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CURRENT STATUS OF TOTAL HIP SURGERYWHAT IS NEW???
ANTHONY S UNGER, MDWASHINGTON, DC
WHAT’S NEW
THA 2012
SURGICAL APPROACH
METAL ON METAL
SURFACE REPLACEMENT
STEMS
CUPS
BEARINGS
DVT PROPHYLAXIS
INFECTION WORK UP
SURGICAL APPROACH
THE DIRECT ANTERIOR APPROACH
DAA ADVANTAGES
PATIENT SUPINE—LL EQUALIZATION
LOWER DISLOCATION RATE
LESS INVASIVE ?
OBESE PATIENTS EASIER
LESS DVT??—LESS KINKING OF FEMORAL VEIN
DAA-TABLE-LESS ADVANTAGES
QUICKER, LESS SET UP
BETTER ASSESSMENT OF STABILITY
CHEAPER—NO TABLE COSTS
BETTER ABILITY TO EQUAL LL
DON’T NEED XRAY
Creatine Kinase Differences between Anterior and Posterior MIS THA
5.5X 1.4X 1.8X
DAA-TABLE-LESS
QUICKER RECOVERY, MORE BLOODLOSS??
BEREND ET AL, JBJS, 2009
DAA vs DL IMPROVED HARRIS HIP SCORE AND LOWER EXT ACTIVITY @ 6 WKS
HIGHER RATE OF D/C TO HOME
INCREASED BLOODLOSS(155CC VS 130 CC)?
DAA-TABLE-LESS
BETTER FUNCTIONAL SCORES
RESTREPO ET AL, J OF A, 2010
PROSPECTIVE FUNCTIONAL OUTCOMES OF DAA VERSUS DIRECT LATERAL
UP TO 2 YRS DAA HAD BETTER FUNCTION SCORES ON SHORT SF-36 AND WOMAC
METAL ON METAL
MOM WARNINGS
BRITISH ORTHOPAEDIC SOCIETY AND BRITISH HIP SOCIETY 2010
YRLY XRAY AND CLINICAL EVAL
METAL IONS, MARS/CT IN SYMPATOMATIC PTS
REPEAT TESTING FOR ELEVATED ION LEVELS(>7PPB)
ENDORSED BY US FDA, AAOS, AAHKS, HIP SOCIETY
METAL ON METAL
EFFECT OF ELEVATED METAL IONS NOT UNDERSTOOD
EFFECT OF FEMORAL HEAD SIZE ON ION LEVELS SHOW CONFLICTING RESULTS
CLINICAL TRIALS COMPARING MOM TO OTHER BEARINGS USING RANDOMISED CONTROLS LACKING
MALVIYA, A. ET AL, JBJS 92:1675, 2010
METAL ON METAL
PSEUDOTUMORS
MARS STUDY(METAL ARTIFACT REDUCTION MRI)
17/30(57%) IN PAINFUL MOM
17/28(61%) IN NON PAINFUL MOM
“COMMON IN WELL POSITIONED IMPLANTS”
HART, A. J. , JBJS 94:317, 2012
METAL ON METAL
PSEUDOTUMORS
ULTRASOUND- MOM VS MOP
42% IN MOM THA
25% IN MOM SRA
12% IN MOP
ION LEVELS DID NOT CORRELATE
WILLIAMS, D.H ET AL, JBJS 93:2164, 2011
AAOSMOM TECH UPDATE 2011
#1 WHAT ARE CLINICAL OTCOMES OF MOM THA VS OTHER BEARINGS??
PTS WITH MOM HAVE GREATER RISK OF REVISION
#2 WHAT ARE THE PT FACTORS THAT BEST PREDICT SUCCESS OF MOM?
LARGE HEAD IN MOM THA INCREASE REVISION
SMALL HEAD SIZE IN MOM SRA INCREASE REVISION
PTS OLDER THAN 65 HAVE HIGHER REVISON RATE
NO GENDER DIFFERENCES
MOMAAOS TECH UPDATE 2011
#3 WHAT IS PREVELANCE OF CLINICAL PROBLEMS WITH MOM THA COMPARED TO OTHER BEARINGS??
MALPOSITIONED IMPLANTS HAVE HIGHER FAILURE RATES AND ELEVATED IONS
CLINICAL SIGNIFICANCE OF ELEVATED IONS UNKNOWN
MOM HIP WORK UP
GET XRAYS, EXAMINE PT
LOOK FOR MECHANICAL FAILURE
KNOW RECALLS( ASR, DUROM)
LOOK FOR ABNORMAL ANTERVERSION OR HIGH ADB ANGLE
MEASURE IONS(>5-7 PPb)
REVISE IF PAINFUL
DO MARS MRI OR ULTRASOUND TO LOOK FOR PSEUDO TUMORS
SURFACE REPLACEMENT
HIP RSURFACING(SRA)
1.4-3.6 INCREASED REVISION RATE COMPARED TO THA
MCGRORY ET AL 2011
REVISION RATE 3.5% IN 29 STUDIES, 10625 SRAS
VAN DER WEEGEN ET AL, 2011
HIP RESURFACING (SRA)
AMSTUTZ ET AL 2010
10 YR SURVIVAL 88.6% IN 100 CONSECUTIVE SRA
NO FAILURE IN HEAD SIZE >46MM
TREACY ET AL 2011
10 YR SURVIVAL 95.5% IN 144 HIPS
98% SURVIVAL IN MALES
SRAAAOS TECH OVERVIEW 2009 #1 ARE REVSION RATES DIFFERENT FOR
SRA VS THA?
ANALYSIS OF 3 REGISTRIES –SRA>REVISION RATE THAN THA
#2 WHAT CHARACTERISTICS FOR PTS WITH SRA GIVE BEST OUTCOMES?
NO CONCLUSIONS
SRAAAOS TECH OVERVIEW 2009
#3 WHAT IS MORE EFFECTIVE TX SRA OR THA??
LIMITED DATA, NO CONCLUSIONS
#4 IS THERE EVIDENCE THAT EXPERIENCE IMPROVES OUTCOME??
LOW QUALITY STUDIES SUGGEST EXPERIENCE IMPROVES OUTCOMES
STEMS
THA-Stems
THA-STEMS
THA-Stem
CUPS
THA-Ceramics
THA-Ceramics
BEARINGS
Cross-linking and Free Radicals
C C C C CH H H H H
H H
CH
H * H
CH
H
C C CH H
H H H
C*
CH
H H
CH
H
CH
H
Cross-link
Irradiation forms free radicals and crosslinks Heating forms more crosslinks and eliminates free radicals
Free Radicals
This information is provided for internal use only and is not intended for general distribution or use. Product availability is subject to the regulatory or medical practices
that govern individual markets. Please contact your Stryker representative if you have any questions about the availability of Stryker products in your area.
Crosslinking Decreases Wear
Reference (7)
This information is provided for internal use only and is not intended for general distribution or use. Product availability is subject to the regulatory or medical practices
that govern individual markets. Please contact your Stryker representative if you have any questions about the availability of Stryker products in your area.
CROSS-LINKED POLY
WEAR RATE .003 VS .051 MM/YR
95% IMPROVEMENT
FU AT 6.8 YRS
MEN AS GOOD AS WOMEN
50 YR HIP???
Mc CALDAN ET AL JBJS, 2009
DVT PROPHYLAXIS-XARELTO
Xarelto(rivaroxaban)
Xa inhibitor
Record Trial
THA 30 days, 10 mg/day
TKA 14 days, 10 meg/day
Lower DVT than Lovenox
No more bleeding
Cheaper
Use in high risk pts??
INFECTION WORK UP
Leucocyte Esterase
Scientific Articles | December 21, 2011 Diagnosis of Periprosthetic Joint Infection: The
Utility of a Simple Yet Unappreciated Enzyme Javad Parvizi, MD, FRCS1; Christina Jacovides,
BS1; Valentin Antoci, MD, PhD1; Elie Ghanem, MD1
1 Rothman Institute of Orthopedics at Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, PA 19107. E-mail address for J. Parvizi: [email protected]
Leukocyte Esterase
Results: On the basis of clinical, serological, and operative criteria, thirty of the 108 knees undergoing revision arthroplasty were infected and seventy-eight were uninfected. When only a ++ reading was considered positive, the leukocyte esterase test was 80.6% sensitive (95% confidence interval [CI], 61.9% to 91.9%) and 100% specific (95% CI, 94.5% to 100.0%), with a positive predictive value of 100% (95% CI, 83.4% to 100.0%) and a negative predictive value of 93.3% (95% CI, 85.4% to 97.2%). The leukocyte esterase level correlated strongly with the percentage of polymorphonuclear leukocytes (r = 0.7769) and total white blood-cell count (r = 0.5024) in the aspirate as well as with the erythrocyte sedimentation rate (r = 0.6188) and C-reactive protein level (r = 0.4719) in the serum.
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