Authored by Yves Cirotteau
This article will show the clinical and
surgical results of a patient who was operated of both hips for a severe
coxarthrosis. The follow up is 30
years for the right hip and, and 26 years for the left hip. The woman
was treated according to a new concept of the femoral stem. The goal of
this
concept is to respect-as close as possible-the physiological bone
metabolism. The femoral implant, instead of being fixed in the medullary
canal, is
fixed on the femoral lateral cortex of the shaft to secure a fixation
during all the patient’s life, whatever his age.
Abstract
The total Hip Arthroplasty of Sir John Charnley was a revolutionary
step in the treatment of hip diseases. Currently, the long-term
follow-up
of such a prosthesis can be estimated from fifteen to twenty years. The
question is: is that delay sufficient to treat young patients with
severe hip
disease. In a recent publication, Rik Huiskes claims that since
Charnley, no so-called innovation has either scientific proof in real
efficiency or in terms
of longer longevity. This should not be a surprise for all total hip
prothesis are placed in the medullary canal, either with or without
cement. In fact,
the so-called innovations are minimal modifications in the design of the
stem. It is obvious that if these modifications are not efficient, one
should
not follow this line of research. It seems that almost everything has
been written on total hip arthroplasty failure. We must therefore work
in another
direction, with other criteria.
Suppose that it is the bone, with all its specifications, which is
the possible reason for that long-term failure. Is the “kuntscher”
imperial road,
the only highway to deal with the shaft of a long bone? A new concept, a
new philosophy to fix a hip stem prosthesis on the femoral shaft
becomes
apparent. In other words, according to this new scientifically point of
view, the mechanical aspect of a stem hip prothesis is no longer of
interest. If
the stem can be placed inside the medullary canal, why could not it be
fixed outside of the shaft, for example on the external part of the
diaphyseal
cortex, below the periosteal layer? It seems that searcher should work
today on bone physiology, instead of working on any mechanical aspect of
surgical fixation in the medullary canal. Using the physiological
properties of a living bone could be the answer to avoid any failure of
the stem all
the life’s patient long.
Pathological Modifications of the Femoral Cortices
Everyone, in his practice, had patients with more or less severe
brain dysfunction, one is hemiplegia [1]. What could happen for the
patient from an orthopedic point of view, on the lower limb when
such a disease happens? The reduced use of the limb reduces the
pressure on the bearing bone and, from a physiological point of view,
a reduction of the mineralization. The bone becomes osteoporotic
[2]. The physical phenomenon is reversible when the pressure
conditions are restored. Here are two examples. This patient had a
right haemorrhagic stroke few years ago. He had a left hemiplegia
and spent a long time in physiotherapy due to the difficulty to
walk. Note the thin both femoral cortical due to the bad utilization
of the left lower limb (Figure a). Few years later, he recovered a
best walk. Note the very good thickening due to the best support
of his body weight by the limb (Figure b). Adversingly, despite the
severe coxarthrosis note the good thickness of the femoral cortex
before surgery (Figure a, b). Few years later the patient had a
hemiplegia. Note the increasing diameter of the femoral medullary
canal (Figure c). What would have happened if an intramedullary
implant was settle in it?
Scientific Reasons of this New Concept
The choice of this implant’s design was done in the aim of a
more physiological respect of the bone structures [3-5].
a) The joint elasticity is mainly due to the cancellous bone
of a joint. Most of the intra-medullary canal implants destroy
it. In this case the cancellous bone is in the upper femoral
metaphyseal neck, more or less in totality (Figure a, b).
b) The bone marrow has one of the most important roles
in bone physiology: vascularization, cells of bone remodeling,
blood cells, proteins and minerals are the major actors of the
normal bone life.
c) The periosteum is acting all lifelong (even after 100 years)
and covers all foreign bodies which are fixed on the shaft,
keeping a fixation stronger and stronger by time (Figure c, d).
d) The pressure on the calcar is necessary to increase and
maintain it thickness. A large crown on the upper part of the
implant rests firmly there so that there is no resorption [8-9].
Minimal Resection of the Cancellous Bone
To fix in the upper femoral metaphysis the prothesis needs a
very few cancellous bone removals as shown on the drawing. It
keeps the elasticity of this part of the femur (Figure a, b).
Technical procedure
A cemented Charnley’s cup in polyethylene was cemented in
the acetabulum. An external stem implant in titanium was fixed on
the lateral cortex of the femoral shaft, below the periosteum. A 22,2
mm diameter of the head was used on the right side. Four years
later, a non-cemented metal back acetabulum with a 22,2 diameter
of the head was placed on the left side. Insert in polyethylene. A
lateral femoral Implant in titanium was screwed. Screws of 5 mm of
diameter for the femoral shaft, 6 mm of diameter to fix the greater
trochanter.
Clinical story and examination
Me T… Françoise is Born the 04 12 1938 - Her Height is
1.59m, her Weight is 59kg. This 80-year-old patient had a bilateral
coxarthrosis. When she was 51 years old, in 1989, she was operated
on the left side. Four years later, a THP as placed on the right side in
1993. She was seen in clinic office in May 2019. Follow up: 30 years
on the right side Follow up: 26 years on the left side She has no pain.
She can climb stairs up and down without difficulty. Over three
floors, she uses the ramp stairs. She walks without help as long as
she wants. One hour without stop She walks without limping.
PM: One hour, without stop in a quiet walk. She has a normal
life.
She practices Sports Taï chi twice a weel, one hour with other
members.
She goes in holydays either vacancies aux Canaries, Greece,
dans les Pyrénées, 0 Saint Jean de luz. She is a grand-ma keeper for
her Little children’s daughter on sunday.
She Plays piano, and sing in a chorus opera
She Has a lot of additional activities
Mobility: Left: 140 0 - 35 20 - 20 20
Right: 140 0 - 40 40 - 30 20
Functional scores
Postel-Merle d’Aubigné (PMA) Pain, Mobility, Walk 4 grades: 18
excellent. Harris hip score: Douleur, function, mobilité, absence de
déformation Score jusquà 100: 90-100: excellent. Oxford hip score:
Activities of the daily Life. Auto-administrated survey with12 items
giving a score: 42-48: excellent.
Discussion
The first planning was to start with a well-considered
definition of the goal expected. It was to secure the femoral
implant on its support so that it would stay all day long, as long
as patient’s life, without physical activity limitation. The second
question was followed by the development of an effective strategy.
Once establishing the goal and the strategy, do we have worked
backwards to identify the next steps? Have we reach the goal
expected? Can we be sure that the fémoral implant will be aware of
complications in 100%.
In fact, the purpose is to answer to three questions:
a. Does bone physiology have been respected? The answer
is yes concerning the cancellous bone, the femoral cortices, the
role of the periosteum. There was no calcar resorption.
b. Do we have had any mechanical complications such as:
broken screws or broken plates. Yes, in a very small cases, some
screws fixing the greater trochanter broke. If the osteotomy of
this apophysis is consolidated, nothing will happen. In some
case the lateral part of the broken screws must be removed
when painful. Since we have changed the design of the screws, (6 mm of diameter) no one broke. Have we reach the goal? In
this experience, the answer is yes [4]. Not any femoral plate was
removed. All patients are either too old now or are in a very
high place in the sky where nobody can reach them or are still
living with their implants.
Conclusion
The lateral femoral implant is, according to this cohorte, one of
the good solutions for a long implant’s life, as long as the patient’s
life, whatever his age [5-7]. But we should stress the difficulty of its
fixation on the upper femoral metaphysis. The greater trochanteric
osteotomy must be perfect. The screws must be of a good size
and length. The consolidation delay of this bone section must be
respected. The patient must walk with two crutches during this
time with only a contact support. Surgeon must keep in mind that
he is not at all a simple machine to operate. He must practice with
his heart and must explain to his patient what he will do and why he
will do for it in order to reach the target [9]. In this way, the surgeon
does not destroy the intra-medullary bone marrow. He keeps as
much as possible the cervical cancellous bone (Figure a, b). The
implant applies a constant pressure on the femoral calcar [8], and
the periosteum osteogenic power covers by time the implant plate,
connecting strongly mechanically both bone and metal. This patient
is in good health, has a normal activity for her age. Both femoral
implants remain stable and will stay so until the end of the story.
Acknowledgment
Conflict of Interest
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