OSTEONECROSIS THA M E Cabanela M D Professor

OSTEONECROSIS - THA M. E. Cabanela, M. D. Professor of Orthopedic Surgery Mayo Clinic College of Medicine Rochester, Minn.

OSTEONECROSIS - ARTHROPLASTY Indication Femoral head collapse

OSTEONECROSIS - ARTHROPLASTY • Hemiresurfacing • Femoral head replacement : monopolar or bipolar • Total resurfacing • Total hip arthroplasty

OSTEONECROSIS - ARTHROPLASTY Bipolar Yr No (yrs) F/U E/G Lachiewitz 88 31 (U/C)4. 6 48% 20% 7% Cabanela 90 23 (C) 9. 2 59% 12% 8% Cabanela 90 14 (U) 5. 3 57% 21% Learmonth 93 38 (C) 4. 7 Takaoka Hannsen 92 87 83 (U/C)5. 5 13 (U/C)5. 0 • Groin Thigh Revision Pain 43% 10. 5% 85% 23. 0% Cabanela ME: Bipolar vs. Total Hip Arthroplasty for Avascular Necrosis of the femoral head. CORR 261: 59 -62, 1990

6 yrs PR

OSTEONECROSIS - ARTHROPLASTY Bipolar • Abandoned • No advantages over THA • Main reason for failure is groin pain

OSTEONECROSIS-THA Advantages • Most predictable pain relief Disadvantages • Terminal Rx (no comeback)

OSTEONECROSIS Cemented THA Results Yr No F-up Stauffer 82 Failure 10 yrs 8 yrs 50% Salvati 86 28 37% Kantor 96 28 7. 7 yrs 12. 5% Garino 97 123 6. 6 yrs 8%

OSTEONECROSIS Uncemented THA Results Yr Type No F-up Stem Socket (yrs) failure (%) Brinker 94 H-G 81 5 19. 7 6. 2 Lins 93 PCA 37 5 18. 9 2. 7 Piston 94 AML 35 7. 5 2. 9 5. 7 D’Antonio 97 HA-Omnifit 53 6 0 15

Are the results of THA for AVN inferior to those of THA for OA?

• Ortiguera CJ, Pulliam IT, Cabanela ME: Total hip arthroplasty for osteonecrosis. Matched-pair analysis of 188 hips with long-term follow-up. J Arthroplasty 14: 21 -28, 1999.

THA OA vs ON • Two matched groups of THA (cemented Charnley) • 94 hips each • Matched for age, sex, surgeon, approach, and prosthesis • 70 m 118 f • 58 yrs (30 -79) Follow-up 17. 8 yrs (10 -25)

THA OA vs ON Results Revision rates ON 18% OA 19% <50 yrs: ON revision rate (p<. 005) Acetabular loosening no different Femoral loosening higher in ON (p<0. 05) Complications same except dislocation higher in ON (p<. 05)

AVN VS DJD Cemented THA Results poorer in AVN Saito S et al: Clin Orth 244: 198, 1989 Ritter M et al: Clin Orth 338: 94, 1997 Ortiguera C et al: J Arthr 14: 21, 1999

AVN VS DJD Uncemented THA • No difference in clinical or radiographic results -Xenakis TA et al: CORR 341: 62, 1997

AVN VS DJD Complications of THA • Instability statistically greater in AVN -Ortiguera CJ: J Arthr 14: 21, 1999 -Parvizi J: MAOA, April 2000

OSTEONECROSIS-THA Technical Considerations • Select implant using same criteria as for other Dx • Do not overream socket • Watch for socket fx • Augment socket fixation with screws • Choose femoral component depending on metaphyseal bone changes from previous surgery

OSTEONECROSIS-THA CONCLUSIONS • Final solution • Not a routine THA • At this time ? ’s remain about complications and durability • Future of AVN rests in avoiding collapse and thus avoiding THA