Arthroplasty

Marielle Marasigan Julie Ann Peano

Avascular Necrosis of Femoral Head

A disease in which the living elements of bone in the femoral head die

Pathogenesis of AVN
Sinusoidal occlusion and venous stasis marrow necrosis and partial osteocyte death Frank bone necrosis and early osteoblast response Early bone repair and inc bone density ate repair and distortion of the femoral head Subchondral fragmentation and articular breakdown

Fracture
!isruption in the integrity of the living bone" involving in#ury to the bone marrow" periosteum and ad#acent soft tissue$

Etiology
%ccurs when force applied to the bone e&ceeds the strength of the involved bone Intrinsic Factors:
' (one)s energy absorbing capacity ' *odulus elasticity ' Strength ' !ensity

 Extrinsic Factors:
' +ate of load ' !uration" !irection and *agnitude of force

Direct Trauma:
' ,rushing" Penetrating -n#uries

Indirect Trauma:
' .raction" ,ompression" +otational Forces

General Principle of Fracture Healing

Ade/uate (lood Supply *inimal 0ecrosis Anatomic +eduction -mmobili1ation Physiologic Stress Absence of -nfection

Fracture Complication
(one 2ealing Abnormalities3
' !elayed 4nion 5 678 months after in#ury ' 0on74nion 7 9 : months after in#ury ' *alunion 5 4nacceptable Position ' Avascular 0ecrosis

Hip Fractures

 2ip fracture is an emergency situation$ -ntertrochanteric fracture and femoral neck fracture accounts ;<= of the hip fracture$ Subtrochanteric fracture >below lesser trochanter? accounts @= 7 A<= of hip fracture$ ;<= of peripheral osteoporotic fracture results to fall$

Categories
-ntracapsular
' ocated distal to the femoral head but pro&imal to the greater and lesser trochanter s$ ' Fre/uently disrupts the blood supply to the femoral head" therefore associated with nonunion and osteonecrosis of the femoral head$ >eg$ Femoral neck fracture?

E&tracapsular
>eg$ .rochanteric Fracture?

Femoral Neck Fracture

Epidemiology
*ore than B@<"<<< hip f& occur in 4S each year >@<= involve the femoral neck?$ C= occur in women" incidence B& every @ to : yrs >96< years? Dounger p& 3 high7energy traumaE elderly >FB yrs?3 low7energy falls -ncidence of femoral neck f& in 4S is :6$6 and BF$F per A<<"<<< >Gomen and *en?

Ris Factors
Female se& Ghite race -ncreasing age Poor health .obacco and alcohol use Previous fracture Fall history ow estrogen level

Anatomy
Hip Joint

ball and socket #t$ ,omposed of femoral head H the acetabulum 2as 6 deg$ of freedom Geight bearing #t$ Femoral epiphysis closes by age of A: yrs Neck-shaft angle3 A6<FI Femoral anteversion3 A<JFI

!igaments
-liofemoral
' D7ligament of (igelow >ant$?

Pubofemoral
' anterior

-schiofemoral
' posterior

"lood #upply
Trochanteric nastamosis Provides the main blood supply to the head of the femur 0utrient arteries pass along the femoral neck beneath the capsule !arts: Superior gluteal artery -nferior gluteal artery *edial femoral circumfle& artery ateral femoral circumfle& artery

Mechanism of $n%ury
"o#-energ$ trauma >most common in elderly?
' Direct
' A fall onto the greater trochanter >valgus impaction? or forced e&ternal rotation of the E

' Indirect
' *uscle forces overwhelm the strength of the femoral neck

 High-energ$ Trauma
' both younger and older patients Eg$ *KA or fall from a significant ht$ >osteoporotic p&?

%$clical "oading-stress Fractures

' .hese are seen in athletes" military recruits" ballet dancers ' P& with osteoporosis and osteopenia are at particular risk

Clinical Evaluation
P& with displaced femoral neck fractures typically are non7ambulatory on presentation" with shortening and e&ternal rotation$ P& with impacted or stress f& may demonstrate subtle findings$ Pain on attempted +%* of the hip Pain on a&ial compression and tenderness to palpation of the groin ook for additional problems

Classification

JOINT REPLACEMENT

Purpose
+elieve of severe disabling pain ,orrect deformities +e7establish function Prevent meliorate painful secondary effects on ad#acent #oints

!imitations
!islocation >post Approach? -nfection >most fatal? !K. Periprothetic fracture oosening

Common causes of &oint 'estruction

%A +A AK0 .raumatic Arthritis egg7,alve7Perthes !se Slipped capital femoral epiphysis And failed Previous operation

Contraindications
&solute 'elative

Active sepsis >local or systemic? Paralysis about the #oint to be replaced 0euro pathic Jt disease Dounger age and obesity Severe muscle weakness Severe osteoporosis Severe uncorrected defects about the #oint Physiological or psychological deficiencies and proportion

(ypes
.otal
' (oth sides of the #oint are replaced

Partial
' %nly one side is replaced

-nterpositional +esectional

Methods of Fi)ation
Polymethylmethacrylate >bone cement? Porous coated7bony ingrowth 2ydro&yapatite coating Press7fit stabili1ation

"earing #urface
*etal7on7metal ,eramic7on7ceramic Polyethylene

Complications
.hromboembolic !isease Prophyla&is
' *echanical3 elevation of the limb early mobili1ation" compression stockings

Aseptic oosening
' P& usually complains of pain in the groin or buttocks or thigh

Pre*operative Education
*uscle Strengthening Strengthening muscles around the #oint operated either by isometrics" isotonic or isokinetic

Post*op Reha+ilitation Program

(oal: to ma&imi1e the p&)s f&n)l status with respect to mobility" A! and also to minimi1e post7operative complications ,emented
' -mmediate G(

0on7cemented
' .oe touch for si& wks ' PG( ne&t : wks

 First day
' P& can stand at bedsite if possible ' (egin ambulating with assistive device

Second day
' ambulation should begin transfers to bed" chair and toilet alone safely

Second week
' Perform mobility task at supervision level

Si&th week
' *uscle strengthening e&ercise

Precautions
0o fle&ion the hip past ;<I 0o leg adduction of the leg past midline 0o abduction beyond 8@I Precautions are maintained for appro&$ 6 months to allow pseudocapsule to form