To conduct surgical intervention the patient can be laid on his back or on his side. Variants of operational access are different, but most often use and consider the most typical anterior and posterior approaches. In the first case, surgical intervention can be performed by putting the patient on both back and side. When using the patient's back access, they are placed on their side.
During the operation, careful hemostasis is necessary due to anemia as a systemic manifestation of the underlying disease, as well as the undesirability of conducting blood transfusions in these patients.
An important step in the operation is the test hip adjustment and assembly of the endoprosthesis assembly. In this case, check the compliance of all elements of the endoprosthesis with each other, their stability, the correctness of the anatomical orientation of the elements relative to each other and the body axes, as well as the volume of movements, perform the dislocation test. Only after this, the final assembly of the femoral component and the endoprosthesis head is performed.
Endoprosthetics of the knee joint
Endoprosthetics of the joints are performed with a pneumatic turnstile on the thigh. Apply parapatellar access (external, often internal). An important stage of the operation is the removal of the pathologically altered synovium, which supports inflammation in the joint surfaces and the development of bone destruction. The preserved pathological synovial tissue can cause the development of aseptic instability by the endoprosthesis component.
The technique of setting resecting patterns, the subsequent selection of the required components of the endoprosthesis and their setting are considered typical for this operation. Differences are due to the peculiarities of the designs of different models and types of endoprostheses.
It is very important to achieve a knee ligament balance during the operation of arthroplasty. Developing with rheumatoid arthritis, valgus deformity leads to insufficiency of the internal ligamentous knee complex. In this regard, in order to achieve a good result during the operation, it is necessary to assess the condition of the ligament apparatus and its complete balancing.
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Endoprosthetics of metacarpophalangeal joints
In arthroplasty, most patients use transverse access in the projection of the metacarpal heads. In this case, the most important in the operation of endoprosthetics of metacarpophalangeal joints is not the placement of the implants themselves, but the complex of interventions on the soft tissues surrounding the joint. For the elimination of sinitis, a synovectomy must necessarily be performed.
Next, we should evaluate the safety of the cartilage and, if joint replacement is performed, a proximal phalanx should be identified. In some cases, its rear cortical layer may have a defect, which should be taken into account when resecting the head. Usually, resection of the phalangeal base is not required. When forming channels, it is important to remember that the phalangeal channel is formed first, since its medullary canal is smaller than the metacarpal canal. This is true for metacarpophalangeal joints II, III and V.
It is also necessary to cut out ulnar portions of the posterior interosseous muscles with nearby ligaments. In the metacarpophalangeal joint II, this can cause the rotation of the finger, therefore, if correction of ulnar deviation can be performed without performing this procedure, one should avoid clipping of these muscles. Such manipulation is performed not only with arthroplasty of joints, but also with synovectomy, then (considering the time reserve), it is possible to transfer these tendons to the radial side of the adjacent finger. Since the deformation is caused by the ulnar displacement of the tendon of the extensor, they perform their radialisation in any way accessible to the surgeon.
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To assess the effectiveness of arthroplasty, joints are used both as tools for instrumental diagnosis (mainly radiography) and for multiple scales and questionnaires. According to X-ray images, the stability of the endoprosthesis, the correct location of its elements, the degree of their migration, the appearance and severity of osteolysis can be assessed. The intensity of pain is assessed by the patient himself on the visual analog scale, and by the doctor when checking the operation of the operated joint, if possible to load the operated limb, the need for additional support, while walking the stairs and for long distances. Only considering the set of factors, it is possible to give an objective assessment of the effectiveness of the operation performed.
After arthroplasty in patients with rheumatological diseases, many researchers note good long-term results: increased functional activity and pain reduction. It was shown that, 10 years after arthroplasty, most patients did not experience pain or pain were insignificant. However, it is believed that pain in patients with rheumatic diseases is the most variable symptom, and the restoration of functional activity is much worse than in patients with other pathologies, which is due to the polyarticular nature of the lesion and the systemic nature of the rheumatological disease. In this situation, it is not always possible to objectively assess the functional state of one particular joint.
Factors affecting the effectiveness of arthroplasty
The effectiveness of arthroplasty of joints is determined by a number of factors, such as:
- somatic state of the patient:
- activity of the disease and severity of systemic disorders;
- number of affected articular surfaces;
- the stage of defeat of the operated joint, the degree of its destruction and the severity of changes in the periarticular tissues;
- preoperative planning and selection of an endoprosthesis;
- an individually selected adequate rehabilitation program; qualification of medical personnel.
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Alternative methods include arthroplasty, corrective osteotomy of the thigh and lower leg, arthrodesis. However, with the development of arthroplasty of joints, the improvement of models of endoprostheses indications for the use of the above methods are narrowed. For example, an isolated corrective osteotomy, whose goal is to change the axis of the load and unload the affected joint, has recently been performing single-implant arthroplasty of joints more often, and arthrodesis is used very narrowly and according to strict indications.
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