Total hip arthroplasty 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 •Sciatic nerve THA- ischiad Indication for THA •Painful condition • + unsuccesful conservative treatment • • Dyscomfort Nik_0007 •Primary osteoarthrosis • •Secondary osteoarthrosis: •congenital, posttraumatic, •after infection • •Revmatoid arthritis •Psoriatic arthropathy • •Avascular necrosis •of the femoral head • •Indications Hauser 15 •Primary osteoarthritis •Historie •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 •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 Polyethylen •UHMWPE : • ultra- high- molecular- weight- polyethylen • THA výuka PE jamka 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 Ceramic •Smoother surface • •Less ammount of wear of particles •Particles are bioinert • • •Wear of head/PE cup • under 0,15 mm/ year • •Wear of ceramic head/ceramic insert •under 0,002 mm/ year THA výuka keram hlavička THA výuka keram vložka 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 Bone cement •Polymethylmetacrylate • •Powder polymer, fluid monomer • •Exothermic reaction 83- 100° C • •Hardening in 10 min. • •Adverse effects: hypotension, coagulation of proteins, cytotoxicity 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 Acetabular component •Cemented: polyethylen • • • •Noncemented: metal- backed • • with PE insert • • with ceramic insert • • THA výuka PE jamka THA výuka keram vložka Luha- Plasma cup •Uncemented cup • • •Primary fixation: mechanical anchorage in the bone • Luha- Plasma cup •Press - fit Jamka CLS •Expansion Zw rtg2 •Threaded Zw rtg2 •Uncemented cup •Secondary fixation: osteointegration of the implant • on the surface of bone •Surface of cementless implant •Macroporosity • •Microporosity • •Pores on the surface 5 µm - 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 •Hydroxyapatite surface •Bioactive • •Osteoconductive • •Chemical bonds bone- hydroxyapatite • • A Porocoat 1 tyks perop 1 •Expansion cup- CLS • Kulichová 11 Jamka CLS 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 stems • vdk30b Luha Transfemo 4 •Proximal fixed •Distal fixed THA výuka Bicontact dřík Uncemented stem •Primary fixation: •Mechanical anchorage • in the bone • •Secondary fixation of the implant on the bone surface Zw dřík2 Indication scheme •Uncemented to 60 y. • •Hybrid 61 - 70 y. • •Cemented over 70 y. • •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 W 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 •Relative: age over 80 y. • elevated ESR Fosa-kyfóza •Approaches Zw foto 1 •MIS- mini invasive surgery Luha MIS 3 Luha- MIS 4 •Physiotherapy 1.In bed 2.Sitting, drainage ex 3.- 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 •Operative technique •Femur – brush • pulsatile lavage • sealing of medular cavity prox.- dist. • drainage of the femur • •Vacuum mixing of bone cement • •Pressurisation of bone cement • •Timing of insertion of the stem • •Continuous pressure 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 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 •Experience of the hospital •Long term results •National registries •Operative technique •Reliable implants •Activity of the patient •Regular follow up • •Principles W •Daily activity after THA •No lifting and wearing of heavy objects •No strenuous manual labor •Limited running and jumping •No contact sports • •Recommened sports: •swimming, bicycle, tennis •tourism, skiing? CLS