Hard Tissues Replacement Implants

1.Orthopedic implants

2.Dental implants

Orthopedic Implants
Hip prosthesis & THR Hip implants Shoulder prosthesis Knee replacement Vertebral discs Joint prostheses & Joint repair Joint replacement Supporting plates, screws, intramedullary nails for bone fracture

Orthopedics
Orthopedics is the study of the musculoskeletal system The musculoskeletal system includes bones, joints, ligaments, tendons, muscles, and nerves.

The Skeletal System

The skeletal system consists of bones and other structures that make up the joints of the skeleton. The types of tissue present are bone tissue, cartilage, and fibrous connective tissue, which forms the ligaments that connect bone to bone.

RECALL

FUNCTIONS OF THE SKELETON

Provides a framework that supports the body; the muscles that are attached to bones move the skeleton. Protects some internal organs from mechanical injury
(For example the rib cage protects the heart and lungs)

Contains and protects the red bone marrow, the primary hemopoietic (blood-forming) tissue.

RECALL

FUNCTIONS OF THE SKELETON

Provides a storage site for excess calcium. Calcium may be removed from bone to maintain a normal blood calcium level, which is essential for blood clotting and proper functioning of muscles and nerves.

RECALL

TYPES OF BONE TISSUE

The bone cells are called osteocytes, and the matrix of bone is made of calcium salts and collagen. The calcium salts are calcium carbonate (CaCO3) and calcium phosphate (Ca3(PO4)2), which give bone the strength required to perform its supportive and protective functions.

TYPES OF BONE TISSUE

Bone matrix is non-living, but it changes constantly, with calcium that is taken from bone into the blood replaced by calcium from the diet. In normal circumstances, the amount of calcium that is removed is replaced by an equal amount of calcium deposited.

TYPES OF BONE TISSUE

In bone as an organ, two types of bone tissue are present 1. Compact bone - Compact bone is made of osteons or haversian systems, microscopic cylinders of bone matrix with osteocytes in concentric rings around central haversian canals. In the haversian canals are blood vessels; the osteocytes are in contact with these blood vessels and with one another through microscopic channels (canaliculi) in the matrix.

TYPES OF BONE TISSUE

1. Spongy bone - looks like a sponge with its visible holes or cavities. Osteocytes, matrix, and blood vessels are present but are not arranged in haversian systems. The cavities in spongy bone often contain red bone marrow, which produces red blood cells, platelets, and the five kinds of white blood cells.

CLASSIFICATION OF BONES
1. Long bones the bones of the arms, legs, hands and feet. (Radius, Ulna, Femur, Tibia, Fibula) 2. Short bonesthe bones of the wrists and ankles. (Carpus, Tarsal, metatorsal, ) 3. Flat bonesthe ribs, shoulder blades, hip bones, and cranial bones. (Scapula, clavicle) 4. Irregular bonesthe vertebrae and facial bones.

BONES STRUCTURE
The shaft of a long bone is the diaphysis, and the ends are called epiphyses. The diaphysis is made of compact bone and is hollow, forming a canal within the shaft. This marrow canal (or medullary cavity) contains yellow bone marrow, which is mostly adipose tissue. The epiphyses are made of spongy bone covered with a thin layer of compact bone. Although red bone marrow is present in the epiphyses of childrens bones, it is largely replaced by yellow bone marrow in adult bones.

Regions of bone
1. Compact or Cortical bone 2. Cancellous or trabecular bone

BONES STRUCTURE

Short, flat, and irregular bones are all made of spongy bone covered with a thin layer of compact bone. Red bone marrow is found within the spongy bone. The joint surfaces of bones are covered with articular cartilage, which provides a smooth surface. Covering the rest of the bone is the periosteum, a fibrous connective tissue membrane whose collagen fibers merge with those of the tendons and ligaments that are attached to the bone. The periosteum anchors these structures and contains both the blood vessels that enter the bone itself and osteoblasts that will become active if the bone is damaged.

JOINTS

SYNOVIAL JOINT
Synovial jointsall diarthroses have similar structure Articular cartilagesmooth on joint surfaces. Joint capsulestrong fibrous connective tissue sheath that encloses the joint. Synovial membranelines the joint capsule; secretes synovial fluid that prevents friction. Bursaesacs of synovial fluid that permit tendons to slide easily across joints.

ARTHRITIS
The term arthritis means inflammation of a joint. Of the many types of arthritis, we will consider
1. Osteoarthritis 2. Rheumatoid arthritis.

OSTEOARTHRITIS
Osteoarthritis is a natural consequence of getting older. In joints that have borne weight for many years, the articular cartilage is gradually worn away. The once smooth joint surface becomes rough, the bones then rub against each other and the affected joint is stiff and painful. The large, weight-bearing joints (knees, hips, ankles) are most often subjected to this form of arthritis.

Rheumatoid arthritis (RA)

Rheumatoid arthritis (RA) can be a truly crippling disease that may begin in early middle age or, less commonly, during adolescence. It is an autoimmune disease, which means that the immune system mistakenly directs its destructive capability against part of the body.

Rheumatoid arthritis (RA)

Exactly what triggers this abnormal response by the immune system is not known with certainty, but certain bacterial and viral infections have been suggested as possibilities.

Rheumatoid arthritis often begins in joints of the extremities, such as those of the fingers. The autoimmune activity seems to affect the synovial membrane, and joints become painful and stiff.

Rheumatoid arthritis (RA)

Sometimes the disease progresses to total destruction of the synovial membrane and calcification of the joint. Such a joint is then fused and has no mobility at all.

Autoimmune damage may also occur in the heart and blood vessels, and those with RA are more prone to heart attacks and strokes (RA is a systemic, not a localized, disease).

ORTHOPEDIC IMPLANTS

Hard Tissue Replacement

Hip replacement
It replaces the painful arthritic joint The modular prosthetic hip replacement system used today has three components the femoral stem, the femoral head, and the acetabulum. Each component has multiple sizes which allow for a custom fit.

Hip replacement
The components are made of cobalt chrome, stainless steel, Titanium alloys, ceramics and ultra high molecular weight polyethylene. Cementless and cemented prosthesis systems are available.

Common Causes of Hip Pain and Loss of Hip Mobility

Osteoarthritis
Usually occurs after age 50 and often in an individual with a family history of arthritis. In this form of the disease, the articular cartilage cushioning the bones of the hip wears away. The bones then rub against each other, causing hip pain and stiffness.

Removing the Femoral Head

Once the hip joint is entered, the femoral head is dislocated from the acetabulum.

Then the femoral head is removed by cutting through the femoral neck with a power saw.

Reaming the Acetabulum

After the femoral head is removed, the cartilage is removed from the acetabulum using a power drill and a special reamer. The reamer forms the bone in a hemispherical shape to exactly fit the metal shell of the acetabular component.

Inserting the Acetabular Component

A trial component, which is an exact duplicate of the hip prosthesis, is used to ensure that the joint will be the right size and fit for the client. Once the right size and shape is determined for the acetabulum, the acetabular component is inserted into place.

Preparing the Femoral Canal

To begin replacing the femoral head, special rasps are used to shape and scrape out femur to the exact shape of the metal stem of the femoral component. Once again, a trial component is used to ensure the correct size and shape.

The surgeon will also test the movement of the hip joint.

Inserting Femoral Stem

Once the size and shape of the canal exactly fit the femoral component, the stem is inserted into the femoral canal.

Attaching the Femoral Head

The metal ball that replaces the femoral head is attached to the femoral stem.

The Completed Hip Replacement

Client now has a new weight bearing surface to replace the affected hip. Before the incision is closed, an x-ray is made to ensure new prosthesis is in the correct position.

Treatment by Kinesiologist
(Postoperative Exercises)
Regular exercises to restore the normal hip motion and strength and a gradual return to everyday activties. Exercise 20 to 30 minutes a day divided into 3 sections. Increase circulation to the legs and feet to prevent blood clots Strengthen muscles Improve hip movement

Video 1

Video 2

Shoulder replacement

Shoulder replacement
The shoulder is made up of three bones
1. clavicle (collarbone) 2. scapula (shoulder blade) 3. humerus (upper arm bone)

As well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder make up the shoulder joints. It is a ball and socket joint

Shoulder replacement

Steps in total shoulder joint replacement

1. Made incision in the shoulder and upper arm 2. The head of the humerus is removed with a bone saw 3. The shaft of the humerus is reamed with a bone rasp to ready it for the prosthesis 4. After the shoulder joint, or glenoid cavity, is similarly prepared, bone cement is applied to areas to receive prostheses. 5. The ball and socket prostheses are put in place, and the incision is closed.

Types of Shoulder Arthroplasty

There are two major types of artificial shoulder replacements
1. 2. Cemented prosthesis Uncemented prosthesis

A cemented prosthesis is held in place by a type of epoxy cement (epoxide + polyamine) that attaches the metal to the bone An uncemented prosthesis has a fine mesh of holes on the surface Bone grows into the mesh. Over time, this anchors the prosthesis to the bone.

Types of Shoulder Arthroplasty

And also other two categories of shoulder arthroplasties are there. 1. Hemiarthroplasty 2. Total Shoulder Replacement
Bipolar hemiarthroplasty
The humeral component is interlocked with a larger metal backed polyethylene shell that articulates with the native glenoid

Hemiarthroplasty
A hemiarthroplasty replaces the head of the humerus with an intramedullary stemmed implant. It consists only the humeral component This is used when the native glenoid surface is in good condition.

Indications Hemiarthroplasty
Osteonecrosis of the humeral head without associated secondary degenerative arthritis Head-splitting fractures of the proximal humerus Certain neoplasms of the proximal humerus Insufficient glenoid bone stock to support a glenoid component Glenohumeral osteoarthritis with massive rotator cuff tear.

Total shoulder replacements (TSR)

Total shoulder replacements (TSR) employ both humeral and glenoid components

They are used in patients with arthritis where the humeral head and glenoid surfaces are damaged.

Design classification of TSR

Non-constrained Constrained Semi Constrained

Non-constrained TSR
These prostheses have no physical link between the humeral and glenoid components and rely on the surrounding musculotendinous cuff for stability. The components attempt to recreate normal anatomy and relationships. This minimizes stresses at interfaces and allows for early rehabilitation. The Precise surgical technique is critical for success The proper tension of capsular, muscular, and tendinous structures needed for stability.

Constrained TSR

This is the first generation designs for total shoulder replacements The humeral and glenoid components are mechanically coupled around a fixed center of rotation. These were used in patients with rotator cuff deficiencies and helped prevent superior migration of the humeral component. This design causes most forces to be borne by the prosthesis and interfaces instead of the surrounding soft tissues, leading to higher rates fracturing of components and loosening. Today, this design type is rarely employed.

Semi-constrained
These prostheses are similar to non-constrained designs except that the superior glenoid component has a superior extension that prevents superior migration of the humeral component. The selection is based on age, lifestyle, and also the surgeon's experience.

Video

Knee Replacement

Knee Replacement
Shaping the Distal Femoral Bone A special cutting jig is placed on the end of the femur This jig is used to make sure that the bone is cut in the proper alignment to the leg's original angles, even if the arthritis has made you bowlegged or knockkneed. The jig is used to cut several pieces of bone from the distal femur so that the artificial knee can replace the worn surfaces with a metal surface.

Knee Replacement
Preparing the Tibial Bone
Then the top of the tibia is cut using another jig that ensures the alignment is satisfactory.

Knee Replacement
Preparing the Patella
The undersurface of the patella is removed.

Knee Replacement
Placing the Femoral Component The metal femoral component is then placed on the femur. When using an uncemented femoral component, the prosthesis is held on the end of the bone through a taper on the end of the bone. The metal prosthesis is cut so that it matches the taper almost exactly.

Contd
Driving the metal component onto the end of the bone holds the component in place by friction The stable implant will allow bone tissue to grow into the porous surface, providing longterm stability. In a cemented femoral component, an epoxy cement is used to attach the metal prosthesis to the bone.

Knee Replacement
Placing the Tibial Components The metal tray that will hold the polyethylene spacer is attached to the top of the tibia. The metal tray is either cemented into place, or may be held with screws if the component is uncemented. The screws are primarily used to hold the tibial tray in place until the bone grows into the porous coating. (The screws remain in place and are not removed.) The plastic spacer is then attached to the metal tray of the tibial component. If this component wears out while the rest of the artificial knee is good, it can be replaced.

Video

Vertebral discs

Spinal repair
The degeneration of disc leads to a condition called Degenerative Disc Disease. Majority of patients can be treated with painkillers, braces, physical therapy, small percentage of such patients do not respond to non-operative treatment and need surgery. There are two types of surgical option in such cases
1. Spinal Fusion 2. Disc Replacement

Spinal Fusion
In spinal fusion surgery, the disc (which is a soft material between two vertebrae) is removed and the space is packed with bone graft. In due course of time, the bone creates a solid bony bridge across the two vertebrae. These grafts will regenerate, grow into the bone, and fuse the vertebrae together. The bones are held in place with one or two metal rods held down with hooks and screws, which also helps to support the fusion of the vertebrae.

Spinal Fusion
Bone can be taken from elsewhere in your body or obtained from a bone bank (a bone graft). The bone is used to make a bridge between vertebrae that are next to each other (adjacent). This bone graft stimulates the growth of new bone. Man-made (artificial) fusion materials may also be used. Metal implants can be used to hold the vertebrae together until new bone grows between them. Metal plates can be screwed into the bone, joining adjacent vertebrae. An entire vertebra can be removed, and the spine then fused. A spinal disc can be removed and the adjacent vertebrae fused.

Disc Replacement

Disc replacement surgery is the most innovative and modern treatment that is now available.

Artificial Disc Replacement (ADR) or Total Disc Replacement (TDR)

It is a surgical procedure in which degenerated intervertebral discs in the spinal column are replaced with artificial devices in the lumbar (lower) or cervical (upper) spine. The procedure is used to treat chronic, severe low back pain and cervical pain resulting from degenerative disc disease. Artificial disc replacement has been developed as an alternative to spinal fusion, with the goal of pain reduction or elimination, while still allowing motion throughout the spine. Another possible benefit is the prevention of premature breakdown in adjacent levels of the spine, a potential risk in fusion surgeries.

Joint repair, Orthopedic supporting aids, fracture fixation

Bone necrosis Interfacial failure: Simple motion between implant and cement or cement and bone was initially thought to contribute to interfacial failure. Particle-induced osteolysis is known as particle disease Osseointegration: a direct contact between living bone and implant (A structural and functional connection between ordered, living bone and the surface of a loadcarrying implant) Bone Cements: bone cements are substances used to repair the damaged or diseased areas of bones or to fix a prosthesis in the bones. e.g
polymers of methylmethacrylate (PMMA) (1940) Acrylate-based plastics Tetrahydrofurfuryl methacrylate (THFMA) Tricalcium phosphateurethane dimethacrylate monomer (UDMA) Tetrahydrofurfuryl methacrylate monomer (THFMA), etc.