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More surgeons turning to resurfacing for DJD in baby boomers' hips and shoulders
These bone-preserving implants are conservative, intermediary steps to TJR in young, active patients.
Hip and shoulder resurfacing arthroplasty gives surgeons the ability to offer bone-conserving surgical options to patients with a minimal amount of degenerative joint disease. It also affords them a good way to match implants to patients’ needs and demands.
This shift in the joint replacement market in a conservative, less invasive direction is noticeable, with many major orthopedic manufacturers seeking to capture part of it with some kind of resurfacing product.
Image: Arthrosurface |
A handful of resurfacing products are already available here.
In young patients for whom more-invasive arthroplasty is not indicated, “You can make an argument to preserve more bone,” said Joseph Iannotti, MD, PhD, Orthopedics Today editorial board member, who has done about 40 humeral head resurfacings.
Resurfacing-style implants avoid the need for a major osteotomy of the femoral or humeral head. The surgeon exposes much of the head, reams it, removes just a small proximal portion where the articular cartilage is worn or diseased, and caps it using a metal prosthesis with a short stem and perhaps a roughened undersurface. Some hip systems allow for implanting an acetabular cup. A few shoulder systems permit implanting a prosthetic glenoid.
Resurfacing can buy a young, active patient added time, up to about 15 years, until they need total hip arthroplasty (THA) or total shoulder arthroplasty (TSA).
Continued developments in this area, like recent FDA approval of the metal-on-metal Birmingham hip resurfacing (BHR) system [Smith & Nephew], have propelled increasing interest in resurfacing. The Australian National Joint Replacement Registry 2006 Annual Report ranked it as the number one primary hip resurfacing prosthesis from 2001 to 2005. The registry reported a 2.2% revision rate with hip resurfacing vs. 1.7% for conventional THA.
Approval sought
The Cormet hip resurfacing system [Corin Group PLC], distributed elsewhere since 1997, is moving closer to FDA approval. Corin CEO Ian Palin told Orthopedics Today in 2003 the last patients were enrolled in the multicenter investigational device exemption (IDE) trial, which involved about 400 devices to mostly treat osteoarthritis (OA).
Should approval be obtained, Stryker Orthopedics has agreed to distribute the Cormet hip. The FDA panel hearing could be held the first quarter 2007, Palin said.
Others await approval of the popular and highly studied Conserve Plus metal-on-metal femoral surface replacement system [Wright Medical Technologies], advocated by Harlan C. Amstutz, MD. Calls to Wright officials for an updated approval status were not returned.
Hip hemi-arthroplasty resurfacing options are available for those with a healthy acetabulum. Biomet’s Recap femoral resurfacing system reduces dislocation risk and may use minimally invasive surgical techniques or a smaller incision, according to the company’s Web site.
The ASR [DePuy, a Johnson and Johnson company] product is approved outside the United States, but is undergoing a clincial trial for the U.S. approval. The femoral resurfacing component of the ASR system is currently available for hemi-arthoplasty applications.
Arthrosurface’s highly conservative cobalt chrome HemiCAP hip implant resurfaces just the smallest possible diseased area of the proximal femur, developers said.
Other sizes and styles of HemiCAP implants, available in diameters up to 40 mm, are approved for shoulder and great toe resurfacing. An IDE study is underway for the femoral condyle, an Arthrosurface spokesperson told Orthopedics Today. Outside the United States, HemiCAP products are approved for the patellofemoral joint.
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Images: Iannotti J |
Shoulder resurfacing options
Shoulder resurfacing provides more treatment options for young patients with shoulder OA, rheumatoid arthritis or avascular necrosis. In addition to the HemiCAP device, the two others sold in the United States are Biomet’s Copeland shoulder, available since 2001, and the Global C.A.P. shoulder hemiarthroplasty prosthesis [DePuy].
Although less data are available for humeral head resurfacings than hip resurfacing prostheses, Stephen A. Copeland reported survivorship of 90% with his eponymous resurfacing implant [Biomet].
Iannotti, a designer of the Global C.A.P. implant, performs shoulder resurfacing in patients with OA and a relatively healthy glenoid for whom TSA may not be indicated.
“It makes a lot of sense not to take the head away and to simply resurface it, assuming you have enough bone proximally to allow for good seating,” he said. Another advantage: “There are probably more options when it fails.”
David S. Bailie, MD, of Phoenix, uses the Copeland shoulder for hemi-arthroplasties in high-demand, athletic patients. “It’s not infrequent to get somebody who rates their shoulder as 100%.”
At 2 years postop, patients’ Simple Shoulder Test scores are 11.1 mean (0-12). They show usual signs of reduced shoulder pain.
Pain scores start at up to 9 points and drop to about 0.7 points, said Bailie, who has the second largest series of Copeland prostheses in young patients and has revised to a TSA just twice.
Bailie agrees joint resurfacing is becoming more widely accepted. He now does most cases outpatient. “I think we’re the only ones in the country doing that.”
For more information:
- Joseph Iannotti, MD, PhD, is with the Cleveland Clinic Foundation, A-41, 9500 Euclid Avenue, Cleveland, OH 44195. He can be contacted at 216-445-5151; fax: 216-445-6255, or iannotj@ccf.org.
- David S. Bailie, MD, is with The Orthopedic Clinic Association, 9377 E. Bell Street, Scottsdale, AZ 85260. He can be contacted at 602-277-6211, fax: 480-905-0426, or david.bailie@dcranch.com.