conservative hip replacement for avascular necrosis e. munting, p. poilvache cliniques...
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Conservative Hip Conservative Hip
Replacement for Replacement for
avascular necrosisavascular necrosisE. Munting, P. PoilvacheE. Munting, P. PoilvacheCliniques Universitaires Saint-Luc, Cliniques Universitaires Saint-Luc,
BruxellesBruxellesClinique Saint-Pierre, OttigniesClinique Saint-Pierre, Ottignies
Hôpital de Waterloo-BraineHôpital de Waterloo-Braine
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THR in patients < THR in patients < 55 y.55 y.Revision rate :Revision rate : from 20 % at 5 yearsfrom 20 % at 5 years
to 12 % after 20 years follow-up to 12 % after 20 years follow-up
- - Conflicting reportsConflicting reports
- Implant dependent- Implant dependent
- Patient dependent (activity…)- Patient dependent (activity…)
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Femoral component : Femoral component : optionsoptions
Preservation of the femoral head Preservation of the femoral head
and resurfacingand resurfacing
Replacement of the femoral head Replacement of the femoral head
and :and :
fixation in the diaphysis (stem)fixation in the diaphysis (stem)
fixation in the metaphysisfixation in the metaphysis
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Femoral head replacement Femoral head replacement with metaphyseal fixation with metaphyseal fixation
… an old idea !… an old idea !
19381938 WilesWiles 19541954 Postel and Merle d'AubignéPostel and Merle d'Aubigné
19411941 McKeeMcKee
19491949 Judet and JudetJudet and Judet
19521952 ThomsonThomson
19531953 HaboushHaboush
1957 1957 PicchioPicchio
1980 1980 Huggler and JacobsHuggler and Jacobs
19821982 Munting and VincentMunting and Vincent
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Specification chart Specification chart
Preserve bone stockPreserve bone stock
Normal stress pattern in the boneNormal stress pattern in the bone
Femoral head replacementFemoral head replacement
Easy revisionEasy revision
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Conception and Conception and Experimental Experimental workwork Design and biomechanical assessment Design and biomechanical assessment
of prototypes on a hip simulator of prototypes on a hip simulator
Finite Element analysis of Finite Element analysis of
experimental and clinical casesexperimental and clinical cases
Hydroxyapatite coating development Hydroxyapatite coating development
and animal experimentsand animal experiments
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Implant design Implant design studystudy
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Femoral Femoral componentcomponent
No medullary stemNo medullary stem
Screws for initial Screws for initial
fixationfixation
Hydroxyapatite coatingHydroxyapatite coating
Modular headModular head
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Angular resection of Angular resection of
the femoral neckthe femoral neck
Lamellae in the Lamellae in the
proximal metaphysisproximal metaphysis
Cortical and Cortical and
cancellous supportcancellous support
Fixation :Fixation :Geometrical Geometrical interferenceinterference
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DXA StudyDXA Study(prospective, 21 hips, 6-9 (prospective, 21 hips, 6-9 y. F-up)y. F-up) BMD is maintained in the BMD is maintained in the
proximal femurproximal femur In patients with low initial values In patients with low initial values
asas
compared to the controlateral compared to the controlateral side, side, BMD increases after surgeryBMD increases after surgery J. Arthroplasty 12, 373-9, 1997
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Pilot studyPilot study
04/1989 – 01/199204/1989 – 01/1992
43 patients, 48 hips43 patients, 48 hips
33 males, 15 females33 males, 15 females
Mean age: 36.4 years (19 – 49)Mean age: 36.4 years (19 – 49)
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Etiology Etiology (pilot study n (pilot study n = 48)= 48)
Primary arthritisPrimary arthritis 6 6 rheumatoïd arthritisrheumatoïd arthritis 4 4 Ankylosing spondylitisAnkylosing spondylitis 5 5 Septic arthritisSeptic arthritis 2 2 Post-traumatic arthritisPost-traumatic arthritis 7 7 Congenital dysplasia / dislocationCongenital dysplasia / dislocation 6 6 Aseptic necrosisAseptic necrosis
1212 Miscellaneous Miscellaneous 6 6
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ResultsResults (pilot study (pilot study n: n: 4848))
Follow-up : 14 to 16 yearsFollow-up : 14 to 16 years 1 patient (2 hips) deceased1 patient (2 hips) deceased 3 lost to follow-up (living abroad)3 lost to follow-up (living abroad) 18 revised18 revised : : 8 early revisions 8 early revisions
(malposition)(malposition) 10 late revisions 10 late revisions (polyethylene wear)(polyethylene wear)
26 hips known to be functional.26 hips known to be functional.
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Revisions secondary to Revisions secondary to implant malposition implant malposition (n=8)(n=8)
Varus positionVarus position : :
CDA CDA << 120° (n=6) 120° (n=6)
lack of contactlack of contact with with
the bone resection the bone resection
(n=2) (n=2)
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Second seriesSecond series
01/1995 – 05/200001/1995 – 05/2000
154 hips154 hips
Mean age: 40.8 years (17 – 56 years)Mean age: 40.8 years (17 – 56 years)
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Second series Second series (01/1995 – (01/1995 – 05/2000)05/2000)
154 hips154 hips
14 early revisions14 early revisions
4 late revisions for poly. 4 late revisions for poly.
wear (alumina/poly.)wear (alumina/poly.)
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Survival probability: Survival probability:
femoral componentfemoral component
0,70
0,75
0,80
0,85
0,90
0,95
1,00
0 2 4 6 8 10 12
( Kaplan - Meier )
n = 48 pilot studyn = 48 pilot study
y
n = 154 second seriesn = 154 second series
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Third series Third series (06/2000 – (06/2000 – 11/2005)11/2005)
130 hips130 hips
Mean age: 42 y. (14-56)Mean age: 42 y. (14-56)
9 early revisions:9 early revisions:
2 broken ceramic heads 2 broken ceramic heads
(alumina/alumina)(alumina/alumina)
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Aseptic necrosis Aseptic necrosis (69 hips)(69 hips)
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Aseptic necrosisAseptic necrosis
From 04/1989 to 02/2003From 04/1989 to 02/2003 56 patients (50 males/6 females)56 patients (50 males/6 females) 64 hips64 hips Mean age: 49 years (22 – 64)Mean age: 49 years (22 – 64) Mean follow-up: 7 yearsMean follow-up: 7 years 5 revisions5 revisions 59 implants still in place59 implants still in place
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Aseptic necrosis (n: Aseptic necrosis (n: 64)64)
5 revisions (7.8%)5 revisions (7.8%)
Mean age at reoperation: 52 yearsMean age at reoperation: 52 years
Mean time in situ: 3 yearsMean time in situ: 3 years
Reasons for revision:Reasons for revision:
Varus positioning causing pain or Varus positioning causing pain or
loosening (4)loosening (4)
Recurrent dislocation (1)Recurrent dislocation (1)
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Aseptic necrosis (n: Aseptic necrosis (n: 64)64)
59 implants in place:59 implants in place:
1 patient complaining of groin pain (psoas 1 patient complaining of groin pain (psoas
tendinitis?)tendinitis?)
1 late instability (poly. wear)1 late instability (poly. wear)
2 patients with mild trochanteric pain (screw?)2 patients with mild trochanteric pain (screw?)
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7 years7 years 14 years14 years
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Need for improved Need for improved instrumentsinstruments
The cutting and drilling guides should be monoblock, in order to avoid rotational mismatch
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ConclusionsConclusions This experience supports that This experience supports that a purely a purely
metaphyseal anchorage of a stemless implant metaphyseal anchorage of a stemless implant
can provide a long lasting fixationcan provide a long lasting fixation This type of implant is This type of implant is suitable even when the suitable even when the
femoral head is destructedfemoral head is destructed It permits the use of a It permits the use of a ceramic on ceramic ceramic on ceramic
bearingbearing It is conservative, as It is conservative, as a primary implant can a primary implant can
easily be used if revision is neededeasily be used if revision is needed