RU2227032C2 - Method for prophylaxis of complications in cement endoprosthesis of large articulations - Google Patents

Abstract

FIELD: medicine, traumatology, orthopedics. SUBSTANCE: invention can be used in endoprosthesis of large articulations using methylmethacrylate-base osseous cement. For this purpose, 24 h before operation rheopolyglucinum in the dose 5-6 ml/kg in combination with 200 mg of trental is administrated intravenously for 60-90 min; 12 h before operation fraxiparine is administrated in the dose 0.3 ml subcutaneously. Reambirinum 1.5% solution in the dose 5-6 ml/kg is administrated intravenously 1 h before application of osseous cement with infusion period for 60-90 min; 2 min before application of osseous cement prednisolone in the dose 1 mg/kg and 2 mg of tavegil are administrated intravenously. In post-operative period rheopolyglucinum in the dose 5-6 ml/kg and 200 mg of trental are administrated for 60-90 min for 3 days intravenously; fraxiparine in the dose 0.3 ml is administrated for 7 days subcutaneously; reambirinum 1.5% solution in the dose 5-6 ml/kg is administrated for 60-90 min for 3 days intravenously. Method provides reducing thrombotic and embolic complications associated with toxic effect of methylmethacrylate and infectious complications also. EFFECT: improved prophylaxis method. 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and can be used for arthroplasty of large joints using bone cement based on methyl methacrylate.

Known methods for the prevention of thromboembolic complications, consisting in the appointment of antiplatelet agents in the postoperative period and anticoagulants before surgery and in the postoperative period (Savelyev B.C., 1999. Bogdanov AA, 2001). However, patients with deforming coxarthrosis already in the preoperative period have significant violations of the rheological properties of blood. The main reason for this is the strengthening of blood structuring due to violations in the regulation system of the state of aggregation of blood (Puchinyan D.M. et al., 1995). Therefore, it is advisable to correct the violations of the rheological status of blood already in the preoperative period.

A known method of antioxidant protection in severe poisoning with neurotoxic substances (Livanov G.A. et al., 2001) and antihypoxic protection of liver cells in acute and chronic liver lesions (Sologub T.V. et al., 2001) using reamberin. But the use of this method is not enough for cement arthroplasty, since it prevents only toxic complications.

Closest to the claimed is a method of preventing complications associated with the toxic effect of methyl methacrylate, which consists in the introduction of antioxidant - erisod and antihypoxant - mufasol before bone cement in order to prevent the development of cellular hypoxia and oxidative stress (Mamaev E.G. et al., 2000) . This method allows to prevent complications associated only with the toxic effect of methyl methacrylate, and does not prevent thromboembolic complications that develop when bone cement is used to fix the components of the endoprosthesis.

The objective of the invention is to develop a system of preventive measures based on the use of a complex of pharmacological preparations (antihistamines, antiplatelet agents, anticoagulants and antihypoxants) to reduce thrombotic, embolic and toxic complications in cement arthroplasty of large joints of the lower extremities.

When solving this problem, a positive therapeutic effect is achieved, consisting in reducing the frequency of thrombotic, embolic complications, effects associated with the toxic effect of methyl methacrylate, reducing infectious complications and related repeated interventions, and reducing overall mortality; economic, consisting in reducing the cost of treatment, reducing the length of stay in the hospital; social - in improving the quality of life.

The technical result is achieved due to the fact that the combination of a complex of pharmacological drugs acts multifactor, preventing both toxic and thromboembolic complications in cement arthroplasty.

When using bone cement, one of its toxic components, methyl methacrylate released during polymerization, can penetrate into the bloodstream, which leads to 1) a cytotoxic effect with the development of cellular hypoxia, caused by the suppression of the total activity of respiratory enzymes, and oxidative stress associated with the depletion of the endogenous antioxidant system (Mamaev E.G. et al., 1999);

2) to the development of coagulopathy, which may result in the development of disseminated intravascular coagulation syndrome (Logan S.W., 1998) and thromboembolic complications;

3) to the development of a hyperergic reaction due to the release of histamine in response to the introduction of cement (Trybab M. et al., 1991. Mitsuhata H. Et al., 1994).

To prevent toxic complications caused by the introduction of cement, it is proposed the use of reamberin, which includes a salt of succinic acid. The protective properties of reamberin are associated with an increase in the power of energy production due to the oxidation of succinic acid in the Krebs cycle, the presence of an additional route for the use of succinic acid, which allows preserving the energy-synthesizing function under conditions of hypoxia. Reamberin restores the activity of the key enzyme of the respiratory chain - cytochrome oxidase, activates the antioxidant system of enzymes and inhibits lipid peroxidation (Petrov A.Yu. et al., 2000, Kovalenko A.L. et al., 2000).

To prevent thromboembolic complications, the combined use of rheopolyglucin antiplatelet agents (dextran-40) and trental and anticoagulant fraksiparin is proposed. With the combined use of dextran-40 and trental, a summation of the effect occurs and, as a result, an increase in the anti-aggregation effect. Due to the fact that patients with deforming coxarthrosis initially have violations of the rheological constants of blood, the introduction of dextran-40 and trental before surgery is proposed.

It is known that solutions containing dextrans with a molecular weight of 30000-40000, contribute to the restoration of blood flow in small capillaries and reduce the aggregation of blood cells. The use of dextran-40 for 3-5 days after surgery significantly reduces the incidence of postoperative deep vein thrombosis of the lower extremities.

Pentoxifylline (trental), which belongs to the group of antiplatelet agents, prevents the formation of platelet and erythrocyte thrombi. In addition, it has an angioprotective property, reduces the increased concentration of fibrinogen in the plasma, enhances fibrinolysis, promotes the bending of red blood cells, thereby facilitating their passage through the capillaries.

The problem is solved due to the fact that a day before surgery, reopoliglukin is administered intravenously at a dose of 5-6 ml / kg in combination with 200 mg of trental for 60-90 minutes; 12 hours before surgery, fraxiparin is administered subcutaneously at a dose of 0.3 ml; 1 hour before the use of bone cement, 1.5% reamberin is administered intravenously at a dose of 5-6 ml / kg, the duration of the infusion is 60-90 minutes; 2 minutes before the use of bone cement, prednisone is administered intravenously at a dose of 1 mg / kg and 2 mg of tavegil; in the postoperative period for 3 days, reopoliglyukin 5-6 ml / kg and 200 mg of trental are administered intravenously for 60-90 minutes; fraxiparin at a dose of 0.3 ml subcutaneously for 7 days; reamberin 1.5% - 5-6 ml / kg intravenously 60-90 min.

The method is carried out in the following way: to improve the rheological properties of blood and to prevent thrombotic, embolic complications, disseminated intravascular coagulation syndrome, a day before surgery, reopoliglyukin 5-6 ml / kg is administered intravenously together with 200 mg of trental for 60-90 minutes, for 12 hours before surgery, 0.3 ml fraxiparin is administered subcutaneously, to increase the energy potential and resistance to toxic effects of methyl methacrylate 1 hour before the use of bone cement, intravenous administration of 1.5% begins reamberin 5-6 ml / kg with an infusion duration of 60-90 min, in order to prevent a hypersensitive reaction to the components of bone cement 2 minutes before its administration, prednisone at a dose of 1 mg / kg and 2 mg of tavegil is administered intravenously. In the postoperative period, intravenous administration of reopoliglukin with trental in the same dose for 3 days is continued, fraxiparin 0.3 ml subcutaneously for 7 days, reamberin intravenously in the same dose for 3 days.

Concrete example

The patient, Baykov S.I., 65 years old, medical history No. 408 for 2002, was admitted to the clinic NNIITO 13.02.02. with a diagnosis of Bilateral gonarthrosis 3 tbsp., varus deformity and combined contracture of both knee joints, gonalgia. The patient had a pronounced concomitant somatic pathology: coronary heart disease, sinus bradycardia, impaired intraventricular conduction along the right leg of the bundle of His, syndrome of early repolarization of the ventricles, hypertension 2 tbsp., Circulatory failure 1 tbsp .; chronic gastritis; chronic tonsillitis, chronic subatrophic pharyngitis; varicose disease of the lower extremities. He had an operational-anesthetic risk of 3 degrees according to the ASA system. 02/18/02. he underwent an operation: Intra-articular prosthetics of the right knee joint by the FS Integral Sulzer system with fixation with bone cement. The operation was performed under conditions of spinal anesthesia with sedation with diazepam with preserved spontaneous respiration. Before the operation, an arterial tourniquet was applied to the right thigh, which was removed after 1 h 5 min. During the intervention, monitoring was performed for hemodynamic parameters, oxygen saturation. The duration of the operation was 1 h 20 min. Surgical blood loss amounted to 250 ml, blood loss through wound drainage 1050 ml. To improve the rheological properties of blood and to prevent thrombotic, embolic complications, disseminated intravascular coagulation syndrome, the patient was given intravenous infusion of rheopolyglucin 5 ml / kg a day together with 200 mg of trental for 80 min, and fraxiparin 0 was administered subcutaneously 12 hours before surgery. 3 ml, to increase the energy potential and resistance to toxic effects of methyl methacrylate 1 hour before the use of bone cement, intravenous administration of 1.5% reamberin 5 ml / kg was started with continued with an infusion duration of 60 min, in order to prevent a hypersensitive reaction to the components of bone cement, 2 min prior to its administration, prednisolone was administered intravenously at a dose of 1 mg / kg and 2 mg of tavegil. Despite the pronounced somatic pathology, the invasiveness of the operation, the use of bone cement, there were no hemodynamic and respiratory system disorders during the operation. In the postoperative period, intravenous administration of reopoliglukin 5 ml / kg and 200 mg of trental continued for 60-90 min for 3 days; subcutaneous administration of fraxiparin in a dose of 0.3 ml for 7 days; intravenous administration of reamberin 1.5% - 5 ml / kg 60-90 min for 3 days. The postoperative period is smooth, without complications. It should be noted that despite the large blood loss (total blood loss amounted to 1300 ml), the patient did not need transfusion of donor red blood cells. At the same time, satisfactory indicators of peripheral blood remained. In a laboratory study, there was no increase in the activity of intracellular enzymes (ACT, ALT, LDH) in blood serum compared with the initial level. 02/28/02. the patient was discharged in satisfactory condition for outpatient treatment.

Claims (1)

A method for the prevention of complications in cement arthroplasty of large joints by the introduction of antihypoxic drugs, characterized in that 5-6 ml / kg of reopoliglyukin is administered intravenously a day before surgery along with 200 mg of trental for 60-90 minutes; 12 hours before surgery, fraxiparin is administered subcutaneously at a dose of 0.3 ml; 1 hour before the use of bone cement, 1.5% reamberin 5-6 ml / kg is intravenously administered with a duration of infusion of 60-90 minutes; 2 minutes before the use of bone cement, prednisone 1 mg / kg and 2 mg of tavegil are intravenously administered; in the postoperative period within 3 days reopoliglyukin 5-6 ml / kg and 200 mg of trental are intravenously administered for 60-90 minutes; fraksiparin in a dose of 0.3 ml subcutaneously for 7 days; reamberin 1.5% - 5-6 ml / kg intravenously 60-90 min for 3 days.