total hip arthroplasty

1. Total Hip
Arthroplasty

2. HISTORY OF HIP
REPLACEMENT SURGERY
Deformed and ankylosed joints surfaces were
contoured with Biological material e.g. Fascia lata
grafts as interpositional layer to resurface the joint
and allow movement in UK an Europe in early 20th
century.

3. 1912- Jones used gold foil as inter-
positional layer
1923- Smith-Petrson introduced
“mould arthroplasy”
Later- Backelite and Celluloid
derivatives
1937- Vitallium implants

4. Professor John Charnley
(1911-1982)
A British Orthopedician, Pioneer of modern hip replacement
Arthroplasty.
Developed the techniques of THR in 1960s.

5. APPLIED BIOMECHANICS

7. STRESS TRANSFER TO BONE
 IMPORTANCE OF QUALITY OF BONE-
APPROPIATE IMPLANT
OPTIMAL METHOD OF FIXATION
RESPONSE OF BONE TO IMPLANT
ULTIMATE SUCCESS OF ARTHROPLASTY

8. RADIOGRAPHIC CATEGORISATION
BY DORR ET AL
TYPE A
 THICK CORTEX AND CANAL
DIMENSION
 LARGE POSTERIOR CORTEX-LAT
VIEW
 CHAMPAGNE FLUTE
APPEARANCE
 MEN AND YOUNGER PATIENTS
 GOOD FIXATION IN BOTH
CEMENTED AND CEMENTLESS

9.  SOME BONE LOSS
 SHAPE IS MAINTAINED
 IMPLANT FIXATION IS NOT
A PROBLEM
 TYPE B

10. TYPE C
 MUCH OF THE CORTEX
LOST FROM MEDIAL AND
POSTERIOR CORTX
 IM CANAL IS WIDE
 LESS FAVORABLE FOR
IMPLANT FIXATION

11. COMPARISON

12.  STRESS TRANSFER IS DESIRABLE
 LESS MODULUS OF ELASTICITY = MORE ELASTIC
=LESS DIAMETER
MORE STRESS TRANSFER TO BONE

13.  PROXIMAL MEDIAL CORTEX-MOST BONE LOSS
 COLLAR-PREVENTS BONE LOSS
 CEMENTLESS IMPLANTS ARE MORE
PHYSIOLOGICAL

14. INDICATIONS OF THR
 1. Arthritis : Rheumatoid
Juvenile rheumatoid (Still disease)
Ankylosing spondylitis
 2. Degenerative joint disease :
: Primary
: Secondary : Slipped capital femoral epiphysis
Congenital dislocation or dysplasia of hip
Coxa plana (Legg-Calvé-Perthes disease)
Paget disease
Traumatic (Fracture/ dislocations)
Hemophilia

15. INDICATIONS OF THR
 Osteonecrosis : Post fracture or Post dislocation
Idiopathic
Slipped capital femoral
epiphysis
Hemoglobinopathi
es
Renal disease
Steroid induced
Alcoholism
Caisson disease
Lupus
Gaucher disease
 4. Nonunion following # NOF
 5. Femoral neck fractures and trochanteric fractures with
head involvement

16. INDICATIONS OF THR
6. Pyogenic arthritis or osteomyelitis : Hematogenous
Postoperative
7. Tuberculosis
8. Congenital subluxation or dislocation
9. Hip fusion and pseudarthrosis
10. Failed reconstruction following: Osteotomy
Cup arthroplasty
Femoral head
prosthesis
Girdlestone
procedure
Total hip replacement
Resurfacing
arthroplasty
11. Bone tumor involving proximal femur or
acetabulum
12. Hereditary disorders (e.g., achondroplasia)

17. TOTAL HIP
COMPONENTS AND
DESIGNS

18. Total Hip
Components
1.Femoral
Components
(Head+ Neck+
Stem)
2.Acetabular
Components

19. Goal of THR
Biomechanically
sound, stable hip joint
by restoration of
normal center of
rotation of femoral
head

20. The location of
center of rotation of
femoral head is
determined by
1. Vertical offset
2. Horizontal(medial) offset
3. Anterior offset
(Anteversion)

21.  WHAT WILL HAPPEN IF THERE IS INADEQUATE
RESTORATION OF MEDIAL OFFSET?
 WHAT WILL HAPPEN IF THERE IS INADEQUATE
RESTORATION OF VERTICAL OFFSET

22.  MEDIAL RESTORATION IS SIMPLY CORRECTED BY
MAKING NECK ADJUSTMENT BUT……
LIMB LENGTH INCREASES

24. VERSION
 NORMAL FEMUR IS 10 TO 15 DEGREE ANTEVERTED.
 USUALLY ACCOMPLISHED BY ROTATING THE
COMPONENT IN FEMORAL CANAL.
 IN PRESS FIT FIXATION IS USED –MODULAR FEMORAL
COMPONENT IS USED.

26. HEAD NECK RATIO
 AFFECTS ROM ,IMPINGEMENT,STABILITY OF ARTICULATION.

27. TYPES OF FEMORAL
COMPONENTS
Cemented stems Cementless stems
porous surface
nonporous surface Specialized custom-made

28. CEMENTED STEMS
 Most designers favour- cobalt chrome alloy
PMMA cement is the standard for
femoral component fixation
Pitfalls-Debonding, Mechanical loosening,
Extensive bone loss with fragmented cement

30. 2. Cementless stems with porous
surface
 Fixation is more biological.
 Material- titanium alloy/ Cobalt-Chromium alloy
 Bone ingrowth into porous metal surface
 Requires: a)immediate mechanical stability at
the time of surgery
b) intimate contact between porous
surface and viable host bone
 So, surgical technique and instrumentation
need to be more precise than cemented
counterpart

32. Specialized custom-made

33. Specialized femoral components for replacement
of variable lengthth of proximal femur. Stem can
be combined with TKR to replace entire femur

34. ACETABULAR
COMPONENTS
Cemented
Cementless
Constrained type
Specialized custom made

35. Cemented acetabular
component
 PMMA spacers (3 mm)
are incorporated into
polymerizing cement,
yeilding uninterrupted
cement mantle
 Satisfactory in elderly,
low demand patient,
Tumour reconstruction,
and in revision
arthroplasty.

36. Cementless acetabular
components
1. Porous coated for
bone-ingrowth
2. Fixation with
trans acetabular screw

37. Constrained acetabular
components
 Mechanism to lock the
prosthetic femoral head into the
polythene liner
 Indications-
-Insufficient soft tissue,
-Deficient hip abductors,
-Neuromuscular disease,
-Hip with recurrent
dislocation despite well-
positioned implants.

38. Alternative bearings
 Highly cross linked polyethylene
 Metal on metal bearings
 Ceramic on ceramic bearings

39. Metal on metal bearings
 Low wear rate
 High carbon cobalt chromium alloy
 Diametral clearance-gap between the two
implants at the equator of articulation.
 Smaller clearance produce films for lubrication
and reduced wear.
 Elevated metal ions in blood that excreted
through urine.

40.  So contraindicated in impending renal failure.
 Placental transfer occur of these metal ions.
 Delayed type hypersensitivity (aseptic lymphocytic vasculitis
associated lesions)
 Pseudotumour
 Recommendation for symptomatic patients is measurement
of blood cobalt and chromium ion level and/MRI or USG.

41. CERAMIC ON CERAMIC
BEARINGS
 ALUMINA CERAMIC IS USED.
 HIGH DENSITY, HYDROPHILLIC, SMOOTHER THAN
METAL.
 CERAMIC IS HARDER THAN METAL AND MORE
RESISTANT TO SCRATCHING.
 LINEAR WEAR RATE IS 4000 TIME LESS THAN COBALT
CHROME ALLOY ON POLYETHYLENE.

42. DISADVANTAGE
 IMPINGEMENT BETWEEN THE FEMORAL NECK AND
RIM OF THE CERAMIC ACETABULAR COMPONENT.
 IMPLANT MALPOSITION
 STRIPE WEAR
 SQUEAKING
 OSTEOLYSIS

43. OXIDIZED ZIRCONIUM
 CERAMIC METAL ALLOY.
 NOT SUSCEPTIBLE TO CHIPPING,FLAKING,OR
FRACTURES.

44. Templating of radiograph
for pre-operative planning

45. 1. Determination
of the amount
of limb
shortening
2. Acetabular
over-lay
templating and
center marking

46.  3. Femoral overlay
templating and
measurement of
precise size of
proximal canal
 4. Selection of
appropriate
neck-length to
restore limb
length and
femoral offset

47.  5. If no shortening
present, we
match the center
head with
previously
marked center of
the acetabulum
 6. If a
discrepancy
exists, the
distance between
the femoral head
center and
acetabular center
should be equal
to the measured
limb length
discrepancy

48. SURGICAL
APPROACHES

50. POSITION OF THE
PATIENT FOR
POSTERIOR
APPROACH

51. POSTERIOR
APPROACH

55. Reaming of acetabulum

56. Femur is retracted anteriorly to
allow clear access to acetabulum

57. REAMING OF
ACETABULUM

58. SOCKET POSITIONING

59. Safe and unsafe
quadrants of
acetabulum
POSTEROSUPERIOR
QUADRANT- SAFEST

60. FIXATION HOLES FOR
CEMENT IN ACTABULUM

61. ACETABULAR CEMENT
PRESSURIZER

62. PRECAUTIONS
FIXATION MUST BE AUGMENTED BY SCREWS OR
SPIKES.
PERIPHERAL PART OF POSTEROSUPERIOR SEGMENT
ARE SAFEST.
PALPATION OF GREATER SCIATIC NOTCH IS MUST.
INTRAOPERATIVE CHANGE IN THE POSITION.

63. PREPARATION
OF THE FEMUR

64. POSITIONING OF FEMUR
FOR REAMING

65. Neck is cut
planned at
appropriate level
and angle by
using trial
components of
templeted size

66. Removal of
remining lateral
edge of femoral
neck and medial
portion of GT with
box osteotome

67. Reaming of
femoral canal
Hand or power
reamer must be
lateralized into
GT to maintain
neutral
alignment of
femoral canal

68. Femoral
broaching
Progressively larger
broaches are inserted,
lateralizing each one
to maintain neutral
alignment

69. Femoral
component
anteversion

70. Calcar
planning
with
prcision
reamer

71. Assembly of trial
head and neck
segments
determined
from pre-
operative
templating

72. Canal
blocking

73. Retrograde
injection of
cement with
gun in early
dough phase

74. Cement
pressurization

75. Manual
cement
packing
(PALACOS
cement)

76. HIP SHOULD BE STABLE IN
 IN FULL EXTENSION WITH 40 DEGREE OF EXTERNAL
ROTATION.
 IN FLEXION TO 90 DEGREE WITH ATLEAST 45
DEGREE OF INTERNAL ROTATION
 WITH THE HIP FLEXED 40 DEGREE WITH ADDUCTION
AND AXIAL LOADING-
 IF HIP DISLOCATE OR SUBLUXATE –USE LONGER
NECK.

77. WHAT IF FRACTURE
OCCUR
 STOP THE INSERTION
 EXPOSE THE FRACTURE
 IF AN INCOMPLETE FRACTURE OCCUR WITH
EXTENSION ONLT AT THE LEVEL OF LT-ENCIRCLAGE
,REINSERT AND REASSESS THE STABILITY.
 BELOW LT –LONGER STEM
 GT IS # AND UNSTABLE-FIX THE GT WITH WIRES.

79. TROCHANTERIC
OSTEOTOMY

80. SURGICALS PROBLEMS
RELATIVE TO SPECIFIC HIP
DISORDER

81. OSTEOARTHRITIS
 MC INDICATION
 REMOVAL OF OSTEOPHYTES MAY BE NECESSARY.
 Difficulty in delivering femoral head.

82. RHEUMATOID ARTHRITIS
 THEY GENERALLY RECEIVES IMMUNOSUPPRESSIVE DRUGS.
 IF BOTH HIP AND KNEE IS INVOLVED EQUALLY, HIP ARTHROPLASTY
SHOULD BE DONE FIRST .

83. OSTRONECROSIS
 STAGE 1 AND 2-CORE DECOMPRESSION
,VASCULARISED GRAFT OR BY VALGUS
OSTEOTOMY
 RESURFACING ARTHROPLASTY IF < 50 % OF HEAD
 MOSTLY AGE GROUP IS 25 TO 45 YEARS-THR IS NOT
VERY SUCCESSFUL.
 IMPROVED RESULT WITH ALUMINA CERAMIC HEAD
HIGHLY CROSSLINKED POLYETHYLENE.

84. DWARFISM/DYSPLASIA
 NARROW CANAL
 BOWING
 ALTERD FEMORAL ANATOMY
 PREVIOUS FEMORAL OSTEOTOMY
 SHORT FEMORAL COMPONENT IS USED .

85. ACUTE FEMORAL NECK
FRACTURE
 THR > HRA>INTERNAL FIXATION
 THOSE WHO ARE LESS HEALTHY,COGNITIVELY
IMPAIRED OR REQUIRE ASSISTIVE DEVICE FOR
AMBULATION ARE BETTER SUITED FOR HRA.

86. Post operative hip
re-dislocation can be avoided by:
 Maintaining abduction using pillows
 Avoiding crossing legs
 Avoiding squating
 Using chairs with armrest
 Not bending forward past 90 degrees
 Using a high-rise toilet seat if necessary
 Avoiding pronation the legs
 Avoiding stairs

87. Exercise Prescription
Early Stage

88. Exercise Prescription
- Later Stages -

89. COMPLICATIONS OF THR
 1. Hematoma formation
 2. Heterotropic ossification
 3. Thromboembolism
 4. Nerve injuries (sciatic, femoral, obturator or sup gluteal
nerve)
 5. Vascular injuries

90. COMPLICATIONS OF THR
 6. Limb length Discrepency
 7. Dislocation and subluxation
 8. Fractures of acetabulum and femur
 9.Trochenteric nonunion and migration
 10. Infection
 11. Loosening ( Femoral and acetabular
component)
 12. Osteolysis

91. POST OPERATIVE
X-RAY

92. THANK YOU