Depew hip joint. DePuy — knee, hip and other endoprostheses: models, materials, technologies and prices

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Over the past 10 years, in the traumatology department of the Regional Clinical Hospital of Rostov-on-Don, with degenerative-dystrophic lesions of the hip joints, fractures and false joints of the femoral neck, injuries of the acetabulum, tumor processes in 356 cases,total hip replacementsmanufactured by MATHYS, Switzerland.

Why do we use prostheses of this company? We can list the following points that forced us to dwell on them. The quality of these hip implants is much higher than domestic ones, a wide range of cementless and cemented models, prostheses for revision arthroplasty, cup originality and excellent stem options. Good, easy-to-use and high-quality instruments allow the operating traumatologist to perform operations successfully.

Of the 356 patients, there were 144 men and 212 women. The age of the patients varied: from 22 to 83 years, but the largest group of patients operated on were 40 to 60 years old - 215 people (61%). According to the pathological processes of the hip joints, the patients were distributed as follows: degenerative-dystrophic lesions of the hip joint of various etiologies - 202; fractures of the femoral neck and nonunion - 63; hip dysplasia - 44; rheumatic lesions, 35; tumors - 12. In most patients, external transgluteal access according to Harding was used. If possible, preference was given to spinal, epidural anesthesia and this type of anesthesia was used in 164 cases, endotracheal anesthesia - in 192 cases. In the immediate postoperative period, blood loss through drains up to 500 ml was observed in 225 (63.2%), from 500 to 900 ml - in 90 (36.8%). During the operation and in the postoperative period, donor plasma and erythrocyte mass were used, but autologous blood was used in 36 cases.

In our observations, cementless endoprostheses were used 220 times, cement - 163. Cement was used by different manufacturers.

For cementless arthroplasty, a titanium-coated RM cup, SHS (Spotorno type) and SVN (Zweimüller type) stems were used. In cement arthroplasty, a standard and lateral CCA (Muller type) stem and a CCA low-profile cup were used. Muller's strengthening CSE component was used in 52 patients with severe acetabular dysplasia, post-traumatic deformities, protrusion coxarthrosis, and severe osteoporosis in elderly patients. The Wagner stem and revision RM cup were used for revision arthroplasty in 10 cases. 26 patients were operated on 2 hip joints. The operation to replace the affected bilateral joint was performed no earlier than 3 months after the first total arthroplasty. None of the operated patients died in the department. Of such formidable complications as deep suppuration of tissues that required the removal of the prosthesis, we met in 2 patients who had a history of purulent processes in the operated hip joint. There were 4 cases of dislocations in the artificial hip joint. In 3 patients, the reduction was successfully performed closed under the image intensifier tube, and only in one patient - in the open way. In one patient, when installing the prosthesis in the thigh, an error was made - the leg of the prosthesis perforated the posterior wall of the thigh, which subsequently required re-endoprosthetics of the femoral component.

Long-term results from 1 to 10 years were followed up in 212 patients. The results were assessed using the Harris scale. There were no revisions. Good results - in 198 (93.3%) patients, satisfactory - in 12 (5.6%), unsatisfactory - in 2 (0.9%).

More than 1200 patients have been operated on in the traumatology department of the Republican Clinical Hospital for 20 years. Endoprostheses of Sivash, Virabov, Gerchev, "Ortotech", "Phoenix", "ESI" were used. Our experience in managing such patients and the results of hip arthroplasty with Mathys prostheses allows us to believe that these prostheses meet the requirements of both traumatologists-orthopedists and operated patients.


Zerkin G.D., Ivanov V.I., Antonets I.P., Basov SV., Chernogorov P.V., Fedotov I.G., Elfimov A.L., Prokhorsky D.A., Ivanov D.V. ., Zinovchenkov V.A.
State Healthcare Institution "Rostov Regional Clinical Hospital"

For patients with stage 3 coxarthrosis, doctors recommend arthroplasty, an operation during which an artificial hip joint is implanted. If the endoprosthesis was correctly selected, the operation was performed by an experienced specialist, the patient underwent a course of postoperative rehabilitation, and the leg functions are restored. For elderly people, the endoprosthesis can serve for life, young people usually need a second operation (revision). But even a single operation is not affordable for many. The cost of arthroplasty depends not only on the skill level of the surgeon, but also on the cost of the endoprosthesis. Does a high-quality prosthesis have to be expensive?

Manufacturers of endoprostheses

1. Zimmer provides an 8-year warranty on products, in practice, hip prostheses of this brand last 15 years or more. At the same time, they are more affordable than the products of other international companies. So, the estimated cost of a unipolar prosthesis is 75 thousand rubles.
2. Biomet, DePuy from the Johnson & Johnson concern, Smith & Nephew are brands popular on the international market, but less in demand in Russia, their products are about twice as expensive as similar Zimmer models.
3. Stryker is a more expensive brand than Zimmer, these endoprostheses are marginally, on average, 10% cheaper than the products of the companies listed in point 2.
4. Copies of promoted American and European brands of Taiwanese, Chinese production. The cost of the prosthesis is about 1.5–2 times lower than the original.

Is it worth saving by purchasing clones of famous brands? It is quite possible that prostheses produced in Asian countries are not inferior in quality to European or American originals. But these products appeared on the market relatively recently, and so far there is no information regarding their actual service life.

Every well-known international company has its own chips. For example, DePuy covers the legs of cementless dentures with hydroxyapatite, and Zimmer equips some models with ribs for more secure fixation. Biomet is known for making cups (acetabular substitute) without liners, although this technology is now being adopted by other manufacturers. Zimmer's cementless Trilogy cups have smaller holes than DePuy's Pinnacle cups. On the one hand, this increases the contact area of ​​the prosthesis with the bone, on the other hand, it complicates the control of the installation of the endoprosthesis in place.

Each company produces dozens of varieties of prostheses, which is better, it is impossible to say for sure. Much depends on the individual preferences of surgeons: it is more convenient for someone to work with one model, for someone else. The femoral stem and cup must be configured on an individual basis. So, it cannot be said that a straight leg is better than a curved one and vice versa, it all depends on the anatomical features of the canal in the femur. In the same way, the statement that a cheaper cement prosthesis is worse than an expensive cementless prosthesis will be incorrect. It is necessary to take into account the condition of the bone tissue, which depends on the age and sex of the patient. Different materials for the manufacture of prostheses also have their pros and cons.

Partial and total dentures

In the formation of the hip joint, 2 bones take part - the femur and the pelvic. The head of the femur enters the acetabulum of the pelvis. Depending on the indications for arthroplasty, the degree of destruction and deformity of the joint, it is possible to restrict the replacement of the femoral component (unipolar, partial arthroplasty) or change both components, femoral and acetabular. A total hip arthroplasty, consisting of 2 components, is about 1.5 times more expensive than a unipolar one.

The following factors also affect the cost of the prosthesis:

• a method for fixing the stem of the femoral component in the medullary canal and the cup in the reamed acetabulum;
• the materials from which the friction pair is made (the head of the femoral component and the liner in the cup);
• design complexity – an anatomical curved stem is more expensive than a universal straight stem, since production costs are higher. Modular legs and multi-piece cups are more expensive than monolithic ones.

An artificial joint with a modular stem is used if a significant part of the femur is affected. The need to use a modular cup arises in the presence of defects in the acetabulum. The shape of a standard cup is corrected with the help of side overlays (augments), which often have to be made according to an individual project.

Cemented and uncemented fixation

Cement-retained prostheses are installed using the tight fit method, driven into a previously prepared seat. They have a rough surface, the bone tissue grows into these roughnesses over time, and the prosthesis with the bone forms a single whole. Cement prostheses have a smooth surface and are fixed with bone cement - polymethyl methacrylate. Immediately before the operation, the powder is mixed with the liquid, the liquid solution polymerizes and hardens 5–8 minutes after preparation. Polymethyl methacrylate in the hardened state combines mechanical strength with high elasticity, able to absorb loads.

Cement-retained dentures are cheaper than cement-retained ones. Within both categories there is also a variation in prices, in particular, the method of making the surface rough or smooth matters. The surface of the legs of tight-fitting prostheses can be processed in the following ways:

• baking compressed balls or wire fibers;
• sandblasting;
• plasma spraying of metal;
• non-metallic coating (hydroxyapatite, calcium phosphate).

The same methods, with the exception of sandblasting, are used for cementless cups. The surface of the legs of cemented prostheses can be polished or satin. Polishing is more expensive, but in practice it has not been proven that a polished surface provides a more secure hold than a satin finish.

What fixing method is best?

There is an opinion that the cementless prosthetic technique is more progressive, of high quality, and provides the most reliable fixation. In fact, everything is not so simple, for one patient an artificial hip joint with cementless fixation is better, for another - with cement. Cement prosthetics are preferred:

• if the patient suffers from osteoporosis (bone density decreases with age, especially in women after menopause);
• if the bone canal is wide and the walls of the femur are thin;
• after fractures of the femoral neck, especially ununited;
• with osteomyelitis and a high risk of infectious complications (an antibiotic can be added to the cement).

The ingrowth of bone tissue into the prosthesis theoretically provides a more reliable fixation than cementing. In addition, this method of fixation simplifies revision surgery. Therefore, young people who actively load the artificial joint and who eventually need to replace it, it is better to perform a tight fit.

But there is a risk of damaging the bone by driving a prosthesis into it, so you need to take into account not only age, but also individual structural features and bone density. Bone cement polymerizes in minutes, but it takes months for bone to grow into a prosthesis. Therefore, the load on the joint after cementless prosthetics should be gentle, after cement fixation, full rehabilitation is faster.

There are also hybrid prostheses: the leg of the femoral component can be driven into the canal, and the cup can be cemented, and vice versa (reverse hybrid). Sometimes, with severe sclerosis of the acetabulum, they resort to additional fixation of cementless cups with screws through the holes.

Denture materials

The components of cemented and cementless prostheses are made from different materials. In the manufacture of endoprostheses, metal alloys are used: titanium, cobalt, iron, zirconium, high molecular weight polyethylene and ceramics. Ceramics is the most expensive material, metal and polyethylene are cheaper. Each component has its own set of materials.

The legs of the femoral component are exclusively metal, the composition of the alloy depends on the method of attachment:

• for cement fixation - based on cobalt with chromium, the composition of the alloy may also include molybdenum;
• for cementless - from a titanium-aluminum alloy with the addition of vanadium or niobium.

Similar titanium-based alloys are also used for cementless cups (acetabular components). Cement is made from high molecular weight cross-linked polyethylene, they are used without liners. The cup liner (or the inner surface of the cup itself) forms a friction pair with the head of the femoral component. Heads are metal and ceramic, liners in cementless cups are made of metal alloys, ceramics and polyethylene. Both components of the friction pair can be made of the same material (metal-metal, ceramic-ceramic) or different (metal-polyethylene, ceramic-polyethylene).

For metal heads, alloys based on iron, titanium and cobalt are used. Each has its own strengths and weaknesses. Titanium heads pair well with titanium stems, but they cause active abrasion of the liners. Contact of a cobalt alloy head with a titanium stem can be accompanied by corrosion. At present, titanium heads are practically not produced, the improved cobalt-chromium alloy and the PROTASUL alloy, which is sometimes called stainless steel, are more popular. In fact, it vastly outperforms conventional stainless steel in strength and durability. Recently, heads made of zirconium alloys have begun to appear, resistant to wear, corrosion, and low toxicity.

Pros and cons of different friction pairs

Metal is a relatively affordable, durable and at the same time elastic, shock-resistant material. The main disadvantage of metal friction pairs is abrasion and penetration of the smallest metal dust into fabrics. In particular, in order to avoid toxic effects on the fetus, endoprostheses with a metal-to-metal friction pair are not installed in pregnant women. A pair of ceramics-ceramics is characterized by high wear resistance, no toxicity. Ceramic is a hard but more brittle material than metal, theoretically ceramic heads and inserts can break. Although the latest generation of ceramic elements combine wear resistance with impact resistance.

Another drawback of endoprostheses with a ceramic friction pair is a pronounced creak during movements, although many prostheses function silently. And their main disadvantage is the high cost, at a price they are 1.5–2 times higher than metal ones. The combination of a metal head with a polyethylene liner is the most budget option. But such friction pairs are short-lived, wear out quickly. Therefore, such prostheses are mainly installed in the elderly. Upon contact with the ceramic head, the polyethylene liner does not wear out as actively as in the previous version, but such a friction pair is also short-lived and belongs to the budget ones.

An expensive endoprosthesis is not always better than a budget one. When choosing these products, the priority is not financial considerations, but how a particular model suits a particular patient. Not all endoprostheses are interchangeable. If the operation is performed according to the quota, the patient can be implanted with a cheap cement prosthesis, although he would be better suited without cement. But it is impossible to use a unipolar prosthesis if there are indications for total prosthetics. Among the products of well-known manufacturers, the products of the Zimmer brand are distinguished by the optimal price-quality ratio.

The most complete answers to questions on the topic: "depuy joint endoprostheses".

Information for the surgeon

For patients with an ASR hip replacement At the heart of DePuy is meeting the needs of its patients. All employees of the company are united by a common goal to improve the quality of life of patients. For DePuy, patients come first. If we find that a product does not meet the high standards of the company and the needs of patients, we take appropriate measures.

In August 2010, DePuy issued a voluntary recall notice for the ASR™ Hip System following new, then unpublished data from the UK Joint Replacement Registry. These data from 2010 showed that while the majority of ASR Hip System patients did not require additional hip surgery, the rate of ASR hip replacement patients requiring revision (called revision) surgery was not consistent with data previously reported in this registry. .

It is important that all ASR patients have a hip examination by their doctor. Patient safety and health are important to DePuy. We are committed to providing ASR patients with the information and support they need to provide medical care related to the recall.

DePuy has made a commitment to cover the actual reasonable costs of examination and treatment for reasons related to the recall, including, if necessary, revision surgery. DePuy also reimburses out-of-pocket patient costs associated with the recall, such as lost wages and travel expenses. For assistance for ASR patients, contact the ASR Helpline at 8-800-700-7747.

There are many different brands of hip endoprostheses, including several brands from DePuy, and the patient may not know which brand of endoprosthesis they have. We recommend that patients contact their surgeon or hospital to find out the brand of hip replacement they have placed.

We understand that product recalls are of concern to patients and their families. On this website, we provide detailed information about the recall and what it means for you personally. If you have additional questions, please contact our ASR hotline at ASR 8-800-700-7747.

Calling the ASR hotline

If you have additional questions, please call the ASR Hotline at 8-800-700-7747 Call Center Hours: Calls are accepted Monday through Friday, 09:00 to 17:00

Reason for ASR Hip System recall

Patient safety is always a top priority for DePuy. In light of this priority, we are constantly evaluating our product data, including the ASR Hip System.

According to data published in 2010 by the UK's independent National Registry, which tracks endoprosthesis scores and outcomes, despite the fact that the majority of ASR Hip System patients did not require additional hip surgery, the rate of ASR patients requiring revision surgery did not correspond to the data previously given in this register. During the revision surgery, the installed hip joint endoprosthesis is removed and replaced with a new one.

Data published in the UK in 2010 showed that within five years of receiving a superficial ASR endoprosthesis, approximately 12 percent of patients required revision surgery, and that within five years of total ASR hip replacement, approximately 13 percent of patients had revision surgery. which was not consistent with the data previously provided in this register.

After reviewing this data, DePuy has determined that a voluntary recall of the ASR Hip System is necessary in the best interests of patients. The company immediately carried out a voluntary product recall in all countries where it is sold.

New data

The company monitors ASR data from a variety of sources, including joint replacement registries, publications, company-sponsored clinical trials, proprietary complaint data, and clinical trial reports from other organizations. A number of data are currently being collected on the revision rate for ASR, and the company is investigating the reason why ASR revisions are reported more frequently than other metal-lined and sheathed hip replacements. For the latest data from the National Joint Replacement Registry in the UK, go to

For the most up-to-date Australian National Registry of Joint Replacement, go to

Anatomical structure of the hip joint

In the natural structure of the hip joint, the femur is connected to the pelvis at the hip joint. The femur has a rounded end called the femoral head. The head of the femur, like a ball, enters the concave surface of the pelvis, called the acetabulum. Therefore, the hip joint is often called the spherical joint. The head of the femur rotates within the acetabulum, which creates freedom of movement. If there is loss of mobility and pain in the hip joint due to osteoarthritis, trauma, or other reasons, a hip arthroplasty or superficial hip arthroplasty may be performed.

ASR Hip System The ASR Hip System was one of many hip replacements offered by DePuy. The ASR Hip System is a one-piece cup with a head that is used for total or superficial hip arthroplasty.

Total Hip Replacement with ASR XL In total hip replacement using the ASR XL system, an all-metal piece called an acetabular cup is placed in the acetabulum. The head of the femur is replaced with a metal ball that is connected to a metal rod inserted inside the thigh.

The ASR XL system consists of two components:

1) metal head of the femur (in the form of a ball) connected to the rod; and

DePuy ASR Hip Replacement System

With DePuy's ASR Surface Hip Replacement System, an all-metal piece called an acetabular cup is placed in the acetabulum and the metal cup is placed over the head of the femur.

The DePuy ASR Hip Replacement System consists of two components:

1) a metal cup that is put on the head of the femur itself; and

2) an all-metal cup that lines the acetabulum.

If you think you are affected by the product recall, you can find more information on what to do next in the What to do tab.

Determine if you have ASR installed

If you had hip surgery prior to July 2003, your prosthesis is not subject to the recall. If you had hip surgery after July 2003, contact your orthopedic surgeon or the hospital where you had your surgery to find out if you had an ASR hip replacement. It will take some time for the surgeon or hospital to get this information for you. For privacy reasons, your orthopedic surgeon or staff at the hospital where you had your surgery may require that you request this information in person.

ASR System Part Number Listing Further actions If your hip replacement is not ASR Your hip replacement is not covered by this recall. Please contact your orthopedic surgeon with any questions you may have regarding your hip replacement.

If you have an ASR hip replacement Contact the DePuy ASR hotline to apply to the company.

Make an appointment with your surgeon.

Whether you have an ASR™ XL Acetabular System or a DePuy ASR™ Hip Resurfacing System, your surgeon will be able to evaluate the performance of your ASR hip replacement. Additional tests and procedures may be required to assess the condition of your hip replacement.

Compensation program DePuy has committed to cover the actual reasonable costs of examination and treatment for reasons related to the recall, including, if necessary, revision surgery. DePuy also reimburses out-of-pocket patient costs associated with the recall, such as lost wages and travel expenses. For assistance for ASR patients, contact the ASR Helpline at 8-800-700-7747.

More information on how to apply and receive compensation can be found on the "Compensation" tab. Dispensary observation Even if you don't have symptoms, it's important that you continue to see your surgeon to evaluate your hip replacement. If you don't have any symptoms, you should talk to your doctor about the frequency of re-dosing.

In some cases, your surgeon may order additional blood tests or x-rays to evaluate the condition of your hip joint. Your surgeon will determine the most appropriate follow-up program for you and will discuss treatment options with you if needed. If you do not know who performed your hip arthroplasty, contact your doctor or the hospital where the operation was performed.

More detailed information about the examination can be found on the "Examination" tab.

Symptoms and Causes
Patients with ASR who needed revision surgery complained of a variety of symptoms prior to surgery, including pain, swelling, and trouble walking. These symptoms are quite common immediately after hip replacement surgery. If symptoms persist or recur, you should consult your surgeon.

Possible reasons Symptoms such as pain, swelling, or trouble walking can be caused by:

Weakening
The endoprosthesis is not fixed to the bone in the desired position.
fracture
Possible bone fracture in the region of the endoprosthesis.
Dislocation
The two parts of the endoprosthesis that are moving relative to each other are no longer aligned with each other.

Survey
The diagnostic examination will help your surgeon assess the condition of your hip joint and, if necessary, make recommendations for future treatment.

What awaits you Your surgeon may use one or more tests to assess the condition of your ASR Hip System:

X-ray examination

An X-ray examination will allow your surgeon to assess the position of the ASR Hip System, whether there is any bone damage, and/or whether the ASR Hip System is anchored to the bone. If x-rays show problems with the ASR Hip System, your surgeon may recommend additional testing or surgery to replace your hip replacement.

Blood tests

The surgeon may order blood tests as part of an examination of the installed ASR Hip System. The surgeon may recommend a second blood test to confirm the results of the first test.

MRI or ultrasound examination

Your surgeon may perform an MRI or ultrasound examination of your ASR Hip System. Your surgeon may recommend additional testing or surgery to replace your endoprosthesis.

More information on applying for and receiving reimbursement for examinations can be found on the Compensation tab.

Treatment
Your surgeon may need to evaluate the performance of your ASR Hip System and decide on the most appropriate course of treatment for you.

More detailed information about tests and examinations can be obtained on the "Examination" tab. If your ASR hip replacement is functioning properly If you do not have any symptoms, or if the test results indicate that you may need to replace your endoprosthesis, you will need to follow your surgeon's recommendations for continued monitoring.

If revision surgery is needed If you need additional surgery, your surgeon will select the appropriate endoprosthetic system for you. The manufacturer and model of any endoprosthetic replacement system can most accurately be chosen only by you and your doctor.

For more information about claiming and receiving medical reimbursement, please see the Reimbursement tab.

Claims and compensation
At the time of the voluntary recall of the ASR Hip Resurfacing System and ASR XL Acetabular System in August 2010, DePuy put in place a reimbursement program to cover the examination and treatment costs associated with the recall. The program is administered by an independent claim processing company, Crawford, and includes compensation for revision surgery and recall-related follow-up care. The program also reimburses other out-of-pocket expenses for patients, which may include co-payments, non-taxable expenses, lost wages, and travel expenses for such patients.

General principles

The choice of material when creating any implant is an important step, often determining the success of the entire complex of developmental research and production work. In this case, two main principles should be taken into account, which, reflecting the close interconnectedness of design and material, can be taken as the basis of medical materials science: 1) the technical and biological features of the design depend on the corresponding features of the material; 2) new materials allow the implementation of new implant design options.

The main design task in creating a total endoprosthesis is to obtain a permanent, long-term functioning implant that eliminates pain and improves the functionality of the hip joint by reproducing its normal spatial geometry, mobility and support ability with artificial articulating components.
The secondary tasks of the general plan are most often considered: simplicity of design and application, saving attitude to tissues during implantation, reliability and high resistance to destruction and wear, durability of functioning, ease of use, minimization of technical difficulties when replacing worn and destroyed implants, convenience for industrial production , cost reduction.

Everything is currently total hip replacements principally include two components: acetabular (acetabular) and femoral. The main requirement for materials for the manufacture of an endoprosthesis is biocompatibility, defined as the ability of a material to cause an acceptable response of a macroorganism or not cause it at all. The negative impact of the material and the products of its wear or degradation should not lead to significant local, systemic and long-term effects, and the positive impact may be in the form of a number of useful manifestations required for solving the problems of endoprosthetics, for example, adhesion or bone tissue ingrowth.

The materials that are currently used in hip arthroplasty include: metals and their alloys, ceramics, bone cement (polymethyl methacrylate), polyethylene.

The main materials from which endoprosthesis components are made

Metals

The general requirements for metals used for the manufacture of endoprostheses are: rigidity, strength, elasticity, corrosion resistance, the ability to create the required surface structure and biocompatibility.

Stainless steels (Fe, C, Or, Ni, Mo) are characterized by a low carbon content, which determines their resistance to corrosion and mechanical stress. The strength of stainless steel can be improved by cold forging. BioDur108 steel alloy, containing Ni, with a high nitrogen content and having significant corrosion resistance and better strength characteristics, is used for the manufacture of cemented endoprosthesis stems.

Titanium and its alloys (CP-Ti (pure titanium - 98 - 99.6%), Ti-6AI-4V, etc.) are characterized by high corrosion resistance and biocompatibility. Pure titanium is more viscous, it is used for porous coatings, fiber metal. Alloy Ti-6A1 -4V has a high mechanical strength. The modules of torsion and axial stiffness are closest to the bone. The alloy is sensitive to damage associated with the formation of microcavities and has a high surface softness.

New titanium alloys - R-titanium (R-Ti) - are characterized by the predominance of the R-phase of the alloy, often due to the high content of Mo (more than 10%), which makes it possible to increase the resistance to fracture, primarily to fatigue, and also by 20%. reduce the modulus of elasticity, bringing it closer to the modulus of elasticity of the bone. Ti-5AI-2.5Fe, Ti-6AI-17 Niobium do not contain relatively toxic V, have a lower modulus of elasticity. Ti-Ta30 has a thermal expansion modulus close to ceramic, which reduces the risk of fracture when combined with metal implants. All titanium alloys are not resistant to debris formation. More often they are used for the manufacture of cementless legs, sometimes after surface hardening by oxidation or proton bombardment, and less often - cement.

Co-Cr alloys (Co-Cr-Mo, Co-Ni-Cr-Mo, Co-Cr-Ni-W, Co-Ni-Cr-Mo-W-Fe) are highly corrosion resistant, possibly have some toxicity and immunogenicity due to the presence of nickel. Co-Ni-Cr has poor frictional properties and forms a large amount of debris. Co-Cr-Mo has high hardness and strength, it is applicable in friction pairs in the manufacture of endoprosthesis heads, as well as in metal-to-metal friction pairs. The latter are characterized by extremely low wear, do not form a large amount of debris, but their use is limited by significant disadvantages: excessive rigidity (partially overcome by installing a metal insert in a polyethylene base), which increases the risk of loosening of the femoral and acetabular components of the endoprosthesis; duration of running-in of rubbing surfaces; an increase in the concentration of metal ions in biological fluids and tissues (toxicity, allergenicity, possibly oncogenicity and teratogenicity); high sensitivity to impingement; risk of osteolytic reactions of bone tissue, high cost. A variant of the metal-to-metal friction pair is the Co-Cr pair with the integration of corundum crystals (Metasul), providing even lower wear.

Zr and Ta alloys have high corrosion resistance, biocompatibility, surface hardness, and low debris formation. It is possible to create trabecular metal. True tantalum-based trabecular metal can significantly increase the possibilities of osseointegration, while not creating the problem of zones of connection of media of different strength.

The surface of the metal components of endoprostheses can be:

1. polished (heads, cup liners with metal-metal friction pairs, cement-fixed legs);
2. rough, which is created by processing in a stream of sand (legs and cups of cementless fixation 5-8 microns);
3. porous, which is created by sintering balls or wire (legs and cups without cement fixation);
4. trabecular, obtained by plasma spraying with metal (cups, as well as cementless fixation legs);
5. coated with hydroxyapatite, calcium phosphate, etc.

The surfaces of the metal components of endoprostheses may not interact with the surrounding tissues, may form a fibrous block, be fixed due to bone adhesion (in the presence of coatings such as hydroxyapatites), as well as due to impaction of the surrounding bone (press-fit) or its ingrowth (rough surface, fibro- and trabecular metal) (Fig. 1).

Rice. 1. Examples of osseointegration of the acetabular and femoral components of the endoprosthesis.

The improvement of ceramic materials has made it possible to consider them as some alternative to metal alloys, and according to some of their characteristics, primarily tribological, the ceramic-ceramic pair has unique properties.

From the point of view of interaction with body tissues, ceramic materials can be divided into 3 groups:

• inert ceramics that retain the shape of the implant and the surface structure without tissue ingrowth;
• bioactive ceramics that preserve the shape of the implant and its internal structure with ingrowth of surrounding tissues;
• biodegradable, which loses its shape, surface and internal structure of the implant with ingrowth into it, partial or complete replacement
• by surrounding tissues.

When creating endoprostheses, the following types of ceramics are used:

1. Based on oxides of Al, Zr, Ti (Al 2 O 3 ZrO, TiO): bioinert, with high biological compatibility and surface strength, applicable in the creation of ceramic-polyethylene and ceramic-ceramic friction pairs. Zirconium ceramics due to the admixture of yttrium is characterized by some toxicity.
2. Carbon ceramics (C with different structure, C-Si): bioinert, with good biocompatibility and surface strength. It is applicable for covering the legs and cups of prostheses, as well as in creating friction pairs.
3. Calcium phosphates and aluminates (Cryst-Ca 5 (PO) 3 (O), CaAl 2 O 3): bioactive, non-biodegradable. They can provide interaction between bone and other biomaterials, be carriers of medicinal and biologically active substances (short duration, surface release). Applicable for biomaterial-induced and biomaterial-dependent osseointegration.
4. Calcium sulfates, aluminates and phosphates (CaSO 4 , CaAl 2 O 3 , Amorph-Ca 5 (PO 4) 3 (OH)): biodegradable, with different replacement periods, can be carriers of medicinal and biologically active substances (long-term release). A similar role in the creation of endoprostheses.

The advantages of ceramic friction pairs are high wear resistance and higher surface finish, high bioinertness, corrosion resistance. Disadvantages: increased rigidity of a ceramic-ceramic pair, a tendency to destruction, including spontaneous destruction in case of violation of the production technology or implantation, as well as causticity (especially ceramic-ceramic pairs) (Fig. 2). The appearance of ceramic debris leads to catastrophically increasing wear of the friction pair (both ceramic-polyethylene and ceramic-ceramic), increased formation of destruction products with the induction of osteolysis processes in the implant bone beds and fibrosis in soft tissues. During revision operations, a separate problem is the impossibility of complete removal of the remains of ceramic particles from the primary endoprosthesis, which increase the wear of the already revision friction pair.

Rice. 2. Destruction of the ceramic head of the endoprosthesis.

The feasibility of using bioactive and biodegradable ceramic coatings is debatable. On the one hand, they improve the process of osseointegration and have an osteoconductive effect; on the other hand, with thick-layer application, there is no complete bone replacement of the ceramic, and its remains under long-term cyclic loads, exfoliating from the metal surface of the implant, can induce the formation of wear products and osteolysis.

Polyethylene

There are low, medium-low, high, ultra-high and ultra-high density cross-linked polyethylenes. Polyethylene is used to create a friction pair. Currently, ultra-high density polyethylene and its derivatives are widely used, as a rule, for the manufacture of the acetabular component. A pair of friction metal (endoprosthesis head) - polyethylene (cup or insert) is still the reference. To modify ultra-high density polyethylene in the late 1970s, carbon fibers were used to increase the modulus of elasticity and wear resistance, reducing the ability to deform (Product Poly II, Zimmer). However, application experience has shown a higher frequency of destruction of elements from Poly II, including surface ones. This was partly due to the poor reproducibility of the manufacturing technology. In the early 90s of the last century, the technology of crystallization of ultra-high density polyethylene without breaking molecular chains and losing molecular weight (Hylamer, DePuy) appeared, which was characterized by an increase in the strength of the product and its resistance to oxidation.

Sterilization of polyethylene products by high-dose gamma irradiation leads to the occurrence of oxidative reactions in them in the form of two main directions: molecular chain breaking and cross-linking. Moreover, if polyethylene degradation reactions predominate on the surface of the sample, then the level of cross-links between its molecules increases in depth.

The technology for creating cross-linked polyethylene, which makes it possible to ensure their formation throughout the entire volume of the substance, as well as to suppress degradation reactions, has led to the production of a high-strength and wear-resistant material, approaching metal-to-metal friction pairs in these parameters, however, avoiding such disadvantages of metal joints as hardness, toxicity and allergenicity (by increasing the concentration of cobalt, nickel and chromium ions in the blood). However, the experience of using cross-linked polyethylene showed that, despite the promise of experimental and first clinical results, there is an instability in the production technology of this material, as well as an increased risk of destruction of products from it under shock loads.

Thus, until now, the most applicable is the standard ultra-high density polyethylene, including the recrystallization option, and cross-linked polyethylene remains highly promising as a new version of a high-strength friction pair.

bone cement

Numerous studies have shown that the advantages of cement prosthetics include the possibility of using simple implant models, the absence of continuous contact of the metal elements of the prosthesis with the bone, the possibility of creating a depot of antibiotics in the surgical area, ensuring stable fixation of prosthesis elements in the presence of post-traumatic and dysplastic defects of the bone bed and osteoporosis of various types. genesis.

The main factors that improve the mechanical quality of cement microadhesion with bone are identified: careful cleaning of the bone bed before cementing, strength and local regenerative capabilities of the bone, quality of cement mixing, use of a cement-tight supply device. For a comprehensive solution to the problem of improving the quality of cement fixation, a system of measures has been developed. The main ones are: distal plug of the femoral canal, retrograde filling of the femoral canal with bone cement, drainage of the femoral bone marrow canal during its filling with cement, formation of holes in the acetabulum for fixation of the acetabular component, vacuum mixing of cement, washing of the cemented bone surface with a pulsating jet (pulsating lavage), cleaning the surface to be cemented with nylon brushes, dehydration of the bone surface before cementing, pressurization of the cement during the installation of the prosthesis. There is evidence of an increase in the efficiency of cementation during centrifugation during mixing. The high quality of cement preparation, its insertion into the bone and the uniform distribution of the cement mantle are ensured by a number of developed devices and equipment. These include: various types of vacuum mixers that prevent the formation of air bubbles in the cement mass ; special syringes for retrograde supply of cement into the cavity, and, above all, into the femoral canal; polyethylene restrictive plugs and guides forming a cement mantle in the femoral canal; finally, devices for pressing or pressing the cement into the bone pores during its laying. The use of improved cementing technology has reduced the number of revisions for infectious complications and implant replacements due to aseptic loosening.

As a rule, bone cement consists of two components - a powder (polymer) and a liquid (monomer). The polymer is the main part of bone cement; the main consumer properties of cement depend on its composition. In some types of cement, copolymers are added to polymethyl methacrylate, for example, methacrylate, butyl methacrylate, stearin. Thus, the addition of methacrylate increases the hydrophilicity of cement, increases its flexibility and viscosity. The addition of stearin increases not only the hydrophobicity, but also the fatigue properties of the cement. The addition of barium sulfate imparts radiopacity to the cement.

The main brands of cement from various manufacturers and the type of polymer, types of monomer, the ratio of liquid and solid parts of the main brands of bone cement and the maximum temperature of their polymerization are presented in the tables.

Main brands of cement and types of polymer

Temperature and polymerization time depending on the brand of cement and the percentage of monomer

When cement is introduced into tissues in the body, both local and general reactions can occur. The high temperature during cement polymerization can be accompanied by damage to the bone in contact with the cement or implant, especially due to the denaturation of the protein structures of the bone tissue. At a cement mantle temperature of 72°C, bone necrosis occurs almost immediately. A temperature of 60°C causes necrosis after 5 seconds of exposure, 55°C - after 30 seconds, 47°C - after 1 minute. Manufacturers are looking for ways to reduce the effect of temperature on fabrics. The general reaction of the body due to the toxic effect of cement is a short-term decrease in blood pressure, transient bradycardia. This reaction is more pronounced when using low-viscosity cement grades.

The dosage of the mixing components is as follows: 10 ml of the liquid component and 20 g of the powder, or 20 and 40 ml, respectively, per 40 and 80 g of powder. You can mix in an open container with a flat spoon or in a special vacuum mixer. The quality of mixing is better in the mixer, but the curing time of the cement depends on the ambient temperature and mixing speed.

Cement acquires antimicrobial properties when antibiotics are introduced into it. The most commonly used antibiotic is gentamicin (Polakos, CMW). Tobramycin was introduced into Simplex cement (England). In recent years, vancomycin has been added to cement more frequently. Independent addition of antibiotic powder to bone cement during surgery is unacceptable, as the chemical structure of bone cement changes. It is better to increase the dose of antibiotic for intramuscular administration.

Dependence of cement preparation time on ambient temperature

R.M. Tikhilov, V.M. Shapovalov
RNIITO them. R.R. Vredena, St. Petersburg

Hip arthroplasty is a major orthopedic surgery to replace a damaged joint with an implant. The basis for surgical intervention is usually increased wear of the joint, as well as bruises and injuries in the area of ​​​​the joints, which result in functional disorders. How much does arthroplasty cost and which is better to buy an implant? The advice and recommendations of orthopedic specialists will help you deal with the issue of choosing the optimal types of modern endoprostheses.

1. What affects the cost of an endoprosthesis?
2. When is the operation performed?
3. Criterias of choice
4. Price of different brands

What does the price depend on?

When planning to buy an implant for yourself, you should not be based only on the level of its cost. In fact, a large number of zeros on the price tag is not always a guarantee of a long and flawless endoprosthesis service. Its price depends on the type of model and the main diagnosis. For example, an implant for the surgical treatment of coxarthrosis is more expensive than a substitute needed for a hip fracture.

The combination of high cost with excellent quality in traumatology does not always look good. Since hip arthroplasty is considered a complex operation, the main thing is the high level of its performance, and not the high cost of the implant. A medical error can negatively affect even the highest quality material. It will be right if the patient entrusts the right to choose a prosthesis to a qualified surgeon. This is the main factor of successful arthroplasty. An experienced specialist will be able to decide which kind of artificial substitute is better to prefer in each case.

The most popular models of artificial joints are produced by international companies DePuy and Zimmer. In addition, Stryker, Smith & Nephew, Biomet, Aesculap, B. Braun are active participants in the modern market. Zimmer manufactures high quality Zimmer Trilogy cups. The DePuy brand is better known for the release of the Pinnacle line of endoprostheses. In terms of purpose and quality of performance, Zimmer and DePuy products are almost identical, so only a professional doctor can make a choice of the best option.

• fracture of the femoral neck and the consequences of traumatic injuries;
• coxarthrosis (deforming osteoarthritis) and other types of arthritis that caused degenerative-dystrophic changes;
• dysplasia;
• violation of the blood supply to the femoral head;
• congenital anomalies;
• some types of tumors;
• aseptic necrosis.

The presence of any of the listed signs is not a mandatory indicator for surgical intervention. In each individual case, the issue of arthroplasty of the patient is decided by the attending physician after a thorough examination. In particular, with coxarthrosis, surgery is prescribed only at stages 2-3 of the disease. Also, the endoprosthesis is installed with unbearable prolonged pain in the hip joint, which do not respond to treatment for six months.

The following circumstances may serve as contraindications for joint replacement surgery with an endoprosthesis:

1. dermatological diseases and damage to the skin in the thigh area;

2. problems with peripheral vessels of the lower extremities;

3. quadriceps paralysis;

4. oncological diseases;

5. severe mental disorders;

6. overweight (more than 120 kg).

When deciding whether to install an endoprosthesis, the age and general health of the patient must be taken into account. Orthopedic surgery is not recommended for young people in cases where it is possible to maintain / restore function with the help of drug treatment.

What to consider when buying?

Externally, the artificial joint is very similar to the real one. In the classic version, it consists of a pin (leg), a cup and a head. The endoprosthesis takes on the usual physical activity and performs the same actions as a healthy organ. The operation to replace a damaged hip joint with an implant is called primary arthroplasty. When it comes to revision arthroplasty, it means the replacement of a previously installed joint.

On sale there are many varieties of prostheses, which are classified according to several criteria.

1. Construction type.

• Unipolar - replacing the head of the hip joint.
• Bipolar - prostheses that are installed instead of the femoral head and acetabulum. Such endoprosthesis is called total. It is often performed in orthopedics and traumatology.

2. Main material (cup and leg).

• Metal and metal - a wear-resistant combination that can last at least two decades. Metal endoprostheses are best installed for men who lead an active lifestyle. Large joint heads allow for a wide range of motion. For women planning a pregnancy, prostheses are not recommended due to the high probability of penetration of metal ions into the fetus. The disadvantages include the high price of the endoprosthesis. In addition, as a result of friction of artificial surfaces, toxic products are formed. According to orthopedists, metal joints are rarely used in practice, and in some countries they are even prohibited.
• Metal and plastic are an inexpensive option with moderate abrasion toxicity. The combination of materials is considered the most short-lived (10-15 years). Such a prosthesis can be purchased for people of an unsportsmanlike nature with a measured and calm lifestyle. Due to the low cost, implants are available to patients of retirement age.
• Ceramics and ceramics - artificial joints are equally well suited to patients of any gender and age. They are durable and non-toxic. The main obstacle to the purchase of a ceramic endoprosthesis is the high cost. In addition, during movement, the implants can creak, which creates significant discomfort for patients.
• Ceramics and plastic are the cheapest type of dentures. The combination is characterized by rapid wear and fragility, therefore it is more suitable for elderly patients of both sexes.

3. Method of fixation.

• Cementless/mechanical - installation of endoprosthesis elements into the bone tissue by wedging or pressing. The joints are coated with a special compound. Thanks to this coating, the bone tissue “fuses” with the endoprosthesis material (usually titanium), firmly fixing it. Non-cemented prostheses are good for young patients. This facilitates further possible revision hip arthroplasty.
• Cemented - all parts of the prostheses are fixed with a special biological solution. This method of connection provides reliable fixation even with osteoporosis. Cemented endoprostheses are best placed in elderly patients and people with reduced physical activity.
• Hybrid-full - individual parts of the prosthesis can be made from different types of materials. The cup is fixed in a cementless way. Artificial legs are fixed with a solution. Hybrid endoprostheses are best recommended for middle-aged patients.

Price overview

In fact, the cost of arthroplasty consists of two parts. This is the price of the implant itself and the cost of the operation along with the stay in the inpatient department. Depending on the type and manufacturer, an endoprosthesis costs from 60,000–80,000 to 220,000–300,000 rubles. On average, an implant costs 130,000 - 150,000.

The average cost of a hip replacement surgery in Russian clinics is 170,000–250,000. The total amount depends on the conditions of stay and the duration of hospitalization. Total endoprosthetics, together with a hospital stay, costs an average of 350,000–370,000 (30,000–220,000 for unipolar prosthetics, 400,000–600,000 rubles for total). In different countries, it is estimated at between 8,000 and 40,000 dollars.

Hip arthroplasty is often the only method for restoring motor activity. The installation of the implant eliminates the pain syndrome that does not leave the patient with diseases of the musculoskeletal system.

Modern types of prostheses are designed to completely imitate the native joint and fulfill its functional abilities.

A hip joint implant with a metal friction pair is used less and less in practice due to metal friction products.

From a large number of endoprostheses, you can choose a suitable implant. Sometimes patients try to choose an implant on their own, study brands, models, varieties. Orthopedists often hear the following from patients:

• Recently I read (-la) that the most reliable prosthesis is made of ceramics.
• A cemented denture is an obsolete model, while a cementless denture is a good option.
• The best prostheses are foreign, they have positive reviews.

First myth, which should be dispelled - there is no best endoprosthesis.

Second- There are many variations of orthopedic constructions for hip replacement: some of them are better, others are inferior in one way, but superior in another. We are talking about well-known companies operating in the orthopedics market for more than a year.

The most durable and expensive implant is with a ceramic friction pair. But this is not always the case: overweight and very active people do not need ceramics - they can crack under load.

There are inexpensive models, but there are also expensive prostheses. This does not mean that the cheaper option can be much worse and provoke complications. When releasing a new implant model, the company is forced to raise its cost, since development, production, and consumables require large investments. New models will take into account the shortcomings of the previous ones and will no longer contain them. It is possible that the service life will be longer.

This can crack ceramics.

In the third case it is necessary to take into account not only the quality of the prosthesis, but also the work of the surgeon. Even an expensive implant does not guarantee the success of the operation with a low qualification of the doctor and no experience in arthroplasty. Therefore, it is worth focusing not only on models and firms, but also on the knowledge of the one who will operate on you. Don't forget the importance of rehabilitation. A full recovery course will guarantee a successful recovery with any type of prosthetic design.

Models of leading foreign firms do not have any particular differences, so it is difficult to say which one is better. Comparison - rather by the standards of price-quality. Well-known firms Zimmer, De-Puy, Biomet produce equivalent samples that do not have pronounced differences.

The ceramic head destroyed the acetabular component.

Second photo of the destruction.

When choosing a prosthesis, look not at the company or cost, but at a more important feature that affects the life of the adaptation - a friction pair.

Types of endoprostheses, their differences

It's important to know! Doctors are shocked: “An effective and affordable remedy for joint pain exists ...” ...

If we talk about the appearance of the prosthesis, it is a complete imitation of a person's native joint, which can withstand everyday stress and has the same functional abilities as the previously destroyed one.

Features and differences are distinguished by the type of arthroplasty:

• superficial. The head of the hip joint and the acetabulum are replaced;
• total. Complete replacement of damaged bone and cartilage with excision of the femoral neck.

An example of a Zimmer surface implant.

Implants are distinguished by the method of attachment:

• Fixation without medical cement. It is used for young patients without signs of osteoporosis. With good bone density, they grow into the prosthesis and secure it. With cementless fixation, a stem having a titanium alloy can be used.
• Fastening with cement. The technique is used in the elderly or in patients whose bone density does not allow the use of a cementless method.

Scheme of implant fixation methods.

Recently, you can often hear the concept of "liquid implant". It is not related to full-fledged endoprosthetics, since it is not a prosthesis. It is supposed to introduce certain types of acids, the purpose of which is to restore the connective tissue of the cartilage. Any expert will tell you that this is impossible. Under the influence of the degenerative-dystrophic process, pathologies, the joint is completely destroyed and does not have the ability to regenerate. The only way out is surgery.

Metal-polyethylene, polyethylene-ceramic, ceramic-ceramic.

Consider friction pairs. It makes no sense to choose a particular brand or focus on price, but it makes sense to consider other characteristics, because wear products will negatively affect the surrounding soft tissues and bones. Here's what you really need to discuss with your doctor.

There are the following varieties:

• metal combined with metal;
• metal and polyethylene;
• ceramics plus ceramics;
• combination of ceramics and polyethylene.

Each type has its own advantages and disadvantages. It cannot be said that the combination of some components will be bad, and the other - good. The prosthesis, as well as friction pairs, are selected individually. What is not suitable for one patient may be recommended for another.

A popular option - a combination of a metal component with a metal one due to its low price, however, is not recommended for installation for everyone - it has a number of limitations. It is more often implanted in men who are accustomed to a more active lifestyle. It is strongly not recommended for women planning future pregnancy: there is a high risk of penetration of toxic products into the placenta, which negatively affects the fetus. In a number of countries, the use of such a combination of components is prohibited.

Wear on metal components is visible to the naked eye.

More often used ceramics in combination with polyethylene: suitable for patients of any category, has no age restrictions. Revision replacement intervention may be needed after 15-20 years.

From 10 to 15% of complications after arthroplasty are associated with incorrect selection of the prosthesis, and more specifically, friction pairs. That is why it is important to find a qualified orthopedist and pay attention not to the brand of the implant, but to its quality.

The highest service life of the friction pair "ceramics plus ceramics". Suitable for almost all patients, the only contraindication is that such prostheses for osteoporosis (low tissue density) are not implanted. The main condition that allows you to extend the duration of use, reduce the risk of reoperation is the correct installation of the structural components.

Hip joint: prosthesis price

The cost of endoprosthetics and the implant itself depends on the medical center of orthopedic surgery. The average price in Moscow according to 2014 statistics is 90,000-120,000 rubles. This price did not include hospital stay and diagnostic tests.

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The price of orthopedic structures depends on the manufacturer and the material used. Foreign companies offer implants in the region of 1300-2000 dollars, domestic ones are several times cheaper.

The quality of arthroplasty is not affected by the cost, but by the quality of the operation and subsequent rehabilitation. Even the most expensive endoprosthesis does not guarantee a therapeutic effect if the intervention is performed incorrectly and there is no correct recovery period.

Where ?

"Doctors hide the truth!"

Even “neglected” joint problems can be cured at home! Just don't forget to brush it once a day...

You will deal with the purchase of an implant to replace the hip joint directly with your doctor. It is they who cooperate with manufacturers and will be able to say how much a certain type costs.

The prosthesis can be bought independently in a specialized store or ordered via the Internet. The service is possible provided that you have agreed in advance all the nuances, found out the required type of prosthesis.

In the cities of Russia there are companies - official distributors of foreign manufacturers of orthopedic implants. More often you can hear about "Legacy MED" (works with the world famous American company "Jonson & Jonson"). Here you can buy titanium and ceramic endoprosthesis. The consultant will tell you the exact price.

The development of such a pathology as hip dislocation after replacement is a rare case; it is diagnosed no more than 2-4 times per 100 operated patients. Symptoms are indistinguishable from dislocation to replacement. The clinical picture is as follows:

• the development of a pain syndrome that is not amenable to relief with painkillers;
• change in the length of the lower limb, its shortening;
• violation of the amplitude of movement, stiffness, a sharp decrease in physical activity.

The cause of dislocations is trauma, but strong muscles, hips, trained in the rehabilitation process, will help prevent this.

To clarify the stability of the design, the patient is introduced into a state of anesthesia, where the doctor deliberately subluxes the prosthesis, then sets it back to its original position. This procedure allows us to assume the causes that provoked the complication, and in the future to reduce the risk of re-dislocation.

The treatment consists in the reduction of the dislocation and the subsequent wearing of a special prosthesis, a course of physiotherapy exercises, physiotherapy, and massage.

Zimmer: hip prostheses

A well-known manufacturer of orthopedic equipment, a company founded in the USA over a hundred years ago - Zimmer (Zimmer). Throughout the entire period of its existence, the company has been constantly developing, introducing the latest technologies, creating new designs, prostheses. Its products are transported to different countries of the world, used in medical centers in Israel, Germany, Russia, and the Czech Republic.

Such popularity is associated with the quality of products: it is distinguished by durability and high adaptive capabilities.

Zimmer is the "Mercedes" of endoprostheses.

The range of the company is wide, it is possible to choose a prosthesis in the price-quality ratio. Even inexpensive implants allow you to completely imitate the native joint and have good wear resistance.

What prosthesis can be purchased, how long does it last? Zimmer manufactures the following implant structures:

• knee replacement prosthesis. The undisputed leader: almost half of the operations are performed with the use of prostheses from this company. Service life - 15 and more years;
• endoprostheses for replacement of the shoulder joint. Unique innovative development - a joint with a maximum level of implantability, restoring hand functions by 95%;
• implants for hip replacement. Large selection of species, there is the possibility of individual selection, including the price.

The main difference between Zimmer products is the high adaptation of the prosthesis, which shortens the rehabilitation period.

According to statistics, the artificial joints of this manufacturer in 99% of cases remain stable for 10-12 years after installation. In almost 85%, the Zimmer's lifespan is approaching 15-18 years. Therefore, such popularity of the company is quite justified.

Patients often ask the following question: is it possible to put our prostheses, how many years will they last? The quality of domestic manufacturers is not much worse, there are many worthy orthopedic companies. When answering another question, there are many factors to consider. Here everything depends no longer on the price of the implant, but on the chosen design - a friction pair, the skillful hands of a doctor and a rehabilitologist.

cost of the hip joint

Rarely, complications develop after joint replacement surgery; in 10% they are associated with an incorrectly selected implant. Patients are diagnosed with a fracture of the neck, the development of an infectious process, edema, hematoma.

Fact: there is no specific prosthesis - a universal model that could fit everyone and not provoke side effects.

The main mistake of many patients is to make a choice of an endoprosthesis design based on reviews from the Internet and on price. A person chooses the most expensive foreign-made prosthesis and performs the operation with a surgeon with little experience. As a result, adaptation is poor, recovery is long, and there are many complications.

If you decide on arthroplasty, pay attention - the price of an implant, Zimmer or ceramic, has nothing to do with the success of the treatment. It makes sense to opt for an inexpensive but suitable orthopedic item for you.

An experienced surgeon has his own preferences in models and brands, so a preliminary consultation and selection is essential. Experts, both private institutions and public medical centers, are more likely to advise choosing Zimmer and DePuy. Although the prostheses of these manufacturers do not have a fundamental difference, they are completely similar in appearance, these are high-quality products with the ability to choose a design taking into account financial capabilities.

How much does treatment with such endoprostheses cost? The average price in Moscow is 200,000 rubles, taking into account a stay in a private clinic, laboratory tests, a hospital and subsequent rehabilitation under the supervision of a specialized doctor.

There is an important point in orthopedic surgery: the basis of a successful recovery is recovery. Not one, even the most expensive, prosthesis guarantees the success of the operation without following the rules of rehabilitation.

In practice, there are enough examples when patients, acquiring the most innovative and expensive implant, completely ignored the restoration, believing that it was not needed due to the high price. The result - patients returned after a few years to the doctor with complaints of pain, swelling, development of lameness. In this case, there can be no conservative treatment - a revision surgery is prescribed, followed by additional costs and long-term rehabilitation.

For the treatment and prevention of DISEASES OF THE JOINTS and SPINE, our readers use the method of fast and non-surgical treatment recommended by the leading rheumatologists of Russia, who decided to oppose pharmaceutical lawlessness and presented a medicine that REALLY TREATS! We got acquainted with this technique and decided to bring it to your attention. Read more…

Very often, replacing a native joint with an artificial one is the only way to restore the normal functioning of the musculoskeletal system. Approach responsibly to the choice of prosthesis, diagnosis, clinic, doctor and further recovery.

How to forget about pain in the joints?

• Joint pain limits your movement and life...
• You are worried about discomfort, crunching and systematic pain ...
• Perhaps you have tried a bunch of medicines, creams and ointments ...
• But judging by the fact that you are reading these lines, they did not help you much ...

But orthopedist Valentin Dikul claims that there is a really effective remedy for joint pain!

During the operation, the installed endoprosthesis of the hip joint replaces those structures in the hip joint in which pathological changes have occurred.

Many medical centers for medial femoral neck fractures, i.e. when the fracture is in close proximity to the head, a total joint arthroplasty is performed. This is done with a complete replacement of the femoral head and acetabulum.

Replacement of only one element of the femur (unipolar prosthesis) is performed:

• in elderly patients in serious condition;
• people with disabilities who are unable to move independently.

Product types

Types of hip endoprostheses are distinguished by the method of their fixation:

• cementless CFP prosthesis;
• prosthesis hybrid;
• standard endoprosthesis.

The doctor knows what is the best prosthesis to use. All dentures have their pros and cons.

The patient does not need to review the photos, study what manufacturers of medical equipment are, and understand the prices. A good surgeon takes into account all the nuances for each patient, selects a suitable prosthesis according to indications. Recently, the Zimmer hip joint implant has been increasingly used; this company has long established itself in the market for this type of product.

Depuy products are not inferior in quality. Russian manufacturers have also achieved success in this matter (for example, ESI). The German company Esculap has also proven itself in the world market, the prosthesis of which has increased wear resistance. Many doctors praise American prostheses.

When is joint replacement indicated?

There are the following indications for hip arthroplasty:

• ankylosis occurring with complications;
• deforming coxarthrosis at the stage of progression;
• arthrosis of the hip joint, which has developed as a result of congenital dislocation of the hip in people who have reached the age of 30–40;
• deformation of the joints as a result of damage by tumor processes in the articular ends and femurs;
• disability that has developed as a result of damage or complication of diseases of the bone skeleton.

There are also contraindications to the installation of an endoprosthesis. These include:

• purulent-inflammatory processes in the joint area, accompanied by complications;
• osteomyelitis and the presence of fistulas;
• tuberculosis of the bones in the acute stage.

Material for the manufacture of prostheses

Hip arthroplasty is an operation that aims to replace a damaged joint with an artificial one. Most often, the femur and acetabulum are replaced.

The artificial ball on the shaft of the prosthesis is made of a solid metal base or ceramics. An artificial cavity is made, as a rule, from polyethylene (durable wear-resistant plastic).

The prosthesis is fixed with bone cement.

The most durable and wear-resistant are metal prostheses. If used correctly, they will last an average of 20 years. The service life of a hip joint endoprosthesis made of another material is 15 years.

The price of the product will also depend on these and other indicators, durable prostheses will be more expensive, less durable ones will be cheaper. In addition, the cost of an endoprosthesis may depend on its brand. For example, a Zimmer endoprosthesis will be more expensive than a conventional prosthesis due to the guaranteed high quality.

Methods for fixing endoprostheses

The endoprosthesis is attached in 3 different ways:

• polymer-based bone cement is used;
• when the bone grows into special porous recesses of the implant;
• mixed way.

It is impossible to say unequivocally which one is the best. The choice is made depending on the age of the patient, the condition of the femoral and acetabular bones. If the patient is over 50 years old, bone growth is not observed, it is better to fasten with bone cement.

And in osteoporosis of the femur, bonding with bone cement is supplemented by the establishment of a metal plate that fixes the implant.

In other cases, a cementless fixing method can be used.

Preparing for the operation

A total joint replacement involves preliminary preparation for surgery. It begins a week before the installation of the prosthesis. There are certain points that are important to find out before the operation:

1. The question of blood transfusion is put as a last resort. Most often, such an operation does not require a blood transfusion if the patient's hemoglobin level shows 12%.
2. All dental pathologies, such as periodontal disease, caries, etc., must be eliminated before arthroplasty, so that bone infection does not occur at the time of the operation.
3. The doctor finds out what medicines the patient is taking and advises on this issue.
4. Diagnostic measures are being taken. Mandatory are a blood test, urine, ECG, chest x-ray. These studies are important before surgery to determine if surgery is allowed.

Rules for staying in the hospital

Patients who are preparing for endoprosthetic surgery must also be prepared to follow certain rules.

On the day of admission to the hospital, the patient must be in the hospital at the strictly appointed time:

• the doctor checks and assesses the state of health of the patient;
• if necessary, the patient undergoes a series of tests;
• The patient goes to see the anesthesiologist.

On the day the operation is scheduled:

1. The patient is transported to the operating room.
2. Performing endoprosthesis surgery. The prosthesis is installed on average in 1-2 hours.
3. For further postoperative recovery, measures are taken to prevent thromboembolism, the necessary drugs are prescribed.
4. Until vital signs stabilize, the patient is under the constant supervision of doctors in the ward.
5. A special diet (liquid or soft food) is prescribed.

To prevent infection from entering a weakened body, broad-spectrum antibiotics are used. So that a person does not feel pain, as well as to prevent the inflammatory process, analgesics and anti-inflammatory drugs are introduced into the operated area.

On the second day after surgery, it is allowed to try to perform simple movements: gently sit down, do flips on a healthy side.

On the third day, in the absence of complications, it is allowed to get up and walk with crutches. After 2 weeks, the patient is discharged. The day before, the doctor removes all stitches.

After the operation, the recovery course will last from 2 to 3 months. In the presence of complications, a person is placed in special rehabilitation centers.

Currently, only 5% of patients experience complications after surgery. Such a low percentage is associated with the good quality of endoprostheses and the improvement of the surgical technique.

After 3 months, with a successful outcome of arthroplasty, a person can safely return to their daily activities and even to some sports.

All movements are performed without any problems. The only caveat: jumping is prohibited, as you can damage the prosthesis and loosen its fasteners. As a result, the service life of the endoprosthesis will be reduced, and it will be necessary to replace it.

1. Indications and contraindications
2. Buy a hip prosthesis
3. Dislocation of the hip prosthesis

Endoprosthetics of the hip joint is practiced for those patients whose natural joint for a number of reasons (illness, injury) can no longer function normally. With the help of these artificial analogs of the joint, it is possible not only to save the patient from unpleasant symptoms of diseases, but also to completely restore his former motor activity.

Modern endoprostheses externally have the same structure as a conventional hip joint. They perform identical functions and can withstand quite a large load.

In most cases, the selection of an endoprosthesis before the operation is carried out by the attending physician, who takes into account many criteria, namely:

• person's weight;
• patient's age;
• a specific diagnosis that led to limited mobility in the joint and neglect of the disease;
• the tendency of a person to all kinds of allergic reactions.

It should be noted right away that it is impossible to determine “by eye” which endoprosthesis is better, because in this case it is necessary to take into account not only the working mechanism of the implant, but also its manufacturer and, without fail, materials.
Fortunately, modern endoprostheses can be quite different, which provides a wide range of choices.

Important! According to doctors, high-quality endoprostheses must be made by trusted manufacturers, have a complete set and a perfect mechanism of operation. At the same time, experts note that such a product and the cost will be quite high. According to the quota, one should not hope for the establishment of a high-quality product.

Every year, hip arthroplasty is performed in thousandths. To understand in more detail its outcome and general impressions of such a surgical intervention, you can view patient reviews:

The price in Moscow for hip replacement is determined by the following factors:

1. The specific clinic where the procedure will take place.
2. Surgeon qualification.
3. The type of anesthesia used.
4. The complexity of the surgical intervention and the goals set by the doctors.

Also, the type of the selected endoprosthesis and what kind of operation it will be (primary joint replacement or revision, which is carried out with the development of complications) play a big role in the cost of such an operation. On average, this surgical intervention in Moscow will cost from 260,000 rubles. If the procedure is practiced in elite private clinics, then the operation will cost much more.

This is what the ceramic components used in hip replacements look like. In the bottom row, the so-called "heads", in the top row, "cups".

Attention! One of the highest quality and at the same time expensive materials for an endoprosthesis is ceramics, the price of which will be quite high. It should be understood that the period of use of such implants can reach up to thirty years, which is considered an excellent indicator.

Ceramic pair of friction assembly.

In order for subsequent rehabilitation to be as easy as possible, even before the operation, a person must successfully choose the type of endoprosthesis for himself.

With special care, it is necessary to select prostheses in case of illness, because the implant, after being installed, should not only provide the possibility of the motor function of the joint, but also minimize the inflammatory process.

There are such types of prostheses (according to materials) that are installed today by surgeons:

1. metal + metal. If successfully installed, they can theoretically last up to ten years. Despite this, due to the fact that the metal can be toxic to the body, in some countries it is forbidden to use prostheses that were made from it. It is recommended to install metal prostheses for men with a large weight, who lead an active lifestyle. Metal implants are contraindicated for women planning a pregnancy.
2. Metal + polyethylene. The use of these types of prostheses is desirable for people who lead a moderate lifestyle and do not practice sports. Unfortunately, due to the pronounced friction, such prostheses need to be replaced after ten years.
3. Ceramics + Ceramics. This is ideal for younger patients. They move well and do not irritate the tissues of the joint. Unfortunately, ceramic products are almost twice as expensive as conventional metal prostheses.
4. Ceramic + polyethylene. This is the most affordable, but also the highest quality type of prosthesis. Its advantage lies in the ceramic head, which practically does not wear out, and the polyethylene cup, which, although it wears out, perfectly cushions like healthy human joints.

As hard as ceramic is, it is also brittle. In the photo you can see the result of the fracture of the TBS ceramic head.

The most commonly used endoprosthesis friction pairs, from left to right: metal-polyethylene, ceramic-polyethylene, ceramic-ceramic.

In addition, the following types of endoprostheses are often used recently:

1. titanium. This is an all-metal prosthesis, which is used for superficial, as well as for combined arthroplasty. Despite the durability, it is this type of implant that often provokes inflammatory reactions in the joint.
2. biopolar the type of prosthesis is provided for the establishment of patients who have suffered a fracture of the femoral neck. Usually they are older people. The design of the bipolar prosthesis has a double knot of movements in the head. Thanks to this, even elderly people with limited physical activity can walk again after the operation.
3. Liquid prosthesis to restore cartilage function. This type of prosthesis is used in the treatment of arthrosis, which affects the cartilaginous tissues of the joint. At the same time, preparations based on hyaluronic acid are administered to the patient, which fill the cavity of the diseased cartilage. Unfortunately, liquid prosthetics will not be effective in case of bone tissue damage.

The photo shows two bipolar endoprostheses without a femoral component. If you look closely, you can see two axes of movement and, accordingly, two planes of friction. The porous surface eliminates the need for cement during installation.

Hip joint, prosthesis: price

The minimum cost of a hip joint from foreign manufacturers is $650. In Moscow, you can order this type of joint both directly from the company and from representatives of the manufacturer.

At the same time, even before buying an endoprosthesis, a person must specifically know what specific material the product should be made of (ceramic, titanium prosthesis, etc.).

Indications and contraindications

Coxarthrosis of the right hip joint. Complete absence of joint space.

The main indications for which joint replacement surgery may be required are:

• arthrosis and its varieties (coxarthrosis, osteoarthritis);
• oncological pathologies of the hip bone;
• dislocation or fracture of the femoral neck;
• arthritis, including the one that developed after a previous injury;
• necrosis of the head of the femur;
• improper fusion of the hip joint;
• joint dysplasia (congenital form).

In turn, it is forbidden to practice this surgical intervention in such cases:

1. The period of bearing a child.
2. The period of lactation in a woman.
3. Poor blood clotting.
4. HIV infection.
5. progressive osteoporosis.
6. Severe pathologies of the cardiovascular system.
7. Epilepsy.
8. Tuberculosis.
9. Serious disturbances in the functions of the kidneys or liver.
10. Infectious lesions, especially in the area where the operation will be performed.
11. The period of acute respiratory diseases.

Endoprosthetics is practiced with caution under such circumstances:

• advanced age of the patient;
• patient with diabetes mellitus;
• tendency to allergic reactions;
• unstable psycho-emotional state of a person, especially neurosis and a period of depression.

Buy a hip prosthesis

As noted above, how much an endoprosthesis costs is determined by its material, country and manufacturer.

The average cost in Moscow for these implants is as follows:

As you can understand, the price of these products also depends on the pair-friction of the joint.

Dislocation of the hip prosthesis

Subluxation or complete dislocation of the hip endoprosthesis, fortunately, is quite rare, but still such a complication is recorded in 1-3% of all cases.

Dislocation of the right hip joint implant (in the picture on the left). This does not happen often, the reason is usually a fall or injury, but it also happens as a result of an initially incorrect installation of the implant.

The fact that a person has a dislocation of the endoprosthesis can be affected by many factors, namely:

1. General physical weakness of human muscle fibers.
2. Endoprosthesis surgery, which was performed not for the first time (revision intervention).
3. An advanced form of hip dysplasia, which led to severe deformities.
4. Incorrect placement of the endoprosthesis.
5. Looseness of the endoprosthesis, especially in the area of ​​its attachment to the bone tissue.
6. Defect of the liner, which acts as articular cartilage.

Deterioration of the polyethylene liner, due to which the head of the endoprosthesis has shifted higher.

Important! The better the physical preparation of the body, the less likely the dislocation of the hip joint. That is why even before the operation, patients must perform special exercises and gymnastics without fail.

The following groups of patients are at increased risk for dislocation of the endoprosthesis after surgery:

• elderly patients;
• women (it is they who have a greater frequency of movements in the articular joints, as well as a smaller weight);
• obese patients;
• tall patients;
• people suffering from cerebral palsy and other severe types of muscle disorders.

The greatest risk of accidental dislocation of the prosthesis is observed in the first days after surgery. It should be understood that this probability is still within a year after surgery. Moreover, due to the above factors, the patient may remain at risk of re-dislocation of the joint.

To avoid dislocation in the first time after the operation, the use of such a roller is recommended.

The main symptoms for a patient to have a dislocation of the prosthesis are:

1. Severe pain with any movement in the joint.
2. Stiffness of movement in the leg.
3. Shortening of the diseased leg by a few cm.
4. Swelling of the diseased limb.

In the event that the patient has such symptoms after the operation, he should consult a doctor as soon as possible until his condition becomes critical. With a complete dislocation of the implant, a person needs to carry out its reduction, which occurs under anesthesia. This procedure can be either open or closed. The attending physician should decide how best to return the prosthesis to its original position in each specific case.

If the implant area hurts, then something is wrong, urgently see a doctor!

Immediately after the joint has been repositioned, the patient may be prescribed a course of therapeutic massage, physiotherapy, or the use of a special orthosis to fix the hip joint.

Remember! In the event that a person repeatedly dislocates an artificial joint, this indicates that the endoprosthesis was initially incorrectly installed (the angle of deviation of the implant does not meet the standards). In this case, the only right decision would be to carry out revision arthroplasty, after which the risk of re-dislocation will significantly decrease.

Additional complications after arthroplasty can be:

The arrows indicate what the complication of an infectious nature looks like in the pictures.

Important! According to research, the experience of the surgeon is directly reflected in the development of complications in humans. Thus, young specialists have about 5% of all cases of unsuccessful operations, while experienced surgeons with a work experience of 20-30 years make mistakes only in 1.5% of cases. Despite this, the age of the patient and the presence of severe pathologies play a significant role in the development of complications.

Zimmer hip prostheses

Endoprostheses of the American company Zimmer are very popular today, since these products are of high quality, which has been tested by time. In Russia, such endoprosthesis models appeared at the beginning of the new century and since then have gained a stable position among the entire range of various hip joint implants.

The price of such products is determined by its configuration, features and materials. Compared to endoprosthesis models from domestic manufacturers, the cost of Zimmer products will be an order of magnitude higher.

The Zimmer, whose service life is at least 15 years, has an anatomical similarity to the normal bone tissue of the joints, so after the operation it is not at all difficult for a person to perform the usual movements of the operated leg.

The picture shows an implant for superficial arthroplasty by Zimmer. Such implants are used less and less.

Today, endoprostheses of this company are used by leading endoprosthesis clinics in America, the Czech Republic and Switzerland, since these products meet the following requirements that surgeons place on them:

1. Protective effect of the pelvic bones in the area of ​​the acetabulum.
2. Possibility of joint maximum motor functions.
3. Excellent patient tolerance of the prosthesis (the implant does not provoke allergic reactions and oxidation).
4. Long service life.
5. Wear resistance.
6. Little access required to carry out the operation.
7. The similarity of the prosthesis with bone and cartilage tissues, which is matched as closely as possible.

Moreover, with the help of such endoprostheses, doctors can change the length of the operated leg during the operation, which is especially important when replacing a joint in children and adolescents.

The service life of these products depends on the method of attachment, the age of the patient, the specific type of prosthesis and the characteristics of its operation.

How long an artificial joint lasts is not only a concern for the patient, but also for the surgeon who will perform the operation. In this case, the following factors are distinguished, in which the duration of wear of the endoprosthesis can be significantly less:

1. Surgery in the presence of serious contraindications (progressive diabetes mellitus, advanced osteoporosis, etc.).
2. Improper placement of the implant.
3. Change in the angle of the thigh after surgical manipulation.
4. Use of a poor-quality prosthesis.

When asked how many years a Zimer prosthesis will last, it is impossible to give an exact answer, since many individual factors influence this. Despite this, the manufacturer gives an almost 100% guarantee for its product, which, if successfully installed, should properly serve for at least ten years.

An example of a damaged acetabular component (polythene cup) Zimmer. The probable cause is an error in the selection of the endoprosthesis.

Here are some common questions patients have about Zimmer implants:

Many patients are interested in whether our prostheses can be placed. At the same time, doctors say that each person must decide for himself what is more acceptable for him at the price and the manufacturer's company. In the event that the patient decides to install a domestic endoprosthesis, he must be sure that a particular product is made with high quality. This is the only way to maximize its service life.

The cost of a hip prosthesis

To better understand which endoprostheses are better, here are the advantages and disadvantages of each of them:

Standard endoprostheses from Zimmer start at $2,800. How much a different type of endoprosthesis costs is determined by their material and the manufacturing company.

For any patient, you can always choose the most suitable variant of the endoprosthesis.

All types of artificial joint analogues have their advantages and disadvantages, therefore, in order not to get confused, it is best to consult with your doctor when choosing a specific product, who will help you make the right choice based on the age, weight and general lifestyle of the patient.

When choosing a particular type of endoprosthesis, it is recommended to pay special attention to Zimmer, whose price is average in the field of joint analogues.

Before you buy an endoprosthesis (prices for them may also depend on the volume of the desired product), you can read comments about the service life and feelings of patients after installing each type of implant.

If we compare all types of endoprostheses, then the best choice would be ceramic, the price of which is fully justified by its quality.

The price in Moscow for the installation of an endoprosthesis is also set by the type of clinic in which the procedure will take place. Moreover, additional costs in such a surgical intervention will be the cost of tests, rehabilitation, as well as daily payment for a hospital bed.

Be sure to consult your doctor before treating diseases. This will help to take into account individual tolerance, confirm the diagnosis, make sure the treatment is correct and exclude negative drug interactions. If you use prescriptions without consulting a doctor, then this is entirely at your own risk. All information on the site is presented for informational purposes and is not a medical aid. You are solely responsible for the application.

In modern medicine, orthopedics, issues of hip arthroplasty are widespread. Today, anyone can implant a prosthesis in the hip joint, the cost of which is considered acceptable by the bulk of the population.

Who is the operation for?

Orthopedic surgeries to replace a damaged joint are considered difficult.

The basis for the replacement are medical indications: high wear of this joint, trauma to the joints, bruises. Such limbs cannot fully function.

• patients with arthritis;
• arthrosis;
• with fractures of the femoral neck;
• dysplasia;
• congenital anomalies;
• oncological diseases.

Operation types

Hip prosthesis replacement can vary by type of surgery:

• replacement of the surface of the hip joint;
• complete replacement (total);
• placement of a partial denture.

What are the designs

Only a doctor will help with the choice of an implant.

Choosing a hip joint prosthesis on your own, deciding which one is better is impossible, only a doctor determines with a similar one, analyzing the type of injury.

The classic version of the implant is a leg (pin), head, cups. Depending on the purpose, they distinguish:

• by type of construction;
• material.

Designs are unipolar, capable of replacing the functions of the head of the joint. Bipolar, replace the head of the femur and acetabulum. The main material for production was metal, plastic, ceramics, their combination.

Fixation methods

There are fixing methods:

• mechanical (cementless), the product is wedged into the bone tissue, the junction is “masked” with a certain substance, after a while the bone “grows” with the product;
• cemented, the product is completely fixed with a biological solution;
• hybrid-hollow, when a product made of different materials is used, the cup is fixed in a cementless way, the legs are fixed with a biological solution.

Worth knowing! Methods of fixation are determined not only by the model of the implanted product, but also by the form of the disease, the age of the patient.

Manufacturers and cost

The cost of the prosthesis depends on the material and manufacturer.

Brand models are in wide demand and popularity: DePuy, Zimmer, Stryker, B. Braun, Smith & Nephew, Biomet, Aesculap.

The cost is formed from the type of model, brand. It is difficult to answer how much a hip joint prosthesis in Moscow costs, its cost can vary from 60,000 rubles to 170,000 rubles.

Abroad, from $8,000 to $40,000. The price in Ukraine fluctuates between 25,000 - 85,000 hryvnia.

The rehabilitation process

The rehabilitation process takes a long time, the patient is recommended to use antibiotics. To prevent pathology: the formation of blood clots, thromboembolism, anticoagulants are prescribed.

The patient is explained how not to bend the leg (toe down, inward; turn 90 °). Sleeping is allowed on the back, not on the injured side.

Important! Restoring full functionality requires a series of workouts, physiotherapy, and therapeutic exercises.