Rilby Karin, van Veghel Mirthe H W, Mohaddes Maziar, van Steenbergen Liza N, Lewis Peter L, Kärrholm Johan, Schreurs Berend W, Hannink Gerjon
Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenberg, Sweden.
Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.
Clin Orthop Relat Res. 2025 Jun 1;483(6):1010-1019. doi: 10.1097/CORR.0000000000003354. Epub 2024 Dec 30.
Advocates of short-stem THA suggest that these devices preserve proximal femoral bone for future revisions. This contention is as yet unsupported by robust evidence, and ultimately, it will be irrelevant if short-stem THA increases the overall risk of premature revision. To our knowledge, large, registry-based efforts have yet to explore the types of stems used in first-time stem revision as well as the survivorship of short versus standard-length femoral stems in THA.
QUESTIONS/PURPOSES: (1) Which stems are used in the first stem revision of primary short-stem and standard-stem THAs? (2) What is the overall cumulative revision rate (CRR) of primary short-stem THAs compared with primary standard-stem THAs? (3) What is the overall cumulative re-revision rate of primary short-stem THAs compared with primary standard-stem THAs?
Patients with short-stem THAs, defined as a short stem with mainly metaphyseal fixation, registered in the Australian Orthopaedic Association National Joint Replacement Register (AOANJRR), the Dutch Arthroplasty Register (Landelijke Registratie Orthopedische Interventies [LROI]), or the Swedish Arthroplasty Register (SAR) between January 2007 and December 2022 were included (n = 15,771), as well as a propensity score-matched cohort (1:2) with standard-stem THAs, defined as a stem with a standard length (n = 31,542). Groups were matched on sex, age, year of procedure, diagnosis, bearing material, and surgical approach. After matching, the groups did not differ in terms of age (mean ± SD 63 ± 11 versus 64 ± 11 years), sex (48% [7546 of 15,771] male versus 48% [15,093 of 31,542] male), and diagnosis (93% [14,655 of 15,771] osteoarthritis [OA] versus 94% [29,585 of 31,542] OA). We used those three registries because all are high-quality national arthroplasty registries with high levels of completeness. Also, the AOANJRR is the only registry globally that reports on short-stem THA as its own entity. The type of stem used in revision surgery was classified as standard stem (< 160 mm) or long stem (≥ 160 mm). Overall CRR of primary THAs at 12 years of follow-up and overall CRR of all first-time revisions at 5 years were calculated using Kaplan-Meier survival analyses. Any type of revision was used as endpoint.
In first-time stem revisions of the short-stem THAs, a standard stem was used more often (58% [116 of 201]) than in the revision of standard-stem THAs (46% [149 of 322]; p = 0.01). The 12-year overall CRRs between primary short-stem and standard-stem THAs did not differ (4.7% [95% confidence interval (CI) 4.0% to 5.5%] versus 5.1% [95% CI 4.5% to 5.7%], respectively; p = 0.20). The overall CRR for a second revision at 5 years also did not differ when primary short-stem THAs were compared with standard-stem THAs (20.9% [95% CI 16.8% to 25.8%]) versus 20.4% [95% CI 17.3% to 23.9%]; p = 0.80).
In light of these findings, there may be a perceived benefit of using short stems in primary THA if a revision is later required, as the short stems included in this study were to a higher degree revised using a standard (more bone-sparing) stem. Further, the first and second overall CRR of the studied short-stem THAs did not differ from that of standard-stem THAs, also supporting use of short-stem THA. Further research, preferably multinational registry-based studies, should be performed to confirm our findings.
Level III, therapeutic study.
短柄全髋关节置换术（THA）的支持者认为，这些器械能保留股骨近端骨质以便未来翻修。这一观点尚未得到有力证据的支持，而且，如果短柄THA增加了早期翻修的总体风险，那么这一观点最终将毫无意义。据我们所知，基于大型注册研究尚未探讨初次翻修时所使用的柄的类型，以及THA中短柄与标准长度股骨柄的生存率。
问题/目的：（1）初次短柄和标准柄THA的首次柄翻修中使用了哪些柄？（2）与初次标准柄THA相比，初次短柄THA的总体累积翻修率（CRR）是多少？（3）与初次标准柄THA相比，初次短柄THA的总体累积再次翻修率是多少？
纳入2007年1月至2022年12月期间在澳大利亚骨科协会国家关节置换注册中心（AOANJRR）、荷兰关节置换注册中心（Landelijke Registratie Orthopedische Interventies [LROI]）或瑞典关节置换注册中心（SAR）登记的短柄THA患者（n = 15771），短柄THA定义为主要采用干骺端固定的短柄，同时纳入倾向评分匹配队列（1:2）的标准柄THA患者（n = 31542），标准柄THA定义为具有标准长度的柄。根据性别、年龄、手术年份、诊断、关节面材料和手术入路对两组进行匹配。匹配后，两组在年龄（均值±标准差63±11岁对64±11岁）、性别（48% [15771例中的7546例] 为男性对48% [31542例中的15093例] 为男性）和诊断（93% [15771例中的14655例] 为骨关节炎 [OA] 对94% [31542例中的29585例] 为OA）方面无差异。我们使用这三个注册中心的数据，因为它们都是高质量的国家关节置换注册中心，数据完整性高。此外，AOANJRR是全球唯一将短柄THA作为独立实体进行报告的注册中心。翻修手术中使用的柄的类型分为标准柄（<160 mm）或长柄（≥160 mm）。采用Kaplan-Meier生存分析计算初次THA在12年随访时的总体CRR以及所有初次翻修在5年时的总体CRR。任何类型的翻修均作为终点。
在短柄THA的首次柄翻修中，使用标准柄的情况（58% [201例中的116例]）比标准柄THA的翻修中（46% [322例中的149例]）更为常见（p = 0.01）。初次短柄和标准柄THA之间的12年总体CRR无差异（分别为4.7% [95%置信区间（CI）4.0%至5.5%] 对5.1% [95% CI 4.5%至5.7%]；p = 0.20）。当比较初次短柄THA与标准柄THA时，5年时二次翻修的总体CRR也无差异（20.9% [95% CI 16.8%至25.8%]）对20.4% [95% CI 17.3%至23.9%]；p = 0.80）。
鉴于这些发现，如果后期需要翻修，初次THA中使用短柄可能有一定益处，因为本研究中的短柄在更高程度上采用标准（更保留骨质）柄进行翻修。此外，所研究的短柄THA的首次和二次总体CRR与标准柄THA的无差异，这也支持短柄THA的使用。应开展进一步研究，最好是基于多国注册研究，以证实我们的发现。
III级，治疗性研究。
