Hussey Daniel K, Madanat Rami, Donahue Gabrielle S, Rolfson Ola, Bragdon Charles R, Muratoglu Orhun K, Malchau Henrik
Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts.
Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts.
J Bone Joint Surg Am. 2016 Nov 16;98(22):1905-1912. doi: 10.2106/JBJS.15.00685.
In the follow-up evaluation of patients with metal-on-metal (MoM) hip replacements, current evidence suggests that orthopaedic surgeons should avoid reliance on any single investigative tool. Current risk stratification guidelines can be difficult to interpret because they do not provide guidance when there are several risk factors in different groups (high and low risk). To improve the clinical utility of risk stratification guidelines, we designed a scoring system to assess the risk of revision.
The study population consisted of 1,709 patients (1,912 hips) enrolled in a multicenter follow-up study of a recalled MoM hip replacement. Eleven scoring criteria were determined on the basis of existing follow-up algorithm recommendations and consisted of patient-related factors, symptoms, clinical status, implant type, metal ion levels, and radiographic imaging results. Forward stepwise logistic regression was conducted to determine the minimum set of predictive variables for the risk of revision and to assign variable weights. The MoM risk score for each hip was then created by averaging the weighted values of each predictive variable.
Receiver operating characteristic curve analysis yielded good discrimination between all revised and unrevised hips, with an area under the curve of 0.82 (p < 0.001). The odds of revision for the group with a high MoM risk score were increased by 5.8-fold (95% confidence interval [CI], 3.1 to 11.0) relative to the moderate risk group and by 21.8-fold (95% CI, 9.9 to 48.0) compared with the low risk group.
Although the use of MoM hip arthroplasty has been limited since 2010, we continue to be faced with the follow-up and risk assessment of thousands of patients who have not had a revision. As more knowledge about risk stratification is gained, the complexity of the algorithms is expected to increase. We propose the use of the MoM risk score as a tool to aid in the clinical decision-making process.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
在对金属对金属（MoM）髋关节置换患者的随访评估中，目前的证据表明，骨科医生应避免依赖任何单一的检查工具。当前的风险分层指南可能难以解读，因为当不同组（高风险和低风险）存在多种风险因素时，它们并未提供指导。为提高风险分层指南的临床实用性，我们设计了一种评分系统来评估翻修风险。
研究人群包括1709例患者（1912髋），这些患者参与了一项对召回的MoM髋关节置换进行的多中心随访研究。根据现有的随访算法建议确定了11项评分标准，包括患者相关因素、症状、临床状况、植入物类型、金属离子水平和影像学结果。进行向前逐步逻辑回归以确定翻修风险的最小预测变量集并分配变量权重。然后通过平均每个预测变量的加权值为每个髋关节创建MoM风险评分。
受试者工作特征曲线分析在所有翻修和未翻修的髋关节之间产生了良好的区分度，曲线下面积为0.82（p<0.001）。与中度风险组相比，MoM风险评分高的组翻修几率增加了5.8倍（95%置信区间[CI]，3.1至11.0），与低风险组相比增加了21.8倍（95%CI，9.9至48.0）。
尽管自2010年以来MoM髋关节置换术的使用已受到限制，但我们仍面临着对数千例尚未进行翻修的患者的随访和风险评估。随着对风险分层的了解增多，算法的复杂性预计会增加。我们建议使用MoM风险评分作为辅助临床决策过程的工具。
治疗水平IV。有关证据水平的完整描述，请参阅作者指南。
