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Primary Total Hip Arthroplasty

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Presentation on theme: "Primary Total Hip Arthroplasty"— Presentation transcript:

1 Primary Total Hip Arthroplasty
Majdi S Qutob MD, FRCSC, MSc, MBA

2 History 1891 Themistocles Glück ( ) carried out the first reported Femoral Hemiarthroplasty in Germany, using ivory to replace the femoral head 1940 Dr. Austin T. Moore (1899–1963), first metallic (Vitallium) Femoral Hemiarthroplasty 1960 Dr. San Baw (1922 –1984) ivory Femoral Hemiarthroplasty for neck fractures 1970 Dr Sir John Charnley (1911 –1982) Low Friction Arthroplasty

3 Demographics By 2030, the demand for primary total hip arthroplasties is estimated to grow by 174% to 572,000 The Journal of Bone & Joint Surgery.  2007; 89:

4 Arthritis Arthritis is the second most common chronic condition in the US (sinusitis is first) Most common among elderly 20-30% of people over age 70 suffer from osteoarthritis (OA) of the hip Arthritis affects over 32 million people in the US Total costs associated with arthritis are over $82B/year, including hospital and drug costs, nursing home costs, and lost productivity and work

5 Normal ROM IR- 35° ER - 45° Flexion - 135° Extension - 15° Abduction - 45° Adduction - 25°

6 Non-Surgical Intervention
Activity Modification Weight Loss Cane/walker Physical Therapy Medications: NSAIDs COX-2 Inhibitors Nutritional supplements Injections: Corticosteroid Viscosupplementation

7 Joint Anatomy Femoral Head Diameter 46mm
Neck Shaft Angle Average 130 degrees > 135 deg coxa valga < 120 deg, coxa vara Femoral Anteversion Angle degrees Femoral Offset variable Acetabular Anteversion Average 15 (0-20) degrees Acetabular Abduction Angle 45 degrees (30-50) AP Curve of Femur is about 4 degrees


9 Biomechanical Considerations
1-2million steps/year 3-6x body weight due to abductors- 7-8x sporting activities Descending stairs causes highest JRF Abductors provide two thirds of the hip joint force parallel to the long axis of femur Increasing the offset and cup medialization reducing the joint reaction force by increasing the abductor lever arm

10 Biomechanical Considerations
Increasing the offset and cup medialization reducing the joint reaction force by increasing the abductor lever arm 10mm increase femoral offset decreases 10% abductors force requirement


12 Bone Biomechanics Young’s Modulus (flexibility) =stress/strain
Stress =force/area Strain= change in length Bone is anisotropic (compression>shear) Exhibits creep: constant pressure will deform at a decreasing rate Strain rate low with rapid application of modest force leads to fracture

13 Singh et. al. JBJS (52-A)

14 Singh Classification for Femoral Neck Osteoprosis
Singh et. al. JBJS (52-A)

15 Dorr suggested that there are three types of proximal femur, A is the normal taper top and thick cortex, C is a clear loss of taper and thin cortex, and B is in between.

16 Types of Total Hip Arthroplasty
Cemented vs Uncemented

17 GOALS of THA “Position the primary arc range of the prosthetic hip in the centre of the functional range of motion required by the patient, in order to optimize the range of motion and reduce the chances of dislocation”

18 Patient’s Goals “Patients’ satisfaction with hip replacement depends on the surgeon’s ability to relieve pain, equalize leg length and produce a stable hip which will not dislocate” Dr. Charles Engh (2007)

19 Cemented Components Polymethylmetacrylate (PMMA) interdigitates within bone (grout) Endosteal heat necrosis 500 micrometers Cement mantle of minimum 2mm circumferentially Cement in Gruen Zone 7 allows load in proximal third femur Third Generation Techniques

20 Cemented Femoral Implants
Two Schools of Thought Surface Properties Implant-to-cement adhesion Increase roughness, precoating, macroscopic grooves Debonding and increased wear debris Implant Shape Smooth stem with straight taper to allow subsidence and create hoop stress Broad laterally than medially diffuse compressive stresses and increase torisional and bending rigidity Less debris

21 Cemented Femoral Implants
Indications Dorr Type C Femurs Singh Grades 1-3 Poor Bone Quality Failure Rates Revision rates 0-5% in 10yrs Poor Operative Technique Revision outcomes worse (26% failure rate)

22 Cemented Acetabular Component
“Not Suitable for younger active patients” Lower demand with soft bone (rheumatoids, acetabular protrusio) High failure rates (10-23% at 10yrs) Causes of failure Poor operative techniques Failure to remove peripheral cartilage Poor pressurization Poor design of implant (flanged sockets)

23 Uncemented Components
“Potential life long dynamic bond between host bone and implant” Decreased failure rates in young patients Surgical trauma causes mesenchymal stem cells to become osteoblasts and intramembranous bony ingrowth or on-growth into the prosthesis

24 Press Fit Femoral Implants
Types Tapered- metaphysis wedge fixation Cylindrical- diaphyseal and metaphyseal fixation Anatomic-metaphyseal fill in coronal and sagittal plains Porous Coating Grit Blasting HA Coating

25 Press Fit Femoral Implants
Metallurgy Cobalt-Chrome High Modulus of Elasticity (Stress Shielding) Stainless Steel Lower fatigue strength Corrosion Lower cost, easy workability Titanium-alloy Lower elastic modulus (reducing stress shielding) Titanium-oxide corrosion resistance Osseointergration Easily scratched and notch sensitivity decrease fatigue life

26 Cortical Defects Perils
Stress patterns of tubular bone return to normal 2 cortical diameters past Stem must bypass 2-3 internal bone diameters 4-5cm of distal femoral isthum and implant Stem greater than 90% canal fill Stem stiffness fourth power of diameter (higher causes more stress shielding)

27 Rules of 50’s Implant-to-host distance minimum 50um
Excessive Interface motion >50um (30-150um)leads to fibrous non-union Pore Density of implant 50% Pore Size < 500um ( um) Gaps Less than 0.5mm Under Reaming 3-4mm significantly increases risk of fracture

28 Bearing Surfaces Hard-on-Soft
Acetabular Liner polyethylene(PE) and fermoral heads of Cobalt-Chrome, Ceramic, Titanium UHMWPE with vitamin E CC-PE 0.28mm/yr volumetric wear C-PE 150um/yr volumetric wear

29 Bearing Surfaces Hard-on-Hard
Ceramic-on-Ceramic, Metal on Metal, Ceramic-on-Metal Initial wear in period self-polishing (2.5-5 um/yr) Aseptic lymphocytic Vasculitis Associated Lesions (ALVAL) Delayed Type Hypersensitivity COC um/yr COC volumetic wear 0.004mm/year Failure rates of 0.004% (Catastrophically!!!)

30 Mechanisms of Wear in THA
Abrasive Wear- two surfaces of differing hardness Adhesive Wear-PE sheared off and deposit in joint space Fatigue Delamination Third Body Wear- particles trapped between joint space causing wear of softer surface

31 Aseptic Loosening & Osteolysis
Four Mechanisms of Cemented Component Failure Pistoning of stem/cement causing subsidence Medial Stem Pivot- varus position stem causes failure in proximo-medial and distolateral areas Calcar Pivoting- distal aspect of stem shifts within distal mantle Cantilever Bending (Fatigue) "Modes of failure" of cemented stem-type femoral components: a radiographic analysis of loosening. Gruen TA, McNeice GM, Amstutz HC 1979

32 Gruen Zone Classification for Femoral Prosthesis Loosening

33 Aseptic Loosening & Osteolysis
micrometres in size (most potent )

34 Head and Head-Neck Ratios
Head Size Less volumetric wear secondary to small arc of motion Greater Linear wear because JRF distributed over smaller area 28mm Head trade-off between volumetric and linear wear (new PE allows 32mm head) Optimal ratio HN is 2:1 Hard on Hard Articulations Hydrodynamic lubrication and low volumetric wear (with suction effect)


36 Abductor Tensioning Increasing lateral offset and neck length increases abductor lever arm and tension, stability and reduces JRF Increases torsional stresses on implant Increases trochanteric bursitis Increases leg length discrepancy Average femoral offset 45mm Sex differences

37 Abductor Tensioning

38 Abductor Tensioning Women Shorter femoral necks Thinner femoral shafts
Lower cervio-diaphyseal angles Lower femoral offsets Greater femoral neck anteversion

39 Leg Length Discrepancy
Lateral Decubitus highest risk Pre-op templating critical Intra-op assessment of patients feet and knees in symmetrical knee flexion Measuring height of femoral cut from top of LT Assess relationship of GT to femoral centre before and after osteotomy

40 Clinical Assessment of a Difficult THA
GOLDEN STEPS! Choosing the right patients Is it the right operation What is the operative plan What are the x-ray land marks Check the template Identify Surgical Landmarks Getting the Leg Length Right

41 Step 1: Choosing the Right Patient
Groin Pain or Thigh Pain or Knee Pain!!! Back Pathology Bilateral Hip Pain No Groin Pain Unable to Localize pain Negative leg roll test Back movement reproduces the pain If in doubt interventional radiology assisted intraarticular injection


43 Step 1: Choosing the Right Patient
Assess Gait and Hip ROM Evaulation knee, lumbosacral spine Actual Limb-Length Discrepancy- ASIS to medial malleolus Functional Limb-Length Discrepancy- Using blocks until patient feels equal

44 Step 1: Choosing the Right Patient
Difference actual and functional lengths evaluate for Suprapelvic Obliquity (scoliosis, DD spine) persists with sitting Intrapelvic Obliquity (necrosis, arthritis, infection, malunions, congenital hemihypertrophy, etc…) corrects with sitting Equalization of functional limb length improves gait and increased comfort

45 Step 2: The Right Operation
Altering the THA to suit the patient High dislocation risk patient Young active patient Small CDH or Juvenile Rheumatoid Patients The Deformity Patient Short Varus Neck Patients Surgical Approach Components Constrained Cups, Modular Implants, etc

46 Step 2: The Right Operation
High Risk Dislocation Patients after THA Initial Leg Length >2cm Fixed Pelvic Tilt Elderly, Cachectic female patient Hypermobility Neuromuscular Problems Fusion Takedown/no Abductors Multiple Previous Surgeries Demented/Substance Abuse Patients Post Fracture neck of femur Patient with a previous spinal fusion

47 Step 3: Planning the Operation Plan A-D
Plan A: Usual default for THA used in 95% of cases Plan B: If “Plan A” Fails (e.g. sterility of instruments breached or implants not available) Plan C: Hand over complex case to senior colleague Plan D: At time of surgery things are going wrong and not able to obtain satisfactory outcome. Call a senior surgeon Close without an implant with skin or skeletal traction

48 Step 4: Xray Landmarks Hips in degrees internal rotation (true AP of femoral neck) Marker of known diameter between legs (coin)

49 X-ray minus 15° rotation X-ray plus 30° rotation True femoral offset will be underestimated if hips are externally rotated Magnification is proportional to the distance between pelvis and film (20%+/-6%)

50 Step 4: AP Xray Landmarks
Tear Drops Superolateral edge of Acetabulum Centre of rotation of Head New Centre of rotation of hip joint Lesser Trochanters

51 Step 4: Lateral Xray Landmarks

52 Step 5: Check the Template
Should follow steps of surgery acetabular side first then femoral Horizontal reference line base of teardrops (most accurate landmark) (can use SI or ischial tuberosities)

53 Step 5: Check the Template
Key Radiographic Landmarks Tear Drop Ilioischial line Superolateral margin of the acetabulum

54 Step 5: Check the Template
Acetabular Templating Cup sized when placed at 40degrees (+/- 10) of abduction medial boarder approximates ilioischial line Must have adequate lateral coverage Inferior boarder cup level with inferior tear drop If cemented uniform cement mantle of 2-3mm Lateral coverage lacking metal augments or bone (number 7 graft) Center of rotation is marked and compared to opposite side

55 Step 5: Check the Template
Protrusio Acetabuli Template to anatomic position lateral to tear drop and Kohler’s line with peripheral rim contact Measure medial defect for graft filling

56 THA for Acetabular Protrusio
Causes: Osteogensis imperfecta Osteomalacia Paget’s Disease Bone Tumors Rheumatoid Arthritis Ankylosing Spondylitis Trauma


58 Step 5: Check the Template
Lateralized Acetabulum Acetabulum reamed until pulvinar, ligamentum teres, cotyloid notch and transverse acetabuluar ligament (beware medial osteophytes!!!)

59 Step 5: Check the Template
Dysplastic Acetabulum Insufficient acetabular coverage and superolateral migration of femoral head Mild/Moderate dysplasia well developed posteriosuperior wall (70%coverage) Additional coverage more proximal (high hip center) or medial non-anatomic position

60 Step 5: Check the Template
Femoral Templating & Restoration of Leg Length GOAL “Achieve adequate alignment and fixation to restore femoral offset and optimize leg length”



63 Step 5: Check the Template
Femoral Templating & Restoration of Leg Length Center of Rotation Line perpendicular to femoral shaft at the level of the tip of the GT inaccurate Coxa Valga- center of rotation is above the GT Coxa Vara or Coxa Brevis- COR below the GT Normal 130 Coxa Vara <120 Coxa Valga >140

64 Step 5: Check the Template
Femoral Offset Restoration of original offset Beware xray rotation!!!! Template off normal contralateral side Measure distance center of rotation to tip GT before neck cut Measure distance proximal LT to COR Measure distance proximal LT to proposed neck cut Cemented stem Optimal diameter distal centralizer, plug size, and depth insertion

65 X-ray minus 15° rotation X-ray plus 30° rotation True femoral offset will be underestimated if hips are externally rotated Magnification is proportional to the distance between pelvis and film (20%+/-6%)

66 Step 5: Check the Template
Utility of Preoperative Templating Eggli et al 1998 (JBJS) 90% agreement cup size 92% agreement stem size Actual difference COR hip 2.5 +/- 1.1mm vertical 4.4 +/- 2.1mm horizontal Mean LLD 3 +/- 1mm clinically, 2 +/- 1 mm radiographically 80% difficulties were anticipated (trochanteric osteotomy, acetabular autografts, reinforcement rings and resection osteophytes)

67 Adapting the Preoperative Planning to Intraoperative Findings
Feedback during acetabular reaming and femoral broaching Reduction of trial prosthesis ROM (removal osteophytes) Soft tissue tension with correct LLD then increase stem with increased offset Elderly tolerate LLD

68 Adult Congenital Hip Disease

69 THA for Congenital Hip Disease
Classifications Crowe Classification <50% 50-75% 75-100% >100%

70 New Classification Dysplastic Contained in true acetabulum
High Dislocation Femur superior posterior Segmental defect rim Increased bone posterosuperior Excessive anteversion Iliac wing hypoplastic and anterverted FN Shorter and anterverted Diaphysis is hypoplastic narrow and thin cortices Dysplastic Contained in true acetabulum Superior defect Fossa osteophytes Low Dislocation Femoral Head articulates false acetabulum Anterio-superior defect Increased anteversion Lack posterior bone FN short

71 Preoperative Planning
Low and High Dislocations obtain CT Estimates bone stock, accurate sizes and anteversion acetabulum and femoral neck Plain films for templating

72 Technical Difficulties
Narrow diaphysis and angular deformities of femur Trochanter osteotomy Restoration true vs high hip center Acetabulum osseous coverage 80% Small 40-42mm cup with thin poly Augmentation superior defects Cotyloplasty

73 Technical Difficulties

74 Technical Difficulties
High Hip Center Lever arm body weight longer than abductors causing excessive shearing and loading forces of the hip Does not correct leg length limp and low back pain Shortening of femur if >4cm lengthening (subtrochanteric osteotomy) Stem short cementless conical distal bearing

75 THA for Arthrodesed Hips

76 THA for Arthodesed Hips
Indications for Conversion: painful pseudarthrosis pseudorthrosis rates are 0-10% using modern techniques for fusion mechanical low back pain -#1 complaint multi-level arthritic changes seen in LS spine malposition (especially increased abduction) is a major cause excessive leg length inequality knee pain/instability Adduction causes ipsilateral pain Abduction causes contralateral pain

77 THA for Arthodesed Hips
Preoperative Evaluation: Physical exam and EMG (abductors) AP pelvis, cross table lateral and Judet Views to identify bone stock CT scan heterotopic bone to neurovascular structures an abductor muscle mass

78 Surgical Considerations
Anterior approach, posterior approach or a direct lateral or a trans-trochanteric (Gaunz) Osteotomy Indications for an trochanteric osteotomy Exposure decrease injury to atrophied/weakened abductors during the case advancement (improve stability) Existing hardware and HO should be removed Neck cut in situ; proximal cuts results in fractures of the pubis and the ischium if in doubt, place guide pins and obtain a radiograph soft tissue releases (ilio psoas, adductors, etc.) PRN



81 Acetabular component:
structural grafting (metal augments) one should be prepared to cement the socket if the shell has <50 % contact with native bone a constrained liner is frequently required because of insufficient soft tissue tension post-op (esp. abductors)

82 Femoral component: modular femoral components
if the trochanter is bald and there are no abductors, the proximal femur can be sewn to the tensor fascia lata anteriorly and the gluteus maximus and ITB posteriorly    

83 Results: relief of low back pain occurs 70-95% of the time leg lengths can usually be improved ipsilateral knee pain typically improves but it persists in at least 1/3 (especiailly if instability was a problem pre-op) a trendelenberg gait typically persists though abductor function improves for 2-5 years results from conversion of spontaneous fusions are typically better than results of conversion of surgical fusions

84 Complications: deep infection % (higher in conversion of surgical fusion) dislocation % sciatic nerve palsy % femoral nerve palsy 3.6%


86 SH 58yo female High Speed MVA (t-boned) 1yr ago ORIF Rt Acetabulum
Referred to office for increasing right hip pain


88 Post Op

89 Today


91 Next Step?

92 Options?



95 SR 63 yr male, previous Lt femoral osteotomy for OA – uncomplicated index surgery plus subsequent hardware removal. Incapacitating pain Lt hip Otherwise well Severely restricted RoM, well healed scars, T/berg/antalgic gait



98 BP 51 yr female, brain damage, LTC resident, recurrent seizures
Previous Rt bipolar for subcap.# Previous Lt DHS for Intertroch # Remote Lt femoral shaft # Pain Lt Hip, unable to weightbear Afebrile


100 BP Family and caregivers request solution for pain and inability to mobilize… 1. No surgery 2. Remove hardware only 3. Stage hardware removal and bipolar 4. Remove hardware and Bipolar 5. Stage hardware removal and THA 6. Remove hardware and THA


102 BP What about the femoral deformity distal to plate?
1. Try to bypass (+/- osteotomy) 2. Ignore


104 KK 34 yr male, OA Lt hip secondary to LCPD
Previous periacetabular osteotomy 6ys prior Severe pain and functional limitation 30° external rotation deformity 2.5cm short


106 KK Direct lateral approach Entire acetabulum retroverted 30°
Tight external rotators – released Ant column “shaved” and Ant column screw advanced to reduce femoral impingement in flexion Iliac screws removed via separate incisions “External landmarks” for cup orientation Posterior aspect shell 20-30% uncovered


108 DS 58yr male, previous acetabular fracture (MVA) – ORIF 12 yrs prior
8hr procedure, transtrochanteric approach, no reported postop complications Severe pain etc No systemic symptoms Fit and good health



111 DS Approach? 1.Transtrochanteric 2. Iliofemoral 3. Direct lateral
4. Posterior 5. Invent a new one

112 DS Hardware removal… 1. Plan to stage 2. Remove all – at time of THA
3. Try to ignore at time of THA

113 Managed to ignore most of the hardware
Lateral approach with unintentional transtrochanteric component

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