Lower back pain after hip arthroplasty. Hip pain after hip arthroplasty

Hip pain, swelling, infectious inflammation, loosening of the prosthesis, impaired walking and lameness - these are not all complications after arthroplasty hip joint(TBS). The operation to replace a joint with an artificial one helps a person get rid of many problems, reduce pain, and return to his former life. But not always the postoperative period passes without complications.

It is important to go through the stages of recovery correctly, following the recommendations of the doctor, so it will be possible to reduce the risks of developing negative consequences.

Possible Complications

General violations

After arthroplasty of large joints, the reaction of the body is unpredictable. Dangerous consequences rarely occur, but there are situations when the patient becomes ill and at this moment it is important to provide first aid in a timely manner. Common complications include:

• Allergic reaction to medications used during surgery. If the patient has any restrictions on taking certain groups of drugs, it is important to inform the doctor about this even before surgical treatment.
• Functional disruption of cardio-vascular system. Hip replacement is under general anesthesia and if the heart muscle is weak, anesthesia has a negative effect on its condition, and can significantly impair performance.
• Problems with motor functions arising from the rejection of the prosthesis by the body, which is a foreign object that causes a corresponding reaction.

Pain and swelling

Patients often experience pain after surgery.

After the rehabilitation period, the patient may be disturbed by unpleasant pain symptoms which, with adequately selected therapy, should soon pass. You can get rid of discomfort by performing recovery exercises. But when the limb hurts and the person gets worse, the doctor decides to do it, because often the cause of the pain is an unsuitable prosthesis and an allergy to its material.

In the postoperative period, many patients swell the operated leg. Edema in this case is a consequence of impaired blood circulation and metabolic processes in the limb. To prevent this from happening, the patient is advised to take comfortable postures during rest and wakefulness, which will not interfere with normal blood flow. Better output excess liquid diuretic drugs prescribed by a doctor will help.

infectious

Infectious and inflammatory complications often occur even in late rehabilitation periods, this is due to the multiplication of pathogenic microflora introduced into the wound during surgical procedures. The patient's legs swell and hurt, pus is discharged from the wound and blood clots. The temperature after hip replacement surgery increases to 38 °C, and if treatment is not started in a timely manner, fistulas form in the operated area.

To prevent infectious complications, surgical treatment antibiotics are prescribed.

Nerve or vascular injury

The patient may feel "goosebumps" on the leg when the nerve is damaged.

If injured nervous tissues, the operated leg may partially lose its functionality. There is a burning sensation and a feeling as if "goosebumps" run over the skin. When the integrity of blood vessels is violated, internal bleeding increases the likelihood of developing deep vein thrombosis and inflammatory complication.

Different limb lengths

After hip arthroplasty, the symmetry of the limbs may be disturbed. This complication is rare, it is associated with a long-standing injury to the femoral neck. If the technique of bone tissue reconstruction has been violated, the length of the diseased limb often changes. If this defect appears after the operation, it is corrected using orthopedic shoes.

Bleeding

Common complications after hip replacement in older people taking wound healing drugs. Therefore, in order to avoid dangerous consequences, doctors recommend stopping taking such medications 4-5 days before the procedure. Less often, but it happens that bleeding caused the surgeon's negligence. Often the head of the endoprosthesis takes the wrong position due to careless movements of the limb, increased physical exertion. Therefore, after replacement of the hip or knee joint, it is recommended to carefully walk on crutches, slowly sit down on a chair or bed, fix the hip joint and knees, using elastic bandage. Lameness may be due to:

• An old fracture of the limb or neck of the joint, due to which the leg became shorter after prosthetics.
• Atrophy of the muscle tissue of the leg due to prolonged immobilization.

It is impossible to completely eliminate pain after arthroplasty, but there are ways to minimize it. The joints become inflamed and swollen, if you do not follow the rules of recovery, randomly take medications and, sparing yourself, do not develop the operated leg. Also great importance is qualified as a doctor.

Why does pain return after surgery?

Allows you to return to ordinary life get rid of symptoms of arthritis that have bothered you for many years. Practice shows that complications after surgery occur in 1% of young and 2.5% of elderly patients. Pain after hip replacement is one of the most common complications. This symptom causes non-compliance with the rules physical activity or insufficient care in the postoperative period. Less often, the cause of the development of complications is the error of the surgeon.

What do the statistics say?

According to the data medical research, knee arthroplasty is fraught with:

• 1.93% - dislocation;
• 1.37% - infection and subsequent septic inflammation;
• 0.3% - the formation of blood clots;
• 0.2% - prosthesis fracture.

If the patient does not follow medical recommendations, then the swelling persists for a very long time.

The patient's condition worsens after discharge, when there is no proper control of the medical staff and the patient begins to gradually relax the regimen. If later enough time, the amplitude of movements of the limb is minimal, the joint is still swollen, this indicates the absence proper rehabilitation and non-compliance medical advice.

It is impossible to avoid painful manifestations even with the highest qualification of the surgeon. During the operation, adjacent muscles are dissected and re-sutured. The restoration of movement in the knee or leg is associated with pain. However, its appearance may indicate the development of complications.

What other complications are possible?

Immediately after surgery

Pain after hip arthroplasty also causes:

A knee prosthesis can move if it is bent 90 degrees.

• wound infection during surgery. Occurs both on the surface and in soft tissues. The place of operation hurts for a long time, swells, turns red. You can be cured long-term use antibiotics. Therapy should begin as soon as possible, otherwise it will be necessary to carry out reoperation for joint replacement.
• Rejection of the implant. It appears very rarely, since before the operation, allergy tests are carried out to determine the tolerance of the material of the future prosthesis. Implants are made by many manufacturers, and it is not difficult to choose the most suitable one.
• displacement of the prosthesis. It manifests itself if the patient does not follow the recommendations of the attending physician to limit movement and exercise. After a knee replacement or hip replacement, bending the leg at an angle of more than 90 degrees is fraught with a similar complication.
• Deep vein thrombosis. Due to the restriction of movement after surgery, blood stagnates in the veins. This can lead to the formation of blood clots. Depending on the size of the thrombus and the direction of blood flow, the patient manifests gangrene of the legs, heart attack, pulmonary thromboembolism. To prevent this complication, it is important to start doing gymnastics in a timely manner. From the 2nd day after the operation, the patient starts taking anticoagulants.
• Change in leg length. Manifested when the prosthesis is incorrectly installed. There is a weakening of nearby muscles, so exercise is extremely important.
• Bleeding. Appears due to a medical error. Help must be provided immediately, otherwise there is a high probability of hemolytic shock and death of the patient.

After a certain period

Gradually, the symptom may be supplemented by lameness, which is an indication for replacement of the prosthesis.

Over time, in addition to pain syndrome there is a possibility of complications that are eliminated only by replacing the hip joint prosthesis:

• lameness;
• dislocation of the implant head;
• destruction of the prosthesis (full or partial);
• weakening and deterioration of the functionality of the joint.

The more accurately the rules of rehabilitation after joint arthroplasty are followed, the lower the risk of complications.

What treatment methods can be used?

We fight pain after arthroplasty at home

• While resting, keep the operated leg slightly elevated. This reduces swelling, the hematoma goes away, the joints hurt less. The knee should not be overstretched or extended. To increase blood flow, it is necessary to periodically change the position of the body, move often. Compression tights or stockings can be worn to prevent blood clots.
• If the joint hurts and becomes inflamed after surgery, ice is applied around the incision for 15-20 minutes every 3 hours to eliminate these manifestations. This reduces soreness in the muscles. To prevent tissue frostbite, it is recommended to wrap the ice in gauze or a towel. Manipulation is especially effective if the joints are swollen.
• Move with crutches. This reduces stress on the hip or knee. Until the muscles get stronger, you need to fully rely on the operated limb under the supervision of a doctor.
• All prescribed drugs must be taken with the frequency prescribed by the doctor in the indicated dosage.
• When the operation site starts to hurt less, swelling on the buttocks, thigh or groin subsides, it is recommended to warm up the joint. This expands the veins, promotes better mobility.

Rehabilitation after hip arthroplasty is one of the components postoperative treatment. Recovery is aimed at normalizing muscle tone and function lower limb. The recovery period consists in limiting the load and special gymnastics.

Recovery periods after hip replacement

After hip surgery, the patient must undergo three rehabilitation period: early, late, remote. Each has a specific set of exercises. How long the rehabilitation lasts, it is impossible to say for sure. This period is different for everyone.

Recovery after knee replacement begins at the hospital where the surgery was performed. The patient is in the hospital for two to three weeks. Limb movements can be restored at home or in a rehabilitation center. Further, you can undergo rehabilitation in the clinic of rehabilitation treatment.

In addition to the implementation of the complex exercise therapy exercises daily recovery walks should be taken. Only in this case, the ligaments and muscles will secure the prosthesis in the correct position.

During the recovery period, the operated person is engaged in a rehabilitation specialist or exercise therapy doctor, who will draw up a treatment program suitable for a particular patient. This takes into account age, comorbidities.

Important! Even after total arthroplasty, it is possible to restore the ability to work. The main thing is the strict implementation of medical recommendations and the desire to move.

The period from the moment of completion of surgery to 1 month lasts.

Goals of this stage

The objectives of the recovery phase are:

1. Improvement of blood circulation in the area of ​​surgical intervention.
2. Prevention of complications (thrombosis, pneumonia complicated by pleurisy, bedsores).
3. Learning to sit up and get out of bed.
4. Puffiness reduction.
5. Healing of the seam in a short time.

Rules for the postoperative period

1. On the first day after the intervention, it is allowed to sleep only on the back.
2. At the end of 1 day after the intervention, you can turn on your healthy side, but only with the help of medical staff. They turn on the stomach 5 days after the operation.
3. You can not make sudden movements, turns in the operated area.
4. Flexion of the limb more than 90 degrees is prohibited.
5. It is forbidden to put the legs together or cross them. A wedge-shaped orthopedic pillow should be placed between the lower limbs.
6. To prevent stagnation of blood in the vessels, it is necessary to perform exercises daily.
7. If the legs swell after the operation, taking diuretics, fixing the limbs in an elevated position, and compresses will help. If the swelling does not go away for a long time, this may indicate complications, dislocation, or an incorrectly selected set of exercises.
8. In the first month and a half, it is advisable not to take hot baths, wash under a warm shower.

Diet after surgery

After the anesthesia wears off, the patient may feel intense thirst or hunger. A small amount of crackers can be eaten six hours after the intervention. Nutrition in the early days should consist of:

1. Meat low-salt broth.
2. Dairy products.
3. Oatmeal or mashed potatoes.
4. Kissel or tea.

Gymnastics for the calf muscles, buttocks and thighs:

For charging to be useful, you must:

1. Every day, every hour, for 20 minutes, you should perform the gymnastics described above.
2. Do not make sudden movements while exercising.
3. Do not forget about breathing: at the moment of muscle tension, inhale, during relaxation, exhale.
4. To prevent the development of pneumonia, you need to perform breathing exercises.
5. In the first three days, do exercises lying on your back, in the following days - in a sitting position on the bed.

Additional exercises

After the intervention, within 10 days, the doctor teaches the patient to turn on the bed correctly, take a sitting position, get up, use crutches.

When the patient is able to stand up and lean on the operated limb, he must perform the exercises in the initial standing position.

1. Grasp the back of the bed and raise the lower limbs in turn, bending them at the knee. This element of gymnastics resembles walking in place.
2. Holding on to the back of the bed, lift one limb, lifting it. Then lower. Do the same with the other leg.
3. Holding on to the back of the bed, take your leg back and return back. Do the same with the other limb.

It is important to understand that early activation and initiation of rehabilitation reduces the likelihood of developing movement limitation.

Late recovery period

Starts 30 days and ends 3 months after prosthetics.

Goals

1. Increase and strengthen muscle tone.
2. Restoration of movement in the field of prosthetics.

After the patient learns to get out of bed and the duration of walking on crutches exceeds 15 minutes four times a day, classes on an exercise bike can be introduced. . At the same time, the duration of exercises on it should be no more than 10 minutes twice a day.

During this period, you need to learn how to move up the stairs.

When climbing stairs, put your healthy foot on the step first. When descending, first with crutches, then the operated limb, and then the second leg.

remote period

The terms of this period are from three months of setting up an artificial joint and up to six months.

Goals

1. Security normal functioning artificial joint.
2. Improving the condition of muscle fibers, ligaments, tendons.
3. Reduced bone recovery time.

This period is aimed at preparing the patient for more heavy loads, to ensure its normal activity in domestic conditions. In addition to gymnastics, the area of ​​prosthetics is affected by a laser, paraffin, mud, therapeutic baths.

Exercises of the early period, which also need to be performed at home, after discharge, need to be supplemented with more complex elements.

1. Lying on your back, take turns pulling the lower limbs to the stomach, performing movements similar to riding a bicycle.
2. Lying on your back, bend your legs alternately and pull them to your stomach with your hands.
3. Lie on your stomach and bend and unbend the limbs at the knees.
4. Lie on your stomach and take the limb back, in turn.
5. Stand up, straighten your spine. Do half squats. At the same time, you need to hold on to something.
6. Place a bar in front of your feet, the height of which should not exceed 10 cm. Stand on it with both feet. Then, in turn, lower the leg: first healthy, and then with a prosthesis. Stand back on the bar in the same sequence. Run at least 10 times.
7. Lean on the back of a chair. On the ankle of the lower limb that has undergone surgery, put on an elastic tourniquet. Tie the other end to something. Pull the operated limb forward. Then turn around and stretch your leg back.
8. Take the leg with the tourniquet to the side and return to its original position. Move at least 10 times. At the same time, you need to hold on to something.

The last two exercises are aimed at restoring movements in the hip joint during its replacement.

Exercises on simulators

For the patient to quickly adapt to living conditions, he should be engaged in physiotherapy exercises on simulators. During this period, the muscular and ligamentous apparatus are ready for training in full. In this regard, physical activity can be made more intense.

1. Spin the pedals back. If this action does not require excessive effort, then you can pedal forward. The duration of classes is 15 minutes twice a day, 4 times a week. Over time, the duration of the lesson should be increased to half an hour. It must be remembered that you can not raise your knees above the hips.
2. On the exercise bike, place the pedals at such a height that each leg is fully extended when they are scrolled.

Set the speed to 2 km/h. Stand on the treadmill with your back forward, grab the handrails. Take slow steps back. The leg, at the moment of full contact of the foot with the track, should be straight.

On a special simulator for extension of the hip joint, focus on a healthy limb. Put the leg with the prosthesis on the roller, which should not be rigidly fixed. In this case, the roller should be located under the femoral region, closer to the knee region. Press on the roller, while bending and unbending the prosthesis will be performed, with the application of effort. The load is provided by a weight attached to the simulator. Over time, the weight of the load must be increased.

According to reviews, some patients experience pain of various localization after hip arthroplasty. It is not always possible to find out why a prosthetic joint hurts. More often, the pain syndrome is associated with the instability of the prosthesis or an infectious process.

If the leg or knee hurts, the groin, especially when turning the limb or under load, this indicates the instability of the femoral component of the prosthesis.

If the lower back hurts after endoprosthetics, then this may be due to an exacerbation of osteochondrosis associated with the alignment of the limbs after surgery.

Soreness can also develop in the case of an inflammatory process. In this case, the pain syndrome does not depend on movements, the pain gradually increases, the presence of fever and changes in the blood is characteristic. With the instability of the prosthesis, pain occurs only when making a movement.

Conclusion

The entire period of rehabilitation after hip arthroplasty at home should take place under strict medical supervision. You can not do exercises on your own, especially on the simulator. At the same time, exercises must be performed daily, but not through force and pain, as this can lead to serious consequences. If all the recommendations of the doctor are followed, the movements in the joint will gradually recover.

artritu.net

In recent decades, total arthroplasty has become one of the main methods of treating pathological diseases.

, and 32-35% of operated patients develop new pain different intensity in the absence of signs of instability of the endoprosthesis and infectious process.
In the course of the staff of the RNIITE them. P.P. Harmful analysis of 470 patients operated on the hip joint, using individual questionnaires (from 2 weeks to 12 months), it was found that 68% (320) of patients complain of pain in the area of ​​the operated limb of various localization and intensity - from feelings of discomfort to moderate pain. Of these, the largest specific gravity(about 23% - 74 patients) falls on pain radiating to the knee joint. It should be noted that such pain syndrome occurs most often (70%) in the early postoperative period and can persist for a long time.
As is known from the literature, the region of the knee joint and the fat body of the acetabulum are innervated by the common branches of the obturator nerve. Taking into account the nature and localization of the pain syndrome, it can be assumed that one of the causes of radiating pain in the knee joint after hip arthroplasty is irritation of the small branches of the obturator nerve in the area of ​​the fat body.
Based on this, the authors developed a method for the prevention of radiating pain in the knee joint by intraoperative excision of the fat body and the introduction of a solution into its stump under the transverse ligament local anesthetic(S. Lidocaini 2% 5 ml) directly to the fibers of the branch of the obturator nerve, causing its irreversible blockade.
At present, the known methods of blockade of the obturator nerve, unfortunately, do not have the desired effect in this situation, they are short-term and reversible.
The disadvantages of the known methods is the manipulation blindly, paraneurally, according to bone landmarks, during which trauma to the neurovascular bundle is possible and the procedure is painful for patients.
The developed method is based on the studies of Japanese and American scientists, who proved that the introduction of an anesthetic of a certain concentration directly into nerve fibers leads to an irreversible violation of the properties of impulse conduction.
The authors conducted a study on 84 patients aged 35 to 60 years with various lesions of the hip joint (coxarthrosis, aseptic necrosis, pseudoarthrosis), admitted to the RNIIT them. P.P. Damaged in 2007-2009. for the purpose of arthroplasty. They were divided into main and control groups of 42 patients. All the studied patients had signs of gonarthrosis and pain in knee joint were absent before the operation.
Patients of the main group underwent hip arthroplasty using the method developed by the authors for the prevention of postoperative pain radiating to the knee joint: after processing the acetabulum with cutters, a complete excision of the fat body and own ligament of the femoral head was performed. Using a sterile syringe, 5 ml of S. Lidocaini 2% was injected under the transverse ligament into the stump of the fat body. Thus, the effect of irreversible blocking of the fibers of the branch of the obturator nerve was induced. Subsequently, the acetabular component of the endoprosthesis was installed and the standard course of the operation continued.
Patients in the control group underwent standard arthroplasty.
In all patients, the postoperative period was uneventful, the wounds healed by primary intention.
The results were evaluated in the early and late postoperative periods using individual questionnaires, where patients independently noted the localization of pain, the relationship with the load before and after surgery. The intensity of the pain syndrome was studied using visual analogue scales reflecting the color and emotional mood patient.
In the main group, 41 patients (97.6%) had no complaints of pain in the knee joint after surgery. In 1 patient (2.4%), pain in the knee joint with irradiation to the lower leg and foot was identified as neuralgia sciatic nerve associated with the lengthening of the operated limb.
In the control group, 10 patients (23.8%) had isolated pain in the knee joint at various times after surgery. It should be noted that the intensity of the pain syndrome is most pronounced during the first two weeks and can persist up to 3 or more months after surgery.
Thus, the authors found high efficiency the method proposed by them, characterized by painlessness, accuracy of intraoperative administration of an anesthetic and the irreversibility of the analgesic effect.
Proven clinical efficacy of the developed method allows us to recommend its use in practice in order to increase the efficiency of arthroplasty and significant improvement quality of life of patients.

News posted Korshunov Anton Viktorovich, company spinet

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spinet.ru

This article will help you understand the advantages and disadvantages of total hip replacement. Here we describe how the joint works, what causes hip pain, what to expect from a hip replacement, and exercises that can help restore your mobility and strength so you can return to your daily life.

If your hip joint has been damaged by arthritis or a fracture, then walking or sitting in a chair can be painful. You may even feel uncomfortable while relaxing.

If the medications you are taking do not help, and the use of special supports does not make life easier for you, you may consider a total hip arthroplasty. The operation is safe and efficient. It will relieve pain, improve movement and help you get back to your daily life.

Common Causes of Hip Pain

Most common cause chronic pain in the hip, arthritis. arthrosis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease.

• Arthrosis is age-related wear and tear. It usually occurs at the age of 50 and older. The cartilage of the thigh bone wears away, then the bones rub against each other, causing pain. Arthrosis can also be caused by a developmental disorder in childhood.
• Rheumatoid arthritis. This autoimmune disease in which the synovial membrane becomes inflamed and thickened. This chronic inflammation can damage cartilage, leading to pain and stiffness.
• Post-traumatic arthritis. May occur after a fracture or serious injury to the hip.
• aseptic necrosis. A hip injury can limit blood flow to the head of the femur. The lack of blood can lead to destruction of the bone surface, leading to arthritis.
• developmental disorder in childhood. Some babies and children have hip problems at birth. Even though these problems are successfully treated in childhood they can still cause arthritis later in life. This is because the hip joint cannot grow normally and the articular surfaces wear off.

Description

In total hip replacement, damaged bone and cartilage are removed and replaced with prostheses.

• The damaged femoral head is removed and replaced with a metal rod that is placed in the hollow center of the femur.
• A metal or ceramic ball is placed on top of the rod. This ball replaces a damaged femoral head.
• The damaged cartilage surface is removed and replaced with a metal one. Screws or cement are sometimes used to hold the structure in place.
• Plastic, ceramic or metal shims are inserted to provide a smooth sliding surface.

Is total hip arthroplasty right for you?

The decision to go for a hip replacement should be made jointly by you, your family, your doctor, and your orthopedic surgeon. The process of making this decision begins with an initial evaluation of the condition of the joint.

Candidates for surgery

Does not exist age restrictions or weight restrictions for total arthroplasty.

Recommendations for surgery are based on the patient's pain and disability, not age. Most patients who undergo total hip replacement are between 50 and 80 years of age, but orthopedic surgeons evaluate patients on an individual basis.

There are several reasons why your doctor may recommend a total hip replacement. Candidates for surgery experience:

• Pain in the thigh when walking or bending.
• Hip pain that continues during day and night rest
• Stiffness in the hip that limits the ability to move or lift the leg
• Insufficient pain relief when taking medications or physical therapy.

Orthopedic Grade

The state assessment consists of several components:

• Disease history. Your orthopedic surgeon will collect information about your general health and ask questions about the extent of your shin pain and how it affects your ability to perform basic movements.
• Physical examination. Assessment of joint mobility.
• X-ray.
• Other tests. Sometimes other tests, such as magnetic resonance imaging (MRI), may be needed to determine the condition of the bones and soft tissues of the thigh.

The decision to go for a total hip arthroplasty

An interview with an orthopedic surgeon

Your orthopedic surgeon will review the results of the health check and discuss with you the feasibility of a total hip replacement as a means to reduce pain and improve your mobility. Other treatment options like medications, physical therapy, or other types of surgery may also be considered.

In addition, your orthopedic surgeon will explain the potential risks and complications of hip replacement, including those related to the operation itself and those that may occur after the operation.

Never hesitate to ask your doctor questions.

Real expectations

It is important to understand what the procedure can and cannot do. Most people who have a total hip replacement experience significant pain relief and improved ability to move.

Excessive activity and excess weight can accelerate the natural wear and tear of the joint. Orthopedists do not advise to abuse impact loads, such as running, jumping or other high-impact sports.

Allowed activities after total hip replacement include walking, swimming, driving, cycling, dancing, and other low-impact sports.

Preparing for the operation

If you decide to have a hip replacement, your orthopedic surgeon will perform a complete physical examination. This is necessary to understand whether you are healthy enough for surgery and how quickly you will recover from surgery.

Tests such as blood and urine tests, ECG, and chest X-ray may be necessary for a clear planning of the operation.

Your skin must be free of any infection or irritation prior to surgery.

Tell your orthopedic surgeon about the medications you are taking.

If you are overweight, your doctor may ask you to lose weight before surgery to minimize stress on your new joint and reduce the risk of surgery.

Although you will be able to walk with crutches after surgery, you will still need some help for a few weeks. For example cooking, shopping, bathing…

Total hip arthroplasty

Most likely your stay in the hospital will take one day.

Anesthesia

After the appointment, you will talk to an anesthesiologist who will select the best type of anesthesia for you. The most common types of anesthesia

• General anesthesia (you fall asleep)
• Epidural anesthesia (you are awake, but your body is numb below the waist).

Implants

There are many various kinds artificial hip joint prostheses. They all consist of two main components: the ball (durable metal or ceramic) and the acetabulum (durable plastic, ceramic or metal).

Implants can be pressed into the bone so your bone can grow into the prosthesis, or they can be cemented in place.

Your orthopedic surgeon will select the type of prosthesis that best suits your needs.

Procedure

The surgical procedure takes several hours. Your orthopedic surgeon will remove the damaged cartilage and bone and then install new prosthesis to restore the function of your hip.

After the operation, you will be transferred to the recovery room where you will stay for several hours. After that, you will be taken to the hospital room.

Hospital stay

You will most likely stay in the hospital for a few days. To protect your hip joint during early recovery tires are installed.

You will feel some pain after the operation, but your surgeon and nurses will provide you with pain medication to keep you comfortable. Pain relief is an important part of your recovery. Movement will begin shortly after the operation.

Physiotherapy

Walking and light activity important to your recovery. You can start the next day after the operation. A physical therapist will teach you specific exercises to strengthen your joint and help you regain movement.

Recovery

The success of your surgery will depend in large part on how you follow your orthopedic surgeon's instructions for home care during the first few weeks after surgery.

seam care

You will have stitches or staples along your wound, which will be removed 2 weeks after surgery.

Avoid getting moisture into the wound until it is completely healed. Bandage the wound to prevent irritation from clothing.

Diet

Some loss of appetite is normal for several weeks after surgery. Balanced Diet promotes tissue healing and restoration of muscle strength. Be sure to drink plenty of fluids.

Activity

Exercise is one of critical components home recovery, especially during the first few weeks after surgery. You must resume your daily activities within 3 to 6 weeks after surgery. You may experience some discomfort at night for several weeks.

Possible complications after surgery

The risk of complications after total hip arthroplasty is very low. Serious complications such as infection occur in less than 2% of patients. Nevertheless, chronic diseases may lead to complications. These complications can prolong the healing process.

Infection

The infection can penetrate superficially in the wound or deeper around the prosthesis. Infection can occur in the hospital or at home. This can happen even years later.

Minor infections are treated with antibiotics. Surgery may be required to treat deep infections.

Blood clots

Blood clots in the veins of the legs or pelvis are the most common complication of total hip replacement. Blood clots are life-threatening if they break off and travel to the lungs. Your orthopedic surgeon will prescribe a blood clot prevention program.

Other complications

There is a very small chance of nerve and blood vessel damage, bleeding, and fracture.

Precautions after surgery

Signs of thrombosis

Follow your orthopedic surgeon's instructions to reduce the risk of blood clots developing during the first few weeks after surgery. Your doctor will prescribe blood thinners.

Signs of thrombosis:

• Pain in the calf muscle and leg that is not related to the suture.
• Pain or redness in the leg
• Swelling of the thigh, calf, ankle, or foot

Signs of a pulmonary embolism. A blood clot has broken off and travels to the lungs if:

• sudden shortness of breath
• Sudden chest pain
• Localized chest pain when coughing

Infection Prevention

After surgical operation you need to take antibiotics.

Signs of infection:

• Constant fever
• Chills
• Increased redness, pain, or swelling of the thigh
• Seam leak
• Increased pain with rest

Avoid falls

A fall during the first few weeks after surgery can damage the new joint and may result in the need for new surgery. Stairs are a particularly dangerous place until your joint is strengthened. You must use a cane, crutches, walker, or handrails, or have someone help you when walking up stairs.

naumenko-ortho.com

Hello.

My mother is 63 years old. Height 156 cm. Weight 72kg. Retired, occupation only in the house-garden, does not smoke and never smoked.

Case History: Suffering from a disease of the left hip joint for thirty years. She was hospitalized at the Saratov Research Institute of Traumatology and Orthopedics. The diagnosis was "Deforming coxarthrosis of the left hip joint III degree. An operation was performed osteotomy of the left iliac bone with the creation of a canopy of the roof of the acetabulum. Despite the operation and further course treatment began to notice a feeling of fatigue, pain, with prolonged walking in the region of the left hip joint. The disease progressed rapidly, the pain syndrome intensified, there was a sharp lameness, a sparing gait, and limitation of movement in the left hip joint.
For this reason, in 1992 The regional hospital in Birobidzhan underwent an operation to install the Elizarov apparatus on the region of the left hip joint, an operation was performed according to Shants-Yelizarov, and a course inpatient treatment. After treatment in 1993. developed pin osteomyelitis. The operation was performed twice to excise the osteomyelitis focus, subsequently there was no exacerbation of osmyelitis.
On R-gram No. 25 dated 25.12.2006. hip joints - Coxarthrosis on the left, III degree, on the right, II degree.
The diagnosis was made: Deforming coxarthrosis of the left hip joint III degree, condition after corrective osteotomy.
Intensive treatment, including NSAIDs, vitamin therapy, chondroprotectors, microcirculants, physical therapy, exercise therapy and massage had no effect. The pain syndrome intensified, the gait rhythm and movement restriction were sharply disturbed.
Consultation of the therapist from 14.09.2009. Complaints of pain in the left hip joint, limps when walking. The general condition is satisfactory, heart sounds are rhythmic, blood pressure is 180/100mm. Hg Vesicular breathing in the lungs. The abdomen is not swollen. Physiological recovery is normal. Diagnosis: Hypertension II degree. Disabled person Group III 16 years.
Objectively:
Status localis: on examination, there is atrophy of the gluteal muscles on the left. Palpation of the joint is painful. He walks limping, the rhythm of gait is sharply disturbed. Shortening of the left thigh by 5 cm.
Diagnosis: deforming coxarthrosis III degree of the left hip joint, right hip joint II degree.

October 27, 2009 the operation "Total arthroplasty of the left t/b joint with the ESI design" was performed

Discharge summary: from 19.10.2009 to 10.11.2009 was in the orthopedic department with a diagnosis of Left-sided dysplastic coxarthrosis III-IV Art., intra-articular bodies. Fracture of the left femur in the wrong position in the diaphysis of the left femur. Combined contracture of the left t/b joint. Shortening of the left lower limb - 4 cm. Pain syndrome.

In the postoperative period, analgesic, symptomatic therapy, physiotherapy, dressings were carried out. A prophylactic course of antibiotic therapy was carried out - Lendacin 1.0 2r. per day, 5 days.
Prevention of thromboembolic complications:
- early activation
- elastic bandage
- anticoagulant therapy (Clexane 0.4 pk)
The early postoperative period was favorable, the postoperative sutures were removed on the 14th day, repair by primary intention, and the patient was discharged in a satisfactory condition.
Recommended:
– observation of a traumatologist
— elastic compression of the lower extremities for 3 months.
- walking on crutches 3 months.
– development of movements of the lower extremities
- tab. Detralex 500 mg. 2 p. per day, 2 months
- tab. cardiomagnyl 1/4 daily for 6 months.

Currently:
Mom walks on crutches, takes prescribed pills and wears compression stockings. Sleeps mainly on the unoperated side and on the stomach. Between the legs always puts a pillow.

Complaints - a week after arriving home (about 10 days after discharge), strong pulling lobes began in the area of ​​the hip joint, in the gluteal region and in the back.

X-rays were taken. pictures of the joint, the surgeon and the orthopedist say that everything with the prosthetic joint is in order, the movement of the joint is normal. They sent me to a neurologist. Neurologist - strong tension muscles of the back and thigh, but nothing can be done - little time has passed after the operation. For pain relief, Movasin was prescribed for severe pain (but they don’t really help).

Tell me please:
1. Can the rejection of the prosthesis start now? And maybe because of this such pain?
2. How can you relax your muscles? Can you give me some painkillers?

forums.rusmedserv.com

The operation to install the prosthesis is over, and the patient hopes to return to a full life very soon. However, surgical intervention does not always have positive results. There are cases when complications appeared in the patient's body after the operation.

Factors that may affect complications after surgery

• Sufficiently advanced age of the patient;
• The presence of concomitant diseases;
• Infections in the hip part of the patient's body;
• transfer abdominal operations in past.

Common Complications

Complications:

• Non-acceptance by the patient's body of a foreign element;
• Infection during surgery;
• Bleeding;
• Incorrect position of the prosthesis;
• Different length of legs;
• The formation of blood clots;
• Increased pain after surgery.

Non-acceptance by the patient of a foreign element

This complication occurs in medical practice quite rare, since before installing the implant, a test is made for acceptance foreign body. If the test shows that the body does not accept this or that prosthesis, then the doctors select another implant.

Infection during surgery

In itself, this complication greatly spoils the reputation of the surgeons who were involved in the installation of the prosthesis. In addition, the disease is severe and requires a very long treatment with antibiotics.

Symptoms of this complication:

• Pain sensations;
• Edema;
• Redness;
• On last stage the formation of a fistula through which purulent fluid flows.

Bleeding

A complication caused by the error of doctors. First aid is blood transfusion. If not in time, death is guaranteed.

Incorrect position of the prosthesis

The patient himself is often to blame for this complication, since he could incorrectly follow or not follow medical recommendations at all.

Different leg lengths

If the prosthesis is not properly installed, the muscles around the femur weaken. The result is a change in the length of the operated leg.

This can be avoided by timely exercise therapy complex. If the exercises are powerless, then a second operation is prescribed.

Thrombus formation

Since the motor activity of the operated leg after surgery is reduced to a minimum, there is a high probability of stagnation of blood in the veins. Stagnation of blood leads to the formation of blood clots.

Therefore, after the operation, it is necessary to use elastic stockings on both legs.

On the first day after the operation, you need to perform simple exercises, take anticoagulants.

Increased pain after surgery

If a person has a wound even with the slightest cut with a knife, then what can we say about the patient's condition after the operation. After any surgical intervention, the operated site hurts. Depending on the level of pain defect, pain is either strong or weak.

The only way out is the use of painkillers prescribed by a doctor.

Endoprosthetics of any joint is a very serious operation. Any complications after it are undesirable, but acceptable. But they should be tolerated, as it is better to feel the pain after the installation of the prosthesis than the pain from the exhaustion of the joints.

Website: msk-artusmed.ru

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Be sure to read other articles:

Arthroscopic resection of the meniscus of the knee

New medical discoveries made possible recovery activity of the lower extremities due to prosthetics of the hip joint. This procedure helps to get rid of debilitating pain and discomfort, restores the functioning of the legs and helps to avoid disability. But sometimes there are different kind complications after hip arthroplasty. Pathologies can develop due to a medical error, infection, non-engraftment of the prosthesis, improper restoration procedures.

Common complications after hip arthroplasty

The operation to replace the hip joint of patients with an artificial one has been carried out for more than thirty years with great success. Such an intervention is especially in demand after hip (neck) fractures, damage to the musculoskeletal system, when the cup wears out due to age-related changes. Regardless of the cost of hip replacement surgery, complications are rare. But with untimely treatment of problems, the patient is threatened with disability, immobility of the lower extremities, and with pulmonary embolism (thromboembolism) - death.

Conventionally, all the causes of the consequences and difficulties of the postoperative period after such prosthetics are divided into several groups:

• caused by non-perception of the implant by the body;
• negative reaction to a foreign body;
• allergy to the material of the prosthesis or anesthesia;
• infection during surgery.

Complications after prosthetics negatively affect not only the thigh area, but also affect the general physical, psychological state, physical activity and walking ability. To restore the former health, it is necessary to undergo a series of rehabilitation measures, which are prescribed based on the developed pathologies and problems. For a quick and effective recovery, it is necessary to establish the causes of complications and restrictions after surgery.

General complications

The development of the medical industry does not stand still, every year there are hundreds of discoveries that can change lives, give a chance to many patients. But complications after surgery are not uncommon. During prosthetics, in addition to specific difficulties, there may be common pathologies:

• Allergy to medications that were used before or during surgery. For example, anesthesia.
• Deterioration of the work of the heart muscle (an operation is always a burden on the heart), which can provoke attacks and diseases of the cardiovascular system.
• Violation of motor activity, which is provoked by the non-perception of a foreign body by the body or an allergy to the implant material (for example, ceramics).

Infection in the area of ​​operation

Quite often, during an arthroplasty operation, such a complication occurs as infection of the soft tissues at the site of the incision or the implant itself. What is the danger of an infectious lesion:

• Arise severe pain in the field of surgical intervention and placement of the endoprosthesis.
• Suppuration, swelling and discoloration are observed at the incision site skin.
• Septic instability of the new joint can become critical, due to which a violation develops. motor function lower limbs.
• Fistula formation with purulent secretions which is especially often observed if timely treatment is not started.

So that complications after prosthetics do not nullify the efforts during the operation, it is necessary to select and start treatment in a timely manner. Taking special antibiotics and using temporary spacers (implants) will help get rid of the infection. The treatment process will be long and very difficult, but the result will please the patient.

Pulmonary embolism

by the most dangerous complication that can develop after the installation of an artificial joint (endoprosthesis) is thromboembolism pulmonary artery. The formation of blood clots is often provoked by the immobility of the leg, which leads to impaired blood circulation in the lower extremities. This disease often ends in death, so you need to carry out preventive measures, for example, take anticoagulants, which are prescribed by a doctor for several postoperative weeks.

blood loss

Bleeding may occur during hip replacement surgery or shortly thereafter. The reasons are medical error, careless movement or abuse of medications that thin the blood. In the postoperative period, anticoagulants are prescribed to prevent thrombosis, but sometimes such caution can play a role. bad joke turning preventive measures into a source of trouble. The patient may need a blood transfusion to replenish supplies.

One of the complications after prosthetics is dislocation of the head of the prosthesis. This complexity is caused by the fact that the endoprosthesis is unable to completely replace the natural joint and its functionality much lower. Falls, improperly performed rehabilitation, performing complex exercises or sudden movements can provoke a dislocation, which will lead to complications. As a result, the work of the musculoskeletal system, the activity of the lower limb will be disrupted.

To avoid complications after arthroplasty, one should be extremely careful in movements in the postoperative period: one should not turn the leg inward too much, its flexion in the hip joint should not be more than 90 degrees. Revision hip arthroplasty will help to eliminate the complication, and for complete healing, it will be necessary to completely immobilize the leg for some time.

Loosening of the endoprosthesis design

As a result of vigorous activity, movements of the legs, loosening of artificial joints occurs. This negatively affects the condition of the bone tissue. Loosening causes destruction of the bone where the endoprosthesis is inserted. Subsequently, such instability of the prosthetic site can lead to a fracture. The only option to prevent loosening is to reduce motor activity, and to eliminate the problem that has already appeared, revision arthroplasty of the hip joint is used.

Lameness

Frequent complication lameness after hip arthroplasty. Such a pathology can develop as a result of some cases:

• Patients who have had a broken leg or femoral neck often experience shortening of one leg after hip replacement surgery, resulting in lameness when walking.
• Long-term immobilization, the state of rest of the lower limb can provoke atrophy of the leg muscles, which will cause lameness.

Helps get rid of complications surgical intervention, during which there is an increase in bone tissue to equalize the length of the legs. Patients and physicians resort to this option extremely rarely. As a rule, the problem is solved by using special insoles, linings in shoes or wearing special shoes with different heights of soles and heels, which are sewn to order.

Groin pain

Rare complication after hip arthroplasty is pain in inguinal region from the surgical intervention. Caused pain can be a negative reaction of the body to the prosthesis, an allergy to the material. Pain often occurs when the implant is positioned anterior section acetabulum. To get rid of the pain syndrome and get used to the new joint will help the implementation of special exercise. If this does not bring the desired result, revision arthroplasty will have to be performed.

Swelling of the legs

After surgery, as a result of keeping the leg at rest for a long time, such a complication as swelling of the lower extremities is often observed. The blood flow, metabolic processes are disturbed, which leads to edema and painful sensations. Taking diuretics, keeping your legs elevated, using compresses that relieve swelling, as well as regular simple exercises will help get rid of such a problem.

Physiotherapy

To get rid of complications after hip arthroplasty, and to make the rehabilitation process as quick and painless as possible, it is necessary to regularly perform physical exercises prescribed by the doctor. Thanks to simple actions the motor activity of the new artificial joint develops, the patient regains the ability to move with his legs without the use of crutches.

A set of exercises for recovery after arthroplasty is selected individually. It takes into account the following factors:

• patient's age;
• activity of the lower limb where the joint was replaced;
• general state patient health;
• psycho-emotional state sick.

When performing physical exercises and while walking, it is important to remember that after surgery, patients are strictly prohibited from:

• crossing legs;
• flexion of the lower extremities in the hip joint by more than ninety degrees;
• twisting the leg to the side.

To make rehabilitation more effective, perform a set of exercises:

1. Take a supine position (a firmer surface is ideal - an elastic mattress or floor), alternately perform a series of simple exercises:

• Bending the legs at the knee joint without lifting the foot from the surface.
• Abduction of the lower extremities to the side (alternately with a leg with an artificial and a natural joint).
• Bike. Raise your legs slightly up and perform movements that simulate riding a two-wheeled pedal vehicle.
• Alternate extension and return to flexed position legs bent at the knees.

1. Change position by turning onto your stomach. In this position, do the following exercises:

• Flexion and extension of the knee joint.
• Raising the leg up.

1. Lying on your side, lift the straight lower limb up, and then take it to the side. Repeat the same exercise on the other side.
2. In a standing position, swing your legs forward, backward and abduct the lower limb to the side.
3. When performing this complex, do not make sudden movements so that the cup of the joint does not pop out, loosen, causing all sorts of complications and pain.

Rehabilitation centers and cost

For rehabilitation and getting rid of complications after arthroplasty, people often choose clinics abroad, preferring sanatoriums or clinics, for example, in Germany, Israel. But on the territory of Russia there are also medical centers where it is possible to undergo recovery after surgery, to cure the pathologies that have arisen after it. There are such clinics in major cities countries, for example, Moscow, Voronezh, St. Petersburg, where qualified doctors work who can assist in rehabilitation.

The cost of rehabilitation measures after hip arthroplasty in different sanatoriums may differ depending on many factors:

• Hospital locations. In sanatoriums located in picturesque corners, the price per day will be much higher than in clinics located on the outskirts of the city.
• Services provided in the clinic. The larger the list of procedures, the higher the cost. Particularly relevant are massage, exercise therapy, classes on special simulators (for example, an exercise bike).
• The comfort of the wards or rooms directly affects the price of living in rehabilitation centers.

Sanatoriums, clinics and the cost of rehabilitation after hip arthroplasty in Moscow and St. Petersburg:

Name of the sanatorium, clinic	Hospital address	Cost of living for 1 person/day, in rubles
Treatment and Rehabilitation Center	Moscow, Ivankovskoe highway, 3
Clinic "K+31"	Moscow, st. Lobachevsky, 42 bldg. 4
Central Institute of Traumatology and Orthopedics. N. N. Pirogova, Federal State Unitary Enterprise	Moscow, st. Priorova, 10
Sanatorium "Dunes"	Primorskoye Highway, 38 km, Saint Petersburg	For recovery after endoprosthetics, methods are used, the effectiveness of which has been proven by many patients: Specialized massotherapy, aimed at postoperative recovery, relief of pain that arose after surgery. Electrotherapy - removes pain and promotes quick recovery. Laser therapy is a procedure that has a beneficial effect on the postoperative suture. Magnetotherapy - promotes tissue regeneration in the area of ​​surgical intervention. The adoption of thermal waters, which contributes to the rapid recovery of the joints, improves their mobility and reduces pain. Physiotherapy, exercise, which is carried out to improve the motor activity of the leg, depending on the physical, psychological and emotional state patient, and is prescribed after a thorough examination. To obtain the maximum result, it is necessary to use all methods in combination. Watch the video to learn more about the methods of dealing with the consequences after arthroplasty:

Dissertation abstractin medicine on the topic Pain syndrome after hip arthroplasty

As a manuscript

DENISOV ALEXEY OLEGOVICH

PAIN SYNDROME AFTER HIP REPLACEMENT

14.01.15 - traumatology and orthopedics

St. Petersburg - 2010

The work was performed at the Federal State Institution “Russian Research Institute of Traumatology and Orthopedics named after A.I. P.P. Harmed by the Federal Agency for High-Tech medical care”(FGU “RNIITO named after R.P. Vreden of Rosmedtekhnologii”),

Scientific adviser: Doctor of Medical Sciences

Shilnikov Viktor Alexandrovich

Official opponents: MD Professor

Linnik Stanislav Antonovich Doctor of Medical Sciences Professor Mashkov Vladimir Mikhailovich Leading organization - St. Petersburg Medical Academy postgraduate education Federal Agency for Health and Social Development.

at a meeting of the dissertation council D.208.075.01 at the Federal State Institution “RNIITO them. P.P. Vreden Rosmedtekhnologii "at the address: 195427, St. Petersburg, st. Academician Baikov, house 8.

The dissertation can be found in the library of the Federal State Institution “RNIITO them. P.P. Harmful of Rosmedtekhnologii.

Doctor of Medical Sciences Professor ^^^^-^"y^ Kuznetsov I.A.

GENERAL CHARACTERISTICS OF THE WORK Relevance of the study

In recent decades, arthroplasty has become one of the main methods of treating patients with severe pathological changes of the hip joint (Kuzmenko V.V., Fokin V.A., 1991; Shaposhnikov Yu.G., 1997; Zagorodniy N.V., 1998; Voloshenyuk A.N., Komarovsky M.V., 2004; Volchenko D. V., Kim N.I., 2006; Parakhin Yu.V., 2006; Shapovalov, V.M. et al., 2008; Harris W., 2009; Morsher E.W., 2003; Heisel C. et al., 2007 ).

However, despite the immediate success of surgical treatment, long-term positive results after arthroplasty are observed only in 76-89% of operated patients (Hailer N.P. et al., 2010).

Among the factors that significantly reduce the quality of life of patients after surgery, there are instability, infections, dislocations, neurological diseases and pain syndrome (Vorontsov A.V., 1992; Finger A.B. et al., 1996; Novik A.A. et al., 2000; Kolesnik A.I., 2002; Akhtyamov I.F., Kuzmin I. .I., 2006; Akhtyamov, I.F. et al., 2007).

According to the registries of endoprosthesis replacement and foreign sources of literature, 17-20% of patients who underwent total hip replacement surgery still have pain, and 32-35% in the period of observation from one to 10 years, in the absence of instability and infection, new sensations are noted. in the form of mild pain or discomfort in the hip joint (Khan N.Q., 1998; Jones C. et al., 2001; Huo M., 2002; Danish Hip Arthroplasty Register, 2003; Bozic K „ 2004; Graves S.E. et

al., 2004; Swedish Hip Arthroplasty Registry, 2006; Bohm E.R. et al., 2010)

Foreign and domestic authors do not have a unanimous opinion on this issue, there is no adequate classification of pain after hip arthroplasty, the nature of its occurrence has not been studied, and differential diagnosis has not been developed, except for cases of instability and infection.

Even experienced doctors far from always being able to differentiate pain, prescribe adequate treatment, not knowing the clear etiopathogenesis of the pain syndrome in each case. This task is especially difficult for outpatient specialists, for whom the presence of an endoprosthesis in itself is a determining etiological factor of pain.

Preserved or newly emerged pain syndrome levels the achieved positive result endoprosthetics, since it is pain relief that is the dominant motive in the patient's decision to agree to surgical treatment.

It is known that the results of surgical treatment largely depend on initial state joint. Therefore, in the leading clinics of the world, more and more operations are performed at the early stages of hip joint damage, when the pain has not yet reached a permanent debilitating nature. After all, the persistence, and even more so the emergence of a new, even if insignificant pain syndrome, causes a negative reaction in patients up to litigation.

Thus, all of the above determines the relevance of this study.

Research objectives:

3. To develop the basics of differential diagnosis of pain syndrome that develops after implantation of an artificial joint.

4. Determine the methods of prevention of pain after hip replacement.

Scientific novelty

5. A method has been developed for the prevention of radiating pain in the knee joint in the postoperative period of hip arthroplasty (RF patent No. 2371128 dated October 27, 2009).

Practical significance

On the basis of the conducted studies, evidence-based criteria for the differential diagnosis, prevention and treatment of pain after hip arthroplasty have been developed. It has been established that the planning of the operation, the correct orientation of the components of the endoprosthesis and the correction of the length of the limb are extremely important for the prevention of pain.

The identified causes of pain after hip arthroplasty and the developed algorithms for their differential diagnosis, prevention and treatment will improve the results of hip arthroplasty, reduce the number of revision operations caused by pain, reduce the number of disabled people, increase the number of good and excellent results and, accordingly, the number of able-bodied patients. population.

Basic provisions for defense

1. After hip arthroplasty, 50-73% of patients have pain syndrome or new pain sensations.

2. The intensity of the pain syndrome after primary operations of hip arthroplasty is mild and moderate.

3. The appearance of pain syndrome often depends on incorrect installation of the endoprosthesis components and incorrect changes in the length of the lower limb.

4. The developed bases for the differential diagnosis of pain after hip arthroplasty make it possible to identify the source and cause of pain and enable surgeons to take preventive measures and conduct adequate treatment in each specific case.

Approbation and implementation of the research results

The main provisions of the dissertation are reported on scientific and practical conference with international participation "New Technologies in Traumatology and Orthopedics" (St. Petersburg, 2008), annual conferences "Vreden Readings" (St. Petersburg, 2007, 2009), International Conference "Traumatology and Orthopedics of the Third Millennium" (Chita-Manzhuria, 2008), at the 1215th meeting of the Society of Traumatologists and Orthopedists of St. Petersburg and the Leningrad Region (St. Petersburg, 2010), a conference of young scientists of the North-Western federal district"Actual Issues of Traumatology and Orthopedics" (St. Petersburg, 2010), IX Congress of Traumatologists and Orthopedists of Russia (Saratov, 2010).

The developed "Pain Syndrome Questionnaire", "Method for Prevention of Radiating Pain in the Knee Joint after Hip Arthroplasty", the basics of differential diagnosis are used in the clinical practice of FGU RNIIT named after A.I. P.P. Harmful.

The structure and scope of the dissertation

The dissertation is presented on 160 pages of text typed on a computer, consists of an introduction, four chapters, a conclusion, conclusions, practical advice and a list of references, which includes 240

sources, including 61 domestic and 179 foreign. The text is illustrated with 4 tables and 71 figures.

The introduction substantiates the topic, defines the purpose of the study, its objectives and provisions submitted for defense, indicates the practical significance and scientific novelty of the work in the detection, differential diagnosis, prevention and treatment of pain after hip replacement surgery.

In the first chapter, an analytical review state of the art question on the topic of the dissertation based on data from domestic and foreign literature. Considered general issues the concept of "pain", methods of its study, the etiology of pain after hip arthroplasty. The evolution of the study of pain syndrome after this type of high-tech medical care is traced. The need for further research is identified.

The second chapter presents methods for examining patients, describes the clinical material and methods of statistical processing.

The basis of the study performed at the Federal State Institution "Russian Research Institute of Traumatology and Orthopedics named after A.I. R.R. Vreden Rosmedtekhnologii” in the period from 2007 to 2010, were the results of observation of patients who underwent hip arthroplasty.

1000 patients were examined at various times after surgery: 2 weeks, 3, 6, 12 months or more, including 591 (59.1%) women and 409 (40.9%) men. The age of the patients varied from 18 to 80 years, on average 52.5±13.5. Patients with instability of endoprosthesis components and infectious complications were excluded from the study.

All patients underwent unilateral primary hip arthroplasty. The indications for surgery were: idiopathic coxarthrosis 3 tbsp. - 629 patients (62.9%), aseptic necrosis of the femoral head - 257 (25.7%), dysplastic coxarthrosis - 50 (5%), fractures and false joints of the femoral neck - 64 (6%). The primary operation was performed using a posterolateral or Harding approach.

All patients underwent clinical examination with the additional use of the Harris scale, radiography of the hip joint in two projections (the angles of the lateral inclination of the acetabular component, the angle of anteversion, the angle of the femoral component, the offset value were measured; the length of the limb was measured before and after the operation), laboratory research(if necessary), neurological examination. Assessment of pain syndrome according to subjective factors was based on the use of a specially developed "Pain Syndrome Questionnaire", which patients independently filled out before discharge from the hospital (usually 2 weeks after surgery) and at consultative visits at various times after surgery (after 3, 6 months , after 1 year or more).

The study revealed 9 most common localizations of pain syndrome: inguinal region, lumbosacral spine, anterior thigh, upper lateral, middle lateral, lower lateral, posterior thigh, knee joint, gluteal region.

A statistical analysis of the combination of pain syndrome of each localization with clinical and radiological signs as possible etiological factors of pain was carried out using

non-parametric statistics methods: /2, Pearson, Fisher's test, Mann-Whitney, median chi-square and ANOVA module.

Also carried out correlation analysis the intensity of the pain syndrome depending on the change in the angle of the lateral inclination of the acetabular component, the angle of varus and flexion deviation of the femoral component, the magnitude of the offset, the angle of anteversion of the acetabular component, the change in the magnitude of excessive elongation and/or the elimination of shortening of the lower limb.

To confirm the statistical results, all patients were divided into groups according to a homogeneous radiographic feature (107 patients were excluded from the analysis as not meeting this requirement):

Group 1: patients with incorrect positioning of endoprosthesis components (n=193);

Group 2: patients with excessive lengthening of the lower limb after surgery by more than 1 cm (n=102);

The third group: patients with elimination of the shortening of the lower limb by more than 1 cm (n=110);

Group 4: patients with standard placement of endoprosthesis components and without anatomical disorders (n=488).

In these groups, a statistical analysis of the combination with each localization of the pain syndrome was also carried out.

Based literary sources and own observations, other possible reasons pain of one or another localization, among them impingement of t. iliopsoas, femoral nerve damage, damage to the lateral cutaneous nerve of the thigh, syndrome piriformis muscle, tenopathy of the gluteal muscle group.

Given the presence a large number etiological factors pain syndrome of each localization and their possible combination, for the reliability of the data, a multivariate analysis using classification trees to identify the dominant cause.

The third chapter presents the results of statistical processing of the data obtained, the etiology and pathogenesis of pain are identified, algorithms for differential diagnosis are developed for each localization of the pain syndrome; methods of prevention and possible treatment of pain after surgery are proposed.

In the analysis of all 1000 examined patients, the frequency of pain syndrome in different dates after hip arthroplasty was 73%, among which 41% were new pain sensations, 10% - preserved, 22% - a combination of new and preserved pain sensations. And only 27% (270) of patients had no complaints.

The assessment of functional results on the Harris scale was, on average, after 3 months. 83 points, after 1 year - 92-94 points. Thus, the majority of patients achieved high functional results. Almost all patients are satisfied with the results of hip arthroplasty.

With the help of questionnaires and visual analogue scales, the average intensity of the pain syndrome was revealed at various times.

It should be noted that after the operation, the intensity of the pain syndrome, determined on a ten-point scale, significantly decreased: from 7 to 2 points. In addition, patients with high pain intensity accounted for minimal amount(8 patients, 0.8%). Patients with mild and medium degree intensity.

Analysis of localizations showed the prevalence of pain in the lumbosacral region (14.9%) and the greater trochanter (14.1%). Pain in the inguinal region was complained of by 11.6% of patients, along the anterior surface of the thigh - by 9.7%; mid-lateral surface of the thigh - 9.6%; in the knee joint - 6.8%; back of the thigh -5.6%; gluteal region - 4.7%; inferolateral surface of the thigh -3.5%.

Held comparative analysis and statistical processing of pain syndrome localizations in groups revealed statistically significant differences, and fluctuations in the frequency of occurrence of various pain syndrome localizations in groups indicate that the characteristics of the groups are one of the etiological factors of pain syndrome.

Pain in the anterior thigh

Out of all 1000 patients, pain syndrome along the anterior surface of the thigh was observed in 132 (13.2%), of which 97 patients complained of new pain sensations.

Statistical analysis of the combination of pain syndrome along the anterior surface of the thigh with radiological signs in 97 patients was carried out. The highest incidence of pain syndrome was found in the case of lengthening of the lower limb - 46 patients (47.4%), with the elimination of shortening of the limb - 20 (20.4%), (p<0,001) и при флексионном положении бедренного компонента - 17 (17,5%).

A high correlation between the change in the intensity of the pain syndrome and the lengthening of the lower limb was also revealed. A correlation was also established between the angle of the flexion position of the femoral component of the endoprosthesis and the intensity of the pain syndrome along the anterior surface of the thigh (correlation coefficient Gamma = 0.66).

With excessive lengthening of the lower limb, pain along the anterior surface of the thigh occurs during extension in the hip joint and

aggravated by flexion at the knee, which is due to the tension of the anterior muscle group, the broad fascia of the thigh, etc. iliopsoas.

Differential diagnosis should be carried out with the flexion position of the femoral component, damage to the femoral nerve, damage to the roots of the spinal nerves.

With the flexion position of the femoral component, the pain syndrome is localized mainly along the anterior surface of the thigh in the projection of the local contact of the endoprosthesis leg with the anterior surface of the medullary canal.

The pain increases with the load on the limb, gradually becoming more pronounced and intense. On palpation of the middle third of the thigh in the projection of the end of the femoral component, pain is determined. The diagnosis is established on the basis of a characteristic x-ray picture when a picture is taken in a lateral projection.

With damage to the femoral nerve, pain along the anterior surface of the thigh often occurs at rest and spreads over its entire surface, which was observed in 8 (8.2%) patients out of 97 with pain of this localization. The reason may be excessive distraction during the reduction of the head of the endoprosthesis in the process of endoprosthesis replacement and compression of the nerve with retractors. In addition, radiating pain can give similar symptoms when the roots of L2-

Pain in the lateral thigh area

Greater trochanter area

Of 1000 patients, pain on the upper lateral surface of the thigh was observed in 174 (17.4%), of which 141 patients complained of new pain sensations.

Statistical analysis of the combination of pain in the region of the greater trochanter with radiological signs in 141 patients was carried out. Most often, pain syndrome occurred with excessive offset of the endoprosthesis components - 56.7% of cases (80 patients), while with insufficient offset - only 12.8% (18) (p<0,001).

Excessive offset was detected in 112 patients, with 80 of them (71%) complaining of pain in the greater trochanter. Insufficient offset was detected in 52 patients, 18 of which (34.6%) also complained of pain in the greater trochanter.

With excessive or insufficient offset created during hip arthroplasty, pain, as a rule, was localized in the projection of the greater trochanter and in the region of the iliac wing.

The etiopathogenesis of these pains is due to an increase in the distance from the top of the greater trochanter to the center of the acetabulum, which, in turn, is accompanied by tension of the middle and small gluteal muscles. Their long-term tension without preventive and therapeutic measures leads to trophic disorders, mainly in the areas where the muscle connects to the bone, with the subsequent development of clinical manifestations of gluteal muscle tenopathy, which in this study was detected in 40 (28.4%) patients out of 141 with pain in areas of the greater trochanter. Tenopathy is characterized by the presence of local pain and tenderness detected by palpation in the outer part of the gluteal region near the greater trochanter.

In addition, in 8 (5.7%) patients out of 141 with pain in the greater trochanter, the pain syndrome along the upper lateral surface was due to damage to the lateral femoral cutaneous nerve.

Mid-lateral surface of the thigh

When examining all 1000 patients, pain in the middle third of the thigh was detected in 122 (12.2%) patients, of which new pain sensations appeared in 96.

Statistical analysis of the combination of pain in the medial lateral surface of the thigh with radiological signs was carried out in 96 patients. The most common pain syndrome was noted in the varus position of the femoral component of the endoprosthesis - 31.2% (30 patients) (p<0,001).

In the present study, 42 patients with varus position of the femoral component were identified, 30 (71.4%) of whom complained of pain in the medial lateral surface of the thigh.

Inferolateral thigh

When examining all 1000 patients, 43 patients (4.3%) complained of pain in the lower lateral surface of the thigh. Of these, new pain occurred in 35 patients.

Statistical analysis of the combination of pain in the lower lateral surface of the thigh with radiological signs in 35 patients was carried out. The highest incidence of pain syndrome was found in the varus position of the femoral component of the endoprosthesis - 37.1% (13 patients).

It is necessary to differentiate the pain syndrome in the region of the lateral surface of the thigh with the defeat of the b5 root.

Pain in the lumbosacral spine The analysis revealed persistent pain in 151 (15.1%) and new pain sensations in 149 (14.9%) out of 1000 examined patients. A statistical analysis of the combination of pain syndrome in the lumbosacral spine with X-ray

signs in 149 patients. The highest frequency of occurrence of pain syndrome was revealed: in case of lengthening of the lower limb after surgery - in 71 patients (47.7%) and in case of elimination of shortening of the lower limb by more than 1 cm - in 33 (22.2%) (p<0,001).

It is necessary to differentiate the pain syndrome in the lumbosacral region with damage to the roots, in which pain radiates to the lower extremities up to the toes.

Pain in the knee joint

Out of 1000 examined patients with pain syndrome in the area of ​​the knee joint, 69 (6.9%) patients had preserved pain and 68 (6.8%) had new pain sensations.

New pain sensations appear immediately after the arthroplasty operation in the form of radiating pains in the knee joint both at rest and during movement.

It is known that the region of the knee joint and the fat body of the acetabulum are innervated by the common branches of the obturator nerve. Taking into account the nature and localization of the pain syndrome, it can be assumed that one of the causes of radiating pain in the knee joint after hip arthroplasty is irritation of the small branches of the obturator nerve in the area of ​​the fat body.

Characterized by aching pains on the anterior and inner surfaces of the knee joint. It should be noted that pain in the knee joint associated with irradiation of the obturator nerve occurs, as a rule, in the early postoperative period and stops by 2-3 months.

We have developed a method for the prevention of radiating pain in the knee joint after hip arthroplasty (RF patent No. 2371128 dated October 27, 2009).

Pain in the gluteal region

Pain in the gluteal region was observed in 86 (8.6%) patients out of 1000 examined, of which 48 patients complained of new pain sensations.

Statistical analysis of the combination of pain in the gluteal region with radiological signs in 48 patients was carried out. The highest frequency of occurrence of pain syndrome was revealed: in case of insufficient offset of the femoral component - in 17 patients (35.4%) (p<0,001), при недостаточной антеверсии ацетабулярного компонента эндопротеза - у 8 (16,7%).

With insufficient offset, pain in the gluteal region is quite pronounced when moving. The diagnosis is established on the basis of a characteristic x-ray picture.

With insufficient anteversion of the acetabular component, the pain syndrome usually appears in the early stages after surgery and is aggravated by excessive bending, sitting on low chairs.

It is necessary to differentiate these complaints from the piriformis syndrome, which was noted in the present study in 7 (14.6%) patients out of 48 patients with pain of this localization.

It should be noted that due to the cutoff of the piriformis muscle from the greater trochanter during hip arthroplasty, this pain syndrome occurs only 3 months after the operation. With the defeat of the roots, pain in the gluteal region also occurs.

Pain in the back of the thigh

Pain on the back of the thigh was observed in 70 (7%) out of 1000 examined patients, of which 56 people noted new pain sensations.

Statistical analysis of the combination of pain on the back of the thigh with radiological signs in 56 patients was carried out. The highest frequency of occurrence of pain syndrome was detected when the shortening of the lower limb by more than 1 cm was eliminated - in 10 (17.9%) patients (p<0,05).

Characteristic symptoms are the appearance of pain on the back of the thigh when flexing at the hip joint and simultaneously extending at the knee.

Pain in the groin

When examining 1000 patients, pain in the inguinal region was observed in 165 (16.5%). 116 patients (11.6%) complained of new pain sensations, 49 (4.9%) patients had old pains.

Statistical analysis of the combination of pain syndrome in the inguinal region with X-ray data in 116 patients was carried out. The highest incidence of pain was found with lengthening of the lower limb from 1 to 4 cm - in 56 (48.3%) patients; with a vertically installed acetabular component of the endoprosthesis (compared to other options for installing endoprosthesis components) - in 23 (19.8%) (p<0,001), при избыточной антеверсии ацетабулярного компонента - у 7 из 116 (6%) с болями в данной локализации.

The correlation analysis of pain syndrome intensity depending on the lengthening of the lower limb illustrates a high correlation between the increase in pain intensity and the increase in limb length. The correlation coefficient was 0.8. The change in the angle of inclination of the acetabular component was correlated with the degree of intensity of the pain syndrome. Correlation coefficient Gamma= 0.66.

Pain in the groin area caused by elongation of the operated limb, as a rule, is combined with pain in the lumbosacral

spine, which may be associated with the formation of a secondary pelvic obliquity when the abductor muscle group is stretched. Pain in the groin area is aggravated by extension of the hip joint. Etiopathogenesis is due to the tension of the anterior muscle group, fascia of the thigh and m.iliopsoas.

With a vertically installed acetabular component of the endoprosthesis, pain in the groin occurs a short time after walking, increases in the position of adducting the hip and when resting on the operated limb, often combined with pain along the anterior upper surface of the thigh and in the supratrochanteric region. The diagnosis is established on the basis of characteristic symptoms in combination with radiographs of the hip joint.

Differential diagnosis should be carried out with T. iliopsoas impingement, which was observed in 38 (32.8%) patients out of 116 with pain in the inguinal region. Verification of impingement is based on the characteristic symptoms.

Pain in the groin usually occurs with active flexion, external rotation, and passive internal rotation, such as getting up from a chair or leaving a car. The diagnosis can be established by the characteristic symptoms described above, as well as using an MRI study.

Differential diagnosis of pain in the inguinal region should also be carried out with options for excessive anteversion of the acetabular component. Pain in the groin here occurs with both passive and active external rotation and is aggravated by pressure on the proximal femur from back to front.

Some pain in the groin may persist even after arthroplasty. These include irradiating radicular

pain with lesions at the level of the L2-L5 segments, which manifest themselves in the inguinal region and the anterior surface of the thigh.

In addition, persistent pain in the groin area may be due to inguinal and femoral hernias, the distinguishing feature of which is aggravation with coughing and heavy lifting, cancer, and abdominal aortic aneurysm (Duffy P.J. et al, 2005).

Based on the principle of mutual exclusion based on the totality of clinical and radiological data, we have developed algorithms for differential diagnosis for each localization of the pain syndrome (Fig.).

Groin area

Rule out neurology

rule out infection

Rg-control

Increase I, ESR, CRP,

leukocytosis, constant pain, did not appear immediately after the operation.

Damage to the roots Pain occurs during extension and external rotation of the thigh, often combined with irradiation to the medial surface of the thigh, knee joint and upper third of the lower leg, sometimes accompanied by a feeling of numbness in certain areas

Aseptic instability

Vertically placed acetabular component: pain occurs shortly after walking, increases in the position of Adduction of the bepp and leaning on the affected limb_,

Excessive anteversion of the acetabular component: pain with severe external rotation and aggravated by pressure on the proximal femur

Behind napeoen

Lengthening of the lower limb: the pain is aggravated by extension in the hip joint. Often combined with pain on the anterior surface ^edpa._,

Impingement sh.yurvoav: pain during active flexion, external rotation and passive internal rotation. Example: getting up from a chair or exiting a car.five_

Rice. Algorithm for the differential diagnosis of pain syndrome on the example of the inguinal region

The fourth chapter presents the developed ethnopathogenetic classification, which allows you to correctly formulate the diagnosis, as well as identify the cause of the pain syndrome in order to choose the right tactics for further treatment.

/. lingering pains

1. Irradiating: a) vertebrogenic; b) somatic.

2. Arthrogenic (arthritis, synovitis).

II. New pain sensations

1. Positional pain - a group of pain symptoms caused by the vicious position of the endoprosthesis components.

2. Adaptive - a group of pain symptoms associated with changes in anatomical parameters in the hip joint.

3. Contact paraarticular pain.

4. A group of pain symptoms of a neurogenic nature.

5. Neuropathic pain (in the suture area).

6. Incongruent pain (psychogenic).

7. A group of pain symptoms associated with the instability of the elements and/or with septic inflammation in the area of ​​the endoprosthesis.

Thus, based on a survey of 1000 patients who underwent hip arthroplasty, it was found that up to 73% of patients complain of pain, in most cases (91%) of mild to moderate intensity.

In the course of statistical, clinical and radiological evaluation of data and features of symptoms, the most common causes of pain of each localization were identified, an ethnopathogenetic classification of pain after hip arthroplasty and algorithms for its differential diagnosis were developed.

This allows not only to diagnose the cause of pain in a timely manner, but also to take measures to relieve the pain syndrome, to carry out targeted prophylaxis, and to assess the importance of adhering to the surgical technique and correct positioning of the endoprosthesis components.

1. The operation of hip arthroplasty significantly improves the quality of life of patients, but does not always completely relieve the patient from pain. In 70% of patients after surgery, preoperative pain persists or new pain sensations of mild severity appear.

2. Pain syndrome after hip arthroplasty can be of different localization and differ in frequency of occurrence and intensity. The most common localization is pain in the lumbosacral spine and the region of the greater trochanter, associated with the elimination of shortening of the lower limb or with excessive lengthening.

3. Each localization of the pain syndrome is characterized by certain etiopathogenetic factors with their own clinical and radiological features. A high correlation was found between the increase in the intensity of the pain syndrome and the lengthening of the lower limb and the change in offset.

4. Algorithms for the differential diagnosis of each localization of the pain syndrome can be based on the principle of mutual exclusion based on the totality of clinical and radiological data.

5. Prevention of pain syndrome consists in planning, observing the operation technique, including the correct orientation of the endoprosthesis components and an adequate change in the length of the limb, and the tactics of postoperative management of patients with pain

syndrome should be determined on the basis of the identified etiopathogenetic factors and aimed at eliminating the pain syndrome, which improves the results of the operation.

1. To assess the results of hip arthroplasty from the standpoint of the presence of pain syndrome, it is advisable to use the developed "Pain Syndrome Questionnaire" and modified visual analogue scales.

2. In order to prevent the occurrence of pain syndrome, the correct orientation of the endoprosthesis components and the correct change in the length of the lower limb using guides are necessary, and in difficult cases, X-ray control on the operating table.

1. Shilnikov V.A., Denisov A.O. Pain syndrome on the background of an arthroplasty of the hip joint // Traumatology and Orthopedics of the Third Millennium: International Conference. - Chita, 2008. - S. 246-248.

2. Shilnikov V.A., Denisov A.O. Prevention of radiating pain in the knee joint after total hip replacement // Traumatology and Orthopedics of the Third Millennium: International Conference. - Chita, 2008. - S. 251-252.

3. Shilnikov V.A., Tikhilov R.M., Denisov A.O. Pain syndrome after hip arthroplasty // Traumatology and Orthopedics of Russia. - 2008. - No. 2. - S. 106-109.

4. Shilnikov V.A., Denisov A.O., Baiborodov A.B. Subjective assessment by patients of the results of hip arthroplasty // Traumatology and Orthopedics of Russia. 2008. - No. 4 (appendix). - S. 145.

5. Shilnikov V.A., Denisov A.O., Baiborodov A.B. Possible causes of pain after hip arthroplasty. Endoprosthetics of large joints: abstracts of the national congress "Man and his health". - SPB., 2009. - S. 134.

6. Denisov A.O., Shilnikov V.A., Baiborodov A.B., Yarmilko A.V. Prevention of radiating pain after hip arthroplasty // Traumatology and Orthopedics of Russia. - 2009. - No. 3. - S. 125-126.

7. Denisov A.O. Pain on the background of an arthroplasty of the hip joint // Topical issues of traumatology and orthopedics: materials of the conference of young scientists of the North-Western Federal District. -SPb., 2010.-S. 34.

8. Denisov A.O., Shilnikov V.A., Baiborodov A.B. Etiopathogenesis of pain syndrome after hip arthroplasty // Collection of abstracts of the IX Congress of traumatologists and orthopedists of Russia. - Saratov, 2010.-T. 1.-S. 364.

1. Pat. 2371128 RF (51) IPC A61 B17/56. A method for the prevention of radiating pain in the knee joint in the postoperative period of hip arthroplasty / Shilnikov V.A., Baiborodov A.B., Denisov A.O. ; Patent holder FGU RNIIT them. P.P. Harmed by Rosmedtekhnologii. - No. 2008121932/14; dec. 05/26/2008; publ. 27.10.2009, Bull. No. 30.

Signed for printing on 15.09.2010. Format 60x84/16 R. l. 1.5 Uch.-ed.l 1.5. Tyr. 100 copies Printed in the printing house of Turusel LLC 191186, St. Petersburg, st. Millionnaya d.

Chapter 1. LITERATURE REVIEW.

1.1. The concept of pain, history and methods of its study.

1.2. History of the study of pain syndrome after hip arthroplasty.

1.3. Modern view of the problem. Possible causes of pain syndrome.

1.4. Methods for diagnosing pain syndrome after arthroplasty.

1.5. Reflection of pain syndrome in registries of arthroplasty

1.6. Pain associated with septic inflammation in the area of ​​the endoprosthesis.

1.7. Pain associated with the instability of the elements of the endoprosthesis.

Chapter 2. MATERIALS AND METHODS.

2.1. Distribution of patients by radiological sign.

2.2. Methods of statistical processing of material.

Chapter 3. RESULTS OF THE RESEARCH.

3.1. Pain in the groin.

3.1.1. Statistical processing.

3.1.2. Symptoms, etiology, pathogenesis, differential diagnosis.

3.1.3. Algorithm for differential diagnosis.

3.1.4. Prevention and treatment.

3.2. Pain in the anterior thigh.

3.2.1. Statistical processing.

3.2.2. Symptoms, etiology, pathogenesis, differential diagnosis.

3.2.3. Algorithm for differential diagnosis.

3.2.4. Prevention and treatment.

3.3. Pain on the lateral surface of the thigh.

3.3.1. Statistical processing.

3.3.2. Symptoms, etiology, pathogenesis, differential diagnostics 92.

3.3.3. Algorithm for differential diagnosis.

3.3.4. Prevention and treatment.

3.4. Pain syndrome in the lumbosacral spine and sacroiliac joint.

3.4.1. Statistical processing.

3.4.2. Symptoms, etiology, pathogenesis, differential diagnosis.

3.4.3. Prevention and treatment.

3.5. Pain syndrome in the knee joint.

3.5.1. Statistical processing.

3.5.2. Symptoms, etiology, pathogenesis, differential diagnosis.

3.5.3. Prevention and treatment.

3.6. Pain syndrome in the gluteal region.

3.6.1. Statistical processing.

3.6.2. Symptoms, etiology, pathogenesis, differential diagnosis.

3.6.3. Algorithm for differential diagnosis.

3.6.4. Prevention and treatment.

3.7. Pain in the back of the thigh.

3.7.1. Statistical processing.

3.7.2. Symptoms, etiology, pathogenesis, differential diagnosis.

3.7.3. Algorithm for differential diagnosis.

3.8. Pain in the seam.

Chapter 4. ETIOPATOGENETIC CLASSIFICATION

PAIN SYNDROME.

Dissertation Introductionon the topic "Traumatology and Orthopedics", Denisov, Alexey Olegovich, abstract

The relevance of research

Treatment and rehabilitation of orthopedic patients with degenerative-dystrophic lesions of the hip joint is an important medical, social and economic problem. Pathology of the hip joint remains the most common cause of temporary disability, and disability, according to various authors, ranges from 7 to 37.6% of all disabled people with lesions of the musculoskeletal system (Sherepo K.M. et al. 1990; Buachidze O.Sh., 1994; Buachidze O. Sh. et al., 1997, 2002; Neverov V. A. et al., 1997; Tankut V. A., 1999; Moskalev V. P., 2001; Sidorenko O. A., 2002; Volokitina E. A., 2005; Nadeev A.A., 2006; Rozhnev E.V., 2007).

In recent decades, arthroplasty has become one of the main methods of treating patients with severe pathological changes in the hip joint (Kuzmenko V.V., Fokin V.A., 1991; Shaposhnikov Yu.G., 1997; Zagorodniy N.V., 1998; Voloshenyuk A.N., Komarovsky M.V., 2004; Volchenko D.V., Kim N.I., 2006; Parakhin Yu.V., 2006; Shapovalov, V.M. et al., 2008; Muller M. E., 1970).

Total hip arthroplasty is considered one of the most revolutionary achievements in orthopedic surgery. In terms of reducing pain, correcting deformity and restoring functions, this operation is unparalleled: no surgical intervention had such profound social consequences and did not bring such a striking early effect (Stillwell W.T., 1987).

However, despite * the immediate successes of surgical treatment achieved (according to the Swedish register of arthroplasty and other foreign sources (for 2006-2008), long-term positive results after arthroplasty are noted only in 76-89% of operated patients (Hailer N.P. et al ., 2010).

Among the complications that significantly reduce the quality * of life of patients after surgery, there are instability, infections, dislocations, neurological diseases and pain syndrome (Vorontsov A.V., 1992; Palchik A.B. et al., 1996; Novik A.A. et al., 2000; Kolesnik A.I., 2002; Akhtyamov I.F., Kuzmin I.I., 2006; Akhtyamov, I.F. et al., 2007).

But according to the registries of endoprosthesis replacement1 and foreign sources of literature, in 17-20% of patients who underwent total hip replacement surgery, pain persists, and in 32-35% in the observation period from one to 10 years in the absence of instability and infectious process5 new sensations in the form of a mild pain syndrome "or discomfort in the hip joint (Khan N.Q., 1998; Jones G. et al., 2001; Huo M., 2002; Danish Hip Arthroplasty Register, 2003; Bozic K., 2004; Graves S.E. et al., 2004; Swedish Hip Arthroplasty Registry, 2006; Böhm E.R. et al., 2010).

In authoritative foreign and domestic publications, there is no consensus on this issue, there is no adequate classification of pain after hip arthroplasty, the nature of its occurrence has not been studied, and differential diagnosis has not been developed, except for cases of instability and infection.

Even experienced doctors are far from always able to differentiate pain, prescribe adequate treatment, without knowing the clear etiopathogenesis of the pain syndrome in each case.

This task seems especially difficult for outpatient specialists, for whom the presence of an endoprosthesis is in itself a determining etiological factor that causes pain.

At the same time, pain during hip arthroplasty is not always caused by the operation, but is a reflection of comorbidity.

The remaining "or newly emerged pain syndrome levels the achieved positive result of arthroplasty, since it is pain relief that is the dominant motive when the patient decides to agree to surgical treatment."

It is known that the results of surgical treatment largely depend on the initial state of the joint. Therefore, in the leading clinics of the world, more and more operations are performed at the early stages of damage to the hip joint, when the pain has not yet reached a permanent debilitating character. After all, the persistence, and even more so the emergence of a new, even if insignificant pain syndrome, causes a negative reaction in patients up to litigation.

Thus, all of the above determines the relevance of this study.

The purpose of the study was to improve the results of treatment by developing the basis for the differential diagnosis of pain after hip arthroplasty.

Research objectives

1. Systematize the nature and localization of the pain syndrome based on statistical processing of clinical material.

2. To identify possible causes of pain syndrome in patients after hip arthroplasty.

3. To develop the basics of differential diagnosis of pain syndrome after implantation of an artificial joint.

4. Determine - methods for preventing pain after hip replacement.

5. To develop tactics for postoperative management of patients who underwent hip arthroplasty in the event of pain syndrome, depending on its etiopathogenetic factors.

Scientific novelty

1. For the first time, statistical processing of data from the study of pain syndrome in patients after hip arthroplasty was performed.

2. For the first time, the causes of some pains after hip arthroplasty were identified.

3. For the first time in Russia, an etiopathogenetic classification of pain syndrome after hip arthroplasty has been developed.

4. Fundamentals of differential diagnosis and prevention of pain syndrome after hip arthroplasty have been developed.

5. A method has been developed for the prevention of radiating pain in the knee joint in the postoperative period of hip arthroplasty (patent No. 2371128 dated October 27, 2009).

6. A method for assessing pain after hip arthroplasty has been developed.

Practical significance

On the basis of the conducted studies, evidence-based criteria for differential diagnosis, prevention and treatment of pain syndrome after hip arthroplasty1 have been developed;

It has been established that the planning of the operation, the correct orientation of the components of the endoprosthesis and the correction of the length of the limb are extremely important for the prevention of pain.

The identified causes of pain after hip arthroplasty and the developed algorithms for their differential diagnosis, prevention and treatment will improve the results! hip arthroplasty, reduce the number of revision surgeries due to pain, reduce the number of disabled people, increase the number of good and excellent results and, accordingly, the number of the working population.

Approbation of work

The main provisions of the dissertation were reported at the scientific-practical^ conference with international participation "New technologies in traumatology and orthopedics" (St. Petersburg, 2008), the annual conferences "Vreden's Readings" (St. Petersburg, 2007, 2009), the International Conference "Traumatology and Orthopedics of the Third Millennium” (Chita-Manzhuria, 2008), at the 1215th meeting of the Society1 of Traumatologists and Orthopedists of St. Petersburg and the Leningrad Region (St. Petersburg, 2010), the conference of young scientists of the Northwestern Federal District “Actual Issues of Traumatology and Orthopedics” (St. Petersburg, 2010 ), IX Congress of Traumatologists and Orthopedists of Russia (Saratov, 2010).

Practical use of research results

Developed - "Questionnaire of pain syndrome", "Method of prevention of radiating pain in the knee joint after hip arthroplasty", the basics of differential diagnosis are used in clinical practice of FGU RNIIT named after A.I. P.P. Harmful.

Scope and structure of the dissertation

The dissertation, presented on 160 pages of text typed on a computer, consists of an introduction, four chapters, a conclusion, conclusions, practical recommendations and a list of references, which includes 61 works by domestic and 179 foreign authors. The text is illustrated with 4 tables and 71 figures.

Conclusion of the dissertation researchon the topic "Pain syndrome after hip arthroplasty"

D. The operation of hip arthroplasty significantly improves the quality of life of patients, but not always, completely relieves the patient of pain. In 70% of patients, preoperative pain persists after * operation or * new pain sensations of mild severity appear.

2. Pain syndrome after hip arthroplasty can be of different localization and differ in frequency of occurrence and intensity. The most common localization is pain in the lumbosacral spine and the region of the greater trochanter, associated with the elimination of shortening of the lower limb or with excessive lengthening.

3. Each localization of the pain syndrome is characterized by certain etiopathogenetic factors with their own clinical and radiological features. A high* correlation was found between the increase in the intensity of the pain syndrome and the lengthening of the lower limb and the change in offset.

4. Algorithms for the differential "diagnosis of each localization of the pain syndrome can be based on the principle of mutual exclusion according to the totality of clinical and radiological data.

5. Prevention of pain syndrome consists in planning, observing the operation technique, including1 the correct orientation of the components of the endoprosthesis and an adequate change in the length of the limb, and the tactics of postoperative management of patients with pain syndrome should be determined based on the identified etiopathogenetic factors and aimed at eliminating the pain syndrome, which can improve operation results.

1. To assess the results of hip arthroplasty in terms of the presence of pain syndrome*, it is advisable to use the developed “Pain Syndrome Questionnaire” and modified visual analogue scales.

2. In order to prevent the occurrence of pain syndrome, the correct orientation of the endoprosthesis components and the correct change in the length of the lower limb using guides are necessary, and in difficult cases, X-ray control on the operating table.

3. To formulate the diagnosis, determine the etiology and tactics of treatment, the developed etiopathogenetic classification can be used.

4. For the prevention of pain in the knee joint, it is advisable to use the proposed method, which allows you to completely prevent pain and consists in the intraoperative injection of a local anesthetic solution into the stump of the fat body in the region of the cutting of the bottom of the acetabulum.

5. In addition, with arthritis and synovitis of an aseptic nature, when inflamed areas of the synovial membrane of the hip joint remain during the operation, pain in the inguinal region may persist, which disturbs both at rest and during exercise. In order to prevent these pains, a complete excision of the altered synovial membrane of the joint is necessary.

6. During the initial examination of patients preparing for hip arthroplasty, it is advisable to clarify complaints in detail to exclude vertebrogenic causes, which makes it possible to predict the persistence or appearance of pain after surgery.

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