of the total hip joint关节髋关节脱位课件

DISLOCATION OF THE DISLOCATION OF THE TOTAL HIP ArthroplastyTOTAL HIP Arthroplasty Ebrahimzadeh M.H. MDEbrahimzadeh M.H. MD Department of Orthopedic Surgery,Department of Orthopedic Surgery, Ghaem Hospital ,Ghaem Hospital , Mashad University of Medical Sciences,Mashad University of Medical Sciences, Mashad - Iran. Mashad - Iran. EbrahimzademhMUMS.ac.irEbrahimzademhMUMS.ac.ir The The point point must must be be made made that that an an occasional occasional post-post- operative operative dislocation dislocation . . is is no no disgrace. disgrace. Patients Patients can can sometimes sometimes be be quite quite irresponsible irresponsible and and unreasonable unreasonable during during this this period period . . It It is is only only in in recurrent recurrent subluxation subluxation or or dislocation dislocation that that the the surgeon surgeon might might have to hold himself responsible“ (?)have to hold himself responsible“ (?) Sir Sir John John Charnley Charnley 1979, 1979, one one of of the the Founding Founding Fathers Fathers of the total hip surgery. of the total hip surgery. The The total total hip hip dislocation dislocation is is a a painful painful complication complication in in which which the the femoral femoral ball ball component component comes comes out out (dislocates) (dislocates) of of its its place place in in the the cup cup component component and and moves outside the total hip. moves outside the total hip. The mechanisms of dislocationThe mechanisms of dislocation impingement impingement of of the the neck neck of of the the femoral femoral component against the rim of the cup component against the rim of the cup Other causesOther causes - Weak soft tissue; abductors, capsule,- Weak soft tissue; abductors, capsule, -Wrong component position-Wrong component position Stability of the total hip jointStability of the total hip joint 1. 1. Restoration Restoration of of balance balance in in soft soft tissues tissues around around the the total hiptotal hip 2. 2. Good position of the components Good position of the components 4. 4. The size of the head component The size of the head component 5. 5. Large head makes the total hip joint more stable Large head makes the total hip joint more stable How often does it happen?How often does it happen? - %0.3 - %3- %0.3 - %3 - - Medicare Medicare patients patients in in the the United United States: States: patients patients operated operated on on by by surgeons surgeons who who performed performed less less than than 6 6 THR THR annually annually experienced experienced 4.2% 4.2% dislocations, dislocations, patients patients operated operated on on by by surgeons surgeons with with 50 50 THR THR annually experienced only 1.5% dislocations annually experienced only 1.5% dislocations Factors increasing risks of dislocation Factors increasing risks of dislocation Usually, not one but several risk factors collaborate.Usually, not one but several risk factors collaborate. Patient risk factors include:Patient risk factors include: - advancing age - advancing age - female gender - female gender - prior surgery - prior surgery - fracture through the hip joint - fracture through the hip joint - posterior approach - posterior approach - weak abductors - weak abductors - neuromuscular disorders- neuromuscular disorders - dementia - dementia - alcohol abuse- alcohol abuse Important surgical risk factors leading Important surgical risk factors leading to dislocation includeto dislocation include - wrong positioning of the total hip components,- wrong positioning of the total hip components, - - failure failure to to restore restore leg leg length length and and / / or or proper proper tension tension of the tissues around the total hip of the tissues around the total hip - - failure failure to to preserve preserve the the strength strength in in the the abductor abductor muscles muscles (the (the strong strong muscles muscles that that move move the the leg leg sideways and keep the femoral ball in the cup). sideways and keep the femoral ball in the cup). Implant risk factors Implant risk factors - - include include total total hip hip models models with with small small femoral femoral heads (22 mm)heads (22 mm) - - femoral femoral heads heads with with thick thick femoral femoral neck neck component. component. How to reduce the chance of DX How to reduce the chance of DX -Right component selection 11-28 Ante, 40+ InclinationAcetabulom;11-28 Ante, 40+ Inclination Femoral stem; 10 Ante version Femoral stem; 10 Ante version -good soft tissue management-good soft tissue management -Patient training-Patient training Soft tissue managementSoft tissue management Repair of capsule, short external rotatorsRepair of capsule, short external rotators Not to damage abductor system Not to damage abductor system Minimal invasive surgeryMinimal invasive surgery - 2 incisions, - 2 incisions, -one short incision -one short incision My experience with minimal My experience with minimal incisionincision - poster lateral approach- poster lateral approach - 6-8 Cm- 6-8 Cm - - Just Just from from posterior posterior tip tip of of greater greater trochanter trochanter as as to to rim of acetabulomrim of acetabulom - 10 patients with Zimmer and Stryker system- 10 patients with Zimmer and Stryker system Patient trainingPatient training - - Using Using an an abduction abduction pillow; pillow; Massachusetts Massachusetts General hospital protocol for all THAsGeneral hospital protocol for all THAs - -Tavantoos aduction pillow- -Tavantoos aduction pillow Massachusetts General HospitalMassachusetts General Hospital Tavan-Toos Abduction PillowTavan-Toos Abduction Pillow Patient trainingPatient training - Noncompliance patients, spica cast- Noncompliance patients, spica cast - How to start sitting, standing and sitting- How to start sitting, standing and sitting - Restroom sitting- Restroom sitting - Not to sleep prone - Not to sleep prone Symptoms and Signs of total hip Symptoms and Signs of total hip dislocationdislocation Total hip dislocation is a very painful Total hip dislocation is a very painful condition condition Symptoms and Signs of total hip Symptoms and Signs of total hip dislocationdislocation - feels very painful “popping“ in the total hip joint. - feels very painful “popping“ in the total hip joint. - - keeping keeping the the whole whole leg leg stiff stiff and and firmly firmly pushed pushed to to the midline and the other leg the midline and the other leg - - In In patient patient with with many many dislocations dislocations in in the the past, past, the the pain may be only moderatepain may be only moderate Treatment of the first dislocationTreatment of the first dislocation CR: CR: Longitudinal Longitudinal traction traction and and slight slight abduction abduction when the head is at the level of the acetabulomwhen the head is at the level of the acetabulom Post Post care: care: adduction adduction orthosis orthosis (15), (15), traction, traction, spica spica cast for 6 weekscast for 6 weeks An 80-years man, Department of Orthopedic An 80-years man, Department of Orthopedic Surgery, Ghaem Hospital 1383Surgery, Ghaem Hospital 1383 It dislocated for 2 times It dislocated for 2 times - We manage the patients with a spica cast - We manage the patients with a spica cast The repeated dislocationThe repeated dislocation The The first first dislocationdislocation that that occurred occurred during during the the first first three three postoperative postoperative weeks weeks and and was was treated treated accordingly accordingly has has a a low low risk risk of of recurrence: recurrence: about about 20 20 to to 30 30 % % during during the the next next years.years. After After another another (second)(second) dislocation dislocation the the risk risk that that the the total total hip hip will will continue continue dislocate dislocate increases increases substantially; substantially; according according to to some some statistics statistics about about 50% 50% of of patients patients who who had had two two dislocations dislocations will will continue continue to to dislocate dislocate their their total total hip hip repeatedly; repeatedly; this this risk risk is is especially especially high high if if the the total total hip hip operation operation was was done done through through posterior posterior approach approach or or if if the the total hip is a model with a small femoral head.total hip is a model with a small femoral head. Examinations after second and Examinations after second and further dislocationsfurther dislocations Comprehensive x-ray Comprehensive x-ray CT-ScanCT-Scan Fluoroscopic study under sedationFluoroscopic study under sedation OPERATIONS TO IMPROVE OPERATIONS TO IMPROVE THE STABILITY THE STABILITY 1. 1. Revision of faulty positioned components Revision of faulty positioned components 2. 2. Operations Operations to to relieve relieve slackness slackness of of soft soft tissues tissues around a total hiparound a total hip A:A: soft tissue advancement soft tissue advancement B:B: Change the length of neck Change the length of neck C:C: Revision Revision D:D: Constrained cups Constrained cups E:E: Bipolar hip prosthesis Bipolar hip prosthesis Dislocation of the polyethylene linerDislocation of the polyethylene liner Dislodgment Dislodgment of of the the polyethylene polyethylene liner liner is is an an increasingly increasingly common common complication complication following following total total hip arthroplastyhip arthroplasty What are the symptomsWhat are the symptoms painful limp and shortening of the limb painful limp and shortening of the limb TreatmentTreatment Operation Operation of of the the dislodged dislodged liner liner is is necessary, necessary, the the surgery should be done as soon as possible surgery should be done as soon as possible ReferencesReferences 1. 1. Bourne J, Mehin R.: J Arthroplasty 2004, Suppl 1, 111- 4 Bourne J, Mehi