Transcript Charnley-Kerboull THA for AVN: A minimal 10-year follow-up study C. Nich, J.P.

Charnley-Kerboull THA for AVN:
A minimal 10-year follow-up study
C. Nich, J.P. Courpied, M. Kerboull
M. Postel, M. Hamadouche
Service A de Chirurgie Orthopédique et Reconstructrice
Université R. Descartes, Hôpital Cochin
Introduction
 THA for AVN
- Higher risk of complication (dislocation)
- High mechanical failure rate
 AVN risk factor itself for failure
Chandler et al., J Bone Joint Surg Am, 1981
Collis et al., J Bone Joint Surg Am, 1984
Cornel et al., Orthop Clin North Am, 1985
Dorr el al., J Bone Joint Surg Am, 1983
Ortiguera et al., J Arthroplasty, 1999
Ranawat et al., J Bone Joint Surg Am, 1984
Aim:
Clinical and Radiographic outcome of
Charnley-Kerboull THA in AVN
Minimum 10-year follow-up
Predictive factors
Materials and Methods
 122 consecutive THAs for AVN (1980 – 1990)
 96 patients: 70 men, 26 females
 Mean age: 50.8 ± 13.3 years (21 to 85)
 3 senior surgeons
 Underlying disease:
idiopathic 40.6 %
Ethanol 16.7 %
Steroids 19.8 %
Post-traumatic 11.5 %
Others 12.2 %
Materials and Methods
Ficat and Arlet grading:
66 % grade III, 34 % grade IV
Extent of necrosis (Kerboull et al., JBJS-Br, 1974):
187° ± 70°
13 hips previous surgery:
- 10 fracture fixation
- 2 core decompression
- 1 Vernon Luck cup
Trans-trochnateric approach
Single THA design: Charnley-Kerboull
monobloc 316L SS, polished (Ra = 0.04 mm)
22.2 mm head
all-polyethylene cup
cemented with CMW 1
Evaluation
Clinical results: Merle d’Aubigné hip score
AP view of the pelvis:
- loosening (Harris et al. JBJS-A, 1982 )
- osteolysis (Maloney et al. JBJS-A, 1990 )
- wear (Livermore et al. JBJS-A, 1990 )
Survival analysis:
- actuarial method
- log rank
RESULTS
13 patients (16 hips) LTFU
3.4 years (0.8 to 6.5)
19 patients (24 hips) deceased
4.3 years (0 to 11,8)
5 patients (7 hips) revised
10.5 years (1.7 to 12)
59 patients (75 hips) not revised
- mean FU 12.8 ± 2.6 years (10 to 20.8)
Complications
Medical (myocardial, cerebral infarction) 2
Dislocation: 4 including
3 single episode
1 recurrent
Greater trochanter nonunion: 1
Brooker class III: 1 (HO removal)
Deep infection: 1
Revisions
7 hips (5 patients): 9.6 ± 3.6 years
1 hip: septic loosening
6 hips: aseptic loosening
high polyethylene wear and osteolysis
no loosened femoral component
acetabular reconstruction (Kerboull device)
Bilat OH AVN (53 years)
Wear and osteolysis 1993
Bilat THA 1983
Bilateral revision
Results
Clinical results:
- 10.8 ± 2.5 pre-op to 17.4 ± 0.6 last FU p < 0.001 (Wilcoxon)
- age, underlying disease: NS
- 94.6% rated excellent to good
Radiographic results
No RL Incplete RL
Acetabular Side
Femoral Side
63
69
10
5
Cplete RL
2
1
Mean wear:
0.06 ± 0.08 mm/year unrevised hips
0.33 ± 0.06 mm/year revised hips
p = 0.008
Mann-Whitney
Survivorship analysis @ 15 years
Revision for any reason:
88.5 ± 4.3 % (95% CI, 80.2 to 96.9%)
Revision for aseptic loosening:
89.8 ± 4.1 % (95% CI, 81.7 to 97.9%)
Survivorship analysis @ 15 years
End-point = Radiographic loosening
100
98.6%
85.6%
Survival rate (%)
80
60
Acetabular components
40
Femoral components
20
0
0
5
10
Follow-up (years)
15
Predictive factors of radiographic loosening
(Log rank)
Age at index THA
Gender
Ficat and Arlet Stage
Underlying disease
Kerboull Necrotic Angle
NS
Survivorship analysis @ 15 years
End-point = Radiographic loosening
100
94.4%
p = 0.04
Log rank
Survival rate (%)
80
60
56.2%
Wear rate ≤ 0.1 mm/year (n=100)
40
Wear rate > 0.1 mm/year (n=22)
20
0
0
5
10
Follow-up (years)
15
Discussion
Controversial published results
Cemented implants: Poor results / osteoarthritis
Chandler et al., J Bone Joint Surg Am, 1981
Collis et al., J Bone Joint Surg Am, 1984
Cornel et al., Orthop Clin North Am, 1985
Dorr el al., J Bone Joint Surg Am, 1983
Ortiguera et al., J Arthroplasty, 1999
Ranawat et al., J Bone Joint Surg Am, 1984
Ritter et al, Clin Orthop, 1997
Cementing technique
Discussion
Cementless implants (early generation):
- high incidence of thigh pain
- failure up to 20.5% @ 9-year FU
Katz et al., Clin Orthop 1992
Kim et al., Clin Orthop 1995
Lins et al., Clin Orthop 1993
Stulberg et al., Clin Orthop 1997
Hartley et al., JBJS A, 2000
- 10 different stems, 3 cup designs
- 79.7 ± 13% @ 10-year FU
Wear and osteolysis
Discussion
Cementless Vs Cemented stems (prospective studies)
- Katz et al., Clin Orthop 1992
- Kim et al., J Bone Joint Surg A, 2003
NS
Berry et al., J Bone Joint Surg A, 2002
- Mayo Hip Register, Charnley THA
- 103 AVN (25-year FU)
- Multivariate analysis: AVN ( odds ratio 0.9, p = .645)
Conclusion
Current study
- single implant, single technique
- min 10-year FU
Low friction = GOLD STANDARD
- wear < 0.1 mm/year
- highly cross-linked PE ?
21-year FU