E. Gallazzi, L. Zagra, IRCCS Istituto Ortopedico Galeazzi, Hip Department, vi R. Galeazzi, Milan, Italy I. Morelli, G. Peretti, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy IRCCS Istituto Ortopedico Galeazzi, via R. Galeazzi Milan, Italy.
Clin Orthop Relat Res. 2019 May;477(5):1176-1187. doi: 10.1097/CORR.0000000000000659.
Femoral osteotomies have been widely used to treat a wide range of developmental and degenerative hip diseases. For this purpose, different types of proximal femur osteotomies were developed: at the neck as well as at the trochanteric, intertrochanteric, or subtrochanteric levels. Few studies have evaluated the impact of a previous femoral osteotomy on a THA; thus, whether and how a previous femoral osteotomy affects the outcome of THA remains controversial.
QUESTIONS/PURPOSES: In this systematic review, we asked: (1) What are the most common complications after THA in patients who have undergone femoral osteotomy, and how frequently do those complications occur? (2) What is the survival of THA after previous femoral osteotomy? (3) Is the timing of hardware removal associated with THA complications and survivorship?
A systematic review was carried out on PubMed, the Cochrane Systematic Reviews Database, Scopus, and Embase databases with the following keywords: "THA", "total hip arthroplasty", and "total hip replacement" combined with at least one of "femoral osteotomy" or "intertrochanteric osteotomy" to achieve the maximum sensitivity of the search strategy. Identified studies were included if they met the following criteria: (1) reported data on THAs performed after femoral osteotomy; (2) recorded THA followup; (3) patients who underwent THA after femoral osteotomy constituted either the experimental group or a control group; (4) described the surgical and clinical complications and survivorship of the THA. The database search retrieved 383 studies, on which we performed a primary evaluation. After removing duplicates and completing a full-text evaluation for the inclusion criteria, 15 studies (seven historically controlled, eight case series) were included in the final review. Specific information was retrieved from each study included in the final analysis. The quality of each study was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire. The mean MINORS score for the historically controlled studies was 14 of 24 (range, 10-17), whereas for the case series, it was 8.1 of 16 (range, 5-10).
The proportion of patients who experienced intraoperative complications during THA ranged from 0% to 17%. The most common intraoperative complication was femoral fracture; other intraoperative complications were difficulties in hardware removal and nerve palsy; 15 studies reported on complications. The survivorship of THA after femoral osteotomy in the 13 studies that answered this question ranged from 43.7% to 100% in studies that had a range of followup from 2 to 20 years. The timing of hardware removal was described in five studies, three of which detailed more complications with hardware removal at the time of THA.
This systematic review demonstrated that THA after femoral osteotomy is technically more demanding and may carry a higher risk of complications than one might expect after straightforward THA. Staged hardware removal may reduce the higher risk of intraoperative fracture and infection, but there is no clear evidence in support of this contention. Although survivorship of THA after femoral osteotomy was generally high, the studies that evaluated it were generally retrospective case series, with substantial biases, including selection bias and transfer bias (loss to followup), and so it is possible that survivorship of THA in the setting of prior femoral osteotomy may be lower than reported.
Level III, therapeutic study.
股骨截骨术已广泛用于治疗多种发育性和退行性髋关节疾病。为此，开发了不同类型的股骨近端截骨术：在颈部以及在转子间、转子下或小转子下水平。很少有研究评估先前股骨截骨术对 THA 的影响；因此，先前的股骨截骨术是否以及如何影响 THA 的结果仍存在争议。
问题/目的：在这项系统评价中，我们提出了以下问题：（1）在接受过股骨截骨术的患者中，THA 后最常见的并发症是什么，这些并发症发生的频率有多高？（2）THA 在前股骨截骨术后的生存率是多少？（3）内固定去除的时间是否与 THA 并发症和生存率有关？
我们在 PubMed、Cochrane 系统评价数据库、Scopus 和 Embase 数据库中进行了系统评价，使用了以下关键词：“THA”、“全髋关节置换术”和“全髋关节置换术”，并结合了至少一个“股骨截骨术”或“转子间截骨术”，以实现搜索策略的最大敏感性。如果研究符合以下标准，我们将其纳入：（1）报告了股骨截骨术后进行的 THA 数据；（2）记录了 THA 随访；（3）股骨截骨术后接受 THA 的患者构成实验组或对照组；（4）描述了 THA 的手术和临床并发症和生存率。数据库搜索共检索到 383 项研究，我们对这些研究进行了初步评估。在去除重复项并对纳入标准进行全文评估后，有 15 项研究（7 项为历史对照研究，8 项为病例系列研究）被纳入最终综述。从最终分析中纳入的每项研究中检索到具体信息。使用非随机研究方法学指数（MINORS）问卷评估每个研究的质量。历史对照研究的 MINORS 平均得分为 24 分中的 14 分（范围为 10-17 分），而病例系列研究的平均得分为 16 分中的 8.1 分（范围为 5-10 分）。
THA 术中并发症的发生率从 0%到 17%不等。最常见的术中并发症是股骨骨折；其他术中并发症包括内固定去除困难和神经麻痹；15 项研究报告了并发症。在回答这个问题的 13 项研究中，THA 在前股骨截骨术后的生存率从 43.7%到 100%不等，研究的随访时间从 2 年到 20 年不等。有 5 项研究描述了内固定去除的时间，其中 3 项详细描述了在 THA 时去除内固定的更高风险。
这项系统评价表明，THA 在前股骨截骨术后技术上更具挑战性，并且可能比人们预期的单纯 THA 术后并发症风险更高。分期去除内固定可能会降低更高的术中骨折和感染风险，但目前没有明确的证据支持这一观点。尽管股骨截骨术后 THA 的生存率通常较高，但评估它的研究通常是回顾性病例系列研究，存在较大的偏倚，包括选择偏倚和转移偏倚（失随访），因此，股骨截骨术后 THA 的生存率可能低于报告的水平。
III 级，治疗性研究。
