RESURFACING: quando e come la revisione. · 6 mm of the lateral offset, so the resurfacing...
Transcript of RESURFACING: quando e come la revisione. · 6 mm of the lateral offset, so the resurfacing...
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RESURFACING:RESURFACING:quando e come la revisione.quando e come la revisione.
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J Shoulder Elbow Surg (2004) 13 (3), 266-271
Cementless surface replacement arthroplasty(Copeland CSRA) for osteoarthritis of the
shoulderOfer Levy, Stephen A. Copeland, Reading, United Kingdom
Radiographically, one humeral implant and three glenoid implants had evidence of
loosening. Four revisions were performed in the total shoulder replacement group.
No revision surgery was needed in the hemiarthroplasty group
Between 1986 and 1997, 79 CSRAs
Revision rate TSA : 9.5 %Revision rate HHR : 0 %
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Cementless Humeral ResurfacingArthroplasty in Active Patients Less
Than Fifty‐five Years of Age
DS Bailie, PJ Llinas, TS EllenbeckerJ Bone Joint Surg [Am] January 2008; 90-A (1): 110-17
“Radiographic evaluation did not demonstrate any case of
obvious loosening of the implant at any time-period.”
ONE shoulder ONE shoulder was converted to a stemmed total shoulder arthroplasty at twenty-four
months because of pain, but the implant was not loose at the revision.
Revision rate 2.8 %
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“To date, no implant revisions have been
necessary.”
AverageAverage FollowFollow--upup3 3 yearsyears
Treatment of Osteonecrosis of the HumeralHead with Cementless SurfaceReplacement Arthroplasty
P Raiss, P Kasten, F Baumann, M Moser, M Rickert, M LoewJ Bone Joint Surg [Am] February 2009; 91-A (2): 340-9
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Sperling JW, Cofield RH, Rowland CMJ Shoulder Elbow Surg 13 (6): 604-613, 2004
Revision rate HHR to TSA forpainful glenoid arthrosis
15.3 %15.3 %Mean time: 8.6 ys
Minimum fifteen-year follow-up of Neerhemiarthroplasty and total shoulder arthroplastyin patients aged fifty years or younger
GlenoidGlenoid erosionerosionwas present in 38 of 53 HHRwas present in 38 of 53 HHR
72%72%
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“…in comparison with HHR, TSR for the treatment of primary glenohumeral osteoarthritis significantly improves pain relief, range of motion, and satisfaction and has a significantly lower rate of revision surgery.”
Radnay CS, Setter KJ, Chambers L, Levine WN, Bigliani LU, Ahmad CSJ Shoulder Elbow Surg. 16 (4): 396-402, 2007
Revision rate HHR to TSA forpainful glenoid arthrosis
8.1 %8.1 %
Total shoulder replacement compared with humeral head replacement for the treatment of primary of glenohumeralosteoarthritis: a systemic review
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DL Burgess, MS McGrath, PM Bonutti, DR Marker, RE Delanois, MA MontJ Bone Joint Surg [Am] May 2009; 91-A (5): 1228-1238
Current Concepts ReviewShoulder Resurfacing
“The revision rates of humeral resurfacing prostheses appear to be comparable with, or better than, those of stemmed prostheses.”
1) loosening of humeral and/or glenoid component2) glenoid erosion
3) infection 4) fracture
5) improper implant size
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QuandoQuando……??SETTEMBRE 2006 – AGOSTO 2009
3131 Protesi di RivestimentoProtesi di Rivestimento
3 ARTHROSURFACE 3 ARTHROSURFACE
19 Artropatia gleno-omerale primitiva concentrica8 Artropatia eccentrica secondaria a CTA2 Artropatia post-traumatica4 Necrosi asettica1 Artropatia di Charcot
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4 REVISIONI4 REVISIONI1 instabilit1 instabilitàà anteroantero--superioresuperiore per insufficienza di cuffiaper insufficienza di cuffia3 usura glenoidea3 usura glenoidea
11.7 % di revisioni entro il primo anno dall’impianto !
1 revisione di protesi dolorosa (usura glenoidea) eseguita in altra sede+
ARTHROSURFACEARTHROSURFACE (Follow-up > 12 mesi) 3/3 risultati eccellenti3/3 risultati eccellenti
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““Resurfacing of the Resurfacing of the humerushumerus increased the humeral offset by a mean of increased the humeral offset by a mean of 5 mm (from 23 to 28 mm) but there was a mean preoperative erosio5 mm (from 23 to 28 mm) but there was a mean preoperative erosion of n of 6 mm of the lateral offset, so the resurfacing reestablished the6 mm of the lateral offset, so the resurfacing reestablished the anatomic anatomic
offset that had been lost as a result of erosion.offset that had been lost as a result of erosion.””
Thomas SR et al.J Shoulder Elbow Surg 2005;14:186-192
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Overstuffing
A AB B
A + B A + B
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Orientamento della componenteOrientamento della componenteseguendo il collo anatomicoseguendo il collo anatomico
Posizionamento in VAROPosizionamento in VARO
Posizionamento in VALGOPosizionamento in VALGO
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Corretto posizionamento componenteCorretto posizionamento componente• Corretta esposizione• Rimozione osteofiti• Corretto posizionamento del filo guida (fino
alla corticale contro-laterale)• Allineamento della maschera con l’inserzione della cuffia postero-superiore
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ARTHROSURFACEARTHROSURFACE®®
Minor possibilità di “over-stuffing” per il migliore allineamento con la superficie articolare
PartialPartialResurfacingResurfacing
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Therefore, it is necessary for us to do the minimum to get the maximum, and whatever we do we must have a fall-back procedure and it must be easily revisable.
Therefore, it is necessary for us to do the minimum to get the maximum, and whatever we do we must have a fall-back procedure and it must be easily revisableeasily revisable.
Stephen CopelandJ Bone Joint Surg [Am] 2006; 88-A (4): 1232-44
*The Robert Jones Lecture presented at the Annual Meeting of the British Orthopaedic Association, Birmingham, United Kingdom, September 21, 2005.
The Continuing Developmentof Shoulder Replacement:“Reaching the Surface”*
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♀ 61 anni
Arto destro dominante
Casalinga
Lunga storia di dolore (anche a riposo) della spalla destra
ESAME CLINICOESAME CLINICO
Limitazione articolare su tutti i piani
Elevazione anteriore 150°; ER con braccio “at side”
10° e 50° a 90° di abduzione; IR a livello del sacro
Constant score 42 / 100
Spalla controlaterale 83 / 100
Samilson – Prieto stadio 2
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RMN RMN multiplanaremultiplanare
Buon trofismo muscolare della cuffia dei rotatori (anche del sottoscapolare sulle sezioni coronali), non segni di rottura
Normale versione glenoidea
Tipo A2 sec. Walch
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HumeralHumeral head head resurfacingresurfacingMaggio 2007
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8 MESI POST8 MESI POST--OPOP- Dolore progressivamente ingravescente
- Grave limitazione del ROM attivo: elevazione anteriore 90° ed ER “at side”
10° (associata ad estremo discomfort)
- Normale conta leucocitaria e piastrinica; PCR e VES nella norma;
Fibrinogeno nella norma
- Paziente non soddisfatta
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Revisione Revisione HumeralHumeral Head Head ResurfacingResurfacing con con protesi cefalica protesi cefalica ““stemlessstemless””
Febbraio 2008
Residua difetto osseo centrale della testa omerale
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2006 2007 2008
Progressiva usura glenoideaProgressiva usura glenoidea
ARTROLISI ARTROSCOPICA ARTROLISI ARTROSCOPICA per dolore e rigiditper dolore e rigiditàà
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Blocco spaziatore con cemento antibiotato
(Vancomicina + Amikacina)
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INSTABILITINSTABILITÁÁ ANTEROANTERO--SUPERIORESUPERIOREInsufficienza del sottoscapolare a 11 mesi
Sistemi modulari di IV generazioneSistemi modulari di IV generazione
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CONCLUSIONICONCLUSIONI--11ResurfacingResurfacing……quandoquando la revisione?la revisione?
Mobilizzazione settica ed asettica Mobilizzazione settica ed asettica
InstabilitInstabilitàà
Protesi dolorosa Protesi dolorosa
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Mobilizzazione setticaMobilizzazione setticaNostra preferenza: Nostra preferenza: ““TwoTwo--stagestage revisionrevision””
I STAGEI STAGE espianto + blocco spaziatore con cemento antibiotato + terapia antibiotica (8 settimane)
II STAGEII STAGE a normalizzazione degli indici di flogosi,reimpianto (anatomica o inversa)
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InstabilitInstabilitààPazienti giovani
TRANSFER TRANSFER (risultato incerto)
INVERSAINVERSA
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Protesi dolorosaProtesi dolorosaOverstuffingOverstuffing ed usura glenoideaed usura glenoidea
• Revisione con protesi “tradizionale” ( con e senza stelo )
• Protesi di glena
• Resurfacing biologico
• Protesi inversa
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CONCLUSIONICONCLUSIONI--22• Impianto “non facile” (varo,valgo, over-size)
• Corretto “bilanciamento” (release) come nelle
protesi tradizionali
• Evitare l’overstuffing (usura glenoidea, dolore,
stress sulla cuffia)
• Resurfacing TSA: tecnicamente più difficile, ma
potrebbe fornire risultati migliori
• Necessità di nuovi design