ARTROPLASTIA OLDULUI N COXARTROZA DUP DISPLAZIA CONGENITAL DE OLD

Gh. Tomoaia, T. Socol, H. Benea, E. Harabagiu, I. Stan Clinica Ortopedie-Traumatologie Cluj-Napoca, Secia a- II-a Cuvinte cheie: artroplastie, displazie, coxartroz, centru de rotaie, recuperare Comunicare oral-varia Introducere Displazia coxo-femural este o malformaie congenital caracterizat prin dezvoltarea anormal a articulaiei oldului, fiind afectate acetabulul, extremitatea proximal a femurului i structurile periarticulare (capsul, tendoane, muchi). Conceptul include att anomalii referitoare la dimensiunile sau forma acetabulului i a capului femural, ct i modificri ale proporiilor acestora i a modalitilor de aliniere. n cele mai multe cazuri, acetabulul este insuficient dezvoltat i disproporionat n raport cu capul femural, fapt determinant i pentru apariia simptomatologiei clinice. n general tratamentul luxaiei congenitale de old urmrete dou obiective: 1. Readucerea capului femural n cotil 2. Meninerea permanent la acest nivel a capului femural. Acestea pot fi obinute prin dezvoltarea unui acoperi adecvat al cotilului i corectarea anteversiei colului femural, cu sau fr devalgizarea acestuia. Proteza total de old ca indicaie n tratamentul coxartrozei secundare DDH i propune s rezolve trei aspecte specifice acestei patologii: 1. Restaurarea ct mai anatomic a centrului de rotaie a oldului 2. Refacerea funciei de contenie acetabular prin reconstrucie stabil cu autogref cortico-spongioas din capul femural rezecat 3. Reconstituirea stocului osos acetabular. Material i metod n perioada 2004-2006 n Clinica Ortopedie-Traumatologie Cluj-Napoca am practicat 18 artroplastii totale de old n coxartroza secundar displaziei congenitale. oldul stng a fost afectat n 14 din totalul de 18 cazuri. Vrsta pacienilor a fost cuprins ntre 45 i 72 de ani, cu o medie de 56 de ani. Abordul a fost lateral (de tip Hardinge) cu bolnavul n decubit dorsal. Dup capsulotomia total s-a identificat ligamentul transvers i baza lamei patrulatere la nivelul gurii obturatorii. Prepararea acetabular s-a realizat prin frezare orizontal cu frez mic pn la lama patrulater n vederea obinerii unei medializri maxime, urmat de frezare supero-medial n limitele distanei ntre cele dou coloane acetabulare. S-a practicat verificarea cu cupa de prob a poziiei fa de osul iliac (unghiul de nclinaie, anteversia cupei i gradul de acoperire al ei). Din punct de vedere al poziionrii 10 cupe au fost implantate n paleocotil i 8 n poziie intermediar. Nu am practicat osteotomia marelui trohanter i nici cea de scurtare a femurului. Artroplastia oldului a fost realizat n 12 cazuri cu cupe necimentate i n 6 cazuri cu cupe cimentate. Acetabuloplastia cu gref osoas structurat din capul femural a fost realizat n dou cazuri. Severitatea displaziei a fost apreciat dup clasificarea Crowe, codificnd precis gradul de subluxaie sau dislocaie de care depind aprecierea anomaliilor de stoc osos, patologia prilor moi periarticulare, genunchiului ipsilateral, coloanei lombare i

inegalitatea de membre. n lotul studiat, am avut 11 cazuri Crowe I, 5 cazuri Crowe II i 2 cazuri Crowe III. Rezultate Rezultatele au fost apreciate dup parametrii cotaiei Harris (durere, funcie articular, activitate, deformare, mobilitate articular), fiind n proporie de 80 % bune i foarte bune i 20 % slabe. Rezultatele au fost marcate n continuare de diformitile oldului contralateral, genunchiului i coloanei lombare. Scorul Harris a fost n medie de 45 puncte preoperator, ajungnd la 80 postoperator. Controlul radiologic postoperator a evideniat 15 cupe n poziie anatomic i 3 cupe situate inferolateral, sub nivelul liniei de referin prin U-ul radiologic. Au existat 3 malpoziionri ale componentei femurale. Nu am nregistrat pareze de nerv sciatic. Nu s-a nregistrat nici o complicaie postoperatorie de tipul luxaiei imediate a protezelor implantate i nici hematoame extinse. Discuii n realizarea artroplastiei ca tratament pentru displazia congenital a oldului, un rol important l are selecia corect a pacienilor. Muli pacieni cu aceste diformiti au o evoluie favorabil pn la o vrst mijlocie i intervenia chirurgical ar trebui luat n considerare doar dac durerea devine invalidant. Reconstrucia prin artroplastie total la pacienii cu displazie congenital de old ntmpin unele probleme particulare cum ar fi: scurtarea membrului inferior, displazia cavitii acetabulare, hipoplazia femurului, atrofia musculaturii i imposibilitatea micrii bazinului n timpul mersului. La pacienii cu luxaii unilaterale, lungimea membului afectat ar trebui refcut parial sau total chirurgical. La pacienii cu luxaii bilaterale alungirea unui membru ar determina discrepane considerabile dac procedura ar fi efectuat doar unilateral. Adeseori alungirea unui membru ar trebui compensat prin scurtarea femurului pentru a plasa capul femural n adevrata cavitate cotiloid. n subluxaii sau luxaii, prezena unui numr de diformiti ale osului sau esuturilor moi are importan chirurgical: capul femural este mic i deformat, colul femural este scurtat i ngustat i adeseori anteversat, marele trohanter este mic i deseori localizat posterior, canalul femural este ngustat. Faptul c femurul este ngustat i ncurbat anterior face prepararea canalului dificil. Preoperator este necesar efectuarea radiografiilor antero-posterioare i laterale ale bazinului i femurului proximal pentru a determina cu acuratee: - cantitatea i calitatea osului n care se va fixa cupa - nivelul la care se face fixarea - gradul de ngustare i ncovoiere a femurului - necesitatea osteotomiei femurului - mrimea i tipul componentelor ce vor fi utilizate. Dac capul femural este luxat proximal, cavitatea cotiloid este deformat i are acoperiul erodat. n luxaiile nalte i intermediare capul femural determin formarea unui fals cotil care de obicei nu este nici destul de mare nici destul de adnc pentru cupa protezei. Cea mai dens structur osoas se gsete la nivelul adevratului cotil i aici ar trebui plasat cupa protezei. Muchii abductori, adductori, psoas i cvadriceps sunt de obicei scurtai. Capsula este elongat i ngroat n partea inferioar, mpiedicnd revenirea capului femural n adevratul cotil. Disecia la acest nivel va necesita ligaturarea ramurilor arterelor circumflexe mediale i obturatorii. Capsulectomia extins i tenotomia psoasului, dreptului femural i adductorilor ar putea fi necesar pentru a corecta diformitatea. 2

Cotilul displazic este puin adnc i necesit o component acetabular de 40 mm sau mai puin. Implanturile de acest fel nu fac parte de obicei din trusele de artroplastie i ar trebui special comandate. Un cap de 22 mm ar trebui folosit deoarece este inadecvat folosirea unui cap mare cu o cup mic. Componenta femural trebuie plasat ntr-o poziie neutr sau n uoar retroversie i n relaie cu axul articulaiei genunchiului. Anteversia colului femural poate determina eroare la introducerea componentei femurale a protezei, uneori fiind necesar o osteotomie de derotare pentru plasarea corect a ei. Anteversia femural excesiv poate fi corectat cu o component femural modular care poate fi rotit n orice grad de anteversie. Totui aceasta nu poate corecta deplasarea posterioar a marelui trohanter, care poate determina rotaie extern. Stabilitatea iniial a componentei femurale este unul dintre factorii care asigur durabilitatea protezei necimentate. Frezarea canalului femural i implantarea unei cozi strns fixate reduc micromicrile i ntresc prognosticul pe termen lung. Unele luxaii sunt totui ireductibile prin metodele clasice datorit obstruciei date de esuturilor moi, capului femural mare, prezenei unui esut fibros sau osos la nivelul cotilului i de asemenea datorit tendonului ilio-psoas deosebit de contractat. Rezultatele funcionale postoperatorii sunt n strns corelaie cu restabilirea centrului de rotaie a oldului, care se reface prin plasarea cupei n paleocotil i prin egalizarea lungimii membrelor inferioare. Rezultatele sunt mai bune dac situaia preoperatorie a oldului este mai apropiat de normal n plus utilizarea adevratului cotil faciliteaz alungirea membrului, mbuntete funcia de abducie i de asemenea, n acest caz, se utilizeaz componenta osoas cea mai bun din punct de vedere calitativ. La disecia oldului capul femural este dislocat din falsul cotil, iar locaia adevratului cotil s-ar putea sa nu fie imediat reperat. Adncimea cotilului este adesea diminuat, peretele anterior este adeseori subire i poate fi fracturat cu uurin, dar peretele posterior este de obicei destul de gros. De aceea cnd se efectueaz lrgirea cotilului dinspre anterior spre posterior se va rezeca mai mult din peretele posterior dect din cel anterior. n artroplastia total de old, plasarea cupei acetabulare n poziie neanatomic, mai ales supero-lateral, duce la obinerea unor rezultate mai slabe, permind o defixare, att a componentei acetabulare, ct i a celei femurale. Refacerea centrului anatomic de rotaie reprezint un deziderat de baz n reconstrucia oldului displazic, cu toate c atingerea acestui scop face operaia dificil din punct de vedere tehnic. Nu exist un consens asupra dimensiunii minime a defectului acetabular care s determine instabilitatea cupei. Au fost imaginate mai multe modele de apreciere a suprafeei portante i neportante a cupei acetabulare, pentru estimarea mrimii grefei osoase. n acest sens, Prof.dr. Mihai Popescu i colab. au apreciat defectul de suprafa portant a cupei folosind raportul dintre suprafeele S2/S1, care n varianta maxim nu trebuie s depeasc unitatea. Concluzii 1.Artroplastia total pe old displazic este o problem dificil care necesit un planning preoperator exact. 2. Artroplastia oldului la pacienii cu acetabul displazic ridic probleme tehnice dificile cu complicaii frecvente n comparaie cu artroplastiile obinuite. 3. Deficiena de stoc osos de la nivelul acetabulului reprezint o situaie des ntlnit n displazia congenital a oldului constituind un handicap n plasarea cupei protezei. 4. Rata de supravieuire mai mic a implantului poate fi explicat prin vrsta tnr i anomaliile de geometrie acetabular.

5. O terapeutic raional se bazeaz pe un planning corect n ceea ce privete tipul displaziei, posibilitatea de coborre a capului protetic n paleocotil i acoperirea defectului acetabular. 6. Pentru corectarea anteversiei este necesar plasarea distal i lateral a marelui trohanter. Osteotomia intertrohanterian a femurului este necesar cnd anteversia este mai mare de 50. Tenotomia trebuie evitat ntruct fora muscular trebuie pstrat, ajutnd n acelai timp la protecia nervului sciatic. 7. Pentru a evita decimentarea precoce, cupa trebuie meninut n totalitate n esut osos. Dac contenia este insuficient se va face acetabuloplastia cu gref osoas din capul femural rezecat, cu condiia s nu se acopere mai mult de 50% din suprafaa portant a cupei. Cnd coborrea este mai mare de 3 cm, existnd riscul unei pareze de nerv sciatic, poziia corect de repaus este cu coapsa n extensie i cu genunchiul n flexie de 90 la marginea patului. 8. Succesul deplin al operaiei de artroplastie a oldului ca tratament pentru coxartroza secundar displaziei congenitale de old, este posibil numai prin indicaia operatorie corect, folosirea implanturilor adecvate i corecta lor poziionare. Beneficiul adus bolnavilor trebuie s corespund riscurilor i efortului depus.

HIP ARTHROPLASTY IN SECONDARY OSTEOARTHRITIS DUE TO DEVELOPMENTAL DYSPLASIA OF THE HIP

Gh. Tomoaia, T. Socol, H. Benea, E. Harabagiu, I. Stan Cluj-Napoca Orthopedics and Traumatology Clinic, 2nd Department Keywords: arthroplasty, dysplasia, hip osteoarthritis, rotation centre, rehabilitation Oral presentation Introduction In this study we want to analyze the problem of hip arthroplasty in secondary osteoarthritis due to developmental dysplasia of the hip (DDH), based on our experience. As known, many patients with this deformity have a good evolution up to middle age and so the surgical intervention has to be taken into account if the pain becomes invalidating. This retrospective study included 18 patients with osteoarthritis of the dysplasic hip operated in our clinic from 2004 to 2006 with total hip replacement, with uncemented or cemented prostheses. The analyzed criteria: pain, stability and mobility of the hip, station and walking, were evaluated by clinical and radiological controls done immediately postoperative and at periods of one, three and six months, followed by annual controls. Functional rehabilitation began the next day after surgery and continued progressively, obtaining a good articular mobility and an adequate standing on the affected limb in a period of 4 to 6 weeks. The choice of the right type of prosthesis, use of highquality implants and an accurate surgical technique allowed us to obtain good results, with considerable amelioration of the articular function and excellent rehabilitation. The full success of hip arthroplasty as treatment for secondary osteoarthritis due to developmental dysplasia of the hip is achievable only by correct surgical indication, use of adequate implants and their good positioning. The benefit brought to the patient has to correspond to the risks and effort performed. The scope of the study Coxo-femural dysplasia is a congenital deformity characterized by abnormal development of the joint that affects the acetabulum, proximal femoral extremity and the surrounding structures (capsule, tendons and muscles). The concept includes shape and size abnormalities of the acetabulum and femoral head, but also changing in their proportions and alignment modalities. In most cases, the acetabulum is insufficiently developed and disproportioned in comparison with the femoral head, causing the clinical symptoms onset. Generally, the treatment of developmental dysplasia of the hip associated with luxation has two objectives: 1. Reposition of the femoral head in the acetabular cavity 2. Permanent maintaining of the femoral head in this position. These can be achieved by obtaining an adequate acetabular coverage and correcting the femoral neck anteversion, with or without valgus correction. As treatment for hip osteoarthritis secondary to DDH, total hip replacement intends to overcome three specific aspects of this pathology: 1. A more anatomical restoration of hip centre of rotation 2. Reestablish the acetabular contention by a stable reconstruction with cortical and trabecular bone grafting from the femoral head 3. Restoring acetabular bone stock.

Materials and methods Between 2004-2006 in the 2nd Department of Orthopedics and Traumatology Clinic of Cluj-Napoca we have performed 18 total hip arthroplasties in osteoarthritis secondary to DDH. The left hip was affected in 14 out of 18 cases. The patients were aged between 45 and 72 years, with a mean age of 56 years. We have used lateral Hardinge approach, with the patient layd on his back. After capsulotomy we have identified the transverse ligament and patrulateris blade base. Acetabular preparation was done by horizontal reaming with small reams up to the patrulateris blade, in order to obtain a maximal medialization, followed by supero-medial reaming between the two acetabular columns. We have verified the position of the cup to the iliac bone using a probe implant and checking its inclination, anteversion and bone coverage. We have positioned 10 cups in the normal position and 8 cups in an intermediary position. We did perform neither greater trochanter osteotomy nor femoral shortening osteotomy. We have used 12 cemented and 6 uncemented prostheses. Acetabuloplasty with femoral head graft was done in two cases. The severity of the dysplasia was analyzed after Crowe classification, taking into account the subluxation degree or dislocation, which determines bone stock estimation, the pathology of periarticular tissue, ipsilateral knee, lumbar spine and limb inequality. According to this classification, we had 11 Crowe I cases, 5 Crowe III cases and 2 Crowe III cases. Results Functional rehabilitation began the next day after surgery and continued progressively, obtaining a good articular mobility and an adequate standing on the affected limb in a period of 4 to 6 weeks. The choice of the right type of prosthesis, use of highquality implants and an accurate surgical technique allowed us to obtain good results, with considerable amelioration of the articular function and excellent rehabilitation. The results were appreciated using Harris score parameters: pain, activity, articular deformity, mobility and function. They were good and very good in 80% and fair in 20% of the cases. The results were still influenced by the contralateral hip, knees and lumbar spine remaining deformities. Harris score increased from a preoperative mean of 45 to a postoperative mean of 80. The postoperative radiographic control showed 15 cups in anatomic position and 3 cups situated inferolaterally below the "U"-shaped reference line. We noticed three malpositions of the femoral component. We did not record any sciatic nerve palsy. We did not find any postoperative complications like immediate dislocation of the prosthesis or extensive hematomas. Discussions In obtaining a successful hip arthroplasty in secondary osteoarthritis due to DDH, the correct patient selection plays an important role. Many patients with this deformity have a good evolution up to middle age, so the surgical intervention has to be taken into consideration when pain becomes invalidating. Reconstruction by total hip arthroplasty in patients with DDH faces some particular issues: limb shortening, acetabular dysplasia, femoral hypoplasya, muscular atrophy, impossibility of pelvis movements during gait. In patients with unilateral involvement, limb length should be restored by surgery, totally or at least partially. In case of bilateral disease lengthening of a limb would create important discrepancies if the procedure is done unilaterally. 6

Femoral shortening, in order to position the femoral head in the real cothiloid cavity should often compensate limb lengthening. In subluxations or dislocations, the presence of bone and surrounding tissues deformities is important for surgery: the femoral head is small and deformed, the femoral neck is shortened and narrow and often in anteversion, the greater trochanter is small and often located posterior, femoral medullar canal is narrow. Femoral narrowing and anterior curvature make its preparation more difficult. Anteroposterior and lateral preoperative radiographies of the pelvis and proximal femur are necessary for an accurate assessment of: - bone quantity and quality for acetabular cup implant - level of fixation - narrowing and curvature degree of the femur - femoral osteotomy necessity - size and type of the prosthesis components. If the femoral head is proximally displaced, the cotiloid cavity is deformed with the "roof" eroded. In high and intermediary dislocations, the femoral head determines the formation of a fake cotiloid cavity, which usually is neither deep, nor large enough for prosthesis cup. The densest bony structure is situated at the level of the true cotiloid cavity and here is where the prosthesis should be placed. The abductors, adductors, psoas and quadriceps muscles are usually shortened. The articular capsule is elongated and thickened on the inferior side, preventing the femoral head from to slide back in the true cotiloid cavity. At this level, the dissection will implicate ligatures of the medial circumflex and obturatory arterial branches. Extensive caapsulectomy and tenotomy of the psoas, rectum femoris and adductor muscles could be necessary to correct the deformity. Dysplasic acetabulum is not so deep, necessitating a 40 mm or less acetabular cup. These kind of implants are not usually contained in arthroplasty sets and should be ordered separately. Also, a 22 mm diameter femoral head should be used, as big head is incongruent with a small cup. The femoral component should be placed in a neutral position or in slight retroversion and in relation with the knee articular axis. Femoral neck anteversion can lead to malposition of the femoral component, making sometimes necessary a derotation osteotomy in order to place it correctly. Excessive femoral anteversion can be corrected with the help of a modular femoral component, which can be placed in various degrees of anteversion. But it still cannot correct the posterior displacement of the greater trochanter, which can determine external rotation of the limb. The initial stability of the femoral component is one of the factors that ensure the durability of the prosthesis. Femoral medullar canal reaming and implant of a tightened femoral stem reduce small movements and improve the long-term prognosis. Some dislocations are still irreducible by classic methods because of soft tissue obstruction, big femoral head, and presence of fibrous or osseous tissue at the cotiloid level and because of a very tightened iliopsoas tendon. The postoperative functional results are strongly correlated with restoration of the hip center of rotation, which is done by placement of the cup in the real cotiloid cavity and equalization of inferior limb length. The results are better if the preoperative condition of the hip is closer to normal. Moreover, the placement in the real cotiloid cavity facilitates limb lengthening, improves abduction and determines the usage of the best bone quality acetabular component. When dissecting the hip, the femoral head is displaced from the fake cothiloid cavity, and the location of the real cothile may not be quickly discovered.

In many cases, the profundity of the cothile is decreased, the anterior wall is thin and can be easily fractured, but the posterior wall is usually thick enough. That's why during cotiloid cavity preparation it should be resected more from the posterior wall than from the anterior wall. In total hip arthroplasty, placing the cup in a less anatomical position, especially superior and lateral, can lead to poor results, with early loosening of the ace tabular cup or femoral stem. Restoration of the anatomical center of rotation of the hip represents a fundamental goal of the dysplasic hip reconstruction, although it makes surgery technically more difficult. There is no union of opinions regarding the minimal acetabular defect that would determine the instability of the cup. There were imagined several models for determining the bearing and the nonbearing surfaces of the acetabular cup, in order to estimate the size of the bone graft. In this way, Prof. Dr. Popescu Mihai and his collaboratories estimated the acetabular bearing surface defect using the fraction S2/S1, which should be less than 1. Conclusions 1. Total hip arthroplasty for secondary osteoarthritis due to developmental dysplasia of the hip is a difficult operation which necessitates an adequate preoperative planning. 2. Surgical procedure faces difficult technical problems, with an increased rate of complications than in standard hip replacements. 3. Acetabular bone stock deficit represents a common situation in developmental dysplasia of the hip and it represents an obstacle in the good positioning of the acetabular cup. 4. Decreased life span of the implants can be explained by the relative young age and hip conformation abnormalities. 5. A rationale treatment is based on an accurate planning that considers the type of dysplasia, the possibility of femoral head descent in the real cotiloid cavity and good acetabular coverage. 6. The correction of femoral anteversion requires a lateral and distal placement of the greater trochanter. Intertrochanteric femoral osteotomy is necessary when the anteversion is greater than 50o. Tenotomy must be avoided as muscle strength should be preserved and in the same time the sciatic nerve should be kept safe. 7. In order to avoid early loosening, the cup should be placed in a full contact with the bony surface. If the acetabular coverage is not sufficient, acetabuloplasty with bone graft from the femoral head should be performed, but it should be less than 50% of the cup's bearing surface. When femoral head descent is greater than 3 cm there is a risk of sciatic nerve palsy and in this case the correct resting position is extension of the thighs with 90o of knee flexion (at the edge of the bed). 8. The full success of hip arthroplasty as treatment for secondary osteoarthritis due to developmental dysplasia of the hip is achievable only by correct surgical indication, use of adequate implants and their good positioning. The benefit brought to the patient has to correspond to the assumed risks and to the effort performed.