OSTEONECROSIS OF THE FEMORAL HEAD: Modern Results of Total Hip Arthroplasty
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OSTEONECROSIS OF THE FEMORAL HEAD:
Modern Results of Total Hip Arthroplasty
Daniel J. Berry, MD
Prof and Chairman
Mayo Clinic
Rochester, MN
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OSTEONECROSIS: THAIntroduction
Advantages of THA:• THA is the one form
of treatment for osteonecrosis with an extremely high likelihood of excellent pain relief and good function
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OSTEONECROSIS: THAResults
• What are the results of THA in the osteonecrosis patient population?
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OSTEONECROSIS: THAResults
Pain Relief and Function:• Good• Similar pain relief
and function to THA for other diagnoses
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OSTEONECROSIS: THAResults
Pain Relief and Function:• THA provides more complete/
reliable pain relief than hemiarthroplasty or head sparing procedures
Ito et al, CORR 2000
Cabanela, CORR 1990
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OSTEONECROSIS: THAResults
THA Durability in osteonecrosis:
• The most controversial topic when discussing THA for osteonecrosis
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OSTEONECROSIS: THAResults
• Difficult to disentangle the fact that most osteonecrosis cohorts have high frequency of demographic factors and underlying diagnoses that put them at risk for implant loosening and wear
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OSTEONECROSIS: THAResults
• Osteonecrosis patients frequently young and active
• Osteonecrosis includes very high activity subgroups; e.g. post-traumatic
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OSTEONECROSIS: THAResults
Durability: Literature• One body of literature: THA for osteonecrosis less
durable (loosening/lysis) than THA for osteoarthritis• Another body of literature: little difference in durability
between THA for osteonecrosis and other diagnoses
Ortiguera et al, J Arthrop, 1999 Sarmiento et al, JBJS(A), 1990Chiu et al, J Arthrop, 1997 Mont, Hungerford, JBJS(A) 1995Xenakis et al, CORR, 1997
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THA FOR OSTEONECROSISUncemented THA
• These are historical results• What are the results with
more modern techniques?
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THA FOR OSTEONECROSISNew Mayo Series
• 98 uncemented THA• 1991-2000• 60 male, 38 female• Mean age 37 years• Mean F/U 6 yrs
Guyen, Cabanela, Berry, 2005
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THA FOR OSTEONECROSISNew Mayo Series
• All treated with uncemented HA coated tapered stem
• 28 mm head on conventional PE
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THA FOR OSTEONECROSISNew Mayo Series
Re-operations for aseptic femoral or acetabular loosening:
• 0/98 = 0%
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THA FOR OSTEONECROSISNew Mayo Series
Re-operations for bearing wear/osteolysis:
• 8/98 = 8%*
* all had conventional PE bearing
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OSTEONECROSIS: THAResults
Literature comparison: • Good results with other successful
uncemented designs*- extensively porous coated femoral
implants**- successful tapered uncemented stems***
* Xenakis et al, CORR 1997
** Piston et al, JBJS(A) 1994
***D’Antonio et al, CORR 1997
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THA FOR OSTEONECROSISLessons Learned
• Modern uncemented THA is outperforming historical results of cemented THA osteonecrosis patients
• The fixation results are comparable to uncemented THA for other diagnoses
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THA FOR OSTEONECROSISLessons Learned
• Wear and osteolysis rates in this young patient group are unacceptable with conventional PE bearing surface
• Alternative bearings (ceramic, metal, crosslinked PE) are justified
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THA FOR OSTEONECROSISDislocation Risk
• Are osteonecrosis patients at higher risk for dislocation?
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LONG TERM DISLOCATION RISKMaterials and Methods
• All primary Charnley THA performed at Mayo Clinic 1969-1984
• 6623 hips
JBJS (A), Jan 2004
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OSTEONECROSIS: THAComplications
• Dislocation risk is elevated in AVN population
0
10
20
0 5 10 15 20 25 30
Years after surgeryYears after surgery
AVNAVN
DJDDJDCumulative
probability ofdislocation
(%)
Cumulativeprobability ofdislocation
(%)
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LONG TERM DISLOCATION RISKResults
Risk of Dislocation (Compared to Osteoarthritis)
Factor Relative Risk (CI)
Dx=Osteonecrosis 1.9 (1.1-3.2)
p<0.01
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OSTEONECROSIS: THAComplications
Literature: Dislocation rate also high in other series:
• compliance problems in subgroups of patients (EtOH)
• less capsular hypertrophy in osteonecrosis than osteoarthritis
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THA FOR OSTEONECROSISLessons Learned
Instability risk elevated in osteonecrosis:
• Efforts to minimize instability justified - anterior approaches or- posterior approach with
capsular repair- larger head size (≥ 32 mm)