EBM. Comparative Systematic Review of the Open Dislocation, Mini-Open, and Arthroscopic Surgeries for Femoroacetabular Impingement

Transcription

1 EBM Comparative Systematic Review of the Open Dislocation, Mini-Open, and Arthroscopic Surgeries for Femoroacetabular Impingement ~ Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 2 (February), 2011: pp 骨科部運動醫學科 Fellow: 黃柏樺

2 Introduction Femoroacetabular impingement (FAI): a prearthritic mechanism proximal femur abuts the acetabulum with range of motion ~OKU 10

3 Introduction Operative treatment for FAI: osseous, labral, chondral pathology Open dislocation surgery Mini-open surgery Arthroscopic hip surgery

4 Open dislocation surgery ~ J Bone Joint Surg [Br] 2001;83-B:

5 Mini-open surgery Anterior Hueter approach incision length varied from 2 ~ 12 cm adjunctive arthroscopy

6 Arthroscopic hip surgery

7 Purpose a systematic review of the outcome and comparisons of the surgical treatment for FAI Open Mini-open Arthroscopic Arthroscopic and mini-open procedures offer similar outcomes to the historic gold standard of open dislocation surgery

8 Methods 2010/01/25 4 databases 1. PubMed 2. EMBASE 3. Ovid 4. Cochrane Review 13 different queries (1) femoroacetabular impingement OR FAI (2) hip impingement (3) cam impingement (4) pincer impingement (5) surgical dislocation AND impingement (6) osteotomy AND impingement (7) hip AND treatment AND impingement (8) hip arthroscopy (9) mini-open (10) Hueter AND impingement (11) osteochondroplasty (12) osteoplasty AND impingement (13) rim trimming

9 Hand search 1. Arthroscopy Methods 2. The Journal of Bone and Joint Surgery (American and British) 3. American Journal of Sports Medicine 4. Clinical Orthopaedics and Related Research 5. Journal of the American Academy of Orthopaedic Surgeons 6. Journal of Arthroplasty

10 Methods

11 Result

12 Result 18 studies, Level of Evidence III or IV Open dislocation studies (6) all retrospective, 184 hips in 171 patients, 1 Level III study Mini-open studies (4) all retrospective, 176 hips in 168 patients, 1 Level III study Arthroscopic studies (8) 4 prospective and 4 retrospective, 587 hips in 561 patients, 2 Level III studies

13 Open dislocation studies

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18 Mini-open studies

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23 Arthroscopic studies

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29 Discussion 11 studies, open/mini-open/arthroscopy: 6/1/4 Overall clinical success rate: 65% ~ 96% over a mean follow-up of 3.2 years All improvement in pain and function Total hip conversion rate: 0% ~ 26% Complication rate: 0% ~ 18% No comparisons were made between surgical methods

30 19 studies, open/arthroscopy: 7/12 Open techniques did not have better outcomes than those of the arthroscopic methods Not include mini-open outcome studies

31 This systematic review Clinical success rate: 65% ~ 94% with a mean follow-up of 2.5 years All improvement in pain and function THA conversions rate: 0% ~ 30% Major complication rate: 0% ~ 20%

32 Open (6) Mini-open (4) Arthroscopy (8) Clinical success rate 65 ~ 94% 92% (1 study) 67 ~ 90% THA conversion rate Major complication rate 0 ~ 30% 0 ~ 11% 0 ~ 9% 0 ~ 20% 0 ~ 17% 0 ~ 5%

33 Open dislocation group The highest success rate was seen in a study with possible selection bias because no patients > 40 y/o Complication primarily from trochanteric nonunion No femoral neck fractures, osteonecrosis, or deep infections

34 Open dislocation group longest outcome experience relatively high THA conversion rate Patient selection had negative influence on the outcomes of the 2 earliest studies relatively greater proportion of higher grade osteoarthritic patients (Tonnis 2, 3) and/or concurrent instability (dysplasia) THA conversion rate: early studies (26 ~ 30%) recent studies (0 ~ 5%) Not reflective of the failure rates

35 Mini-open group No osteonecrosis, 1 femoral neck fracture, 2 deep infection The largest study (100 hips) with longest mean follow-up (4.9 years) 11 THA conversions 17 repeat surgeries: 8 failures of labral refixation 6 inadequate femoral osteoplasties 1 heterotopic ossification 2 infections Clinical success rate: 71 ~92%

36 Mini-open group Arthroscopic femoral osteoplasty is a technically challenging procedure Excessive osseous resection: iatrogenic femoral neck fracture Insufficient resection: residual impingement A clinical study and 2 recent cadaveric studies: no significant difference in the ability of open and arthroscopy to perform femoral osteoplasty

37 Arthroscopic group The lowest arthroscopic success rate (67%): the labral debridement (89.7% in labral refixation) Most of the arthroscopic studies were performed by single experienced arthroscopic hip surgeons The experience of the arthroscopic surgeons affect the outcomes

38 Open: Complications Osteotomy-related complications: nonunions (20%) / bursitis (24%) Heterotopic ossification Post-OP intra-articular adhesions (6%) Mini-open: Lateral femoral cutaneous nerve (LFCN) injuries (45%) 1 femoral neck fracture, 2 deep infection Failure of labral refixation and inadequate osteoplasties

39 Complications Arthroscopy: neurapraxias of the pudendal nerve or LFCN (9%) sciatic neurapraxia (2%) 2 inadequate femoral osteoplasty 2 heterotopic ossification 1 iatrogenic anterior hip dislocation 1 osteonecrosis rare fluid extravasation The lowest overall complication rate (1.4~1.5%) The majority of complications were minor and related to hip distraction

40 Open: Length of hospital stay ( post-op recovery) 1 study: mean 3 days 3 studies: 6 or more weeks of crutch-protected partial weight-bearing 1 study: emphasized the limitation of hip flexion to < 70 for at least 6 weeks Mini-open: 1 study: mean 2.6 days and 5 days of post-op crutch protection with immediate full weight bearing significant incidence of failed labral refixations (8%) converted to a 4-week period of protected weight bearing with crutches

41 Length of hospital stay Arthroscopy: ( post-op recovery) No length of stay, outpatient procedure early exercise bicycling crutch-protected partial weight bearing for 1 ~ 4 weeks (6 ~ 8 weeks for s/p microfracture chondroplasty) Faster rehabilitation and return to sports with less invasive surgery Professional hockey players: open (9.6 months) / scopy (3.9 months)

42 Limitations of this review Open and mini-open: retrospective, small case series, single surgeons, short-term follow-up Arthroscopic: 50% prospective, larger cohorts, single surgeons, short-term followup Level III and IV studies without nonsurgical control groups

43 Limitations of this review Varying outcome measures comparisons more difficult Elderly arthritic patients V.S Active/athletic patients Wide range and overlap of scores No confidence intervals No follow-up Tonnis scores Various definitions of surgical success, failure, and significant complications

44 Conclusions 3 methods for treating symptomatic FAI are effective in improving pain / function and relatively safe in short ~ midterm studies

45 Open dislocation: Conclusions the historical gold standard comparatively high major complication rate: trochanteric osteotomy related issues Mini-open: comparable efficacy bridge the gap between the open dislocation and arthroscopic methods a significant incidence of iatrogenic injury to the LFCN Arthroscopic: equal to or better than the other methods a lower rate of major complications (experienced surgeons)

46 Thanks for your listening!