“evolution of the modern hip replacement” prof eric ... · cementing technique was frequent....
TRANSCRIPT
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Saturday November 17th Silver Springs Hotel Cork
“Evolution of the Modern Hip Replacement”
Prof Eric Masterson, Consultant Orthopaedic Surgeon, Bon Secours Health System, Irish representative to the European Hip Society
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The Evolution of the Modern Total Hip Replacement
Professor Eric Masterson BSc MCh FRCSI FRCS(Orth)
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• 1800 – 1900s – Surgeons used various tissues, fascia lata, skin, pig
bladder and submucosa between the femoral head and acetabulum
• 1891 German surgeons (Gluck) used ivory to replace femoral head
for patients who’s femoral heads were destroyed by tuberculosis
History of Total Hip Replacement
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• 1925 – Smith- Peterson created first mould prosthesis out of glass
• 1930s – Smith-Peterson and Wiles trialled stainless steel prosthesis
• 1938 – Judet developed short stemmed acrylic prosthesis
• 1938 – Wiles total hip utilises nail and plate.
• 1939 – Thompson and Moore developed monobloc femoral stems
History of Total Hip Replacement
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• 1947 – Scott-Venable developed Vitallium prosthesis
• 1951 – Haboush implanted first metal on metal resurfacing
• 1951 – McKee develops first cementless metal on metal THR
• 1956 – Sivash developed cementless THR
History of Total Hip Replacement
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• 1960s – Charnley starts to develop low friction arthroplasty
• PTFE Double cup implant
• Numerous materials (Teflon, plastic)
• Acrylic resin as method of fixation
• 22mm articulation
• High molecular weight polyethylene (HMWPE)
• ‘Greenhouse’ clean air enclosure
History of Total Hip Replacement
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• 1960s
• Peter Ring develops cementless MoM
• McKee/Farrar develops first cemented metal on metal
• Metal and metal from Sulzer
• Huggler & Muller
History of Total Hip Replacement
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History of Total Hip Replacement
• 1966 – Muller doesn’t want to follow same route as Charnley
and develops curved Muller stem with 28 & 32mm
articulation
• 1970 – Boutin develops ceramic on ceramic
• 1977 – Muller develops the straight stem
• 1977 – Boutin develops modular ceramic bearing
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History of Total Hip Replacement
• 1970s – Smith-Peterson cemented metal on poly resurfacing
• 1970 – First Exeter hip stem implanted (tapered, polished)
• 1970 – Ring metal on metal
• 1971 – Judet develops prosthesis with ‘direct anchoring’
• 1971 – Freeman & Furuya conduct poly on metal resurfacing
• 1972 – Zimmer GB launch Stanmore Stem
• 1974 – Lord develops prosthesis with balls for cementless
fixation
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• 1970s see development in differing cement philosophies
• Taper slip (Exeter, CPT etc)
• Full cement mantle (2-4mm) and stem subsidence
• Composite Beam (Stanmore, Charnley)
• Perfect bonding at the stem-cement interface. Contact
between stem and bone in M/L plane aims to promote
additional stability
• French paradox
History of Total Hip Replacement
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• 1970s Cement disease
• Early failure of cemented stems with first generation
cementing technique was frequent.
• Attributed to localised areas of bone destruction and
resorption. (osteolysis)
• Intially thought to be infection, but was subsequently
attributed to local inflammatory response to cement
particles
History of Total Hip Replacement
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• 1970s rise in cementless stem development
• Lord
• Judet
• Autophor Mittlemeier
History of Total Hip Replacement
Gerard Lord AutophorMittelmeier
Judet
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• 1970s rise in cementless stem development
• Full circumferential fixation
• Distal fixation/loading of the femur
• Stress loading in diaphysis = thigh pain
• Oseopenia
• Proximal bone resorption
History of Total Hip Replacement
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History of Total Hip Replacement
• 1977 – Engh and Zweymueller development cementless stems
• 1978 – Wagner develops metal on poly resurfacing
• 1980s – Sulzer metal on metal
• 1980s – Second generation cementing technique
• 1983 – Biomet launch Taperloc with plasma sprayed titanium coating
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History of Total Hip Replacement
• 1980 cementless components evolve because of ‘particle disease’
• Stems incorporate circumferential coating to aid osseo-
intergration
• Cups designs vary on geography
• Threaded versus coated?
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• 1987 – Wagner introduced long splined revision stem
• 1988 – Exeter modular stem launched
• 1990 – Zimmer launch CPT
• 1990’s – Introduction of highly cross linked polyethylene (HXLPE)
• 1990’s – Corin introduce Birmingham metal on metal resurfacing
• 1991 – 3M launch Capital Hip (Low cost Charnley hip copy)
• 1995 – CeramTec launch Biolox Forte ceramic
• 1999 – Implex introduce Hydrocel to market (Trabecular metal)
History of Total Hip Replacement
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• 2002 – ODEP set up to monitor NICE hip guidelines
• 2002 – National Joint Registry for England and Wales
• 2004 – CeramTec launch Biolox delta ceramic
• 2005 – DePuy launch ASR
• 2005 – Total Hip Replacement reclassified as Class 3 Device
• 2010 – Biomet launch first vitamin E stabilised polyethylene
• 2014 – Beyond Compliance set up to help reduce risk
History of Total Hip Replacement
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The Five R’s
• 1. Resection
• 2. Realignment
• 3. Replacement
• 4. Resurfacing
• 5. Arthrodesis
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Girdlestone Arthroplasty
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Intertrochanteric osteotomy
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Periacetabular Osteotomy
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Hip arthrodesis
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JUDET
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McKEE-FARRAR
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HOWSE
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Ring Prosthesis
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Fixation Techniques
Cement Versus No Cement
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Cementing Techniques
1st generation: digital insertion
2nd generation: canal occlusion, thorough bone cleaning, cement gun
3rd generation: vacuum mixing, centrifuge cement, centralisers
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SOLUTION
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HARRIS-GALANTE II
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G7 Instruments and Surgical Technique
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• Uncemented THRs are quicker
• Uncemented cups last longer
• Well cemented & Uncemented stems are equivalent
• Cemented stems have a role in old, soft bone
• Cemented components are cheaper
Cemented or UncementedImplants?
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Bearing Surfaces in Total Hip Replacement:
Metal
Plastic
Ceramic
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Polyethylene liners
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Metal Liners
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Developed in conjunction with healthcare professionals.
G7 ACETABULAR SYSTEMSurgical Technique
Ceramic liners
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The Hip Resurfacing Experiment
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Birmingham Hip Resurfacing
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Hip Resurfacing
• Birmingham Hip Resurfacing still in production
• ASR (De Puy) withdrawn
• Technically demanding
• Inferior Registry Data
• Concerns over Chromium & Cobalt ion levels
• Concerns over ARMD, ALVAL
• The Lawyers dream
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Choice of Surgical Approach to the Hip
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Minimally Invasive Hip Replacement
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Minimall Invasive THR
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Minimally Invasive Hip Replacement
• Industry-led
• Inappropriate marketing tool
• Higher complication rates
• Reductions in inpatient stay from improved patient education, not smaller skin incisions
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• The Patient
• The Surgeon
• The Healthcare Provider
Choosing a THR in 2018
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• Allow normal function
• Never loosen
• Never wear out
• Never dislocate
• Never become infected
Patient perspective:
“My THR should..”
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• Ease of insertion• Immediate
stability• Friendly
instruments• Sufficient
modularity• Allow normal
bone loading
Surgeon Perspective
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Value For Money
Healthcare Provider Perspective
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• Predictable osseointegration
• Initial stability
• Cemented implants for the elderly
• Minimal wear-related osteolysis
Patient: “My THR should never come loose”
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• Range of head sizes
• Minimize cup/stem impingement
• Compromise between head size & liner thickness
• Availability of constrained & dual-mobility options
Patient: “My THR should never dislocate”
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Bearing Surfaces appropriate to age and activity level
Metal/Polyethylene
Metal/Metal
Ceramic/Polyethylene
Ceramic/Ceramic
Patient: My THR should never wear out
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• General anti-infection measures
• Antibiotic-impregnated bone cement
• Anti-bacterial coatings on uncementedimplants
Patient: “My THR should never become infected”
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• Easy instruments
• Predictable initial scratchfit
• Predictable liner locking mechanism
• Range of screw & liner options
• Sufficient size range
• Good porous ingrowth surface
Surgeon requirements: The Acetabular Component
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• Sufficient range of stems to fill the medullary canal & reproduce offset
• Proximal porous coating with metaphyseal loading preferable
• Predictable initial stability to allow immediate weight-bearing
• Predictable porous ingrowth surface
• Availability of cemented options for elderly bone
Surgeon requirements: Femoral Components
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And finally, the
healthcare provider…
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It’ a battle…
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Future Challenges
• We now have a predictable THR with 99% good results at 10 years
• Minor technical improvements will continue
• The main challenge lies in future population demographics
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We are facing huge challenges
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Garry likes his shooting...
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Thank You