Ten-year survivorship broken down by acetabular and femoral Outerbridge Grades III and IV, compared with Grades 0 to II, showed a decrease for the higher grades of damage from 80% to between 12% and 20%. This decrease in survivorship associated with cartilage damage is consistent with a previous report of decreased survivorship from 86% to 57% for nonarthritis and arthritis groups, respectively . The 10-year survivorship of the arthroscopy procedure for labral tears was 90% as long as the acetabular and femoral Outerbridge grades were low (0 to II). Studies suggest the labrum minimizes the risk of premature arthritis by maintaining proper biomechanical stability of the hip with the purpose of a labral repair to restore this function [6, 12, 16, 24]. Our findings that a labral tear without articular lesions can be successfully treated with arthroscopy and maintain long-term survivorship of the natural hip provides strong support for the early detection and treatment of a labral tear with arthroscopy before the resulting instability causes further cartilage damage leading to worse long-term outcomes.
The need for treatment before cartilage damage occurs was further supported by our finding that femoral and acetabular Outerbridge grades were independent predictors of failure of the arthroscopic procedure defined as eventual THA. Although the previous long-term study identified only a trend between lower mHHS and preoperative diagnoses of osteoarthritis or avascular necrosis , our data show higher acetabular and femoral Outerbridge grades of III and IV predict eventual need for a THA. Also, previously published short- and midterm studies have indicated the presence and severity of arthritis or chondral degradation were predictors of worse questionnaire scores, mHHS, modified Farjo and Glick classifications, and Larson hip scores (Table 7) [4, 10, 21, 31, 32]. Because the treatment for articular lesions in the hip, namely judicious removal or microfracture surgery, is similar to that in the knee, this finding is not surprising given similar conclusions . However, our study challenges the conclusions from a 5-year followup study by Kamath et al. , which reported postoperative mHHS after hip arthroscopy for labral tear repair was not affected by the presence of arthritis. Although previous works discussed the influence of cartilage changes on outcome, none of these studies has broken down the cartilage changes by acetabular and femoral severity. Our results indicate although cartilage changes in both the acetabular socket and femoral head are important, the risk of failure for hips with femoral head cartilage changes is over two times as high as the risk associated with acetabular changes. The knowledge that patients with cartilage damage are 20 to 60 times more likely to require an eventual THA can be combined with a high-resolution arthro-MRI scan to more effectively screen patients who will benefit the most from hip arthroscopy. In addition to identifying damage on the acetabular or femoral chondral surfaces as a predictor of eventual need for THA, older age was also indicated as increasing the risk of failure by 3.6 times. This is consistent with previous findings from short-, mid-, and long-term studies showing a negative effect of older age on postoperative surveys (Table 7) [2, 4, 21]. Gender did not predict eventual need for THA. This finding is contradictory to the gender relationship seen in knee arthroscopy procedures in which females are at greater risk for failure in both short-term recovery and in long-term studies up to 20 years [7, 9, 25], and no current hip arthroscopy studies report gender as a predictor of outcome. Importantly, our study supplements the observed trend that arthritis and older age negatively affect mHHS at 10 years followup  with the conclusion that patients with cartilage damage of Outerbridge grades of III or I to V as well as patients older than 40 years have increased risk for eventual THA after arthroscopy.
Combining the predictors of eventual THA, a chart was made showing the probability that a patient will require a THA by 10 years postoperatively based on the various combinations of risk factors. This is previously unreported and can serve as a guide for physicians and patients during the decision-making process about whether to proceed with the arthroscopy. The intended use of this probability algorithm is to aid in clinical decisions while serving as a benchmark to compare with future long-term studies.
This is the only long-term study of hip arthroscopy large enough to report statistically relevant conclusions. Our results suggest caution should be taken when treating older individuals with articular cartilage damage using this technique but that long-term preservation of a well-functioning hip is possible in patients with labral tears and/or minimal cartilage damage. Additionally, the 90% survivorship 10 years after treatment of labral tears without associated cartilage damage indicates long-term preservation of a natural hip can be achieved with treatment using hip arthroscopy.
We thank David Zurakowski, PhD, Department of Orthopedic Surgery, Children’s Hospital, for his assistance with the statistical analysis.
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