PATOLOGIA DELL’ARTROSI COXOFEMORALE:
IL BONE-LOSS
NELLA CHIRURGIA PROTESICA DI REVISIONE
Stefano Zanasi
Policlinico di Monza
IV Unità Operativa di Ortopedia
Responsabile: Dr. Stefano Zanasi
e-mail: zanasis.orth@virgilio.it
STEFANO ZANASI
REVISION HIP ARTHROPLASTY
NEEDS
TO RECOGNIZE BONE LOSS
REVISION HIP ARTHROPLASTY
NEEDS
OF BONE-LOSS CLASSIFICATION
BONE-LOSS
CLASSIFICATION
• PRE-OPERATIVE PLANNING
• COMMON LANGUAGE for
REPORTING SURGICAL RESULTS
( A.A.O.S. COMMITEE ON THE HIP, 1993 )
BONE LOSS
CLASSIFICATIONS
•
•
•
•
•
°
Engelbrecht ( 1987 )
Gustilo-Pasternak (1988)
Engh et Coll. ( 1988 )
Tanzer et Coll. ( 1992 )
Gross et Coll. (1993
Chandler et Coll. (1989)
- Oakeshott et Coll. (1987)
- Mallory et Coll. (1988)
- Schmitt et Coll. (1992)
- Pipino - Molfetta (1992)
- Paprosky et Coll. (1993)
- D’Antonio et Coll. (1995)
LIMITS of
CLASSIFICATIONS
• COMPLEXITY
difficulty in application
• RELATED to IMAGING
• MANY CASES BORDERLINE
• INTRAOPERATIVE DEVELOPMENT OF BONE
DEFECTS
The BONE-LOSS
CLASSIFICATION
in hip revision surgery
Italian Society of Revision Surgery-GIR
ACETABULAR BONE-LOSS
GRADE I
° Loosening
GRADE II
° Loosening
° Enlargement and ° Enlargement and
deformation of
deformation of
acetabulum
acetabulum
GRADE III
° Loosening
° Enlargement and
deformation of
acetabulum
Defect in TWO• NO wall defect Defect in ONE wall
MORE walls
GRADE IV
MASSIVE
and
OVERALL
Periacetab.
Defect
FEMORAL BONE-LOSS
GRADE I
Proximal canal
enlargement
with cortical
thinning
NO cortical
zone defect
GRADE II
GRADE III
Proximal canal
enlargement
with cortical
thinning
Proximal
canal
enlargement
with cortical
thinning
Defect in TWO
or MORE
zones
Defect in ONE
cortical zone
GRADE IV
PROXIMAL
CIRCUMFERENTIAL &
MASSIVE
Defect
ACETABULAR BONE-LOSS
(Grade I – cavitary defect)
• Loosening
Host bone CAN CONTAIN
the cup and ensure its
stability.
• Enlargement and
deformation of
acetabulum
NO WALL DEFECT
C.O.R. is not (or slightly)
translated
ACETABULAR BONE-LOSS
(Grade I)
FILLING of the cavity
SURGICAL
STRATEGY
(Larger or elliptical
cups, Cement, Bone
chips, etc.)
ACETABULAR BONE-LOSS
(Grade II )
Loosening
• Enlargement and
deformation of
acetabulum
Defect in
ONE WALL
Host bone
MAY NOT CONTAIN
the Cup
C.O.R. always translated
ACETABULAR BONE-LOSS
(Grade II)
SURGICAL
RECONSTRUCTION
of the
DISRUPTED WALL
STRATEGY
(Rings, Cages, Conventional or
Jambo cup, Bone grafts, etc.)
b
a
c
ACETABULAR BONE-LOSS
(Grade III)
• Loosening
- Host bone CAN'T
CONTAIN the CUP
• Enlargement and
deformation of
acetabulum
- DEFECT of
SUPPORTING WALL
• Defect in TWO or
MORE WALLS
- ARTICULAR BIOMECHANICS
ALTERED
ACETABULAR BONE-LOSS
(Grade III)
SURGICAL
STRATEGY
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 IV)
MASSIVE
and
OVERALL
PERIACETABULAR
Defects
(hemipelvis fracture)
Host bone
CAN’T CONTAIN
the cup
Biomechanics is
deeply altered
ACETABULAR BONE-LOSS
(Grade IV)
SURGICAL
STRATEGY
ANCHORAGE in the
superior wall
(Rings, Cages, Stemmed
cups, Allografts, etc. )
FEMORAL BONE-LOSS
(Grade I – cavitay defect)
Proximal canal
enlargement
with cortical
thinning
NO CORTICAL
ZONE Defect
PROXIMAL FEMUR
CAN’T CONTAIN
the stem
Biomechanics is not altered
( leg length, muscle balance,
head/neck offset )
FEMORAL BONE-LOSS
(Grade I)
FILLING of the femoral canal
SURGICAL
STRATEGY
(larger and longer stem, cement,
morsellized grafts, etc.
Restoring the appropriate
head-neck offset
FEMORAL BONE-LOSS
(Grade II – segmental defect)
Defect in ONE
CORTICAL
ZONE
(Lesser trochanter,
reabsorption,
osteolysis, perforation,
window, etc.)
Proximal femur MAY
CONTAIN the stem
and ensure its stability.
Biomechanics is
partially compromised
FEMORAL BONE-LOSS
(Grade II)
SURGICAL
RECONSTRUCTION
of cortical defect
(bone grafts, proximal anchorage
with long stem, ev. cerclages )
STRATEGY
Restoring the appropriate
head/neck offset
FEMORAL BONE-LOSS
(Grade III)
Defect of TWO or
MORE ZONES
Proximal femur
CAN'T CONTAIN and
STABILIZE the stem
total PROXIMAL
CIRCUNFERENTIAL
defect
Biomechanical ability
is significantly compromised
FEMORAL BONE-LOSS
(Grade III)
ANCHORAGE in INTACT BONE
(Below the defect)
SURGICAL
STRATEGY
Modular or Custom-made stems
Distal anchorage stems
Massive allografts,
FEMORAL BONE-LOSS
(Grade IV)
PROXIMAL
CIRCUNFERENTIAL
MASSIVE
defect
Proximal bone
CAN’ T CONTAIN
the stem
Biomechanical ability
is significantly compromized
FEMORAL BONE-LOSS
(Grade IV)
SURGICAL
STRATEGY
ANCHORAGE the stem
in distal bone
Massive allografts,
Distal anchorage stems,
Modular stems (tumor prosth.)
Grazie