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General Principles

and Techniques
in
THR Surgery
MAIN OBJECTIVE

relief of pain
restore motion
improve function
improve quality of life
ETIOLOGY -
PREDISPOSING FACTORS

age
sex
heredity
obesity
INCITING FACTORS

inflammatory processes
metabolic
biomechanical
hormonal
steroids
INDICATIONS
severe degenerative osteoarthritis
post - traumatic arthritis
rheumatoid arthritis
hip dysplasia
avascular necrosis
seronegative spondyloarthropathies
reconstruction of tumors around the hip
PATIENT PREPARATION

physical
psychological / mental
social interaction
financial
Type of Prosthesis

Cemented
Uncemented
Hybrid
- uncemented cup,
cemented stem
Risk of Hematogenous
Total Joint Infection
Immunocompromised / Immunosuppressed
Patients
- Inflammatory Arthropathies
( SLE, Rheumatoid Arthritis )

- disease, drug, radiation


( induced immunosuppression )
Risk of Hematogenous
Total Joint Infection
Other Patients
- Type I diabetes
- malnourishment
- 1st 2 yrs after joint replacement
- previous prosthetic joint infectins
Total Joint Replacement
( THR )
Sir John Charnley, 1968
acetabulum replaced by polyethylene cup
femoral head replaced by metallic head /
stem component
PMMA acts as grout between bony bed & implant
Pre-Operative Planning
x-rays: pelvis AP, lateral, Judet ( revision )

Implant Preparation - Use of Templates


- determine properly sized acetabular cup
- determine proper femoral stem size
- level of neck resection ( equalize leg length )
Antibiotic Prophylaxis

Cephalosporin ( Cefazolin or Cefuroxime )


- 1 dose pre-op, 1 dose intra-op
Antibiotic - Impregnated
Bone Cement
for high -risk patients
1 - 2 gms of antibiotic / 40 gms of cement
avoids major mechanical weakening of PMMA
Antibiotics Used
Admixed with PMMA
Gentamycin Cefazolin
Tobramycin Clindamycin
Vancomycin Erythromycin
Oxacillin Penicillin G
Surgical Approaches

Anterolateral Watson - Jones


Lateral Hardinge
Posterolateral Modified Gibson
Moore ( Southern )
Trochanteric Osteotomy
Prosthesis Selection
& Placement
ACETABULUM
- anatomic position at level of true notch
- complete bony coverage
- in a dysplastic hip: at least 80% bony coverage
- use of femoral head for grafting
Prosthesis Selection
& Placement
ACETABULUM
35 - 45O abduction
10 - 20O anteversion

at least 8 mm thickness ( all poly )


Prosthesis Selection
& Placement
FEMORAL STEM
- neutral or slight valgus
- not in varus, increases bending stresses

10 - 15O anteversion
Acetabular Preparation
adequate exposure
ream until bleeding subchondral bone
multiple fixation holes
- increases torisional resistance
- do not penetrate the pelvis esp. the medial wall
Femoral Head Size
correlated with polyethylene wear
average poly wear = 0.13 mm / year
Femoral Head Size
32 mm Head
- greater volumetric wear due to large
articulating surface area
- cause of wear debris induced loosening
and bone loss
- thin acetabular polyethylene cup
Femoral Head Size
22 mm Head
- greater linear wear, high penetration
into the cup
- reduced volumetric wear, maximizes
poly thickness
- large diameter of neck tapers restricts ROM
increases potential for post-op dislocation
Cementing Technique
FIRST GENERATION
- finger packing of doughy cement
- unplugged femoral canal
- femoral stem: sharp corners, narrow medial
borders
- stainless steel
Cementing Technique
SECOND GENERATION
- canal plug: 2-3 cm distal to stem tip
allows for greater pressure & better filling
- pulsatile lavage
reduces risk of fat / marrow emboli
- cement gun
low vicosity cement / chilling the monomer
- femoral stem: broad medial borders,
rounded corners
- superalloys: CoCr
Cementing Technique
THIRD GENERATION
- porosity reduction
vacuum mixing / centrifugation
- pressurization
cement compressor
- surface modifications on stems
Cementing Technique
FOURTH GENERATION
- third generation techniques plus:
stem centralization - proximally and distally

cannulated instruments
ensure uniform mantle / proper position
Cementing Technique
hypotensive ( spinal ) anesthesia
- to reduce blood at cement - bone interface

keep bed clean & dry


- adrenalin- soaked sponge, H2O2, iced saline

cement mantle
- acetabulum: uniform 2mm
- femur: 3 - 4mm proximal; 1.5 - 2mm distal
Uncemented THR

significant revision rates and loss of bone stock


on long term follow-up of cemented THR led to
heavy use of uncemented THR in the 1980s

most poupular femoral components have porous


ingrowth surfaces
Uncemented THR

requires progressive canal reaming

cup fixation using rigid hemispheric press - fitting


screw, fin or lug fixation
RESULTS:
Uncemented THR
high incidence of residual thigh pain, early or
late subsidence, osteolysis, increased
polyethylene wear

at 5 - 10 yrs ff-up, faiulre rate of 10-20%

femoral and acetabular osteolysis, 20 - 25%


Complications of THR

infection
- unexplained post-op pain
- hip joint aspiration is definitive diagnosis

dislocation
- 1 - 5% of cases, due to malposition of components

loosening
- poor fixation / cementing technique
Complications of THR

heterotopic ossification
- 60% of cases
- indomethacin prevents formation

neurovascular
- sciatic nerve / femoral nerve palsy
Complications of THR

trochanteric non - union


- loss of abductor strength

femoral fractures
- poor technique / reaming
Thank You