Parvizi Bone Loss

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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/


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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



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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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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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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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REVISION CUPS


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REVISION CUPS


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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

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Parvizi Bone Loss