Avoid Early Failure: Use Standard Length Cemented Femoral Stems - - PowerPoint PPT Presentation

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May 18, 2023 478 likes •718 views

Femoral Bone Preservation Avoid Early Failure: Use Standard Length Cemented Femoral Stems Matthew Hepinstall, MD Mikhail Khaimov, DO Center for Joint Preservation & Reconstruction Disclosures M. Hepinstall : Paid Consulting: Corin,

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Center for Joint Preservation & Reconstruction

Femoral Bone Preservation

Avoid Early Failure: Use Standard Length Cemented Femoral Stems

Matthew Hepinstall, MD Mikhail Khaimov, DO

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Center for Joint Preservation & Reconstruction

Disclosures M. Hepinstall : Paid Consulting: Corin, Stryker Institutional Research Support: Acelity, Stryker Royalties: Corin Speaking: Stryker, Smith & Nephew Disclosures M. Khaimov : None

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Center for Joint Preservation & Reconstruction

WHY TO PRESERVE FEMORAL BONE?

■ Looks better on x-ray? ■ Preserve muscular attachments ■ Have bone left over for revision ■ Have bone left over for re-revision!

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Center for Joint Preservation & Reconstruction

WHAT FEMORAL BONE TO PRESERVE?

■ Preserve muscular attachments – TROCHANTERS ■ Have bone left over for revision – ISTHMUS ■ Have bone left over for re-revision! – ISTHMUS ■ Avoid re-revision! – EARLY FAILURE

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Center for Joint Preservation & Reconstruction

HOW TO PRESERVE FEMORAL BONE?

■ Cut less the first time?

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Center for Joint Preservation & Reconstruction

HOW TO PRESERVE FEMORAL BONE?

■ Cut less the first time? ■ Avoid early failure and revision ■ can result in subsequent need for re-revision!

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Center for Joint Preservation & Reconstruction

HIP RESURFACING?

■ Preserves femur ■ May not preserve acetabulum ■ Does bone preservation matter without abductors? ■ Avoid metal wear!

Amanatullah, et al. Orthopedics 2016 Nawabi, et al. JBJS 2013

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Center for Joint Preservation & Reconstruction

SHORT STEMS?

■ Not all short stems preserve trochanteric bone ■ Beware of lateral flare stems that undermine the trochanter

Santori, et al. Bone & Joint J 2010

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Center for Joint Preservation & Reconstruction

SHORT STEMS?

■ Early revisions don’t preserve femoral bone

Von Lewinski, et al.Orthopedics 2015

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Center for Joint Preservation & Reconstruction

SHORT STEMS?

■ Durability does not meet

benchmark with fixation confined to femoral neck

■ Benchmark achieved when

fixation extends further

Van Oldenrijk, et al. Acta Orthopaedica 2014

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Center for Joint Preservation & Reconstruction

STANDARD LENGTH CEMENTLESS STEMS?

■ Workhorse stem in USA ■ Registry results don’t match

cemented fixation

Wyatt, et al. World Journal of Orthopedics 2014

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Center for Joint Preservation & Reconstruction

UK REGISTRY

10th Annual Report NJR of England, Whales and Northern Ireland, 2013, available at: njrcentre.org.uk

■ Fewer revisions

at every time point with cement or hybrid

vs. cementless

■ Controlling for

bearing surface

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Center for Joint Preservation & Reconstruction

NORWEGIAN ARTHROPLASTY REGISTER

■ Cases from 1987-2015 ■ Pooled data far better

for cemented

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Center for Joint Preservation & Reconstruction

NORWEGIAN ARTHROPLASTY REGISTER

Norwegian Arthroplasty Register, 2016 ■ Cases from 1987-2015 ■ Pooled data still far

better for cemented

■ Newer data is closer ■ But remember,

cemented fixation dominates Norwegian clinical practice in

lder adults,

potentially masking issues in this population!!!

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Center for Joint Preservation & Reconstruction

NEW ZEALAND REGISTRY

■ More early revisions with

cementless fixation (failure of osseointegration)

■ Cementless fixation

equivalent by 10 years (fewer cases of loosening)

■ My take: Early revisions

more likely to result in re- revision, so cement may still win on bone preservation

Wyatt, et al. World Journal of Orthopedics 2014

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Center for Joint Preservation & Reconstruction

CAN YOU PRESERVE BONE IF YOU FAIL WITHIN 90 DAYS?

■ Cementless stems => more early revisions for fixation failure or

femoral fracture

■ May tank your bundle

Wyatt, et al. World Journal of Orthopedics 2014

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Center for Joint Preservation & Reconstruction

EARLY FAILURES ATTRIBUTABLE TO CEMENTLESS FIXATION

■ Femoral fixation failure + fractures account for 26.5% of revisions

5 years after THA

Melvin, et al. J Arthroplasty 2014

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Center for Joint Preservation & Reconstruction

CEMENTLESS STEMS CONFER SIGNIFICANT INCREASE IN RISK OF PERIPROSTHETIC FRACTURE OVER AGE 65

Wyatt, et al. World Journal of Orthopedics 2014

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Center for Joint Preservation & Reconstruction

IS “MIS” THE PROBLEM?

■ Minimally invasive THA may be a

risk factor for early cementless fixation failure.

Ball et al. JBJS 2006 Graw et al. CORR 2010 Panichkul et al. Orthopedics 2016 Eto et al. J Arthroplasty 2016 Meneghini et al. JBJS 2017

■ But patients like fast recoveries

and no precautions

■ DAA is not going away! ■ Need successful fixation strategy ■ Preserve bone by preventing failure

Panichkul, et al. Orthopedics 2016

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Center for Joint Preservation & Reconstruction

AS WE EMBRACE ANTERIOR APPROACH

■ At our center, experience with DAA correlates with increasing

use of cement (unpublished data)

■ 1% in 2012 ■ 5% in 2013 ■ 6% in 2014 ■ 14% in 2015-6

■ “Game-time” decision? ■ Embrace cemented stems as a reliable, rapid recovery,

"premium" strategy in patients >70 and osteopenic patients >60.

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Center for Joint Preservation & Reconstruction

REGISTRY RESULTS

■ THA beats resurfacing ■ Cement beats cementless; particularly in patients 75+

Stea, et al. JBJS 2014 Prosser, et al. Acta Orthopaedica, 2010

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Center for Joint Preservation & Reconstruction

Femoral Bone Preservation

Avoid Early Failure: Use Standard Length Cemented Femoral Stems in Older Patients and Osteopenic Bone

Matthew Hepinstall, MD Mikhail Khaimov, DO

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Center for Joint Preservation & Reconstruction