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  1. 1. Recent AdvancementHip Surgery AndHip-ReplacementCME ON Prepared by - Dr. Md Nazrul islam, MBBS, M.Sc. Supervised by - Dr. Sk. Abbas uddin Ahmed MS (ortho), ao(basic), ao(spine). Presenting by - Dr. Golam Mahamud Suhash From - Department Of Orthopaedic & Traumatology, Shaheed Suhrawardy Medical College Hospital. Dhaka. 1
  2. 2. Recent AdvancementHip Surgery AndHip-Replacement Hip-disorders Recent Advancement Hip Surgery And Hip-Replacement 2
  3. 3. Recent AdvancementHip Surgery AndHip-ReplacementOver view Hip is the joint where your thigh bone meets your pelvis bone. Hips are very stable. When they are healthy, it takes great force to hurt them. Common Hip-disorders are-  Strains  Bursitis  Dislocations  Fractures 3
  4. 4. Recent AdvancementHip Surgery AndHip-Replacement  Functions of Hip-jointContents:  Mechanisms Hip injury  Most Common Types of Hip Injury-  Epidemiology  Anatomy of Hip-joint  Pathophysiology of Hip-Injury  Clinical features of Hip-Injury-  Investigations  Diagnosis  Management  Rehabilitations  Complications  Prognosis Of Hip-Replacement-  Conclusions  Total Hip Replacement at Shaheed Suhrawrdy Medical College Hopital- 4
  5. 5. Recent AdvancementHip Surgery AndHip-Replacement Functions of Hip-joint  To provide stability for weight bearing- standing, walking & running.  To allow mobility of the leg in space.  To transmit the loads from the thigh and then to the lower limb. 5
  6. 6. Mechanisms Hip injury- Direct Stresso Femoral Neck fractureo Inter-trochanteric fracture Repeated stresso Degenerative joint disease (DJD) of theHip Deformitieso Congenital dislocation of the Hip (CDH)/ Developmental dysplasia of the Hip (DDH). 6
  7. 7. Recent AdvancementHip Surgery AndHip-Replacement Most CommonMost CommonTypes Of Hip Injury- Types Of Hip Injury-  Hip Strain is an overuse or injury that tears or stretches the muscle fibers. Strains  Most of the time, muscle strains in the hip area occur when a stretched muscle is forced to contract suddenly. A fall or direct blow to the muscle, overstretching and overuse can tear muscle fibers, resulting in a strain. 7
  8. 8. Recent AdvancementHip Surgery AndHip-Replacement  Bursa is a fluid filled sac that allows smooth motion between two unevenMost Common surfaces.Types Of Hip Injury- Hip bursitis is a common problem  that causes pain over the outside of the upper thigh. Bursitis  When the bursal sac becomes inflamed, each time the tendon has to move over the bone, pain results. Because patients with hip bursitis move this tendon with each step, hip bursitis symptoms can be quite painful. 8
  9. 9. Recent AdvancementHip Surgery AndHip-ReplacementMost Common Dislocations- HIPTypes Of Hip Injury- Types of dislocation:  Congenitical  Acquired  Anterior  Central  Posterior (90%) 9
  10. 10. Recent AdvancementHip Surgery AndHip-Replacement AO/OTA ClassificationDislocations  Most thorough.  Best for reporting data, to allow comparison of patients from different studies.  30-D10 Anterior Hip Dislocation  30-D11 Posterior Hip Dislocation  30-D30 Obturator (Anterior- Inferior) Hip Dislocation 10
  11. 11. Recent AdvancementHip Surgery AndHip-Replacement HIP can break at any age, but theMost Common great majority of hip fractures occurTypes Of Hip Injury- in people older than 65.Fractures .  Fracture of Acetabular Component  Acetabular fracture  Central dislocation  Fracture of Femoral Components.  1. Femoral Neck fracture (NOF),  2. Femoral head fracture  3. Slipped capital femoral epiphysis in children  4. Trochanteric fracture 11
  12. 12. Recent AdvancementHip Surgery AndHip-Replacement Epidemiology  Worldwide gender distribution of Hip Fracture  Men: 4-5 per 1,000  Women: 8-10 per 1,000  Men: 30%  Women: 70%  Morbidity and Mortality Mortality 20% within 1 year Hip Fracture o Men: 31% mortality in 1 year o Women: 17% mortality in 1 year o ADL assistance needed in 50% of Hip Fractures o Long term care needed in 25% of Hip Fractures. Cooper (1992) Osteoporos Int 2:285-9 Forsen (1999) Osteoporos Int 10:73-8 12
  13. 13. Recent Advancement Anatomy of Hip-jointHip Surgery AndHip-Replacement Introduction to hip joint anatomy The hip joint is a ball and socket joint, formed by the head of the Femur (thigh bone) and the acetabulum of the pelvis. The dome-shaped head of the femur forms the ball, which fits snuggly into the concave socket of the acetabulum. The hip joint is a very sturdy joint, due to the tight fitting of the bones and the strong surrounding ligaments and muscles. 13
  14. 14. Recent AdvancementHip Surgery AndHip-Replacement Anatomy of Hip-joint Vital Components of Hip-joint -  Bones of the hip joint  The hip joint capsule  Ligaments of the hip joint  Labrum of the hip joint  Muscle Groups surrounding the hip joint.  Neuro-vascular Components. 14
  15. 15. Recent AdvancementHip Surgery AndHip-ReplacementAnatomy of Hip-joint Bones  The ilium: This is the largest area of the hip bones.  The ischium: The ischium consists of 2 broad curves of Hip bones - bone, one on each side, which lie below the ilium,  The pubis: The pubis is the front-most area of the hip bones. It attaches to the ilium on the sides and the ischium on the bottom. 15
  16. 16. Recent AdvancementHip Surgery And Muscles And Ligaments-Hip-Replacement Muscles  Muscles which attach to or cover the hip joint: • Gluteals. • Quadriceps- • Iliopsoas. • Hamstrings. • Groin muscles.  Ligaments. • Iliofemoral ligament: • Pubofemoral ligament: • Ischiofemoral ligament: 16
  17. 17. Recent AdvancementHip Surgery AndHip-ReplacementBlood supply Neurovascular Components  Mainly by – Medial and lateral circumflex femoral arteries.  And Deep division of the superior gluteal artery Inferior gluteal artery Posterior division of the obturator artery(Head of the femur ). 17
  18. 18. Recent Advancement Neurovascular Components Hip Surgery And Hip-ReplacementNerve supply  Femoral nerve - Via nerve to the rectus femoris muscle  Obturator nerve - Via it’s anterior division.  Sciatic nerve - Via the nerve to the quadratus femoris muscle.  Superior gluteal nerve - Here the femoral, sciatic and oburator nerves also supply the knee joint, so hip disease may cause a refered pain to the hipjoint. 18
  19. 19. Pathophysiology of Hip-Injury Recent AdvancementHip Surgery AndHip-Replacement  Age. The rate increases for people 65 and older.  Gender. Women have two to three times asWho isvulnerable to many hip fractures as men.hip fracture?  Heredity. A family history of fractures in later life, particularly in Caucasians and Asians. A small-boned, slender body.  Nutrition. A low calcium dietary intake or reduced ability to absorb calcium.  Personal habits. Smoking or excessive alcohol use.  Physical impairments. Physical frailty, arthritis, unsteady balance, and poor eyesight.  Mental impairments. Senility, dementia, e.g., Alzheimers disease. Weakness or dizziness from side effects of 19 medication
  20. 20. Recent AdvancementHip Surgery And Clinical features of Hip-Hip-Replacement fracture(prox. Femur)  Shortened limb on Fracture side  Hip externally rotated andSigns - abducted (But internally rotated and adducted in post. dislocation of hip).  Tenderness to palpation over injured hip  Limited range of motion oDo not test ROM unless XRay 20
  21. 21. Recent Advancement Hip Surgery And Hip-Replacement Hip fractures usually are caused by a fall. If you fracture your hip, you may experience the following symptoms:Clinical features Severe pain in your hip or pelvicof Hip-Injury- area symptoms Bruising and/or swelling in your hip area Inability to put weight on your hip Difficulty walking The injured leg may look shorter than the other leg and may be turned outward. 21
  22. 22. Recent AdvancementHip Surgery AndHip-Replacement Investigations  Complete medical history  Physical examination to assess hipThe mobility, strength, and alignment.orthopaedic  Blood testsevaluation  X-rays (radiographs) to determine thewill extent of damage or deformity in yourtypicallyinclude - hip.  MRI / CT scan.  Ultrasound scans  Bone scans  Biopsy 22
  23. 23. Recent AdvancementHip Surgery AndHip-Replacement Investigations Routine Pre-operative Investigations- 1. Blood tests. 2. Kidney, Liver tests. 3. Lungs, Heart and Neurological assessments. Bone pathology specific Investigations- 1. Assessment of bone strength 2. Assessment of bone infection 3. Assessment of bone TB/ Carcinoma. 4. Assessment of metabolic/systemic bone diseases. 23
  24. 24. MR Arthrogram Recent Advancement Hip Surgery And Hip-Replacement  Hip XrayImaging  Usually identifies Fracture and Dislocation  Hip MRI (T1-weighted)  Indicated for high suspicion despite normal XRay  Test Sensitivity: 100% An MRI may identify a  Does not require delay after injury hip fracture otherwise missed on plain X-ray.  Hip Bone Scan with Technetium Tc99m Polyphosphate  Test Sensitivity: 98%  Delay scan at least 72 hours MR Arthrogram after time of injury 24
  25. 25. Recent Advancement DiagnosisHip Surgery AndHip-Replacement Subjective Assessment  Pain localized in hip region  Exaggerated gait pattern (limp)  Increase in pain when weight barring  Reduction in the degree of ROM  As the degeneration of the joint worsen, individual may be awakened at night with pain  Bone spurs may occur 25
  26. 26. Recent AdvancementHip Surgery AndHip-Replacement Objective Assessment  Gait pattern – Adaptive walking pattern that reduces pressure on the affected side.Diagnosis  Muscle atrophy – Muscles in affected area are not used as much due to pain, therefore, use-it-or-lose-it applies.  Active Range Of Motion – Limited ROM, stiffness Passive ROM – End feels causes severe pain  X-ray – clear degeneration of the bone  MRI – determines underlying complications (e.g.avascular necrosis) 26
  27. 27. Recent AdvancementHip Surgery AndHip-Replacement Management Treatment for hip disorders may include- Medical-  Rest,  Medicines,  Physical therapy  Immobilization and/ or  Reduction(dislocation) 27
  28. 28. Management  Surgical-  Osteotomy  ORIF  HIP Resurfacing  Hip replacement. 28
  29. 29. Recent AdvancementHip Surgery AndHip-Replacement Common HIP ConditionFixation Which Requires Internal Fixation- Acetabular Component-  Dysplasia, Impingement. Femoral Components. 1. Femoral Neck fracture (NOF), 2. Femoral head fracture 3. Slipped capital femoral epiphysis in children 4. Trochanteric fracture 29
  30. 30. Recent AdvancementHip Surgery AndHip-Replacement HIP Resurfacing- Surface hip replacements Developed in late nineties in UK by Dr.Derek Mcminn  Longevity of any primary THA cannot be predicted  Revision remains an issue  Young/active patient may outlive primary THA.  Hip resurfacing extends continuum of care in young patients with hip disease 30
  31. 31. Recent AdvancementHip Surgery And Candidates for hipHip-ReplacementHIP Resurfacing resurfacing  Young & active patients with hip arthritis or secondary osteo- arthritis  Primary OA in young patients  Avascular necrosis  Ankylosing spondylitis  Post traumatic arthritis  DDH  Slipped capital femoral epiphysis www.hipsurgery.in 31
  32. 32. Recent AdvancementHip Surgery AndHip-ReplacementHIP Resurfacing Hip resurfacing- considerations and steps-  Head of femur is sculpted and not chopped off to receive a cap or resurfaced.  Socket is deepened and a new socket banged in  Could survive for long term as bearings are made of metal on metal – Unknown at present  Recovery is faster.  Function is better. 32
  33. 33. Recent AdvancementHip Surgery AndHip-ReplacementHIP Alternative NamesREPLACEMENT • Hip arthroplasty; • Total hip replacement; • Hip hemiarthroplasty. Definition of Hip joint replacement: Hip joint replacement is surgery to replace all or part of the hip joint with an artificial joint. The artificial joint is called a prosthesis. 33
  34. 34. Description: The artificial hip joint has 4 parts:HIP A. A socket that replaces your old hipREPLACEMENT socket. The socket is usually made of metal. B. The liner fits inside the socket. It is usually plastic, but some surgeons are now trying other materials, like ceramic and metal. The liner allows the hip to move smoothly. C. A metal or ceramic ball that will replace the round head (top) of your thigh bone. D. A metal stem that is attached to the shaft of the bone to add stability to the joint. 34
  35. 35. Recent AdvancementHip Surgery AndHip-Replacement Types of Hip ReplacementHIPREPLACEMENT  Traditional (Conventional) Hip Replacement Traditional hip replacement surgery involves making a 10- to 12-inch incision on the side of the hip. The muscles are split or detached from the hip, allowing the hip to be dislocated.  Minimally Invasive Hip Replacement Minimally invasive hip replacement surgery allows the surgeon to perform the hip replacement through one or two smaller incisions (2 to 4 inch). 35
  36. 36. Recent AdvancementHip Surgery AndHip-Replacement Hip conditions that frequentlyHIP lead to total hip replacementREPLACEMENT are the following-  Rheumatoid Arthritis  Secondary Osteoarthritis  Ankylosing Spondylitis  Old Perthes disease  Broken hip  Bone tumor  Avascular necrosis of the femoral head  Fused Hip Joint. 36
  37. 37. Recent AdvancementHip Surgery AndHip-Replacement Benefit from hip replacement surgery if:  Hip pain limits your everyday activities such as walking or bending.  Hip pain continues while resting, either day or night.  Stiffness in a hip limits your ability to move or lift your leg.  You have little pain relief from anti- inflammatory drugs or glucosamine sulfate.  You have harmful or unpleasant side effects from your hip medications.  Other treatments such as physical therapy or the use of a gait aid such as a cane do not relieve hip pain. 37
  38. 38. Recent AdvancementHip Surgery AndHip-Replacement 38
  39. 39. Recent AdvancementHip Surgery AndHip-ReplacementIntelligent Hip surgery 39
  40. 40. Recent AdvancementHip Surgery AndHip-Replacement 40
  41. 41. Recent AdvancementHip Surgery AndHip-Replacement Conventional Total Hip replacements  Introduced in 1960’s by Dr.John Charnley, an English Orthopedic surgeon.  Upper end of the femur is resected consisting of the head and neck portion .  Socket of the pelvic bone is deepened  Prosthesis is implanted with bone cement.  Metal articulates with High density polyetheylene.  Risk of dislocation results in poor function  Recovery takes upto three months 41
  42. 42. Recent AdvancementHip Surgery AndHip-Replacement Minimally invasive Hip surgery - What is it?  Skin incisions are smaller than conventional surgery  It is not Key hole or arthroscopic surgery  Inside soft tissue dissection is less.  More Bone, tendons, soft tissues are preserved 42
  43. 43. Recent AdvancementHip Surgery And Difference Between Traditional and Minimally Invasive Hip ReplacementHip-Replacement Surgery- Traditional Hip Minimally Invasive Hip Replacement Surgery- Replacement Surgery-  Proven in clinical studies and successfully performed for  Long-term effects and success decades are being studied  Allows surgeon full  Smaller incisions/ Scars (2-4 visualization of operative area inches)  Larger incision/ scar (12-18  Potentially less disruption of inches) muscles and tissues  More disruption of muscles and  May lead to less blood loss tissues  Potential for less postoperative  May lead to more blood loss . pain  May lead to a extendeded  May lead to a shortened hospital stay/ recovery time hospital stay/ recovery time 43
  44. 44. Recent AdvancementHip Surgery AndHip-Replacement PROSTHESIS TYPE 1. Conventional 1. Conventional total hip 2. Metal-on-metal 1. Metal-on-metal total hip 3. Ceramic 1. Ceramic total hip 4. Cemented / Cementless 1. Cemented and cementless total hip 5. Other prostheses 1. Prostheses for other operations 44
  45. 45. Recent AdvancementHip Surgery AndHip-Replacement The major problems with standard hip replacements are:  Wearing out of plastic sockets.  Loosening of the bond between the implant and bone. In time the cement can crack, directly resulting in loosening.  Secondly, the body reacts to minute fragments of cement, plastic or metal, and attempts to remove them, and also removes bone adjacent to the particles, leaving the bone structurally weakened.  If the implant loosens, a second surgery may become necessary to reattach it. 45
  46. 46. Recent AdvancementHip Surgery AndHip-Replacement There has been much research into the loosening problem. This led to the development of the:  Cementless Hip Replacement in which the surface of the metal parts is porous, and looks like coral. Bone can grow into the metal pores and bond the implant to the bone without the use of cement.  The AML Total Hip Replacement (DePuy / Johnson & Johnson) is the most widely used cementless implant in the world, and has the longest track record (since 1978).  Cement is still used with very soft bones, regardless of age. 46
  47. 47. Recent AdvancementHip Surgery AndHip-Replacement Technique: Total Hip Replacement  Insertion of acetabular component 47 Acetabular reaming
  48. 48. Recent AdvancementHip Surgery AndHip-Replacement Technique: Total Hip Replacement Insertion of femoral component Reaming/broaching of 48 femoral component
  49. 49. Recent AdvancementHip Surgery AndHip-Replacement Technique: Total Hip Replacement Final implant Femoral head impaction 49
  50. 50. Recent AdvancementHip Surgery AndHip-Replacement What are the alternative operations?  Arthroscopy  Osteotomy  Surface replacement  Fusion (arthrodesis) of the hip  Some alternative operations for avascular hip necrosis • Core decompression • Vascularized graft • Hemiarthroplasty • Resection arthroplasty - Girdlestone 50
  51. 51. Recent AdvancementHip Surgery AndHip-Replacement Rehabilitations REHAB GOALS Get the patient up out of bed and moving (the fracture is painful, but the pt must get moving) opain is usually a symptom of stress on fx Begin functional activities Prevent DVTs Prevent inactivity. 51
  52. 52. Recent Advancement Hip Surgery And Hip-ReplacementRehabilitations The Donts  Dont cross your legs at the knees for at least 8 weeks.  Dont bring your knee up higher than your hip.  Dont lean forward while sitting or as you sit down.  Dont try to pick up something on the floor while you are sitting.  Dont turn your feet excessively inward or outward when you bend down.  Dont reach down to pull up blankets when lying in bed.  Dont bend at the waist beyond 90°.  Dont stand pigeon-toed.  Dont kneel on the knee on the unoperated leg (the good side).  Dont use pain as a guide for what you may or may not do. The Dos  Do keep the leg facing forward.  Do keep the affected leg in front as you sit or stand.  Do use a high kitchen or barstool in the kitchen.  Do kneel on the knee on the operated leg (the bad side).  Do use ice to reduce pain and swelling, but remember that ice will diminish sensation. Dont apply ice directly to the skin; use an ice pack or wrap it in a damp towel.  Do apply heat before exercising to assist with range of motion. Use a heating pad or hot, damp towel for 15 to 20 minutes.  Do cut back on your exercises if your muscles begin to ache, but dont stop doing them! 52
  53. 53. Recent AdvancementHip Surgery AndHip-ReplacementRehabilitations An appropriate and progressive rehab program should be started early in the treatment of patients with hip injuries. Several rehab techniques are available, none of which require expensive equipment or great time commitments. Selecting the best exercise approach for each patient’s hip problem is not difficult. A closely monitored home exercise program allows the doctor of Chiropractic to provide cost-efficient, yet very effective rehabilitation care. 53
  54. 54. Recent Advancement ComplicationsHip Surgery AndHip-Replacement  The most common hip problem that may arise soon after hip replacement surgery is hip dislocation.  The most common later complication of hip replacement surgery is an inflammatory reaction  Heterotopic bone formation (bone growth beyond the normal edges of bone). Leg length discrepancy which may be caused by the prosthesis or by weakness in the muscles of the hip  Breakage of the prosthesis which may require an additional surgery for replacement  Wound infection. 54
  55. 55. Other (systemic) complications include:Complications  Blood clots in the deep veins of the leg (deep vein thrombosis or DVT) that can move to the lung and cause pulmonary embolism (PE)  Urinary infection or difficulty with urination  Pneumonia that may result from difficulty taking deep breaths and coughing after anesthesia. 55
  56. 56. Recent AdvancementHip Surgery AndHip-ReplacementComplications- 56
  57. 57. Recent Advancement Failure rates for individual hipHip Surgery AndHip-Replacement diseases FAILURE RATES FOR INDIVIDUAL HIP DISEASES FAILURE RATE HIP DISEASE (during ten years after operation)  A-vascular necrosis 0%  Slipped epiphysis 3%  Congenital hip dysplasia 5%  Rheumatoid arthritis 15 %  Previous hip fracture 18% 57
  58. 58. Recent AdvancementHip Surgery AndHip-Replacement Prognosis Of Hip- Replacement- Hip replacement surgery results are usually excellent. Most or all of your painOutlook and stiffness should go away.(Prognosis):  Some people may have problems with infection or loosening, or even dislocation, of the new hip joint.  Over time -- sometimes as long as 20 years -- the artificial hip joint will loosen. A second replacement may be needed.  Younger, more active, people may wear out parts of their new hip. It may need to be replaced before the artificial hip loosens. 58
  59. 59. Recent AdvancementHip Surgery AndHip-Replacement Conclusions-  Next to Spine injury, Hip-joint is the most important issue in orthopedic surgery.  Hip disorder/ injury needs throughout assessment before starting treatment.  Treatment strategy/ plan is changing rapidly with the advent of new research/ investigation procedures/ biomaterial.  Hip Replacement surgery in orthopedics changing our life with rapidly increasing success.  Successful Hip replacement surgery in orthopedics’ can play a pivotal role in medical science. 59
  60. 60. Recent AdvancementHip Surgery AndHip-Replacement Name Of Operation: Total Hip Replacement.“Total Hip Replacement” Patient Name: Md Sayoeb Ahmed,Age:27 ys.At- Shaheed Suhrawrdy Indication: Rheumatoid Arthritis ( Lt. Hip ).Medical College Hopital- Team Leader: Associate Professor Dr. Sheikh Abbasuddin Team Members: Associate Professor Dr.Paritosh Ch.Debenath Assistant Professor Kazi Shamimuzzaman Dr. Md Nazrul Islam, Resident Surgeon. Assistant Professor Md. Hasan Masud (NITOR), Dr Golam Mahamud Susash ( Suhash ) . Anesthesiologist : Dr. Julfiqar Bhai(Consultant). Dr. Nizam Bhai (Consultant). & Dr. Shamim-Ara (Apa), Dr. Nizam Bhai And Dr. Anwar Hossain Venue: Shaheed Suhrawardy Medical college Hospital, Department Of Orthopaedics & Traumatology. 60
  61. 61. Recent AdvancementHip Surgery AndHip-Replacement “Total Hip Replacement”done at Shaheed Suhrawardy Medical College Hospital, December-2010”. Department of Orthopadic & Traumatology. 61
  62. 62. Recent AdvancementHip Surgery AndHip-Replacement “Total Hip Replacement” At- Shaheed Suhrawrdy Medical College Hopital-2010 62
  63. 63. Recent AdvancementHip Surgery AndHip-Replacement 63
  64. 64. Recent AdvancementHip Surgery AndHip-Replacement Mobile Hip, Mobile Man. Have a Healthy Hip with Fruitful Life.From- Department Of Orthopedics’ & Traumatology Shaheed Suhrawardy Medical College Hospital. 64
  65. 65. Recent AdvancementHip Surgery AndHip-Replacement Associate Prof. Dr. P. C. Debenath Associate Prof. Dr. Sheikh Abbas Uddin. Associate Prof. Dr. Ziaul Haq Associate Prof. Dr. Shamimul Haq Associate Prof. Dr. Monowarul Islam Associate Surgeon Dr. Md. Aminur Rahman Assistant Prof. Dr. Kazi Shamimuzzaman Assistant Prof. Dr. A T M Bahar Uddin Dr. Abdul Hannan Mr. Anisul Haque Khandaker (Incepta). & Dr. Md Nazrul Islam Resident Surgeon, Department of Orthopedic & Traumatology. Shaheed Suhrawardy Medical College Hospital. 65