Abstract
Background
Currently, three surgical approaches are available for the treatment of cam femoroacetabular impingement (FAI), namely surgical hip dislocation (SHD), hip arthroscopy (HA), and the miniopen anterior approach of the hip (MO). Although previous systematic reviews have compared these different approaches, an overall assessment of their performance is not available.
Questions/purposes
We therefore executed a multidimensional structured comparison considering the benefits, opportunities, costs, and risk (BOCR) of the different approaches using multicriteria decision analysis (MCDA).
Methods
A MCDA using analytic hierarchical process (AHP) was conducted to compare SHD, HA, and MO in terms of BOCR on the basis of available evidence, institutional experience, costs, and our understanding of pathophysiology of FAI. A preclinical decision-making model was created for cam FAI to establish the surgical approach that better accomplishes our objectives regarding the surgical treatment. A total score of an alternative’s utility and sensitivity analysis was established using commercially available AHP software.
Results
The AHP model based on BOCR showed that MO is the best surgical approach for cam FAI (normalized score: 0.38) followed by HA (normalized score: 0.36) and SHD (normalized score: 0.25). The sensitivity analysis showed that HA would turn into the best alternative if the variable risks account for more than 61.8% of the priority during decision-making. In any other decision-making scenario, MO remains as the best alternative.
Conclusions
Using a recognized method for decision-making, this study provides supportive data for the use of MO approach as our preferred surgical approach for cam FAI. The latter is predominantly derived from the lower cost of this approach. Our data may be considered a proxy performance measurement for surgical approaches in cam FAI.
Level of Evidence
Level II, economic and decision analyses. See the Guidelines for Authors for a complete description of levels of evidence.
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References
Anderson LA, Peters CL, Park BB, Stoddard GJ, Erickson JA, Crim JR. Acetabular cartilage delamination in femoroacetabular impingement. Risk factors and magnetic resonance imaging diagnosis. J Bone Joint Surg Am. 2009;91:305–313.
Ayeni OR, Naudie D, Crouch S, Adili A, Pindiprolu B, Chien T, Beaulé PE, Bhandari M. Surgical indications for treatment for femoroacetabular impingement with surgical hip dislocation. Knee Surg Sports Traumatol Arthrosc. 2012 Oct 13 [Epub ahead of print].
Ayeni OR, Wong I, Chien T, Musahl V, Kelly BT, Bhandari M. Surgical indications for arthroscopic management of femoroacetabular impingement. Arthroscopy. 2012;28:1170–1179.
Banuelas R, Antony J. Modified analytic hierarchy process to incorporate uncertainty and managerial aspects. Int J Prod Res. 2004;42:3851–3872.
Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Clin Orthop Relat Res. 2004;418:67–73.
Botser IB, Smith TW Jr, Nasser R, Domb BG. Open surgical dislocation versus arthroscopy for femoroacetabular impingement: a comparison of clinical outcomes. Arthroscopy. 2011;27:270–278.
Byrd JW. Hip arthroscopy utilizing the supine position. Arthroscopy. 1994;10:275–280.
Byrd JWT, Jones KS. Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement. Clin Orthop Relat Res. 2009;467:739–746.
Byrd JWT, Jones KS. Hip arthroscopy in athletes: 10-year follow-up. Am J Sports Med. 2009;37:2140–2143.
Clohisy JC, St John LC, Schutz AL. Surgical treatment of femoroacetabular impingement: a systematic review of the literature. Clin Orthop Relat Res. 2010;468:555–564.
Dolan JG, Boohaker E, Allison J, Imperiale TF. Patients’ preferences and priorities regarding colorectal cancer screening. Med Decis Making. 2013;33:59–70.
Dolan JG. Multi-criteria clinical decision support: a primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare. Patient. 2010;3:229–248.
Erkut E, Tarimcilar M. On sensitivity analysis in the analytic hierarchy process. IMA J Management Math. 1991;3:61–83.
Field RE, Rajakulendran K. The labro-acetabular complex. J Bone Joint Surg Am. 2011;93(Suppl 2):22–27.
Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, Berlemann U. Surgical dislocation of the adult hip: a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br. 2001;83:1119–1124.
Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;417:112–120.
Hunt D, Prather H, Harris Hayes M, Clohisy JC. Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. PM R. 2012;4:479–487.
Jaberi FM, Parvizi J. Hip pain in young adults: femoroacetabular impingement. J Arthroplasty. 2007;22:37–42.
Lavigne M, Parvizi J, Beck M, Siebenrock KA, Ganz R, Leunig M. Anterior femoroacetabular impingement: part I. Techniques of joint preserving surgery. Clin Orthop Relat Res. 2004;418:61–66.
Leunig M, Huff TW, Ganz R. Femoroacetabular impingement: treatment of the acetabular side. Instr Course Lect. 2009;58:223–229.
Malik AK, Chou DTS, Witt JD. Anterior approaches to the hip for the treatment of femoro-acetabular impingement: a cadaveric study. Hip Int. 2010;20:482–488.
Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy. 2011;27:252–269.
McCarthy JC, Lee J-A. History of hip arthroscopy: challenges and opportunities. Clin Sports Med. 2011;30:217–224.
Parvizi J, Huang R, Diaz-Ledezma C, Og B. Mini-open femoroacetabular osteoplasty: how do these patients do? J Arthroplasty. 2012;27:122–125.e1.
Parvizi J, Leunig M, Ganz R. Femoroacetabular impingement. J Am Acad Orthop Surg. 2007;15:561–570.
Plante M, Wallace R, Busconi BD. Clinical diagnosis of hip pain. Clin Sports Med. 2011;30:225–238.
Saaty RW. The analytic hierarchy process—what it is and how it is used. Math Model. 1987;9:161–176.
Saaty TL, Özdemir MS. The Encyclicon: A Dictionary of Decisions With Dependence and Feedback Based on the Analytic Network Process. Pittsburgh, PA, USA: R W S Publications; 2005.
Saaty TL, Vargas LG. Uncertainty and rank order in the analytic hierarchy process. Eur J Oper Res. 1987;32:107–117.
Saaty TL. How to make a decision: the analytic hierarchy process. Eur J Oper Res. 1990;48:9–26.
Sajjad Zahir M. Incorporating the uncertainty of decision judgements in the analytic hierarchy process. Eur J Oper Res. 1991;53:206–216.
Sampson TG. Arthroscopic treatment for chondral lesions of the hip. Clin Sports Med. 2011;30:331–348.
Shearer DW, Kramer J, Bozic KJ, Feeley BT. Is hip arthroscopy cost-effective for femoroacetabular impingement? Clin Orthop Relat Res. 2012;470:1079–1089.
Sink EL, Beaulé PE, Sucato D, Kim Y-J, Millis MB, Dayton M, Trousdale RT, Sierra RJ, Zaltz I, Schoenecker P, Monreal A, Clohisy J. Multicenter study of complications following surgical dislocation of the hip. J Bone Joint Surg Am. 2011;93:1132–1136.
Sloane EB, Liberatore MJ, Nydick RL. Medical decision support using the Analytic Hierarchy Process. J Healthc Inf Manag. 2002;16:38–43.
Sussmann PS, Ranawat AS, Lipman J, Lorich DG, Padgett DE, Kelly BT. Arthroscopic versus open osteoplasty of the head-neck junction: a cadaveric investigation. Arthroscopy. 2007;23:1257–1264.
Tannast M, Goricki D, Beck M, Murphy SB, Siebenrock KA. Hip damage occurs at the zone of femoroacetabular impingement. Clin Orthop Relat Res. 2008;466:273–280.
Wang Y-M, Elhag TMS. An approach to avoiding rank reversal in AHP. Decis Support Syst. 2006;42:1474–1480.
Wijnmalen DJD. Analysis of benefits, opportunities, costs, and risks (BOCR) with the AHP–ANP: a critical validation. Math Comput Model. 2007;46:892–905.
Zahedi F. The Analytic Hierarchy Process—a survey of the method and its applications. Interfaces. 1986;16:96–108.
Zahedi F. Group consensus function estimation when preferences are uncertain. Oper Res. 1986;34:883–894.
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One of the authors (JP) certifies that he has or may receive payments or benefits, during the study period, an amount of USD 10,000–USD 100,000 from Zimmer Inc (Warsaw, IN, USA), an amount of USD 10,000–USD 100,000 from Smith & Nephew Inc (Memphis, TN, USA), and has intellectual properties in SmarTech™ (Philadelphia, PA, USA).
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
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Diaz-Ledezma, C., Parvizi, J. Surgical Approaches for Cam Femoroacetabular Impingement: The Use of Multicriteria Decision Analysis. Clin Orthop Relat Res 471, 2509–2516 (2013). https://doi.org/10.1007/s11999-013-2934-6
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DOI: https://doi.org/10.1007/s11999-013-2934-6