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 Rheumatoid 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 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. • 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