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

PROGRAMME D’ORTHOPÉDIE ÉDOUARD SAMSON

Fonds de Recherche et d’Enseignement en Orthopédie de Montréal

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

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

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

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

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

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

Group description

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 )

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

Femoral Side Revision with Revitan Revision Pathology Both components loosening 29 Femoral loosening 18 Infection 17 Massive Ostheolysis 11 Periprosthetic Fx 3 Recurrent Dislocation 1 Acetabular loosening 1 Total : 80 Revisions

Femoral Side Revision with Revitan 3rd revision # Revisions: First 44 Second 12 Third 13 Fourth 9 Fifth 1 Sixth 1 N= 80 Revisions

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

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

Surgery

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

Femoral Side Revision with Revitan Surgical Caracteristics Average Time : 3 hrs 12 min Average Bleeding : 1600 ml Allogenic Femoral Bone Graft Femoral Morcelized 8 Structural 18

Clinical Results

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

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

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

Radiological Results

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

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

Radiological Results/Bone Remodeling 19 equal,

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

Complications

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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%

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 1- 6.2 (3,2) 58 4%

PO 3M 1Y

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

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

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

Merci! Dr Alain Roy POES