Chapter 32 Sugery for arthritis in the hip and knee.2023.10.09.pptx

SUGERY FOR
ARTHRITIS IN THE
HIP AND KNEE
吕晨 Chen Lv
Dept. of Orthopaedics of
1st
Affiliated Hospital of WMU

normal hip arthritic hip
femoral neck and head
acetabulum
1. formation of osteophyte
2. hyperplasia of acetabulum
3. narrowing of joint space

normal knee arthritic knee
1. formation of osteophyte
2. osteosclerosis
3. narrowing of joint space (medial
gap stenosis is most common)
4. rising of intercondylar eminence
femur
tibia
varus
deformity

Definition of Osteoarthritis
(OA)
 which is also known as
degenerative joint disease
(DJD), is a progressive
disorder of the joints
caused by gradual loss of
cartilage and resulting in
the development of bony
spurs and cysts at the
margins of the joints.

Arthritis
 Painful joint
 Limp
 Lower quality of life
Middle-aged and elderly patients
Joint degeneration
Trauma
Overwork, etc

The pathogeny (etiology) is unknown, and is
generally believed to be related to:
1. degeneration of cartilage
2. aging
3. trauma
4. inflammation
5. obesity
6. metabolism
7. genetic
Pathogeny of arthritis

The bone and joint decade
(joint motion 2000-2010)
Launched by WHO in 1998

Epidemiology of arthritis
 Osteoarthritis of hip and knee occur in 10-
25% of people with age over 65 years, and
more in the future.
 Over half a million total hip replacements
worldwide each year.
 Approximately 130,000 knee replacements
are performed every year in USA.

Anatomy & Biomechanics
 HIP
 KNEE

HIP:
 A ball and socket
joint
 With a considerable
ROM (Range Of
Motion)
 Stabilized by
strong ligament,
joint capsule and
muscles

HIP---anteriorly
underlying muscle superficial muscle

HIP---posteriorly
Abduction (piriformis only), external
rotation of the hip joint.

Load on the hip when standing on
one leg
 The hip joint is the
fulcrum of lever arm
 Force of M = 3 times
BW
 Load on hip J = M +
BW = 4 BW
J
M
BW

Actions of muscles on the hip
 To stabilize the hip
 The abductors to support the pelvis
when standing on one leg
These muscles act on the hip via the lever
arm of the femoral neck
The forces passing through the hip are far
greater than the body weight

KNEE:
 A complex hinge joint
 Some rotation and glide between the joint surfaces
 Collateral ligaments and ACL/PCL to stabilize the
knee

Stabilizing system of the knee
 The collateral
ligaments control
medialateral stability
 The cruciate ligaments
control anteroposterior
stability
 The menisci act as
load-spreading spacers

Problems in the hip by age group
baby adult elderly people the disabled

At birth - congenital hip dislocation
 Occurs at birth, but
usually be found for
delayed walking
 The head of the right
femur is displaced out
of the shallow right
acetabulum.

Newborn – septic arthritis
 Clinical presentation:
acute onset of pain in the
involved hip.
 X-ray shows there is
displacement of the head
of the left femur from the
acetabulum and the
articular space is
widened.

Child – Perthes’s disease
 There is sclerosis and
loss of height of the
fragmented capital
epiphysis of the right
femur. The width of the
epiphyseal plate is
unchanged.
Stephanie PA et al. Legg- Calve- Perthes
disease. Curr Opin Orthop 2007,18:544–
549.

Adolescent – slipped femoral epiphysis
 The left epiphysis
no longer
protrudes a little
beyond the outer
margin of the
femoral neck. The
epiphyseal plate
narrows.

Adult – secondary arthritis
 The secondary diseases include:
Avascular necrosis (AVN) of femoral
head
Rheumatoid arthritis
Traumatic arthritis
Ankylosing spondylitis
etc.

Elderly – osteoarthritis （ OA ）
 Articular space narrows for the degeneration of
articular cartilage
 The most common cause for joint replacement
normal involved

Senile – fracture of femoral neck
 The fracture often
occurs at daily life
activity of senile
persons, and
indicates the severe
osteoporosis.
Artificial femoral head replacement

All of problems in the hip
Arthritis
Pain
Decrease of ROM
Deformity

Causes of arthritis of the hip
 CDH --- abnormal congruence
 Septic lesion --- articular cartilage demaged
 Perthes’ disease --- collapse of femoral head
 Slipped epiphysis --- abnormal growth plate
 Secondary arthritis --- articular cartilage destroyed
 Traumatic arthritis --- incongruent joint
 Primary OA --- cause unknown
Degeneration of articular cartilage
osteoarthritis

Problems in the knee
 Osteoarthritis
 Rheumatoid arthritis
 Traumatic arthritis
 Septic arthritis
 Synovitis
Degeneration of articular cartilage and malalignment
Pain and malfunction

Options for major joints arthritis
 Non-operative methods
 Operative methods

Non-operative measures
 Pain-killers
NSAIDs (Non-Steroid Anti-Inflammatory Drugs)
 Walking aids and splint
 Mondifications around the house
 Physiotherapy
Massage, thermotherapy
 Weight loss

Operative measures
 Arthroscopy
 Arthrodesis
 Osteotomy
 Joint replacement = arthroplasty

arthroscopy
 First choice for synovitis
 Outcome for OA is still
controversial
 To give long lasting relief of
arthritic symptoms
 To delay the requirement for
more extensive surgery

arthrodesis
 Indications: OA secondary to trauma in
the young adult.
 Contraindications:
secondary OA in the older patient
with back problems
arthritis in other joints of lower extremity
Only one joint involved and young

Hip arthrodesis Knee arthrodesis

Advantages of hip arthrodesis
 Produces a painless hip
 Does not wear out
 Can be replaced with a
THA later
 Ideal for a young, active
patient
 Successful case leaves
very little disability.

osteotomy
 Indications:
Young not suitable for joint replacement
With problems on other joints not suitable
for arthrodesis

Tibial osteotomy for varus deformity of knee
in the young patients

Femoral osteotomy for hip dysplasia

Joint replacement
--- the final measure for arthritis

Indications for joint replacement
 Pain – uncontrolled by non-operative
measures
 Interference with mobility and quality
of life – secondary indication
 Age is not considered in severe case
No pain, no arthroplasty

Diagnosis for Total Hip Replacement

Preoperative preparation
1. Elimination of contraindications
2. Preassessment
3. Prophylactic antibiotics
4. Thromboprophylaxis
5. Anaesthesia
6. Urinary catheterisation
7. Theatre requirement

1. Elimination of contraindications
Any potential lesions of infection
A history of myocardial infarction or
cerebrovascular accident within 6 months
Bed bound for any other systemic
diseases
Diabetes mellitus or hypertension before
well controlled
A past history of deep vein thrombosis

2. Preassessment
Basic investigations include:
 Weight-bearing radiographys of the involved joint
 Blood exam: blood routine, ESR, CRP, liver
function test, coagulation time, electrolytes, etc.
 Adjunct ex.: ECG, echocardiography, X-ray of
chest, etc.
 Drug history: aspirin, steroids
 Transfusion preparation

3. Prophylactic antibiotics
 At lease 3 doses of a broad-spectrum antibiotics
should be used to cover the operation.
 One dose of the antibiotics should be given within
½ hr before making incision.
 The other 2 doses to cover the next 24 hrs.
 Any longer antibiotics using does not confer any
added benefit, except increasing the cost.

4. Thromboprophylaxis – perioperative
Methods of thromboprophylaxis:
 Early active or passive motion of the limb
 Mechanical methods: elastic stocking or
foot pump
 Chemical methods: low molecular weight heparin,
warfarin
excluding aspirin

Venous thromboembolism (VTE)
DVT-
deep vein thrombosis
PE -
pulmonary embolism
fatal

 DVT is common (30-50%).
 PE is rare (0.1-0.4%) but always fatal.
 VTE occurs most frequently in major
orthopaedic operations.
 It is a consensus that joint
replacement is absolute indication for
thromboprophylaxis.
 Thromboprophylaxis has become the
standard of care for total joint
arthroplasty.

5. Anaesthesia
Epidural ( spinal ) anaesthesia is choice of
first, to reduce operative blood loss and DVT.
General anaesthesia is rarely used .
Peripheral nerve block ( femoral & sciatic n)
is increasingly used for knee replacement in
my patients.

General anaesthesia Spinal anaesthesia
1. epidural anesthesia
2. lumbar anesthesia

Peripheral nerve block anesthesia
Sciatic nerve block Femoral nerve block

6. Urinary catheterisation
It is necessary to catheterise the patient
prior to surgery, as postoperative urinary
retention is inevitable following spinal
anaesthesia.
Catheterisation can be avoided if peripheral
nerve block is used.

7. Theatre requirement
 Laminar-flow ventilation system
 To wear disposable gowns and double
gloves
 Minimum movement into and out of the
theatre
 Minimum visitor during operation
in order to prevent the
disastrous consequences
of infection postoperatively

HOW TO DO IT
 THA --- Total Hip Arthroplasty
 TKA --- Total Knee Arthroplasty

Total hip arthroplasty
 Approach
 Procedure
 Methods of fixing implants
 Bearing surface

Approach for THA
 Anterolateral approach
 Posterior approach
 Trochanteric approach

Anterolateral approach
Cutting abductor muscles (gluteus medius and gluteus minimus)

Posterior approach
Cutting external rotator muscles （ piriformis muscle, superior twin
muscle, inferior twin muscle, etc. ）

Trochanteric approach
Cutting greater trochanter
of the femur, exposing the
capsule of the hip joint and
expose the femoral head.

Common approaches to THA
approach advantages disadvantages
posterior Excellent view Risk of dislocation
postoperatively
trochanteric Simple approach,
Good view
Problems reattaching
trochanter
anterolateral Stable after surgery Access is not so good,
limited hip abduction

Procedure of THA
 Preparation of the acetabulum
 Implantation of acetabular component (cup)
 Preparation of the femoral canal
 Insertion of femoral component
 Reduction of artificial joint

Preparation of the acetabulum
Anteversion angle 10-15 degrees
Abduction angle 40-55 degrees
Implantation of acetabular component (cup)

Preparation of the femoral canal
Insertion of femoral component

Methods of fixation of implants
 Cement
 Cementless
(biologic fixation)

Acetabular component
cementless cement

Femoral component
cementless cement
The biological type has better bone growth, and the cement type is used in
elderly patients due to osteoporosis.

Cementing techniques
A plug is inserted into the canal, cement is extruded into
the cavity and pressurised

Methods of fixing implants
methods advantages disadvantages indications
Cement Easy,
Well-proven
result
Cement reaction,
Difficult to remove
at revision
At all age group,
esp. for pt. with
osteoporosis
Cement-
less
More secure Difficult,
Perfect fit-press
Thigh pain,
Younger pt. with
good bone
quality

Bearing surface of joint
 Metal on polyethylene
 Ceramic on polyethylene
 Ceramic on ceramic
 Metal on metal
☆People keep on pursuing a bearing surface with
lower coefficient of friction and slower wear,
which can get a longer survival of the artificial joint.
---wearing interface between acetabular cup and femoral head

This is the most frequently
used THA system currently
Metal on polyethylene
Ceramic on polyethylene

Pros and cons of bearing surfaces
Type advantages disadvatages
M-on-PE Well proven
Cheap
High friction
High wear rates
C-on-PE Lower friction Ceramic shatter
Expensive
C-on-C Lowest friction Ceramic shatter
Expensive
M-on-M Lower friction
Larger femoral head
Metal hypersensitivity
Effect of metal ions
Expensive

Total knee arthroplasty
 Alignment
 Balance of soft tissue
knee

Procedure of TKA
 Explosion of knee cavity
 Osteotomy for proper alignment
 Soft tissue releasing for balancing
 Implantation of components

operative incision Medial patellar approach
Exposed articular surface

The tibia bone osteotomy
Medial and lateral horizontal osteotomy
5 degrees retrograde osteotomy
Due to the different design concept, the
osteotomy angle is not the same in different
joint prostheses.

Balance of ligment
Releasing soft tissue Balancing at flexing and extending

Postoperative care
 Regular monitoring of vital signs immediately
 Adequate analgesia at the first 24 hrs
 Using antibiotic for less than 3d
 Anticoagulation for more than 10d
 Rehabilitation of the joint including ROM and
strength by physiotherapist

Postoperative rehabilitation
 Standing on the first
postoperative day and take a few
steps.
 Begin ambulation with a walker or
crutches; initiate progressive gait
training on the postop. 2-6 d.
 Active assisted exercise,
progress to active ROM motion
and strengthening exercises.
 For TKA, 90º of flexion should be
obtained at the first week.

Postoperative complications
 Infection: <1%, rare but catastrophic
 Dislocation: <5%, mostly within the first 3 month
 Deep Vein Thrombosis: 40-60%, but
asymptomatic, and high risk leading to fatal PE
 Myositis ossificans (heterotopic ossification) :
<1%, lead to a stiff hip
 Periprosthetic osteolysis: the final result of
artificial joint, lead to aseptic loosening of prosthesis,
the most common reason for revision surgery

Myositis ossificans
Various degrees of heterotopic ossification

osteolysis 1983
1984
1995
2002

How successful are these operations?
 At 1 year, nearly 95% of patients can expect a
good to excellent clinical result.
 These results are generally maintained at 6 to
10 years after the procedure.
 There is about a 1% failure rate per year,
yielding about a 90% success rate at 10 years.
 Generally, this is one of most successful
surgeries.

revision
 If the durability of artificial joint is not
longer than the individual longevity
 Reasons for revision
Aseptic loosening
Deep infection
Recurrent dislocation
Periprosthetic fracture

Revision of acetabular component

HIGHLIGHTS
 Problems affecting hip in each age group
 Options for treatment of arthritis
 Indications for arthroplasty and its options
 Perioperative management for arthroplasty
 All boxes in your textbook

Thank You for Your Attention
谢谢

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