75岁以上THA患者是该应用骨水泥型假体柄还是生物型假体柄？

来源：304关节学术

Is Cemented or Cementless Femoral Stem Fixation More Durable in Patients Older Than 75 Years of Age? A Comparison of the Best-performing Stems

75岁以上THA患者是该应用骨水泥型假体柄

还是生物型假体柄，比较两类假体的寿命

译者：马云青

Background: There is ongoing debate concerning the best method of femoral fixation in older patients receiving primary THA. Clinical studies have shown high survivorship for cemented and cementless femoral stems. Arthroplasty registry studies, however, have universally shown that cementless stems are associated with a higher rate of revision in this patient population. It is unclear if the difference in revision rate is a reflection of the range of implants being used for these procedures rather than the mode of fixation.

背景：接受初次THA的老年患者中，最佳股骨假体的选择仍有争论。临床研究表明，骨水泥型和生物型假体柄的生存率都很高。然而，关节置换登记系统的数据研究表明，老年患者中，生物型假体柄翻修率更高。目前尚不清楚术后翻修率的差异是不同手术操作的原因，还是不同假体固定方式的原因。

Questions/purposes: (1) Is the risk of revision higher in patients older than 75 years of age who receive one of the three cementless stems with the highest overall survivorship in the registry than in those of that age who received one of the three best-performing cemented stems? If so, is there a difference in risk of early revision versus late revision, defined as revision within 1 month after index surgery? (2) Are there any diagnoses (such as osteoarthritis [OA] or femoral neck hip fracture) in which the three best-performing cementless stems had better survivorship than one of the three best-performing cementless stems? (3) Do these findings change when evaluated by patient sex?

研究目的：（1）75岁以上患者接受关节登记系统中存活率最高的三种生物柄中的一种植入后的翻修风险是否高于三种性能最好的骨水泥柄中的一种？如果是的话，早期翻修与晚期翻修的风险是否有差异，早期和晚期的时间节点为术后1个月。（2）是否存在某种诊断(如骨关节炎[OA]或股骨颈骨折)在植入生物型柄后具有更高的假体生存率？（3）在按性别进行分组评估时，生存率是否有差异？

Methods: The Australian Orthopaedic Association National Joint Replacement Registry data were used to identify the best three cemented and the best three cementless femoral stems. The criteria for selection were the lowest 10-year revision rate and use in > 1000 procedures in this age group of patients regardless of primary diagnosis. The outcome measure was time to first revision using Kaplan-Meier estimates of survivorship. Comparisons were made for THAs done for any reason and then specifically for OA and femoral neck fracture separately.

方法：采用澳大利亚的关节置换登记系统中术后10年具有最低翻修率的三种骨水泥型和生物型股骨柄假体。纳入标准是在患者年龄大于75岁，在不考虑术前诊断的前提下，假体柄的植入量大于1000例/年。衡量标准是术后初首次接受翻修的时间，并使用Kaplan-Meier生存曲线评估。首先对所有接受THA的患者进行比较，然后分别对诊断为OA和股骨颈骨折的患者进行比较。。

Results: Overall, the cumulative percent revision in the first 3 months postoperatively was lower among those treated with one of the three best-performing cemented stems than those treated with one of the three best-performing cementless stems (hazard ratio [HR] for best three cementless versus best three cemented = 3.47 [95% confidence interval {CI}, 1.60-7.53], p = 0.001). Early revision was 9.14 times more common in the best three cementless stems than in the best three cemented stems (95% CI, 5.54-15.06, p = 0.001). Likewise, among patients with OA and femoral neck fracture, the cumulative percent revision was consistently higher at 1 month postoperatively among those treated with one of the three best-performing cementless stems than those treated with one of the three best-performing cementless stems (OA: HR for best three cementless versus best three cemented = 8.82 [95% CI, 5.08-15.31], p < 0.001; hip fracture: HR for best 3 cementless versus best three cemented = 27.78 [95% CI, 1.39-143.3], p < 0.001). Overall, the cumulative percent revision was lower in the three best cemented stem group than the three best cementless stem group for both males and females at 1 month postoperatively (male: HR = 0.42 [95% CI, 0.20-0.92], p = 0.030; female: HR = 0.06 [95% CI, 0.03-0.10], p < 0.001) and for females at 3 months postoperatively (HR = 0.15 [95% CI, 0.06-0.33], p < 0.001), after which there was no difference.

结果：三种表现最佳的骨水泥型柄在术后3个月累积翻修率比生物型假体低(HR=3.47[95%{CI}，1.60-7.53]，p=0.001)。早期翻修在生物型柄中更常见，是水泥柄的近9.14倍(95%CI，5.54-15.06，p=0.001)。在OA和股骨颈骨折的患者中，术后1个月内，用三种表现最佳的生物型柄的累积翻修率始终高于骨水泥型柄的患者(OA：HR值为8.82[95%CI，5.08-15.31]，p<0.001；髋部骨折：HR值为27.78[95%CI，1.39-143.3]，p<0.001)。不论男性还是女性患者在术后1个月时，骨水泥柄的累积翻修率均低于生物型柄(男性：HR=0.42[95%CI，0.20-0.92]，p=0.030；女性：HR=0.06[95%CI，0.03-0.10]，p<0.001)，女性患者中在术后3个月时骨水泥柄的翻修率仍然低于生物型柄(HR=0.15[95%CI，0.06-0.33]，p=0.001)，3个月后两者无差异。

Conclusions: Cementless femoral stem fixation in patients 75 years or older is associated with a higher early rate of revision, even when only the best-performing prostheses used in patients in this age group were compared. Based on this review of registry data, it would seem important to ensure the proper training of contemporary cementing techniques for the next generation of arthroplasty surgeons so they are able to use this option when required. However, the absence of a difference in the two groups undergoing THA after 3 months suggests that there can be a role for cementless implants in selected cases, depending on the surgeon's expertise and the quality and shape of the proximal femoral bone.

结论：75岁以上患者中，生物型股骨柄与较高的早期翻修率有关，即使是等级系统中生存率最高的假体。根据对关节登记系统中的数据分析，更重要的是培训年轻关节外科医生使其能够熟练掌握髋关节骨水泥技术，以便其能够在需要时正确使用。在术后3个月，接受不同类型股骨柄的两组患者翻修率没有差异，因此生物型股骨柄仍然可以通过合适的病例选择发挥作用，这些取决于外科医生的专业知识和患者股骨近端的骨量以及髓腔形状。

文献出处：Tanzer M, Graves SE, Peng A, Shimmin AJ. Is Cemented or Cementless Femoral Stem Fixation More Durable in Patients Older Than 75 Years of Age? A Comparison of the Best-performing Stems [published correction appears in Clin Orthop Relat Res. 2020 May;478(5):1131]. Clin Orthop Relat Res. 2018;476(7):1428-1437. doi:10.1097/01.blo.0000533621.57561.a4