Ceramic hip replacement
A Nigerian patient sought a hip replacement in India. He was suffering from a neglected posterior dislocation of hip with avascular necrosis. He was given an advanced Ceramic on Ceramic hip. Although the US FDA only recently accorded sanction for ceramic on metal hip replacement, this procedure had been done by us since the last two years.
Hip replacement in neglected acetabular fracture
Dr.A.K.Venkatachalam
Consultant Orthopedic surgeon, Chennai,
www.hipsurgery.in
Acetabular fractures are often sustained in four wheeler accidents. Most patients are young. The ideal treatment is internal fixation in displaced fractures. In neglected fractures or following improper fixation, avascular necrosis and secondary osteoarthritis result. In such cases total hip replacement is required. This case report shows a total hip replacement for a neglected acetabular fracture.
Case report- Mr. S A, a 30 year old Nigerian male presented with a neglected acetabular fracture of two years duration.
The head of the femur is lying posteriorly on the ischium.
He was taken up for a one stage acetabular reconstruction and a total hip replacement.
Technique
Acetabular reconstruction was achieved with a cortico cancellous bone graft from the femoral head. The posterior wall was recreated with bone graft fixed in place by a contoured reconstruction plate.
After achieving a contained acetabulum, it was prepared to receive an uncemented Pinnacle cup. This multi holed cup was fixed with four screws. A Corail stem was used on the femora side. The bearings were Ceramic on ceramic. This case report can be seen here
E mail- drvenkat@kneeindia.com
Avascular necrosis is the most common cause of hip pain in the young and middle aged population. The most common reason is idiopathic or unknown. Other causes include steroid intake, blood disorders, fractures of the neck of femur, alcoholism.
The disease is very common in the age group 20 to 50.
Treatment options are
1) Non surgical- This has a poor rate of cure.
2) Surgical- Surgical treatments can be further divided into joint replacement or non joint replacement. Non joint replacement measures are core decompression and regenerative therapy with bone forming stem cells. This modality of treatment is relatively new and is available in India at a modest cost.
Joint Replacement- This consists of hip resurfacing, BHR, Birmingham mid head resection (BMHR),Short stem hip replacements, Birmingham mid head resection and total hip replacement with an uncemented or cementless prosthesis.
The bearings used need to be long lasting and devoid of side effects. Metal on metal bearings are used in Hip resurfacing and BMHR.
Ceramic on ceramic or ceramic on metal or ceramic on poly bearings can be used with short stem and total hip replacements. Ceramic on ceramic bearings result in the least amount of wear. Metal bearings can produce some amount of wear particles.
Most procedures mentioned above are bone preserving operations with the exception of a total hip replacement.
We have been performing short stem hip replacements with the Proxima hip since the last 5 years.
People dread getting old. If you are Caucasian and approaching your forties, you may have already noticed that some of the things you did as a teenager aren’t that easy anymore. As a general rule, if you take care of yourself when you are young, getting old will be easier. Joint pains develop and progress to restrict your life style and stop you enjoying outdoor activities.
A lot of people will have to face as a part of the aging process one of those things is hip replacements for hip pain.
According to The National Institue of Arthritis and Musculoskeletal and Skin Diseases there are over 193000 hip replacements performed in the U.S. each year. In the UK, the numbers are about 5, 00000 per year.
Hip resurfacing operation
More & more young & active patients world wide are in need of hip replacement surgery. In such cases, it is imperative to pay special attention to the technique to ensure a successful outcome & longevity of the operation.
Traditionally a total hip replacement was performed in the older age group.
Young patients with hip pain either had to endure pain or subject themselves to a total hip replacement with its inherent disadvantages of dislocation and life span of 10 to 15 years.
Now, recent advances in bio- materials and techniques have made it possible for young patients to get a satisfactory & successful outcome after a hip arthroplasty.
Definition of a young patient- The deciding factor is not necessarily the patient’s age, but their activity level. Even many older patients like to play Tennis, Golf or participate in physical activity. This applies also to anyone who can be expected to live for a long time, is biologically (not chronologically) young and has good bone quality. Today even septuagenarians meet these pre requisites. Surgeons have to re think their conventional strategy of putting in a total hip with a metal on poly bearing. Resurfacing also poses several un answered questions and cannot be considered as a panacea.
Causes leading to hip pain in young patients-
Avascular necrosis is the leading cause leading to hip arthritis followed by developmental dysplasia of the hip. Perthes disease, slipped upper femoral epiphyses, sickle cell disease and post traumatic arthritis are other causes leading to the common outcome of secondary osteo-arthritis. In middle and older Caucasian patients, Primary osteoarthritis is the commonest cause of hip pain.
Limitations of hip resurfacing
Off late, hip resurfacing has been vigorously promoted on the internet as a possible & preferred treatment. However there are some inherent un answered problems with hip resurfacing. Elevated metal ion levels, metal allergy, metallosis are some of the side effects of metal on metal hip resurfacing. The long term impact of raised metal ion levels is unknown. Females in all age groups are high risk candidates because of the risk of fertility curbs in young & femoral neck fracture in the older. However the attraction of a hip resurfacing drives many females to ignore these risks and choose a hip resurfacing.
Dr.Venkatchalam of www.hipsurgery.in discusses an alternate bone sparing safe approach in young & active patients. These approaches combine the advantages of a hip resurfacing and total hip replacement.
Why do you prefer the short stem?
The various short stem prostheses like the Proxima hip & METHA combine
Proxima hip prosthesis
the advantages of resurfacing & THR.
On the acetabular side a full range of options is available to the surgeon.
The force transfer in the femur is more proximal and more biological. Lack of a distal stem component eliminates the incidence of thigh pain. In addition these implants open up the vast range of bio materials available.
All biomaterial combinations like metal on metal, metal on poly, ceramic on poly, ceramic on ceramic are possible. These promise excellent
METHA hip
longevity. If a revision becomes necessary, then one can switch to a standard stem. Some of these models like the METHA hip make it possible for the surgeon to tailor the implant to the individual’s anatomy.
What other innovations can you use to ensure a proper implant positioning?
Navigation allows the surgeon to place the implant in the optimal position.
What are the special considerations in Asian patients?
Dysplasia and osteo necrosis constitute the most common indications for total hip replacement in India & Asia. Primary osteo-arthritis is rare.
Moreover these patients are younger and more active. Their social and religious habits such as sitting with crossed legs dictate to the surgeon that he must use a prosthesis which provides a large range of movement. Risk of dislocation has to be reduced. Anatomic differences also exist. All these variables require a special implant concept and very wear resistant materials with a large diameter.
To summarize, treatment of hip arthritis in the young poses a challenge to surgeons and scientists. Hip resurfacing while offering a possible solution has some draw backs. Short stem prostheses with newer bio materials promise to overcome these deficiencies and offer a long lasting surgical outcome.
Contact us- drvenkat@kneeindia.com
Avascular necrosis or Osteonecrosis is a fairly common hip condition.
Young patients are affected. Some of the causes leading to osteonecrosis are steroid intake, alcoholism, connective tissue disorders like SLE, Sickle cell disease, hypertension, decompression sickness, thrombosis, In a large number of individuals the cause is unknown or Idiopathic. Young and middle aged patients are affected. Involvement of both hips is fairly common.
Hip AVN
Hip showing advanced changes of avascular necrosis
Diagnosis- It takes a long time for the bony changes to be visible on plain x rays.
MRI scans and nuclear bone scans reveal the diagnosis early on when the condition is suspected. Both hips need to be imaged simultaneously. CT scans help to identify the extent of the bony involvement.
Treatment
The treatment depends on the stage of the disease. Most often conservative or non operative measures fail. Surgical treatment ranges from core drilling to total hip replacements. In the early stages core drilling can lead to a positive result in a good proportion of cases.
When this has failed, or the stage is more advanced, hip resurfacing is advised. However the surgeon should do so after a diligent assessment of the extent of disease. Hip resurfacing can be done when the extent of the femoral head involvement is less than 30 percent. In early cases partial hip resurfacing can be done in a few selected centers
Hip resurfacing operation
The presence of cysts makes hip resurfacing more difficult to perform with confidence. In these cases there are two options.
One is the Proxima hip replacement
where the bone is amputated at the base of the head similar to the BMHR. Then a short stem is impacted into the top portion or Proximal part of the neck and metaphysis of the femur. This has a large ball of the same diameter as the natural femoral head. The socket is also lined with a metal cup. Thus a trunnion of large diameter metal on metal results. The advantages are stability and less bone loss. The Proxima hip has a ten year follow up in the hands of its designer surgeon.
The other option is the Mid head resection Birmingham hip or BMHR.
Birmingham Mid head resection prosthesis
This operation involves amputating almost the entire head of the femur containing the cysts, impacting a conical stem into the neck portion of the femur and attaching a Birmingham hip like prosthesis. The cup also gets a metal liner.
All the options mentioned are bone sparing options.There is not much difference in the extent of the bony resection in the Proxima hip replacement and the Birmingham Mid head resection prosthesis. The former has a longer follow up.
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X ray of Hip replacement ( uncemented THR)
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