ARTHROPLASTY

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ARTHROPLASTY (grech, arthron a joint + plastike sculpture, plastics) — the operation providing recovery of movements of the ankylosed or slow-moving joint. The arthroplasty includes also substitution of defect of the joint end which is formed after an oncotomy as a result of inflammatory process or an injury. To the middle of 19 century its violent bending and extension was generally applied to mobilization of a motionless joint. The first operational way of mobilization of a joint was a subtrochanterian osteotomy executed by Barton (J. R. Barton, 1826) at an anchylosis of a hip joint with the purpose to achieve mobility between fragments of the crossed bone. Described by Wolff (J. Wolff, 1887) operation of an arthrolysis — separation of the joint surfaces spliced by cicatricial commissures — though was not widely adopted, but served as premises to an arthroplasty, subperiostal arthrectomy. In the second half of 19 century the arthroplasty arthrectomy in Russia was manufactured by H. N. Novitsky, N. V. Sklifosovsky, K. K. Reyer, N. A. Velyaminov. The following step in improvement of an arthroplasty resection and equipment A. use of various biological fabrics as laying between the resected ends of bones — fascial and a giro - a fascial rag on a leg was [the Lexer (E. Lexer)], a free rag of a wide fascia of a hip (P. G. Kornev), a pork bubble (R. R. Vreden), skin, beeswax for greasing of opil of bones (V. A. Oppel), a fibrinous film (N. V. Novikov), and also synthetics (capron, lavsan, teflon).

For the first time this idea stated in 1863 by A.A. S. Verneuil was successfully realized by I. F. Sabaneev (1892) who used a muscular rag at And. temporal and mandibular joint.

Great practical value got use at And. for substitution of defects of one of the joint ends of a bone auto-and gomotransplantat, synthetics (see. Alloplasty ); total endoprostheses knee (the Valduis models and CYTO) and coxofemoral joints are used (Mac-Ki's models, Charnli, Sivash), indications, technology of operation in relation to separate joints, age of the patient are in detail developed. So, children have, e.g., M. V. Volkov, in view of the continuing growth of bones, at And. a hip joint gives preference to an amnioplastika — use for interposition of the cap from a multilayer amniotic cover got on a head of a hip.

And. the ankylosed joint demands individual approach. It is necessary to consider an etiology of an anchylosis, its prescription, earlier carried out treatment, age of the patient, his profession, existence of compensatory adaptations, readiness to transfer all difficulties of the postoperative period.

The indication for And. are: a bilateral anchylosis of a hip joint after a pseudorheumatism, Bekhterev's disease and the bilateral deforming arthrosis of a hip joint with sharply limited movements and severe pains. And. a knee joint it is absolutely shown at a bilateral anchylosis with flexion contractures.

To patients with the anchylosis of both elbow joints after a pseudorheumatism, a burn or heavy damages experiencing difficulties at self-service it is also shown And. one or both struck joints. At an anchylosis of one large joint in functionally comfortable position of the indication for And. are relative.

Contraindications for And. are: existence of fistulas, pustulous diseases of skin, the multiple, soldered to a bone hems, rough anatomic changes in muscles, shortening of an extremity more than on 3 cm, organic diseases of internals or their considerable functional disturbances is hidden the proceeding inflammatory process in the ankylosed joint.

Optimum age for And. 18 — 35 years. At ankiloza of an infectious origin And. make not earlier than in 1 — 2 years after complete elimination of process that surely is confirmed by repeated researches of a picture of blood and a koagulogramma, contrast roentgenograms and data of an objective research of the patient.

Preparation to And. includes all-therapeutic actions, massage of muscles of the operated extremity and sports exercises.

Technology of operation A. there are generally of creation of broad access to a joint, separations of the spliced joint ends, formations of new joint surfaces and laying of interpozitsionny fabric (some surgeons do not apply laying).

And. a shoulder joint it is made extremely seldom. At tumors of the proximal end of a humeral bone, at an old unreducible dislocation-fracture of a shoulder resect an affected area, and replace the formed defect preserved gomotransplantaty or an endoprosthesis.

Fig. 1. Arthroplasty of an elbow joint: 1 — the line of a skin section; 2 — a section of a sinew of a tricipital muscle; 3 — opila of bones; 4 — recorded a fascia (laying) between the joint ends of bones.

At And. an elbow joint (fig. 1) the back section which is bending around an elbow shoot cut soft tissues, allocate an elbow nerve and delay it aside. Cut a sinew of a tricipital muscle in the frontal plane, podnadkostnichno allocate area of an anchylosis and a chisel separate the bones of a shoulder and a forearm spliced among themselves. Economically resect bones, form diastases 1,5 — 2 cm; model the ends, cover them dublikatury a rag auto-or a tinned fascia, after a careful hemostasis, laying of a nerve on the place and sewings together of a sinew sews up a wound. The hand is fixed a plaster torako-brachial bandage.

At And. a hip joint anteroexternal access Smith-Petersen cut soft tissues, a chisel cut a bone plate from a comb of an ileal bone with the sinews of muscles which are attached to it and the educated skin and fascial and muscular rag is turned off by knaruzh. Chisel cut the splice of a head with a haunch bone and dislocate the end of a hip in a wound. A chisel, a mill and a rasp form a new hollow, create a head, leaving diastases between bones 2 cm; cover with a rag of a fascia or a cap a head and set it in a hollow. The careful hemostasis is necessary. The wound is sewn up, enter a drainage for the 48th hour into a bottom corner of a wound. An extremity fix a coxitis - ache a plaster bandage.

The ampere-second, across Sivash, is produced by use of a total endoprosthesis of a hip joint from a slit on an outer surface of a hip. After a section of soft tissues a chisel beat off a big spit and with the sinews which are attached to it delay up. Podnadkostnichno saw a femur at the level of a trochantin. A chisel and mills create a hollow, ream the marrowy channel to diameter of a pin of a prosthesis. The pin of an endoprosthesis is driven in into an educated bed, and its nest in a hollow. The big spit is strengthened on a spline of a prosthesis. The wound is sewn up and impose a plaster splint on a leg.

Fig. 2. Arthroplasty of a knee joint: 1 — the line of a skin section; 2 — a section of a sinew the four-head of a muscle of a hip; 3 — preparation of joint surfaces; 4 — the recorded fascial rags (laying) between the joint ends of bones.

And. knee joint: the section bypassing a patella cut soft tissues. The sinew the four-head of a muscle of a hip is cut in the frontal plane. A chisel cut the patella spliced with a femur and delay it with the distal end of a dissect sinew (fig. 2) from top to bottom. Allocate to Podnadkostnichno area of an anchylosis and cut the femoral and tibial bones which grew together among themselves. Economically resect the ends of bones, model them and a patella. Dublikatura stack a fascial rag; the ends of a sinew the four-head of a muscle are sewed. The wound is closed tightly. Apply a koksitny bandage a leg.

In the postoperative period carry out transfusion therapy (blood, Polyglucinum), appoint cordial and anesthetics, antibiotics and anticoagulants under control of a koagulogramma. From the 2nd day start respiratory gymnastics. In 48 hours after operation delete the entered drainage. In 12 — 15 days after operation remove a plaster bandage and on the special tire begin the dosed passive and active movements in the operated joint.

Complications. Treat early complications: hematoma, suppuration, phlebothrombosis, decubituses, shift of opil of bones (incomplete dislocation, dislocation). Late complications: the operated joint pains, the accruing restriction of movements, the deforming arthrosis, permanent disturbances of peripheric circulation.

Ambassador A. on the lower extremity walking on crutches with an easy support is allowed in 2 months, without crutches — not earlier than in 3 — 4 months.

The period of functional adaptation of a new joint lasts 1 — 2 years. It is possible to judge final results only after the expiration of this term.

Refer recovery of painless basic function and movements in a joint in volume of not less than one third of normal to good results.


Bibliography: P.P is harmful. The modern provision of a question of mobilization of the ankylosed joints by an arthroplasty, It is new. hir. arkh., t. 19, book 2, page 172, 1929; Imamaliyev A. S. Homoplasty of the joint ends of bones, M., 1964, bibliogr.; The multivolume guide to orthopedics and traumatology, under the editorship of Η. P. Novachenko, t. 1, page 336, M., 1967; Chapchal G. Erfahrungen mit der Hüftgelenksarthroplastik «mit Vital-liumkappe», Z. Orthop., Bd 79, S. 417, 1950; DebeyreJ. etDoliveux P. Les arthroplasties de la hanche, P., 1954, bibliogr.; E n t i n M. A., Daniel G. Kahn D. Transplantation of autogenous half-joints, Arch. Surg., v. 98, p. 359, 1968; Lexer E. Wiederherstellungs-Chirurgie, Lpz., 1920, Bibliogr.; N i 1 s ο η n e U. Homologous Joint-transplantation in man, Acta orthop. scand., v. 40, p. 429, 1969; Payr E. Gelenksteifen und Gelenkplastik, Bd 1, B., 1934, Bibliogr.

M. D. Mikhelman.

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