Honored Professor Lecture: Why Did We Leave Charnley Total Hip Replacement? John J. Callaghan, M.D. The Lawrence & Marilyn Dorr Chair University of Iowa Iowa City, IA Orthopaedic Summit December 2017
Disclosures • Consultant and Royalties (DePuy) for intellectual property transfer for hip & knee implant designs. • Royalties (Wolters Kluwer) for books edited. • Board Membership – Journal of Arthroplasty – International Hip Society – OREF (Orthopaedic Research and Education Foundation) – Knee Society
• Courage • Perseverance in face of problems • Innovation to overcome problems • Evolution • Used best science of the day
35 year FU
Timeline of Femoral Components Used By RCJ 1970 Polished Charnley
35-year Cumulative Survival 84.9 ± 7% 92.5 ± 5% JBJS 2009
Final Outcome: All Patients Hips % Original prosthesis 295 88.2 2nd hip 22 for aseptic loosening 20 6.1 for dislocation 2 0.6 3rd hip, for aseptic loosening 3 0.9 4th hip, for dislocation 1 0.3 Girdlestone 9 2.7
The challenge comes when patients between 45 & 50 years of age are to be considered for the operation, because then every advance in technical detail must be used if there is to be a reasonable chance of 20 & more years of trouble-free activity.
87.6% 70.1% N = 93
95.1% 92.4% N = 93
Functional Results: SF-36 Mean = 50, Std Dev = 10 60 55 53.2 51.6 50 44.7 42.3 40 35.1 30 20 10 0 Physical Physical >= 2 Mental Mental >= 2 (Study) (Norm) Cormobid (Study) (Norm) Cormobid P = 0.16 P = 0.74
Physical Function: 6-minute Walk Test 486 440 500 395 450 400 304 350 300 250 200 150 100 50 0 Study Group Normative >= 2 No Cormorbid Cormorbid P = 0.002
• Low Wear - 22 mm head • Low Femoral Loosening - polished stem • Low Osteolysis - low wear - polished stem
Pre-Op Post-Op 35 Year FU
Post op 35 Year FU
Dick Johnston left Charnley. 21%
Results: Revision and Loosening Prevalence All Patients at 10 Years Matte Grit Polished (30 Ra) (80 Ra) (5 Ra) 2.0% 10.8% 0% Revision for Aseptic Femoral Loosening 3.6% 13.0% 0% Radiographic Femoral Everything you work on in the lab Loosening does not work out in the body. - Salvati JBJS 89-A, 2007
“Choices and Compromises” Presidential Address Knee Society 1988 Grit blasted stems: • Great for fixation to cement • Terrible, if cement debonds from prosthesis My wife Kim would say the same about our marriage.
Maxian et al. Stinchfield Award. 1996 CORR 333 Why the low wear rate with Charnley THR?
Sliding distance is key to polyethylene wear Gait Analysis
Effect of Head Size
Steady State wear rate: 0.04 mm/yr Total linear head penetration (mm) Duration of time THA in situ (years) Bedard et al. JOA 2014
2 Steady State wear rate: 1.8 0.03 mm/yr Total linear head penetration (mm) 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 0 2 4 6 8 10 12 14 Duration of time THA in situ (years) Patients Under Age 50 Greiner et al. JOA 2015
Hip Simulator Wear Rate Four serum changes / million cycles 20 18 Wear mg/mil cycles Control 16 14 12 10 8 Cross 6 Linked 4 2 0 22 32 38 46 Femoral Head Size (mm) Crowninshield
Concerns with Metal on Crosslinked Polyethylene Lachiewicz et al. CORR 474, 2016 • 10 Mrad remelt polyethylene • Linear wear rate: 0.024 mm/year • Volumetric wear rates: – 32 mm head: 57 mm 3 /year – 36/40 mm head: 156 mm 3 /year p = 0.0005 14% small osteolytic lesions
We Left Cemented Fixation for Cementless Fixation
25-30 Year Follow-up PCA Cementless THA 100 hips (91 patients) Age at surgery: 58 yrs (range 22-81) Femoral revision: 7% • 3% loosening • 4% osteolysis (only proximal osteolysis) Acetabular revision: 23% • 22% loosening and osteolysis • 1% dissociation JBJS, 85-A, 2003 JBJS 2017
HGI Min 20 Y FU Hips 120 Patients 108 Age at Surgery 62.8 years avg (26 to 86) Revision for loosening: 0.8% (no additional rad loose) Wear rate: 0.1186 mm/year Osteolysis: 12% of living patients Stefl, Callaghan et al. JBJS, 94-A, 2012
Fiber Mesh Acetabular Components HG-I HG-II 10-18 Year Follow Up Patients Under Age 50 Hips 144 Patients 118 Age at Surgery 40.5 years avg (22 to 50) Revision: loosening: 1.4%, osteolysis 15% Wear rate: 0.19 mm/year Callaghan, Johnston et al. JOA 2012
Post Rev 15 Yr FU Post op
• 0% revised • 0% radiographically loose • 0.03-0.04 mm/yr wear rate • 1 case osteolysis
Prodigy Extensively Coated Stem Results Min 10 year fu 100 hips 91 patients 10 yr fu 63:28 MF No Revision Femoral Loosening No Radiographic Loosening 2 Reoperations (dislocation, fem fx) Hennessy, Callaghan et al. CORR 2009
Prodigy Extensively Coated Stem Results Min 10 year fu Under Age 50 115 hips 100 patients 10 yr fu 63:37 MF No Revision for Loosening No Radiographic Loosening Takenaga, Callaghan et al. JBJS 2012
Tapered Femoral Stems
Tapered Stem 10 Year Follow-Up • 100 hips • All bone ingrown • Only 1 with significant stress shielding • Min 10 year, no clinical or radiographic loosening Carlson, Callaghan et al. JOA 2016 10 Year FU
Bone Remodeling: None or minimal stress shielding – 87% Pre-op Post-op 10 years
Can Get Stress Shielding
• 261 hips • 2-4 yr f/u • 259 hips bone ingrown (99%) • thigh pain: – 16% mild – 9% moderate/severe
With smaller head sizes, became more concerned about issues related to dislocation Engagement Kinetics Impingement Dislocating Moment Egress Site Resisting Moment
Scifert et al. CORR 355
@ 45 degrees of cup abduction 22 mm Head Dislocation 36 mm Head Dislocation Drop Height 11 mm Drop Height 7 mm Lateral Lateral Displacement Displacement 14 mm 21 mm Crowninshield et al
“Trunnionosis” wear corrosion wear
Large heads in MoM THA Large heads create large moment arm head center of rotation trunnion center of pressure 40mm 56mm Elkins et al. CORR 2014
Ceramic on Ceramic had high hopes …. but
Catastrophic Crack Propagation eXtended Finite Element Modeling (XFEM) 36 mm cups Squatting Alumina, σ max = 150 MPa
Metal on Metal also had high hopes … but Serum Levels: Cobalt 304 ug/L Chromium 31 ug/L
• LYDIA – lymphocyte dominated immunological answer • ALVAL – aseptic lymphocyte-dominated vasculitis associated lesion
MoM Impingement Impingement Egress Scraping Wear (Archard) Sub-modeling, Hertzian validation: 8% error Elkins et al. CORR 2011
MoM Modular Acetabular Component at 5-12 Years N = 163 Components revised: • Femoral components: - 3-5 yr: 0% for ALVAL - 5-12 yr: 3.8% for ALVAL • Acetabular components: 0 • Osteolysis: 4.4% to 13.3% Greiner, Callaghan et al JOA 2016
36mm Head Results 20° Femoral Anteversion Inclination (deg ) 00 10 20 30 40 25 35 45 55 65 THA Performance Score >90 Anteversion (deg ) <10 Elkins et al. Stinchfield Award 2015
36 mm Inclination (deg) 25 35 45 55 65 40 THA 30 Performance Cup Anteversion (deg) Score 100 Lewinnek “safe zone” 20 10 0 0
Are we throwing out the baby with the bathwater?!
Why did the Charnley Total Hip Replacement work? 1. 22 millimeter head 2. Thick polyethylene (9 or 11 mm) 3. Two stem sizes 4. Cement friendly design (geometry, polished) 5. Lateralization of greater trochanter 35 yr fu
What did we learn from our Charnley experience? 1. Cemented fixation provides durable results in THR. 2. Small head size good for reducing wear. 3. Polished flatback Charnley stem extremely durable at 35 years. 4. Acetabular fixation is less durable long term than is femoral fixation.
What aspects of the Charnley Total Hip Arthroplasty have we abandoned? 1. Cemented acetabular fixation for cementless acetabular fixation. 2. Cemented femoral fixation for cementless femoral fixation in most patients.
What aspects of the Charnley Total Hip Arthroplasty have we abandoned? 3. Clean air for clean air with antibiotics. 4. Smaller head sizes for larger head sizes (only because of dislocation, and hopefully better polyethylene available). Large heads were also optimal for hard bearings (ie ceramics & MoM) 5. Trochanteric osteotomy for other approaches.
Remember The Important Thing is What Works not What’s New!!!
Remember The Charnley THR worked. Hopefully, what we are doing today will work as well.
Orthopaedic Research and Education Foundation Discovering the Future of Orthopaedics www.oref.org
Thank You
Recommend
More recommend
