IRCCS Ospedale SanIRCCS Ospedale San Raffaele MilanoRaffaele Milano U.O. Ortopedia e TraumatologiaU.O. Ortopedia e Traumatologia
*Scuola di Specializzazione di Ortopedia*Scuola di Specializzazione di OrtopediaPerugiaPerugia
Paolo SirtoriPaolo Sirtori, Rashwan Gogue*, Riccardo Cecchinato , Rashwan Gogue*, Riccardo Cecchinato
ee
Gianfranco FraschiniGianfranco Fraschini
RAZIONALE DEL TRATTAMENTO RAZIONALE DEL TRATTAMENTO FARMACOLOGICO DA ASSOCIARE FARMACOLOGICO DA ASSOCIARE
AD UN IMPIANTO DA REVISIONEAD UN IMPIANTO DA REVISIONE
Malchau H, Herberts P, Ahnfelt L. Prognosis of total hip replacement in Sweden. Follow-up of 92,675 operations performed 1978-1990. Acta Orthop Scand 1993;64(5):497-506
Total Hip Arthroplasty FailureTotal Hip Arthroplasty Failure
Total Hip Arthroplasty FailureTotal Hip Arthroplasty Failure
Prosthetic Dislocation (2%)
Total Hip Arthroplasty FailureTotal Hip Arthroplasty Failure
Periprosthetic Fractures (< 2%)
Total Hip Arthroplasty FailureTotal Hip Arthroplasty Failure
Infections (10%)
Total Hip Arthroplasty FailureTotal Hip Arthroplasty Failure
Fatigue Breakage (<2%)
Aseptic Loosening (79%)
Total Hip Arthroplasty FailureTotal Hip Arthroplasty Failure
Malchau H, Herberts P, Ahnfelt L. Prognosis of total hip replacement in Sweden. Follow-up of 92,675 operations performed 1978-1990. Acta Orthop Scand 1993;64(5):497-506
FIRST ACETABULAR IMPLANT’S FIRST ACETABULAR IMPLANT’S SURVIVALSURVIVAL
(Baker 2009 - (Baker 2009 - Clin Orth Rel Resear)Clin Orth Rel Resear)
(69 pz(69 pz) )
•88.8% to 15 years88.8% to 15 years
FIRST ACETABULAR IMPLANT’S FIRST ACETABULAR IMPLANT’S SURVIVALSURVIVAL
(Clarius 2009 – (Clarius 2009 – Int. Orthop.)Int. Orthop.)
(127 pz(127 pz) )
•75% to 17 years75% to 17 years
FIRST ACETABULAR AND FEMORAL FIRST ACETABULAR AND FEMORAL UNCEMENTED IMPLANT’S SURVIVALUNCEMENTED IMPLANT’S SURVIVAL
YOUNG SUBJECTS (< 50 ANNI)YOUNG SUBJECTS (< 50 ANNI)
(Kearns 2006 - (Kearns 2006 - Clin Orth Rel Resea)Clin Orth Rel Resea)
(221 pz(221 pz) )
• 98.7% to 5 years98.7% to 5 years
• 84.6% to 10 years84.6% to 10 years
• 52.5% to 15 years52.5% to 15 years
ACETABULAR CUP ACETABULAR CUP
• 98.7% to 5 years98.7% to 5 years
• 84.6% to 10 years84.6% to 10 years
• 52.5% to 15 years52.5% to 15 years
FEMORAL STEMFEMORAL STEM
• 99.3% to 5 years99.3% to 5 years
• 98.9% to 10 years98.9% to 10 years
• 96.8% to 15 years96.8% to 15 years
EARLY FAILURE IN TOTAL HIP EARLY FAILURE IN TOTAL HIP ARTHROPLASTYARTHROPLASTY
(Dobzyniak M. G. 2006 – Clin Orthop Rel Res)(Dobzyniak M. G. 2006 – Clin Orthop Rel Res)
(824 pz(824 pz) )
35 % of revision were performed during the 35 % of revision were performed during the first 5 yearsfirst 5 years
CAUSES OF FAILURES in THACAUSES OF FAILURES in THA
• Absence of primary stabilityAbsence of primary stability
• Implant instability Implant instability
• InfectionsInfections
• Painful THA/ discrepancy in leg Painful THA/ discrepancy in leg lengthening lengthening
• Periprosthetic fractures Periprosthetic fractures
• Aseptic bone looseningAseptic bone loosening
HARRIS 2006 - Clin Orth Rel ResearHARRIS 2006 - Clin Orth Rel Resear
HOPLIN 2008 – RadioGraphics HOPLIN 2008 – RadioGraphics
MOST FREQUENT CAUSE MOST FREQUENT CAUSE
OF FAILURES IN THAOF FAILURES IN THA
Aseptic Bone LooseningAseptic Bone Loosening
Aseptic Bone LooseningAseptic Bone Loosening
Multifactorial etiologyMultifactorial etiology
• Aging and systemic bone lossAging and systemic bone loss
• Adaptive bone remodeling or stress shieldingAdaptive bone remodeling or stress shielding
• Individual cellular response to wear debriesIndividual cellular response to wear debries
• Bone metabolic status Bone metabolic status
FAILURES IN THAFAILURES IN THA
SUNDFELDT 2006 – Acta OrthopaedicaSUNDFELDT 2006 – Acta Orthopaedica
Aseptic Bone LooseningAseptic Bone Loosening
• Absence of osteo-integrationAbsence of osteo-integration
• Lost of osteo-integrationLost of osteo-integration
FAILURES IN THAFAILURES IN THA
Multifactorial events those lead to mid and long term Multifactorial events those lead to mid and long term failures, secondary to……. failures, secondary to…….
Aseptic Bone LooseningAseptic Bone Loosening
FAILURES IN THAFAILURES IN THA
La qualità dell’ossoin una revisione
è più scadente!?!
Come è fallito il primo impiantofallirà anche la
revisione?!!
Quali fattori devoconsiderare per
affrontare bene unarevisione?!!
Extrinsic FactorsExtrinsic Factors
•Implant typology Implant typology
•Bone graftBone graft
•CoatingCoating
Revision for Aseptic Bone LooseningRevision for Aseptic Bone Loosening
• Bone Metabolic AlterationsBone Metabolic Alterations
• Osteoporosis/Osteopenia Osteoporosis/Osteopenia
• Genetic PredisposalGenetic Predisposal
Intrinsic FactorsIntrinsic Factors
Revision for Aseptic Bone LooseningRevision for Aseptic Bone Loosening
ORA TI MOSTROI FATTORI
ESTRINSECIPREFERISCO BERE
LA MIA BIRRA
Optimal stability of revision socket deviceOptimal stability of revision socket device
Good distal encourage Good distal encourage with obturatoris hookwith obturatoris hook
Good proximal encourage Good proximal encourage with wings and screwswith wings and screws
Good osteo-conductive Good osteo-conductive surfacesurface
THA REVISION – EXTRINSIC FACTORSTHA REVISION – EXTRINSIC FACTORS
IMPLANT TYPOLOGYIMPLANT TYPOLOGY
Trabecular Metal Modular Augmentation
THA REVISIONTHA REVISION
IMPLANT TYPOLOGYIMPLANT TYPOLOGY
THA REVISION – EXTRINSIC FACTORSTHA REVISION – EXTRINSIC FACTORS
IMPLANT TYPOLOGYIMPLANT TYPOLOGY
Bone Allograft integrationBone Allograft integration
Bone AllograftBone Allograft
Morsellised Chips – Morsellised Chips – Optimal Shape Optimal Shape (2x2x4 mm)(2x2x4 mm)
THA REVISION - EXTRINSIC FACTORSTHA REVISION - EXTRINSIC FACTORS
BONE GRAFTSBONE GRAFTS
Hypothetical use of osteoinductive Hypothetical use of osteoinductive factors like PRP or stem cells.factors like PRP or stem cells.
Morsellised chips to fill the cavity; They Morsellised chips to fill the cavity; They posses osteoconductive and limited posses osteoconductive and limited
osteoinductive properties.osteoinductive properties.
THA REVISION - EXTRINSIC FACTORSTHA REVISION - EXTRINSIC FACTORS
BONE GRAFTSBONE GRAFTS
Synthetic bone graft substitutesSynthetic bone graft substitutes
Bone substitutes Bone substitutes calcium/phosphate + Mgcalcium/phosphate + Mg
Osteoconductive Osteoconductive capabiilitycapabiility
Macro e micro porosityMacro e micro porosity
THA REVISION - EXTRINSIC FACTORSTHA REVISION - EXTRINSIC FACTORS
BONE GRAFTSBONE GRAFTS
ORA TI MOSTROI FATTORI INTRINSECI
NON HO ANCORATERMINATO DI BERE
LA BIRRA
Deficienza
ipovitaminosi
normale
43%43%
21%21%
36%36%
Vitamin D active metabolite: 25 OH DVitamin D active metabolite: 25 OH D33
Hypo and Deficiency of Vitamin DHypo and Deficiency of Vitamin D33
THA REVISIONS (Intrinsic Factors)THA REVISIONS (Intrinsic Factors)
Bone Metabolic AlterationsBone Metabolic Alterations
(n=62)(n=62)
Iper PTHsecondario
Iper PTHnormo Ca
Iper PTHprimitivo
Normali
4%4%
84%84%
5%5%
7%7%
Parathyroid Hormones: PTH vs CaParathyroid Hormones: PTH vs Ca++++
HyperparathyroidismHyperparathyroidism
THA REVISIONS (Intrinsic Factors)THA REVISIONS (Intrinsic Factors)
Bone Metabolic AlterationsBone Metabolic Alterations
(n=62)(n=62)
elevato
normale
elevato
normale66%66%
44%44% Index of osteoblast activity Index of osteoblast activity BGPBGP
65%65%35%35%Index of osteoclast activity Index of osteoclast activity D-PyrD-Pyr
Higth bone turnover and Higth bone turnover and uncopling of bone remodelinguncopling of bone remodeling
THA REVISIONS (Intrinsic Factors)THA REVISIONS (Intrinsic Factors)
Bone Metabolic AlterationsBone Metabolic Alterations
(n=62)(n=62)
Osteoporosi
Normale82%82%
18%18%Vertebral BMDVertebral BMD
Osteoporosi
Normale75%75%
25%25%
Femoral BMD (neck)Femoral BMD (neck)
Osteoporosis has been releved in interesting Osteoporosis has been releved in interesting amount of subjects, with prevalence in femoral site.amount of subjects, with prevalence in femoral site.
THA REVISIONS (Intrinsic Factors)THA REVISIONS (Intrinsic Factors)
OsteoporosisOsteoporosis
(n=62)(n=62)
• Polymorphism in Polymorphism in metalloproteases MMP-1 and metalloproteases MMP-1 and interleuchin IL-6interleuchin IL-6
• Gender-dependent role of the Gender-dependent role of the T393C polymorphism in aseptic T393C polymorphism in aseptic looseningloosening
• ““Calcium Sensing ReceptorCalcium Sensing Receptor”” unspecific alterationsunspecific alterations
1) Malik MHA; Ann Rhem Dis 20072) Godoy Santos AL; J Arthroplasty 20093) Bachmann HS; J Orthopaedic Research 20084) Gallo J; BMC Medical Genetics 2009
THA REVISIONS (Intrinsic Factors)THA REVISIONS (Intrinsic Factors)
Genetic PredisposalGenetic Predisposal
PARATHYROIDSPARATHYROIDS regulation in PTH secretionregulation in PTH secretionTHYROID regulation in Calcitonin secretionKIDNEY riduced the phosphaturic activity of PTHBONEBONE inibizione osteoclasticainibizione osteoclastica
Calcium-Sensing Receptor (CaSR)Calcium-Sensing Receptor (CaSR)
THA REVISIONS (Intrinsic Factors)THA REVISIONS (Intrinsic Factors)
Genetic PredisposalGenetic Predisposal
P<0.005
THA REVISIONS (Intrinsic Factors)THA REVISIONS (Intrinsic Factors)
Genetic PredisposalGenetic PredisposalPTH suppression test (CaSR) in hip fracture subjectsPTH suppression test (CaSR) in hip fracture subjects
Secondary Hyperparthyroidism due to hyocalcemia
Secondary Hyperparthyroidism due to unspecific alterations in
CaSR
Factors should be Factors should be considered inconsidered in
revision surgery of THArevision surgery of THA
Extrinsic FactorsExtrinsic Factors
• Implant typology Implant typology • Bone graftBone graft• CoatingCoating
• Bone Mineral Metabolism Bone Mineral Metabolism Alterations;Alterations;
• OsteoporosisOsteoporosis
Intrinsic FactorsIntrinsic Factors
Genetic FactorsGenetic Factors
• Polymorphism in metalloprotease MMP-1Polymorphism in metalloprotease MMP-1
• Gender-dependent T393C polymorphism Gender-dependent T393C polymorphism
• Calcium Sensing Receptor unspecific alterationsCalcium Sensing Receptor unspecific alterations
Fattori intrinseci coinvolti nel fallimento di Fattori intrinseci coinvolti nel fallimento di una revisione di artroprotesi di ancauna revisione di artroprotesi di anca
Riassorbimento Riassorbimento periprotesicoperiprotesico
Microparticelle di materiale Microparticelle di materiale proveniente dall’usura delle proveniente dall’usura delle
componenti protesichecomponenti protesiche
Stress meccanico Stress meccanico dell’impianto sulla struttura dell’impianto sulla struttura
ossea accettanteossea accettante
AttivazioneAttivazione OCOC
Iperparatiroidismo Iperparatiroidismo Deficienza di Vit DDeficienza di Vit D
Inibizione Inibizione OBOB
Difetto diDifetto diintegrazioneintegrazione
protesicaprotesica
OsteoporosiOsteoporosi DiminuitoDiminuito““Bone Stock”Bone Stock”
Fallimento dellaFallimento dellaREVISIONEREVISIONE
Domani farò una Domani farò una revisione di ancarevisione di anca
Ricordati di valutareil metabolismo mineralee di trattare il paziente
Biochemical Index of Bone MetabolismBiochemical Index of Bone Metabolism• Calcio ionico serico (Ca2+ )
• Vitamina D (25OHD)
• Paratormone (PTH)
Biochemical Index of Bone RemodelingBiochemical Index of Bone Remodeling• Osteocalcina (BGP)
• Lisilpiridinolina urinaria (D-Pyr)
THA REVISIONS (Intrinsic Factors)THA REVISIONS (Intrinsic Factors)
Evaluation of Bone Metabolic AlterationsEvaluation of Bone Metabolic Alterations
MOC - DXA scanMOC - DXA scan
Lumbar siteLumbar site
Femoral siteFemoral site
THA REVISIONS (Intrinsic Factors)THA REVISIONS (Intrinsic Factors)
Evaluation of Bone Mineral DensityEvaluation of Bone Mineral Density
macrophagemacrophage
MesenchymalMesenchymalstem cellstem cell
HematopoeticHematopoeticstem cellstem cell
Stromal cellStromal cell
AdipocyteAdipocyte
Pre-osteoblastPre-osteoblast
Pre-osteoclastPre-osteoclast
OsteoclastOsteoclastLining cellLining cell
OsteocyteOsteocyte
OsteoblastOsteoblast
AAttivarettivare
DDeprimereeprimere
MModulareodulare
il rimodellamento osseoil rimodellamento osseo
macrophagemacrophage
MesenchymalMesenchymalstem cellstem cell
HematopoeticHematopoeticstem cellstem cell
Stromal cellStromal cell
AdipocyteAdipocyte
Pre-osteoblastPre-osteoblast
Pre-osteoclastPre-osteoclast
OsteoclastOsteoclastLining cellLining cell
OsteocyteOsteocyte
OsteoblastOsteoblast
1) ATTIVARE1) ATTIVARE
1,25 (OH)1,25 (OH)22 - Vitamin D - Vitamin D
Promotes Promotes differentiation of differentiation of osteoblast and osteoblast and osteoclast precursorsosteoclast precursors
(+)(+)
macrophagemacrophage
MesenchymalMesenchymalstem cellstem cell
HematopoeticHematopoeticstem cellstem cell
Stromal cellStromal cell
AdipocyteAdipocyte
Pre-osteoblastPre-osteoblast
Pre-osteoclastPre-osteoclast
OsteoclastOsteoclastLining cellLining cell
OsteocyteOsteocyte
OsteoblastOsteoblast
BisphosphonatesBisphosphonates
(-)(-)
Inhibits osteoclast functionInhibits osteoclast function
2) DEPRIMERE2) DEPRIMERE
(-)(-)
Inhibits pre-osteoclastInhibits pre-osteoclast
macrophagemacrophage
MesenchymalMesenchymalstem cellstem cell
HematopoeticHematopoeticstem cellstem cell
Stromal cellStromal cell
AdipocyteAdipocyte
Pre-osteoblastPre-osteoblast
Pre-osteoclastPre-osteoclast
OsteoclastOsteoclastLining cellLining cell
OsteocyteOsteocyte
OsteoblastOsteoblast
(-)(-)
Inhibits osteoclast functionInhibits osteoclast function
MODULAREMODULARE
Strontium-RStrontium-R
(+)(+)
Increases expression Increases expression of RANK-L + OPGof RANK-L + OPG
Ranelato di Ranelato di StronzioStronzio
OsteoblastaOsteoblasta OsteoclastaOsteoclastaCaSrRanCaSrRan CaSrRanCaSrRan
Espressione di OPG & RANKL2
(4) Hurtel et al, J Biol Chem 2009 (5) Hurtel et al, submitted
(1) Chattopadyay et al, Biochem Pharmacol 2007(2) Brennan et al, Br J Pharmacol 2009(3) Fromingué et al, JCMM 2009
Replicazione1 RANKL expression2
Apoptosi4
Differenziazione5Sopravvivenza3
Lo Stronzio è un modulatore del turnover osseo Lo Stronzio è un modulatore del turnover osseo
a vantaggio della attività osteoblasticaa vantaggio della attività osteoblastica
Lo Stronzio è un modulatore del turnover osseo Lo Stronzio è un modulatore del turnover osseo
a vantaggio della attività osteoblasticaa vantaggio della attività osteoblastica
AAttivazione del rimodellamento osseo con: 1,25(OH)ttivazione del rimodellamento osseo con: 1,25(OH)22 DD33
Depressione della attività osteoclastica con: DIFOSFONATI
Modulazione del rimodellamento osseo sbilanciandolo a favore della attività osteoblastica con: R. di STRONZIO
TRATTAMENTO FARMACOLOGICO DA TRATTAMENTO FARMACOLOGICO DA ASSOCIARE AD UN IMPIANTO DA REVISIONE ASSOCIARE AD UN IMPIANTO DA REVISIONE
(ADM)(ADM)
TRATTAMENTO FARMACOLOGICO DA TRATTAMENTO FARMACOLOGICO DA ASSOCIARE AD UN IMPIANTO DA REVISIONE ASSOCIARE AD UN IMPIANTO DA REVISIONE
(ADM)(ADM)
ALLO SCOPO DI FACILITARE LA ALLO SCOPO DI FACILITARE LA OSTEOINTEGRAZIONE DEL NUOVO IMPIANTOOSTEOINTEGRAZIONE DEL NUOVO IMPIANTO
ALLO SCOPO DI FACILITARE LA ALLO SCOPO DI FACILITARE LA OSTEOINTEGRAZIONE DEL NUOVO IMPIANTOOSTEOINTEGRAZIONE DEL NUOVO IMPIANTO
AAttivazione: ROCALTROL 0.5 ttivazione: ROCALTROL 0.5 µg/die per 30 gg.µg/die per 30 gg.
Depressione: ALENDRONATO/RISENDRONATO (70 o 35 mg/ sett) per 6 mesi.
Modulazione: RANELATO di STRONZIO 2g/die per 6 mesi
MODALITA’ DI TRATTAMENTO MODALITA’ DI TRATTAMENTO
(ADM)(ADM)
MODALITA’ DI TRATTAMENTO MODALITA’ DI TRATTAMENTO
(ADM)(ADM)
NB: mantenere adeguato apporto del metabolita 25OHD durante la fase D e MNB: mantenere adeguato apporto del metabolita 25OHD durante la fase D e MNB: mantenere adeguato apporto del metabolita 25OHD durante la fase D e MNB: mantenere adeguato apporto del metabolita 25OHD durante la fase D e M
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