Background 

Joint arthroplasty registries traditionally report survivorship outcomes mainly on primary joint arthroplasty. The outcome of first revision procedures is less commonly reported, because large numbers of primary procedures are required to analyze a sufficient number of first revision procedures. Additionally, adequate linkage of primary procedures to revisions and mortality is required. When undertaking revision hip surgery, it is important for surgeons to understand the outcomes of these procedures to better inform patients.

Questions/purposes 

Using data from a large national joint registry, we asked: (1) What is the overall rate of revision of the first aseptic revision procedure for a primary THA? (2) Does the rate of revision of the first revision vary by the diagnosis for the first revision? (3) What is the mortality after the first revision, and does it vary by the reason for first revision?

Methods 

The Australian Orthopaedic Association National Joint Replacement Registry longitudinally maintains data on all primary and revision joint arthroplasties, with nearly 100% capture. The analyses for this study were performed on primary THA procedures in patients with a diagnosis of osteoarthritis up to December 31, 2020, who had undergone subsequent revision. We excluded all primary THAs involving metal-on-metal and ceramic-on-metal bearing surfaces and prostheses with exchangeable necks because these designs may have particular issues associated with revisions, such as extensive soft tissue destruction, that are not seen with conventional bearings, making a comparative analysis of the first revision involving these bearing surfaces more complicated. Metal-on-metal bearing surfaces have not been used in Australia since 2017. We identified 17,046 first revision procedures from the above study population and after exclusions, included 13,713 first revision procedures in the analyses. The mean age at the first revision was 71 ± 11 years, and 55% (7496 of 13,713) of the patients were women. The median (IQR) time from the primary procedure to the first revision was 3 years (0.3 to 7.3), ranging from 0.8 years for the diagnosis of dislocation and instability to 10 years for osteolysis. There was some variation depending on the reason for the first revision. For example, patients undergoing revision for fracture were slightly older (mean age 76 ± 11 years) and patients undergoing revision for dislocation were more likely to be women (61% [2213 of 3620]). The registry has endeavored to standardize the sequence of revisions and uses a numerical approach to describe revision procedures. The first revision is the revision of a primary procedure, the second revision is the revision of the first revision, and so on. We therefore described the outcome of the first revision as the cumulative percent second revision. The outcome measure was the cumulative percent revision, which was defined using Kaplan-Meier estimates of survivorship to describe the time to the second revision. Hazard ratios from Cox proportional hazards models, adjusting for age and gender, were performed to compare the revision rates among groups. When possible, the cumulative percent second revision at the longest follow-up timepoint was determined with the available data, and when there were insufficient numbers, we used appropriate earlier time periods.

Results 

The cumulative percent second revision at 18 years was 26% (95% confidence interval [CI] 24% to 28%). When comparing the outcome of the first revision by reason, prosthesis dislocation or instability had the highest rate of second revision compared with the other reasons for first revision. Dual‐mobility prostheses had a lower rate of second revision for dislocation or instability than head sizes 32 mm or smaller and when compared to constrained prostheses after 3 months. There was no difference between dual-mobility prostheses and head sizes larger than 32 mm. There were no differences in the rate of second revision when first revisions for loosening, periprosthetic fracture, and osteolysis were compared. If cemented femoral fixation was performed at the time of the first revision, there was a higher cumulative percent second revision for loosening than cementless fixation from 6 months to 6 years, and after this time, there was no difference. The overall mortality after a first revision of primary conventional THA was 1% at 30 days, 2% at 90 days, 5% at 1 year, and 40% at 10 years. A first revision for periprosthetic fracture had the highest mortality at all timepoints compared with other reasons for the first revision.

Conclusion 

Larger head sizes and dual-mobility cups may help reduce further revisions for dislocation, and the use of cementless stems for a first revision for loosening seems advantageous. Surgeons may counsel patients about the higher risk of death after first revision procedures, particularly if the first revision is performed for periprosthetic fracture.

Level of Evidence Level III, therapeutic study.

中文翻译：

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骨关节炎初次THA的第一次翻修手术结果如何？澳大利亚骨科协会国家关节置换登记处的一项研究

背景 

关节置换术登记处传统上主要报告初次关节置换术的生存结果。第一次修正程序的结果很少被报告，因为需要大量的初级程序来分析足够数量的第一次修正程序。此外，需要将主要手术与翻修和死亡率充分联系起来。在进行髋关节翻修手术时，外科医生必须了解这些手术的结果，以便更好地告知患者。

问题/目的 

使用来自大型国家联合登记处的数据，我们询问：(1) 初次 THA 的首次无菌翻修手术的总体翻修率是多少？(2) 第一次翻修的翻修率是否因第一次翻修的诊断而异？(3) 第一次翻修后的死亡率是多少，它是否因第一次翻修的原因而异？

方法 

澳大利亚骨科协会国家关节置换登记处纵向维护所有初次和翻修关节置换术的数据，捕获率接近 100%。本研究的分析是对截至 2020 年 12 月 31 日诊断为骨关节炎的患者进行的初次 THA 手术进行的，这些患者随后进行了翻修。我们排除了所有涉及金属对金属和陶瓷对金属轴承表面和可更换颈部假体的初级全髋关节置换术，因为这些设计可能存在与翻修相关的特殊问题，例如大范围的软组织破坏，这是传统轴承所没有的，对涉及这些轴承表面的第一次修订进行比较分析更加复杂。自 2017 年以来，澳大利亚未使用金属对金属轴承表面。我们确定了 17 个，来自上述研究人群的 046 次首次修订程序和排除后的分析包括 13,713 次首次修订程序。第一次翻修时的平均年龄为 71 ± 11 岁，55%（13,713 人中的 7496 人）为女性。从初次手术到第一次翻修的中位 (IQR) 时间为 3 年（0.3 至 7.3），范围从诊断脱位和不稳定的 0.8 年到骨质溶解的 10 年。根据第一次修订的原因，存在一些差异。例如，接受骨折翻修术的患者年龄稍大（平均年龄 76 ± 11 岁），而接受脱位翻修术的患者更有可能是女性（61% [3620 人中的 2213 人]）。登记处已努力使修订顺序标准化，并使用数字方法来描述修订程序。第一次修订是对主要程序的修订，第二次修订是对第一次修订的修订，依此类推。因此，我们将第一次修订的结果描述为第二次修订的累积百分比。结果测量是累积修正百分比，其定义是使用 Kaplan-Meier 生存率估计来描述第二次修正的时间。Cox 比例风险模型的风险比根据年龄和性别进行调整，用于比较各组间的修正率。在可能的情况下，最长随访时间点的累积秒修正百分比是根据可用数据确定的，当数量不足时，我们使用适当的较早时间段。等等。因此，我们将第一次修订的结果描述为第二次修订的累积百分比。结果测量是累积修正百分比，其定义是使用 Kaplan-Meier 生存率估计来描述第二次修正的时间。Cox 比例风险模型的风险比根据年龄和性别进行调整，用于比较各组间的修正率。在可能的情况下，最长随访时间点的累积秒修正百分比是根据可用数据确定的，当数量不足时，我们使用适当的较早时间段。等等。因此，我们将第一次修订的结果描述为第二次修订的累积百分比。结果测量是累积修正百分比，其定义是使用 Kaplan-Meier 生存率估计来描述第二次修正的时间。Cox 比例风险模型的风险比根据年龄和性别进行调整，用于比较各组间的修正率。在可能的情况下，最长随访时间点的累积秒修正百分比是根据可用数据确定的，当数量不足时，我们使用适当的较早时间段。这是使用 Kaplan-Meier 生存率估计来定义的，以描述第二次修订的时间。Cox 比例风险模型的风险比根据年龄和性别进行调整，用于比较各组间的修正率。在可能的情况下，最长随访时间点的累积秒修正百分比是根据可用数据确定的，当数量不足时，我们使用适当的较早时间段。这是使用 Kaplan-Meier 生存率估计来定义的，以描述第二次修订的时间。Cox 比例风险模型的风险比根据年龄和性别进行调整，用于比较各组间的修正率。在可能的情况下，最长随访时间点的累积秒修正百分比是根据可用数据确定的，当数量不足时，我们使用适当的较早时间段。

结果 

18 年时二次翻修的累积百分比为 26%（95% 置信区间 [CI] 24% 至 28%）。当按原因比较第一次翻修的结果时，与其他原因的第一次翻修相比，假体脱位或不稳定的第二次翻修率最高。与 32 毫米或更小的头部尺寸相比，与 3 个月后的受限假体相比，双活动假体因脱位或不稳定而进行的二次翻修率较低。双活动假肢和大于 32 毫米的头部尺寸之间没有差异。当比较松动、假体周围骨折和骨质溶解的第一次翻修时，第二次翻修率没有差异。如果在第一次翻修时进行了骨水泥固定，从 6 个月到 6 年，松动的二次翻修累积百分比高于非骨水泥固定，并且在这段时间之后，没有差异。首次常规 THA 翻修后的总死亡率在 30 天时为 1%，在 90 天时为 2%，在 1 年时为 5%，在 10 年时为 40%。与第一次翻修的其他原因相比，第一次翻修假体周围骨折在所有时间点的死亡率最高。

结论 

较大的头部尺寸和双活动杯可能有助于减少脱位的进一步修正，并且使用非骨水泥柄进行松动的第一次修正似乎是有利的。外科医生可能会告知患者第一次翻修手术后死亡风险较高，特别是如果第一次翻修是针对假体周围骨折进行的。

证据等级 III，治疗研究。