THA Revisions Using Impaction Allografting With Mesh Is Durable for Medial but Not Lateral Acetabular Defects
THA Revisions Using Impaction Allografting With Mesh Is Durable for Medial but Not Lateral Acetabular Defects
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DOI：
10.1007/s11999-015-4483-7
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发表时间：
2015-12-01
影响因子：
4.2
通讯作者：
Garcia-Cimbrelo, Eduardo
中科院分区：
文献类型：
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作者：
Garcia-Rey, Eduardo;Madero, Rosario;Garcia-Cimbrelo, Eduardo
背景大多数髋臼翻修术依靠骨长入采用非骨水泥半球形或椭圆形金属植入物。尽管如此，髋臼骨量的丧失和不能实现安全的假体固定是全髋关节翻修术设置中的挑战。使用同种异体骨的嵌入性骨移植(IBG)是治疗该问题的一种选择。然而，当IBG用于大型节段性缺损时，髋臼移位和植骨吸收是有限的，IBG的确切作用以及网片在这种情况下的使用尚不清楚。因此，我们评估了接受髋臼翻修手术的患者，使用IBG和骨水泥杯修复大型骨缺损的患者，以确定(1)有Paprosky 3A和3B缺陷的髋关节和使用或不使用金属网片的髋关节在手术中恢复髋关节中心的频率；(2)在严重Paprosky 3A和3B缺陷的患者中，IBG髋臼翻修重建术的存活率；以及(3)重建失败的危险因素，包括网片的使用和缺陷的严重程度(3A和3B)。在此期间，在这种情况下使用IBG的适应症包括没有骨盆中断的Paprosky 3A和3B缺陷。其中204例(90.2%)可进行至少5年的随访(平均10年；范围为5-17年)。术中Paprosky 3A和3B分别为100个和104个髋关节。应用内侧和/或外侧金属网片治疗142个髋臼内侧或边缘非包裹性缺损。两组均按Ranawat标准确定术后放射杯位置及髋臼重建髋臼。结果：术后髋臼外展角度、垂直、水平和髋关节旋转中心距离均有改善(p<；0.001)。骨缺损组3A组有9个髋关节出现放射性松动，3B组有16个髋关节出现放射性松动。3A组松动15年存活率为83%(95%可信区间，71%~95%)，3B组为73%(95%可信区间，60%~84%)(P=0.04)。有无网片松动15年存活率为89%(95%CI，74%~99%)，内侧网片85%(95%CI，72%~97%)，外侧网片80%(95%CI，67%~91%)，内、外侧网片54%(95%CI，31%~76%)(P=0.008)。在控制了最相关的混杂变量后，我们发现与松动相关的最重要的因素是侧方网片的使用(p=0.008；风险比，2.942；95%CI，1.328-6.516)。结论在髋臼翻修手术中，骨盆造影有助于髋关节旋转中心的重建。虽然结果对于内涵性或内侧性大的缺陷是好的，但有边缘或外侧节段性缺陷的髋关节可能需要其他选择来重建这些具有挑战性的手术。
Background Most acetabular revisions are managed with cementless hemispherical or elliptical metal implants relying on bone ingrowth. Nonetheless, loss of acetabular bone stock and inability to achieve secure component fixation represent challenges in the setting of revision total hip arthroplasty. Impaction bone grafting (IBG) using allograft represents one option for treatment of this problem. However, cup migration and bone graft resorption are limitations when IBG is used for large segmental defects, and the precise role of IBG as well as the use of mesh (and the kinds of defects for which mesh does not work well) in this setting remains unknown.Questions/purposes We therefore evaluated patients undergoing acetabular revision surgery using IBG and a cemented cup in large bone defects to determine (1) the frequency with which the hip center could be restored in hips with Paprosky 3A and 3B defects and in hips with or without the use of metallic mesh during surgery; (2) survivorship of IBG acetabular-revision reconstructions in patients with severe Paprosky 3A and 3B defects; and (3) risk factors for failure of the reconstruction, including the use of mesh and defect severity (3A versus 3B).Methods Between 1997 and 2009, we performed 226 acetabular revisions using IBG. During that time, indications for using IBG in this setting included Paprosky 3A and 3B defects without pelvic discontinuity. Of these, 204 (90.2%) were available for followup at a minimum of 5 years (mean, 10 years; range, 5-17 years). There were 100 hips with an intraoperative bone defect of Paprosky 3A and 104 with a 3B. Medial or rim acetabular uncontained defects were treated with medial and/or lateral metallic mesh in 142 hips. We determined the postoperative radiological cup position and acetabular reconstruction of the hip center according to Ranawat in both groups. We assessed the appearance of cup loosening and the possible risk factors with regression analysis.Results Mean postoperative acetabular abduction angle and vertical, horizontal, and hip rotation center distances improved (p < 0.001 in all parameters). Nine hips showed radiological loosening in the group with bone defect 3A and 16 in Group 3B. The survival rate for loosening at 15 years was 83% (95% confidence interval [CI], 71%-95%) for Group 3A and 73% (95% CI, 60%-84%) for Group 3B (p = 0.04). The survivorship for loosening when using mesh or not at 15 years was: no mesh 89% (95% CI, 74%-99%), medial mesh 85% (95% CI, 72%-97%), lateral mesh 80% (95% CI, 67%-91%), and medial and lateral meshes 54% (95% CI, 31%-76%) (p = 0.008). After controlling the most relevant confounding variables we found that the most important factor associated with loosening was lateral mesh use (p = 0.008; hazard ratio, 2.942; 95% CI, 1.328-6.516).Conclusions IBG provides an improvement in reconstruction of the hip rotation center in acetabular revision surgery. Although results are good for contained or medial large defects, hips with a rim or lateral segmental defect may need other options for reconstruction of these challenging surgeries.