Hip arthroplasty for coxarthrosis: price in Moscow

As clinical experience shows, a wide range of problems with the hip joint can only be solved surgically. The majority of surgical interventions are performed for coxarthrosis - a progressive degenerative-dystrophic lesion of articular cartilage with further deformation of the joint. Pathology among all diseases of the musculoskeletal system ranks 1st in prevalence among older people. It most often leads to disability: up to 40% of disabled persons in the general structure of disability are listed with this diagnosis. The only effective treatment tactic for advanced forms of arthrosis of the hip joint is arthroplasty. You will learn about the unique surgical technology from our article.

Femoral head with coxarthrosis.

Arthroplasty: what is it?

In case of severe degenerative processes, a sharp limitation of all movements in the joint, wasting of the muscles of the pelvis, thigh and leg, any of the methods with preservation of the joint is considered as palliative treatment. In severe cases, the patient will only benefit from arthroplasty, or endoprosthetics.

Hip arthroplasty is a high-tech operation during which the worn-out “native” joint is replaced with an artificial analogue of a healthy joint. As a result, the ability to move normally independently returns, pain ceases, and all components of the patient’s quality of life improve.

Functional implants (endoprostheses) for arthroplasty are available in various sizes. The large size range allows the patient to individually select a model that is suitable for him at the stage of planning the operation. That is, taking into account the anatomically determined volume of the femoral head, acetabulum, shape and size of the medullary canal, etc.

• The structure of the endoprosthesis includes a head and a leg for installation in the femur area and a cup for placement in the notch of the iliac bone. More often these components are made of titanium and cobalt alloys. Ceramic products can also be used for arthroplasty.
• The materials used are resistant to high loads and are not rejected by the body. They are not destroyed in the internal environment of the human biological system. They have an optimal modulus of elasticity, harmoniously combined with the elasticity properties of bone tissue.
• The complete hip prosthesis includes an anti-friction component made of high molecular weight polyethylene, which is inserted into the cup. Otherwise called a polymer insert, the head will rotate in it. The insert allows you to reduce friction between metal or ceramic surfaces, stabilize the head well and improve its sliding in the bowl, and further enhance shock-absorbing properties.
• Contact fixation of the bone-implant is performed using the press-fit technology (hammering, pressing in) or by the method of cementation using bone cement. The acetabular component can be additionally fixed with screws.

Device of implants.

Arthroplasty localized in the hip region of the limb is performed annually by approximately 1 million people worldwide. In 95% or more cases, with a competently implemented operation and high-quality rehabilitation, pain is eliminated, and the functions of the prosthetic leg are restored to values ​​close to normal. The process of social adaptation takes 2.5-4 months.

Intertrochanteric corrective osteotomy of the femur

Today, descriptions of more than 40 OT techniques can be found in the literature. Many of these techniques are used for various types of underdevelopment of the femur. Osteotomy allows you to simultaneously correct a large number of changed or impaired parameters of the hip joint.

Results of a successfully completed operation:

• normalization of biomechanical conditions in the hip joint;
• more uniform distribution of pressure on different joint structures;
• elimination of factors that injure articular cartilage;
• positive dynamics of disease development.

Correction scheme.

Intertrochanteric osteotomies are rarely used as a single intervention. Most often they are combined with operations on the pelvic bones or performed in case of ineffectiveness of pelvic OT.

Intertrochanteric osteotomies lead to disruption of the anatomy of the femur. This can cause serious problems if the person requires hip replacement in the future.

Indications for surgery

The feasibility of arthroplasty is determined on the basis of clinical studies. Doctors are guided by imaging diagnostic data (CT, MRI, X-ray images), as well as functional tests, including:

• checking the amplitude, range of movements, support in the hip joint;
• measuring the circumference of the thigh and lower leg;
• limb length measurement;
• assessment of the level of the lumbar line;
• assessment of the patient’s postures and walking style;
• study of the pain threshold.

If the violations are severe and severely depress the patient’s vitality, such an operation will most likely be recommended. Diagnoses for which it is prescribed:

• deforming arthrosis;
• femoral neck fracture;
• rheumatoid arthritis;
• aseptic necrosis with deformation of the femoral head;
• pseudarthrosis (false joint);
• congenital hip dysplasia;
• fibrous and bone ankylosis;
• instability of a previously installed endoprosthesis;
• post-traumatic complications and some types of tumors.

Noticeable shortening of the limb, lameness, intense pain symptoms in a chronic form, and the ineffectiveness of conservative treatment for 6 months are reasons for an early operation.

Which breeds are more likely to suffer from hip dysplasia?

Hip dysplasia is most often diagnosed in large breed dogs. This is due to their natural physiology: heavy weight, power, rapid growth. It is recommended to pay special attention to the largest and most active puppies in the litter. Large size is often considered an advantage, but do not forget that this is an unbearable load for joints that have not yet formed and are not fully strengthened.

The following breeds are susceptible to dysplasia:

• Saint Bernard;
• Rottweiler;
• Caucasian Shepherd Dog;
• Newfoundland;
• Mastino-Neapolitan;
• Dogue de Bordeaux;
• malamutes, huskies;
• golden retrievers;
• German Shepherd.

Dysplasia can be detected in any other breed, when the animal has abnormal skeletal structure and an imbalance of proportions. Or if the dog has been kept in unsuitable conditions since birth and experiences regular stress that is not appropriate for its age and breed.

Shepherds are one of the breeds at risk

Types of arthroplasty

Taking into account all the features of the clinical case, the orthopedic surgeon chooses the type of arthroplasty by which he will restore the problem area. There are 4 main methods, each of them has its own goals and objectives.

• Partial arthroplasty. During surgery, the head and fragment of the femoral neck are replaced with an implant; the acetabulum remains intact. During movements, the artificial head will be in close relationship with the natural articular surface of the pelvic cavity. This method is also called unipolar prosthetics. It is prescribed only for unilateral damage to the articulation (in the area of ​​the femur). It is often used in cases of violation of the integrity of the femoral neck and osteonecrosis of the head, if the cartilaginous covers of the acetabular bed are in good condition. The disadvantage of incomplete plastic surgery is the need to frequently replace the implanted implant, on average every 7 years.
• Total hip replacement. In this case, arthroplasty is performed on the femur and pelvic bone simultaneously. The entire joint is completely resected, and then all the removed areas are replaced with elements of a total (full) prosthesis. Complete arthroplasty is recommended for extensive degeneration, which has destroyed, deformed and disabled the entire articular apparatus. The technique is recognized as the best, as it gives the most productive results in restoring full movement. In addition, total structures have the highest margin of strength and durability, with a service life of 15-30 years.

  Total and superficial surgery on x-ray.

• Superficial arthroplasty. The intervention involves covering only the upper part of the femoral head with an implant. The bone spherical element of the femur, as you can understand, is not removed at all; the remnants of destroyed cartilage are only removed from it. A so-called cap prosthesis made of metal is placed on top of the head, cleared of cartilage. A metal component is also inserted into the acetabulum. This technology preserves bone tissue, promotes rapid rehabilitation and does not cause the feeling of a “changed limb.” But, despite all the advantages, it does not have bright prospects. Plastic surgery of articular surfaces only leads to early revision (in the first 5 years) due to the development of local inflammatory processes due to the high concentration of metal ions in the blood at the metal-to-metal friction unit. According to some reports, it can cause the development of tumors.

• Revision surgery. This is a repeat surgical procedure at one time or another after primary hip arthroplasty. It is prescribed if it is necessary to carry out a second replacement if parts of the endoprosthesis are worn out, damaged or were initially installed incorrectly. It is also recommended when serious complications are detected: infections, purulent-septic focus, bone fracture, etc. The scale of the volume of resection measures for re-intervention is greater than for primary endoprosthetics.

  Infectious complication and installation of an additional dilator.

results

Among 38 patients who underwent resection arthroplasty of the hip joint with non-free transplantation of the island flap of the hip joint, in 31 (81.6%) patients (group 1) the early postoperative period proceeded well. In 7 (18.4%) patients (group 2), revision of the postoperative wound was required within a period of up to 14 days due to the emptying of an infected hematoma or the presence of wound discharge for a long time, which was regarded as a relapse of PJI. All patients included in the study were discharged with a healed wound and sutures removed. In 36 (95%) patients, it was possible to achieve stable remission of the infectious process for 2-8 years (Me 4 years). In 2 (5%) patients (one from each group), a recurrence of PJI with the formation of a fistulous tract was detected at the control visit. In both cases, the infection was controlled through a sanitizing operation.

The comparison groups were comparable in terms of gender, age, duration of PJI and the number of previous operations (Table 1).

Table 1. Characteristics of clinical comparison groups Note. PPI—periprosthetic infection; TBS - hip joint. In 21 (55.3%) patients, PJI developed after primary hip replacement. The median number of previous operations in the study sample was 4 (25-75% IQR 3-5), the median number of operations for PJI was 2 (25-75% IQR 2-3).

Despite the absence of statistically significant differences, the higher rates of systemic inflammation before surgery in patients with recurrent PJI are noteworthy: ESR - 61.5 and 35 mm/h, CRP - 37.5 and 27 mg/l, respectively, in the 2nd and 1st groups. In addition, it was found that the duration of the operation in patients of group 2 was significantly longer than in group 1 (p <0.05). At the same time, the volumes of intra- and postoperative blood loss are comparable. In the majority of patients in both groups, the bone defects that form the hip joint formed during sanitation are classified as minor. At the same time, the structure of bone defects in the comparison groups is comparable.

Bacteriological studies of tissue biopsies were performed in 37 (97.4%) cases. In 2 cases, no growth of microorganisms was observed. The leading pathogens of PJI were S. aureus and coagulase-negative staphylococci. Despite the fact that in 29 (76.3%) patients staphylococci were present among the pathogens of PJI, in 30 (78.9%) patients the infection was caused by a microbial association, including in 22 (73.3%) it involved gram-negative bacteria (Table 2).

Table 2. Features of the etiology of PJI in comparison groups Note. Differences were assessed using the χ2 test. DTT (difficult-to-treat) - difficult-to-treat microorganisms - rifampicin-resistant staphylococci, ciprofloxacin-resistant gram-negative bacteria, Candida fungi; MRS - methicillin-resistant staphylococci (MRSA+MRSE). In the group of patients with early relapse, infection was more often caused by microbial associations involving methicillin-resistant staphylococci (MRS) and gram-negative bacteria, including those related to DDT pathogens (p>0.05). At the same time, monobacterial infection occurred in group 2 almost 2.5 times less often than in group 1. The relative risk of recurrent PJI increased more than 4 times (RR 4.364, 95% CI 0.581–32.787) with polymicrobial infection involving gram-negative bacteria and decreased (RR 0.256, 95% CI 0.034–1.916) with monobacterial infection (p>0.05 ).

Analysis of the dynamics of laboratory parameters compared with the preoperative period revealed the development of hypoproteinemia after surgery in patients of both groups (p<0.05). At the same time, in patients of group 2, hypoproteinemia was accompanied by a statistically significant (p<0.05) decrease in hemoglobin levels (Table 3),

Table 3. Dynamics of laboratory parameters in groups Note. 1 — p<0.05 compared to group 1; 0 — p<0.05 compared with the preoperative value in the same group. which at 6-7 and 10-11 days was significantly lower than in group 1. The median number of leukocytes significantly exceeded (p<0.05) the same preoperative indicator in the 1st group on the 10-11th day, and in the 2nd group already on the 6-7th day after surgery. In patients of group 1, there was no statistically significant increase in such indicators of systemic manifestations of infection as the level of CRP and ESR; on the contrary, a significant decrease (p<0.05) in the level of CRP was detected by the 10-11th day of the postoperative period. In patients of group 2 after surgery there was a significant (p<0.05) increase in ESR compared to that before surgery with the value in group 1. The CRP level increased by days 6–7 from 37.5 to 96.6 mg/l and reached 58.5 mg/l by days 10–11 after surgery (p<0.05).

How is the operation performed?

An arthroplasty procedure using the method of total reconstruction of the TB joint has the most optimistic prognosis for a successful outcome. It also allows you to significantly increase the time until revision intervention. Total surgery is the gold standard of modern endoprosthetics. We offer you to familiarize yourself in an understandable form with how it is done.

1. The patient receives anesthesia, usually in the form of general endotracheal anesthesia.
2. After extensive antisepsis of the skin and tourniquet of the problematic limb, an incision is made using the posterolateral approach technique. The posterolateral approach is performed in the area of ​​the greater trochanter.
3. The muscle tissue is gently moved to the sides. The open surgical field is fixed with a surgical retractor.
4. After opening the joint capsule, the head of the femur is dislocated and resected, partially involving the cervical component.
5. Next, using cutters of the required size, the integumentary structures of the pelvic bed are cut off until the subchondral bone plate is exposed. The bowl is tightly immersed in the prepared bed. A polyethylene liner is inserted into the bowl.
6. In the position of a bent knee, the limb is rotated and adducted so that the lower leg takes a vertical position. Thanks to this position, the proximal femoral section is well brought into the wound for further preparation for implantation.
7. Next, the doctor perforates the medullary canal in the femur and forms a bed of optimal size in it in order to implant the prosthetic leg into it.
8. When the leg is immersed in the created medullary compartment, a spherical element (artificial head) is put on its free end. The last stage of implantation is the reduction of the head into the installed cup.
9. The final stage of surgery is layer-by-layer suturing of the wound and installation of drainage systems. An elastic bandage is applied to the operated leg.

The maximum incision size after hip arthroplasty is 8 cm. The duration of the operating session is about 1 hour.

The probability of developing complications does not exceed 5%, of which intraoperative consequences practically do not occur. Complications such as dislocation of implant components and periprosthetic fractures predominate, which often occur due to the patient’s non-compliance with the prescribed orthopedic regimen.

Minimally invasive endoprosthetics in the Czech Republic: doctors, rehabilitation, terms and prices.

Find out more

Triple pelvic osteotomy

There are several triple OT techniques. Each of them involves the intersection of all components of the pelvic ring (pubis, ilium and ischium). After this, the acetabulum is set in the desired position, and the bone fragments are fixed with titanium structures. The screws are removed after 1-1.5 years, that is, after the bones have firmly fused.

Disadvantages of triple osteotomies:

• high traumatic rate;
• high probability of damage to nerves and blood vessels;
• increased risk of developing avascular necrosis;
• the possibility of divergence of the pubic and ischial bones;
• long recovery period;
• narrowing of the pelvic ring in girls, which has negative consequences in the future.

Most often, several triple osteotomy techniques are used in orthopedics. These include OT according to Tonnis, Steel, Chiari, rotational acetabular and a number of modifications such as Bernese, Ganz, RAO. All of these techniques provide good mobilization of the acetabulum and allow it to be placed in the most advantageous position.

Specifics of rehabilitation

If the patient’s condition corresponds to the postoperative norm, then the very next day after the operation he begins to move on crutches, and after another 1-2 days he begins to sit. In order to prevent thrombosis and thromboembolism, he is prescribed drugs with heparin, and to prevent the development of infection, a strong broad-spectrum antibiotic. The need to use crutches, depending on the type of endoprosthesis used, ranges from 10 to 45 days. Afterwards they switch to a cane, which is used until final recovery.

The patient is discharged from the hospital approximately 12 days after surgery. Rehabilitation after discharge should continue in an outpatient setting or a specialized rehabilitation center for as long as necessary. Return to active life and professional activities for most people occurs closer to 4-5 postoperative months.

Diagnosis of the disease in dogs

Only a veterinarian can diagnose hip or other joint dysplasia in your pet. He performs a general clinical and orthopedic examination, as well as taking x-rays.

It is performed under general anesthesia so that the dog can be placed in a certain position. The specialist analyzes the received X-ray images, measures angles and calculates indices to make the correct diagnosis.

If necessary, special tests are prescribed to determine joint dysplasia. The Ortolani test (creating pressure on the knee joint) or the Bardens test (holding the fingers on the ischial tuberosity) is used.

Together with the diagnosis, the specialist determines the type of lesion of the hip joint: acetabular (in this case, the neck-shaft angle is 135°) or neck-shaft (in this case, the angle is more than 150°).

Prices for hip arthroplasty

In Moscow, only the service of a surgeon in well-known clinics (Semashko Children's Clinical Hospital, Burdenko State VKG, etc.) will cost the patient 35-40 thousand rubles. The price of the operation, together with the cost of a hip joint endoprosthesis from an imported manufacturer, in Moscow medical institutions is at least 100 thousand rubles. An operation with the installation of domestic brands of implants is estimated at approximately 60-70 thousand rubles. In Russia, you can go through the procedure using a quota, the costs are compensated by the state budget according to the state program for high-tech medical care. Quota treatment is provided on a first-come, first-served basis, with a waiting period of 3-12 months.

Abroad - in Germany, Israel, the Czech Republic - replacement is carried out very high quality, and only prostheses of world brands made of high-quality materials are implanted. Surgical procedures together with the prosthetic structure and consumables in Germany cost patients an average of 16.5-18 thousand euros, in Israel - 23-28 thousand dollars. Rehabilitation, every day of hospital stay will require additional investments. In the Czech Republic there is rehabilitation (minimum 4 weeks) for both its citizens and foreign patients. In Czech clinics, turnkey treatment (diagnosis, surgeon’s work, endoprosthesis, postoperative recovery) costs no more than 12 thousand euros.

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