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total hip arthroplasty

total hip arthroplasty

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total hip arthroplasty

  1. 1. Total Hip Arthroplasty
  2. 2. HISTORY OF HIP REPLACEMENT SURGERY Deformed and ankylosed joints surfaces were contoured with Biological material e.g. Fascia lata grafts as interpositional layer to resurface the joint and allow movement in UK an Europe in early 20th century.
  3. 3. 1912- Jones used gold foil as inter- positional layer 1923- Smith-Petrson introduced “mould arthroplasy” Later- Backelite and Celluloid derivatives 1937- Vitallium implants
  4. 4. Professor John Charnley (1911-1982) A British Orthopedician, Pioneer of modern hip replacement Arthroplasty. Developed the techniques of THR in 1960s.
  5. 5. APPLIED BIOMECHANICS
  6. 6. STRESS TRANSFER TO BONE  IMPORTANCE OF QUALITY OF BONE- APPROPIATE IMPLANT OPTIMAL METHOD OF FIXATION RESPONSE OF BONE TO IMPLANT ULTIMATE SUCCESS OF ARTHROPLASTY
  7. 7. RADIOGRAPHIC CATEGORISATION BY DORR ET AL TYPE A  THICK CORTEX AND CANAL DIMENSION  LARGE POSTERIOR CORTEX-LAT VIEW  CHAMPAGNE FLUTE APPEARANCE  MEN AND YOUNGER PATIENTS  GOOD FIXATION IN BOTH CEMENTED AND CEMENTLESS
  8. 8.  SOME BONE LOSS  SHAPE IS MAINTAINED  IMPLANT FIXATION IS NOT A PROBLEM  TYPE B
  9. 9. TYPE C  MUCH OF THE CORTEX LOST FROM MEDIAL AND POSTERIOR CORTX  IM CANAL IS WIDE  LESS FAVORABLE FOR IMPLANT FIXATION
  10. 10. COMPARISON
  11. 11.  STRESS TRANSFER IS DESIRABLE  LESS MODULUS OF ELASTICITY = MORE ELASTIC =LESS DIAMETER MORE STRESS TRANSFER TO BONE
  12. 12.  PROXIMAL MEDIAL CORTEX-MOST BONE LOSS  COLLAR-PREVENTS BONE LOSS  CEMENTLESS IMPLANTS ARE MORE PHYSIOLOGICAL
  13. 13. INDICATIONS OF THR  1. Arthritis : Rheumatoid Juvenile rheumatoid (Still disease) Ankylosing spondylitis  2. Degenerative joint disease : : Primary : Secondary : Slipped capital femoral epiphysis Congenital dislocation or dysplasia of hip Coxa plana (Legg-Calvé-Perthes disease) Paget disease Traumatic (Fracture/ dislocations) Hemophilia
  14. 14. INDICATIONS OF THR  Osteonecrosis : Post fracture or Post dislocation Idiopathic Slipped capital femoral epiphysis Hemoglobinopathi es Renal disease Steroid induced Alcoholism Caisson disease Lupus Gaucher disease  4. Nonunion following # NOF  5. Femoral neck fractures and trochanteric fractures with head involvement
  15. 15. INDICATIONS OF THR 6. Pyogenic arthritis or osteomyelitis : Hematogenous Postoperative 7. Tuberculosis 8. Congenital subluxation or dislocation 9. Hip fusion and pseudarthrosis 10. Failed reconstruction following: Osteotomy Cup arthroplasty Femoral head prosthesis Girdlestone procedure Total hip replacement Resurfacing arthroplasty 11. Bone tumor involving proximal femur or acetabulum 12. Hereditary disorders (e.g., achondroplasia)
  16. 16. TOTAL HIP COMPONENTS AND DESIGNS
  17. 17. Total Hip Components 1.Femoral Components (Head+ Neck+ Stem) 2.Acetabular Components
  18. 18. Goal of THR Biomechanically sound, stable hip joint by restoration of normal center of rotation of femoral head
  19. 19. The location of center of rotation of femoral head is determined by 1. Vertical offset 2. Horizontal(medial) offset 3. Anterior offset (Anteversion)
  20. 20.  WHAT WILL HAPPEN IF THERE IS INADEQUATE RESTORATION OF MEDIAL OFFSET?  WHAT WILL HAPPEN IF THERE IS INADEQUATE RESTORATION OF VERTICAL OFFSET
  21. 21.  MEDIAL RESTORATION IS SIMPLY CORRECTED BY MAKING NECK ADJUSTMENT BUT…… LIMB LENGTH INCREASES
  22. 22. VERSION  NORMAL FEMUR IS 10 TO 15 DEGREE ANTEVERTED.  USUALLY ACCOMPLISHED BY ROTATING THE COMPONENT IN FEMORAL CANAL.  IN PRESS FIT FIXATION IS USED –MODULAR FEMORAL COMPONENT IS USED.
  23. 23. HEAD NECK RATIO  AFFECTS ROM ,IMPINGEMENT,STABILITY OF ARTICULATION.
  24. 24. TYPES OF FEMORAL COMPONENTS Cemented stems Cementless stems porous surface nonporous surface Specialized custom-made
  25. 25. CEMENTED STEMS  Most designers favour- cobalt chrome alloy PMMA cement is the standard for femoral component fixation Pitfalls-Debonding, Mechanical loosening, Extensive bone loss with fragmented cement
  26. 26. 2. Cementless stems with porous surface  Fixation is more biological.  Material- titanium alloy/ Cobalt-Chromium alloy  Bone ingrowth into porous metal surface  Requires: a)immediate mechanical stability at the time of surgery b) intimate contact between porous surface and viable host bone  So, surgical technique and instrumentation need to be more precise than cemented counterpart
  27. 27. Specialized custom-made
  28. 28. Specialized femoral components for replacement of variable lengthth of proximal femur. Stem can be combined with TKR to replace entire femur
  29. 29. ACETABULAR COMPONENTS Cemented Cementless Constrained type Specialized custom made
  30. 30. Cemented acetabular component  PMMA spacers (3 mm) are incorporated into polymerizing cement, yeilding uninterrupted cement mantle  Satisfactory in elderly, low demand patient, Tumour reconstruction, and in revision arthroplasty.
  31. 31. Cementless acetabular components 1. Porous coated for bone-ingrowth 2. Fixation with trans acetabular screw
  32. 32. Constrained acetabular components  Mechanism to lock the prosthetic femoral head into the polythene liner  Indications- -Insufficient soft tissue, -Deficient hip abductors, -Neuromuscular disease, -Hip with recurrent dislocation despite well- positioned implants.
  33. 33. Alternative bearings  Highly cross linked polyethylene  Metal on metal bearings  Ceramic on ceramic bearings
  34. 34. Metal on metal bearings  Low wear rate  High carbon cobalt chromium alloy  Diametral clearance-gap between the two implants at the equator of articulation.  Smaller clearance produce films for lubrication and reduced wear.  Elevated metal ions in blood that excreted through urine.
  35. 35.  So contraindicated in impending renal failure.  Placental transfer occur of these metal ions.  Delayed type hypersensitivity (aseptic lymphocytic vasculitis associated lesions)  Pseudotumour  Recommendation for symptomatic patients is measurement of blood cobalt and chromium ion level and/MRI or USG.
  36. 36. CERAMIC ON CERAMIC BEARINGS  ALUMINA CERAMIC IS USED.  HIGH DENSITY, HYDROPHILLIC, SMOOTHER THAN METAL.  CERAMIC IS HARDER THAN METAL AND MORE RESISTANT TO SCRATCHING.  LINEAR WEAR RATE IS 4000 TIME LESS THAN COBALT CHROME ALLOY ON POLYETHYLENE.
  37. 37. DISADVANTAGE  IMPINGEMENT BETWEEN THE FEMORAL NECK AND RIM OF THE CERAMIC ACETABULAR COMPONENT.  IMPLANT MALPOSITION  STRIPE WEAR  SQUEAKING  OSTEOLYSIS
  38. 38. OXIDIZED ZIRCONIUM  CERAMIC METAL ALLOY.  NOT SUSCEPTIBLE TO CHIPPING,FLAKING,OR FRACTURES.
  39. 39. Templating of radiograph for pre-operative planning
  40. 40. 1. Determination of the amount of limb shortening 2. Acetabular over-lay templating and center marking
  41. 41.  3. Femoral overlay templating and measurement of precise size of proximal canal  4. Selection of appropriate neck-length to restore limb length and femoral offset
  42. 42.  5. If no shortening present, we match the center head with previously marked center of the acetabulum  6. If a discrepancy exists, the distance between the femoral head center and acetabular center should be equal to the measured limb length discrepancy
  43. 43. SURGICAL APPROACHES
  44. 44. POSITION OF THE PATIENT FOR POSTERIOR APPROACH
  45. 45. POSTERIOR APPROACH
  46. 46. Reaming of acetabulum
  47. 47. Femur is retracted anteriorly to allow clear access to acetabulum
  48. 48. REAMING OF ACETABULUM
  49. 49. SOCKET POSITIONING
  50. 50. Safe and unsafe quadrants of acetabulum POSTEROSUPERIOR QUADRANT- SAFEST
  51. 51. FIXATION HOLES FOR CEMENT IN ACTABULUM
  52. 52. ACETABULAR CEMENT PRESSURIZER
  53. 53. PRECAUTIONS FIXATION MUST BE AUGMENTED BY SCREWS OR SPIKES. PERIPHERAL PART OF POSTEROSUPERIOR SEGMENT ARE SAFEST. PALPATION OF GREATER SCIATIC NOTCH IS MUST. INTRAOPERATIVE CHANGE IN THE POSITION.
  54. 54. PREPARATION OF THE FEMUR
  55. 55. POSITIONING OF FEMUR FOR REAMING
  56. 56. Neck is cut planned at appropriate level and angle by using trial components of templeted size
  57. 57. Removal of remining lateral edge of femoral neck and medial portion of GT with box osteotome
  58. 58. Reaming of femoral canal Hand or power reamer must be lateralized into GT to maintain neutral alignment of femoral canal
  59. 59. Femoral broaching Progressively larger broaches are inserted, lateralizing each one to maintain neutral alignment
  60. 60. Femoral component anteversion
  61. 61. Calcar planning with prcision reamer
  62. 62. Assembly of trial head and neck segments determined from pre- operative templating
  63. 63. Canal blocking
  64. 64. Retrograde injection of cement with gun in early dough phase
  65. 65. Cement pressurization
  66. 66. Manual cement packing (PALACOS cement)
  67. 67. HIP SHOULD BE STABLE IN  IN FULL EXTENSION WITH 40 DEGREE OF EXTERNAL ROTATION.  IN FLEXION TO 90 DEGREE WITH ATLEAST 45 DEGREE OF INTERNAL ROTATION  WITH THE HIP FLEXED 40 DEGREE WITH ADDUCTION AND AXIAL LOADING-  IF HIP DISLOCATE OR SUBLUXATE –USE LONGER NECK.
  68. 68. WHAT IF FRACTURE OCCUR  STOP THE INSERTION  EXPOSE THE FRACTURE  IF AN INCOMPLETE FRACTURE OCCUR WITH EXTENSION ONLT AT THE LEVEL OF LT-ENCIRCLAGE ,REINSERT AND REASSESS THE STABILITY.  BELOW LT –LONGER STEM  GT IS # AND UNSTABLE-FIX THE GT WITH WIRES.
  69. 69. TROCHANTERIC OSTEOTOMY
  70. 70. SURGICALS PROBLEMS RELATIVE TO SPECIFIC HIP DISORDER
  71. 71. OSTEOARTHRITIS  MC INDICATION  REMOVAL OF OSTEOPHYTES MAY BE NECESSARY.  Difficulty in delivering femoral head.
  72. 72. RHEUMATOID ARTHRITIS  THEY GENERALLY RECEIVES IMMUNOSUPPRESSIVE DRUGS.  IF BOTH HIP AND KNEE IS INVOLVED EQUALLY, HIP ARTHROPLASTY SHOULD BE DONE FIRST .
  73. 73. OSTRONECROSIS  STAGE 1 AND 2-CORE DECOMPRESSION ,VASCULARISED GRAFT OR BY VALGUS OSTEOTOMY  RESURFACING ARTHROPLASTY IF < 50 % OF HEAD  MOSTLY AGE GROUP IS 25 TO 45 YEARS-THR IS NOT VERY SUCCESSFUL.  IMPROVED RESULT WITH ALUMINA CERAMIC HEAD HIGHLY CROSSLINKED POLYETHYLENE.
  74. 74. DWARFISM/DYSPLASIA  NARROW CANAL  BOWING  ALTERD FEMORAL ANATOMY  PREVIOUS FEMORAL OSTEOTOMY  SHORT FEMORAL COMPONENT IS USED .
  75. 75. ACUTE FEMORAL NECK FRACTURE  THR > HRA>INTERNAL FIXATION  THOSE WHO ARE LESS HEALTHY,COGNITIVELY IMPAIRED OR REQUIRE ASSISTIVE DEVICE FOR AMBULATION ARE BETTER SUITED FOR HRA.
  76. 76. Post operative hip re-dislocation can be avoided by:  Maintaining abduction using pillows  Avoiding crossing legs  Avoiding squating  Using chairs with armrest  Not bending forward past 90 degrees  Using a high-rise toilet seat if necessary  Avoiding pronation the legs  Avoiding stairs
  77. 77. Exercise Prescription Early Stage
  78. 78. Exercise Prescription - Later Stages -
  79. 79. COMPLICATIONS OF THR  1. Hematoma formation  2. Heterotropic ossification  3. Thromboembolism  4. Nerve injuries (sciatic, femoral, obturator or sup gluteal nerve)  5. Vascular injuries
  80. 80. COMPLICATIONS OF THR  6. Limb length Discrepency  7. Dislocation and subluxation  8. Fractures of acetabulum and femur  9.Trochenteric nonunion and migration  10. Infection  11. Loosening ( Femoral and acetabular component)  12. Osteolysis
  81. 81. POST OPERATIVE X-RAY
  82. 82. THANK YOU

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