Arthroplasty. Current Research New England Baptist Hospital Daniel M. Ward, M.D. October 1, 2008.

Arthroplasty Arthroplasty

Current Research Current Research

New England Baptist HospitalNew England Baptist Hospital

Daniel M. Ward, M.D.Daniel M. Ward, M.D.

October 1, 2008October 1, 2008

Areas of InterestAreas of Interest

Total hip Total hip replacementreplacement

Revision total hip Revision total hip replacementreplacement

Deep Vein Deep Vein ThrombosisThrombosis

New polymers in New polymers in total hip total hip replacementreplacement

Total Hip ReplacementTotal Hip Replacement

Hips over time fail for may Hips over time fail for may reasonsreasons– Plastic wearPlastic wear– Bone destructionBone destruction– FractureFracture– InfectionInfection– Recurrent dislocationRecurrent dislocation

Total Hip ReplacementTotal Hip Replacement

Number of total hip Number of total hip replacements in the replacements in the US is increasing US is increasing about 15-20% a yearabout 15-20% a year

Earlier interventionEarlier intervention More active More active

populationpopulation Need better Need better

equipment equipment componentscomponents

Total Hip ReplacementTotal Hip Replacement

Study involving a Study involving a new plastic shell/linernew plastic shell/liner

High density plastic High density plastic manipulated with manipulated with heat/gamma heat/gamma radiation to harden radiation to harden plastic and reduce plastic and reduce wearwear

Hopefully reducing Hopefully reducing wear and osteolysis-wear and osteolysis-bone destructionbone destruction

Total Hip ReplacementTotal Hip Replacement

Study involves 25 Study involves 25 patients from patients from multiple institutionsmultiple institutions

5 years of follow up 5 years of follow up with yearly with yearly xrays,data xrays,data sheets,phone callssheets,phone calls

Paper to be Paper to be submitted at 5 years submitted at 5 years

Hopefully funding to Hopefully funding to continue to 15 yearscontinue to 15 years

Total Hip ReplacementTotal Hip Replacement

Bearing are modular Bearing are modular plastic, metal, plastic, metal, ceramicceramic

This study focused This study focused of plastic.of plastic.

Called X3 because Called X3 because of the plastic of the plastic preparation processpreparation process

Now at 2 yearsNow at 2 years

Hip Replacement Hip Replacement StudyStudy

CeramicCeramic Ceramic hip replacementCeramic hip replacement Dr. Bierbaum and about 10 other Dr. Bierbaum and about 10 other

institutions. Study now entering 12 institutions. Study now entering 12 years of follow up.years of follow up.

Bone destruction seen is less than 1%Bone destruction seen is less than 1%– Expect about 22% based on controlsExpect about 22% based on controls

Revision for all reasons is less than Revision for all reasons is less than 2%- equal to the best data we have 2%- equal to the best data we have about total hip replacement today.about total hip replacement today.

Revision Hip Revision Hip ReplacementReplacement Reconstruction of the socket can Reconstruction of the socket can

be challengingbe challenging In some cases almost no bone is In some cases almost no bone is

left in the acetabulumleft in the acetabulum Need fixation in the cup-socket Need fixation in the cup-socket

that allows for long term fixationthat allows for long term fixation

Revision Hip Revision Hip ReplacementReplacement

Revision Hip Revision Hip ReplacementReplacement 10 total sites in 10 total sites in

the USthe US NEBH closed NEBH closed

enrollment at 6 enrollment at 6 months.months.

Initial goal was Initial goal was 18 months to 18 months to have 180 have 180 patients enrolled patients enrolled

Revision Hip Revision Hip ReplacementReplacement Now at 2 years of follow upNow at 2 years of follow up NO cups have been revised for NO cups have been revised for

looseningloosening No osteolysisNo osteolysis Very early follow upVery early follow up Will need to follow these people Will need to follow these people

for 10-15 yearsfor 10-15 years

Revision Hip Revision Hip ReplacementReplacement Different types of stems available Different types of stems available

for hip replacementfor hip replacement Issues with many are Issues with many are

intraoperative fractureintraoperative fracture Orientation of the stem may not Orientation of the stem may not

be optimalbe optimal Fixed length of the stemFixed length of the stem

Revision Hip Revision Hip ReplacementReplacement Study looks at a modular stem that Study looks at a modular stem that

can asses modularity, leg length, can asses modularity, leg length, ease of placement, significantly ease of placement, significantly decreased fracture fatedecreased fracture fate

Over 100 patientsOver 100 patients Retrospective studyRetrospective study Preliminary review looks promisingPreliminary review looks promising

Revision Hip Revision Hip ReplacementReplacement

Revision Hip Revision Hip ReplacementReplacement Study looks at a Study looks at a

modular stemmodular stem

Revision Hip Revision Hip ReplacementReplacement

Revision Total HipRevision Total Hip

Will add significantly to the current Will add significantly to the current literature about revision total hipliterature about revision total hip

Helps validate a current method of Helps validate a current method of treatmenttreatment

Significant improvement to post Significant improvement to post operative managementoperative management

Weight bearing as tolerated, decrease Weight bearing as tolerated, decrease dislocation rate, improve hip functiondislocation rate, improve hip function

Decrease patient morbidityDecrease patient morbidity

Deep Vein ThrombosisDeep Vein ThrombosisDVTDVT

Significantly affects patient outcomes Significantly affects patient outcomes after Total hip replacement (THA)after Total hip replacement (THA)

Can become a Pulmonary Embolus-PECan become a Pulmonary Embolus-PE PE can be a cause of death of THAPE can be a cause of death of THA Mandated by Federal Programs that all Mandated by Federal Programs that all

patients have a specific treatment for patients have a specific treatment for DVT after THA and TKADVT after THA and TKA

Deep Vein ThrombosisDeep Vein ThrombosisDVTDVT

Study randomly and prospectively Study randomly and prospectively places patients into a protocol to places patients into a protocol to prevent DVTprevent DVT

The Baptist has been aggressively The Baptist has been aggressively treating DVT pre-op for a week treating DVT pre-op for a week and then post op for a total of and then post op for a total of treatment to be 6 weekstreatment to be 6 weeks

Deep Vein ThombosisDeep Vein ThombosisDVTDVT

Three arms to studyThree arms to study– 1. Coumadin for 1week before surgery at 1. Coumadin for 1week before surgery at

1mg and then continued post op at 1mg.1mg and then continued post op at 1mg.– 2. Arixtra 2.5mg post op for one month2. Arixtra 2.5mg post op for one month– 3.Adjusted dose coumadin post-op for 3.Adjusted dose coumadin post-op for

one monthone month– All arms have been proven effective with All arms have been proven effective with

DVT,PE and death as the outcomesDVT,PE and death as the outcomes

Deep Vein ThombosisDeep Vein ThombosisDVTDVT

Three arms to studyThree arms to study– The study will hopefully identify that low The study will hopefully identify that low

dose coumadin will be as effective as the dose coumadin will be as effective as the other 2 arms at preventing DVT,PE, death.other 2 arms at preventing DVT,PE, death.

– Benefits-no blood monitoring,extremely Benefits-no blood monitoring,extremely low cost, no bleeding into new jointlow cost, no bleeding into new joint

– Less infection due to lower blood loss into Less infection due to lower blood loss into jointjoint

– Significantly safer for patients.Significantly safer for patients.

Deep Vein ThombosisDeep Vein ThombosisDVTDVT

Patients will need post op duplex ultrasound Patients will need post op duplex ultrasound at 1 month after procedure at NEBH-non at 1 month after procedure at NEBH-non invasive studyinvasive study

Blood drawn at follow up and as needed for Blood drawn at follow up and as needed for adjusted dose coumadin armadjusted dose coumadin arm

Arixtra medication is freeArixtra medication is free Potentially one of the most significant studies Potentially one of the most significant studies

in modern orthopedics.in modern orthopedics. Extremely well controlled. Significant cost to Extremely well controlled. Significant cost to

perform this study. Need the help of both perform this study. Need the help of both surgeons and patientssurgeons and patients

THANK YOUTHANK YOU