aseptic lossening of cup in a 62 year old female 4 year postop

Resonably fixed charnley stem and loose cup

Why did it fail?

Poor acetabular cementing

Medial wall penentration  could cause other problems but not loosening.

Tips for good acetabular cementing

Dont ream the subchondral bone off

The last reamer used should be at least 2 mm or 4 mm more than the cup size to get at least a 2 mm cement mantle with good penetrarion

Don't ream the subchondral bone. Multiple(8 to 10 in no) 4 mm peg holes better than large key holes. Make the key holes wider than the  mouth for macro locking.

Dry acetabular bed before cementing

Pressurise after inserting doughy cement

Apply cement on the back of the cup too to avoid blood at the cement implant interface

Insert the cup locking the inferior cement first in an open position before  bringing it to 40 degrees and anterverting. Maintain pressure with the head shaped pusher while removing excess cement from the periphery till its hard

Remove any peripheral osteopyhtes to prevent impingement

 Finally it is easier to do an uncemented cup well than a cemented cup for the beginner

 Do we revise the cup alone?

If we do this, the dislocation chances are higher due to neck cup impingement. To correct this one needs to revise the stem to use a 32 mm or 36 mm head.

 How do we revise the stem?

a. ETO and distal fixing uncemented stem

b. Cement on cement revision as advised by  Dr. Phil Roberts

 We did a cement on cement stem and an uncemented cup without removing the medial cement, obtained could posterior superior contact

Used a high speed drill and stem extraction and cementeda tapered stem with an oxinium on xlpe liner

52 year old male with aseptic loosening at 3 years

The patient was advised by the surgeon that the implant was rejected.. This is an example of bad cementing or polywear causing loosening.

Removal of debri, washing out the blood, dry field are mandatory before cement application. Pressuring, cement gun introduction and timing of implant introduction depends on the type of cement and room temp.

This was definitely not rejected

jacob

migrated cup

Acetabular loosening are best managed early. Do we need to wait till major bone loss before revision? This is a 55 year rheumatoid lady 10 years post primary hip replacement.
Problms
Eplantation of cup
Vscular risk
Acetabular defect managnement
well fixed stem

Knee pain

Sports were designed to improve fitness of ordinary mortals. In our quest for higher level of fitness we sometimes damage joints beyond repair. Some amount of cyclical loading is good for cartilage (the softer shock absorbing ends of bones) nutrition. A Swedish prospective study comparing degenerative wear with exercise compared daily exercise, with thrice daily exercise and no exercise and concluded that thrice daily exercise probably had the least wear.

Eg. Cartlilage culture

Once a mechanical change to the alignment or stability of knee occurs, it becomes the beginning of the end of knee. Ligament injuries which contribute to stability are akin to suspension and wheel alignment of our cars. Your continuous driving without correction wears out the tyres similar to the softer cartilage of the knee.

Degemeric MRI

Pain is a protective phenomenon evolved to prevent further damage to oneself and administering of pain killers alone without investigation and treatment of the cause could further deteriorate the joint.. As far diagnosis of cartilage injuries, MRI scans upto 3 Tesla magnets with de-gemmeric software to look at cartilage has improved the diagnosis of cartilage injuries. These days easy reproducible minimal access surgery is available world wide to correct alignment, ligament reconstruction and resurfacing of cartilage injuries using osteoarticular grafts, bioscapholds and matrix assisted autologous implantation.

The use or abuse of exercise is ever increasing in our quest for healthier hearts. Over doing the same has exacerbated the possible incidence of osteoarthritis in knees. Weight reduction is the first simple step to reduce the wear across the cartilage. Six times one’s the body weight goes through our knees while walking. It is akin to driving a truck with cycle tyres. The smaller bony part of the knee has to take the excessive load which is already getting stiffer due to chemical changes and decrease water content with aging. Stronger and fitter muscles do take part of the load.

The role of neutrocaeuticals for arthritis has been controversial. Glucosamine and chondroitin sulphate are normal constituents of articular cartilage, but only 8% gets absorbed and how much reaches the knee is unclear. There are no studies to prove that the cartilage becomes normal with ingestion of neutricaeuticals. It at best could reduce the rate of degradation and might have analgesic effects. There use has been widespread so as to avoid the deleterious side effects of long term use of analgesics which are proven to cause Gastrointestinal and renal problems.

Viscosupplementation have been used to delay the inevitable and recently been talked about as a disease modifying intervention. This is yet to be proved and at best would be a stop gap arrangement till the inevitable knee replacement occurs.

Knee replacement has been shows to be in medium to long term, the best option once end stage arthritis occurs. Newer designs, materials like oxinium and crosslinking of polyethylene have proven to reduce the wear rates and improve the longevity of the implant. The complications of Pulmonary embolism, infection has been decreased with better drugs and early mobilization. As younger arthritic patients are demanding better function newer partial knees are being tested.





Correction of alignement(HTO) in an young patient with arthritis







preop with knee deformity



post knee repalcement op of the same patient



Pre Knee replacement

post knee replacement

Reducing blood loss during joint replacement

Methods to avoid transfusion, more so in bilateral TKR are possibly being achieved by using transxemic acid ,Thrombin, aquamantis and other methods. Our preliminary trial shows a trend towards minimising blood loss in Rheumatoids and bilateral tkrs using FLOSEAL.

Does size matter

The size of the incision or the implant does nothing to the longeivity or function of the implants. It is the technique, quality of bearing, fixation and alignment which is paramount. The approach whether anterior or posterior if done well does not matter. Why are we stuck on the size? yes, it could be a marketing tool. These fads fade away  and what matters most is the function and longievity. Smaller Proximal loading stems might have a role in preserving proximal bone. Till date No hip other than resurfacing maitain bone in gruen zone 1 and 6. With the metal on metal controversies surface replacement is used in select cases only.

Wounds heal side to side and possibly better rehab and multimodal analgesis will help to get the patient up quickly.

migrating stem

65 year old lady 10 years post primary THR.

Well fixed cup with no major wear.

Migrated stem with varus remodelling of proximal femur

Plan- ETO for correcting the femoral deformity while revison. cup was also revised . unfortunately only 22 mm heads were available in india then in 2000.

type 3 valgus knee

76 year old lady with 60 degree valgus with no medial end point
Only A rotating hinge TKR is possible in heras she has an incompetent MCL.

Risks include a foot drop postop when you correct the deformity.

I used the Link Devise succesfully in her. She is 3 years postop with no major problems

protrusio acetabuli in RA

This is 36 year old Doctor with RA on long term steroids. Presented with pain in hip as well as knee.

Why do we wait to complicate reconstruction?

Problems

1. Severe Osteoporosis

2.Huge cavitatory acetabulum with deficient medial and anterior wall

Young patient

Any comments on Options for acetabular reconstruction.

 We used a Cone prosthesis and a wagner uncemented cage with ceramic on poly bearing.

 A peripheral fitting cup was an option but due to the osteopenia, we opted for  a cage which came in 2 sizes. I understand Zimmer has withdrawn both these products from Sulzer.

Dislocation in in bipolar of 3 weeks duration

76 year old female presented with dislocated bipolar of 3 weeks duration. she is asa gr 3, memory loss and is a household ambulator. The dislocation occured while sitting on the toilet

The lesser trochanter appears more prominent

Possible causes in general for dislocation

Inadequate Offset

abnormal version and impingement

Options

1. Closed reduction and abductor bracing

2.if found unstable at closed reduction the options

The cup has been medialised slightly and a capture cup inserted. Tripolar cup was not available at present. the problems include cup loosening and  disimpaction of the head neck junction

Trochlear dysplasia in an 18 year old boy

18 year old engineering student presented with recurrent patellar dislocation and pain.

O/E

positive apprehension test. tuber sulcus angle of 10 degrees

xray- crossing sign and trochlear bump present

MRI showed a convex trochlea

Trochleoplasty was done to reshape the trochlea
After removing subchondral bone from the trochlea from proximal to disatal direction and collapsing the cartilage to ereshape the trochlea.

the final ic at 6 weeks during Chondron implantation for the patella

medial patellar facet chondral defect

grade 4 medial patella r defect 3 cm circumference in a 19 year old male student. Normal TT:TG diatance. MPFL intact. No history of injury.

cartilage mapping at 6 months. this was done in 2010 has good function till date 10 years followup.

ceramic on metal cleared by FDA

It was anounced that FDA approved ceramic on metal bearing by depuy for use recently. We have been using this bearing couple over the last 2 years with no untoward problems( 11 cases with 2 year follow up). Ever since J. fishers article in j of biomechanics(2004) suggesting decrease in metal debris as well as decrease chances of liner fracture, this was an option to look forward to.

Does this reduced metal debris cause problems

will this evolve to other new bearing Viz; ceramic on oxinium bearings.

anterior column fracture with posterior hemitransverse in an 82 year old male

anterior column is displaced with an essentilly undispalced hemitransverse fracture as described by letournel.

would you fix it or treat him conservatively

or fix and repalce it ?

He was advised PTH for severe porosis 2 years before> it was deferred by the patient due to percieved immediate cost.

This patient was advised antiresorptive therapy 2 years ago. He refused and paid the price. We fixed the posterior column and used a ganz cage to cement a cup.. the trochanrteric flip was used to improve exposure. A single screw was used to stabilse the anterior column thru the cage . He was mobilised on day 3 PWB. Awaiting for the six week review.

recurrant dislocation of patella.

16 year old girl with 3 episodes of patellar dislocation.

Apprehension test positive for lateral patellar subluxation

No clinical torsional abnormality.

normal xrays

MRI- show laterally subluxed patella mild trochlear hypoplasia. No chondral damage

CT Scan- 14 degree anteversion

TT_TG distnce 23 mm

Plan- MPFL reconstruction with tibial tubercle transfer(fulkerson)