Total hip arthroplasty J. Emmer, Z. Rozkydal kyčel- anat Hip joint Enarthrosis Img0193 Kyčel- rtg pánve Pelvis kyčel- femur celý Femur kyčel- svaly zepředu Muscles kyčel- svaly zezadu 1 kyčel- svaly zboku kyčel- n Femoral nerve THA- ischiad Sciatic nerve THR indications •Painfull hip joint condition •Poor effect of conservative therapy •Life comfort deteriorated •No salvage surgeries indicated • • • Nik_0007 Primary osteoarthrosis Secondary osteoarthrosis: congenital, posttraumatic, after infection Rheumatoid arthritis Psoriatic arthropathy Avascular necrosis of the femoral head Indications Hauser 15 Primary osteoarthritis THR indications •OA primary •OA secundary •Psoriatic arthropathy •Aseptic femoral head necrosis •Rheumatoid arthropathy •Tumors •Intracapsular femoral neck fracture, no indication for OS or conservative therapy (vital indication!) • • • THR contraindications •Poor general condition, poor physical status (ASA IV) •Persistent infection •Severe comorbidity with poor prognosis •Extreme obesity •No compliance • • • • Contraindication •Active infection of the hip •Infection in the body •General condition not good •Neurogenic arthropathy •Extreme low bone quality •No cooperation of the patient • elevated ESR, CRP Fosa-kyfóza History Sir John Charnley Low friction arthroplasty Acrylic dental cement Polymethylmetacrylate – bone cement Charnley 1962 Nik_0011 Low friction arthroplasty THA Muller 1 THA muller 3 THA Muller 4 1964 -1965 Setzholzprothese 1966 Banana - shaped 1977 Geradschaftprothese THA čech 1 THA POldi typy Prof. MUDR.Oldřich Čech, DrSc. Stems Poldi- Čech 1972 1986 THA čech 5 THR fixation options •Cemented –Both components fixed with bony cement –Older patients > 70 y.o. –Poor bone quality - osteoporosis – – • • THR fixation options •Hybrid –One component fixed with bone cement (femoral) –65-70 y. –Better implant survival – – • • THR fixation options •Cementless –Both components fixed without cement – age bellow 65 y.o. –Good bone quality –Contraindication for bone cement (alergy, right ventricle function) –Best implant survival –The most expensive – – • • Fixation in the bone Types of THA Bártová 2 vdk27b Nik_0004 Cemented Hybrid Uncemented Primary THA Nik_0004 Head Neck Stem Polyethylene cup Revision THA Obr Luha Transfemo7 For tumors RD palas 88 RD palas 5-95 THA výuka- CKP Femoral head prosthesis Thompson Zl Metal •Steel • •Cobalt - chromium- molybdenum alloys • •Titanium alloys Luha Exeter 1 Bone cement •Polymethyl methacrylate (metylesther metacrylic acid) •Powder polymer, liquid monomer •Exotermic response •Stabilisation of the implant in 10 minutes •Cytotoxic effect •Protein coagulation (termical + chemical) •Microembolisation • • • • – • • Luha- cross section 1 Cemented THA Luha - cement dřík Luha- cross section 1 Luha- cross section 2 5-7 mm 2 mm Cementing technique •Interdigitation into bone trabeculae • •Regular layer: • under the cup 3 mm • around the stem 2- 7 mm • Luha - cement dřík 5 -7 mm 2 mm Luha- cross section 1 Polyethylen •UHMWPE : • ultra- high- molecular- weight- polyethylen • THA výuka PE jamka PE •Polyethylen –Longest used material for cup –Viscoelastic –Plastic deformation (cold flow) –Higer wear rate –Oxidative degradation • PE •Polyethylen –UHLMWH - Ultra high molecular – weight polyethylen –HXLPE – cross - linked –PE + vit E –Aim: •Wear reduction •Oxidative degradation reduction •Keeping elasticity modulus • Polyethylen •Linear wear 0,1 - 0,2 mm / year •Volumetric wear 0,3 - 10 mg / year • •Cold flow – plastic deformation •Abrasion and delamination •Oxidative degradation • •Modern trends: highly crosslinked polyethylen •with vitamin E THA výuka PE jamka o PE částice PE wear particles, 1 um XPE- highly-cross-linked polyethylen + vitamin E • • A vit E PE Antioxidant Increases mechanical properties of PE Ceramic •Corundum or Zirconium AL2O3 •Smooth surface •Less wear: 0,005 - 0,15 mm / year THA výuka keram hlavička THA výuka keram vložka Materials – ceramic •Pure aluminium oxide - AL2O3 - corundum •ZrO2 – zirkonium oxide •Extremely smooth surface, minimal friction ratio •An order of magnitude smaller wear rate comapare to metal •Fragile •Expensive • • • • • • – • • Materials – ceramic •Biolox forte –Pure AL2O3 (yellow) •Biolox delta –Stronger –Lower grain size – even more smooth –More homogenic –Pink –AL2O3 –ZrO2 –Zirconium oxides stabilized by Ytrium – • • • • • • – • • A Biolox delta 1 Materials – Oxinium •Zirconium oxides •Combines properties of alloy and ceramic •2x harder than ceramic •Abrasion and scratch resistant •Fracture resistance •Trace amount of Ni only (hypoallergenic) •20% lighter than CoCr • • • • – • • • • • • – • • Contact : head - cup •Metal- polyethylen •Ceramic- polyethylen •Ceramic -ceramic • CLS obrázek THA výuka keram vložka THA výuka PE jamka THA výuka- kovová hlavička THA výuka keram hlavička Diameter of the head 22, 28, 32, 36, 38, 40 mm Advantage of 36 mm head: Higher stability Greater range of motion Less impingement neck- edge of the cup A Pinnacle 5 CDH pojetová 2 o10 Acetabular component •Cemented: polyethylen • • • •Noncemented: metal- backed • • with PE insert • • with ceramic insert • • THA výuka PE jamka THA výuka keram vložka Luha- Plasma cup Materials •Cementless implants requirements – bone adjacent surface –Trabecular titan –Trabecular tantal –Hydroxyapatite surface – – • • Hydroxyapatite surface Bioactive Osteoconductive Chemical bonds bone- hydroxyapatite A Porocoat 1 Surface of cementless implant Macroporosity Microporosity Pores on the surface 50µm - 600 µm Pores above 800 µm- fibrous tissue Adhesive surfaces: Trabecular Metal Trabecular Titan Pores 300 µm High initial stabiity A plasma cup 6 A Trabecular titan 1 Uncemented cup Primary fixation: mechanical anchorage in the bone Luha- Plasma cup Press - fit Zw rtg2 Threaded Zw rtg2 Uncemented cup Secondary fixation: osteointegration of the implant on the surface of bone vdk27a vdk27b Bicon – Zweyműller cup Zw Bicon1 Femoral component •High polished surface • for cementing fixation • •Porous surface • for cementless fixation • Luha Exeter 3 THA výuka Bicontact dřík Cemented Cementless Morscher, Spotorno MS – 30 stem cemented MS- rtg po10 letech MS- dřík celý Uncemented stem •Primary fixation: •Mechanical anchorage • in the bone • •Secondary fixation of the implant on the bone surface Zw dřík2 Uncemented stems vdk30b Luha Transfemo 4 Proximal fixed Distal fixed THA výuka Bicontact dřík Indication scheme •Uncemented to 60 y. • •Hybrid 61 - 70 y. • •Cemented over 70 y. • Approaches Zw foto 1 MIS- mini invasive surgery Luha MIS 3 Luha- MIS 4 Physiotherapy Day: 1.Sitting, drainage ex 2.- 5. walking 6. + stairs 7-21 – in physiotherapy dpt. 3 months- spa resort Full weight bearing. Cemented THA after one month Uncemented after 12 weeks Fast track physiotherapy, discharge 3-4 days, home care Post op. management •ITU - one day •Hospitalisation at orthopedic ward for 5 days •Verticalisation the first post op. day •Complex rehabilitation protocol, rehabitalitation nurse obligatory •6. day – transfer to rehabilitation ward •Spa resort in CZ covered by public health insurance in 3 post op. months •DVT prevention – 6 weeks •Prevention of dislocation of THR- no adduction, no deep flection, no axial extremity traction! • Modern trends: Shortening of inpatients period (risc of nosocomial infection, economic aspects) •Fast track physiotherapy •Outpatient surgery? • – • – • • • Follow up •Standardized •First check up: by orthopedical surgeon in 6 weeks (X ray included) •Second check up: in 3 months, then 6 month •Every 2 years (X ray included) if no problem present •EDUCATION –Activity, limitation and régime with THR –PJI prevention –Urgent check – up if suspected PJI – • – • • • Complications •Peri and early post op. morbidity and mortality –Nervous and vascular injury –Blood loss –Perioperative fracture –Hip displacement (luxation) –Pulmonary embolism –IM –General decompensation –Development of delirium • • Complications •THR dislocation –Shortening and (extra)rotation of extremity, pain, no active hip flexion –No active walking and no weight - bearing – –Therapy: •Close hip redduction attempt. Hip orthesis with reduced ROM obligatory •Revision, identification of cause, solution •Longer head, stabilisation elements •Replantation – • • Aseptic loosening - therapy – • • • Aseptic loosening - therapy •Revision, replantation •Revision systems, augments, spongioplasty (alografts)… •Double ATB combination – higer infection risk •Higher complication rate •Inferior outcome •Lower ROM •Longer no full weight bearing period (3M) •Higher mortality •Higher displacement risk ratio – • • • Revision THA • Luha Paprosky acet 3A Luha Paprosky femur 2C Nik_0014 Nik_0016 Nik_0011 Pinosová 5 sklerotické dno Pinosová 6 oživení dna Revision of the acetabulum Pinosová 7 spongio Pinosová 8 nová jamka CLS Barvířová 3 Barvířová 4 Revision THA W Bártová 1 Vaverková4 vaverkova 1511-2 Periprosthetic fracture •Relatively frequent complication •Femur in the most cases, acetabulum rarely •Older patients, worse general condition •Osteoporosis, poor implant retention •High mortality and morbidity rate •High compliction rate •Demanding surgeries (experienced surgeon) • • • Periprosthetic femoral fracture - classification • • • • • Periprosthetic femoral fracture - therapy • • • 11 12 Periprosthetic femoral fracture - therapy •OS (LCP, control cable ) • • • • Periprosthetic infection St. aureus St. coagulase negative Streptococci Enterococci, others MRSA, MRSE Polyresistant G- bacteria Sessile form and planctonic Race for surface They produce glycocalyx- mucose substance of glycoproteins It leads to high resistence to antibodies and antibiotics biofilmLifeCycle.jpg Biofilm Biofilm biofilmLifeCycle.jpg Adhesion of bacteria - reversible Exopolymers - glycolalyx - extracelular matrix irreversible Releas to surrounding tissue Periprostetic infection- diagnostics Clinicly Labor: CRP, leu, ESR aspiration of pus X-ray- osteolysis, loosening USG (abscesus) Scintigraphy Sonication of the implant Bacteriological examination Long cultivation r trnka 4 Periprostetic infection- PPI Acute PPI Chronic PPI Late haematogenic PPI Park Hájková 1 copy Management To start treatment as soon as possible: 10-14 days from the onset of symptoms Prerequisity: cooperation of the patient informed physician Periprosthetic infection-treatment Debridement One stage surgery Two stage surgery Resection artroplasty Antibiotic suppresion Park Hájková 3 copy r černý 6 Park Hájková 1 copy Park Hájková 3 copy Park Hájková 4 H spacer 1 Hip spacers Two stage surgery Better ROM Better walking Revision is easier Local concentration of antibiotics - Gentamycin a Vancomycin - Cover 90 % of all pathogens H spacer 2 H spacer 3 H spacer 6 Prerequisity for good result Choise of the patient Preop. examination Prevention of infection Choise of the implant Operative technique Postop. management Activity of the patient Regular follow- up Prevetion of infection Prevention of aseptic loosening Long term results National registries W Daily activity after THA No lifting and wearing of heavy objects No strenuous manual labor Limited running and jumping No contact sports Recommeded sports: swimming, bicycle, tennis tourism, skiing? CLS