Acetabular Revision Surgery The Story of Three Revolutions.

Acetabular Revision Acetabular Revision

SurgerySurgery

The Story ofThe Story ofThree RevolutionsThree Revolutions

William H Harris, MDWilliam H Harris, MDThe Alan Gerry ProfessorThe Alan Gerry Professor

of Orthopædic Surgeryof Orthopædic Surgery

Harvard Medical SchoolHarvard Medical Schoolandand

Massachusetts General HospitalMassachusetts General Hospital

Three Key Problems in Three Key Problems in Acetabular RevisionsAcetabular Revisions

1.1. FixationFixation

2.2. LysisLysis

3.3. DislocationDislocation

Revolution 1Revolution 1

Obtaining FixationObtaining Fixation

SolutionSolution

The Harris-Galante design of The Harris-Galante design of socketsocket

A hemispherical porous socket, either A hemispherical porous socket, either fixed with screws orfixed with screws orpress fitpress fit

That design or its look-a-like is That design or its look-a-like is

now widely accepted now widely accepted

worldwide,and has been worldwide,and has been

copied by nearly every copied by nearly every

implant manufacturerimplant manufacturer

Additional Unique concepts Additional Unique concepts that we introduced with it that we introduced with it

The High Hip CenterThe High Hip Center

The Jumbo CupThe Jumbo Cup

• Cemented Acetabular Revisions Cemented Acetabular Revisions

in general did not have a good in general did not have a good

track record,especially in cases track record,especially in cases

with marked loss of bone stock.with marked loss of bone stock.

MGH SeriesMGH Series

•From 188 consecutive From 188 consecutive revisions by one surgeon, revisions by one surgeon, 122 had 10 year plus data, 122 had 10 year plus data, average 12.5 yearsaverage 12.5 years

•Average ageAverage age 5454•58 58 High Hip CentersHigh Hip Centers•13 13 Jumbo cups Jumbo cups (65 mm or greater)(65 mm or greater)•Femoral head penetration Femoral head penetration 0.11 0.11 mm/yearmm/year

Rerevised for ASL 5/ 188 (2.6%) 5/ 122 (4%)

Pelvic lysis (plain films) 9.6%

Rush-Presbyterian SeriesRush-Presbyterian Series

• 109 hips at 10.5 years109 hips at 10.5 years

• Kaplan-Meier for ASL @ 11.5 yearsKaplan-Meier for ASL @ 11.5 years

98%98%

• Kaplan-Meier @ 11.5 years for revision Kaplan-Meier @ 11.5 years for revision

for any cause plus ASL, not revisedfor any cause plus ASL, not revised 84%84%

Iowa SeriesIowa Series

• 61 hips followed to death or 61 hips followed to death or

to 13-15 years to 13-15 years

5%5%

00

• Pelvic lysis (plain films)Pelvic lysis (plain films)

• Loose or revised for being looseLoose or revised for being loose

SummarySummary

358 Acetabular revisions with 292@ 7-15 years

Rerevised for ASL 5/292 (2%) Pelvic lysis 9%

Thus, the first revolution has

taken place. The fixation issue

is solved.

Major players in the Major players in the management of large bone loss management of large bone loss in acetabular revision THR arein acetabular revision THR are

1) 1) The Jumbo CupThe Jumbo Cup

2) 2) The High Hip CenterThe High Hip Center

Advantages of a Jumbo SocketAdvantages of a Jumbo Socket

• Large contact area with host boneLarge contact area with host bone

• Decreased load per unit area at Decreased load per unit area at interfaceinterface

• Thick polyethyleneThick polyethylene

• Restores hip center if high and if Restores hip center if high and if protrusioprotrusio

Jumbo Cup SeriesJumbo Cup Series

• N=N= 24 consecutive hips (24 pts)24 consecutive hips (24 pts)

• Shell Diameter ≥ 66 mm (66-74)Shell Diameter ≥ 66 mm (66-74)

• Minimum follow-up of 5 years. Minimum follow-up of 5 years. Average follow up 7 yearsAverage follow up 7 years

Study GroupStudy Group

ResultsResults

0 0 revisionsrevisions

0 0 looseloose

0 0 continuous RLLcontinuous RLL

One with pelvic lysisOne with pelvic lysis around screwaround screw

deceaseddeceased

Acetabular ComponentsAcetabular Components

Cementless sockets Cementless sockets

require rigid fixation in require rigid fixation in

intimate apposition to intimate apposition to intactintact

viableviable hosthost bonebone . . . . . . . .

If the only If the only intact viable intact viable

hosthost bonebone is up high is up high

. . . .. . . .

Do a high hip center!Do a high hip center!

LateralLateral hip centers are hip centers are

bad, but nearly all high hip bad, but nearly all high hip

centers are just centers are just highhigh, not , not

laterallateral

Prerequisites for successful Prerequisites for successful high hip center :high hip center :

• Restore leg lengths with long Restore leg lengths with long neck or calcar femoral prosthesisneck or calcar femoral prosthesis

• Restore abductor tension by Restore abductor tension by advancing the trochanteradvancing the trochanter

• Eliminate any impingement in Eliminate any impingement in normal ROMnormal ROM

High Hip Center SeriesHigh Hip Center Series

• N=N= 46 consecutive hips (44 pts)46 consecutive hips (44 pts)

• Post-reconstruction hip centerPost-reconstruction hip center≥ 35 mm above interteardrop line ≥ 35 mm above interteardrop line

• Minimum follow-up of 8 yearsMinimum follow-up of 8 years

Study GroupStudy Group

ResultsResults

• No shell revisionsNo shell revisions

• One loose shell (4%)One loose shell (4%)

• Two with pelvic lysis Two with pelvic lysis One around screwOne around screw One with loose shellOne with loose shell

Acetabular ComponentsAcetabular Components

Fixation of the component Fixation of the component

in Acetabular in Acetabular

reconstruction in revision reconstruction in revision

surgery is now vastly surgery is now vastly

improved.improved.

Revolution Number 1Revolution Number 1

Bulk allografts are nowBulk allografts are nowvery rare.very rare.

Impaction grafting is a rare, Impaction grafting is a rare, but helpful operation.but helpful operation.

Pelvic discontinuity and Pelvic discontinuity and extremely massive bone loss extremely massive bone loss cases require other techniques.cases require other techniques.

CagesCages

Not needed very oftenNot needed very often

• Can be very valuableCan be very valuable

• Less successful than the Less successful than the simpler techniquessimpler techniques


Eliminating LysisEliminating Lysis

Ceramic on Ceramic : Ceramic on Ceramic : AdvantagesAdvantages

• Long duration human useLong duration human use• Low lysis incidenceLow lysis incidence• Relatively inert materialRelatively inert material


Metal on Metal : Metal on Metal : AdvantagesAdvantages

Highly Crosslinked Highly Crosslinked Polyethylene : AdvantagesPolyethylene : Advantages


Highly Crosslinked Polyethylene :Highly Crosslinked Polyethylene :Additional AdvantagesAdditional Advantages

• CostCost• Impingement is benignImpingement is benign• Tolerates socket malpositionTolerates socket malposition• AdaptableAdaptable• ForgivingForgiving• Not brittleNot brittle• Not produce metalosisNot produce metalosis• No remote metal depositsNo remote metal deposits

10 year follow-up of the low 10 year follow-up of the low friction arthroplasty of the hip friction arthroplasty of the hip using alumina-ceramic and using alumina-ceramic and crosslinked polyethylene in crosslinked polyethylene in 14 hips14 hips

Wroblewski, Siney, Fleming ‘99 Wroblewski, Siney, Fleming ‘99

After the initial bedding in period, After the initial bedding in period, the subsequent calculated the subsequent calculated annual average wear rate was annual average wear rate was 20 microns 20 microns per yearper year

Wroblewski, Siney, Fleming ‘00Wroblewski, Siney, Fleming ‘00

This later rate was four times This later rate was four times less than the rate of wear of less than the rate of wear of stainless steel hips on ultra high stainless steel hips on ultra high molecular weight polyethylene molecular weight polyethylene in the contra- lateral hips in 4in the contra- lateral hips in 4of these patients.of these patients.

The initial penetration rate The initial penetration rate during the first 2 years was 0.15 during the first 2 years was 0.15 mm per year and thereafter was mm per year and thereafter was 0.06 mm per year, against a0.06 mm per year, against a28-mm chrome cobalt head.28-mm chrome cobalt head.

Oonishi Oonishi && Coworkers ‘98 Coworkers ‘98

•Charnley (1975)

•No wear

•No osteolysis

•Charnley 9yr PO

•2mm wear

•Charnley 24yr PO

•4.5mm wear

•Pta 4yr PO

•No wear

•Pta 19yr PO

•No wear

•(Ref. C.W.C. 65 Yrs)

85 of the 103 hips had 85 of the 103 hips had nono detectable weardetectable wear at an at an average follow-up of 15.5 average follow-up of 15.5 years.years.

In total, 145 total hip In total, 145 total hip replacements in patients with replacements in patients with highly crosslinked polyethylene highly crosslinked polyethylene were followed 10-22 years. The were followed 10-22 years. The data on wear are outstanding.data on wear are outstanding.

Hip Simulator Wear Test Results

0

200

400

600

800

1000

1200

1400

1600

1800

2000

0 5 10 15 20 25 30

Cycles (millions)

To

tal W

ea

r (c

ub

ic m

m) Conventional

Polyethylene 32 mm

22 mm

Cross Linked Polyethylene - 22 mm and 32 mm

There is There is nono detectable detectable wearwear

Gravimetrically Gravimetrically - - no detectable wearno detectable wear

CMM machine CMM machine -- no detectable wearno detectable wear

Millipore filter the serum - Millipore filter the serum - nono particlesparticles

The machine marks are still present after The machine marks are still present after 30 million cycles30 million cycles

Alumina Third Body Particles

E-beam treated and conventional E-beam treated and conventional polyethylene liners subjected to polyethylene liners subjected to

0.15mg/cc Alumina particles continually 0.15mg/cc Alumina particles continually circulating through test chamber. circulating through test chamber.

Average Weight Change of Conventional and Durasul Inter-Op Components in the Presence of Alumina Third Body

Debris

-700-650-600-550-500-450-400-350-300-250-200-150-100-50

050

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5Total Cycles (Millions)

Wei

ght

Cha

nge

(mg)

Durasul Motion Cups Conventional Motion Cups

No Particles 0.15mg/cc Aluminaparticles added

Clinical study-RSAClinical study-RSA

RSA data available at follow upRSA data available at follow up(08 2002)(08 2002)

1 year - 561 year - 56crosslink = 27 / control = 29crosslink = 27 / control = 29

2 year - 43crosslink = 19 / control = 24

ConclusionConclusionOn the standing films, there is no change in the superior penetration into the crosslinked polyethylene between 1 and 2 years. Using this interval, the highly crosslinked polyethylene has significantly less penetration, p<0.03.

0 6 12 18 24

months

0

0,05

0,1

0,15mm

"cross-linked"

control


Eliminating DislocationEliminating Dislocation

SolutionSolution The Big Head The Big Head

Zimmer 38mm and 46 mm Control and Longevity Acetabular CupsAverage Weight Change-140

-120

-100

-80

-60

-40

-20

0

20

40

0.00 1.00 2.00 3.00 4.00 5.00

Total Cycles (Millions)

Wei

ght

Ch

ange

(m

g)

38 mm Control 38 mm Longevity

46 mm Control 46 mm Longevity

Because E-beam highly crosslinked Because E-beam highly crosslinked

poly has such low wear and poly has such low wear and

particularly because wear particularly because wear is is

independent of headindependent of head size,size, the issue of the issue of

dislocation can be addressed directly dislocation can be addressed directly

with larger head sizes.with larger head sizes.

Amstutz has shown the Amstutz has shown the

marked advantages of using marked advantages of using

large head diameters in cases large head diameters in cases

of recurrent dislocation or high of recurrent dislocation or high

risk for recurrent dislocationrisk for recurrent dislocation

Consider the advantages of larger Consider the advantages of larger femoral head sizes in terms of:femoral head sizes in terms of:

•ROMROM•ImpingementImpingement•StabilityStability•ADLADL•Dislocation rateDislocation rate

• Recall that Charnley’s first THR had a Recall that Charnley’s first THR had a head size of 41.5 mmhead size of 41.5 mm

• The plastics available to him 50 years The plastics available to him 50 years ago could not withstand that head sizeago could not withstand that head size

• He was forced to drop down He was forced to drop down progressively until he settled on progressively until he settled on 22.25 mm22.25 mm

Neck Length Flexion IR @ 90 Flexion ER @ 0 flexion

-3.5 104 17 70

0 105 19 70

3.5 107 22 70

7 98 8 58

10.5 98 9 59


-3.5 102 16 63

0 104 18 64

3.5 106 18 64

7 99 9 51

10.5 99 9 53

Versys®Stem Natural®Stem

Type of Impingement28mm Femoral Head

0º

FemoralAnteversion

30º

15º


-3.5 109 33 55

0 114 34 56

3.5 116 37 56

7 108 23 44

10.5 108 24 44


-3.5 111 31 45

0 115 34 45

3.5 117 36 48

7 112 26 35

10.5 113 25 35


-3.5 112 37 45

0 117 42 45

3.5 120 45 43

7 111 38 31

10.5 111 38 31


-3.5 116 38 34

0 121 43 35

3.5 123 45 38

7 118 39 25

10.5 117 39 24

Component on Component

Component on Bone

Bone on Bone


-8 102 17 70

-4 106 20 73

0 108 23 73

4 110 25 73

8 113 27 73


-8 103 19 69

-4 105 22 70

0 107 24 71

4 110 26 73

8 112 28 74

Versys®Stem Natural®Stem

Type of Impingement38mm Femoral Head

0º

FemoralAnteversion

30º

15º


-8 109 33 57

-4 112 38 56

0 118 40 56

4 119 42 56

8 121 44 58


-8 110 29 57

-4 116 35 57

0 118 38 57

4 120 41 56

8 123 42 58


-8 111 36 47

-4 114 41 48

0 120 45 47

4 122 48 46

8 123 50 47


-8 115 35 50

-4 119 41 48

0 124 47 47

4 125 48 48

8 127 51 49

Component on Component

Component on Bone

Bone on Bone

Large heads eliminate Large heads eliminate component-component component-component contact .contact .

• Only limit to ROM is Only limit to ROM is patient’s bony anatomy .patient’s bony anatomy .

In ShortIn Short

Acetabular revision surgery Acetabular revision surgery has seen one Revolution and has seen one Revolution and two more are immediately two more are immediately availableavailable

We We havehave solved the solved the

fixation problem, using the fixation problem, using the

hemispherical porous socket hemispherical porous socket

fixed with pressfit or screws.fixed with pressfit or screws.

It is highly likely that we It is highly likely that we

have made a major advance in have made a major advance in

the lysis issue by the electron-the lysis issue by the electron-

beam irradiated, highly beam irradiated, highly

crosslinked, melted UHMWP.crosslinked, melted UHMWP.

Probable Revolution # 2Probable Revolution # 2

Probable Revolution # 3Probable Revolution # 3

• Because with E-beam highly Because with E-beam highly crosslinked poly, wear is crosslinked poly, wear is independent of head independent of head diameter,we can attack the diameter,we can attack the dislocation problem directly dislocation problem directly using much larger heads.using much larger heads.

Thank You

Acetabular Revision Surgery The Story of Three Revolutions.

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