All Things Arthoplasty Outcome and complication Dr. Bahaa Ali Kornah, Prof. Of Orthopedic and Trauma Al-Azhar University Cairo. Egypt

Arthroplasty Latinarth - joint Greekplastica - molding

is an orthopedic surgical procedure where the articular surface of a musculoskeletal joint is replaced, remodeled, or realigned by prosthesisorthopedic surgical procedure It is an elective procedure

Goals of Joint Replacement Surgery Relieve pain!!! Restore function, mobility

There are many types used to do the procedures interpositional arthroplasty with interposition of some other tissue like skin, muscle or tendon to keep inflammatorysurfaces apart or tissueskinmuscletendoninflammatory excisional arthroplasty in which the joint surface and bone was removed leaving scar tissue to fill in the gap.scar resection(al) arthroplasty, resurfacing arthroplasty, mold arthroplasty, cup arthroplasty, silicone replacement arthroplasty

Indications Osteoarthritis (OA) Osteoarthritis Rheumatoid arthritis (RA) Rheumatoid arthritis Avascular necrosis (AVN) or osteonecrosis (ON) Avascular necrosis Congenital dislocation of the hip joint (CDH) Hip dysplasia (human)Hip dysplasia (human) Acetabular dysplasia (shallow hip socket) Frozen shoulder, loose shoulder Traumatized and malaligned joint Joint stiffness

Background Total joint replacement is one of the most commonly performed and successful operations in orthopaedics as defined by clinical outcomes and implant survivorship* *

Background Total joint replacement (TJR) is one of the most cost-effective procedures in all of medicine.

TJA Volume Estimates

TJA: Indications

Surgical Treatment Options Joint preserving operations – Arthroscopy – Cartilage transplantation – Osteotomy Arthroplasty Options: – Hemiarthroplasty – Resurfacing arthroplasty – Total joint arthroplasty

Anatomy—Hip

Anatomy of Hip

Hip Joint Ball and socket –Ball is the femoral head –Socket is Acetabulum Half sphere depression Lined with cartilage –Horseshoe shape

Hip Joint Femur –Neck-shaft angle ~ –2/3 rd of head is covered with cartilage –Head fits into acetabulum Suction effect during dislocation

Rheumatoid arthritis Body's immune system attacks synovium and cartilage –Joint arthrosis –Deformity –Stiffness –Women are more often affected than men

Plain X-rays Loss of joint space Subchondral sclerosis Subchondral Cysts Irregularity of joint surface Subluxation

THA Implants

Types of Implants Implants may be –Cemented –Porous coated Mesh of holes on implant surface Secured as bone in grows

Implant Choice Cemented Cemented: Elderly (>65) Low demand Better early fixation ? late loosening

Cemented type

Implant Choice Cementless Cementless: Younger More active Protected weight- bearing first 6 weeks ? Better long-term fixation

Porous Coated Implants

Implant Choice Cementless Cementless: Younger More active Protected weight- bearing first 6 weeks ? Better long-term fixation

Implant Choice Cementless Cementless: Younger More active Protected weight- bearing first 6 weeks ? Better long-term fixation

Acetabular component Shell is made of metal Plastic liner –Load bearing –Fits snugly inside shell

Femoral Stem Made of metal –Usually titanium –Head Diameter –28, 32 mm Material –Cobalt chrome –Ceramic

Surgical Procedure

Anatomic Approach l Anterior Approach l Anterior-Lateral Approach l Posterior Approach l Medial Approach

Surgical Procedure An incision about eight inches long Exposure hip joint –Anterior –Posterior

Removal of Femoral Head Femoral head is dislocated from acetabulum Neck cut –Femoral head is removed

Femoral Neck Cut

Acetabulum Reaming Acetabular cup is reamed into a hemisphere Cartilage is removed

Technique: Total Hip Replacement Acetabular reaming Insertion of acetabular component Insertion of acetabular component

Inserting the Acetabular component Acetabular shell –Porous coated Press fit Screws for stability –Cemented A hard smooth plastic liner is inserted into metal shell

Insertion of Acetabular component

Reaming of Femoral Canal Intramedullary canal finder –Manual insertion of a rod Distal intramedullary reaming with a straight reamer Rasping

Femoral Stem Insertion Press fit Cemented –Pressurization Canal plug Cement vacuum mix Cement Gun

Inserting Femoral Stem

Technique: Total Hip Replacement Femoral head impaction Final implant Final implant

Femoral Head A metallic head is attached to stem

Hip Reduction Ball is reduced into acetabular liner –Soft tissue tension is tested –Leg length may be a problem

Conventional THA

Hip Arthroplasty Traditional Stem Design Extended Offset

Hip Arthroplasty Traditional Stem Design Standard Offset

Hip Arthroplasty Traditional Stem Design Standard Offset -3.5 Head

Hip Arthroplasty Traditional Stem Design Standard Offset +0 Head

Hip Arthroplasty Traditional Stem Design Standard Offset +3.5 Head

Hip Arthroplasty Traditional Stem Design Extended Offset +0 Head

Hip Arthroplasty Traditional Stem Design Extended Offset +3.5 Head

Acrylic Cement Fixation

Cementless Fixation

Hybrid Fixation Acetabular cup – Press fit Femoral stem – Cemented

Care after Surgery A suction drain –May be used for 1-2 days after surgery Intravenous fluids & antibiotics Pain medication Elastic stockings, compression stockings and blood thinners –To decrease chances of blood clots For first 6-8 weeks –Low sitting may cause dislocation

Rehabilitation FWB immediately Range of motion, strengthening exercises Progress as quickly as possible

Care after Surgery Physical therapy –Getting in and out of bed –Standing and walking Crutches or a walker Discharge from hospital –Usually in 3-5 days Continued PT, OT

Complications Thrombophlebitis –Blood clots within deep veins –Swelling of leg Become warm to touch Painful –May lead to pulmonary embolus and death Infection Dislocation Loosening

Anatomy—Knee

TKA State-of-the Art Posterior cruciate retention Posterior cruciate sacrificing Both achieve 95%+ success at 10 yrs Metal/PE articulation

Knee Replacement—Implants Patellar component

Knee Replacement—Bone Cuts

Knee Replacement—Implants

Complications Infection Bleeding Per Prosthetic fracture dislocation Loosening Mechanical wear Failure

Causes of TJR Failure Wear of articular bearing surface Aseptic/mechanical loosening Osteolysis Infection Instability Peri-prosthetic fracture Implant Failure

TJR Failure Despite the success achieved with most primary TJR procedures, factors related to implant longevity and a younger, more active patient population have led to a steady increase in the number of failed TJR’s

Timing of TJR Failure Early (<10%) – Dislocation – Infection – Implant failure Late (> 5 yrs post op) – Wear of articular bearing surface – Osteolysis – Mechanical loosening – Peri-prosthetic fracture

Dislocation/Instability

Infection

Wear of Articular Bearing Surface

Osteolysis Osteolysis is an active resorption of bone matrix by osteoclastsresorptionboneosteoclasts

Aseptic/Mechanical Loosening

Peri-Prosthetic Fracture Sri: PP fracture

Implant Failure

Major Osseous Defects

Bahaa Ali Kornah د / بهاء قرنة

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The End