What Are the Functional, Radiographic, and Survivorship Outcomes of a Modified Cup-cage Technique for Pelvic Discontinuity?

IF 4.2 2区 医学 Q1 ORTHOPEDICS
Wenbo Mu, Boyong Xu, Tuerhongjiang Wahafu, Fei Wang, Wentao Guo, Chen Zou, Li Cao
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Our study aims to evaluate a modified technique in which the cup position is determined by the placement of the overlying cage, allowing for adjustments to achieve optimal orientation.</p><p><strong>Questions/purposes: </strong>Among patients treated for PD with a cup-cage construct in which the cup position was dictated by the position of the cage: (1) What are Harris hip scores achieved at a minimum of 2 years of follow-up? (2) What is the Kaplan-Meier survivorship free from aseptic loosening or component migration? (3) What is the Kaplan-Meier survivorship free from revision for any reason? (4) What surgical complications are associated with the procedure?</p><p><strong>Methods: </strong>Between October 2013 and January 2022, we performed 805 acetabular revisions. Among these, 33 patients with PD confirmed intraoperatively were considered potentially eligible for a cup-cage construct; no other method of surgical management was used. 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Kaplan-Meier analysis was used to estimate implant survivorship and radiographic loosening, with aseptic loosening or component migration as the endpoint, as well as survivorship free from any reoperation.</p><p><strong>Results: </strong>The Harris hip score improved from a median of 39 (range 30 to 66) preoperatively to a median of 76 (range 30 to 90) postoperatively (median difference 33 [range 2 to 48]; p < 0.01). Within the limitations of two-dimensional (2D) radiographic imaging, successful bone graft integration and the healing of PD were noted in 83% (25 of 30) of patients. Kaplan-Meier survivorship free from radiographic signs of aseptic loosening or component migration was 100% (95% CI 100% to 100%) at 115 months. When any revision related to the acetabular component was considered the endpoint, survivorship free from acetabular component revision at 115 months after revision surgery was 100% (95% CI 100% to 100%). 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引用次数: 0

Abstract

Background: Pelvic discontinuity (PD) presents a complex challenge in revision hip arthroplasty. The traditional cup-cage construct, which involves a screw-secured porous metal cup and an overlying antiprotrusio cage, has shown promising mid- to long-term results. However, there is limited information on the outcomes of modifications to the original technique. Our study aims to evaluate a modified technique in which the cup position is determined by the placement of the overlying cage, allowing for adjustments to achieve optimal orientation.

Questions/purposes: Among patients treated for PD with a cup-cage construct in which the cup position was dictated by the position of the cage: (1) What are Harris hip scores achieved at a minimum of 2 years of follow-up? (2) What is the Kaplan-Meier survivorship free from aseptic loosening or component migration? (3) What is the Kaplan-Meier survivorship free from revision for any reason? (4) What surgical complications are associated with the procedure?

Methods: Between October 2013 and January 2022, we performed 805 acetabular revisions. Among these, 33 patients with PD confirmed intraoperatively were considered potentially eligible for a cup-cage construct; no other method of surgical management was used. We performed 64% (21 of 33) of these procedures from October 2013 to January 2018, with 6% (2 of 33) of patients lost to follow-up before the minimum study follow-up of 2 years; these 19 patients were monitored over a period ranging from 70 to 115 months. A further 12 patients underwent this procedure from January 2018 to January 2022, with one lost to follow-up before the minimum study follow-up of 2 years; the other patients met the minimum 2-year follow-up requirement. The remaining 30 patients with data analyzed here (10 men, 20 women) had a mean ± SD age of 61 ± 12 years and a median BMI of 29 kg/m 2 (range 20 to 33 kg/m 2 ) at the time of revision surgery. Twenty-one patients underwent revision due to aseptic loosening, and nine due to periprosthetic joint infection (PJI). The causes of PD in our patients were as follows: cup aseptic loosening without significant osteolysis in 20% (6 of 30), where the loose cup caused erosion of the host bone, leading to PD; PJI in 30% (9 of 30); intraoperative iatrogenic PD in 3% (1 of 30); and osteolysis in 47% (14 of 30), which also resulted in aseptic loosening. The median follow-up time was 79 months (range 25 to 115 months). The Harris hip score was used to evaluate clinical outcomes, with preoperative values compared with the most recent follow-up. Radiographs were reviewed by two experienced surgeons at each follow-up visit to assess component loosening (defined as migration > 5 mm or the presence of circumferential radiolucent lines) or clear migration. PD was considered healed if bridging callus or trabecular bone was visible across the site of the discontinuity. Complications were assessed through a comprehensive review of electronic medical records. Kaplan-Meier analysis was used to estimate implant survivorship and radiographic loosening, with aseptic loosening or component migration as the endpoint, as well as survivorship free from any reoperation.

Results: The Harris hip score improved from a median of 39 (range 30 to 66) preoperatively to a median of 76 (range 30 to 90) postoperatively (median difference 33 [range 2 to 48]; p < 0.01). Within the limitations of two-dimensional (2D) radiographic imaging, successful bone graft integration and the healing of PD were noted in 83% (25 of 30) of patients. Kaplan-Meier survivorship free from radiographic signs of aseptic loosening or component migration was 100% (95% CI 100% to 100%) at 115 months. When any revision related to the acetabular component was considered the endpoint, survivorship free from acetabular component revision at 115 months after revision surgery was 100% (95% CI 100% to 100%). When the need for any reoperation was considered the endpoint, survivorship free from needing reoperation at 115 months after revision surgery was 85% for all patients (95% CI 73% to 100%). When including only patients with a follow-up time of > 4 years (20 of 30), survivorship free from needing reoperation at 115 months after revision surgery was 90% (95% CI 78% to 100%). Postoperative complications during the follow-up period included one early dislocation on the fifth day after surgery, treated with closed reduction and 6 weeks of abduction bracing. One femoral stem loosening occurred at 56 months postoperatively, although the acetabular component remained securely fixed; this patient declined revision surgery. One patient experienced a dislocation 5 months after surgery but refused treatment and opted for prolonged bed rest. Additionally, one patient underwent a debridement, antibiotics, and implant retention procedure 1 week after the revision surgery and subsequently showed no signs of infection at the latest follow-up, 38 months postoperatively.

Conclusion: Our study highlights the effectiveness of a modified cup-cage technique in complex hip revisions, showing promising results in terms of construct survivorship and low complication rates. Surgeons could consider delaying screw fixation until after positioning the cage within the porous cup to allow for optimal adjustment and using metal augments for severe bone defects to achieve better alignment. Surgeon experience with the cup-cage technique is crucial for achieving optimal outcomes. Future studies should focus on long-term follow-up visits to assess the durability and effectiveness of these modifications and explore the comparative effectiveness versus other methods, such as custom triflange components and jumbo cups with distraction.

Level of evidence: Level III, therapeutic study.

骨盆不连的改良髋臼杯-骨盆笼技术在功能、影像学和存活率方面的效果如何?
背景:骨盆不连续(PD)是翻修髋关节置换术中的一个复杂难题。传统的杯笼结构包括用螺钉固定的多孔金属髋臼杯和覆盖在其上的抗前突髋臼笼,这种结构已显示出良好的中长期效果。然而,有关对原始技术进行改良的结果的信息却很有限。我们的研究旨在评估一种改良技术,在这种技术中,髋臼杯的位置是由上覆骨笼的位置决定的,可以通过调整达到最佳方向:在使用杯笼结构(杯的位置由笼子的位置决定)治疗PD的患者中:(1)至少随访2年的Harris髋关节评分是多少?(2)无菌性松动或组件移位的 Kaplan-Meier 存活率是多少?(3)不因任何原因进行翻修的 Kaplan-Meier 存活率是多少?(4) 与该手术相关的手术并发症有哪些?2013年10月至2022年1月,我们共进行了805例髋臼翻修手术。其中,33 例经术中确诊为髋臼发育不良的患者被认为有可能符合杯笼结构的条件;未采用其他手术治疗方法。我们在 2013 年 10 月至 2018 年 1 月期间实施了其中 64% 的手术(33 例中的 21 例),6% 的患者(33 例中的 2 例)在最短研究随访 2 年之前失去了随访机会;我们对这 19 例患者进行了 70 至 115 个月的监测。另有 12 名患者在 2018 年 1 月至 2022 年 1 月期间接受了该手术,其中 1 名患者在最短研究随访 2 年之前失去了随访机会;其他患者符合最短 2 年随访要求。本文分析的其余30名患者(10名男性,20名女性)的平均(±SD)年龄为61±12岁,接受翻修手术时的中位体重指数为29 kg/m2(范围为20至33 kg/m2)。21名患者因无菌性松动接受翻修手术,9名患者因假体周围感染(PJI)接受翻修手术。我们的患者出现假体置换术后并发症的原因如下:20%的患者(30 例中有 6 例)出现假体杯无菌性松动,但无明显骨溶解,松动的假体杯导致宿主骨侵蚀,从而导致假体置换术后并发症;30%的患者(30 例中有 9 例)出现假体周围感染;3%的患者(30 例中有 1 例)出现术中先天性假体置换术后并发症;47%的患者(30 例中有 14 例)出现骨溶解,这也导致了无菌性松动。中位随访时间为79个月(25至115个月)。Harris髋关节评分用于评估临床结果,并将术前值与最近的随访值进行比较。每次随访时,由两名经验丰富的外科医生对X光片进行复查,以评估组件松动(定义为移位> 5 mm或出现周向放射线)或明显移位。如果不连续性部位可见桥接胼胝体或骨小梁,则认为 PD 已愈合。并发症通过对电子病历的全面审查进行评估。Kaplan-Meier分析法用于估算植入物存活率和放射学松动率(以无菌性松动或组件移位为终点),以及无再次手术的存活率:Harris髋关节评分从术前的中位数39(范围30-66)提高到术后的中位数76(范围30-90)(中位数差异33[范围2-48];P < 0.01)。在二维(2D)放射成像的限制下,83% 的患者(30 例中有 25 例)成功实现了植骨整合和 PD 愈合。在115个月时,无无菌性松动或组件移位的Kaplan-Meier存活率为100%(95% CI为100%至100%)。如果将任何与髋臼组件相关的翻修视为终点,则翻修手术后115个月时无髋臼组件翻修的存活率为100%(95% CI 100%至100%)。如果将是否需要再次手术作为终点,则所有患者在翻修手术后115个月内无需再次手术的存活率为85%(95% CI为73%至100%)。如果仅将随访时间超过 4 年的患者(30 人中有 20 人)计算在内,那么翻修手术后 115 个月无需再次手术的存活率为 90%(95% CI 78% 至 100%)。随访期间的术后并发症包括术后第五天发生的一次早期脱位,当时采取了闭合复位术和6周的外展支具治疗。一名患者在术后56个月时发生股骨干松动,但髋臼组件仍被牢牢固定;该患者拒绝了翻修手术。一名患者在术后5个月出现脱位,但拒绝治疗,选择长期卧床休息。此外,一名患者在翻修手术后一周接受了清创、抗生素和植入物保留手术,随后在术后38个月的最近一次随访中未发现感染迹象。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
7.00
自引率
11.90%
发文量
722
审稿时长
2.5 months
期刊介绍: Clinical Orthopaedics and Related Research® is a leading peer-reviewed journal devoted to the dissemination of new and important orthopaedic knowledge. CORR® brings readers the latest clinical and basic research, along with columns, commentaries, and interviews with authors.
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