Innovative Techniques in Hip & Knee Arthroplasty. Biomedica 2014 Markus Tingart

Transkript

1 Innovative Techniques in Hip & Knee Arthroplasty Biomedica 2014 Markus Tingart

2 Innovative Techniques materials navigation MIS patient-specific implants knee hip

3 Background: Osteoarthritis 35% of individuals over 65 yrs hip & knee arthroplasties (D, 2012) Demographic factors 2050: 70% more over 65 yrs. 220% more over 80 yrs. Predisposing factors (weight, sports) increasing relevance of hip & knee replacement Span, Z.Ortho Unfall, 2011; Statistisches Bundesamt, 2007; Beske, IGSF, 2007

4 Conventional total knee replacement: Results: 91-95% implantat-survivorship (10 yrs.) Do we need innovative techniques? Robertsson et al., JBJS Am., 2007; Swedish Arthroplasty Register 2010

5 Problems & Pitfalls: Conventional Technique wrong size Tibia in varus instability 7 valgus malalingment

6 Conventional Technique femoral entrypoint Intramedullary rod long / short thick / thin up to > 8 of varus / valgus deviation Reed, J. Arthroplasty, 1997

7 Soft tissue management & rotation of the femoral component

8 Bone cuts cutting blade deviation in sclerotic bone error 2 varus-valgus no intraoperative control! Otani, J. Arthroplasty, 1993 Plaskos, J. Arthroplasty, 2002

9 Leg Alingment & Survivorship implantat-survivorship (10 yrs): 97% within ±3 varus / valgus 86% out of ±3 varus / valgus Jeffery, JBJS, 1991; Ritter, CORR, 1994; Behrend, CORR, 2004 conventional surgical technique: up to 30% leg deviation > 3 Petersen, J Arthroplasty, 1988; Quack, Tingart et al., Biomed. Tech., 2012

10 CT-free Navigation Bäthis, Tingart et al., Int. Orthop., 2004; Bäthis, Tingart et al., JBJS Br., 2004

11 Hypothesis Navigtion allows for a more precise reconstruction of the leg axis and a better component positioning. H.K., 72 J., prä-op H.K., 72 J., post-op

12 Results: Reconstrucion of leg axis 1000 patient, prospective study 95% 74% 3% 2% 20% 6% navigation conventional deviation ± 3 deviation 3-5 deviation > 5 Tingart et al., Knee Surg. Sports Traumatol. Arthrosc., 2008

13 Component positioning component navigation conventional p - value frontal femur 1,2 ± 1,1 2,6 ± 2,1 < 0,01* tibia 1,1 ± 1,1 2,0 ± 1,5 < 0,01* sagittal femur 5,9 ± 4,4 10,3 ± 3,3 < 0,01* tibia 2,6 ± 3,6 2,5 ± 2,2 = 0,71

14 Leg alingment & component positioning metaanalyses studies sig. better reconstruction of leg axis sig. more pricise positioning of components Bauwens, JBJS Am 2007, Cheng, KSSTA, 2011; Fu, Knee, 2011; Hetaimis, J. Arthroplasty, 2012

15 Hypothesis Clinical results of computer-assisted total knee arthroplasty are significantly better. S.G., 69 J.

16 Studydesign - retrospective, matched pair - 2 groups: 50 vs conventional vs. navigated - follow up: 6.3 yrs. - main endpoints: - WOMAC - Total Knee Score - x-rays analysis Lüring, Tingart et al., Int. Orthop. 2012

17 Clinical Results & Function ns navigated conventional ns 50 ns 0 WOMAC KSS flexion ns = not significant Lüring, Tingart et al., Knee Surg. Sports Traumatol. Arthrosc., 2011

18 Discussion: Clinical Results Lützner et al. KSSTA, 2010: prospective random. study cases: n = 80, follow up: 20 months no significant difference Knee Society Score, Euroquol Cheng, Surgical Innovation, 2011: metaanalysis 6 studies, cases: n = 443 no significant difference: range of motion, scores, complications

19 Minimally-invasive Knee Arthroplasty shorter incisions (patients) new products (companies) shorter rehabilitation (heath system) MIS as precise & clinical results as good? Bonutti, JBJS Am., 2004; Dalury, CORR, 2005; Kolisek, J. Arthroplasty, 2007

20 points Clinical results & function 300 ns ns conv. MIS MIS-nav weeks 12 weeks ns = not significant Lüring, Tingart et al., Knee Surg. Sports Traumatol. Arthrosc., 2008

21 Metaanalyses: clinical results MIS-technique: better clinical results in first week more problems with wound healing & infection no difference in implant positioning Vavken, Z. Orthop. Unfall, 2008 Cheng, CORR, 2010

22 Patienten-specific cutting blocs

23 Pro & Contra Pro: less instruments save time & money (sterilisation, operation) leg alingment & component positioning more accurate Contra: time-consuming preoperative not address soft tissue, no intraoperative documentation additional costs (cutting blocs, MRI or CT) Barrack, JBJS Br., 2012; Conteduca, KSSTA, 2012; Nunley, CORR, 2012

24 Literature: costs Barrack, JBJS Br, 2012: $ (MRI, cutting blocs) - 320$ (sterilisation, saving time) $ Stöve, Pauwels Conference, AC, 2012: (CT, cutting blocs) (sterilisation) (-30min OR-time) + 290

25 Discussion: Leg alingment & precision Lustig, J. Arthroplasty, 2013, n = 60: - compared pre-op planed cutting planes with real intra-op ones performed with pat.specific blocs: - frontal: 80% of cuts difference ±2 - sigaittal: 55% of cuts difference ±3 Nam, Knee, 2012, n = 80: conventional technique vs. patient-specific blocs 71% of patients leg axis ±3 patient-spec. blocs

26 Hip Arthroplasty: Conventional Technique 92-96% implantat-survivorship (10 yrs.) Goal: Positioning the cup in safe zone (Lewinnek Zone) inclination 45 ± 10 anteversion 15 ± 10 Schwedisches Hüftarthroplastie-Register, 2005; Lewinnek et al., JBJS, 1978

27 Cup Positioning: Results up to 50% of cups are out of safe zone variable position of pelvis dislocation DiGoia et al. CORR, 1998; Saxler et al., Int. Orthop., 2004; Kalteis, Tingart et al., JBJS Br., 2006; Beckmann, Tingart et al., Arch Orthop Traum Surg, 2009

28 Problem: Malpositioned Cup - inclination of 55 instead of 45 - wear is increased by 40% earlier loosening Patil et al., JBJS Am, 2003; Schwedisches Hüftprothesen-Register, 2005

29 Metaanalysis: Cup navigation 80% reduced risk of malpositioning the cup out of the safe zone Beckmann, Tingart et al., Acta Orthop., 2009

30 MIS Hip: Metaanalysis 28 studies, patients Harris Hip Score: idem OR-time: idem malposition: idem incision length: - 8 cm (MIS) Blood loss (intra-op): less (MIS) nerve lesions: higher (MIS) (N. Cut. Fem. Lat.) Smith, Int. Orthop., 2011

31 Perspectives: Hip Arthroplasty stem - navigation Goals: better reconstruction of leg length higher range of motion less risk of dislocation

32 Revision Surgery no revision software off-label use better reconstruction of the joint line better reconstruction of the leg axis Perlick, Tingart et al., Orthopäde, 2006

33 I-Pod Navigation pictures: Prof. Dr. H. Bäthis

34 Conclusions: better reconstruction of leg axis & leg length better component positioning intraoperative control of leg axis, leg length, cutting planes and stability no significant differences in clinical results using navigation or MIS (long term results missing) expect higher survivorship (less wear, less malalingment) learning curve, longer OR-time, higher costs

35 Thank you very much for your attention! Foto: Susanne Wollgarten

36 Implantat Failure: Reasons Sharkey, CORR, 2002

37 Discussion: Reconstruction of leg axis metaanalysis 33 studies 25% reduced risk of malalingment > ± 3 Bauwens et al., JBJS Am., 2007

38 Entwicklung: Stellenwert Navigation Umfragen 2002 zu 2010: 60 zu 77% Navigation ist sinnvoll 32 zu 60% der Kliniken navigieren 13 zu 29% aller Knie TEPs navigiert Bäthis, Tingart et al., Z Orthop, 2005; Rath, Z Orthop & Unfall, 2011 Pubmed - Einträge, letzten 10 bzw. 2 Jahre & zu total knee arthroplasty 750 & 180 zu computer assisted

39 Erfahrungsgrad Operateur: Beinachse & OP-Dauer Navigation: Ø plus 9 min Kein signifikanter Unterschied Tingart et al., Knee Surg. Sports Traumatol. Arthrosc., 2008

40 Kosten der Navigation pro Fall aus: Cerha, Kirschner et al., 2009 < 629 $ pro Fall, Kostenersparnis f. Gesundheitssystem Cerha, Orthopäde, 2009; König, Z. Orthop, 2009; Novak, JBJS Am. 2007

41 Optimale Arthrosetherapie in jedem Lebensalter 44 Jahre ACT- Knie 84 Jahre - Hüftprothese Foto: Susanne Wollgarten

42 Hüftendoprothetik ca pro Jahr in Deutschland > 50% der Hüft-TEPs bei 65Jährigen (USA, 2030) jungen Patienten im Focus 49jähriger Patient; Hüftprothese re. BV Med, 2008; Bozic, JBJS Am,, 2009

43 Prothesentypen: Oberflächenersatz Kurzschaft Standardschaft

44 Ergebnisse: Oberflächenersatz Metaanalyse (2011): 29 Studien, n = Prothesen Nachuntersuchung: 6 Mo. 10 J. Revisionsrate: 3,5% Kein Implantat erfüllt nationalen Qualitätsstandards für 10 J.-ÜR Van der Weegen, JBJS Br, 2011

45 Kurzschaftprothese unzureichende Datenlage! CUT, ESKA Proxima, DePuy Druckscheibe, Zimmer CFP, LINK Metha, Äsculap Nanos, S & N Mayo, Zimmer

46 Individualprothesen: Prinzip: Patienten-spezifisches Instrumentarium Anfertigung der Prothese nach präoperativem CT-Datensatz Zeit- & Kostenersparnis Ziele: geringerer Knochenverlust bessere Passgenauigkeit & biomechanische Rekonstruktion bessere Funktion iuni iduo itotal bisher keine wiss. Ergebnisse