COXITIS

From Big Medical Encyclopedia

COXITIS (coxitis; lat. coxa a hip joint + - itis) — the general name of all inflammatory diseases of a hip joint, preferential infectious origin. To. treats the most frequent arthritises of large joints and meets at any age (see. Arthritises ).

The AETIOLOGY

On an etiology To. are subdivided on inf. specific (tubercular, gonorrheal, syphilitic, dysenteric, brucellous, etc.), inf. nonspecific, caused more often by coccal flora (so-called purulent To.), rhematoid (see. Pseudorheumatism ), rheumatic (see. Rheumatism ), To. owing to Bekhterev's disease (see. Bekhtereva disease ). To. can be a complication of infectious diseases.

The PATHOGENY AND PATHOLOGICAL ANATOMY

From other arthritises To. differs in a row morfol, the features caused by size hip joint (see), depth of its bedding in a powerful layer of soft tissues, features of very tectonics and vascularization of the elements making it. A characteristic pathoanatomical sign To., as well as any arthritis, the expressed inflammatory changes of a synovial membrane are (see. Synovitis ). They can be primary with the subsequent involvement in process of a head of a femur and an acetabular hollow or secondary when primary and bone forms K., extending, involve a synovial membrane and all joint in process. Inflammatory changes in a joint can proceed with dominance of exudative or proliferative changes and be followed by formation of a serous, serofibrinous, serous and purulent or purulent exudate. At To., caused by not coccal activators (measles, dysentery, etc.), synovial forms are observed. Purulent To., caused by coccal microflora, result or a drift of microbes in the hematogenous way, or owing to transition of inflammatory process to a joint from the bones forming it, and also as a result of a drift of an infection from the outside — fire To., complications of operations on a hip joint; they are characterized by bent to big destructions of a joint and formation of purulent zatek. These features are most expressed at children's age. At tubercular To. the proliferative and curdled and necrotic changes developing in a synovial membrane and bones of a joint with the subsequent destruction and removal of the last are combined. Anatomo-funkts. disturbances are even more aggravated with the dystrophy caused hron, tubercular intoxication.

The CLINICAL PICTURE

Symptoms To. are defined by features of inflammatory process in a joint, first of all character and expressiveness of inflammatory changes of a synovial membrane. Depending on it To. share on acute and chronic. The earliest a wedge, manifestations To. — pain in the affected joint or in other segments of an extremity, restriction of mobility in a joint and formation of myogenetic contractures (see) with installation of an extremity in vicious situation. The exudate in a cavity of a hip joint leads to formation of a swelling over it, edges is defined only at considerable accumulation of liquid or poor development of muscles — at children or the exhausted subjects. In some cases exudate goes beyond the joint capsule, and is formed abscess (see) or phlegmon (see). Local temperature over a joint is, as a rule, increased; extent of increase it is an indicator of sharpness of inflammatory process. The general symptoms (fever, weakness, vegetative disturbances, etc.), as well as local, can be expressed in various degree; it is defined by character of a contagium, reactivity of an organism, its reference state etc. At purulent and tubercular To. further there is a destruction of an acetabular hollow, head and neck of a femur to dislocation and removal of the last up, shortening of an extremity and strengthening of its vicious situation. Especially big destruction is observed at children's age that leads to delay of growth of an extremity, and also, in connection with its vicious situation, to a lordotic and scoliotic curvature of lumbar department of a backbone (see. Lordosis , Scoliosis ) and secondary deformation of a basin. An effect purulent To. quite often is bone anchylosis (see) a joint. For tubercular To. the false ankylosis is more characteristic. In cases of restriction of an inflammation of a synovial membrane in a cover cartilage and bone elements of a joint the dystrophic changes leading to more or less expressed arthrosis with the corresponding dysfunction of a joint develop. Secondary deformations and the phenomena of arthrosis appear also in other joints of an extremity in connection with change of load of them.

Complications at To. are defined by its etiology, the general condition of an organism of the patient, timeliness and correctness of treatment. Formation of abscesses and fistulas is most characteristic at tubercular and purulent To., what can lead further to development of an amyloidosis of internals (see. Amyloidosis ). Rough destructions of elements of a joint bring to patol, installation of an extremity and deformation of other parts of a skeleton. Adverse effect of synovial forms K. it is necessary to consider an anchylosis of a hip joint in vicious situation.

The DIAGNOSIS

Diagnosis To. it is based on a wedge., rentgenol, and lab. research of the patient. At survey study outward of the patient and the affected joint. Depending on an etiology To., duration of a disease, the general reference state of an organism of the patient his outward can be characterized both by the insignificant, and expressed changes, up to extreme degrees of exhaustion. At survey of a joint reveal increase in its volume, discoloration of skin over it, the strengthened drawing of hypodermic venous network, the separate protrusions caused by accumulation of exudate, fistulas with various quantity of purulent separated. Character of pus, its quantity, color and a smell matters. E.g., fetid blue-green pus is characteristic of the infection caused by a pyocyanic stick, grayish inodorous — for tuberculosis etc. Survey reveals also expressed disturbances of installation of an extremity and deformation of all skeleton, shortening or lengthening of a leg and its separate segments, an atrophy of soft tissues. These data are specified by means of a goniometer and a centimetric tape.

Assessment of gait is important. Lameness at To. it can be caused by pain (the sparing lameness at active process) or disturbance of ratios of elements of a joint at K. U effects of children, especially at early stages tubercular To., there can be an alternating lameness, it has the expressed painful character.

Character and degree of ratio distortions of joint elements define by a number of indirect signs: studying of the line of Roser — Nelatona, Kuslik's line, Brayent's triangle, Shemaker's line, the horizontal line through the upper edge of a pubic joint, etc. By means of these signs establish the shift of a hip up (see. Hip joint ).

Assessment of restriction of mobility in a hip joint has a certain diagnostic value. At acute inflammatory processes in a joint the contracture is caused, as a rule, by pain, and at a careful and careful research reduction ^ muscles quite often manages to be overcome to a nek-swarm of degree. At hron, processes and effects postponed To. the desmogenny contracture develops, the edge is not eliminated even under anesthetic. For assessment of expressiveness of a contracture Thomas's reception, i.e. definition of position of a sore leg at the improved situation of a basin is reasonable that is reached by bending of a healthy hip (fig. 1, 1).

The hip joint is most available to a palpation in an upper part femoral triangle (see) knaruzh from a femoral artery (a projection of a head of a femur). At the same time big or smaller morbidity of a joint, increase in its volume, consolidation in the thickness of muscles (abscesses, infiltrates) is defined, in inguinal area are palpated increased regional limf. nodes.

Fig. 1. Receptions of a research of mobility of a hip joint: 1 — definition of degree of a flexion contracture of the right hip joint by the maximum bending of a healthy hip according to Thomas; 2 — a research of overextension of the right hip joint on Krasnobayev and Ternovsky (the arrow specified the direction of the passive movement).

Characteristic symptom To. the thickening of a skin fold on that hip where the joint (Alexandrov's symptom) is affected is. This phenomenon described at tubercular To., equally treats also other its forms, confirming an inflammation of intra joint elements. One of early symptoms To. restriction of overextension of a joint (fig. 1,2) is what Krasnobayev and Ternovsky's symptoms are based on. Also the symptom of muscular «brake» which is shown at the sharp passive movements in a joint is characteristic. The progressing weakness of an average gluteus leads to quite early emergence of a positive symptom of Trendelenburga (see. Hip joint ). Further it is aggravated at the expense of supraplacement of a hip and rapprochement of points of an attachment of this muscle.

Rentgenol, a research at To. it is directed not only to identification, but also to assessment of prescription and activity patol, process, definition of its exact localization and prevalence. At To. a fire origin rentgenol, the research allows to establish also existence or lack of foreign bodys and their location.

The main technique rentgenol, researches at To. is X-ray analysis (see), to-ruyu begin with the survey picture which is surely taking both hip joints for their comparative assessment. More exact data on the nature of destructive bone changes can be obtained with the help tomographies (see). To identification initial, unsharply expressed rentgenol, signs To., insufficiently convincing on usual roentgenograms, the X-ray analysis with direct increase in the x-ray image can promote. For objective assessment of degree of osteoporosis and dynamics of a current patol. process apply X-ray densitometry (see).

One of the first rentgenol, signs To. is osteoporosis (see) the bones making a hip joint. At acute inflammatory processes, in particular purulent, osteoporosis develops rather quickly, but keeps not for long, and in process of a zatikhaniye of the inflammatory phenomena and transition To. to a proliferative phase can even disappear. At hron, specific To. osteoporosis, as a rule, accrues and develops slowly, but can reach so considerable degree that is easily distinguished on the survey roentgenogram at comparative study struck and healthy coxofemoral joints. It serves as important differential and diagnostic criterion at nonspecific and specific To.

Fig. 2. Roentgenogram of the right hip joint: a specific (tubercular) osteitis of an acetabular hollow (it is specified by an arrow), the expressed osteoporosis of a neck and a big spit of a femur.

Characteristic for rentgenol, pictures K. narrowing of a joint crack and destruction of joint surfaces (fig. 2) is. At accumulation in a cavity of a joint of inflammatory exudate on the roentgenogram find insignificant or the expressed shift of a head of a femur of a knaruzha and a little up is distinct. Existence of the destructive centers in the bones of a joint more often observed at places of an attachment of the joint capsule indicates development of active inflammatory process in a hip joint. Such centers at To. can be observed not only in a neck and a head of a femur, but also in ileal, sciatic and pubic bones.

Fig. 3. The roentgenogram of a basin and hip joints of the child at a left-side purulent coxitis: the head and a neck of the left femur are destroyed, in the remained proximal part of a femur (2) two destructive centers (1) are visible, they are surrounded with a rim of sclerous consolidation of a bone tissue, nabedrenny bone considerable periosteal stratifications (3); consolidation of soft tissues of the left hip.

In an initial stage of bone inflammatory process both at nonspecific, and at specific To. the destructive center has the small sizes and indistinct contours. Therefore for detection of the similar centers the tomographic research is recommended. Unlike tubercular To., at nonspecific To. the destructive centers and cavities are usually multiple, have accurately designated contours, are surrounded with the sclerosed bone rim (fig. 3).

At same wedge, forms K. can be observed various rentgenol, symptoms, and different forms K. can be followed more or less identical rentgenol. signs. Therefore in differential radiodiagnosis To. it is necessary to be guided not only results rentgenol. researches but also to consider all set a wedge, pictures

K. Klien., biochemical, and datas of laboratory are caused by an etiology To., features of an organism of sick and inflammatory process. So, at tubercular To. they are characteristic of tuberculosis, at purulent To. — for osteomyelitis and septic states. Bacterial, a research of the exudate received by means of a puncture of a joint is important. The puncture is made in front — in a projection of a head of a femur or outside — over a big spit. Bakteriol, a research of pus allows to establish a contagium and to define its sensitivity to antibacterial drugs. In some cases there is a need of a biopsy, to-ruyu carry out by means of a thick needle, a trocar or at an arthrotomy. Most often gistol, subject to a research operational material.

TREATMENT

Fig. 4. An immobilization of the right hip joint struck with a coxitis, a big bilateral koksitny plaster bandage.
Fig. 5. Various options of an immobilization of a hip joint (across Kornev): 1 — a big unilateral plaster bandage; 2 — a short plaster bandage; 3 — a plaster bandage with a stirrup; 4 — the splint corset.

At establishment inf. the nature of a disease antibacterial therapy taking into account sensitivity of microflora to antibacterial drugs is shown. Apply the antibiotics and himiopreparata which are mutually strengthening action of each other. The immobilization of a sore joint by means of the big koksitny bandage (fig. 4) taking all sore extremity, a pelvic girdle, a trunk to nipples, and in some cases and a healthy hip is in most cases shown. If necessary this bandage can be executed in the form of fenestrated or bridge-like for overseeing by a sore joint or other segments of an extremity. In process of a zatikhaniye of process degree of an immobilization of a joint is reduced, patients gradually transfer to vertical position in removable the splint corset (fig. 5), with crutches in the beginning, then without them, gradually increasing load of an extremity. At some synovial forms K. with a serous and serofibrinous exudate so strict immobilization is not obligatory, and at early the begun treatment of rather bed rest.

Fig. 6. The diagrammatic representation of a front arthrotomy of a hip joint on Menara (the dotted line specified border of a resection of a bone).
Fig. 7. The diagrammatic representation of back counteropening — a skin section (solid line) at an arthrotomy of a hip joint on Langenbeka (the dotted line designated contours of bones).

Operational treatment is shown at destructive processes in a joint. In the active period operation is shown preferential at acute purulent To. also consists in drainage of a joint by means of a front arthrotomy and back counteropening on Langenbeka (fig. 7). At rough processes with extensive destructions, especially at posttraumatic To., this operation supplement with a resection (e.g., on Menara, fig. 6) the most struck fragments of a joint — usually heads and necks of a femur (the so-called draining resection). At the compensated and calmed down destructive processes the economical coxectomy is shown. Use of an intra joint artrodeziruyushchy spline from auto-or allokost (e.g., across Pokotilov) promotes stronger fixing of a joint in the postoperative period and in the subsequent accelerates approach of an anchylosis. Use of effective antibacterial agents quite often allows to avoid an extensive arthrectomy and to make different radical recovery operations.

The FORECAST

At timely treatment in many cases is possible not only to liquidate inflammatory process, but also to keep or recover function of a joint.

SEPARATE TYPES of the COXITIS

the Tubercular coxitis

the Tubercular coxitis — the most often found form of inflammatory diseases of a hip joint. Tubercular To. it is characterized long hron, a current, frequent aggravations and adverse anatomo-funkts. outcome. It results from usually hematogenous dissimination of an infection. Development of secondary arthritis from initial bone focus — primary is most characteristic osteitis (see). Much less often initially the synovial membrane with development of primary sumochny forms differing in rather smaller destructive changes than secondary arthritises is surprised.

The most frequent localization of primary osteitises — a body of an ileal bone in the field of an acetabular hollow. Primary osteitises divide on rentgenol, a picture on lateral, medial and mediotsentralny. In a neck and a head of a femur in departments of sciatic and pubic bones, adjacent to a joint, primary osteitises are localized less often. Than further from a joint the center is located, especially the beginning of a disease is imperceptible. Tubercular arthritis develops as a result of break of the center in a cavity of a joint, or owing to gradual germination of a granuloma on a synovial membrane with the subsequent defeat of joint surfaces. Extent of secondary destruction and the nature of inflammatory process considerably are defined by the sizes of the center.

As a result of destruction of a head and a neck of a femur it is displaced up (patol, dislocation) that in total with the bringing contracture which is already available usually flexion causes disturbance of installation of all extremity. In process of a zatikhaniye of process on site of the joint destroyed by tubercular process the cicatricial fabric promoting an otgranicheniye, but not elimination of the center develops. Thus, and at the calmed-down process a recurrence is possible.

Wedge, a picture and course of a tuberculosis of bones and joints, according to P. G. Kornev, are subdivided into three phases: preartritichesky when the center did not break in a joint, arthritic with three stages (the beginning, a heat and a zatikhaniye) and post-arthritic yet.

In a preartritichesky phase in a joint only reactive changes felt by the patient in the form of temporary mild pains and the alternating lameness develop. Small expressiveness and vagueness a wedge, symptoms explain frequent overdue negotiability to the doctor and a late initiation of treatment.

In most cases tubercular To. diagnose in an arthritic phase, edges it is characterized by the expressed pains in a hip joint, restriction of mobility of a hip and trophic disturbances of an extremity. Gradually the flexion bringing contracture of a joint develops. The general condition of the patient suffers a little in the beginning, note the subfebrile temperature, disorder of appetite, weakness, perspiration and other vegetative disturbances characteristic for tuberculosis (see).

Fig. 8. Outward of the patient with a tubercular coxitis in an arthritic phase: contracture of a hip joint, atrophy of soft tissues of an extremity.

In an arthritic phase the general state considerably worsens, local manifestations of process amplify. Pains become constant and intensive, the contracture and a muscular atrophy (fig. 8) increases. The joint increases in volume, skin temperature considerably increases, expanded saphenas become visible. At a palpation sometimes it is possible to find hypodermic abscesses. Duration of the active period is various and without treatment can reach several years then subsiding of inflammatory changes begins.

In a post-arthritic phase the joint becomes «dry» and «cold», painless at inspection, but remain the effect postponed To. in the form of vicious installation of an extremity, its shortening, an atrophy of soft tissues, skin hems on site fistulas, pains in the affected joint after its loading. The false ankylosis of a joint is sometimes formed bone or, more often. The extremity lags behind in growth, its shortening progresses. The delimited centers and sacculated abscesses create danger of a recurrence even through a wide interval of time.

Early diagnosis tubercular is extremely important To., but at early stages it is most difficult. Timely made roentgenograms are of great diagnostic value (see. Tuberculosis of bones and joints ). In an arthritic phase diagnosis is facilitated by existence expressed a wedge, symptoms. It is necessary to differentiate a disease with purulent and others inf. specific To., osteogene sarcoma (see), a coxarthrosis (see. Arthroses ), a Brodie's abscess (see. Brody abscess ), osteoid osteoma (see) etc.

To early rentgenol, signs tubercular To. it is necessary to carry the outlined osteoporosis of bones of joints, small shift of a head of a femur lateralno and up, the limited site of osteoporosis and disturbance of normal bone structure in the place of the developing specific osteitis. Primary center of a tubercular osteitis (an arthritic phase) is located most often in a body of an ileal bone, a neck of a hip or, more rare, in a head of a femur, sciatic and pubic bones. The form of the center various — roundish, oval, triangular, diameter it fluctuates from several millimeters to several centimeters, and borders at active process have indistinct contours. In the center small spongy sequesters are quite often visible.

Upon transition of process to a joint destruction extends to joint surfaces, the joint crack is narrowed, osteoporosis and an atrophy of the bones forming a joint accrues.

At a zatikhaniye tubercular To. outlines of the destructive centers and contours of the destroyed joint ends become more accurate, osteoporosis decreases, the bast layer of a bone begins to be thickened, however osteoporosis and an atrophy of bones of an extremity remain for many years. At an aggravation contours of the centers of destruction lose clearness, osteoporosis amplifies, the atrophy of a diaphysis of a femur accrues.

In a post-arthritic phase the false ankylosis is most often observed or, at considerable destruction of joint surfaces, patol, dislocation of a femur with the shift of a head up and knaruzh.

Treatment tubercular To. is based on three principles formulated by P. G. Kornev: planned character, complexity and activity. The first means early identification and timely treatment; complexity means association of the general and local to lay down. actions; activity — a rational combination of antibacterial, sanatorium and orthopedic and surgical methods of treatment. Prolonged conservative treatment quite often comes to the end with operation, and surgical manipulations are surely supplemented with sanatorium and orthopedic measures. Fortifying treatment (vitamin therapy, Ural federal district and other physiotherapeutic procedures, massage, LFK etc.) raises the general tone of an organism and its resistance to an infection. Carry out antibacterial therapy by specific antitubercular drugs (streptomycin, PASK and their derivatives, drugs isonicotinic to - you and drugs of «second row»). Use not less than two drugs at the same time, and in active stages — three taking into account the mechanism of effect of each drug is obligatory (e.g., streptomycin + Tubazidum + PASK). Antibacterial therapy is most effective in early stages of a disease when the centers are not surrounded with a zone of a necrosis and cicatricial fabric yet, and at synovial forms K. It allows to operate also patients with the minimum risk of generalization of a tuberculosis infection.

Topical treatment tubercular To. consists in an immobilization of a hip joint by means of plaster bandages. An obligatory component of such treatment is prevention and elimination of contractures, muscular atrophies and other trophic disturbances.

Fig. 9 the Diagrammatic representation of lines of skin cuts (solid line) at front quick accesses to the destructive centers (the shaded circles) located in a head and a neck of a hip: 1 — across Eger — to Tekstor to the privertelny center; 2 — on Gyutera to the central cervical center; 3 — across Lyukka and Sheda to the subepiphyseal center; 4 — across Garibdzhanyan to the capitate center; and — an inguinal sheaf — a femoral artery; the dotted line designated contours of bones.
Fig. 10. The diagrammatic representation of a skin section (solid line) at various accesses to the necrotic centers located in distal departments of a neck of a hip (the dotted line specified contours of bones): 1 — Whyte; 2 — Shprengelya; 3 — Gagen-Thorn in Postnikov's modification; 4 — Shassenyaka.
Fig. 11. The diagrammatic representation of an intra joint necretomy of the capitate centers at Chaklin's access: the trepanation opening in day of an acetabular hollow is visible (a dotted line — contours of bones).

At focal and destructive processes and in the absence of effect of the conservative treatment, and also at effects postponed tubercular To. the surgical method supplemented by sanatornoortopedichesky actions is shown. Operations are most effective at an otgranicheniya of destructive focuses; at the active progressing forms K. in connection with diffusion of process operational treatment is less effective. In these cases it is applied only at forced indications, napr, progressing of process at full intolerance by the patient of antitubercular drugs. Sanitation of the centers in a preartritichesky phase belongs to the category of radical preventive operations because prevents transition of process to a joint. For the purpose of the minimum traumatization of a joint use the differentiated quick accesses for each its segment. So, apply the following accesses to the centers located in front departments of a neck and a head of a hip: to the privertelny center — access across Eger — to Tekstor, to central cervical — access on Gyutera, to subepiphyseal — across Lyukka and Sheda, to capitate — across Garibdzhanyan fig. 9). The extraarticular necretomy of distal department of a neck of a hip is carried out also access according to Whyte (fig. 10, 1). The centers from a nadatsetabulyarny zone sanify access across Shprengel (fig. 10, 2), and the back atsetabulyarny centers — access according to Gagen-Thorn to Postnikov's (fig. 10, 3) modifications. The lower atsetabulyarny centers operate by means of Kornev's access. To the back cervical centers approach is most rational by means of Shassenyak's (fig. 10, 4) access. The Mediotsentralny centers delete with intra pelvic access across Chaklin from a body of an ileal bone. The same access is applicable for a necretomy of the capitate centers (fig. 11).

In a stage of a heat of an arthritic phase of operation apply seldom. In a stage of a zatikhaniye the economical resection and an artrodezirovaniye of a hip joint are the most widespread. At the same time treatment tubercular is provided To. and recovery of an oporosposobnost of a hip, but with loss of function of a joint. The operations of radical recovery character directed to elimination of specific process with simultaneous preservation or recovery of function of a joint are widely adopted. The intra joint necretomies modeling resections and modeling arthrolyses, alloplastichesky operations as addition to intra joint necretomies concern to them. At hron, recurrent tubercular To. in a post-arthritic phase, in the presence of big destructions, atypical coxectomies at which the hip is implemented directly into a hollow are shown. In some cases for improvement of a statics recovery of a cervical and diaphyseal corner across Novachenko is reasonable. Recovery of mobility in a joint can be reached with the help alloplasties (see), endoprosthesis replacements (see) or implementations of a big spit in a hollow with the subsequent development of movements in again formed «joint». Results of these operations are less effective, however it is necessary to resort to them in the presence of special indications, napr, at bilateral To. The philosophy of its treatment — creation of a basic extremity, on the one hand, at the expense of an anchylosis in a joint and recovery of mobility — on the other hand. At the unremovable flexion bringing contractures resort to a tenotomy of sgibatel and adductors of a hip.

Maintaining the patient in the postoperative period is defined by the nature of intervention. At radical operations the bed rest and an immobilization last up to 4 — 6 months, at radical recovery treatment the philosophy is observed: early movements and late loading of a joint. The antibacterial, fortifying and symptomatic treatment is obligatory (see. Tuberculosis of bones and joints ).

Acute coxites after scarlet fever, measles, dysentery, pneumonia

They are shown by high temperature, all extremity pains, are followed by early contractures. The diagnosis in an initial stage is difficult because of not typicalness of symptoms and small informational content of a X-ray analysis. Through a nek-swarm time in a cavity of a joint accumulates exudate, the palpation of a joint becomes painful, its function is broken. The disease usually proceeds as polyarthritis, but also cases of monoarthritis are frequent. Exudate more often serous or serous and purulent; at staphylococcal flora — purulent. Heavy disease meets big destructions of a joint seldom. At children inf. To. this group have a pneumococcal etiology more often. Ankiloza at children of early age are formed seldom due to the lack of ossification of a head of a femur at them. At later age, especially later scarlatinal To., ankiloza are frequent.

A gonorrheal coxitis

the Gonorrheal coxitis in comparison with other inf. arthritises meets seldom. There is it on 2 — 3rd week of a disease of gonorrhea. The beginning is acute, with severe pain and a plentiful exudate in a joint. Fever can be considerable, but can be absent. The high leukocytosis is characteristic. Treatment is directed to a basic disease. On a zatikhaniya of the acute inflammatory phenomena carry out physical therapy, massage and LFK for recovery of mobility of a joint.

Typhus and paratyphoid coxites

Typhus and paratyphoid coxites meet also seldom; are characterized by a heavy current and massive destruction of a head and a neck of a femur, frequent patol, dislocations. Process quite often comes to an end with an anchylosis. The general treatment is directed to a basic disease. Local actions come down to an immobilization of a joint (extension, gypsum). Punctures of a joint with evacuation of an exudate and introduction of antibiotics are reasonable. At the expressed destruction treatment by rules of treatment purulent is shown To.

Purulent coxitis

Fig. 12. The diagrammatic representation of ways of distribution of pus from area of a hip joint at a coxitis (continuous shooters — knutr from a joint and a basin, dotted — knaruzh from them): 1 — a big lumbar muscle; 2 — a pear-shaped muscle; 3 — a coccygeal muscle; 4 — an internal locking muscle; 5 — the edge muscle (is partially removed); 6 and 11 — a long adductor (the middle part is removed); 7 — a sinew of a thin muscle; 8 — an outside locking muscle; 9 — a short adductor; 10 — a big adductor; 12 — a medial wide muscle of a hip; 13 — a semimembranous muscle; 14 and 16 — a direct muscle of a hip (the myogaster is removed); 15 — an intermediate wide muscle of a hip; 17 — an average gluteus; 18 — a sinew of a sartorial muscle; 19 — an ileal muscle; 20 — a square muscle of a waist. Ways of distribution of zatek: I \under an iliolumbar muscle (in the drawing it is removed); II \between adductors of a hip; III \under a big gluteus; IV \via the locking channel in a small pelvis; V \on a back surface of a pubic bone (in the drawing it is not represented); VI \from a small pelvis in an ileal pole with formation of retroperitoneal phlegmon; VII \between muscles of a stomach and a cross fascia (in the drawing it is not represented); VIII \between a direct muscle of a hip and a medial wide muscle of a hip; IX \under a sartorial muscle in a femoral (skarpovsky) triangle and along femoral vessels to the femoral and subnodal channel; X \in an interval between a sartorial, direct muscle of a hip, a napryagatel of a wide fascia, lateral and wide muscles of a hip; XI \under average and small buttock muscles.

The purulent coxitis arises or a hematogenous way at a septicopyemia, or at break of pus in a joint from the osteomiyelitichesky center in one of bones of a hip joint, and also of the para-articular abscesses formed owing to osteomyelitis of other localization (a basin, a backbone). It is extremely seldom observed purulent To. as postoperative complication.

An onset of the illness, as a rule, acute, rough with the expressed phenomena of intoxication, an oznobama, fever and the general serious condition of the patient. Severe pain can be localized in other place in the beginning that quite often complicates diagnosis. In the first days local pain can be absent in this connection pneumonia, typhus etc. are quite often mistakenly diagnosed. The areactive current purulent is occasionally observed To. — without pains, substantial increase of temperature and without heavy general reaction of an organism. It is usually connected with considerable change of virulence of coccal flora as a result of long-term use of antibiotics, and also is observed at hyporesponsiveness of an organism of the patient.

In an early stage of development acute purulent To. (on average to 2 weeks) when only the synovial membrane of the joint capsule, rentgenol is changed. the picture of a joint remains normal. Osteoporosis, emergence regional uzur heads at the place of an attachment of the capsule, narrowing of a joint crack owing to destruction of a cartilage, partial ossifluence of the closing joint plate belong to the first rentgenol, displays of a disease.

At further distribution of destructive process the immovability in a joint caused by severe pain develops. The joint swells up a little, reddens, are formed purulent flow. The disease quickly progresses. Spontaneous opening of abscesses or an arthrotomy considerably reduce intoxication and pain, but there is fistula with big or smaller purulent separated; destructions of a joint progress, leading to vicious installation of an extremity and rough anatomo-funkts. to disturbances.

On the roentgenogram joint surfaces get indistinct and uneven contours, the head of a femur decreases, the joint hollow extends, osteoporosis accrues.

In a phase of a zatikhaniye the gradual outcome in the deforming coxarthrosis or in fibrous or bone is observed anchylosis (see).

Are most dangerous To., developing owing to umbilical sepsis or epiphyseal osteomyelitis — so-called infantile arthritises.

In these cases of destruction of the proximal end of a femur are especially big and anatomo-funkts. disturbances are very expressed.

For treatment purulent To. definition of sensitivity of microflora to antibiotics is important. Treatment includes an obligatory strict immobilization of a joint. Operations are shown at the expressed destructive processes and existence of purulent zatek. A task them is broad opening of a joint and purulent accumulations with creation of free outflow of pus. Therefore in an active phase purulent To. the most frequent operation — the draining arthrotomy with opening of all zatek. In fig. 12 are represented flow, having the greatest clinical value (according to V. F. Voyno-Yasenetsky). Through washing of a joint antibiotics and antiseptic agents, disintoxication actions, fortifying therapy, passive immunization by means of anti-staphylococcal plasma, anti-staphylococcal gamma-globulin allow to achieve in some cases elimination of process and further to recover mobility of a joint. However more typical outcome — a bone or false ankylosis of a hip joint. In case of an ankilozirovaniye in vicious position of an extremity further it is necessary to resort to corrective operations (see. Osteotomy ).

Especially hard proceed purulent To. a fire origin in connection with availability of the smashed and nekrotizirovanny fabrics, bone splinters and foreign bodys in a wound etc. Development of extensive phlegmons is characteristic. Fire To. more often than others are complicated by sepsis, a septicopyemia, wound exhaustion. Treatment of these To. essentially the same, but more extensive resections are necessary. Outcomes of these To. less favorable.



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Century of H. Guryev, AA. P. Mathis; L. M. Freydin (rents.).

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