1. Femoral Revision What predict success?
Dr Dominique Rouleau, MD, PGY4
Dr Alain Roy, MD, FRCSC
Dr Pascal-André Vendittoli , MD, FRCSC
Dr Martin Lavigne, MD, FRCSC
Dr Benoit Benoit, MD, PGY4
Université de Montréal

2. PROGRAMME D’ORTHOPÉDIE
ÉDOUARD SAMSON

3. Fonds de Recherche et d’Enseignement en Orthopédie de Montréal

4. Scientific and technical support
Stephanie Lapointe,
Research assistant
Daniel Lusignan, I.L.
Research Nurse
Charles Dupont,
Datamed, statistic
Dr Mihai Radulescu

5. Introduction Growing number of hip revision surgery
Surgery technically demanding
 Osteolysis
 Major bone lost
 Altered anatomy

6. Why studying hip revision?
Overall complication rate for hip revision of 30% to 50%1,2,3
1 Bernstein, Clinical orthop, 1995
2 Paprosky, ICL 2000
3 Weber, SICOT, 2002

7. REVITAN - Revision System
Designed by Dr LeBéguec in 1992 in France
In North America in 1999
Versatile
Modularity
Anteversion adjustment
Proximal and/or distal fixation prevent sinking
Wagner Design stem
Unique CrCo junction

8. Retrospective Study - Method
Objective Clinical Evaluation
ROM, limb length, surgery, complications
Files review and physical examination
Subjective Clinical Evaluation
Pain, Autonomy, quality of life
 Questionnary
 WOMAC
Radiologic Evaluation
 X-ray review
INDEPENDANT
EVALUATOR

9. Research Question
What predict success?
…..Or, can we avoid complications?

10. Group description

11. Femoral Revision with Revitan Retrospective Study
November 1999 to March 2004
Follow-up > 12 mths
70 patients
80 hips
38 mths (12-63)
37, 33
Age : 58 y.o. (28 to 77 )

12. Femoral Side Revision with Revitan
Original Hip Pathology
N = 80 Hips

13. Femoral Side Revision with Revitan
Revision Pathology
Both components loosening 29
Femoral loosening
Infection
Massive Ostheolysis
Periprosthetic Fx
Recurrent Dislocation 1
Acetabular loosening 1
Total : Revisions

14. Femoral Side Revision with Revitan
3rd
revision
# Revisions:
First 44
Second 12
Third 13
Fourth 9
Fifth
Sixth
N= 80 Revisions

15. Femoral Side Revision with Revitan
Bone deficit type
Type:
II 33
IIIA 20
IIIB 11 II
III A
III B
Paprosky, Orthop. Clin., 1998 #29

16. Femoral Side Revision with Revitan
Bone deficit type
Type:
II 34
IIIA 26
IIIB 13
IV 4
“V” 3
N = 80 Hips IV V
Paprosky, Orthop. Clin., 1998 #29

17. Surgery

18. Femoral Side Revision with Revitan Surgical Approach
Endofemoral 26
2 w transverse osteotomy
3 Sagital alignement osteotomy
Trochanteric osteotomy 14
3 w sagital osteotomy
Extended subtrochanteric osteotomy 40
4 medials alignement osteotomy
N = 80

19. Femoral Side Revision with Revitan Surgical Caracteristics
Average Time : 3 hrs 12 min
Average Bleeding : ml
Allogenic Femoral Bone Graft Femoral
Morcelized 8
Structural 18

20. Clinical Results

21. Femoral Side Revision with Revitan Clinical Results
N = 63 pts FU > 12 months
7 incomplete informations:
2 patient died (1 bilateral)
1 patient Alzheimer
3 patients lost at F.U.
1 Girdle Stone for recurrent infection
72 hips

22. Femoral Side Revision with Revitan Clinical Results
N = 63 FU > 12 months
Average WOMAC : 74%
(100% = perfect)
Questionnaire (24 questions) on
Pain
Stiffness
Physical Function
Western Ontario and McMaster Universities Arthritis Index

23. Femoral Side Revision with Revitan Clinical Results
Average ROM N = 72 hips
Anterior flexion: 107°
Internal rotation: 25°

24. Radiological Results

25. Femoral Side Revision with Revitan Radiological Results - FIXATION
Diaphyseal 66
Perfect fit 62
Slight undersize 4
Sinking 8
Average 8mm (2-16)
Metaphyso-diaphyseal 6
Sinking 0
N = 72 hips

26. Radiological Results/Bone Remodeling
47 Improve,
01/02
03/09
Pre-op

27. Radiological Results/Bone Remodeling
19 equal,

28. Radiological Results/ Bone Remodeling
6 lower
01/10
03/09

29. Complications

30. Femoral Side Revision with Revitan - Complications
38/72 Revisions
54 % of complications
First revision: 40%
Multiple revision: 65%

31. Femoral Side Revision with Revitan Complications
Fracture 19
Per-op
Femoral proximal 5
Femoral distal 3
Volet 3
Acetabular 1
Post-op
Femoral 1
Trochanter 3
Neurologic 2
Vascular 1

32. Femoral Side Revision with Revitan Complications
Dislocation 11
7 cup revisions
Non-union
Gr. Trochanter 6
Volet Fx 3
Hematoma 3
DVT 3
N = 72

33. Femoral Side Revision with Revitan Post-op Complications N = 80
Infection 5
One stage revision 2
Two stages revision 1
Girdlestone
recurent infection
Debridement-Lavage 1

34. What predict succes in femoral revision?
Data analysis
What predict succes in femoral revision?

35. ? Data Analysis Patient’s Characteristics Outcome Age Sex
Nbr of Revision
Surgical’s characteristics
Bone quality
Outcome
Complications
WOMAC
ROM
Reoperation ?

36. Data Analysis R1 vs RM Dislocation 7% vs 32% P=0,01 Outcome
Complications
WOMAC
ROM
Reoperation
Patient’s Characteristics
Age
Sex
Nbr of Revision
Surgical’s characteristics
Bone quality
R1 vs RM
Dislocation
7% vs 32%
P=0,01

37. Data Analysis R ac+fe vs R fe Dislocation 12% vs 29% P>0,05 Outcome
Complications
WOMAC
ROM
Reoperation
Patient’s Characteristics
Age
Sex
Nbr of Revision
Surgical’s characteristics
Bone quality
R ac+fe vs R fe
Dislocation
12% vs 29%
P>0,05

38. Dislocation → ↓↓↓ WOMAC
Data Analysis
Outcome
Complications
WOMAC
ROM
Reoperation
Patient’s Characteristics
Age
Sex
Nbr of Revision
Surgical’s characteristics
Bone quality
Dislocation → ↓↓↓ WOMAC
62% vs 76,6%
P=0,04

39. No augmentation of complications
Data Analysis
Outcome
Complications
WOMAC
ROM
Reoperation
Patient’s Characteristics
Age
Sex
Nbr of Revision
Surgical’s characteristics
Bone quality
Acetabulum Revision
No augmentation of complications

40. Data Analysis Number of revision↑ → ↓bone quality p=0,001 Outcome
Complications
WOMAC
ROM
Reoperation
Patient’s Characteristics
Age
Sex
Nbr of Revision
Surgical’s characteristics
Bone quality
Number of revision↑
→ ↓bone quality
p=0,001

41. Data Analysis Number of revision↑ → ↑ Complications R1: 40% RM: 65%
Outcome
Complications
WOMAC
ROM
Reoperation
Patient’s Characteristics
Age
Sex
Nbr of Revision
Surgical’s characteristics
Bone quality
Number of revision↑
→ ↑ Complications
R1: 40% RM: 65%
p=0,001

42. Stem Lenght → ↑ Complications
Data Analysis
Outcome
Complications
WOMAC
ROM
Reoperation
Patient’s Characteristics
Age
Sex
Nbr of Revision
Surgical’s characteristics
Bone quality
Stem Lenght → ↑ Complications
158 cm vs 180 cm
p=0,02

43. Data Analysis Bleeding Infection 2400 ml vs 1500ml P=0,02 Outcome
Complications
WOMAC
ROM
Reoperation
Patient’s Characteristics
Age
Sex
Nbr of Revision
Surgical’s characteristics
Bone quality
Bleeding
Infection
2400 ml vs 1500ml
P=0,02

44. Data Analysis Age↑ vs Sinking P=0,06 Outcome Patient’s Characteristics
Complications
WOMAC
ROM
Reoperation
Patient’s Characteristics
Age
Sex
Nbr of Revision
Surgical’s characteristics
Bone quality
Age↑ vs Sinking
P=0,06

45. Data Analysis Hip flexion ↓ Reoperation 98° vs 108° p=0,03
Outcome
Complications
WOMAC
ROM
Reoperation
Patient’s Characteristics
Age
Sex
Nbr of Revision
Surgical’s characteristics
Bone quality
Hip flexion ↓
Reoperation 98° vs 108° p=0,03
Infection 97° vs 108° p=0,05
Hematoma 89° vs 108° p=0,01

46. Result Comparaison – Complications THA Revision without ciment
Study N Fx
LLD
Disl.
Inf.
Nerve
DVT
Death
Kinkel
Multiple
169
6.5% ?
8.3%
4.7%
1.8%
0.6%
Boisgard
Wagner 52 4%
15% 8% 0%
Bohm
129
29%
20% 5% 2%
0.8%
Wirtz
MRP-Titan
142
1.4%
7.7%
0.7%
Kwong
MP RHS
143
2.4%
2.8%
Roy
Revitan 80
24%
14% 6% 3%
1.5%

47. Result Comparaison- Modular Revision Stems
Authors N
F/U years (Mean)
Age
Loosening
Rerevision Rate
Bono
S-ROM 63
4-9 (5.9) 57 6%
14%
Cameron S-ROM 97
2-13 (7.5) 64 0% 3%
Christie
129
4-7 (6.2)
2.9%
<1%
Kwong
Link MP
143
2-6 (3.3) 67
2.8%
Wirtz
MRP-Titan
142
1-6.3 (2.3)
4.9%
Roy et al
Revitan 80
(3,2) 58 4%

48. PO 3M 1Y

49. Take Home Message
Revitan stem seems to promote bone regeneration like the Wagner stem with an acceptable sinking rate

50. Take home message Dislocation’s risk factors in femoral revisions
Multiple revision
Keeping the old cup
Dislocation affect outcome more than any other features according to Womac Score
Adding cup revision don’t increase morbidity

51. Take home message
Post operative infection is associate with higher blood lost
Local complication decrease ROM

52. Merci!
Dr Alain Roy
POES