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TOTAL HIP REPLACEMENT Vojtech HAVLAS

TOTAL HIP REPLACEMENT Vojtech HAVLAS. HISTORY. AIM : PAIN RELIEF & MOBILE JOINT INITIAL ATTEMPTS : - ARTHRODESIS - OSTEOTOMY - NERVE DIVISION - JOINT DEBRIDEMENTS TRIALS WITH – MUSCLE, FAT

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TOTAL HIP REPLACEMENT Vojtech HAVLAS

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  1. TOTAL HIP REPLACEMENT Vojtech HAVLAS

  2. HISTORY • AIM : PAIN RELIEF & MOBILE JOINT • INITIAL ATTEMPTS : - ARTHRODESIS - OSTEOTOMY - NERVE DIVISION - JOINT DEBRIDEMENTS TRIALS WITH – MUSCLE, FAT - CHROMATIZED PIG BLADDER - GOLD, MAGNESIUM, ZINC

  3. HISTORY • IN 1925, DR. SMITH PETERSON (BOSTON) USED GLASS PIECE TO RESURFACE HIP JOINT ( “MOLD ARTHROPLASTY”) • DID NOT WITHSTAND STRESS & FAILED • LATER USED PLASTIC & STAINLESS STEEL • IN 1936, SCIENTISTS MANUFACTURED COBALT CHROMIUM ALLOY - STRONG - RESISTANT TO CORROSION FAILED – PAIN RELIEF NOT GOOD - HIP MOVEMENT REMAINED LIMITED

  4. HISTORY • IN 1938, DR. JEAN JUDET & DR. ROBERT JUDET (PARIS) USED ACRYLIC MATERIAL TO REPLACE HIP SURFACES - PROVIDED SMOOTH SURFACE - BUT TENDED TO COME LOOSE DR. EDWARC J. HABOUSH (NEW YORK) USED THE “FAST SETTING DENTAL ACRYLIC” TO GLUE THE PROSTHESIS TO BONE (NEW ERA IN FIXATION TECHNIQUE)

  5. HISTORY • IN ENGLAND, SIR JOHN CHARNLEY, PURSUED METHODS OF REPLACING FEMORAL HEAD & ACETABULUM • HE WAS BANISHED TO ISOLATED TB SANATORIUM • IN 1958, HE REPLACED THE SOCKET WITH TEFLON & FEMORAL HEAD WITH METAL • REPLACED TEFLON WITH POLYETHYLENE SOCKET • BORROWED PMMA FROM DENTISTS & USED AS “BONE CEMENT”

  6. PROFESSOR SIR JOHN CHARNLEY (1911-1982) • BORNIN BURY, LANCASHIRE 29 AUG 1911 • FATHER, ARTHUR, A CHEMIST, MOTHER, LILY, A NURSE AT CRUMPSALL HOSPITAL • IN 1929, MEDICAL SCHOOL AT VICTORIA UNIVERSITY OF MANCHESTER. MB CHB IN 1935 • IN 1936, FRCS, ENGLAND (AT YOUNGEST ACCEPTABLE AGE) • RESIDENCY: SALFORD ROYAL HOSP, KINGS COLLEGE, LONDON, MANCHESTER INFIRMARY • IN 1940, ARMY SEVICE IN NORTHERN IRELAND, MIDDLE EAST, EVACUATION OF DUNKIRK

  7. PROFESSOR SIR JOHN CHARNLEY • IN 1947, VISITING SURGEON TO PARK HOSP, DAVYHULME & IN 1949 TO WRITINGTON HOSP • IN 1957, MARRIED JILL HEAVER, CHILDREN TRISTRAM & HENRIETTA • CHARNLEY’ CONTRIBUTIONS TO ORTHOPAEDICS - CLOSED TREATMENT OF COMMON FRACTURES - COMPRESSION ARTHRODESIS - TOTAL HIP ARTHROPLASTY

  8. INDICATIONS • ARTHRITIS : - RHEUMATOID ARTHRITIS - JUVENILE RA - OSTEOARTHRITIS . PRIMARY . SECONDARY - SCFE - CDH - PERTHES - TRAUMATIC DISLOCATION - FRACTURE ACETABULUM

  9. INDICATIONS • AVN : - POST # / DISLOCATION - IDIOPATHIC - SCFE - HAEMOGLOBINOPATHIES - STEROID INDUCED - ALCOHOLISM - CAISSONS DISEASE . HIP FUSION / PSEUDOARTHROSIS

  10. INDICATIONS • FAILED RECONSTRUCTIONS : - OSTEOTOMY - CUP ARTHROPLASTY - FEMORAL HEAD PROSTHESIS - GIRDLESTONE PROCEDURE - THR - RESURFACING ARTHROPLASTY . BONE TUMOURS : PROX FEMUR / ACETABULUM . HEREDITARY DISORDER (ACHONDROPLASIA)

  11. CONTRAINDICATIONS • ABSOLUTE : - ACTIVE INFECTION IN HIP / ANYWHERE - UNSTABLE MEDICAL ILLNESS . RELATIVE : - NEUROPATHIC JOINT - ABSENT / INSUFFICIENCY OF ABDUCTOR MUSCULATURE - RAPIDLY PROGRESSIVE NEUROLOGIC DISEASE

  12. PRE-OPER PLANNING • ROUTINE BLOODS • ECG, CXR • PROPHYLAXIS FOR VENOUR THROMBOSIS • ANTIBIOTIC PROPHYLAXIS • PATIENTS ON WARFARIN - STOPPED 2-4 DAYS BEFORE SURGERY - CONSIDER UNFRACTIONED HEPARIN INFUSION - INR : 1.5 – 2.1 ACCEPTABLE • DIABETIC PATIENTS - STOP ON THEATRE DAY MORNING - START ON SLIDING SCALE

  13. PRE-OPER PLANNING • MEDICAL CONDITION • AUTOLOGOUS BLOOD TRANSFUSION - EXPECTED BLOOD LOSS : 1000 – 1500 ML - PRE-OPER / INTRA-OPER - 3 UNITS FOR PRIMARY, 5 UNITS FOR REVISION - PHLEBOTOMIES AT 5 DAYS INTERVAL - BLOOD CAN BE STORED UPTO 35 DAYS

  14. PRE-OPER X-RAYS • AP PELVIS & LAT HIP – MINIMAL - IF BONE IS SUFFICIENT FOR ACETABULAR COMPONENT FIXATION - HOW MUCH REAMING NECESSARY ? - BONE GRAFTING NEEDED ? - PROTRUSION / OSTEOPHYTE MAKE DISLOCATION DIFFICULT - MEDULLARY CANAL WIDTH . IN DYSPLASTIC HIP : BONE STOCK FOR CUP FIXATION . OLD # / DISLOCATIONS : OBTURATOR / ILIAC OBLIQUE VIEWS / CT

  15. TEMPLATING • REMOVESGUESS WORK & SHORTENS OPER TIME • X-RAY HIP AP IN 15’ IR (SHOWS BETTER FEMORAL GEOMETRY & OFFSET) • TAPE A MAGNIFICATION MARKER (LEAD SPHERES) • A LINE CONNECTING ISCHIAL TUBEROSITIES & A LINE CONNECTING LESSER TROCHANTERS, SHOWS THE SHORTENING • SELECT A TEMPLATE THAT MATCHES ACETABULAR CONTOUR (MEDIAL POSITION OF TEMPLATE IS AT TEAR DROP AND INF MARGIN AT OBTURATOR FORAMEN LEVEL)

  16. TEMPLATING

  17. TEMPLATING ACETABULUM

  18. TEMPLATING • MARK THE CENTRE OF ACETABULAR COMPONENT (NEW CENTRE OF ROTATION OF HIP) • SELECT FEMORAL TEMPLATE THAT MATCHES THE CONTOUR OF PROX CANAL (ALLOWING THICKNESS FOR CEMENT MANTLE) • SELECT NECK LENGTH (TO RESTORE LIMB LENGTH & FEMORAL OFFSET) - IF NO SHORTENING, MATCH THE CENTRE OF HIP WITH CENTRE OF ACETABULUM - IF DISCREPENCY EXISTS, DISTANCE BETWEEN FEMORAL HEAD CENTRE AND ACETABULAR CENTRE SHOULD EQUAL PREVIOUSLY MEASURED LIMB LENGTH DISCREPANCY

  19. TEMPLATING FEMUR

  20. TEMPLATING FEMUR

  21. PREPARATION & DRAPING • USE U-DRAPE TO SEAL OFF PERINEAL & GLUTEAL AREAS • PREPARE WITH BACTERICIDAL SOLUTION • FOOT & LEG COVERED WITH STOCKINETTE • FINAL DRAPES OF IMPERVIOUS MATERIAL

  22. SURGICAL APPROACHES • POSTERIOR APPROACH • LATERAL APPROACH • ANTERO-LATERAL APPROACH • ANTERIOR APPROACH : - SINGLE GROIN INCISION - DONE UNDER X-RAY CONTROL - HIGH CHANCE OF ERROR . MINI INCISION HIP REPLACEMENT : - RECENT DEVELOPMENT - BY POSTERIOR APPROACH . TWO INCICION APPROACH : - VERY RECENT DEVELOPMENT - ONE IN GROIN, ONE AT THE BACK - NORMAL WALKING IN < 2 WEEKS

  23. SURGICAL APPROACHES • ORIGINAL CHARNLEY TECHNIQUE: - ANTERO-LAT WITH TROCHANTERIC OSTEOTOMY - PROBLEMS WITH REATTACHMENT OF TROCHANTER . HARDINGE LATERAL APPROACH : - MUSCLE SPLITTING OF MEDIUS & MINIMUS - EXCELLENT ACETABULAR EXPOSURE - RESIDUAL ABDUCTOR WEAKNESS DUE TO . AVULSION OF REPAIR . DIRECT INJURY TO SUP GLUTEAL NERVE

  24. SURGICAL APPROACHES • DALL VARIATION OF HARDINGE : - REMOVAL OF ABDUCTORS WITH BONE - BETTER ABDUCTOR FUNCTION . HEAD et al MODIFICATION OF DIRECT LAT APPROACH - VASTUS LATERALIS REFLECTED ANTERIORLY IN CONTINUITY WITH ABDUCTOR CUFF - BETTER EXPOSURE OF PROX FEMUR - APPROPRIATE FOR REVISION SURGERY . POSTLAT APPROACH : - ABDUCTOR FUNCTION NOT COMPROMISED - EXPOSURE OF ANT ACETABULUM DIFFICULT - POST DISLOCATION RATE HIGHER

  25. ANATOMY – POST APPROACH

  26. ANATOMY – POST APPROACH

  27. SURGICAL TECHNIQUE POSTERIOR APPROACH • SKIN INCISION AT THE LEVEL OF ASIS ALONG THE POST EDGE OF GREATER TROCHANTER • EXTEND TO CENTRE OF TROCHANTER AND ALONG THE SHAFT TO 10 CMS • DIVIDE THE FASCIA ALONG THE SKIN INCISION • SPLIT THE GLUTEUS MAXIMUS ALONG THE FIBRES • EXPOSE SHORT EXT ROTATORS AND SUTURES IN PYRIFORMIS & OBTURATOR INTERNUS • CUT THE EXT ROTATORS INCLUDING THE PROX HALF OF QUADRATUS FEMORIS

  28. PATIENT POSITIONING

  29. SKIN INCISION

  30. EXPOSING & CUTTING SER

  31. SURGICAL TECHNIQUE POSTERIOR APPROACH • BLUNTLY DISSECT BETWEEN THE GLUTEUS MINIMUS & SUP CAPSULE. CUT/EXCISE CAPSULE • DISLOCATE THE HIP POST BY FLEXION, ADDUCTION & INTERNAL ROTATION • IF CANNOT BE DISLOCATED (PROTRUSIO), CUT THE FEMORAL NECK & REMOVE THE HEAD • AFTER DISLOCATION, CUT THE FEMORAL NECK AT DESIRED LEVEL

  32. CUTTING CAPSULE

  33. DISLOCATING HIP

  34. ACETABULAR PREPARATION • RETRACT THE FEMUR ANT & DIVIDE THE CAPSULE • EXCISE THE LABRUM & REMAINING CAPSULE • EXCISE LIG TERES & REMOVE SOFT TISSUES • BEGIN WITH SMALLEST REAMER AND DIRECT IT MEDIALLY DOWN • DIRECT SUBSEQUENT REAMERS IN THE SAME PLANE AS THE OPENING FACE OF ACETABULUM • REAMING IS COMPLETE WHEN : - ALL CARTILAGE HAS BEEN REMOVED - REAMERS HAVE CUT BONE OUT TO PERIPHERY - HEMISPHERICAL SHAPE HAS BEEN PRODUCED . CURRETTE SUBCHONDRAL CYSTS & PACK WITH BG

  35. PREPARING ACETABULUM

  36. CEMENTED ACETABULAR COMPONENT • MAKE MULTIPLE 6 MM DRILL HOLES • INJECT CEMENT IN EARLY DOUGH PHASE • PRESSURISE THE CEMENT : PLUNGER TYPE WITH SHEET OF POLYPROPYELENE ON SILICONE CAP • PALACOS : NO LOW VISCOSITY STATE, BEST INSERTED MANUALLY • INSERT PROSTHESIS WITH APPROPRIATE DEVICE : INCLINATION OF 45 & ANTEVERTION OF 20. • CHECK THE STABILITY BY PRESSING ON SEVERAL PT • COMPONENT IS LOOSE IF : - MOTION IS DETECTED - BLOOD / BUBBLES APPEAR IN THE INTERFACE

  37. REAMING ACETABULUM

  38. CEMENTING & PROSTHESIS POSITIONING

  39. UNCEMENTED ACETABULAR COMPONENT • ACETABULUM DIVIDED INTO 4 QUADRANTS : - LINE A EXTENDS FROM ASIS THROUGH CENTRE OF ACETABULUM TO POST ASPECT OF FOVEA - LINE B IS PERPENDICULAR TO LINE A AT MIDPOINT OF ACETABULUM . ANT SUP QUADRANT: INJURY TO EXT ILIAC VESSELS . ANT INF QUADRANT: INJURY TO OBTURATOR N&V . POST INF QUADRANT: SCIATIC N & SUP GLUTEAL V . SAFEST FOR SCREW PLACEMENT : POST SUP QUADRANT . ANT SUP SHOULD BE AVOIDED

  40. FEMORAL PREPARATION • EXPOSE THE FEMUR BY IR FEMUR SOTHAT TIBIA IS PERPENDICULAR TO FLOOR • REMOVE BONE FROM LAT ASPECT OF NECK AND MED ASPECT OF GR TROCHANTER • IF INADEQUATE BONE IS REMOVED FROM THESE AREAS, - STEM MAY BE PLACED IN VARUS - STEM MAY BE UNDER SIZED - LAT FEMORAL CORTEX MAY BE PERFORATED - GR TROCHANTER MAY BE FRACTURED

  41. FEMORAL PREPARATION

  42. FEMORAL PREPARATION • FROM THE INSERTION POINT AIM THE REAMER TOWARDS THE MEDIAL FEMORAL CONDYLE • PROCEED WITH LARGER REAMERS UNTIL CORTICAL REAMING IS FELT • REMOVE THE RESIDUAL BONE FROM THE MED ASPECT OF THE NECK WITH BROACHES • MAINTAIN 10-15 ANTEVERSION AS THE BROACH IS IMPACTED • TRAIL REDUCTON ATTEMPTED

  43. FEMORAL PREPARATION

  44. FEMORAL PREPARATION • OCCLUDE THE FEMORAL CANAL TO - ALLOW PRESSURISATION - PREVENT CEMENT RUNNING DISTALLY . CEMENT RESTRICTORS : - PLASTIC PLUG - BONE CEMENT - BONE BLOCK . INJECT CEMENT & PRESSURISE WITH OCCLUSIVE SEAL THAT ALLOWS INJ OF MORE CEMENT THROUGH IT . INSERT THE PROSTHESIS AND FIT THE MODULAR HEAD . REDUCE THE HIP AND CHECK STABILITY

  45. CEMENT RESTRICTOR

  46. CEMENTING & PROSTHESIS POSITIONING

  47. COMPLICATIONS : GENERAL 1. NERVE INJURIES : 0.7 – 3.5 % SCIATIC, FEMORAL, OBTURATOR, PERONEAL 2. HAEMORRHAGE & HAEMATOMA SOURCE : - . BRANCH OF OBTURATOR VESSELS . CRUCIATE ANASTAMOSIS . MEDIAL CIRCUMFLEX VESSELS . BRANCH OF FEMORAL VESSELS . BRANCH OF SUP & INF GLUTEAL VESSELS

  48. COMPLICATIONS : GENERAL 3. VASCULAR INJURIES : 0.2 – 0.3 % FEMORAL, OBTURATOR, COMMON ILIAC LATE : - THROMBOSIS OF ILIAC VESSELS - AV FISTULAS - FALSE ANEURYSM 4. INFECTION : 1% STAPH. AUREUS, EPIDERMIDIS . ANTIBIOTICS . I & D . DEBRIDEMENT, GIRDLESTONE RESECTION . ONE / TWO STAGE REVISION

  49. COMPLICATIONS : GENERAL 5. THROMBOEMBOLISM : - COMMON CAUSE OF DEATH WITHIN 3 MONTHS - WITHOUT PROPHYLAXIS: 40-70 % - RISK FACTORS: . PREVIOUS DVT . CCF . PREVIOUS VENOUS SURG . IMMOBILIZATION . PREV ORTHO SURG . OBESITY . ADVANCED AGE . OCP . MALIGNANCY . EXT BLOOD LOSS 6. BLADDER INJURY & UT COMPLICATION

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