Hip Endoprosthesis

Endoprosthetics( replacement) of the hip joint

Endoprosthetics of the hip joint is one of the most modern methods of operative treatment of diseases of the musculoskeletal system. During the operation, pathologically altered tissues of the structures that make up the hip joint are replaced with artificial prostheses.


Structure and function of the hip joint

The hip joint is considered the largest joint of the bones of the human body. The loads that he has to experience in the process of vital activity are very large. After all, he connects both lower limbs with the pelvis.

In the formation of the hip joint involved:

  • The head of the femur - the spherical upper end of the thigh;

  • The acetabulum is a deepening of pelvic bones in the form of a funnel in which the femoral head is fixed;

  • Articular cartilage - a soft cartilaginous tissue with a gel-like lubricant, facilitating the performance of movements;

  • Intra-articular( synovial) fluid is a jelly-like mass that feeds cartilage and softens friction between articular surfaces;

  • The ligamentous device and the joint capsule are a dense connective tissue that holds the joint surfaces and provides stability of the hip joint.

Muscles and their tendons attached to the hip joint, contracting, provide movement in it. A healthy hip joint is mobile enough, and produces movements in almost all planes and directions. This volume of movements is sufficient to adequately provide the function of support, walking and performing strength exercises.


Why is endoprosthetics required?

It is quite natural that to perform a hip replacement with an artificial prosthesis there should be weighty indications. They are based on such a destruction of the components of the joint, in which a person either experiences painful pain, or is unable to perform the elementary movements of the affected limb. In other words, the joint ceases to meet its physiological purpose and becomes an unnecessary part of the body, as it sharply worsens the quality of life. In such cases, endoprosthetics is the only way out of their situation.

Among the diseases that can provoke destructive changes in the joint structures, most often occur:

  • Deforming osteoarthritis of the hip joint( coxarthrosis), which occurs simultaneously from both sides at 2 and 3 degrees of the disease;

  • Coxarthrosis of 3 degrees with deformation of one joint;

  • Unilateral deforming arthrosis of the hip joint of 2-3 degrees in combination with ankylosis( complete immobility) of the knee or ankle of the affected limb;

  • The defeat of one hip joint with coxarthrosis of 2-3 degrees in combination with ankylosis of the same articulation on the opposite side;

  • Single- and double-sided ankylosis of the hip joints with Bechterew's disease and rheumatoid arthritis;

  • Fracture of the femoral head( aseptic necrosis) due to trauma or circulatory failure;

  • Traumatic injuries of the head and neck of the femur in the form of a fracture or a false joint in persons over 70 years of age;

  • Malignant tumors in the ankle, requiring surgical treatment. After resection of the tumor, one-stage endoprosthetics is performed.


Contraindications to operation

Unfortunately, people who need hip replacement are not always able to perform such an intervention.

The main limitations are:

  • Clinical cases when a person for any reason is not capable of independent movement. Completed endoprosthetics they do not eliminate the existing defect and therefore is considered impractical;

  • Chronic pathology, which is in the stage of decompensation( heart failure, severe heart defects and arrhythmias, cerebral circulation disorders with neurologic deficiency, hepatic-renal failure).The operation carries a high risk of aggravation of existing problems;

  • Chronic pathology of the lungs, accompanied by severe ventilation and respiratory insufficiency( asthma, pneumosclerosis, bronchiectasis, emphysema);

  • Any inflammation of the skin, soft tissues or bones in the hip;

  • Foci of chronic infection in the body requiring sanation;

  • Septic states and reactions. The operation is not performed even for those patients who have had sepsis for several years, since there is a high risk of suppuration of the prosthesis;

  • Paresis and paralysis of the limb to be replaced;

  • Severe osteoporosis and insufficient bone strength. Such patients, even after an ideally performed operation, can break the femur or pelvic bones during normal walking;

  • Strong cross-allergy to various medications;

  • Pathological conditions, accompanied by a lack in the femur of the medullary canal.


Species and types of endoprostheses

An endoprosthesis that will replace a pathologically altered hip joint should have sufficient strength, reliability of fixation, high functional abilities and be sufficiently inert to the tissues of the human body. All these requirements are met by products made of high-quality metal alloys, polymers and ceramics. As a rule, one endoprosthesis contains a combination of all these materials. This is due to the fact that the appearance and qualities of the product should resemble a human's hip joint.

Its components are represented by:

  • Endoprosthesis cup. This is the part that should replace the acetabulum of the pelvic bones. It is usually made of ceramics. But there are cups of polymer materials;

  • The head of the prosthesis. It is a metal ball-shaped piece coated with a polymer. In this way, it is possible to achieve the softest possible sliding when the head rotates in the prosthesis cup during limb movements;

  • With the prosthetic leg. It is made exclusively of metal, because it experiences the greatest loads compared to other parts of the endoprosthesis. If the head of the prosthesis imitates the head of the femur, then its foot replaces the cervix and the upper third of the femur.

Another important category in the classification of products for prosthetics of the hip joint is their division into single-pole and bipolar. The first type is represented exclusively by the leg and the head, by which the corresponding structures of the femur are replaced. In this case, the joint will be represented by an artificial lower part and a natural acetabulum. Such interventions have been widely performed before. Due to poor functional results and a large number of acetabular fractures with the failure of the endoprosthesis in the pelvic cavity, modern orthopedists do not practically perform such operations.

Bipolar endoprosthesis is more often called total. This means that the composition of the product is represented not only by the part that prosthetics the femur, but also by the cup, which plays the role of the acetabulum. Such endoprostheses are perfectly fixed in bone tissues and are maximally adapted, which significantly increases the effectiveness of the operation and reduces the number of complications. This is especially true when performing endoprosthetics in elderly people with osteoporosis and in young physically active individuals.


Cement and cementless endoprosthetics

A very urgent issue, both for specialists and their patients, is the choice of the method of fixing the endoprosthesis. In this respect, everything is not so simple. After all, metal and ceramic materials should be firmly connected with the bones. Only if this condition is met, it is possible to perform the functions of support and walking with a limb.

After determining the correct type of endoprosthesis and its size, the physician chooses the method of connecting the prosthesis to the tissues during surgical intervention, guided by such tactical solutions:

  • Fixation of the endoprosthesis with cement - a special biological glue that after hardening will firmly connect the bone tissue with the structures of the endoprosthesis;

  • Cementless fixation. These products have a special design and are designed in such a way that on their surface there are many small protrusions, depressions, irregularities and holes. Over time, bone tissue sprouts in them, and the prosthetic bone becomes one with the endoprosthesis;

  • Hybrid or mixed fixation. Assumes a combination of cement and cementless methods. The leg is fixed in the femur with cement, and the cup is screwed into the acetabulum.

The long-term observations of specialists after the patients after such interventions made it possible to draw such practical conclusions:

  • Cement at cooling creates a very high temperature. This leads to an acceleration of the destruction of the surrounding bone tissue, which can cause the prosthesis to fail and fall into the pelvic cavity;

  • Cement fixation accelerates rehabilitation and shortens the recovery period for patients, but its use is limited in patients with osteoporosis and the elderly;

  • Cementless endoprosthetics is associated with an extended period of full rehabilitation. Patients should observe a limited motor regime much longer in connection with a high risk of dysfunction of the prosthesis;

  • The most optimal is endoprosthetics with combined methods of fixing different parts of the product. This rule is the gold standard of medical treatment for patients of all age groups.


Preparation for operation

All patients who need endoprosthetics and who have undergone the necessary studies to determine the condition of the hip joint( radiography, MRI, ultrasound), must also undergo a comprehensive examination. This is necessary in order to exclude the presence of possible contraindications.

Complex of diagnostic measures includes:

  • General clinical tests of blood and urine;

  • Determination of blood glucose level, and for people with diabetes - glycemic profile;

  • Biochemical blood test;

  • Determination of blood electrolytes( potassium, magnesium, sodium, calcium, chlorine);

  • Coagulation study( coagulogram, prothrombin index, clotting time and bleeding time);

  • Determination of blood type and Rh factor;

  • Blood test for RV and Australian antigen;

  • ECG;

  • Examination of the functions of external respiration;

  • Radiographic examination of the lungs;

  • Consultations of narrow specialists in the presence of relevant chronic pathology.

No special preparations are required before hip endoprosthetics. If no contraindications are established during the examination, the date of the operation is assigned. On the eve of the evening a light dinner is allowed, but not earlier than 8 hours before the intervention. In the morning, the skin in the hip and thigh area is carefully shaved. Take food and drink water is prohibited. Before the patient is transported to the operating room, elastic shinning of the shins is performed, a prophylactic dose of the antibiotic is administered and premedication is performed.


What happens during the operation?

After the patient is delivered to the operating room and placed on the operating table, anesthesia is performed. Usually the method of anesthesia is chosen by the patient in conjunction with an anesthesiologist. Since the duration of the operation is from 1.5-2 to 3-3.5 hours, either spinal anesthesia or a complete combined anesthesia with controlled respiration and complete muscle relaxation is optimal. The first method is less harmful, so it is preferable for elderly patients.

After anesthesia, surgeons process the surgical field and access the hip joint. The size of the incision that passes through the central part of the articulation is about 20 cm. Then the capsule of the joint is opened and the head of the femur is removed into the wound. It is performed by resecting it on the emergency line before exposing the medullary canal.

The bone is modeled according to the shape of the endoprosthesis, which is fixed in it by one of the optimal methods( most often with the help of cement).Then, with a special drill, the acetabulum is treated with the purpose of completely removing the articular cartilage from its surface. In the prepared funnel, the cup of the prosthesis is fixed and fixed.

Prosthetic surfaces are compared and strengthened by stitching dissected tissues. In the wound, an active aspiration drainage system is installed, along which the detachable drainage will flow. A dressing is applied.


Possible complications of

Endoprosthetics of the hip refers to extensive and complex interventions.

Its complications can be:

  • Bleeding from a postoperative wound;

  • The formation of thrombi in the veins of the lower extremities with migration to the vessels of the lungs and pulmonary embolism;

  • Suppuration of the postoperative wound and endoprosthesis;

  • Hematoma of the operated area;

  • Insolvency of the endoprosthesis and its rejection;

  • Heart and brain problems in the presence of chronic pathology( IHD, atherosclerosis, dyscirculatory encephalopathy, etc.);

  • Dislocation of the endoprosthesis.


Real results of

According to statistical data based on long-term follow-up of operated patients and personal experience of leading specialists engaged in hip replacement, most patients are satisfied with the results of treatment. If the operation is performed in somatically healthy individuals of relatively young age who do not have concomitant diseases, the functional abilities of the hip joint are almost completely restored. This allows a person to walk and practice physical culture. Sports and movements associated with the strength of the lower limbs are impossible. Patients are either not able to perform them, or in the course of performance there is a violation of the integrity of the endoprosthesis.

Like any operation, endoprosthetics can not do without complications and unsatisfactory results. Basically, they are associated with old age, concomitant diseases and non-compliance of patients with treatment regimen in the early and late postoperative period. More than 20% of operated patients expected better results from endoprosthetics compared to those that were received.


Rehabilitation after hip arthroplasty

Rehabilitation measures to restore motor activity after hip replacement start from the first hours after surgery. They include exercise therapy, respiratory gymnastics, early revitalization. The operated limb should be in a state of functional rest, but movements must be carried out. They can be active when the patient independently reduces muscles, and passive, performed with the help of medical personnel or relatives. The main rule of the postoperative and rehabilitation and rehabilitation periods is the sequence of incremental loads.

The first day after the operation

Most patients spend it in the intensive care unit. This is necessary in order to monitor the vital signs around the clock and react instantly to any pathological changes. A few hours after the intervention, a person may be in a sitting position with the lower legs lowered. Movements in the knee and ankle are not limited.

Prosthetic hip joint can not be bent more than 90 degrees, as this can lead to a disruption in its design and fixation in the bones. To sit better under the supervision of medical personnel or relatives. They can help move the operated limb and help in case of dizziness( this sometimes happens when a person moves from a horizontal position to a vertical position).Patients with a history of comorbidities in relation to concomitant diseases and disruption of the general condition are necessarily prevented from developing bedsores( changes in body position, light back massage of the skin and in the area of ​​the bony protuberances, treatment with camphor alcohol, and control over the condition of the laundry).

Regarding the volume of permitted movements, the patient can:

  • Carry out movements with a healthy limb in any volume;

  • To get out of bed with support solely on a healthy leg is allowed only to young people without concomitant diseases, if the general condition allows it;

  • Move fingers and perform slight flexion in the knee joint of the operated leg;

  • Lift up the operated rectified lower limb, tearing it from the bed as much as possible;

  • Perform active movements of the upper limbs in any volume;

  • Walking in the first day is not recommended;

  • You do not have to lie on your side.

You can lay patients half-way by padding a pillow or a large tissue roller between your knees;

When can I get out of bed?

Independently to get out of bed after hip endoprosthetics during the first 24 hours is strongly discouraged. Support for a healthy leg without additional devices is contraindicated for several weeks. As an auxiliary means of rehabilitation, crutches, walking sticks and other orthopedic products are used. If the general condition after surgery is not violated, you can get up the next day. Most patients feel weakened and refuse early activation.

When can I walk?

Walking is allowed 2-3 days after the operation. Be sure to meet all the conditions when going to the vertical position. This is, first of all, the movement of the operated limb with the help of hands or a healthy leg, after which it hangs down from the bed. Relying on a healthy leg and crutches, you can get up. The patient's leg must be in a suspended state, since any attempts to support it are strictly forbidden for a month. The use of crutches during walking is recommended for at least 3 months.

If the recovery period proceeds without complications, then a simple cane can be used as an auxiliary means for support. It is allowed to lean on a sick leg a month later. In no case can not lean on it with all the weight. You need to start with the exercises in the form of a leg to the side with the subsequent reduction, as well as its raising and lowering, while standing. The load should begin with an easy support, which within 2 months can not exceed half the weight of the patient without taking into account the weight caused by obesity. Full-fledged walking without the use of supporting means is possible in 4-6 months.

How to eat right?

One of the most important elements of the postoperative period is the proper nutrition of patients. The diet should be enriched with a sufficient amount of protein, vitamins, microelements and other nutrients. Since the motor activity of patients is limited, it is not necessary to increase the calorie content of food. Excess energy substratum, which will not be consumed by the body, will turn into fat deposits and increase the recovery time. It is better to abandon the products of dough, fried and fatty dishes, smoked products, marinades and seasonings. The main emphasis is on lean meats, poultry, fish, vegetables and fruits in raw and boiled form, eggs, cereals. Strongly exclude any alcoholic beverages, strong coffee and tea.

Timing of treatment

Within the walls of a medical facility, most patients are in the course of 2-3 weeks. This is necessary in order to check the healing of the postoperative wound. In typical cases, postoperative sutures are removed after 9-12 days. Drainage from the wound is removed as the discharge stops( an average of 2-3 days).The expediency of staying in a hospital after the removal of stitches is caused by the need to teach the patient and relatives the rules of behavior and basic rehabilitation skills. After a lapse of 3 months, an x-ray examination of the hip joint is mandatory. This is necessary in order to determine the state of fixation of the endoprosthesis and bone formations in which it is located.

How long does the rehabilitation last?

After discharge from the hospital, it is advisable to consult a rehabilitation physician who will draw up an individual rehabilitation plan. Under the control of this plan, the recovery period will be as short and safe as possible. Most active patients return to their usual lifestyle after 6 months. Until this time it is better to use rehabilitation tools that minimize the burden on the operated limb and the prosthetic hip joint.


You can not do this!

Regardless of the period of the postoperative period, it is impossible:

  • Use too low chairs or a toilet bowl;

  • Cross the lower limbs while lying down on the back or on the side;

  • Sharply torso with fixed extremities and pelvis;

  • Lay on the side, not placing the roller between the knees.

All these actions can cause a dislocation of the endoprosthesis, which will require repositioning in a medical facility.

Endoprosthetics of the hip joint - an excellent achievement of modern medicine. Its effectiveness depends on both the correctness of the operation and the patient's compliance with the rehabilitation period.

Author of the article: Candidate of Medical Sciences Volkov Dmitry Sergeevich, surgeon

ayzdorov.ru

Endoprosthetics of the hip joint in Moscow. Basic indications, operation and rehabilitation

Operation. Hip joint replacement

The operation for the replacement of the hip joint is performed under general anesthesia and lasts, as a rule, about two hours. The surgical team consists of 2-3 orthopedic specialists, an operating nurse and an anesthesiologist. During the operation, purulent complications are prevented through the use of modern antibiotics, and, if necessary, blood transfusion is performed.

Immediately after the operation, the patient is transferred to the intensive care unit for some time. Antibiotic therapy continues in standard cases for 7 days. For the prevention of thrombophlebitis and thromboembolism, the patient takes drugs that prevent blood clotting. It should be noted that for the prevention of complications, in particular thrombophlebitis and stagnant phenomena in the lungs, a small amount of movement is allowed from the first day after endoprosthetics.

You can do uncomplicated movements, gymnastics, including breathing, and also sit down on the bed. Walking with the help of an instructor is possible for 3-4 days. For this, crutches are used. An extract from the hospital is possible already for 10-12 days after the operation.

After issue of

  • Metal - plastic. Suitable for both sexes who do not exercise and lead a measured lifestyle. This pair is considered acceptable for the elderly( when long revision of the joint is not required because of its wear and tear).This combination has the shortest service life.
  • Metal - metal. It is usually set for men who lead an active lifestyle( metal prostheses have the longest life, and they are considered to be the strongest).Not suitable for women planning pregnancy, since metal ions have the property of penetrating into the fetus, increasing the concentration of iron by 15%.
  • Ceramics - ceramics. It is suitable for all patients at any age, but the choice of a ceramic pair for many is not suitable because of their rather high cost. Of the advantages of this type of prosthesis can be identified their longevity and non-toxicity.
  • Ceramics - plastic. The cheapest version of the endoprosthesis. This ceramic combination is better suited for older patients, as young people with high activity will quickly fail( they have a high degree of wear and short life).
  • What can be called ideal?

    Sometimes complications occur in endoprosthetics( approximately 5-15% of all cases).Their cause is the wrong choice of an endoprosthesis, the instability of the aseptic profile, the fracture of the prosthesis in the leg, infections, hematomas, chronic diseases. Therefore it is very important to choose the right product.

    Unfortunately, it is impossible to advise now concrete endoprostheses, since there are no universal models. All prostheses differ, and the best way to understand their characteristics is only an experienced specialist. People who know about dentures only on reviews on the Internet are too tempted to make a choice, focusing only on one price. Remember: there are many qualitative and affordable endoprostheses, and it is not necessary that the more expensive they are, the better.

    Surgeon who will perform the surgery will advise the patient about the choice of

    endoprosthesis. Although hip joint endoprostheses should be the most optimal in price-quality combination, the quality of the operation itself, and not the cost of materials, remains important in endoprosthetics. Sometimes improper installation of the implant can damage even the most expensive orthopedic product, and a carefully installed model of the average price category can last several decades. The main factor of success in endoprosthetics is the experience of the surgeon conducting the operation, rather than the price of endoprostheses.

    The main manufacturers and the cost of

    Surgeons who have a lot of prosthetics have preferences for choosing a prosthesis of one type or another. The most important players in the market for the manufacture of high-quality prostheses are Zimmer, which manufactures Zimmer Trilogy cups, and DePuy, which manufactures Pinnacle hip joint prostheses. Zimmer or DePuy are almost identical in design and appearance, but there are differences( in terms of fixation, wear, coating material and thread diameter for screws).An experienced surgeon chooses which endoprosthesis, Zimmer or DePuy, is best for each specific case, or offers the patient a number of alternative options.

    The cost of surgery for endoprosthetics in private clinics is approximately 230 thousand rubles. The cost includes the preparation of the patient before the operation, the replacement process of the endoprosthesis and the primary rehabilitation after the operation( the recovery period is 2-3 weeks).The final cost may vary depending on the price of the prosthesis.

    How to choose a surgeon

    Do not think that the best surgeon is an elderly doctor with different awards. For the success of endoprosthetics, it is not the age of a specialist that is important, but how many operations he performed on the hip joint. In many clinics, you can meet 30-year-old doctors, who every day spend 3-5 prosthetics of the hip joint. An experienced surgeon who performs from 50 surgical interventions on the hip joint for a year can be considered. In the case of fewer operations, the surgeon is considered a student regardless of the amount of gray hair on his head.

    It is better to trust a surgeon with more experience in performing this kind of operations.

    In addition to the skills of a specific surgeon, you need to carefully study the reviews about the clinic where you are going to perform the operation on the hip joint. The fact is that no matter how experienced the doctor, but without the necessary equipment, he will not be able to carry out the endoprosthesis at the proper level. For the operation, not only the prostheses themselves are needed, but also the "right" tools( power equipment and other materials considered expendable).

    When choosing a surgeon, it is better to give preference not to a "professor with titles", but to a practicing specialist. There are many such doctors in our country. If you want to perform an operation to install a hip joint prosthesis abroad, we recommend that you contact the German clinics, as they are famous for their good results in the field of endoprosthetics.

    There are many different endoprostheses that differ in the type of attachment, structure, price and service life. You do not need to buy a prosthesis yourself. Entrust a suitable endoprosthesis to the surgeon.

After returning home, it is necessary to continue rehabilitation activities, following all the recommendations of the attending physician. You can also use the services of rehabilitation centers or individually engage with a doctor-rehabilitologist. At home, in a domestic environment, you must adhere to several rules that will help you to recover faster and significantly reduce the risk of complications.

Rules for rehabilitation after endoprosthetics

  1. Do not allow full bending of the hip joint;
  2. In the sitting position, the knees should be below the level of the hip joint. To do this, always lay the pillow , when you sit down. Sitting on a chair, always set your feet lightly;
  3. Never cross the legs of the : neither in a sitting position, nor in a reclining position. Do not lean forward, sit down and stand up keeping your back straight, not leaning forward;
  4. Observe the mode of movement on crutches .Use shoes with a non-slip sole, moving along the stairs, stick to the railing;
  5. Immediately notify the doctor if you experience pain in the joint region or the overall body temperature has increased. Do not also forget that no matter how modern the prosthesis was, it is not eternal. But the rate of wear of the prosthesis is largely determined by the patient himself;
  6. It will be prudent if you give up active sports and lifting weights. Also, it is very important to monitor your own weight.

We hope that these simple rules will help you to recover and significantly extend the life of the endoprosthesis. More information about rehabilitation after endoprosthetics, you can read here.

Stay healthy!

med-kvota.ru

Hip joint implants are completely different - there are several dozens of them.

  • Types of endoprostheses by design:
  • Single-pole - only the femoral head of the hip is prosthetic.
  • Bipolar - a prosthesis and a cavity, and a bone head.
  • Types of prostheses by the method of their fixation:
  • Prostheses with cementless fixation method - the bones are "adjusted" to the endoprosthesis( "ingrowth effect").It is used most often for young patients, since they are more likely to need replacement of the prosthesis after its wear.
  • Prostheses with cement fastening method - securely fixed with a special solution, very difficult to remove after wear of the prosthesis, so they are installed for people with the least activity.
  • Hybrid type - the cup of the endoprosthesis is fixed with a cementless method, and its legs - with cement.
  • Types of dentures by their material( cup-foot):

prokoksartroz.ru

Hip replacement

The hip joint is perhaps the most important element of the human musculoskeletal system. The joint is subject to considerable mechanical stress, and only its normal function allows you to maintain an upright position and stay confidently on your legs. With painful forms of joint pathology against the background of progressive disorders of his work, it is gradually becoming impossible not only physically active, but also ordinary everyday life, often leading the patient to disability.

The most common causes of hip dysfunction are diseases of destructive( destructive) nature. First of all, it is deforming arthrosis, rheumatoid arthritis and avascular osteonecrosis. Much less often the joints are destroyed by arthroses or arthritis of a different nature: posttraumatic arthrosis after fractures in the joint region, psoriatic or postinfectious arthritis, congenital or acquired deformities. In the early stages, all these diseases are successfully treated with conservative methods. Restriction of physical activity, the use of chondroprotectors, anti-inflammatory and analgesic drugs, injections of steroidovil hyaluronidase, properly selected physiotherapy reduce the pain syndrome for some time, but can not completely stop the progress of the disease. The destruction of the joint continues, the limitation of mobility increases, the pains become permanent. All these symptoms lead the suffering person to a decision about the need for surgical care.

Many patients with arthrosis of the hip joint( coxarthrosis) postpone the endoprosthesis to the last, intending to go through it only if they are completely deprived of the opportunity to walk. In fact, this is not the best strategy. Delaying the arrival to the surgeon, such a patient completely in vain continues to experience pain in the joint, which could be avoided by doing surgery earlier.

In addition, when a person with this disease is in no hurry to undergo a hip replacement surgery( which has long been needed), this tightening only worsens the course of the disease. At this time, the disease continues to adversely affect human health and is increasing every day, thereby extending the terms of rehabilitation and a return to a healthy life.

Modern hip endoprosthesis

These are complex technical products. The prosthesis consists of a leg, a head, a cup and an insert. All the details have their sizes and only during the operation the surgeon can finally decide on the choice of the necessary product for each particular patient.

This operation is the most radical of all listed, but at the same time very effective. Its essence lies in the fact that it completely replaces the hip joint. With the pelvic bone, the remains of the cartilaginous tissue are removed, and a new - ceramic or metallic - articular bed is placed in its place.

The other part of the artificial joint consists of a metal pin of high strength, which is made of titanium, stainless steel or other metals, and an articular head, which can also be made of metal or of high-quality ceramics. The metal pin penetrates into the femur and is fixed there, ensuring the reliability and stability of the entire structure, and the head of the prosthesis is attached directly to it.

The operation to replace the hip joint with a prosthesis is a complex, high-tech procedure. Therefore, preoperative examination of the patient, the selection of an adequate type for an endoprosthesis, as well as strict adherence to recommendations after the operation, is of great importance.

Hip joint surgery is sometimes the only form of medical intervention that can solve the problem of a worn or injured joint, for example:

  • the formation of false joints and non-growing fractures of the head and neck of the femur;
  • fresh fractures of the femoral neck and acetabulum in patients older than 65 years;
  • rheumatoid arthritis;
  • coxarthrosis in the second or third stage;
  • arthrosis, which occurs with psoriasis;
  • tumors of the hip joint.

What should the patient know about the operation of endoprosthetics?

This is a very precise surgical intervention, the purpose of which is to give you a mobile painless joint, which allows you to return to your usual life. The development of technical progress has led to the appearance of materials that can replace worn joint artificial. Just like a normal hip joint, an artificial joint consists of a round head and a concave cavity in which the head rotates, allowing a normal volume of movement. For each specific case, a suitable prosthesis is selected.

Rehabilitation after endoprosthesis

After the operation of endoprosthetics of the hip, knee or other joints, great attention should be paid to the rehabilitation.

During the first few days after endoprosthesis surgery, the patient should take antibiotics and pain medications. Under certain parts of the human body, a roller is placed to support the operated limb in the required position.

Starting from the second day after the operation, the patient is allowed to sit down on the bed, exercise cautious movements, except for the operated site. After hip replacement, the patient can begin to walk around the room on the third day after the operation, and the seams are removed 10-12 days before discharge from the department.

After a knee replacement, the patient can also proceed with slow walking on the third day after the intervention. As an additional support should be used crutches, handrails or other improvised means. The period of initial recovery after knee replacement is also 10-12 days. That the knee joint after endoprosthetics performed its functions in full, rehabilitation measures should be performed after discharge from the hospital, guided by the recommendations of the surgeon.

The average length of the period during which the restrictions should be observed when loading the operated limb is about six weeks from the date of the operation - during this period additional support should be used during walking and other physical activities. Therefore, even during the preparation for surgery, you should purchase or rent crutches( for the initial rehabilitation period) and a cane( for subsequent recovery at home).

Complications after endoprosthetics are extremely rare and occur mainly as a result of exceeding the maximum permissible loads by the patients during the rehabilitation period, or, conversely, due to the complete lack of physical activity in the operated limb for a long time.

If there are enough serious indications for joint replacement, a lot of attention should be paid to choosing a medical institution for examination and performing surgical intervention. In the conditions of our clinic, the patient has the opportunity to get information about the possibility of carrying out the operation and to take advantage of the services of good trauma doctors, having previously reviewed recommendations and feedback on their work.

When deciding on an endoprosthesis replacement, the prices for this type of services should be studied, given the fact that the cost of the endoprosthesis is directly proportional to the quality of the material from which it is manufactured and the professionalism of the operating physician of the trauma specialist.

A good surgeon will choose the right model of an endoprosthesis for himself or offer reasonable alternatives where they are possible. Do not need to look for a better endoprosthesis - look for the best surgeon!

Recording on card loading. ..

Moscow, st. Krasnodar, 52, building.2 How to get from the metro: From the subway exit Lublino, "The last car from the center", under the sign of TC Moscow, 150 m from the metro Phone: 8( 495) 641-06-06 daily from 9.00 to 21.00 © 2015 Clinic №1

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There are several variants of prostheses and methods of conducting the operation. For example, the replacement of TBS may differ in the degree of intervention:

  1. Partial replacement - single-pole prosthetic TBS.It is almost always performed by a mini-invasive method.
  2. Total hip arthroplasty - complete replacement of the joint and bone parts( bipolar prosthesis of TBS).In this case, during surgery, both the cavity and the head are changed. Total hip arthroplasty can be performed by a mini-invasive method or traditional surgical method.

Depending on the technology by which the prosthesis is attached to the bone, distinguish:

  1. The cementless fixation of the endoprosthesis - fixation of the prosthesis occurs due to the growth of bone tissue in the structure of the implant.
  2. Cement anchorage of the endoprosthesis - is carried out by fixing both constituent parts of the prosthesis with a special cement solution.
  3. Hybrid( combined) method - a method where the cup is fixed with cementless technology, and the foot - with cement.

Now more and more clinics offer their clients endoprosthetics of the knee joint using computer-based navigation technology. With the help of infrared rays and sensors, the image of the replaced joint is constructed on the computer monitor, which allows you to accurately determine the desired position of surgical instruments. Use in the operation of computer navigation allows you to accurately compare the bones and elements of the prosthesis, which is not easy to do with a normal operation.

When the operation is necessary

Endoprosthetics are a complex process, recovery after it is long, which is why operation can be assigned only in exceptional situations. Surgery on the hip joint is performed:

  • with Bekhterov's disease;
  • non-fissile hip fracture;
  • for arthritis or arthrosis;
  • withers the tissues of the femoral head.

Only a doctor can prescribe an operation to replace a joint, as a rule, he does this only when no other conservative methods of treating the disease-causes have produced a good result.

Replace the hip joint in the event that other methods do not have any positive effect. Especially if the patient suffers from regular significant pain, can not self-care for themselves.

For thinking and weighing the situation given a certain amount of time, if the patient shows arthrosis TBS.In case of a fracture of the femoral neck, the decision on prosthetics should be taken within a few hours after the injury. With necrosis of the head of the thigh, surgical intervention should be immediate, as it is not only a rapidly developing process, but also extremely painful.

Preparation of

Before carrying out the operation on prosthetics, careful preparation for hip arthroplasty is needed. A person is assigned an X-ray examination, during which the doctors determine the degree of deterioration of the TBS according to the pictures.

When making a decision to conduct an operation, possible contraindications, the patient's condition and age category are taken into account. To assess the condition, a physical examination is performed, and tests are assigned.

In addition to the above studies, before the operation to replace the hip joint prosthesis, it is necessary: ​​

  1. To cure chronic or acute inflammation in the body, as they increase the possibility of infection of the implantation zone.
  2. Call the dentist to resolve all problems associated with dental diseases.
  3. In case of obesity, you need to consult a dietician. During excessive stress on the artificial joint, the risk of blood clots or inflammatory processes increases.
  4. Buy crutches with armrests. After endoprosthetics, a new joint requires a long time of rehabilitation and careful handling. During several months, the full load on it is prohibited.

Progress of

The hospital is required to arrive the day before the scheduled operation. During the operation, the patient is under anesthesia - general or spinal( during it the person is awake, but his lower half of the body is anesthetized and loses sensitivity).

In the course of hip replacement, the operation is performed in several steps:

  1. An anesthetic or anesthetic is injected, then the surgeon makes an incision and removes the affected joint.
  2. An artificial joint is fixed and fixed. This happens with the help of a special cement or cogs. When large defects occur in the bones, bone screws are used.
  3. The completion of the surgical procedure is the examination of the new joint( before the suture is applied).The surgeon must make sure that the prosthesis is securely attached to the bone and to check if there is a dislocation of the prosthesis when performing various amplitude moves( movements and turns).

Surgery for endoprosthetics is carried out in several stages of

. Since a wound may accumulate liquid during the implantation of an artificial tuberculosis, drainage is connected, the incision is covered with a soft tissue. In general, the operation lasts up to two hours.

Postoperative period

In a hospital, you will have to spend 10 to 12 days after the operation. The fact is that the doctor needs constant monitoring of the behavior of the new joint and the reaction of the patient's body in the course of adaptation to the object injected into the body. In addition, the pain symptoms and swelling are normal after the operation, so measures are needed to eliminate the symptoms( the patient should be anesthetized and antibiotics the first days).

For the normal passage of the recovery process after arthroplasty of the joint, the leg should be correctly fixed. For these purposes, between the legs put a cushion, when the patient lies( we recommend to find and see a video from the Internet to understand how to properly place the roller).

From the second day after prosthetics it is possible:

  • to sit on the bed;
  • carry out a complex of static exercises for the feet;
  • to carry out respiratory gymnastics.

If complications after hip arthroplasty do not occur, then on the third or fourth day the patient is allowed to walk a little with the help of crutches or an arena. The day before discharge from hospital, the stitches are removed. At the time of writing, the patient can already climb and descend the stairs with crutches. After 5-6 weeks, the patient already leaves the crutches and starts using the cane.

After discharge for another six months, rehabilitation procedures are needed - massage, special diet, physiotherapy, exercise therapy( you can practice in the gym with a coach or at home on a video that the doctor advises).

Repeated intervention

In some cases, the replacement of TBC over a period of time turns out to be unsuitable for use and re-revision of the hip joint may be necessary. Replace the prosthesis may be necessary in the case of development of infection in the tissues surrounding the prosthesis, or if there was a destruction of bone tissue at the site of its fixation. Rehabilitation after such an operation can be delayed( at least a year).

In our time, endoprosthetics of TBS and re-prosthesis are quite common. After it, a person has the opportunity to get rid of constant pain and again lead a normal lifestyle.

Disability after prosthetics

Disability after endoprosthetics of TBS - it sounds like a sentence. But usually a disability in the case of a prosthesis is given for a short period of time, until the functionality of the limb is restored. For confirmation of disability, certain documents are required, after registration in relevant organizations, a person is included in the category of people under social care.

If, after the set time after treatment and rehabilitation, the examination at the doctor determines that the functionality of the leg is restored, then the disability will be lifted, but if the joint does not come to the proper norm - the disability will be prolonged and the treatment will continue.

Choosing a clinic and the cost of

For the operation to replace TBS, it is better to select not a "professor with awards" but a practicing orthopedist who has gained sufficient experience during hundreds of such operations( at least five years in the field of orthopedic prosthetics).There are enough such doctors in Russia. If you decide to operate abroad, we recommend that you contact the German specialists, as they are famous in the field of endoprosthetics. Choose a clinic not for advertising videos and photos, but reviews of patients, qualifications and experience of specialists.

The prices for an operation of this type in Germany are too high

The cost of surgery for endoprosthetics in private clinics is about 230 thousand rubles, but this amount can vary depending on how much the hip joint endoprosthesis costs. It includes the preparation of the patient before the operation, the process of hip replacement and the management of the patient after the operation. During the initial rehabilitation, the patient remains in the ward for several weeks. The cost of services for endoprosthetics does not include the treatment of possible associated pathologies. The total cost varies depending on the price of the prosthesis itself.

You can learn more about endoprosthetics from the video:

Reviews

Елена, 27 лет

I never thought that I could face the problem of joints. All the same young, active always was. And then a couple of years ago began to constantly get dislocations, it became impossible to walk on his heels - it hurts. I went to the doctor and heard a disappointing diagnosis - dysfunction of the left hip joint - he just fell apart into pieces. The choice I had was not great - either a disability or an endoprosthesis. By not knowing, I thought that the difference is small - once put the prosthesis in the leg, then I will forever be disabled. But it turned out that I was an alarmist. The operation went well. Quickly recovered. And now I do not remember that I have a foreign object in my leg.

Grigory, 55 years old

The operation to replace the joint for a prosthesis went well. From 3 days they allowed me to walk with a stick. After 15 days, the seams have already been removed. A month later I started walking alone. In a year the leg was completely restored and the cane is no longer needed.

Leo, 61 year

If you need to put a prosthesis - put it! Do not be afraid. Now this operation is very common, and doctors have worked it to the smallest detail. I put a prosthesis in Moscow. The operation took only half an hour. Already on the fourth day I went with knuckles down the corridor.

Lisa, 37 years old

Mom last year did not successfully fall and got a fracture. A simple gypsum, unfortunately, it was not done. They made endoprosthetics. Honestly, they were already tuned to the fact that it would remain lying - after all, the turning point is heavy and the age makes itself felt. But, hooray, everything turned out. Has transferred or carried mum operation easily. She never complained of pain. Of course, the recovery was not as fast as that of the thirty-year-olds - it was necessary to collect patience in a fist. For several months she went with a walker. Then they switched to a wand. She limped for a long time, since ligaments were partially cut at the surgery site. But when they recovered, the limp passed.

Prokoksartroz.ru

Endoprosthetics of the hip

Endoprosthetics is a surgical operation in which the affected joint of the patient is removed and replaced with an artificial endoprosthesis. The main indications for hip replacement are:

  • Coxarthrosis of different etiology
  • Fracture of the femur neck
  • Aseptic necrosis of the femoral head

The development of technical progress has led to the appearance of materials that can replace the worn joint with an artificial one. Just like a normal hip joint, an artificial joint consists of a round head and a concave cavity in which the head rotates, allowing a normal volume of movements.

For each specific case, there is an appropriate endoprosthesis suitable for the type and size. According to the method of attachment to the bone, the prosthesis is cemented and not cemented. The leg is fixed in the canal of the femur. The head, metal or ceramic, is installed on the neck, which ends the leg of the prosthesis. The cup of the prosthesis - polyethylene, ceramic or metal, replaces worn articular cartilage, in it the head rotates. The cup is placed in the acetabulum of the pelvis. Like the normal hip joint, the endoprosthesis allows free, painless movements.

Preparation for operation

The orthopedic surgeon during the consultation will clarify the etiology of the disease, determine the indications and contraindications to joint replacement, perform the necessary research and selection of the appropriate prosthesis. The choice of the prosthesis depends on the age of the patient, the degree of anticipated physical activity, weight, bone condition and some other factors. X-ray study will help to determine the degree of deterioration of the joint, to clarify the nature of the fracture, to make the necessary measurements. Undoubtedly, you will be warned about possible risks of surgery and anesthesia, about possible blood transfusion or taking your blood for transfusion during the operation.

The most common complications are the development of infection in the field of surgery, blood loss during or after surgery, thromboembolism or pneumonia.

Before the operation, you need to undergo a complete clinical examination that allows you to assess the risk of surgery and anesthesia, identify possible contraindications, and anticipate possible complications. The examination includes the delivery of tests, the performance of electrocardiography, echocardiography, esophagogastroduodenoscopy, ultrasound of lower extremity vessels, fluorography, consultation of the therapist, if necessary, other specialists, as well as an anesthesiologist.

Before the operation, it is necessary to take certain actions in order to prevent possible complications.

  • Reduce body weight if it exceeds allowable digits
  • Visit a dentist, cure sick teeth that can be a source of infectious complications.
  • Quit smoking or reduce the number of cigarettes smoked
  • If you are taking any medications, consult your doctor about the advisability of stopping them before surgery.
  • Discuss with the doctor the possibility of blood donation for the purpose of creating a reserve for the operation
  • Prepare compression knitwear for the lower extremities for the prophylaxis of thromboses during and after operation.
  • Pick up additional support means: crutches, walkers

Hospitalize patient on the eve of surgery. In the morning on the day of operation, food and water intake are excluded.

Operation of

endoprosthetics The operation is performed from a 10-20 cm long incision on the side of the affected joint. After the cut, the affected head of the femur is removed, the acetabulum of the pelvis is cleaned of the damaged elements and polished. A new artificial hollow is established - a "cup".In the femur is inserted the endoprosthesis foot on which the head is worn. After the endoprosthesis components are installed, the volume of movements in the artificial joint is checked. The wound is sutured.

In standard cases, implantation of the artificial joint lasts 1-1.5 hours. All this time the patient is under the influence of spinal anesthesia, the necessary medications are poured. For the prevention of infectious complications, intravenously administered antibiotic, blood-substituting drugs. In order to prevent thromboembolic complications on the eve of surgery, anticoagulants are administered. If necessary, donate blood is transfused.

1 day after surgery

Immediately after the operation, the patient is transferred to the intensive care unit for observation, adequate anesthesia in the postoperative period, and injections of antibiotics for a day. Between the legs for a period of 1-2 days there will be a special pillow holding the operated leg in the correct position.

Rehabilitation

Activation in bed is allowed already on the 1st day after surgery under the guidance of an instructor or a doctor in charge. You can sit down in bed, start static exercises for the muscles of the lower extremities, do respiratory gymnastics. Walking is usually permitted from the 2nd to the 2nd day after the operation, and with the load on the operated leg, but with the help of crutches or walkers. The complex of exercises of physical therapy is being taught.

On the 12th day after the operation, the stitches and the extract are taken home. Upon return, it is necessary to continue rehabilitation activities, strictly following the recommendations of the operating surgeon. If necessary, it is possible to be hospitalized in a rehabilitation center for rehabilitation under the guidance of physician-kinesitherapists.

Household recommendations for patients

At home, several simple rules should be observed that will reduce the risk of possible complications:

1. You can not allow the hip to bend more than 90 degrees:

  • in sitting position, the knees should be slightly lower than the thighs,for this, a small pillow should be placed on the chair seat;
  • does not cross legs - both sitting and lying down;
  • not to bend forward, get up with a straight back;
  • sit down, legs apart.

2. If prescribed - strictly observe the walking regimen on crutches;

3. When climbing and descending the stairs, hold onto the railing;

4. Wear low-heeled shoes with a non-slip sole;

5. At each visit to the doctor, warn that you have implanted an artificial joint;

6. Do not hesitate to contact your surgeon if there is sudden pain in the area of ​​surgery, general or local temperature will rise.

Undoubtedly, most of the recommendations are not life-long, but only 6-8 months after the operation.

ortopedov.ru

Endoprosthetics in Germany

  • Endoprosthetics in Germany: figures and facts

Welcome to the Department of Traumatology, Orthopedics and Endoprosthetics of our clinical center in Friedrichshafen, offering effective treatment in Germany. Operations on arthroplasty of joints occupy leading positions in the activity of our center.

Professor, doctor of medical sciences. O. Winter with his team has extensive experience in such areas as hip and knee replacement in patients with chronic pain in the knees and hips( more than 30 thousand operations in Germany).The cause of chronic pain in the hip and knee area, as a rule, is arthrosis. Surgical treatment of knee and hip arthrosis is indicated only if conservative treatment( nonoperative measures, for example, taking medications) does not help in sufficient measure and the patient agrees to endoprosthetics. The most suitable surgical method for the patient is determined in accordance with the stage of arthrosis of the knee and hip joint. If the arthrosis is not yet at a much advanced stage, surgical interventions are performed that allow the joint to be preserved. If the knee or hip joint is very damaged, endoprosthetics of the knee and hip joint are used.

To date, the predictions of a successful outcome after hip and knee replacement have been very positive. It can be assumed that 20 years after the operation, more than 90% of the artificial joints installed in Germany will remain firmly fixed and retain high functionality. For each operative method of treatment of knee and hip arthrosis in accordance with its stage, a step-by-step concept is developed, which will be described below.

Stepwise concept for the treatment of arthrosis of the knee joint

Arthrosis of the knee joint at its final stage destroys articular cartilage, the bones begin to rub against each other.

Operations with joint preservation

In case, for example, the knee joint is deformed and the joint gap is not completely destroyed, it is possible to straighten the axis of the lower limb by means of a corrective osteotomy. With the help of arthroscopy of the knee joint, damage to cartilage and meniscus is eliminated. The purpose of this intervention is to postpone the endoprosthesis replacement of the knee joint for as long as possible.

Knee replacement

Complete destruction of the cartilage of the knee joint and unbearable pain in the knee are indications in the presence of which knee arthroplasty is indicated. In this case, the destroyed surface of the joint is replaced, that is, the so-called "prosthesis replacing the joint surface" is implanted. With the help of VISIONAIRE technology, each individual patient is implanted with an individually fitted endoprosthesis.

This guarantees the best possible shape and high durability of the endoprosthesis.

After the operation, the patient remains in our clinic for about 10 days. The operated leg can be immediately exposed to normal loads. We will gladly organize for you a subsequent rehabilitation.

Phased concept of arthrosis of the hip joint

For arthrosis of the hip joint, the articular cartilage is destroyed at the terminal stage, the bones begin to rub against each other.

Operations with joint preservation

If the hip joint is well preserved, then, for example, excessive, interfering part of the bone is removed using arthroscopy of the hip joint and also cartilage interventions are performed. The purpose of this intervention is to preserve the natural hip joint as long as possible. Clinical Center Friedrichshafen is one of the few clinics in which arthroscopy of the hip joint is performed.

Hip Endoprosthetics

Complete destruction of the hip joint cartilage and unbearable pain in the hip are indications for artificial joint implantation. In the clinical center of Friedrichshafen, we use different types of hip joint endoprostheses, they will be described below.

The more bone is preserved with hip replacement, the better. The decisive factor determining the successful endoprosthesis replacement of is bone quality. In young patients, bone quality is usually still very good, so endoprostheses are used to keep as much bone as possible.

BHR = Surface hip arthroplasty Birmingham Hip Resurfacing( also called "McMinn's prosthesis")

In cases where surface hip replacement is used, the head and neck of the thigh are almost completely preserved. The head of the thigh is carefully milled, after which a metal cap is put on it. In this case we are talking about the so-called "prosthesis replacing the surface of the joint".The advantages of this method are the preservation of bone, as well as the preservation of normal strength for the movement of the femur.

Due to this, the hip joint can be subjected to unlimited loading. Such a method as superficial hip arthroplasty has very good long-term results in 200 thousand cases around the world. More than 95% of implanted superficial endoprostheses according to McKinn( the creator of the prosthesis) retain their functionality for more than 15 years.

BMHR = Birmingham Mid Head Resection

If the upper part of the femoral head is not strong enough to accommodate a metal hood, then using the resection of the middle part of the femur head BMHR, you can keep the lower part of the femoral head as well as the femoral neck. This system was developed by McMinn from Birmingham and has very good long-term results.

BMHR endoprosthetics have been performed since 2003. The indication with the use of this method is the case where surface hip replacement( BHR) is impossible due to the instability of the joint that has developed due to necrosis of the femoral head. In the Friedrichshafen clinic, the first was replaced by "BMHR" in September 2008. Read more. ..

Modular hip joint endoprosthesis Metha

If it is not possible to perform a surface endoprosthesis, then the next step is implantation of a modular hip joint endoprosthesis. The use of this prosthesis also allows you to keep the femur. The use of this method of endoprosthetics assumes good bone quality. Especially with this operating method, minimally invasive access to the hip joint with maximum soft tissue stiffness can be used. Endoprosthetics of the hip with Metha modular prosthesis has very good long-term results.

Systemic hip arthroplasty Bicontact

If it is not possible to perform a superficial prosthesis of BHR and BMHR or hip arthroplasty using a modular Metha prosthesis, for example, due to insufficient bone quality, one of the most reliable hip prostheses is used, the Bicontact systemic endoprosthesis. This prosthesis has been used throughout the world for 20 years. During this time, more than 500 thousand operations were carried out. The prosthesis has a very long life( more than 90% of endoprostheses serve more than 19 years).

Endoprosthetics in Germany: figures and facts

Currently, about 400,000 endoprostheses are implanted in Germany annually. Thus, endoprosthetics is one of the most frequently performed operations in Germany and refers to routine procedures.

Most of the prostheses to be installed are artificial knee joints and hip joints. In Germany, for example, about 210,000 hip replacement procedures and 165,000 knee joints are performed annually. Out of the number of endoprostheses that are annually installed, 25,000 of them are on the shoulder joint. On the contrary, the need for endoprosthetics of the elbow and ankle arises rarely. A year in Germany implant 1500 ankle and 150 ulnar endoprostheses - this indicates that this type of implantation does not apply to routine interventions.

Along with primary endoprosthetics, in Germany, 35,000 procedures for revision replacement of the prosthesis are performed annually. Revision refers to the surgical replacement of a previously implanted damaged, loosened or worn endoprosthesis.

To determine which type of prosthesis is most suitable for each individual patient, the patient must undergo a preliminary examination at the Friedrichshafen Clinical Center. In this case, the patient will also be able to get acquainted with the doctors and the clinic. In special cases, in addition to conventional X-ray examination of the hip, we can perform bone thickness analysis, as well as arthro-MRI( special MRI study) of the hip. The Friedrichshafen Clinical Center is one of the few clinics in Germany where arthro-MRI is performed.

If the patient is ready for endoprosthetics, he will be assigned the date of admission to hospital stay. After the operation, the patient remains in our clinic for about 10 days. With all types of prosthetic knee and hip joint, the patient can immediately subject the operated leg to full load. We will gladly organize for you a subsequent rehabilitation.

klinikum-friedrichshafen.com

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