人工髋关节置换术后初次翻修的原因分析及翻修术疗效评估

Evaluation of causes and clinical effects of revision surgery after artificial hip replacement

目的探讨人工髋关节置换术后初次翻修的原因、翻修术疗效及髋部再手术原因。方法回顾性分析2010年1月至2016年12月人工髋关节置换术后初次翻修的患者344例(351髋),男141例,女203例;年龄(65.64±10.81)岁(28~87岁);随访(60.38±22.75)个月(24~105个月)。假体周围感染患者行假体旷置后二期翻修,其他病例均行一期翻修。比较术前和末次随访时Harris髋关节评分的差异,观察翻修假体的生存率。根据患者翻修术距初次关节置换的时间分为早期翻修(5年内)和晚期翻修(超过5年),以55岁为界分为两个年龄组,比较两组患者的翻修原因、Harris髋关节评分、再手术及再翻修率。结果351髋初次翻修原因:无菌性松动238髋(67.8%),假体周围骨折41髋(11.7%),假体周围感染30髋(8.5%),复发性脱位23髋(6.6%),假体磨损19髋(5.4%)。早期翻修组(90髋)的假体周围感染率(21.1%)高于晚期翻修组(261髋)的4.2%(χ^2=24.443,P<0.001),晚期翻修组的无菌性松动率(72.4%)高于早期翻修组的54.4%(χ^2=9.899,P=0.002)。16例翻修术后再次行髋部手术,手术原因:复发性脱位6例、无菌性松动4例、假体周围骨折3例、假体周围感染3例;其中8例行再次翻修术,包括无菌性松动4例、假体周围骨折2例、复发性脱位2例。首次翻修至再次翻修平均(22.1±10.0)个月(1~75个月),翻修假体5年和8年生存率分别为99.3%[95%CI(98.3%,100.3%)]和92.6%[95%CI(87.1%,98.1%)]。翻修年龄≤55岁组(55髋)的假体周围感染率和磨损率分别为16.4%和12.7%,高于翻修年龄>55岁组(296髋)的7.1%和4.1%,差异均有统计学意义(χ^2=3.981,P=0.046;χ^2=5.226,P=0.022);翻修年龄>55岁组的无菌性松动率(70.3%)高于翻修年龄≤55岁组(54.5%),差异有统计学意义(χ^2=5.254,P=0.022)。翻修年龄≤55岁组和翻修年龄>55岁组的翻修假体8年生存率分别为76.8%[95%CI(50.5%,103.1%)]和95.4%[95%CI(91.1%,99.7%)]。结论髋关节置换术后初次翻修的主要原因为无菌性松动,翻修术后再手术原因主要为复发性脱位,年轻的翻修患者术后再翻修风险较高。

Objective To investigate the clinical effects of primary revision after artificial hip replacement and causes of revision surgery. Methods A total of 344 patients who underwent revision surgery after total hip arthroplasty (THA) and artificial femoral head replacement from January 2010 to December 2016 were retrospectively analyzed. There were 141 males and 203 fe-males, with a mean age 65.64±10.81 years (28-87 years). A total of 351 hip revisions were performed in 344 patients with 7 pa-tients in bilateral revisions. All patients were followed up for 60.38±22.75 months (24-105 months). All patients with periprosthet-ic infection underwent two-stage revision after prosthesis placement, and all others underwent one-stage revision. The clinical out-comes of revision surgery were assessed with the Harris hip score and the survival rate of the revision prosthesis. According to the duration from artificial hip replacement to revision surgery, all patients were divided into early revision (less than 5 years) and late revision (more than 5 years) groups. They were also divided into two groups according to the age of the patient in revision sur-gery:>55-year-old and ≤55-year-old groups. The causes of revision, hip reoperation and re-revision were recorded. Results In the 351 hip revisions, a total of 238 (67.8%) had aseptic loosening, 41 (11.7%) periprosthetic fractures, 30 (8.5%) periprosthetic infection, 23 (6.6%) recurrent dislocation and 19 (5.4%) the eccentric liner wear. The infection rate was significantly higher in the early revision group (21.1%) than that in the late revision group (4.2%)(χ^2=24.443, P<0.001). The aseptic loosening rate was sig-nificantly higher in the late revision group (72.4%) than that in the early revision group (54.4%)(χ^2=9.899, P=0.002). Sixteen pa-tients underwent hip surgery after revision, including 6 recurrent dislocations, 4 aseptic loosening, 3 periprosthetic fractures, and 3 periprosthetic infections. Eight of them underwent revision surgery, including 4 cases of aseptic loosening, 2 cases of periprosthet-ic fractures, and 2 cases of recurrent dislocation. The duration from the primary revision to the second revision was 22.1±10.0 months (1-75 months). The 5-year and 8-year survival rates of the revision prostheses were 99.3%[95%CI(98.3%, 100.3%)] and 92.6%[95%CI(87.1%, 98.1%)], respectively. The proportions of prosthetic infection and eccentric liner wear in the ≤55-year-old group were significantly higher than those in the >55-year-old group (χ^2=3.981, P=0.046;χ^2=5.226, P=0.022), while the propor-tion of aseptic loosening in the >55-year-old group was significantly higher than that in the ≤55-year-old group (χ^2=5.254, P=0.022). The 8-year survival rates of the revision prostheses of ≤55-year-old group and >55-year-old group were 76.8%[95%CI(50.5%, 103.1%)] and 95.4%[95%CI(91.1%, 99.7%)], respectively. Conclusion Young patients have a higher risk of re-revi-sion after revision THA.