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關(guān)節(jié)鏡治療與保守治療髖關(guān)節(jié)撞擊綜合征:最新綜述（2024）關(guān)節(jié)鏡治療與保守治療髖關(guān)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(zhuǎn)載文章的原鏈接1：https://pubmed.ncbi.nlm.nih.gov/39092294/?轉(zhuǎn)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(guān)節(jié)撞擊(FAI)綜合征的治療策略隨著對(duì)FAI對(duì)髖關(guān)節(jié)健康影響的了解的增加而不斷發(fā)展。早期干預(yù)，包括關(guān)節(jié)鏡手術(shù)，由于有可能延緩骨關(guān)節(jié)炎的進(jìn)展而越來(lái)越受歡迎。關(guān)節(jié)鏡手術(shù)治療FAI綜合征的療效顯著，來(lái)自隨機(jī)對(duì)照試驗(yàn)和系統(tǒng)評(píng)價(jià)的有力證據(jù)支持其應(yīng)用。盡管關(guān)節(jié)鏡手術(shù)很成功，但并發(fā)癥和再手術(shù)并不少見(jiàn)。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(jù)支持它們?cè)贔AI綜合征中的常規(guī)應(yīng)用。在保守治療方法中，關(guān)節(jié)內(nèi)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(yù)后，但它們的長(zhǎng)期療效仍然是一個(gè)有爭(zhēng)議的話題。保守治療和關(guān)節(jié)鏡治療的比較研究強(qiáng)調(diào)了個(gè)性化治療FAI綜合征的重要性?？傊?，F(xiàn)AI綜合征管理的最新進(jìn)展闡明了各種治療方式。關(guān)節(jié)鏡手術(shù)是一種關(guān)鍵的干預(yù)措施，在疼痛緩解、功能和生活質(zhì)量方面提供了實(shí)質(zhì)性的好處。然而，仔細(xì)的患者選擇和術(shù)后監(jiān)測(cè)是優(yōu)化結(jié)果的關(guān)鍵。輔助生物制劑和關(guān)節(jié)內(nèi)注射顯示出前景，但需要進(jìn)一步研究。在優(yōu)化FAI綜合征管理中，根據(jù)患者個(gè)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(shí)體。從那時(shí)起，關(guān)于FAI的文章數(shù)量在過(guò)去10年里增加了大約3.4倍。根據(jù)2022年發(fā)表的一項(xiàng)研究，早在3000年前，古努比亞就存在FAI綜合征——盡管它可能沒(méi)有被認(rèn)為是一種疾病。2)FAI綜合征的當(dāng)代定義主要基于2016年沃里克協(xié)議共識(shí)，該協(xié)議強(qiáng)調(diào)癥狀、臨床體征和影像學(xué)結(jié)果的三重特征來(lái)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(guān)節(jié)、背部、臀部或股骨前側(cè)與運(yùn)動(dòng)或位置相關(guān)的疼痛4)。除了疼痛外，機(jī)械性癥狀，如抓、鎖、讓位或咔噠聲也可能在受限的運(yùn)動(dòng)范圍內(nèi)發(fā)生5)。FAI綜合征的臨床癥狀最常用的是屈曲、內(nèi)收和內(nèi)旋(FADIR)試驗(yàn)，因?yàn)樗撵`敏度很高6)。FAI綜合征的診斷影像學(xué)主要集中在盆腔正位片、Dunn片、跨臺(tái)側(cè)位片或蛙腿側(cè)位片上尋找具有外側(cè)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(duì)這種疾病的進(jìn)一步了解，F(xiàn)AI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(guān)節(jié)骨關(guān)節(jié)炎的報(bào)道。這一概念是由Stulberg等人(8)以“未被識(shí)別的兒童髖關(guān)節(jié)疾病”一詞提出的，該疾病可能導(dǎo)致髖關(guān)節(jié)特發(fā)性骨關(guān)節(jié)炎。2003年，Ganz等人(4)回顧了600多例病例，建議早期干預(yù)FAI以延緩年輕患者髖關(guān)節(jié)骨性關(guān)節(jié)炎。目前，隨著關(guān)節(jié)鏡手術(shù)的日益普及，F(xiàn)AI綜合征的標(biāo)準(zhǔn)治療包括活動(dòng)調(diào)節(jié)、康復(fù)或手術(shù)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(yù)后10,11,12,13)。Cam病變更常見(jiàn)于青春期后男性。而鉗形病變?cè)谥心陭D女中更為普遍14)。已經(jīng)確定，鉗形病變與隨后的骨關(guān)節(jié)炎的發(fā)展有關(guān)，但鉗形病變與骨關(guān)節(jié)炎之間的關(guān)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(diǎn)更側(cè)重于預(yù)防繼發(fā)骨關(guān)節(jié)炎，而不是治療FAI綜合征本身，因此它不同于髖關(guān)節(jié)置換術(shù)等最終治療，后者是終末期髖關(guān)節(jié)骨關(guān)節(jié)炎的金標(biāo)準(zhǔn)。對(duì)于保守治療，活動(dòng)調(diào)節(jié)，物理治療，口服鎮(zhèn)痛藥控制疼痛，關(guān)節(jié)內(nèi)注射是常用的處方3,16)。對(duì)于手術(shù)，傳統(tǒng)的開(kāi)放手術(shù)和關(guān)節(jié)鏡手術(shù)都有報(bào)道有效，但后者由于恢復(fù)快，最近可能越來(lái)越受歡迎。澄清FAI綜合征治療策略的臨床證據(jù)正在迅速聚集，但治療方式的有效性存在爭(zhēng)議16,18)。因此，本研究的目的是回顧最近的文獻(xiàn)，評(píng)估關(guān)節(jié)鏡治療FAI綜合征的有效性，并與保守治療進(jìn)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(guān)節(jié)鏡手術(shù)治療FAI綜合征的成功案例迅速增加。基于全球開(kāi)展的可靠隨機(jī)對(duì)照試驗(yàn)(RCTs)和系統(tǒng)評(píng)價(jià)/薈萃分析的高水平證據(jù)，為關(guān)節(jié)鏡治療FAI綜合征提供了理論依據(jù)19,20,21,22,23,24,25)。由于關(guān)節(jié)鏡的侵入性較小，手術(shù)結(jié)果可比較，因此在FAI綜合征中，髖關(guān)節(jié)鏡正逐漸取代開(kāi)放手術(shù)。在美國(guó)，髖關(guān)節(jié)鏡手術(shù)的數(shù)量在2004年至2009年間增加了3倍以上(26)。2013年，關(guān)節(jié)鏡手術(shù)治療FAI的病例為1908例，而英國(guó)的開(kāi)放手術(shù)僅為491例(27)。ThedistinctivemorphologicfeaturesofFAIsyndromearedirectlyvisualizedthrougharthroscopicexamination.28)Duringarthroscopicsurgery,camlesionsorpincerlesions,aswellasthesubtlechondrallesionsorlabraltears,areobserved.29)Someoftheselesionsarenotreadilyvisualizedincomputedtomographyscansormagneticresonanceimagingbutonlyfoundinarthroscopicexamination.28,29)Arthroscopicconfirmationofsuspectedlesions,aswellasconsequenttreatmentperformeddirectlythrougharthroscopicmanagement,isoneofthefactorsthatcontributetotheincreasingpopularityofarthroscopicsurgery.關(guān)節(jié)鏡檢查可直接觀察到FAI綜合征的獨(dú)特形態(tài)學(xué)特征28)。在關(guān)節(jié)鏡手術(shù)中，可觀察到凸輪病變或鉗形病變，以及細(xì)微的軟骨病變或唇裂29)。其中一些病變?cè)谟?jì)算機(jī)斷層掃描或磁共振成像中不易觀察到，而只有在關(guān)節(jié)鏡檢查中才能發(fā)現(xiàn)。以及隨后的治療直接通過(guò)關(guān)節(jié)鏡管理，是促成關(guān)節(jié)鏡手術(shù)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(xiàn)為撞擊。通常，凸輪型病變發(fā)生在股骨頸的前上側(cè)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(guò)度覆蓋有關(guān)，通常與先前存在的髖臼成熟有關(guān)11)。然而，應(yīng)該注意的是，同時(shí)伴有凸輪和鉗形病變的混合型FAI綜合征非常常見(jiàn)。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(xué)的角度，對(duì)12項(xiàng)關(guān)于凸輪型FAI綜合征的研究進(jìn)行了系統(tǒng)回顧(173例凸輪病變與177例對(duì)照)，并報(bào)道凸輪病變降低了髖關(guān)節(jié)矢狀面運(yùn)動(dòng)范圍、髖關(guān)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(bào)道，在凸輪型FAI綜合征中，關(guān)節(jié)鏡下凸輪切除后，20°內(nèi)旋時(shí)的峰值接觸應(yīng)力下降了近一半(26.6~11.4MPa)。另一項(xiàng)對(duì)鉗形病變進(jìn)行有限元建模的研究顯示，與對(duì)照組相比，髖臼前上緣的最大應(yīng)力應(yīng)變?cè)黾恿?至3.4倍。ArecentsystematicreviewconcludedwhenarthroscopicsurgeryisperformedforFAI,flexionandinternalrotationofthehipjointoftenimproveaftersurgery,butexternalrotationanglemaynotincreasesignificantly.20)ThesestudiesprovideabiomechanicalbackgroundonhowarthroscopicsurgerycouldaidinpainandfunctionalimprovementinFAIsyndrome.最近的一項(xiàng)系統(tǒng)綜述得出結(jié)論，當(dāng)關(guān)節(jié)鏡手術(shù)治療FAI時(shí)，髖關(guān)節(jié)的屈曲和內(nèi)旋通常在手術(shù)后得到改善，但外旋角度可能不會(huì)顯著增加20)。這些研究為關(guān)節(jié)鏡手術(shù)如何幫助FAI綜合征的疼痛和功能改善提供了生物力學(xué)背景。?PatientSelectioninArthroscopicSurgeryforFAISyndromePatientselectionintreatingFAIsyndromeisespeciallyimportantinthatthecomplicationratecouldvaryamongdifferentpatientdemographics.ItiscommonlyacceptedthatobesepatientswhodevelopedarthritisarenottheidealcandidatesforsurgicalprocedurestotreatFAIsyndrome.Somestudieshaveconstructedevidenceonidealfeaturesofpatientstobetreatedwitharthroscopicsurgery.21,22)治療FAI綜合征的患者選擇尤其重要，因?yàn)椴煌颊叩牟l(fā)癥發(fā)生率可能不同。人們普遍認(rèn)為，患有關(guān)節(jié)炎的肥胖患者并不是手術(shù)治療FAI綜合征的理想人選。一些研究已經(jīng)為關(guān)節(jié)鏡手術(shù)患者的理想特征提供了證據(jù)21,22)。Kayetal.21)reportedfactorsaffectingpain,function,andqualityoflifeinpatientswhoareincludedintheFIRST(FemoroacetabularImpingementRandomisedControlledTrial)studyin2021.Theresultsofthestudyshowedthat1yearaftersurgery,theimprovementinqualityoflifewasgreaterinyoungerpatients,andtheimprovementinpainwasgreaterinpatientswithlowerbodymassindex(BMI).Nofactorsshowedanassociationwithreoperation,whichoccurredin13%.21)Kayetal.21)報(bào)道了2021年FIRST(股骨髖臼撞擊隨機(jī)對(duì)照試驗(yàn))研究中患者的疼痛、功能和生活質(zhì)量的影響因素。研究結(jié)果顯示，術(shù)后1年，年輕患者的生活質(zhì)量改善更大，體重指數(shù)(BMI)較低的患者疼痛改善更大。無(wú)因素顯示與再手術(shù)相關(guān)，再手術(shù)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(xiàng)研究(4,063例)中關(guān)注FAI綜合征關(guān)節(jié)鏡手術(shù)后恢復(fù)運(yùn)動(dòng)，發(fā)現(xiàn)89%的患者能夠在3年內(nèi)恢復(fù)運(yùn)動(dòng)。特別是術(shù)前年齡較小、體重較輕、關(guān)節(jié)炎分期較低(T?nnisI級(jí))、髖關(guān)節(jié)功能較好的患者，術(shù)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(lái)越多的證據(jù)支持關(guān)節(jié)鏡手術(shù)治療FAI綜合征的療效19,22,23,24,32,33)。為了比較特定關(guān)節(jié)鏡手術(shù)的療效，F(xiàn)IRST研究在加拿大、芬蘭和丹麥的10家機(jī)構(gòu)進(jìn)行了多中心、盲法隨機(jī)對(duì)照試驗(yàn)25)。比較關(guān)節(jié)鏡下骨軟骨成形術(shù)與關(guān)節(jié)鏡下灌洗術(shù)在疼痛、剩余功能和生活質(zhì)量方面的結(jié)果。本研究的背景反映了目前對(duì)FAI綜合征的認(rèn)知，該綜合征已成為一個(gè)巨大的經(jīng)濟(jì)負(fù)擔(dān)，而對(duì)手術(shù)的有效性尚未達(dá)成共識(shí)。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(xiàng)試驗(yàn)中試圖報(bào)告臨床過(guò)程，特別是在骨軟骨成形術(shù)組。他們?cè)谑中g(shù)后基線、2周、6周、3個(gè)月、6個(gè)月和12個(gè)月評(píng)估疼痛和功能評(píng)分。術(shù)后疼痛視覺(jué)模擬量表迅速改善，功能評(píng)分逐漸恢復(fù)，但6個(gè)月后無(wú)明顯改善32)。2022年，Almasri等(33)將隨機(jī)與灌洗組、隨機(jī)與骨軟骨成形術(shù)組、拒絕參加RCT但接受骨軟骨成形術(shù)的患者、不符合納入標(biāo)準(zhǔn)但接受骨軟骨成形術(shù)的患者的并發(fā)癥和功能評(píng)分進(jìn)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(duì)診斷性髖關(guān)節(jié)注射無(wú)反應(yīng)的患者，但在這組患者中，骨軟骨成形術(shù)顯示出較低的再手術(shù)率和較大的功能改善。至于原因，作者認(rèn)為，由于納入隨機(jī)對(duì)照試驗(yàn)的患者是隨機(jī)的，他們傾向于報(bào)告更輕微的癥狀，因?yàn)樗麄冋J(rèn)為他們接受了隨機(jī)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(xiàng)系統(tǒng)綜述中回顧了10項(xiàng)前瞻性研究，分析了470例手術(shù)。這項(xiàng)研究是在平均年齡小于16歲的年輕患者中進(jìn)行的，經(jīng)過(guò)兩年多的隨訪，94%的患者能夠恢復(fù)運(yùn)動(dòng)。另一項(xiàng)系統(tǒng)綜述了5項(xiàng)關(guān)節(jié)鏡下髖臼唇修復(fù)的研究。210例患者在手術(shù)后2年內(nèi)恢復(fù)運(yùn)動(dòng)，34個(gè)月時(shí)所有臨床評(píng)分均有所改善24)。在2021年，Annin等人(19)報(bào)道了一項(xiàng)系統(tǒng)綜述，包括18項(xiàng)研究和1123例FAI運(yùn)動(dòng)員關(guān)節(jié)鏡手術(shù)后恢復(fù)運(yùn)動(dòng)和功能。在手術(shù)技術(shù)方面，唇部修復(fù)術(shù)比切除術(shù)多3倍以上，重建術(shù)很少。90%以上的病例行股骨成形術(shù)。他們的結(jié)論是，與損傷前相比，F(xiàn)AI綜合征的關(guān)節(jié)鏡治療可顯著改善運(yùn)動(dòng)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(jī)對(duì)照試驗(yàn)和系統(tǒng)評(píng)價(jià)在內(nèi)的高質(zhì)量研究一致認(rèn)為關(guān)節(jié)鏡手術(shù)治療FAI綜合征是有效的(19,22,23,24,32,33)。然而，由于沒(méi)有單獨(dú)研究具體的手術(shù)類型(唇清創(chuàng)、唇修復(fù)、髖臼成形術(shù)和股骨成形術(shù))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(guān)節(jié)鏡手術(shù)在FAI綜合征中具有突出的價(jià)值，但不良事件并不罕見(jiàn)。關(guān)節(jié)鏡手術(shù)后并發(fā)癥和再手術(shù)的發(fā)生率分別為1%~31%和4%~13%。常見(jiàn)的不良事件包括持續(xù)髖關(guān)節(jié)疼痛、唇部再損傷、股外側(cè)皮神經(jīng)暫時(shí)性感覺(jué)異常、會(huì)陰神經(jīng)暫時(shí)性感覺(jué)異常、cam病變復(fù)發(fā)、關(guān)節(jié)囊粘連、髖關(guān)節(jié)骨關(guān)節(jié)炎和淺表感染。Ohlin等人(34)報(bào)道，86.5%的不良事件在關(guān)節(jié)鏡手術(shù)后24個(gè)月內(nèi)消失，沒(méi)有危及生命的并發(fā)癥。作者進(jìn)一步通過(guò)骨軟骨成形術(shù)、唇部修復(fù)或引流治療關(guān)節(jié)鏡翻修手術(shù)的持續(xù)并發(fā)癥，無(wú)任何實(shí)質(zhì)性損傷34)。同樣，Annin等人在一項(xiàng)包括18項(xiàng)研究和904例患者的系統(tǒng)綜述中報(bào)告了5.5%的翻修手術(shù)和0.6%的后續(xù)全髖關(guān)節(jié)置換術(shù)。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(shù)治療和非手術(shù)治療。在FIRST試驗(yàn)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(yàn)中的骨軟骨成形術(shù)組(8%和14%)，拒絕隨機(jī)分組但接受骨軟骨成形術(shù)的患者(10%和4%)，以及不符合納入標(biāo)準(zhǔn)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(duì)列報(bào)道了FAI綜合征關(guān)節(jié)鏡手術(shù)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(shù)率為13%。翻修手術(shù)最常在指數(shù)手術(shù)后中位15個(gè)月(范圍1-25個(gè)月)進(jìn)行，超過(guò)86%的不良事件在24個(gè)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(xiàng)針對(duì)青少年FAI綜合征的關(guān)節(jié)鏡手術(shù)的系統(tǒng)綜述中，在平均28個(gè)月的隨訪中，約1%的患者出現(xiàn)并發(fā)癥，5%的患者需要再次進(jìn)行關(guān)節(jié)鏡手術(shù)。最常見(jiàn)的并發(fā)癥是股外側(cè)皮神經(jīng)暫時(shí)性感覺(jué)異常(0.4%)和會(huì)陰神經(jīng)暫時(shí)性感覺(jué)異常(0.4%)。作者得出結(jié)論，關(guān)節(jié)鏡手術(shù)對(duì)青少年FAI綜合征的髖關(guān)節(jié)疼痛、功能和生活質(zhì)量是有益的23)。在一項(xiàng)專門(mén)針對(duì)FAI綜合征的關(guān)節(jié)鏡下唇部修復(fù)的系統(tǒng)綜述中，術(shù)后38個(gè)月平均再手術(shù)率為4.3%，2%需要關(guān)節(jié)置換術(shù)24)。一項(xiàng)對(duì)患有FAI綜合征的運(yùn)動(dòng)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(shù)。?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(shù)已被開(kāi)發(fā)用于FAI綜合征的關(guān)節(jié)鏡手術(shù)，并提高了臨床結(jié)果。值得注意的是，這些手術(shù)大多是在關(guān)節(jié)鏡手術(shù)期間或手術(shù)之外進(jìn)行的，而不是作為關(guān)節(jié)內(nèi)注射等獨(dú)立手術(shù)進(jìn)行。這些生物治療包括骨髓濃縮液、富血小板血漿(PRP)、生長(zhǎng)因子、培養(yǎng)擴(kuò)增間充質(zhì)干細(xì)胞和自體軟骨細(xì)胞衍生物35,36,37,38,39,40,41,42,43,44)。在大多數(shù)研究中，生物制劑的主要靶點(diǎn)是軟骨病變，而不是唇部病變。盡管自體軟骨細(xì)胞植入與收獲困難和所遞送的軟骨細(xì)胞濃度變化有關(guān)，但研究報(bào)告了臨床評(píng)分的不同改善35,38,40)。使用PRPs作為輔助治療的研究與對(duì)照組相比，在臨床評(píng)分、額外手術(shù)37,42,43)在FAI綜合征中使用生物輔助治療沒(méi)有強(qiáng)有力的證據(jù)支持，目前不應(yīng)主要考慮使用生物輔助治療。?COMPARISONWITHCONSERVATIVETREATMENTThemainstreamtreatmentmodalityforFAIsyndromehasbeensurgical,especiallyarthroscopicinthecontemporaryliterature.However,itisreportedthatawiderangeofpatientsbenefittedfromvariousconservativetreatments.45,46,47,48)Theefficacyofarthroscopicsurgeryshouldbecomparedwithconservativetreatmentduetoitsinvasiveness.在當(dāng)代文獻(xiàn)中，F(xiàn)AI綜合征的主流治療方式是手術(shù)，尤其是關(guān)節(jié)鏡。然而，據(jù)報(bào)道，各種保守治療對(duì)廣泛的患者有益45,46,47,48)。由于關(guān)節(jié)鏡手術(shù)的侵入性，其療效應(yīng)與保守治療進(jìn)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(guān)節(jié)內(nèi)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(shí)間及其臨床影響一直存在爭(zhēng)議，并且仍然存在爭(zhēng)議51,52,53,54)事實(shí)上，并沒(méi)有很多高水平證據(jù)的研究報(bào)道了注射治療FAI綜合征的結(jié)果。Abateetal.45)在2014年報(bào)道，在超聲引導(dǎo)下對(duì)20例FAI患者進(jìn)行透明質(zhì)酸注射，1年內(nèi)無(wú)一例患者需要手術(shù)，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?jiān)诒Ｊ刂委熤邢拗苹顒?dòng)或物理治療而不是注射。Zogby等人進(jìn)行了一項(xiàng)前瞻性研究，對(duì)先前治療無(wú)效的患者按以下順序進(jìn)行治療:限制活動(dòng)、藥物治療、注射、關(guān)節(jié)鏡手術(shù)。5年時(shí)，兩組患者的臨床評(píng)分均無(wú)顯著差異。然而，僅接受活動(dòng)限制和藥物治療的患者恢復(fù)運(yùn)動(dòng)的比率最高，這可能是由于選擇偏倚，因?yàn)椴∏樵絿?yán)重，患者越有可能接受更強(qiáng)化的治療56)。2019年發(fā)表的一項(xiàng)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(xiàng)RCT，比較了曲安奈德和透明質(zhì)酸注射在FAI綜合征患者中的作用。分別服藥后無(wú)改善的患者交替給藥2周。結(jié)果，兩種藥物對(duì)疼痛都有效，但只有服用交叉藥物的患者在功能方面表現(xiàn)出明顯的改善。通過(guò)藥物治療，曲安奈德能迅速緩解疼痛，而透明質(zhì)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(shí)，最常見(jiàn)的是面部潮紅和月經(jīng)異常。Ina2-yearfollow-upstudy,208patientsunderwentarthroscopicsurgeryforFAIsyndromeafterinjectionofbetamethasoneandlidocaine.58)Thosewhorespondedtotheinjectionhadbetter2-yearclinicaloutcomesthanthosewhodidnotrespondtoinjectionsafterarthroscopicsurgery.ThisstudyhighlightedthepredictivevalueoftheinjectiononsubsequentarthroscopicsurgeryinFAIsyndromeregardlessoftheefficacyindiagnosisorpainrelief.58)在一項(xiàng)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(guān)節(jié)鏡手術(shù)治療FAI綜合征58)。關(guān)節(jié)鏡手術(shù)后，對(duì)注射有反應(yīng)的患者比對(duì)注射無(wú)反應(yīng)的患者有更好的2年臨床結(jié)果。該研究強(qiáng)調(diào)了注射對(duì)FAI綜合征后續(xù)關(guān)節(jié)鏡手術(shù)的預(yù)測(cè)價(jià)值，無(wú)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(jù)最近的文獻(xiàn)，在FAI綜合征中關(guān)節(jié)內(nèi)注射似乎對(duì)一些患者的疼痛緩解和進(jìn)一步治療的預(yù)后預(yù)測(cè)是有效的。然而，對(duì)于患有FAI綜合征的患者，應(yīng)該考慮而不是強(qiáng)制使用，并警告其效果可能略好于或與物理治療相當(dāng)(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(duì)3項(xiàng)隨機(jī)對(duì)照試驗(yàn)的650例患者進(jìn)行meta分析，發(fā)現(xiàn)手術(shù)組與保守治療組的功能無(wú)顯著差異。然而，由于納入研究的隨訪期為6個(gè)月至2年，長(zhǎng)期影響尚不清楚。相比之下，另一項(xiàng)對(duì)6項(xiàng)隨機(jī)對(duì)照試驗(yàn)(包括1187例患者)的薈萃分析報(bào)告，與保守治療相比，關(guān)節(jié)鏡手術(shù)在1年內(nèi)顯著提高了臨床評(píng)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(guān)節(jié)鏡下治療FAI綜合征的手術(shù)主要包括唇清創(chuàng)、唇修復(fù)、髖臼成形術(shù)和股骨成形術(shù)9,18,24,33)。然而，保守治療的方式差異很大，這可能導(dǎo)致效果不一致。為了客觀比較保守治療和關(guān)節(jié)鏡手術(shù)治療FAI綜合征的效果，UKFASHIoN(關(guān)節(jié)鏡手術(shù)治療髖關(guān)節(jié)撞擊與最佳常規(guī)治療的完全隨機(jī)對(duì)照試驗(yàn))在英格蘭、蘇格蘭和威爾士的24家醫(yī)院進(jìn)行了一項(xiàng)多中心隨機(jī)對(duì)照試驗(yàn)61)。本研究比較了個(gè)體化保守治療和關(guān)節(jié)鏡手術(shù)治療FAI綜合征的效果。保守治療組接受個(gè)性化髖關(guān)節(jié)治療，由物理治療師、內(nèi)科醫(yī)生、外科醫(yī)生共同主導(dǎo)，療程12-24周。個(gè)性化髖關(guān)節(jié)治療的核心內(nèi)容是:(1)運(yùn)動(dòng)計(jì)劃，(2)患者教育，(3)關(guān)節(jié)內(nèi)類固醇注射或不注射止痛61)。關(guān)節(jié)鏡手術(shù)組共171例患者與保守治療組177例患者進(jìn)行比較。在1年的隨訪中，兩組的國(guó)際髖關(guān)節(jié)預(yù)后工具評(píng)分均有所增加，但髖關(guān)節(jié)鏡組的改善明顯更大。然而，患者報(bào)告的不良事件在手術(shù)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(guān)節(jié)鏡相比，保守治療更受青睞的因素之一可能是髖關(guān)節(jié)鏡手術(shù)的陡峭學(xué)習(xí)曲線62,63)。盡管最近很流行，但髖關(guān)節(jié)鏡手術(shù)程序在技術(shù)上具有挑戰(zhàn)性，甚至從牽引應(yīng)用和入路開(kāi)始64)。為了獲得FAI綜合征關(guān)節(jié)鏡手術(shù)預(yù)期的良好結(jié)果，外科醫(yī)生應(yīng)該克服學(xué)習(xí)曲線。2014年對(duì)該主題進(jìn)行了系統(tǒng)回顧，建議至少使用30例病例作為髖關(guān)節(jié)鏡學(xué)習(xí)曲線的截止值65)。2020年，You等人(63)報(bào)道，在190例FAI綜合征髖關(guān)節(jié)鏡手術(shù)的前瞻性研究中，手術(shù)效果在110例后達(dá)到最大。Mehta等人(62)比較了低容量和高容量的外科醫(yī)生，報(bào)道519例職業(yè)容量是降低后續(xù)髖關(guān)節(jié)手術(shù)風(fēng)險(xiǎn)的最佳臨界值。這些結(jié)果表明，髖關(guān)節(jié)鏡醫(yī)師應(yīng)達(dá)到一定的手術(shù)量水平，以提供關(guān)節(jié)鏡手術(shù)的預(yù)期結(jié)果，可能超過(guò)保守治療。TheefficacyofconservativetreatmentandarthroscopicsurgeryinFAIsyndromeseemstobecomparable.59,60)TheremightbesomeconfoundingfactorssuchasthesubtypesofFAIsyndromeoraccompanyingintra-articularpathologies.Intheclinicalsettings,however,surgicalinterventionisusuallyconsideredafteracertaindurationofconservativetreatment.56)Therefore,inpatientswhohaveintractablepainevenaftersufficientpersonalizedconservativetherapy,arthroscopicsurgerycouldbebeneficialifperformedcarefullyfollowingrightindications.保守治療和關(guān)節(jié)鏡手術(shù)治療FAI綜合征的療效似乎是相當(dāng)?shù)?9,60)。可能存在一些混淆因素，如FAI綜合征的亞型或伴隨的關(guān)節(jié)內(nèi)病變。然而，在臨床上，通常在保守治療一段時(shí)間后才考慮手術(shù)干預(yù)56)。因此，對(duì)于難治性疼痛的患者，即使經(jīng)過(guò)充分的個(gè)性化保守治療，如果按照正確的指征仔細(xì)進(jìn)行關(guān)節(jié)鏡手術(shù)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(mén)診常見(jiàn)的問(wèn)題提供了以下答案。關(guān)節(jié)鏡手術(shù)治療FAI綜合征在髖關(guān)節(jié)疼痛、功能、恢復(fù)運(yùn)動(dòng)、活動(dòng)范圍和生活質(zhì)量方面是有效的。然而，雖然髖關(guān)節(jié)疼痛迅速改善，但6個(gè)月后功能恢復(fù)似乎趨于平穩(wěn)。關(guān)節(jié)鏡手術(shù)在年齡較小、BMI較低或術(shù)前功能較好的患者以及注射反應(yīng)良好的患者中效果相對(duì)較好，大多數(shù)并發(fā)癥在2年內(nèi)解決。約4%至13%的患者需要在關(guān)節(jié)鏡手術(shù)后再次手術(shù)。目前沒(méi)有強(qiáng)有力的證據(jù)表明生物輔助治療在關(guān)節(jié)鏡手術(shù)治療FAI綜合征中是有效的。關(guān)節(jié)內(nèi)注射治療FAI綜合征可能有效，取決于患者，在手術(shù)前對(duì)藥物缺乏反應(yīng)的情況下可以考慮。關(guān)節(jié)鏡手術(shù)的初始功能結(jié)果可能與保守治療沒(méi)有顯著差異。