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THA after Chiari osteotomy: Intraoperative complications and behaviour of cup fixation in 24 cases

THA after Chiari osteotomy: Intraoperative complications and behaviour of cup fixation in 24 cases. Migaud H., Beniluz J., Gougeon F., Pinoit Y., Besson A., Duquennoy A. Department of Orthopaedic Surgery, University Hospital of Lille, France. PETERS CJ : J Arthroplasty, 2001

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THA after Chiari osteotomy: Intraoperative complications and behaviour of cup fixation in 24 cases

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  1. THA after Chiari osteotomy: Intraoperative complications and behaviour of cup fixation in 24 cases Migaud H., Beniluz J., Gougeon F., Pinoit Y., Besson A., Duquennoy A. Department of Orthopaedic Surgery, University Hospital of Lille, France.

  2. PETERS CJ : J Arthroplasty, 2001 13 hips : worse result THR after failed TIO. Fw-up 36 m. HASHEMI-N A : J Arthroplasty, 2002 28 hips : THR after Chiari results = to primary THR, but less pelvic bone grafting Fw-up 60 m. PARVIZI J : CORR, 2004 41hips : THR after PAO caution to acetabular retroversion (23/41) Fw-up 6,9 years Introduction : • Conservative surgery to prevent or stabilize arthrosis without worsening the result of a subsequent THR : • Problems related to THR after proximal osteotomy of the femur • Few papers related to the THR after pelvic osteotomies

  3. Introduction : Purpose of the study • Modifications of the acetabulum related to the Chiari osteotomy • Medial displacement • Enlargement • Vascular and bone support • Concerns about 1) long term fixation of the cup 2) Functional result 3) Intraoperative complications

  4. Patients and Methods • 204 Chiari osteotomies (1975-2000) 29 hips conversed to THR • 24 THR with a follow-up > 5 years were assessed retrospectively • 23 patients (20 F, 3 M) • Mean age at the time of conversion = 50 y. (range, 36-63)

  5. Patients and Methods (n = 24) • Chiari were “dome shaped” and performed through a Smith Petersen • Fixed with lag screws • Indication for Chiari : • Dysplasia (15/24 CE < 5°) • Arthrosis (20/24 had joint space narrowing)

  6. Patients and Methods (n = 24) • Conversion after a mean follow-up of 8 y.(range 1-24 y.) • All THR through a Postero-Lateral approach • No patient lost for follow-up • Mean THR follow-up = 10 +/- 3 y. (range, 6-15)

  7. Components (n = 24)

  8. Functional Results (n = 24, Fw-up = 10y.) • Favorable functional results • All the walking scores at follow-up > 5 points Merle d’Aubigné Hip rating

  9. Number of Hips with a Trendelenburg Functional Results (n = 24) • No postoperative dislocation despite medial displacement by Chiari osteotomy • Post-operative Limp

  10. Results: Intraoperative complications • No neurovascular injury • Screw removal necessary in 9 cases • To avoid contact between screws used for Chiari and cup fixation or to ease bone preparation • Difficult in 2 cases(the distal part of the screw was broken and left in place)

  11. Results: Cup fixation and bone coverage • Three cases of lack in bone coverage > 20% of the cup (all posterior and superior) • 1 treated by deepening • 1 treated by few bone chips • 1 treated by autograft • One additional case of autograft to correctly locate the hip center in a dislocated hip

  12. Results: Cup fixation and Impingement • Anterior impingement with the Major trochanter in 2 cases (excessive anterior coverage) • Bone resection required on the pelvic bone in 2 cases

  13. Results: Cup orientation • Mean frontal angle = 43° +/-9° [20° to 58°] • 3 cups had inclination < 35° and 2 over 55° • 4 hips had M-M bearings (in 28 mm) without impingement

  14. #1 Results: Cup Fixation • None of the cemented cups and 18/21 cementless cups = free of osteolysis, no radiolucencies, no migration • 3 of the cementless cups had radiolucencies (2 of them had progressive lucencies and severe osteolysis reoperation) 10 y.

  15. #1 #1 4y. Post Results: Reoperation • Only 2 patients had revision surgery (osteolysis, wear) • No revision was related to the prior osteotomy : • #1 (@ 5y.) osteolysis + cup loosening (osteolysis) = • Intra-articular migration of metallic debris from the coating (Fibermesh) • Bone grafting + cup revision #1

  16. #2 Post-op #2 1y. Post Results: Reoperation • #2 (@15y.) Osteolysis + loosening cup + femur = • Severe polyethylene wear • Poor fixation of the insert in the metallic shell • Overweight (BMI = 31) • Pelvic grafting with cup and femoral revision (cementless locked stem) #2

  17. Conclusions (1) • Conversion of a Chiari to THR = simple procedure • Low rate of acetabular augmentation (bone grafting) despite severe dysplasia before the Chiari) • Attention should be paid to bone-to-bone impingement if excessive bone coverage

  18. THR post Chiari Primary THR Conclusions (2) • Chiari osteotomy : 1) does not modifiy rehabilitation program versus with primary THR 2) does not worsen cup fixation = only 2 revisions but none related to the prior osteotomy 3) gives the opportunity to insert larger cups (resistance to wear)

  19. Thank you for your attention

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