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關節(jié)鏡治療與保守治療髖關節(jié)撞擊綜合征:最新綜述（2024）關節(jié)鏡治療與保守治療髖關節(jié)撞擊綜合征:最新綜述（2024）ArthroscopicTreatmentofFemoroacetabularImpingementSyndrome:AnUpdatedReview?ParkJW,HwangJM,YooJJ.ArthroscopicTreatmentofFemoroacetabularImpingementSyndrome:AnUpdatedReview[J].ClinOrthopSurg,2024,16(4):517-525.?轉載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/39092294/?轉載文章的原鏈接2：https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11262938/?AbstractTreatmentstrategiesforfemoroacetabularimpingement(FAI)syndromehaveevolvedintandemwithincreasedcomprehensionofFAI’simpactonhipjointhealth.Earlyintervention,includingarthroscopicsurgery,hasgainedpopularityduetoitspotentialtodelaytheprogressionofosteoarthritis.ArthroscopicsurgeryhasdemonstratedsignificantefficacyintreatingFAIsyndrome,withrobustevidencefromrandomizedcontrolledtrialsandsystematicreviewssupportingitsuse.Despitearthroscopicsurgery’ssuccess,complicationsandreoperationsarenotuncommon.Theincidencerangesfrom1%to31%and4%to13%,respectively.Adjunctivebiologictreatments,suchasbonemarrowaspirateconcentratesandplatelet-richplasma,haveshownpromiseinchondrallesionmanagement.However,robustevidencesupportingtheirroutineuseinFAIsyndromeiscurrentlylacking.Amongconservativetreatmentmethods,intra-articularinjectionsofferdiagnosticandtherapeuticbenefitsforFAIpatients.Whiletheymayprovidepainreliefandaidinprognosis,theirlong-termefficacyremainsasubjectofdebate.ComparativestudiesbetweenconservativeandarthroscopictreatmentshighlighttheimportanceofpersonalizedapproachesinmanagingFAIsyndrome.Inconclusion,recentadvancementsinFAIsyndromemanagementhaveilluminatedvarioustreatmentmodalities.Arthroscopicsurgerystandsasapivotalintervention,offeringsubstantialbenefitsinpainrelief,function,andqualityoflife.However,carefulpatientselectionandpostoperativemonitoringarecrucialforoptimizingoutcomes.Adjunctivebiologicsandintra-articularinjectionsshowpromisebutrequirefurtherinvestigation.TailoringtreatmenttoindividualpatientcharacteristicsremainsparamountinoptimizingFAIsyndromemanagement.髖關節(jié)撞擊(FAI)綜合征的治療策略隨著對FAI對髖關節(jié)健康影響的了解的增加而不斷發(fā)展。早期干預，包括關節(jié)鏡手術，由于有可能延緩骨關節(jié)炎的進展而越來越受歡迎。關節(jié)鏡手術治療FAI綜合征的療效顯著，來自隨機對照試驗和系統(tǒng)評價的有力證據支持其應用。盡管關節(jié)鏡手術很成功，但并發(fā)癥和再手術并不少見。發(fā)病率分別為1%-31%和4%-13%。輔助生物治療，如骨髓抽吸濃縮液和富血小板血漿，在軟骨病變治療中顯示出希望。然而，目前缺乏有力的證據支持它們在FAI綜合征中的常規(guī)應用。在保守治療方法中，關節(jié)內注射為FAI患者提供了診斷和治療的益處。雖然它們可以緩解疼痛和幫助預后，但它們的長期療效仍然是一個有爭議的話題。保守治療和關節(jié)鏡治療的比較研究強調了個性化治療FAI綜合征的重要性?？傊?，FAI綜合征管理的最新進展闡明了各種治療方式。關節(jié)鏡手術是一種關鍵的干預措施，在疼痛緩解、功能和生活質量方面提供了實質性的好處。然而，仔細的患者選擇和術后監(jiān)測是優(yōu)化結果的關鍵。輔助生物制劑和關節(jié)內注射顯示出前景，但需要進一步研究。在優(yōu)化FAI綜合征管理中，根據患者個體特征定制治療仍然是最重要的。?Keywords:Femoroacetabularimpingement,Arthroscopicsurgery,Conservativetreatment,Treatmentoutcome,Review?Femoroacetabularimpingement(FAI)syndromewasfirstdescribedasadiseaseentitybyGanzetal.1)inacetabularandfemoralanatomyin2001.Sincethen,thenumberofarticlesonFAIhasincreasedapproximately3.4timesduringthepast10years.Accordingtoastudypublishedin2022,FAIsyndrome—althoughitmightnothavebeenrecognizedasadisease—waspresentinancientNubiaasearlyas3,000yearsago.2)ThecontemporarydefinitionofFAIsyndromeislargelybasedonthe2016WarwickAgreementconsensus,whichemphasizesthetriadofsymptoms,clinicalsigns,andimagefindingstodiagnosethecondition.3)3.GriffinDR,DickensonEJ,O’DonnellJ,etal.TheWarwickAgreementonfemoroacetabularimpingementsyndrome(FAIsyndrome):aninternationalconsensusstatement.BrJSportsMed.2016;50(19):1169-76.2001年，Ganz等人1)首次將股髖臼撞擊綜合征(FAI)描述為一種疾病實體。從那時起，關于FAI的文章數量在過去10年里增加了大約3.4倍。根據2022年發(fā)表的一項研究，早在3000年前，古努比亞就存在FAI綜合征——盡管它可能沒有被認為是一種疾病。2)FAI綜合征的當代定義主要基于2016年沃里克協(xié)議共識，該協(xié)議強調癥狀、臨床體征和影像學結果的三重特征來診斷病情。3)TheprimarysymptomofFAIsyndromeisthemotion-orposition-relatedpainthatislocatedonthehip,back,buttock,oranteriorthigh.4)Otherthanpain,mechanicalsymptomssuchascatching,locking,givingway,orclickingcouldoccurwitharestrictedrangeofmotion.5)TheclinicalsignofFAIsyndromeismostcommonlytestedwithflexion,adduction,andinternalrotation(FADIR)testduetoitshighsensitivity,butitdoesnotshowhighspecificity.6)DiagnosticimagingofFAIsyndromemainlyfocusesonfindingthepincerorcamlesionswithlateraloranteriorcenter-edgeangleonpelvicanteroposterior,Dunnview,cross-tablelateral,orfrog-leglateralradiographs.7)FAI綜合征的主要癥狀是髖關節(jié)、背部、臀部或股骨前側與運動或位置相關的疼痛4)。除了疼痛外，機械性癥狀，如抓、鎖、讓位或咔噠聲也可能在受限的運動范圍內發(fā)生5)。FAI綜合征的臨床癥狀最常用的是屈曲、內收和內旋(FADIR)試驗，因為它的靈敏度很高6)。FAI綜合征的診斷影像學主要集中在盆腔正位片、Dunn片、跨臺側位片或蛙腿側位片上尋找具有外側或前中心邊緣角的鉗形或cam病變。TreatmentsofFAIsyndromehaveevolvedalongwiththefurtherunderstandingofthedisease.TherationalefortreatingFAIsyndromestemsfromthereportsthatFAIsyndromecausesosteoarthritisofthehipjoint.ThisnotionwasproposedbyStulbergetal.8)withtheterm,“unrecognizedchildhoodhipdisease,”whichcouldcauseidiopathicosteoarthritisofthehip.In2003,Ganzetal.4)reviewedover600casesandsuggestedtheearlyinterventionofFAItodelayosteoarthritisofthehipinyoungpatients.Currently,thestandardtreatmentofFAIsyndromeconsistsofactivitymodification,rehabilitation,orsurgerywiththeincreasingpopularityofarthroscopicsurgery.3,9)Itshouldbenoted,however,thatcam-typeFAIsyndromeandpincer-typeFAIsyndromehavedifferentclinicalfeaturesandprognoses.10,11,12,13)Camlesionsaremorecommonlyfoundinpost-adolescentmen,whilepincerlesionsaremoreprevalentinmiddle-agedwomen.14)Ithasbeenestablishedthatcamlesionsareassociatedwiththedevelopmentofsubsequentosteoarthritis,buttherelationshipbetweenpincerlesionsandosteoarthritisislessevident.15)隨著對這種疾病的進一步了解，FAI綜合征的治療方法也在不斷發(fā)展。治療FAI綜合征的基本原理源于FAI綜合征引起髖關節(jié)骨關節(jié)炎的報道。這一概念是由Stulberg等人(8)以“未被識別的兒童髖關節(jié)疾病”一詞提出的，該疾病可能導致髖關節(jié)特發(fā)性骨關節(jié)炎。2003年，Ganz等人(4)回顧了600多例病例，建議早期干預FAI以延緩年輕患者髖關節(jié)骨性關節(jié)炎。目前，隨著關節(jié)鏡手術的日益普及，FAI綜合征的標準治療包括活動調節(jié)、康復或手術3,9)。然而，需要注意的是，Cam型FAI綜合征和鉗型FAI綜合征具有不同的臨床特征和預后10,11,12,13)。Cam病變更常見于青春期后男性。而鉗形病變在中年婦女中更為普遍14)。已經確定，鉗形病變與隨后的骨關節(jié)炎的發(fā)展有關，但鉗形病變與骨關節(jié)炎之間的關系不太明顯。AstheprimaryendpointofthetreatmentofFAIsyndromeismorefocusedonpreventingsubsequentosteoarthritisratherthancuringFAIsyndromeitself,itdiffersfromthedefinitivetreatmentsuchasarthroplasty,whichisthegoldstandardforend-stagehiposteoarthritis.Forconservativetreatment,activitymodification,physiotherapy,paincontrolwithoralanalgesics,andintra-articularhipjointinjectionarecommonlyprescribed.3,16)Forsurgery,bothtraditionalopensurgeryandarthroscopicapproachhavebeenreportedeffectivebutthelattermayberecentlygainingmorepopularityduetofastrecovery.1,17)However,theclinicalevidencetoclarifythetreatmentstrategyofFAIsyndromeisrapidlyaggregatingwithcontroversialeffectivenessofthetreatmentmodality.16,18)Therefore,thepurposeofthisstudywastoreviewrecentliteraturetoassesstheeffectivenessofarthroscopictreatmentofFAIsyndromeandcomparewiththatofconservativetreatment.由于FAI綜合征治療的主要終點更側重于預防繼發(fā)骨關節(jié)炎，而不是治療FAI綜合征本身，因此它不同于髖關節(jié)置換術等最終治療，后者是終末期髖關節(jié)骨關節(jié)炎的金標準。對于保守治療，活動調節(jié)，物理治療，口服鎮(zhèn)痛藥控制疼痛，關節(jié)內注射是常用的處方3,16)。對于手術，傳統(tǒng)的開放手術和關節(jié)鏡手術都有報道有效，但后者由于恢復快，最近可能越來越受歡迎。澄清FAI綜合征治療策略的臨床證據正在迅速聚集，但治療方式的有效性存在爭議16,18)。因此，本研究的目的是回顧最近的文獻，評估關節(jié)鏡治療FAI綜合征的有效性，并與保守治療進行比較。?ARTHROSCOPICSURGERYFORFAISYNDROMERecently,therehasbeenaswiftriseinaccountsofsuccessfulresultsfromarthroscopicsurgeryperformedtotreatFAIsyndrome.High-levelevidencebasedonrobustrandomizedcontrolledtrials(RCTs)andsystematicreviews/meta-analyses,whichweregloballyconducted,addsrationaletoarthroscopictreatmentinFAIsyndrome.19,20,21,22,23,24,25)Duetothelessinvasivenessandcomparablesurgicaloutcomes,hiparthroscopyisgraduallyreplacingopensurgeryinFAIsyndrome.IntheUnitedStates,thenumberofhiparthroscopyincreasedover3timesbetween2004and2009.26)In2013,arthroscopicsurgeriesforFAIaccountedfor1,908cases,whileopensurgeryaccountedforonly491casesintheUnitedKingdom.27)最近，關節(jié)鏡手術治療FAI綜合征的成功案例迅速增加?；谌蜷_展的可靠隨機對照試驗(RCTs)和系統(tǒng)評價/薈萃分析的高水平證據，為關節(jié)鏡治療FAI綜合征提供了理論依據19,20,21,22,23,24,25)。由于關節(jié)鏡的侵入性較小，手術結果可比較，因此在FAI綜合征中，髖關節(jié)鏡正逐漸取代開放手術。在美國，髖關節(jié)鏡手術的數量在2004年至2009年間增加了3倍以上(26)。2013年，關節(jié)鏡手術治療FAI的病例為1908例，而英國的開放手術僅為491例(27)。ThedistinctivemorphologicfeaturesofFAIsyndromearedirectlyvisualizedthrougharthroscopicexamination.28)Duringarthroscopicsurgery,camlesionsorpincerlesions,aswellasthesubtlechondrallesionsorlabraltears,areobserved.29)Someoftheselesionsarenotreadilyvisualizedincomputedtomographyscansormagneticresonanceimagingbutonlyfoundinarthroscopicexamination.28,29)Arthroscopicconfirmationofsuspectedlesions,aswellasconsequenttreatmentperformeddirectlythrougharthroscopicmanagement,isoneofthefactorsthatcontributetotheincreasingpopularityofarthroscopicsurgery.關節(jié)鏡檢查可直接觀察到FAI綜合征的獨特形態(tài)學特征28)。在關節(jié)鏡手術中，可觀察到凸輪病變或鉗形病變，以及細微的軟骨病變或唇裂29)。其中一些病變在計算機斷層掃描或磁共振成像中不易觀察到，而只有在關節(jié)鏡檢查中才能發(fā)現。以及隨后的治療直接通過關節(jié)鏡管理，是促成關節(jié)鏡手術日益普及的因素之一。?BiomechanicsofFAISyndromeCam-typeandpincer-typeFAIsyndromeexhibitimpingementatdifferentsitesoffemoralneck.Typically,cam-lesionsdevelopattheanterosuperioraspectofthefemoralneck,whichwasoriginallydescribedastheextensionoftheabnormalepiphysisofthefemoralhead.12,13)Incontrast,pincerlesionsarerelatedtotheacetabularovercoverage,oftenwiththematurationofpreexistingosacetabuli.11)However,itshouldbenotedthatmixedtypeFAIsyndromewithbothcamandpincerlesionsareverycommonlyfound.10)凸輪型和鉗型FAI綜合征在股骨頸的不同部位表現為撞擊。通常，凸輪型病變發(fā)生在股骨頸的前上側面，最初被描述為異常股骨頭骨骺的延伸12,13)。相反，鉗形病變與髖臼過度覆蓋有關，通常與先前存在的髖臼成熟有關11)。然而，應該注意的是，同時伴有凸輪和鉗形病變的混合型FAI綜合征非常常見。Fromabiomechanicalpointofview,asystematicreviewwasconductedon12studiesoncam-typeFAIsyndrome(173cam-lesionsvs.177controls)andreportedthatcamlesionsreducethesagittalrangeofmotionofthehipjoint,maximumextensionangle,andabductionangleofthehipjointanddecreaseiliopsoasmusclepowerandwalkingspeed.13)VanHouckeetal.30)reportedthatincamtypeFAIsyndrome,thepeakcontactstressduring20°ofinternalrotationnearlydecreasedbyhalf(26.6–11.4MPa)afterarthroscopiccamresection.Anotherstudyusingfiniteelementmodelingonpincerlesionsshowedthatthemaximumstress-strainincreased2to3.4timesintheanterosuperioracetabularrimcomparedtothatinthecontrolgroup.31)從生物力學的角度，對12項關于凸輪型FAI綜合征的研究進行了系統(tǒng)回顧(173例凸輪病變與177例對照)，并報道凸輪病變降低了髖關節(jié)矢狀面運動范圍、髖關節(jié)最大伸展角和外展角，并降低了髂腰肌力量和步行速度13)。VanHoucke等人報道，在凸輪型FAI綜合征中，關節(jié)鏡下凸輪切除后，20°內旋時的峰值接觸應力下降了近一半(26.6~11.4MPa)。另一項對鉗形病變進行有限元建模的研究顯示，與對照組相比，髖臼前上緣的最大應力應變增加了2至3.4倍。ArecentsystematicreviewconcludedwhenarthroscopicsurgeryisperformedforFAI,flexionandinternalrotationofthehipjointoftenimproveaftersurgery,butexternalrotationanglemaynotincreasesignificantly.20)ThesestudiesprovideabiomechanicalbackgroundonhowarthroscopicsurgerycouldaidinpainandfunctionalimprovementinFAIsyndrome.最近的一項系統(tǒng)綜述得出結論，當關節(jié)鏡手術治療FAI時，髖關節(jié)的屈曲和內旋通常在手術后得到改善，但外旋角度可能不會顯著增加20)。這些研究為關節(jié)鏡手術如何幫助FAI綜合征的疼痛和功能改善提供了生物力學背景。?PatientSelectioninArthroscopicSurgeryforFAISyndromePatientselectionintreatingFAIsyndromeisespeciallyimportantinthatthecomplicationratecouldvaryamongdifferentpatientdemographics.ItiscommonlyacceptedthatobesepatientswhodevelopedarthritisarenottheidealcandidatesforsurgicalprocedurestotreatFAIsyndrome.Somestudieshaveconstructedevidenceonidealfeaturesofpatientstobetreatedwitharthroscopicsurgery.21,22)治療FAI綜合征的患者選擇尤其重要，因為不同患者的并發(fā)癥發(fā)生率可能不同。人們普遍認為，患有關節(jié)炎的肥胖患者并不是手術治療FAI綜合征的理想人選。一些研究已經為關節(jié)鏡手術患者的理想特征提供了證據21,22)。Kayetal.21)reportedfactorsaffectingpain,function,andqualityoflifeinpatientswhoareincludedintheFIRST(FemoroacetabularImpingementRandomisedControlledTrial)studyin2021.Theresultsofthestudyshowedthat1yearaftersurgery,theimprovementinqualityoflifewasgreaterinyoungerpatients,andtheimprovementinpainwasgreaterinpatientswithlowerbodymassindex(BMI).Nofactorsshowedanassociationwithreoperation,whichoccurredin13%.21)Kayetal.21)報道了2021年FIRST(股骨髖臼撞擊隨機對照試驗)研究中患者的疼痛、功能和生活質量的影響因素。研究結果顯示，術后1年，年輕患者的生活質量改善更大，體重指數(BMI)較低的患者疼痛改善更大。無因素顯示與再手術相關，再手術發(fā)生率為13%。Morerecently,Migliorinietal.22)focusedonreturntosportsafterarthroscopicsurgeryforFAIsyndromein41studies(4,063cases)andfoundthat89%wereabletoresumewithin3years.Inparticular,patientswithyoungerage,lowerbodyweight,lowerarthritisstage(T?nnisgradeI)beforesurgery,andbetterhipfunctionhadbetterpostoperativefunction.最近，Migliorini等人(22)在41項研究(4,063例)中關注FAI綜合征關節(jié)鏡手術后恢復運動，發(fā)現89%的患者能夠在3年內恢復運動。特別是術前年齡較小、體重較輕、關節(jié)炎分期較低(T?nnisI級)、髖關節(jié)功能較好的患者，術后功能較好。?ClinicalOutcomesofArthroscopicSurgeryinFAISyndromeRecently,thereisagrowingbodyofevidencetosupporttheefficacyofarthroscopicsurgeryinFAIsyndrome.19,22,23,24,32,33)Tocomparethespecificarthroscopicproceduresintermsofefficacy,FIRSTstudywasconductedasamulticenter,blindedRCTin10institutionsinCanada,Finland,andDenmark.25)Arthroscopicosteochondroplastywascomparedwitharthroscopiclavageregardingoutcomesofpain,remainingfunctions,andqualityoflife.ThebackgroundofthisstudyreflectsthecurrentperceptionofFAIsyndrome,whichhasbecomeahugeeconomicburdenwithouttheconsensusontheeffectivenessofthesurgery.25)最近，越來越多的證據支持關節(jié)鏡手術治療FAI綜合征的療效19,22,23,24,32,33)。為了比較特定關節(jié)鏡手術的療效，FIRST研究在加拿大、芬蘭和丹麥的10家機構進行了多中心、盲法隨機對照試驗25)。比較關節(jié)鏡下骨軟骨成形術與關節(jié)鏡下灌洗術在疼痛、剩余功能和生活質量方面的結果。本研究的背景反映了目前對FAI綜合征的認知，該綜合征已成為一個巨大的經濟負擔，而對手術的有效性尚未達成共識。Almasrietal.32)soughttoreporttheclinicalcourse,especiallyintheosteochondroplastygroup,intheFIRSTtrial.Theyevaluatedpainandfunctionalscoreatbaseline,2weeks,6weeks,3months,6months,and12monthsafterthesurgery.Painvisualanalogscaleimprovedrapidlyafterthesurgeryandfunctionalscoresgraduallyrecovered,buttherewasnosignificantimprovementafter6months.32)In2022,Almasrietal.33)comparedrandomizedtolavagegroup,randomizedtoosteochondroplastygroup,thosewhodeclinedtoparticipateintheRCTbutreceivedosteochondroplasty,andthosewhodidnotfittheinclusioncriteriabutreceivedosteochondroplastyintermsofcomplicationandfunctionalscores.Painandfunctionimprovedinallpatientgroupsafter1year.ManyofthegroupsnotincludedintheRCTwerepatientswhodidnotrespondtodiagnostichipinjection,butinthisgroupofpatients,osteochondroplastyshowedalowerreoperationrateandgreaterfunctionalimprovement.Asforthecause,theauthorssuggestedthatbecausepatientsincludedinRCTswererandomized,theytendedtoreportmoreminorsymptomsbecausetheybelievedtheyhadreceivedtherandomlyassignedtreatmentinsteadofthebestpossibletreatment.33)Almasri等人(32)在第一項試驗中試圖報告臨床過程，特別是在骨軟骨成形術組。他們在手術后基線、2周、6周、3個月、6個月和12個月評估疼痛和功能評分。術后疼痛視覺模擬量表迅速改善，功能評分逐漸恢復，但6個月后無明顯改善32)。2022年，Almasri等(33)將隨機與灌洗組、隨機與骨軟骨成形術組、拒絕參加RCT但接受骨軟骨成形術的患者、不符合納入標準但接受骨軟骨成形術的患者的并發(fā)癥和功能評分進行了比較。1年后，所有患者組的疼痛和功能均有所改善。許多未納入RCT的組是對診斷性髖關節(jié)注射無反應的患者，但在這組患者中，骨軟骨成形術顯示出較低的再手術率和較大的功能改善。至于原因，作者認為，由于納入隨機對照試驗的患者是隨機的，他們傾向于報告更輕微的癥狀，因為他們認為他們接受了隨機分配的治療，而不是最好的治療。In2021,Migliorinietal.23)reviewed10prospectivestudiesandanalyzed470surgeriesinasystematicreview.Thestudywasconductedonyoungpatientswithanaverageageoflessthan16years,and94%wereabletoreturntosportsaftermorethan2yearsoffollow-up.Anothersystematicreviewwasconductedon5studiesofarthroscopicacetabularlabralrepair.In210cases,patientsreturnedtoexercisewithin2yearsofsurgery,andallclinicalscoresimprovedat34months.24)In2021,Anninetal.19)reportedasystematicreviewincluding18studiesand1,123patientsonreturntoexerciseandfunctionuponreturnafterarthroscopicsurgeryinathleteswithFAI.Regardingsurgicaltechniques,labralrepairwasperformedmorethan3timesmoreoftenthanresection,andreconstructionwasrarelyperformed.Femoroplastywasperformedinover90%ofcases.Returntoexercisewasreportedin73%to100%.19)Theyconcludedthatintheathletes,arthroscopictreatmentofFAIsyndromeresultedinsignificantfunctionalimprovementcomparedtothepreinjurylevel.19)2021年，Migliorini等人(23)在一項系統(tǒng)綜述中回顧了10項前瞻性研究，分析了470例手術。這項研究是在平均年齡小于16歲的年輕患者中進行的，經過兩年多的隨訪，94%的患者能夠恢復運動。另一項系統(tǒng)綜述了5項關節(jié)鏡下髖臼唇修復的研究。210例患者在手術后2年內恢復運動，34個月時所有臨床評分均有所改善24)。在2021年，Annin等人(19)報道了一項系統(tǒng)綜述，包括18項研究和1123例FAI運動員關節(jié)鏡手術后恢復運動和功能。在手術技術方面，唇部修復術比切除術多3倍以上，重建術很少。90%以上的病例行股骨成形術。他們的結論是，與損傷前相比，FAI綜合征的關節(jié)鏡治療可顯著改善運動員的功能。High-qualitystudiesincludingRCTsandsystematicreviewsagreethatarthroscopicsurgeryiseffectiveinFAIsyndrome.19,22,23,24,32,33)However,therearestillsomelimitationsthatthespecifictypeofsurgery(labraldebridement,labralrepair,acetabuloplasty,andfemoroplasty)orthetypeofFAIsyndrome(pincer,cam,ormixed)wasnotseparatelyinvestigated.包括隨機對照試驗和系統(tǒng)評價在內的高質量研究一致認為關節(jié)鏡手術治療FAI綜合征是有效的(19,22,23,24,32,33)。然而，由于沒有單獨研究具體的手術類型(唇清創(chuàng)、唇修復、髖臼成形術和股骨成形術)或FAI綜合征的類型(鉗形、鉗形或混合型)，仍然存在一些局限性。?ComplicationsandReoperationsafterArthroscopicSurgeryinFAISyndromeDespitetheprominentvalueofthearthroscopicsurgeryinFAIsyndrome,theadverseeventsarenotrare.Theincidenceofcomplicationsandreoperationsafterarthroscopicsurgeryrangefrom1%to31%and4%to13%,respectively.22,24,33,34)Thecommonadverseeventsincludedpersistenthippain,labralre-injury,temporaryparesthesiaofthelateralfemoralcutaneousnerve,transientperinealnerveparesthesia,recurrenceofcamlesion,capsulolabraladhesions,hiposteoarthritis,andsuperficialinfection.22,24,33,34)However,Ohlinetal.34)reportedthat86.5%oftheadverseeventsresolvedwithin24monthafterarthroscopicsurgeryandtherewerenolife-threateningcomplications.Theauthorsfurthertreatedpersistentcomplicationswithrevisionarthroscopicsurgerywithosteochondroplasty,labralrepair,ordrainageforinfectionwithoutanysubstantialimpairment.34)Similarly,Anninetal.19)reported5.5%ofrevisionsurgeryand0.6%ofsubsequenttotalhiparthroplastyinasystematicreviewincluding18studiesand904patients.盡管關節(jié)鏡手術在FAI綜合征中具有突出的價值，但不良事件并不罕見。關節(jié)鏡手術后并發(fā)癥和再手術的發(fā)生率分別為1%~31%和4%~13%。常見的不良事件包括持續(xù)髖關節(jié)疼痛、唇部再損傷、股外側皮神經暫時性感覺異常、會陰神經暫時性感覺異常、cam病變復發(fā)、關節(jié)囊粘連、髖關節(jié)骨關節(jié)炎和淺表感染。Ohlin等人(34)報道，86.5%的不良事件在關節(jié)鏡手術后24個月內消失，沒有危及生命的并發(fā)癥。作者進一步通過骨軟骨成形術、唇部修復或引流治療關節(jié)鏡翻修手術的持續(xù)并發(fā)癥，無任何實質性損傷34)。同樣，Annin等人在一項包括18項研究和904例患者的系統(tǒng)綜述中報告了5.5%的翻修手術和0.6%的后續(xù)全髖關節(jié)置換術。IntheFIRSTstudy,thecomplicationsweredividedintooperativelytreatedonesandnonoperativelytreatedones.ThosewhowereallocatedinthelavagegroupintheFIRSTtrialshowedthehighestcomplicationrate(18%and13%),followedbytheosteochondroplastygroupintheFIRSTtrial(8%and14%),thosewhodeclinedtorandomizationbutreceivedosteochondroplasty(10%and4%),andthosewhodidnotfittheinclusioncriteria(4%and4%).33)在FIRST研究中，并發(fā)癥分為手術治療和非手術治療。在FIRST試驗中被分配到灌洗組的患者并發(fā)癥發(fā)生率最高(18%和13%)，其次是FIRST試驗中的骨軟骨成形術組(8%和14%)，拒絕隨機分組但接受骨軟骨成形術的患者(10%和4%)，以及不符合納入標準的患者(4%和4%)。Ohlinetal.34)reportedin2020onadverseeventsduringarthroscopicsurgeryinFAIsyndromebasedontheFIRSTstudycohort.Thepercentageofadverseeventsthatoccurredduringthe2-yearfollow-upwas24%andreoperationwas13%.Revisionsurgerywasmostcommonlyperformedatamedianof15months(range,1–25months)aftertheindexsurgeryandover86%oftheadverseeventsresolvedwithinthe24-monthfollow-up.34)Ohlin等人(34)于2020年基于FIRST研究隊列報道了FAI綜合征關節(jié)鏡手術期間的不良事件。2年隨訪期間不良事件發(fā)生率為24%，再手術率為13%。翻修手術最常在指數手術后中位15個月(范圍1-25個月)進行，超過86%的不良事件在24個月的隨訪中解決。InasystematicreviewonthearthroscopicsurgeryforFAIsyndromeinadolescents,complicationswerereportedinapproximately1%,andarthroscopicreoperationwasrequiredin5%atameanof28monthsoffollow-up.Themostcommoncomplicationsweretemporaryparesthesiaofthelateralfemoralcutaneousnerve(0.4%)andtransientperinealnerveparesthesia(0.4%).Theauthorsconcludedthatarthroscopicsurgerywasbeneficialforhippain,function,andqualityoflifeinadolescentFAIsyndrome.23)InasystematicreviewspecificallyonthearthroscopiclabralrepairforFAIsyndrome,thereoperationratewas4.3%andarthroplastywasrequiredin2%at38monthsaftersurgeryonaverage.24)AsystematicreviewonathleteswhohadFAIsyndromeshowedthat5.5%ofthepatientsrequiredreoperationataminimumof2yearsoffollow-up.在一項針對青少年FAI綜合征的關節(jié)鏡手術的系統(tǒng)綜述中，在平均28個月的隨訪中，約1%的患者出現并發(fā)癥，5%的患者需要再次進行關節(jié)鏡手術。最常見的并發(fā)癥是股外側皮神經暫時性感覺異常(0.4%)和會陰神經暫時性感覺異常(0.4%)。作者得出結論，關節(jié)鏡手術對青少年FAI綜合征的髖關節(jié)疼痛、功能和生活質量是有益的23)。在一項專門針對FAI綜合征的關節(jié)鏡下唇部修復的系統(tǒng)綜述中，術后38個月平均再手術率為4.3%，2%需要關節(jié)置換術24)。一項對患有FAI綜合征的運動員的系統(tǒng)綜述顯示，5.5%的患者在至少2年的隨訪中需要再手術。?TheRoleofAdjunctiveBiologicsinArthroscopicSurgeryforFAISyndromeManyadjunctiveprocedureshavebeendevelopedtobeusedduringarthroscopicsurgeryforFAIsyndromeandenhancetheclinicaloutcomes.Itshouldbenotedthattheseproceduresaremostlyperformedduringandinadditiontoarthroscopicsurgeryratherthanasanindependentproceduresuchasintra-articularinjection.Thesebiologictreatmentsincludebonemarrowaspirateconcentrates,platelet-richplasma(PRP),growthfactors,culture-expandedmesenchymalstemcells,andautologouschondrocytederivatives.35,36,37,38,39,40,41,42,43,44)Inmoststudies,themaintargetofbiologicswasthechondrallesionsratherthanthelabrallesions.Althoughautologouschondrocyteimplantationwasrelatedtodifficultyinharvestingandvarietyintheconcentrationofthedeliveredchondrocytes,studiesreportedvariableimprovementsinclinicalscores.35,38,40)StudiesusingPRPsasanadjunctivetherapyresultedinnostatisticaldifferencecomparedtothecontrolgroupintermsofclinicalscores,additionalsurgery,andsubsequentarthroplasty.37,42,43)TheuseofbiologicadjunctsinFAIsyndromeisnotsupportedwithrobustevidenceandshouldnotbeconsideredprimarilyinthecurrentstatus.許多輔助手術已被開發(fā)用于FAI綜合征的關節(jié)鏡手術，并提高了臨床結果。值得注意的是，這些手術大多是在關節(jié)鏡手術期間或手術之外進行的，而不是作為關節(jié)內注射等獨立手術進行。這些生物治療包括骨髓濃縮液、富血小板血漿(PRP)、生長因子、培養(yǎng)擴增間充質干細胞和自體軟骨細胞衍生物35,36,37,38,39,40,41,42,43,44)。在大多數研究中，生物制劑的主要靶點是軟骨病變，而不是唇部病變。盡管自體軟骨細胞植入與收獲困難和所遞送的軟骨細胞濃度變化有關，但研究報告了臨床評分的不同改善35,38,40)。使用PRPs作為輔助治療的研究與對照組相比，在臨床評分、額外手術37,42,43)在FAI綜合征中使用生物輔助治療沒有強有力的證據支持，目前不應主要考慮使用生物輔助治療。?COMPARISONWITHCONSERVATIVETREATMENTThemainstreamtreatmentmodalityforFAIsyndromehasbeensurgical,especiallyarthroscopicinthecontemporaryliterature.However,itisreportedthatawiderangeofpatientsbenefittedfromvariousconservativetreatments.45,46,47,48)Theefficacyofarthroscopicsurgeryshouldbecomparedwithconservativetreatmentduetoitsinvasiveness.在當代文獻中，FAI綜合征的主流治療方式是手術，尤其是關節(jié)鏡。然而，據報道，各種保守治療對廣泛的患者有益45,46,47,48)。由于關節(jié)鏡手術的侵入性，其療效應與保守治療進行比較。?Intra-articularInjectionforFAISyndromeAmongconservativetreatment,intra-articularinjectionforFAIsyndromeisknownforitseffectivenessinbothdiagnosis49)andpainrelief.50)However,thedurationofpainreliefanditsclinicalimpacthaslongbeenandisstillcontroversial.51,52,53,54)Infact,therewerenotmanystudieswithhigh-levelevidence,reportingtheresultsofinjectionforFAIsyndrome.Abateetal.45)reportedin2014thatwhenhyaluronicacidinjectionwasperformedunderultrasoundguidancein20FAIpatients,allclinicalsymptomsimprovedwithoutanypatientrequiringsurgeryfor1year.在保守治療中，關節(jié)內注射治療FAI綜合征以其診斷和緩解疼痛的有效性而聞名50)。然而，疼痛緩解的持續(xù)時間及其臨床影響一直存在爭議，并且仍然存在爭議51,52,53,54)事實上，并沒有很多高水平證據的研究報道了注射治療FAI綜合征的結果。Abateetal.45)在2014年報道，在超聲引導下對20例FAI患者進行透明質酸注射，1年內無一例患者需要手術，所有臨床癥狀均得到改善。Somestudiesadvocateactivityrestrictionorphysicaltherapyovertheinjectionsinconservativetreatment.55,56)Zogbyetal.56)conductedaprospectivestudyinwhichpatientswhodidnotrespondtotheprevioustreatmentweretreatedinthefollowingorder:activityrestriction,drugtreatment,injection,andarthroscopicsurgery.Therewasnosignificantdifferenceinclinicalscoresinanypatientgroupat5years.However,therateofreturntoexercisewashighestinthegroupofpatientswhoreceivedonlyactivityrestrictionsanddrugtreatment,whichmaybeduetoselectionbiasinthatthemoreseverethecondition,themorelikelythepatientsweretoreceivemoreintensivetreatment.56)Ameta-analysispublishedin2019comparedthephysicaltherapygroupandtheinjectiongroupamongconservativetreatments,andbothpainandfunctionshowedbetterresultsinthephysicaltherapygroupthantheinjectiongroup.55)一些研究主張在保守治療中限制活動或物理治療而不是注射。Zogby等人進行了一項前瞻性研究，對先前治療無效的患者按以下順序進行治療:限制活動、藥物治療、注射、關節(jié)鏡手術。5年時，兩組患者的臨床評分均無顯著差異。然而，僅接受活動限制和藥物治療的患者恢復運動的比率最高，這可能是由于選擇偏倚，因為病情越嚴重，患者越有可能接受更強化的治療56)。2019年發(fā)表的一項薈萃分析比較了保守治療中的物理治療組和注射組。在疼痛和功能方面，物理治療組均優(yōu)于注射組。Leeetal.57)publishedanRCTin2016thatcomparedtriamcinoloneandhyaluronicacidinjectioninpatientswithFAIsyndrome.Patientswhohadnoimprovementaftertakingeachdrugonebyonewerealternatelyadministeredfor2weeks.Asaresult,bothdrugswereeffectiveforpain,butonlypatientswhotookthecross-medicationshowedasignificantimprovementintermsoffunction.Bymedication,triamcinoloneshowedrapidpainrelief,whilehyaluronicacidhadaslowereffectbutresultedingreaterfunctionalimprovement.Sideeffectsmainlyoccurredwhenusingtriamcinolone,themostcommonbeingfacialflushingandmenstrualabnormalities.57)Leeetal.57)在2016年發(fā)表了一項RCT，比較了曲安奈德和透明質酸注射在FAI綜合征患者中的作用。分別服藥后無改善的患者交替給藥2周。結果，兩種藥物對疼痛都有效，但只有服用交叉藥物的患者在功能方面表現出明顯的改善。通過藥物治療，曲安奈德能迅速緩解疼痛，而透明質酸的效果較慢，但能更大程度地改善功能。副作用主要發(fā)生在使用曲安奈德時，最常見的是面部潮紅和月經異常。Ina2-yearfollow-upstudy,208patientsunderwentarthroscopicsurgeryforFAIsyndromeafterinjectionofbetamethasoneandlidocaine.58)Thosewhorespondedtotheinjectionhadbetter2-yearclinicaloutcomesthanthosewhodidnotrespondtoinjectionsafterarthroscopicsurgery.ThisstudyhighlightedthepredictivevalueoftheinjectiononsubsequentarthroscopicsurgeryinFAIsyndromeregardlessoftheefficacyindiagnosisorpainrelief.58)在一項為期2年的隨訪研究中，208例患者在注射倍他米松和利多卡因后接受了關節(jié)鏡手術治療FAI綜合征58)。關節(jié)鏡手術后，對注射有反應的患者比對注射無反應的患者有更好的2年臨床結果。該研究強調了注射對FAI綜合征后續(xù)關節(jié)鏡手術的預測價值，無論在診斷或緩解疼痛方面是否有效58)。Accordingtotherecentliterature,intra-articularinjectioninFAIsyndromeseemstobeeffectiveinsomepatientsintermsofpainalleviationandprognosispredictionforfurthertreatment.However,itshouldbeconsideredratherthanmandatedinthosewithFAIsyndromewithwarningsthattheeffectscouldbeslightlybetterorcomparabletothephysicaltherapy.49,50,51,52,53,54,57,58)根據最近的文獻，在FAI綜合征中關節(jié)內注射似乎對一些患者的疼痛緩解和進一步治療的預后預測是有效的。然而，對于患有FAI綜合征的患者，應該考慮而不是強制使用，并警告其效果可能略好于或與物理治療相當(49,50,51,52,53,54,57,58)。?ComparisonofClinicalResultsbetweenConservativeversusArthroscopicTreatmentsIn2020,Bastosetal.59)reportedthattherewasnosignificantfunctionaldifferencebetweenthesurgerygroupandtheconservativetreatmentgroupinameta-analysisof650patientsincludedin3RCTs.However,asthefollow-upperiodoftheincludedstudiesrangedfrom6monthsto2years,thelong-termeffectswereunknown.Incontrast,anothermeta-analysison6RCTsincluding1,187patientsreportedthatarthroscopicsurgerysignificantlyimprovedclinicalscoreswithin1yearcomparedtoconservativetreatment.60)2020年，Bastosetal.59)對3項隨機對照試驗的650例患者進行meta分析，發(fā)現手術組與保守治療組的功能無顯著差異。然而，由于納入研究的隨訪期為6個月至2年，長期影響尚不清楚。相比之下，另一項對6項隨機對照試驗(包括1187例患者)的薈萃分析報告，與保守治療相比，關節(jié)鏡手術在1年內顯著提高了臨床評分。OneofthecausesofdiscrepancyamongcomparisonsseemstobethediversityofconservativetreatmentforFAIsyndrome.ArthroscopicsurgeryforFAIsyndromemainlyconsistsoflabraldebridement,labralrepair,acetabuloplasty,andfemoroplasty.9,18,24,33)However,themodalityofconservativetreatmentvariesgreatlyandthismightleadtoinconsistenteffects.ToobjectivelycomparetheeffectsofconservativetreatmentandarthroscopicsurgeryinFAIsyndrome,UKFASHIoN(FullRandomisedControlledtrialofArthroscopicSurgeryforHipImpingementversusbestCoNventional)trialwasconductedasamulticenterRCTin24hospitalsinEngland,Scotland,andWales.61)ThisstudycomparedtheeffectivenessofindividualizedconservativetreatmentandarthroscopicsurgeryinFAIsyndrome.Theconservativetreatmentgroupreceivedpersonalizedhiptherapy,whichwasledbytheconsensusofphysiotherapists,physicians,andsurgeonsfor12–24weeks.Thecorecomponentsofthepersonalizedhiptherapywere(1)anexerciseprogram,(2)patienteducation,and(3)painreliefwithorwithoutintra-articularsteroidinjection.61)Atotalof171patientsinthearthroscopicsurgerygroupwerecomparedwith177patientsintheconservativetreatmentgroup.At1-yearfollow-up,theinternationalHipOutcomeToolscoreincreasedinbothgroups,buttheimprovementwassignificantlygreaterinthehiparthroscopygroup.However,patient-reportedadverseeventswerealsohigherinthesurgerygroup.61)比較差異的原因之一似乎是FAI綜合征保守治療的多樣性。關節(jié)鏡下治療FAI綜合征的手術主要包括唇清創(chuàng)、唇修復、髖臼成形術和股骨成形術9,18,24,33)。然而，保守治療的方式差異很大，這可能導致效果不一致。為了客觀比較保守治療和關節(jié)鏡手術治療FAI綜合征的效果，UKFASHIoN(關節(jié)鏡手術治療髖關節(jié)撞擊與最佳常規(guī)治療的完全隨機對照試驗)在英格蘭、蘇格蘭和威爾士的24家醫(yī)院進行了一項多中心隨機對照試驗61)。本研究比較了個體化保守治療和關節(jié)鏡手術治療FAI綜合征的效果。保守治療組接受個性化髖關節(jié)治療，由物理治療師、內科醫(yī)生、外科醫(yī)生共同主導，療程12-24周。個性化髖關節(jié)治療的核心內容是:(1)運動計劃，(2)患者教育，(3)關節(jié)內類固醇注射或不注射止痛61)。關節(jié)鏡手術組共171例患者與保守治療組177例患者進行比較。在1年的隨訪中，兩組的國際髖關節(jié)預后工具評分均有所增加，但髖關節(jié)鏡組的改善明顯更大。然而，患者報告的不良事件在手術組也更高(61)。Oneofthefactorsthatmightfavorconservativetreatmentoverarthroscopycouldbethesteeplearningcurveofhiparthroscopicsurgery.62,63)Despitetherecentpopularity,hiparthroscopicsurgeryproceduresaretechnicallychallenging,evenstartingfromthetractionapplicationandportalplacement.64)ToachievethefavorableoutcomesexpectedfromarthroscopicsurgeryforFAIsyndrome,surgeonsshouldovercomethelearningcurve.Asystematicreviewonthissubjectwasconductedin2014andsuggestedthatatleast30caseswereusedasthecutoffvalueforthelearningcurveforhiparthroscopy.65)In2020,Youetal.63)reportedthatsurgicaleffectivenesswasmaximizedafter110casesinaprospectivestudyof190casesofhiparthroscopicsurgeryinFAIsyndrome.Comparingthelow-andhigh-volumesurgeons,Mehtaetal.62)reportedthat519casesofcareervolumesweretheoptimalcutoffvaluefordecreasingtheriskofsubsequenthipsurgery.Thesefindingsindicatethathiparthroscopistsshouldreachacertainlevelofsurgicalvolumetoprovidetheexpectedoutcomesofarthroscopicsurgerythatcouldsurpassthoseofconservativetreatments.與關節(jié)鏡相比，保守治療更受青睞的因素之一可能是髖關節(jié)鏡手術的陡峭學習曲線62,63)。盡管最近很流行，但髖關節(jié)鏡手術程序在技術上具有挑戰(zhàn)性，甚至從牽引應用和入路開始64)。為了獲得FAI綜合征關節(jié)鏡手術預期的良好結果，外科醫(yī)生應該克服學習曲線。2014年對該主題進行了系統(tǒng)回顧，建議至少使用30例病例作為髖關節(jié)鏡學習曲線的截止值65)。2020年，You等人(63)報道，在190例FAI綜合征髖關節(jié)鏡手術的前瞻性研究中，手術效果在110例后達到最大。Mehta等人(62)比較了低容量和高容量的外科醫(yī)生，報道519例職業(yè)容量是降低后續(xù)髖關節(jié)手術風險的最佳臨界值。這些結果表明，髖關節(jié)鏡醫(yī)師應達到一定的手術量水平，以提供關節(jié)鏡手術的預期結果，可能超過保守治療。TheefficacyofconservativetreatmentandarthroscopicsurgeryinFAIsyndromeseemstobecomparable.59,60)TheremightbesomeconfoundingfactorssuchasthesubtypesofFAIsyndromeoraccompanyingintra-articularpathologies.Intheclinicalsettings,however,surgicalinterventionisusuallyconsideredafteracertaindurationofconservativetreatment.56)Therefore,inpatientswhohaveintractablepainevenaftersufficientpersonalizedconservativetherapy,arthroscopicsurgerycouldbebeneficialifperformedcarefullyfollowingrightindications.保守治療和關節(jié)鏡手術治療FAI綜合征的療效似乎是相當的59,60)?？赡艽嬖谝恍┗煜蛩兀鏔AI綜合征的亞型或伴隨的關節(jié)內病變。然而，在臨床上，通常在保守治療一段時間后才考慮手術干預56)。因此，對于難治性疼痛的患者，即使經過充分的個性化保守治療，如果按照正確的指征仔細進行關節(jié)鏡手術也是有益的。?CONCLUSIONRecentstudiesprovidedthefollowinganswerstothequestionsfrequentlyaskedbypatientswithFAIsyndromeinoutpatientclinics.ArthroscopicsurgeryforFAIsyndromewaseffectivewithregardtohippain,function,returntoexercise,rangeofmotion,andqualityoflife.However,whilehippainimprovedquickly,functionalrecoveryseemedtoplateauafter6months.Arthroscopicsurgeryshowedrelativelybetterresultsinyoungerpatients,patientswithlowBMIorgoodpreoperativefunction,andthosewhorespondedwelltoinjection,andmostcomplicationswereresolvedwithin2years.Reoperationafterarthroscopicsurgerywasrequiredinapproximately4%to13%ofpatients.ThereiscurrentlynorobustevidenceshowingthatbiologicadjunctsareeffectiveinarthroscopicsurgeryforFAIsyndrome.Intra-articularinjectionforFAIsyndromemaybeeffectivedependingonthepatientandcouldbeconsideredincasesofthelackofresponsetomedicationbeforesurgery.Theinitialfunctionalresultsofarthroscopicsurgerymaynotdiffersignificantlyfromthoseofconservativetreatment.最近的研究為FAI綜合征患者在門診常見的問題提供了以下答案。關節(jié)鏡手術治療FAI綜合征在髖關節(jié)疼痛、功能、恢復運動、活動范圍和生活質量方面是有效的。然而，雖然髖關節(jié)疼痛迅速改善，但6個月后功能恢復似乎趨于平穩(wěn)。關節(jié)鏡手術在年齡較小、BMI較低或術前功能較好的患者以及注射反應良好的患者中效果相對較好，大多數并發(fā)癥在2年內解決。約4%至13%的患者需要在關節(jié)鏡手術后再次手術。目前沒有強有力的證據表明生物輔助治療在關節(jié)鏡手術治療FAI綜合征中是有效的。關節(jié)內注射治療FAI綜合征可能有效，取決于患者，在手術前對藥物缺乏反應的情況下可以考慮。關節(jié)鏡手術的初始功能結果可能與保守治療沒有顯著差異。