1. Primary THAs for Hip Osteonecrosis in < 50 years old and active patients C Delaunay, H. Migaud and the SFHG group

2. 1ary THA for osteonecrosis in < 50 & active patients Introduction  More than type of implant fixation, polyethylene (PE) wear is the major factor impairing the longevity of THA  More than young age, high activity level is the major cause of conventional PE wear  Concerns about THA in AVN : patients are mostly young and active

3. 1ary THA for osteonecrosis in < 50 & active patients Litterature : THA for AVN !?…  1985, Cornell et al. (OCNA) : overall cemented THA failure rate x 4 in AVN vs 1ary arthritis  1999, Ortiguera et al. (JA) : at 17,8 y-FU, 50% revision rate and more dislocation (6%) in < 50 years old AVN patients  1997, D’Antonio et al. (CORR) : Ctless HA stem OK, but cups failure due to thin PE liner wear with 32mm-metallic heads

4. 1ary THA for osteonecrosis in < 50 & active patients Litterature : THA for AVN !?…  2005, Radl et al. (AO) : 5 Ctless +/-HA stems, higher failure rate and migration in AVN versus osteoarthrosis  2005, Radl et al. (JA) : correlation between survival of Ctless stems and the etiology of AVN (worst if systemic desease)  2004, Schneider & Knahr (AOS) : 2 Ctless non-HA THAs with A-PE or A-A bearings « could not confirm that AVN is a risk factor »

5. SFHG Meeting, November 2004 1ary THA in active patients < 50 Inclusion criteria :  1ary THA on virgin hips  < 50 years old patients  activity level > Devane 3 Exclusion criteria :  High dysplasia > Crowe I  Rheumatoïd and juvenile arthritis 1419 1ary THAs (cementless, 72%) Mean age, 41.2 ; Devane 4&5, 60% 12 teams

6. 1ary THA for osteonecrosis in < 50 & active patients 1 diagnosis : AVN (36%) 2 Dysplasia, 28% 3 1ary arthtitis, 22,5%

7. IMK Meeting, February 2006 1ary THA for AVN in patients < 50 « Charnley-Kerboull » (Cochin) « Ostéal-Cerafit » (Lariboisière-Pt.Labbé) « Symbios » (Marseille) « ABG » (ABG group) « Corail » (Artro group) « Omnifit-Arc2f » (Bruay) « Alloclassic-Armor » (Lille) « Alloclassic-CSF » (Lonjumeau) 493 1ary THA in 388 patients with non traumatic AVN 8 teams

8. 1ary THA for osteonecrosis in < 50 & active patients Aim of the study To compare THA outcome between the AVN group and the cohort of 1ary THA performed for all other diagnosis in less than 50 years old and active patients, focusing on :  demographic data  clinical evaluation  complications (dislocation)  and 10 year survivorships

9. Material & methods THA in < 50-y & active AVN patients

10. 1ary THA for osteonecrosis in < 50 & active patients 1 all cemented « C-Kerboull » 1 « Hybrid » « Ostéal-Cerafit » Material - implants (45 hips, 9.1%) (31 hips, 6.3%)

11. 1ary THA for osteonecrosis in < 50 & active patients 4 cementless HA-coated : « Symbios » « ABG », « Corail » & « Omnifit-Arc2f » (374 hips, 75,6%)

12. 1ary THA for osteonecrosis in < 50 & active patients 2 cementless non HA-coated Alloclassic-SL & CSF ring or Armor cup (43 hips, 9%) 417 Cementless 1ary THAs (84,6% of the AVN hips)

13. 1ary THA for osteonecrosis in < 50 & active patients Material – Bearings, 9 couples 22,228 (68%) 32total Ml-PE51311092 Al-PE-21424238 Zr-PE-30- Al-Al-2975104 Ml-Ml-29- total51333109493 Hard-soft 73%Hard-hard27% 1.Al-PE 28 (43%) 2. Al-Al 32 (15,2%) +/- Ceramic in 75,4%

14. 1ary THA for osteonecrosis in < 50 & active patients Couple Série M-PE 22 M-PE 28 M-PE 32 A-PE 28 A-PE 32 Zr-PE 28 Al-Al 28 Al-Al 32 MoM 28 tota l 1. CK45 ------- 2. Osteal Cerafit ------- 31 - 3. Symbios -4- 88 24----116 4. ABG624---2622--78 5. ARTRO --- 34 --2--36 6.Omnifit Arc2f -310 78 -4544-144 7. SL Armor --------19 8. SL CSF --- 14 ----1024 total 513110 214 243029 75 29 493 bearings, 3 homogeneous series

15. THA in < 50-y & active AVN patients Demographics 388 patients

16. 1ary THA for osteonecrosis in < 50 & active patients Mean age : AVN, 40.4 years / 41.9

17. 1ary THA for osteonecrosis in < 50 & active patients Charnley B patients : 31.4% / 32%

18. 1ary THA for osteonecrosis in < 50 & active patients Bilateral THA : 27% / 15.2% (p=0,45)

19. 1ary THA for osteonecrosis in < 50 & active patients Sex ratio M/F : 5.9/1 / 0.94/1 (p=.0001)

20. 1ary THA for osteonecrosis in < 50 & active patients Activity D4&5 : 65.5% / 52% (p=.0001)

21. Results 493 1ary THA THA in < 50-y & active AVN patients

22. 1ary THA for osteonecrosis in < 50 & active patients Average FU : 7.7years / 8 years

23. 1ary THA for osteonecrosis in < 50 & active patients Clinical results PMA Score : Pre-op., 9.15 pts / 9.69 : Post-op.,17.47pts / 17.25 : Post-op.,17.47pts / 17.25

24. 1ary THA for osteonecrosis in < 50 & active patients Radiographic results Worrying X-Ray : 8.5%/10.2% (p=.35)

25. 1ary THA for osteonecrosis in < 50 & active patients Worrying X-Ray / average FU

26. 1ary THA for osteonecrosis in < 50 & active patients Sedel D in 3% vs 4.6% (p=.21)

27. 1ary THA for osteonecrosis in < 50 & active patients Complications Dislocation : 3.45% vs 2.18% (p=.21)

28. 1ary THA for osteonecrosis in < 50 & active patients Revision : 6.5% vs 8.3% (p=.28)

29. 1ary THA for osteonecrosis in < 50 & active patients % rev. for disloc.: 22%/2.8% (p=.0048)

30. 1ary THA for osteonecrosis in < 50 & active patients % rev. for disloc. – series 6 : no longer significant ; 8.3%/1.6% (p=.38)

31. 1ary THA for osteonecrosis in < 50 & active patients Survivorships 10-years, Revision for any reason cted hyb cementless HA+ HA- dislocations

32. 1ary THA for osteonecrosis in < 50 & active patients 10-years, Revision for any reason cted hyb cementless HA+ HA- dislocations

33. 1ary THA for osteonecrosis in < 50 & active patients 10-years, Rev. for aseptic loosening cted hyb cementless HA+ HA-

34. 1ary THA for osteonecrosis in < 50 & active patients 10-years, Rev. for aseptic loosening cted hyb cementless HA+ HA-

35. 1ary THA for osteonecrosis in < 50 & active patients 10-years, stem rev., aseptic loosening cemented cementless HA+ HA-

36. 1ary THA for osteonecrosis in < 50 & active patients 10-years, stem rev., aseptic loosening cemented cementless HA+ HA-

37. 1ary THA for osteonecrosis in < 50 & active patients 10-years, cup rev., aseptic loosening cted HA- cementless HA+ HA-

38. 1ary THA for osteonecrosis in < 50 & active patients 10-years, cup rev., aseptic loosening cted HA- cementless HA+ HA-

39. 1ary THA for osteonecrosis in < 50 & active patients 10-years, all bearings’ survival

40. 1ary THA for osteonecrosis in < 50 & active patients 10-years, all bearings’ survival

41. 1ary THA for osteonecrosis in < 50 & active patients 10-years, 265 bearings’ survival Hard-soft Hard-hard 45 112 34 14 31 29

42. 1ary THA for osteonecrosis in < 50 & active patients Bearings, ONA vs all < 50 THA 1 Alumina head 1 fracture = 2 (2,2/1000)

43. Synthesis of Results THA in < 50-y & active AVN patients

44. 1ary THA for osteonecrosis in < 50 & active patients AVN THA vs others Demographic data 86% male patients  Sex ratio, 6M/1F vs 1M/1F (47% hip dysplasia) S+++ (p=.0001) 65,5% with activity level D4&5  higher than in (any) other group of < 50-years old patients S+++ (52% D4&5, p=.0001)

45. 1ary THA for osteonecrosis in < 50 & active patients AVN THA vs others Clinical results Same or even slightly better  Clinical score (PMA > 17.3 points)  X-Ray alterations (8.5%/10.5%, p=.35)  Overall evaluation (Sedel D, 3%/4,6%)  Revision rate (6.5%/8.3%, p=.28)  No specific correlation with AVN etiology

46. 1ary THA for osteonecrosis in < 50 & active patients AVN THA vs others Complications Dislocation rate non signif. higher  3.45% vs 2.18 (p=.12)  PL ap., 5,6% vs A&AL, 0.48% (p=.004),no longer after exclusion of series 6 (p=.23) Revision rate for dislocation  S+ higher (22% vs 2,8%, p=.0048), but no longer after exclusion of series 6 (p=.38)

47. 1ary THA for osteonecrosis in < 50 & active patients AVN THA vs others 10-year survivorships Same or slightly better for  THA revision for any reason  THA revision for aseptic loosening  Stem or cup revision for aseptic loosening  Bearing revision for mechanical failure

48. THA in < 50-y & active AVN patients Conclusions

49. 1ary THA for osteonecrosis in < 50 & active patients  Our comparative study of 1ary THA (85% ctless) in non-traumatic AVN does not support previous negative considerations in the literature  If 1ary THA in AVN coud have showed poorer outcome, this is only due to the high prevalance of yound and very active male patients who require stronger implant fixation and better wear resistant bearings (27% hard-hard, 100% survival/10y) Conclusion

50. 1ary THA for osteonecrosis in < 50 & active patients  In this group of young and active patients, even at ten year FU, survival analysis are unable (yet ?) to show significant differences between bearing surfaces, but still support the eventuality of some possible advantages of « hard- on-hard » bearings on 1ary THA outcome and longevity  Longer FU will be necessary … Conclusion

51. 1ary THA for osteonecrosis in < 50 & active patients  No benefit with 28mm Zirconia heads on conventional PE  For use of bulk alumina liner, fixation of cementless acetabular component must improve  Post surgery, long-term caution in alcoholic addicted patients operated on with 28mm bearings via postero- lateral approach Final advices

52. THA in < 50-y & active AVN patients Thank you 1. L Kerboull, M Hamadouche, JP Courpied et M Kerboull 2. P Bizot, F Gaucher, L Sedel 3. C Pelegri, X Flecher, JM Aubaniac, JN Argenson 4. C Nourissat, G Asencio, D Berteaux et le groupe ABG 5. JP Vidalain et le groupe ARTRO 6. JA Epinette 7. H Migaud, A Jobin, P Laffargue, J Girard 8. C Delaunay et AI Kapandji