Charnley-Kerboull THA for AVN: A minimal 10-year follow-up study C. Nich, J.P. Courpied, M. Kerboull M. Postel, M. Hamadouche Service A de Chirurgie Orthopédique et Reconstructrice Université R. Descartes, Hôpital Cochin

Introduction  THA for AVN - Higher risk of complication (dislocation) - High mechanical failure rate  AVN risk factor itself for failure Chandler et al., J Bone Joint Surg Am, 1981 Collis et al., J Bone Joint Surg Am, 1984 Cornel et al., Orthop Clin North Am, 1985 Dorr el al., J Bone Joint Surg Am, 1983 Ortiguera et al., J Arthroplasty, 1999 Ranawat et al., J Bone Joint Surg Am, 1984

Clinical and Radiographic outcome of Charnley-Kerboull THA in AVN Minimum 10-year follow-up Predictive factors Aim:

Materials and Methods  122 consecutive THAs for AVN (1980 – 1990)  96 patients: 70 men, 26 females  Mean age: 50.8 ± 13.3 years (21 to 85)  3 senior surgeons  Underlying disease: idiopathic 40.6 %Ethanol 16.7 % Steroids 19.8 % Post-traumatic 11.5 % Others 12.2 %

 Ficat and Arlet grading: 66 % grade III, 34 % grade IV  Extent of necrosis (Kerboull et al., JBJS-Br, 1974) : 187° ± 70°  13 hips previous surgery: - 10 fracture fixation - 2 core decompression - 1 Vernon Luck cup Materials and Methods

 Trans-trochnateric approach  Single THA design: Charnley-Kerboull monobloc 316L SS, polished (Ra = 0.04  m) 22.2 mm head all-polyethylene cup cemented with CMW 1

Evaluation  Clinical results: Merle d’Aubigné hip score  AP view of the pelvis: - loosening (Harris et al. JBJS-A, 1982 ) - osteolysis (Maloney et al. JBJS-A, 1990 ) - wear (Livermore et al. JBJS-A, 1990 )  Survival analysis: - actuarial method - log rank

RESULTS  13 patients (16 hips) LTFU 3.4 years (0.8 to 6.5)  19 patients (24 hips) deceased 4.3 years (0 to 11,8)  5 patients (7 hips) revised 10.5 years (1.7 to 12)  59 patients (75 hips) not revised - mean FU 12.8 ± 2.6 years (10 to 20.8)

Complications  Medical (myocardial, cerebral infarction) 2  Dislocation: 4 including 3 single episode 1 recurrent  Greater trochanter nonunion: 1  Brooker class III: 1 (HO removal)  Deep infection: 1

Revisions  7 hips (5 patients): 9.6 ± 3.6 years  1 hip: septic loosening  6 hips: aseptic loosening high polyethylene wear and osteolysis no loosened femoral component acetabular reconstruction (Kerboull device)

Bilat OH AVN (53 years) Bilat THA 1983 Wear and osteolysis 1993Bilateral revision

Results  Clinical results: ± 2.5 pre-op to 17.4 ± 0.6 last FU p < (Wilcoxon) - age, underlying disease: NS % rated excellent to good  Radiographic results  Mean wear: 0.06 ± 0.08 mm/year unrevised hips 0.33 ± 0.06 mm/year revised hips Acetabular Side63102 No RL Incplete RL Cplete RL Femoral Side6951 p = Mann-Whitney

Survivorship 15 years  Revision for any reason: 88.5 ± 4.3 % (95% CI, 80.2 to 96.9%)  Revision for aseptic loosening: 89.8 ± 4.1 % (95% CI, 81.7 to 97.9%)

Follow-up (years) Survival rate (%) Acetabular components Femoral components 85.6% 98.6% Survivorship 15 years End-point = Radiographic loosening

Age at index THA Gender Ficat and Arlet Stage Underlying disease Kerboull Necrotic Angle NS Predictive factors of radiographic loosening (Log rank)

Survivorship 15 years End-point = Radiographic loosening Follow-up (years) Survival rate (%) Wear rate ≤ 0.1 mm/year (n=100) Wear rate > 0.1 mm/year (n=22) 94.4% 56.2% p = 0.04 Log rank

Discussion  Controversial published results  Cemented implants: Poor results / osteoarthritis Chandler et al., J Bone Joint Surg Am, 1981 Collis et al., J Bone Joint Surg Am, 1984 Cornel et al., Orthop Clin North Am, 1985 Dorr el al., J Bone Joint Surg Am, 1983 Ortiguera et al., J Arthroplasty, 1999 Ranawat et al., J Bone Joint Surg Am, 1984 Cementing technique Ritter et al, Clin Orthop, 1997

Discussion  Cementless implants (early generation): - high incidence of thigh pain - failure up to 9-year FU  Hartley et al., JBJS A, different stems, 3 cup designs ± 10-year FU Katz et al., Clin Orthop 1992 Lins et al., Clin Orthop 1993 Kim et al., Clin Orthop 1995Stulberg et al., Clin Orthop 1997 Wear and osteolysis

Discussion  Cementless Vs Cemented stems (prospective studies) - Katz et al., Clin Orthop Kim et al., J Bone Joint Surg A, 2003 NS  Berry et al., J Bone Joint Surg A, Mayo Hip Register, Charnley THA AVN (25-year FU) - Multivariate analysis: AVN ( odds ratio 0.9, p =.645)

Conclusion  Current study - single implant, single technique - min 10-year FU  Low friction = GOLD STANDARD - wear < 0.1 mm/year - highly cross-linked PE ? 21-year FU