OSTEONECROSIS OF THE FEMORAL HEAD: Modern Results of Total Hip Arthroplasty

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OSTEONECROSIS OF THE FEMORAL HEADModern Results
of Total Hip Arthroplasty

• Daniel J. Berry, MD
• Prof and Chairman
• Mayo Clinic
• Rochester, MN

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OSTEONECROSIS THAIntroduction

• Advantages of THA
• THA is the one form of treatment for
  osteonecrosis with an extremely high likelihood
  of excellent pain relief and good function

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OSTEONECROSIS THAResults

• What are the results of THA in the osteonecrosis
  patient population?

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OSTEONECROSIS THAResults

• Pain Relief and Function
• Good
• Similar pain relief and function to THA for
  other diagnoses

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OSTEONECROSIS THAResults

• Pain Relief and Function
• THA provides more complete/ reliable pain relief
  than hemiarthroplasty or head sparing procedures

Ito et al, CORR 2000 Cabanela, CORR 1990
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OSTEONECROSIS THAResults

• THA Durability in osteonecrosis
• The most controversial topic when discussing THA
  for osteonecrosis

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OSTEONECROSIS THAResults

• Difficult to disentangle the fact that most
  osteonecrosis cohorts have high frequency of
  demographic factors and underlying diagnoses that
  put them at risk for implant loosening and wear

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OSTEONECROSIS THAResults

• Osteonecrosis patients frequently young and
  active
• Osteonecrosis includes very high activity
  subgroups e.g. post-traumatic

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OSTEONECROSIS THAResults

• Durability Literature
• One body of literature THA for osteonecrosis
  less durable (loosening/lysis) than THA for
  osteoarthritis
• Another body of literature little difference in
  durability between THA for osteonecrosis and
  other diagnoses

Ortiguera et al, J Arthrop, 1999 Sarmiento et
al, JBJS(A), 1990 Chiu et al, J Arthrop,
1997 Mont, Hungerford, JBJS(A) 1995 Xenakis et
al, CORR, 1997
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THA FOR OSTEONECROSISUncemented THA

• These are historical results
• What are the results with more modern techniques?

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THA FOR OSTEONECROSISNew Mayo Series

• 98 uncemented THA
• 1991-2000
• 60 male, 38 female
• Mean age 37 years
• Mean F/U 6 yrs

Guyen, Cabanela, Berry, 2005
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THA FOR OSTEONECROSISNew Mayo Series

• All treated with uncemented HA coated tapered
  stem
• 28 mm head on conventional PE

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THA FOR OSTEONECROSISNew Mayo Series

• Re-operations for aseptic femoral or acetabular
  loosening
• 0/98 0

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THA FOR OSTEONECROSISNew Mayo Series

• Re-operations for bearing wear/osteolysis
• 8/98 8
• all had conventional PE bearing

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OSTEONECROSIS THAResults

• Literature comparison
• Good results with other successful uncemented
  designs
• - extensively porous coated femoral implants
• - successful tapered uncemented stems

Xenakis et al, CORR 1997 Piston et al,
JBJS(A) 1994 DAntonio et al, CORR 1997
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THA FOR OSTEONECROSISLessons Learned

• Modern uncemented THA is outperforming historical
  results of cemented THA osteonecrosis patients
• The fixation results are comparable to uncemented
  THA for other diagnoses

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THA FOR OSTEONECROSISLessons Learned

• Wear and osteolysis rates in this young patient
  group are unacceptable with conventional PE
  bearing surface
• Alternative bearings (ceramic, metal, crosslinked
  PE) are justified

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THA FOR OSTEONECROSISDislocation Risk

• Are osteonecrosis patients at higher risk for
  dislocation?

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LONG TERM DISLOCATION RISKMaterials and Methods

• All primary Charnley THA performed at Mayo Clinic
  1969-1984
• 6623 hips

JBJS (A), Jan 2004
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OSTEONECROSIS THAComplications

• Dislocation risk is elevated in AVN population

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LONG TERM DISLOCATION RISKResults

• Risk of Dislocation (Compared to Osteoarthritis)
• Factor Relative Risk (CI)
• DxOsteonecrosis 1.9 (1.1-3.2)

plt0.01
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OSTEONECROSIS THAComplications

• Literature Dislocation rate also high in other
  series
• compliance problems in subgroups of patients
  (EtOH)
• less capsular hypertrophy in osteonecrosis than
  osteoarthritis

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THA FOR OSTEONECROSISLessons Learned

• Instability risk elevated in osteonecrosis
• Efforts to minimize instability justified
• anterior approaches or
• posterior approach with capsular repair
• larger head size ( 32 mm)