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TOTAL HIP
ARTHROPLASTY
MODERATORS: PRESENTED BY:
Dr.RAVINATH
M.S.,(ORTHO) Dr. ASHOK .J. SAMPAGAR.
P.G. In orthopedics
Dr.MALLIKARJUN
REDDY
M.S.,(ORTHO ) DATE: 14-09-2011
INTRODUCTION :
• Total hip arthroplasty is an
operative procedure in which
the diseased and destroyed
hip joint is resected and
replaced with a new bearing
surface.
They are :
• Fibrous capsule
• Iliofemoral ligament or
ligament of bigelow
• Pubo-femoral ligament
• Ischio-femoral ligament
• Ligamentum teres
• Transverse ligament of
acetabulum
Neck shaft angle or angle of
inclination
• It is the angle between
the axis of the femoral
neck and the long axis
of the femoral shaft.
• On average, it is 135
degrees in the adults
Anteversion or angle of femoral
torsion
• Refers to the degree of
forward projection of
femoral neck from the
coronal plane of the
femoral shaft.
• In an adult, it is about
10-15 degrees
APPLIED BIOMECHANICS
• The total hip component must withstand many
years of cyclical loading equal to atleast 3 to 5
times the body weight and at time they may be
subjected to overloads of as much as 10 to 12
times the body weight
• So, the basic knowledge of biomechanics of the
THR and hip is necessary to properly perform the
procedure, to successfully manage the problems
that may arise during and after surgery, to select
the components.
• The ratio of the length of the
lever arm of the body weight
to that of the abductor
musculature is about 2.5:1.
• So the force of the abductor
muscles must approximate
2.5 times the body weight to
maintain the pelvis level
when standing on the one
leg.
• The estimated load on the
femoral head in the stance
phase of gait is atleast 3 (5/6
BW on femoral head )times
the body weight.
Forces acting on hip
• To describe the forces
acting on the hip joint, the
body weight may be
depicted as a load applied
to a lever arm extending
from the body’s center of
gravity to the center of the
femoral head.
• The abductor musculature,
acting on lever arm
extending from the lateral
aspect of the greater
trochanter to the center of
the femoral head.
• Force on hip act in coronal
and saggital direction
• Coronal- tend to deflect
stem medially ,
saggital(esp in flexed hip)-
tend to deflect stem
posteriorly
• Hence Implanted femoral
components must
withstand substantial
torsional forces even in
the early postoperative
period
CHARNLEY’S LOW FRICTION
ARTHROPLASTY
Charnley advocated the shortening of the body
weight lever arm by
• Deepening the acetabulum and by using small
head.
Abrasive-THR
Adhesive -THR
Fatigue - TKR
The factors that determine wear are :
• Femoral components
Head
Neck
stem
FEMORAL COMPONENTS :
• Neck length and offsets :
The ideal femoral reconstruction reproduces
the normal center of rotation of femoral head,
which can be determined by
-Vertical height (vertical offset)
-Medial head stem offset ( horizontal offset)
-Version of the femoral neck (anterior
offset)
• Vertical offset- LT to center of the
femoral head. Restoration of this
distance is essential in correction of leg
length.
• Medial head stem offset- distance from
the center of the femoral head to a line
through the axis of the distal part of
stem.
• Medial offset if inadequate, shortens the
moment arm – limp, increase, bony
impingement and dislocation.
• Excessive medial offset –increase stress
on stem and cement which causes stress
fracture or loosening.
• Ceramic –Mittelmeir
• Custom made
• Modular System
FEMORAL COMPONENTS USED WITH CEMENT
• Range of head sizes – 22, 26, 28 & 32 mm.
• Incidence of dislocation is higher for smaller
head.
• Neck diameter : Original charnleys was 12.5
mm but has been reduced to 10.5 mm –
reduced neck diameter avoids impingement
during flexion and abduction.
• Range of stem lengths -120 mm to 170 mm.
• The main problem is mechanical loosening
and extensive bone loss associated with
fragmented cement
CEMENTLESS STEMS WITH POROUS SURFACES
Basic principle
• Based on the principle-bone ingrowth from
the viable host bone into porous metal
surfaces of implant.
• Indications for cementless components
involves
1.primarily active young patients
2.and revisions of failed cemented
components.
• Two prerequisites for bone ingrowth
1.immediate implant stability at the time of surgery
2.and intimate contact between the porous surface
and viable host bone
• Implants must be designed to fit the endosteal
cavity of the proximal femur as closely as
possible.
• In general, the selection of implant type and size,
as well as the surgical technique and
instrumentation, must all be more precise than
with their cemented counterparts
Current porous stem designs
• Most cementless
acetabular components
are porous coated over
their entire
circumference for bone
ingrowth
• Fixation of the porous
shell with
transacetabular screws
• Pegs and spikes driven
into prepared recesses
in the bone provide
some rotational stability
but less than that
obtained with screws.
• ZTT socket
Hemispherical , porous
coated cup designed
with dome screw holes
and transacetabular
screws for stability. Six
peripheral screw holes
provide choice of screw
locations for additional
stability and also lock in
the polyethylene insert.
Two techniques involved
1.Initial stability of the metal shell against the
acetabular bone using screws, spikes , lugs, or fins
2. Stratch fit- underream the acetabular bone bed
by 1-2 mm and use the roughness of the outer
surface of metal shell to achieve scratch fit
• Expansion cup method-Cup diameter is reduced
with with a special instrument , cup then
implanted and then allowed to return to initial
diameter.
polyethylene liner
• Most modern modular acetabular components are
supplied with a variety of polyethylene liner choices
• The polyethylene liner must be fastened securely to
the metal shell.
• Current mechanisms include plastic flanges and metal
wire rings that lock behind elevations or ridges in the
metal shell, and peripherally placed screws
• in vivo dissociation of polyethylene liners from their
metal backings has been reported micromotion
between the nonarticulating side of the liner and the
interior of the shell may be a source of polyethylene
debris generation, or “backside wear.”
Alternative Bearings
• Osteolysis secondary to polyethylene particulate debris
has emerged as the most notable factor endangering the
long-term survivorship of total hip replacements.
• alternative bearings have been advocated to diminish this
problem
• These are-
-highly cross linked polyethylene
-metal-on-metal
-ceramic-on-ceramic
-Ceramic on Polyethylene
Highly Cross-Linked Polyethylene
• Higher doses of radiation(gamma or
electron,10mrad) can produce polyethylene
with a more highly cross-linked molecular
structure.
• This material has shown remarkable wear
resistance.
• Only short-term data on the performance of
highly cross-linked polyethylenes are presently
available
• Diadvantage -lower fracture toughness and
tensile strength
Metal-on-Metal Bearings
• Metal-on-metal implants seem to be tolerant of
high impact loading, and mechanical failure has
not been reported.
• wear rates less than 10 mm/y for modern metal-
on-metal articulations
• But there remains major concern regarding the
production of cobalt and chromium metallic
debris, and its elimination from the body.
• metal-on-metal (MOM) bearings have a ‘suction-
fit’ less chance of dislocation
(J Bone Joint Surg [Br] 2003;85-B:650-4)
Ceramic-on-Ceramic Bearings
• Alumina ceramic has many properties that make it
desirable as a bearing surface in hip arthroplasty
• high density- surface finish smoother than metal
implants
• The hydrophilic nature- ceramic promotes lubrication
• Ceramic is harder than metal and more resistant to
scratching from third-body wear particles.
• The linear wear rate of alumina-on-alumina has been
shown to be 4000 times less than cobalt-chrome alloy–
on–polyethylene.
• Ceramic-on-ceramic arthroplasties may be more
sensitive to implant malposition than other bearings. (J
Bone Joint Surg [Br] 2003;85-B:650-4
EVALATION 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
• 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.
ROENTEGENOGRAPHIC EVAL U ATION
• AP view of pelvis with both hips with upper third
femur with limbs in 15degrees 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.
Templating
• Draw horizontal lines:
one joining both IT and
other joining both
lesser trochanters.
Measure the limb
length discrepancy as
the difference in the
length of lesser
trochanter .
• Acetabulum :place
acetabular template on
the film and select a
size that closely
matches the contour of
the pts acetabulam
• Medial surface of the
cup is at tear drop and
inferior limit is at the
level of obturator
foramen
• Femur : select a size
that most precisely
matches the contour of
proximal canal with 2-
3mm of cement
mantle.select a neck
length so that the diff in
the height of femoral
and acetabular centre is
equal to LLD
• Mark the level of
anticipated neck cut
and measure its
distance from lesser
trochanter. template
the femur similarly in
lateral view
PREPARATION :
– Charnley (1969 ) 8. 9 %
– Fitzgerald (1995) 0 – 11 %
• Rheumatoid Arthritis
• Recurrent UTI
• Oral corticosteroids
• Diabetes
• Tooth extraction
INSTITUITION RELATED RISK FACTORS:
• Reduce hospital stay(pre-op and post-op)
• Prior pre op assessment as OP
• Clean theatre setup
• Closed door procedure
• Laminar air flow
• Body exhaust system
• U V light
PROCEDURE PRECAUTIONS
• Take / give bath in the morning
• Skin preparation
Shaving just before in the side room
• Providone iodine cleaning before and after shave
• Pre op antibiotics
( 1.5 gm Cefuroxime Sodium)
30 – 45 MINUTES BEFORE SURGERY
• Use incise drape ALWAYS
• Use double gloves ALWAYS
• Handle tissues with least trauma
• Wound irrigation, Good hemostasis
Fit z geralds classification of infection in THR :
Acute post operative - within 3 months
Delayed –3 to 24 months
Late (Haematogenous) – after 2 years
Stage 1
• Acute post operative period
• Classic fulminant wound infection
• Infected deep hematoma
• Superficial infection that subsequently extend to deep infection
Stage 2
• Deep delayed infection
• Indolent and become manifest from 6-24 months after surgery
Stage 3
• Late infection occur 2 year or longer after surgery in a previously
asymptamatic patient.
THA
Clinical Sepsis
Acute/Hematogenous
Resection
2-stage Replantation- Arthroplasty
2-stage Reimplantation-
1st stage-
through debridement and reimplantation
with antibiotic coated cement
2nd stage
definitive reimplantation 3 months later
6 . Fractures :