CONGENITAL HIP DISEASE IN YOUNG ADULTS CLASSIFICATION AND TREATMENT WITH THA. Th. KARACHALIOS, MD, DSc PROF IN ORTHOPAEDICS

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1 CONGENITAL HIP DISEASE IN YOUNG ADULTS CLASSIFICATION AND TREATMENT WITH THA Th. KARACHALIOS, MD, DSc PROF IN ORTHOPAEDICS EDITOR IN CHIEF HIP INTERNATIONAL UNIVERSITY OF THESSALIA, LARISA HELLENIC REPUBLIC OSTEOARTHRITIS 660 HIPS WITH END STAGE OA SECONDARY TO CHD 356 (54%) IDIOPATHIC 272 (41%) UNCERTAIN 32 (5%) Hartofilakidis, Karachalios Orthopaedics 2000 Hartofilakidis, Karachalios Clin Orthop 2002 Karachalios J Eur Radiol

2 CONGENITAL HIP DISEASE IN YOUNG ADULTS THE DYSPLASTIC HIP WHY NOT???.BECAUSE NOT ALL DYSPLASTIC HIPS ARE THE SAME. Karachalios, Hartofilakidis JBJS Br 2010 CLASSIFICATION RECOGNITION OF LOCAL ABNORMALITIES PREOPERATIVE PLANNING RECONSTRUCTION TECHNIQUES BETTER COMMUNICATION DOCUMENTATION EVALUATION OF RESULTS Eftecar JBJS 1978 Crowe JBJS 1979 Hartofilakidis JBJS 1988 Hartofilakidis, Karachalios JBJS 1996 Hartofilakidis, Karachalios JBJS

3 CONGENITAL HIP DISEASE IN ADULTS DYSPLASTIC HIP CONGENITAL DISLOCATION OF THE HIP (CDH) DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH) CONGENITAL HIP DISEASE Stanisavligenic JBJS 1963 Arnold JBJS 1964 Robin Am J Publ Health 1965 Harris and Stulberg JBJS 1973 Wedge and Wasylenko Clin Orth 1978 Walker JBJS 1980 Thomas JBJS 1982 Hartofilakidis, Karachalios JBJS 1996 Karachalios, Hartofilakidis JBJS Br 2010 NATURAL HISTORY CONGENITAL HIP DISEASE IN CHILDHOOD DYSPLASIA SUBLUXATION COMPLETE DISLOCATION.BECOME. IN ADULTHOOD DYSPLASIA LOW DISLOCATION HIGH DISLOCATION Weistein Clin Orthop 1987 Hartofilakidis, Karachalios Orthopaedics

4 DYSPLASIA THE FEMORAL HEAD IS CONTAINED WITHIN THE TRUE ACETABULUM DYSPLASIA SEGMENTAL DEFICIENCY OF THE SUPERIOR WALL (ROOF) OSTEOPHYTE COVERS THE FOSSA SECONDARY SHALLOWING ONSET OF SYMPTOMS AVERAGE AGE 34 YRS (18-48) Hartofilakidis, Karachalios JBJS 1998 Harthofilakidis, Karachalios Orthopaedics

5 LOW DISLOCATION THE FEMORAL HEAD ARTICULATES WITH A FALSE ACETABULUM WHICH PARTIALLY COVERS THE TRUE ACETABULUM LOW DISLOCATION SUPERIOR SEGMENTAL DEFICIENCY ANTERIOR (MAINLY) AND POSTERIOR SEGMENTAL DEFICIENCY NARROW OPENING ONSET OF SYMPTOMS AVERAGE AGE 33 YRS (17-50) Hartofilakidis, Karachalios JBJS 1998 Harthofilakidis, Karachalios Orthopaedics

6 HIGH DISLOCATION THE FEMORAL HEAD IS MIGRATED SYPERIORLY AND POSTERIORLY IN RELATION TO THE HYPOPLASTIC TRUE ACETABULUM HIGH DISLOCATION SEGMENTAL DEFECT OF THE ENTIRE PERIPHERY INADEQUATE DEPTH NARROW OPENING ABNORMAL DISTRIBUTION OF BONE STOCK EXCESSIVE ANTEVERSION Hartofilakidis, Karachalios JBJS 1996 Hartofolakidis, Karachalios JBJS 1998 Hartofilakidis, Karachalios JBJS 2004 ONSET OF SYMPTOMS WITH A FALSE ACETABULUM AVERAGE AGE 31 YRS (18-40) WITHOUT A FALSE ACETABULUM AVERAGE AGE 46 YRS (30-65) 6

7 CONGENITAL HIP DISEASE ABNORMAL FEMORAL BONE IN LOW AND ESPECIALLY IN HIGH DISLOCATION SMALL NARROW CANAL SHORT NECK EXCESSIVE ANTEVERSION Hartofilakidis, Karachalios JBJS 1996 Hartofilakidis, Karachalios JBJS 1998 Hartofilakidis, Karachalios JBJS 2004 QUESTIONS SUBLUXATION???? DYSPLASIA OR LOW DISLOCATION??? LOW OR HIGH DISLOCATION??? THE NEED FOR CT-SCAN 7

8 VARIATIONS Hartofilakidis, Babis CORR 2012 LOW DISLOCATION 1 EXTENDED COVERAGE (53.5%) LOW DISLOCATION 2 LIMITED COVERAGE (46.5%) WHY????? VARIATIONS HIGH DISLOCATION 1 WITH FALSE ACETABULUM (62%) HIGH DISLOCATION 2 WITHOUT FALSE ACETABULUM (38%) WHY???? 8

9 CONGENITAL HIP DISEASE TREATMENT WITH THA PLANNING 3D CT SCAN EVALUATION OF BONE DEFICIENCIES SCANOGRAM EVALUATION OF LEG LENGTH CONGENITAL HIP DISEASE IMPLANTS SMALL ACETABULAR COMPONENTS THIN FEMORAL STEMS CUSTOM MADE PROSTHESIS 9

10 1.PRINCIPLE RECOGNISION OF LOCAL ANATOMIC ABNORMALITIES DYSPLASIA LOW DISLOCATION HIGH DISLOCATION TRUE ACETABULUM DIMENSIONS 2.PRINCIPLE ACETABULAR CUP COVERAGE SUPERIOR DYSPLASIA LOW DISLOCATION SUPERIOR, ANTERIOR AND POSTERIOR LOW DISLOCATION HIGH DISLOCATION Hartofilakidis, Karachalios JBJS 1996 Hartofolakidis, Karachalios JBJS 1998 Hartofilakidis, Karachalios JBJS

11 3.PRINCIPLE LOCATION OF CENTER OF HIP ROTATION HIGH HIP CENTER ANATOMIC CENTER OF ROTATION LOW AND HIGH DISLOCATION PRINCIPLE ANATOMIC CENTER OF ROTATION BONE STOCK HIP BIOMECHANICS FIXED PELVIC DEFORMITY LATE RECOVERY Karachalios Clin Orthop 1993 Yoder Clin Orthop

12 ARGUMENT COMPLEX FIXED DEFORMITY THE PELVIC TILT AND OBLIQUITY ISSUE CUP AT THE LEVEL OF FALSE ACETABULUM Christodoulou Clin Orthop 2010 SURGICAL TECHNIQUE INDENTIFICATION OF TRUE ACETABULUM LOW AND HIGH DISLOCATION POSTERIOR AND/OR ANTERIOR CAPSULE RELEASE FOLLOW THE INFERIOR PART OF THE CAPSULE PLACEMENT OF INFERIOR RETRACTOR 12

13 4. PRINCIPLE ACETABULAR RECONSTRUCTION TECHNIQUES OPTIONS TECHNIQUE DYSPLASIA SUPERIOR SEGMENTAL DEFICIENCY UNCOVERED SUPERIOR CUP ANATOMIC CENTER OF ROTATION ORDINARY IMPLANTS BEAWARE OF CUP OPENING 13

14 IMPLANT DESIGN DYSPLASIA AND LOW DISLOCATION A SUPERIOR SEGMENTAL DEFICIENCY THE EXCEED ABT DESIGN PRINCIPLE THE 15 DEGREES FACE CHANGING CUP Courtesy of Mr E. J. Smith, FRCS, Bristol UK TECHNIQUE OPTION LOW AND HIGH DISLOCATION HIGH HIP PLACEMENT INCONSISTENT CLINICAL RESULTS Hampton, Harris JBJS 2006 Russotti, Harris JBJS

15 TECHNIQUE A AND B LOW DISLOCATION SUPERIOR AND MINOR POSTERIOR SEGMENTAL DEFICIENCY AUGMENTATION WITH STRUCTURAL AUTO OR ALLOGRAFT MID TERM HIGH FAILURE RATE Mallory, Harris JBJS 1990 Harris Orthop Clin North Am 1993 Pagnano JBJS 1996 RECENT LITERATURE DATA DETERMINANTS OF GRAFT SURVIVAL LOCATION GRAFT MORPHOLOGY TYPE OF FIXATION MECHANICAL LOADING De Jong JBJS 2006 Kim Clin Orthop

16 TECHNIQUE A AND B LOW AND HIGH DISLOCATION CONTROLLLED MEDIALISATION 75-80% COVERAGE OF THE CUP NEW IMPLANTS TRABECULAR METAL Malizos, Karachalios Clin Orthop 2008 TECHNIQUE A AND B LOW DISLOCATION AND HIGH DISLOCATION COTYLOPLASTY» FRACTURE OF THE MEDIAL WALL» CONTROLLED MEDIALISATION» MORSELISED AUTOGRAFT Hartofilakidis, Stamos JBJS 1988 Hartofilakidis, Karachalios JBJS 1998 Hartofilakidis, Karachalios JBJS

17 ACETABULAR RECONSTRUCTION THE ROLE OF THE MEDIAL WALL INNER PERIOSTEAL LAYER FEMORAL HEAD AUTOGRAFT 17

18 COTYLOPLASTY CUMMULATIVE SUCCESS RATE (%) 10 YRS 15 YRS 20 YRS 25 YRS 30 YRS No CASES REMAINING CUP 91.6 SE: SE: SE: SE: SE: STEM 93.0 SE: SE: SE: SE: SE: LONG TERM RESULTS 92% SURVIVAL RATE AT 10 YEARS 79% SURVIVAL RATE AT 15 YEARS 59% SURVIVAL RATE AT 20 YEARS 54% SURVIVAL RATE AT 25 YEARS Hartofilakidis, Karachalios JBJS 1996 Karachalios, Hartofilakidis BJJ (former JBJS Br) 2013.LATE FAILURE. 28 YRS DOWN THE LINE PE WEAR ADEQUATE BONE STOCK 18

19 CUMMULATIVE SUCCESS RATE % CUMMULATIVE SUCCESS RATE (%) 12/27/2016 COTYLOPLASTY 25 YRS 17 YRS INFERIOR SURVIVAL IN PTS YOUNGER THAN 50 YRS DEGREE OF MEDIALIZATION???? LONG TERM SURVIVAL DATA ACETABULAR COMPONENT SURVIVAL CUP OVERALL LPWS OFFSET BORE DIAGNOSIS AND TYPE OF PROSTHESIS DEPENDED SURVIVAL LPWS CUPS SUPERIOR SURVIVAL LOW DISLOCATION INFERIOR SURVIVAL Y 5YRS 10YRS 15YRS 20YRS 25YRS 30YRS Y ACETABULAR COMPONENT SURVIVAL TYPE OF THE DISEASE 5YRS 10YRS 15YRS 20YRS 25YRS 30YRS CUP OVERALL LD 1 LD 2 HD 1 HD 2 19

20 TECHNIQUE SELECTED CASES LOW AND HIGH DISLOCATION SEVERE DEFICIENCIES RECONSTRUCTION RINGS BAD EXAMPLE MIS HIP SURGERY???? HIGH HIP PLACEMENT INADEQUATE BONE STOCK EARLY FAILURE COMPLEX REVISION SURGERY 20

21 A PROBLEM SMALL DIMENSIONS SMALLER THAN 44MM?? 35MM OFFSET BORE CUP Ioannidis, Hartofilakidis, Karachalios JBJS 1998 CONGENITAL HIP DISEASE FEMUR TROCHANTERIC OSTEOTOMY LEVEL OF NECK OSTEOTOMY SUBTROCHANTERIC OSTEOTOMY DIAPHYSEAL OSTEOTOMY COMBINATION LONGER FEMURS KNEE VALGUE DEFORMITY Koulouvaris J Arthroplasty 2008 Hartofilakidis, Babis JBJS

22 HIGH DISLOCATION COMBINATION TECHNIQUE 12 CASES 5-10 YEAR F-UP CONGENITAL HIP DISEASE IMPLANTS SMALL ACETABULAR COMPONENTS THIN CONE SHAPED FEMORAL STEMS BEARING SURFACES - COC Malizos, Bargiotas, Karachalios Clin Orthop

23 LITERATURE SEARCH NON UNIFORM LONG TERM STUDIES TYPE OF DISEASE SURGICAL TECHNIQUES INCONSISTENT RESULTS Garcia-Cimbrelo J Arthroplasty 1993 Callaghan JBJS 2005 RESULTS OLD SERIES ( ) 229 HIPS SURVIVAL RATES AT 15 YEARS DUSPLASIA OVER 90% LOW DISLOCATION ~80% HIGH DISLOCATION ~80% ACETABULAR COMPONENT SUPERIOR IN HIGH DISLOCATION FEMORAL COMPONENT SUPERIOR IN LOW DISLOCATION Hartofilakidis, Karachalios JBJS 1998 Hartofilakidis, Karachalios JBJS

24 CUMMULATIVE SUCCESS RATE (%) 12/27/2016 FEMORAL STEM SURVIVAL FEMORAL COMPONENT OVERALL SURVIVAL LOW AND HIGH DISLOCATION CASES 72% AT 20 YRS 65% AT 25 YRS 41% AT 30 YRS Y 5YRS 10YRS 15YRS 20YRS 25YRS 30YRS RESULTS AVERAGE LEGTHENING 4.2 CM (2-7.5) NERVE PALSY DYSPLASIA 1 LOW 1S AND F HIGH 1S AND 1F DISLOCATIONS 8 TROCHANTERIC FIBROUS UNION DYSPLASIA 4% LOW 13% HIGH 22% NONUNION 3 Hartofilakidis, Karachalios JBJS

25 CONGENITAL HIP DISEASE WIDE EXPOSURE INSTRUMENTATION CHOICES OF IMPLANTS AND TECHNIQUES RESULTS NEW SERIES (OUT OF 724) PATIENTS MODERN IMPLANTS NO FAILURES YET Malizos, Karachalios, Bargiotas CERAMIC ON CERAMIC BEARING SURFACES??? FAILED SURGERY PERFORMED IN CHILDHOOD 25

26 TAKE HOME MESSAGES RECOGNITION OF LOCAL ABNORMALITIES PROPER PREOP PLANNING SEVERAL TECHNIQUES AVAILABLE VARIETY OF DIFFERENT IMPLANTS CHALLENGING PROCEDURE KNOWLEDGE ENSURES SATISFACTORY CLINICAL RESULTS 26