Large-diameter Metal-on-metal Total Hip Arthroplasty: Dislocation Infrequent but Survivorship Poor
Large-diameter Metal-on-metal Total Hip Arthroplasty: Dislocation Infrequent but Survivorship Poor
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DOI：
10.1007/s11999-014-3976-0
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发表时间：
2015-02-01
影响因子：
4.2
通讯作者：
Sneller, Michael A.
中科院分区：
文献类型：
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作者：
Lombardi, Adolph V., Jr.;Berend, Keith R.;Sneller, Michael A.
大直径金属对金属（MoM）关节在THA中的使用增加了，至少部分原因是有可能在体外获得更好的关节稳定性和优异的磨损特性。然而，随后有关于金属碎片（ARMD）的不良反应、假肿瘤和与金属离子相关的全身并发症的报道。本研究的目的是在至少2年的随访中确定(1)脱位患者的比例；(2)使用这些植入物获得的短期存活；(3)失败原因及发生ARMD的患者比例；(4)是否存在可识别的修订风险因素。我们回顾了1235例患者的结果，这些患者接受了1440例大直径MoM原发性tha手术，使用了来自单一制造商的两个髋臼装置，随访时间至少为2年。在研究期间，有48%（3567例中有1695例）的原发性tha使用了大直径MoM装置。我们通常将这些植入物用于年轻、更活跃、需求更高的患者，被认为有较高不稳定风险的患者，以及有足够的骨储备无需使用螺钉即可实现稳定固定的患者。我们回顾了临床记录和x线片，以确定翻修的发生率和病因。将髋关节翻修的患者与未翻修的患者进行比较，以确定危险因素；Kaplan-Meier生存分析作为多变量分析，在评估危险因素时考虑潜在的混杂变量。最小随访时间为2年（平均7年，范围2-12年）；85%的髋部（1695例中的1440例）获得了完全随访。1髋脱位（< 1%，1440例中1例）。Kaplan-Meier分析显示，12年无成分修订的生存率为87%（95%置信区间，84%-90%）。两种最常见的适应症是ARMD（48%， 108例髋关节翻修中的47例）和内生长松动或失败（31%，108例翻修中的34例）。部件翻修的危险因素为手术年龄较小（相对危险度[RR]每增加1年0.98,p = 0.02）、杯倾角较大（相对危险度每增加1度RR为1.03,p = 0.04）、女性（相对危险度RR为1.67,p = 0.03）。大直径MoM tha的脱位率非常低，但继发于ARMD和松动或缺乏长入的失败经常发生。应鼓励MoM THA患者返回进行临床和影像学随访，临床医生应保持较低的阈值以进行系统评估。建议早期诊断和适当治疗，以防止晚期ARMD的破坏性影响。四级，治疗性研究。
Use of large-diameter metal-on-metal (MoM) articulations in THA increased, at least in part, because of the possibility of achieving improved joint stability and excellent wear characteristics in vitro. However, there have been subsequent concerning reports with adverse reactions to metal debris (ARMD), pseudotumors, and systemic complications related to metal ions.The purpose of this study was to determine at a minimum of 2 years' followup (1) the proportion of patients who experienced a dislocation; (2) the short-term survivorship obtained with these implants; (3) the causes of failure and the proportion of patients who developed ARMD; and (4) whether there were any identifiable risk factors for revision.We reviewed the results of 1235 patients who underwent 1440 large-diameter MoM primary THAs at our institution using two acetabular devices from a single manufacturer with minimum 2-year followup. Large-diameter MoM devices were used in 48% (1695 of 3567) of primary THAs during the study period. We generally used these implants in younger, more active, higher-demand patients, in patients considered at higher risk of instability, and in patients with adequate bone stock to achieve stable fixation without use of screws. Clinical records and radiographs were reviewed to determine the incidence and etiology of revision. Patients whose hips were revised were compared with those not revised to identify risk factors; Kaplan-Meier survivorship analysis was performed as was multivariate analysis to account for potential confounding variables when evaluating risk factors. Minimum followup was 2 years (average, 7 years; range, 2-12 years); complete followup was available in 85% of hips (1440 of 1695).Dislocation occurred in one hip overall (< 1%; one of 1440). Kaplan-Meier analysis revealed survival free of component revision was 87% at 12 years (95% confidence interval, 84%-90%). The two most common indications for revision were ARMD (48%; 47 of 108 hips revised) and loosening or failure of ingrowth (31%; 34 of 108). Risk factors for component revision were younger age at surgery (relative risk [RR] 0.98 per each increased year; p = 0.02), higher cup angle of inclination (RR 1.03 per each increased degree; p = 0.04), and female sex (RR 1.67; p = 0.03).Large-diameter MoM THAs are associated with a very low dislocation rate, but failure secondary to ARMD and loosening or lack of ingrowth occur frequently. Patients with MoM THA should be encouraged to return for clinical and radiographic followup, and clinicians should maintain a low threshold to perform a systematic evaluation. Early diagnosis and appropriate treatment are recommended to prevent the damaging effects of advanced ARMD.Level IV, Therapeutic study.