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OSTEONECROSIS OF THE FEMORAL HEAD: Modern Results of Total Hip Arthroplasty

OSTEONECROSIS OF THE FEMORAL HEAD: Modern Results of Total Hip Arthroplasty. Daniel J. Berry, MD Prof and Chairman Mayo Clinic Rochester, MN. OSTEONECROSIS: THA Introduction. Advantages of THA:

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OSTEONECROSIS OF THE FEMORAL HEAD: Modern Results of Total Hip Arthroplasty

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  1. OSTEONECROSIS OF THE FEMORAL HEAD:Modern Results of Total Hip Arthroplasty Daniel J. Berry, MD Prof and Chairman Mayo Clinic Rochester, MN

  2. 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

  3. OSTEONECROSIS: THAResults • What are the results of THA in the osteonecrosis patient population?

  4. OSTEONECROSIS: THAResults Pain Relief and Function: • Good • Similar pain relief and function to THA for other diagnoses

  5. 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

  6. OSTEONECROSIS: THAResults THA Durability in osteonecrosis: • The most controversial topic when discussing THA for osteonecrosis

  7. 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

  8. OSTEONECROSIS: THAResults • Osteonecrosis patients frequently young and active • Osteonecrosis includes very high activity subgroups; e.g. post-traumatic

  9. 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), 1990 Chiu et al, J Arthrop, 1997 Mont, Hungerford, JBJS(A) 1995 Xenakis et al, CORR, 1997

  10. THA FOR OSTEONECROSISUncemented THA • These are historical results • What are the results with more modern techniques?

  11. 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

  12. THA FOR OSTEONECROSISNew Mayo Series • All treated with uncemented HA coated tapered stem • 28 mm head on conventional PE

  13. THA FOR OSTEONECROSISNew Mayo Series Re-operations for aseptic femoral or acetabular loosening: • 0/98 = 0%

  14. THA FOR OSTEONECROSISNew Mayo Series Re-operations for bearing wear/osteolysis: • 8/98 = 8%* * all had conventional PE bearing

  15. 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

  16. 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

  17. 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

  18. THA FOR OSTEONECROSISDislocation Risk • Are osteonecrosis patients at higher risk for dislocation?

  19. LONG TERM DISLOCATION RISKMaterials and Methods • All primary Charnley THA performed at Mayo Clinic 1969-1984 • 6623 hips JBJS (A), Jan 2004

  20. AVN Cumulativeprobability ofdislocation(%) DJD Years after surgery OSTEONECROSIS: THAComplications • Dislocation risk is elevated in AVN population

  21. 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

  22. OSTEONECROSIS: THAComplications Literature: Dislocation rate also high in other series: • compliance problems in subgroups of patients (EtOH) • less capsular hypertrophy in osteonecrosis than osteoarthritis

  23. 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)

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