\\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png TOTAL HIP REPLACEMENT MUDR. JAN EMMER, I. ORTOPEDICKÁ KLINIKA FNUSA V BRNĚ \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png HISTORY •1891 Profesor Themistocles Glück (Germany) •Femoral head replacement made of ivory (post TBC) •Further attempts with interposition arthroplasy (fascia lata, xenogenic tissues) •1925 Marius Smith-Petersen – glass, stainless steel •1953 George McKee •Co-Cr acetabular component + cemented Thompson´s stem (stainless steel) • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png HISTORY •1960´ Sir John Charnley – Low friction artroplasty •Bone (dental) cement, polyethylen, alloy •1. st modern functional THR • • • • • • • Nik_0011 Charnley \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png HISTORY • • • • • • • 1964-1965 1966 • Setzholzprothese Banana – shaped • • 1977 Geradeschaft • • • THA Muller 1 THA muller 3 THA Muller 4 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png HISTORY •Prof. MUDR. Oldřich Čech, DrSc. (1928-2020) •Stems Poldi – Čech 1969 – present days • • • • • • • THA čech 1 THA POldi typy \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ANATOMY •Enarthrosis – simple joint •Ball – socket, limited ROM •Acetabulum - hemisphere •Femoral head •2/3 surface of ball •Diameter aprox 2,5 cm • • kyčel- anat \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ANATOMY •Ligaments: •Lig iliofemorale •Lig pubofemorale •Lig. ischiofemorale •Zona orbicularis •Lig. Capitis femoris •Joint capsule • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ANATOMY •Muscles of hip joint – flexors •M. iliopsoas (flexon + aditional hip adduction; n. femoralis, plexus lumbalis) •Muscles of hip joint – extenzors, abductors •M. gluteus maximus (extension + ER + abduction; n. gluteus inferior) •M. gluteus medius (abduction, IR; n. gluteus superior) •M. gluteus minimus (IR; n. gluteus superior) •M. tensor fasciae latae (aditional flexor, abductor, IR; knee extension at standing position; n. gluteus superior) • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ANATOMY •Muscles of hip joint - pelvitrochanteric muscles •M. piriformis (abduction in flexion, ER ; plexus sacralis) •M. gemellus superior (ER, plexus sacralis) •M. gemellus inferior (ER, plexus sacralis) •M. obturatorius internus (ER, plexus sacralis) •M. quadratus femoris (ER, plexus sacralis) • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png THR INDICATIONS •Painfull hip joint condition •Poor effect of conservative therapy •Life comfort deteriorated •No salvage surgeries indicated • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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!) • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png THR CONTRAINDICATIONS •Poor general condition, poor physical status (ASA IV) •Persistent infection •Severe comorbidity with poor prognosis •Extreme obesity •Strong malcompliance • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png THR FIXATION OPTIONS •Cemented •Both components fixed with bony cement •Older patients > 70 y.o. •Poor bone quality - osteoporosis •Inferior implant survival •The cheepest option • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png THR FIXATION OPTIONS •Hybrid •One component fixed with bone cement (femoral) •65-70 y.o. •Compromise bone quality •Better implant survival •Price? • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png THR FIXATION OPTIONS •Cementless •Both components fixed with no bone cement •<65 y.o. •Good bone quality •Contraindication for bone cement (alergy, right ventricle function) •Best implant survival •The most exepensive • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png HIP REPLACEMENT RANGE •Cervicocapital replacement •Not frequently nowdays, fracture if patient polymorbid •Acetabular abrasion •Inferior results •Total •Methafyseal conservative stems - why? • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png MATERIALS •Polyethylen •Longest used material for cup •Viscoelastic •Plastic deformation (cold flow) •Higer wear rate •Oxidative degradation • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png MATERIALS •Polyethylen •UHLMWH - Ultra high molecular weight polyethylen •HXLPE – cross - linked •Tocoperol doped PE (vit E) •Aim: •Wear reduction •Oxidative degradation reduction •Keeping elasticity modulus • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png MATERIALS •Femoral component - requirements •Biocompatibility •Mechanical strenght •Osteointegration (cementless implants) •Antialergic implants (if metal allergy presented) •Future? Biofilm resistance • • • Luha Exeter 1 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png MATERIALS •Cementless implants requirements – bone adjacent surface •Trabecular titan •Trabecular tantal •Hydroxyapatite surface • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png MATERIALS – BONE CEMENT •Poly methyl 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 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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 • • • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png 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 • • • • • • • • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ACETABULAR COMOPONENT CEMENTED •Cement + PE, monobloc •RTG marker (metal wire around) •Structured surface for cement retention • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ACETABULAR COMOPONENT CEMENTLESS •Metalback + inlay (ev. monobloc) •Material of inlay variable •Offset optional •Double cup – lower displacemet risk •Osteoinductive surface • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ACETABULAR COMOPONENT CEMENTLESS • • • • • • • • Press fit Threaded Expansion Jamka CLS \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ACETABULAR COMOPONENT CEMENTLESS • • • • • • • • Press fit Threaded Expansion \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ACETABULAR COMOPONENT CEMENTLESS •Press fit •Golden standard, most cases •Theraded •Best primary fixation •Postdisplastic arthritis, shellow acetabulum, low / defect ac. wall support •Partial acetabular defects •Expasion •Obsolent, worse results •PE/bone contact •Failure – leafs breaking off • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png FEMORAL COMPONENT •Smooth polished surface •cement •Porous osteoinductive surface •Non cement •Different designs •Straight •Anatomic •Banana - shaped •Metaphyseal conservative •Revision, Tumorous, total femur… • • • • • Luha Exeter 3 THA výuka Bicontact dřík \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png FEMORAL COMOPONENT •Colodiafyzar angle (CCD) •Pysiolgical 126° •Always respect anatomy! •115-140° range •High offset option • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png FEMORAL COMOPONENT •Cone: •12/14mm •Always use compatible head/stem, never mix producers! •Structured surface for head retention •If ceramic head replaced, always use revision! • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png FEMORAL COMOPONENT CEMENTED •Highly polished surface •Dirct x anatomical shape •Equally cemet layer around the stem! •Never direct contact stem x bone •Centraliser •Obturator • • • • • • • Luha - cement dřík \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png FEMORAL COMOPONENT CEMENTLESS •Osteoinductive surface •Metafyzar x diafyzar anchoring • • • • • • • • THA výuka Bicontact dřík A plasma cup 6 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png HEAD •Alloy x ceramic x oxinium •28, 32, 36 mm •„head lenght“ – depth of bore for cone •Bigger head diameter incerases ROM and stability • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ARTICULATION SURFACES MATCHING • •PE/alloy head •PE/ceramic head •Ceramic inlay/ceramic head •Alloy/alloy head •Oxinium • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png SURGICAL TECHNIQUES •Standardized, routine •Standardized approaches •Anterolateral (Watson Jones) •Dorzal (Moore, Langenback) •Anterior (Smith – Petersen) •Lateral (Harding) •MIS • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png SURGICAL TECHNIQUES •Operation field overview •Gentle soft tissue treatment •Lavage – PAO development prevention •Standardized approaches – minimal nerve and vessels leasions risk •Correct compoent alignment – impotrant for ROM and stability •Reliable suture! • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PREOPERATIVE EXAMINATION •ASA risk ratio •Infection focus exclusion (neg FW, CRP), stomatological examination incl. OPG •CAVE! •Warfarin •NOAK •NSAID •PAD • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC JOINT INFECTION (PJI) PREVENTION •Preop. Examination! •ATB perioperatively – Cefazolin i.v. 1 dose before + 3 doses post op. •Drainage EX in 24h •If urinary catheter present - ATB •Strict régime at op. theater •Wound care till healing •Lege artis diagnostic and therapy protocol of eventual PJI • • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png POST OP. MANAGEMENT •ICU (post op ward) one day if no complication •Hospitalization at orthopedic ward for 5 days •Verticalization fhe first post op. day •Complex rehabilitation protocol, rehabitalitation nurse obligatory •6. day – transfer to rehabilitation ward •Spa – in CZ covered by public health insurance in 3 post op. months •DVT prevention – 6 weeks •Displacment prevention – no adduction, no deep flection, no axial extremity traction! •Trends: Shortening inpation period (risc of nosocomial infection, economic aspects) • Fast track physiotherapy • Outpatient surgery? • • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png FOLLOW UP •Standardized •First check up by orthopedical surgeon in 6 weeks (X ray included) •Second in 3 months, then 6 month •Further each 2 years (X ray included) if no problem present •EDUCATION, EDUCATION, EDUCATION! •Activity, limitation and régime with TKR •PJI prevention •Urgent check – up if suspected PJI • • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPLICATIONS •Peri and early pos op. morbidity and mortality •Nervous and vascular injury •Blood loss •Perioperative fracture •Hip displacement (luxation) •Pulmonary embolism •IM •General decompensation •Development of delirium • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPLICATIONS •THR luxation (displacement) •Shortening and (extra)rotation of extremity, pain, no active hip flexion •No active walking and no weight - bearing •Downfall •Risky movement (adduction in hip, deep felxion) •Wrong mainpulation with pac. (Axial leg traction) •Primary instable prosthesis (incorrect implantation) •Therapy: •Close hip redduction attempt. Hip orthosis with reduced ROM obligatory •If close reduction impossible, revision, identification of cause, solution •Different („longer“) head, stabilisation elements •If malposition of components present, replantation • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPLICATIONS •Peri and early pos op. morbidity and mortality •Nervous and vascular injury •Blood loss •Perioperative fracture •Hip displacement (luxation) •Pulmonary embolism •IM •General decompensation •Development of delirium • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPLICATIONS •THR luxation (displacement) •Shortening and (extra)rotation of extremity, pain, no active hip flexion •No active walking and no weight - bearing •Downfall •Risky movement (adduction in hip, deep felxion) •Wrong mainpulation with pac. (Axial leg traction) •Primary instable prosthesis (incorrect implantation) •Therapy: •Close hip redduction attempt. Hip orthosis with reduced ROM obligatory •If close reduction impossible, revision, identification of cause, solution •Different („longer“) head, stabilisation elements •If malposition of components present, replantation • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPLICATIONS •Peri and early pos op. morbidity and mortality •Nervous and vascular injury •Blood loss •Perioperative fracture •Hip displacement (luxation) •Pulmonary embolism •IM •General decompensation •Development of delirium • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPLICATIONS •THR luxation (displacement) •Shortening and (extra)rotation of extremity, pain, no active hip flexion •No active walking and no weight - bearing •Downfall •Risky movement (adduction in hip, deep felxion) •Wrong mainpulation with pac. (Axial leg traction) •Primary instable prosthesis (incorrect implantation) •Therapy: •Close hip redduction attempt. Hip orthosis with reduced ROM obligatory •If close reduction impossible, revision, identification of cause, solution •Different („longer“) head, stabilisation elements •If malposition of components present, replantation • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPLICATIONS •Periprosthetic infeciton (PJI) – 1-2% primo, 5-10% revision •Early – up to 2 weeks after surgery •Late hematogenic • •Diagnostic •General symptomas of infection •Local condition, persistant pain •Punction + aspiration, cultivation + PCR •Synovasure (α defensine) test perioperatively •Implant sonication + cultivation •Fistula with purulent secretion •Radiolucent periprosthehic lines around implant on X ray (chronic PJI) • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPLICATIONS - PERIPROSTHETIC INFECTION (PJI) •Therapy •Up to 2 weeks from manifestation - DIAR (debridement, ATB, implant retention) •Uprard of 2 weeks – revision, debridement, replantation •One stage – dubious outcome •Two stage – cemented ATB spacer, after healing ínfection revision and new implant possible •ATB supression of chronic infection optional (old patients with no perspective to surgery) •ATB therapy •Cultivation (punciton + aspiration, perioperativly samples, sonication of implant) •ATB i.v. 2 weeks minimum •6 weeks p.o. \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPLICATIONS - PERIPROSTHETIC INFECTION (PJI) •ATB spacers •Custom – made •Ready - made rinkovský 3 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png COMPLICATIONS - PERIPROSTHETIC INFECTION (PJI) Ultimum refugium – sec. Girdlestone Park Hájková 1 copy \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ASEPTIC LOOSENING •Most frequent THR revision reason •Macrophage-induced inflammatory response resulting in bone loss and implant loosening •PE particle inducted granuloma • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ASEPTIC LOOSENING - THERAPY • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ASEPTIC LOOSENING - THERAPY •Revision, replantation •Revision systems, augments, spongioplasty (alografts)… •Double ATB combination – higer infection risk •Higer complication rate •Inferior outcome •Lower ROM •Longer no full weight bearing period (3M) •Higer mortality •Higer displacement risk ratio • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ASEPTIC LOOSENING - THERAPY • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ASEPTIC LOOSENING - THERAPY •Revision, replantation •Revision systems, augments, spongioplasty (alografts)… •Double ATB combination – higer infection risk •Higer complication rate •Inferior outcome •Lower ROM •Longer no full weight bearing period (3M) •Higer mortality •Higer displacement risk ratio • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ASEPTIC LOOSENING - THERAPY •Revision stems: •Modular x monobloc •Wide range of option •Cemented x cement less • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ASEPTIC LOOSENING - THERAPY •Revision acetabular component systems •Spongioplasty x augments •Trabecular metal, titan tantal •Cemented x cement less •Pelvis discontinuity often • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ACETABULAR DEFECTS •Classification - Paprosky • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ACETABULAR DEFECTS •Solution - mechanic •Bone cement • • • • • 41 41 IM001067 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ACETABULAR DEFECTS •Solution - mechanic •Augmentation • • • • • double buble \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ACETABULAR DEFECTS •Solution - biologic •Impact grafting • • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ACETABULAR DEFECTS •Solution - biologic •Solid allograft • • • • • P1000626 poop \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ACETABULAR DEFECTS •Ring and cage reconstruction • • • • • bs-ring BS 5 Beznosta BS perop \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png ACETABULAR DEFECTS •Ring and cage reconstruction • • • • • Obrtlíková 7 Kubíčková 5 300 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC FRACTURE •Relatively frequent complication •Femur in the most cases, acetabulum rarely •Starší pacienti, v horším klinickém stavu •Older patients, worse general condition •Osteoporosis, poor implant retention •High mortality and morbidity rate •High compliction rate •Demanding surgeries (experienced surgeon) • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC FEMORAL FRACTURE - CLASSIFICATION • •Vancouver •Frequently used •Guide to therapy • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC FEMORAL FRACTURE - THERAPY •Conservative •No/minimal displacecement •Implant retention •Poor patient genetal condition • •Surgiclal •Revision stem + cerclage (cables, wires) •Ostheosynthesis (LCP x cables/wires) • • • • 11 12 \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png PERIPROSTHETIC FEMORAL FRACTURE - THERAPY •OS (LCP, control cable ) • • • • \\DROBO-FS\QuickDrops\JB\PPTX NG\Droplets\LightingOverlay.png •Thank you for yor attention