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

Javad Parvizi , MD, FRCS and Opera
• Contact: www.neareastspine.org
Making Sense of Bone Loss:
Revision Strategy and Techniques
Javad Parvizi MD, FRCS
Professor
Rothman Institute of Orthopedics at Thomas
Jefferson UNiversity, Philadelphia, PA

SPINE Meeting, Beirut June 24-27, 2010

 SPINE Meeting

 Dr Raja Chaftari
 Dr Tony Tannoury
Parvizi’s Case
 Conflict of Interest
 Research support:
 NIH
 OREF
 DOD  Consultant for:
 Aircast  Stryker Orthopaedics
 MTF
 Stryker Orthopaedics
 Pfizer  Intellectual Property:
 The Knee Society  Smartech
 Kimberly Clark  Smith and Nephew
 Ortho McNeill
 Stryker Orthopeadics
 Adolor
 Cubist  CyruMed
 3M
 KCI
COMPLEX INTERPLAY
POLYETHYLENE
WEAR

CLINICAL OSTEOLYSIS
SYMPTOMS
INDIVIDUAL RESPONSE TO
WEAR DEBRIS
 Bone Loss Around THA

Preoperative work up
Treatment options

Surgical Execution
What is the Best Method to Evaluate
Polyethylene Wear?
Determine the Remaining
Liner Thickness
Repeat X-Ray at Optimal kV
Setting for the Pelvis

64 kV 84 kV
Retroacetabular
Stress Shielding
Or
Ostolysis
Immediate postop 1 yr postop
Immediate postop 10 yrs postop
Immediate postop 11years postop
Radiographs
underestimate
Osteolysis
Immediate postop 9 years postop
 What is the Value of CT in
Management of Osteolysis?
-Can quantitate polyethylene thickness
-Can detect ischial and posterior rim
osteolysis
- Can detect cortical erosions (size of
break in medial cortical wall)
- Can quantitate volume of osteolysis
- Can quantitate cup support
8 yrs postop
Volume Measurements of Osteolysis

28.7 cm3
Quantification of Cup Support
 Polyethylene Thickness
Measurements

Immediate postop 6 yrs postop

 Purple: > 4 mm
Pink: 4 mm
Red: 3 mm
Green: 2 mm
Blue: 1 mm

Minimum Thickness
1.9 mm
 Bone Loss Around THA

Preoperative work up
Treatment options

Surgical Execution
 CHOICES FOR
INTERVENTION

OBSERVATION
MEDICATION
OPERATION
 OBSERVATION

KEEP AN EYE ON IT

WAIT FOR PAIN TO DEVELOP

DOCUMENT PROGRESSION
 KEEP AN EYE ON IT

WAIT FOR
PAIN
TO DEVELOP
 DOCUMENT PROGRESSION

HOW MUCH PROGRESSION?

HOW TO DOCUMENT PROGRESSION

Pubic Ramus Fracture
 MEDICATION

FOSAMAX

MUTING RESPONSE
NOT SOLVING THE PROBLEM
 OPERATION

 TIMING
 CHOICE OF
PROCEDURE
 STAGING ACETABULAR
OSTEOLYSIS

I WEAR ONLY
IIA WEAR AND PAIN, NO LYSIS SEEN
IIB WEAR AND LYSIS, NO PAIN
III WEAR AND LYSIS AND PAIN
 STAGE I

WEAR ONLY
 STAGE IIA

WEAR AND PAIN, NO LYSIS SEEN

 STAGE IIB

WEAR AND LYSIS, NO PAIN

 STAGE III

WEAR AND LYSIS AND PAIN

 LESSONS LEARNED

EARLIER STAGE - EASIER REVISION

WHEN YOU SEE WEAR - TELL
PATIENT
WHEN YOU SEE LYSIS -
REVISE PATIENT
 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)
 CHOICES FOR REVISION

REVISE LINER AND SHELL

REVISE LINER, LEAVE SHELL

INTACT
 LINER ONLY REVISION

CUP LOCKING MECHANISM SATISFACTORY

MAY CEMENT LINER IN PLACE

POLY THICKNESS SATISFACTORY

ORIENTATION OF CUP SATISFACTORY

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
TYPE II
SOCKET STABLE
LINER NOT REPLACEABLE

REVISE CUP BONE GRAFT

DEFECTS
CEMENT LINER
ALGORITHM FOR LYSIS
TYPE III

SOCKET LOOSE

REVISE CUP
 Bone Loss Around THA

Preoperative work up
Treatment options

Surgical Execution
 ACETABULAR REVISION

Treatment Options:
 Cemented sockets

 Cemented socket with graft

 Bipolar

 Uncemented hemispherical socket

 Special uncemented sockets

 Antiprotrusio devices
Acetabular Classification
• Type I - Cavitary
• Type II - Segmental
• Type III - Combined
• Type IV - Pelvic Discontinuity
Cavitary
Segmental

CM 05/25/00
Discontinuity
Is Component Loose?
NO YES

Type I Revision Type III Revison

Type II Revision Revise Cup

Will Part Fill Defects?

NO YES

Use Cementless
Cup
What Bone Graft is needed?
Structural Supplemental

Cementless Cup
Cemented Cup
Cage
 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
Concerns with Socket Removal

- Associated bone loss

- Ability to achieve successful bone ingrowth
with the revision component
- Increased morbidity
Concerns with Socket Retention

- High dislocation rate

- Incomplete exposure of the lytic area
- Progression of osteolytic lesion?
Indications for Cementless
Cups
Segmental Cavitary Combined

95%
Contra-indications
• Pelvic discontinuity
• Post-irradiation
• <50% host bone
in contact with cup
<5%
 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

Contained Acetabular
Defects

Fill with Bone

or Metal?
• Supplemental
 ACETABULAR REVISION
Technique
 Don’t ream too medially
 Usually just let the reamer work
the rim and gently ream until
you get dome or medial wall
contact
 ACETABULAR REVISION
Technique
Most Common Error:
Failure to use a large
enough cup
 ACETABULAR REVISION
Technique
Most Common Errors:
Ream away posterior
wall
 Impaction Grafting:
 Works
 Requires attention to detail
 Is tedious/demanding
 Is a valuable tool for the “revisionist”
Acetabular Impaction Grafting
Principles
• Sloof et.al.
• Contain the defect (mesh)
• Fresh frozen morcellized allograft
• Large 10-15mm graft morsels
• “Vigorous” impaction
• Pressurized cement
Immediate postop 17 yrs postop
REVISION CUPS
Trabecular Metal Acetabular
Components

6/25/2010
6/25/2010
6/25/2010
6/25/2010
6/25/2010
6/25/2010
6/25/2010
6/25/2010
 Summary
Bone Loss
- Requires careful radiographic follow-
up
- CTs can help in decision making
- The algorithm for management of
osteolysis is evolving
Thank You