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Making Sense of Bone Loss:
Revision Strategy and Techniques
Professor of Orthopaedic Surgery
Vice chairman for Research
The Rothman Institute at Thomas
Jefferson University Interest:
Regenerative Medicine
Tissue engineering
Outcome Research
Design: Self Protective Smart Implants
Enjoys Biking, Hiking, Travel, Reading
and Opera
Contact: www.neareastspine.orgJavad Parvizi , MD, FRCS
http://www.neareastspine.org/http://www.neareastspine.org/8/7/2019 Parvizi Bone Loss
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Making Sense of Bone Loss:Revision Strategy and Techniques
Javad Parvizi MD, FRCSProfessor
Rothman Institute of Orthopedics at Thomas
Jefferson UNiversity, Philadelphia, PA
SPINE Meeting, Beirut June 24-27, 2010
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SPINE Meeting
Dr Raja Chaftari
Dr Tony Tannoury
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Parvizis Case
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Research support: NIH
OREF DOD
Aircast
MTF
Stryker Orthopaedics
Pfizer
The Knee Society
Kimberly Clark
Ortho McNeill
Adolor Cubist
3M
KCI
Consultant for: Stryker Orthopaedics
Intellectual Property: Smartech
Smith and Nephew
Stryker Orthopeadics
CyruMed
Conflict of Interest
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COMPLEX INTERPLAYPOLYETHYLENE
WEAR
CLINICALSYMPTOMS
OSTEOLYSIS
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INDIVIDUAL RESPONSE TO
WEAR DEBRIS
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Bone Loss Around THA
Preoperative work up
Treatment options
Surgical Execution
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What is the Best Method to EvaluatePolyethylene Wear?
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Determine the Remaining
Liner Thickness
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Repeat X-Ray at Optimal kV
Setting for the Pelvis
64 kV84 kV
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Retroacetabular
Stress ShieldingOr
Ostolysis
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Immediate postop 1 yr postop
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Immediate postop 10 yrs postop
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Immediate postop 11years postop
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Radiographs
underestimateOsteolysis
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Immediate postop 9 years postop
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What is the Value of CT in
Management of Osteolysis?-Can quantitate polyethylene thickness
-Can detect ischial and posterior rimosteolysis- Can detect cortical erosions (size ofbreak in medial cortical wall)- Can quantitate volume of osteolysis- Can quantitate cup support
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8 yrs postop
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28.7 cm3
Volume Measurements of Osteolysis
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Quantification of Cup Support
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Polyethylene ThicknessMeasurements
Immediate postop 6 yrs postop
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Purple: > 4 mm
Pink: 4 mm
Red: 3 mmGreen: 2 mm
Blue: 1 mm
Minimum Thickness
1.9 mm
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Bone Loss Around THA
Preoperative work up
Treatment options
Surgical Execution
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CHOICES FOR
INTERVENTION
OBSERVATION
MEDICATION
OPERATION
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OBSERVATION
KEEP AN EYE ON IT
WAIT FOR PAIN TO DEVELOP
DOCUMENT PROGRESSION
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KEEP AN EYE ON IT
WAIT FORPAIN
TO DEVELOP
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DOCUMENT PROGRESSION
HOW MUCH PROGRESSION?
HOW TO DOCUMENT PROGRESSION
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Pubic Ramus Fracture
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MEDICATION
FOSAMAX
MUTING RESPONSENOT SOLVING THE PROBLEM
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OPERATION
TIMING CHOICE OF
PROCEDURE
STAGING ACETABULAR
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STAGING ACETABULAR
OSTEOLYSIS
I WEAR ONLYIIA WEAR AND PAIN, NO LYSIS SEEN
IIB WEAR AND LYSIS, NO PAIN
III WEAR AND LYSIS AND PAIN
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STAGE I
WEAR ONLY
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STAGE IIA
WEAR AND PAIN, NO LYSIS SEEN
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STAGE IIB
WEAR AND LYSIS, NO PAIN
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STAGE III
WEAR AND LYSIS AND PAIN
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LESSONS LEARNED
EARLIER STAGE - EASIER REVISION
WHEN YOU SEE WEAR - TELLPATIENT
WHEN YOU SEE LYSIS -
REVISE PATIENT
When Do I Operate on
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When Do I Operate on
Asymptomatic Patients with Pelvic
Osteolysis?
When:
- the lesion develops rapidly (first 5
postoperative years)
- the lesion is increasing in size (serial x-
rays required)
- the lesion is eroding away cortical cup
support (CT)
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CHOICES FOR REVISION
REVISE LINER AND SHELL
REVISE LINER, LEAVE SHELL
INTACT
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LINER ONLY REVISION
CUP LOCKING MECHANISM SATISFACTORY
MAY CEMENT LINER IN PLACE
POLY THICKNESS SATISFACTORY
ORIENTATION OF CUP SATISFACTORY
ALGORITHM FOR LYSIS
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ALGORITHM FOR LYSIS
TYPE I
SOCKET STABLE
LINER REPLACEABLE
intact locking mechanism
good socket position
new liner available
poly thick enough
BONE GRAFT DEFECTS
REPLACE LINER
ALGORITHM FOR LYSIS
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ALGORITHM FOR LYSIS
TYPE II
SOCKET STABLE
LINER NOT REPLACEABLE
REVISE CUP BONE GRAFT
DEFECTS
CEMENT LINER
ALGORITHM FOR LYSIS
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ALGORITHM FOR LYSIS
TYPE III
SOCKET LOOSE
REVISE CUP
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Bone Loss Around THA
Preoperative work up
Treatment options
Surgical Execution
ACETABULAR REVISION
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ACETABULAR REVISION
Treatment Options:
Cemented sockets
Cemented socket with graft
Bipolar
Uncemented hemispherical socket
Special uncemented socketsAntiprotrusio devices
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Type IV - Pelvic Discontinuit
Acetabular Classification
Type I - Cavitary
Type II - Segmental
Type III - Combined
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Cavitary
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CM 05/25/00
Segmental
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Discontinuity
Is Component Loose?
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What Bone Graft is needed?
Will Part Fill Defects?
NO YES
Type I Revision
Type II Revision
Type III Revison
Revise Cup
Use Cementless
Cup
YESNO
SupplementalStructural
Cementless Cup
Cemented CupCage
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Surgery for Pelvic Osteolysis
If the components are stable:
- Polyethylene exchange and grafting
If components are unstable or thickness of
new polyethylene liner would be less than 6
mm:- Complete cup exchange and grafting
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Concerns with Socket Removal
- Associated bone loss
- Ability to achieve successful bone ingrowth
with the revision component
- Increased morbidity
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Concerns with Socket Retention
- High dislocation rate
- Incomplete exposure of the lytic area
- Progression of osteolytic lesion?
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I di i f C l
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Indications for Cementless
CupsSegmental Cavitary Combined
95%
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C i di i
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Contra-indications
Pelvic discontinuity
Post-irradiation
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ACETABULAR REVISION
Uncemented Sockets
How Much Bone Contact is Enough?
No clear cut data
50% rule of some value
Support around rim and dome best
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Contained Acetabular
Defects
Fill with Boneor Metal?
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Supplemental
ACETABULAR REVISION
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Technique
Dont ream too medially
Usually just let the reamer work
the rim and gently ream until
you get dome or medial wall
contact
ACETABULAR REVISION
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Technique
Most Common Error:
Failure to use a largeenough cup
ACETABULAR REVISION
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Technique
Most Common Errors:
Ream away posteriorwall
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I ti G fti
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Impaction Grafting:
Works
Requires attention to detail
Is tedious/demanding
Is a valuable tool for the revisionist
A t b l I ti G fti
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Sloof et.al.
Contain the defect (mesh)
Fresh frozen morcellized allograft
Large 10-15mm graft morsels
Vigorous impaction
Pressurized cement
Acetabular Impaction Grafting
Principles
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Immediate postop 17 yrs postop
REVISION CUPS
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REVISION CUPS
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6/25/2010
Trabecular Metal Acetabular
Components
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Summary
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Summary
Bone Loss
- Requires careful radiographic follow-
up
- CTs can help in decision making
- The algorithm for management of
osteolysis is evolving
Thank You
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Thank You