D. T. S. Chou, L. B. Solomon, K. Costi, O. T. Holubowycz, D. W. Howie, Discipline of Orthopedics & Trauma, University of Adelaide, Adelaide, South Australia D. T. S. Chou, L. B. Solomon, K. Costi, S. Pannach, D. W. Howie, Department of Orthopedics & Trauma, Royal Adelaide Hospital, Adelaide, South Australia.
Clin Orthop Relat Res. 2019 May;477(5):1126-1134. doi: 10.1097/CORR.0000000000000571.
The Bernese periacetabular osteotomy (PAO) is a complex surgical procedure with a substantial learning curve. Although larger hospital and surgeon procedure volumes have recently been associated with a lower risk of complications, in geographically isolated regions, some complex operations such as PAO will inevitably be performed in low volume. A continuous structured program of distant mentoring may offer benefits when low numbers of PAOs are undertaken, but this has not been tested. We sought to examine a structured, distant-mentorship program of a low-volume surgeon in a geographically remote setting.
QUESTIONS/PURPOSES: The purposes of this study were (1) to identify the clinical results of PAO performed in a remote-mentorship program, as determined by patient-reported outcome measures and complications of the surgery; (2) to determine radiographic results, specifically postoperative angular corrections, hip congruity, and progression of osteoarthritis; and (3) to determine worst-case analysis of PAO survivorship, defined as nonconversion to THA, in a regionally isolated cohort of patients with a high rate of followup.
Between August 1992 and August 2016, 85 PAOs were undertaken in 72 patients under a structured, distant-mentorship program. The patients were followed for a median of 5 years (range, 2-25 years). There were 18 males (21 hips) and 54 females (64 hips). The median age of the patients at the time of surgery was 26 years (range, 14-45 years). One patient was lost to followup (two PAOs) and one patient died as a result of an unrelated event. Patient-reported outcome measures and complications were collected through completion of patient and doctor questionnaires and clinical examination. Radiographic assessment of angular correction, joint congruity, and osteoarthritis was undertaken using standard radiology software. PAO survivorship was defined as nonconversion to THA and is presented using worst-case analysis. The loss-to-followup quotient-number of patients lost to followup divided by the number of a patients converted to THA-was calculated to determine quality of followup and reliability of survivorship data.
The median preoperative Harris hip scores of 58 (range, 20-96) improved postoperatively to 78 (range, 33-100), 86 (range, 44-100), 87 (range, 55-97), and 80 (range, 41-97) at 1, 5, 10, and 14 years, respectively. Sink Grade III complications at 12 months included four relating to the PAO and one relating to the concomitant femoral procedure. The median lateral center-edge angle correction achieved was 22° (range, 3°-50°) and the median correction of acetabular index was 19° (range, 3°-37°). Osteoarthritis progressed from a preoperative mean Tönnis grade of 0.6 (median, 1; range, 0-2) to a postoperative mean of 0.9 (median, 1; range, 0-3). Six hips underwent conversion to THA: five for progression of osteoarthritis and one for impingement. At 12-year followup, survivorship of PAO was 94% (95% confidence interval [CI], 85%-98%) and survivorship with worst-case analysis was 90% (95% CI, 79%-96%). The loss-to-followup quotient for this study was low, calculated to be 0.3.
When PAO is performed using a structured process of mentoring under the guidance of an expert, one low-volume surgeon in a geographically isolated region achieved good patient-reported outcomes, a low incidence of complications at 12 months, satisfactory radiographic outcomes, and high survivorship. A structured distant-mentorship program may be a suitable method for initially learning and continuing to perform low-volume complex surgery in a geographically isolated region.
Level IV, therapeutic study.
伯尔尼髋臼周围截骨术（PAO）是一种具有复杂学习曲线的手术。尽管较大的医院和外科医生手术量与较低的并发症风险相关，但在地理上孤立的地区，一些复杂的手术，如 PAO，将不可避免地在低手术量下进行。当进行的 PAO 数量较少时，持续的远程指导结构化计划可能会带来好处，但这尚未得到检验。我们试图在地理偏远的地区，检查低手术量外科医生的结构化、远程指导计划。
问题/目的：本研究的目的是：（1）通过患者报告的结果测量和手术并发症，确定在远程指导计划下进行的 PAO 的临床结果；（2）确定影像学结果，特别是术后角度矫正、髋关节一致性和骨关节炎进展；（3）确定在一个高随访率的区域性孤立患者队列中，PAO 存活率的最坏情况分析，定义为未转换为 THA。
1992 年 8 月至 2016 年 8 月期间，72 名患者接受了 85 次结构化、远程指导计划下的 PAO。患者平均随访 5 年（范围，2-25 年）。18 名男性（21 髋）和 54 名女性（64 髋）。手术时患者的中位年龄为 26 岁（范围，14-45 岁）。一名患者失访（两例 PAO），一名患者因无关事件死亡。通过完成患者和医生问卷以及临床检查收集患者报告的结果测量和并发症。使用标准放射学软件评估角度矫正、关节一致性和骨关节炎的影像学评估。PAO 存活率定义为未转换为 THA，并使用最坏情况分析进行表示。失访率-失访患者数除以转换为 THA 的患者数-用于确定随访质量和存活率数据的可靠性。
58 例（范围，20-96）的术前 Harris 髋关节评分中位数改善至术后的 78 分（范围，33-100）、86 分（范围，44-100）、87 分（范围，55-97）和 80 分（范围，41-97），分别在 1、5、10 和 14 年时。12 个月时出现 Sink 分级 III 级并发症，其中 4 例与 PAO 有关，1 例与同期股骨手术有关。中位外侧中心边缘角度矫正达到 22°（范围，3°-50°），髋臼指数中位矫正为 19°（范围，3°-37°）。骨关节炎从术前平均 Tönnis 分级 0.6（中位数，1；范围，0-2）进展到术后平均 0.9（中位数，1；范围，0-3）。6 髋进行了 THA 转换：5 髋为骨关节炎进展，1 髋为撞击。在 12 年随访时，PAO 的存活率为 94%（95%置信区间，85%-98%），最差情况分析的存活率为 90%（95%置信区间，79%-96%）。本研究的失访率较低，计算值为 0.3。
当 PAO 由一名低手术量的外科医生在地理孤立地区使用指导专家的结构化过程进行指导时，获得了良好的患者报告结果，12 个月时并发症发生率低，影像学结果满意，存活率高。结构化的远程指导计划可能是在地理孤立地区最初学习和继续进行低手术量复杂手术的合适方法。
四级，治疗研究。
