RECONSTRUCTION FEMORALE PAR GREFFONS MORCELES ET TIGE CIMENTEE

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RECONSTRUCTION FEMORALE PAR GREFFONS MORCELES ET TIGE CIMENTEE Powered By Docstoc
					   THA after Chiari osteotomy:
Intraoperative complications and
  behaviour of cup fixation in 24
              cases

  Migaud H., Beniluz J., Gougeon F., Pinoit Y.,
           Besson A., Duquennoy A.
Department of Orthopaedic Surgery,
 University Hospital of Lille, France.
                                    PETERS CJ :
                                    J Arthroplasty, 2001
Introduction :                             13 hips : worse result
                                           THR after failed TIO.
                                           Fw-up 36 m.
•   Conservative surgery to HASHEMI-N A :
    prevent or stabilize            J Arthroplasty, 2002
    arthrosis without                      28 hips : THR after
                                           Chiari results = to
    worsening the result of a              primary THR, but less
    subsequent THR :                       pelvic bone grafting
                                           Fw-up 60 m.
     – Problems related to THR      PARVIZI J :
       after proximal osteotomy of CORR, 2004
       the femur                           41hips : THR after PAO
     – Few papers related to the           caution to acetabular
                                           retroversion (23/41)
       THR after pelvic osteotomies
                                           Fw-up 6,9 years
 Introduction : Purpose of the study
• Modifications of the
  acetabulum related to
  the Chiari osteotomy
  – Medial displacement
  – Enlargement
  – Vascular and bone support
• Concerns about
  1) long term fixation of the cup
  2) Functional result
  3) Intraoperative complications
Patients and Methods

• 204 Chiari osteotomies (1975-2000)
     29 hips conversed to THR

• 24 THR with a follow-up > 5 years were
  assessed retrospectively
• 23 patients (20 F, 3 M)
• Mean age at the time of conversion = 50 y.
  (range, 36-63)
Patients and Methods (n = 24)

• Chiari were “dome
  shaped” and performed
  through a Smith
  Petersen
• Fixed with lag screws
• Indication for Chiari :
  – Dysplasia (15/24 CE < 5°)
  – Arthrosis (20/24 had joint
    space narrowing)
Patients and Methods (n = 24)

• Conversion after a mean follow-
  up of 8 y. (range 1-24 y.)
• All THR through a Postero-
  Lateral approach
• No patient lost for follow-up
• Mean THR follow-up = 10 +/- 3 y.
  (range, 6-15)
 Components (n = 24)

         Cemented          Cementless
Stems       19                5
         Muller/Kerboull   CLS/Alloclassic

Cups           3                 21
            Full Poly       Harris/Allofit
 Functional Results (n = 24, Fw-up = 10y.)

• Favorable functional      18
                            16
  results                   14

• All the walking scores    12
                            10                     17
  at follow-up > 5 points    8
                             6      11,7
                             4
                             2
                             0
                                   Before THR    Follow-up

                                 Merle d’Aubigné Hip rating
Functional Results (n = 24)

• No postoperative      18
                        16
  dislocation despite   14

  medial displacement   12
                        10
  by Chiari osteotomy    8       14
                         6
                         4
• Post-operative Limp    2
                         0
                              Before THR      Post THR

                        Number of Hips with a Trendelenburg
Results: Intraoperative complications
• No neurovascular injury
• Screw removal necessary in 9
  cases
  – To avoid contact between screws
    used for Chiari and cup fixation or
    to ease bone preparation
  – Difficult in 2 cases (the distal part
    of the screw was broken and left in
    place)
Results: Cup fixation and bone coverage
• Three cases of lack in
  bone coverage > 20% of
  the cup (all posterior and
  superior)
  – 1 treated by deepening
  – 1 treated by few bone chips
  – 1 treated by autograft
• One additional case of
  autograft to correctly
  locate the hip center in a
  dislocated hip
 Results: Cup fixation and Impingement

• Anterior impingement
  with the Major
  trochanter in 2 cases
  (excessive anterior
  coverage)
• Bone resection
  required on the pelvic
  bone in 2 cases
Results: Cup orientation

• Mean frontal angle =
  43° +/-9° [20° to 58°]
• 3 cups had inclination
  < 35° and 2 over 55°
• 4 hips had M-M
  bearings (in 28 mm)
  without impingement
 Results: Cup Fixation

• None of the cemented cups
  and 18/21 cementless cups
  = free of osteolysis, no
  radiolucencies, no migration
• 3 of the cementless cups
  had radiolucencies (2 of
  them had progressive
  lucencies and severe
  osteolysis  reoperation)      10 y.   #1
 Results: Reoperation
• Only 2 patients had revision
  surgery (osteolysis, wear)
• No revision was related to
  the prior osteotomy :
                                       #1

• #1 (@ 5y.) osteolysis + cup
  loosening (osteolysis) =
  – Intra-articular migration of
    metallic debris from the coating
    (Fibermesh)
                                                  #1
  – Bone grafting + cup revision       #1
                                       4y. Post
Results: Reoperation

• #2 (@15y.) Osteolysis +
  loosening cup + femur =
  – Severe polyethylene wear
  – Poor fixation of the insert in
    the metallic shell
  – Overweight (BMI = 31)
  – Pelvic grafting with cup and                #2
    femoral revision
    (cementless locked stem)
                                  #2        #2
                                  Post-op   1y. Post
Conclusions (1)

• Conversion of a Chiari to
  THR = simple procedure
• Low rate of acetabular
  augmentation (bone grafting)
  despite severe dysplasia
  before the Chiari)
• Attention should be paid to
  bone-to-bone impingement if
  excessive bone coverage
Conclusions (2)
• Chiari osteotomy :
1) does not modifiy
  rehabilitation program
  versus with primary THR       THR post   Primary THR
                                 Chiari
2) does not worsen cup
  fixation = only 2 revisions
  but none related to the
  prior osteotomy
3) gives the opportunity to
  insert larger cups
  (resistance to wear)
Thank you for your attention

				
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posted:1/5/2013
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