Use of implant in surgery

IMPLANT IN SURGICAL PRACTICE
PRINCIPLES OF USE OF IMPLANT
USES OF IMPLANT IN SURGERY

1. USE OF IMPLANT IN SURGERY DR BASHIR YUNUSA SURGERY RESIDENT AKTH 26/01/16

2. OUTLINE INTRODUCTION CLASSIFICATION PRINCIPLES OF USAGE COMPLICATIONS USES OF IMPLANTS EMERGING TRENDS CONCLUSION REFERENCES

3. INTRODUCTION An implant is a surgically inserted foreign material or device to replace a biological missing structure , support damage structure or enhance an existing structure . An implant is a foreign material or device that is inserted , embeded or fixed into a living tissue for functional or cosmetic reasons .

4. EPIDEMIOLOGY Use of implant is on the rise world wide attributed to cosmetic augmentations, rising disease incidence and reduce the need for transplant. Estimated 20-25million US patients have had a medical device implanted. In African sub-regions due to development of specialties.

5. QUALITY OF AN IDEAL IMPLANT An ideal implant should: Not cause inflammatory or foreign body response Non-allergenic Non-carcinogenic Resistant to strain Fabricated into desired form Sterilizable Radio-opaque Non yet to be found

6. INDICATIONS Reconstruction e.g breast reconstruction after mastectomy, Augmentation e.g breast augmentation mammoplasty, dental implant bone augmentation. Fixation & stabilization e.g fractures, dentures Replacement e.g missing structure, deformed or painful joint.

7. CLASSIFICATION US classification The US Food and Drug Administration(FDA) classify medical devices base on the risk to the user Class 1- least amount of risk, rquires least amount of control e.g arm sling, hand held surgical instrument Class 2- need more regulation than class 1. are required to undergo specific requirement before FDA approval. E.g X-rays, monitors Class 3- requires most regulatory control, since device sustain or support life – medical implants Temporary or permanent Soft or hard Biodegradable & nonbiodegradable Synthetic or biological Base on the chemical properties of the implant; metals, calcium ceramics, biodegradable, polymers

8. BASE ON THE CHEMICAL PROPERTIES OF IMPLANT METALS Are used mainly in orthopedics, craniomaxillofacial and hand surgeries. Eg Kirschner wires, cranial plates, artificial joints. Currently used metals; Titanium , stainless steel, valium,gold . Properties; biocompatible, strength, resistance to corrossives , radio-opaque. Titanium is light weight 6 times stronger than compact bone, modulus of elasticity is 5 times greater than compact bone. Most commonly used is commercially pure titanium or titanium- aluminuim -vanadium

9. CALCIUM CERAMICS Hydroxyl apartite Tricalcium phosphate Tetra calcium cement ( hydroxylapatite cement)

10. BIODEGRADABLE MATERIALS Collagen fibrel

11. POLYMERS Silicone Polyurethrane Polymethyl metacrylate Polyester (Dacron, mersilene ) Poly ethylene Polypropylene Cyanoacrylate Polytetrafluroethylene PTFE

12. PRINCIPLES PRE-OPERATIVE Patient must meet indications Perioperative prep & mgt – All physiological derangement is corrected Informed consent Selection Depends on the specific requirement for its use Site & strength of the tissue Appropriate size Availability Affordability Expertise

13. INTRA-OP Adequate anaethesia Strict aseptic techniques Antibiotic prophylaxis Adequate incision Adequate soft tissue cover Must be accessible for removal if necessary For injectable one should be cautious not to inject in vessels Implant be of appropriate size and shape to avoid sharp curves and edges

14. Post-op Wound X-ray Follow Complications Failure

15. COMPLICATIONS Local FAILURE – inadequate for function expected. or failure to produce a satisfactory result Causes of such failure can be grouped into four categories: surgical material; Fatigue failure, Corrosion, Implant wear, Loosening, Breakage Idiosyncratic patient compliance Extrusion Infection Tissue reaction migration Hematoma Seroma Systemic Allergies Carcinogenesis

16. USES OF IMPLANT ORTHOPAEDIC SURGERY Nails Wires Screws Plates and screws Bone cements Joint prosthesis

17. Plates

18. screw Cortical Cancellous Locking

19. Kirschner’s wire

20. NAILS Intramedullary nails

21. JOINT REPLACEMENT

22. GENERAL SURGERY Polypropylene mesh implants in hernia repairs Palliative stents of malignant obstructive lesions ( endoluminal prosthesis) Bile duct drainage (latex T-tube)

23. PLASTIC SURGERY Breast implants using silicone Malar and submalar implants using subcut materials like ePTFE Body contouring like buttock enhancement using silicone Use of gold as upper eyelid weight .

24. CARDIOVASCULAR SURGERY Heart valve replacement Drug eluting biodegradable coated stents in coronary vascular disease Pacemakers Septal defect repair using nylon patches Vascular stents using ePTFE in aneurysm repairs

25. PACEMAKER

26. UROLOGY Ureteric stent Urethral stents Penile implants using inflatable silastic tubes in mgt of ED Penile enlargement implants Testicular implants

27. Ureteric stent

28. Penile implant

29. NEUROSURGERY Ventricular shunts using silastic tubes in hydrocephalus Excimer laser non occlusive anastomosis (ELANA) in cerebral vascular bypass using laser catheter.

30. ENT SURGERY Nasal reconstruction using silicone, tricalcium phosphate cements Palatal implants using inserts (made from silicone, polyester ) in soft palate in surgical management of snoring and obstructive sleep apnoea Cochlear implants in sensorineural deafness

31. Cochlear implants

32. OPHTHALMOLOGY Glaucoma drainage device made from silicone (silicone tube and plate) Lens implants Globe implants

33. Dental surgery Endo- osteal Subperiosteal Transosteal Intramucosal

34. MESH Synthetic High tensile strength Unsuitable for intraperitoneal placement Tissue reaction, stiffness, fibrosis E.g polypropylene, PTFE, ePTFE , polysters . Biological Collagen base- human or porcine use intra or extra-peritoneal Can be used to contaminated or infected surgical field Overcome the problems of chronic inflammation and foreign body reaction, stiffness and fibrosis associated synthetic mesh. Composite Dual coated,- visceral and parietal side. Visceral side repels tissue ingrowth and decrease adhesion. Synthetic parietal side promotes strong repair Microporous <10um Allows bacteria but prevent macrophage passage, cannot clear infection Granuloma more likely to form leading to stiffness of scar. Multifilament Macroporous > 75um Allow infiltration by macrophage, blood vessels, fibroblast and collagen More flexible becomes of avoidance of granuloma. monofilament

35. BREAST IMPLANT Subcutaneous, subglandular, submuscular Implant in submuscular plane is better whenever muscle is not removed during surgery .(better soft tissue covering and hide irregular contour) If muscle is removed as in radical mastectomy, then subcutaneous implant is placed. Silicon gel implants Saline implant complications Pain , exposure of implant and rupture Displacement , extrusion Infection Capsular contraction Rippling

36. HEART VALVES Mechanical; manufatuerd from varieties of materials like alloys, silicon, rubber etc. donot resemble native valve. Risk of thrombo -embolism. Requires anticoagulant. Tilting disc valves Bileaflet valve Biological; they are made from human or animal tissue. Have good hemodynamic performance, the thromboembolic risk is small. Can be used without anticoagulant. But short lived(5-10years), hence requires 2 nd operation. Especially in young patient Allograft Glutaraldehyde -treated porcine(pig) valves Glutaraldehyde -treated pericardial valves Choice of valve

37. EMERGING TREND Biodegradable fixation Minimally invasive Saline filled breast implants Implants incorporated into bone growth

38. CONCLUSION Implants are invaluable in surgical therapy especially in replacing damage body part. Availability, affordability, and expertise is paramount for a successful therapy. They are not without side-effects . The world still awaits emergence of an ideal implant .

39. REFERENCES M.A.R.Al-Fallouji:Postgraduate surgery,2nd Edition. Apley’s system of orthopaedics Eight Edition Bailey and Love’s “Short Practice of Surgery” 26th edition CRC press Taylor and Francis group. 2013 E.A Badoe et al, “Principles and Practice of surgery including pathology in the tropics” 4th edition, Assembly of God Literature Center ltd, 2009 A.S . Breitbart & V.J.Ablaza:Dept of plastic & Reconstructive surgery,New York University Medical Center . Deporah , Shatin , et al; “Data base for studying the epidemiology of implanted medical devices” The Bionic Human pp115-132 Van Eck, Chen AF et al; “the classification of implants” J long term Eff Med Implant 2009; 19(3) 185-93

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