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Revisin del acetbulo

Mdulo de Cadera

Dr. Jorge Luis de la Vega Barraza


Residente de 4to ao

Asesores:
Dr. Arnoldo Abrego Trevio
Dr. Toms Ramos Morales
Dr. Victor M. Seplveda Oyervides

INTRODUCCIN

Revisin de ATC 17% por ao


Reconstruccin acetabular
Manejo controversial
Sporer SM, Paprosky WG, O Rourke M: Managing Bone
Loss in acetabular revision: selected instructional course
lecture. J Bone Joint Surg Am 2005; 87-A(7): 1620-30.

INDICACIONES
Aflojamiento asptico sintomtico
Inestabilidad
Infeccin
Osteolisis
Desgaste

Contraindicaciones
Infeccin severa
Baja esperanza de vida

La planificacin preoperatoria es el primer y


ms importante paso al realizar una
artroplastia de revisin de cadera.

Kearns SR, McDonald SJ. Preoperative radiographic evaluation and


classification of defects. Chapter 32. Surgical treatment of hip arthritis.

PLANIFICACIN
EVALUACIN RADIOLGICA
-Rx. AP Pelvis
-Rx. AP y LAT Cadera
-Proyecciones Judet
ESTUDIOS COMPLEMENTARIOS
-TC
-Angiografa

PLANIFICACIN
IDENTIFICAR DISEO DEL IMPLANTE

PRUEBAS DE LABORATORIO
-BH completa
-VSG
-PCR

- QS
- Perfil bioqumico
- Perfil nutricional

ARTROCENTESIS
Barrack RL, Harris WH. The value of aspiration of the hip joint
before revision total hip arthroplasty. J Bone Joint Surg Am
1993; 75:66-76.

La cantidad de prdida sea y la migracin del


componente acetabular son elementos
fundamentales para planificar una revisin
acetabular.
Gerber A, Pisan M, Zurakowski D: Ganz reinforcement ring for
reconstruction of acetabular defects in revision total Hip
Arthroplasty. J Bone Joint Surg Am 2003; 85-A(12): 2358-64.

clasificaciones
Paprosky
Gross
AAOS
Harris
Lombardi

clasificacin

AAOS

I. Defecto segmentario
II. Defecto cavitario
III. Defecto combinado
IV. Discontinuidad plvica

AAOS

Tipo I defecto segmentario


Prdida del soporte seo del
anillo acetabular

D'Antonio JA, et al. Classification and


management of acetabular deformities in total
hip arthroplasty. CORR 1989; 243: 126-137.

AAOS

Tipo II defecto cavitario


Prdida de hueso del fondo
con anillo intacto

D'Antonio JA, et al. Classification and


management of acetabular deformities in total
hip arthroplasty. CORR 1989; 243: 126-137.

AAOS

Tipo III defecto combinado


Combinacin de los dos
defectos

D'Antonio JA, et al. Classification and


management of acetabular deformities in total
hip arthroplasty. CORR 1989; 243: 126-137.

AAOS

Tipo IV discontinuidad plvica

D'Antonio JA, et al. Classification and


management of acetabular deformities in total
hip arthroplasty. CORR 1989; 243: 126-137.

clasificacin

Paprosky

I. Mnimo defecto seo


IIA. Defecto superior pequeo
IIB. No hay cpula superior
IIC. Defecto de pared medial
IIIA. Prdida sea grave
IIIB. Osteolisis severa

paprosky

Defecto acetabular tipo I


- Lisis focal
-Anillo y columnas
intactas

Paprosky WG, Perona PG, Lawrence JM. Acetabular defect


classification and surgical reconstruction in revision arthroplasty. A
six year follow-up evaluation. J Arthroplasty 1994; vol. 9.

Defecto acetabular tipo IIA


- Lisis superomedial
- Migracin <3 cm
- Kohler grado 1
Paprosky WG, Perona PG, Lawrence JM. Acetabular defect
classification and surgical reconstruction in revision arthroplasty. A
six year follow-up evaluation. J Arthroplasty 1994; vol. 9.

Defecto acetabular tipo IIB


- Deficiencia de anillo
superior
- Kohler grado I-II
- Migracin < 3 cm

Paprosky WG, Perona PG, Lawrence JM. Acetabular defect


classification and surgical reconstruction in revision arthroplasty. A
six year follow-up evaluation. J Arthroplasty 1994; vol. 9.

Defecto acetabular tipo IIC


- Anillo intacto
- Kohler grado III
- Migracin: < 3 cm

Paprosky WG, Perona PG, Lawrence JM. Acetabular defect


classification and surgical reconstruction in revision arthroplasty. A
six year follow-up evaluation. J Arthroplasty 1994; vol. 9.

Defecto acetabular tipo IIIA


- Lisis lgrima moderada
- Lisis isquitica moderada
- Kohler grado II-III
- Migracin >3 cm

Paprosky WG, Perona PG, Lawrence JM. Acetabular defect


classification and surgical reconstruction in revision arthroplasty. A
six year follow-up evaluation. J Arthroplasty 1994; vol. 9.

Defecto acetabular tipo IIIB


- Lisis lgrima severa
- Lisis isquitica severa
- Kohler grado III
- Migracin > 3 cm

Paprosky WG, Perona PG, Lawrence JM. Acetabular defect


classification and surgical reconstruction in revision arthroplasty. A
six year follow-up evaluation. J Arthroplasty 1994; vol. 9.

abordaje algoritmico
Tipo IIA (defecto cavitario)
*Copa hemisfrica

No

El centro de
cadera >3 cm por
encima del centro
nativo

Medial a
lnea de
Kohler
Si

No

Si

Press fit con


componente
prueba

Tipo IIB (defecto segmentario <30%)


*Copa hemisfrica
Si

Tipo IIC (protrusio)


*Aloinjerto esponjoso medial
*Copa hemisfrica
Tipo IIIA (remodelacin esfrica)
*Copa Jumbo

Esfrica

No

Existe el potencial de
una fijacin biolgica
duradera con una
copa hemisferica

Si

Forma de
remodelacin
acetabular

Oblonga

Tipo IIIA (remodelacin oblonga)


*Injerto estructural femoral distal
*Copa trabecular metlica con
aumento superior
*Copa Oblonga

Sporer SM, Paprosky WG, O Rourke M: Managing Bone


Loss in acetabular revision: selected instructional course
lecture. J Bone Joint Surg Am 2005; 87-A(7): 1620-30.

abordaje algoritmico
Tipo IIIB sin discontinuidad
Fijacin no biolgica
*Aloinjerto con anillo

Existe el potencial
de una fijacin
biolgica duradera
con una copa
hemisferica
Si

Fijacin biolgica
* Aumentos con metal trabecular
* Implantes personalizados
No

No

El centro de
cadera >3 cm
por encima del
centro nativo

Tipo IIIB (discontinuidad aguda)


Compresin
*Anillo con placa y aloinjerto
*Placa interna con metal trabecular

Discontinuidad
plvica
Si
Si

Potencial de
curacin

Tipo IIIB (discontinuidad crnica)


Distraccin
* Trasplante acetabular
* Aumentos con metal trabecular
* Implante personalizado

No
Sporer SM, Paprosky WG, O Rourke M: Managing Bone
Loss in acetabular revision: selected instructional course
lecture. J Bone Joint Surg Am 2005; 87-A(7): 1620-30.

TCNICA QUIRRGICA
Abordaje
Osteotoma
Toma de cultivos
Instrumental adecuado
Mltiples implantes

opciones
No biolgicas

Biolgicas

Copa cementada

Copa porosa no cementada

Aloinjerto estructurado +
copa cementada anillo de
reforzamiento

Copa Jumbo

Empaquetamiento seo
anillo de reforzamiento

Copa porosa no cementada


aloinjerto estructurado

Injerto acetabular total

Copa porosa + aumentos


metlicos trabeculares

Copa Oblonga

GOLD STANDARD

Uso de componentes acetabulares porosos


no cementados para la realizacin de
revisiones acetabulares
Templeton JE, Callaghan JJ, Goetz DD, Sullivan PM, Johnston RC.
Revision of a cemented acetabular component to a cementless
acetabular compo- nent. A ten to fourteen-year follow-up study. J Bone
Joint Surg Am. 2001;83:1706-11.
Gaffey JL, Callaghan JJ, Pedersen DR, Goetz DD, Sullivan PM,
Johnston RC. Cementless acetabular fixation at fifteen years. A
comparison with the same surgeons results following acetabular
fixation with cement. J Bone Joint Surg Am. 2004;86:257-61.

implantes
ALOINJERTOS

Triturado
Estructural

96% xito a 10 aos


Sporer SM, O'Rourke M, Chong P, Paprosky WG, The use of structural
distal femoral allografts for acetabular reconstruction. Average Ten-Year
Follow-Up, J Bone Joint Surg Am. 2005;87:760-765.

Gross AE, Blackley H, Wong P, Saleh K, Woodgate I, The


role of allografts in revision arthroplasty of the hip, J
Bone Joint Surg Am. 2002;84:655-667.

implantes
COPA JUMBO

95% xito a 10 aos

Dearborn JT, Harris WH. Acetabular revision arthroplasty using


so- called jumbo cementless components: an average 7-year
follow-up study. J Bone Joint Surg Am. 2006;88:559-563.

Whaley AL, Berry DJ, Harmsen WS, Extra-large uncemented


hemispherical acetabular components for revision total hip
arthroplasty. J Bone Joint Surg Am. 2001;83:1352-1357.

IMPLANTES
COPA OBLONGA

Falla 25% a 5 aos


Chen WM, C. Anderson Engh, Hopper RH, McAuley JP, Engh CA, Acetabular
Revision with Use of a Bilobed Component Inserted without Cement in Patients Who
Have Acetabular Bone-Stock Deficiency. J Bone Joint Surg Am. 2000;82:197-206.

IMPLANTES
ANILLO DE REFORZAMIENTO

Falla 25% a 5 aos


Goodman S, Saastamoinen H, Shasha N, Gross A: Complications
of ilioischial reconstruction rings in revision total hip arthroplasty. J
Arthroplasty 2004; 19: 436-46.

Winter E, Piert M, Volkmann R, et al: Allogenic cancellous bone graft and a


Burch-Schneider ring for acetabular reconstruction in revision hip arthroplasty.
J Bone Joint Surg [Am] 2001; 83-A: 862-7.

IMPLANTES
EMPAQUETAMIENTO OSEO

Slooff TJ, Huiskes R, Van Horn J, Lemmens AJ, Bone


grafting in total hip replacement for acetabular
protrusion, Acta Orthop Scand 1984, 55: 593-596.

implantes
COPA TRABECULAR CON AUMENTOS

xito 92% a 6 aos


Sporer SM, Paprosky WG, The use of a trabecular metal
acetabular component and trabecular metal augment for severe
acetabular defects, J Arthroplasty. 2006 Sep;21(6 Suppl 2):83-6.

IMPLANTES
IMPLANTES PERSONALIZADO TRIFLANGE

DeBoer DK, Christie MJ, Brinson MF, Morrison JC,


Revision Total Hip Arthroplasty for Pelvic Discontinuity,
J Bone Joint Surg Am. 2007;89:835-840.