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IRCCS Ospedale San Raffaele Milano U.O. Ortopedia e Traumatologia U.O. Ortopedia e Traumatologia *Scuola di Specializzazione di Ortopedia Perugia Paolo.

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Presentazione sul tema: "IRCCS Ospedale San Raffaele Milano U.O. Ortopedia e Traumatologia U.O. Ortopedia e Traumatologia *Scuola di Specializzazione di Ortopedia Perugia Paolo."— Transcript della presentazione:

1 IRCCS Ospedale San Raffaele Milano U.O. Ortopedia e Traumatologia U.O. Ortopedia e Traumatologia *Scuola di Specializzazione di Ortopedia Perugia Paolo Sirtori, Rashwan Gogue*, Riccardo Cecchinato e Gianfranco Fraschini RAZIONALE DEL TRATTAMENTO FARMACOLOGICO DA ASSOCIARE AD UN IMPIANTO DA REVISIONE

2 Malchau H, Herberts P, Ahnfelt L. Prognosis of total hip replacement in Sweden. Follow-up of 92,675 operations performed Acta Orthop Scand 1993;64(5): Total Hip Arthroplasty Failure

3 Prosthetic Dislocation (2%)

4 Total Hip Arthroplasty Failure Periprosthetic Fractures (< 2%)

5 Total Hip Arthroplasty Failure Infections (10%)

6 Total Hip Arthroplasty Failure Fatigue Breakage (<2%)

7 Aseptic Loosening (79%) Total Hip Arthroplasty Failure Malchau H, Herberts P, Ahnfelt L. Prognosis of total hip replacement in Sweden. Follow-up of 92,675 operations performed Acta Orthop Scand 1993;64(5):

8 FIRST ACETABULAR IMPLANTS SURVIVAL (Baker Clin Orth Rel Resear) (69 pz ) 88.8% to 15 years88.8% to 15 years

9 FIRST ACETABULAR IMPLANTS SURVIVAL (Clarius 2009 – Int. Orthop.) (127 pz ) 75% to 17 years75% to 17 years

10 FIRST ACETABULAR AND FEMORAL UNCEMENTED IMPLANTS SURVIVAL YOUNG SUBJECTS (< 50 ANNI) (Kearns Clin Orth Rel Resea) (221 pz ) 98.7% to 5 years 98.7% to 5 years 84.6% to 10 years 84.6% to 10 years 52.5% to 15 years 52.5% to 15 years ACETABULAR CUP 98.7% to 5 years 98.7% to 5 years 84.6% to 10 years 84.6% to 10 years 52.5% to 15 years 52.5% to 15 years FEMORAL STEM 99.3% to 5 years 99.3% to 5 years 98.9% to 10 years 98.9% to 10 years 96.8% to 15 years 96.8% to 15 years

11 EARLY FAILURE IN TOTAL HIP ARTHROPLASTY (Dobzyniak M. G – Clin Orthop Rel Res) (824 pz ) 35 % of revision were performed during the first 5 years 35 % of revision were performed during the first 5 years

12 CAUSES OF FAILURES in THA Absence of primary stability Absence of primary stability Implant instability Implant instability Infections Infections Painful THA/ discrepancy in leg lengthening Painful THA/ discrepancy in leg lengthening Periprosthetic fractures Periprosthetic fractures Aseptic bone loosening Aseptic bone loosening HARRIS Clin Orth Rel Resear HOPLIN 2008 – RadioGraphics

13 MOST FREQUENT CAUSE OF FAILURES IN THA Aseptic Bone Loosening Aseptic Bone Loosening

14 Aseptic Bone Loosening Multifactorial etiology Aging and systemic bone loss Aging and systemic bone loss Adaptive bone remodeling or stress shielding Adaptive bone remodeling or stress shielding Individual cellular response to wear debries Individual cellular response to wear debries Bone metabolic status Bone metabolic status FAILURES IN THA SUNDFELDT 2006 – Acta Orthopaedica

15 Aseptic Bone Loosening Absence of osteo-integration Absence of osteo-integration Lost of osteo-integration Lost of osteo-integration FAILURES IN THA Multifactorial events those lead to mid and long term failures, secondary to……. Aseptic Bone Loosening FAILURES IN THA

16 La qualità dellosso in una revisione è più scadente!?! Come è fallito il primo impianto fallirà anche la revisione?!! Quali fattori devo considerare per affrontare bene una revisione?!!

17 Extrinsic Factors Implant typologyImplant typology Bone graftBone graft CoatingCoating Revision for Aseptic Bone Loosening

18 Bone Metabolic Alterations Bone Metabolic Alterations Osteoporosis/Osteopenia Osteoporosis/Osteopenia Genetic Predisposal Genetic Predisposal Intrinsic Factors Revision for Aseptic Bone Loosening

19 ORA TI MOSTRO I FATTORI ESTRINSECI PREFERISCO BERE LA MIA BIRRA

20 Optimal stability of revision socket device Good distal encourage with obturatoris hook Good proximal encourage with wings and screws Good osteo-conductive surface THA REVISION – EXTRINSIC FACTORS IMPLANT TYPOLOGY

21 Trabecular Metal Modular Augmentation THA REVISION IMPLANT TYPOLOGY

22 THA REVISION – EXTRINSIC FACTORS IMPLANT TYPOLOGY

23 Bone Allograft integration Bone Allograft Morsellised Chips – Optimal Shape (2x2x4 mm) THA REVISION - EXTRINSIC FACTORS BONE GRAFTS

24 Hypothetical use of osteoinductive factors like PRP or stem cells. Morsellised chips to fill the cavity; They posses osteoconductive and limited osteoinductive properties. THA REVISION - EXTRINSIC FACTORS BONE GRAFTS

25 Synthetic bone graft substitutes Bone substitutes calcium/phosphate + Mg Osteoconductive capabiility Macro e micro porosity THA REVISION - EXTRINSIC FACTORS BONE GRAFTS

26 ORA TI MOSTRO I FATTORI INTRINSECI NON HO ANCORA TERMINATO DI BERE LA BIRRA

27 43% 21% 36% Vitamin D active metabolite: 25 OH D 3 Hypo and Deficiency of Vitamin D 3 THA REVISIONS (Intrinsic Factors) Bone Metabolic Alterations (n=62)

28 4% 84% 5% 7% Parathyroid Hormones: PTH vs Ca ++ Hyperparathyroidism THA REVISIONS (Intrinsic Factors) Bone Metabolic Alterations (n=62)

29 66% 44% Index of osteoblast activity BGP 65% 35% Index of osteoclast activity D-Pyr Higth bone turnover and uncopling of bone remodeling THA REVISIONS (Intrinsic Factors) Bone Metabolic Alterations (n=62)

30 82% 18% Vertebral BMD 75% 25% Femoral BMD (neck) Osteoporosis has been releved in interesting amount of subjects, with prevalence in femoral site. THA REVISIONS (Intrinsic Factors) Osteoporosis(n=62)

31 Polymorphism in metalloproteases MMP-1 and interleuchin IL-6Polymorphism in metalloproteases MMP-1 and interleuchin IL-6 Gender-dependent role of the T393C polymorphism in aseptic looseningGender-dependent role of the T393C polymorphism in aseptic loosening Calcium Sensing Receptor unspecific alterations Calcium Sensing Receptor unspecific alterations 1) Malik MHA; Ann Rhem Dis ) Godoy Santos AL; J Arthroplasty ) Bachmann HS; J Orthopaedic Research ) Gallo J; BMC Medical Genetics 2009 THA REVISIONS (Intrinsic Factors) Genetic Predisposal

32 PARATHYROIDSregulation in PTH secretion THYROIDregulation in Calcitonin secretion KIDNEYriduced the phosphaturic activity of PTH BONEinibizione osteoclastica Calcium-Sensing Receptor (CaSR) THA REVISIONS (Intrinsic Factors) Genetic Predisposal

33 P<0.005 THA REVISIONS (Intrinsic Factors) Genetic Predisposal PTH suppression test (CaSR) in hip fracture subjects Secondary Hyperparthyroidism due to hyocalcemia Secondary Hyperparthyroidism due to unspecific alterations in CaSR

34 Factors should be considered in revision surgery of THA Extrinsic Factors Implant typology Implant typology Bone graft Bone graft Coating Coating Bone Mineral Metabolism Alterations; Bone Mineral Metabolism Alterations; Osteoporosis Osteoporosis Intrinsic Factors Genetic Factors Polymorphism in metalloprotease MMP-1 Polymorphism in metalloprotease MMP-1 Gender-dependent T393C polymorphism Gender-dependent T393C polymorphism Calcium Sensing Receptor unspecific alterations Calcium Sensing Receptor unspecific alterations

35 Fattori intrinseci coinvolti nel fallimento di una revisione di artroprotesi di anca Riassorbimentoperiprotesico Microparticelle di materiale proveniente dallusura delle componenti protesiche Stress meccanico dellimpianto sulla struttura ossea accettante Attivazione OC Iperparatiroidismo Deficienza di Vit D Inibizione OB Difetto di integrazioneprotesica OsteoporosiDiminuito Bone Stock Fallimento della REVISIONE

36 Domani farò una revisione di anca Ricordati di valutare il metabolismo minerale e di trattare il paziente

37 Biochemical Index of Bone Metabolism Calcio ionico serico (Ca 2+ ) Vitamina D (25OHD) Paratormone (PTH) Biochemical Index of Bone Remodeling Osteocalcina (BGP) Lisilpiridinolina urinaria (D-Pyr) THA REVISIONS (Intrinsic Factors) Evaluation of Bone Metabolic Alterations

38 MOC - DXA scan Lumbar site Femoral site THA REVISIONS (Intrinsic Factors) Evaluation of Bone Mineral Density

39 macrophage Mesenchymal stem cell Hematopoetic Stromal cell Adipocyte Pre-osteoblast Pre-osteoclast Osteoclast Lining cell Osteocyte Osteoblast A ttivare D eprimere M odulare il rimodellamento osseo

40 macrophage Mesenchymal stem cell Hematopoetic Stromal cell Adipocyte Pre-osteoblast Pre-osteoclast Osteoclast Lining cell Osteocyte Osteoblast 1) ATTIVARE 1,25 (OH) 2 - Vitamin D Promotes differentiation of osteoblast and osteoclast precursors (+)

41 macrophage Mesenchymal stem cell Hematopoetic Stromal cell Adipocyte Pre-osteoblast Pre-osteoclast Osteoclast Lining cell Osteocyte Osteoblast Bisphosphonates (-) Inhibits osteoclast function 2) DEPRIMERE (-) Inhibits pre-osteoclast

42 macrophage Mesenchymal stem cell Hematopoetic Stromal cell Adipocyte Pre-osteoblast Pre-osteoclast Osteoclast Lining cell Osteocyte Osteoblast (-) Inhibits osteoclast function MODULARE Strontium-R(+) Increases expression of RANK-L + OPG

43 Ranelato di Stronzio Osteoblasta Osteoclasta CaSrRan CaSrRan Espressione di OPG & RANKL 2 (4) Hurtel et al, J Biol Chem 2009 (5) Hurtel et al, submitted (1) Chattopadyay et al, Biochem Pharmacol 2007 (2) Brennan et al, Br J Pharmacol 2009 (3) Fromingué et al, JCMM 2009 Replicazione 1 RANKL expression 2 Apoptosi 4 Differenziazione 5 Sopravvivenza 3 Lo Stronzio è un modulatore del turnover osseo a vantaggio della attività osteoblastica

44 A ttivazione del rimodellamento osseo con: 1,25(OH) 2 D 3 D epressione della attività osteoclastica con: DIFOSFONATI M odulazione del rimodellamento osseo sbilanciandolo a favore della attività osteoblastica con: R. di STRONZIO TRATTAMENTO FARMACOLOGICO DA ASSOCIARE AD UN IMPIANTO DA REVISIONE (ADM) ALLO SCOPO DI FACILITARE LA OSTEOINTEGRAZIONE DEL NUOVO IMPIANTO

45 A ttivazione: ROCALTROL 0.5 µg/die per 30 gg. D epressione: ALENDRONATO/RISENDRONATO (70 o 35 mg/ sett) per 6 mesi. M odulazione: RANELATO di STRONZIO 2g/die per 6 mesi MODALITA DI TRATTAMENTO (ADM) NB: mantenere adeguato apporto del metabolita 25OHD durante la fase D e M

46 Grazie


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