M. K. Dwyer, C. Tumpowsky, J. Lee, J. C. McCarthy, Kaplan Joint Center, Newton Wellesley Hospital, Newton, MA, USA M. K. Dwyer, J. C. McCarthy, Department of Orthopaedics, Massachusetts General Hospital, Boston, MA, USA A. Boone, Tufts University School of Medicine, Boston, MA, USA.
Clin Orthop Relat Res. 2019 May;477(5):1211-1220. doi: 10.1097/CORR.0000000000000717.
Few studies have examined long-term outcomes for patients after arthroscopic treatment for intraarticular hip conditions, and none have done so beyond 10 years postarthroscopy. Examining outcomes beyond 10 years is necessary to determine factors that contribute to conversion to THA in patients undergoing hip arthroscopy for labrochondral damage.
QUESTIONS/PURPOSES: (1) What is hip survivorship free from THA in patients who underwent arthroscopic labral débridement, with or without chondroplasty at least 15 years before? (2) What factors are associated with conversion to THA after arthroscopic labral débridement, with or without chondroplasty? (3) Can these data be used to estimate the risk of conversion to THA based on patient- and hip-related factors?
Between 1989 and 2000, one surgeon performed 552 arthroscopic hip procedures for symptomatic labral tears, with or without associated articular cartilage damage. Of these, the hip status was known in 404 hips (73%) at a minimum of 15 years after the index procedure, with 20 of those patients having died during the followup period. During the study period, patients were offered hip arthroscopy for labral tears with mechanical symptoms, with or without underlying articular cartilage damage. Patient age, sex, acetabular and femoral head Outerbridge grade at surgery, and presence of labral tear were recorded. We determined survivorship free from THA using a Kaplan-Meier survivorship estimator. A stepwise multivariable logistic regression analysis was conducted to determine factors associated with the eventual conversion to THA after hip arthroscopy for labrochondral injuries. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for all significant independent factors. Odds ratios for combinations of significant factors were used to create a risk assessment.
The survivorship free from conversion to THA at 20 years was 59% (95% CI, 53-64. Factors that affected survival included age ≥ 40 years and the presence of combined femoral head and acetabular chondral damage. After controlling for confounding factors, we found that age ≥ 40 years (OR, 2.0; 95% CI, 1.2-3.4; p = 0.011), the absence of all chondral damage (OR, 0.1; 95% CI, 0.03-0.32; p < 0.001), the presence of acetabular damage with severe femoral head damage (OR, 5.0; 95% CI, 2.4-10.3; p < 0.001), and the presence of severe acetabular damage with femoral head damage (OR, 3.7; 95% CI, 2.0-6.8; p < 0.001) were associated with conversion to THA at long-term followup. Based on the calculated ORs, the probability of conversion to THA by 20 years postarthroscopic treatment for labrochondral injuries ranged from 12% (95% CI, 8-17) for a patient younger than 40 years with a Grade 0-II femoral and acetabular Outerbridge grade to 92% (95% CI, 86-95) for a patient older than 40 years with a Grade III-IV femoral and acetabular Outerbridge grade.
Our study revealed that survivorship free from THA at 20 years after arthroscopic labral débridement was associated with both patient age at time of index procedure and, more importantly, the presence of combined femoral head and acetabular chondral damage. Patients should be counseled as to the increased probability of conversion to THA, depending on the health of their articular cartilage after surgery. Future studies should examine survivorship free from THA or clinical symptoms in patients undergoing hip arthroscopy with bone reshaping procedures or with labral repair or reconstruction up to and exceeding 20 years.
Level III, therapeutic study.
很少有研究检查关节内髋关节疾病关节镜治疗后患者的长期结果，并且没有超过关节镜检查后 10 年的研究。检查 10 年以上的结果对于确定接受髋关节镜检查治疗髋臼唇软骨损伤的患者中导致转换为全髋关节置换术（THA）的因素是必要的。
问题/目的：（1）在至少 15 年前接受关节镜下盂唇清创术，伴或不伴软骨成形术的患者中，不进行 THA 的髋关节生存率是多少？（2）哪些因素与关节镜下盂唇清创术，伴或不伴软骨成形术后发生 THA 有关？（3）这些数据能否根据患者和髋关节相关因素来估计转换为 THA 的风险？
在 1989 年至 2000 年期间，一位外科医生为有症状的盂唇撕裂患者进行了 552 次髋关节镜手术，其中伴或不伴有相关的关节软骨损伤。在这些患者中，至少在指数手术后 15 年，404 髋（73%）的髋关节状况得到了随访，在随访期间，有 20 名患者死亡。在研究期间，对于有机械症状的盂唇撕裂患者，可选择进行髋关节镜手术治疗，伴或不伴潜在的关节软骨损伤。记录患者年龄、性别、手术时的髋臼和股骨头 Outerbridge 分级以及盂唇撕裂的存在。我们使用 Kaplan-Meier 生存估计法确定免于 THA 的生存率。进行逐步多变量逻辑回归分析，以确定与关节镜治疗髋臼唇软骨损伤后最终转换为 THA 相关的因素。计算所有显著独立因素的比值比（OR）和 95%置信区间（95%CI）。使用显著因素的组合计算比值比，以创建风险评估。
20 年免于转换为 THA 的生存率为 59%（95%CI，53-64）。影响生存的因素包括年龄≥40 岁和股骨头与髋臼软骨损伤的联合存在。在控制混杂因素后，我们发现年龄≥40 岁（OR，2.0；95%CI，1.2-3.4；p=0.011）、无任何软骨损伤（OR，0.1；95%CI，0.03-0.32；p<0.001）、髋臼损伤伴严重股骨头损伤（OR，5.0；95%CI，2.4-10.3；p<0.001）和髋臼损伤伴股骨头损伤（OR，3.7；95%CI，2.0-6.8；p<0.001）与长期随访时的转换为 THA 相关。根据计算的 OR，关节镜治疗髋臼唇软骨损伤后 20 年的转换为 THA 的概率范围从 40 岁以下患者的 12%（95%CI，8-17）到 40 岁以上患者的 92%（95%CI，86-95），后者的股骨和髋臼 Outerbridge 分级为 III-IV 级。
我们的研究表明，关节镜下盂唇清创术后 20 年免于 THA 的生存率与患者指数手术时的年龄以及更重要的是股骨头和髋臼软骨损伤的联合存在有关。应根据患者手术后关节软骨的健康状况，告知患者转换为 THA 的可能性增加。未来的研究应检查接受髋关节镜检查、骨重塑手术或盂唇修复或重建的患者在 20 年及以上时间免于 THA 或临床症状的生存率。
III 级，治疗性研究。
