Operations. Total joint arthroplasty (Joint endoprosthetics)

Total hip arthroplasty

Hip disease is a major problem due to the high percentage of disability and the involvement of young and active patients.

The generally accepted and most effective treatment today is hip replacement. Currently, 1,500,000 operations to replace a joint with an artificial one are performed annually in the world.

The long-term viability of the endoprosthesis is ensured by the high wear resistance of the materials during friction and strength under mechanical (cyclic) loading. Practical results indicate that endoprostheses J . Charnley are capable of working in the human body for 25 years or more. In active patients, endoprostheses fail earlier due to wear of the rubbing surfaces.

• Clinical and radiological CLASSIFICATION of coxarthrosis.
• Indications for hip replacement.
• Indications for knee replacement.
• Contraindications to total endoprosthetics.
• Types of prostheses and manufacturers of artificial joints and prosthetic options.
• Preoperative preparation and surgery.
• Postoperative treatment.

POLYTRAUMA / POLYTRAUMA

Egiazaryan K.A., Korobushkin G.V., Sirotin I.V., Abilemets A.S., Yuusibov R.R., Subbotin N.A.

State budgetary healthcare institution of the city of Moscow “City Clinical Hospital No. 1 named after. N.I. Pirogov Department of Health of the City of Moscow", State Budgetary Educational Institution of Higher Education "Russian National Research Medical University named after. N.I. Pirogov" Ministry of Health of Russia, Moscow, Russia

CLINICAL CASE OF SURGICAL TREATMENT OF ACQUIRED HETEROTOPIC OSSIFICATION IN A PATIENT WITH SEVERE COMBINED TRAUMA

Objective : to consider a clinical case of treatment of a patient with severe concomitant injury and further development of heterotopic ossification of the hip joint area. Materials and methods. A brief review of the world literature on the problem of heterotopic ossification in patients who have suffered severe combined trauma is presented. A clinical example of the treatment of patient B., 29 years old, injured as a result of a traffic accident, with subsequently developing heterotopic ossification of the hip joint as a long-term complication of severe concomitant injury, is presented for consideration. Results. A patient with a severe concomitant injury was treated, with the development of heterotopic ossification of the hip joint in the long-term period. Surgical treatment was performed - hip replacement. A good functional result was obtained after 2 years (86 out of 100 points on the Harris Scale). Based on a clinical example, we demonstrated the effectiveness of existing diagnostic methods at various stages of treatment of heterotopic ossification, with the aim of minimizing the percentage of radical treatment, minimizing disability in patients with long-term consequences of severe combined trauma. Conclusions. Identification of this problem at an earlier stage of the formation of the pathological process, assessment of the importance of the process for further rehabilitation and the patient’s quality of life would allow for a more thorough diagnosis, study of the world literature on this problem and make a decision on early surgical treatment, which, perhaps, would allow for less radical correction methods. We were unable to find a sufficient number of described cases of the development of heterotopic ossification in patients with severe concomitant trauma in the literature with an assessment of the rational time for surgical intervention. It is necessary to pay special attention to the study of the problem of heterotopic ossification, which may allow us to further use the mechanisms of patho-osteogenesis to solve the problems presented to us, to avoid the final disability of patients after severe combined trauma, despite the complete elimination of post-traumatic changes.

Keywords:

heterotopic ossification; polytrauma; osteoregeneration; ossification

Heterotopic ossification (HO) is the process of formation of mature lamellar bone tissue in places that are atypical and morphologically unusual for the formation of bone tissue, which do not have precursor cells for osteoformation in the main pool of cells.

GO classification

[1, 2]

HO is conventionally divided into two main types: Acquired form, represented mainly by traumatic genesis of origin. Hereditary form. I. The acquired form is divided according to the morphology of the damaged system: 1. The main source of damage, identified as a trigger for the development of HO, is located in the nodes of the musculoskeletal system. 2. The main source of damage is located at one of the levels of the central nervous system: 2.1. Spinal cord injuries. 2.2. Brain damage. 2.3. Damage to the membranes of the brain. II. The inherited form of HO is divided according to the substrate of bone tissue formation and various mutations in different genes: 1. Formation of bone mass through the enchondral pathway (progressive fibroplasia ossificans). 2. Formation of bone mass through the intramembranous pathway and the pathway of muscular heteroplasia (progressive bone heteroplasia, Albright's hereditary osteodystrophy).

Identification of conditions for the development of civil defense

The process of bone mass formation in the case of HO development resembles the process of normal bone repair and has similar conditions for its occurrence, but differs in greater intensity and localization. The similarity of the processes of osteoregeneration and HO, the presence of similar stages also causes difficulties in the case of attempts at pharmacological treatment, since the points of application of pharmaceuticals are the links responsible for the normal growth of bone tissue, fracture consolidation and the development of heterotopic ossifications. However, with multiple and combined injuries, priority is given to the consolidation of fractures rather than stopping the progression of ossification growth. The main conditions for initiating the development of HO are the following [3]: 1. Osteoinduction is the process of stimulating osteoformation by transmitting key signals by protein fractions such as bone morphogenetic protein (BMP) and inflammatory mediators, which manifest themselves in patients with severe combined trauma. 2. The presence of osteogenic progenitor cells—pluripatent mesenchymal stem cells (MSCs)—that migrate, differentiate, and proliferate in response to BMP stimulation. 3. Environment for osteogenesis (“maternal bed”, in the case of HO, most often represented by damaged muscle tissue or well-perfused areas of the capsular-ligamentous apparatus). 4. Decrease in partial pressure (pO2), which is more characteristic of the endochondral path of ossification development [3]. 5. Another factor that distinguishes the formation of heterotopic ossification from the normal process of osteoregeneration is the presence of an infectious agent. The world literature considers both a generalized type of infection and a local infectious focus.

Brief description of civil defense development mechanisms

At the moment, the exact mechanism of development of HO is not fully understood. This is partly due to the polymorphism of possible development triggers and a large number of complex cascades of biochemical reactions. However, some parts of the complex mechanism of GO formation are known. In the event of damage to any part of the central nervous system, the world literature highlights the absence of an inhibitory (regulatory) effect of the central nervous system on the metabolism of MSC precursor cells. Major candidate molecules that regulate MSC cellular function include leptin, glutamate, calcitonin, substance P, vasoactive intestinal peptide, and catecholamines. In case of damage to the central nervous system, an imbalance in the concentration of these regulatory substances and hyperstimulation of MSC precursor cells along the osteogenesis pathway occurs [5]. Systemic factors are also considered in combination with local stimulating factors, such as interleukins SIRS (systemic inflammatory response) - hyperproduction of IL-6, Il-10 [6], MCp-1, MIP1f, Hif1α [7]. Taking into account such morphological and biochemical features of the process of development of HO, an approximate model of a patient who has a predisposition to the formation of an acquired form of HO is formed - a patient with combined or multiple trauma best suits the description.

Ways to prevent the development of HO

Currently, the world literature presents a medical option for preventing the development of HO by taking non-steroidal anti-inflammatory drugs (NSAIDs) (the main representative in this group is Indomethacin) [8]. Options for targeted radiotherapy are also being considered [9]. Based on this, the following clinical risk factors for the development of HO can be identified [10]: 1. The patient has a traumatic brain or spinal injury. 2. The patient's age is under 30 years. 3. Amputations, multiple limb injuries. 4. The severity of the associated injury, determined by the ISS scale of 16 or more. 5. Prolonged stay in a coma, prolonged stay on a ventilator. 6. CNS injury with predominant muscle spasticity. 7. Male gender. 8. A high level of inflammatory interleukins (more precisely, their imbalance) – IL-6, IL-10, MCP-1, MIP1a, MCp-1, MIP1f, Hif1α – is a sign of the development of SIRS [11]. 9. Local or generalized infection. Each of the above clinical risk factors has a certain morphological basis, which in one way or another affects the mechanisms of HO development presented above. At the moment, surgical treatment of HO is the most effective. Indications for surgical treatment are increasing the range of motion in the joints of the limb, giving the limb a normal position (removal from the pathological position). Release of neurovascular structures trapped in the focus of ossification in case of mechanical compression or bending.

Complications and dangers during surgical treatment

Due to the potential unlimited growth of ossification, there remains a high risk of large intraoperative blood loss due to the large volume of tissue removed, loss of the main stabilizers of the joint in the case of a periarticular location of the pathological focus, and trauma to neurovascular structures. There is a high risk of infection in the postoperative period associated with the formation of a cavity (minus tissue), as well as a higher risk of developing thromboembolic complications (major soft tissue injury, release of tissue clotting factor into the channel). There is a high probability of developing a relapse of HO.

Consideration of the issue of the most rational choice of time for surgical treatment of HO in order to minimize the risks of developing the complications presented above

In the world literature, there are two main opinions about the timing of surgical treatment: 1. Recurrence of HO is less likely if surgery is delayed until HO reduces its metabolic activity, confirmed by scintigraphy [12]. 2. More recent scientific works suggest that it is worth removing ossifications before a critical decrease in metabolic activity, which minimizes intraoperative trauma and allows the process to be stopped before important structures are involved [12]. Surgical excision of HO before the metabolic activity of ossification is achieved according to scintigraphy is of greater clinical interest, since such tactics can reduce intraoperative trauma, preserve formations that have not yet been affected by the process, and avoid or reduce the risk of many complications associated with tissue trauma. Less intraoperative trauma reduces the local activity of inflammatory mediators and reduces the likelihood of re-activation of MSCs along the path of osteogeneration and relapse of HO. This allows the patient to be activated much earlier in the postoperative period.

CLINICAL CASE STUDY

Objective : to consider a clinical case of treatment of a patient with severe concomitant injury and further development of heterotopic ossification of the hip joint area. The study was carried out in accordance with the ethical principles of the Declaration of Helsinki (World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013) and the “Rules of Clinical Practice in the Russian Federation” (Order of the Ministry of Health of the Russian Federation dated June 19, 2003 No. 266) with written consent from the patient to participate in the study and approved by the local ethics committee (protocol No. 64179375THR2001 dated May 28, 2021). Patient B., 29 years old, was admitted to the intensive care unit of City Clinical Hospital No. 1 on October 4, 2011 (road accident, pedestrian). At the prehospital stage, clinical death of the patient was recorded. Upon admission, the condition was serious. GCS 8 points (moderate coma). Breathing on your own. Blood pressure 100/70 mm Hg. Art. NPV 21 per minute. The patient was examined by a resuscitator, neurosurgeon, and traumatologist. Tracheal intubation was performed and mechanical ventilation was performed. The examination has been completed. A CT scan of the pelvis did not reveal any evidence of osteo-traumatic changes in the pelvic bones and hip joints. X-ray of damaged segments. A clinical diagnosis was established: “Severe combined injury, open craniocerebral injury, brain contusion, traumatic subarachnoid hemorrhage, fracture of the squama of the right temporal bone, with transition to the pyramid. Open comminuted fracture of the bones of the right leg in the middle third with displacement of fragments (Gastilo 3a). Fracture of the nasal bones. Closed fracture of the right clavicle with displacement of fragments. Fracture of the head of the right rib on the left. Lung contusion. Aspiration of blood. Multiple bruised wounds to the soft tissues of the head and right leg. Clinical death at the prehospital stage." Score of the severity of the injury on the ISS scale = 34 points. Stratification of the risk of developing heterotopic ossification in this patient: 1. Age less than 30. 2. Type of injury - high-energy (road accident). 3. Presence of TBI – yes. 4. Multiple injuries - yes. 5. Prolonged coma, mechanical ventilation - yes 14 days. 6. CNS injury with predominant spasticity - yes. 7. SIRS - yes. 8. The severity of the injury according to ISS is more than 16 points. 9. Infection – yes (multiple wounds, open fracture of the leg bones). Staged treatment of the patient was carried out in accordance with the principles of staged treatment of Damage control orthopedics (DCO). On the day of injury, primary surgical treatment of the wound of an open fracture of the tibia and fixation of fragments with a rod apparatus were performed. Intensive therapy was carried out in the intensive care unit (infusion, noovasotropic, antibacterial therapy, blood transfusion, prevention of venous thromboembolic complications). On the 22nd day after the injury, after stabilization of the patient’s condition, the patient was transferred to the neurosurgery department, where treatment was continued for 13 days; Afterwards, with positive dynamics, the patient was transferred to the department of traumatology and orthopedics. On the 35th day after the injury, the rod apparatus was dismantled and the right shin was immobilized with a plaster cast. On the 35th day, the patient complained of discomfort when moving in the left hip joint, and an x-ray of the hip joint was performed. X-rays of the hip joint revealed a HO pattern in the area of ​​the left hip joint (Fig. 1). Conservative therapy was prescribed (indomethacin 25 mg per day for 8 weeks).

Figure 1. X-ray of the left hip joint in the axial projection. Performed on the 35th day from the moment of injury. There are initial radiological signs of developing heterotopic ossification of the greater and lesser trochanters

On the 37th day after the injury, intramedullary osteosynthesis of the tibia bones was performed. At the time of discharge, the patient was activated and walked independently without support on the right lower limb. Movements in the left hip joint are full and painless. Noteworthy is some discomfort when moving in the left hip joint, but it does not in any way limit the range of movement or prevent activation. 1.5 years after the injury, the patient complained of lack of movement in the left hip joint. On the radiograph of the left hip joint, heterotopic ossification of the area of ​​the left hip joint Brooker class 4 [13] (Fig. 2) is determined; based on the radiographs, the damage to the capsular-ligamentous apparatus of the joint and the iliacus muscle on the left is determined topically.

Figure 2. X-ray of the pelvis 1.5 years after injury. Heterotopic ossification of the capsular-ligamentous apparatus of the left hip joint and the iliacus muscle on the left is determined

Scintigraphy was performed, which showed high metabolic activity of the heterotopic ossification focus (184% of the accumulation of the pharmaceutical drug from the norm), and a decision was made to refuse surgical intervention. Scintigraphy from 2015 (4 years after the injury) revealed minimal metabolic activity of the ossification focus (76% of the drug accumulation from the norm). An X-ray taken in 2021 (5 years from the moment of injury) revealed that the ossification did not change. The patient complained of lack of movement in the left hip joint, lameness, and decreased quality of life. In order to determine the exact localization of the space-occupying lesion and assess the damage to surrounding structures, a computed tomography scan of the pelvis was performed (Fig. 3).

Figure 3. CT scan of the pelvis 5 years after injury. Heterotopic ossification of the left hip joint area is determined. Localization of a space-occupying lesion in the area of ​​the capsule and iliacus muscle of the left hip joint

In order to restore movement in the left hip joint, a decision was made to undergo surgical treatment. It was decided to determine the volume of intervention intraoperatively: perform only removal of ossifications or, after removal of ossifications, perform hip replacement. Risks of surgery

: blood loss was assumed, in the area affected by the development of heterotopic ossification, the arteries that bend around the neck of the femur are located;
arteries are embedded in bone tissue, making hemostasis difficult. A high risk of complete devitalization of the femoral head was identified, followed by intraoperative assessment of the likelihood of aseptic necrosis in the future. Intraoperatively
: ossifications represent a completely ossified capsule of the left hip joint and the left iliacus muscle (Fig. 4). When excision of heterotopic ossifications, it was revealed that all the main sources of blood supply to the femoral head are included in the pathological process; with their complete excision to restore the possibility of movement in the joint, the femoral head will remain devitalized. A decision was made to undergo total hip replacement (Fig. 5). A histological examination of the removed ossifications was performed (Fig. 6). According to research results, the removed tissue corresponds to compact bone substance.

Figure 4. Photograph of the intraoperative wound. The arrow indicates the zone of heterotopic ossification along the iliacus muscle. The tissue density corresponded to the density of the cortical bone. Ossification corresponded to the joint capsule and left iliacus muscle

Figure 5. Control radiograph of the pelvic bones after excision of ossifications and total arthroplasty of the left hip joint.

Figure 6. Microscopic specimen of removed tissue, the substance corresponds to compact bone tissue

Functional result:

on the Harris scale 86 points out of 100, which corresponds to a good result (Fig. 7-10).

Figure 7. Control X-ray of the pelvic bones 2 years after surgical treatment

Figure 8. Demonstration of the function of the left hip joint 2 years after surgical treatment (abduction)

Figure 9. Demonstration of the function of the left hip joint 2 years after surgical treatment (flexion)

Figure 10. Demonstration of the function of the left hip joint 2 years after surgical treatment (flexion)

CONCLUSIONS:

Primary manifestations of heterotopic ossification of the hip joint area in the patient were detected on the 35th day from the moment of injury. Taking NSAIDs to prevent the development of HO has not been very successful. The tactics of performing surgical intervention after the complete formation of ossification can significantly reduce the risks of developing a relapse of HO, but it leads to the need to perform a larger volume of surgery and also causes more radical types of operations, not allowing one to settle on organ-preserving methods. The problem of HO in patients with severe combined trauma remains controversial to this day and requires further study.

Funding and conflict of interest information

The study had no sponsorship. The authors declare that there are no obvious or potential conflicts of interest related to the publication of this article.

LITERATURE:

1. Elfimov SV, Kuznetsova NL, Solodovnikov AG. Prediction of heterotopic ossification after operations and injuries to hip joint. Polytrauma

.
2011; (2): 14-19. Russian (Elfimov S.V., Kuznetsova N.L., Solodovnikov A.G. Prediction of heterotopic ossification after operations and injuries of the hip joint //Polytrauma. 2011. No. 2. P. 14-19) 2. Ruoshi X., Jiajie Hu, Xuedong Z., Yingzi Y. Heterotopic ossification: Mechanistic insights and clinical challenges. Bone.
2018;
109: 134-142 3. Loder S, Agarwal S, Sorkin M, Breuler C, Li J, Peterson J et al. Lymphatic contribution to the cellular niche in heterotopic ossification. Ann Surg
.
2016; 264(6): 1174-1180 4. Qureshi AT, Dey D, Sanders EM, Seavey JG, Tomasino AM, Moss K et al. Inhibition of mammalian target of rapamycin signaling with rapamycin prevents trauma-induced heterotopic ossification. American Journal of Pathology
.
2017; 187(11): 2536-2545 5. Dey D, Bagarova J, Hatsell SJ, Armstrong KA, Huang L, Ermann J et al. Two tissue-resident progenitor lineages drive distinct phenotypes of heterotopic ossification. SciTransl Med
.
2016; 8(366): 366ra163 6. Agarwal S, Loder SJ, Sorkin M, Li S, Shrestha S, Zhao B et al. Analysis of bone-cartilage-stromal progenitor populations in trauma induced and genetic models of heterotopic ossification. Stem Cells.
2016;
34(6): 1692-701 7. Agarwal S, Loder SJ, Breuler C, Li J, Cholok D, Brownley C et al. Strategic targeting of multiple BMP receptors prevents trauma-induced heterotopic ossification. MolTher.
2017;
25(8): 1974-1987 8. Milakovic M, Popovic M, Raman S, Tsao M, Lam H, Chow E. Radiotherapy for the prophylaxis of heterotopic ossification: a systematic review and meta-analysis of randomized controlled trials. Radiotherapy and Oncology.
2015;
116(1): 4-9 9. Kan SL, Yang B, Ning GZ, Chen LX, Li YL, Gao SJ at al. Nonsteroidal anti-inflammatory drugs as prophylaxis for heterotopic ossification after total hip arthroplasty. Medicine (Baltimore).
2015;
94(18): e828 10. Agarwal S, Loder SJ, Cholok D, Peterson J, Peterson J, Li J et al. Scleraxis-lineage cells contributeto ectopic bone formation in muscle and tendon. Stem Cells.
2017;
35(3): 705-710 11. Qureshi AT, Dey D, Sanders EM, Seavey JG, Tomasino AM, Moss K et al. Inhibition of mammalian target of rapamycin signaling with rapamycin prevents trauma-induced heterotopic ossification. American Journal of Pathology.
2017;
187(11): 2536-2545 12. Zhang X, Jie S, Liu T, Zhang X. Acquired heterotopic ossification in hips and knees following encephalitis: case report and literature review. BMC Surgery
.
2014; 14: 74 13. Hug KT, Alton TB, Gee AO. Classifications in brief: Brooker classification of heterotopic ossification after total hip arthroplasty. Clin Orthop Relat Res.
2015; 473(6): 2154-2157

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Clinical and radiological CLASSIFICATION of coxarthrosis.

• Stage 1 - characterized by pain in the hip joint, radiating to the knee joint and inner thigh, the patient limps, there is an apparent shortening of the limb, abduction and adduction to a good extent. There is some atrophy of the gluteal and thigh muscles. Radiologically, slight bone atrophy without osteophyte formation is noted.
• Stage 2 - characterized by constant pain, significant limitation of movements, progressive shortening of the limb, severe lameness. There are no rotational movements. Extension in the hip joint is limited, and there is atrophy of the gluteal muscles. X-rays reveal pronounced osteophytes, deformation of the femoral head, narrowing of the joint space, sclerosis and round cyst-like cavities, both in the head and in the roof of the articular cavity. A characteristic feature of stage 2 is periodic exacerbations of pain, forcing the patient to remain in bed or at times resort to crutches.
• Stage 3 - constant pain, significant shortening of the limb, stiffness of the joint in a state of hip adduction, complicating physiological functions; due to the pain syndrome, there is significant loss of ability to work and difficulty in self-care. Radiologically, pronounced morphological changes are determined.

Indications for hip replacement.

1. Rheumatoid polyarthritis,
2. ankylosing spondylitis,
3. systemic lupus erythematosus,
4. coxarthrosis of various origins,
5. hip dysplasia,
6. chronic congenital dislocation in adults,
7. pseudoarthrosis of the femoral neck,
8. aseptic necrosis of the head of various origins,
9. deformation of the acetabulum area due to the consequences of injury,
10. tumors of the proximal femur,
11. some forms of tuberculous coxitis,
12. heterotopic ossifications of the hip joint area
13. unsuccessful outcomes of previous operations on the joint.

The above diseases of the hip joint are accompanied by severe pain, a sharp decrease in working capacity, and loss of the ability to self-care.

Joint ossifications - where they develop and how they are diagnosed

The ossification process can be lengthy, taking several months. The intensity of the formation of ectopic bone tissue depends on the size of the lesion, its proximity to the joint, and the loads it experiences.

Causes of pathology

The etiology and pathogenesis of the appearance of these bone formations is not completely clear. But today the main factors of the disease have been identified:

• massive soft tissue bruises, fractures of long bones, joint injuries;
• diseases of the central and peripheral nervous system, including injuries to the spine, brain, strokes, which are accompanied by muscle hypertonicity and loss of consciousness;
• operations on bone structures.

Extraskeletal ossification, according to statistical data, is observed in almost 40% of patients with nervous and joint pathologies. The ability to move in the affected area is lost on average in one out of ten patients.

Stages of formation

At the site of the hematoma, the damaged tissue disintegrates and connective tissue begins to form. Granulations appear around the lesion, where the biosynthesis of bone and cartilage formations begins. Chondroid tissue and bone trabeculae are formed.

Mineralization gradually occurs, some of the young bone structures mature, the other part atrophies. That is, osteogenesis and destruction, resorption occur simultaneously.

Over time, the ossificate becomes covered with a dense capsule, inside of which there is spongy bone.

Where does it develop?

Bone tumors form in various tissues of the body:

1. In muscles, ossification on x-rays has the shape of lace tissue: there are clearings between the bone bridges. This picture resembles a sarcoma; a thorough examination is necessary.
2. In tendons and ligaments, bone formations form at points of maximum tension.
3. In joint capsules, ossification is provoked by dislocations and occurs in damaged areas of the capsule. The x-ray shows an arched shadow around the articular end of the affected bone.

Bone neoplasms

Symptoms

Complaints arise after injury, surgery, or against the background of a disease:

• swelling;
• pain that gets worse with movement;
• difficulty moving.

A doctor's examination reveals:

• fever, redness of the skin, hemorrhages in the joint area;
• thickening of the skin;
• limitation of range of movements, up to complete immobility;
• identification of local compactions by palpation;
• decreased sensitivity of the skin over the joint.

This pathology can be confused with a number of diseases - thrombophlebitis, arthritis, sarcoma, post-traumatic hematoma. Therefore, a thorough examination of the patient is performed.

Diagnostics

Various examination methods are used to help identify the process and its degree of maturity. First of all, the patient is prescribed an x-ray.

Radiography

In photographs taken several weeks after the injury, you can see a blurry shadow or several fuzzy islands near the affected area. After 2 months they thicken, the contours become clear.

After about six months, the formation of the ossificate is completed, it is considered mature and has a bone structure. An x-ray clearly shows a dense capsule covering the ossificate, corresponding to the cortical layer, with looser spongy bone tissue located inside.

Sometimes there may be fusion with the nearest bone, the formation of elements similar in structure nearby.

A biopsy of the lumps is performed. A blood test shows an increase in alkaline phosphatase levels (a marker of osteogenic transformation).

Features of pathological foci of different localization

Ossification of the lower extremities is typical of spinal injuries, of the upper extremities is characteristic of strokes and traumatic brain injuries.

Ossification of the hip joints as a complication occurs with advanced coxarthrosis, spinal cord lesions of various etiologies, with a fracture of the femoral neck, after endoprosthetics. It is often difficult to completely remove a bone formation surgically. Operations must be gentle. The goal is to regain the ability to care for oneself and move independently.

Bone tumors of the knee joint are found in athletes; they form quite quickly, and as they grow, they significantly impair motor functions.

The ankle joint is damaged as a result of dislocations, sprains, and fractures of the bones of the foot.

Most often, ectopic bones form near the elbow joint. It is well supplied with blood, so injuries are accompanied by the formation of extensive hematomas. Ossifications are located in the intermuscular connective tissue; they occur after brain injuries and strokes.

Locations of heterotopic ossifications of the elbow joint

In addition, strokes lead to contracture of the shoulder joint, which causes ossification of the ligaments and tendons of the adductor muscles of the shoulder.

Complications

Pathology leads to the following consequences:

• ankylosis;
• vascular thrombosis;
• development of bedsores;
• disruption of innervation due to compression of peripheral nerves;
• malignant degeneration of ossification.

Absolute contraindications to surgery are:

1. Diseases of the cardiovascular and bronchial-pulmonary systems in the stage of decompensation
2. The presence of a focus of purulent infection in the body (tonsillitis, carious teeth, chronic sinusitis and otitis, pustular skin diseases)
3. Psychiatric or neuromuscular disorders that increase the risk of various disorders and disorders in the postoperative period
4. Active or latent infection in the hip joint less than 3 months old
5. Skeletal immaturity
6. Acute vascular diseases of the lower extremities (thrombophlebitis, thromboembolism)

Types of prostheses and manufacturers of artificial joints and prosthetic options.

In the Russian market today, several foreign manufacturers of endoprostheses from the USA, Switzerland, Germany, and Great Britain compete, which offer a huge number of different models and systems for endoprosthetics.

All these companies and their products are quite competitive with each other and, by and large, differ only in service.

Modern joint endoprostheses are detachable and consist of an acetabular component (cup), a femoral component (leg) and a prosthetic head.

All components are made of steel or titanium, the prosthetic cup consists of polyethylene or titanium with an insert. The head can be steel or ceramic, with a fit on the conical neck of the leg.

In principle, all joint endoprostheses are divided into three large classes according to the type of fixation of the prosthesis in the bone:

endoprostheses with cementless and cemented fixation and their combinations. Cementless prostheses in their design are intended for young patients; for other patients, various options for cement and combined fixation are possible.

Postoperative treatment.

1. Intensive therapy.

• Infusion therapy;
• Blood transfusions;
• Plasma transfusions.
• Anticoagulant therapy (Clexane or Fraxiparine).

2. Systemic antibiotic therapy. 3. Immunotherapy. 4. Physiotherapeutic treatment: postoperative massage (chest and general), exercise therapy and learning to walk with crutches from the 2nd day after surgery. 5. Local treatment of the wound (dressing after removal of the drains on the 2nd day) once every 2 days.
Postoperative outpatient treatment (14-17 days from the date of surgery)

1. Dressings and examination by a surgeon once every 3 days.
2. Removal of sutures on the 12th day.
3. Control radiography at 3 and 6 months (further once a year).
4. Walking with the help of crutches with a measured load on the operated leg.
5. Exercise therapy, massage and physiotherapy.

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Treatment and development of ossifications

The main problem with existing ossifications is their development and elimination.

There are two methods of how you can remove ossifications or at least reduce them to such a size that they will not interfere with a full life: the development of ossifications using exercise therapy, using physical therapy, as well as removing ossifications using surgery.

Development of ossifications using exercise therapy and physiotherapy

The development process is quite long and must be carried out very carefully so as not to cause harm or provoke further growth of ossifications.

With each injury to the ossification, or even worse, when the ossification is broken, further neoplasms can be provoked, this will only complicate and worsen the situation.

Of course, the ideal is to find an instructor who will carry out the development, but provided that the instructor understands what he is dealing with. If it is not possible to hire an instructor, then you need to remember, I repeat once again, all exercises must be performed carefully, without jerking, smoothly.

More effectiveness can be obtained from exercises if the exercises are performed in a large number of repetitions of movements, and not taken by force. During physical therapy exercises, it is necessary to maintain the range of movements as far as ossification allows.

Several exercise therapy exercises to develop ossification in the hip joints

1. The patient lies down on a couch or bed with his legs dangling (we hang only the legs from the knees and below, the hips and pelvis remain on the bed). Whoever is doing the exercise rests his hand on the pelvis so that when raising the leg, the pelvis does not rise with the leg; if it is not convenient to do the exercise, then you can put a weight on it.

And so, one hand holds the pelvis, and with the other hand we take it under the knee or slightly higher and lift it with a bent leg so that flexion is performed at the hip joint. We perform it as far as the amplitude in the hip allows.

Perform 10-15 repetitions and switch to the other leg for 3-4 approaches.

2. If the first exercise is difficult for an assistant to perform, then you can resort to another exercise.

As above, lie down with your legs dangling, the assistant takes the leg under the knee, resting the foot on the assistant’s thigh. The assistant, by moving his hip forward and pulling his leg under the knee, bends the leg at the knee and hip joint, and by moving his hip back, the assistant straightens the leg. To prevent the pelvis from rising, place a weight on the pelvis. It is necessary to ensure that the leg should not go to the side, and the foot should not turn out.

3. After the first two exercises, lie down completely on the bed.

We fix one leg with a weight. The assistant stands on the side of the leg that will be affected, takes the leg under the knee, and with the other hand supports the thigh and moves forward to bend the hip and knee joint.

Physically, this exercise will be difficult for an assistant to perform; you can replace it with the 2nd exercise. When performing this exercise, you must ensure that your leg does not move to the sides. Under no circumstances should you make violent jerks. And so on for each leg.

4. The next exercise is a continuation of the previous one. We also fix one leg, and your assistant should lift the other leg straight as far as the amplitude allows until the pelvis begins to rise.

And ideally, the instructor himself should determine and select the exercises. All the exercises described above refer to the most common forms of ossification.

The surgical method is possible only after the ossification has matured. It is possible to determine whether the ossification is ripe or not using x-rays.

The problem with surgical removal of ossification is that no one will give you a guarantee that ossification will not appear again, and severe complications are possible after removal. Also, the problem with surgical removal is that few people undertake this type of operation, and our surgeons do not have much experience.

Today there are only drugs that slow down and stop the growth of ossifications.

I can say that perhaps ossifications increase spasticity due to the fact that ossifications compress muscles and tendons and in this way irritation occurs and spasticity increases.

Series of messages “You asked”:
Best regards, Rimmaz

Part 1 - Your own psychologist: How to make yourself the measure of your actions and desires Part 2 - Removing mold... Part 35 - How to forgive Part 36 - If you have heel pain Part 37 - Ossification - foci of pathological ossification in tissues (ligaments, tendons, muscles) Part 38 - Male mistakes Part 39 - When she spoke badly about you Part 40 - How to fall asleep quickly Part 41 - President of Russia. Services for citizens to contact...(click on the pictures) Part 42 - Complete INFORMATION BY COUNTRY..