SSSR HIP PROSTHESIS MODELS AND MATERIALS SURGICAL TECHNIQUES APPROACHES. Patrick Zingg Department of Orthopaedics University of Zurich, Balgrist
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1 HIP PROSTHESIS MODELS AND MATERIALS SURGICAL TECHNIQUES APPROACHES Patrick Zingg Department of Orthopaedics University of Zurich, Balgrist Zürich, Switzerland
2 IMPLANT TO BONE INTERFACE CEMENTLESS Grid-blasted (Morscher Pressfit) Porous-coated (Pinnacle) Threaded (Bicon) CEMENTED Polyethylene (Müller Flachprofil) Polished metal (Versacem)
3 COPING WITH BONE LOSS Trabecular metal augments Enforcement rings (Ganz, Burch-Schneider) Tumor prostheses (Link)
4 ARTICULATING SURFACES advantage wear reliable, forgiving wear wear stability disadvantage breakage (head) wear squeaking breakage metal ion blood level pseudotumor
5 MoM PROSTHESIS / MODULAR NECK Risk of: - osteolysis -ALVAL 1 : Investigation: aseptic lymphocyte-dominated vasculitisassociated lesion pseudotumor - blood serum 2,3 : 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, EFFORT, Consensus statement, April 16, MHRA UK. Medical device alert. Metal-on-metal total hip replacements Apr
6 MANAGEMENT MHRA UK. Medical device alert. Metal-on-metal total hip replacements Apr
7 PRIMARY STEMS courtesy H. Rüdiger, CHUV 2013
8 TRENDS IN FIXATION OF PRIMARY THR Hybrid Cementless Cemented Australian Joint Replacement Registry 2012 Swedish Joint Arthroplasty Registry 2010
9 CEMENTLESS FIXATION Inital mechanical stability shape oversize strength and stiffness Surface features relating to biocompatibility and bone attachment ingrowth: sintered beds, fiber mesh, porous metal ongrowth: grit blasting, plasma spraying Khanuja H, JBSJ A, 93:500, 2011
10 MODULAR STEM DESIGN Modularity allows a more accurate reconstruction - how much accuracy is needed? - better functional outcome? - risk: breakage, fretting corrosion
11 ANATOMICAL STEM - SPS More antamomic canal filling shape: - less stress shielding? - better functional outcome? - superior survivalship?
12 CUSTOM-MADE STEMS complex and unusual intra-medullary anatomy gross extra-medullary deformity high costs (alternative: cemented stem)
13 MATERIAL - Titanium-aluminium-vanadium alloy - Cobalt-chromium-molybdenum alloy Callaghan, The Ault Hip, LWW, 2007
14 SURGICAL APPROACHES anterior anterolateral lateral posterolateral posterior Hoppenfeld, Surgical Exposures, LWW, 1994
15 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
16 ..the size of incision.. minimal-invasiv versus Hartzband MA, Orthop Clin North Am, 35:119, 2004 Dorr LD, JBJS Am, 89:1153, 2007 < 10cm < conventional
17 ..the size of incision.. minimal-invasiv versus conventional
18 ..the aim to minimize trauma to muscles.. shortest way intermuscular internervous N.obturatorius adduktoren
19 MINIMAL-INVASIVER ANTERIORER ZUGANG R S S S v o N. 1 Hoppenfeld, Surgical Exposures, LWW, 1994
20 TEMPLATING R S S S N. 1 v o
21 LEG HOLDER
22 AVOID THE LAT. CUTANEOUS NERVE
23 DRAPING
24 INCISION
25 ENTER FASCIAL SHEAT
26 RETRACT TFL LATERALLY
27 MOBILIZE RECTUS FEMORIS
28 LIGATE AND COAGULATE
29 EXPOSE CAPSULE
30 INSTRUMENTALIZE THE CAPSULE
31 INTRACAPSULAR RETRACTOR
32 SAW
33 TRACTION
34 EXTRACTION OF FEMORAL HEAD
35 REAMER
36 REAMER
37 CHECK POSITION AND RESECT POSTERIOR OSTEOPHYTES
38 PULL 1
39 90 OF EXTERNAL ROTATION
40 EXTENSION
41 EXPOSURE OF FEMUR
42 BROACH
43 CHECK LEG LENGTH
44 IMPLANT THE STEM
45 CHECK STABILITY
46 READAPT THE CAPSULE
47 CLOSE FASCIA
48 RESULT R S S S N. 1 v o
49 ANTERIOR APPROACH standard approach primary THR full weight bearing advantages: less muscel damage, fast rehabilitation, low dislocation rate Limits: stem revision Bremer 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
50 TRANSGLUTEAL APPROACH Hoppenfeld, Surgical Exposures, LWW, 2009
51 TRANSGLUTEAL APPROACH THR with revision of abductor tendons 6 weeks: partial weight bearing, no deep flexion, no acitve abduction, no passive adduction Gluteus medius Greater trochanter Vastus lateralis
52 POSTERIOR APPROACH Hoppenfeld, Surgical Exposures, LWW, 2009
53 POSTERIOR APPROACH revision arthroplasty 6 weeks: no deep flexion, no flexion/internal rotation/adduction advantage: very versatile ( repair of hip abductors) diagastric trochanteric OT extended trochanteric OT
54 DIGASTRIC TROCHANTERIC OSTEOTOMY R S S S v o N. 1 Hoppenfeld, Surgical Exposures, LWW, 2009
55 EXTENDED TROCHANTERIC OSTEOTOMY
56 SUMMARY majority of THR uncemented, not yet proven to be superior to cemented no perfect bearing surface anterior approach widely used for primary THR posterior approach very versatile
57
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