Uncemented thr.....the debate

Debate in favour of uncemented total hip replacement

1. UNCEMENTED TOTAL HIP REPLACEMENT DR SABYASACHI BARDHAN Consultant Trauma & Joint Replacement Surgeon

2. INTRODUCTION THR is a very successful orthopaedic procedure Total hip replacement development began with cementless THR . McKee and Watson-Farrar documented an early model of an artificial hip joint between 1956 and 1960.[#] Charnley’s Low Friction Arthroplasty emerged as GOLD STANDARD # McKee GK, Watson-Farrar J. Replacement of arthritic hips by the McKee-Farrar prosthesis. J Bone Joint Surg Br 1966;48: 245–59 .

3. Outcomes of other cemented THR procedures were markedly poor Loosening occurred in 34% at 7.4 years after surgery using the Charnley-Müller type ; 40% at 10 years after surgery using the Müller type Cementless THR was developed in the late 1960s Smooth Surface: Poor outcome The development of material engineering during the 1980s completely changed the condition because materials that allow bone ingrowth became available . Kawamoto K, Hasegawa Y, Iwase T, Iwasada S, Kanamono T, Iwata H. Failed cementless total hip arthroplasty for osteoarthrosis due to hip dysplasia: a minimum fi ve -year follow-up study. Bull Hosp Joint Dis 1998;57:130–5 .

4. PRINCIPLE OSTEOINTEGRATION: bone ingrowth & ongrowth Implant design, Appropriate surface treatment, Primary mechanical stability, and Patient’s osteogenesis

5. Femoral Stems Mont Group Classification a) Single Wedge b) Double wedge metaphyseal filling c) Tapered d) Cylindrical fully coated e) Modular f) Anatomic

6. Acetabular Cups 1st generation 2nd generation 3rd generation

7. WHY UNCEMENTED

8. ASEPTIC LOOSENING Commonest cause of failure (51.9%) [ Int Orthop . 2008 Oct; 32(5): 597–604.Published online 2007 Apr 19]

9. CEMENTATION Exacting process Difficult to master Variability Steep learning Curve- needs 4 months to train a junior – BOA Seminar 2010 FEMORAL CEMENTING TECHNIQUES: CURRENT TRENDS IN THE UK Ann R Coll Surg Engl 2006; 88 : 127–130 However , inconsistencies in the time-dependent material properties of cement remain a cause of concern . Uncontrolled and inconsistent temperature is an important contributing factor.

10. Caton J, Papin P. Total Hip Arthroplasty in France Typologie et épidémiologie des prothèses totales de hanche en France.  e- mémoires de l’Académie Nationale de Chirurgie .  2012;11:1–7. It is recommended nowadays not to use a cemented titanium stem because it can generate tremendous amount of Ti debris once loosened, and to use proximally or fully hydroxyapatite -coated cementless titanium stem Ollivere B, Wimhurst JA, Clark IM, Donell ST. Current concepts in osteolysis .  J Bone Joint Surg Br.  2012;94:10–15  low dose of ultra-high molecular weight polyethylene (UHMWPE) or PMMA particles (0.63 mg/ mL ) displayed strong alkaline phosphatase activity

11. J Orthop Res.   2011 May;29(5):781-6. doi : 10.1002/jor.21287. Epub 2010 Dec 7 . Polymethylmethacrylate and titanium alloy particles activate peripheral monocytes during periprosthetic inflammation and osteolysis . Yang SY 1 ,  Zhang K ,  Bai L ,  Song Z ,  Yu H ,  McQueen DA ,  Wooley PH PMMA readily activate peripheral monocytes and promote the cell trafficking to the debris-containing prosthetic tissues. Acta Orthop 2005; 76: 375 – 385 . Hydroxyapatite coating of the prosthesis may prevent osteolysis following injection of intra-articular particles by sealing the implant-bone interface from their ingression though the promotion of osseointegration at this interface

12. MORTALITY Donaldson ;British Journal Anaesth 2009 Recommends avoid cemented implants in elderly /IHD /COPD Scandinavian Journal of Surgery 102: 124–128, 2013 T. Yli-Kyyny et al perioperative cardiovascular disturbances occur when modular cemented stems are used in hip fracture patients

13. JBJS.Br 1987 Jan 69(1): 45-55

14. Uncemented proximally coated stems showed significant better long term survivorship than its cemented counterpart Cemented Versus Cementless Stems: A Verdict Is In Robert B. Bourne, MD, FRCSC; Kristoff Corten , MD Orthopedics September 2010 - Volume 33 · Issue 9 SURVIVORSHIP

15. SURVIVORSHIP New Zealand Joint Registry 13 yrs FU : Kaplan-Meier survival curve – Uncemented long term survival was better in young and those over 70 yrs

16. SURVIVORSHIP

17. Orthopedic Reviews 2013; volume 5:e8: Cemented versus uncemented fixation in total hip replacement: a systematic review and meta-analysis of randomized controlled trials :Ali Abdulkarim , et al SURVIVORSHIP

18. Aseptic loosening of the acetabular component in relation to the positioning of prosthesis Shishir Rastogi ,   V Trikha ,   S Bhan ,   C Bal All India Institute of Medical Sciences, New Delhi, India Forty-eight patients having 64 cemented or cementless total hip arthroplasties were followed up. The follow up period ranged from 18 to 120 months (mean 37 months). The overall clinical outcome was better in cementless than in cemented prostheses . SURVIVORSHIP Factors affecting aseptic loosening of 4750 total hip arthroplasties : multivariate survival analysis BMC Musculoskeletal Disorders 2007 8 :69 cemented cups and stems have a higher risk of failure compared with uncemented

19. PERIPROSTHETIC FRACTURE We found a high incidence of early PPF associated with the CPT stem in this old and frail patient group. A possible explanation may be that the polished tapered stem acts as a wedge, splitting the femur after a direct hip contusion.

20. The postoperative fracture prevalence for cemented primary arthroplasties was 0.6% of the 17,579 cemented primary arthroplasties and 0.4% of the 2,078 uncemented primary arthroplasties 2.8% of fractures occurring in the 3,265 cemented revision cases and 1.5% of the 1,132 uncemented revision cases

21. PERIPROSTHETIC FRACTURE B2 loose stem; good bone o Fixation alone will not work o Revise the femoral component ,+/- strut allograft, +/- plates o Best results seen with patients revised with uncemented, extensively porous coated femoral stems o May also consider use modular, fluted taper stems § Need good quality intact diaphyseal bone to engage the taper. § The more proximal the intact diaphysis the better § Consider placing a cerclage around intact bone Periprosthetic Fractures Around THA – When/How to fix, When to Revise Boot Camp 2013 Phoenix, AZ ota.org/media/80921/14-Horwitz-Periprosthetic-Fx.pdf

22. Geriatr Orthop Surg Rehabil . 2012 Sep; 3(3): 107 – 120. doi :    10.1177/2151458512462870 A Review of Periprosthetic Femoral Fractures Associated With Total Hip Arthroplasty Daniel Marsland , MRCS, MSc (SEM) 1   and   Simon C. Mears , MD, PhD Revision of a loose stem has traditionally been performed with a long-stem cemented prosthesis , although complication rates can be high. only 60% of patients had a stable implant with fracture union. PERIPROSTHETIC FRACTURE

23. CONCLUSION Growing popularity and acceptance Survivorship: comparable in elderly , better for young patients Easier to master Shorter surgery Safer than cemented hip Better results in periprosthetic fractures

24. THANK YOU