M. E. Cabanela, M.D.M. E. Cabanela, M.D.Professor of Orthopedic SurgeryProfessor of Orthopedic SurgeryMayo Clinic College of MedicineMayo Clinic College of Medicine
Rochester, Minn.Rochester, Minn.
OSTEONECROSIS - THAOSTEONECROSIS - THA
Femoral head collapseFemoral head collapse
OSTEONECROSIS - ARTHROPLASTYOSTEONECROSIS - ARTHROPLASTYIndicationIndication
• HemiresurfacingHemiresurfacing• Femoral head replacement : Femoral head replacement :
monopolar or bipolarmonopolar or bipolar• Total resurfacingTotal resurfacing• Total hip arthroplastyTotal hip arthroplasty
OSTEONECROSIS - ARTHROPLASTYOSTEONECROSIS - ARTHROPLASTY
Yr Yr No No F/U F/U E/G GroinE/G Groin ThighThigh RevisionRevision(yrs)(yrs) Pain Pain Pain Pain
Lachiewitz Lachiewitz 88 88 31 (U/C)4.6 31 (U/C)4.6 48% 48% 20% 7% 20% 7%
Cabanela Cabanela 90 90 23 (C) 23 (C) 9.2 9.2 59% 59% 12% 12% 8% 8%
Cabanela Cabanela 90 90 14 (U) 14 (U) 5.3 5.3 57% 57% 21% 43% 21% 43%
Learmonth Learmonth 93 93 38 (C) 38 (C) 4.7 4.7 10.5% 10.5%
Takaoka Takaoka 92 92 83 (U/C)5.5 83 (U/C)5.5 85%85%Hannsen 87 13 (U/C)5.0 23% 23.0%Hannsen 87 13 (U/C)5.0 23% 23.0%
• Cabanela ME: Bipolar vs. Total Hip Arthroplasty for Avascular Necrosis of the femoral Cabanela ME: Bipolar vs. Total Hip Arthroplasty for Avascular Necrosis of the femoral head. CORR 261:59-62,1990head. CORR 261:59-62,1990
OSTEONECROSIS - ARTHROPLASTYOSTEONECROSIS - ARTHROPLASTYBipolarBipolar
6 yrs PR6 yrs PR6 yrs PR6 yrs PR
OSTEONECROSIS - ARTHROPLASTYOSTEONECROSIS - ARTHROPLASTYBipolarBipolar
• AbandonedAbandoned• No advantages No advantages
over THAover THA• Main reason for Main reason for
failure is groin failure is groin painpain
AdvantagesAdvantages
• Most predictable pain reliefMost predictable pain relief
DisadvantagesDisadvantages
• Terminal Rx (no comeback)Terminal Rx (no comeback)
OSTEONECROSIS-THAOSTEONECROSIS-THA
OSTEONECROSISOSTEONECROSISCemented THA ResultsCemented THA Results
Yr Yr No No F-up F-up
FailureFailure
Stauffer Stauffer 8282 10 yrs10 yrs 50% 50%
Salvati Salvati 8686 28 28 8 yrs 8 yrs 37% 37%
Kantor Kantor 9696 28 28 7.7 yrs7.7 yrs
12.5%12.5%
GarinoGarino 9797 123123 6.6 yrs6.6 yrs 8% 8%
Yr Yr No No F-up F-up
FailureFailure
Stauffer Stauffer 8282 10 yrs10 yrs 50% 50%
Salvati Salvati 8686 28 28 8 yrs 8 yrs 37% 37%
Kantor Kantor 9696 28 28 7.7 yrs7.7 yrs
12.5%12.5%
GarinoGarino 9797 123123 6.6 yrs6.6 yrs 8% 8%
OSTEONECROSISOSTEONECROSISUncemented THA ResultsUncemented THA Results
Yr Yr Type Type NoNo F-upF-up Stem StemSocketSocket
(yrs)(yrs) failure failure failurefailure
(%) (%)(%) (%)
BrinkerBrinker 9494 H-GH-G 8181 5 5 19.7 19.7 6.2 6.2
LinsLins 9393 PCAPCA 3737 5 5 18.9 18.9 2.7 2.7
PistonPiston 9494 AMLAML 3535 7.5 7.5 2.9 2.9 5.7 5.7
D’AntonioD’Antonio 9797 HA-OmnifitHA-Omnifit 5353 6 6 0 0 15 15
Yr Yr Type Type NoNo F-upF-up Stem StemSocketSocket
(yrs)(yrs) failure failure failurefailure
(%) (%)(%) (%)
BrinkerBrinker 9494 H-GH-G 8181 5 5 19.7 19.7 6.2 6.2
LinsLins 9393 PCAPCA 3737 5 5 18.9 18.9 2.7 2.7
PistonPiston 9494 AMLAML 3535 7.5 7.5 2.9 2.9 5.7 5.7
D’AntonioD’Antonio 9797 HA-OmnifitHA-Omnifit 5353 6 6 0 0 15 15
Are the results of THA for Are the results of THA for
AVN inferior to those of AVN inferior to those of
THA for OA?THA for OA?
• Ortiguera CJ, Pulliam IT, Cabanela Ortiguera CJ, Pulliam IT, Cabanela ME: Total hip arthroplasty for ME: Total hip arthroplasty for osteonecrosis. Matched-pair analysis osteonecrosis. Matched-pair analysis of 188 hips with long-term follow-up. of 188 hips with long-term follow-up. J Arthroplasty 14:21-28, 1999.J Arthroplasty 14:21-28, 1999.
THATHAOA vs ONOA vs ON
• Two matched groups of THA Two matched groups of THA (cemented Charnley)(cemented Charnley)
• 94 hips each94 hips each• Matched for age, sex, surgeon, Matched for age, sex, surgeon,
approach, and prosthesisapproach, and prosthesis• 70 m 118 f70 m 118 f• 58 yrs (30-79)58 yrs (30-79)
Follow-up 17.8 yrs (10-25)Follow-up 17.8 yrs (10-25)
THATHAOA vs ONOA vs ON
ResultsResultsON 18%ON 18%
Revision rates Revision rates OA 19%OA 19%
<50 yrs: ON <50 yrs: ON revision rate (p<.005) revision rate (p<.005)Acetabular loosening no differentAcetabular loosening no differentFemoral loosening higher in ON (p<0.05)Femoral loosening higher in ON (p<0.05)Complications same exceptComplications same except
dislocation higher in ON (p<.05)dislocation higher in ON (p<.05)
Results poorer in AVNResults poorer in AVN
AVN VS DJDAVN VS DJDCemented THACemented THA
Saito S et al: Clin Orth 244:198, 1989Saito S et al: Clin Orth 244:198, 1989Ritter M et al: Clin Orth 338:94, 1997Ritter M et al: Clin Orth 338:94, 1997Ortiguera C et al: J Arthr 14:21, 1999Ortiguera C et al: J Arthr 14:21, 1999
• No difference in clinical orNo difference in clinical orradiographic resultsradiographic results
AVN VS DJDAVN VS DJDUncemented THAUncemented THA
-Xenakis TA et al: CORR 341:62, 1997-Xenakis TA et al: CORR 341:62, 1997
• Instability statistically greaterInstability statistically greaterin AVNin AVN
AVN VS DJDAVN VS DJDComplications of THAComplications of THA
-Ortiguera CJ: J Arthr 14:21, 1999-Ortiguera CJ: J Arthr 14:21, 1999-Parvizi J: MAOA, April 2000-Parvizi J: MAOA, April 2000
OSTEONECROSIS-THA OSTEONECROSIS-THA Technical ConsiderationsTechnical Considerations
• Select implant using same criteria as Select implant using same criteria as for other Dxfor other Dx
• Do not overream socketDo not overream socket• Watch for socket fxWatch for socket fx• Augment socket fixation with screwsAugment socket fixation with screws• Choose femoral component depending Choose femoral component depending
on metaphyseal bone changes from on metaphyseal bone changes from previous surgeryprevious surgery
• Select implant using same criteria as Select implant using same criteria as for other Dxfor other Dx
• Do not overream socketDo not overream socket• Watch for socket fxWatch for socket fx• Augment socket fixation with screwsAugment socket fixation with screws• Choose femoral component depending Choose femoral component depending
on metaphyseal bone changes from on metaphyseal bone changes from previous surgeryprevious surgery
OSTEONECROSIS-THAOSTEONECROSIS-THACONCLUSIONSCONCLUSIONS
• Final solutionFinal solution• Not a routine THANot a routine THA• At this time ?’s remain about At this time ?’s remain about
complications and durabilitycomplications and durability• Future of AVN rests in avoiding Future of AVN rests in avoiding
collapse and thus avoiding THAcollapse and thus avoiding THA
