W. Hoskins, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.
W. Hoskins, R. Bingham, Traumaplasty Melbourne, East Melbourne, Victoria, Australia.
Clin Orthop Relat Res. 2021 Jan 1;479(1):72-81. doi: 10.1097/CORR.0000000000001447.
THA is a reasonable surgical option for some patients with fragility fractures of the femoral neck, but it has the risk of prosthesis dislocation. The prosthesis combination that reduces the risk of dislocation and the rate of revision surgery is not known.
QUESTIONS/PURPOSES: In patients receiving primary THA for a femoral neck fracture, does (1) the rate of all-cause revision or (2) the reason for revision and rate of revision for dislocation differ among THA with a standard head size, large head size, dual mobility (DM), or constrained liner? (3) Is there a difference in the revision risk when patients are stratified by age at the time of surgery?
Data were analyzed for 16,692 THAs performed to treat fractures of the femoral neck reported in the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from January 2008 to December 2018, as this included the first use of DM prostheses. The AOANJRR includes information on more than 98% of arthroplasty procedures performed in Australia. Most patients were female (72%) and the mean age was 74 years ± 11. There were 8582 standard-head prostheses, 5820 large-head prostheses, 1778 DM prostheses, and 512 constrained prostheses identified. The cumulative percent revision (CPR) was determined for all causes as well as CPR for dislocation. The time to the first revision was described using Kaplan-Meier estimates of survivorship, with right censoring for death or closure of the database at the time of analysis. The unadjusted CPR was estimated each year of the first 10 years for standard heads, 10 years for large heads, 8 years for constrained liners, and 7 years for DM prostheses, with 95% confidence intervals using unadjusted pointwise Greenwood estimates. The results were adjusted for age, sex, femoral fixation, and head size where appropriate and were considered by age groups < 70 and ≥ 70 years.
When adjusted for age, sex, femoral fixation and head size, there was no difference in the rate of all-cause revision at 7 years for any of the four groups. There was no difference in the rate of all-cause revision when patients were stratified by < 70 or ≥ 70 years of age. Dislocation was the most common reason for revision (32%). When analyzing revision for dislocation alone, large-head THA had a lower rate of revision for dislocation compared with standard head (HR 0.6 [95% CI 0.4 to 0.8]; p < 0.001) and DM prostheses had a lower rate of revision for dislocation than standard head for the first 3 months (HR 0.3 [95% CI 0.1 to 0.7]; p < 0.004) but not after this time point.
The Australian registry shows that there is no difference in the rate of all-cause revision for standard-head, large-head, DM prostheses or constrained liner THA after femoral neck fractures for all patients or for patients stratified into younger than 70 years and at least 70 years of age groups. Dislocation is the most common cause of revision. Large-head prostheses are associated with a lower revision risk for dislocation and DM prostheses have a lower rate of revision for dislocation than standard heads for the first 3 months only. Surgeons treating a femoral neck fracture with THA might consider a large head size if the diameter of the acetabulum will allow it and a DM prosthesis if a large head size is not possible. The age, life expectancy and level of function of patients with femoral neck fractures minimizes the potential long-term consequences of these prostheses. The lack of significant differences in survival between most prosthesis combinations means surgeons should continue to look for factors beyond head size and prosthesis to minimize dislocation and revision surgery.
Level III, therapeutic study.
对于一些股骨颈脆弱性骨折的患者，全髋关节置换术（THA）是一种合理的手术选择，但存在假体脱位的风险。目前还不知道哪种假体组合可以降低脱位风险和翻修手术率。
问题/目的：在接受初次 THA 治疗股骨颈骨折的患者中，（1）全因翻修率，或（2）翻修原因和脱位翻修率是否因标准头大小、大头大小、双动（DM）或约束衬垫的假体而不同？（3）当患者按手术时的年龄分层时，翻修风险是否存在差异？
对澳大利亚矫形协会全国关节置换登记处（AOANJRR） 2008 年 1 月至 2018 年 12 月期间报告的 16692 例股骨颈骨折接受初次 THA 治疗的患者数据进行了分析，因为这包括 DM 假体的首次使用。AOANJRR 包含了澳大利亚进行的超过 98%的关节置换手术的信息。大多数患者为女性（72%），平均年龄为 74 岁±11 岁。确定了 8582 个标准头假体、5820 个大头假体、1778 个 DM 假体和 512 个约束假体。所有原因的累积翻修率（CPR）以及脱位的 CPR 均进行了确定。使用 Kaplan-Meier 估计的生存情况描述了首次翻修的时间，在右截止时间为分析时死亡或数据库关闭。标准头每年调整一次未调整的 CPR，10 年为大头，8 年为约束衬垫，7 年为 DM 假体，使用未调整的点估计 Greenwood 置信区间。结果适当地调整了年龄、性别、股骨固定和头大小，并按<70 岁和≥70 岁的年龄组进行了考虑。
在调整了年龄、性别、股骨固定和头大小后，任何四组在 7 年时的全因翻修率均无差异。在按<70 岁或≥70 岁分层的患者中，全因翻修率无差异。脱位是最常见的翻修原因（32%）。单独分析脱位翻修时，大头 THA 的脱位翻修率低于标准头（HR 0.6 [95%CI 0.4 至 0.8]；p<0.001），DM 假体在前 3 个月的脱位翻修率低于标准头（HR 0.3 [95%CI 0.1 至 0.7]；p<0.004），但此后时间点则无差异。
澳大利亚登记处显示，在所有患者或按年龄<70 岁和≥70 岁分层的患者中，标准头、大头、DM 假体或约束衬垫 THA 治疗股骨颈骨折后，全因翻修率或因脱位而翻修的比率没有差异。脱位是最常见的翻修原因。大头假体与较低的脱位翻修风险相关，DM 假体与标准头相比，在前 3 个月的脱位翻修率较低，但此后时间点则无差异。治疗股骨颈骨折的 THA 时，如果髋臼直径允许，外科医生可能会考虑使用大头假体，如果不能使用大头假体，则可以考虑使用 DM 假体。股骨颈骨折患者的年龄、预期寿命和功能水平将最大限度地减少这些假体的潜在长期后果。大多数假体组合之间的生存差异不显著，这意味着外科医生应继续寻找除头大小和假体以外的因素，以最大限度地减少脱位和翻修手术。
III 级，治疗性研究。
