ENDOPROSTHESIS REPLACEMENT (Greek endon inside + fr. prothese, from Greek prosthesis accession, addition) — substitution by implants (endoprostheses) of elements of a musculoskeletal system and parts of the internals which lost the function as a result of an injury or a disease. Endoprostheses are used practically in all fields of surgery. However the term «endoprosthesis replacement» gained the greatest distribution in orthopedics and traumatology.
The indication for E. the technical impossibility or inefficiency of other recovery operations is (including with use of an autoplasty or alloplasty).
In traumatology and orthopedics distinguish endoprosthesis replacement of soft and woven educations (ligaments and sinews) and substitution of bones and joints. Endoprostheses of elements of soft tissues, as a rule, produce from polymeric elastic materials; эндопр#тезы for substitution of bones and joints — from hard materials (metal, high-strength plastic, ceramics, etc.). The main requirements imposed to materials of endoprostheses are their mechanical strength, bioinertness, a possibility of ensuring high precision at production of details of an endoprosthesis, and also a possibility of its strong fastening to fabrics of the perceiving bed.
The general contraindication for E. existence of the centers of an infection in an organism is (caries of teeth, a furunculosis, etc.).
Preoperative preparation is carried out taking into account specifics of the forthcoming operative measure, degree of operational risk and the general condition of the patient (see. Preoperative period). Special preparation is not required.
AA. carry out most often under anesthetic (see), especially at substitution of bones and large joints; in some cases use intra bone, peridural and conduction anesthesia (see Anesthesia local), napr, at substitution of linking of a knee joint, at E. bones and joints of a brush.
Endoprosthesis replacement of sheaves and sinews is known since the beginning of 20 century. For recovery of an integrity of sheaves and sinews or their creation used silk surgical threads. Further for this purpose began to apply tapes and a grid from biocompatible polymer — polycaproamid (nylon, capron, a perlon, silon). But the endoprostheses of sheaves and sinews made of it had no the necessary durability since this material in an organism gradually collapsed.
In a crust, time for E. ligaments and sinews apply polymeric material — polyethyleneterephthalate (those-relen, lavsan), to-ry has high durability, is not exposed to considerable changes in an organism and does not cause the expressed inflammatory reaction. Close-meshed mylar tapes, in to-rye connecting fabric almost does not burgeon, use for plastics of sinews (except sinews of a brush); in coarse mylar tapes connecting fabric well burgeons, and they are used for plastics of sheaves. Durability of mylar tapes, especially close-meshed, much more surpasses durability of the fabrics replaced by them; in operating conditions the mylar tape well keeps the elastic properties.
AA. ligaments and sinews carry out hl. obr. at patol. the mobility of a joint connected with damage of the copular device and also at vicious installation of a segment of an extremity owing to damage of muscles, napr, at the patients who had poliomyelitis or damage of peripheral nerves.
There are several methods of fastening of mylar tapes to a bone: by carrying out via bone channels, fastenings in the form of a loop or a node, by means of chreskostny seams, etc. Usually the method of fixing is chosen depending on anatomic features and the forthcoming load of an implant. Fastening of an endoprosthesis of a sinew to a muscle is most effective in the way «in a split»: a tendinous and muscular part of a muscle is cut in the frontal plane throughout 5 — 6 cm, then enter the end of a mylar tape into this section and hemmed 6 — 8 mylar seams. The tension of a tape is checked during operation by bending and extension of an extremity; the direction of an artificial sinew shall correspond to a functional axis, to-ruyu the muscle as a result of its change gets.
In a crust, time more than 50 types of endoprosthesis replacement with use of mylar tapes (lavsano-plastics) are known. Distinguish two main types of a lavsanoplastika — lavsanodez and to a miolavsanoplastik.
Lavsanodez — group of the operations which are carried out for the purpose of restriction of certain movements in a joint. According to indications and the equipment lavsanodez it is similar to a fasciodesis (see), but instead of transplants from a fascia at a lavsanodeza use mylar tapes. A typical example of this operation is lavsanodez an ankle joint (fig. 1) at paralytic (so-called horse) foot (see. Horse foot, Foot). In about
last of a distal metaepiphysis of a tibial bone, and also in cubical and medial wedge-shaped bones of foot create channels, through to-rye carry out the mylar tape limiting bending of foot and fixing it in functionally advantageous position.
Fig. 1. The diagrammatic representation of a lavsanodez at paralytic (so-called horse) foot: 1 — the middle part of a mylar tape is fixed in distal department of a tibial bone; 2 — the end of the mylar tape fixed on medial klynovid-ache bones; 3 — the end of the mylar tape fixed on a cubical bone.
The operation applied to strengthening of a shoulder joint at habitual dislocation of a shoulder is called a lavranosuspenziya of a shoulder. Via bone channels in a middle part of a proximal metaphysis. a humeral bone carry out a mylar tape; the ends fix it on acromial and coronoid shoots of a shovel (fig. 2). Podob-yay operation complete just as the final stage after a resection of the proximal end of a humeral bone (see Tikhov — Linberg operation) •
Fig. 2. The diagrammatic representation of operation of a lavsanosuspen-ziya at habitual dislocation of a shoulder: Wednesdays
a ny part of a mylar tape (1) is fixed in proximal department of a humeral bone, the ends — on acromial (2) and coronoid (3) shoots of a shovel.
The dotted line showed channels in bones for carrying out a mylar tape.
Miolavsanoplastika includes operations of substitution of the injured sinews mylar tapes or creation new, artificial a sinew, e.g. at changes of muscles; at the same time one end of a mylar tape is attached to a muscle, another — to a bone. Miolavsanoplastika is effective at injury of sinews of a biceps of a shoulder, the four-head of a muscle of a hip, calcaneal (akhillov) sinew. The miolavsanotranspozition of muscles of a back on a hip can be an example of such operation at the paralysis of gluteuses which is often observed at patients with residual yavle-
with niya of poliomyelitis. At the same time use two mylar tapes; top end of one mylar tape is fixed to the muscle straightening a trunk (m. erector spinae), and another — to the broadest muscle of a back (t. latissimus dorsi); the lower ends fix to a femur (fig. 3). Operation creates uslo-
Fig. 3. The diagrammatic representation of a miolavsanotr and with p about-zitsii muscles of a back on a hip at paralysis of gluteuses at the patient with the residual phenomena of poliomyelitis: 1 — places of a podshivaniye of mylar tapes to the muscle straightening a trunk and to the broadest muscle of a back; 2 — places of fixing of mylar tapes to a femur.
the Viy for stabilization of a hip joint.
A specific place in a lavsanoplastika is held by substitution of the damaged linking of a knee joint. For this purpose use a close-meshed mylar tape 7 — 10 mm wide, to-ruyu carry out via the bone channels created in condyles of femoral and tibial bones and fix its ends. So, at E. a front crucial ligament most often drill 2 channels with a diameter of 5 mm — one in an outside condyle of a femur, another in a metaphysis of a tibial bone. Mylar tape carry out at first via the channel in a femur, and then from a cavity of a joint via the channel in bolypeber-
Fig. 4. Diagrammatic representation of a lavsanoplastika of a front crucial ligament of a knee joint: 1 — a mylar tape; 2 — the place of fixing of a tape to a tibial bone; 3 — the place of fixing of a tape to an outside condyle of a femur. The dotted line showed channels in femoral and tibial bones for carrying out a mylar tape.
tsovy bone; one end of a tape is fixed chreskostno on an outside condyle of a femur, another — on a tibial bone (fig. 4). Similarly replace a side linking of a knee joint by means of a coarse mylar tape 10 — 15 mm wide.
Endoprosthesis replacement of bones and joints arose rather recently. Endoprostheses of joints can
be single-pole (replacing one of the joint ends) and total (intended for full substitution of joints). Total endoprostheses happen demountable and one-piece. Depending on material distinguish metal endoprostheses, metalpolymeric, polymeric. Recently began to use endoprostheses from corundum ceramics, carbon.
From operations E. bones and joints the greatest distribution was gained by operations of substitution of a hip joint or its elements. Smith-Petersen (M. of N. Smith-Peter-sen) in 1938 suggested to use for recovery of function of a hip joint a cap from metal alloy — vitalli-mind, to-ry densely put on a head of a femur after giving of rounded shape to it. In 1940. Moscow criminal investigation department (A. T. of Moore) created a metal endoprosthesis of a head of a femur with a figured leg (fig. 5, a).
Fig. 5. Single-pole endoprostheses of a hip joint: and — Moore's endoprosthesis; — an endoprosthesis Jude; in — Moore's endoprosthesis — CYTO; — Thomson's endoprosthesis.
In 1946 brothers Jude (J. Judet, R. L. Judet) offered the endoprosthesis representing the acrylic head strengthened on a three-blade metal nail (fig. 5, b). The described endoprostheses intended for substitution of the joint end of one of bones of a joint received the name of single-pole. Further the design of single-pole endoprostheses for a hip joint was improved. There were Moore's endoprostheses — CYTO (fig. 5, c), Thomson (fig. 5, d) and others.
Single-pole E. a hip joint carry out most often by means of Moore or Moore's endoprosthesis — CYTO. As the indication to this operation serve usually changes and nearthroses of a neck of a femur at persons of advanced and senile age, the Crimea is not recommended a long immobilization and
an osteosynthesis (see) metal nail.
At single-pole E. a hip joint open with posterolateral access a hip joint, cross a neck of a femur at the basis and delete together with a head. By means of rasps create the channel in a femur, densely clog into it a leg of an endoprosthesis, then set a head of an endoprosthesis in an acetabular hollow, previously having removed from it a linking of a head of a femur. Recover the capsule of a hip joint. Because at single-pole E. a hip joint the metal head of an endoprosthesis constantly contacts to a cartilage of an acetabular hollow and puts upon it pressure, dystrophic changes of a cartilage can develop further. Therefore single-pole E. do not recommend to persons of young and middle age, and also the patients having the deforming arthrosis.
To. M. Sivash in 1959 applied an all-metal endoprosthesis of a hip joint, the nerazjemnost of acetabular and femoral components was provided in Krom. In 1960 the total endoprosthesis of a hip joint of Charnli including two components — a polymeric cup of an acetabular hollow and a metal endoprosthesis of a head of a femur was applied (fig. 6, a). The endoprosthesis of Sivash
(fig. 6, c) was widely adopted in the USSR. On its basis Shersher's endoprosthesis was developed later. In endoprostheses of Movshovi-cha (fig. 6, d), Virabov, the Imam of a liyev, etc. femoral and acetabular components are also strongly connected among themselves, but unlike an endoprosthesis of Sivash they can be separated, thanks to it replacement of one of components of an endoprosthesis, napr is possible, at a fracture of his leg or its razbaltyvaniya in a femur. Designs endopro-
Fig. 6. Total endoprostheses of a hip joint: and — Charnli's endoprosthesis; — Poldie's endoprosthesis — the Czech; in — an endoprosthesis of Sivash; — Movsho-vich's endoprosthesis.
Charnli, Müller, Poldie's tez — the Czech (fig. 6, b) and others similar also allow to replace separate components of a prosthesis.
Total endoprostheses of a hip joint successfully apply at the deforming arthrosis, an aseptic necrosis of a head of a femur, the pseudorheumatism complicated by an anchylosis of a joint, nearthroses of a neck of a femur. Total endoprostheses fix to bones in two ways: mechanical or by means of special polymer — the akriltsement representing samopolimerizuyu-shchiysya structure on the basis of methylmethacrylate.
At mechanical fastening of an endoprosthesis after removal of a head and a neck of a femur (at endoprosthesis replacement across Sivash cut also a big spit) process an acetabular hollow (with the help spetsi-
Fig. 7. Diagrammatic representation of cement fastening of a total endoprosthesis of a hip joint: 1, 4 —
a layer akriltsemen-that by means of which the prosthesis is fixed in an acetabular hollow and in a marrowy cavity of a femur (it is shown in black color); 2 — a polymeric cap of an endoprosthesis; z — a metal head; 5 — a metal leg of an endoprosthesis.
alny mills) and a marrowy cavity of a femur (development) according to the sizes of an endoprosthesis. At endoprosthesis replacement by methods of Sivash and Shersher at first enter a leg of an endoprosthesis into a femur, and then fix a pelvic component of a prosthesis in an acetabular hollow. At endoprosthesis replacement by Movshovich's method at first enter a cup of an endoprosthesis into an acetabular hollow, fix it in a wall of an acetabular hollow by means of radially dispersing thorns, then into the canal of a femur (without cutting off of a spit) enter a leg of an endoprosthesis; enter a polymeric cap into a cup of an endoprosthesis and set in it a head of a prosthesis then pelvic and femoral components of an endoprosthesis connect a fixing ring.
For cement fastening of an endoprosthesis the akriltsement is applied on an outer surface of a cup of an endoprosthesis and an acetabular hollow, in walls the cut by means of mills is done by 4 — 5 deepenings for the best fixing of cement. After that the cup of an endoprosthesis is installed and fixed the tool to a zatver
of a devaniye of cement (10 — 12 min.); similarly fix a leg of an endoprosthesis in the channel of a femur which is previously processed by a rasp, then set a metal head in a polyethylene cup (fig. 7).
Fig. 8. The diagrammatic representation tse l to a nometallicha - a sky monocentric endoprosthesis of Sivash replacing a knee joint: 1 — a femur; 2 — the hinge of an endoprosthesis; z — a tibial bone; 4 — legs of an endoprosthesis.;
AA. a knee joint make, as a rule, total endoprostheses with substitution of joint surfaces of femoral and tibial bones. The endoprosthesis of Sivash (fig. 8), elements can be an example of a total one-piece all-metal monocentric endoprosthesis of a knee joint to-rogo are connected as «a door loop».
Demountable polycentric total endoprostheses, napr, Imamaliyev's endoprosthesis — Chemyanova, and also the sliding endoprostheses reproduce kinematics of a knee joint more precisely. The sliding endoprostheses (fig. 9) usually include a metal femoral component and polymeric tibial; they are applied in case of safety of side linking of a knee joint. At the same time economically resect the joint surfaces of femoral and tibial bones, process them according to a design of an endoprosthesis and fix the last in bones by means of an akriltsement.
In recent years after operative measures concerning malignant tumors femoral braids -
Fig. 9. The diagrammatic representation of cement fastening of the total sliding metalpolymeric endoprosthesis of a knee joint: J, 4,
6 — a layer of the fixing akriltsement (it is shown in black color); 2 — the metal component of an endoprosthesis strengthened on the joint end of a femur; 3 — the polymeric component of an endoprosthesis strengthened on the joint end of a tibial bone; 5 — the polymeric component of an endoprosthesis strengthened on the joint surface of a patella *
ti began to apply total endoprosthesis replacement a basinobedrenny joint, femur and knee joint. For this purpose use the endoprostheses of coxofemoral and knee joints of Sivash connected by a tetrahedral titanic pin (an endoprosthesis of Sivash — Zatsepina).
AA. humeral, elbow and talocrural joints make seldom. For E. a shoulder joint apply both single-pole, and total endoprostheses, strengthening them mechanically or with the help acryle -
Fig. 10. Movshovich's endoprosthesis — Grishina (a) and the diagrammatic representation of endoprosthesis replacement with its help of a metacarpophalangeal joint of the II finger of a brush: 1,3 — silicone legs of an endoprosthesis with metal cores; 2 — the silicone bent part of an endoprosthesis.
cement. For E. an elbow joint use generally all-metal total hinged prostheses, to-rye fix in humeral and elbow bones mechanically or by means of an akriltsement; previously resect a head of a beam bone. AA. an ankle joint carry out polymeric and metalpolymeric endoprostheses; in the latter case on an astragalus fix a metal component, on a tibial bone — polymeric; fastening is made the akriltse-cop.
The special group is made by silicone endoprostheses of joints and bones of a brush, foot, a head of a beam bone, etc., having good elasticity. For the first time such prostheses are offered by Svanson (And. Century of Swanson) in 1968.
At E. joints of a brush the capsule of a joint is excised and resect a head of a metacarpal bone throughout several more than 1 cm; legs of an endoprosthesis enter into the prepared marrowy canals. Unlike Svanson's prosthesis in legs of a domestic endoprosthesis of Movshovich — Grishina (fig. 10, and, 6) metal cores that
188 ENDORADIO SOUNDING give
the chance stronger to fix it in a bone are available and allows to begin development of movements in joints earlier. Es a navicular make by means of a silicone endoprosthesis of Movshovich — Voskresensky. Distinctiveness of an endoprosthesis is the fastening in the form of the mylar tape pressed in its case allowing to fix a prosthesis to the capsule of a radiocarpal joint. The indication to operation are nesrosshiye-sya the changes and nearthroses of a navicular which are followed by an aseptic necrosis of its fragments. After removal of fragments of a navicular enter an endoprosthesis and fix on a bone by means of a fixing tape. AA. heads of a beam bone make a domestic silicone endoprosthesis, to-ry has the special device for fixing of a leg of a prosthesis in the created channel of a beam bone. After a resection of a head of a beam bone ream its marrowy channel according to a form of an endoprosthesis, enter a leg of an endoprosthesis and fix it in the channel of a bone by means of a special insert. The head is set in a joint, and the wound is layer-by-layer sewn up.
Maintaining the postoperative period at E. same, as at other orthopedic operations. The immobilization of an extremity, terms a cut is necessary are defined by features of operation, and the subsequent development of movements in joints. During the replacement of sheaves and sinews terms of an immobilization make from 3 to 5 — 6 weeks. After E. joints the passive and active movements begin in 1 — 2 week; full load is allowed at mechanical fastening of endoprostheses in 5 — 6 months, and during the use acryle-cement — in 1 month.
In the postoperative period development of inflammatory process, thrombophlebitis, etc. is possible. Characteristic for E. complications are instability of an endoprosthesis (its shaking in a bone), dislocations of a head of an endoprosthesis of a femur from an acetabular hollow, and also a protrusion in a pelvic cavity of a pelvic component of a total endoprosthesis. So-called fatigue changes of endoprostheses are possible. In case of instability of an endoprosthesis it is replaced new and use at the same time bone cement. Patients with suppuration have wounds if process does not manage to be stopped, the prosthesis is deleted. In these cases for recovery of an oporosposobnost of an extremity the end of a femur is pulled together with an acetabular hollow (and at an opportunity implement it in an acetabular hollow) and fixed imposing of a plaster bandage for a period of 2 months. After a wound repair thanks to formation of cicatricial unions the proximal end of a femur keeps in close proximity to an acetabular hollow.
Prevention of complications includes rational maintaining patients in the postoperative period (see), and also the correct selection of endoprostheses, their strong fixing.
The forecast in the absence of complications favorable. In most cases endoprosthesis replacements of bones and joints it is possible to recover function of a joint and extremity substantially.
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