primary thas for hip osteonecrosis in < 50 years old and active patients c delaunay, h. migaud...

Primary THAs for Hip Primary THAs for Hip Osteonecrosis in < 50 years Osteonecrosis in < 50 years old and active patientsold and active patients

C Delaunay, H. MigaudC Delaunay, H. Migaudand the SFHG groupand the SFHG group

1ary THA for osteonecrosis in < 50 & active patients1ary THA for osteonecrosis in < 50 & active patients

IntroductionIntroduction

More than type of implant fixation,More than type of implant fixation, polyethylene (PE) wearpolyethylene (PE) wear is the major is the major factor impairing the longevity of THAfactor impairing the longevity of THA

More than young age,More than young age, high activity high activity level level is the major cause of conventional is the major cause of conventional PE wearPE wear

Concerns about THA in AVN : Concerns about THA in AVN : patients are mostly young and active patients are mostly young and active


Litterature : THA for AVN !?…Litterature : THA for AVN !?…

19851985, Cornell et al. , Cornell et al. (OCNA)(OCNA) : overall : overallcemented THA failure rate xcemented THA failure rate x 44 in AVN vs in AVN vs 1ary arthritis1ary arthritis

19991999, Ortiguera et al. , Ortiguera et al. (JA)(JA) : at 17,8 y-FU, : at 17,8 y-FU, 50% revision rate and more dislocation50% revision rate and more dislocation (6%) (6%) in < 50 years old AVN patientsin < 50 years old AVN patients

19971997, D’Antonio et al. , D’Antonio et al. (CORR)(CORR) : Ctless HA : Ctless HA stem OK, but cups failure due to thin PE stem OK, but cups failure due to thin PE liner wear with liner wear with 32mm-metallic heads32mm-metallic heads


Litterature : THA for AVN !?…Litterature : THA for AVN !?…

20052005, Radl et al. , Radl et al. (AO)(AO) : 5 Ctless +/-HA : 5 Ctless +/-HA stems, stems, higher failure rate and migrationhigher failure rate and migration in in AVN versus osteoarthrosisAVN versus osteoarthrosis 20052005, Radl et al. , Radl et al. (JA)(JA) : correlation : correlation between between survival of Ctless stems and thesurvival of Ctless stems and theetiology of AVNetiology of AVN (worst if systemic desease) (worst if systemic desease)

20042004, Schneider & Knahr , Schneider & Knahr (AOS)(AOS) : 2 Ctless : 2 Ctless non-HA THAs with A-PE or A-A bearings non-HA THAs with A-PE or A-A bearings «« could not confirm that AVN is a risk could not confirm that AVN is a risk factorfactor » »

SFHG Meeting, November 2004SFHG Meeting, November 20041ary THA in active patients < 501ary THA in active patients < 50

Inclusion criteria :Inclusion criteria :

1ary THA on virgin hips1ary THA on virgin hips

< 50 years old patients< 50 years old patients

activity level > Devane 3activity level > Devane 3

Exclusion criteria :Exclusion criteria :

High dysplasia > Crowe I High dysplasia > Crowe I

Rheumatoïd and juvenile arthritisRheumatoïd and juvenile arthritis

1419 1ary THAs1419 1ary THAs (cementless, 72%)(cementless, 72%)Mean age, 41.2 ; Devane 4&5, 60%Mean age, 41.2 ; Devane 4&5, 60%

12 teams


1 diagnosis : 1 diagnosis : AVN (36%)AVN (36%) 22 Dysplasia, 28% Dysplasia, 28% 33 1ary arthtitis, 22,5%1ary arthtitis, 22,5%

45

30

56

50

54

38

37

83

0 20 40 60 80 100

Cochin

Larib / Pt Labbe

St Eti/Hyeres

Marseille

ABG

ARTRO

Bruay

Longjum/Lille

IMK Meeting, February 2006IMK Meeting, February 20061ary THA for AVN in patients < 501ary THA for AVN in patients < 50

« Charnley-Kerboull » (Cochin)« Charnley-Kerboull » (Cochin)

« Ostéal-Cerafit » (Lariboisière-Pt.Labbé)« Ostéal-Cerafit » (Lariboisière-Pt.Labbé)

« Symbios » (Marseille) « Symbios » (Marseille)

« ABG » (ABG group)« ABG » (ABG group)

« Corail » (Artro group) « Corail » (Artro group)

« Omnifit-Arc2f » (Bruay) « Omnifit-Arc2f » (Bruay)

« Alloclassic-Armor » (Lille)« Alloclassic-Armor » (Lille)

« Alloclassic-CSF » (Lonjumeau)« Alloclassic-CSF » (Lonjumeau)

493 1ary THA in 388 patients 493 1ary THA in 388 patients with non traumatic AVNwith non traumatic AVN

8 teams


Aim of the studyAim of the study

To compare THA outcome between To compare THA outcome between the AVN group and the cohort of the AVN group and the cohort of 1ary THA performed for all other 1ary THA performed for all other diagnosis in less than 50 years old diagnosis in less than 50 years old and active patients, focusing on :and active patients, focusing on :

demographic datademographic data clinical evaluationclinical evaluation complications (dislocation)complications (dislocation) and 10 year survivorshipsand 10 year survivorships

Material &Material &methodsmethods

THA in < 50-y & active AVN patientsTHA in < 50-y & active AVN patients


1 all cemented « C-Kerboull »

1 « Hybrid » « Ostéal-Cerafit »

Material - implantsMaterial - implants

(45 hips, 9.1%) (31 hips, 6.3%)(31 hips, 6.3%)


4 cementless HA-coated : « Symbios » « ABG », « Corail » & « Omnifit-Arc2f »

(374 hips, 75,6%)


2 cementless non HA-coated

Alloclassic-SL

& CSF ring

or Armor cup

(43 hips, 9%)

417 Cementless 1ary THAs 417 Cementless 1ary THAs ((84,6% of the AVN hips)84,6% of the AVN hips)


Material – Bearings, 9 couplesMaterial – Bearings, 9 couples22,2 28

(68%)32 total

Ml-PE 51 31 10 92

Al-PE - 214 24 238

Zr-PE - 30 - 30

Al-Al - 29 75 104

Ml-Ml - 29 - 29

total 51 333 109 493

Hard-Hard-softsoft

73%73%

Hard-hardHard-hard

27%27%

1.1. Al-PE 28 (43%)Al-PE 28 (43%)

2.2. Al-Al 32 (15,2%)Al-Al 32 (15,2%)

+/- Ceramic +/- Ceramic in 75,4% in 75,4%


Couple

Série

M-PE 22

M-PE 28

M-PE

32A-PE

28

A-PE

32

Zr-PE

28

Al-Al

28Al-Al

32

MoM

28 total

1. CK 45 - - - - - - - 45

2. Osteal Cerafit

- - - - - - - 31 - 31

3.

Symbios

- 4 - 88 24 - - - - 116

4. ABG 6 24 - - - 26 22 - - 78

5. ARTRO

- - - 34 - - 2 - - 36

6.Omnifit

Arc2f

- 3 10 78 - 4 5 44 - 144

7. SL Armor

- - - - - - - - 19 19

8. SL

CSF

- - - 14 - - - - 10 24

total 51 31 10 214 24 30 29 75 29 493

bearings, 3 homogeneous seriesbearings, 3 homogeneous series


DemographicsDemographics388 patients388 patients


Mean age : Mean age : AVN, 40.4 years AVN, 40.4 years // 41.941.9

4041 42,746

3940,5 43 43,5

3941 41

43,537

41 39,646

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Others


Charnley B patients : Charnley B patients : 31.4% 31.4% // 32%32%

71,5

34

46,540

15

22,7

50 49

2218,617,6

9

31

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Bilateral THA : Bilateral THA : 27% 27% // 15.2% 15.2% (p=0,45)(p=0,45)

28,631,8

10,710,524,7

15,6

34,5

3,7

16,112

33,3

14,1 18,7

31,226,3

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Others


6

0,34

2,5

1,3

4,8

0,96

6,2

1,77

14,5

1

6,7

0,77

7

4,3

18

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Others

Sex ratio M/F : Sex ratio M/F : 5.9/15.9/1 / / 0.94/1 0.94/1 ((p= .0001p= .0001))


Activity D4&5 : Activity D4&5 : 65.5% 65.5% // 52% 52% ((p= .0001p= .0001))

34,339,5

8980

51,650,1 46

5865

90

33

8775

68,5

50

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Others

ResultsResults493 1ary THA493 1ary THA



Average FU : Average FU : 7.7years7.7years / / 8 years8 years

14,2

8,6

4

6,8

12

6,8 6,4

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16,6

13,6

8,17,9

4,23,11

6,77

11,912,5

7,57,9

6,36,17,67,5

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AVNOthers


17,517,1 17,317,3 1717 17,517,3 17,717,4 17,917,8 17,317,1 17,217,2

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Others

Clinical resultsClinical resultsPMA Score : Pre-op., PMA Score : Pre-op., 9.15 pts9.15 pts / / 9.699.69 : Post-op.,: Post-op.,17.47pts17.47pts / / 17.2517.25


Radiographic resultsRadiographic resultsWorrying X-Ray : Worrying X-Ray : 8.5%8.5%//10.2% 10.2% (p= .35)(p= .35)

2218,8

9,7

12,8

2,62,2

4

15

8,3

15,5

13

8

0 0

4,23,8

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Worrying X-Ray / Worrying X-Ray / average FUaverage FU2218,8

14,2

9,7

12,8

8

2,62,2

4 4

15

6,88,3

15,5

1213

87,7

0 0

6,24,23,8

7,5

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Others

FU in years


Sedel D in Sedel D in 3%3% vs vs 4.6%4.6% (p= .21)(p= .21)

6,6

5,3

3,2

1

4

7

0

3,4

0

3,3

4,2

3,5

0

10

0

7,7

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0 0

3,2

1,7

0,86

2,2

0

1,8

0

2,4

9

7

0 0

2

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ComplicationsComplicationsDislocation : Dislocation : 3.45%3.45% vs vs 2.18%2.18% (p=.21)(p=.21)


6,7

11,2

0

5,26

7,4 7,78

1110,7

5,5

8,8

0 0

16,6

7,7

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Revision : Revision : 6.5%6.5% vs vs 8.3%8.3% (p=.28)(p=.28)


0 0 0 014,3

0 0

11

0 0

62

10

0 0

25

0

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Others

% rev. for disloc.: % rev. for disloc.: 22%22%//2.8% 2.8% (p=.0048)(p=.0048)


0 0 0 014,3

0 0

11

0 0 0 0

25

0

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% rev. for disloc. – series 6 : no % rev. for disloc. – series 6 : no longer significant ; longer significant ; 8.3%8.3%//1.6% 1.6% (p=.38)(p=.38)


SurvivorshipsSurvivorships10-years, Revision for any reason10-years, Revision for any reason

94,9 100 96,6 97,3 97 94

75,4

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cted hyb cementless HA+ HA-cted hyb cementless HA+ HA-

dislocationsdislocations


10-years, Revision for any reason10-years, Revision for any reason94,995,6 10090,4 96,696,197,390,9 9795 9493,2

75,483,4

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AVNTHA<50y


dislocationsdislocations


10-years, Rev. for aseptic loosening10-years, Rev. for aseptic loosening

97,3 100 98,4 100 100 97,8 100

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10-years, Rev. for aseptic loosening10-years, Rev. for aseptic loosening97,396,6 100

92,398,498,3 100100 10099 97,898,9 100100

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THA<50y



10-years, stem rev., aseptic loosening10-years, stem rev., aseptic loosening

97,3 100 98,4 100 100 100 100

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AVN

cemented cementless HA+ HA-cemented cementless HA+ HA-


10-years, stem rev., aseptic loosening10-years, stem rev., aseptic loosening97,397,6 100

93,998,498,6 100100 10099 100100 100100

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THA<50y

cemented cementless HA+ HA-cemented cementless HA+ HA-


10-years, cup rev., aseptic loosening10-years, cup rev., aseptic loosening100 100 100 100 100 97,7 100

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cted HA- cementless HA+ HA-cted HA- cementless HA+ HA-


10-years, cup rev., aseptic loosening10-years, cup rev., aseptic loosening10099 10096,1 10099,7 100100 100100 97,798,8 100100

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THA<50y

cted HA- cementless HA+ HA-cted HA- cementless HA+ HA-


10-years, all bearings’ survival10-years, all bearings’ survival97,6 100 100 100 97 97,8 100

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-PE

22,

2

A-A

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(1

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A-P

E 2

8

A-P

E &

A-A

Met

asu

l

AVN


10-years, all bearings’ survival10-years, all bearings’ survival97,698,5 10098,6 10099,3 10096 9799 97,896,3 100100

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THA<50y


10-years, 265 bearings’ survival10-years, 265 bearings’ survival97,6 100 97

74,5

100 100

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-PE

22

,2

A-P

E 3

2&

28

A-P

E 2

8

A-P

E 2

8

A-A

32

Me

tas

ul

Hard-soft Hard-hardHard-soft Hard-hard

45 45 112 34 14 112 34 14 3131 2929


Bearings, Bearings, ONAONA vs vs all < 50 THAall < 50 THA

97,698,5 10099,3 9799

74,578,6

10098,6 100100

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22

,2

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2&

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A-P

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Me

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11 Alumina head 1 Alumina head 1 fracture = 2 fracture = 2 (2,2/1000)(2,2/1000)

Synthesis Synthesis of Resultsof Results



AVNAVN THA vsTHA vs othersothersDemographic data Demographic data

86% male patients86% male patients Sex ratio, Sex ratio, 6M/1F6M/1F

vs vs 1M/1F1M/1F (47% hip dysplasia) (47% hip dysplasia) S+++ (p=.0001)S+++ (p=.0001)

65,5% with activity level D4&565,5% with activity level D4&5 higher than in (any) other group of higher than in (any) other group of

< 50-years old patients < 50-years old patients S+++ (52% D4&5, p=.0001) S+++ (52% D4&5, p=.0001)


AVNAVN THA vsTHA vs othersothersClinical resultsClinical results

Same or even slightly betterSame or even slightly better

Clinical score (PMA > 17.3 points)Clinical score (PMA > 17.3 points) X-Ray alterations (X-Ray alterations (8.5%/8.5%/10.5%, 10.5%, p=.35)p=.35) Overall evaluation (Sedel D, Overall evaluation (Sedel D, 3%/3%/4,6%)4,6%) Revision rate (Revision rate (6.5%/6.5%/8.3%8.3%, p=.28), p=.28) No specific correlation with AVN etiologyNo specific correlation with AVN etiology


AVNAVN THA vsTHA vs othersothersComplicationsComplications

Dislocation rate non signif. higherDislocation rate non signif. higher 3.45%3.45% vs vs 2.18 2.18 (p=.12)(p=.12) PL ap., 5,6% vs A&AL, 0.48%PL ap., 5,6% vs A&AL, 0.48% (p=.004),no (p=.004),no

longer after exclusion of series 6 (p=.23)longer after exclusion of series 6 (p=.23)Revision rate for dislocationRevision rate for dislocation S+ higher (S+ higher (22%22% vs vs 2,8%,2,8%, p=.0048), but no p=.0048), but no

longer after exclusion of series 6 (p=.38)longer after exclusion of series 6 (p=.38)


AVNAVN THA vsTHA vs othersothers10-year survivorships10-year survivorships

Same or slightly better forSame or slightly better for

THA revision for any reasonTHA revision for any reason THA revision for aseptic loosening THA revision for aseptic loosening Stem or cup revision for aseptic Stem or cup revision for aseptic

looseningloosening Bearing revision for mechanical failureBearing revision for mechanical failure


ConclusionsConclusions


Our comparative study of 1ary THA Our comparative study of 1ary THA (85% ctless)(85% ctless) in non-traumatic AVN in non-traumatic AVN does not support previous negative does not support previous negative considerations in the literatureconsiderations in the literature

If 1ary THA in AVN coud have If 1ary THA in AVN coud have showed poorer outcome, this is only showed poorer outcome, this is only due to the high prevalance of yound due to the high prevalance of yound and very active male patients who and very active male patients who require stronger implant fixation and require stronger implant fixation and better wear resistant bearings better wear resistant bearings (27% (27% hard-hard, 100% survival/10y)hard-hard, 100% survival/10y)

Conclusion Conclusion


In this group of young and active In this group of young and active patients, even at ten year FU, patients, even at ten year FU, survival analysis are unable (yet ?) survival analysis are unable (yet ?) to show significant differences to show significant differences between bearing surfaces, between bearing surfaces, but still support the eventuality of but still support the eventuality of some possible advantages of « hard-some possible advantages of « hard-on-hard » bearings on 1ary THA on-hard » bearings on 1ary THA outcome and longevityoutcome and longevity

Longer FU will be necessary …Longer FU will be necessary …

Conclusion Conclusion


No benefit with 28mm Zirconia No benefit with 28mm Zirconia heads on conventional PEheads on conventional PE

For use of bulk alumina liner, For use of bulk alumina liner, fixation of cementless acetabular fixation of cementless acetabular component must improvecomponent must improve

Post surgery, long-term caution in Post surgery, long-term caution in alcoholic addicted patients operated alcoholic addicted patients operated on with 28mm bearings on with 28mm bearings viavia postero- postero-lateral approach lateral approach

Final advices Final advices


Thank youThank you1. L Kerboull1. L Kerboull, M Hamadouche, JP Courpied et M Kerboull , M Hamadouche, JP Courpied et M Kerboull 2. 2. P BizotP Bizot, F Gaucher, L Sedel, F Gaucher, L Sedel 3. 3. C PelegriC Pelegri, X Flecher, JM Aubaniac, JN , X Flecher, JM Aubaniac, JN Argenson 4. Argenson 4. C NourissatC Nourissat, G , G Asencio, D Berteaux et le groupe ABG 5. Asencio, D Berteaux et le groupe ABG 5. JP VidalainJP Vidalain et le groupe ARTRO et le groupe ARTRO 6. 6. JA EpinetteJA Epinette 7. 7. H H MigaudMigaud, A Jobin, P Laffargue, J Girard , A Jobin, P Laffargue, J Girard 8. 8. C DelaunayC Delaunay et AI Kapandji et AI Kapandji

primary thas for hip osteonecrosis in < 50 years old and active patients c delaunay, h. migaud...

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