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Ernesto Pintore Clinica Malzoni Agropoli - Italie. Aseptic loosening of Hip Prostheses. Prosthetic Surgery = Life quality. AIM OF REVISION SURGERY. GOOD FUNCTION QUALITY OF LIFE. TECHNICALLY DIFFICULT VARIETY OF IMPLANTS LEARNING CURVE INSTRUMENTS. RECENT PROGRESS:

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Ernesto pintore clinica malzoni agropoli italie

Ernesto Pintore

Clinica Malzoni

Agropoli - Italie

Aseptic loosening of Hip Prostheses


Prosthetic surgery life quality
Prosthetic Surgery=Life quality


Aim of revision surgery
AIM OF REVISION SURGERY

  • GOOD FUNCTION

  • QUALITY OF LIFE


TECHNICALLY DIFFICULT

VARIETY OF IMPLANTS

LEARNING CURVE

INSTRUMENTS


RECENT PROGRESS:

-BIOMATERIALS

-DESIGNS

-IMPROVED CEMENTING TECHNIQUE

-MODULAR PROSTHESES



Septic loosening
SEPTIC LOOSENING

  • CLINIC

  • LABORATORY

  • X-RAY

  • SCINTIGRAPHY


SEPTIC

LOOSENING


Aseptic loosening

ASEPTIC LOOSENING

MECHANICAL FAILURE:

“Aseptic loosening of one or both components, fracture of a component, recurrent dislocation of the hip, fracture of the femoral shaft.”

Callaghan JJ; Salvati E.A. et al.

JBJS 1985


Aseptic loosening of the femur
ASEPTIC LOOSENING OF THE FEMUR

  • MALPOSITION OF THE STEM

  • FRACTURE OF THE IMPLANT

  • FRACTURE OF THE FEMUR

  • RECURRENT DISLOCATION

  • INADEQUATE STEM DESIGN

  • INADEQUATE CEMENTING TECHNIQUE

  • INADEQUATE CEMENT LAYER


Aseptic loosening of the cup
ASEPTIC LOOSENING OF THE CUP

  • POOR BONE COVERAGE

  • MALORIENTATION too vertical, >60°

  • POLYETHYLENE FAILURE

  • EXCESSIVE HIGHT OF THE CUP >35mm compared to the contralateral

  • INADEQUATE CEMENT TECHNIQUE fixation holes and thickness of cement layer

  • SMOOTH CUPS and RE-CEMENTED

  • THREATED CUPS


X ray femur
X-RAY FEMUR

  • VARUS-VALGUS OF THE STEM

  • VERTICAL SUBSIDENCE

  • HORIZONTAL MIGRATION

  • RADIOLUCENCY

  • OSTEOLYSIS

  • FRACTURE OF THE CEMENT


X ray acetabulum
X-RAY ACETABULUM

  • VERTICAL MIGRATION

  • HORIZONTAL MIGRATION

  • CUP HIGHT

  • CUP ANGLE

  • RADIOLUCENCY

  • OSTEOLYSIS

  • POLYETHYLENE FAILURE


Femoral bone stock

FEMORAL BONE STOCK

Poor: if the thickness of either aspect of the cortex on the AP x-ray had decreased by 50%, along a 10 cm segment of femoral stem, compared with the original arthroplasty, or if the thickness of both aspect of the cortex had decreased this amount along a 5 cm segment


Acetabular bone stock
ACETABULAR BONE STOCK

  • CUP MEDIAL TO THE KOHLER’S LINE (any part of the implant)

  • MEDIAL WALL (< 2mm thickness)

  • VERTICAL DISTANCE ( > 1 cm between the line trough the tear drop and the higher point of the cement layer compared to the contralateral)


A a o s classification for bone stock damage
A.A.O.S.Classification for bone stock damage

  • MILD

  • MODERATE

  • SEVERE


Clinic

CLINIC

- PAIN

- START UP HECITANCY


Definition of acetabular loosening harris and mc gunn jbjs 1986
DEFINITION OF ACETABULAR LOOSENING(Harris and Mc Gunn JBJS 1986)

  • DEFINITE LOOSENING:

  • change of position of the implant, or cement.

  • fracture of the cement

  • radiolucency at the cement-implant interface

  • PROBABLE LOOSENING:

  • no migration or change of position

  • continuous radiolucency (100%) at cement-bone

  • interface

  • POSSIBLE LOOSENING:

  • radiolucency 50%-99% at the cement-bone interface


Wear debris

WEAR DEBRIS

The wear debris is responsible of a local inflammatory reaction with histyocytes and mast cells proliferation, that leads to osteolysis and loosening of the implant.


Operative technique
OPERATIVE TECHNIQUE

  • CHOICE OF THE APPROACH

  • POSTERO-LATERAL APPROACH

  • OSTEOTOMY OF THE TROCHANTER

  • FEMORAL “WINDOW”

  • WAGNER TECHNIQUE

  • REMOVAL OF THE CEMENT

  • IMPLANTS


Implants
IMPLANTS

  • STANDARD STEM

  • LONG STEM

  • SURFACE

  • MODULAR PROSTHESES

  • “LOCKING NAIL” PROSTHESES


Bone graft
BONE GRAFT

  • AUTOGRAFT

  • HOMOGRAFT

  • ALLOGRAFT

    Only an accurate reconstruction of the

    anatomy can allow a good result in the

    revision surgery ( Bone bank)



ALTHOUGH MODIFICATION AND IMPROVING OF CEMENTING TECHNIQUE HAVE DECREASED THE INCIDENCE OF FEMORAL AND ACETABULAR LOOSENING IN THR, THRE IS NO EVIDENCE DEMONSTRATING BENEFITS IN REVISION SURGERY WITH THE CEMENT.

Engh C.; Glassman A.

(Instructional course lecture 1991)


Criteria for determining biologic fixation
CRITERIA FOR DETERMINING BIOLOGIC FIXATION TECHNIQUE HAVE DECREASED THE INCIDENCE OF FEMORAL AND ACETABULAR LOOSENING IN THR, THRE IS NO EVIDENCE DEMONSTRATING BENEFITS IN REVISION SURGERY WITH THE CEMENT.

  • BONE INGROWTH

  • STABLE BONE-FIBROUS TISSUE

  • UNSTABLE IMPLANT


Bone ingrowth

BONE INGROWTH TECHNIQUE HAVE DECREASED THE INCIDENCE OF FEMORAL AND ACETABULAR LOOSENING IN THR, THRE IS NO EVIDENCE DEMONSTRATING BENEFITS IN REVISION SURGERY WITH THE CEMENT.

NO IMPLANT MIGRATION

ADAPTIVE REMODELING OF THE SURROUNDING BONE


Causes of success in femoral revision
CAUSES OF SUCCESS IN FEMORAL REVISION TECHNIQUE HAVE DECREASED THE INCIDENCE OF FEMORAL AND ACETABULAR LOOSENING IN THR, THRE IS NO EVIDENCE DEMONSTRATING BENEFITS IN REVISION SURGERY WITH THE CEMENT.

  • FRESHENING THEBONE

  • RESTORE THE BONE STOCK

  • IMPROVED TROCHANTERIC FIX.

  • TREATEMENT OF PERFORATIONS

  • ADEQUATE STEM:

    -Extensevely porous coated

    -Design (filling)


Causes of failure
CAUSES OF FAILURE TECHNIQUE HAVE DECREASED THE INCIDENCE OF FEMORAL AND ACETABULAR LOOSENING IN THR, THRE IS NO EVIDENCE DEMONSTRATING BENEFITS IN REVISION SURGERY WITH THE CEMENT.

  • BAD BONE STOCK

  • TROCHANTERIC PROBLEMS

  • MISDIAGNOSED PERFORATIONS

  • INADEQUATE DESIGN OF THE IMPLANTS

  • DYSPLASIC AND NECROTIC HIPS

  • INFECTION

  • CURVE OF LEARNING


Results of uncemented revisions c engh a glassman

RESULTS OF UNCEMENTED REVISIONS TECHNIQUE HAVE DECREASED THE INCIDENCE OF FEMORAL AND ACETABULAR LOOSENING IN THR, THRE IS NO EVIDENCE DEMONSTRATING BENEFITS IN REVISION SURGERY WITH THE CEMENT.(C. Engh - A. Glassman)

163 hips

80,7% of bone ingrowth

12,3% of stable fibrous tissue

3,5% unstable implants re-revised


Complications
COMPLICATIONS TECHNIQUE HAVE DECREASED THE INCIDENCE OF FEMORAL AND ACETABULAR LOOSENING IN THR, THRE IS NO EVIDENCE DEMONSTRATING BENEFITS IN REVISION SURGERY WITH THE CEMENT.

SYSTEMIC COMPLICATIONS

  • Urinary infections

  • Cardiac problems

  • DVT

  • Pulmonary embolism

  • Blood loss (1000-1500 ml)


Local complications
LOCAL COMPLICATIONS TECHNIQUE HAVE DECREASED THE INCIDENCE OF FEMORAL AND ACETABULAR LOOSENING IN THR, THRE IS NO EVIDENCE DEMONSTRATING BENEFITS IN REVISION SURGERY WITH THE CEMENT.

  • Superficial and deep infections

  • Trochanteric nonunion (10%)

  • Trochanteric problems

  • Fracture of the femur

  • Perforation of the femur

  • Fracture of the pelvis

  • Recurrent dislocations (9-12%)

  • Ectopic bone


Aseptic loosening of a Bousquet cup 6 years later TECHNIQUE HAVE DECREASED THE INCIDENCE OF FEMORAL AND ACETABULAR LOOSENING IN THR, THRE IS NO EVIDENCE DEMONSTRATING BENEFITS IN REVISION SURGERY WITH THE CEMENT.


Revision with uncemented cup and auto-homograft TECHNIQUE HAVE DECREASED THE INCIDENCE OF FEMORAL AND ACETABULAR LOOSENING IN THR, THRE IS NO EVIDENCE DEMONSTRATING BENEFITS IN REVISION SURGERY WITH THE CEMENT.


Revision surgery is technically difficult and requires an experienced surgeon and economic means to achieve the most performant devices.

There are many complications and the results are not always good.

The learning curve is long

but despite this we beleave

that this is the surgery wich

we have to develop in the

future.


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