GIRARD Julien,

Service d’orthopédie C,

CHRU Lille

HIP RESURFACING IN YOUNG ATHLETES

Professeur Julien GirardCHRU Lille (France)

The author claims to have participated in clinical trials, scientific research, consultancy, conferences, seminars for companies Smith and Nephew, Wright Medical Technology, Zimmer, DePuy.

Repeated loading traumatism: wear- Wear if hard on soft bearing (PE+++)

- Fracture risk if CoC

- Risk of aseptic loosening if repeated loading

High traumatism:

- Dislocation: pb for dangerous sports (ski, hikking, trekking…)

- Femoral fracture if femoral stem

- Implant fracture

RISKS for SPORTS with THA

SSMKS Chambéry 2005

Recommandations

Healy W (Am J Sport Med 1999)

Members of Hip Society

Klein G (J of arthroplasty 2007)

Members of HS and AAHKS

Exclusion for high impact sports (tennis, running, snowboard…)

Evolution of recommandations according to new hard on hard bearings

THA and SPORT

In 2013, what is the best hip arthroplasty for a young and active patient???

We can « play » with:

1. Bearing

2. Stem (yes or no) and design

3. Head diameter

1. Bearing

Bearing: minimize the wear

If hard on soft bearing (PE) then choose a soft sport activity:

- no loading impact

- no impact (jump, running…)

- choose a soft sport with gentle RoM without loading

- no impact sport (vélo, natation)

SSMKS Chambéry 2005

Bearings

Adaptation de la prothèse à l’activité sportive :

MoMWear resistantNo osteolysisChrome/Cobalt Wear 0,001 à 0,003 mm/year

PE/Mele plus ancien mais activité augmente usure25 à 35 ans de reculDébris PE / ostéolyse Usure 0,1 à 0,3 mm/an.

CoCWear resistantNo osteolysisFracture de la céramique (1/5000)Wear 0,001 à 0,005 mm/an

Ceramic : problems

FractureFRACTURE :

Less and less with tribological advancesRisk difficult to assess: 1/1000 to 1/10000

Ceramic : problem

- Risk of fracture if high impact (See et al. JoA 2003, Koo et al. JBJS Br 2008…)

- Risque de « chipping » par effet came (Stewert et al. JoA 2009)

- - Risque de squeaking 1 à 10%

Pour bcp d’auteurs : CI aux sports à impact avec CoC…

Badminton PTH 3 ans 38 ans

DISLOCATION….

Impossible to obtain anatomical head diameter (40 mm max) except with MoM …But femoral head diameter is 52mm for male and 47 for female

52mm 32mm

DISLOCATION

Whatever the rate (1-5%) after THA, it will be too great…

Correlation between dislocation rate and sport activity (Naal et al. CORR 2008)

BFH = 0% of dislocation and great RoM … (Amstutz, JOA 2007; Girard, RCO 2007; Vendittoli, Hip 2008; Mont, JoA 2008)

2. Stem (yes or no)

What is the main pb with a femoral stem?

Risk of femoral fracture with THA

SSMKS Chambéry 2005

What is the main pb with a femoral stem?

Risk of implant fracture

SSMKS Chambéry 2005

SSMKS Chambéry 2005

- No wear : no PE and hard on hard bearing (CoC or moM)

- No head fracture: pas de CoC

- No dislocation: BFH

- No stem fracture: very short stem or no stem

- Preservation of hip proprioception: preserve femoral neck (proprioceptors)

Ideal hip arthroplasty

RESURFACING

ADVANTAGES

- Femoral bone stock preservation

- Biomechanical preservation

- Optimization of stress transfert

- Stability

- BFH

LITTERATURE

SPORT AND RSA

Return to sport and THA

N age recul % préop % postop

Chatterji (2004) 235 67.8 18 m 80% 53%

Huch (2005) 420 60.5 5 ans 56% 32%

Dubs (1983) 110 55 3 ans 78% 36%

71% 40%

SPORT and RSA

Return to sport and RSA

N Age Recul % préop % postop

Banerjee (1) 152 52.6 23.4 m 98% 98%

Naal (2) 112 46.4 24 m 95% 98%

Amstutz (3) 350 41.2 5.5 y 31.5% 51.1%

Daniel (4) 446 43.8 8.2 y 60% 87%

(1) Banerjee M. Am J Sport Med 2010 71% 83%(2) Naal F. Am J Sport Med 2010(3) Amstutz H. Clin Orthop 2007(4) Daniel J. J Bone Joint Surg Br 2004

TENNIS and RSA

58 tennis players (75 hips)

Mean age: 50 years (38-58 ans)

Return to tennis: 6 months after procedure

Mean practice 3x/week

Same tennis practice level +++

96% survivorship at 8 years of FU (95 à 98% in non active population)

Mont et al. 1999. Am J Sports Med.

RSA and HIGH IMPACT SPORT

Personnal series (Girard et al. Inter Orthop 2013)

55 RSA (50 patients)

All impact sport (more 4) during preop period

Running, Foot, Rugby, Tennis, Ski, Hockey

Mean age 45.5 ans

Mean FU 4 ans

Return to sport 98% +++

No surgical revision +++

RSA and RUNNINGGirard et al. Am J Sport Med 2012

43 RSA

Running more than 3h/week

Mean FU 3 ans

No revision +++

All patients Before 50 years old After 50 years old

Before After p value Before After p value Before After p value

Time

(hours) 5.2 5.1 0.536 5.2 5.1 0.317 5.1 5.1 1

Mileage

(km) 48.9 48.4 0.009 50.7 52.1 0.25 48.1 46.5 0.009

RSA and RUNNING Girard et al. Am J Sport Med 2012

Return to competition:

Same level than preopNo significant différence for compétition

22 21

10

7

2

12

7

1 2 2

0

5

10

15

20

25

nu m be r of h ips

None 10 km Half-marathon

marathon triathlon

lev e l in c o m p e titio n

before

after

RCT: THA vs RSA Girard et al, OTSR 2008

p = 0.022

5

26

28

7

4

12

38

15

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

THA SRA

Activity level one year after surgery

high impact

moderate impact

light impact

no physicalactivity

RETURN TO SPORTS…Girard et al, Am J Sport Med 2009

p=0.00772%

39%

5%

22%34%

50% 49%

20%12% 8%

0%

20%

40%

60%

80%

100%

Heavy/sport Moderate/recreational Mild/w alking Sedentary

THA

SRA

IONS and SPORT

De Smet et al. JBJS Br 2007 :

Triathlète with MoM RSABefore Cr = 0,5 Co = 0,7After Ironman (12h35) Cr = 0,7 Co = 1,1 NSD2 Cr = 0,6 Co= 0,7 NS

Experience personnelle : (Girard et al. JBJS Am in press)

31 runners during half marathon with MoM RSA

Before race Co = 0,7 Cr = 0,92 h after Co = 1 Cr = 1,2 NSD1 Co = 0,8 Cr = 0,8 NS

Conclusion

L’arthroplastie conventionnelle moderne est compatible avec des activités d’impact faible (+/- intermédiaire) mais pas plus….

Conclusion

Absence de luxation et absence d’usure

RTH implant idéal pour des patients pratiquant des sports d’impact élevé.

Aucune contre indication +++

Course à pied possible même en compétition +++