The 50 Year Old Gym Rat with Primary Osteoarthritis THA is Cost - - PowerPoint PPT Presentation

Geoffrey Westrich, MD

Professor of Clinical Orthopedic Surgery Hospital for Special Surgery New York, New York

The 50 Year Old Gym Rat with Primary Osteoarthritis THA is Cost Effective & Yields the Best Outcome

The 50 Year Old Gym Rat with Primary Osteoarthritis

• Surgical Options
• Hip Arthroscopy?
• Osteotomy?
• Fusion?
• Hip Resurfacing?
• Total Hip Replacement?

Hip Arthroscopy - High failure rate in the setting of osteoarthritis

• Failed hip arthroscopy (persistent pain or

eventual THR) has been attributed to incorrect preoperative diagnosis & poor patient selection.

• Kim et al reported that arthroscopic intervention

for early-stage osteoarthritis in the presence of femoroacetabular impingement is associated with poor clinical results because of a failure to alleviate symptoms of osteoarthritis.

• Philippon: “…failure in diffuse osteoarthritis”

Hip Osteotomy - High Failure Rate in the Setting of Osteoarthritis

• Osteotomy is a good alternative ONLY if the patient is

young and arthritis is in a small area of hip joint. Arthritic bone is rotated away from hip joint, placing weight bearing on uninvolved portions of the ball and socket

• Varus or varus femoral osteotomy or pelvic osteotomy

not appropriate in this patient with diffuse OA

• Periacetabular Osteotomy for Acetabular Dysplasia

in Patients Older than 40 Years: A Preliminary Study

• “PAO will give satisfactory functional and pain scores

in patients over age 40 having dysplastic hips with mild or no arthrosis.” (Millis 2009)

Hip Fusion – Really?

• Obvious why this is a poor choice
• No one wants their hip fused!

Hip Resurfacing

• Historically considered “bone preserving”
• Bearing surface metal-on-metal (cobalt chromium)
• Very sensitive to edge loading and poor positioning
• Risk of ALTR and femoral neck fracture
• Fallen out of favor

Hip Replacement – Of Course!

• THR is the BEST option for 50 year old

patient with advanced osteoarthritis

• Bearing surface options:
• Ceramic on Ceramic
• Ceramic on Polyethylene
• Dual Mobility with Ceramic on Poly

Hip Replacement Considerations

• Regional Anesthesia (IV sedation and spinal)
• Posterolateral or Anterior Approach
• Multimodal Pain Management
• Periarticular Injection
• Physical Therapy Immediately
• Reinforce Hip Precautions and Avoiding Impact
• Set proper expectations PREOPERATIVELY

Wear Analysis of Highly Cross-Linked Polyethylene in Young and Active Patients at Average 14 years. J Arthroplasty 2017, Ranawat

• 57 hips (mean age 53 yo) 28 mm heads with 1st generation HXLPE
• Mean 14 year follow up
• Metal head on 1st generation HXLPE: wear rate of 0.03 mm/year
• Excellent wear and clinical results at 10 to 17 years in young active patients
• Survivorship 100% and no osteolysis.

Wear Rates With Large Metal and Ceramic Heads on 2nd Generation Highly Crosslinked Polyethylene at Mean 6 Year Follow-Up. J Arthroplasty 2017, Ranawat

• 60 patients with non-cemented THR and 32 or 36 mm ceramic heads on

polyethylene matched to 60 patients with similar metal heads

• Mean 6 year follow up
• Metal on poly wear rate was 0.018 mm/year
• Ceramic on poly wear rate was 0.012 mm/year (0.06 mm/50 years!)
• Authors recommend ceramic on poly to avoid trunnionosis with metal

heads.

Hard-on-Hard Bearings Are Associated With Increased Noise Generation in Young Patients Undergoing Hip Arthroplasty. Clin Orthop 2016, Nam and Barrack

• Overall 9% of young patients undergoing THA reported noise generation.
• Females 12% have increased likelihood of noise versus males 7%
• Ceramic-on-ceramic or metal-on-metal: 14% increased grinding, popping,

and clicking versus 3% with a polyethylene liner with a ceramic, oxidized zirconium, or cobalt-chromium femoral head

• Noise generation associated with increased pain and stiffness after THA.

Cost-effectiveness of timely vs delayed primary THR in Germany. 2017

• Evaluated costs and health benefits of timely primary THR
• Compared to nonsurgical treatment and then THR and nonsurgical

treatment alone

• Evaluated health outcomes and QALY
• Timely THR is cost-effective, generating large quality of life benefits at low

additional cost to the health care system

Dual Mobility:

• 0% Dislocation

Fixed Bearing

• 5.1% Dislocation
• 5/7 Cups In

Lewinnek Safe Zone

Sensitivity analysis: Worst case scenario if all DM dislocations required surgery: STILL COST EFFECTIVE!

Conclusions



The 50 year old gym rat with primary osteoarthritis is best served with a THR



THA is cost effective & yields the best outcome

Thank you