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DOES THE PAVI FEMORAL NAIL ALLOWS THE

IMMEDIATE TOTAL WEIGHT BEARING IN HIP


ARTHROPLASTIES?

P.D. SRBU, R. SOVA,


R. ASAFTEI, G.
BEREA, B. PUHA
Orthopaedic
Department
University of Medicine
Iasi, Romania

OBJECTIVES

outline the biological and mechanical problems in


treating femoral neck fractures

identify the indication for fixation and arthroplasty

ANATOMY

medial circumflex artery

Blood supply

Piet de Boer, York, UK.; Ian Harris, Adelaide, Australia; Mariusz Bonczar, Crocow , Poland

ANATOMY
Blood supply
Cranial anastomosis

biological effect
The posterior retinacular vessels from the medial circumflex artery
provides the main nutrition of the femoral head
Piet de Boer, York, UK.; Ian Harris, Adelaide, Australia; Mariusz Bonczar, Crocow , Poland

Garden Classification (1961)

II

III

IV

appearance of the trabeculae of the femoral head on AP X-ray

high degree of interobserver variation


difficult to predict complication ( esp. grade III and IV )
only division on undisplaced ( I, II) and displaced (III, IV)

Classification

GARDEN III

Complete with partial displacement

Classification

GARDEN IV

Complete with total


displacement

Incidence

Elderly

Majority

Low energy

Osteoporosis

Female

Young

High energy

Male

Diagnosis

AP and lateral x-ray

Hip pain in elderly patient post-fall with normal xray

Bone scan

Limited MRI (magnetic resonance imaging)

CT (computed tomography) scan

Vascular emergency

Displaced fractures

Elderly patients (the majority)

High rate of failure for internal fixation

Joint arthroplasty gives most reliable results

Early weight bearing

Lower failure rate

Young patients

Internal fixation is more reliable than in elderly

Arthroplasty is less reliable

SURGICAL OPTION IN ELDERLY


PATIENTS
Controversies surround the optimum management
The best femoral head is the patients own (few will argue)
Even in fit patients arthroplasty may provide a more
predictable fracture management with low rate of reoperation 1
Internal fixation 40% reoperation rate2
Arthroplasty treatment of choice

1 Bandari M. JBJS AM 2003; Lu-Yao JBJS America 1994


2 Keating JBJS 2006

SURGICAL OPTION IN ELDERLY


PATIENTS
Prosthetic replacement controversies

The choice of prosthesis: unipolar, bipolar, total arthroplasty


Prosthetic fixation: cemented or uncemented
Decision making:
- patient activity
- estimated life expectancy
- bone quality

UNCEMENTED
First generation - uncemented Austin Moore
HEMIARTHROPLASTY
Minimally ambulatory patients1
Tight pain and acetabular erosion (Ambulatory and active patients) 2
Still an option: medically infirmed patients
minimally or non-ambulatory nursing home residence
advanced dementia or severe cardio-pulmonary
comorbidities

1 Sharif Injury 2002


2 Faraj Injury 1999

UNCEMENTED
HEMIARTHROPLASTY
Second generation uncemented unipolar hip
prosthesis
Multiple femoral sizes and antirotation fins (better
fit)
Modular neck sleeves (soft tissue balancing and
restoration of leg length and femoral offset
Newer designs offer: improved methapyseal
geometry
roughened surfaces (facilitate
bony ongrowth)

CEMENTED HEMIARTHROPLASTY
Cemented Hemiartrhoplasty provides superior clinical
results versus uncemented Hemiartrhoplasty1
immediate, secure prosthesis fixation
some risk of sudden death ! (1 at 500)2
- elderly patients - diminished pulmonary
reserve
- fatty marrow
contents
- multiple comorbidities and
non
elective operation
carefully lavage and drying the femoral channel
very gentle cement pressurization
1 Lou-Yao JBJS 1994
2. Parvisi Clin Orth Relat 1999
3. Pitto Arch Orthop Trauma Surg 2000

Decreased rate of
embolization3

BIPOLAR VS UNIPOLAR
HEMIARTHROPLASTY
The bipolar design
- benefits of transferring stress from the articular
cartilage
to the internal metal-on-polyetylene bearing1
- preservation of motion at the bipolar bearing
debatable
- rotation in the sagital plane at the bipolar interface?
- amount of bearing motion necessary to decrease
stress in
acetabulum unknown
- excellent long term survivorship few complication 2
- failures: femoral loosening AND not acetabular
1.wear
Dalldorf JBJS AM 1995
2. Haidukewich Clin Ortho Relat Research 2002

BIPOLAR VS UNIPOLAR
HEMIARTHROPLASTY
Bipolar bearing favorable decrease acetabular
erosion rates over unipolar designs1

BUT !
Additional cost of the bipolar
bearing
Higher rates of volumetric
polyethylene wear
osteolysis in more active
patients
1. Lou- Yao JBJS 1994

A.A., Female, 74 yrs

BIPOLAR VS UNIPOLAR
HEMIARTHROPLASTY
Several studies1,2,3
no differences in function, morbidity, mortality or
other complications at shot to midterm follow-up
some advantages in lower reoperation rates and a
very low rate of symptomatic acetabular wear1
further researches required

1. Lou- Yao JBJS 1994


2. Faraj Injury 1999
3. Ong J Ortho Trauma 2002

TOTAL HIP ARTHROPLASTY


Historically symptomatic acetabular degenerative
change1
More recently a trend to expand the indication
Multiple studies pain relief and excellent functional
improvement
- DISLOCATION !!!! 10%1,2
poor soft-tissues, dementia, adduction and flexion
contractures, inability to fallow hip precautions
Total hip arthroplasty superior outcome vs. internal
fixation or cemented hemiarthroplasty2
1. Lee JBJS AM 1998
No
increased
2. Keating
JBJS AM 2006 morbidity, mortality or costs

THE ROLE OF TOTAL


Decision of total
vs hemiarthroplasty:
hemiarthroplasty activity
ARTHROPLASTY

level, physiological age, expected longevity, status of


acetabular articular surface
Community ambulatory patients
good results with cemented hemiarthroplasty,
no or minimal pain, low reoperation rate, dislocation
rate of
less then 2%1
- total hip arthroplasty better
function but higher dislocation rate

Antero-lateral approach and larger femoral heads


1 Haidukewich Clin Ortho Relat Research 2002

RETROSPECTIVE CLINICAL STUDY

468 hemiarthroplasties with bipolar uncemented


prostheses (PAVI-nail) Groupe Lepine
Age range = 42-89 yrs

311 patients aged > 65 yrs

Does PAVI nail allows immediate total


weight-bearing ?

PAVI
TiAl4V alloy
no collarette
8 sizes: 9 (dysplasia ) 16
length of 130 - 170 mm
inox and ceramics heads
(diameters of 22, 28 and
32mm)

PAVI HIGH TECH

Dual layering
(T40 +HAP)

VPS
VACUUM
SPRAY

PLASMA

VPS VACUUM PLASMA SPRAY


Optimisation for:

Bind layer to material


Bind surface particles
Endurance to mechanical
stress

PAVI mechanical testing


ISO 7206-4

430 kg: 100 kg individual


walking by 5km/h

NO cracks, NO failures
following 10 mil cycles

Male 74 yrs

Second day
postop

Female - 80
yrs

48h postop

24 h postop

30 days
postop

Male 55 yrs

Female 78
yrs

Female 78
yrs

2 hours postop

Female 63 yrs

Female 56 yrs + old femoral neck


fracture

12 hrs

Female 56
yrs

3 weeks

6 weeks

Male 45 yrs old femoral neck


fracture

CONCLUSIONS

arthroplasty vs internal fixation (in elderly)

In the elderly, cement is preferred not by us


No significant difference between bipolar and
unipolar
Hemi-arthroplasty vs total hip

For every 100 patients with arthroplasty instead


of IF, 17 revisions can be avoided but with 4 more
wound infections, 4 additional deaths and 1 hip
dislocation

Smaller operation
Lower dislocation rate
May not last as long as total joint replacement

Anterolateral vs posterior approach