Hannouche Didier, Devriese Flore, Delambre Jérôme, Zadegan Frédéric, Tourabaly Idriss, Sedel Laurent, Chevret Sylvie, Nizard Rémy
Department of Orthopaedic Surgery and Traumatology, AP-HP, Hôpital Lariboisière, Université Paris 7 Denis Diderot, 2 Rue Ambroise Paré, 75010, Paris, France.
Department of Biostatistics and Medical Informatics, AP-HP, Hôpital Saint Louis, Université Paris 7 Denis Diderot, Paris, France.
Clin Orthop Relat Res. 2016 Feb;474(2):520-7. doi: 10.1007/s11999-015-4546-9. Epub 2015 Sep 4.
Poor survival of THA implants in very young patients has been attributed to use of cemented implants, wear of conventional polyethylene, and the presence of morphologic deformities in the proximal femur or in the acetabulum. Few studies have reported the long-term results of ceramic-on-ceramic implants in THAs in patients younger than 20 years.
QUESTION/PURPOSES: We determined: (1) the proportion of patients who experienced complications related to the ceramic bearing (squeaking, fracture); (2) the survivorship free from loosening and free from revision for any reason; (3) whether patients with osteonecrosis had inferior survivorship compared with patients whose surgical indication was all other diagnoses including sequelae of pediatric hip disorders (developmental dysplasia of the hip, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis); and (4) clinical function.
Between 1979 and 2013, we performed 113 primary THAs in 91 patients younger than 20 years at the time of surgery. Of those, 105 THAs (83 patients) were done with ceramic-on-ceramic bearings (91% of the 91 patients); during that period, a ceramic-on-ceramic bearing couple was indicated in all patients younger than 20 years. In eight patients (eight hips), a cemented polyethylene cup was implanted because the diameter of the acetabulum was smaller than the smallest available ceramic cup (46 mm), or because adequate fixation of a ceramic press-fit cup could not be achieved despite careful reaming of the acetabulum. The most common diagnosis indicating THA was avascular necrosis of the femoral head (56.2%; 59 hips). Thirty-five patients (40 hips) had undergone previous operations before the replacement. Three patients (4%; four hips) died from unrelated causes, nine patients (11%; 13 hips) were lost to followup, and four patients (five hips) had a followup greater than 8.5 years but have not been seen in the last 5 years. Patients were assessed clinically (using the Merle d'Aubigne-Postel score, Hip disability and Osteoarthritis Outcome score (HOOS), and the SF-12(®) Health Survey, and radiographically for signs of radiolucencies, subsidence, or osteolysis on plain films. The mean followup was 8.8 ± 6.1 years (range, 2-34.4 years).
Five patients experienced transient noise generation, defined as a snap in four patients and squeaking in one. Seventeen hips underwent revision surgery-16 for aseptic loosening and one for septic loosening. The implant survival rate at 10 years with aseptic loosening as the endpoint was 90.3% (95% CI, 82.4%-98.9%). No hip had acetabular or femoral osteolysis. Survivorship in patients with osteonecrosis did not differ from survivorship in patients with other diagnoses. The Merle d'Aubigne-Postel score increased from 10.1 ± 4.0 to 17.6 ± 1.1 (p < 0.01); the mean HOOS score was 79.3 ± 13.8 (range, 50.6-100); the mean SF-12(®) physical and mental component scores were 48.1 ± 7.9 (range, 21.4-57.6), and 47.4 ± 12.2 (range, 24.5-99.4), respectively.
We found that patient-reported outcomes scores improved in most patients undergoing THA in this very young study group. Underlying diagnosis did not affect long-term survivorship. However, the revision-free survival rate at 10 years is lower than published estimates in older patients, and with 11% of patients lost to followup, our estimates may represent a best-case scenario. Therefore, we believe THA should be performed as a last resort in this population.
Level IV, therapeutic study.
在非常年轻的患者中，全髋关节置换（THA）植入物的生存率较低，这归因于使用骨水泥型植入物、传统聚乙烯的磨损以及股骨近端或髋臼存在形态学畸形。很少有研究报道20岁以下患者THA中陶瓷对陶瓷植入物的长期结果。
问题/目的：我们确定：（1）经历与陶瓷轴承相关并发症（吱吱声、骨折）的患者比例；（2）无松动且无因任何原因翻修的生存率；（3）与手术指征为包括小儿髋关节疾病后遗症（发育性髋关节发育不良、Legg-Calvé-Perthes病、股骨头骨骺滑脱）在内的所有其他诊断的患者相比，股骨头坏死患者的生存率是否较低；以及（4）临床功能。
1979年至2013年期间，我们对91例手术时年龄小于20岁的患者进行了113例初次THA。其中，105例THA（83例患者）采用陶瓷对陶瓷轴承（91例患者中的91%）；在此期间，所有20岁以下患者均使用陶瓷对陶瓷轴承。8例患者（8髋）植入了骨水泥聚乙烯杯，原因是髋臼直径小于最小可用陶瓷杯（46mm），或者尽管对髋臼进行了仔细扩孔，但仍无法实现陶瓷压配杯的充分固定。表明进行THA的最常见诊断是股骨头缺血性坏死（56.2%；59髋）。35例患者（40髋）在置换前曾接受过手术。3例患者（4%；4髋）死于无关原因，9例患者（11%；13髋）失访，4例患者（5髋）随访时间超过8.5年，但在过去5年中未再就诊。对患者进行临床评估（使用Merle d'Aubigne-Postel评分、髋关节残疾和骨关节炎结果评分（HOOS）以及SF-12®健康调查），并通过X线片评估是否存在透亮线、下沉或骨溶解迹象。平均随访时间为8.8±6.1年（范围，2 - 34.4年）。
5例患者出现短暂的噪音产生，其中4例为咔哒声，1例为吱吱声。17髋接受了翻修手术——16例为无菌性松动，1例为感染性松动。以无菌性松动为终点的10年植入物生存率为90.3%（95%CI，82.4% - 98.9%）。没有髋关节出现髋臼或股骨骨溶解。股骨头坏死患者的生存率与其他诊断患者的生存率无差异。Merle d'Aubigne-Postel评分从10.1±4.0提高到17.6±1.1（p<0.01）；平均HOOS评分为79.3±13.8（范围，50.6 - 100）；平均SF-12®身体和精神成分评分分别为48.1±7.9（范围，21.4 - 57.6）和47.4±12.2（范围，24.5 - 99.4）。
我们发现，在这个非常年轻的研究组中，大多数接受THA的患者报告的结果评分有所改善。潜在诊断不影响长期生存率。然而，10年无翻修生存率低于老年患者的已发表估计值，且有11%的患者失访，我们的估计可能代表了最佳情况。因此，我们认为在这个人群中THA应作为最后手段进行。
IV级，治疗性研究。
