Kim Young-Hoo, Park Jang-Won, Kim Jun-Shik, Rastogi Devarshi
The Joint Replacement Center, MokDong Hospital, Ewha Womans University School of Medicine, 911-1 MokDong, YangChun-Ku, Seoul, 158-710, Republic of Korea,
Clin Orthop Relat Res. 2015 Sep;473(9):2990-3000. doi: 10.1007/s11999-015-4358-y. Epub 2015 May 27.
Numerous studies have investigated the clinical and radiographic results of revision THAs with use of cementless stems and cortical strut allografts. However, to our knowledge, no long-term followup studies have evaluated patients undergoing revision THA with use of cortical strut allografts where the allografts provided the primary stability for extensively coated femoral stems in the presence of extensive femoral diaphyseal bone defects.
QUESTION/PURPOSES: We performed this study to determine (1) validated outcomes scores; (2) radiographic signs of fixation and allograft healing; (3) frequency of complications; and (4) survivorship of the components after use of cortical strut onlay allografts in Types IIIB and IV femoral diaphyseal bone defects.
Between 1994 and 2003, we performed 140 revision THAs in 130 patients with Paprosky Types IIIB and IV femoral diaphyseal defects. The patients were treated using extensively coated femoral stems and cortical strut allografts because primary axial or rotational stability could not be achieved without grafting. Ten of the patients (10 hips; 7.7%) were lost to followup or died before 10 years; the remaining 120 patients (130 hips) represent the study group in this retrospective study. There were 66 men and 54 women. Their mean age at the time of index surgery was 59 ± 18 years (range, 36-67 years). The primary diagnosis was predominantly osteonecrosis of the femoral head (53%). The most common reason for revision was aseptic loosening (97%), followed by periprosthetic fracture (3%). The mean time from primary to revision THA was 12 years (range, 8-27 years). The mean duration of followup was 16.1 years (range, 12-20 years).
The mean Harris hip score was 39 ± 10 points before revision and improved to 86 ± 14 points at 16 years followup (p = 0.02). The mean preoperative WOMAC score was 62 ± 29 (41-91) points and improved to 22 ± 19 (11-51) points at 16 years followup (p = 0.003). Of the 130 stems, 113 (87%) had bone ingrowth, five (4%) had stable fibrous ingrowth, and 12 (9%) were unstable. All allografts were incorporated. Four hips (3%) had a displaced femoral shaft fracture at the stem tip; four (3%) had a postoperative dislocation; and six (5%) had early postoperative infection. Kaplan-Meier survivorship analysis, with revision or radiographic failure as the endpoint, revealed that the 16-year rate of survival of the components was 91% (95% CI, 0.88%-0.96%).
Supportive cortical strut onlay allografts provided high survivorship beyond 12 years of followup in revision THAs. Future studies might compare this approach with allograft-prosthesis composites, proximal femoral replacement, or modular fluted, tapered stems.
Level IV, therapeutic study.
大量研究调查了使用非骨水泥型股骨柄和皮质支撑骨移植进行翻修全髋关节置换术（THA）的临床和影像学结果。然而，据我们所知，尚无长期随访研究评估使用皮质支撑骨移植进行翻修THA的患者，在存在广泛股骨干骨缺损的情况下，骨移植为广泛涂层股骨柄提供主要稳定性的情况。
问题/目的：我们开展本研究以确定：（1）验证后的疗效评分；（2）固定和骨移植愈合的影像学表现；（3）并发症发生率；（4）在III B型和IV型股骨干骨缺损中使用皮质支撑嵌贴骨移植后假体组件的生存率。
1994年至2003年期间，我们对130例患有Paprosky III B型和IV型股骨干缺损的患者进行了140例翻修THA。由于不进行移植无法实现主要的轴向或旋转稳定性，患者采用广泛涂层股骨柄和皮质支撑骨移植进行治疗。10例患者（10髋；7.7%）失访或在10年前死亡；其余120例患者（130髋）为本回顾性研究的研究组。其中男性66例，女性54例。初次手术时他们的平均年龄为59±18岁（范围36 - 67岁）。主要诊断主要为股骨头坏死（53%）。翻修的最常见原因是无菌性松动（97%），其次是假体周围骨折（3%）。初次THA至翻修THA的平均时间为12年（范围8 - 27年）。平均随访时间为16.1年（范围12 - 20年）。
翻修前Harris髋关节平均评分为39±10分，16年随访时提高至86±14分（p = 0.02）。术前WOMAC平均评分为62±29（41 - 91）分，16年随访时提高至22±19（11 - 51）分（p = 0.003）。130个股骨柄中，113例（87%）有骨长入，5例（4%）有稳定的纤维长入，12例（9%）不稳定。所有骨移植均已融合。4髋（3%）在股骨柄尖端发生股骨干骨折移位；4髋（3%）发生术后脱位；6髋（5%）发生术后早期感染。以翻修或影像学失败为终点的Kaplan - Meier生存率分析显示，假体组件16年生存率为91%（95%CI，0.88% - 0.96%）。
在翻修THA中，支撑性皮质支撑嵌贴骨移植在超过12年的随访期内提供了较高的生存率。未来研究可将此方法与骨移植 - 假体复合物、股骨近端置换或模块化带槽、锥形股骨柄进行比较。
IV级，治疗性研究。
