Transcript Joint Arthroplasty THR & TKR

Joint Arthroplasty
THR & TKR
THR
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is one of the most successful orthopedic procedures
performed today .
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It is estimated that over 300,000 total hip
arthroplasties are performed each year in the United
States alone .
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THA can relieve pain, can restore function, and can
improve quality of life .
Anatomy
Definition
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THA is a procedure whereby the diseased articular surfaces
are replaced with synthetic materials .
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THA is an elective procedure and should be considered as
an option among other alternatives .
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the articular surfaces of both the acetabulum and femur are
replaced .
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Indication
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If there is Hip pain , that has been failed to be treated
conservatively and cause a significant decrease in the
activities of daily living .
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If there were No pain , Patients with significant
deformity and limitation of motion may be candidates
.
Indications
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Osteoarthritis
Rheumatoid arthritis
Avascular necrosis
Traumatic arthritis
Certain hip fractures
Benign and malignant bone tumors
The aims are pain relief and improvement in hip
function
Contraindication
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Active infection (local or systemic)
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Preexisting significant medical problems (eg, recent
myocardial infarction, unstable angina, heart failure, or
severe anemia)
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Skeletal immaturity
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Paraplegia or quadriplegia
Contraindication
Permanent or irreversible muscle weakness , nerves or
blood vessels that could endanger limbs.
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Joint disease which may require alternative
reconstruction (osteotomy)
 Allergy to implants, particularly to metals (e.g.: cobalt,
chromium, nickel, etc.)
 Pregnancy
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Contraindication
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Age itself is not a contraindication to proceeding with
replacement.
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Because the joint replacement can fail with time, the
revision rate is lower if surgery is delayed as long as
possible.
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On the other hand, patients who elect surgery at a
better level of functional status have better functional
outcomes
Complications
INTRAOPERATIVE COMPLICATION
1. Perforation or fracture of the femur or acetabulum
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2.
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Nerve and vascular injury ,
Injury to the sciatic nerve is most common
vascular injuries that may be recognized postoperatively
are arteriovenous fistulas, arterial thromboses, and
pseudoaneurysms .
Complications
POSTOPERATIVE COMPLICATIONS
1. Thromboembolic disease , Without thromboprophylaxis,
perioperative mortality from pulmonary embolus (PE) occurs
in 2 to 3 percent. With thromboprophylaxis, there is a 0.1
percent rate of post-discharge fatal PE at 90 days
postoperatively.
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2.
Infection , less that 1 %
3.
Postop Dislocation , overall incidence of dislocation can reach
2%
Complications
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1.
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3.
Osteolysis and wear
Is the most common long-term complication seen in
young and physical active pt
the most frequent reason for implant failure.
The process begins as wear particles from the hip
implant are phagocytosed by macrophages that become
activated. These activated macrophages release
osteolytic factors and stimulate osteoclasts to dissolve
surrounding bone
Eccentric position of femoral head within cup
consistent with polyethylene wear .Focal osteolysis
with endosteal scalloping in proximal femur due to
particle disease.
Complications
Aseptic loosening
1. The commonest cause of long term faliure
2. 10-20% after 10 years
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Heterotropic bone formation
1. In 20% after 5 years
2. is a process by which the soft tissues around the hip
become ossified
3. (NSAIDs) and external beam radiation have been
used most successfully in preventing HO .
Ill-defined and
nonbridging early
heterotopic
ossification
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Well-defined, late
heterotopic
ossification
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Total Knee replacement
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As of 2010, over 600,000 total knee replacements
were being performed annually in the United States
and were increasingly common
Anatomy
Definition
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is a surgical procedure whereby the diseased knee
joint is replaced with artificial material.
The end of the femur bone is removed and replaced
with a metal shell.
The end of the lower tibia is also removed and
replaced with a channeled plastic piece with a metal
stem.
Depending on the condition of the patella, a plastic
"button" may also be added under its surface.
Indication
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1.
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Most commonly due to OA
Pain limiting daily activities
limited function or mobility
Failure of other methods
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resting, weight loss, physical therapy, a cane or
other walking aid, medications, braces and
surgery
Deformity
Indication
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Total knee arthroplasty is performed in patients of all
ages (except the skeletally immature) and better
outcome were found in those less than 55
Patients should understand the risks as well as
the benefits before making these decisions.
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Contraindications
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2.
3.
4.
5.
Absolute contraindications:
Active infection in the knee or anywhere in the
body
Extensor mechanism dysfunction
Severe vascular disease
Recurvatum deformity secondary to muscular
weakness
The presence of a well-functioning knee
arthrodesis
Contraindications
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2.
3.
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5.
Relative contraindications:
Medical conditions that preclude safe anesthesia
and the demands of surgery and rehabilitation.
Skin conditions within the field of surgery (e.g.,
psoriasis)
Past history of osteomyelitis around the knee
Neuropathic joint
Obesity
Complications
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3.
Thromboembolism
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without any prophylaxis has been reported at
40-88%
Infection
Patellofemoral complications
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Patellofemoral instability, patellar fracture,
patellar component failure, and extensor
mechanism tendon rupture
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Common reasons for reoperation
Complications
4.
5.
Neurovascular complications
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Arterial thrombosis following total knee
replacement is a rare (ie, 0.03-0.17%) but
devastating.
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Peroneal nerve palsy is the commonly reported
nerve palsy
Periprosthetic fractures
 Supracondylar fractures of the femur are not
common following total knee replacement (ie, 0.21%)
Complications
6.
7.
Aseptic loosening
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Leads to the ultimate failure of the prosthesis
and occurs at an approximate rate of 5-10% of
patients at 10-15 years
Arthrofibrosis
 Excessive scar tissue causing restriction of knee
movement
 Occurs in less than 1%
Postop & Follow up
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Physical therapy is an extremely important part of
rehabilitation
Patients can begin physical therapy 48 hours after
surgery
Some degree of pain, discomfort, and stiffness can be
expected during the early days of physical therapy.
Knee immobilizers are used in order to stabilize the
knee while undergoing physical therapy, walking,
and sleeping. They may be removed under the guidance
of the therapist for various portions of physical therapy.
Postop & Follow up
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Continuous passive motion (CPM) machine can help
speed the recovery process. The CPM machine is
first attached to the operated leg. The machine then
constantly moves the knee through various degrees
of range of motion for hours while the patient
relaxes.
Patients will start walking using a walker and
crutches. Eventually, patients will learn to walk up
and down stairs and grades. A number of home
exercises are given to strengthen thigh and calf
muscles.
Postop & Follow up
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Most patients seem satisfied with their knee
replacements.
The majority of patients are able to return to lowimpact sporting activity.
Long-term studies confirm satisfactory functional scores
and show a 91-96% prosthesis survival rate at 14-15
years of follow-up.
Cementless designs do not have the same length of
follow-up, but studies at 10-12 years report a 95%
prosthesis survival rate.
Excision Arthroplasty
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- intractable joint infection
- when previous operations have failed
- the joint has been irremediably destroyed ,
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EXCISION ARTHROPLASTY is the solution
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Excision Arthroplasty
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to excise the articular ends of the bone forming the
joint , creating where movement can occur
femoral head & neck are excised leaving a false
articulation ( pseudoarthrosis ) between the upper
end of the femur & the acetabulum
The joint is obviously unstable , but because of local
fibrosis & the effect of powerful surrounding muscles ,
the pt can still take weight on the side & can walk
about though with marked limp
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