Hitting the Target: Natural History of the Hip Based on Achieving an Acetabular Safe Zone Following Periacetabular Osteotomy
Hitting the Target: Natural History of the Hip Based on Achieving an Acetabular Safe Zone Following Periacetabular Osteotomy
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DOI：
10.2106/jbjs.19.01503
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发表时间：
2020-10-07
影响因子：
5.3
通讯作者：
Sierra, Rafael J.
中科院分区：
文献类型：
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作者：
Wyles, Cody C.;Vargas, Juan S.;Sierra, Rafael J.
背景：髋臼周围截骨术(PAO)仍然是治疗骨龄成熟患者髋臼发育不良的金标准。这项多中心队列研究的目的是根据髋臼骨折的最终位置来描述PAO术后髋关节发育不良的长期放射学自然病史。方法：对1996-2012年间在3个学术机构接受PAO治疗的髋臼发育不良伴或不伴髋臼发育不良的患者进行评估，这些患者由4名保留髋关节外科医生进行。288例患者获得了平均9年(5~21年)的临床和放射学随访。根据首次就诊时拍摄的X线片判断髋臼骨折是否落入安全区，依据的标准是髋臼骨折无后倾角、外中缘角(LCEA)25°~40度、前中缘角(ACEA)25°~40度、Tonnis角0°~10度。根据Tonnis分级(0至3级)对每一张可用后续X线片进行退行性改变评估。进展时间用COX比例风险回归和多态模型分析。结果：在随访期间，只有没有倒退与进展至少1级的风险独立相关：危险比(HR)为0.6(95%可信区间[CI]为0.38至0.94；p=0.025)。达到ACEA安全区后，停留在Tonnis 0级或1级的时间增加最多(在安全区拥有ACEA的时间为43年，而在安全区不拥有ACEA的时间为28年)，其次是没有倒退(没有倒退的34年，有倒退的24年)。然而，达到Tonnis角或LCEA安全区并没有延迟进展。增加安全区的实现通常会延长患者在Tonnis 0级或1级的时间：0安全区为25年，1安全区为36年，2安全区为29年，3安全区为37年，4安全区为44年。结论：本研究证实了在PAO术后实现适当的髋臼重定位以延长髋关节寿命的重要性。虽然LCEA和Tonnis角是评估适当的髋臼矫正最常用的指标，但这项研究表明，适当地解决髋臼后倾和ACEA对改善自然病史有更大的影响。
Background: Periacetabular osteotomy (PAO) remains the gold-standard treatment for acetabular dysplasia in skeletally mature patients with preserved cartilage. The purpose of this multicenter cohort study was to delineate the long-term radiographic natural history of the dysplastic hip following PAO based on the final position of the acetabular fragment. Methods: We evaluated patients who underwent PAO performed by 4 hip preservation surgeons to treat acetabular dysplasia with or without concomitant retroversion from 1996 to 2012 at 3 academic institutions. There were 288 patients with a mean clinical and radiographic follow-up of 9 years (range, 5 to 21 years). Postoperative radiographs made at the first clinical visit were used to determine if the acetabular fragment fell into a safe zone according to the absence of retroversion, a lateral center-edge angle (LCEA) of 25 degrees to 40 degrees, an anterior center-edge angle (ACEA) of 25 degrees to 40 degrees, and a Tonnis angle of 0 degrees to 10 degrees. Every available subsequent radiograph was assessed for degenerative changes by the Tonnis classification (grades 0 to 3). The time to progression was analyzed using Cox proportional hazards regression and multistate modeling. Results: Only the absence of retroversion was independently associated with a decreased risk of progressing at least 1 Tonnis grade during follow-up: hazard ratio (HR), 0.60 (95% confidence interval [CI], 0.38 to 0.94; p = 0.025). Achieving the ACEA safe zone yielded the greatest time increase for remaining in Tonnis grade 0 or 1 (43 years for having an ACEA in the safe zone compared with 28 years for not having an ACEA in the safe zone), followed by the absence of retroversion (34 years for the absence of retroversion compared with 24 years for the presence of retroversion). However, attaining the Tonnis angle or LCEA safe zones did not delay progression. The achievement of additional safe zones generally increased the length of time that patients spent in Tonnis grade 0 or 1: 25 years for 0 safe zones, 36 years for 1 safe zone, 29 years for 2 safe zones, 37 years for 3 safe zones, and 44 years for 4 safe zones. Conclusions: This study demonstrates the importance of achieving appropriate acetabular reorientation to enhance the longevity of the native hip following PAO. Although the LCEA and the Tonnis angle are the most common metrics used to assess appropriate acetabular correction, this study shows that adequately addressing retroversion and the ACEA has a greater impact on improving the natural history.