Lec # 06 - 08

Anatomy
Total Joint Replacement
Knee joint

Anatomy
Causes
Types of implants
Components
Knee implant fixations
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A joint is where the ends of two or more

bones meet.
There are different types of joints within
the body.

For example, the knee is considered a

"hinge" joint, because of its ability to bend
and straighten like a hinged door.
The hip and shoulder are "ball-and-socket"
joints, in which the rounded end of one bone
fits into a cup-shaped area of another bone.
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Several conditions can cause joint pain and

disability and lead patients to consider joint
replacement surgery.
In many cases, joint pain is caused by damage to
the cartilage that lines the ends of the bones
(articular cartilage)either from arthritis, a
fracture, or another condition.
If nonsurgical treatments like medications, physical
therapy, and changes to your everyday activities
do not relieve your pain and disability, your doctor
may recommend total joint replacement.
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Total joint replacement is a surgical procedure in which

parts of an arthritic or damaged joint are removed and
replaced with a metal, plastic or ceramic device called
a prosthesis. The prosthesis is designed to replicate
the movement of a normal, healthy joint.
In 2011, almost 1 million total joint replacements were
performed in the United States. Hip and knee
replacements are the most commonly performed joint
replacements, but replacement surgery can be
performed on other joints, as well, including the ankle,
wrist, shoulder, and elbow.

Lec # 06

The knee is the largest joint in the body and having healthy knees is
required to perform most everyday activities.
The knee is made up of the lower end of the thighbone (femur), the
upper end of the shinbone (tibia), and the kneecap (patella). The
ends of these three bones where they touch are covered with articular
cartilage, a smooth substance that protects the bones and enables
them to move easily.
The menisci are located between the femur and tibia. These C-shaped
wedges act as "shock absorbers" that cushion the joint.
Large ligaments hold the femur and tibia together and provide
stability.
All remaining surfaces of the knee are covered by a thin lining called
the synovial membrane. This membrane releases a fluid that
lubricates the cartilage, reducing friction to nearly zero in a healthy
knee.
Normally, all of these components work in harmony. But disease or
injury can disrupt this harmony, resulting in pain, muscle weakness,
and reduced function.
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The most common cause of chronic knee pain and

disability is arthritis. Although there are many types of
arthritis, most knee pain is caused by just three types:
osteoarthritis, rheumatoid arthritis, and post-traumatic
arthritis.

Osteoarthritis.This is an age-related "wear and tear" type

of arthritis. It usually occurs in people 50 years of age and
older, but may occur in younger people, too. The cartilage
that cushions the bones of the knee softens and wears away.
The bones then rub against one another, causing knee pain
and stiffness.
Rheumatoid arthritis.This is a disease in which the
synovial membrane that surrounds the joint becomes
inflamed and thickened. This chronic inflammation can
damage the cartilage and eventually cause cartilage loss,
pain, and stiffness.
Post-traumatic arthritis.This can follow a serious knee
injury. Fractures of the bones surrounding the knee or tears of
the knee ligaments may damage the articular cartilage over
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time, causing knee pain and limiting knee function.

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1. Fixed Bearing Implants

The most common knee replacement implant is
referred to as a fixed-bearing implant. It is referred
to as fixed because the polyethylene cushion of
the tibial component is fixed firmly to the metal
platform base. The femoral component then rolls
over this cushion.

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The fixed-bearing prostheses provide a

good range of motion andjust as long
lasting as other implantsfor most
patients.
In some cases, excessive activity and/or
extra weight can cause a fixed-bearing
prosthesis to wear down more quickly.
This wear can cause loosening of the
implant, causingpain and joint failure.
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2. Mobile Bearing Implants

If you are younger, more active, and/or overweight, your
doctor may recommend a rotating platform/mobilebearing knee replacement. These implants are
designed for potentially longer performance.
The difference between a fixed-bearing implant and a
mobile bearing implant is in the bearing surface.
Fixed-bearing implants and mobile-bearing implants use
the same three components.
In a mobile-bearing knee, a similar metal implant is
inserted into the tibia, but the polyethylene tray is
placed on a circular stem that allows slight rotation of
the tray on the metal tibial platform during knee motion.

This rotation allows patients a few degrees of

greater rotation to the medial and lateral sides
of their knee.

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Because of this mobility, mobile-bearing

knee implants do require more support
from the ligaments surrounding the
knee. If the soft tissues are not strong
enough, though, the knee is more likely
to dislocate.
Mobile-bearing implants may also cost a
bit more than fixed-bearing implants.

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Typical total knee replacement implants have three basic

components: femoral, tibial and patellar.
Thefemoralcomponent is generally made of metal and
curves around the end of the femur (your thighbone).
There is a groove down the center of this part of the
implant which allows the patella (kneecap) to move up
and down as the knee bends and straightens.
Thetibialcomponent is a flat metal platform with
apolyethylene (plastic) insertor spacer. This component
varies in structure, depending on which type of surgery
is performed.
Thepatellarimplant is a dome-shaped piece of
polyethylene that mimics the kneecap. This implant is
used in some knee replacements; not in others.
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The other big difference between types of knee

replacements is fixation. There are cemented,
cementless, and hybrid (combination of cemented
and cementless) designs.
1. Cementedprostheses utilize a special kind of
bone cement that helps hold the components of
the artificial joint in place. The majority of knee
replacements are generally cemented. Cemented
knee replacements have been used successfully
in all types of knee replacement patients.
Historically, some younger, more active patients
had problems with loosening cement but the
material is now much improved.
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Cement lessimplant designs become fixed by bone

growth into the surface of the implant. Most implant
surfaces are textured or coated with a porous
material so that the new bone actually grows into the
surface of the implant. Screws or pegs may also be
used to stabilize the implant until bone ingrowth
occurs. Recovery does generally take a bit longer as
the bone grows into the prosthesis. Cement less
implants are not usually a viable for patients with
osteoporosis, as the existing bone must be in good
shape in order to grow into the implant.
3. Some surgeons also use ahybridof the two
methods of fixation, though this is more common in
hip replacement surgery.
2.

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Lec # 07

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The hip is one of the body's largest joints. It is a ball-andsocket joint. The socket is formed by the acetabulum,
which is part of the large pelvis bone. The ball is the
femoral head, which is the upper end of the femur
(thighbone).
The bone surfaces of the ball and socket are covered with
articular cartilage, a smooth tissue that cushions the
ends of the bones and enables them to move easily.
A thin tissue called synovial membrane surrounds the
hip joint. In a healthy hip, this membrane makes a small
amount of fluid that lubricates the cartilage and eliminates
almost all friction during hip movement.
Bands of tissue called ligaments (the hip capsule)
connect the ball to the socket and provide stability to the
joint.
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The most common cause of

disability
is
arthritis.
Osteoarthritis,
rheumatoid
arthritis,
and
traumatic
arthritis are the most common
forms of this disease.
Osteoarthritis.The cartilage
cushioning the bones of the
hip wears away. The bones
then rub against each other,
causing hip pain and stiffness.
Osteoarthritis may also be
caused or accelerated by
subtle irregularities in how the
hip developed in childhood.
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Rheumatoid arthritis.This is an
autoimmune disease in which the synovial
membrane becomes inflamed and thickened.
This chronic inflammation can damage the
cartilage, leading to pain and stiffness.
Post-traumatic arthritis.This can follow a
serious hip injury or fracture. The cartilage
may become damaged and lead to hip pain
and stiffness over time.

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Avascular necrosis.An injury to the hip, such as a

dislocation or fracture, may limit the blood supply to
the femoral head. This is called avascular necrosis.
The lack of blood may cause the surface of the bone
to collapse, and arthritis will result.
Childhood hip disease.Some infants and children
have hip problems. Even though the problems are
successfully treated during childhood, they may still
cause arthritis later on in life. This happens because
the hip may not grow normally, and the joint
surfaces are affected.

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Hip implants are medical devices intended to restore mobility and

relieve pain usually associated with arthritis and other hip diseases
or injuries. Factors that influence the longevity of the device
include the patients age, sex, weight, diagnosis, activity level,
conditions of the surgery, and the type of implant chosen.
There are currently five types of total hip replacement devices
available with different bearing surfaces. These are:
1.
Metal-on-Polyethylene: The ball is made of metal and the
socket is made of plastic (polyethylene) or has a plastic lining.
2.
Ceramic-on-Polyethylene: The ball is made of ceramic and
the socket is made of plastic (polyethylene) or has a plastic
lining.
3.
Metal-on-Metal: The ball and socket are both made of metal.
4.
Ceramic-on-Ceramic: The ball is made of ceramic and the
socket has a ceramic lining.
5.
Ceramic-on-Metal: The ball is made of ceramic and the
socket has a metal lining.
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Many different types of designs and materials are

currently used in artificial hip joints. All of them consist
of two basic components:
A cup : A cup (made of stainless steel or titanium)
that is placed in the patients acetabulum. In the
cup, a liner (made of polyethylene or ceramic) is
impacted and serves as an interface between the
cup and the replacement femoral head.

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A femoral implant comprised of :

A round head (made of stainless steel or
titanium) that is placed on the neck of the stem
and articulates with the liner.
A neck (cone-shaped) that can be fixed on the
stem or a modular neck. When the femoral
stem can accommodate a modular neck, the
surgeon can choose between different necks
that can be adapted to the shape of the femur.
A femoral stem (made of stainless steel or
titanium) inserted in the femur.
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The prosthetic components may be

"press fit" into the bone to allow your
bone to grow onto the components or
they may be cemented into place.
The decision to press fit or to cement
the components is based on a number
of factors, such as the quality and
strength of your bone.
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Although shoulder joint replacement is less

common than knee or hip replacement, it is
just as successful in relieving joint pain.
Shoulder replacement surgery was first
performed in the United States in the 1950s
to treat severe shoulder fractures. Over the
years, shoulder joint replacement has come
to be used for many other painful
conditions of the shoulder, such as different
forms of arthritis.
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Your shoulder is made up of three bones:

your upper arm bone (humerus),

your shoulder blade (scapula), and
your collarbone (clavicle).

The shoulder is a ball-and-socket joint: The ball, or head, of your

upper arm bone fits into a shallow socket in your shoulder blade.
This socket is called the glenoid.
The surfaces of the bones where they touch are covered with
articular cartilage, a smooth substance that protects the bones
and enables them to move easily.
A thin, smooth tissue called synovial membrane covers all
remaining surfaces inside the shoulder joint. In a healthy
shoulder, this membrane makes a small amount of fluid that
lubricates the cartilage and eliminates almost any friction in your
shoulder.
The muscles and tendons that surround the shoulder provide
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stability and support.

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One of the most common cause of

shoulder joint pain is arthritis. The most
common types of arthritis are:

Osteoarthritis (OA)
Post-traumatic arthritis
Rheumatoid arthritis (RA)

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The artificial shoulder joint can have

either two or three parts, depending on
the type of surgery required.

The humeral component (metal) is

implanted in the humerus.
The humeral head component (metal)
replaces the humeral head at the top of
the humerus.
The
glenoid
component
(plastic)
replaces the surface of the glenoid socket.
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Total Shoulder Replacement

The typical total shoulder replacement involves
replacing the arthritic joint surfaces with a highly
polished metal ball attached to a stem, and a plastic
socket.
These components come in various sizes. They may be
either cemented or "press fit" into the bone. If the
bone is of good quality, your surgeon may choose to
use a non-cemented (press-fit) humeral component.
If the bone is soft, the humeral component may be
implanted with bone cement.
In most cases, an all-plastic glenoid (socket)
component is implanted with bone cement.
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The elbow is a hinge joint which is made up of three bones:

The humerus (upper arm bone)

The ulna (forearm bone on the pinky finger side)
The radius (forearm bone on the thumb side)

The surfaces of the bones where they meet to form the elbow
joint are covered with articular cartilage, a smooth substance
that protects the bones and enables them to move easily.
A thin, smooth tissue called synovial membrane covers all
remaining surfaces inside the elbow joint. In a healthy elbow,
this membrane makes a small amount of fluid that lubricates
the cartilage and eliminates almost any friction as you bend
and rotate your arm.
Muscles, ligaments, and tendons hold the elbow joint together.

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In total elbow replacement surgery, the damaged

parts of the humerus and ulna are replaced with
artificial components.
The artificial elbow joint is made up of a metal and
plastic hinge with two metal stems. The stems fit
inside the hollow part of the bone called the canal.
Hinge allows the two pieces of the new joint to glide
easily against each other as you move your elbow.
The hinge allows the elbow to bend and straighten
smoothly.

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The metal replacement parts are made

of chrome-cobalt alloy or titanium and
there is a liner made of polyethylene
(plastic).
The bone cement is made of
polymethylmethacrylate (acrylic, a
type of plastic).

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There are two different ways to hold the

artificial elbow in place.
Acemented prosthesisuses a special
type of epoxy cement to glue it to the
bone.
Anuncemented prosthesishas a fine
mesh of holes on the surface. Over
time, the bone grows into the mesh,
anchoring the prosthesis to the bone.
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