FEMORAL REVISION IN TOTAL HIP ARTHROPLASTY
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1 FEMORAL REVISION IN TOTAL HIP ARTHROPLASTY Jean-Noël Argenson, MD Professor and Chairman of Orthopedic Surgery Hip and Knee Replacement The Aix-Marseille University Hopital Sainte-Marguerite Marseille, France
2 LOOSENING REVISION OSTEOLYSIS?
3 OSTEOLYSIS Paprosky W., Lawrence J., Cameron H. - Femoral defect classification. Clin. application Orthop. Rev., 1990, 19, Suppl. 9, 9. STAGE 1: Intact metaphysis et diaphysis Partial calcar osteolysis
4 OSTEOLYSIS Paprosky W., Lawrence J., Cameron H. - Femoral defect classification. Clin. application Orthop. Rev., 1990, 19, Suppl. 9, 9. STAGE 1: Proximal stability Proximal fixation No reconstruction «Primary THA»
5 OSTEOLYSIS STAGE 2A: Complete calcar osteolysis without extension to subtrochanteric area Intermediate fixation for rotational stability Longer stem, Bone graft
6 OSTEOLYSIS STAGE 2B: Complete calcar osteolysis without extension to subtrochanteric area + lateral cortex lesion
7 OSTEOLYSIS STAGE 2C: Complete calcar osteolysis + extension to subtrochanteric area
8 OSTEOLYSIS STAGE 2B and C: Need for distal fixation + bone grafting Example: Segmental allograft
9 OSTEOLYSIS STAGE 3: Non supportive metaphysis No calcar Major ant. and post. diaphysis defect Reconstructive stem structural femoral allograft
10 OSTEOLYSIS Stage > 2A : Distal fixation with cementless stem locking Femoral structural graft + cemented stem Massive reconstructive prosthesis Or
11 MORCELIZED IMPACTED ALLOGRAFT
12 Acetabulum : Impaction grafting + cementless ring 1 year
13 HISTORY Sloof Acta Orthop Scand 1984 : Impacted allograft for acetabulum revision Exeter: Impacted allograft for femoral revision Gie, Ling JBJS 1993: Surgical technique + instrumentation
14 ADVANTAGES Restore bone stock «Conservative» Young patient ( iterative revision)
15 PRINCIPLES Graft stability obtained with cement stem loading in graft area «Controled progressive migration» Graft in compression
16 GREFFE MORCELEE IMPACTEE ET TIGE CIMENTEE EVALUATION DE LA RECONSTRUCTION ET DES PROBLEMES TECHNIQUES X. FLECHER, R.GRAVIER, JN. ARGENSON, JM. AUBANIAC SOFCOT 1999
17 PROBLEMS
18 PROBLEMS Distal fracture tip stem (if diaphysis osteolysis) Longer stem (+3 cm)
19 Surgical technique Watson-Jones approach No trochanter osteotomy Stem removal Impacted allograft Guide + distal plug Progressive graft filling Compaction with smooth canulated rasp Trials Retrograde cementing Final stem
20
21 PROBLEMS Migration > 1 cm Collar
22 PROBLEMS Fixed CCD angle Adapted offset
23 CDH
24 OFFSET
25 Cemented adapted femoral stem + impaction grafting Patients 32 femmes, 48 hommes 62 ans ( 29-83) Harris 51 (range 21-79) 91 (range )
26 Revision technique for femoral loosening using impacted morselized grafts associated with adapted cemented femoral stem R. Gravier, JN Argenson, JM Aubaniac, SOFCOT patients 14 women, 11 men 63 years (range, 41-81), n =11 < 60 years Follow-up = 40 months ( range,24-60)
27 Cemented adapted femoral stem + impaction grafting A.V.N. 8 Primary osteoarthritis : 6 Post.trauma OA.: 5 DDH: 6
28 Cemented adapted femoral stem + impaction grafting NUMBER OF REVISIONS First : 16 Second : 5 Third : 4
29 Cemented adapted femoral stem + impaction grafting PMA: N=5 PMA<9 N=19 10<PMA<12 N=1 PMA>13 PMA 10,2 15,4 SOFCOT Classification Stage 0 = 1 Stage 1 = 7 Stage 2 = 8 Stage 3 = 6 Stage 4 = 3
30 Cemented adapted femoral stem + impaction grafting MEAN BONE LOSS Medial = 96 mm Lateral = 107 mm
31 Cemented adapted femoral stem + impaction grafting POST OPERATIVE RADIOLOGICAL EVALUATION Stem positioning Varus > 5 n=4 Anterior contact n=5 Migration mean = 4 mm ( range 0-10) RxLuc.: Bone / cement = 7 ; Prosthesis /cement = 3
32 Cemented adapted femoral stem + impaction grafting ALLOGRAFT INCORPORATION ( PIERCHON ET AL) Stage 1: «White bread aspect» Stage 2: Homogenization Stage 3: Condensation Stade 4: Spongy trabeculations Stade 5: Corticalisation + consolidation Stade 6: Graft osteolysis
33 Cemented adapted femoral stem + impaction grafting FEMORAL RECONSTRUCTION Cortical thickening : 60% med + lat. Zones at 3 levels Average = 2 to 3 mm
34 Cemented adapted femoral stem + impaction grafting FEMORAL RECONSTRUCTION Normalization or improvement = 21 No change = 3 Worsened = 1
35 Mr D.A, 53 years, Pre-op
36 Mr D.A, 53 years, J1
37 Mr D.A, 53 years, J+3 ans
38 Pre-op J+1 year J+3 years Mrs F.A, 61 years
39 CONCLUSION impaction grafting + adapted femoral stem Stem position Distal fracture Cement removal
40 CONCLUSION impaction grafting + adapted femoral stem Restore bone stock «Conservative» Young patient Adapted stem Correct leg length Correct lever arm
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