models and materials surgical techniques hip …
TRANSCRIPT
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HIP PROSTHESIS
MODELS AND MATERIALS SURGICAL TECHNIQUES
APPROACHES
Patrick Zingg
Department of OrthopaedicsUniversity of Zurich, Balgrist
Zürich, Switzerlandwww.balgrist.ch
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IMPLANT TO BONE INTERFACE
CEMENTLESSGrid-blasted(Morscher Pressfit)
Threaded(Bicon)
Porous-coated(Pinnacle)
CEMENTED
Polished metal(Versacem)
Polyethylene(Müller Flachprofil)
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Enforcement rings(Ganz, Burch-Schneider)
Tumor prostheses(Link)
Trabecular metalaugments
COPING WITH BONE LOSS
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ARTICULATING SURFACES
advantage disadvantage
wear ↓ breakage (head)
reliable, wearforgiving
wear ↓↓↓ squeakingbreakage
wear ↓↓ metal ion blood levelstability pseudotumor
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MoM PROSTHESIS / MODULAR NECK
Risk of:- osteolysis- ALVAL1: aseptic lymphocyte-dominated vasculitis-
associated lesion pseudotumor
Investigation: - blood serum2,3: cobalt: > 2-7 µg/l (>119nmol/l)
chrom: >134.5 nmol/l- CT / MARS (metal artifact-reducing sequences) MRI
1 Watters TS, Am J Clin Pathol 134: 886, 20102 EFFORT, Consensus statement, April 16, 20123 MHRA UK. Medical device alert. Metal-on-metal total hip replacements. 2012 Apr
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MANAGEMENT
MHRA UK. Medical device alert. Metal-on-metal total hip replacements. 2012 Apr
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PRIMARY STEMS
courtesy H. Rüdiger , CHUV 2013
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Hybrid
Cementless
CementedAustralian Joint Replacement Registry 2012
Swedish Joint Arthroplasty Registry 2010
TRENDS IN FIXATION OF PRIMARY THR
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CEMENTLESS FIXATION
Inital mechanical stabilityshapeoversizestrength and stiffness
Surface features relating to biocompatibility and boneattachment
ingrowth: sintered beds, fiber mesh, porous metalongrowth: grit blasting, plasma spraying
Khanuja H, JBSJ A, 93:500, 2011
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MODULAR STEM DESIGN
Modularity allows a more accurate reconstruction
- how much accuracy is needed?
- better functional outcome?
- risk: breakage, fretting corrosion
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ANATOMICAL STEM - SPS
More antamomic canal filling shape:
- less stress shielding?
- better functional outcome?
- superior survivalship?
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complex and unusual intra-medullary anatomy
gross extra-medullary deformity
high costs
(alternative: cemented stem)
CUSTOM-MADE STEMS
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MATERIAL
- Titanium-aluminium-vanadium alloy
- Cobalt-chromium-molybdenum alloy
Callaghan, The Ault Hip, LWW, 2007
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• anterioranterolateral
• lateralposterolateral
• posterior
SURGICAL APPROACHES
Hoppenfeld, Surgical Exposures, LWW, 1994
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„minimally invasive hip arthroplasty..
..is clearly open to interpretation.
It may reflect....the size of incision..the aim to minimize trauma to muscles ..change in pain management and
physical therapy protocols..attitude concerning the length of time
recovery should take.“
Wall SJ, Arthroplasty; 23 Suppl 1: 55, 2008
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„..the size of incision..”
„minimal-invasiv“
versus
Hartzband MA, Orthop Clin North Am, 35:119, 2004
Dorr LD, JBJS Am, 89:1153, 2007
„conventional“
< 10cm <SSSR
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„..the size of incision..”
versus
„minimal-invasiv“ „conventional“
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• shortest way
• intermuscular
• internervous addukto-ren
N.obturatorius
„..the aim to minimize trauma to muscles ..”
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MINIMAL-INVASIVER ANTERIORER ZUGANG
Hoppenfeld, Surgical Exposures, LWW, 1994
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TEMPLATING
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LEG HOLDER
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AVOID THE LAT. CUTANEOUS NERVE
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DRAPING
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INCISION
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ENTER FASCIAL SHEAT
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RETRACT TFL LATERALLY
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MOBILIZE RECTUS FEMORIS
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LIGATE AND COAGULATE
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EXPOSE CAPSULE
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INSTRUMENTALIZE THE CAPSULE
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INTRACAPSULAR RETRACTOR
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SAW
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TRACTION
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EXTRACTION OF FEMORAL HEAD
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REAMER
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REAMER
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CHECK POSITION AND RESECT POSTERIOR OSTEOPHYTES
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PULL
1
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90° OF EXTERNAL ROTATION
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EXTENSION
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EXPOSURE OF FEMUR
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BROACH
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CHECK LEG LENGTH
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IMPLANT THE STEM
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CHECK STABILITY
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READAPT THE CAPSULE
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CLOSE FASCIA
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RESULT
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ANTERIOR APPROACH
standard approach primary THRfull weight bearing
advantages: less muscel damage, fast rehabilitation, low dislocation rate
Limits: stem revisionBremer A, JBJS Br, 93:886, 2011
Bergin P, JBSJ A, 93:1392, 2011
Alecci, J Orthop Traumatol, 12:123, 2011
Sariali F, J Arthroplasty, 23:266, 2008
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TRANSGLUTEAL APPROACH
Hoppenfeld, Surgical Exposures, LWW, 2009
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TRANSGLUTEAL APPROACH
THR with revision of abductor tendons
6 weeks: partial weight bearing, no deepflexion, no acitve abduction, nopassive adduction
Gluteus medius
Vastus lateralis
Greater trochanter
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POSTERIOR APPROACH
Hoppenfeld, Surgical Exposures, LWW, 2009
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POSTERIOR APPROACH
revision arthroplasty
6 weeks: no deep flexion, noflexion/internal rotation/adduction
advantage: very versatile( repair of hip abductors) diagastric trochanteric OT extended trochanteric OT
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DIGASTRIC TROCHANTERICOSTEOTOMY
Hoppenfeld, Surgical Exposures, LWW, 2009
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EXTENDED TROCHANTERICOSTEOTOMY
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SUMMARY
majority of THR uncemented, not yet proven to be superior to cemented
no perfect bearing surface
anterior approach widely used for primary THRposterior approach very versatile
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