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.

26. 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

28. PACEMAKER

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

30. Ureteric stent

31. Penile implant

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

34. 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

35. Cochlear implants

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

37. Dental surgery
Endo-osteal
Subperiosteal
Transosteal
Intramucosal

38. 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

39. 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

40. 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 2nd operation. Especially in young patient
• Allograft
• Glutaraldehyde-treated porcine(pig) valves
• Glutaraldehyde-treated pericardial valves
• Choice of valve

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

42. 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.

43. 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

44. • Thank you for listening