The key aspects of the study: 1) what has changed in the structure of revisions in recent years? 2) what is the spectrum of reasons for revision after primary hip arthroplasty and re-revision? 3) what are the demographic features of patients’ population undergoing the revision? Materials and methods. The authors conducted a retrospective evaluation of 2415 hip revision cases during the period of time from 2014 until 2018. Separately the authors assessed revisions after primary surgeries and re-revisions as well as the group of early revisions. Results. In the period from 2014 until 2018 the overall share of revisions was 16,6% from all total hip arthroplasties, at the same time the authors reported the absolute 1.7 times increase in number of revisions as well as increased share of revisions in the total structure of hip arthroplasty from 12,5% to 18,9% without significant variances in the number of primary procedures. The share of early revisions increased from 32.9% in 2013 to 56.7% while the number of early revisions amounted to 37.4% of all primary revisions. Gender composition in primary and revision hip arthroplasty varied insignificantly. Mean age at the moment of hip revision was 59.2% (95% CI from 58.7 to 59.7; Me 60 years) which is slightly less than in primary replacement — 60.2 years (95% CI from 58.9 to 61.1; Me 62 years), but such variances had a high statistical significance, р0.001. The main reasons for primary revisions were aseptic loosening of prosthesis components (50.3%), infection (27.6%), polyethylene wear and osteolysis (9.0%) as well as dislocations (6,2%). Re-revisions structure featured prevalence of infection (69.0%), aseptic loosening (20.8%) and dislocations (7,8%). Mean period of time after primary hip arthroplasty to revision was 7.9 years (95% CI from 7.7 to 8.2; Me 7.3), to first re-revision — 2.9 (95% CI from 2.6 to 3.2; Me 1.2), to second re-revision — 2.2 (95% CI from 1.8 to 2.7; Me 1.1), to third — 2,2 (95% CI from 1.7 to 2.8; Me 1.1), to fourth — 1.0 (95% CI from 0.6 to 1.3; Me 0.6), remaining cases demonstrated rather high heterogeneity. Conclusion. In the result of the present study the authors observed increased number of all revision hip arthroplasties, especially the share of early revisions within first five years from the moment of previous surgery. The most often reason for revision after primary hip arthroplasty was aseptic loosening of one or both components of prosthesis. Infection was the absolute leader in the group of re-revisions constituting over half of all reasons for secondary intervention.
обзоры и рецензии т р а в м а т о л о г и я и о р т о п е д и я р о с с и и 2013-4 (70)
Purposes are to determine1) what frequency and what degree is of custom acetabular implants malposition in comparison with planned position, 2) what the reason of malposition is and 3) what the malposition consequences we can wait for.Patients and methods. The observation group included 20 patients (18 women and 2 men) with severe ac-etabular defects. Mean age of patients made up 53 (22-72) years. Position of the implants was compared with the parameters of preoperative planning using 5 postoperative CT indices (inclination, anteversion of semi-spherical part of the implant, spatial location of the rotation center in three axes). More than 10° deviation for inclination or anteversion and 5° dislocation of the rotation center in any axis was considered as a malposition of the component.Results. Only 5 of 20 constructions matched conditionally permissible limits by all the parameters. Most often excessive dislocation of the rotation center in lateral direction (10 cases) and excessive anteversion (9 cases) were observed. During 6 weeks follow up no complications related to the acetabular component position were recorded.Conclusion. It was shown that at revision arthroplasty with custom-made implants the probability of implant malposition as compared to the preoperative plan. The main reason could be the complexity of intraoperative orientation under conditions of abnormal hip anatomy. Malposition of the implants beyond the stated values did not result in complications within the early postoperative period. The longer follow up is required for the assessment of the long-term results.
Несмотря на то что первичное эндопротезирование тазобедренного сустава является методом выбора, позволяющим в сравнительно короткие сроки купировать болевой синдром и улучшить качество жизни пациентов, проблема имплантации ацетабулярного компонента в условиях массивного остеолиза вертлужной впадины при ревизионном эндопротезировании остается одной из актуальных у ортопедов как в России, так и за рубежом. Анализ литературы по данной проблеме указывает на существование целого ряда методик ревизионной ацетабулопластики: от классических до современных высокотехнологичных решений. Результаты ревизионного эндопротезирования в условиях массивного ацетабулярного остеолиза при использовании различных методик сопоставимы, а выживаемость эндопротеза после ревизии существенно ниже в сравнении с первичной артропластикой. Применение структурных трансплантатов для восстановления костной основы вертлужной впадины является классической методикой, позволяющей попытаться увеличить костную массу, что имеет наибольшую актуальность у молодых пациентов, однако требует мастерства исполнения и имеет свои особенности в послеоперационной реабилитации. Костно-пластическое замещение дефектов может быть достойной альтернативой современным высокотехнологическим ревизионных системам, однако требует анализа с целью сравнения результатов. В публикации представлен анализ долгосрочных результатов использования структурных аллотрансплантатов для замещения массивных дефектов вертлужной впадины. Ключевые слова: ревизионное эндопротезирование, ацетабулярные костные дефекты, структурные аллотрансплантаты. Cheboksary, doc-karpukhin@yandex.ru Despite the fact that primary total hip arthroplasty is a method of choice that allows in a relatively short period of time to reduce pain syndrome and improve the quality of life for the patients, the problem of implantation of the acetabular shell in the situations of massive acetabular osteolysis in revisions is one of the topical problems for surgeons in Russia and abroad. Analysis of the literature on this problem points to the existence of a number of methods of revisions from classical to modern high-tech solutions. The results of revisions with massive acetabular osteolysis using different techniques are comparable and the survival rate is significantly lower in comparison with primary arthroplasty. The use of structural grafts to restore the bone stock of the acetabulum is a classic technique that allows to try to increase acetabular bone stock, which is most relevant in young patients, but requires surgeons skills and has its own peculiarities in postoperative rehabilitation. Structural bone grafting in acetabular revisions can be an alternative to modern high-tech revision systems but requires analysis to compare results. The publication presents an analysis of the long-term results of the use of structural allografts in acetabular revisions. Ключевые слова: acetabular revision, acetabular defects, structural allografts. THE USE OF STRUCTURAL ALLOGRAFTS IN REVISION SURGERY WITH MASSIVEКак известно, энд...
Цель работы: оценить эффективность первого этапа двухэтапной хирургической методики лечения параэндопротезной инфекции и выявить возможные факторы, влияющие на результат. Материал и методы. Проведен анализ результатов лечения 217 пациентов с параэндопротезной инфекцией, оперированных в РНИИТО им. Р.Р. Вредена в 2008-2012 годах. Средний возраст больных составил 56,1 лет (95% ДИ от 48,3 до 67,4). Всем пациентам выполнены санирующие операции с удалением эндопротеза тазобедренного сустава и установкой блоковидного или артикулирующего спейсера в разные сроки после первичного (77%) или ревизионного (23%) эндопротезирования. Результаты. У 139 больных (64,1%) отмечена стойкая ремиссия инфекционного процесса, позволившая в среднем через 10,2 недели (95% ДИ от 7,9 до 14,3) выполнить замену спейсера на полноценный эндопротез. Рецидивы инфекционного процесса наблюдались в 78 (35,9%) случаях. Заключение. Основными факторами риска развития рецидива инфекционного процесса являются сочетание и вид микроорганизма, лабораторные показатели, вес пациента и тип предшествующей операции. Ключевые слова: ревизионное эндопротезирование, параэндопротезная инфекция, двухэтапная ревизия.
; 2 ГБОУ ВПО «Северо-Западный государственный медицинский университет им. И.И. Мечникова» Минздрава России, Санкт-Петербург В исследование были включены 96 пациентов с костными анкилозами тазобедренного сустава (ТБС). Из них 24 пациента с костными анкилозами на фоне анкилозирующего спондилоартрита (АС), 10 пациентов с анкилозами гетеротопической оссификации (ГО) и 62 пациента с анкилозами ятрогенной этиологии. При проведении исследования учитывались следующие показатели: степень отклонения конечности в ТБС от функционально выгодного положения, шкала Харрис, EQ-5D-5L, визуально-аналоговая шкала (ВАШ) текущего состояния, Oswestry и ВАШ боли в монолатеральном коленном суставе, состояние средней ягодичной мышцы, интраоперационное изменение офсета и длины конечности, остаточная деформация бедренной кости. По данным корреляционного анализа было установлено, что основное влияние на сроки эндопротезирования оказывает степень сохранения опорной функции конечности, которая зависела от типа анкилоза. Длительность отсутствия движений в ТБС и степень изменений анатомии ацетабулярной области и бедренной кости также зависели от причины формирования анкилоза и оказывали непосредственное влияние на итоговые результаты эндопротезирования тазобедренного сустава. Выявленные закономерности указывают на необходимость строго индивидуального подхода к определению показаний и сроков выполнения эндопротезирования тазобедренного сустава пациентам данной категории. Ключевые слова: тотальное эндопротезирование тазобедренного сустава, анкилоз тазобедренного сустава, артродез, анкилозирующий спондилоартрит, гетеротопическая оссификация, опорная функция конечности. The study included 96 patients with bone hip ankylosis. 24 of them was a patient with ankylosing spondylitis (АС), 10 patients with ankylosis heterotopic ossification (HO) and 62 patients after hip arthrodesis. We studied: the degree of deviation of the limb at the hip by a functionally advantageous position, Harris, EQ-5D-5L, Visual Analogue Scale (VAS) condition of the patient, Oswestry and VAS pain is monolateral knee scales, gluteus medius condition, intraoperative change of offset and leg length, and postoperative femur deformation. According correlation analysis of total hip replacement periods directly related to the degree of conservation of the supporting limb function which depends directly on the type of ankylosis. The results of the total hip replacement depended both on the duration of ankylosis and on the degree of changes in the anatomy of the acetabular region and femur on the side of ankylosis. The revealed laws point to the necessity of a strictly individual approach to the definition of indications and timing of hip arthroplasty for these patients. TOTAL HIP IN CASE OF HIP BONE ANKYLOSIS DIFFERENT ETIOLOGY, REASONS
Osteomyelitis remains one of the most intractable diseases. The nature of the pathogen and its resistance to antibiotics significantly affect the outcome and cost of treatment.The aim of the study: to analyze the dynamics of the spectrum and antibiotic resistance of the leading pathogens of orthopedic infection for the period 2012– 2017.Material and methods. The structure of pathogens isolated from the focus of infection from 2774 patients with periprosthetic infection and chronic osteomyelitis was retrospectively analyzed. Antibiotic resistance of the leading pathogens that occupied more than 4% in the species structure was studied. Comparative analysis of changes in the spectrum of pathogens and antibiotic resistance was carried out for the periods 2012-2013, 2014–2015 and 2016-2017. Epidemiological analysis was performed in the program „microbiological monitoring system” Microbe-2. Statistical processing of the obtained data was carried out using the Z-criterion.Results.From 2774 patients with orthopedic infection have been isolated 4359 strains, in the structure of which about 73.5% were occupied by S. aureus, S. epidermidis, E. faecalis, E. faecium, P. aeruginosa, Acinetobacter sp. representatives of the family Enterobacteriacea. In 27% of the cases, microorganisms of other species were identified. Microbial associations were identified in 19.4% of cases. In the structure of the leading Gram(+) pathogens, a significant decrease in the incidence of S. aureus was detected, while the share of S. epidermidis increased significantly. Among the leading Gram(-) microorganisms, a significant increase in the proportion of representatives of the fam. Enterobacteriacea was found, against the background of a decrease in the share of Acinetobacter sp. and P. aeruginosa. The level of resistance of MSSA to the studied antibiotics ranged from 0.1 to 8.8%, for MSSE the spread was from 1.9 to 16.7%. Negative dynamics of growth of resistance of non-fermenting bacteria is established. The strains of Acinetobacter sp. demonstrated greater resistance to tested antibiotics in comparison with P. aeruginosa.Conclusion.An increase in the role of S. epidermidis and K. pneumoniae in the etiology of orthopedic infection was established. The revealed increase in the resistance of microbial pathogens to most tested and used antibiotics should be taken into account in the appointment of empirical antibiotic therapy. The extremely high frequency of resistance of gram-negative bacteria to cephalosporins and fluoroquinolones excludes the possibility of their empirical use, which requires the management of carbapenems in the starting treatment regimens. High resistance to fluoroquinolones limits the ability of oral antibiotic therapy in patients with periprosthetic infection.
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