金属对金属髋关节置换术后金属屑不良反应患者中不存在推荐翻修手术的阈值：346 例翻修的回顾性队列研究。
No Threshold Exists for Recommending Revision Surgery in Metal-on-Metal Hip Arthroplasty Patients With Adverse Reactions to Metal Debris: A Retrospective Cohort Study of 346 Revisions.
机构信息
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, United Kingdom; Research Department, The Royal Orthopaedic Hospital, Birmingham, United Kingdom.
Research Department, The Royal Orthopaedic Hospital, Birmingham, United Kingdom.
出版信息
J Arthroplasty. 2019 Jul;34(7):1483-1491. doi: 10.1016/j.arth.2019.03.022. Epub 2019 Mar 13.
BACKGROUND
Surgeons currently have difficulty when managing metal-on-metal hip arthroplasty (MoMHA) patients with adverse reactions to metal debris (ARMD). This stems from a lack of evidence, which is emphasized by the variability in the recommendations proposed by different worldwide regulatory authorities for considering MoMHA revision surgery. We investigated predictors of poor outcomes following MoMHA revision surgery performed for ARMD to help inform the revision threshold and type of reconstruction.
METHODS
We retrospectively studied 346 MoMHA revisions for ARMD performed at 2 European centers. Preoperative (metal ions/imaging) and intraoperative (findings, components removed/implanted) factors were used to predict poor outcomes. Poor outcomes were postoperative complications (including re-revision), 90-day mortality, and poor Oxford Hip Score.
RESULTS
Poor outcomes occurred in 38.5%. Shorter time (under 4 years) to revision surgery was the only preoperative predictor of poor outcomes (odds ratio [OR] = 2.12, confidence interval [CI] = 1.00-4.46). Prerevision metal ions and imaging did not influence outcomes. Single-component revisions (vs all-component revisions) increased the risk of poor outcomes (OR = 2.99, CI = 1.50-5.97). Intraoperative modifiable factors reducing the risk of poor outcomes included the posterior approach (OR = 0.22, CI = 0.10-0.49), revision head sizes ≥36 mm (vs <36 mm: OR = 0.37, CI = 0.18-0.77), ceramic-on-polyethylene revision bearings (OR vs ceramic-on-ceramic = 0.30, CI = 0.14-0.66), and metal-on-polyethylene revision bearings (OR vs ceramic-on-ceramic = 0.37, CI = 0.17-0.83).
CONCLUSION
No threshold exists for recommending revision in MoMHA patients with ARMD. However postrevision outcomes were surgeon modifiable. Optimal outcomes may be achieved if surgeons use the posterior approach, revise all MoMHA components, and use ≥36 mm ceramic-on-polyethylene or metal-on-polyethylene articulations.
背景
外科医生在处理对金属碎屑有不良反应的金属对金属髋关节置换术（MoMHA）患者时存在困难。这源于缺乏证据，不同全球监管机构对考虑 MoMHA 翻修手术的建议存在差异，进一步强调了这一点。我们研究了 MoMHA 翻修手术治疗 ARMD 后不良结局的预测因素，以帮助确定翻修阈值和重建类型。
方法
我们回顾性研究了欧洲 2 个中心进行的 346 例 MoMHA 翻修术，用于 ARMD。使用术前（金属离子/影像学）和术中（发现、取出/植入的部件）因素来预测不良结局。不良结局为术后并发症（包括再次翻修）、90 天死亡率和 Oxford 髋关节评分较差。
结果
38.5%的患者出现不良结局。翻修手术时间较短（<4 年）是唯一的术前不良结局预测因素（优势比[OR]为 2.12，95%置信区间[CI]为 1.00-4.46）。术前金属离子和影像学检查并不影响结局。单组件翻修（与全组件翻修相比）增加了不良结局的风险（OR=2.99，95%CI=1.50-5.97）。术中可改变的因素降低了不良结局的风险，包括后路入路（OR=0.22，95%CI=0.10-0.49）、翻修头尺寸≥36mm（<36mm：OR=0.37，95%CI=0.18-0.77）、陶瓷对聚乙烯翻修轴承（与陶瓷对陶瓷相比：OR=0.30，95%CI=0.14-0.66）和金属对聚乙烯翻修轴承（与陶瓷对陶瓷相比：OR=0.37，95%CI=0.17-0.83）。
结论
对于 ARMD 的 MoMHA 患者，不存在推荐翻修的阈值。然而，翻修后的结果是可以由外科医生改变的。如果外科医生使用后路入路、翻修所有 MoMHA 组件，并使用≥36mm 的陶瓷对聚乙烯或金属对聚乙烯关节，可能会获得最佳结果。
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