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PATOLOGIA DELL’ARTROSI COXOFEMORALE:
IL BONE-LOSSNELLA CHIRURGIA PROTESICA DI REVISIONE
Stefano ZanasiPoliclinico di Monza
IV Unità Operativa di Ortopedia Responsabile: Dr. Stefano Zanasi
e-mail: [email protected]
STEFANO ZANASI
REVISION HIP ARTHROPLASTY
NEEDS
TO RECOGNIZE BONE LOSS
REVISION HIP ARTHROPLASTY
NEEDS
TO RECOGNIZE BONE LOSS
REVISION HIP ARTHROPLASTY
NEEDS
OF BONE-LOSS CLASSIFICATION
REVISION HIP ARTHROPLASTY
NEEDS
OF BONE-LOSS CLASSIFICATION
•PRE-OPERATIVE PLANNING
•COMMON LANGUAGE for REPORTING SURGICAL RESULTS
( A.A.O.S. COMMITEE ON THE HIP, 1993 )
•PRE-OPERATIVE PLANNING
•COMMON LANGUAGE for REPORTING SURGICAL RESULTS
( A.A.O.S. COMMITEE ON THE HIP, 1993 )
BONE-LOSSCLASSIFICATION
BONE-LOSSCLASSIFICATION
• Engelbrecht ( 1987 ) - Oakeshott et Coll. (1987)• Gustilo-Pasternak (1988) - Mallory et Coll. (1988)• Engh et Coll. ( 1988 ) - Schmitt et Coll. (1992)• Tanzer et Coll. ( 1992 ) - Pipino - Molfetta (1992)• Gross et Coll. (1993 - Paprosky et Coll. (1993)° Chandler et Coll. (1989) - D’Antonio et Coll. (1995)
• Engelbrecht ( 1987 ) - Oakeshott et Coll. (1987)• Gustilo-Pasternak (1988) - Mallory et Coll. (1988)• Engh et Coll. ( 1988 ) - Schmitt et Coll. (1992)• Tanzer et Coll. ( 1992 ) - Pipino - Molfetta (1992)• Gross et Coll. (1993 - Paprosky et Coll. (1993)° Chandler et Coll. (1989) - D’Antonio et Coll. (1995)
BONE LOSSCLASSIFICATIONS
BONE LOSSCLASSIFICATIONS
• COMPLEXITY
• RELATED to IMAGING
• MANY CASES BORDERLINE
• INTRAOPERATIVE DEVELOPMENT OF BONE INTRAOPERATIVE DEVELOPMENT OF BONE DEFECTSDEFECTS
• COMPLEXITY
• RELATED to IMAGING
• MANY CASES BORDERLINE
• INTRAOPERATIVE DEVELOPMENT OF BONE INTRAOPERATIVE DEVELOPMENT OF BONE DEFECTSDEFECTS
difficulty in applicationdifficulty in application
LIMITS ofCLASSIFICATIONS
LIMITS ofCLASSIFICATIONS
The BONE-LOSSCLASSIFICATION
in hip revision surgery
The BONE-LOSSCLASSIFICATION
in hip revision surgeryItalian Society of Revision Surgery-GIRItalian Society of Revision Surgery-GIR
° Loosening° Loosening
° Enlargement and ° Enlargement and deformation of deformation of acetabulumacetabulum
° Loosening° Loosening
° Enlargement and ° Enlargement and deformation of deformation of acetabulumacetabulum
GRADE I GRADE II GRADE GRADE I GRADE II GRADE IIIIII GRADE I GRADE II GRADE GRADE I GRADE II GRADE IIIIII° Loosening° Loosening
° Enlargement and ° Enlargement and deformation of deformation of acetabulumacetabulum • NONO wall defectwall defect
° Loosening° Loosening
° Enlargement and ° Enlargement and deformation of deformation of acetabulumacetabulum • NONO wall defectwall defect Defect inDefect in ONE ONE wallwallDefect inDefect in ONE ONE wallwall Defect inDefect in TWOTWO--
MOREMORE wallswallsDefect inDefect in TWOTWO-- MOREMORE wallswalls
GRADE IVGRADE IVGRADE IVGRADE IV
MASSIVEMASSIVEand and OVERALLOVERALLPeriacetab.Periacetab. DefectDefect
MASSIVEMASSIVEand and OVERALLOVERALLPeriacetab.Periacetab. DefectDefect
ACETABULAR BONE-LOSSACETABULAR BONE-LOSS
° Loosening° Loosening
° Enlargement and ° Enlargement and deformation of deformation of acetabulumacetabulum
Proximal canalProximal canal enlargement enlargement with corticalwith cortical thinningthinning
NONO cortical cortical zonezone defectdefect
Proximal canalProximal canal enlargement enlargement with corticalwith cortical thinningthinning
NONO cortical cortical zonezone defectdefect
Proximal canalProximal canalenlargement enlargement with corticalwith cortical thinningthinning
Proximal canalProximal canalenlargement enlargement with corticalwith cortical thinningthinning
Defect in Defect in ONEONE cortical zonecortical zoneDefect in Defect in ONEONE cortical zonecortical zone
Defect inDefect in TWOTWO oror MOREMORE zoneszones
Defect inDefect in TWOTWO oror MOREMORE zoneszones
Proximal canalProximal canalenlargement enlargement with corticalwith corticalthinningthinning
Proximal canalProximal canalenlargement enlargement with corticalwith corticalthinningthinning
PROXIMAL PROXIMAL CIRCUMFE-CIRCUMFE-RENTIAL &RENTIAL &MASSIVEMASSIVE DefectDefect
PROXIMAL PROXIMAL CIRCUMFE-CIRCUMFE-RENTIAL &RENTIAL &MASSIVEMASSIVE DefectDefect
GRADE I GRADE II GRADE GRADE I GRADE II GRADE IIIIII GRADE I GRADE II GRADE GRADE I GRADE II GRADE IIIIII
GRADE IVGRADE IVGRADE IVGRADE IV
FEMORAL BONE-LOSSFEMORAL BONE-LOSS
• Loosening
• Enlargement and deformation of acetabulum NO WALL DEFECT
• Loosening
• Enlargement and deformation of acetabulum NO WALL DEFECT
Host bone CAN CONTAINthe cup and ensure its stability.
C.O.R. is not (or slightly) translated
Host bone CAN CONTAINthe cup and ensure its stability.
C.O.R. is not (or slightly) translated
ACETABULAR BONE-LOSS(Grade I – cavitary defect)
ACETABULAR BONE-LOSS(Grade I – cavitary defect)
SURGICALSURGICAL STRATEGYSTRATEGY
SURGICALSURGICAL STRATEGYSTRATEGY
FILLINGFILLING of the cavity of the cavity FILLINGFILLING of the cavity of the cavity
(Larger or (Larger or elliptical elliptical cups, Cement, cups, Cement, Bone chips, Bone chips, etc.)etc.)
(Larger or (Larger or elliptical elliptical cups, Cement, cups, Cement, Bone chips, Bone chips, etc.)etc.)
ACETABULAR BONE-LOSS (Grade I)
ACETABULAR BONE-LOSS (Grade I)
Loosening Loosening • Enlargement and Enlargement and deformation of deformation of acetabulumacetabulum
Defect in Defect in ONEONE WALL WALL
Loosening Loosening • Enlargement and Enlargement and deformation of deformation of acetabulumacetabulum
Defect in Defect in ONEONE WALL WALL
Host bone Host bone MAY NOT CONTAINMAY NOT CONTAIN
the Cupthe Cup
C.O.R. always translatedC.O.R. always translated
Host bone Host bone MAY NOT CONTAINMAY NOT CONTAIN
the Cupthe Cup
C.O.R. always translatedC.O.R. always translated
ACETABULAR BONE-LOSS (Grade II )
ACETABULAR BONE-LOSS (Grade II )
SURGICALSURGICAL
STRATEGYSTRATEGY
SURGICALSURGICAL
STRATEGYSTRATEGY
RECONSTRUCTIONRECONSTRUCTION of the of the
DISRUPTED WALLDISRUPTED WALL
((Rings, Cages, Conventional or Rings, Cages, Conventional or Jambo cup, Bone grafts, etcJambo cup, Bone grafts, etc.).)
RECONSTRUCTIONRECONSTRUCTION of the of the
DISRUPTED WALLDISRUPTED WALL
((Rings, Cages, Conventional or Rings, Cages, Conventional or Jambo cup, Bone grafts, etcJambo cup, Bone grafts, etc.).)
ACETABULAR BONE-LOSS (Grade II)
ACETABULAR BONE-LOSS (Grade II)
a
b
c
- Host bone CAN'T CONTAIN the CUP
- DEFECT of SUPPORTING WALL
- ARTICULAR BIOMECHANICS ALTERED
- Host bone CAN'T CONTAIN the CUP
- DEFECT of SUPPORTING WALL
- ARTICULAR BIOMECHANICS ALTERED
ACETABULAR BONE-LOSS (Grade III)
ACETABULAR BONE-LOSS (Grade III)
• LooseningLoosening
• Enlargement and Enlargement and deformation of deformation of acetabulumacetabulum • Defect in Defect in TWO orTWO or MOREMORE WALLS WALLS
• LooseningLoosening
• Enlargement and Enlargement and deformation of deformation of acetabulumacetabulum • Defect in Defect in TWO orTWO or MOREMORE WALLS WALLS
CUP ANCHORAGE in intact bone
( Rings, Cages, Conventional or Jumbo cup, Stemmed cup,Oblong or asymetric cups,
Morsellized bone grafts, etc. )
CUP ANCHORAGE in intact bone
( Rings, Cages, Conventional or Jumbo cup, Stemmed cup,Oblong or asymetric cups,
Morsellized bone grafts, etc. )
ACETABULAR BONE-LOSS (Grade III)
ACETABULAR BONE-LOSS (Grade III)
SURGICALSURGICAL
STRATEGYSTRATEGY
SURGICALSURGICAL
STRATEGYSTRATEGY
Host bone CAN’T CONTAIN the cup
Host bone CAN’T CONTAIN the cup
Biomechanics is deeply alteredBiomechanics is deeply altered
ACETABULAR BONE-LOSS (Grade IV)
ACETABULAR BONE-LOSS (Grade IV)
MASSIVE MASSIVE andand
OVERALLOVERALLPERIACETABULARPERIACETABULARDefectsDefects
(hemipelvis fracture)(hemipelvis fracture)
MASSIVE MASSIVE andand
OVERALLOVERALLPERIACETABULARPERIACETABULARDefectsDefects
(hemipelvis fracture)(hemipelvis fracture)
ANCHORAGE in the superior wall ANCHORAGE in the superior wall
(Rings, Cages, Stemmed cups, Allografts, etc. )(Rings, Cages, Stemmed cups, Allografts, etc. )
ACETABULAR BONE-LOSS (Grade IV)
ACETABULAR BONE-LOSS (Grade IV)
SURGICALSURGICAL
STRATEGYSTRATEGY
SURGICALSURGICAL
STRATEGYSTRATEGY
PROXIMAL FEMUR CAN’T CONTAIN the stem
Biomechanics is not altered ( leg length, muscle balance, head/neck offset )
PROXIMAL FEMUR CAN’T CONTAIN the stem
Biomechanics is not altered ( leg length, muscle balance, head/neck offset )
FEMORAL BONE-LOSS (Grade I – cavitay defect)
FEMORAL BONE-LOSS (Grade I – cavitay defect)
Proximal canalenlargementwith corticalthinning
NO CORTICALZONE Defect
FEMORAL BONE-LOSS (Grade I)
FEMORAL BONE-LOSS (Grade I)
SURGICALSURGICAL
STRATEGYSTRATEGY
SURGICALSURGICAL
STRATEGYSTRATEGY
FILLING of the femoral canal
(larger and longer stem, cement, morsellized grafts, etc.
Restoring the appropriatehead-neck offset
FILLING of the femoral canal
(larger and longer stem, cement, morsellized grafts, etc.
Restoring the appropriatehead-neck offset
Proximal femur MAY CONTAIN the stem and ensure its stability.
Biomechanics is partially compromised
Proximal femur MAY CONTAIN the stem and ensure its stability.
Biomechanics is partially compromised
FEMORAL BONE-LOSS (Grade II – segmental defect)
FEMORAL BONE-LOSS (Grade II – segmental defect)
Defect in ONECORTICALZONE
(Lesser trochanter,reabsorption,osteolysis, perforation,window, etc.)
RECONSTRUCTION of cortical defect (bone grafts, proximal anchorage with long stem, ev. cerclages )
Restoring the appropriate head/neck offset
RECONSTRUCTION of cortical defect (bone grafts, proximal anchorage with long stem, ev. cerclages )
Restoring the appropriate head/neck offset
SURGICALSURGICAL
STRATEGYSTRATEGY
SURGICALSURGICAL
STRATEGYSTRATEGY
FEMORAL BONE-LOSS (Grade II)
FEMORAL BONE-LOSS (Grade II)
Proximal femur CAN'T CONTAIN and
STABILIZE the stem
Biomechanical ability is significantly compromised
Proximal femur CAN'T CONTAIN and
STABILIZE the stem
Biomechanical ability is significantly compromised
FEMORAL BONE-LOSS (Grade III)
FEMORAL BONE-LOSS (Grade III)
Defect of TWO orMORE ZONES
total PROXIMALCIRCUNFERENTIALdefect
ANCHORAGE in INTACT BONE (Below the defect)
Modular or Custom-made stems Distal anchorage stems Massive allografts,
ANCHORAGE in INTACT BONE (Below the defect)
Modular or Custom-made stems Distal anchorage stems Massive allografts,
FEMORAL BONE-LOSS (Grade III)
FEMORAL BONE-LOSS (Grade III)
SURGICALSURGICAL
STRATEGYSTRATEGY
SURGICALSURGICAL
STRATEGYSTRATEGY
Proximal bone CAN’ T CONTAIN the stem
Biomechanical ability is significantly compromized
Proximal bone CAN’ T CONTAIN the stem
Biomechanical ability is significantly compromized
FEMORAL BONE-LOSS (Grade IV)
FEMORAL BONE-LOSS (Grade IV)
PROXIMALCIRCUNFERENTIALMASSIVEdefect
ANCHORAGE the stem in distal bone
ANCHORAGE the stem in distal bone
Massive allografts, Distal anchorage stems, Modular stems (tumor prosth.)
Massive allografts, Distal anchorage stems, Modular stems (tumor prosth.)
FEMORAL BONE-LOSS (Grade IV)
FEMORAL BONE-LOSS (Grade IV)
SURGICALSURGICAL
STRATEGYSTRATEGY
SURGICALSURGICAL
STRATEGYSTRATEGY
Grazie
