Adobe Systems MUDr. Robert Vyskočil Orthopaedic Dpt., University Hospital Brno Head of Dpt: Prof. MUDr. Martin Repko PhD. Adobe Systems ̶Resection of destroyed joint surfaces – cartilage and subchondral bone and replacement with metal implants ̶Return patients back to pain free life, active lifestyle, improvement of mobility, ROM ̶Hip, knee, shoulder, small joints hand/foot, ankle, elbow, wrist ̶ Adobe Systems Adobe Systems Indication Adobe Systems •1. Total Hip Replacement Adobe Systems Total Hip Replacement X Cervicocapital prosthesis CCEP Adobe Systems Adobe Systems ̶Narrowing of joint space ̶Subchondral sclerotization ̶ ̶Osteophytes ̶ ̶Soft tissues changes Adobe Systems pain, over GT and groin pain Stress pain rest pain Contracture of soft tissues stiffness + reduction of ROM Morning stiffness Pain at night Lower quality of life Adobe Systems Epidemiology ̶ more in women primary : secondary 45% : 55% Caucasian, europian population ̶ > 65 years of age - 50% of people ̶ > 75 years of age - 80% of people ̶ Adobe Systems Risk factors ̶ ̶Age ̶sex – women ̶Genetics ̶Obesity ̶Trauma of the hip joint ̶Geography Adobe Systems X ray classification Kellgren – Lawrence 1957 ̶ Adobe Systems Coxarthrosis – therapy 1. Non-farmacological - weight reduction, RHB, fysio, swiming, excersises 2. Farmacological - Analgetics / Paracetamol / NSAiDs / COX inhibitors / SYSADOA – chondroprotectives, viskosupplementation /glukosamin, Hylauronic acid/ 3. Surgical – total joint replacement ̶ Adobe Systems Subjective complaints + X ray finding Conservative treatment without effect indication of THR Cemented/ Noncemented / Hybrid ̶In Czech Republic 10.000 / year ̶University Hospital brno 400 / year Adobe Systems 1. Cemented THR ̶ UHWMPE - Polyethylen cup /sir. John Charnley, 1962 / ̶ polished hip stem/ Co-Cr-Mo, Ni, Ti,…/ 7.5, 10, 12.5, 15, 17.5 ̶ fixation with bone cement – / PMMK, Haboush 1953 / ̶ metal head Adobe Systems Obsah obrázku zeď, interiér, obloha Popis se vygeneroval automaticky. Adobe Systems 2. non-cemented THR ̶Metal cup + polyethylen / ceramic / insert ̶ ̶„rough“ stem, covered with hydroxyapatit layer „Press-fit“ technique – osteointegration of the metal to the bone different sizes of the stem – femoral canal ̶Metal / ceramic head ̶ ̶ Adobe Systems Adobe Systems 3. Hybrid THR ̶Noncemented metal cup + insert – polyethylen / ceramic ̶ ̶Cemented stem ̶ ̶ceramic / metal head ̶ Adobe Systems Adobe Systems Surgical approaches anterior, anterolateral, lateral, posterior www.orthobullets.com 1.Anterior approach – Smith Petersen Septum : M. tensor fasciae latae - M. Sartorius Adobe Systems ̶2. Anterolateral – Watson – Jones supine position Septum : M. Gluteus med et min – M. vastus lateralis Adobe Systems ̶3. Posterior approach – Southern, Moore / Uk, USA / ̶Lateral decubitus position ̶Through muscle fibres of M. Gluteus Maximus ̶CAVE!! – n. Ischiadicus Adobe Systems ̶1. surgical approach ̶2. reaming and cup insertion /cemented, noncemented/ ̶3. preparation of the femoral canal for the stem /cemented, noncemented / ̶4. neck + head /M,L,XL,XXL/ ̶5. check stability, leglenght, ROM ̶6. definitive implantation of components ̶7. poop RHB, 3/12 PWB with crutches FWB Adobe Systems Complications 1.Pain - pathology of lumbo-sacral spine - aseptic loosening - infection - periprosthetic fractures / growing of incidence/ 2. Aseptic loosening - mechanical wear, osteolysis lost of fixation - need of revision / aprox. 60 / year Adobe Systems Adobe Systems 3. Infection Perop – postop (haematogennous way from infected focuses) / GIT, lungs, urogenital, skin infection, ulcer of the shin ../ Strict asepsis in Operation theatre + all infection focuses must be cured!!! Th – long-term ATB iv / min. 3 months / Infected TJR – need for revision, „two-stage“ 1. Extraction of THR and spacer implantation + iv. ATB 2. reimplantation THR ̶ Adobe Systems 4. THR luxation 1-5%, / revisions up to 20% / -Per-op technique failure – malposition of components, impingement – bony osteofytes, soft tissues - Post-op. Luxation prevention Th - reposition with / without GA, hip brace for 6 weeks >3 luxation op. revision ̶ Adobe Systems 5. Periprosthetic fractures /around THR/ ̶ Perop 3,5 % uncemented THR 0,4 % cementeded THR ̶ Postop /fall/ 0,1 – 4 % growing incidence most often aroud the stem th - ORIF – open reduction internal fixation Adobe Systems THR periprosthetic fractures Vancouver classification http://fractureguide.zimmer.com/wp-content/uploads/2012/06/2.1-13.jpg Výřez obrazovky Výřez obrazovky Adobe Systems C:\Users\Robin\Desktop\hyperion zimmer.png C:\Users\Robin\Desktop\cables.png Image result for NCB plate pdf Výřez obrazovky Výřez obrazovky Adobe Systems 6. Leg-lenght discrepancy 18-32% leg prolongation th - shoe inserts, orthopaedic shoes THR on the contralateral side 7. Neurovascular injury a. femoralis – CAVE per-op. injury!! n. ischiadicus, n. femoralis – perop. injury x haematoma/dragging of the nerve th – anti - oedema therapy, EMG, US, MRI spontaneous reparation in 6 weeks x revision ̶ Adobe Systems C:\Users\Robin\Desktop\FN MOTOL\ps-knee pic.jpg Adobe Systems Adobe Systems Classification: Kellgren – Lawrence, ICRS, Outerbridge Adobe Systems Types of TKR: ̶CR – Cruciate retaining, PCL reserved ̶ ̶ PS – Posterior stabilized /PCL resected/ ̶Revision TKR - CCK Condylar Constrained knee - RH Rotating hinge knee /tumour resection, loose colletaral ligaments/ Adobe Systems CR PS CCK RH C:\Users\Robin\Desktop\FN MOTOL\imagesTVOYYZBG.jpg C:\Users\Robin\Desktop\FN MOTOL\ps-knee pic.jpg C:\Users\Robin\Desktop\FN MOTOL\Constrained-Condylar-Knee.jpg https://encrypted-tbn1.gstatic.com/images?q=tbn:ANd9GcSfd39RJlqUttiDRpvOP1Rupw6aM5f2aS4-zhjU0ZreZyY o3MmC Adobe Systems fixation ̶Cemented – „gold standard“, most of TKRs ̶Noncemented – higher risk of revisions, technically demanding revisions ̶Hybrid – femoral component noncemented, tibial fixated with cement, unsure results Adobe Systems Approach Medial parapatellar Midvastus Subvastus Adobe Systems 1.Approach 2.Menisci and Hoffa fad pad resection, synovectomy, medial release /varus knee/ 3.IM femoral guide, distal femur resetion 4.EM tibial guide, tibial plato resection 5.Femur sizing and resestion via template 6.Soft tissues balancing 7.Insert trial, full ROM, flection and extention gap 8.Cementing of componenets 9.PF removal of ostheophytes, denervation 10.RHB, fysio, ROM, PWB with crutches, then FWB 11.DVT prophylaxis 5/52 Adobe Systems Adobe Systems Complications 1.Operating mistake – malrotation of components, „nonbalanced“ knee 2.Pain – up to 10% unknown reason 3.Per/postop infection two-stage replantation 4.Aseptic loosening one-stage Replantation of TKR 5.Periprosthetic fractures growing incidence th. ORIF – plate, cables x revision TKR 6. Neurovascular injury – a. poplitea, n. peroneus Adobe Systems 3. TEP omi, Shoulder replacement Adobe Systems Adobe Systems Adobe Systems •4. TEP cubiti, Elbow replacement ̶ Rheumatoid arthritis postraumatic arthritis, tumour resection, bilateral ankylosis Pain, restriction of ROM Contraindication – septic arthritis, infection arthrodesis Adobe Systems Types of implants: ̶Non-constrained ̶ ̶Semi-constrained ̶ ̶Constrained ̶ ̶ Adobe Systems •5. Total ankle replacement art. Talocruralis – TAR ̶Lord/Marrot 1970 – implantation THR into ATC J ̶Arthrosis of T-C joint, RA, postraumatic, Necrosis tali, osteochondrosis dissecans, arthropathies… ̶cemented noncemented ? Arthrodesis x TAR … still unclear… ? Adobe Systems •6. Hand/Foot joint replacements ̶wrist, MCP/ MTP, IP joints,… ̶ ̶RA, arthrosis uncertain results arthrodesis preferred ̶Ortk FN Brno – silastic prosthesis of I. MTP joint / hallux rigidus / Adobe Systems thank you for the attention Adobe Systems