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research methods.

Introduction in medical practice of various additional methods of inspection has substantially facilitated diagnostics of diseases of a hip joint against an osteoporosis and the complications arising after an arthroplasty.

From special additional methods by us it was applied: roentgenography, a densitometry. Ultrasonic, KT, MRT, an electromyography, biochemical analyses of blood and urine, and also functional methods of research.

Functional methods of research [5].

For the fullest representation about disturbances in impellent sphere

Patients we spent definition of active and passive movements in the amazed joint, “measured length“ healthy ' j amazed extremities? Calculated Harris's indicator. Spent tool (EMG, ENG, RVG, goniometrija, miotonusometrija, a dynamometry, podografija) and biomechanical (a load on the bottom extremities, reaction of a leg of the bottom extremities, rntm walkings, rate of walking) researches.

At patients with pathological fractures of proximal department of a hip specified the trauma mechanism (falling from height of the growth, podvorachivanie extremities, a bruise of area of a hip joint). At the collecting of the anamnesis paid attention to earlier spent treatment (preparations, a dosage, courses, effect). During survey presence of deformation and an edema in the field of a hip joint, a basin warp, signs of an oligotrophy of the muscular apparatus paid attention to a posture, a lameness ’. The palpation of area of both hip joints allowed to tap muscle tone changes, to specify localisation of pains, to tap pathological mobility, a crepitation of osteal fragments.

By means of a centimetric tape defined degree of an atrophy of muscles of a hip and an anticnemion, taped absolute and relative shortings. A goniometer defined amplitude of active and passive movements, contracture degree.

As for definition of degree of functional disturbances in statodinamicheskoj to sphere used a bodily machinery method. Inspection of patients spent on the biomechanical equipments corporation BTS LIFE engineering (Italy) and MBN (Russia) under the standard program.

The structure of the equipments includes two multicomponent platforms switched with the personal computer. The package of applied programs is allowed to study following characteristics of standing and walking of the patient: reaction of a leg of the bottom extremities and its variability, amplitude of reactions of a leg, time of a leg of extremities, rate and "rhythm of walking," load size on each foot.

Tool methods it is investigated.

Roentgenography.

Рентгеноірафическое Research is the most accessible method of inspection of a hip joint, and as estimations of a condition of components of an endoprosthesis in various terms after operation.

All patient carried out survey roentgenography of pelvic bones with both hip joints, proximal department of a hip from the amazed and healthy party in back, axial and lateral projections, nojasnichno - krestsovogo backbone department, if necessary knee and ankle joints. Thus, specified the disease diagnosis, degree of expression of pathological process, estimated anatomic parametres of a femur for the purpose of an optimum choice implantata and type of its bracing.

(Research spent on apparatus Phillips in department of radial methods of diagnostics FGU tsito of N.N.Priorova, the principal - the doctor of medical sciences A.K.frost).

Basin roentgenography carried out in position of the patient on a back. For elimination perek'osa a basin the bottom extremities had strictly in parallel, on the average position, with the whirlbones turned upwards. A fascicle rentgenluchej referred strictly to the sacrum centre. For ренггеноірафин proximal department of a hip from the amazed party used special packing: the bottom extremities were in position of internal rotation on 15 ’, and the x-ray beam was referred strictly to the centre of a head of a femur (the rotation centre). The distance from a X-ray emitter to the cartridge - 120 see hip joint Roentgenography in a lateral projection carried out in position of the patient laying on the investigated party, the opposite hip is incurvated. The central fascicle of x-ray beams-referred-in-centres-pahovoj of a cord-roentgenography-in-axial of a projection carried out in position of the patient on a back, an investigated hip on the average position (a whirlbone to top, the intercondylar axis of a femur is parallel to a table surface). The cartridge with Membranula established more proximally a wing of an ileal bone under an angle 35е to an axis of a body of the patient. A x-ray beam referred to the middle of an inguinal cord to perpendicularly cartridge, an opposite extremity incurvated in a hip joint and took away.

To estimate a condition of compensatory adaptations of a backbone (a basin warp at an extremity shorting) carried out its roentgenography pojasinchno-krestsovogo department in back and lateral projections, with tsentratsiej a x-ray beam on L5. A picture carried out after preliminary preparation of the patient (on the eve of research a cleansing enema, in the morning in day of research of 6 tablets of the activated coal).

For recalculation of the data received at roentgenography used specially made plastic gauge with lead globules on the extremities (fig. 2.20). The distance between lead globules was equaled 10 Such technique of roentgenography see allows to eliminate projective distortions at the analysis рентгеноірамм. Before a X-ray inspection, the gauge by means of an adhesive plaster, was attached to an external surface of a femur so that its lead top globule was at level of top of the big spit.

ABOUT MM

Drawing 2.20. A photo of a plastic gauge.

Thus, at the analysis of x-ray films with a gauge we obtained real data.

At all patients with degenerativnodistroficheskimi processes and traumas proksimalnoju femur department the local osteoporosis, which degree of expression on M Singh took place was on the average equaled 3.

Densitometry.

The densitometry is a method of revealing of loss MPKT of proximal department of a femur and lumbar department of a backbone, and as estimations of condition MPKT round endoprosthesis components in various terms after operation.

Research 48 patients (27 women and 21 man) was spent on corporation General Electrix apparatus Lunar in unit of radial diagnostics FGU tsito by it N.N.Priorova (the principal - the doctor of medical sciences A.K.frost). The densitometer (with an English database specific on a floor and age) gives the chance to define automatically size MPK in the most loaded departments of a skeleton - in lumbar department of a backbone and in the field of proximal department of a femur. Sizes MPK (BMD) in g/sm2, quantity of minerals bones (Naval Forces) in grammes, (SD) the received indicators from age norm (Z - criterion) and from peak osteal mass (T ~ criterion) processed a standard deviation by means of a package of statistical programs already put in pawn in the densitometer computer, and as computer programs for Microsoft XL et Statistica for Windows XP 2001. Condition MPKT round a femoral component of an endoprosthesis was estimated under the special orthopedic program which has been put in pawn in a database of a densitometer.

Besides, in a manual regimen the apparatus allowed us to measure size MPK in any zone interesting us and to define geometrical parametres of scanned department of a skeleton.

Magnitno-resonant (MRT) n computer (KT) tomographies.

Most "информатйвньїкПіз Іі sinvaz і ї vnghmetodov researches is the magnitno-resonant and computer tomographies, allowing to visualise as osteal, and mjagkotkanye structures of a hip joint and proximal department of a femur.

Accuracy of diagnostics at MRT research makes 78-82 % (Derme M, Ventura M, 1992, Barronian A, 1989).

MRT we spent research at 26 patients. KT research at 20 patients. The damages taped at MRT and KT research corresponded to that at a X-ray inspection.

Ultrasonic research.

Ultrasonic research allows to study on echoic structure a condition soft hip joint areas, a bone and cartilage surface, also on depression ehogennosti to define an edema of tissues, a liquid clump in a cavity of a joint or okolosustavnyh formations, to define presence pristenochnyh and flotirujushchih thrombuses. Ultrasonic doplerografija vessels of the bottom extremities (UZDG) it is executed before and after endoprotezirovanija to 21 men and 27 women in unit of functional diagnostics FGU tsito (the principal of unit - the doctor mednauk by N.A.Eskin).

Stabn.tometricheskoe research.

Attempts of registration of position of the general centre of masses were undertaken by researchers for a long time, however only last 5-7 years this method finds application in clinicodiagnostic practice that is bound to comprehensible forms its hardware-software realisation. Use stabilometrii in traumatology-orthopedy is limited. For today stabilometrija it is surveyed as a method of research of function of balance, iroprioretseptivnoj systems, the visual analyzer, a vestibular mechanism and other functions of an organism expressly or by implication bound to maintenance of balance (Kondratev I.V. from co-workers., 1999).

For studying of function of balance and balance of a body in the basic rack some techniques were offered. For example: registration двігжений heads in a horizontal plane which considerably correlate with movements of the centre of pressure (Sakaguchi M et al., 1995), including by means of non-contact ultrasonic gauges (Takaguchi T et al., 1990).

The comparative analysis of data stabilometrii and registration of movements of a head and a trunk (Kilbum K.N., Warshaw R.H., Hanscom V. 1994) has shown, that stabilometrija and registration head movement yield similar result. Such, exotic enough methods of registration of fluctuations of a body in the basic rack, as magnitometricheskie (Dean E.M were used also., Griffiths С.J., Murray A, 1986). Registration of accelerations of a body in two or three mutually perpendicular areas (Amblard V ct al is applied., 1985; Kamen G. et al., 1998). However the leading place occupies studying of function of balance of a body by means of platforms with the gauges sensitive to a vertical load.

In our work computerised platform MBN was used

(Moscow) consisting of the rigid basis on which 3 gauges sensitive to force are fixed, applied on them on a vertical. From above on gauges the rigid plate is established. Calculation of the equally effective force enclosed to a platform is made programmno taking into account value of each gauge. At quiet standing of the patient on a platform equally effective shows a projection on a vertical on a platform of the general centre of gravity surveyed. As the basic rack — process dynamic, that, measurements were made with some constant frequency (about 20 times a second), as a result received a trajectory of moving of an equally effective load, i.e. the general centre of gravity (Skvortsov D.V., 2000).

It is necessary otmstit, that the centre of gravity coincides with a projection of the centre of pressure only in a case when the surveyed is absolutely motionless (Winter D.A., 1995; Smirnov G. V, 1994). Fluctuations at which tsyontr “gravities (the general centre of masses) has various accelerations usually become perceptible. If the general centre of masses makes fluctuation with frequency exceeding 0,2 Hz its projection and the pressure centre can be various [Gurfinkel V.S., 1973]. For the decision of a return problem of reception from data stabilometrii projections of the general centre of masses of a body to a vertical are used mathematical models of various degree of complexity (King D.L., Zatsiorsky V.M., 1997; Kuczinski M, 1999; Smirnov G. V, 1994; Winter D.A., 1995; Gurfinkel V.S, 1973).

Hardware-software complex MbN-Stabilometrija allows to spend registration of fluctuations of the general centre of masses in two standard tests: stabilo.mstricheskom and test Romberga. In norm the vector of weight of a body in the basic rack falls from the head centre (which level corresponds to an auricle aperture), passes on one centimetre to front from a body of the fourth lumbar vertebra, through the hip joint centre, ahead of knee and lays down on a leg plane on 4-5 sm to front from a line of internal malleoluses. In this condition coxofemoral and knee joints become isolated passively and the strain of corresponding active stabilizers do not demand. The ankle joint becomes isolated activly a strain tryohglavoj anticnemion muscles, i.e. for the basic rack of the healthy person that knee and hip joints are in position of passive short circuit is characteristic and their deduction in this position does not demand energy expenses. Thus, ankle joint actions supervise balance of a body of the basic rack.

The feedback on maintenance of the basic rack occurs from visual, proprioretseptivnoj and vestibular systems. However the vestibular system participates in a special way in slow and highly peak movements which are absent in a normal rack of the healthy person. The basic control system of balance is constructed on the signals arriving from muscular receptors, articulate and mechanioreceptors. The appreciable share (in norm) is occupied with the visual information (V. et al., 1997).

In too time results of research Allum J.H.J. et al., devoted to studying of balance in the basic rack at change of position of a plane of a leg testify that propriorstseptivnyj the control from the receptor apparatus of a hip and a trunk is more important, than vestibular analyzer activity (Allum J.H.J., Bloem B.R., Carpenter M.G., 1998; Allum J.H.J., Carpenter M.G., Bloem B.R, 1999).

Moving of the centre of pressure to the basic rack at the healthy person on the average keeps within the area nearby 100 мм2, i.e. in one square centimetre. Thus the balance monitoring system (The Fine Postural Control System) reacts in the most precise image to the most insignificant external or internal indignations. Change proprioreieptivnogo feelings makes appreciable impact on stability of balance (Nakagawa I, Ohashi N., Watanabe Y., 1993).

For the purpose of rising informativnosti stabilometrichsskih researches original functional tests have been developed.

For revealing of differences in impellent patterns of the amazed and healthy extremities suggested the examinee to keep balance, standing serially on a straight line to a healthy and sick foot. At an estimation stabilogramm considered

Absolute position of the centre of pressure, deviation of the centre of pressure about average position, the average area statokinezogrammy. An electromyography.

The method of registration of bioelectric activity of muscles — an electromyography (EMG) is used in researches of function of muscles at the person in norm and a pathology. These researches are generalised in a number of fundamental works (Buresh I, Petran M, Zahar I, 1962; Geht B.M., Kasatkina L.F., Samoilov M. I, Sanadze A.G, 1997; JUsevich THAT. S, 1963; Gurfinkel V. S, 1961; Persons of River S, 1965; Ufljand J. M, 1965; Brazier M, I960.).

For the decision of the problems put in given work, it was used

-Technique of a superficial - (epicutaneous) electromyography;—---------——

Bioelectric potentials registered from the muscles of the healthy and damaged extremity with the same name at their maximum any isometric strain, investigated "work" miits-sinsrgistov and antagonists. Biological currents took away from muscles both damaged, and the intact segment of an extremity. For record of electromyograms of 8 mm, and also miograficheskimi elekzrodami MEDICOR used specially made rectangular silver electrodes in diameter. Record of biological currents and analysis EMG made 8 channel computerised hardware-software complexes CoNan with the help. Record of bioelectric activity of muscles spent at their any maximum reduction and at a nerve boring rhythmical (0,75 Hz) stimulating square-wave pulse duration of 1 km/s in

Standard points. For registration of biological currents used chstmrehkanalnyj the amplifier Key Poind (fig. 2.21) with the filter of frequencies from 0,1 to 3000 Hz (USA). Biological currents from investigated muscles took away by means of standard gelevyh unprofitable electrodes. EMG carried out on the healthy and amazed extremities. At decoding of electromyograms considered

Amplitude of following of biological potentials and type of bioelectric activity of muscles on J.S.Jusevichu.

Rate of carrying out of impulse on a nerve defined under the formula:

V = (L2-Ll)/S, where: V - rate of carrying out of impulse on a nerve; L2, L1 - latent time of reaction of muscles; S - distance between top n bottom points of an investigated nerve. The received results compared and estimated in dynamics with use of a package of applied computer programs.

At the analysis of electromyograms considered average amplitude, spent a spectral analysis on a method of fast transformation Fure.

Drawing 2.21. The four-channel amplifier Key Poind (USA). Investigated bioelectric activity antigravitarnyh hip joint stabilizers (cluneal muscles and taking away a hip of muscles). A drawing 2.22. Registered bioelectric activity of symmetric sites okolosustavnyh muscular groups, both in rest, and at the maximum strain. Thus, received the information on a functional condition of the nervously-muscular apparatus and level of its activity.

Inspection of patients was spent before operative treatment in 7-14 days, 3. 6, 12 months, and in the subsequent annually within 3 years. 48 patients (21 man and 27 women) with pathological fractures of proximal department of a femur are surveyed. All patients had

Deviations in E.MG to a picture, towards deterioration of indicators of amplitude and frequency.

Drawing 2.22. The schedule of any activity of cluneal muscles written down during biomechanical testing.

On the above-stated schedule the electromyographic picture of cluneal muscles of the patient with pathological fracture of a neck of the left femur because of an osteoporosis (observation № 3) is shown.

Top curve EMG corresponds to a healthy extremity, bottom - amazed. It is visible, that at the left electromyographic indicators (the amplitude and frequency) is better, than on the right.

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A source: NAZAROV Alexander Evgenevich. the CLINICO-EXPERIMENTAL SUBSTANTIATION of USE IMPLANTATA SFEN TS FOR ENDOPROTEZIROVANIJA the HIP JOINT At SICK of the OSTEOPOROSIS. The DISSERTATION on competition of a scientific degree of the candidate of medical sciences. Moscow. 2005

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