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`Page 1 of 32
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`ZIMMER EXHIBIT 1023
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`ZIMMER EXHIBIT 1023
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`Page 1 of 32
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`CANALE: Techniques in Operative Orthopaedics
`
`VOLUME I
`Surgical Techniques and Approaches
`1-1
`Removal of tibial graft, 17
`Removal of fibular graft, 18
`Removal of iliac bone graft, 20
`Approaches to interphalangeal joints, 22
`Medial approach to metatarsophalangeal joint of great toe, 23
`Dorsomedial approach to metatarsophalangeal joint of great toe, 23
`Approaches to metatarsophalangeal joints of second, third, fourth, and fifth toes, 23
`Medial approach to calcaneus, 23
`Lateral approach to calcaneus, 25
`U approach to calcaneus, 25
`, Kocher approach (curved L) to calcaneus, 26
`Anterolateral approach to tarsirs and ankle, 26
`’ Anterior approach to tarsus and ankle, 27
`Kocher lateral approach to tarsus and ankle, 27
`Ollier approach to tarsus, 28
`'Posterolateral approach to ankle, 28
`Posterior approach to ankle, 29'
`' Medial approach to ankle (Koenig and Schaefer), 30
`Medial approach to ankle (Colonna and Ralston), 30
`Anterior approach to tibia, 3l
`Medial approach to tibia, 31
`Posterolateral approach to tibia, 31
`Posteiior approach to superomedial region of tibia, 31
`Posterolateral approach to fibula, 34
`Anteromedia‘l parapatellar appr
`Subvastus (southern) anterome‘di
`Anterolateral approach to knee,
`Posterolateral approach to knee,
`
`Posteromedial approach to kn
`
`
`Medial approach to knee and
`'gfim Li“
`Medial approach to kneeand
`ing‘smuetures (Hoppenfeld and deBoer), 39
`
`Transverse approaches to merit
`g2
`;
`,
`~
`
`Lateral approach to knee .andspp
`.u etagr'es (Bruser), 40
`Lateral approach to knee and supporting structures (Brown et al.), 41
`Lateral approach to knee and supporting structures (Hoppenfeld and deBoer), 43
`‘Extensile approach to knee (McConnell), 45
`Extensile approach to knee (Fernandez), 46
`Posterior approach to knee (Brackett and Osgood; Putti; Abbott and Carpenter), 49
`Posterior approach to knee (Minkoff, Jaffe, and Menendez), 50
`Anterolateral approach to femur, 5 3
`Lateral approach to femur, 54
`Posterolateral approach to femur, 54
`Posterior approach to femur, 55
`Medial approach to posterior surface of femur in popliteal space, 55
`Lateral approach to posterior surface of femur in popliteal space, 56
`Lateral approach to proximal shaft and trochanteric region, 57
`Anterior approach to hip (Smith-Petersen), 58
`Anterior approach to hip (Somerville), 60 _
`Anterolateral approach to hip, 61
`Lateral approach to hip (Watson-Jones), 6l
`Lateral approach to hip (Harris), 62
`Lateral approach to hip (McFarland and Osborne), 65
`Lateral approach to hip (Hardinge), 65
`Lateral approach to hip (McLauchlan; Hay), 66
`Posterolateral approach hip, 67
`Posterior approach to hip. (Osborne), 68
`Posterior approach to hip (Moore), 69
`Medial approach to hip, 71
`Anteromedial approach to the hip, 73
`
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`Page 3 0f 32
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`Page 3 of 32
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`

`

`,_.
`
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`Ilioinguinal approach to acetabulum and pelvis, 73
`lliofemoral approach to acetabulum‘and pelvis, 76
`Posterior approach to acetabulum and pelvis, 77
`Extended iliofemoral approach'to acetabulum and pelvis (Letournel and Judet), 78
`Extended iliofemoral approach to acetabulum and pelvis (Reinert et a1), 80
`Triradiate extensile approach to acetabulum and pelvis, 82
`Extensile approach to acetabulum, 84
`Approach to ilium, 86
`Approach to ischium, 86
`Approach to symphysis pubis, 86
`Posterior approach to sacroiliac joint, 87
`Anterior approach to sacroiliac joint, 87
`Approach to both sacroiliac joints or sacrum, 87
`Approach to sternoclavicular joint, 88
`.
`Approach to acromioclavicular joint, 88
`Anteromedial approach to shoulder (Thompson; Henry), 89
`Anteromedial approach to shoulder (Cubbins, Callahan, and Scuderi), 90
`Deltoid—splitting approach to shoulder, 90
`TranSacromial approach to shoulder, 92
`Posterior approach to shoulder, 93
`Posterior approach to shoulder (King, as described by Brodsky et 31.), 93
`Posterior inverted U approach to shoulder, 93
`'
`Anterolateral approach to humerus, 97
`Posterior approach to proximal humerus, 99
`Approaches to distal humeral shaft, 100
`Posterolateral approach to elbow, 100
`Extensile posterolateral approach to. elbow, 102
`Extensile posterior approach to elbow, 104
`Lateral approach to elbow, 106
`' Lateral I approach to elbow, 106
`Medial approach with osteotomy of medial epicondyle, 106
`Medial and lateral approach to elbow, 109
`' Approach to proximal and middle thirds of posterior surface of radius, 109
`Posterolateral approach to radial head and neck, 111
`Anterior approach to entire shaft, 111
`Anterior approach to distal half of radius, 111
`Approach to proximal third of ulna and fourth of radius (Boyd), 113
`Approach to proximal third of ulna and fourth of the radius (Gordon), 113
`Dorsal approach to wrist, 113
`Dorsal approach to wrist, 116
`Volar approach to wrist, 116
`Lateral approach to wrist, 119
`Media] approach to wrist, 119
`
`l
`
`\D 00
`
`III
`
`Arthrodesis ofAnkle, Knee, and Hip
`3—1
`Tibiotalar arthrodesis with iliac crest bone graft, 164
`[\J
`Tibiotalar arthrodesis with screw fixation, 164
`Compression arthrodesis of ankle using Calandruccio ll external fixation device, 167
`Tibiotalar arthrodesis with narrowing osteotomies of malleoli, 170
`Tibiotalar arthrodesis with sliding bone graft, 171
`,
`Tibiocalcaneal arthrodesis with Calandruccio 11 external fixation device, 171
`Tibiocalcaneal arthrodesis with intramedullary nailing, 175
`Posterior arthrodesis of ankle and subtalar joints, 177
`Compression arthrodesis with external fixation, 179
`Knee arthrodesis with intramedullary rod fixation, 182
`Knee arthrodesis with intramedullary nail fixation, 183
`Hip arthrodesis with plate fixation. 185
`Hip arthrodesis with muscle—pedicle bone graft, 188
`Hip arthrodesis with cobra plate fixation, 189
`Hip arthrodesis with hip compression screw fixation, 191
`Hip arthrodesis in absence of femoral head (Abbott, Fischer, and Lucas), 192
`Hip arthrodesis in absence of femoral head (Bosworth), 192
`Hip arthrodesis in absence of femoral head (Kostuik and Alexander), 192
`
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`Page 4 of 32
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`Page 4 of 32
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`

`

`Arthrodesis of Shoulder, Elbow, and Wrist
`4-1
`Compression arthrodesis of shoulder—external fixation, 202
`4-2
`. Compression arthrodesis of shoulder—internal fixation (Cofield), 203
`4—3
`Compression arthrodesis of shoulder through posterior approach—internal
`fixation, 204
`Compression arthrodesis of shoulder through posterior approach (Mohammed), 204
`Compression arthrodesis of shoulder—double plating technique (AO Group), 204
`Compression arthrodesis of shoulder—pelvic reconstruction plate
`(Richards et al.), 206
`Elbow arthrodesis (Steindler), 208
`Elbow arthrodesis (Brittain), 209
`Elbow arthrodesis (Staples), 209
`Elbow arthrodesis (Arafiles), 210
`. Elbow arthrodesis (Muller et al.), 211
`Elbow arthrodesis (Spier), 212
`Wrist arthrodesis (A0 Group), 214‘
`Wrist arthrodesis (Louis et al.), 215
`Wrist arthrodesis (Haddad and Riordan), 215
`’ Wrist arthrodesis (Watson and Vendor), 216
`
`4—4
`, 4—5
`4—6
`
`4-7
`4-8
`4-9
`4—10
`4-11
`4—12
`4—13
`4-14
`4-15
`4—16
`
`'
`
`-
`
`Arthroplasty ofAnkle and Knee
`6-.1
`Bone preparation for primary tricompartmental knee replacement, 268
`_ 6-2
`Unicondylar knee arthroplasty, 278
`V
`6-3
`Arthrodesis with intramedullary nail for infected total knee arthroplasty, 285
`
`lI
`
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`~
`Arthroplasty of Hip
`'7-1
`Preoperative roentgenograms for hip arthroplasty, 347
`7—2
`Total hip arthroplasty through posterolateral approach with posterior
`» dislocation of hip, 350
`Implantation of cementless acetabular components, 354
`Implantation of cemented acetabular components, 356
`Implantation of bipolar prosthesis, 358
`Implantation of cementless femoral components, 360
`Implantation of cemented femoral components, 364
`Surgical approach to revision of total hip arthroplasty, 439
`Stem removal in revision of total hip arthroplasty, 440
`Removal of implants with extensive distal bone ingrowth, 442
`- Extended trochanteric osteotomy for difficult femoral revisions, 442
`Removal of broken stem, 444
`Removal of fractured cobalt—chrome stem, 444
`Removal of broken stem (Moreland, Marder, and Anspach), 445
`Removal of broken stem, 445
`Removal of cement from femur, 447
`Removal of distal cement from femur, 448
`Removal of femoral cement using “controlled perforations,” 449
`Removal of polyethylene cup and cement from acetabulum, 450
`Removal of metal-backed, cemented acetabular cemponent, 450
`Removal of cement remaining in acetabulum, 451
`Removal of a cementless acetabular component, 452
`Repair of cavitary deficits, 453
`Repair of segmental deficits, 454
`Structural grafting for segmental acetabular deficiency, 458
`Femoral allograft, 467
`
`7—21
`7~22
`7—23
`7-24
`7-25
`7—26
`
`Arthroplasty 0f Shoulder and Elba-w
`8-1
`Hemiarthroplasty for chronic painful incongruity of shoulder, 492
`Basic approach to total shoulder arthroplasty, 495
`Revision of humeral component, 507
`Interpositional (fascial) arthroplasty of elbow, 519
`Resection arthroplasty of elbow, 521
`Total elbow replacement arthroplasty, 522
`Capitellocondylar total elbow arthroplasty, 525
`Radial head implant arthroplasty, 526
`
`00000000000000OO\IO\U\-$>U~)I\)
`
`Continued on back endsheets.
`
`Page 5 of 32
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`

`

`CAMPBELL’S
`
`
`
`
`
`
`
`
`
`
`Page 6 of 32
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`Page 6 of 32
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`

`

`The following handheld software also is available to accompany your Campbell’s Operative
`Orthopaedics, tenth edition. Each PDA contains 75 to 150 Operative procedures that have been
`written in bulleted format.
`
`_
`Canale: PDA Series
`Techniques in Operative Orthopaedics: PDA Set
`ISBN Retail: 0-323-02289-8
`
`_
`
`Canale: PDA Series '
`
`Techniques in Operative Orthopaedics: Adult Reconstruction ’
`ISBN Retail: 0—323—02275-8
`'
`Download: 0-323-02276—6
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`._
`Canale: PDA Series ‘
`Techniques in Operative Orthopaedics: Congenital Anomalies and Pediatrics
`ISBN Retail: 0-323-02277—4
`Download: 0—323-02278-2
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`Canale: PDA Series
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`
`Techniques in Operative Orthopaedics: Spine
`ISBN Retail: 0-323-02279-0
`Download: 0—323-02280—4
`
`Canale: PDA Series
`
`Techniques in Operative Orthopaedics: Sports Medicine and Arthroscopy
`ISBN Retail: 0—323-02269-3
`Download: 0-323—02270-7
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`Canale: PDA Series
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`.
`
`Techniques in Operative Orthopaedics: Hand
`ISBN Retail: 0—323-02267-7
`Download: 0—323-02268-5
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`Canale: PDA Series
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`Techniques in Operative Orthopaedics: Ankle and Foot
`ISBN Retail: 0-323-02273-1
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`Download: 0—323-02274-X '
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`Canale: PDA Series
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`Techniques in Operative Orthopaedics: Trauma
`ISBN Retail: 0-323—02271-5
`Download: 0—323-02272-3
`
`Page 7 of 32
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`Page 7 of 32
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`

`

`
`
`Volume One
`
`TENTH EDITION
`
`CAMPBELL’.S
`”' OPERATIVE #
`ORTHOPAEDICS
`
`
`
`
`
`
`Edited by
`
`s; TERRY CANALE, MD
`Professor and Chairman, Department of Orthopaedic Surgery
`University of Tennessee—Campbell Clinic;
`Chief of Pediatric Orthopaedics
`Le Bonheur Children’s Medical Center
`
`Memphis, Tennessee
`
`Editorial Assistance by
`
`KAY DAUGHERTY and LINDA JONES
`
`Art coordination by
`
`B A R RY B U R N S
`
`4'
`
`~
`
`1:!»
`
`With over 9000 illustrations
`
`NA Moshy
`An Affiliate of Elsevier Science
`St. Louis London Philadelphia Sydney Toronto
`
`Page 8 of 32
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`Page 8 of 32
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`

`

`NA Mosby
`
`. An Affiliate of Elsevier Science
`
`The Curtis Center
`Independence Square’West
`Philadelphia, Pennsylvania 19106
`
`CAMPBELL’S OPERATIVE ORTHOPAEDICS
`Copyright © 2003, Mosby, Inc. All rights reserved.
`
`ISBN 0-323—01240-X
`
`‘No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
`mechanical, including photocopying, recording, or any information storage and retrieval system, without
`permission in writing from the publisher (Mosby, Inc., 11830 Westline Industrial Drive, St. Louis).
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`Notice
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`from this publication.
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`Medicine is an ever-changing field. Standard safety precautions must be followed, but as new research and
`clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary
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`administration, and contraindications. It is the responsibility of the licensed prescriber, relying on experience
`and knowledge 'of the patient, to determine dosages and the best treatment for each individual patient. Neither
`the publisher nor the author assumes any liability for any injury and/or damage to persons or property arising
`
`Previous editions copyrighted 1939, 1949, 1956, 1963. 1971, 1980, 1987, 1992, 1998'
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`International Standard Book Number 0-323-01240-X
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`Publishing Director: Richard H. Lampert
`Development Director: Kathryn H. Falk
`Publishing Services Manager: Patricia Tannian
`Project Manager: John Casey
`Design Manager:. Gail Morey Hudson
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`Cover Design: Renée Duenow
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`Lastdigitistheprintnumberz9 8
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`7
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`Page 9 of 32
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`Page 9 of 32
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`

`

`CHAPTER
`
`
`
`Arthroplasty off-lip
`
`
`
`
`
`James W. Harkess
`
`Applied biomechanics. 318
`Forces acting on the hip, 318
`Centralization of head and lengthening of
`abductor lever arm, 3l9
`Neck length and offsets, 320
`Head and neck diameter, 322
`Coefficient of friction and frictional
`torque, 323
`Wear, 324
`Lubrication, 326
`Stress transfer to bone, 326
`Design and selection of total hip
`components, 329
`Femoral components, 330
`Femoral stems used with cement, 330
`Cementless stems with porous
`surfaces, 332
`Nonporous cementless femoral
`components, 336
`Specialized and custom—made femoral
`components, 336
`Acetabular components. 337
`Cemented acetabular components, 338
`Cementless acetabular components. 338
`Bipolar acetabular components, 340
`Acetabular reconstruction rings, 340
`Surface replacement arthroplasty, 342
`Indications for total hip arthroplasty. 343
`Contraindications in total hip
`arthroplasty. 345
`Preoperative evaluation, 345
`Preoperative roentgenograms. 347
`Preparation and draping. 348
`Surgical approaches and techniques, 348
`Total hip arthroplasty through
`posterolateral. approach with
`posterior dislocation of hip, 350
`Implantation of cementless acetabular
`components, 353
`Implantation of cemented acetabular
`components, 356
`
`'
`
`Implantation of bipolar prosthesis. 358
`Implantation of cementless femoral
`components, 360
`Implantation of cemented femoral
`components, 363
`Trochanteric osteotomy, 368
`Surgical problems relative to specific hip
`disorders, 372
`Arthritic disorders, 372
`Degenerative arthritis (primary or
`secondary hypertrophic arthritis or
`osteoarthritis), 372
`Rheumatoid arthritis, 372
`Avascular necrosis, 373
`Protrusio acetabuli, 374
`Developmental dysplasia, 378
`Dwarfs, 383
`Posttraumatic disorders, 383
`Femoral neck and trochanteric fractures
`and nonunions, 383
`Acetabular fractures. 386
`Failed reconstructive procedures, 387
`Proximal femoral osteotomy and
`deformity, 3S7
`Arthrodesis, 388
`Painful hemiarthroplasty. 391
`Failed resurfacing procedures, 392
`Metabolic disorders, 392
`Paget disease, 392
`Gaucher disease, 393
`Sickle cell anemia. 394
`Chronic renal failure, 395
`Hemophilia, 395
`Infectious disorders, 395
`Pyogenic arthritis. 395
`Tuberculosis, 396
`Tumors, 396
`Neurological disorders, 396
`Complications, 396
`Nerve injuries, 397
`Vascular injuries. 398
`
`Hemorrhage and hematorna formation,
`398
`Bladder injuries and urinary tract
`complications, 399
`Limb length discrepancy. 400
`Dislocation and subluxation, 402
`Heterotopic ossification, 406
`Thromboembolism, 407
`Fractures, 410
`Trochanteric nonunion and migration, 414 ‘
`Loosening, 4l6
`_
`Femoral loosening, 417
`Acetabular loosening, 422
`Diagnosis, 424
`Infections, 426
`Management of infections, 427
`Reconstruction after infection, 430
`Osteolysis, 432
`Stem failure, 435
`Miscellaneous complications, 436
`Revision of total hip arthroplasty, 437
`Indications and contraindications, 437
`Preoperative planning, 438
`Surgical approach, 439
`Stem removal. 440
`Removal of broken stem. 444
`Removal of cement from femur, 446
`Removal of cup and cement from
`acetabulum. 450
`Reconstruction of acetabular
`deficiencies. 452
`Cavitary deficits. 453
`Segmental deficits, 454
`Reconstruction of femoral deficiencies.
`459
`Segmental deficits, 460
`Cavitary deficits, 461
`Femoral deformity, 465
`Femoral allograft, 466
`Postoperative management of total hip
`arthropiasty, 470
`
`Total hip arthroplasty is the most commonly performed adult
`reconstructive hip procedure. This chapter discusses cemented
`and nonccmented bipolar arthroplasties, as well as the current
`status of resurfacing procedures. In addition, the current status
`of revision hip arthroplasty is reviewed. which comprises an
`enlarging segment of procedures performed.
`
`An awareness of the history of hip arthroplasty is necessary
`to appreciate not only its current status but also its future. The
`use of biological and inorganic materials for hip arthroplasty
`became popular in the early twentieth century. Deformed or
`ankylosed joint surfaces were contoured and an interpositional
`layer inserted to resurface the joint and ailovv motion. Fascia
`
`3325
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`Page 10 of 32
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`Page 10 of 32
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`

`

` PART I I I e Arthroplasty
`
`
`lata grafts and periarticular soft tissues were used extensively in
`the United States and Europe. Sir Robert Jones used gold foil
`as an interpositional layer in 1912. Results remained unpre—
`dictable, with residual pain and stiffness being the primary
`causes of failure.
`In 1923, Smith—Petersen introduced the
`concept of “mould arthroplasty” as an alternative to the
`interpositional membrane. The procedure was intended to
`restore congruous articular surfaces by exposing bleeding
`cancellous bone of the femoral head and acetabulum, with
`subsequent metaplasia of the fibrin clot to fibrocartilage under
`the influence of gentle motion. Glass was chosen as the material
`for the first mold, after Smith-Petersen discovered a smooth
`
`synovial membrane surrounding a glass foreign body removed
`from a patient's back. Although all the glass molds implanted
`broke within a few months, the initial results were encouraging
`and prompted a search for more durable materials. Pyrex,
`viscalloid (a celluloid derivative), and Bakelite versions also
`were discarded because of fragility or severe foreign body
`reaction. After the development of Vitallium by Venable and
`Stuck in 1937,
`implants of sufficient durability became
`available. The Smith—Petersen cup arthroplasty with subsequent
`modifications by Aufranc became the
`standard for hip
`reconstruction until
`the advent of modern~day total hip
`arthroplasty,
`
`result of many
`a
`Total hip arthroplasty evolved as
`improvements in design of a femoral head prosthesis,
`the
`availability of suitable component materials and manufacturing
`techniques. a better understanding of hip mechanics, and the
`need for resurfacing the acetabulum. The Judet brothers used a
`
`heat—cured acrylic femoral head prosthesis. but fragmentation
`of the acrylic with wear resulted in severe tissue reaction.
`including bone destruction (Fig. 7—1). Both Thompson and
`Moore developed metallic endoprostheses with medullary
`stems for skeletal fixation. Longer stems allowed transmission
`of wei ght—bearing forces along the axis of the femur, rather than
`generating the high shear forces of a short stem placed within
`the femoral neck. All these designs depended on a press—fit
`fixation and produced varying degrees of femoral bone loss.
`However, it was the erosion of bone on the pelvic side that
`brought attention to the need for resurfacing of the acetabulum.
`The metal—on-metal
`total hip implants
`that Urist, Ring,
`McKee—Fairar, and others designed were not satisfactory
`because friction and metal wear resulted in an unacceptably
`high incidence of loosening and pain. Special recognition must
`be given to the late Sir John Charnley for his pioneering work
`in all aspects of total hip arthroplasty. including the concept
`of low frictional
`torque arthroplasty. surgical alteration of
`hip biomechanics.
`lubrication. materials. design. and operat—'
`
`C
`
`D
`
`
`
`Some steps in evolution of total hip arthroplasty. A, When patient was 33 years of age.
`Judet acrylic femoral head prosthesis was inserted for degenerative arthritis. Three years later
`osteolysis and pathological fracture were present in proximal femur. B, Prosthesis was removed. and
`lytic area was biopsied. Head of prosthesis was irregular. and its edges were cracked. Biopsy
`revealed particles of acrylic material in fibrous tissue. Fracture healed. When patient was 36 years
`of age. lytic area was bone grafted. and Moore femoral head prosthesis was inserted. C. Function
`was satisfactory for about 16, years. and then hip became painful and limited in motion. B. When
`patient was 57 years of age. Charnley total hip arthroplasty was performed: l5 years later. hip was
`painless. and motion was excellent.
`
`Page 11 of32
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`Page 11 of 32
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`

`

`C H A P TIER 7 O Arthroplasty of Hipn
`
`itself or in the polyethylene used for the fabrication of implants
`have not been substantive. The basic concept of low frictional
`torque arthroplasty has become established, and the metal-on-
`polyethylene articulation is the standard in total hip arthro-
`plasty. The Charnley total hip arthroplasty results are the
`benchmark for evaluating the performance of other arthroplas-
`ties. The laboratory and clinical contributions of Sir John
`Charnley have improved the quality of life for many patients.
`Nevertheless,
`the history of hip arthroplasty has been
`dynamic, and research continues to improve results, especially
`in young patients. Investigation has proceeded along two major
`paths, one to eliminate the use of cement and the other to
`improve the cemented hip. Both concepts have strong pro-
`ponents and can be supported by the literature—considerable
`controversy remains.
`.
`In response to the problem of loosening of the stem and cup
`based on the alleged failure of cement, press-fit, porous—coated,
`and hydroxyapatite-coated stems and cups are‘being investi-
`gated as ways to eliminate the use of cement and to use bone
`ingrowth or ongrowth as a means of achieving durable skeletal
`fixation. Although some initial cementless implant designs
`have proved very successful, others have been beset by
`premature and progressive failure because of inadequate initial
`fixation, excessive wear, and periprosthetic bone loss due to
`particle-induced osteolysis. As experience has accumulated, the
`importance of certain design parameters has become apparent.
`Reduction of wear debris and the exclusion of such debris from
`
`prosthetic interfaces are the topics of much contemporary
`implant design research.
`A number of different techniques have evolved to improve
`cemented femoral fixation, including injection of low—viscosity
`cement, occlusion of the medullary canal, reduction of porosity,
`pressurization of the cement, and centralization of the stem.
`Similar techniques have been less successful in improving the
`results of acetabular fixation. Stem fracture has been largely
`eliminated by routine use of superalloys in their fabrication.
`As technological advances improve the longevity of implant
`fixation, problems related to wear of articulating surfaces have
`emerged. Ceramic—ceramic and metal—metal articulations are
`being evaluated because of their low coefficient of friction and
`superior wear characteristics. Titanium alloy has been recog—_
`nized as one of the strongest and most biocompatible implant
`materials. Unfortunately, its poor hardness and wear character—
`istics make it unsuitable for use as an articulating surface in its
`native state (see Chapter 5), and titanium femoral heads are no
`longer available in contemporary total hip systems.
`Modular systems initially provided only for selection of
`various head sizes and neck lengths. More recent innovations
`allow independent sizing of various portions of the stem. A vast
`array of implant sizes can thereby be assembled from a modest
`inventory of individual components—The durability of modular
`implants is of concern, and the optimal method for the mating
`of parts remains to be determined. Corrosion and generation of
`metallic debris from modular implant interfaces have been
`demonstrated, but longer follow-up is necessary to determine
`the clinical significance of these problems.
`
`ing room environment. A major advancement was his use
`of cold-curing acrylic cement
`(polymethylmethacrylate, 'or
`'PMMA) for fiXation of the components. His periodic reviews,
`as well as those of other investigators, of the results in
`significant numbers of patients have been invaluable, especially
`concerning wear, infection, loosening, and stem failure.
`Chamley interpreted the squeak sometimes heard in patients
`with a Judet prosthesis as being caused by marked friction
`between the acrylic head and the acetabulum. Because of this
`resistance to moVement, sufficient
`torque was produced to
`loosen the stern, and thus movement was sometimes greater
`about
`the stem than I in the joint. He confirmed the low
`coefficient of normal joint friction reported by Jones and agreed
`with Keith that synovial fluid did act as a lubricant, but that
`joint replacement presented the problem of boundary lubrica—
`tion. After finding that the coefficient of friction of a steel ball
`. against
`'polytetrafluoroethylene approached that of normal
`joints, he inserted a Moore prosthesis and lined the acetabulum
`_ with a thin polytetrafluoroethylene shell. He later resurfaced the
`acetabulum with a plastic shell and the femoral head with a
`metallic cup but abandoned this procedure because of avascular
`necrosis of the femoral head. He then cemented thestem of the
`
`femoral prosthesis and the plastic cup with polymethyl-
`methacrylate to fix the components securely in the bone and to
`trans'fer'stress more uniformly to a larger bone surface. The
`diameter of the head of the femoral component was reduced
`from the 40 mm or more'of the Moore—type femoral head
`
`to reduce resistance to movement by
`prosthesis to 22 mm,
`reducing the moment or lever arm of the frictional force. He
`realized that with a larger head the pressure per unit of surface
`was less and that this would tend to reduce wear. However, he
`
`considered it more important to reduce frictional torque and for
`the cup to have a thicker wall. Because of excessive wear and
`tissue reaction, polytetrafluoroethylene was replaced by high-
`density polyethylene (HDPE) and later by ultrahigh molecular
`weight polyethylene (UHMWPE).
`The Charnley total hip arthroplasty initially was greeted
`with considerable reluctance because of the previous unfavor- ‘
`
`able experiences with the Judet acrylic (polymethylmethacry-
`late) femoral head (see Fig. 7-1), the polyurethane prosthesis
`(Ostamer) for fracture fixation, and the wear and tissue reaction
`following the use of polytetrafluoroethylene. But by 1970 a
`number of investigators in the United States reported that
`exceSsive wear did not occur with polyethylene cups and that
`pain relief and improved function were quite spectacular.
`However,
`it
`immediately became apparent
`that
`success
`
`depended on careful selection and evaluation of patients, as
`well as on meticulous attention to operative technique and
`asepsis. Only with long-term follow-up studies of more than 5
`years did it becomeapparent that loosening and,
`to a lesser
`extent, problems with fixation of the trochanter, stem failure,
`and protrusion of the cup were major problems. These issues
`gave rise to a number of changes in the design and materials
`used for
`fabrication of
`the femoral prosthesis and cup,
`
`improvement in how cement is used, and changes in surgical
`approaches and techniques. However, changes in the cement
`
`Page 12 of 32
`
`Page 12 of 32
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`

`318 ,‘
`
`PART III e Arthroplasty
`
`Some investigators report good results with short—term
`follow—up of new designs, and several of the new concepts
`are attractive, especially in young patients. However,
`it
`is
`important
`to consider
`the problems of previous design
`modifications that did not become apparent until a sufficient
`number of 5-year or more follow-up studies were available.
`Early reports of the revision of total hip arthroplasty
`indicated that the results were almost comparable to primary, or
`index, total hip arthroplasty. However, a number of more recent
`
`papers have documented that this is not true, and in many
`instances revision must be considered a salvage procedure.
`There is no doubt that primary total hip arthroplasty offers the
`best chance of success. Therefore selection of the appropriate
`patient, the proper implants, and the technical performance of
`the operation are of the utmost importance.
`Total hip arthroplasty procedures require the surgeon to be
`familiar with the many technical details of the operation.
`However, to successfully contend with the many problems that
`occur and to evaluate new concepts and implants, a working
`knowledge of biomechanical principles, materials, and design
`also is necessary.
`
`Applied Biomechanics
`
`The biomechanics of total hip arthroplasty are different from V
`those of the screws, plates, and nails used in bone fixation
`
`because these latter implants provide only partial support and
`only until
`the bone unites. Total hip components must
`withstand many years of cyclic loading equal to at least 3 to 5
`times the body weight, and at times they can be subjected to
`overloads of as much as 10 to'12 times the body weight.
`Therefore a basic knowledge of the biomechanics of the hip and
`of total hip arthroplasty is necessary to perform the procedure
`properly, to manage the problems that may arise during and
`after surgery'successfully,
`to select the components intelli-
`_ gently, and to counsel patients concerning their physical
`activities.
`'
`
`FORCES ACTING ON THE HIP
`“‘To‘deSCribe the forces acting on the hip joint, the body weight
`can be depicted as a load applied to a leVer arm extending from
`the body’s center of gravity to the center of the femoral head
`
`(Fig. 7-2). The abductor musculature, acting on a lever arm
`extending from the lateral aspect of the greater trochanter to the
`~ center of the femoral head, must exert an equal moment to hold
`the pelvis level when in a one-legged stance, and a greater
`moment to tilt the pelvis to the same side when walking or
`running. Since the ratio of the length of the lever arm of the
`body weight to that of the abductor musculature is about 2.5 : l,
`the force of the abductor muscles must approximate 2.5 times
`the body weight to maintain the pelvis level when standing on
`one leg. The estimated load on the femoral head in the stance
`phase of gait is equal to the sum of the forces created by the
`
`
`
`
`Lever arms acting on hip joint. Moment produced by
`Fig. 7-2
`body weight applied at body’s center of gravity, X, acting on lever
`arm, B-X, must be counterbalanced by moment produced by
`abductors, A, acting on shorter lever arm, A-B. Lever arm A-B may
`be shorter than normal in arthritic hip. Centralization of head
`shortens lever arm B—X, and lateral reattachment o'f trochanter
`lengthens lever armA-B.
`
`abductors and the body weight and is at least 3 times the body
`weight;
`the load on the head during straight leg raising is
`estimated to be about the same.
`
`Crowninshield et al. calculated peak contact forces across
`the hip joint during gait ranging from 3.5 to 5 times the body
`weight. Others have predicted values as high as 6 times the
`body weight during single-limb stance. Experimentally mea-
`sured forces about the hip joint using instrumented prostheses
`generally are lower than those predicted by analytical models.
`Davey et al. recorded joint contact forces of 2.6 to 2.8 times the
`
`body weight during single-limb stance phase of gait. Rydell
`recorded contact forces during gait with peak values of 3 times
`the body weight. However, when lifting, running, or jumping,
`the load may be equivalent
`to 10 times the body weight.
`Therefore excess body weight and increased physical activity
`add significantly to the forces that act to loosen, bend, or break
`the stem of a femoral component.
`'
`
`The forces on the joint act not only in the coronal plane, but
`because the body’s center of gravity (in the midline anterior to
`the second sacral vertebral body) is posterior to the axis of the
`joint (Fig. 7-3), they also act in the sagittal plane to bend the
`stem posteri