Avoid Early Failure: Use Standard Length Cemented Femoral Stems - PowerPoint PPT Presentation

Femoral Bone Preservation Avoid Early Failure: Use Standard Length Cemented Femoral Stems Matthew Hepinstall, MD Mikhail Khaimov, DO Center for Joint Preservation & Reconstruction

Disclosures M. Hepinstall : Paid Consulting: Corin, Stryker Institutional Research Support: Acelity, Stryker Royalties: Corin Speaking: Stryker, Smith & Nephew Disclosures M. Khaimov : None Center for Joint Preservation & Reconstruction

WHY TO PRESERVE FEMORAL BONE? ■ Looks better on x-ray? ■ Preserve muscular attachments ■ Have bone left over for revision ■ Have bone left over for re-revision! Center for Joint Preservation & Reconstruction

WHAT FEMORAL BONE TO PRESERVE? ■ Preserve muscular attachments – TROCHANTERS ■ Have bone left over for revision – ISTHMUS ■ Have bone left over for re-revision! – ISTHMUS ■ Avoid re-revision! – EARLY FAILURE Center for Joint Preservation & Reconstruction

HOW TO PRESERVE FEMORAL BONE? ■ Cut less the first time? Center for Joint Preservation & Reconstruction

HOW TO PRESERVE FEMORAL BONE? ■ Cut less the first time? ■ Avoid early failure and revision ■ can result in subsequent need for re-revision! Center for Joint Preservation & Reconstruction

HIP RESURFACING? ■ Preserves femur ■ May not preserve acetabulum ■ Does bone preservation matter without abductors? ■ Avoid metal wear! Amanatullah, et al. Orthopedics 2016 Nawabi, et al. JBJS 2013 Center for Joint Preservation & Reconstruction

SHORT STEMS? ■ Not all short stems preserve trochanteric bone ■ Beware of lateral flare stems that undermine the trochanter Santori, et al. Bone & Joint J 2010 Center for Joint Preservation & Reconstruction

SHORT STEMS? ■ Early revisions don’t preserve femoral bone Von Lewinski, et al. Orthopedics 2015 Center for Joint Preservation & Reconstruction

SHORT STEMS? ■ Durability does not meet benchmark with fixation confined to femoral neck ■ Benchmark achieved when fixation extends further Van Oldenrijk, et al. Acta Orthopaedica 2014 Center for Joint Preservation & Reconstruction

STANDARD LENGTH CEMENTLESS STEMS? ■ Workhorse stem in USA ■ Registry results don’t match cemented fixation Wyatt, et al. World Journal of Orthopedics 2014 Center for Joint Preservation & Reconstruction

UK REGISTRY ■ Fewer revisions at every time point with cement or hybrid vs. cementless ■ Controlling for bearing surface 10 th Annual Report NJR of England, Whales and Northern Ireland, 2013, available at: njrcentre.org.uk Center for Joint Preservation & Reconstruction

NORWEGIAN ARTHROPLASTY REGISTER ■ Cases from 1987-2015 ■ Pooled data far better for cemented Center for Joint Preservation & Reconstruction

NORWEGIAN ARTHROPLASTY REGISTER ■ Cases from 1987-2015 ■ Pooled data still far better for cemented ■ Newer data is closer ■ But remember, cemented fixation dominates Norwegian clinical practice in older adults, potentially masking issues in this population!!! Norwegian Arthroplasty Register, 2016 Center for Joint Preservation & Reconstruction

NEW ZEALAND REGISTRY ■ More early revisions with cementless fixation (failure of osseointegration) ■ Cementless fixation equivalent by 10 years (fewer cases of loosening) ■ My take: Early revisions more likely to result in re- revision, so cement may still win on bone preservation Wyatt, et al. World Journal of Orthopedics 2014 Center for Joint Preservation & Reconstruction

CAN YOU PRESERVE BONE IF YOU FAIL WITHIN 90 DAYS? ■ Cementless stems => more early revisions for fixation failure or femoral fracture ■ May tank your bundle Wyatt, et al. World Journal of Orthopedics 2014 Center for Joint Preservation & Reconstruction

EARLY FAILURES ATTRIBUTABLE TO CEMENTLESS FIXATION ■ Femoral fixation failure + fractures account for 26.5% of revisions 5 years after THA Melvin, et al. J Arthroplasty 2014 Center for Joint Preservation & Reconstruction

CEMENTLESS STEMS CONFER SIGNIFICANT INCREASE IN RISK OF PERIPROSTHETIC FRACTURE OVER AGE 65 Wyatt, et al. World Journal of Orthopedics 2014 Center for Joint Preservation & Reconstruction

IS “MIS” THE PROBLEM? ■ Minimally invasive THA may be a risk factor for early cementless fixation failure . Ball et al. JBJS 2006 Graw et al. CORR 2010 Panichkul et al. Orthopedics 2016 Eto et al. J Arthroplasty 2016 Meneghini et al. JBJS 2017 ■ But patients like fast recoveries and no precautions ■ DAA is not going away! ■ Need successful fixation strategy Panichkul, et al. Orthopedics 2016 ■ Preserve bone by preventing failure Center for Joint Preservation & Reconstruction

AS WE EMBRACE ANTERIOR APPROACH ■ At our center, experience with DAA correlates with increasing use of cement (unpublished data) ■ 1% in 2012 ■ 5% in 2013 ■ 6% in 2014 ■ 14% in 2015-6 ■ “Game-time” decision? ■ Embrace cemented stems as a reliable, rapid recovery, "premium" strategy in patients >70 and osteopenic patients >60. Center for Joint Preservation & Reconstruction

REGISTRY RESULTS ■ THA beats resurfacing ■ Cement beats cementless; particularly in patients 75+ Prosser, et al. Acta Orthopaedica , 2010 Stea, et al. JBJS 2014 Center for Joint Preservation & Reconstruction

Femoral Bone Preservation Avoid Early Failure: Use Standard Length Cemented Femoral Stems in Older Patients and Osteopenic Bone Matthew Hepinstall, MD Mikhail Khaimov, DO Center for Joint Preservation & Reconstruction

Center for Joint Preservation & Reconstruction