使用MRI评估不良局部组织反应(ALTR)的自然史患病率仅集中在金属对金属(MoM)轴承表面上,而没有与非MoM轴承表面进行比较。
确定(1)髋关节表面置换术(HRA)患者血液金属离子水平的纵向变化和差异,陶瓷对陶瓷(CoC)THA,和金属对聚乙烯(MoP)THA与接受陶瓷对聚乙烯(CoP)THA的比较;(2)HRA患者滑膜反应分类的纵向变化,CoCTHA,MoPTHA与接受CoPTHA的人进行比较,以及MRI上ALTR或金相的存在是否与患者报告的结果相关,或存在囊裂开;和(3)在MRI上接受具有ALTR或金属学的HRA患者与没有这些病症的HRA患者之间血液金属离子水平的差异。
2014年3月至2019年2月,22,723例患者在一个中心接受了原发性HRA和THA。患者根据手术后所需的运动水平以及正常的髋臼和股骨近端骨形态而没有骨质减少或骨质疏松症,接受了HRA。2%(22,723人中的342名)的患者被联系参加,71%(206例患者中342例,243例)纳入基线分析.患者因退行性关节病接受关节成形术,25名患者在研究过程中退出。我们纳入了术后1年以上的患者。所有参与者都进行了MRI检查和血清离子测试,并完成了四年来每年的髋关节残疾和骨关节炎结果评分调查(基线,第1年、第2年、第3年)。由一名不参与患者护理的放射科医生评估形态学和敏感性降低的MR图像是否存在滑膜炎和滑膜炎分类(GwetAC1:0.65至0.97),滑膜厚度,和体积(重复性系数:1.8cm3)。线性混合效应模型用于比较平均滑膜厚度,滑膜体积,和髋关节残疾和骨关节炎结果评分亚表在每个时间点的轴承表面之间和随着时间的推移在每个轴承表面内。边际Cox比例风险模型用于比较仅发生ALTR的时间和风险,仅金属学,和轴承表面之间的ALTR或金属。所有模型都根据年龄进行了调整,性别,BMI,和植入长度基于已知的混杂因素髋关节置换术。使用Dunnett-Hsu方法进行多重比较的调整。
单侧HRA患者的钴和铬血清离子水平较高(基线:1.8±0.8ppb,第1年:2.0±1.5ppb,第二年:2.1±1.2ppb,第3年:1.6±0.7ppb)比具有单边CoP轴承的那些(基线:0.0±0.1ppb,第1年:0.1±0.3ppb,第2年:0.0±0.2ppb,第3年:0.0±0.0ppb)在所有时间点(每个时间点p<0.001)。接受HRA的患者比接受CoP轴承的患者更多(风险比4.8[95%置信区间1.2至18.4];p=0.02)。MRI对ALTR或金属成分的滑膜反应的纵向变化与患者报告的结果之间没有关联。此外,基线时开裂的存在与随后的ALTR或金属化发展之间没有关联,MRI上看到的.与在MRI上没有ALTR或金属学的患者相比,在第1年在MRI上存在ALTR或金属学的单侧HRA患者的钴(4.7±3.5ppb)和铬(4.7±2.6ppb)血清水平升高(钴:1.8±1.0ppb,平均差4.7ppb[95%CI3.3至6.0];p<0.001;铬:2.3±0.5ppb,平均差异3.6ppb[95%CI2.2至5.0];p<0.001)以及第3年的铬(3.9±2.4ppb对2.2±1.1ppb,平均差1.3ppb[95%CI0.3至2.4];p=0.01)。
我们发现,与CoP患者相比,HRA患者的MRI上ALTR或金属成分的比例更高,即使患者在MRI上自我评估有ALTR或金属成分的患者的症状学与没有这些特征没有什么不同.MRI在高功能患者中检测到ALTR,强调仅依靠调查或血液离子检测的年度临床评估可能无法检测软组织并发症。这项研究的结果与先前关于使用MRI作为该患者人群常规随访方案的一部分的共识建议一致。
III级,治疗性研究。
The evaluation of the natural history prevalence of adverse local tissue reactions (ALTRs) using MRI has focused only on metal-on-metal (MoM) bearing surfaces without comparison to nonMoM bearing surfaces.
To determine (1) the longitudinal changes and differences in blood metal ion levels in patients with hip resurfacing arthroplasty (HRA), ceramic-on-ceramic (CoC) THA, and metal-on-polyethylene (MoP) THA compared with those undergoing ceramic-on-polyethylene (CoP) THA; (2) how the longitudinal change of synovial reaction classification in patients with HRA, CoC THA, and MoP THA compares with those undergoing CoP THA, and whether there is an association between the presence of an ALTR or metallosis on MRI with corresponding patient-reported outcomes, or the presence of capsular dehiscence; and (3) differences in blood metal ion levels between patients undergoing HRA with an ALTR or metallosis on MRI and those with HRA without these conditions.
Between March 2014 and February 2019, 22,723 patients underwent primary HRA and THA at one center. Patients received an HRA based on their desired athletic level after surgery and the presence of normal acetabular and proximal femoral bone morphology without osteopenia or osteoporosis. Two percent (342 of 22,723) of patients were contacted to participate, and 71% (243 of 342 hips in 206 patients) were enrolled for analysis at baseline. The patients underwent arthroplasty for degenerative joint disease, and 25 patients withdrew over the course of the
study. We included patients who were more than 1 year postarthroplasty. All participants had an MRI examination and blood serum ion testing and completed a Hip Disability and Osteoarthritis Outcome Score survey annually for four years (baseline, year 1, year 2, year 3). Morphologic and susceptibility-reduced MR images were evaluated by a single radiologist not involved in the care of patients for the presence and classification of synovitis (Gwet AC1: 0.65 to 0.97), synovial thickness, and volume (coefficient of repeatability: 1.8 cm3). Linear mixed-effects models were used to compare the mean synovial thickness, synovial volume, and Hip Disability and Osteoarthritis Outcome Score subscales between bearing surfaces at each timepoint and within each bearing surface over time. Marginal Cox proportional hazards models were used to compare the time to and the risk of developing ALTR only, metallosis only, and ALTR or metallosis between bearing surfaces. All models were adjusted for age, sex, BMI, and length of implantation based on known confounders for hip arthroplasty. Adjustment for multiple comparisons was performed using the Dunnett-Hsu method.
Patients with unilateral HRA had higher cobalt and chromium serum ion levels (baseline: 1.8 ± 0.8 ppb, year 1: 2.0 ± 1.5 ppb, year 2: 2.1 ± 1.2 ppb, year 3: 1.6 ± 0.7 ppb) than those with unilateral CoP bearings (baseline: 0.0 ± 0.1 ppb, year 1: 0.1 ± 0.3 ppb, year 2: 0.0 ± 0.2 ppb, year 3: 0.0 ± 0.0 ppb) at all timepoints (p < 0.001 for each time point). More patients who received an HRA developed ALTR or metallosis on MRI than did patients with CoP bearings (hazard ratio 4.8 [95% confidence interval 1.2 to 18.4]; p = 0.02). There was no association between the longitudinal change of synovial reaction to ALTR or metallosis on MRI with patient-reported outcomes. In addition, there was no association between the presence of dehiscence at baseline and the subsequent development of ALTR or metallosis, as seen on MRI. There were elevated cobalt (4.7 ± 3.5 ppb) and chromium (4.7 ± 2.6 ppb) serum levels in patients with unilateral HRA who had an ALTR or metallosis present on MRI at year 1 compared with patients without an ALTR or metallosis on MRI (cobalt: 1.8 ± 1.0 ppb, mean difference 4.7 ppb [95% CI 3.3 to 6.0]; p < 0.001; chromium: 2.3 ± 0.5 ppb, mean difference 3.6 ppb [95% CI 2.2 to 5.0]; p < 0.001) as well as for chromium at year 3 (3.9 ± 2.4 ppb versus 2.2 ± 1.1 ppb, mean difference 1.3 ppb [95% CI 0.3 to 2.4]; p = 0.01).
We found a higher proportion of ALTR or metallosis on MRI in patients with HRA compared with patients with CoP, even when patient self-assessed symptomatology of those with an ALTR or metallosis on MRI was not different than the absence of these features. MRI detected ALTRs in high-function patients, emphasizing that an annual clinical assessment dependent on survey or blood ion testing alone may not detect soft tissue complications. The results of this
study are in line with prior consensus recommendations of using MRI as part of a routine follow-up protocol for this patient population.
Level III, therapeutic
study.