This document provides information about hip and knee replacement services at Humanitas Research Hospital in Italy. It discusses the history and founding of hip replacement research and education centers in Pietra Ligure and Rozzano led by Prof. Lorenzo Spotorno and Prof. Guido Grappiolo. It highlights the hospital's high volume of joint replacements per year, focus on research and education, and use of innovative techniques like fast track recovery programs and mini-invasive surgeries. Early results with a new uncemented short stem hip implant called GTS are also summarized, showing outcomes comparable to previous implants.

1. Hip & Knee
Replacement
@
HUMANITAS
RESEARCH
HOSPITAL
Gianluca Cusmà Dovico Guatteri M.D.

2. where are you from ?
2
700 km from Rome
400 from Florence
300 km from Milan

3. the beginning
3Pietra Ligure – Savona - Italy

4. Lorenzo Spotorno
4

5. LORENZO
SPOTORNO

6. 1976 19831977 1979

7. 1983 1997 2004
Since December 1983 the CLS hip
has been a worldwide best seller

8. Fondazione Scienza & Vita
@ Pietra Ligure Public Hospital
• Research in biomechanics and matherials
• Joint replacement education and courses
• CLS hip system surgical demonstrations
8

9. Beginnings of the new century…
Prof. Spotorno moved to private health system in northern Italy
and left Guido Grappiolo to lead the Pietra Ligure Hospital
Centre and the Research Foundation

10. 2002 opening @ Rozzano (MI)
10

11. Spotorno
Hip Replacement Center
@ Humanitas Rozzano - Milano
• around 800 hip / year
• patients coming from all Italy
• Zimmer facility for education and courses
11

12. www.humanitas.it
12

13. 2008
Prof. Guido Grappiolo
• HUMANITAS RESEARCH HOSPITAL
• PRIVATE UNIVERSITY OPENING

14. 14
 Surgery: 2000 hip&knee replacements/year
 Research:
design, MoM survey, bone substitutes
 Comunication
national and international congresses
 Medical Education
cadaver labs, visiting fellows, live surgery
The G Group – 8 surgeons

15. Biomet GTS
• from 2009 R&D
• from 2010 routinerly use
15

16. Hip & Knee Division of Surgery
Dir: Prof. G. Grappiolo
GTS STEM:
RESULTS AT 2 YEARS
G.Grappiolo - F.Astore - G.Cusmà

17. ANTEVERSION
COMBINADA EN
ATC PRIMARIA
(antès el femur…)
Prof. Guido Grappiolo
Dr. Gianluca Cusmà Guatteri
Centro Cirugìa
Protesica y Artroscopica
de Cadera y Rodilla
@ Bergamo - Italia

18. CONCLUSIONS
In our experience the femur first technique is easy to perform, usefull in any cup or liner design and matherials, doesn’t affect the surgery time and is
very cheap, since it could be performed using standard metal on metal tools. Specially with poly liners and 32 or 36 mm. heads this procedure becomes
crucial. But also in hard-on-hard tribology, where large diameter heads use is permitted, it is important to search for an ideal position. Thus in order to
avoid edge loading effects that could lead to ions production, ceramic rupture and cup loosenings. If “staying into the safe zone” avoids dislocation,
“staying exactly in the middle of the safe zone” gives a larger Theoretical ROM, absence of edge loading and impingement and therefore is the basis of
a durable implant.
DISCUSSION
Theoretical safe ROM is closely related to several factors:
- head-neck ratio leading to technical ROM (θ),
- cup lateral opening or abduction (ά),
- cup anterior opening or anteversion (β),
- neck angle of the femoral component from the transverse plane (a),
- neck antetorsion around the vertical axis from the transverse plane (b)
- additional components design
Yoshimine found that the optimum reciprocal position of components should match this
formula: (ά)+(β)+0.77(b)=84.3 (a less vertical cup requires higher values of femoral an-
tetorsion and/or cup anteversion). Hisatome decided to fix the cup abduction at 45°, pro-
posing the formula (β)+0.7(b)=42°.
But how a surgeon could use these formulas in practice, considering that anatomical si-
tuation of the patient often conditions component’s position?
The charts here displayed show some evidences:
1) we should avoid 22 mm and 28 mm. heads, since the safe zone that they can grant is
very narrow;
2) Safe zone with 32 mm heads and bigger heads, in case of cup abduction of 45°, is
quite larger, and is always respected for a sum of femoral antetorsion and cup antever-
sion of 40°: that line stands in the middle of the safe area, between 25° and 50° critical
values
3) With a more vertical cup, such as with an abduction of 55°, the safe zone is a little
wider and translated to smaller values, between 15° and 45°, with the line of the 35°
safely in the middle of the area.
So it is clear that, with the new prosthetic designs, which allow large technical ROMs, it
is easy for the surgeon to safely remain inside the “safe zone”. The surgeon could even
choose to put a more vertical cup (from 55° to 50°) with varized stems and a more cove-
ring cup (from 50° to 45°) when using a standard 135° stem. We do not recommend a fixed ideal value of inclination, but we suggest to follow the indi-
cation obtained by the femur first technique, always keeping in mind to search for a safe zone slightly less than 40° when it is needed to put a very ver-
tical cup, while a safe zone of exactly 40° or slightly more is best in more covering cups.
© Hisatome T, Hideo D. Theoretically optimum position of the prosthesis in total hip arthroplasty to fulfill the severe
range of motion criteria due to neck impingement, J Orthop Sci. 2011;16:229-37, reproduced with permission of the Authors
RESULTS
We do not observe any increase of intra operative complications in comparison with our previous data. In the hospitalization period we had only one luxa-
tion since the beginning of the procedure. We found a slight increase in surgery time (average time moved from 61’ to 69’).
REFERENCES
1) D’Lima DD, Urquhart AG, Buehler KO, et al. The effect of the orientation of the acetabular and femoral components on the Range Of Motion of the hip at different head-neck ratios, J Bone Joint Surg Am. 2000;82:315-21
2) Hisatome T, Hideo D. Theoretically optimum position of the prosthesis in total hip arthroplasty to fulfill the severe range of motion criteria due to neck impingement, J Orthop Sci. 2011;16:229-37
3) Widmer KH. Containment versus impingement: finding a compromise for cup placement in total hip arthroplasty, Int Orthop. 2007;31(1):S29-33
4) Yoshimine F. The safe-zones for combined cup and neck anteversions that fulfill the essential range of motion and their optimum combination in total hip replacements, J Biomech. 2006;39:1315-23
5) Lewinnek GE, Lewis JL, Tarr R, et al. Dislocations after total hip-replacement arthroplasties, J Bone Joint Surg Am. 1978;60:217-20
6) Muller ME. Total hip prosthesis. Clin Orthop. 1970;72:46-68
7) Ranawat CS, Maynard MJ. Modern technique of cemented total hip arthroplasty, Tech Orthop. 1991;6:17-25
8) Jolles BM, Zangger P, Leyvraz PF. Factors predisposing to dislocation after primary total hip arthroplasty. A multivariate analysis, J Arthroplasty. 2002;17:282-8
This way we performed 570 THA (31 bilateral): 282 males, 257 females, average age 57,8 years. Etiology: idiopathic 61%, F.A.I. related 21%, secondary
18% (41 DDH, 19 femoral head necrosis, 11 Perthes sequelae, 9 post-traumatic arthritis). Tribology: 306 ceramics on poly, 103 ceramics on ceramics,
81 metal on metal, 80 metal on poly. We prospectically evaluated our patients with clinical and x-ray controls at 1, 3, 6 and 12 months.
- mark acetabular surface (anterior/posterior) along plane defined by trial head’s diameter;
- cup implantation respecting the bony marks and liner insertion;
- reduction and definitive check of component‘s reciprocal position.
MATERIALS AND METHODS
Developed during 2009, in January 2010 we began using a “femur first technique” in primary THA with a standard postero-lateral approach to the hip
joint; after femur exposure, osteotomy and preparation we leave femoral planned/last rasp in situ:
- after acetabulum standard exposure, 2 mm. under-reaming to planned;
- hip reduction with a hemispherical plastic trial head, slightly undersized to last reaming;
- limb positioned in neutral abduction and internally rotated in 40° angle on the horizont;
INTRODUCTION
THA is a well known, safe and widely used procedure, also in young people who need high performances and more durable results. Dislocation risk and
post op ROM are closely related to component’s placement. Computer assisted surgery tried to definitively solve the problem but several errors and bias
can affect definitive measurements. Anyway the position must be correct in static and dynamic situations to avoid impingement and improve tribology:
poly wear, ceramic rupture, ion release are often the primary cause of cups loosening. The “safe zone” concept by Lewinnek (1978) requires a cup posi-
tion with a range of 30°-50° in vertical inclination and 5°-25° in anterior version. Muller was more restrictive about cup position and in his papers he also
recommends a stem anteversion of 10°. Ranawat in 1991 understood that single position of components is not so crucial and introduced the concept of
“reciprocally correct position” leading to a “combined anteversion” (sum of cup anteversion and stem antetorsion - suitable 45° for female and between
20° and 30° for male patients) which is the basis for modern definition of “safe zone”.
18
CONCLUSIONS
Early clinical and radiographic follow up was comparable to our previous results with a straight uncemented standard stem. With new GTS stem we could appro-
priately reconstruct the pre-op morphotype and morphometry on a wide range of population without any increase in complications rate also without any patient
selection.
DISCUSSION
Register data shows that demographic range gets wider and patient’s activity level rises continuously. Straight uncemented stems for THA show very good clini-
cal and radiographic results but leave important questions open regarding bone and muscle sparing. Short stems allow M.I.S. and bone stock preservation but
leave questions open regarding their primary stability and restore of morphometric parameters capability that had limited their indications (ranging from 5% to
30% in italian surgery centers). Our off-set dispersion chart (above) demonstrates how it’s possible with GTS stem to reproduce hip native morphology combi-
ning size and CCD options (varized 122° and standard 133°) without any increase in complication rate.
RESULTS
We found average clinical scores similar to our previous studies with other stems.
We performed a radiographic analysis of implants with a 1 year minimum follow up (100 stems, 96 patients). We measured cervico-diaphyseal angle,
flare index and cortico-medullary index on pre op x-rays and cervico-diaphyseal angle, metaphyseal filling rate and bone resorption signs on post op
x-rays. We also evaluated legs length discrepancy and off-set reconstruction. The average pre-op C/D angle and off- set were 130.7 degrees and 51.0
mm. while post-op were 128.3 degrees and 50.23 mm. with a legs lenght discrepancy that ranges from 12.0 to 2.0 mm. No clinical or radiological signs
of loosenings at 1 year follow-ups.
In the whole 570 hips we had five cases (0,9%) of intra-op femoral crack (3 required immediate treatment by wiring or screw). One traumatic fracture
in the rehabilitation period was revised with a long conical stem and 3 cases of early septic complications underwent debridement. We reported only one
luxation, early manually reduced.
Arthritis Etiology
Secondary;18%
F.A.I.Related;21%
Idiopathic;61%
Secondary Causes
Post-traumatic Arthritis;11%
Perthes;14%
Femoral Head Necrosis;24%
DDH;51%
Cups Tribology
Metal On Poly;9%
Metal On Metal;15%
Ceramicson Ceramics;19%
Ceramicson Poly;57%
MATHERIALS AND METHODS
In first 12 months 539 patients (570 hips, 31 bilateral) undergone a THA based on GTS: 282 males, 257 females, average age 57,8 years. Etiology: idio-
pathic 61%, F.A.I. related 21%, secondary 18% (41 DDH, 19 femoral head necrosis, 11 Perthes sequelae, 9 posttraumatic arthritis). Tribology: 306 cera-
mics on poly, 103 ceramics on ceramics, 81 metal on metal, 49 metal on poly. Standard 133° stem in 485 cases and varus 122° stem in 85 cases. We
prospectically evaluated our patients with clinical and x-ray controls at 1, 3, 6 and 12 months.
INTRODUCTION
In January 2010 we began our experience with a new uncemented short stem. GTS is a throcanter sparing stem with a grit blasted titanium alloy and a
tapered wedge geometry with full-surface fins.
EARLY RESULTS OF THE NEW GTS UNCEMENTED STEM:
OUTCOME OF FIRST 570 CONSECUTIVE CASES

19. guests from all over the world
19

20. international cooperation
20

21. Livio SciuttoF O N D A Z I O N E
www.fondazione.it

24. 24
2014 January opening @ Bergamo

25. what’s new… hot topics
• Mini-invasive procedures as a standard
• Micro-invasive for selected cases
• Fast Track rehab for all primary cases
• Information and patient’s cooperation
25

26. FAST TRACK
operative care flow with
a patient centered
multidisciplinary approach
26

27. What’s our fast track ?
27
Peri-op multimodal program in order to:
• Increase patient satisfaction
• Better clinical outcome
• Get Faster rehab
• Obtain Early discharge to home
• No increase in overall complications

28. results
• No difference in terms of deambulation, rom and
strenght recovery in comparison to control group at
first clinical consultation (35-45 days)
• Faster indipendence recovery than controls
(clothing, crutches resign, driving)
No increase in early complications !
28

29. Mini
invasive
THA
patient
…
29
at 24 hours
from surgery

30. 30
thank
you