1. Aseptic loosening of Hip Prostheses
Ernesto Pintore
Clinica Malzoni
Agropoli - Italie

2. Prosthetic Surgery = Life quality

3. AIM OF REVISION SURGERY
GOOD FUNCTION
QUALITY OF LIFE

4. TECHNICALLY DIFFICULT
VARIETY OF IMPLANTS
LEARNING CURVE
INSTRUMENTS

5. RECENT PROGRESS: -BIOMATERIALS -DESIGNS -IMPROVED CEMENTING TECHNIQUE
-MODULAR PROSTHESES

6. SEPTIC LOOSENING
ASEPTIC LOOSENING

7. SEPTIC LOOSENING
CLINIC
LABORATORY
X-RAY
SCINTIGRAPHY

8. SEPTIC
LOOSENING

9. ASEPTIC LOOSENING MECHANICAL FAILURE:
“Aseptic loosening of one or both components, fracture of a component, recurrent dislocation of the hip, fracture of the femoral shaft.”
Callaghan JJ; Salvati E.A. et al.
JBJS 1985

10. ASEPTIC LOOSENING OF THE FEMUR
MALPOSITION OF THE STEM
FRACTURE OF THE IMPLANT
FRACTURE OF THE FEMUR
RECURRENT DISLOCATION
INADEQUATE STEM DESIGN
INADEQUATE CEMENTING TECHNIQUE
INADEQUATE CEMENT LAYER

11. ASEPTIC LOOSENING OF THE CUP
POOR BONE COVERAGE
MALORIENTATION too vertical, >60°
POLYETHYLENE FAILURE
EXCESSIVE HIGHT OF THE CUP >35mm compared to the contralateral
INADEQUATE CEMENT TECHNIQUE fixation holes and thickness of cement layer
SMOOTH CUPS and RE-CEMENTED
THREATED CUPS

12. X-RAY FEMUR VARUS-VALGUS OF THE STEM VERTICAL SUBSIDENCE
HORIZONTAL MIGRATION
RADIOLUCENCY
OSTEOLYSIS
FRACTURE OF THE CEMENT

13. X-RAY ACETABULUM VERTICAL MIGRATION HORIZONTAL MIGRATION CUP HIGHT
CUP ANGLE
RADIOLUCENCY
OSTEOLYSIS
POLYETHYLENE FAILURE

14. FEMORAL BONE STOCK
Poor: if the thickness of either aspect of the cortex on the AP x-ray had decreased by 50%, along a 10 cm segment of femoral stem, compared with the original arthroplasty, or if the thickness of both aspect of the cortex had decreased this amount along a 5 cm segment

15. ACETABULAR BONE STOCK
CUP MEDIAL TO THE KOHLER’S LINE (any part of the implant)
MEDIAL WALL (< 2mm thickness)
VERTICAL DISTANCE ( > 1 cm between the line trough the tear drop and the higher point of the cement layer compared to the contralateral)

16. A.A.O.S. Classification for bone stock damage
MILD
MODERATE
SEVERE

17. - PAIN - START UP HECITANCY
CLINIC
- PAIN
- START UP HECITANCY

18. DEFINITION OF ACETABULAR LOOSENING (Harris and Mc Gunn JBJS 1986)
DEFINITE LOOSENING:
change of position of the implant, or cement.
fracture of the cement
radiolucency at the cement-implant interface
PROBABLE LOOSENING:
no migration or change of position
continuous radiolucency (100%) at cement-bone
interface
POSSIBLE LOOSENING:
radiolucency 50%-99% at the cement-bone interface

19. WEAR DEBRIS
The wear debris is responsible of a local inflammatory reaction with histyocytes and mast cells proliferation, that leads to osteolysis and loosening of the implant.

20. OPERATIVE TECHNIQUE CHOICE OF THE APPROACH POSTERO-LATERAL APPROACH
OSTEOTOMY OF THE TROCHANTER
FEMORAL “WINDOW”
WAGNER TECHNIQUE
REMOVAL OF THE CEMENT
IMPLANTS

21. IMPLANTS STANDARD STEM LONG STEM SURFACE MODULAR PROSTHESES
“LOCKING NAIL” PROSTHESES

22. BONE GRAFT AUTOGRAFT HOMOGRAFT ALLOGRAFT
Only an accurate reconstruction of the
anatomy can allow a good result in the
revision surgery ( Bone bank)

23. CEMENT OR NOT CEMENT?

24. ALTHOUGH MODIFICATION AND IMPROVING OF CEMENTING TECHNIQUE HAVE DECREASED THE INCIDENCE OF FEMORAL AND ACETABULAR LOOSENING IN THR, THRE IS NO EVIDENCE DEMONSTRATING BENEFITS IN REVISION SURGERY WITH THE CEMENT.
Engh C.; Glassman A.
(Instructional course lecture 1991)

25. CRITERIA FOR DETERMINING BIOLOGIC FIXATION
BONE INGROWTH
STABLE BONE-FIBROUS TISSUE
UNSTABLE IMPLANT

26. NO IMPLANT MIGRATION ADAPTIVE REMODELING OF THE SURROUNDING BONE
BONE INGROWTH
NO IMPLANT MIGRATION
ADAPTIVE REMODELING OF THE SURROUNDING BONE

27. CAUSES OF SUCCESS IN FEMORAL REVISION
FRESHENING THE BONE
RESTORE THE BONE STOCK
IMPROVED TROCHANTERIC FIX.
TREATEMENT OF PERFORATIONS
ADEQUATE STEM:
-Extensevely porous coated
-Design (filling)

28. CAUSES OF FAILURE BAD BONE STOCK TROCHANTERIC PROBLEMS
MISDIAGNOSED PERFORATIONS
INADEQUATE DESIGN OF THE IMPLANTS
DYSPLASIC AND NECROTIC HIPS
INFECTION
CURVE OF LEARNING

29. RESULTS OF UNCEMENTED REVISIONS (C. Engh - A. Glassman)
163 hips
80,7% of bone ingrowth
12,3% of stable fibrous tissue
3,5% unstable implants re-revised

30. COMPLICATIONS SYSTEMIC COMPLICATIONS Urinary infections
Cardiac problems
DVT
Pulmonary embolism
Blood loss ( ml)

31. LOCAL COMPLICATIONS Superficial and deep infections
Trochanteric nonunion (10%)
Trochanteric problems
Fracture of the femur
Perforation of the femur
Fracture of the pelvis
Recurrent dislocations (9-12%)
Ectopic bone

32. Aseptic loosening of a Bousquet cup 6 years later

33. Revision with uncemented cup and auto-homograft

34. Revision surgery is technically difficult and requires an experienced surgeon and economic means to achieve the most performant devices.
There are many complications and the results are not always good.
The learning curve is long
but despite this we beleave
that this is the surgery wich
we have to develop in the
future.