-10 years or more. This has led to the presence of disability of different stages in half of the patients.
The main diseases that led to affecton of the hip joints were hip dysplasia, deforming coxarthrosis, rheumatoid arthritis, aseptic necrosis of the femoral head; traumatic injuries and ankylosing spondylitis. All patients had bilateral disease process. All patients had dysplastic arthrosis deformans diagnosed with stage 2 and 3, and in aseptic necrosis of the femoral head stage 3 and 4. Preoperative assessment Harris scale was 40.6 points, biomechanical parameters were affected in 86.5 % of patients.
When planning operations conventional radiographic parameters for selecting prosthesis and fixation method, as well as gender, constitutional parameters of patients and the primary disease caused by anatomical changes were taken into account.
Results and discussion.
It was found that, except for two deaths, including two patients operated on for “deep suppuration” in the joint in all cases, the wounds healed by first intention. Cases of superficial suppuration or fistula formation was not observed.
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Section 8. Medical science
In connection with the development of various complications 5 patients have been successfully operated. Reported deaths of two patients due to pulmonary embolism, develops 1-2 days after surgery. In our study, mortality rate was lower than indicated in the literature — 0.29-0.69 % [9].
Intraoperative complications were diagnosed in 5 of303 patients. Periprosthetic fractures were recorded in 3 cases, with an average of 0.8-2.3 %. In the early stages of work one case with massive blood loss and one premature polymerization of bone cement were noted.
The frequency of occurrence of early dislocation of the head after the THR, according to different authors, comprises 0.5-3.0 % (1.2). We have obtained this complication only in 4 observations, which is consistent with the literature.
These data on the incidence of thrombophlebitis and embolism veins of the lower extremities, including pulmonary thromboembolism fatal also comparable with literature data.
A similar conclusion can be drawn regarding cases with “deep infection", the frequency of which is minimal (0.28 %), as well as in terms of frequency of occurrence of neurological disorders (0.56 %) occurs much less frequently than other researchers mentioned.
It can be regarded as obvious that the reduction of various complications mainly due to the successful implementation of the first stages of the developed complex of rehabilitative treatment; targeted preparation of the patient and the rational planning of the operation, preventive measures, as well as the early onset of therapeutic exercises. Naturally, the leading role at this stage is a careful observance of the safety of surgical intervention with the use of modern tools.
Development of late postoperative complications often lead to reoperation and largely determines the degree of social and physiological adaptation of the patient. According to Von Knoch M. C. et al. [7] who summarized the experience of 19,680 operations, head dislocations occur in 2.6 % of cases, of which 32 % occur after 5 or more years after the surgery, which leads to the development of the instability of the endoprosthesis (EP). I. F. Akhtyamov and I. I. Kuzmin [1] indicate that the “secondary” dislocations (up to 5 years after surgery) occur in 9.6 % of cases. A relatively high incidence of this complication marked by V. I. Nuzhdin et al. [4] is to explain complex technical conditions encountered by the authors. After reimplantation of the joint due to infection the incidence of dislocations increases from 6 to 18 % of cases [10].
It should be noted that the incidence of late postoperative complications in our study was significantly lower than in many distinguished literature. This conclusion holds true for the frequency of formation after surgical complications, which we only diagnosed in 18 patients and only 10 of them belonged to 2nd and 3rd class of Harris score.
Effective complex of rehabilitative treatment as an effective method of preventing the development of postoperative complications confirms outcome assessment of hip operations on Harris score.From this it is clear that excellent and good results were achieved in 49.1 % of cases.
Primary prevention of intra- and postoperative complications was the system of remediation activities we developed at all stages of the treatment, which included:
- rational planning of the operation;
- a set of post-operative preparation: treatment of the underlying disease, relief of pain and inflammation in the affected hip by medications and physiotherapy facilities, psychological preparation of the patient, teaching patients therapeutic exercises and urging the patient its performance;
- medicational prevention;
- carefully-observance of the safetyof operation and intervention constant brigade led by an experienced surgeon and anesthetist;
- rehabilitative treatment in early, immediate and late postoperative period (up to 1 year) until complete physiological and social rehabilitation of the patient;
- antibiotic treatment carried out according to the “longterm” moment of sedation by internal administration of antibiotics for no more than 3-5 days;
- low molecular weight heparins (Fraxiparine, Clexane, Fragmin) in prophylactic doses (0.3, 04-2500 IU respectively) were used 7-10 days to prevent venous thromboembolism;
- elastic bandaging of the lower extremities is required;
- physiotherapy at all stages, starting from 1st day after surgery is included as part of the range of preventive therapy.
The effectiveness of this method is confirmed by longterm results of treatment (more than three years from the date of surgery) tracked in 67 patients of working age. It is determined that they returned to their former employment in various specialties (drivers, welders, guides, accountants, and others), and 29 of them refused to continue the disability, since they adapted well to the conditions of social and employment environments.
Thus, concluding the discussion of the problem, it should be noted that, unfortunately, it was impossible to completely avoid complications during or after THR. However, the proposed system of complex staged treatment allowed to minimize the frequency of both early and late complications.
Conclusion
1. Reduction of various complications is mainly due to the successful implementation of the first stages of complex restorative treatment we developed.
2. Development of late postoperative complications often lead to conduct reoperations and largely determines the degree of social and physiological adaptation of the patient.
3. The complex restorative treatment as an effective method of prevention of postoperative complications is confirmed by the assessment of the outcomes of hip surgery.
4. The main method of primary prevention of intra- and postoperative complications is system of rehabilitative actions we have developed which must be undertaken at all stages of treatment.
5. The proposed system of complex stage treatment enables to minimize the frequency of both early and late complications.
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Children vascular anomalies management: results of photodynamic therapy in Uzbekistan
References:
1. Akhtyamov I. F., Kuzmin I. Errors and complications of hip replacement. - Kazan: Center of operational print, 2006. - Р. 328.
2. Zagorodnii V D. Arthroplasty during injuries and diseases of the hip joint (doctoral dissertation). - 1998. - Р. 34.
3. Mamontov V D. Infectious complications of hip replacement. Book: Traumatology and Orthopedics. Injuries and diseases of the lower limb. - St. Petersburg: “Hippocrates”, 2006. - Р. 251-285.
4. Nuzhdin V I., Trotsenko V V., Erohin P. A. Total hip replacement in patients undergoing osteotomy of the proximal femur. Bulletin of traumatology and orthopedics. - Moscow, 2007. - Р. 72-79.
5. Berry D. J., Von Knoch M., Schleck C. D. The Cumulative long-Term risk of dislocation after primery Charnley Total Hip Arthroplasty.//Z. Bone Jt Sarg. - 2009: 86. - Р. 9-14.
6. Koval K. C., Zuckerman Z. D. Handbook of Fractures. 2nd ed. - Lippincott Williams &Wilkens, Phil, 2010. - Р. 22-24.
7. Von Knoch M., Berry D. J., Harmsen W. S. Late Dislacation after Total hip arthroplasty//Z. Bone Jt Sarg. - 2002. -84. - Р. 1949-1953.
8. Ochsner P. E. Total Hip Rentacement. - Spinger, Verlag, 2008. - Р. 107-122.
9. Paavolainen P., Pakkala E., PulkKinen P. Causes of death atter total Hip Arthoplasty: a Nation Wide cohort study with 24 638 patents.//Z. Arthroplasty, 2002. - 17. - Р. 274-281.
10. Hsieh P. N., Shin C. N., Chang V N. Two-Stage Revision Hip arthropiasty for infection: complasty for infection: Compari-sion between the interin use of antibiotic-loaded cement beeds and a spacer protesis.//Z. Bone Z.T Surg. Am. J. - 2004. -86. - Р 1989-1997.
11. Wooison S. T. Intermitten Pneumatic Compression Prophylaxis for Proximal Deep Venous Thrombosis after Total Hip Replacement.//Z. Bone Jt Surg. - 2009. - Vol. 784, № 11. - Р. 1735-1770.
Sadykov Rasul Rustamovich, Tashkent Medical Academy, Surgery Department E-mail: srrdoktor@yahoo.com
Children vascular anomalies management: results of photodynamic therapy in Uzbekistan
Abstract: This study reports about the role of photodynamic therapy in management of children vascular anomalies. A 3-year (2009-2012) retrospective study on the challenges and outcome of245 children with vascular anomalies referred for surgical management was undertaken at the Tashkent Medical Academy, Uzbekistan. After multidisciplinary discussion, all patients underwent photodynamic therapy under general anesthesia, with 5-ALA as the photosensitising agent. In a time of treatment 85 out 108 patients who presented with long-term pain reported improvement after treatment. Also, 43/46 reported significant reduction of bleeding related to their vascular anomaly. Improvement of swelling was reported by 189/199 patients; while reduction of infection episodes was evident in 61/63 patients and 176/205 reported reduction in the disfigurement caused by their pathology. Clinical assessment showed that more than half of the patients had good response to the treatment. Significant clinical response was reported by 148 (60.4 %) patients, moderate result by 70 (28.6 %). Radiological and ultrasound assessment comparing imaging 6-week post-PDT to the baseline showed moderate response in 78 (31.8 %) patients and significant response in 122 (49.8 %) patients.
Keywords: haemangioma, congenital and infantile, malformations, children, laser, surgery.
Introduction
Vascular anomalies are congenital anomalies of vascular development causing a variable degree of soft tissue abnormalities. These anomalies tend to occur most commonly in the head and neck and affect approximately 1 in 22 children. The most recent classification of vascular anomalies ISSVA includes two main categories: vascular tumours and vascular malformations [14]. Vascular tumours include infantile type and congenital type haemangiomas; the former being the most common vascular tumour as well as vascular anomaly.
Other types include pyogenic granuloma, tufted angiomas and haemangioendotheliomas, angiosarcomas [3].
Vascular malformations, involve a variety of aberrations including: venous, arteriovenous, capillary and lymphatic. Slow-flow ones include capillary, venous and lymphatic; while, arteriovenous malformations are fast-flow. Vascular malformations differ, from vascular tumours, by having progressively enlarging aberrant and ecstatic vessels composed of a particular vascular architecture and do not contain hyperplastic cells [10].
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