Biomechanics collection

By

Cap. Dr. Mahmoud Massoud, MD

Helmya Military hospital
Military Academy
AFCM Lecturer

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Reference books:
-Concise orthopedic notes
-AO book
-Manual of internal fixation
-Stanmore trauma book
-Google schoolar
-Helmya trauma protocol
-McRae orthopedic
-Orthobullet

Content:

-General Biomechanics, 3
-sstress strain curve, 5
-Tribology, 7
-implant maufucturing, 9
-AO classification, 11
-Some important definitions, 13
-Principles of fracture treatment, 17
-Non operative fracture treat, 17
- Operative fracture treat, 20
(kwire/screw/plate/nail/ex.fix)
-Non union, 30
-Arthroplasty biomechanics, 33
-Bone cement, 36
-UHMWPE, 38
-TOTAL HIP REPLACEMENT, 39
(primary/revision/special)
-TKR, 57
-Shoulder arthroplasty, 65

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JOINTS Connection 2 bone ends
Fibrous bones connected by fibrous tissue eg.Skull, Distal tibio-fibular
Cartilaginous Bones connected by hyaline or fibro-cartilage eg.Intervetebral
Synovial: articular surface + synovial membrane
Isotropic Possess same mechanical properties in all directions of load (metal, ceramic)
Anisotropic Have mechanical properties that vary with change direction of loading (bone, ligament)
Property of structure (bone) not material (cortical/cancellous bone)
Effective joint space defined as area around prosthetic joint where fluid can dissipate freely
Geometry:

Bone is calcified connective tissue composed of: 25%water +

45% inorganic 30% organic matrix
Ca hydroxyappetite crystals Ptn collagen mainly
Give hardness & rigidity Give elasticity & flexibility
Function: support body eg.long bone & spine
protect inside SC & brain
attach muscles , ligaments,tendons
move joints
BM cell production
Mineral reservoir ca/p
Self repairing / remodling =
resorption( osteoclast) + reformate (osteoblast)

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BIOMECHANICS
Science of structure and function of biological tissues
Statics: Study of forces acting on rigid bodies, either at rest or at constant velocity
Dynamics: Study of forces acting on rigid bodies in motion
Kinetics: Study of forces acting on rigid bodies to produce movements
Kinematics: The branch of mechanics concerned with the motion of objects without reference to the
forces which cause the motion.
Kinesiology: The study of human movement
Newton’s Laws of Motion
First law: An object remains constant velocity, unless acted upon by a force ‫انجسم ساكن ما نم يتاثر بقىه‬
Second law: (F = ma). the mass × acceleration ‫انقىه تساوي انكتهت فً انسرعو‬
Third law: every action has an equal and opposite reaction ‫نكم فعم رد فعم مساوي نو فً انمقدار مضاد االتجاه‬
Force: has both magnitude and direction, making it a vector quantity
Types of forces:
←��→ Tensile 2 forces pull away from each other along same line
→��← Compressive 2 forces push against each other along same line
↑��↓ Shear parallel (tangential) to surface but not along same direction
�ↄ Torque Rotational force (turning moment) perpendicular to long axis of a body (large femoral
head in THR produces larger torque, leading to more volumetric wear)
Moment Force acting at distance from body (pivot) Causes twist (turning)
‫طاقة‬Energy: Ability to do work Potential Due to body position
Kinetic Work required to move body from rest to a velocity
‫محجه‬Vector: A quantity that has both magnitude and direction
Typically represented by an arrow whose direction is the same as that of the quantity and whose
length
is proportional to its magnitude.
‫ العزم‬Moment: Effect of a force at a perpendicular distance from the axis, which results in a rotational
movement andangular acceleration
Working length It is the unsupported length of a construct
Length between most distal point of fixation in proximal fragment and most proximal point of fixation
Longer working length - stress distributed over longer area of implant - construct is less stiff
Shorter working length - stress concentrated over small area – increases stiffness of implant
Moment of inertia (area) Ability of structure to resist deformation
Depends on mass and material & cross-sectional distribution of structure
Forces and lever arms Methods to resolve forces about a body:
1) Trigonometry Calculating values
2) Vectors estimating the direction of resulting vector
Lever:‫الروافع‬
Rigid structure that turns around fixed point (e.g. bones)
Moment arm: Perpendicular distance from pivot point (fulcrum) to line of action of force
Classes of levers:
-1st class Fulcrum between force and load
eg.Atlanto-occipital joint between erecter
spinae and head Scissors
-2nd class load between force and fulcrum
eg.Body weight on ankle between calf
muscles and toes when standing on tip toes
Nut cracker
-3rd class force between fulcrum and load
eg.Elbow flexion muscles between elbow and
hand

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 STRESS/ STRAIN CURVE
Deformation of material at distinct intervals of load (Unique for each material)
Stress Force per unit area (N/m2) 1N/ m2 = 1 Pascal , Can be tensile or compressive
Strain Change of length (deformation) of material when force is applied
Change in length/original length, therefore ratio/percentage
Fractures of cortical bone occur at 2% strain and cancellous bone fractures at 75% strain
Stiffness Ability of material to resist deformation, The steeper the slope the stiffer the material
NB. Stiffness is of a material, rigidity is of the whole structure
Elastic zone Elastic deformation - Reversible
Elasticity Ability to return to resting length/shape (zero strain) when stress removed
Area under elastic slope called resilience
Hooke law Stress is proportional to strain in elastic zone of stress-strain curve until proportionate limit
Yield point Transition from elastic (reversible) to plastic (irreversible) zone
Once material passes it, it no longer displays elastic behaviour
Plastic zone Material will not regain original shape when stress removed
Plastic deformation - irreversible (permanent)
Ultimate tensile Strength (UTS) Maximum stress (strength) before failure Broken instrument/stress
fracture
Strain hardening Occurs due to rearrangement of metal crystals, making them more intermingled to form ,
stronger structure during plastic deformation
Necking Between ultimate tensile strength and fracture/rupture Stress reduces as strain increases

Osteoporotic bone – yield point occurs at same strain as normal trabecular bone but the stress required to
achieve yield point is much less (osteoporotic bone is less stiffer than normal bone, but is more
brittle).
Osteomalacia – lower stiffness + higher ductility
Brittle material little or no plastic deformation eg. Ceramics & PMMA
Ductile material large plastic deformation before failure eg. Metal
Toughness Amount of energy material can absorb before failure or fracture
Strain hardening plastic deformation increases resistance to deformity

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Young modulus of elasticity Describes stiffness of material
Ability to resist deformation in elastic zone
Ceramic - Co-Cr alloy - Stainless steel - Titanium - Cortical bone - PMMA -
Polyethylene - Cancellous bone - Tendon/ligament – Cartilage

Fatigue Failure Progressive failure due to application of cyclical stresses below the UTS.
Starts at stress-risers
Stress shielding from modulus mismatch Seen with stiffer implants and extensively porous coated stems
Proximal coating allow proximal bone loading and less stress shielding

VISCOELASTIC MATERIALS
-Viscous behaviour Rate- and time-dependent change in stress-strain relationship
)‫مادة نسجت‬Viscosity - Internal friction of material or resistance of liquid to flow‫(انعسم‬
-Elastic behaviour return to original shape after deforming force removed
Characteristics:
-Creep Increased deformation of material with time under constant load
Cement, intervertebral disc, Ponseti technique
-Hysteresis Loss of energy under repeated loads
Unloading curve does not follow loading curve
Difference between two curves is energy dissipated due to internal friction
-Stress relaxation Decreased stress over time with constant strain
Tendons & ligaments (Ponseti treatment)
Hoop stresses during insertion of femoral stem , Cycling of ACL graft
Rate Dependent Strain Behaviour stiffer and stronger at high strain rates than at low strain rates

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 Tribology ‫جقابل المىاد‬
Science of interacting surfaces in relative motion Includes friction and lubrication and wear
Type of fluids Newtonian linear stress/strain relation, e.g. Salin
Non-Newtonian Synovial fluid (thixotropic characteristics: Viscosity decreases and the
fluid
thins over a period of continued stress.)
1.Friction
Resistance to motion of surfaces sliding over each other Converts kinetics into heat
Reduced by lubrication
Depend on load and coefficient of friction, Does not depend on surface area
Coefficient of friction - Articular cartilage < ceramic-on-ceramic < metal-on-metal < metal-on-poly
2.Lubrication
Process to reduce friction between opposing articulating surfaces by interposition of lubricant
Lubrication in THR
Boundary Contact between asperities due to high surface roughness of PE
Roughness/smoothness – depends on height of surface asperities (Ra)
Separated by lubricant, lubricin monolayer prevents direct contact of joint surfaces
Lambda ratio < 1
Hydrodynamic (fluid film) ‫طبقات‬
Movements create thin fluid film separates joint surfaces (Hard on hard)
Lambda ratio fluid film thickness/surface roughness > 3 for fluid film lubrication
Usually require low loads at high speed

Lubrication in articular cartilage ‫انطبيعً بتاع ربنا احسن‬

Squeeze film When standing still and
parallel surfaces get closer
Produces compressed film of synovial
fluid
Weeping Fluid exudes from loaded
articular cartilage
Boosted low molecular synovial
components are pushed into articular
cartilage leaving thicker Hyaluronic acid
behind
Elasto-hydrodynamic Elastic
deformation of articular bearing cartilage
to increase surface area During weight
transfer or toe-off stage of gait Fluid
pushed along

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3.Wettability
Affinity of surface material to lubricant Measured using Theta contact angle
Small angle < 450 – hydrophilic – better lubrication
Large angle > 900 – hydrophobic
Ceramic has greater wettability than metal
4.Hardness/notch sensitivity
Surface property Ability of material to resist scratching
Ceramic has greater Hardness than metal
5. WEAR & OSTEOLYSIS ‫مهم مهم‬
Wear: Progressive loss of bearing substance from the material secondary to either mechanical or chemical
(corrosive) action
a. Chemical dissolving of metal (corrosion) Unwanted loss of metal in an environment of solution
- Crevice Fatigue cracks or scratches with low oxygen tension
eg.316L stainless steel most prone to crevice corrosion
-Galvanic Electrochemical Between dissimilar metals such as stainless steel and cobalt-chrome,
-Fretting Micro-motion of two materials (abrasion of asperities‫ )بروزاث‬Movement disrupts
protective oxide layer E.g. under head of screw or Trunnionosis of male taper (ARMD)
- Pitting Localized crevice corrosion leading to formation of tiny holes on surface when
Passivating layer is removed (joint fluid comes in contact with metal – reoxidation of
Layer releases H+ that dissolves titanium and Co-Cr implants
b. Mechanical
- Adhesive Due to bonding between two bearing surfaces pressed together Material pulls away
from weaker surface
- Abrasive Asperities of harder material eroding softer one
- Fatigue Failure under ultimate tensile strength due to repeated loading cycles Also called
delamination Related to stress/strain curve and material stiffness
Quantification of wear:
- Volumetric volume of material Directly related to square of radius of head (increased sliding
distance) Dependant on type of articulation, lubrication and load
- Linear Height of material Distance prosthesis has penetrated into liner
Modes of wear:
1 Between normal bearing surfaces as intended by designer
2 Between bearing and non-bearing surfaces femoral head with acetabular shell following poly wear
Femoral component against tibial base plate
3 Normal bearing surfaces with interposed 3rd body
4 Two non-bearing surfaces back side of acetabulum poly liner and shell
Femoral neck against acetabular shell
Factors contributing to joint replacement wear ‫مهم جدااااا انا والعيان والمفصل‬
- Patient factors
Activity level, cultural demands // BMI // Co-morbidities
- Implant factors
Modular Vs mono-block // UHMWPE thickness // Fixation method // Implant constraint
Bearing material used
- Surgical factors
Soft tissue balance // Surgeon experience // 3rd body wear // Implant orientation
Wear rates
-Titanium poor resistance to wear
-UHMWPE 0.1-0.2 mm (100 – 200 MicroM)/year
-HXLPE Smaller wear particles & more resistant to wear 40 MicroM/year
-Metal on metal Small wear particles & more resistant to wear 5 MicrM/year Size of metal particles, 50
Nm
-Ceramics lowest wear rate, 2.5 MicroM/year

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 IMPLANT MANUFACTURING
�‫ قانب‬Casting pouring molten metal into mould
‫ انتعدين‬Annealing Heating to just below melting temperature then cooling and then cold-working
Decreases free radicals // Heat treatment alters material to increase ductility and make it more workable
� Work hardening Also called cold working Repeated tensile loading of metal alloy until it plastically
deforms // This will reduce voids and increase stiffness
� ‫سبيكت‬Alloying adding small amounts of other elements to pure metal to alter qualities
� When asked to talk about a material Manufacturing//Surface properties //Material properties
Surface properties Smooth/rough-hard/notched-wet/lubricant
Material properties Tough/fatiguable-stiff/stress shield-viseco/elastic

Composition Advantage Disadvantage

Stainless-steel Ductile, Susceptible to crevice
Carbon + iron = Steel stiff, corrosion & galvanic
Steel + > 4% Chromium = Stainless Steel good fatigue corrosion (with Co-Cr
3,16,L 3 % Molybdenum, 16% Nickel, L (low carbon) resistance heads)
< 0.03% (High carbon makes material more brittle), and cheap, Does not self passivate
20% Chromium + Molybdenum - reduces pitting corrosion Made by casting

Titanium � Biocompatible � Low resistance to wear

Titanium, aluminium &
Vanadium – TiAL6V4
Uses Plates, Screws,
Nails, femoral stems
Co-cr
Ceramic
Metallic (types) and non-metallic hardest material known
(Ca HA, silicon, TCP – Tri-
Calcium Phosphate) elements
bonded ioincally in highly
oxidized environment
Types
� Alumina (Aluminium oxide)
1st generation Yellow
� Zirconia (Zerconium oxide) 2nd As a result of these surface
generation Reduced grain size,
reduce porosity
� Delta (alumina + Zirconium)
Strontium to stop crack
propagation
Yttrium-stabilized tetragonal
zirconia particles – platelet like
� Closely match stiffness of bone (½
young modulus of Stainless steel)-
prevent stress shielding
� Titanium is 1.6 times tougher > SS
� Self-passivation (self-oxidation) -
formation of adherent oxide coating
on titanium implants
Enable titanium to become corrosion
resistant
� High fatigue resistance, ideal for
load bearing implants such as nails
Excellent resistance to crevice
corrosion
Excellent biocompatibility
Ductile
Imperfect lattice structure -
work hardening & annealing
allow dislocation
� Hard - Scratch resistant, 3rd
� Smooth Low co-efficient of
friction, good scratch profile
� Wettable - Strong hydrogen
bond with synovial fluid -
fluid film lubrication
� Low surface roughness
� Good scratch profile
properties
� High wear resistance- The
lowest wear rates of any
bearing combination. Wear
debris particles smaller than
PE
wear particles, less
� Notch sensitivity
� Rough
� Cold welding - when physical
disruption of passivation layer with
locking screws
Poor scratch profile
Co-Cr generally used for cemented
implants
� Brittle - no plastic deformation
before failure
� Fracture – increased risk with high
BMI and smaller head size, fracture
produces multiple hard sharp debris,
can
damage morse taper, revision includes
synovectomy to remove debris (0.04%
fracture risk with newer ceramics)
� Not tough
� Squeaking- due to edge loading
from malpositioning leading to loss of
fluid film lubrication
� Less modularity- fewer neck length
options
� Stripe wear- caused by contact
between femoral head and rim of cup

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crystals to prevent initiation and
propagation of cracks
Pink colour is due to the
chromium oxide (Cr2 O3) that
improves the hardness of the
composite
material
� Oxinium - Surface made of
oxidized zirconium over a metal
core
biologically active particles,
less abrasive and linear wear
� Bioinert (Chemically
inactive)- no risk of cancer
� High young‟s modulus of
elasticity - stiff, resists
deformation, not subject to
creep
� Does not corrode
during partial subluxation,
Result in crescent shaped line on
femoral head, Clinical significance
unknown
� Expensive
When revising THR with a pre-
existing ceramic implant, it is
recommended to use ceramic again
because there will be
ceramic debris from the original
ceramic and the ceramic has the best
hardness

Ti Co-cr ceramic
ss

Manufacturing ceramics
Sintering ceramic powder and water into pre-fabricated casts (smaller grain size – stronger ceramic),
sintering (hot isostatic pressing binds individual grains more tightly – increases density and toughness),
powder heated to below melting and subjected to high isostatic pressure. This will improve density and
avoid defects
Oxinium
Metal alloy of Zirconium with surface transformed to ceramic by oxidation in air
Thus ceramic is a part of the material and not a coating
Superior resistance to abrasion compared to metal without risk of brittle fracture
Used as bearing surface in people with metal allergy
Expensive

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Bone fracture
AO classification coding Algorithm

Bone: Each has a number 1,2,…9

- Segments, location:
prox.1/mid2/distal3 + neck femur, Malleolus

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Some important definitions

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Absolute stability is the absence of motion between fracture fragments under normal physiological loading.
Fixation methods and corresponding predominant
type of fracture healing
Compression Primary healing direct cortical
plate healing (‘cone-cutting’)
Cast treatment Secondary healing –
enchondral and
intramembranous ossification
Intramedullary Secondary healing –
nailing enchondral and
intramembranous ossification
External fixation Secondary healing –
enchondral and
intramembranous ossification

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 PRINCIPLES OF FRACTURE TREATMENT

The three fundamental principles are:

1. Reduction. 2. Immobilization. 3. Preservation of function.

REDUCTION
The decision about whether a fracture requires
reduction is based primarily on the likely functional
result of the existing position. Although imperfect
apposition may often be accepted, a few degrees of
malalignment or rotation can have a significant effect
on functional outcome. Reduction can be achieved by
closed manipulation, traction or open (surgical)
reduction.

IMMOBILIZATION
Not every fracture requires immobilization. Indications include:
1. Prevention of fracture angulation or displacement.
2. Prevention of excessive movement that could inhibit fracture healing.
3. Pain relief.
Techniques for fracture immobilization can fall into one of four categories:
Non-operative fracture fixation 1. Cast/external splint. 2. Traction.
Operative fracture fixation 3. Internal fixation. 4. External fixation.

NON-OPERATIVE FRACTURE FIXATION

Many fractures can be treated non-operatively provided that adequate reduction can be achieved and maintained.

1.CASTING Used when the fracture pattern is deemed stable, or in patients in whom operative treatment is
contraindicated, casting is the mainstay of treatment. The two materials used mostly are as follows:
a. Plaster of Paris ‫ – جبس ابيض‬hemihydrated calcium sulphate. In contact with water, it reacts to form
hydrated calcium sulphate. This reaction is exothermic. Plaster is pliable and slow to set, allowing time for
moulding of the cast.(sizes 5/10/15/20 cm)
b. Fibreglass ‫ – جبس بالتسحي‬knitted fibreglass is impregnated with a resin that polymerizes and hardens when
immersed in water. Fibreglass is lighter in weight and more radiolucent than plaster of Paris; however,
moulding is more difficult.(inch 3/5/7)

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 NB.Warmer water causes both materials to harden more quickly. In general, the temperature of the water
should be tepid or slightly warm for plaster and cool or room temperature for fibreglass.
Whichever material is used, a number of principles should be adhered to when applying a cast:
Avoid local pressure during hardening of the plaster to prevent skin ischaemia.
The joints proximal and distal to the fracture should be included, unless the fracture is very distal (e.g.
distal radius fracture/ankle malleolar fracture).
Allow joints that are not immobilized to move freely.
Ensure that bony prominences are adequately padded.
Treatment of fresh fractures should be with a cast that allows for subsequent swelling (back slab/split
cast) to reduce the risk of compartment syndrome.
Moulding „A bent cast produces a straight bone‟. Sir John Charnley first described the principle of three-point
fixation. Three-point fixation can be achieved only with a complete (i.e. circumferential) cast.
NB.If a fracture displaces within a well-moulded cast, it is by definition unstable and requires another method of
fixation.
Complications of casts
Burns – resulting from hot water and/or exothermic reaction as cast sets.
Swelling in the area of extremity distal to the cast (e.g. fingers).
Pressure areas. Joint stiffness. Muscle atrophy from disuse.
Compartment syndrome . Although normally the result of excessive pressure within a fascial
compartment, swelling within a circumferential cast (or bandage) may produce the same clinical entity.

2.FUNCTIONAL BRACING
First introduced in the 1960s, functional bracing has a major advantage over traditional casting in that it allows
early movement of the muscles and joints while maintaining fracture alignment. The object is to achieve good
function in the limb with minimal discomfort while allowing fracture healing to occur. Together with the
functional brace, the soft tissues play an important role in fracture fragment stabilization, by allowing controlled
motion at the fracture site and thus enhancing secondary fracture healing.
The most famous example of functional bracing is Sarmiento‟s non-operative treatment of tibial shaft fractures.
After initial satisfactory fracture alignment is achieved, the injured leg is placed into a long-leg cast with the knee
in nearly full extension. This cast is then removed, and the functional brace (custom or „off the shelf‟) is applied
after early signs of union, usually 2–4 weeks after the injury. The functional brace principle allows
weightbearing as tolerated by the patient, coupled with ankle and knee movements. Sarmiento reported union
rates of 98.5 per cent in tibial shaft fractures treated in this way. However, the high success of this treatment
modality is reliant upon careful patient selection . The functional brace treatment has also been successfully
applied to humeral shaft and isolated ulnar fractures.
eg. Functional bracing of the tibia
Indications Relative contraindications
1.Low-energy closed transverse fractures that are either 1.Selected diaphyseal tibial fractures with an intact
non-displaced or have been reduced and made axially fibula.
stable. 2.Fractures in polytraumatized patients.
2.Closed axially unstable fractures (i.e. oblique, spiral 3.Axially unstable fractures with initial shortening
or comminuted fractures) that demonstrate <12 mm of >12 mm.
initial shortening.
3.Low-energy closed segmental fractures with minimal
displacement between fragments, with initial shortening
of ≤12 mm.
4.Grade I open fractures that meet the same criteria as
described for the first three categories.
5.All of the above, provided angulation is ≤5° after
reduction and application of the initial or corrective
above-knee cast.
6. Isolated tibial or fibular fractures that meet the
requirements outlined above in patients who have other
fractures that do not preclude ambulation with the aid of
external support.

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3.TRACTION Traction (either skin or skeletal) can be used to reduce and hold fractures, but it is more
commonly used as a temporizing measure to relieve muscle spasm, prevent shortening and limit pain while
awaiting definitive fixation.
A.Skin traction
Adhesive tapes or bandages connect the extremity
to the traction weight system. In modern fracture
management, skin traction is used mostly for
stabilizing paediatric femoral fractures or for
temporary stabilization of adult hip or femoral
shaft fractures. It is rarely used as definitive
treatment in adults. A maximum of 10 lb should
be used in adults, to prevent excessive shearing
forces. This maximum is greatly reduced in
children and adults with fragile skin (elderly
patients; prolonged steroid use). The skin beneath
the traction tapes should be inspected at regular
intervals.
B.Skeletal traction
Placement of a wire or pin through a bone allows traction to be applied in a more controlled and powerful
manner (up to 20 per cent of body weight) and for longer periods of time. Although skeletal traction has now
been superseded by external fixation in many instances, one example of its continued use is in the initial
management of acetabular fractures awaiting surgical fixation. Typical placement of the skeletal traction pin is in
the distal femur or, more frequently, the proximal tibia .
Distal femoral pin insertion
The pin should be passed from medial to lateral to avoid injury to the femoral artery as the pin exits.
The ideal entry point is immediately proximal to the adductor tubercle.
If the pin is inserted too distally, it risks penetrating the joint at the intercondylar notch.
If the pin is inserted too proximally, there is potential for damage to the femoral artery at the adductor
canal.
The pin should be parallel to the knee joint, not perpendicular to the femoral shaft.
Proximal tibial pin insertion
This is the preferred site for many injuries.
The ideal entry point is 2.5 cm posterior and inferior to the tibial tuberosity.
If the pin is inserted too proximally, there is an increased risk that metalwork will cut through the weak
metaphyseal bone.
If the pin is inserted too distally, the common peroneal nerve is potentially endangered.
Os calcis pin insertion
The pin should be passed from medial to lateral 2.5 cm inferoposterior to the medial malleolus.

Complications of skeletal
traction:
Pin tract infection.
Neurovascular damage.
Pull out of traction pin
Overdistraction of the fracture
(long bone).

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 OPERATIVE FRACTURE FIXATION
INTERNAL FIXATION
In 1958, the AO formulated four basic principles, which have become the guidline to internal fixation

Before any form of surgical intervention, it should be ensured that adequate radiological investigations have been
performed and reviewed, the correct implants are available, and that the surgeon is sufficiently familiar with the
equipment.
Management of specific fractures is discussed in the appropriate chapters. General indications for operative
fracture fixation include: PVONU
Multiple fractures/polytrauma patients. / Pathological fractures.
Vascular injury associated
Open fractures
Neuro injury associated (spine)
Unstable fractures. Irreducible fractures. Or cant maintain stability
Fracture non-union..

1.Kirschner wires
First used in the early 1900s, these flexible wires range in size from 0.6–3.0 mm and may be smooth or threaded,
diamond or trochar tipped, and single ended or double ended.
Kirschner wires (K-wires) may be used for:
a. Provisional fixation, where b. Definitive fixation, if the forces acting across a fracture site are
initial intraoperative maintenance of relatively small. Examples include fractures near a joint and fractures
fracture reduction is difficult. where the length of the bone is small. In definitive fracture management,
Provisional wire placement may also K-wires may be used: To compress the fracture fragment by engaging
facilitate the subsequent insertion of both cortices. In this instance, an initial wire should be placed at right
cannulated screws (e.g. tibial plateau angles to the fracture plane, with a second wire placed obliquely to the
fracture fixation). first, to provide additional stability .
As an intramedullary device for rotationally stable
fractures (e.g. oblique fractures of MCB).
As a buttressing device (e.g. Kapandji technique).

Advantages of Kirschner Disadvantages

wire fixation:
Minimal soft tissue/periosteal
disruption. No expert knowledge
of equipment required.
Multiple wire insertion allows
multiplanar stability.
Percutaneous placement can lead to neurovascular/other soft tissue
damage.
Wires can migrate (back out or bury subcutaneously).
Fracture often requires additional fixation method (e.g. cast).
Risk of infection exists from percutaneous wires remaining in situ for
several weeks.

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 2.Screw fixation
A screw is a device that converts torsional force into axial force.
Screws may be used as a sole fixation device or in combination with other implants. The screw has a
common design consisting of a tip, shaft, thread and head. The screw can be non-tapping (round tip) or
self-tapping (fluted tip). Flute Remove bone debris in self tapping screws.
Head Attachment for screw driver that helps
to arrest forward motion and allows -Major diameter – The thread diameter is small for cortical
compression through a dynamic screws, designed for compact diaphyseal bone. Cancellous
compression plate //Has conical part for screws, for use in metaphyseal trabecular bone, have a larger
countersinking or flat Hexagonal - avoids thread. Screws are referred to by their major diameter.
slippage and better torque spread across 6 -Minor diameter – the shaft diameter, which determines the
points Star or Cross shape screw‟s resistance to breakage.
Run out Transitional area between head -Pitch – the distance between adjacent threads.
and thread – weakest part of the screw -Lead – the distance a screw advances with one complete turn.
Allow counter sink If the screw is single threaded, the lead is the same as the pitch.
If the screw is double threaded (designed for faster screw
Shaft Dictates bending and rotational
insertion), the lead is twice the pitch . cortical screw has finer
strength
pitch than cancellous
Thread Determine outer diameterDeeper
-Torsional rigidity is proportional to 4 th power core diameter
thread – the greater resistance to pull-
-Bending rigidity proportional to 4 th power of radius of core
out//Outer
diameter dictates pull-out strength
Thread depth = (outer - core diameter)/2
Tip Blunt or self-tapping

Diameter of core determines drill used ‫حفظ مهم‬

Mini set→‫بنطه‬
1.5mm cortical screw→ 1.1
2.0mm cortical screw →1.5
2.7mm cortical screw →2.0
Small set
3.5mm cortical screw →2.5
4.0mm (locking) →3.2
4.0mm (cancellous) → 2.5
Large set
4.5mm cortical screw→3.2
5.0mm (locking) →4.3
6.5mm (cancellous) → 3.2
7.3mm (cannulated) →5.0

Dr. Ma§ǫud | 21
 -Factors improving screw performance:
Design modification
Increase minor diameter.
Increase major diameter.
Decrease minor diameter.
Increase thread density (pitch).
How to maximize pullout strength
� Larger outer/inner core diameter ratio (thread depth)
Increase outer diameter Decrease inner diameter
� More threads Smaller pitch Longer screw
� Locking screw � More threads

Screw function-There are two main modes in a which a screw may be used in the context of fracture
fixation: as a lag screw and as a neutralization or positional screw.
a.-Lag screws:
Lag screws are used to compress fracture fragments. The thread „grips‟ into the cancellous bone or opposite
cortex, but it slides through the near cortex. Tightening the screw presses the screw head against the near cortex,
thus compressing the fracture fragments. Ideally, a lag screw should be perpendicular to the fracture plane. Most
lag screws require an additional fixation method to neutralize shearing or torsional forces .
Ratio of length of fracture /diameter of bone should be at least 2:1
Lag screw is weak against shear and bending forces – add neutralization plate
Fully threaded versus partially threaded and
lag screws:
For a fully threaded screw to act in a lag mode, the
near cortex must be overdrilled to the size of thread
diameter of the screw, so that the thread does not
obtain purchase in the near cortex . This glide hole
must be along the same axis as the thread hole (which
is the same diameter as the core of the screw) in the far
cortex. One of two techniques can be employed:
1. Drill both cortices with the thread hole–sized drill,
and then overdrill the near cortex.
2. Create the gliding hole first, insert a drill sleeve for
the thread hole drill bit through this gliding hole and
finally drill the far cortex.
Partially threaded screws are specifically designed as
lag screws. The threads engage the far cortex with
the smooth shaft sliding in the near cortex. The
threads of the partially threaded screw must lie
beyond the fracture line.

Herbert screw Differential pitch with coarse

pitch distally (advancing more than proximal end of
screw with each turn) /Cannulated /Lower thread
depth results in decreased pull out strength
Headless Self-tapping Self-drilling Double-pitch
Countersink
To increase surface area to reduce stress (stress=force/area)
Only on cortical bone Countersinking cancellous bone will leave soft bone which less able to resist stress –
use washer Washer acts as 1-hole plate to improve compression, spreads load applied by head on
underlying cortex preventing screw head from breaking through thin cortex.

b.Neutralization or positional screws:

Neutralization or positional screws are used to attach another implant (e.g. a plate) to the bone. The function of
this screw type can be modified to provide fracture compression, either by directing the screw across the fracture
site in a lag mode or by eccentrically placing the screw through oval shaped holes on a dynamic compression
plate (DCP).

Dr. Ma§ǫud | 22
3.Tension band principle
Device that transform distraction tensile forces into compression forces by translating center of rotation of a
fracture from compression side to tensile side
Pre-requisites Need to neutralize rotational forces with K wires/screws
Implant (plate or wire) strong enough to withstand tensile forces should be used on tensile surface
Need strong opposite cortex to bear compressive load
Intact buttress of opposite cortex - Fracture should not be comminuted (as it will lead to collapse)
Devices K-wires and cerclage wire Plate
Sites olecranon, patella, medial malleolus, GT of humerus, 5 th MT
Tension-band plating of femur (on lateral aspect)
Can be used for small fractures that can‟t be fixed with other techniques
In patella quadriceps muscle and patellar tendon exert tension on anterior aspect
Cerclage wire resists tensile forces ,and energy transferred to posterior articular aspect as compressive
With tension band configurations, tensile fracture
distracting forces are converted into compression
forces at the opposite cortex (usually an articular
surface). It is essential that the cortex distant from the
tension band side (i.e. the articular surface) is strong
enough to bear the applied compressive load. The
tension band principle can be applied to wires, cables,
suture, plates and external fixators .
The most common clinical uses are with K-wires and
a figure-of-eight cerclage wire technique in fractures
of the patella, olecranon and medial malleolus.
Advantage: This technique permits an early range of
movement.
Disadvantage : Metal work can back out or cut out,
necessitating removal.

4.Plates
Definition: Stripe of biomaterial containing holes that accept screws, conventional or locking
Plates can be classified according to their design (compression/one-third tubular, reconstruction, locking) or
function (compression, neutralization, antiglide, buttress, bridging).
General principles of plate use:
Soft tissue stripping should be minimized.
The selected plate should be appropriate for the function intended.
It is important to ensure that sufficient screws are used either side of the fracture .
As the distance of the closest screws to the fracture (the working distance) increases, the plate-screw
construct becomes less rigid.
More than one plate may be required if the fracture is unstable in multiple planes. Minimum number of
screws required for adequate fixation with a conventional (non-locking) plate

Number of screws Number of cortices

Forearm 3 6
Humerus 3–4 6–8
Tibia 4 7–8
Femur 4–5 8
Mechanical properties of a plate
-The strength of a plate varies according to the material from which it is manufactured and the second moment
of area (SMA). The SMA refers to the spatial distribution of material within the plate structure. The rigidity of
a plate is therefore proportional to the third power of the plate‟s thickness.
-For a structure with a quadrilateral cross-section (e.g. a plate), the value of the SMA = wh 3/12.
Stability of construct determined by screw-plate interface rather than bone-plate interface
Uses thicker screws – increased core diameter and lower pitch (as stiffness of construct depends on
bending stiffness of screw and not on their pull-out strength)

Dr. Ma§ǫud | 23
 Stability increases with
� bicortical locking screws � Increased number of screws
� Screw divergence from screw hole < 5 deg (cross-threading reduces overall bending
stiffness by 30 - 60%) � Longer plate
Working length distance between two screws closest to fracture
Unsupported section on both sides of fracture
Decrease working length to decrease strain across fracture
Use 6 – 8 cortices on each fracture side to neutralize torsional forces
Rigidity (bending stiffness) is proportional to cube value (3 rd power) of thickness (rectangular
structure)

a. Compression plates
Fracture healing is promoted by compression at the fracture site. Compression plates can achieve fracture
compression in one of two ways:
1. Static compression – pre-stressing of a plate can produce axial compression at the fracture site nearest the
plate, but it can produce fracture distraction at the cortex opposite the plate. To reduce this fracture distraction,
the plate should be contoured to ensure a concave bend, creating compressive forces on both the far and near
cortices of the fracture .
One-third tubular plate
This plate is thin (1 mm). Its pliability allows relatively
easy contouring. It is primarily used as a neutralization
plate, when a lag screw has already provided fracture
compression (e.g. lateral malleolar ankle fractures).
Oval holes on the plate allow for a small degree of
fracture compression.
Reconstruction plates
These plates are thinner than DCPs but thicker than
one-third tubular plates. Deep notches in the side of the
plate allow contouring in three planes. Oval screw
holes allow limited fracture compression.

2. Dynamic compression – the screw holes in DCPs are oval and shaped with an angle of inclination orientated
away from the fracture . A screw is eccentrically placed at the end of the hole farthest from the fracture; when
tightened, the screw head slides down the angle of inclination, resulting in movement of the bone relative to
the plate and creating compression at the fracture site.
The plate-bone interface creates a „compartment‟ under the plate that
can result in periosteal compromise and subsequent necrosis. Limited-
contact DCPs (LC-DCPs) are designed to limit stress shielding and
vascular compromise from plate fixation, by decreasing plate-to-bone
contact. In principle, this leads to improved cortical perfusion with
increased preservation of the periosteal vascular network, potentially
optimizing union.

Dr. Ma§ǫud | 24
 b. Locking plates
-Locking Threaded screw hole that allows screw to lock
into plate and perform as fixed-angle device
-Acts as internal external-fixator
-Useful for Osteoporotic bone
-To bridge comminuted fractures
-Can use unicortical locking screws in presence of other
obstructing irremovable metalwork
-Better pull out strength of the whole construct
-Preserve periosteal blood supply (sits off bone)
-Expensive
-Cold welding – difficult to remove screws
Since their introduction, locking plates have become increasingly popular, and indications for their use
continue to expand. The holes in a locking screw plate are threaded, as are the heads of the corresponding
screws, which therefore lock into the plate when tightened . This configuration provides a rigid construct for the
fixation of fractures and acts along a biomechanical principle similar to that of external fixators. Consequently,
locking plate systems have been referred to as „internal, external fixators‟.
Locking plates systems have a number of advantages over conventional non-locking plates:
They do not require precise adaptation of the plate to the contours of underlying bone. In non-locking
systems, failure to ensure intimate contact of the plate on the bone can result in loss of reduction upon screw
tightening. Because the screws lock into the plate, they can stabilize a fracture fragment without the need to
compress the plate to the bone. However, placement of locking screws cannot alter fracture reduction.
• Because locking plates sit slightly off the bone, the underlying periosteum is compromised much less than with
conventional plates .
• Locking plate systems have been shown to provide a more stable fracture fixation, even in poor quality bone.
• Some locking plate systems can be inserted percutaneously, creating multiple small incisions, as opposed to a
single large incision („minimally invasive plate osteosynthesis‟ – MIPO). A potential drawback of this technique
is the higher chance of malunion; accurate reduction is more easily obtained via an open approach.
Many locking plates have combination holes
(combi-hole DCP)allowing insertion of either a
locking screw or a conventional screw. Non-locking
screws allow fracture compression by eccentric
screw placement or permit lagging through the
plate. This must be undertaken before the first
locking screw is sited.
Indications for the use of locking plates include:
Complex periarticular fractures.
Comminuted metaphyseal or diaphyseal fractures.
Periprosthetic fractures.
Fractures occurring in poor quality bone (e.g. osteoporotic bone).
Metaphyseal fractures of long bones in which intramedullary nail fixation may have a high
likelihood of malalignment.
Some advocates of locking plates claim that unicortical locking screws provide adequate fixation. The
authors‟ preference, however, is to use bicortical locking screws where possible; unicortical locking screws
have lower torsion fixation strength than non-locking bicortical constructs. A minimum of two bicortical or
three unicortical screws on either side of the fracture should be used.
The following factors maximize locking plate construct stability:
Use of bicortical locking screws. Use of a large number of screws.
Minimization of screw divergence from the screw hole (<5°). Use of a long plate.

Less invasive stabilization system (LISS)

Mini incision / percutinous/ locked /unicortical / preserve periosteal blood supply

Dr. Ma§ǫud | 25
Plate usage: ‫مهم مهم مهم‬
Plates are mainly used in one of six modes:
1. Neutralization – this protects lag screw fixation from bending, torsional and shearing forces.
2. Compression – plates provide compression at the fracture site.
3. Bridging – no screws are placed at the level of the fracture. This provides relative stability, relative
length and alignment in fractures where there has been bone stock loss (comminuted, unstable fractures).
A bridging plate preserves the blood supply to the fracture fragments.
-Plate Span Ratio: Total Plate Length / Fracture Length
2-3 times in large comminuted fractures, screws close tofracture
8-10 times in short fractures, screws NOT too close to fracture but 1-3 empty holes in bridging
titanium plate are usually efficient Sufficient, but not excessive screw number
-More than 3 or 4 bi-cortical screws in bone shaft segment do not add much to axial stiffness or
torsional stiffness respectively
-Plate Screw Density:Number of Screws/ Number of Holes
Value usually < 0.5 or 0.4 in shaft: less than half of diaphyseal holes filled tends to reduce failure risk
4. Buttress – the plate counteracts compression and shear forces that often occur with fractures of the
metaphysis and epiphysis. The buttress plate is always fixed to the larger fracture fragment; however, it
does not necessarily require fixation to the smaller.
5. Antiglide plate – this is a development of the buttress plate. The plate is secured at the apex of an
oblique fracture, creating an „axilla‟ which prevents shortening or angular displacement.
Resists shear forces during axial loading Plate must conform to bone contour
Intra-articular – buttress Diaphysis – anti-glide
6. Tension band plate – this works in accordance with the tension band principle. A plate applied to the
tensile side of an eccentrically loaded bone converts the tension forces into compressive forces at the
fracture site.

4.Intramedullary nailing
The primary use of intramedullary nails is in the stabilization of diaphyseal long bone fractures, by acting
as load-sharing devices(Load sharing device Can be load bearing if there is significant bone loss)
. This technique allows early joint mobilization, ambulation and weight bearing and promotes both
endochondral and intramembranous fracture healing.
Mechanical properties of a nail:
The mechanical properties of an intramedullary nail rely upon a number of factors:
-Bending rigidity – This depends upon the elastic modulus and the polar moment area (PMA) of the nail.
Thus the bending rigidity of the nail is proportional to the fourth power of the radius. Increasing the nail
diameter by 10 per cent increases bending rigidity by 50 percent.
For a structure with a circular cross-section, the value of the SMA = πr4/2.
-Torsional rigidity – Torsional rigidity depends upon the shear modulus and the polar moment of inertia
of the nail. A slotted or cannulated nail has a decreased moment of inertia when compared with a solid
nail of the same length and diameter and therefore less torsional rigidity.
� Working length
Length of bone between most proximal and most distal fixation points
Reaming reduces working length of nail by jamming bigger diameter nail at isthmus – stiffer
construct
Fragmented fracture – increased working length – partial weight bearing
Transverse fracture – short working length – FWB
� Slotted nails
Allow compression by isthmus and tighter fit
Reduced nail mass will reduce ability to resist forces and rigidity reduced
Slot disrupts hoop stresses and reduces rigidity and resistance to torque
� Hollow nails
More flexible to anatomical variations than solid nails
Reduced rigidity due to reduced mass compensated by reaming to use larger nail

Dr. Ma§ǫud | 26
 Increase risk of bacterial infection persistence
End caps prevent bone ingrowth into nail // Extend nail height if it is over inserted
-Reamed versus unreamed nails
The practice of sequential reaming of the medullary canal before nail insertion has both advantages and
disadvantages:
Advantages Disadvantages
-Reaming allows for a 1.The potential exists for fat embolism syndrome. Reaming can increase the
larger diameter nail to be pressure within the femoral canal, thus leading to embolization of medullary
used, resulting in a more contents into blood vessels. Animal studies suggest significant risk of pulmonary
rigid fixation. injury, although this has not been demonstrated in clinical practice.
-Reaming allows accurate 2.The endosteal blood supply is disrupted (diaphyseal bone has a two-thirds
sizing of the nail to be endosteal, one-third periosteal blood supply). The clinical effect of this is
inserted debatable because at 12 weeks after operation, the endosteal blood supply has
-Reaming may carry bone been restored in both reamed and unreamed nails. Over-reaming of the canal,
graft material into the relative to the size of the nail to be inserted, allows space for the endosteal blood
fracture site, thereby supply to regenerate.
potentially aiding fracture 3.Thermal necrosis – This has not been shown to be of clinical significance;
healing. however, the use of a tourniquet should be avoided to allow heat generated by
-Union rates are increased. reaming to be dissipated by blood flow through the limb.
Time to union is decreased.
Generations of femoral nails
1st Antegrade (cephalomedullary & retrograde)
2nd 2 recon screws, proximal diameter 13 mm(cervicomedullary)
3rd PFN /Gamma/IMHS Sliding screws Wider proximally, 16 mm(centromedullary)
4th Compression of fracture - InterTAN
Interlocking screws provide axial and rotational and angular stability
Increased radiation exposure // Holes weaken nail

1st 2nd 3rd 4rd

Locking configurations
Locking of a nail provides rotational stability. Locking configurations may be static or dynamic. The standard
locking configuration in all primary intramedullary nailing procedures is static, where screws are passed through
non-slotted (circular) holes in the nail. Static locking provides axial, as well as rotational, stability and is
particularly useful when the fracture is unstable, or early weightbearing is preferable. A statically locked nail is
more load bearing.
With dynamic locking, screws are passed though slotted (oval) holes maintaining rotational control while
allowing a degree of axial compression at the fracture site . This configuration should be reserved for stable
fracture patterns, and in such circumstances, the nail can be more load sharing. It is common practice to insert
screws into both slotted and non-slotted locking holes, to allow conversion from static to dynamic locking at a
later stage. This is achieved by removal of the screw from the non-slotted hole, and it may be of use in some
cases of delayed union.

Dr. Ma§ǫud | 27
5.EXTERNAL FIXATORS

External fixators employ percutaneously placed, transosseous pins, wires or a combination of

Dynamic locking screw. The screw isboth, attached to external scaffolding. Many techniques and external fixator
configurations are available; however, three basic concepts should be adhered to when applying the construct:
1. Pins and wires should avoid vital structures.
2. Access to the zone of injury should not be impeded.
3. The construct should be appropriate for the mechanical demands of the patient and the injury.
Principles Avoid placing pins inside zone of injury
Avoid bone necrosis, pilot drill hole cooling with saline irrigation, stop-start technique
Safe corridors to avoid NV injury, Circular frame require safe corridor on both sides of bone
Increase rigidity as below
Convert to ORIF before 2 weeks to reduce risk of infection

Indications for the use of external fixators in the trauma setting may be broadly divided into temporizing versus
definitive.
Definitive fracture fixation Temporary fracture fixation
-Open fractures – minimizing further soft tissue damage. -Damage control surgery (e.g. long
-Periarticular fractures – where the close proximity of the fracture to bone fractures in the polytrauma
the articular surface would make patient).
other forms of operative fixation technically difficult.The use of -Pelvic ring injury.
bridging external fixation (i.e. -Periarticular fractures, where
crossing the affected joint) can allow fracture reduction by temporary bridging of the joint can
ligamentotaxis. allow swelling to subside before open
-Paediatric fractures – particularly in long bone fractures where the use reduction and internal fixation are
of intramedullary devices could compromise the physis. undertaken.
Advantages of external fixators over other operative Disadvantages
techniques -Pin sites require prolonged
-Minimal soft tissue and periosteal damage occurs. nursing care, with a high incidence
-The procedure is relatively quick and technically straightforward. of pin tract infections.
-Blood loss is reduced. -It can be difficult to achieve
-Flexibility of design – the position of transosseous pins/wires can be adequate fracture reduction.
chosen according to fracture pattern or soft tissue coverage. Multiplanar -Percutaneous pin placement may
stability is achievable. result in neurovascular damage.
-Can be used for temporary or definitive fracture management. -Tethering of muscles or tendons
-Rigidity of fixation is adjustable without surgery. inhibits rehabilitation.
-Excellent stability can allow for early range of movement or -They are often uncomfortable,
weightbearing. cumbersome or aesthetically
-Can be used even in the presence of osteomyelitis. displeasing.
Easily removed.

External fixator constructs

External fixator constructs fall into two broad groups – unilateral frames and circular/ring frames. (A hybrid
construct comprises a unilateral frame with ring attachments.) Both groups have components consisting of:
Pins/wires – these should be bicortical.
Clamps – these are used to attach pins/wires to scaffold.
Scaffold – this provides a rigid construct for fracture stability.
Unilateral frame: This relatively simple design is positioned on one side of the limb. The most stable
construct is achieved by inserting the screws in a „near-near, far-far‟ configuration; two screws, one either side of
the fracture, are placed as close as possible to the fracture (near-near) while two more pins are sited at some
distance proximal and distal to the fracture (far-far) .
If the fracture pattern is stable, one bar connecting all pins is usually sufficient to provide fixation. However, in
unstable fractures or those with significant bone loss, two bars are mounted, either both in one plane or in two
different planes, and joined together. This modularity of the external fixator makes it versatile and allows it to be
used for both fracture reduction and fracture fixation.

Dr. Ma§ǫud | 28
 The stability of unilateral external fixators can be increased by:
Ensuring contact between bone ends (most important).
Using larger-diameter pins (next most important).
Using additional pins in different planes.
Decreased bone to rod distance.
Use of additional rods in the same plane („rod stacking‟).
Use of additional rods in different planes.
Increased spacing between pins („near-near, far-far‟).
Circular/ring external fixators
These external fixators use rings (entire or partial) that encircle the limb, rods that interconnect the rings and
transosseous, tensioned pins that pass from the rings. The large variation in fixator configuration allows for
multiplanar stability/correction.
In the trauma setting, ring fixators are particularly useful in:
-Multifragmentary fractures or fractures with bone loss.
-Fractures associated with severe soft tissue compromise.
- Fractures of the proximal or distal diaphysis with extension into the metaphysis, or where there is
metaphyseal-diaphyseal separation. The stability of the ring configuration is variable. Complete rings
provide the most rigidity; however, partial rings are useful for providing stability in periarticular regions
while allowing access for wound care. Smaller-diameter rings confer greater stability; the smallest-
diameter ring that will fit the limb should be used (although a circumferential 2-cm space between skin
and frame should be maintained to allow for swelling). The use of two rings per main fracture fragment
further increases construct stability, and rings should be arranged, perpendicular to the long axis of the
bone, in a „near-near, far-far‟ configuration.
-The ring scaffolding supports the underlying bone through the transosseous transfixation wires and
half-pins; stability increases with wire diameter. Wire tensioning (usually to 130 Nm) provides added
rigidity and stability, and addition of half pins confers additional resistance to bending and torsion.
Wires should ideally be inserted perpendicular to one another. Wires placed at an angle of less than 60°
to one another increase the risk of bone sliding along the wire, although this can be reduced by using
olive wires to produce a buttress effect.
Factors that increase stability of circular external fixators:
Decreased ring diameter. Increased number of rings.
„Near-near, far-far‟ configuration. Larger wire diameter.
Increased wire tension. Wires crossing perpendicular to one other.
Olive wires. Additional wires.
Frame types
When used for fracture immobilization, unilateral or circular frames may be non-spanning or joint spanning.
Non-spanning frames
These frames are typically used for diaphyseal fractures, to allow movement at adjacent joints. A
particularly useful development has been the Taylor Spatial Frame, allowing postoperative correction in
all six degrees of freedom. This means that the fixator can be applied very quickly in the damage-
limitation setting and subsequently „fine-tuned‟.
Joint spanning
This configuration is typically used for periarticular fractures, either temporarily or to provide definitive
fixation through ligamentotaxis. Articulating joint spanning external fixators are used for periarticular
fractures associated with ligamentous injury (usually ankle, elbow or knee), to allow some joint
movement. Non-articulating joint spanning external fixators potentially provide a more stable construct,
but with an increased risk of long-term stiffness in the affected joint.
Factors that increase rigidity
1. Most important factor is anatomical reduction
2. 2nd most important factor is diameter of pins - be aware that if > 1/3 bone diameter can cause fracture
3. Decreased bone to rod distance to reduce near cortex stress - allow 2 inches for dressing change
4. Reduce working length of pins
5. Placement of central pins closer to fracture (near-near), but outside the zone of injury
6. Placement of peripheral pins farther from fracture (far-far)

Dr. Ma§ǫud | 29
7. Addition of pins and bars in same or another plane
8. HA coating of pins 9. Placing pins in multiple planes
Rigidity of ring & wire fixator
1. Increase diameter of wire, 1.8 for adult and 1.5 for child
2. Increase tension of wires, 130N for adult and 110N for child
3. 1 wire above ring and another below to prevent ring deformation
4. Increase crossing angle, Ideally 900
5. Increase number of wires and/or number of rings
6. Opposing olive wires, Prevent slippage of wires
7. Decrease diameter of ring 8. Use slotted bolts

Non union
Stop in the fracture repair process, non healing of a fracture of a bone
-delayed union:
taking longer than expected to heal, failure to reach bony union by 6 months post-injury
Anatomical: large segmental bone defects
Pathophysiology: (Classification:)
Local Genseral: (atrophic nonunion)
1. inadequate fracture stabilization (hypertrophic nonunion-oligotrophic) DM ,smoking, excess NSAIDs
2.poor blood supply(atrophic nonunion) 3.infection(Septic non union) Immune suppression,
4. pseudoarthrosis malnutrition.
C/P: persistant pain+ mobility at #
Imaging: x-ray/CT better
Lab.: CBC,ESR,CRP exclude infection
Delayed
Nonoperative bone stimulators(Ca+vit D)
+fracture brace immobilization
Infected nonunion
- need to remove all infected/devitalized soft tissue.
- use antibiotic beads, VAC dressings to manage the wound .
-with significant bone loss, bone transport may be an option.
-muscle flaps can be critical in wound management with soft tissue loss.
Pseudoarthrosis
-pseudo capsule may be encountered with operative exposure
-removal of atrophic, non-viable bone ends
- internal fixation with mechanical stability
-maintenance of viable soft tissue envelope
Hypertrophic nonunions
internal fixation with application of appropriate mechanical stability
Atrophic nonunions
-ensure biologically viable bony
-fixation needs to be mechanically stable

Dr. Ma§ǫud | 30
-Establishment of healthy soft tissue flap/envelope +Bone stimulators: electrical stimulation
decrease osteoclast activity and increase osteoblast activity, calcification
1. direct & alternating current 2. pulsed Ultrasound 3. pulsed & combined electromagnetic fields
4. Extracorporial shock wave

Bone Growth Factors:

I- Bone Morphogenetic Protein (BMP)
Mechanism Osteoinductive, leads to bone formation activates mesenchymal cells to transform into
osteoblasts and produce bone
FDA-approved uses
1. rhBMP-2: in spine fusion, open tibial shaft fractures before union
2. rhBMP-7: bone nonunions
contraindications : skeletal immaturity, pregnancy, allergy, infection, tumor
II- Transforming Growth Factor-B (TGF-B)
Mechanism stimulates osteoblast and osteoclasts, Type II collagen synthesize
III- Insulin-like Growth Factor 1 (IGF-1)
Mechanism induce proliferation without maturation of the growth plate and thus induce
linear skeletal growth ‫يطىل‬
V- Fibroblast Growth Factor (FGF) IV- Insulin-like Growth Factor 2 (IGF-2)
VI- Platelet-derived growth factor (PDGF)
Mechanism stimulates type I collagen production// stimulates cartilage matrix synthesis
stimulates cellular proliferation // stimulates bone formation.
Bone Defects Defect < 6cm? >6cm Bone graft Bone transport
- Bone graft (BG) (indication) fill defect ( + - / ) bridging Cyst-nonunion-arthrodesis
-Structure: cortical / cancellus/ osteocoductive/ osteogentic/ Support-scaphold
Contain active cells/ So better combine.
-Function: Osteogentic/ Osteoinduction/osteoconduction
Remain alive in new site stimulate stem cells differantiat into osteoblast // Scaffold for cells & vessels
-Source : -Graft techniques: Wire p.172
1.Autograft: from same person Adv. no immune 1. On lay ( cortical + cancellous) > defect Better
reaction regection dual onlay- bridge –stability
Disadv. Delayed ambulation, donor site But < metal stability ‫محشىر‬
comorbodites 2.In lay: inside < defect eg.arthrodesis
eg. *Tibia prox.medial part. *Femur prox. Lat part 3.Multi chips: cancellous/ ilium
(Troch.) *Tibia & Femur RAI 4.Hemi cylindrical: large defect femur tibia
(Reamer aspirator irrigator) 5.Whole bone transport: fibula?
*Fibula: Prox.1/3 Mid1/3 Hyaline cartilage Large –less disability- vascular Replace tibial
Vascularized BG / microsurgery For DER Distal defect, Distal1/3 radius
fibula/ AVN… 6.Membrane induced Masqulete technique:
2.Allograft: from other person -in children no Stage1-Use cement spacer (MMA) in defect
enough support -osteoprotic periprosthetic# -OCD induce formation of bioactive
3.Heterograft: from other spicies Face graft membrane (+ Benha Ortho.dep. modify use of k
rejection wire int.fixation special fram )
4.Bone bank: safe- sterile- usefull Screen toxin Stage 2-Spacer removed 4-8w later & put
infection malignant Sterilize by EO or irradiation cancellous BG
Stored by deep freez( -700c) Adv. prevent graft absorp- promot
Fresh Dried Better structure Osteoinductive Revascularization-consoldation new bone
Articular Demineralized More osteoconductive Iliac crest (gold standard)
5.Synthetic: cancellous BG substitutes Eg. Give: Corticocancellous / pieces-chips-BM Whole -
-BM -Reamer aspirator irrigator -Demineralized ant. 2/3 - post.1/3
Bone matrix one cortex- medulla-wedge
-Ca-S -Ca-P -Collagen polymer -Bioactive glass Risk : superficial NS neuroma eg. Ilioing
Sup. Cluneal N. 8cm from ASIS – LFCN.

Dr. Ma§ǫud | 31
Dr. Ma§ǫud | 32
 Arthroplasty biomechanics
FREE BODY DIAGRAM
� Method of determining static forces and moments acting on a joint (fulcrum) by isolating the body part
and ensuring that it is in static equilibrium (i.e. sum of forces and moments is zero)
Centre of gravity of human in standing position is just anterior to S2
Force = mass x distance // Weight = mass × gravity
� Assumptions bones are rigid rods/ Joints are frictionless hinges
Weight of body is at centre of body mass / Muscle force in direction of belly
Muscle act only in tension and JRF in compression
�� Joint Reaction Force (JRF) Vector sum of all forces acting on the joint
Force generated within a joint in response to external forces (Muscle contractions and weight )
JRF = FBW + F (Muscle)
If force applied in line with fulcrum it will cause translation, but if applied at a distance it will cause
rotation // Anti-clockwise forces should be equal to clock-wise forces
Hip
� Fixed is femur and mobile is pelvis
� Abductor force vector is anticlockwise to balance pelvis
� Weight force vector is clockwise
� 1st class lever between body weight and abductor force
� Coxa vara – reduces FAb – increase abductor force
� Trendelenburg gait – shift gravity to reduce B (abductor lever arm)
� Weight of the body and abductors act as compressive forces
� Abductor force is 3 times closer to fulcrum (b=5 cm vs a=15 cm)
� FBw - Weight in single limb stance is 5/6 total body weight
JRF of hip = FBw + FAb
FAb x b = FBw x a
FAb = (5/6th BW x a)/ B
FAb = (5/6) BW x 15 / 5 = 2.5 x body weight

To reduce hip joint reaction forces

� Lose weight - reduce FBw – reduce JRF
� Help abductors, Stick on other hand.
Some body-weight transferred through it provides additional moment to reduce torque (coupling principle)
-Reduce JRF up to 60%
� Weight on same side
� Valgus osteotomy- Increase lever arm of abductors Normal neck shaft angle is 1250, but hip is made 1350
� THR – medialise cup and increase offset Lateralise greater trochanter

Knee joint
Pivot is knee // Fixed component is tibia
Mobile component is the femur // GRF opposite to body weight
Increased JRF with knee in flexion

Dr. Ma§ǫud | 33
PFJ
� Force of quads equivalent to
force of patellar tendon
� Patellectomy reduces quadriceps
moment arm and therefore
increases quadriceps force

Elbow
� Class 3 lever
� 900 with weight in hand
� Pivot is ulnohumeral articulation
� Biceps insertion 5 cm distal to
elbow
� Centre of gravity of forearm
(weight) is 15 cm from elbow

Shoulder
� Deltoid has to counteract weight
of arm and weight in person's hand
� If person bends elbow - reduce
moment arm of weight in the hand
and force required of deltoid to
elevate arm will be reduced

Dr. Ma§ǫud | 34
Spine
� Pivot point in middle of disc
� Fixed is L5 and mobile is L4
� Weight vector to front Clock
wise
Draw moment arm
� Erector spinae force Counter-
clockwise Draw the short moment
arm
� Bending knees and holding
objects close to body will
reduce weight moment arm and
therefore reduce force
of weight and counterforce of
spinal muscles will be
reduced resulting in reduced JRF

Dr. Ma§ǫud | 35
 BONE CEMENT
Synthetic material commonly used for implant fixation or used as filler
Mechanical properities: Viscoelastic material – exhibits creep and stress relaxation
High compressive strength// Poor tensile and shear strength
Uses
� Fixation grout rather than adhesive, friction or hoop stresses at interface with implant
Interdigitation with bone
� Void filler non-maliganat lesions//Osteoporotic vertebral collapse//Revision THR and TKR
� Masquelet technique
Ingredients
� Powder � Liquid colourless
- Methylmethacrylate polymer for strength Packaged in ampoules
-Barium Sulphate or zirconium for radio Methylmethacrylate
opaqueness monomer (PMMA) for
-Initiator (Benzoyl Peroxide) of exothermic handling
polymerisation once liquid contacts with powder Accelerator (N-diMethyl-
-Impregnated with Aminoglycosides ABx p-toluidine) and inhibitor
-Chlorophyll dye (in Palacos) and ethanol and (hydroquinone)
ascorbic acid (in CMW DePuy)
The process called polymerisation
� The reaction is exothermic and energy inefficient
� Carbon to Carbon double bonds are broken down and new single bonds are formed to give long chain
polymers that are linear and relatively free of cross-linking

Phases of cement setting

� Mixing phase 50 sec - 2min for low viscosity
� Dough phase from mix to phase when cement is non-sticky, includes mixing time
If the cement is inserted too early, blood mixes into it reducing its strength
Increased humidity lengthens dough phase
� Working phase Implantation phase, from end of dough time to begening of setting
Up to 7 minutes from start
Increased temp & increased mixing and handling reduces working phase
� Hardening phase Implant should be kept still, as cement is still notch sensitive
� Setting time From mixing till it reaches maximum heat and becomes hard
In vivo temperatures are reported to be between 40 and 56
Increased theatre temperature and humidity reduces setting time

Types
Viscosity is a measure of the resistance of a fluid to deformation under shear forces
�Low viscosity long doughy phase
�Medium viscosity reaches doughy stage later than high viscosity
�High viscosity

Dr. Ma§ǫud | 36
Cementing technique generations of development
�1st generation: hand mixing, finger packing
�2nd generation: cement gun, pressurization with cement restrictor, pulse lavage, femoral brushing.
Biodegradable cement restrictors can cause inflammatory reaction and cortical thinning
�3rd generation: +vacuum to reduce porosity, distal centralizer
�4th generation:+ proximal centralizer

NB.
-Abx must be thermally stable//Wide spectrum//Long elution time, 6-8 weeks//Not compromise mechanical
stability of cement eg 1 g Tobramycin or Gentamycin//Clindamycin or G + Vancomycin
Abx mix loss some ductility of cement
-Gamma irradiation for sterilization – higher risk of fatigue
-Pulse lavage to bone Reduce risk of fat embolism
-Vacuum reduce pores (bubbles) – reduce cracks & increase tensile strength
-Pressurization - to enhance interlock at bone cement interface

Bone cement syndrome

Hypoxia - hypotension - cardiac arrhythmia - cardiac arrest
Causes Not fully understood. Several mechanisms have been proposed
� MMA monomer mediated model � embolic model � histamine release and hypersensitivity
� complement activation � Multimodal model
1. Identification of patients at high risk of cardiorespiratory compromise:
a) Increasing age
b) Significant cardiopulmonary disease
2. Preparation of team(s) and identification of roles in case of severe reaction:
a) Pre-operative multidisciplinary discussion when appropriate
b) Pre-list briefing and World Health Organization Safe Surgery checklist „time-out‟
3. Specific intra-operative roles:
a) Surgeon: Inform the anaesthetist that you are about to insert cement
Thoroughly wash and dry the femoral canal
Apply cement in retrograde fashion using the cement gun with a suction catheter and intra-medullary
plug in the femoral shaft
Avoid vigorous pressurisation of cement in patients judged to be at risk of cardiovascular compromise
b) Anaesthetist Ensure adequate resuscitation pre- and intra-operatively
Confirm to surgeon that you are aware that he/she is about to prepare/apply cement
Maintain vigilance for signs of cardiorespiratory compromise.
Aim for a systolic blood pressure within 20% of pre-induction value
Prepare vasopressors in case of cardiovascular collapse

Which cement would you use?

High Viscosity short dough time and long working time
Green colour from Chlorophyll– greater visibility
Abx release 0.5 g Broad spectrum covering G +ve and G -ve
Sterilized using Ethylene Oxide – preserve mechanical integrity

Dr. Ma§ǫud | 37
UHMWPE
� Introduced by Charnley in 1970s
� Concerns in regard to wear debris and osteolysis and loosening – HXLPE developed
Properties
� Polymer: A substance which has molecular structure built up from large number of similar units bonded
together
� Plastic polymer containing long carbon chains of millions of Ethylene units
� Ductile � Tough � Not hard - Susceptible to abrasion
Rough - high friction � Not wetable
Production process
Manufacturing
�Ethylene Oxide polymerized in low-temp and low-pressure environment to produce UHMWPE powder
�From petroleum or compression of air at high Temperature
- Ram bar extrusion: put powder in tube then heat
- Sheet moulding: Between 2 sheets then compression
- Direct compression moulding
o Best o Directly from PE powder to desired product o Requires least machining post-manufacture
Sterilization
�Ethylene Oxide gas
- Prevent free radicals - Prevent cross linking
�Gamma irradiation: packaged in O2 free environment (vacuum or inert gas) to prevent catastrophic
failure
Cross linking
�Repeated Gamma irradiation in O2 depleted environment
Advantages Disadvantages
- Improved resistance to wear - Generates smaller wear particles compared to non-
- Increased young modulus cross linked
- Lab based hip simulator tests demonstrated 70% - Decreased ductility and toughness
reduction in wear over earlier generation
polyethylene
Vit E addition
�Antioxidant �To limit annealing and maintain mechanical properties
�Can decrease cross-link density and increase wear compared to HXLPE
� BioPoly - composite of UHMWPE and Hyaluronic Acid
Catastrophic wear of PE
� Macroscopic premature failure of PE due to Cause:
delamination �Thickness of < 8 mm (metal tray thickness is 2
� Delamination - mode of failure for the composite mm and is added to full thickness)
materials �Flat tibia PE: reduced conformity - increased
� Layers separation with significant loss of contact stress
mechanical toughness due to fatigue cracking �Irradiation of PE in O2 rich environment
� Mostly in TKA prone to point loading �Ram bar machining

Dr. Ma§ǫud | 38
TOTAL HIP REPLACEMENT
� Primary aim of THR: by Proper component positioning
Restore center of rotation Correct leg length Correct offset and abductor tension
Biomechanics design philosophy.
Charnley (Depuy) Exeter (Stryker)
(Design ed by sir Jhon Charnely 1960) (Designed by Ling &Lee: 1st implanted in 1970)
Mono-block stainless steel stem with 22.22222 mm �Modular Stainless Steel Sliding matt finish
head
� Composite or shape closed beam design � Double tapered,Self-locking sliding taper or
force-closed design (trunnion)
� Rough surface (matt-finish) to prevent �Polished stem with controlled-subsidence as
subsidence cement undergoes creep and stress relaxation. This
� Considered a rod within two tubes, an inner transfers load to cement evenly
cement tube and an outer bone tube � The hoop stresses provide circumferential
� Once inserted the stem should not move and is compression around the stem ??
expected to behave as a single unit. Stability depends Viscoelastic properties of Poly-Methyl
on strong cement bonds between bone and implant MethAcrylate (PMMA) will result in radial forces
� Acts on the principles of single unit, and three- being generated as a resultof axial loading and
point fixation wedging of the stem within the mantle. These are
transferred to bone as hoop stresses,
which enhance fixation and stability of the stem
� Any subsidence, at the implant–cement or bone–
cement interface represents loosening and failure �Intended to subside to a stable position, 1.5 mm
� Shear forces can cause cement fracture in 12 months??
� Generates greater wear debris when loose
� Cement bonds to bone and not to implant
� The load is transmitted from the prosthetic femoral
head via the stem to its tip, to the distal bone cement � Avoid gaps in cement mantle
and subsequently to the host bone by-passing the � Cement strongest under compression
proximal femur leading on to stress shielding As � Centralizer allows subsidence without point
the proximal bone is not loaded according to Wolff‟s loading on cement and keeps stem central within
law, it will lead to osteolysis uniform mantle. ensure minimum 2 mm cement
� Addition of collar will provide for some amount of surrounding implant to minimize risk of cement
calcar- loading and protects from stress shielding fracture.

� No collar; neck cut level & orientation not

critical

When asked to talk about a stem discuss

� Shape: straight or curved � Tip: tapered or blunt
� Surface finish: Smooth or rough � Modular or mono-block
� Collar or collarless � Neck, Morse taper (trunnion)
� Offset

Dr. Ma§ǫud | 39
Templating
� Aids selection of favourable implant
size to restore anatomy & biomechanics
� Help to reduce LLD
� Estimate position and insertion depth of
both components
� Facilitate operating room preparation
and assure availability of appropriate size
selection
� Predict potential complications and
detect anatomic anomalies
� Help to guide neck cut to restore length

� Tear drop: Develops at 18 months of age

Radiographic landmark created by superimposition of the most distal part of medial wall of the acetabulum
and, tip of anterior and posterior horn of articular surface comprised of the quadrilateral surface and
cotyloid fossa
� Get low AP pelvic radiograph: X-ray beam centered on pubis & coccyx pointing to symphysis
Symmetrical obturator foramina//10-15o of internal rotation - places femoral neck parallel to cassette
External rotation - falsely decreases offset//Create valgus appearing femoral neck
Falsely decrease femoral canal diameter
� Establish LLD by the distance between the two parallel lines drawn on AP pelvis X-ray. Inter-ischial
line (lowest point of ischial tuberosities) and inter lesser tuberosity line (most proximal part of LT)
Templating the Acetabulum
�Draw horizontal line connecting tear drops
�Template acetabular component first to determine center of rotation of new hip with inclination of 40 deg
and adequate cup coverage
�Medial border of cup should approximate ilioischial line close to tear drop
� Inferior border of cup should be at level of inferior teardrop line
Templating the Femur
� Appropriately sized femoral stem to fill medullary canal
� Insertion depth is determined to optimize limb length inequality

COR: Center Of Rotation

Dr. Ma§ǫud | 40
Head
� Head skirted or non-skirted: skirts are attachments used to extend the length of the femoral neck.
Skirts decrease the head-neck ratio
� Small vs. Large heads
Volumetric wear proportional to the square of radial diameter of femoral head
Small heads (22.2 mm): Large heads (36mm):
- Low torque, low friction and less volumetric - Greater ROM and decreased dislocation rates due
wear; increased linear wear and dislocation to increased head-neck ratio.
- Linear wear is more with smaller heads because - But greater torque, friction and volumetric wear
of small contact area. and decreased poly thickness

Trunnion (Morse Taper) Taper: uniform change

� Cone within a cone the male portion and the bore is the female portion in diameter of cylindrical
interference fit object measured along its
� Contact is side to side – The Morse taper is NOT end-loading axis
� 12/14 is the difference of diameters between each end
Head locking mechanism:
�Conical femoral taper compresses walls of bore
� Tapers of angle <7o will result in self-locking
�The smaller the taper angle, more rigid the locking ‫يدخم اكتر نجىه‬
�Van Der Waals forces and Cold welding may occur
� Deformation of ridges
Trunnionosis:
�Wear at the femoral head-neck interface �Mechanism – fretting
�Mode 4 of wear
� Produce metal debris � Protect and dry trunnion

Choose of stem type : Dorr femoral bone classification & index (Canal / Isthmus)
A: Narrow canal with thick cortices (Champagne A<0.5 Uncemented
flute canal)
B: Moderate cortical wall thickness B=0.5-0.75 Uncemented
C: Wide canal with thin cortical walls (Stove pipe C>0.75
canal) Cemented

Dr. Ma§ǫud | 41
Uncemented Stem
Implants manufactured from titanium alloy
Osseo-integration:
Attachment of lamellar bone to implant
without intervening fibrous tissue
Must have viable bone
Avoid in prior irradiation
� Saves intra-op time � High cost
� Difficult to control version
� Calcar fracture
� Needs rigid fit to reduce micro-motion to <
50 μM to prevent formation of fibrous tissue at
implant-bone interface
Cemented Stem
Made of stainless steel or Cobalt Chrome ??
�Titanium less stiff leading to cement fatigue and
prosthesis cement failure
Increased risk of cement fracture if mantle is < 2mm
�Avoid varus placement of stem by starting at the
lateral-most entry point
�Useful in abnormal anatomy
� Better in osteoporotic and irradiated bone
�� Antibiotics in cement reduce deep infection,
reduce mechanical strength

Stem Geometry Stem Geometry

� Flat-tapered
Achieve early fixation by wedging a rectangle
into a circular hole. Mismatch of geometry
achieves good
torsional stability. Fixation occurs by medial-
lateral engagement
�Dual taper
Achieve fixation by completely filling
metaphyseal canal and circumferentially
engages the femoral cortex
�Round corners and stiff stem to reduce stress on
cement mantle �Square cross-sectional stems are
limited in size due to their contact against inner cortex
� Oval cross-sectional stems have good fit
� Cemented stems are smaller than press-fit stems and
unable to tolerate as much cantilever bending
��Mantle defect is area where prosthesis touches
cortical bone with no cement in between

Two methods
Cementing technique generations of development
Press-fit technique: Line-to-line
slightly larger technique: size of
�1st generation: hand mixing, finger packing
implant than what implant is the same � 2nd generation: cement gun, pressurization with
was reamed/ as what was cement restrictor, pulse lavage, femoral brushing.
broached is wedged reamed/broached, Biodegradable cement restrictors can cause
into position, relies screws often placed inflammatory reaction and cortical thinning
on hoop stresses for in acetabulum if �3rd generation: +vacuum to reduce porosity, distal
initial stability (4 – 6 reamed line-to-line centralizer
weeks) then on bone �4th generation:+ proximal centralizer
in/on-growth

Bonding to bone
Bone in-growth Bone on-growth

Porous coated Divots not pores

Titanium plasma Grit-blasting of
spray Aluminum Oxide to
Extensively porous create a surface
stem with fiber mesh roughness,
Thickness of coating Plasma spray of
Calcium HA
Osteo-conductive,
(50 uM) shorter time to
Pore size ( 50uM) biologic fixation
50% porosity -(4-7 uM)

Dr. Ma§ǫud | 42
 -�Too little – weak �Extensively coated:
fixation fixation strength is
-�Too much – less than porous
shearing of metal coated

Extent of coating: Khaunja classification ‫جحث‬

-�Proximal
-�Extensive - Better initial fixation
-�Stress-shielding of proximal bone

Uncemented stem Loosening grades:

�Well fixed (with bone in-growth): no
radiolucent line, proximal stress shielding
� Stable (with fibrous in-growth): uniform
radiolucent <1mm line, no surrounding
sclerosis, no subsidence
�Unstable (loose): irregular wide radiolucent
lines
�Spot welding: Small areas of sclerosis
originating from endosteal surface and abutting
femoral stem. They are strong indicators
of stability
�Bone pedestal: Transverse sclerotic line
below the tip of cementless stem, sometimes but
not always associated with loosening
Gruen modes of cemented femoral stem failure
1) Pistoning
A: subsidence of stem within cement
B: subsidence of stem & cement within bone, lucency
in all zones
2) Medial mid-stem pivot
Fixed in middle, proximal part tilts medially and distal
part laterally, fracture mid stem
3) Calcar pivot
Fixed proximally; toggling of distal stem, lucency zone
4&5
4) Bending cantilever
Loss of proximal fixation leaving distal end fixed
(distal pivot), likely cause of fractured stem, lucency 1,
7, 2 & 6

Eg.Uncemented Stems commonly used

�Accolade (Stryker): proximally coated,
collarless, flat tapered wedge design
�Corail (Depuy): most commonly used
cementless stem in UK
�Taperloc (Biomet): Proximally porous coated,
flat taper

Grading of cement technique (Barrack and Harris)

A: White out
B: Near complete filling with slight lucency
C1: Lucency more than 50%
C2: Cement mantle less than 1mm in some areas
D: Lucency more than 100% or absence of cement
distal to tip

Dr. Ma§ǫud | 43
Kaunja Classification uncemented stem

Dr. Ma§ǫud | 44
Bearing Surfaces
MoP CoP
�Metal (cobalt-chrome) femoral head on polyethylene acetabular �Reduced fracture and squeaking
liner risks
�Longest track record, Lowest cost, most modularity �Revision rates 2.4 % (in males)
�Higher wear rate and osteolysis compared to MOM and ceramics and 2.9% (in females) at 15 year
�Smaller heads when compared to MoM follow up in 75+ age group, but
�4.63% (in males) and 2.99% (in females) revision rates at 15 years 4.3-8.3% revision rates in <55, 55-
in 75+ age group, but 5.10-11.82% revision rates in younger age 64, 65-74 age groups (16th NJR
groups (16th NJR data 2019) data 2019)

MoM
�Cobalt Chrome alloys
�Better wear properties than MoP
�Larger head improves stability
�Increased metal ions in serum and urine
�No proven cancer link
�Pseudotumor formation
�More expensive than MoP
�Contraindications
Child-bearing age women, renal disease, metal
hypersensitivity due to metal ions
�Disadvantages or reasons of failure
Edge loading leading to ALVAL (aseptic lymphocyte
dominated vasculitis associated lesion), ARMD
(Adverse
reaction to metallic debris) and Pseudotumor
�Nickel allergy: No staples
Type IV hypersensitivity – confirm by patch testing
�Use uncemeted hip
CoC:
�Ceramic components
�Best wear properties of all bearing surfaces
�Lowest coefficient of friction of all bearing
surfaces
�Inert particles
�More expensive than MoP
�Disadvantages or reasons of failure
Alumina is brittle, low fracture toughness
Squeaking
Less modularity with fewer neck length options
�Lowest revision rates in <55 age group with
hybrid THR, 5.6% (in males) and 4.3% (in
females) revision rates at 15
years in <55 years age group
�In age group 55-74 years, reduced rates of
revision are noted too (4 % in males, 3 % in
females) 16th NJR data 2019

Dr. Ma§ǫud | 45
Cup fixation
Uncemented Cup Cemented Cup
�� Trident (Stryker): 13A* �� All poly rather than metal-backed
Two types to allow use of thicker poly
- PSL shell with oversized periphery �� Ogee (Depuy) 13A* ODEP rating
-Hemispherical shell, under-reaming of acetabulum Flange for better pressurisation
�� Trilogy (Zimmer) 13A* �� Exeter Rimfit/contemporary
Porous coated with titanium (Stryker) – most common cemented cup
�� Exceed (Biomet) 13A* used in UK
Porous coated �� ZCA (Zimmer)
Hemispherical �� Mararthon (Depuy)
Line to line fixation
�� Pinnacle (Depuy) � Steps
Most commonly used cementless cup in UK -3 holes with Charnley drill to
encourage intrusion of cement into bone
� Risk of intra-operative fracture: - Trial flange rim should fit within rim
-Under-reaming <2 mm of acetabulum
-Elliptical cup - Minimum of 2 mm cement mantle -
-In instances of suboptimal coverage with trial component, cement spacers to help maintain a
check for insufficient reaming of medial osteophyte up to tear uniform cement mantle
drop - Cement at 2 min and insert cup at 4
-Minimal thickness of poly insert is 6 mm min
-Screw holes may act as passage route for wear debris to bone - 40 deg abduction & 20 deg anteversion
- Use Transverse Acetabular Ligament
�� To test primary fixation for version:
-Move handle of introducer between index and thumb in Reamer should be just deep to rim of
supero-inferior direction- because component squeezed TAL
between anterior & posterior columns - Thicker poly reduces stresses
- Look for stress shielding in postoperative X-rays transmitted to cement mantle

Acetabulum quadrants (Wasielewski)

Line from ASIS to centre of acetabulum
and another line perpendicular
To determine safe quadrant for placement of
screws

Dr. Ma§ǫud | 46
Periprosthetic Fractures
�Intraoperative fractures: 3.5 % of uncemented; 0.5 % of cemented
�Cemented tend to fracture after 5 years and uncemented within 6 months
Risk Factors
� Press fit � Osteoporosis � Paget‟s disease � Distorted anatomy � Revision Surgery
Classification & Management
Vancouver Classification The Unified classification system – by Duncan
a. Trochanteric and Haddad (BJJ 2014)
AG AL �Core principles:
-Non-operative, restricted weight -Check for -The location of fracture
bearing, if undisplaced prosthesis -The fixation of the component
-Cable or claw plate if displaced stability -The adequacy of bone stock and bone strength
-Non-union can result in pain and supporting the implants
gait difficulties �Types:
A – “Apophyseal” fracture
b.Around stem B - Fracture through “bed” of implant
B1 (Well- B2 (Loose B3 (Loose C - Fracture away from the implant bed / “clear” of
fixed stem) stem; Good stem; Poor implant
proximal bone proximal bone D - Fracture in the bone between two implants /
stock) stock) “dividing” bone between two implants
-Locking plate -Long porous -Diaphyseal E - Fracture involving both bones supporting one
with coated fixation stem; arthroplasty / “each” bone fracture
unicortical cementless if adequate F - Fracture of the bone “facing” and articulating
screws or stem by-pass bone stock 4 with hemiarthroplasty
cables fracture by > cm proximal Type Subtype Fracture description Treatment
proximally 2 cortical to isthmus A Fracture in trochanteric region AG AL
-Better to use diameters -Impaction B Fracture around stem or just below
bicortical -Supplement bone grafting B1 Well – fixed stem ORIF
screws with cables or -Proximal B2 Loose stem with good proximal bone stock
variable angle plates to femoral Revision THA
plate maintain replacement - B3 Loose stem with poor bone quality Revision
-Be aware of reductio Attach THA
transverse and abductors to C Fracture occurring well below tip of stem ORIF
short oblique prosthesis or D Fracture of femoral shaft between well fixed hip
fractures as to vastus and knee replacements ORIF
they don‟t lateralis E Both femur and acetabulum fractures after THA
heal due to F Fractured acetabulm with femur hemiarthroplasty
damaged intra in situ Revision THA
and periosteal
blood supply Acetabular fracture
�Stable cup: add screws
c. Distal to stem �Unstable cup: remove cup, stabilize fracture,
-Avoid metalwork in the fracture reinsert cup with screws
-Wall to wall fixation with screws to achieve �Pelvic discontinuity stabilize fracture +/- cup
long working distance cage construct or allograft or custom-made
- Avoid stress-risers implants using 3D Printing
- Overlap stem with plate with cables

Dr. Ma§ǫud | 47
Aseptic Loosening (Osteolysis)

Mechanism
�Histological inflammatory response to wear debris resulting in resorption of bone around prosthesis
�Debris attracting macrophages (Metal on metal stimulates lymphocytes, as it generates high volume
smaller particles 50-100nm)
�Debris can be poly, metal, PMMA, ceramic (wear particles of submicron 0.1-0.5 um most biologically
active) �Macrophages release osteolytic factors (cytokines) �PDG �TNF alpha �Prostaglandin E2
�Hydrogen peroxide �IL 1 & 6 � RANKL, which activate osteoclasts � Acid Phosphatase
�� Can lead to prosthesis micro-motion, which can be measured with RSA
�� Final stage is dissemination of more particulate debris
�� Failure from aseptic loosening of hip replacement is silent in 30%
�� Schmalzried JBJS Am 1992 – gave the concept of “effective joint space”
�� MARS (Metal Artefact Reduction Sequence) MRI: cystic or mass lesion or fluid collection
�� Metallosis: deposition and build-up of metal debris in soft tissues of body
�� ALVAL (Pseudotumor): Adverse local tissue reaction to metal debris (ARMD)
Type IV hypersensitivity Aseptic lymphocyte-dominated vasculitis-associated lesion
Metal ions slowly released from bearing surfaces as a by-product of normal wear
Wear particles + native proteins = Haptens
Granulomatous inflammatory mass causes extensive collateral damage
Local destructive response leads to pain, osteolysis, and loosening of prosthesis

Consequences of Wear and Wear Particles

� Synovitis Aseptic Osteolysis and Loosening
� Systemic distribution � Immune reaction � Increased friction of the joint
� Misalignment of the joint and catastrophic failure

Aseptic Osteolysis and Loosening

Step 1: Particulate Debris Formation
Step 2: Macrophage Activated Osteoclast genesis and Osteolysis
� Particles result in macrophage activation and further macrophage recruitment
� Macrophage releases osteolytic factors (cytokines)including:
� TNF- alpha// osteoclast activating factor //oxide radicals//hydrogen peroxide//acid phosphatase
interleukins (Il-1, IL-6)//prostaglandins//Osteoclast activation and osteolysis//increase of TNF- alpha
� Increase of VEGF with UHMWPE particles enhance RANK and RANKL activation
� RANKL mediated bone resorption - an increase in production of RANK and RANKL gene transcripts
leads to osteolysis
Step 3: Prosthesis Micromotion
� micromotion leads to increase particle wear and further prosthesis loosening
� N-telopeptide urine level is a marker for bone turnover and are elevated in osteolysis
Step 4: Debris Dissemination
� Increase in hydrostatic pressure leads to dissemination of debris into effective joint space
� increased hydrostatic pressure is result of inflammatory response
� dissemination of debris into effective joint space further propagates osteolysis

Clinical Features
� Start-up pain: (Triphasic) occurs after many painless years with insidious onset of groin, buttock or
thigh, triggered by walking, settle down with continued walking and again aggravates after prolonged
walking
� Aging - decreased cortical bone thickness causes stem to move away from cement - lucency at the bone
cement interface - this does not indicate a loose stem
�X-rays to check for loosening
�Look for poly wear on X-rays
�can be due to infection (septic) lysis without prosthesis wear

Dr. Ma§ǫud | 48
Radiological Features
� Femoral stem loosening - Stem fracture, cement mantle fracture, new radiolucent line, changes in stem
position / subsidence, modes of loosening
� Acetabular loosening - Bone cement lucency >2mm and/or progressive, medial cup migration, change
in inclination, eccentric poly wear, cup/cement fracture
�Technical issues contributing to loosening - failure to remove medial cancellous bone, cement
movement during implantation, less quantity, laminations and voids, inadequate pressurization, varus stem
position
�Revision operations should be performed before massive bone destruction
�DeLee & Charnley zones: ‫مهم مهم‬
Radiolucency around acetabular component on an
AP&Lat. radiograph.
Vertical & horizontal lines from centre of
acetabulum
�Gruen classified lucency around femoral stem

Indications for surgery

�Fracture Impending fracture
�Pain

Bilateral THA
� Increased infection from pressure in lateral position
� GA Increased bleeding - Tranexamic acid

Minimally invasive THR

� Advantages: Cosmesis, Reduced blood loss
� No difference in early gait kinematics
� Technically demanding and high learning curve
� Techniques: 2 incision
� Mini stems
� Preservation of proximal bone stock
� Less stress shielding of proximal femur
� Ease of revision
� Reduction of risk of thigh pain
� Soft tissue sparing procedure, ideal implant for use with direct anterior approach
� Do not have long-term results

Dr. Ma§ǫud | 49
Hip resurfacing
�Uncemented cup and cemented femoral component
�Best outcomes in young males with good bone stock
Advantages Disadvantages
�Low rate of wear � Requires larger exposure than conventional
�Hydrodynamic fluid film lubrication THR
�Bone conserving on femoral side: Reduced risk of � Acetabular implants are press fit and can‟t be
LLD; Revision easier augmented with screws
�Normal femoral loading: Avoids stress shielding � Can‟t adjust offset & LLD
�Reduced risk of dislocation: Neuromuscular � MOM complications
disorder � Steep learning curve
�Indicated for patients with deformed femur shaft � Cup made of Co/Cr - stiffer than titanium
Contraindications Complications
� Femoral head cyst > 1cm � Neck fracture: MC early complication
� Coxa vara: increased risk of fracture �Due to Notching 0.5%: Avoid by central
� Female of child bearing age (MOM) � Renal failure pin placement (Upsize femoral head)
(MOM) �Varus placement: vertical shear force on
� RCT in BMJ, 2012 by Costa et al - No evidence of neck
difference in hip function 1 year after THR versus resurfacing �Underlying AVN or osteoporosis
arthroplasty using Oxford and Harris hip scores � MOM complications
�McGrory JAAOS 2010 – Review article, Modern MoM � Femoral head collapse 1.5% usually
hip resurfacing good for selective indications – young males due to pre-existing AVN
with primary OA, and head size >50mm � Divot sign: Erosion at superior implant
�Why ASR failed? (Langton JBJS Br 2011) bone junction, due to implant-bone
Less spherical than BHR (1600), causes edge loading and impingement or stress-shielding fromstiff
fluid lock-out - associated with higher wear rate Co/Cr - Uncertain prognostic value

Dislocated THR
� 3-5% over life of implant
� Look for eccentric position of femoral head as an indication of polyethylene wear and risk for impending
dislocation
Factors influencing stability of THR
: sRadiograph details Surgical factors
– patient details �Surgeon experience; poor technique
– anteroposterior (AP) and �Impingement from osteophytes or retained excess cement
lateral views
1. Leg length �Soft tissue tensioning & function
2. Acetabular inclination - abductor complex
3. Acetabular version NB– Dislocation rates with posterior approach is similar toanterolateral
4. Acetabular cement mantle approach, with careful posterior soft tissue and capsular repair)
5. Femoral stem inclination
(varus/valgus angulation
�Prosthesis alignment:
and AP angulation)
- Cup 15° + 10°Anteversion and 40 + 10°Inclination (Lewinnek safe
6. Femoral stem version
7. Femoral stem tip positioning zone 1978)
8. Femoral stem cement mantle - Beware that in lateral position, the ipsilateral pelvis is adducted by 10°
9. Cement interdigitation with - Aim for apparent inclination of 35°
bone in acetabulum - Stem: 15-20°Anteversion
10. Cement interdigitation with - Combined version = 40°
bone in femur �Avoid over-medialization of acetabular cup
�Femoral offset: Perpendicular distance between centre of femoral head
to line down centre of femur

Dr. Ma§ǫud | 50
- CT to assess position before - Increased offset increases abductor moment arm, decrease abductor
discussing about revising force require and decrease JRF but puts higher stress on stem
component
Patient factors Implant factors
�Female: male 2:1 �Limited ROM �Arc of movement- range of motion prior to
�Soft tissue laxity & muscle impingement (Native hip has greater arc than THR) depend on:
weakness due to neurological disease -Aim for a large head / neck ratio
( spinal stenosis) -Excursion/jump distance - distance femoral head must travel to
�Patient: non-compliant, cognitive dislocate
dysfunction, alcoholic -½ diameter of femoral head; Increased with larger heads
�Poor anatomy: Revision surgery -Use of lipped liner: Elevated rim
with compromised abductor function -Use of face changing liner: Liner angled by 10 deg in relation to
or previous infection or trauma shell
�GT advancement: places abductor -Constrained liner (capture cup): used for un-repairable soft-tissue
complex under tension insufficiency, severe cognitive disorders, and late dislocations with
�Spinal stiffness Reduced spino- well-positioned components.
pelvic motion. For each 10 – there is
0.90 of hip compensation �Early loosening �Wear �Exchange of liner

Classification (Based on time)

Early: <6mths Intermediate 6mths- 5yrs Late >5yrs
�Non-compliance to post-op instructions, �Older age, female gender, �Trauma, soft tissue laxity,
technical error in surgery decreased muscle mass, neurological decline,
�Malposition of components, impingement, predisposing factors like younger age with poly wear,
retained cement, faulty soft tissue repair AVN and RA female and weight loss
Work-up
� Check OT records: get information regarding the �Approach used
��Implant used and design features of the implant esp. the head size
� X rays: I will assess the Vertical and horizontal offset restoration,
-Component position (acetabulum anteversion and inclination),
-Femoral anteversion, any features of impingement
Management
� Attempt closed reduction under GA in OT followed by checking stability
� If successful: short period of bed rest followed by hip abduction brace 6 weeks
� If closed reduction fails: Open reduction and assessment of soft-tissue interposition in the acetabulum,
soft-tissue tension or an impingement problem. If a simple cause is identified, one must be prepared to
address this.
� The hip dislocates again or unstable: CT scan to assess component orientation (anteversion femoral
stem, acetabular component version. Rule out infection (check history ,blood tests-inflammatory markers)
� Intraoperative considerations if stable hip not achieved:
�Resection arthroplasty last resource
�PLAD - posterior lip augmentation device
�Dual-mobility cupƀ √√√√√

Dr. Ma§ǫud | 51
REVISION THR
� Assess available bone stock
Indications
� Osteolysis start-up pain
� Infection - night pain
� Instability
� Fracture of bone or implant
Imaging
� Judet views: Assess columns
� CT scan: Assess osteolysis and
component position
� Delineate bony anatomy and
assist with planning surgical
reconstruction
� Acetabulum Look for
protrusion and superior migration
� Get angiogram if in doubt
Goals
� Removal of implants & cement
� Reconstruction of bone
� Stable hip
� Restoration of centre of rotation
Special Instruments
� OSCAR (ultrasonic cement remover)
� Curved acetabular gouges (Renovation)
� Explant acetabular cup removal system (Zimmer)
� Acetabular component forceps
� Flexible and straight and curved revision osteotomes and burs
� Cerclage wires
� Impaction graft
� cable system (crimp, crimper, tensioner, cable passer)

Classification
AAOS classification of acetabular deficiencies
I.Segmental (Rim or medial wall):
Structured allograft &
Reconstruction/non-protrusio cage to
form foundation - If rim incompetent
(<2/3 remain)
-Concerns about graft vascularization and
resorption – collapse

II.Cavitary (Volumetric loss):

Peripheral or central
Morselized impaction bone graft –
Reverse ream to impact

III.Combined (Cup – cage construct):
Use trabecular metal cup as a replacement
to the allograft doesn‟t have to be in
anatomical position
Cage fixed into the ischium and ilium
Acetabular cup cemented independent of
the position of the cage
IV.Pelvic discontinuity (Between superior and inferior
columns): Neurovascular assessment
Recon plates & anti-protrusion
reinforcement cage
Custom triflange acetabular components
V.Ankylosis
Hemispherical porous coated cup augmented with
screw-Trabecular metal- If >2/3 of rim is competent
- Tritanium (Stryker) - porous tantalum
- TMARS (Zimmer) - Trabecular metal augment

Dr. Ma§ǫud | 52
AAOS classification Femoral Deficiencies
�Segmental Deficient supporting shell of
femur
�Cavitary Loss of endosteal bone with
intact cortex
Use morselized fresh frozen impaction
(compressed) bone graft
�Combined
�Mal-alignment Loss of femoral
geometry due to surgery, trauma or
disease
�Stenosis From trauma or bony
hypertrophy
�Femoral discontinuity from fracture

Paproksy classification
Type 1 sufficient proximal bone to support any implant
Primary stem using double wedge taper design which provides proximal fill
If compromised rotational stability - fully porous stem (diaphyseal in-growth)
Type 2 insufficient metaphyseal bone stock to support the stem
Implant must have some diaphyseal porous coating for in-growth
Or extensively Porous-coated Cylindrical
Type 3A no metaphyseal bone stock
Some deficient proximal diaphyseal bone stock Requires diaphyseal fixation.
Extensively Porous-coated Cylindrical
Type 3B even less diaphyseal bone stock yet the femoral isthmus remains supportive
The Modular stem designs are the best option
Type 4 No supportive diaphysis to obtain initial press-fit to allow for bony in-growth
Require total femoral replacement

Cemented Uncemented
�Cement in cement with downsizing of stem if bone-cement interface �Extensively porous coated
is good �Modular Coned / broached /
�Must be aseptic with well fixed cement to bone fixation calcar body
�Use same type of previous cement to improve bond Conical fluted / bowed stem
�Clear shoulder of prosthesis from cement and bone, which obstructs �Stem achieves wedge press fit
stem removal and causes GT fracture for axial stability
�Mueller revision drills and reamers to remove cement �Flutes for rotational stability
�Meticulous impaction bone grafting followed by long cemented stem �Also relies on the body-
�Use cement drill and cement tap metaphyseal bone interface

Dr. Ma§ǫud | 53
Trochanteric osteotomy
ETO: Between gluteus medius and vastus
lateralis // Cable distal to prevent crack
propagation
Use burr to avoid sharp edges Narrow and
rounded distally to avoid stress fracture
�Prophylactic cerclage cable to prevent
propagation of fracture
�Multiple osteotomes to lever out

THA Rheumatoid hip

� Osteopaenic bone, fracture: better to use cemented implants
� Protrusio: need bone graft
� Double rate of infection

THR in Tubercular arthritis

� THR is safe with extensive debridement and anti-tubercular treatment for 3 months before surgery and 9
months post-surgery

THR in PAGET DISEASE (OSTEITIS DEFORMANS)

�Pre-op Orthopaedic considerations
-Good quality full-length radiographs and templating, restoring the mechanical alignment, offset and
version
-Diagnostic dilemma with hip pain - Looking for referred pain from spine, stress fractures, radiographic
bone destruction suggesting sarcomatous change, detailed focused history and examination and diagnostic
intra-articular injection
�Pre-op anaesthesia considerations
-Pre-op Bisphosphonates/ calcitonin 3/12 pre-op
-Increased bleeding requiring adequate blood for transfusion, consider cell salvage, pre-op donation,
hypotensive anaesthesia
-Pre-op surgical optimization -High output cardiac failure
�Intra-op femoral considerations
-Bone is very hard and sclerotic, burrs may be needed for entry, broaching can lead to increased intra-op
fractures and also post-op fractures
-Deformity of femur necessitating osteotomy, increased intramedullary cortical sclerosis might interfere
with cemented fixation, large canal requiring extra cement, large bone plugs
�Intra-op Acetabular considerations
-Acetabular protrusio might cause increased risk of fractures during hip dislocation
-May need correction with bone grafts or anti-protrusio cages
-Increased risk of intra-op fractures, HO, increased loosening.

THR HIP AVASCULAR NECROSIS (AVN)

-Higher rate of loosening in cemented
-Poor results with higher revision rates in - sickle cell, renal failure +/- transplant, Gaucher‟s
-NJR 16th annual report – for selection of THR (though it doesn‟t specify outcome of any particular fixation
in AVN). Results of cemented THR have improved because of better cementing techniques and XLPE
liners.

Dr. Ma§ǫud | 54
HIP ARTHRODESIS Conversion from Arthrodesis to THR
Indications: Precautions:
�Back pain �Function & results related to integrity of abductor complex
�Ipsilateral knee pain �Pre-op investigation of abductors - MRI+EMG studies
�Contralateral hip pain �If abductors non-functional - May need constrained component
�Painful pseudoarthrosis �Sciatic closer/ add psoas tenotomy prior to THA
�Poor position of arthrodesis �Post-op crutches for 3-6mths for recovery of gluteal and abductor
consider osteotomy first muscle function it takes up to 2yrs to get full benefit of surgery
Complications
�Deep infection �sciatic / femoral nerve injury �dislocation
� Survival: 95% in 10 years; competence of gluteal musculature is predictive of ambulatory success
�CORR (2011) retrospective comparative:
Conversion of hip arthrodesis to THA provides improvement of hip function and QoL, good survival, and
high level of patient satisfaction comparable primary THA

THR HIP DYSPLASIA

Templating Acetabulum
� Critical in restoring the anatomical hip center, � True acetabulum identification can be aided by
anticipating cup uncoverage, addressing leg length intraoperative x -rays and drill holes in the
discrepancy, deciding femoral stem size and designs acetabular medial wall
� GT - small and posteriorly displaced � Acetabular coverage by bulk femoral head
� Risk of sciatic nerve injury and dislocation is autograft and auto-allografts, oblong cup, tantalum
increased 10x augments
Cup positioning:
Anatomical: Non-anatomical:
-Facilitates lengthening -High hip centre
-Restoration of hip centre -Hip centre proximal to inter-teardrop line
-Better hip function, < JRF -Easier - No bone graft, no femoral osteotomy
-Best bone stock available for cup placement -Early loosening and higher rate of dislocation
-Risk traction injury to sciatic N due to -GT impingement requires osteotomy and
lengthening advancement
-Subtrochanteric osteotomy & intra-operative -Small acetabular component
nerve monitoring -Revision difficult as bone stock is not restored
Linde et al (Acta Orthop Scand 1988)
42% loosening at 15 years if cup placed non-anatomically
13% loosening if placed anatomically
Sanchez-Sotelo et al JAAOS (2002)
Uncemented cups augmented with screws give better results in DDH reconstruction
Cotyloplasty fracture medial wall to place acetabular component within available iliac crest
Femur
� Narrow femoral canal may make femoral reaming difficult
� Marked anteversion of the femoral neck make component positioning difficult
� Derotation with subtrochanteric osteotomy (STO) may be necessary to place the component in the
proper orientation (consider if anteversion >40°).
� Another option would be to use modular femoral stem systems or the use of custom-made femoral
stems.
� STO also indicated when > 4cm shortening is required, risk of sciatic nerve palsy increase with >2-5 cm
lengthening (various studies reporting different limits)

Dr. Ma§ǫud | 55
THA in PROTUSIO ACETABULUM
Definition
Intra-pelvic displacement of the acetabulum and
femoral head, so that the femoral head projects
medial to the ilioischial line or Kohlers line or the
tear drop

Causes
�Decreased bone density - Osteoporosis, Osteomalacia, Osteogenesis Imperfecta, Rickets, RA, AS,
�Normal density - OA, idiopathic
�Increased density- Hypophosphatasia, Paget‟s
Aetiology
�Primary - delayed triradiate cartilage ossification
�Infective - septic arthritis, TB
�Inflammatory - RA, AS
�Metabolic - Paget‟s, Osteomalacia, Rickets
�Genetic – Otto pelvis
�Neoplastic - Neurofibromatosis, Multiple myeloma
�Trauma - Acetabular fracture
Management
-�Template to avoid offset and leg length discrepancies
-�Because of medial migration of the femur, the sciatic nerve is often nearer the joint than normal and
should be identified early and protected
-�Hip dislocation can be difficult due to the excessive depth of acetabulum and medial displacement of
femoral head. Perform controlled hip dislocation after extensive capsular incision avoiding excessive force
as this may result in fracture of posterior wall of the acetabulum or proximal femur. Consider in-situ neck
osteotomy. In severe cases a trochanteric osteotomy may be required for adequate exposure
-�Placing the hip centre back into the correct anatomical position is essential to restore proper joint
biomechanics and to lower joint reactive force.
-�The medial wall of the acetabulum is typically thin, and does not usually need reaming. The general
principle is to bone graft the floor and lateralize the cup.
-�Important to achieve good rim press fit using a cementless shell as thin or deficient medial wall is not
relied on.
-�Add supplementary acetabular screws for further stability. Consider using lateralized liner, judicious
lateralization to avoid trochanteric pain.
-�Femoral head bone autograft should be placed on the medial wall, especially if there are significant
cavitatory and central segmental bony defects.
-�In severe deformity, a reconstruction cage may be required
Intra-operative complications :
-�Acetabular fracture, neurovascular injury, and visceral injury.
-�Penetration of the medial wall may place intra-pelvic structures such as the bladder, ureter, bowel and
external iliac artery at risk.
-�Sometimes the posterior soft tissue envelope of the capsule and external rotators will not reach the
posterolateral trochanter for repair.
-�Most common postoperative complications include loosening and medial migration of tacetabular
component.
-�Others include dislocation, infection and LLD.

Dr. Ma§ǫud | 56
TKR
Poly ethelen Insert designs
1) Based on the conformity of the insert 2) Based on mobility of the insert
�Deeper congruent joint, deeper cut PE - �Fixed bearing
Decreases contact stress �Mobile bearing
�Flat geometry -Dual surface articulation
-Improves femoral rollback and optimizes flexion -Maximize conformity of tibial and femoral
-Increases contact stress due to low contact surface components
�Highly congruent -Reduce polyethylene delamination, wear and failure
-Reduce implant-bone interface stress
-Self-adjusting to overcome slight component
positioning errors
�LCS (Low Contact Stress) – rotating platform
which might compensate for mal-rotation between
tibia andfemur and reduce patello-femoral
maltracking
� Disadvantages
-High contact stresses and back-side wear
-Poly Spin-out if flexion gap too loose

Femoral designs
Single radius Double radius:
�Maintains collateral ligaments isometric J shaped- in sagittal plane, femoral component has
�Reduce joint reaction forces larger radius distally to distribute loads over larger
�Allows conformity area and more curved posterior part to improve roll
back.
Medial pivot Referencing
�Dynamic MRI studies showed asymmetrical roll �Anterior
back LFC > MFC -Respect anterior part of femur – no notching
�Dual radius -Cuts posterior condyles – risk of loose gap in
flexion
-If between 2 sizes – downsize
�Posterior
-Respect posterior femoral condyles -Risk of
notching if downsized

Weight bearing mechanical axis of lower limb

�� Line from centre of femoral head to 5 mm medial to centre of ankle joint
�� Pass through centre of knee in neutrally aligned knee
�� Medial to intercondylar notch in varus knee
�� Allows equal load sharing between medial and lateral compartments

Femoral preparation

Dr. Ma§ǫud | 57
� IM alignment - Entry point 1 cm anterior to insertion of PCL and 3-5mm medial to intercondylar notch -
Goes down anatomical axis � „Starts away from surgeon and directed towards surgeon‟
� Mechanical axis from centre of femoral head to intercondylar notch
� Valgus Cut angle = Angle between AAF and MAF (5-70), to get femoral cut perpendicular to
mechanical axis of femur, match other side if normal
� Size determined by anterior or posterior referencing
� Posterior femoral condylar axis in 30 internal rotation in relation to epicondylar axis (to accommodate 3 0
varus of tibial articular surface, so jig referencing from posterior condylar axis has in-built 30 of external
rotation for posterior femoral cut
� Medial femoral condyle larger and extends more distal to lateral condyle
� Posterior referencing could be unreliable in valgus knee with lateral condyle bone loss, use:
� Epicondylar axis referencing, parallel to tibial cut surface
� Whiteside line:
-Eponymous name for AP axis at right angle to trans-epicondylar axis.
-Runs from base of trochlear groove to apex of intercondylar notch
� Inappropriate rotation can lead to lose/tight medial/lateral gaps and PFJ instability

Grand-piano sign
� Asymmetrical bone resection produced on resected surface of medial and lateral aspects of anterior
distal femur when external rotation angle applied to resection
� In valgus knee, reference from medial condyle

Tibial preparation
� Extramedullary / Intramedullary referencing alignment
� External rotation while flexing to dislocate tibia - Reduce risk to patella tendon rupture and improves
tibial exposure
� Mechanical and anatomical axis: from centre of proximal tibia to centre of ankle
� Sagittal alignment: in line with fibula axis
� Varus – valgus alignment
Proximal tibia cut perpendicular to mechanical axis (Loss of anatomical 3 0 varus at tibia)
� Tibial slope: 3 – 100 (normal is 70)
Need to recreate natural tibial slope for PCL to function in CR TKR

Natural tibial plateau is 30 in varus to mechanical axis to accommodate larger medial femoral condyle.
However, it is recommended that cut is perpendicular to allow even loading and prevent fractures
� Rotational alignment: Tibial component should align with medial 1/3rd of tibial tubercle
� Cemented Metal backed → � Mono-block � Modular (Allows better checking for posteriorly
extruded cemented- More expensive -Forms extra surface-All poly - increased poly thickness)
�� In valgus knee, reference from good side (medial)

Dr. Ma§ǫud | 58
Dr. Ma§ǫud | 59
 Q angle If increased Q angle - lateral subluxation of patella
Patellar mal-tracking is the most common complication of TKA
Avoid:
�Medialization / Internal rotation of femoral & tibial
component
�Placing patella button lateral on patella
If maltracking noted intra-operatively
�Tourniquet deflation to release tethered quads and re-
evaluate
�Recheck position of all components
�Consider lateral release with diathermy
If maltracking noted post-operatively
�CT to compare epicondylar axis to posterior condylar
axis of femoral

Femoral rollback phenomenon

� Posterior transition of femoral-tibial contact with
progressive flexion
� Controlled by ACL & PCL
� Improve range of knee flexion by preventing
posterior impingement during deep flexion (clear
femur from tibia)
� Also increases lever arm of extensors by moving
centre of rotation further behind centre of patella
� To compensate, newer designs move concavity
where femoral condyles rest more posterior
� Steeper posterior slope to aid with flexion
� Cam is responsible for rollback in PS implants

Constraint Ladder
� Use as little constraint as possible to decrease transmission of forces at bone/cement/implant interface
Cruciate Retaining Posterior Stabilized
�Roll back, improved flexion �Tibial post & femoral cam to create mechanical roll back
�Retain some proprioceptive �Post does not provide varus/valgus stability but some AP
function (sagittal) stability
�Add to AP stability �More conforming (round on round design)
�Perform better with 3-50 posterior Indications
slope -inflammatory arthritis due to risk of late PCL rupture
�Low conformity: Tibial insert flat -Patellectomy - weak extensor mechanism leads to increases AP
to allow rollback (Round on flat instability and subsequent failure of PCL
design) -FFD > 150, might have to do PCL release
Disadvantages: -Patients with PCL injury
-Technically difficult to balance knee -Fixed varus/valgus
-PCL contracture limits balancing in Disadvantages
severe deformity -Cam jump - posterior dislocation if loose in flexion
-PCL stretches over time – may lead -Bone loss
to delayed flexion instability -Extra poly
-Less constraint - Point loading, -Patella clunk syndrome

Dr. Ma§ǫud | 60
causes increased wear
-Important to restore posterior tibial
slope and Posterior condylar offset to
achieve high flexion
-More conforming - more stress transfer to implant bone interface
� Systematic review, J Knee Surg (2018) Longo UG : Higher
ROM with PS knee when compared to CR, but similar patient
reported outcomes PROMs
NB. Anterior stabilized
�No cam-post mechanism, PCL sacrificed
�Tibia insert highly congruent with raised anterior lip
�No rollback

Constrained non-hinged Constrained hinged/linked

�Large central post and deep femoral box to
substitute for MCL or LCL
�Varus/valgus instability from LCL/MCL laxity
�Consider in obese patients with BMI> 35
�Increased force transmission to implant-cement
interface, therefore need intramedullary stem to
distribute forces over larger area
�For inadequate ligaments function and the use
of extension stems and augments
Eg. LCCK Nexgen (Zimmer) Legacy Constrained
Condylar Knee
TC3 (Depuy)
�Femur & tibia connect via bar
�Mobile bearing allows rotation to reduce loosening
due to rotational forces Or can have fixed bearing
�Indications:
-Global (multiple) ligament deficiency
-Polio
-Massive bone loss
-Knee resection for tumour or infection
�Intramedullary stem to address high rotational loads
Eg. �S-ROM Noiles (Depuy)
�Nexgen RHK - Rotating Hinge Knee

Dr. Ma§ǫud | 61
Soft Tissue Balancing Techniques
Measured resection:Position implants according to bony anatomy then release ligaments to balance
Gap balancing: McPherson’s rule
�Tensioning device to place �Symmetrical gap in flex/ext: address tibia
MCL & LCL under equal tension Tight - cut more tibia -- Loose - thicker poly
�Create rectangular flexion / � Asymmetrical gap: address femur (distal/posterior femoral
extension gap to equalize tension cuts)
on medial / lateral sides �Tight extension: FFD management
� Sagittal Flexion/extension �Tight flexion:
gaps should be equal - Downsize femur
FFD -Increase tibia slope
-Release posterior osteophytes �Both tight: Cut more tibia or use thinner insert
-Release posterior capsule with �Loose extension
Cobb - Add distal femoral augment
-Cut more distal femur - Downsize femur and thicker poly
-Release PCL �Loose flexion: larger femur with posterior augment
-Release gastrocnemius
�Both loose: Thicker poly
Coronal �Valgus knee �Varus knee
-Defect in femur (Seen on X-ray) -RA
�Lateral release �Medial release
1. Osteophytes 1. Osteophytes
2. Lateral capsule 2.Deep MCL & capsule
3. Tight in extension: ITB 3. PCL release
Z-plasty or release off Gerdy 4. Semimembranosus
tubercle or multiple transverse - Pie-crusting of medial soft tissue sleeve
stab incisions. - Superficial MCL: sub-periosteal elevation only
4. Tight in flexion: sub-periosteal - Anterior MCL if tight in flexion
release of popliteus off LFC - Posterior Superficial MCL if tight in extension
5. Tight in both flexion & - Full release will lead to instability
extension: LCL release - If >16mm poly insert required, use constrained TKR
- Can cause AVN of medial condyle – place tibial plate on cortical
bone

Patello-Femoral Arthroplasty Patella Resurfacing

Indications
�Isolated PF arthritis
�Young patient (<50 years)
Contra-indications
�PF instability
�Medial or lateral compartment
arthrosis
�High demand patient with false
expectations
�Inflammatory arthritis
�BMI >30 (relative contra-indication)
Pros
�Restore patella height and
optimize extensor mechanism
�Reduce re-operation rate for
anterior knee pain
� Normal thickness around 25 mm
� Place component slightly medial to improve tracking
� Minimum bony thickness (critical thickness) of 12 mm is
necessary to avoid fracture
� Advances in TKA design developed "patella-friendly"
implants to improve patello-femoral kinematics and thus decrease
anterior knee pain
� Deepening trochlear groove and increasing conformity of
patella to trochlear groove, extending anterior flange
� Patelloplasty - excise marginal osteophytes and reshape patella
with circumpatellar electrocautery failure rates, Van Jonbergen
et al. J Arthroplasty (2010)
Cons
�Over-resection, can lead to fracture or AVN
�Need to recreate patella thickness to optimize JRF
�Over-stuffing patella
- Loss of extension - Anterior knee pain - Patella maltracking

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Peri-prosthetic Patella Fractures
� Type I: Stable implant extensor mechanism intact
� Type II: Stable implant & extensor mechanism disrupted
� Type IIIa: Loose implant & preserved bone stock
� Type IIIb: Loose implant & loss of bone stock
� Increased risk with central single peg implant, Uncemented fixation & Metal backed
�Patella ORIF if extensor mechanism disrupted

Peri-prosthetic fracture
�Causes
-Notching o long stem revision; CT to assess implant stability
o Poor bone stock- distal femoral prosthesis -Forceful MUA
Classification (Lewis and Rorabeck)
-I: undisplaced, fixed implants (plaster)
-II: displaced, fixed implants – fix (Retrograde nail if CR)
-III: displaced, loose implants

�Sub-muscular plating has reduced non-union risk compared to extensive lateral approach
�Revision if implant loose

Loosening- Non-progressive, radiolucent lines < 2 mm have shown no correlation with poor clinical
outcome. Drill sclerotic bone to improve inter-digitation
� Unconstrained PCL retaining round-on-flat tibial insert produces high contact stress but allow rotation
and femoral rollback without excessive PCL tension. This non-conformity creates areas of high conformity
within UHMPWE which is design specific.
� Conforming PCL sacrificing round-on-round designs with concavity in both sagittal and coronal planes
(double dishing) reduces contact stress but with penalty of reduced rotation. This in turn increases the shear
stress at the bone implant surface.
� Sakellariou et al. HSS Journal(2013) suggested using conventional UHMWPE for TKR as XLPE has
reduced adhesive and abrasive wear but increased risk of crack propagation, deformation, pitting and
delamination in TKR (increased fatigue wear)

Instability:
�In flexion
-Giving way and difficulty climbing stairs
-Due to lose flexion gap or damage to PCL at surgery or attrition rupture
� Varus/valgus
Causes -Patella maltracking -Muscle weakness

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Revision TKR
Goals of revision surgery
�Adequate exposure
�Extraction of components with minimal
bone loss and destruction
�Restoration of bone deficiencies & joint
line with augments
�Balance knee ligaments
�Stable revision implants
Steps
�Aim osteotome at implant-cement (not
cement-bone) interface
�Determine tibial platform
�Finish tibia augmentation
�Long stem to share load with diaphysis
due to metaphyseal bone loss and to reduce
torsional forces from additional constraint
(anatomic or offset to accommodate
anatomical variations)
�Prepare femur
�Determine femoral rotation
�Titanium baseplate reduces early
loosening compared with cobalt chrome
To optimize exposure
�longer skin incision
�Extended medial parapatellar approach
�Synovectomy
�Sublux rather than evert patella to reduce risk to patella
tendon
�Tibial tubercle osteotomy for patella baja
�Rectus snip or quadriceps turndown
Type Description(Anderson Orthopaedic Research
Institute (AORI) classification of bone loss in revision
TKR)
Type I -Metaphyseal bone is intact
- Minor bone defects, not compromising component
stability
Type II
IIa -Defect in one condyle or plateau
IIb -Defect in both
-Metaphyseal bone is DAMAGED -Cancellous bone lost,
Type III
-Metaphyseal bone is DEFICIENT
-Bone loss compressing major portion of condyle or plateau
Bone loss cavity filling
� Cavitary: Cement < 1cm & Bone graft > 1cm
� Segmental: Use of wedges/augments for
reconstruction
� Porous metaphyseal sleeves for massive
metaphyseal loss
� Massive bone loss - Endoprosthesis
� Start on tibial side first to establish joint line
� Then balance flexion – extension gaps,
recreate of posterior femoral condyles to
maintain stability in flexion
� Removal of well-fixed patellar component can
result in severe bone loss - retain if possible.
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Shoulder arthroplasty
Pre-operative planning for shoulder Arthroplasty
-� Essential to assess glenoid bone loss
� Aids decision making about type of implant
� Axial CT is best method to assess glenoid bone loss
� Friedman et al described a method using an axial slice at the level of the coracoid tip. The version is
equal to the angle subtended by a line drawn between the scapular axis (from medial tip of scapula to
midpoint of glenoid) and glenoid face (between anterior and posterior margins of the glenoid face)
Hemiarthroplasty Resurfacing
- Best indications are AV, trauma, or poor glenoid bone stock (RA) - Maintains anatomy by
- Trauma stem has holes for GT and LT reattachment placing the prosthesis in the
- In a young active – high risk of glenoid replacement loosening native anatomical location
- Can be used in rotator cuff arthropathy- must have intact deltoid and CA - Requires well preserved
arch head bone stock and intact
- Used when glenoid bone stock inadequate rotator cuff and no significant
- Progressive glenoid arthrosis and erosion requires conversion to TSR glenoid disease
- Increased rate of revision surgery compared to TSR - Smaller operation and
-� Implant height: reduced risk of dislocation
oTip of GT 10 mm below tip of articular surface of humeral head - Good option in young
oDistance from top of prosthesis to upper border of pec major 6 cm patients to preserve bone
- Tuberosity displacement following reattachment is the most stock
common cause of failure for fractures - Easy to overstuff
treated with hemiarthroplasty �Numbers reducing as TSA
-� Role for Pyrocarbon heads: closer Young‟s modulus to bone, less wear and Hemiarthroplasty more
to glenoid. Still low numbers also an option in OA in young active consistent

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Total Shoulder Arthroplasty Reverse shoulder replacement
- Indications � Better than hemi in trauma with comminuted GT
�glenoid wear �Glenohumeral arthritis with intact fracture as healing unpredictable especially in
cuff elderly
- Contraindications � Use convex glenoid (hemispheric ball) and
�Non-functioning deltoid �Rotator cuff tear ?????? concave humerus (articulating cup)
→Loosening due to unopposed contracture of deltoid � Acromiohumeral distance < 7mm and disrupted
– (Rocking horse phenomenon movement of the shoulder Shenton line indicate rotator cuff massive
humeral head sup ↔ inf or ant ↔ post) tear
�Superior migration and eccentric loading (edge � Moves glenohumeral joint‟s centre of rotation
loading) medially & inferiorly compared to native anatomy
�Infection Based on Gramont‟s principle-� Increase deltoid
�Insufficient glenoid bone stock: erosion down to lever (moment) arm to compensate for rotator cuff
coracoid or excessive eccentric erosion resulting in a deficiency – increase power
need for “high sided reaming” > 15 0 � Prosthetic design can be subclassified by
Routman et al into
Glenoid -Build up with iliac crest bone graft and
designs with centre of designs with centre of
not cement -Only 1.5 cm deep rotation (COR) 5mm rotation (COR) > 5mm
�Glenoid component pear shaped to match or less from glenoid from glenoid face
glenoid face (medialised (lateralised glenoid,
�Concentric reaming to improve contact glenoid MG) LG)
�Peg design biomechanically superior to keel �MG designs improve � LG designs
design, to counter shear stress fixation by decreasing medialise COR
�Polyethylene-backed superior to metal-backed shear stress and relatively less
components (lateralize joint line – tightness) imparts greater resulting in shorter
�Uncemented glenoid has the lower rate of moment arm for deltoid moment arm
loosening deltoid but potentially but can give a better
Humeral osteotomy: shorten and weaken “deltoid wrapping”
�0 – 30o retroversion, increased retroversion residual cuff muscles effect improving
improves ext rotation. and produce less tensioning of the
�45o to long access “deltoid wrapping” deltoid.
-� Complications: contributing to
�Stiffness instability
�Malposition of components ◊ instability and
-� There also designs to medialise or lateralise the
dislocation
humerus too.
�Glenoid erosion or loosening NB. Rotator cuff tear -� Must have intact deltoid and adequate glenoid
repair to avoid glenoid loosening bone stock Mount glenosphere onto baseplate
�Subscapularis repair failure & anterior shoulder -� Reconstruction socket achieving fixation in
instability glenoid, coracoid and acromion. salvage for failed
�most common cause of failure in RA RSR
�From poly debris (Osteolysis) -� Consider latissimus dorsi transfer for a better
�Humeral/glenoid fracture external rotation.
�Stem loosening: same rate in cemented & Complications
cementless (1-2%) �Glenoid prosthetic loosening the most common
mechanism of failure due to high torque forces
-� NICE 2010; No difference in function & pain �Scapula notching decreased by placing the
relief between resurfacing & TSR glenoid component as inferior as possible with
-� AAOS 2009; suggests total shoulder arthroplasty inferior tilt Instability and dislocation
over hemiarthroplasty �Stiffness �Infection �Impingement
-�Meta-analysis - Bryant – JBJS – 2005; at
�Periprosthetic and scapula fracture
minimum of 2 years follow-up, TSA provided better
pain relief and function than hemiarthroplasty for �Axillary nerve injury
patients with OA

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