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非模块化锥形带槽钛柄在翻修全髋关节置换术中短期内能可靠地实现骨整合。

Nonmodular Tapered Fluted Titanium Stems Osseointegrate Reliably at Short Term in Revision THAs.

作者信息

Sandiford Nemandra A, Garbuz Donald S, Masri Bassam A, Duncan Clive P

机构信息

Division of Reconstructive Orthopaedics (Hip and Knee), Faculty of Medicine, University of British Columbia, 3rd Floor 910 West 10th Avenue, Vancouver, BC, V5Z 4E3, Canada.

Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.

出版信息

Clin Orthop Relat Res. 2017 Jan;475(1):186-192. doi: 10.1007/s11999-016-5091-x. Epub 2016 Sep 26.

Abstract

BACKGROUND

The ideal femoral component for revision THA is undecided. Cylindrical nonmodular stems have been associated with stress shielding, whereas junctional fractures have been reported with tapered fluted modular titanium stems. We have used a tapered fluted nonmodular titanium femoral component (Wagner Self-locking [SL] femoral stem) to mitigate this risk. This component has been used extensively in Europe by its designer surgeons, but to our knowledge, it has not been studied in North America. Added to this, the design of the component has changed since early reports.

QUESTIONS/PURPOSES: We asked: (1) Does the Wagner SL stem have low rates of rerevision and other complications at a minimum 2 years after surgery? (2) Is the Wagner SL stem associated with high levels of patient function and pain relief at a minimum 2 years after surgery? (3) Does the Wagner SL stem have low rates of subsidence at a minimum 2 years after surgery? (4) Is the Wagner SL stem associated with proximal femoral bone remodeling at a minimum 2 years after surgery?

METHOD

Between May 2011 and December 2012, we performed 198 femoral revisions, of which 104 (53%) were performed using the Wagner SL femoral stem; during that period, our institution gradually shifted toward increasing use of these stems for all but the most severe revisions, in which modular fluted stems and proximal femoral replacements still are used on an occasional basis. Median followup in this retrospective study was 32 months (range, 24-46 months), and one patient was lost to followup before the 2-year minimum. The femoral deformities in this series were Paprosky Type I (10 hips), Paprosky Type II (26), Paprosky Type IIIA (52), Paprosky Type IIIB (nine), and Paprosky Type IV (two). Functional assessment was performed using the Oxford Hip Score (OHS), WOMAC, SF-12, and the University of California Los Angeles (UCLA) activity score. All complications and cases of revision were documented. All patients had radiographs performed within 1 year of the latest followup. These were assessed by two surgeons for signs of proximal femoral bone remodeling and subsidence.

RESULTS

Complete preoperative scores were available for 98 patients (98 of 104; 94%). The mean OHS preoperatively and at final followup were 39 (SD, 15) and 87 (SD, 19), respectively (p < 0.001; mean difference, 48; 95% CI, 43-53). Average WOMAC scores were 44 (SD, 15) and 87 (SD, 20), respectively (p < 0.001; mean difference, 43; 95% CI, 38-48). At final followup, signs of restoration of proximal femoral bone stock was noted in 45 of 103 hips (44%). Six (six of 104; 6%) patients had subsidence of 10 mm to 15 mm. In the remainder (98 of 104; 94%), the mean subsidence was 2 mm (range, 0-9 mm). One revision was performed for loosening associated with infection.

CONCLUSIONS

The Wagner SL stem is a viable option for patients with Paprosky Types II and III defects undergoing revision THA. This component provides high levels of patient function with low revision rates and low rates of subsidence during the early postoperative phase. They provide a viable alternative to modular components for treatment of Types II and III defects without the risk of junctional fractures. They can be used for very selected Type IV defects, however this extent of bone loss is most easily addressed with other techniques such as a proximal femoral replacement.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

摘要

背景

翻修全髋关节置换术(THA)中理想的股骨假体尚未确定。圆柱形非模块化柄与应力遮挡有关,而锥形带槽模块化钛柄则有交界性骨折的报道。我们使用了一种锥形带槽非模块化钛股骨假体(瓦格纳自锁[SL]股骨干)来降低这种风险。该假体已被其设计医师在欧洲广泛使用,但据我们所知,在北美尚未进行研究。此外,自早期报道以来,该假体的设计已经改变。

问题/目的:我们提出以下问题:(1)瓦格纳SL柄在术后至少2年时再次翻修率和其他并发症发生率是否较低?(2)瓦格纳SL柄在术后至少2年时是否与患者的高功能水平和疼痛缓解相关?(3)瓦格纳SL柄在术后至少2年时下沉率是否较低?(4)瓦格纳SL柄在术后至少2年时是否与股骨近端骨重塑相关?

方法

2011年5月至2012年12月期间,我们进行了198例股骨翻修手术,其中104例(53%)使用了瓦格纳SL股骨干;在此期间,我们的机构逐渐增加了这些柄的使用,除了最严重的翻修手术外,模块化带槽柄和股骨近端置换仍偶尔使用。在这项回顾性研究中,中位随访时间为32个月(范围24 - 46个月),1例患者在达到至少2年的随访前失访。该系列中的股骨畸形为帕普罗斯基I型(10髋)、帕普罗斯基II型(26髋)、帕普罗斯基IIIA型(52髋)、帕普罗斯基IIIB型(9髋)和帕普罗斯基IV型(2髋)。使用牛津髋关节评分(OHS)、WOMAC、SF - 12和加利福尼亚大学洛杉矶分校(UCLA)活动评分进行功能评估。记录所有并发症和翻修病例。所有患者在最近一次随访的1年内进行了X线检查。由两名外科医生评估这些X线片,以观察股骨近端骨重塑和下沉的迹象。

结果

98例患者(104例中的98例;94%)有完整的术前评分。术前和最终随访时的平均OHS分别为39(标准差,15)和87(标准差,19)(p < 0.001;平均差异,48;95%可信区间,43 - 53)。平均WOMAC评分分别为44(标准差,15)和87(标准差,20)(p < 0.001;平均差异,43;95%可信区间,38 - 48)。在最终随访时,103髋中的45髋(44%)有股骨近端骨量恢复的迹象。6例患者(104例中的6例;6%)下沉10 mm至15 mm。其余患者(104例中的98例;94%)平均下沉2 mm(范围0 - 9 mm)。因感染相关的松动进行了1次翻修。

结论

对于接受翻修THA的帕普罗斯基II型和III型缺损患者,瓦格纳SL柄是一个可行的选择。该假体在术后早期为患者提供了较高的功能水平,翻修率低且下沉率低。它们为治疗II型和III型缺损提供了一种可行的模块化假体替代方案,且无交界性骨折风险。它们可用于非常特定的IV型缺损,然而,这种骨量丢失程度最容易通过其他技术如股骨近端置换来解决。

证据水平

IV级,治疗性研究。

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