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关节镜治疗与保守治疗髋关节撞击综合征:最新综述（2024）关节镜治疗与保守治疗髋关节撞击综合征:最新综述（2024）ArthroscopicTreatmentofFemoroacetabularImpingementSyndrome:AnUpdatedReview?ParkJW,HwangJM,YooJJ.ArthroscopicTreatmentofFemoroacetabularImpingementSyndrome:AnUpdatedReview[J].ClinOrthopSurg,2024,16(4):517-525.?转载文章的原链接1：https://pubmed.ncbi.nlm.nih.gov/39092294/?转载文章的原链接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.髋关节撞击(FAI)综合征的治疗策略随着对FAI对髋关节健康影响的了解的增加而不断发展。早期干预，包括关节镜手术，由于有可能延缓骨关节炎的进展而越来越受欢迎。关节镜手术治疗FAI综合征的疗效显著，来自随机对照试验和系统评价的有力证据支持其应用。尽管关节镜手术很成功，但并发症和再手术并不少见。发病率分别为1%-31%和4%-13%。辅助生物治疗，如骨髓抽吸浓缩液和富血小板血浆，在软骨病变治疗中显示出希望。然而，目前缺乏有力的证据支持它们在FAI综合征中的常规应用。在保守治疗方法中，关节内注射为FAI患者提供了诊断和治疗的益处。虽然它们可以缓解疼痛和帮助预后，但它们的长期疗效仍然是一个有争议的话题。保守治疗和关节镜治疗的比较研究强调了个性化治疗FAI综合征的重要性。总之，FAI综合征管理的最新进展阐明了各种治疗方式。关节镜手术是一种关键的干预措施，在疼痛缓解、功能和生活质量方面提供了实质性的好处。然而，仔细的患者选择和术后监测是优化结果的关键。辅助生物制剂和关节内注射显示出前景，但需要进一步研究。在优化FAI综合征管理中，根据患者个体特征定制治疗仍然是最重要的。?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)首次将股髋臼撞击综合征(FAI)描述为一种疾病实体。从那时起，关于FAI的文章数量在过去10年里增加了大约3.4倍。根据2022年发表的一项研究，早在3000年前，古努比亚就存在FAI综合征——尽管它可能没有被认为是一种疾病。2)FAI综合征的当代定义主要基于2016年沃里克协议共识，该协议强调症状、临床体征和影像学结果的三重特征来诊断病情。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综合征的主要症状是髋关节、背部、臀部或股骨前侧与运动或位置相关的疼痛4)。除了疼痛外，机械性症状，如抓、锁、让位或咔哒声也可能在受限的运动范围内发生5)。FAI综合征的临床症状最常用的是屈曲、内收和内旋(FADIR)试验，因为它的灵敏度很高6)。FAI综合征的诊断影像学主要集中在盆腔正位片、Dunn片、跨台侧位片或蛙腿侧位片上寻找具有外侧或前中心边缘角的钳形或cam病变。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)随着对这种疾病的进一步了解，FAI综合征的治疗方法也在不断发展。治疗FAI综合征的基本原理源于FAI综合征引起髋关节骨关节炎的报道。这一概念是由Stulberg等人(8)以“未被识别的儿童髋关节疾病”一词提出的，该疾病可能导致髋关节特发性骨关节炎。2003年，Ganz等人(4)回顾了600多例病例，建议早期干预FAI以延缓年轻患者髋关节骨性关节炎。目前，随着关节镜手术的日益普及，FAI综合征的标准治疗包括活动调节、康复或手术3,9)。然而，需要注意的是，Cam型FAI综合征和钳型FAI综合征具有不同的临床特征和预后10,11,12,13)。Cam病变更常见于青春期后男性。而钳形病变在中年妇女中更为普遍14)。已经确定，钳形病变与随后的骨关节炎的发展有关，但钳形病变与骨关节炎之间的关系不太明显。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综合征治疗的主要终点更侧重于预防继发骨关节炎，而不是治疗FAI综合征本身，因此它不同于髋关节置换术等最终治疗，后者是终末期髋关节骨关节炎的金标准。对于保守治疗，活动调节，物理治疗，口服镇痛药控制疼痛，关节内注射是常用的处方3,16)。对于手术，传统的开放手术和关节镜手术都有报道有效，但后者由于恢复快，最近可能越来越受欢迎。澄清FAI综合征治疗策略的临床证据正在迅速聚集，但治疗方式的有效性存在争议16,18)。因此，本研究的目的是回顾最近的文献，评估关节镜治疗FAI综合征的有效性，并与保守治疗进行比较。?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，关节镜手术治疗FAI综合征的成功案例迅速增加。基于全球开展的可靠随机对照试验(RCTs)和系统评价/荟萃分析的高水平证据，为关节镜治疗FAI综合征提供了理论依据19,20,21,22,23,24,25)。由于关节镜的侵入性较小，手术结果可比较，因此在FAI综合征中，髋关节镜正逐渐取代开放手术。在美国，髋关节镜手术的数量在2004年至2009年间增加了3倍以上(26)。2013年，关节镜手术治疗FAI的病例为1908例，而英国的开放手术仅为491例(27)。ThedistinctivemorphologicfeaturesofFAIsyndromearedirectlyvisualizedthrougharthroscopicexamination.28)Duringarthroscopicsurgery,camlesionsorpincerlesions,aswellasthesubtlechondrallesionsorlabraltears,areobserved.29)Someoftheselesionsarenotreadilyvisualizedincomputedtomographyscansormagneticresonanceimagingbutonlyfoundinarthroscopicexamination.28,29)Arthroscopicconfirmationofsuspectedlesions,aswellasconsequenttreatmentperformeddirectlythrougharthroscopicmanagement,isoneofthefactorsthatcontributetotheincreasingpopularityofarthroscopicsurgery.关节镜检查可直接观察到FAI综合征的独特形态学特征28)。在关节镜手术中，可观察到凸轮病变或钳形病变，以及细微的软骨病变或唇裂29)。其中一些病变在计算机断层扫描或磁共振成像中不易观察到，而只有在关节镜检查中才能发现。以及随后的治疗直接通过关节镜管理，是促成关节镜手术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)凸轮型和钳型FAI综合征在股骨颈的不同部位表现为撞击。通常，凸轮型病变发生在股骨颈的前上侧面，最初被描述为异常股骨头骨骺的延伸12,13)。相反，钳形病变与髋臼过度覆盖有关，通常与先前存在的髋臼成熟有关11)。然而，应该注意的是，同时伴有凸轮和钳形病变的混合型FAI综合征非常常见。Fromabiomechanicalpointofview,asystematicreviewwasconductedon12studiesoncam-typeFAIsyndrome(173cam-lesionsvs.177controls)andreportedthatcamlesionsreducethesagittalrangeofmotionofthehipjoint,maximumextensionangle,andabductionangleofthehipjointanddecreaseiliopsoasmusclepowerandwalkingspeed.13)VanHouckeetal.30)reportedthatincamtypeFAIsyndrome,thepeakcontactstressduring20°ofinternalrotationnearlydecreasedbyhalf(26.6–11.4MPa)afterarthroscopiccamresection.Anotherstudyusingfiniteelementmodelingonpincerlesionsshowedthatthemaximumstress-strainincreased2to3.4timesintheanterosuperioracetabularrimcomparedtothatinthecontrolgroup.31)从生物力学的角度，对12项关于凸轮型FAI综合征的研究进行了系统回顾(173例凸轮病变与177例对照)，并报道凸轮病变降低了髋关节矢状面运动范围、髋关节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等人报道，在凸轮型FAI综合征中，关节镜下凸轮切除后，20°内旋时的峰值接触应力下降了近一半(26.6~11.4MPa)。另一项对钳形病变进行有限元建模的研究显示，与对照组相比，髋臼前上缘的最大应力应变增加了2至3.4倍。ArecentsystematicreviewconcludedwhenarthroscopicsurgeryisperformedforFAI,flexionandinternalrotationofthehipjointoftenimproveaftersurgery,butexternalrotationanglemaynotincreasesignificantly.20)ThesestudiesprovideabiomechanicalbackgroundonhowarthroscopicsurgerycouldaidinpainandfunctionalimprovementinFAIsyndrome.最近的一项系统综述得出结论，当关节镜手术治疗FAI时，髋关节的屈曲和内旋通常在手术后得到改善，但外旋角度可能不会显著增加20)。这些研究为关节镜手术如何帮助FAI综合征的疼痛和功能改善提供了生物力学背景。?PatientSelectioninArthroscopicSurgeryforFAISyndromePatientselectionintreatingFAIsyndromeisespeciallyimportantinthatthecomplicationratecouldvaryamongdifferentpatientdemographics.ItiscommonlyacceptedthatobesepatientswhodevelopedarthritisarenottheidealcandidatesforsurgicalprocedurestotreatFAIsyndrome.Somestudieshaveconstructedevidenceonidealfeaturesofpatientstobetreatedwitharthroscopicsurgery.21,22)治疗FAI综合征的患者选择尤其重要，因为不同患者的并发症发生率可能不同。人们普遍认为，患有关节炎的肥胖患者并不是手术治疗FAI综合征的理想人选。一些研究已经为关节镜手术患者的理想特征提供了证据21,22)。Kayetal.21)reportedfactorsaffectingpain,function,andqualityoflifeinpatientswhoareincludedintheFIRST(FemoroacetabularImpingementRandomisedControlledTrial)studyin2021.Theresultsofthestudyshowedthat1yearaftersurgery,theimprovementinqualityoflifewasgreaterinyoungerpatients,andtheimprovementinpainwasgreaterinpatientswithlowerbodymassindex(BMI).Nofactorsshowedanassociationwithreoperation,whichoccurredin13%.21)Kayetal.21)报道了2021年FIRST(股骨髋臼撞击随机对照试验)研究中患者的疼痛、功能和生活质量的影响因素。研究结果显示，术后1年，年轻患者的生活质量改善更大，体重指数(BMI)较低的患者疼痛改善更大。无因素显示与再手术相关，再手术发生率为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项研究(4,063例)中关注FAI综合征关节镜手术后恢复运动，发现89%的患者能够在3年内恢复运动。特别是术前年龄较小、体重较轻、关节炎分期较低(T?nnisI级)、髋关节功能较好的患者，术后功能较好。?ClinicalOutcomesofArthroscopicSurgeryinFAISyndromeRecently,thereisagrowingbodyofevidencetosupporttheefficacyofarthroscopicsurgeryinFAIsyndrome.19,22,23,24,32,33)Tocomparethespecificarthroscopicproceduresintermsofefficacy,FIRSTstudywasconductedasamulticenter,blindedRCTin10institutionsinCanada,Finland,andDenmark.25)Arthroscopicosteochondroplastywascomparedwitharthroscopiclavageregardingoutcomesofpain,remainingfunctions,andqualityoflife.ThebackgroundofthisstudyreflectsthecurrentperceptionofFAIsyndrome,whichhasbecomeahugeeconomicburdenwithouttheconsensusontheeffectivenessofthesurgery.25)最近，越来越多的证据支持关节镜手术治疗FAI综合征的疗效19,22,23,24,32,33)。为了比较特定关节镜手术的疗效，FIRST研究在加拿大、芬兰和丹麦的10家机构进行了多中心、盲法随机对照试验25)。比较关节镜下骨软骨成形术与关节镜下灌洗术在疼痛、剩余功能和生活质量方面的结果。本研究的背景反映了目前对FAI综合征的认知，该综合征已成为一个巨大的经济负担，而对手术的有效性尚未达成共识。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)在第一项试验中试图报告临床过程，特别是在骨软骨成形术组。他们在手术后基线、2周、6周、3个月、6个月和12个月评估疼痛和功能评分。术后疼痛视觉模拟量表迅速改善，功能评分逐渐恢复，但6个月后无明显改善32)。2022年，Almasri等(33)将随机与灌洗组、随机与骨软骨成形术组、拒绝参加RCT但接受骨软骨成形术的患者、不符合纳入标准但接受骨软骨成形术的患者的并发症和功能评分进行了比较。1年后，所有患者组的疼痛和功能均有所改善。许多未纳入RCT的组是对诊断性髋关节注射无反应的患者，但在这组患者中，骨软骨成形术显示出较低的再手术率和较大的功能改善。至于原因，作者认为，由于纳入随机对照试验的患者是随机的，他们倾向于报告更轻微的症状，因为他们认为他们接受了随机分配的治疗，而不是最好的治疗。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)在一项系统综述中回顾了10项前瞻性研究，分析了470例手术。这项研究是在平均年龄小于16岁的年轻患者中进行的，经过两年多的随访，94%的患者能够恢复运动。另一项系统综述了5项关节镜下髋臼唇修复的研究。210例患者在手术后2年内恢复运动，34个月时所有临床评分均有所改善24)。在2021年，Annin等人(19)报道了一项系统综述，包括18项研究和1123例FAI运动员关节镜手术后恢复运动和功能。在手术技术方面，唇部修复术比切除术多3倍以上，重建术很少。90%以上的病例行股骨成形术。他们的结论是，与损伤前相比，FAI综合征的关节镜治疗可显著改善运动员的功能。High-qualitystudiesincludingRCTsandsystematicreviewsagreethatarthroscopicsurgeryiseffectiveinFAIsyndrome.19,22,23,24,32,33)However,therearestillsomelimitationsthatthespecifictypeofsurgery(labraldebridement,labralrepair,acetabuloplasty,andfemoroplasty)orthetypeofFAIsyndrome(pincer,cam,ormixed)wasnotseparatelyinvestigated.包括随机对照试验和系统评价在内的高质量研究一致认为关节镜手术治疗FAI综合征是有效的(19,22,23,24,32,33)。然而，由于没有单独研究具体的手术类型(唇清创、唇修复、髋臼成形术和股骨成形术)或FAI综合征的类型(钳形、钳形或混合型)，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.尽管关节镜手术在FAI综合征中具有突出的价值，但不良事件并不罕见。关节镜手术后并发症和再手术的发生率分别为1%~31%和4%~13%。常见的不良事件包括持续髋关节疼痛、唇部再损伤、股外侧皮神经暂时性感觉异常、会阴神经暂时性感觉异常、cam病变复发、关节囊粘连、髋关节骨关节炎和浅表感染。Ohlin等人(34)报道，86.5%的不良事件在关节镜手术后24个月内消失，没有危及生命的并发症。作者进一步通过骨软骨成形术、唇部修复或引流治疗关节镜翻修手术的持续并发症，无任何实质性损伤34)。同样，Annin等人在一项包括18项研究和904例患者的系统综述中报告了5.5%的翻修手术和0.6%的后续全髋关节置换术。IntheFIRSTstudy,thecomplicationsweredividedintooperativelytreatedonesandnonoperativelytreatedones.ThosewhowereallocatedinthelavagegroupintheFIRSTtrialshowedthehighestcomplicationrate(18%and13%),followedbytheosteochondroplastygroupintheFIRSTtrial(8%and14%),thosewhodeclinedtorandomizationbutreceivedosteochondroplasty(10%and4%),andthosewhodidnotfittheinclusioncriteria(4%and4%).33)在FIRST研究中，并发症分为手术治疗和非手术治疗。在FIRST试验中被分配到灌洗组的患者并发症发生率最高(18%和13%)，其次是FIRST试验中的骨软骨成形术组(8%和14%)，拒绝随机分组但接受骨软骨成形术的患者(10%和4%)，以及不符合纳入标准的患者(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研究队列报道了FAI综合征关节镜手术期间的不良事件。2年随访期间不良事件发生率为24%，再手术率为13%。翻修手术最常在指数手术后中位15个月(范围1-25个月)进行，超过86%的不良事件在24个月的随访中解决。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.在一项针对青少年FAI综合征的关节镜手术的系统综述中，在平均28个月的随访中，约1%的患者出现并发症，5%的患者需要再次进行关节镜手术。最常见的并发症是股外侧皮神经暂时性感觉异常(0.4%)和会阴神经暂时性感觉异常(0.4%)。作者得出结论，关节镜手术对青少年FAI综合征的髋关节疼痛、功能和生活质量是有益的23)。在一项专门针对FAI综合征的关节镜下唇部修复的系统综述中，术后38个月平均再手术率为4.3%，2%需要关节置换术24)。一项对患有FAI综合征的运动员的系统综述显示，5.5%的患者在至少2年的随访中需要再手术。?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.许多辅助手术已被开发用于FAI综合征的关节镜手术，并提高了临床结果。值得注意的是，这些手术大多是在关节镜手术期间或手术之外进行的，而不是作为关节内注射等独立手术进行。这些生物治疗包括骨髓浓缩液、富血小板血浆(PRP)、生长因子、培养扩增间充质干细胞和自体软骨细胞衍生物35,36,37,38,39,40,41,42,43,44)。在大多数研究中，生物制剂的主要靶点是软骨病变，而不是唇部病变。尽管自体软骨细胞植入与收获困难和所递送的软骨细胞浓度变化有关，但研究报告了临床评分的不同改善35,38,40)。使用PRPs作为辅助治疗的研究与对照组相比，在临床评分、额外手术37,42,43)在FAI综合征中使用生物辅助治疗没有强有力的证据支持，目前不应主要考虑使用生物辅助治疗。?COMPARISONWITHCONSERVATIVETREATMENTThemainstreamtreatmentmodalityforFAIsyndromehasbeensurgical,especiallyarthroscopicinthecontemporaryliterature.However,itisreportedthatawiderangeofpatientsbenefittedfromvariousconservativetreatments.45,46,47,48)Theefficacyofarthroscopicsurgeryshouldbecomparedwithconservativetreatmentduetoitsinvasiveness.在当代文献中，FAI综合征的主流治疗方式是手术，尤其是关节镜。然而，据报道，各种保守治疗对广泛的患者有益45,46,47,48)。由于关节镜手术的侵入性，其疗效应与保守治疗进行比较。?Intra-articularInjectionforFAISyndromeAmongconservativetreatment,intra-articularinjectionforFAIsyndromeisknownforitseffectivenessinbothdiagnosis49)andpainrelief.50)However,thedurationofpainreliefanditsclinicalimpacthaslongbeenandisstillcontroversial.51,52,53,54)Infact,therewerenotmanystudieswithhigh-levelevidence,reportingtheresultsofinjectionforFAIsyndrome.Abateetal.45)reportedin2014thatwhenhyaluronicacidinjectionwasperformedunderultrasoundguidancein20FAIpatients,allclinicalsymptomsimprovedwithoutanypatientrequiringsurgeryfor1year.在保守治疗中，关节内注射治疗FAI综合征以其诊断和缓解疼痛的有效性而闻名50)。然而，疼痛缓解的持续时间及其临床影响一直存在争议，并且仍然存在争议51,52,53,54)事实上，并没有很多高水平证据的研究报道了注射治疗FAI综合征的结果。Abateetal.45)在2014年报道，在超声引导下对20例FAI患者进行透明质酸注射，1年内无一例患者需要手术，所有临床症状均得到改善。Somestudiesadvocateactivityrestrictionorphysicaltherapyovertheinjectionsinconservativetreatment.55,56)Zogbyetal.56)conductedaprospectivestudyinwhichpatientswhodidnotrespondtotheprevioustreatmentweretreatedinthefollowingorder:activityrestriction,drugtreatment,injection,andarthroscopicsurgery.Therewasnosignificantdifferenceinclinicalscoresinanypatientgroupat5years.However,therateofreturntoexercisewashighestinthegroupofpatientswhoreceivedonlyactivityrestrictionsanddrugtreatment,whichmaybeduetoselectionbiasinthatthemoreseverethecondition,themorelikelythepatientsweretoreceivemoreintensivetreatment.56)Ameta-analysispublishedin2019comparedthephysicaltherapygroupandtheinjectiongroupamongconservativetreatments,andbothpainandfunctionshowedbetterresultsinthephysicaltherapygroupthantheinjectiongroup.55)一些研究主张在保守治疗中限制活动或物理治疗而不是注射。Zogby等人进行了一项前瞻性研究，对先前治疗无效的患者按以下顺序进行治疗:限制活动、药物治疗、注射、关节镜手术。5年时，两组患者的临床评分均无显著差异。然而，仅接受活动限制和药物治疗的患者恢复运动的比率最高，这可能是由于选择偏倚，因为病情越严重，患者越有可能接受更强化的治疗56)。2019年发表的一项荟萃分析比较了保守治疗中的物理治疗组和注射组。在疼痛和功能方面，物理治疗组均优于注射组。Leeetal.57)publishedanRCTin2016thatcomparedtriamcinoloneandhyaluronicacidinjectioninpatientswithFAIsyndrome.Patientswhohadnoimprovementaftertakingeachdrugonebyonewerealternatelyadministeredfor2weeks.Asaresult,bothdrugswereeffectiveforpain,butonlypatientswhotookthecross-medicationshowedasignificantimprovementintermsoffunction.Bymedication,triamcinoloneshowedrapidpainrelief,whilehyaluronicacidhadaslowereffectbutresultedingreaterfunctionalimprovement.Sideeffectsmainlyoccurredwhenusingtriamcinolone,themostcommonbeingfacialflushingandmenstrualabnormalities.57)Leeetal.57)在2016年发表了一项RCT，比较了曲安奈德和透明质酸注射在FAI综合征患者中的作用。分别服药后无改善的患者交替给药2周。结果，两种药物对疼痛都有效，但只有服用交叉药物的患者在功能方面表现出明显的改善。通过药物治疗，曲安奈德能迅速缓解疼痛，而透明质酸的效果较慢，但能更大程度地改善功能。副作用主要发生在使用曲安奈德时，最常见的是面部潮红和月经异常。Ina2-yearfollow-upstudy,208patientsunderwentarthroscopicsurgeryforFAIsyndromeafterinjectionofbetamethasoneandlidocaine.58)Thosewhorespondedtotheinjectionhadbetter2-yearclinicaloutcomesthanthosewhodidnotrespondtoinjectionsafterarthroscopicsurgery.ThisstudyhighlightedthepredictivevalueoftheinjectiononsubsequentarthroscopicsurgeryinFAIsyndromeregardlessoftheefficacyindiagnosisorpainrelief.58)在一项为期2年的随访研究中，208例患者在注射倍他米松和利多卡因后接受了关节镜手术治疗FAI综合征58)。关节镜手术后，对注射有反应的患者比对注射无反应的患者有更好的2年临床结果。该研究强调了注射对FAI综合征后续关节镜手术的预测价值，无论在诊断或缓解疼痛方面是否有效58)。Accordingtotherecentliterature,intra-articularinjectioninFAIsyndromeseemstobeeffectiveinsomepatientsintermsofpainalleviationandprognosispredictionforfurthertreatment.However,itshouldbeconsideredratherthanmandatedinthosewithFAIsyndromewithwarningsthattheeffectscouldbeslightlybetterorcomparabletothephysicaltherapy.49,50,51,52,53,54,57,58)根据最近的文献，在FAI综合征中关节内注射似乎对一些患者的疼痛缓解和进一步治疗的预后预测是有效的。然而，对于患有FAI综合征的患者，应该考虑而不是强制使用，并警告其效果可能略好于或与物理治疗相当(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)对3项随机对照试验的650例患者进行meta分析，发现手术组与保守治疗组的功能无显著差异。然而，由于纳入研究的随访期为6个月至2年，长期影响尚不清楚。相比之下，另一项对6项随机对照试验(包括1187例患者)的荟萃分析报告，与保守治疗相比，关节镜手术在1年内显著提高了临床评分。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)比较差异的原因之一似乎是FAI综合征保守治疗的多样性。关节镜下治疗FAI综合征的手术主要包括唇清创、唇修复、髋臼成形术和股骨成形术9,18,24,33)。然而，保守治疗的方式差异很大，这可能导致效果不一致。为了客观比较保守治疗和关节镜手术治疗FAI综合征的效果，UKFASHIoN(关节镜手术治疗髋关节撞击与最佳常规治疗的完全随机对照试验)在英格兰、苏格兰和威尔士的24家医院进行了一项多中心随机对照试验61)。本研究比较了个体化保守治疗和关节镜手术治疗FAI综合征的效果。保守治疗组接受个性化髋关节治疗，由物理治疗师、内科医生、外科医生共同主导，疗程12-24周。个性化髋关节治疗的核心内容是:(1)运动计划，(2)患者教育，(3)关节内类固醇注射或不注射止痛61)。关节镜手术组共171例患者与保守治疗组177例患者进行比较。在1年的随访中，两组的国际髋关节预后工具评分均有所增加，但髋关节镜组的改善明显更大。然而，患者报告的不良事件在手术组也更高(61)。Oneofthefactorsthatmightfavorconservativetreatmentoverarthroscopycouldbethesteeplearningcurveofhiparthroscopicsurgery.62,63)Despitetherecentpopularity,hiparthroscopicsurgeryproceduresaretechnicallychallenging,evenstartingfromthetractionapplicationandportalplacement.64)ToachievethefavorableoutcomesexpectedfromarthroscopicsurgeryforFAIsyndrome,surgeonsshouldovercomethelearningcurve.Asystematicreviewonthissubjectwasconductedin2014andsuggestedthatatleast30caseswereusedasthecutoffvalueforthelearningcurveforhiparthroscopy.65)In2020,Youetal.63)reportedthatsurgicaleffectivenesswasmaximizedafter110casesinaprospectivestudyof190casesofhiparthroscopicsurgeryinFAIsyndrome.Comparingthelow-andhigh-volumesurgeons,Mehtaetal.62)reportedthat519casesofcareervolumesweretheoptimalcutoffvaluefordecreasingtheriskofsubsequenthipsurgery.Thesefindingsindicatethathiparthroscopistsshouldreachacertainlevelofsurgicalvolumetoprovidetheexpectedoutcomesofarthroscopicsurgerythatcouldsurpassthoseofconservativetreatments.与关节镜相比，保守治疗更受青睐的因素之一可能是髋关节镜手术的陡峭学习曲线62,63)。尽管最近很流行，但髋关节镜手术程序在技术上具有挑战性，甚至从牵引应用和入路开始64)。为了获得FAI综合征关节镜手术预期的良好结果，外科医生应该克服学习曲线。2014年对该主题进行了系统回顾，建议至少使用30例病例作为髋关节镜学习曲线的截止值65)。2020年，You等人(63)报道，在190例FAI综合征髋关节镜手术的前瞻性研究中，手术效果在110例后达到最大。Mehta等人(62)比较了低容量和高容量的外科医生，报道519例职业容量是降低后续髋关节手术风险的最佳临界值。这些结果表明，髋关节镜医师应达到一定的手术量水平，以提供关节镜手术的预期结果，可能超过保守治疗。TheefficacyofconservativetreatmentandarthroscopicsurgeryinFAIsyndromeseemstobecomparable.59,60)TheremightbesomeconfoundingfactorssuchasthesubtypesofFAIsyndromeoraccompanyingintra-articularpathologies.Intheclinicalsettings,however,surgicalinterventionisusuallyconsideredafteracertaindurationofconservativetreatment.56)Therefore,inpatientswhohaveintractablepainevenaftersufficientpersonalizedconservativetherapy,arthroscopicsurgerycouldbebeneficialifperformedcarefullyfollowingrightindications.保守治疗和关节镜手术治疗FAI综合征的疗效似乎是相当的59,60)。可能存在一些混淆因素，如FAI综合征的亚型或伴随的关节内病变。然而，在临床上，通常在保守治疗一段时间后才考虑手术干预56)。因此，对于难治性疼痛的患者，即使经过充分的个性化保守治疗，如果按照正确的指征仔细进行关节镜手术也是有益的。?CONCLUSIONRecentstudiesprovidedthefollowinganswerstothequestionsfrequentlyaskedbypatientswithFAIsyndromeinoutpatientclinics.ArthroscopicsurgeryforFAIsyndromewaseffectivewithregardtohippain,function,returntoexercise,rangeofmotion,andqualityoflife.However,whilehippainimprovedquickly,functionalrecoveryseemedtoplateauafter6months.Arthroscopicsurgeryshowedrelativelybetterresultsinyoungerpatients,patientswithlowBMIorgoodpreoperativefunction,andthosewhorespondedwelltoinjection,andmostcomplicationswereresolvedwithin2years.Reoperationafterarthroscopicsurgerywasrequiredinapproximately4%to13%ofpatients.ThereiscurrentlynorobustevidenceshowingthatbiologicadjunctsareeffectiveinarthroscopicsurgeryforFAIsyndrome.Intra-articularinjectionforFAIsyndromemaybeeffectivedependingonthepatientandcouldbeconsideredincasesofthelackofresponsetomedicationbeforesurgery.Theinitialfunctionalresultsofarthroscopicsurgerymaynotdiffersignificantlyfromthoseofconservativetreatment.最近的研究为FAI综合征患者在门诊常见的问题提供了以下答案。关节镜手术治疗FAI综合征在髋关节疼痛、功能、恢复运动、活动范围和生活质量方面是有效的。然而，虽然髋关节疼痛迅速改善，但6个月后功能恢复似乎趋于平稳。关节镜手术在年龄较小、BMI较低或术前功能较好的患者以及注射反应良好的患者中效果相对较好，大多数并发症在2年内解决。约4%至13%的患者需要在关节镜手术后再次手术。目前没有强有力的证据表明生物辅助治疗在关节镜手术治疗FAI综合征中是有效的。关节内注射治疗FAI综合征可能有效，取决于患者，在手术前对药物缺乏反应的情况下可以考虑。关节镜手术的初始功能结果可能与保守治疗没有显著差异。北京潞河医院骨关节科科普号