Barwon Centre for Orthopaedic Research and Education, St. John of God Hospital Geelong, Geelong, Australia.
School of Medicine, Deakin University, Geelong, Australia.
Clin Orthop Relat Res. 2022 Oct 1;480(10):1940-1949. doi: 10.1097/CORR.0000000000002293. Epub 2022 Jun 28.
Loss of glenoid fixation is a key factor affecting the survivorship of primary total shoulder arthroplasty (TSA). It is not known whether the lower revision rates associated with crosslinked polyethylene (XLPE) compared with those of non-XLPE identified in hip and knee arthroplasty apply to shoulder arthroplasty.
QUESTIONS/PURPOSES: We used data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to compare the revision rates of primary stemmed anatomic TSA using XLPE to procedures using non-XLPE. In patients receiving a primary stemmed anatomic TSA for osteoarthritis, we asked: (1) Does the rate of revision or reason for revision vary between XLPE and non-XLPE all-polyethylene glenoid components? (2) Is there any difference in the revision rate when XLPE is compared with non-XLPE across varying head sizes? (3) Is there any difference in survival among prosthesis combinations with all-polyethylene glenoid components when they are used with XLPE compared with non-XLPE?
Data were extracted from the AOANJRR from April 16, 2004, to December 31, 2020. The AOANJRR collects data on more than 97% of joint replacements performed in Australia. The study population included all primary, stemmed, anatomic TSA procedures performed for osteoarthritis using all-polyethylene glenoid components. Procedures were grouped into XLPE and non-XLPE bearing surfaces for comparison. Of the 10,102 primary stemmed anatomic TSAs in the analysis, 39% (3942 of 10,102) used XLPE and 61% (6160 of 10,102) used non-XLPE. There were no differences in age, gender, or follow-up between groups. Revision rates were determined using Kaplan-Meier estimates of survivorship to describe the time to the first revision, with censoring at the time of death or closure of the database at the time of analysis. Revision was defined as removal, replacement, or addition of any component of a joint replacement. The unadjusted cumulative percent revision after the primary arthroplasty (with 95% confidence intervals [CIs]) was calculated and compared using Cox proportional hazard models adjusted for age, gender, fixation, and surgeon volume. Further analyses were performed stratifying according to humeral head size, and a prosthesis-specific analysis adjusted for age and gender was also performed. This analysis was restricted to prosthesis combinations that were used at least 150 times, accounted for at least four revisions, had XLPE and non-XLPE options available, and had a minimum of 3 years of follow-up.
Non - XLPE had a higher risk of revision than XLPE after 1.5 years (HR 2.3 [95% CI 1.6 to 3.1]; p < 0.001). The cumulative percent revision at 12 years was 5% (95% CI 4% to 6%) for XLPE and 9% (95% CI 8% to 10%) for non-XLPE. There was no difference in the rate of revision for head sizes smaller than 44 mm. Non-XLPE had a higher rate of revision than XLPE for head sizes 44 to 50 mm after 2 years (HR 2.3 [95% CI 1.5 to 3.6]; p < 0.001) and for heads larger than 50 mm for the entire period (HR 2.2 [95% CI 1.4 to 3.6]; p < 0.001). Two prosthesis combinations fulfilled the inclusion criteria for the prosthesis-specific analysis. One had a higher risk of revision when used with non-XLPE compared with XLPE after 1.5 years (HR 3.7 [95% CI 2.2 to 6.3]; p < 0.001). For the second prosthesis combination, no difference was found in the rate of revision between the two groups.
These AOANJRR data demonstrate that noncrosslinked, all-polyethylene glenoid components have a higher revision rate compared with crosslinked, all-polyethylene glenoid components when used in stemmed anatomic TSA for osteoarthritis. As polyethylene type is likely an important determinant of revision risk, crosslinked polyethylene should be used when available, particularly for head sizes larger than 44 mm. Further studies will need to be undertaken after larger numbers of shoulder arthroplasties have been performed to determine whether this reduction in revision risk associated with XLPE bears true for all TSA designs.
Level III, therapeutic study.
肩臼固定丧失是影响初次全肩关节置换术（TSA）存活率的关键因素。目前尚不清楚在髋关节和膝关节置换术中与交联聚乙烯（XLPE）相关的较低返修率是否适用于肩部置换术。
问题/目的：我们使用澳大利亚矫形协会国家关节置换登记处（AOANJRR）的数据，比较使用 XLPE 的初次带柄解剖型 TSA 与使用非 XLPE 的初次带柄解剖型 TSA 的返修率。在接受初次带柄解剖型 TSA 治疗骨关节炎的患者中，我们提出了以下问题：（1）在使用 XLPE 和非 XLPE 全聚乙烯臼的情况下，返修率或返修原因是否存在差异？（2）在不同头大小的情况下，与非 XLPE 相比，XLPE 的返修率是否存在差异？（3）当使用 XLPE 时，与非 XLPE 相比，所有聚乙烯臼的假体组合的生存率是否存在差异？
我们从 2004 年 4 月 16 日至 2020 年 12 月 31 日从 AOANJRR 中提取数据。AOANJRR 收集了澳大利亚超过 97%的关节置换数据。研究人群包括所有使用全聚乙烯臼进行初次、带柄、解剖型 TSA 治疗的骨关节炎患者。将这些患者分为 XLPE 和非 XLPE 两种轴承表面进行比较。在 10102 例初次带柄解剖型 TSA 中，39%（3942/10102）使用了 XLPE，61%（6160/10102）使用了非 XLPE。两组在年龄、性别和随访时间上没有差异。使用 Kaplan-Meier 生存估计来确定返修率，以描述初次关节置换后的首次返修时间，以死亡或数据库关闭时间为终点。返修定义为任何关节置换部件的移除、更换或添加。计算并比较了初次关节置换后未经调整的累积返修百分率（95%置信区间[CI]），并使用 Cox 比例风险模型进行了调整，包括年龄、性别、固定和手术医生数量。还根据肱骨头大小进行了进一步分析，并对年龄和性别进行了调整的假体特异性分析。这项分析仅限于使用次数至少 150 次、至少进行了 4 次返修、有 XLPE 和非 XLPE 选择以及至少有 3 年随访的假体组合。
在 1.5 年时，非 XLPE 的返修风险高于 XLPE（HR 2.3 [95% CI 1.6 至 3.1]；p < 0.001）。在 12 年时，XLPE 的累积返修率为 5%（95% CI 4%至 6%），而非 XLPE 的累积返修率为 9%（95% CI 8%至 10%）。在头大小小于 44mm 时，两种固定方式的返修率没有差异。在头大小为 44 至 50mm 时，非 XLPE 在 2 年内的返修率高于 XLPE（HR 2.3 [95% CI 1.5 至 3.6]；p < 0.001），而在整个时期，头大小大于 50mm 时，非 XLPE 的返修率也高于 XLPE（HR 2.2 [95% CI 1.4 至 3.6]；p < 0.001）。有两种假体组合符合假体特异性分析的纳入标准。在其中一种假体组合中，在使用非 XLPE 时，1.5 年后的返修风险高于使用 XLPE（HR 3.7 [95% CI 2.2 至 6.3]；p < 0.001）。对于第二种假体组合，两组之间的返修率没有差异。
这些 AOANJRR 数据表明，在初次带柄解剖型 TSA 治疗骨关节炎时，与交联聚乙烯相比，非交联全聚乙烯臼的返修率更高。由于聚乙烯类型可能是返修风险的一个重要决定因素，因此应在有条件的情况下使用交联聚乙烯，特别是对于头大小大于 44mm 的患者。需要进行更多的肩部关节置换术后研究，以确定这种与 XLPE 相关的返修风险降低是否适用于所有 TSA 设计。
III 级，治疗性研究。
