Issue 2, Friday 31 March
Hip 2day Totally Hip Meeting 2017 • Preservation to Revision • 29 March -1 April 2017 • Gothenburg, Sweden
Tradition meets innovation By Prof. Guido Grappiolo and Mattia Loppini, Unit of Hip Diseases and Joint Replacement Surgery, Humanitas Research Hospital, Rozzano (Milan), Italy
In the eighties, fixation rules included maximum fit and fill and circumferential porous coating for bone ingrowth and distal anchorage. The CLS® hip stem is instead a collarless, tapered straight, gritblasted stem with a wider proximal and lateral portion and a thinner distal and medial portion. The tapered geometry provides press-fit in the metaphysis (taper-lock effect) encouraging a more physiological proximal load transfer. Moreover, anterior and posterior ribs help enhance the primary rotational stability through interdigitation with cancellous bone. Finally, the bone ongrowth on the roughened surface helps foster longterm stability.1
Although the CLS hip stem demonstrated excellent clinical and radiographic long-term results1-6, a new standard is arising after thirty years, which aims to maintain the metaphyseal press-fit concept with a less invasive stem. GTS® Hip System was designed with a reduced trochanteric shoulder and shortened length to spare the greater trochanter bone stock and preserve the femoral diaphysis. The metaphyseal anchorage and rotational stability are provided by the tapered elliptic-octagonal stem crosssection, longitudinal anterior and posterior fins and femoral bone compaction. Despite their design differences according to a biomechanical study the CLS and GTS hip stems show comparable rotational stability.7
In our case series of 425 hips managed in 2010 with the GTS stem, the cumulative survival rate at 5 year-follow-up was 99.5% with aseptic loosening as endpoint. Clinical picture after surgery was rated as very satisfactory/satisfactory in almost 95% of patients. At radiographic follow-up, no patients showed stress shielding, and cortical femoral hypertrophy was detected in less than 2% of the hips. A slightly varus positioning (3°–5°) was reported in almost 15% of the hips. The GTS hip stem provided excellent mid-term results in unselected population, including both young and old patients. Radiographic findings reported over a 5 year follow-up and results from RSA studies predict successful outcomes also in the long term.8-11
1. Evola, F.R. et al. The Bone and Joint Journal. 96(B):455-61, 2014. 2. Streit, M. et al. Clinical Orthopaedics and Related Research. 474:1697-1706, 2016. 3. Terre, R. 20:70-8, 2010. 4. MÜller, L. et al. Arch Orthopedic Trauma Surgery. 130: 269-75, 2010. 5. Hwang, K. et al. The Journal of Arthroplasty. 27(8), 2012. 6. Grappiolo, G. et al. Hip International.12(2): 55 – 72. 2002. 7. Nadorf, J. et al. Archives of Orthopaedic and Trauma Surgery. 134:19-26, 2014. 8. Morales, J. et al. European Journal of Orthopaedic Surgery and Traumatology. 24:359-63, 2014. 9. Vehmeijer, S.B.W. et al. Roentgen stereophotogrammetry analysis of the Global Tissue Sparing (GTS) stem compared with the uncemented Taperloc stem, a randomized controlled trial. European Federation of National Associations of Orthopedics and Traumatology. 2016. 10. Jerosch, J. et al. Deutscher ÄrzteVerlag GmbH. 11:115-22, 2012. 11. Grappiolo, G. et al. Clinical and radiological findings with a new short stem: The GTS™ experience at a minimum follow-up of 3 years. Poster presentation at European Hip Society, 2014.
Hip Arthroplasty in Turkey By Prof. Emre Toğrul – Private Ortopedia Hospital, Adana, Turkey
I began working with Zimmer, and now Zimmer Biomet, six years ago in a medical education capacity. Surgery can be a difficult exercise, with a lot at stake in which surgeons and their OR staff need involved people. I want to thank the Turkish Zimmer Biomet team for their support and service. I am a hip surgeon and in my hospitals we treat around 12 hips in one operation day including diversified cases such as fractures, trauma, congenital hip disorders, adolescents’ disorders, patients with high risk of dislocation, hip trauma sequels etc from difficult primaries to complex revision cases. Dealing with so many different indications, my OR is like a big kitchen, in which instrumentation platforms are my cooking tools and I must find as many options as possible to treat as many cases as possible. Turkey has greatly improved in hip arthroplasty in the last 15 years. We receive many patients from surrounding countries and we also practice in other countries. A growing number of young surgeons practice primary hip arthroplasty because it is rewarding, giving great satisfaction with standard results and satisfied patients. They tend to treat some cases as primary when they should be treated as proper revision cases. Those cases end up being very complex revisions afterwards. Also in Turkey we have problems for these indications presenting large bone defects for which we lack bone substitute or appropriate systems. To improve on this side we need to complete our product portfolio with augments, good bone grafts, and definitely we need an emphasis on good education. We have to teach surgeons how to use modular revisions femoral revision systems so they feel more comfortable revising hips and don’t delay anymore. On the topic of education, I have been to many meetings. This week in Gothenburg, all hip arthroplasty topics will be covered. There is a fantastic faculty, with a great topic selection and I am looking forward for the discussion times after presentations. Furthermore, for young surgeons this is a fantastic opportunity to learn, get to meet experienced surgeons and share.
Today’s Key Statistics • • •
54% attendees who don’t perform joint preservation surgery are now considering it 35% of surgeon attendees perform 50-100 hip replacements per year 45% practices include only hip & knee arthroplasty
Zimmer Biomet Hip 2day
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How Important is Networking?
Clinical Graphics: 3D Motion Simulations for Hip Preservation Surgery
Prof. Dr. med. Daniel Kendoff, Berlin, Germany
By Dr. ir. Peter Krekel, Managing Director, Clinical Graphics B.V.
Getting to meet with surgeons from all over the world is not only important from a scientific standpoint, but also relevant because there are limited opportunities to spend multiple days dedicated on a very specific topic like hip surgery. In large meetings, such as AAOS or EFORT, it is hard to find such a large group going into so much detail. Being here for three full days, we are not only discussing topics formally during sessions, but we also have informal opportunities during meals and between sessions. These informal talks are very constructive too. This meeting gives us the chance to meet new people while creating new connections and working relationships. The benefit of the meeting lasts long after it has officially ended, with new fellow exchanges and extension of multicenter studies. From a technical standpoint, no matter how experienced you are, you always have something to learn from others.
The Clinical Graphics 3D motion simulation service is a new and exciting addition to the Zimmer Biomet portfolio. The concept is simple: Take a standard CT or MRI scan, extract the bone contours and put it in motion so you can see the dynamics of the joint. It is a low-effort service for surgeons: radiology uploads the images and we generate the 3D report, which is made available to you via e-mail and our online platform. Available first for hip preservation surgery, the interactive 3D reports contain various simulations such as hip flexion, abduction and internal rotation. Additionally, the reports contain morphological parameters: femoral and acetabular version, LCE angles, acetabular coverage and more. This all provides a comprehensive overview on your patient’s hip, who will appreciate your graphically-supported explanation of the hip’s condition. Inadequate resections are known to be an important cause for unsuccessful hip preservation surgery.1 Having the 3D report available before surgery makes sure you go in well-prepared. Knowing what areas of the joint to address may help you achieve a better outcome. 1.
Revision Hip Arthroscopy, Marc J. Philippon, MD, Mara L. Schenker, Karen K. Briggs, MPH, MBA, David A. Kuppersmith, R. Brian Maxwell, Allston J. Stubbs, MD, The American Journal of Sports Medicine, Vol 35, Issue 11, pp. 1918 - 1921
This meeting is a fantastic opportunity to gather so many surgeons together. Face-toface meetings are critical for learning and sharing experiences. I am very pleased to see that some of the faculty members and speakers come from Turkey and Russia. A total of 250 people attending this meeting are coming emerging countries, representing 25% of the audience. Medical education is of highest importance for surgeons active in emerging markets and this meeting is key in working together towards our common goal to improve patient care across the globe. Lluis Torrella, Senior Vice President Spain, Portugal and Emerging Markets
My Experience with the Anterolateral Approach Using the CLS® Spotorno® Hip Stem Prof. Reinhard Elke, Merian Iselin Clinic, Basel, Switzerland
Stability Made Simple
Why Settle for Less? Give yourself peace of mind knowing the G7® Acetabular System provides more liner and sizing options to help resist dislocation than any other acetabular system on the market today.1–7
My patients appreciate the anterolateral approach1,2 because the functional and cosmetic results are very good and the complication rate is low. Patients recover quickly after surgery. The postoperative abductor function is good, so the rehabilitation process is straight forward with full weight bearing right from the beginning. Patients don’t report much pain after surgery, the scar is not disturbing the groin and remains hidden behind the contour of the tensor muscle. The anterolateral approach also offers many advantages to surgeons. I have found patient positioning reliable and quick3. Compared with other positions, I think that surgical draping is reliable since the risk of contamination due to leaking drapes is less of a concern. Most types of implants can be used, including the well documented “shoulder-designs” (e.g: CLS Spotorno Hip Stem)4-7 Furthermore, spinal anesthesia is possible. During surgery, acetabular and femoral exposures are good, even with obese patients, an extension of the approach is straight forward and the insertions of the abductors are readily accessible8. Together with appropriate planning, I experienced precise and reliable positioning of the components. Few instruments are necessary during the whole surgical procedure and no angled reamers are needed for the acetabulum.
1. Pinnacle Hip Solutions. Polyethylene Surgical Technique. Part No 0612-83-512. DePuy Orthopaedics, Inc. 2013. 2. R3 Acetabular System. Surgical Technique. Part No 71381395. Smith & Nephew, Inc. 2010. 3. Trident Acetabular System. Hemispherical Surgical Protocol. Part No TRIDEN-SP-2. Stryker Corporation. 2015. 4. Zimmer Biomet G7 Acetabular System Ordering Information. 0562.1-OUS-en REV0716. 2016. 5. Zimmer Biomet G7 BiSpherical Surgical Technique. BMET0857.0-INT REV0914. 2014. 6. Zimmer Biomet G7 Dual Mobility Surgical Technique. 0004.1-GLBLen REV1115. 2015. 7. Data on file at Zimmer Biomet. 2015 G7 Competitive Matrix EMEA Sales Guide.
I consider the anterolateral approach safe, given that no scars are disturbing the nervus femoralis or the arteria femoralis and the abductor function is very good.9
All content herein is protected by copyright, trademarks, and other intellectual property rights owned by or licensed to Zimmer Biomet or its affiliates unless otherwise indicated, and must not be redistributed, duplicated or disclosed, in whole or in part, without the express written consent of Zimmer Biomet. This material is intended for health care professionals, the Zimmer Biomet sales force and Zimmer Biomet employees. Distribution to any other recipient is prohibited. For complete product information, including indications, contraindications, warnings, precautions, and potential adverse effects, see the package insert and www.zimmerbiomet.com. © 2017 Zimmer Biomet
With a low dislocation rate, and a low risk of infection, the short-term complication rate is low. The implantation of well documented components provides excellent long-term results9. 1. Bertin, KC. et al. Clinical Orthopaedics and Related Research. 429. 248-55. 2004. 2. Rottinger H. et al. Operative Orthopädie und Traumatologie. 22(4). 421-430. 2010. 3. Aebi, J. et al. Orthopaedics & Traumatology: Surgery & Research.97(6). 675-80. 2011. 4. Biemond, JE. et al. Journal of Arthroplasty. 26(3). 386-90. 2011. 5. Evola, FR. et al. The Bone & Joint Journal. 96-B(4). 455-61. 2014. 6. Muller, LA. et al. Archives of Orthopaedic and Trauma Surgery. 130(2). 269-75. 2010. 7. Sadoghi, P. et al. International Orthopaedics.37(6). 995-9. 2013. 8. Ito, Y. et al. Clinical Orthopaedics and Related Research. 470(6). 1690-5. 2012. 9. Ince, A. et al. Acta Orthopaedica. 78(1). 86-9. 2007.
International Hip Meeting 29 March -1 April 2017 • Gothenburg, Sweden
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Ten years of Fitmore® Hip stem
Zimmer Biomet, the House of Originals
By Prof. Dr. med. Hubert Nötzli, Bern, Switzerland
“Imitation is the sincerest form of flattery” / C.C. Colton By Claude Rieker, PhD, Scientific Affairs EMEA, Zimmer Biomet
When the Fitmore Hip stem was introduced 10 years ago, there were already various cementless hip stems on the market with excellent long-term results. Therefore survival time wasn’t the point to improve. Dissatisfaction with the classical stem designs could come from the coupling of offsets with stem sizes, meaning that the larger the stem the greater the offset. This may lead to a misfit especially in young men with a narrow femoral canal and in osteoporotic elderly women with a very wide canal. Moreover, the straight introduction of classical stems, with laterally extended shoulders for rotational stability, could interfere with the muscular insertions and eventually may cause unnecessary bone loss and damage muscle insertions. To better fit the individual anatomy, the new design dissociated the stem size from the offset by creating four offset families. In each family the neck length stays the same and is independent from the body size. Altogether, the four families with the different head sizes cover a wide range of offsets unachieved by other designs and allow the use of the Fitmore stem in dysplasia and varus hips thanks to a very long neck. In order to follow the anatomical path, a curved shape without shoulder overhang was given to the new stem aiming at solving the problem of muscle insertion interference and allowing a bone-sparing implantation at the same time. In my opinion, 10 years of use and the high number of implanted stems are proof that the reconstruction of the individual anatomy and the careful handling of soft tissues and bone are highly valued in the orthopaedic community.
Zimmer Biomet is extremely proud to be the House of Originals for hip implants. Zimmer Biomet is the only manufacturer worldwide having such an extended portfolio of originals, implants which are part of the history of total hip arthroplasty. Some examples of these unique originals include: • Original M.E. Müller® Straight cemented stem; first implantation in 1977 and more than 1,300,000 stems implanted1 ODEP rating: 10A* • Alloclassic® Zweymüller® uncemented stem; first implantation in 1979 and more than 750,000 stems implanted1 ODEP rating: 10A* • Original M.E. Müller Low Profile cemented cup; first implantation in 1980 and more than 900,000 cups implanted1 ODEP rating: 10A* • Taperloc® uncemented stem; first implantation in 1983 and more than 1,000,000 stems implanted1 ODEP rating: 10A* • CLS® uncemented stem; first implantation in 1984 and more than 800,000 stems implanted ODEP rating: 10A*1 • Wagner SL Revision® uncemented revision stem; first implantation in 1986 and more than 140,000 stems implanted1 Unfortunately, no ODEP rating is currently available for revision stems • Trilogy® uncemented cup; first implantation in 1993 and more than 1,400,000 cups implanted1 ODEP rating: 10A* • Allofit® uncemented cup; first implantation also in 1993 and more than 600,000 cups implanted1 ODEP rating: 10A* All of these originals were developed over 20 years ago and are still best sellers for Zimmer Biomet today. Even the products developed in the 80’s are sold today in large numbers, some with over 30,000 implants per year. These numbers are remarkable, considering that all these originals compete with numerous other solutions made by small and large competitors. All these originals (primary implants) also have the best possible ODP rating (10A*).2 1. 2.
Data on file at Zimmer Biomet Latest ODEP ratings can be found at www.odep.org.uk .
Faculty Corner By Mr. Steve Jones, University Hospital Llandough, Cardiff, United Kingdom
Today’s meeting kick-off was great, which was full from the beginning. The faculty is a “who’s who” of hip surgery and makes this a unique and exciting event from my point of view. If I wasn’t here as a faculty member I’d be here as a delegate, it’s certainly an opportunity not to miss. My particular research interest is dislocation and instability; I’ve got a talk on avoiding it and also treating it. Another great topic is the issue of infection. This is a major issue for us and I think our biggest future advances will be around what we can do for the patient to improve immune function and help fight infections better. I’m looking forward to the complex revision session. Having the two world-leaders on the management of pelvic discontinuity (Dr. Wayne Paprosky and Dr. Allan Gross) going back-to-back will be a huge highlight. The biggest advantage of this type of meeting is the forum itself. Surgeons really value this interaction and ability to learn from each other. This morning’s Breakfast with the Masters session offered an opportunity to interact with an enthusiastic bunch of residents who wanted to talk about hip surgery at 7am. These programmes are really important to nurturing the surgeons and leaders of the future, they will be the people standing on the platform in a decade’s time.
Inspired by Individual Anatomy
10 Years of Matching Femoral Curvatures Back in 2007, when designing the Fitmore ® Hip System the aim was to offer a bone conserving stem able to reconstruct individual femoral anatomies by matching patient’s medial curvatures thanks to: • Three stem bodies with different medial curvatures • Four offset options independent from stem size • Bone conserving stem design adapted to ASI and other minimally invasive approaches Today, the Fitmore Hip System demonstrates good mid-term clinical results and a 5A* ODEP rating. 1
1. Latest ODEP ratings can be found at www.odep.org.uk ©2017 Zimmer Biomet
Fitmore Hip 14.5x19cm February 2017-v4.indd 1
3/8/17 3:14 PM
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Original M.E. Müller® Stem – 40th Anniversary! By Romain Faury, Product Manager – Primary Femoral stems, Zimmer Biomet Professor Maurice E. Müller, pioneer, visionary and surgeon of the Century1 (SICOT, 2002) designed the Original M.E. Müller Stem in 1971. It was adopted right away and, 40 years later, is still a very well performing stem, counting over 1,385,000 implantations in more than 40 countries2. The success of this stem relies on the “Müller Philosophy”. It consists of achieving a press-fit between the medial and lateral walls of the femur and the prosthesis that leads to an incomplete cement mantle with bone-metal contact. The fluted structure of the stem and two longitudinal grooves anteroposterior in the stem axis enables very good cement adhesion. The design of the stem increases rigidity, decreases stress peaks and supports less micromotion3 For the past four decades, and still today, the Original M.E. Müller Stem demonstrates excellent long-term clinical data, like its ODEP 10A* rating4 ,which makes it a standard in total hip arthroplasty. Maurice Müller with John Charnley, another visionary in Hip Arthroplasty
Year
Authors
Title and Journal
No. of cases available for follow-up
2017
Erivan et al
The Müller self-locking cemented total hip prosthesis with polyethylene liner: After twenty years, what did they become? Int Orthop 2016;1-8.
41
20.6 years
97.9% @ 20 years (stem revision and loosening or migration) 100% @ 20 years (stem, aseptic loosening)
2016
Clauss et al
Similar effect of stem geometry on radiological changes with 2 types of cemented straight stem. Acta Orthop 2016;87(2):120-5.
188
13 years
94% @ 10 years (stem, any reason) 96% @ 10 years (stem, aseptic loosening)
2009
Clauss et al
Fixation and loosening of the cemented Müller straight stem: a long-term clinical and radiological review. J Bone Joint Surg Br 2009 Sep;91(9):1158-63.
36
20 years
81% @ 20 years (stem, any reason) 87% @ 20 years (stem, aseptic loosening)
2006
Descamp et al
The cemented Müller straight stem total hip prosthesis with polyethylene cup and 28 mm head: ten-year results. Revue de Chirurgie Orthopédique et Réoperatrice de l'Appareil Moteur 2006 Feb;92(1):40-4
90
10.4 years
98% @ 10 years (any component, any reason) 100% @ 10 years (stem radiological failure)
2001
Räber et al
Fifteen-year results of the Müller CoCrNiMo straight stem. Arch Orthop Trauma Surg 2001;121(1-2):38-42.
46
14.8 years
94.2% @ 10 years (stem, aseptic loosening) 88.1% @ 15 years (stem, aseptic loosening)
Mean follow-up
Survival rate
What was considered revolutionary in 1977 is still state-of-the-art in 2017!
1. J Bone Joint Surg [Br] 2009;99-B:1263. Obituary 2. Data on file 3. Nikolaou et al. World J Orthop 2013 October 18; 4(4): 303-308. 4. http://odep.org.uk/product.aspx?pid=148, page viewed on 09-Feb-2017. Latest ODEP ratings can be found at www.odep.org.uk.
Tradition Meets Innovation
GTS® Hip System: Clinical Results of a Conservative Hip Stem
1984 – CLS ® Spotorno® Hip Stem
Dr. Jaime José Morales, Hospital Universitari de Vic, Barcelona, Spain
• Pioneering uncemented 3D tapered femoral implants with proximal fins • Over 850,000 stems implanted since 1984 1 • 10A* ODEP rating 2
The use of short stems has been a major advance in prosthetic hip surgery. The idea was born as an alternative to conventional stems for young patients with an important physical activity or even practicing sport. Our experience with the use of conservative GTS hip stems in more than 250 patients has demonstrated a significant survival of 99% at 5 years follow-up.
2010 – GTS® Hip Stem • Adaptation of the Spotorno philosophy to bone conserving and minimally invasive surgery • 3A* ODEP rating 2
We believe our success is related to the concept of Tissue Sparing Surgery, allowing stability without alteration of the proximal femoral anatomy.1 We obtain stability of the stem by adjusting pressure in the metaphysis thanks to the conical wedge design and the compaction of cancellous bone. On the other hand, the cross sections of the elliptic-octagonal design help us gain rotational stability. We must also mention the longitudinal fins designed for anterior and posterior bone compression. Another important topic to help understand the good clinical results with the GTS stem is the simple operative technique. The design of the stem allows us a longitudinal insertion into the femoral canal, facilitating its positioning without requiring maneuvers that require a long learning curve and experience in the use of these stems.
Spotorno, a Philosophy Withstanding Trends! The GTS and CLS Spotorno Hip Stems now fall within the same portfolio, allowing Zimmer Biomet to demonstrate how a 30-year old concept can withstand the trends in THA. Followers of the Spotorno philosophy now have the opportunity to adapt the stem design to patient anatomy and favoured surgical approach.
1. Data on file at Zimmer Biomet 2. Latest ODEP ratings can be found at www.odep.org.uk ©2017 Zimmer Biomet
LS and GTS AdHip2Day Journal-10x14.7cm-February 2017.indd 1
Our experience and good results have allowed us to increase the use of GTS stems, and not only in young patients. We have been able to verify that the results are comparable in young patients and in patients over 65 years of age, as long as they have sufficient cortical mass index.2 For this reason we consider that the use of the GTS hip stem can be considered a good option in prosthetic hip surgery. 1 2
2/23/17 10:20 AM
Morales de Cano, J. et al. Early clinical results of a new conservative hip stem. European Journal of Orthopaedic Surgery & Traumatology. 24-3.359–63. 2014. Morales de Cano, J. et al. Short femoral stem in total hip arthroplasty: stable fixation and low complication rates in elderly patients. Hip International. 2016 Review.
International Hip Meeting 29 March -1 April 2017 • Gothenburg, Sweden
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Why are Modern Cement Techniques Playing an Important Role in Cemented Hip Arthroplasty?
Dr. Andrea Camera, Santa Corona, Pietra Ligure, Italy
By Thomas Gleason, Associate Director Cement & Infection, EMEA, Zimmer Biomet
Since the days of Sir John Charnley, orthopaedic surgeons have been implanting cemented hips that are ready-to-use, and are manufactured with the highest level of quality standards. Unlike these metal, plastic and ceramic components, bone cement, is not ready-to-use! Furthermore, bone cement is also an implant! However, the bone cement is so much more than just an implant; it is also the mode of fixation, may deliver antibiotics, absorbs forces, and creates an interface between bone and the component. Thus, nurses have a very important task in the OR, as they are responsible for mixing cement! After the cement is manufactured, the surgeon creates the final shape of this implant by delivering the cement and pressurising it into the cancellous bone. The quality of the interfaces created by the surgeon is an important step in the quality of this construct. Clinical evidence from the Swedish Hip Arthroplasty Register, first presented by Malchau and Herberts already in 19961, confirmed the importance of Modern Cementing Technique to improve clinical outcomes in Total Hip Arthroplasty. Modern pre-packed vacuum mixing systems are a next-step in Modern Cementing Technique as they enable nurses to optimise the mixing of the bone cement by offering a reproducible and standardised procedure and a safer working environment.2 IMPLANT Thus, the overall quality of a cemented arthroplasty is significantly influenced by the careful mixing of the cement by the nurse, and the skill of the surgeon to form and create the cement mantle and optimise the quality of the interfaces between cement-bone and implant-cement.3
My experience with Professor Spotorno started in 1996, just after I finished my postgraduate specialisation in orthopaedics at Genoa University, Italy. For my professional growth it was the most important meeting of my life and I have always considered myself as one of the world’s luckiest surgeons for this experience. If I have to recap, I would say that this experience has been characterised by two things: concreteness and scientificity. Concreteness because working with Professor Spotorno, both surgically and personally, provided me with everything needed to be quick without losing time at all. Scientificity, because all procedures were based on previous studies and would become the basis of future projects.
CEMENT
When considering bone cement from this perspective, it is easy to understand the important role that Modern Cementing Technique plays in the quality of the implant and the clinical results in cemented hip arthroplasty. 1. 2. 3.
Lessons learned from Prof. Spotorno DEEP DIVES
2
BONE
Malchau, Herberts. Prognosis of Total Hip Replacement Scientific Exhibition presented at the 63rd Annual Meeting of the American Academy of Orthopaedic Surgeons, February 22-26, 1996, Atlanta, USA. Report from SP Technical Research Institute of Sweden (2007 08 13). Airborne methyl methacrylate monomer during the use of different bone cement mixing systems. Malchau, Herberts. Prognosis of Total Hip Replacement Scientific Exhibition presented at the 63rd Annual Meeting of the American Academy of Orthopaedic Surgeons, February 22-26, 1996, Atlanta, USA.
He has been truly a Master to me, “that, right after the name Father, it is the noblest and sweetest appellative that a man can give to another man.” (E. De Amicis - Writer)
INTO DETAIL (Break out sessions) Friday 31 March 2015 - 16:45 - 19:00
Optipac ® Into Detail Session 1: ASI – Difficult primary THA Plenary Room
The proven1, 2 closed vacuum mixing system, pre-packed with bone cement
Into Detail Session 2: Perfecting the cemented Hip Room G1 1. Maiken Stilling et. al., Bone Cement with Initial Slow-Curing Increases Stability of Tibial Trays in TKR , RSA study, Aarhus University Hospital presented at DOS congress Copenhagen 2012
Into Detail Session 3: Hip trauma management Room G2
2. Registered in the Swedish Hip Arthroplasty Register since 2008 All content herein is protected by copyright and trademarks owned by or licensed to Zimmer Biomet. This material is only intended for health care professionals and the Zimmer Biomet sales force. For complete product information, including indications, contraindications, precautions, and potential adverse effects, see the package insert and www.zimmerbiomet.com.
Into Detail Session 4: Cementless fixation “Stems for all seasons?” Room G3
©2017 Zimmer Biomet
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LUNCH SYMPOSIUM: Fixation of periprosthetic fractures of the hip Friday 31 March 12:45 - 13:30* Location: Room J2 Faculty: Prof. Steffen Ruchholtz Objective: Understand the key features of the NCB® PP product and how this helps in treating periprosthetic fractures. *Lunch box will be provided in the meeting room
2/17/17 9:28 AM
Zimmer Biomet Hip 2day
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My Experience with the Avantage™ Acetabular System By Dr. Pierre-Luc Frésard, Clinique Mutualiste, Saint-Etienne, France
We benefited from our experience with the development of the first dual mobility cup with Prof. Gilles Bousquet when designing the Avantage Dual Mobility Acetabular System. I was Prof. Bousquet’s fellow from 1991 to 1994, which allowed me to get familiar with the dual mobility concept. Even though we believed in the potential of this concept, its use was still limited to a few centers, mainly in Rhône-Alpes region in the South East of France. Back in 1990 the future of dual mobility was quite uncertain Because it was innovative and unknown, it wasn’t considered a reliable back-up option. Only a handful companies accepted to investigate and renew the concept; amongst those as Biomet, who helped improve the dual mobility concept with the development of the Avantage Acetabular System. All those first groups working on dual mobility were founded with Prof. Bousquet’s fellows. The Avantage cup was the first among the new generation of DM (Dual Mobility) systems to offer a solution from primary to revision surgeries. We designed an aperture on the shell with the aim to help reduce the risk of impingement. For primary cases, we designed a press fit cup without any plots or screws. We gave a bevel shape to the insert with the aim of limiting the wear between the femoral neck and the liner as well as reducing the risk of intra-prosthetic luxation. This design has become the standard in dual mobility. For revision cases, Avantage was the first DM system to use a cemented cup together with a reconstruction cage. Indeed, we considered that peripheral fastening did not allow impaction and engraftment. The cemented cup allows to keep the expected orientation after bone reconstruction with the reconstruction cage. One of the latest improvements is the use of polyethylene enriched with vitamin E, making it the only DM system to offer this technology. It has been more than 10 years since the dual mobility concept has become popular, in France first, where a high quantity of THA and more than 60% of revision surgeries are managed with DM. Now the use of DM is also gaining more popularity internationally. For instance, the United States is shows a growing interest for this concept even though the use of screws for revision cups is still the standard there. From numerous scientific publications, here is what we know about dual mobility: • Wear is not greater than other standard systems1,2 • Survival rate is equivalent to other systems for THA3 • Range of motion is among the highest compared to standard acetabular systems4 • Unmatched stability results in patients at high risk of dislocation, even after revision surgery where dislocation rate with DM is almost as low as dislocation rate after primary surgery with standard implants5-7 The remaining question is the choice of the correct implant for young and active people. We know that the revision rate for young people is higher than with the older population8. In regards to latest papers and our experience, there is no reason not to use DM for young or high demand patients, especially in cases where the patient is practicing sport requiring stability and high range of motion.9-10 The Avantage cup is almost 20 years old and still the leader in Europe for dual mobility11. 1. Loving, L. et al. The Journal of Arthroplasty 28. 1041–6. 2013. 2. Fresard, PL. et al. European Journal of Orthopaedic Surgery & Traumatology. 23. 425–9. 2013. 3. Philippot, R. et al. Revue de Chirurgie Orthopedique et Reparatrice de L'appareil Moteur. 92(4). 326-31. 2006. 4. Klingenstein, G. et al. The Journal of Arthroplasty. 28. 1173–6. 2013. 5. Mertl, P. et al. HSS Journal. 8(3). 251-6. 2012. 6. Jauregui, J. et al. Hip International. 26 (1): 57-61. 2016. 7. Bayliss, L. et al. www.thelancet.com. Published online February 13, 2017. 8. Vielpeau, C. et al. International Orthopaedics. 35:225–30. 2011. 9. Boyer, B. et al. International Orthopaedics.36:511–8. 2012. 10. Epinette, JA. et al. The Journal of Arthroplasty. 29. 1323–8. 2014. 11. Eucomed data reports.
SIGNATURE SOLUTIONS AT THE BOOTH Friday 31 March
Location: Technology Suite, Signature Solutions Booth 10:30 - 11:00 Rapid Recovery elective hip & knee What can you expect from Zimmer Biomet? Claudia Linke
Discover the Latest in Training and Education
In a recent survey, surgeons indicated Zimmer Biomet provided the best training on the Anterior Supine Approach.* *Blinded, global survey of 133 surgeons conducted by 3rd party researchers. Study funded by Zimmer Biomet.
All content herein is protected by copyright, trademarks, and other intellectual property rights, as applicable, owned by or licensed to Zimmer Biomet or its affiliates unless otherwise indicated, and must not be redistributed, duplicated or disclosed, in whole or in part, without the express written consent of Zimmer Biomet. This material is intended for health care professionals. Distribution to any other recipient is prohibited. Not for distribution in France. ©2017 Zimmer Biomet
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3/3/17 10:31 AM
15:10 - 15:40 Rapid Recovery Fragility Fracture – optimising the quality of care in each step of the patient treatment pathway Ann van Bulck
“We have 110 delegates from the UK and more than 20 staff from marketing and sales management at Totally Hip. Of all the courses in 2017, Totally Hip had the highest demand for space. In fact, the meeting filled up in a matter of weeks and unfortunately we had a sizable waiting list. I am sure this was a result of excellent reputation from the Knee2 meeting run 18 months ago in Gothenburg. In the UK Zimmer Biomet has a very strong presence in arthroplasty in terms of clinical results. As a result we are focusing on significant efforts on the sports medicine field. I find this area of medicine fascinating; a discipline that gives a chance to treat the previously untreatable young patients. I am particularly looking forward to the talks by Mr. SiÔn Glyn-Jones and learning more about conservative treatment of the hip, having said that, the whole agenda looks quite brilliant!” - Simon Oakley, Marketing Director, Northern Europe, Zimmer Biomet
International Hip Meeting 29 March -1 April 2017 • Gothenburg, Sweden
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Biomet Surgeon Network
Avenir® Hip System Concept and Mid-term Results biometnetwork.com
Hip Surgery in Russia By Prof. Rashid Tikhilov, Chairman and Director of Vreden Russian Research Institute of Traumatology and Orthopaedics, Saint Petersburg, Russia
By Prof. Stéphane Boisgard, Orthopaedic Department, University Hospital - Clermont Ferrand, France
Our university hospital of Saint Petersburg is the oldest and biggest hospital in Russia celebrated our 110th anniversary last year. We treat more than 25,000 patients each year, amongst which 6,000 hip and knee surgeries for a broad range of indications such as trauma, peri-implant infection, high risk of dislocation and dysplasia.
In our orthopaedics department during the 1990s, we exclusively used self-locking Original M.E. Müller® cemented stems. The clinical outcomes and long-term survival rates of the Original M.E. Müller stems were excellent, and the technique reproducible. Over time, we became more interested in the cementless fixation concept and in decreasing two potential risks of cementless stems: fracture and subsidence. Those interests resulted in the development of the Avenir stem. Due to the experience with the Original M.E. Müller stem, the Avenir stem shares strong design features of the Müller stem including, a self-locking shape, good adaptation to the femoral shaft, and neck design. Due to the cementless design consideration, the Avenir stem utilises some updated features compared to the Original M.E. Müller stem. The proximal surface is designed to help address subsidence, and hydroxyapatite is coated over the titanium substrate to help facilitate secondary fixation.1,2 The stem also has a distal tapered tip to help address distal impingement and optimised gaps between stem sizes to help address inadequate fit for small femurs. Avenir hip system broaches were designed to help address potential stem malpositioning and are a strong benefit of the technique. The broaches specifically allow cancellous bone compaction according to different areas: three planes of compaction in the metaphysis and two planes of compaction in the diaphysis. This specific design allows a good match between the broach and the final implant to help reduce the risk of fracture, subsidence and suspension. Additionally, the learning curve is short, and not dependent on surgeon experience. All approaches can be used with adapted tools. To assess the stem, we have reviewed 100 consecutive non-selected primary THA in 92 patients. 90 hips could be seen at 7 years and showed the following results3: -
Clinically: Harris score was 93,8 (71-100), all patients were satisfied of surgery, no adverse effect was related to the stem.
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Radiologically: no subsidence, one osteolysis was found in 1 patient at 5 years, no revision for aseptic loosening.
The use of this stem is simple and reproducible, with accurate and stable positioning in the femoral shaft, offering patients good mid-term results.
The definition of a difficult case is very subjective. For some young surgeons a case can be seen as difficult whereas more experienced surgeons would consider it standard primary surgery. Therefore, we have worked on establishing some guidance regarding what a difficult case is, what it includes and how to approach it. For instance, post-traumatic and dysplastic surgeries, complex deformity of the proximal femur after first procedure, unstable joint and other indications can be difficult and require treatment in hospitals offering experienced surgeons and teams along with special organization, including rehabilitation structure. For this reason, guidance, training and collaboration with surgeons is of major importance in our field. In our very large country there are areas with specific indication populations; dysplasia is a good example. Some areas of Russia have over 50% of the population that present at local hospitals with this indication. It is critically important that surgeons know how to approach and treat these cases. In Saint Petersburg University Hospital, we organize numerous trainings with hundreds of surgeons attending for lectures and practice every year. This meeting is also a great opportunity for us to learn. We are able to meet surgeons from many countries, get tips and tricks from others surgeons and help us understand the next steps in hip surgery evolution to prepare for our future practices. I really value the fact that Zimmer Biomet is not only focused on implants but also on delivering systems and services to surgeons. Hip preservation is a great example. It is included in this meeting’s programme because Zimmer Biomet considers the full picture of joint replacement and thinks about the patients’ overall well-being, our common goal.
1. Frayssinet, P. et al. Cells and Materials.5:125-138. 1995. 2. Chambers, B. et al. 22. 4[1]. 71-74. 2007. 3. Erivan, R. et al. Abstract submitted during European Hip Society. 2016.
New EU Medical Device Regulation (MDR): The Clinical Highlights By Erin Osborn, Associate Director, Clinical Affairs, Zimmer Biomet
Let Avenir ® Hip System Be Your Guide
The new European Medical Device Regulation (MDR) has been a source of speculation for several years now. Currently, the final language is under review and up for final vote by European Parliament this spring. It is anticipated that the new MDR will go into force by the end of 2nd quarter 2017 and will have a three year transition period once it becomes law for companies to comply. It is anticipated that the new MDR will implement the most sweeping medical device regulation changes for Europe since the 1990s. Gary Slack, Sr. Vice President at BSI commented last March that “Every device will be affected – from those in development to those that have been on the market for years – due to higher expectations for clinical data and more intense regulatory oversight.”1 What does this mean for new, innovative products? Potentially, this could mean a longer process for new product introduction that could require more pre-market studies before full commercialisation and more robust postmarket vigilance activities. Manufacturers will no longer be able to routinely reference an equivalent device “predicate” for new CE-mark approvals and may be required to provide clinical data on the new device under review. For current products, proposed regulations indicate that clinical data, for all indications, implant design variations, and clinical use, will be required to renew the CE-mark for each implant. Zimmer Biomet has been proactive and implemented many robust clinical research programmes that generate evidence on many of our core technologies and implants, which will be presented at this meeting. We are committed to developing best-in-class products and clinical evidence to support our core products globally and continue to provide the best solutions for you and your patients.
Intuitive Bone Compaction Makes all the Difference • Precise size match between the rasp and the final implant • Bone compaction philosophy subtly balanced to offer cortical contact where needed • Cementless and cemented options within one instrumentation platform
©2017 Zimmer Biomet 1.
Gary Slack, Sr. Vice President, Global Medical Devices, BSI, March 9-10, 2016 AAMI/BSI Conference
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Residents' Corner: A Wonderful Opportunity Dr. Daniela Pereira, Centro Hospitalar de Leiria, Portugal and Dr. Ana Catarina Angelo, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental EPE, Portugal
Zimmer Biomet Hip 2day The Taperloc® Complete Stem, a Long-Term Stem By Prof. Dr. Xavier Gallart, Hospital Clínic, University of Barcelona, Spain, President of Spanish Hip Society
The published long-term results of the original Taperloc Hip System (Biomet, IN, USA) already indicated strong revision rates between 0 and 5%.1-4 The new Taperloc Complete design, developed in 2009, inherits the best features and is still very reliable. In 2010, we started to use the new one at the Hospital Clinic in Barcelona. Since then, we have implanted more than 300 stems. Our revision rate for aseptic loosening is less than 0,5%.5 It is an uncemented titanium stem, proximally coated, double wedged and double-tapered. The most important characteristic is the reduced neck-shaft angle (133°), closer to natural anatomy which, in my opinion, allows an easy restoration of the hip centre of rotation. Moreover, the Taperloc Complete System features three offset sizes: standard, high and coxa vara (123°), which allows greater versatility.
Each day we share the thoughts of some of the participants of the Resident’s Programme. Today, Ana and Daniela discuss their experience. Ana: “The meeting is wonderful, this building is fantastic and the organisation is great, it has been a complete experience.” Daniela: “We are really enjoying the scientific programme. I really like that infection is included, it’s a problem that we face every day and has a huge impact in the life of our patients. We need to learn more to help.” The Faculty & Breakfast with the Masters Ana: “The faculty are so accessible, this is great. As residents, we have a lot of doubts and may wonder if these are invalid, but we can approach them with any question and see they’re real people, not just some face or name on a paper. We usually cite these people in our professional daily life and now we are here with them getting to interact. It is a wonderful opportunity.”
For surgeons that routinely perform templating, it facilitates finding a solution for the morphology of the native femur in each patient and to reproduce a more accurate hip centre. Furthermore, its narrow neck helps increase range of motion.6 Its clinical and radiological behaviour over the years give me confidence. It presents a lower rate of stress-shielding than other designs and shows good results in patients with Dorr-C femur.1 The Taperloc Microplasty® variant, used in younger patients or in Dorr-A femurs, is good for many surgical approaches, especially for the direct anterior approach.1,2,7 The use of this variant required a short learning curve, given the simple surgical technique and the fact that no specific instrumentation is needed. To summarise, the Taperloc Complete is a stem for routine use which should allow reproducible long-term optimum results considering clinical results of the Taperloc legacy system, its predicate.8
1. McLaughlin, JR. et al. The Bone and Joint Journal. 98-B(5):595-600.2016. 2. McLaughlin, JR. et al. Journal of Arthroplasty. 31(6):1275-8.2016. 3. Parvizi, J.et al. Journal of Arthroplasty. 19(2):151-6.2004. 4. Labek, G. et al. Acta Orthopaedica. 82(2): 143–148.2011. 5. On file at Hospital Clínic University of Barcelona (Spain) 6. Widmer, K. et al. Clinical Biomechanics. 20 (7):723–28, 2005. 7. Molli, RG. et al. Clinical Orthopaedics and Related Research. 470(2):450-61.2012. 8. McLaughlin, JR. et al. Orthopedics. 33(9):639.2010.
Daniela: “It was really great to talk with Dr. Lombardi during Breakfast with the Masters. It’s also good to share experiences with our colleagues so we can learn from each other too.” Women in Orthopaedics: A Growing Trend Ana: “The top five orthopaedic surgeons I admire are women, they opened the door for so many. I don’t think orthopaedic surgery is easy for anyone, it is difficult for women and for men, you have to know what you are getting into and accept it’s the same.” Daniela: “I just work with men in my practice, but nowadays in Portugal the residents are divided equally between men and women. It is a growing trend globally.”
Fun Facts of the Day!
• 4,500 Totally Hip Water Bottles • 3,600 Canapés used Wednesday Evening • 243 Airport Transfers (so far)
Chairmen’s Thoughts of the Day By Mr. Andrew Manktelow, Nottingham University Hospitals, Nottingham, United Kingdom
It has been an exciting first day of the meeting. However, today was not the first day of the residents’ meeting. Wednesday was a really busy day with lectures, technical discussions and dry bone workshops. There was even some very imaginative melon carving! This morning saw, the first ‘Breakfast with the Masters’. The chatter feed was going strong at 7am as the residents spent time with faculty members discussing their research and papers. Regarding the main programme, it has been an exciting development to start with a session demonstrating the ‘continuum’ of management of hip disorders with conservative surgery moving into arthroplasty. There were some very exciting talks on the potential aetiology of arthritis. The session gave us an opportunity to review the management of conditions likely, left untreated, to lead to degenerative change. There was very interesting material on new options in imaging which will really enable us to’ look inside’ the hip, to predict those that we would expect to do well with conservative surgery and those that might not. Having heard from some very busy arthroscopic surgeons, it is obvious that this can be a technically difficult surgery. There are increasing numbers of procedures being performed. It is important that the operations are done by those who are well trained, that work in high volume centres and in patients in whom the indications for the procedure are well understood. I was excited by the debate chaired by Professor Javad Parvizi. The personnel involved were very committed to both sides of the argument. Mr. Richard Villar gave an impassioned talk on the importance that hip surgeons doing everything possible to reduce the chances of young patients requiring joint replacement. This was well countered by Dr. Lombardi detailing possible concerns with published outcomes, against a background of excellent hip replacement outcomes. I genuinely feel that even those that don’t perform conservative hip surgery will have a better understanding about the true role of hip arthroscopy.
All content herein is protected by copyright, trademarks and other intellectual property rights, as applicable, owned by or licensed to Zimmer Biomet or its affiliates unless otherwise indicated, and must not be redistributed, duplicated or disclosed, in whole or in part, without the express written consent of Zimmer Biomet. This material is intended for health care professionals. Distribution to any other recipient is prohibited. For product information, including indications, contraindications, warnings, precautions, potential adverse effects and patient counselling information, see the package insert and www.zimmerbiomet.com. Speakers and/or authors may have received remuneration from Zimmer Biomet. The views and opinions expressed in this journal and at this event are solely those of the original authors and other contributors as well as the speakers. These views and opinions do not necessarily represent those of Zimmer Biomet, Zimmer Biomet employees, and/or any/all authors/contributors/speakers. The Zimmer Biomet merger does not infer cross-compatibility of products. Refer to individual product labelling for compatibility information.
