Applied Biomechanics

ARTHROPLASTY

DR ABDA SHAIKH
INTRODUCTION

“The surgical reconstruction or replacement of a joint”.

Arthroplasty is a surgical procedure performed by an orthopedic

surgeon that alters or completely replaces a joint in the body,
usually to restore normal motion and relieve pain in a malformed
or diseased joint, such as the hip, knee, shoulder, elbow or ankle.
INDICATIONS

A. Severe osteoarthritis of the hip and knee joint.

B. Advance rheumatoid arthritis with disabling pain.
C. Quiescent destructive tuberculosis arthritis.
D. Un-united femoral neck fracture.
E. Correction of certain type of deformity especially Hallux Valgus.
F. Avascular necrosis.
G. Hip dysplasia
H. Bone tumors
I. Joint stiffness
J. Instability of hip joint
K. Frozen shoulder and loose shoulder
L. Acetabular dysplasia
M. Failure of conservative management or joint reconstruction procedure.
ABSOLUTE
CONTRAINDICATIONS
A. Active joint infection
B. Systematic infection or sepsis
C. Chronic osteomyelitis
D. Neuropathic of hip joint
E. Severe paralysis of the muscles surrounding the joint.
RELATIVE
CONTRAINDICATIONS
A. Localized infection such as bladder and skin
B. Insufficient function of gluteus medius muscles
C. Progressive neurological disorders
D. Insufficient femoral and acetabular bone stock associated with progressive
bone disease
Types of Arthroplasty

– Depends on severity of the problem of joints and other factors,

1. Resection arthroplasty,
2. Inter-positional arthroplasty
3. Total joint arthroplasty
may be performed.
1. Resection or Excision Arthroplasty,
– the orthopedic surgeon removes a minimal amount of tissue surrounding the
joint in an attempt to restore joint function.
2. Inter-positional Arthroplasty
– the joint is surgically reshaped and, to provide better contact between the
sides of the joint, a material (such as metal, plastic, ceramic or the patient’s
own soft tissue) is positioned at the site where the joint articulates.
3. Total Joint Arthroplasty

– The orthopedic surgeon uses special instruments to remove damaged portions

of the joint and replaces them with artificial components. Stems or pegs on the
artificial joint components are fitted into the healthy, remaining part of the
bone and kept in place with either bone cement or a special coating on the
implant that fosters new bone growth in the area. The fixation method used is
based on the patient’s age, bone quality and activity level.
COMPLICATIONS

I. DEEP VENOUS THROMBOSIS: this occurs due to inadvertent manipulation of thigh

during surgery, venous stasis in the limb due to immobility.
II. INFECTION: this is the most serious of all complications.
III. NERVE PALSIES: the sciatic nerve is the most commonly affected.
IV. VASCULAR INJURY: this is uncommon, but may occur mainly due to technical
reasons.
V. FRACTURE: these may occur during the process of inflammation of the prosthesis
VI. DISLOCATION: it is primarily due to mal-positioning of limb during early post
operative period.
Total Knee Arthroplasty

– Total knee arthroplasty also called total knee replacement.

– It is widely performed procedure for advanced arthritis of the knee, primarily in
older patients (more than 70 years of age) with OA.
– The primary goals of TKA are to relieve pain and improve a patients physical
function and quality of life.
INDICATIONS OF TKA

1. Severe joint pain with weight bearing or motion.

2. Extensive destruction of articular cartilage of knee joint.
3. Marked deformity of the knee such as genu varum or genu valgum
4. Gross instability or limitation of motion
5. Failure of non-operative management
6. Failure of previous surgical procedure
Number of Compartments Replaced

• Uni-compartmental: only medial or lateral joint surfaces replaced

•Bi-compartmental: entire femoral and tibial surfaces replaced
• Tri-compartmental: femoral, tibial, and patellar surfaces replaced
SURGICAL APPROACH

1. Standard/tradition or minimal invasive

2. Quadriceps splitting or Quadriceps sparing
Surgical Approach

– Standard Approach: Anterio-medial para-patellar vertical or curved incision

from the distal aspect of the femoral shaft, running medial of the patella to just
medial of the tibial tubercle, ranging from 8 to 12cm or 13 to 15cm in length.
– Minimally Invasive Approach: Reduced length of anterio-medial skin incision 6-
9cm in length. Anterior capsule release
Implant Design
Degree of Constraint:

– Unconstrained: no inherent stability in the implant design; used primarily with

uni-compartmental arthroplasty
– Semi-constrained: provides some degree of stability with little compromise of
mobility; most common design used for total knee arthroplasty
– Fully constrained: significant congruency of components; most inherent
stability but considerable limitation of motion
Implant Fixation

1. Cemented
2. Non-cemented
3. Hybrid
– Bone cement is methyl-methacrylate compound. Cement can be used with or
without in a joint.
– Cemented is used in elderly patient with expected life of 10-15 years
– Non-cemented hip is used in younger people.
RECOMMENDATION FOR
PARTICIPATION IN TKA
1. Stationary cycling
2. Swimming, water aerobics
3. Walking
4. Ballroom or square dancing
5. Table tennis
NOT RECOMMENDED

1. Jogging, running
2. Basketball
3. Volleyball
4. Baseball
5. Football
6. Gymnastics
7. Squash
Total Hip Arthroplasty

– Total Hip Replacement

– Bone is sheared away and an artificial hip is
implanted
– Osteoarthritis, trauma, and overuse make people
candidates
How does the implant work?

– The ‘stem’ is drilled into the femur

– The ‘ball’, also known as the bearing, acts as the femoral head
– The ‘liner’ acts as the acetabulum
Cemented vs. Un-cemented
Implants
– Cemented
– Liner is permanently attached to the
pelvis
– Un-cemented
– Liner is only temporarily attached
– Liner consists of porous material
compatible for bone growth
– Bone grows and secures liner in
place
Operative Approaches

– It an be divided into two main catyegories:

1. Standard surgical approaches
2. Minimally invasive approaches

1. STANDARD SURGICAL APPROACHES: it can be 3 types:

a) Posterio-lateral approach
b) Direct- lateral approach
c) Anterio-lateral approach
A. Posterio-lateral Approach

– This is the most frequent used approach for

total hip arthroplasty
– In this approach, the gluteus maximus is split
in line with the muscle fibers.
– In this approach, the gluteus medius and
vastus lateralis muscle is not split.
– In this approach, after total hip arthroplasty
early post-operative motion of hip joint is hip
flexion, adduction and internal rotation of hip
joint movement is AVIOD.
B. Direct- lateral Approach

– In tis approach, requires longitudinal division of the tensor fascia latae, one-half
of the gluteus medius and longitudinal splitting of vastus minimus.
– In this approach, disruption of the abductor mechanism is associated with post-
operative weakness and gait abnormalities.
– In direct lateral approach, the positive Trendelenburg sign is present.
C. Anterio-lateral Approach

– In addition to the gluteus medius, soft tissues disturbed include gluteus

minimus, tensor fascia latae, iliopsoas, rectus femoris, and vastus lateralis
muscles as well as the anterior capsule is disturbed.
2- Minimal Invasive Approaches

– It can be of two types:

1. Single incision approach
2. Two incision approach

Incision must be less than 10cm.

Precautions
Goals after THA

1. A pain free hip joint.

2. A stable joint for lower extremity weight bearing and function ambulation
3. Adequate ROM for functional activities.
4. Strength of lower extremity for functional activity.
Pre-operative Management

– Evaluation:
i. Pain
ii. Deformity
iii. ROM
iv. Muscular power
v. Muscular atrophy
vi. Ambulation and Gait
Pre-operative Physiotherapy

1. Deep breathing and coughing.

2. Strong and sustained isometric contraction.
3. Guidance of ROM and strengthening exercises.
4. To teach proper limb positioning.
5. Resisted exercises.
6. To teach appropriate technique of transfer.
7. To mentally prepare the patient for the painful active stage ahead.
Biomechanical Importance

1. The role of biomechanics is intricately involved in total joint replacement from

its inception to its clinical use.
2. By integrating knowledge of joint function and material properties, the
artificial joint is designed and tested.
3. After clinical use, the joint function is again studied and failure modes are
defined.
4. Biomechanics is the single most important discipline that can be employed to
study the cause of failure in order to improve design and technique.
5. This will increase the reliability of, and decrease the incidence of failure
associated with, total joint replacement.
6. The biomechanics of the hip joint provide an understanding of the
development, evolution, and treatment of many disabling conditions of this
joint.
7. The available methods of biomechanical analysis include in vitro studies, in
vivo studies, and theoretical mathematic analyses.
8. The information obtained from these analyses have enabled the design of
therapeutic programs to alleviate the symptoms of, and possibly delay the
progression of, hip disease.
CPM

– CPM is an abbreviation for continuous passive motion. A CPM device is a machine

that is used to move a joint without the patient having to exert any effort. CPM
device, which constantly moves the joint through a controlled range of motion; the
exact range is dependent upon the joint

– The CPM has a motor that bends the joint back and forth to a set number of
degrees. The amount of movement of the CPM can be adjusted.

– After surgery for knee replacement, ACL reconstruction, and frozen shoulder
surgery, a stiff joint can be a major complication. Therefore, some surgeons use a
CPM to try to prevent scar tissue formation and improve the joint mobility.