Transcript Document

Partial Surface Replacement
5 to 14 Years Results
T. JUDET T.SIGUIER J-L.MARMORAT P.PIRIOU
B.BRUMPT M.SIGUIER
Raymond Poincaré
Jouvenet
IMK 2006
Osteonecrosis mainly affects young
patients: How to avoid THR?
• Core decompression
• Cancellous bone
grafting
• Vascularized bone
grafting
• Intertrochanteric
osteotomies
• Rotationnal basicervical ostéotomies
Drawbacks, limits and failures of
conservative surgery
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Technically over-demanding procedure
Long lasting rehabilitation
Unpredictable results
Controversial efficiency
Major anatomical disturbance of the upper
femur
Partial resurfacing concept
Marc Siguier 1990
• Minimalist design and operative technic
• Replacement anatomically limited to the
pathologic area
• Preservation of the hip anatomy
• Preservation of the mecanical properties of
the femoral neck
The MMS Implant
• 120° Covering area
• Range 40 to 60 mm
diameter to match
the exact sphericity
(2mm increment)
• Dedicated
instrumentation for
each size
• Cemented fixation
Surgical technic
• Anterior approach on
fracture table
• T-shaped capsulotomy
• Anterior dislocation
preserving circumflex
vessels
• Excision of the
ostéochondral collapse
and under-lying loose
necrotic bone
Surgical technic
• Measurement of the
femoral head
• Preparation of the
prosthesis setting in
line with the center of
the head
Surgical technic
• Trial implantation without
tilting and flush or
beneath the surface of the
healthy remaining
cartilage
• Cementation of the
definitive prosthesis
Post operative care
Immediate rehabilitation and full weight-bearing
Interrogations and potential
problems
• Quality of bone-implant fixation
• Evolutivity of the pre-OP necrotic area
• Post-OP extension of the necrotic area
toward the pre OP limits
• Cartilage tolerance to the implant and
further degenerative changes
Previous published results
• Siguier M , Judet T, Siguier T & al
J.Arthroplasty 1999
Preliminary results of partial surface replacement of the femoral head
in osteonecrosis
25 procedures 6 failures (FU 20-60 mths)
• Siguier T, Siguier M, Judet T & al
Clin. Orthop. 2001
Partial resurfacing arthroplasty of the femoral head in avascular
necrosis Methode, indication and results
37 procedures 9 failures (FU 24-89 mths)
Actual Serie
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Continuous Serie April 1991 - Jan 2001
61 MMS procedures (54 patients)
Age 42 years (24 - 59)
45 Males et 9 females
Aetiologies
Post trauma
6 cases
Steroïds
11 Cases (9 patients)
Alcool/tobacco 7 cases (5 patients)
Idiopathic
35 cases (32 patients)
Clinical Pre- operative Status
• Postel Merle-d’Aubigné score
12 pts (8 - 17)
Pain 2,3 pts (1 - 4)
No preventive surgery
Radiological Pre-operative status
• Ficat & Arlet Staging
– Stade II : 1 case
– Stade III : 41 cases (67 %)
– Stade IV : 19 cases (31 %)
Radiological Pre-operative status
• Evaluation of the
necrotic area size after
M.Kerboul
-Angular
measurement on AP
view and Lequesne
false profile view
Mean angle AP : 121° (70 to
180)
Mean angle Profile : 116° (50
to 180)
Radiological Pre-operative status
• Evaluation of the necrotic area
size
-Max depth of the necrotic
area; 4 zones to define
superficial or deep involvement
Stage 2 : 28 %
Stage 3 : 53 %
Stage 4 : 19 %
Results : 56 over 61 implants
1 deceased (2 hips) and
2 patients (3 hips) lost to FU before 5 Yrs
• Implant removal :
31 cases
• Implant still in place : 25 cases
Results : Implant removal : 31 cases
- early technical failure
- extension of the necrotic zone - head collapse
Results : Implant removal : 31 cases
- sinking of the implant
- joint line narrowing and
degenerative changes
No difference statistically significant : failure vs Ficat staging
Difference statistically significant : failure vs depth (p < 0,01)
Relatively correct bone/implant
stability
Survival curve
Cumulativ e Surv iv al
100
90
80
% Surviving
70
60
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10
11
Years
• End point : implant removal
12
13
14
Second look surgery
• THR through the same mini invasive
anterior approach
• Resurfacing arthroplasty
• No difficulty related to the previous surgery
Conclusion
• Optimistic : for 25 patients 40 yrs old,
improvement lasting 8 years (5 - 14,5) with a
pain scoring rising from 2,3 to 5,1.
No deleterious effect on secondary procedure
• Realistic : survey curve 50 % à 10 years
46,5 % à 14 years
Conclusion
• Prospective
in the up to date context of
mini-invasive surgery,
mini-implants are highly
attractive and our long term
experience of partial hemi
resurfacing of the femoral
head must render any
surgeon very prudent
concerning analogous
procedures.
Conclusion
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THANK YOU
MERCI