BRIEF PPT ON TOTAL JOINT REPLACEMENT

1. JOINT REPLACEMENT: HIP, KNEE, ELBOW
AND SHOULDER
DR VIRENDRA K BHASME
MBBS, MS (Ortho), DNB (Ortho)
Associate Professor
Department of Orthopaedics
KIMS HUBLI

2. HEMIARTHROPLASTY
(Partial joint replacement)
• This means replacing only one side of a joint.
• For instance the head of the femur is replaced with an
artificial component while the acetabulum is left as it is.

4. • Total Joint replacement is a procedure whereby both the
components forming a joint are replaced with artificial
components (called prosthesis)
• e.g., the head as well as the acetabulum are replaced
in a total hip replacement operation
TOTAL JOINT REPLACEMENT

5. TOTAL HIP REPLACEMENT
• This is an operation where both, the acetabulum and the
head of the femur are replaced with artificial components.
• For the acetabulum, a cup made of high density polyethylene
is used, and
• For the head a specially designed prosthesis made of metal
alloy (cobalt-chromium alloy) is used.
• Both components are fixed in place with or without bone
cement.

6. • The procedure was first developed by Sir John Charnley in 1960.
• It has proved to be a successful operation giving 15-20 years of good
function.

7. Indications
• The primary indication for THR is incapacitating PAIN. .
• Pain in the hip in the presence of destructive process as
evidenced by X-ray changes is an indication.
• THR is an option for nearly all patients with diseases of the
hip that cause chronic discomfort and significant functional
impairment.

8. • Arthritis
– Rheumatoid
– Juvenile Rheumatoid (Still disease)
– Ankylosing spondylitis
• Degenerative joint disease (osteoarthritis, hypertrophic)
– Primary
– Secondary
• Slipped capital femoral epiphysis
• Congenital dislocation or dysplasia of hip
• Coxa plana (Legg-Calvé-Perthes disease)
• Paget disease
• Traumatic dislocation
• Fracture acetabulum
• Hemophilia

9. • Osteonecrosis
– Postfracture or dislocation
– Idiopathic
– Slipped capital femoral epiphysis
– Hemoglobinopathies (sickle cell disease)
– Renal disease
– Cortisone induced
– Alcoholism
– Caisson disease
– Lupus
– Gaucher disease
– Nonunion,
– femoral neck and
– trochanteric fractures with head involvement
• Pyogenic arthritis or osteomyelitis
– Hematogenous
– Postoperative

10. • Tuberculosis
• Congenital subluxation or dislocation
• Hip fusion and pseudarthrosis
• Failed reconstruction
– Osteotomy
– Cup arthroplasty
– Femoral head prosthesis
– Girdlestone procedure
– Total hip replacement
– Resurfacing arthroplasty
• Bone tumor involving proximal femur or acetabulum
• Hereditary disorders (e.g., achondroplasia)

11. • Most common reasons for total hip
replacement:
– Osteoarthritis 60%
– Rheumatoid arthritis 07%
– Fractures/dislocations 11%
– Aseptic bone necrosis 07 %
– Revision 06 %
– Other 09%

12. CONTRAINDICATIONS
• Absolute
– a) Patient with unstable medical illness that would
significantly increase the risk of morbidity and mortality.
– b) Active infection of the hip joint or anywhere else in
the body.
• Relative
– Any process that is rapidly destroying bone eg.
neuropathic joint, generalized progressive osteopenia.
– Insufficiency of abductor musculature.
– Progressive neurological disorder.

13. Hip Replacement Components
• Acetabular component consists of two components
–Cup :usually made of titanium
–Liner :can be plastic, metal or ceramic

14. • Femoral Component:
– 3 Components
• Head
• Neck
• Stem

15. Goal of THR
• Biomechanically sound, stable hip joint by
restoration of normal center of rotation of femoral
head
• The location of center of rotation of femoral head is
determined by
-Vertical height (vertical offset)
-Medial head stem offset ( horizontal offset)
-Version of the femoral neck (anterior offset)

17. TYPES OF FEMORAL COMPONENTS
• Cemented stems
• Cementless stems
– porous surface
– nonporous surface
• Specialized custom-made

18. TYPES OF ACETABULAR COMPONENTS
• Cemented
• Cementless
• Constrained type
• Specialized custom made

19. EVALUATION BEFORE SURGERY
• Evaluate whether pain is sufficient to justify surgery.
• Assess patient’s general condition (thorough medical
examination with laboratory test is must)
• Investigate for any ongoing infection
• Physical examination of spine, both lower limbs, soft tissue
around the hip.
• Assess the strength of abductor mechanism
• Any fixed flexion deformity assessed.
• Limb length
• Neurological status

20. • When both the hip and knee are arthritic usually
hip should be operated first because THR alters the
knee mechanics.
• If bilateral involvement present operate on most
painful hip first and after 3 months operate on the
other side.

21. ROENTEGENOGRAPHIC EVALUATION
AP view of pelvis with both hips with upper third
femur with limbs in 15 degrees internal rotation.
Spine, knee x-ray taken
Note the following :
• Acetabulum : Bone stock, floor, migration, protrusio,
osteophytes and cup size.
• Femur : Medullary cavity (size & shape). Limb
length discrepancy, Neck.

22. PREPARATION
• Take an informed consent.
• Bath the entire extremity and hip with germicidal
solution twice daily after patients is admitted to
the hospital.
• Shave the extremity, perineal area, hemipelvis to
at least 10 cm proximal to the iliac crest and wash
with soap as soon before surgery as possible and
cover with sterile towels.

23. PROPHYLACTIC ANTIBIOTICS
• In the operating room 15 to 30 minutes before the skin
incision
• Profound blood loss, an additional operative dose after
4 hours appears justifiable
• 1st generation cephalosporine-cefazolin (Prefered)
IRRIGATING THE WOUND
• Irrigating the wound with a physiological solution
during surgery –keeps the tissues moist, –removes
debris and blood clots, –dilutes the number of
bacteria t

24. SURGICAL APPROACHES AND TECHNIQUES
• Each approach has relative advantages and
drawbacks. Choice of specific approach for
THR is largely a matter of personnel
preference.
• Posterolateral approach with patient in
lateral position without greater trochanter
osteotomy and dislocating the hip
posteriorly is commonly done.

26. POSTOPERATIVE MANAGEMENT
• Hip is positioned in approximately 15 degree abduction and
neutral rotation, with the help of a triangular pillow splint.
• Light skin traction may be applied for 24 hours. .
• Gentle isometric exercise for few minutes each hour when
they are awake from first operative day.
• On the second postoperative day patient may sit on side of
the bed avoiding excessive flexion at hip.
• Drains removed 24-48 hours.

27. • Gait training begun on 2nd postoperative day,
non weight bearing with a walker,
• if cemented-early weight bearing to tolerance is
permitted
• If cementless-touchdown weight bearing for 6-8
weeks.
• Patient can be discharged when patient can
walk on even surfaces, get out of bed, climb
few steps.
• Follow-up at 6 weeks. Roentgenograms are
taken, full weight bearing advised

29. COMPLICATIONS
Inherent to any major surgical procedure in elderly patients.
Specifically related to the procedure of THR:
EARLY
Nerve injury
Hemarthrosis/vascular injury
Thromboembolism
Bladder injuries
LATE
-Loosening
-Component failure
-Osteolysis
-Heterotrophic ossification

30. INDEPENDENT OF TIME
Infection
Dislocation
Trochanteric non union
Femoral fracture
Limbs length discrepancy

31. TOTAL KNEE REPLACEMENT
• Total Knee Arthroplasty (TKA) is the surgical
procedure to replace the weight bearing surfaces of
the knee joint
• In true sense, the term total knee replacement is a
misnomer, as only the damaged articular surface is
sliced off to prepare the bone ends to take the
artificial components which ‘cap’ the ends of the
bones.

33. • Quality of life severely affected
• Daily pain
• Restriction of ordinary activities
• Evidence of significant radiographic changes
of the knee
Who Is A Candidate For TKR?

34. Implants
The artificial knee joint consists of the following parts
1. A U-shaped femoral component to ‘cap’ the
prepared lower end of the femur.
2. A tibial base plate to cover the cut flat surface of
the upper end of the tibia. Either both cruciates
or only anterior cruciate is excised.
3. A plastic tray inserted between the above two
metallic components.
4. A patellar button made of polyethylene to replace
the damaged surface of the patella.

36. • Classification of Implants Design
• Unconstrained
– Cruciate
– Cruciate retaining
– Cruciate substituting
• Mobile bearing knees
• Constrained (Hinged)
• Unicondylar Prosthesis
• Total Condylar Prosthesis

38. INDICATIONS
• Severe arthritis
• Young pts with systemic arthritis with
multiple joint involvement
• Osteonecrosis with subchondral collapse of a
femoral condyle
• Severe pain from chondrocalcinosis and
pseudogout in elderly
• Severe patello femoral arthritis rarely

40. CONTRAINDICATIONS
• Recent/current knee sepsis
• Remote source of ongoing infection
• Extensor mechanism discontinuity
• Recurvatum deformity secondary to muscle
weakness
• Presence of painless, well functioning knee
arthrodesis

41. TKR should be done before things get out of hand
and the patient experiences a severe decrease in
ROM, deformity, contracture, joint instability or
muscle atrophy

42. Evaluation Of Patient Before Surgery
• A Complete Medical History
• Thorough Physical Examination
• Laboratory Workup
• Anesthesia Assessment

43. Radiographs
• Standing Sunrise Ap & Lateral
• Merchant view Hip to ankle x–- rays
– Bony deformity
– Short stature ( < 150 cm)
– Very tall ( > 190 cm)

44. • Femoral and tibial cut
• Position of femoral canal entry
• Bone defects
• Joint subluxation
• Ligament stretch out
• Ligament release
• Constraint needed

45. GOAL
• Pain relief
• Restoration of normal limb alignment
• Restoration of a functional range of motion

46. Technical Goals Of Knee Replacement Surgery
• The restoration of mechanical
alignment
• Preservation (or restoration) of the
joint line
• Balanced Ligaments
• Maintaining or restoring a normal Q
angle

47. Mechanical Alignment
• TKA aims at restoring the
mechanical axis of the lower
limb by
– Sequential soft tissue
releases
– Correction of bone defects
by grafts or prosthetic
augments

48. Ligament Balancing
a. Coronal Plane
– For varus deformities
– For valgus deformities
b. Sagittal Plane
– Flexion contractures
– Extension contractures

49. Complications
1. Infection:
• Infection could be minor in the form of wound
breakdown, or a major infection necessitating
another operation to clean up
• Sometimes the infection may not be
controlled, and removal of the prosthesis and
fusion of the joint may become necessary.

51. 2. Deep Venous Thrombosis (DVT): It occurs as a
result of immobility.
3. Nerve palsy: Common peroneal nerve palsy
sometimes occurs in cases requiring dissection on the
lateral side of the knee. Spontaneous recovery occurs in
most cases.

52. 4. Fractures:
• Fractures may occur while performing the operation,
particularly in osteoporotic bones of a bedridden
rheumatiod patient.
• Fractures may occur late through the bones near the
prosthesis due to stress concentration in that area.

53. 5. Extensor mechanism complications:
• Handling of extensor mechanism is required during
the course of the operation.
• These may occur due to avulsion of the patellar
tendon, inadvertent cutting of the tendon etc.
6. Knee stiffness:
• The patient may not be able to regain range of
motion due to heterotropic bone formation or intra-
articular adhesions.

54. Post Operative Rehabilitation
• Rapid postoperative mobilization
• Range of motion exercises started
• CPM
• Passive extension by placing pillow under foot
• Flexion by dangling the legs over the side of bed
• Muscle strengthening exercises
• Weight bearing is allowed on first post op day

56. NAVIGATION ASSISTED TKR
• The technique involves the attachment of active or
passive trackers on femur and tibia which are then
tracked by a computer Assisted camera
• Computer gives realtime feedback about alignment
of bony cuts in all three anatomic planes, which
allows surgeon to make changes and to measure
the accuracy of the bony cuts.

58. TOTAL ELBOW ARTHROPLASTY
• A treatment option primarily for
the older individual with
debilitating, late-stage elbow
arthritis.
• TEA now is considered as
preferred surgical alternative to
open reduction and internal
fixation for management of
severely comminuted, intra-
articular distal humeral fractures
sustained by elderly patients.

59. Indications for Surgery
• Debilitating pain and loss of functional use of the
upper extremity
• Gross instability of the elbow
• Acute comminuted, intra-articular fracture and
nonunion fracture of the distal humerus
• Failed interposition arthroplastyor radial head
resection
• Marked limitation of motion of the elbows

60. Contraindications
Absolute
• The presence of active infection
• Neurological dysfunction leading to paralysis and
inadequate control of elbow musculature
Relative
• History of previous elbow infection
• Irreparable supporting ligaments
• Insufficient bone stock
• The younger patient, particularly one who must lift
heavy loads (>10 lb) after TEA

61. Implant design
• Early designs were hinged allowed only flexion and
extension of the elbow joint and joint dislocation
were common complications.
• At present, an arc of flexion and extension,
contemporary designs provide 5°to 10°of varus and
valgus and a small degree of rotation

62. • The designs of total elbow replacement can be
classified into two broad categories: linked
(articulated) and unlinked (non-articulated).
• Rather than being fully constrained, as the
early components were, linked humeral and
ulnar implants are now loosely constrained,
referred to as semiconstrained designs.

65. Complications
Intraoperative complications.
• Fracture and component mal-positioning, can
significantly affect short-and long-term outcomes.
• Ulnar damage or irritation, either transient or
permanent, also can occur intra-operatively

66. Postoperative complications.
• Deep infection
• Joint instability
• Wound healing problems
• Triceps insufficiency

67. TOTAL SHOULDER ARTHROPLASTY
Shoulder options:
• Hemi arthroplasty
• Total shoulder replacement
– Replace the ball and socket joint
• Reverse shoulder replacement
– Replace with a “reversed” ball and socket joint

69. INDICATIONS
• Osteoarthritis
• Rheumatoid arthritis
• Rotator cuff tear
• Fracture with secondary arthritis
• Reduced blood supply to humerus (AVN)

70. Contraindications
• Insufficient glenoid bone stock
• rotator cuff arthropathy
• deltoid dysfunction
• irreparable rotator cuff (hemiarthroplasty or reverse
total shoulder are preferable)
– risk of loosening of the glenoid prosthesis is high
("rocking horse" phenomenon)
• active infection
• brachial plexus palsy

72. • Replace glenoid with either:
– plastic (PE) which requires cement for fixation
or
– metal component that requires screws
• Replace humerus with stem/head ( uncemented or
cemented)
• Requires intact rotator cuff muscles to balance the
shoulder replacement and provide function to move
the joint

77. Reverse shoulder replacement
• Gained popularity over the last 15 years
• Increasing world wide use
• Glenoid and humeral components are reversed
• Relies on different muscles to provide function to
the shoulder
– Deltoid
• Generally used in patients with irreparable rotator
cuff injuries in the setting of arthritis
• Difficult to salvage this replacement so reserved
for elderly

80. Complications
• Glenoid Loosening
• Humeral Stem loosening
• Subscapularis repair failure
• Malposition of components
• Improper soft tissue balancing
• Iatrogenic rotator cuff injury
• Stiffness
• Infection
• Neurologic Injury
• Periprosthetic fracture

81. Thank You!!!