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

Innovative Techniques in Hip & Knee Arthroplasty Biomedica 2014 Markus Tingart

Innovative Techniques materials navigation MIS patient-specific implants knee hip

Background: Osteoarthritis 35% of individuals over 65 yrs. 380.000 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

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

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

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

Soft tissue management & rotation of the femoral component

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

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

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

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

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

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

Leg alingment & component positioning metaanalyses 33-41 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

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

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

Clinical Results & Function 200 150 100 ns navigated conventional ns 50 ns 0 WOMAC KSS flexion ns = not significant Lüring, Tingart et al., Knee Surg. Sports Traumatol. Arthrosc., 2011

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

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

points Clinical results & function 300 ns ns conv. MIS MIS-nav.. 200 100 0 6 weeks 12 weeks ns = not significant Lüring, Tingart et al., Knee Surg. Sports Traumatol. Arthrosc., 2008

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

Patienten-specific cutting blocs

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

Literature: costs Barrack, JBJS Br, 2012: + 1.500$ (MRI, cutting blocs) - 320$ (sterilisation, saving time) + 1.180$ Stöve, Pauwels Conference, AC, 2012: + 720 (CT, cutting blocs) - 180 (sterilisation) - 250 (-30min OR-time) + 290

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

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

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

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

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

MIS Hip: Metaanalysis 28 studies, 2.850 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

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

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

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

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

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

Implantat Failure: Reasons Sharkey, CORR, 2002

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

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 9.700 & 2.500 zu total knee arthroplasty 750 & 180 zu computer assisted

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

Kosten der Navigation 400 500 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

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

Hüftendoprothetik ca. 200.000 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

Prothesentypen: Oberflächenersatz Kurzschaft Standardschaft

Ergebnisse: Oberflächenersatz Metaanalyse (2011): 29 Studien, n = 10.600 Prothesen Nachuntersuchung: 6 Mo. 10 J. Revisionsrate: 3,5% Kein Implantat erfüllt nationalen Qualitätsstandards für 10 J.-ÜR Van der Weegen, JBJS Br, 2011

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

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