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SICOT e-Newsletter

Issue No. 54 - March 2013

Expert Corner

How I do a Primary Total Hip Arthroplasty (THA)

Jacques H. Caton
SICOT Publications & Communications Committee Chairman & SICOT Hip Arthroplasty Subspecialty Committee Chairman - Lyon, France
 

Introduction

Today, Total Hip Arthroplasty (THA) is one of the most dramatically successful procedures performed in the field of medicine.

The number of THAs performed in France in 2010 was estimated to be 147,513. The first modern, commonly accepted technique for THA was developed by Sir John Charnley in 1962 [5], 50 years ago, and has achieved very good long-term results.

On that basis, since 1979, for my patients with osteoarthritis (OA), osteonecrosis (ON), or femoral neck fracture, I use a Charnley type THA with a 22.2 mm metallic or ceramic head and, in the last 33 years, I have performed this operation on more than 5,000 patients.

The operation

THA is performed using a "no-touch technique", after careful preoperative planning, and involves the application of templates to restore offset, determine the anatomic centre of the hip and ensure equal leg length. The patient is placed in strict lateral decubitus position. Surgery is conducted under general anaesthesia, closely following a checklist, and with two assistants.

After skin preparation and draping, I perform a minimally-invasive posterolateral approach with an incision between 10 to 15 cm, with conservation of the piriformis tendon and quadratus femoris, as well as longitudinal section of the capsule, which is thus preserved.

I remove the head after posterior dislocation of the hip and then, to avoid bleeding of the femur, I prepare first the acetabulum which is exposed with a MacKee retractor.

I subsequently remove any osteophytes and the subchondral bone with an osteotome, then perform reaming using a reamer the same size as the size of the cup (size for size).

I preserve always the medial wall of the acetabulum and, if there are some cysts, they are debrided of soft tissue and graft by cancellous bone of the head.

The cup is implanted at an abduction angle of 45° and an anteversion angle between 15° and 20°.

I always use a metal/polyethylene torque with, according to the patient's age:

  • a cementless press-fit cup with HA coating and two screws before 60 years of age (Figure 1a);
  • a cemented Charnley polyethylene cup after 60 years of age (Figure 1b);
  • and a QUATTRO® cementless dual mobility cup (groupe Lépine – Genay – France), always with HA coating, for patients over 70 years of age, as well as in the case of patients with fractures of the femoral neck, neurological diseases or cognitive impairment (Figure 2).

Then I prepare the femur for implantation. I always use a STALLION® Charnley-type cemented stem (groupe Lépine – Genay – France) according to a third-generation cementing technique involving a resorbable plug with events AIR PLUG® (groupe Lépine – Genay – France) in order to avoid thrombo and fat embolisms.

The antibiotics impregnated cement is inserted slowly by gradually applying pressure with a special syringe, the same for the stem.

After verifying that the prosthesis shows proper stability, I suture the capsule and reattach the external rotator muscles. I conclude the operation by suturing the fascia lata totally closing the wound, with the addition of a drain that is left in place for two days.

I administer Non Steroidal Anti-inflammatory Drugs (NSAIDs) for a period of 8 days to prevent heterotopic ossifications. The patient is allowed full weight bearing 24 hours after the operation and full recovery requires 8 days.

Results

Long-term results are very good with very few complications: less than 0.5% infection and less than 0.5% of early dislocation.

At 10 years' follow-up, there is only 1% of revision for dislocation with QUATTRO® cementless dual mobility cup [6,7,8].

We have observed a 5% risk of serious medical complications called "medical risk".

Over 25 years, survival after Charnley's total hip arthroplasty is very good in our series [3,4], with a survival curve of 85% as reported by DJ Berry et al. [1] or JJ Callaghan et al. [2].

After more than 40 years of experience, in surviving patients, there is wear of the cup as reported by M Wroblewski et al. [9]. We can classify wear ranges in 3 categories of patients:

  • One-third show an excessive wear pattern of more than 0.1 mm/year;
  • One-third show a "normal" and regular wear pattern of 0.1 mm/year;
  • One-third show no wear at all.

Conclusion

Finally, there are many factors that can influence the longevity of the polyethylene and we hope that with the new polyethylenes (highly cross-linked or vitamin E diffused UHMPWPE) the long-term results will be better in the future.

References

  1. Berry DJ, Harmisen WS, Cabanela ME, Money BE. - Twenty five years survivorship of two thousand consecutive primary Charnley total hip replacements. J Bone Joint Surg Am 2002 ; 84 : 171-7.
  2. Callaghan JJ, Bracha P, Liu SS, Piyaworakkum S, Goetz DD Johnston RC. - Survivorship of a Charnley total hip arthroplasty, a concise follow-up at a minimum of 35 years. Previous reports. J Bone Joint Surg BR 2009 ; 91 : 2617-21.
  3. Caton J, Michel F, Picault C - Charnley.Total hip arthroplasty 33 years of world wide experience. 2nd symposium Charnley International Lyon 1995. Edition Groupe ACORA, Lyon 1995. pp 25-30, 33-36, 71-78, 83-90.
  4. Caton J, Prudhon JL. - Over 25 years survival after Charnley’s total hip arthroplasty. Int Orthop (SICOT) 2011 ; 35 : 185-8.
  5. Charnley J. - Arthroplasty of the hip. A new operation. Lancet 1961 ; 1 : 1129-32.
  6. Farizon F, De Lavison R, Azoulai JJ, Bousquet G – Results with a cementless alumine-coated cup with dual mobility. A twelve-year follow-up study. Int Orthop 1998 ; 22(4) : 219-24.
  7. Lachiewicz PF, Watters TS - The use of Dual-mobility components in total hip Arthroplasty - J Am Acad Orthop Surg 2012 ; 20 : 481-86
  8. Vielpeau C, Lebel B, Ardouin L., Burdin G, Lautridou C – The dual mobility socket concept : experience with 668 cases - Int Orthop (SICOT) 2011 ; 35 : 225-30.
  9. Wroblewski BM, Siney PD, Fleming PA. - Charnley low friction arthroplasty-Survival patterns to 38 years. J Bone Joint Surg Br 2007 ; 39 : 1015-18.


Figure 1a: X-ray of Charnley STALLION® with HA cementless press-fit cup (left)
Figure 1b: X-ray of Charnley STALLION® with cemented cup (right) 


Figure 2: X-ray of HA cementless dual mobility cup