Surgical Treatment Of Femoroacetabular Impingement Research Articles

Knotless Labral Repair Using the Inversion Technique in Hip Arthroscopy

Background: Hip arthroscopy is technically demanding with a steep learning curve, and labral repair is an important component of the surgical treatment of femoroacetabular impingement (FAI) syndrome. As hip arthroscopy indications and techniques are evolving, it is important to remain focused on teaching techniques that are easily mastered and have a measurable benefit to patient outcomes. Indications: Patients with FAI syndrome and labral tear who have failed conservative treatment may benefit from hip arthroscopy, labral repair, and femoroplasty. Technique Description: Labral repair is an essential component of the surgical treatment of FAI syndrome. The hip is accessed in standard fashion, and multiple knotless anchors are used for labral repair. Repair sutures are passed around the labrum in an inverted fashion. This inversion technique ensures the labrum is not everted away from the acetabular rim and that the final position of the labrum will restore a good suction seal on the femoral head. Femoroplasty and capsule closure are always performed. Results: Patients can reliably expect improvements in hip pain and function. A cohort of 62 patients was investigated, and these patients demonstrated significant improvement in multiple patient-reported outcomes related to physical function, activity, and pain at 2 years after hip arthroscopy. Forty-seven percent stated they felt “completely better” at 2 years postoperatively. Discussion/Conclusion: Good hip arthroscopy technique in the proper patient can yield excellent results. The inversion labral repair technique reliably restores the suction seal and prevents eversion of the labrum to preserve normal function. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Inflammatory and Immunologic Contributions in Femoroacetabular Impingement Syndrome.

Femoroacetabular impingement (FAI) is one of the most common causes of labral and early cartilage damage in the nondysplastic hip. FAI is increasingly recognized as a cause for hip and groin pain in the young, active patient, and the surgical treatment of FAI with hip arthroscopy has risen exponentially. Although our understanding of FAI and the progression to degenerative osteoarthritis of the hip has historically been considered a mechanical "wear-and-tear" disease of an imperfectly shaped, aspherical, femoral head within a deep or overcovering acetabulum leading to cartilage injury, our understanding of the intrinsic pathophysiologic mechanisms underlying the development of FAI and joint degeneration of the hip remains poor. For example, many patients with FAI morphology may never develop hip pain or osteoarthritis; there remains more to discover regarding the pathophysiology of arthritis in the setting of FAI. Recent work has begun to identify a strong inflammatory and immunologic component to the FAI disease process that affects the hip synovium, labrum, and cartilage and may be detectable from peripheral clinical samples (blood and urine). This review highlights our current understanding of the inflammatory and immunologic contributions to FAI and potential therapeutic strategies to supplement and augment the surgical management of FAI.

Low-dose prophylaxis protocol for heterotopic ossification after hip preservation surgery in a sport participants cohort.

Heterotopic ossification (HO) is a well-known complication of arthroscopic and open surgical treatment of femoroacetabular impingement (FAI). Incidence of heterotopic ossification has been reported in the literature between 0% and 44% after hip arthroscopy and between 18.2% and 25% after anterior mini-open surgery. Currently, pharmacological prophylaxis with NSAIDs and selective COX-2 inhibitors are commonly used and their effectiveness is well documented in literature. We hypothesized that the low-dose prophylaxis protocol with selective cox-2 inhibitors decreases the risk of heterotopic ossification in open or arthroscopic hip preservation surgery in athletes. This study is an analysis of prospectively gathered data on 98 sport participant patients who underwent arthroscopic or anterior mini-open treatment for FAI between April 2008 and April 2018. All the patients received postoperative oral prophylaxis with 60mg etoricoxib once daily for two weeks. Post-operative X-rays were performed at 1, 3, and 12 months after surgery and reviewed by two orthopedic surgeons blinded to the type and side of surgery. HO were graded according to the Brooker classification. Descriptive statistics was used to analyze demographic data. Bivariate analysis was performed to analyze the association of HO with each of the following variables: type of surgery, physical activity, time of evolution of symptoms, age at surgery, and sex. Finally, a regression model analysis was performed to determine the presence of confounding effects between variables. The study cohort was composed of 54 patients in the arthroscopic treatment group and 44 patients in the anterior mini-open group. HO was identified in 6 (13.6%) patients in the mini-open group. No HO was identified in the arthroscopic group. In the bivariate analysis, "type of surgery" was the only variable that showed a statistically significant association with HO (p=0.007). Results of this study suggest that anterior mini-open treatment was characterized by a higher risk of HO development compared to hip arthroscopy for femoroacetabular impingement treatment regardless of pharmacological prophylaxis. The treatment regimen of 60 mg etoricoxib daily for two weeks was an effective prophylaxis for HO formation in sport participant patients compared with data available in the literature.

Ten-year outcome following surgical treatment of femoroacetabular impingement

The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome. Prospectively collected data of a consecutive single-surgeon cohort, operated for FAI between January 2005 and January 2015, were retrospectively studied. The cohort comprised 393 hips (365 patients; 71% male (n = 278)), with a mean age of 34.5 years (SD 10.0). Over the study period, techniques evolved from open surgical dislocation (n = 94) to a combined arthroscopy-Hueter technique (HA + Hueter; n = 61) to a pure arthroscopic technique (HA; n = 238). Outcome measures of interest included modes of failures, complications, reoperation, and patient-reported outcome measures (PROMs). Demographic, radiological, and surgical factors were tested for possible association with outcome. At a mean follow-up of 7.5 years (SD 2.5), there were 43 failures in 38 hips (9.7%), with 35 hips (8.9%) having one failure mode, one hip (0.25%) having two failure modes, and two hips (0.5%) having three failure modes. The five- and ten-year hip joint preservation rates were 94.1% (SD 1.2%; 95% confidence interval (CI) 91.8 to 96.4) and 90.4% (SD 1.7%; 95% CI 87.1 to 93.7), respectively. Inferior survivorship was detected in the surgical dislocation group. Age at surgery, Tönnis grade, cartilage damage, and absence of rim-trimming were associated with improved preservation rates. Only Tönnis grade was an independent predictor of hip preservation. All PROMs improved postoperatively. Factors associated with improvement in PROMs included higher lateral centre-edge and α angles, and lower retroversion index and BMI. FAI surgery provides lasting improvement in function and a joint preservation rate of 90.4% at ten years. The evolution of practice was not associated with inferior outcome. Since degree of arthritis is the primary predictor of outcome, improved awareness and screening may lead to prompt intervention and better outcomes.Cite this article: Bone Jt Open2022;3(10):804-814.

Revision Surgery and Progression to Total Hip Arthroplasty After Surgical Correction of Femoroacetabular Impingement: A Systematic Review

Background: Femoroacetabular impingement (FAI) is a major cause of hip pain in young adults and athletes. Surgical treatment of FAI is recommended in cases of failed nonoperative treatment that have the typical clinical and radiographic findings. At present, the role of risk factors for revision surgery and progression to total hip arthroplasty (THA) in patients with FAI is still unclear. Purpose: To investigate the possible association between (1) rate of revision and progression to THA and (2) patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores. Study Design: Systematic review; Level of evidence, 4. Methods: The present systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In October 2020, the main online databases were accessed. All articles concerning surgical correction for selected patients with FAI were accessed. Patient characteristics, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores were assessed. The outcomes of interest were the possible association between these variables and the rate of revision and subsequent progression to THA using a multivariate analysis through the Pearson product-moment correlation coefficient. Results: Data from 99 studies (9357 procedures) were collected. The median follow-up was 30.9 months (interquartile range, 24.0-45.0). The mean ± SD age was 33.4 ± 9.3 years; mean body mass index (BMI), 24.8 ± 4.8; percentage right side, 55.8% ± 8.0%; and percentage female sex, 47.5% ± 20.4%. The overall rate of revision was 5.29% (351 of 6641 patients), while the rate of subsequent progression to THA was 3.78% (263 of 6966 patients). Labral debridement (P < .0001), preoperative acetabular index (P = .01), and BMI (P = .03) all showed evidence of a statistically positive association with increased rates of THA. No other statistically significant associations were found between patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, or pre- and postoperative scores and the rate of revision and/or progression to THA. Conclusion: Although surgical procedures to treat FAI led to satisfactory outcomes, there was a revision rate of 5.29% in the 9357 procedures in the present systematic review. The rate of progression to THA after a median follow-up of 30 months was 3.78%. Patients who have a higher BMI and/or have a pathologic acetabular index and/or undergo labral debridement during correction of FAI are more at risk for a subsequent THA. We advocate additional education of this patient population in terms of expected outcomes and suggest surgical labral repair instead of debridement if needed.

Sex Differences in Clinical Outcomes Following Surgical Treatment of Femoroacetabular Impingement.

Sex-based differences in clinical outcomes following surgical treatment of femoroacetabular impingement remain largely uncharacterized; this prospective, multicenter study evaluated these differences both directly and adjusted for covariates. Hips undergoing surgical treatment of symptomatic femoroacetabular impingement were prospectively enrolled in a multicenter cohort. Patient demographics, radiographic parameters, intraoperatively assessed disease severity, and history of surgical procedures, as well as patient-reported outcome measures, were collected preoperatively and at a mean follow-up of 4.3 years. A total of 621 (81.6%) of 761 enrolled hips met the minimum 1 year of follow-up and were included in the analysis; 56.7% of analyzed hips were female. Univariate and multivariable statistics were utilized to assess the direct and adjusted differences in outcomes, respectively. Male hips had greater body mass index and larger α angles. Female hips had significantly lower preoperative and postoperative scores across most patient-reported outcome measures, but also had greater improvement from preoperatively to postoperatively. The preoperative differences between sexes exceeded the threshold for the minimal clinically important difference of the modified Harris hip score (mHHS) and all Hip disability and Osteoarthritis Outcome Score (HOOS) domains except quality of life. Preoperative sex differences in mHHS, all HOOS domains, and Short Form-12 Health Survey physical function component score were greater than the postoperative differences. A greater proportion of female hips achieved the minimal clinically important difference for the mHHS, but male hips were more likely to meet the patient acceptable symptom state for this outcome. After adjusting for relevant covariates with use of multiple regression analysis, sex was not identified as an independent predictor of any outcome. Preoperative patient-reported outcome scores were a strong and highly significant predictor of all outcomes. Significant differences in clinical outcomes were observed between sexes in a large cohort of hips undergoing surgical treatment of femoroacetabular impingement. Despite female hips exhibiting lower baseline scores, sex was not an independent predictor of outcome or reoperation. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Surgical Treatment of Femoroacetabular Impingement: Minimum 10-Year Outcome and Risk Factors for Failure.

Background:Femoroacetabular impingement (FAI) is a well-known cause of hip pain and dysfunction in young adults. Surgical treatment has been widely popularized during the past decade. However, most reported results have been limited to short-term and intermediate-term follow-up. The long-term success rate and risk factors for failure are largely unknown. This study aimed to report the long-term (minimum, 10 years) clinical outcomes of surgical treatment of FAI and to describe the clinical and radiographic parameters associated with the failure of treatment involving femoroacetabular osteoplasty (FAO) and labral repair.Methods:Using our prospective hip preservation database, 164 patients (178 hips) who had undergone FAO between January 2005 and April 2009 were identified. Patient demographic characteristics, clinical history, duration of preoperative symptoms, radiographic parameters (preoperative and postoperative alpha angles, hip dysplasia and retroversion, Tönnis grade for osteoarthritis), and intraoperative findings were reviewed and compared between the success and failure groups. At a minimum 10-year follow-up, clinical functional outcomes (modified Harris hip score [mHHS] and Short Form-36 [SF-36] at 6 weeks, 6 months, 1 year, and 10 years) and failure rates (conversion to total hip arthroplasty [THA]) were collected.Results:The mean patient age (and standard deviation) was 34.3 ± 8.4 years, and 65 patients (40%) were female. After the surgical procedure, there was significant improvement in the mean mHHS (59.3 ± 7.3 points preoperatively to 88.4 ± 7.3 points postoperatively) and the mean SF-36 (61.3 ± 8.4 points preoperatively to 89.1 ± 7.2 points postoperatively). At a mean follow-up of 12.5 years, 12% (22 hips) required conversion to THA, with a mean time to THA of 5.3 ± 2.0 years. Older age, longer preoperative symptomatic period, higher preoperative and postoperative alpha angles, presence of hip dysplasia, a higher Tönnis grade, joint space narrowing, and a full-thickness acetabular chondral lesion at the time of the FAO were identified as risk factors for failure and conversion to THA.Conclusions:Patients with symptomatic FAI who undergo a surgical procedure experience pain relief and functional improvement that appear to endure over a decade in the majority of patients. This study on a relatively large cohort with a long-term follow-up has also identified patients who are at a higher risk for treatment failure.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Why Does Hip Arthroscopy Fail? Indications and PEARLS for Revision Success.

The surgical treatment of femoroacetabular impingement has been shown to have successful early and mid-term clinical outcomes. Despite these favorable clinical outcomes that have been published in the literature, there is a subgroup of patients that present with continued or recurrent symptoms after surgical treatment. Not only has there been an increase in the number of hip arthroscopy procedures, but also there has been a corresponding increase in the number of revision hip arthroscopy and hip preservation surgeries. Previous studies have reported residual deformity to be the most common reason for revision hip arthroscopy. However, chondral, labral, and capsular considerations also are important when addressing patients not only in the primary but also, the revision setting. In this review, we outline the evaluation and treatment of the patient that presents with continued hip and groin pain after undergoing a hip.

Age-Associated Pathology and Functional Outcomes After Hip Arthroscopy in Female Patients: Analysis With 2-Year Follow-up

Background: Previous research has demonstrated a statistically significant relationship between hip arthroscopy outcomes and age. Purpose: To investigate the link, if any, between hip arthroscopy outcomes and intraoperative pathology as well as with patient age and sex. Study Design: Cohort study; Level of evidence, 3. Methods: Of 272 female patients aged ≥14 years undergoing primary hip arthroscopy for femoroacetabular impingement between August 2010 and September 2017, and with 2-year patient-reported outcome scores, a total of 194 (71.3%) were included for final analysis. These patients were separated into 3 age-based cohorts: <30 years (n = 44), 30 to 45 years (n = 74), and >45 years (n = 76). Their data were then analyzed and compared with respect to patient characteristic information, intraoperative pathology, and functional outcome scores for statistical significance, which was set at P < .05. Results: When an analysis of variance was conducted for the 3 age groups at 2-year follow-up, there was a statistically significant difference for modified Hip Harris Score (P = .0003; <30 years, 88.26 ± 13.1 [mean ± SD]; 30-45 years, 82.68 ± 18.0; >45 years, 75.03 ± 19.5). The results of an analysis of variance comparing 2-year Non-arthritic Hip Score were also statistically significant (P = .0002; <30 years, 89.9 ± 13.7; 30-45 years, 85.8 ± 15.8; >45 years, 78.1 ± 17.2). Results of logistic regression demonstrated that the odds of a cam-type lesion decreased by 0.971 for every additional year in age among female patients. The odds of achieving the patient-acceptable symptomatic state decreased by a factor of 0.96 for each additional year in age (P < .0004). Conclusion: Surgical treatment of femoroacetabular impingement in females led to improved functional outcomes at 2 years of follow-up, although older female patients did worse after hip arthroscopy as compared with their younger counterparts. There may be an age-dependent decrease in incidence of cam-type lesions in female patients.

Low rate of adverse events in a randomized controlled trial addressing the surgical treatment of femoroacetabular impingement (FAI) syndrome.

The femoroacetabular impingement randomised controlled trial (FIRST) is a multi-center randomized controlled trial (RCT), comparing arthroscopic osteochondroplasty with arthroscopic lavage in adults aged 18-50years diagnosed with non-arthritic femoroacetabular impingement (FAI) syndrome. The purpose of the present study is to report the prevalence, distribution and severity of adverse events during and within 24-month follow-up period. Of the 220 patients included, 6 were adjudicated as ineligible, for a total of 214 patients included in the final analysis. An independent Adjudication Committee evaluated operatively treated and non-operatively treated adverse events that were related to the hip. Adverse events were also reported directly by each participating clinical site. Continuous variables were reported as mean and standard deviation, categorical variables were reported as counts and percentages. There were a total of 52 (24.2%, 52/214) adverse events in 46 (21.5%) patients (mean age 34.2 ± 7.9years, 58.7% male) during the 24-month follow-up. There were 12.6% (27/214) operatively treated adverse events for: hip pain, re-injury of labrum and heterotopic ossification. There were 11.7% (25/214) non-operatively treated adverse events for predominantly: hip pain, hip tendinopathy and hip popping/snapping. Approximately, 87% of adverse events resolved within the 24-month follow-up time. Given the inherent challenges with conducting RCTs, the results of this adverse event study from the FIRST trial demonstrate that it is safe to perform an RCT addressing FAI syndrome. Level III.

Return to Sport After Hip Arthroscopy for Femoroacetabular Impingement Syndrome in NCAA Division I Athletes: Experience at a Single Institution.

Background:The rate of return to sport after surgical treatment of femoroacetabular impingement (FAI) syndrome (FAIS) has been studied in high-level athletes. However, few studies examining this rate have focused exclusively on National Collegiate Athletic Association (NCAA) Division I athletes.Purpose:To evaluate the return-to-sport rate after hip arthroscopy for FAIS and to examine the influence of sport type on the clinical presentation of FAIS in collegiate athletes.Study Design:Case series; Level of evidence, 4.Methods:Included in this study were NCAA Division I student-athletes who underwent hip arthroscopy for FAIS at our institution between 2010 and 2017. Exclusion criteria were history of previous hip pathology, pediatric hip disease, radiographic evidence of osteoarthritis (Tönnis grade >0), prior lower extremity procedure, history of chronic pain, osteoporosis, or history of systemic inflammatory disease. Athletes were categorized into 6 subgroups based on the type of sport (cutting, contact, endurance, impingement, asymmetric/overhead, and flexibility) by using a previously reported classification system. Patient characteristics and preoperative, intraoperative, and return-to-sport variables were compared among sport types.Results:A total of 49 hip arthroscopies for FAIS were performed in 39 collegiate athletes (10 females, 29 males; mean age, 19.5 ± 1.3 years). A total of 1 (2.6%) cutting athlete, 15 (38.5%) contact athletes, 8 (20.5%) impingement athletes, 6 (15.4%) asymmetric/overhead athletes, and 9 (23.1%) endurance athletes were included in the study. There were no differences among sports groups with respect to the FAI type. Endurance athletes had lower rates of femoral osteochondroplasty (45.5%) and labral debridement (0.0%) (P < .0001). Contact sport athletes had higher rates of labral debridement (50.0%; P < .0001). Patients were evaluated for return to sport at an average of 1.96 ± 0.94 years. Overall, the return-to-sport rate was 89.7%. There were no differences in return-to-sport rates based on the sport type except for endurance athletes, who returned at a lower rate (66.6%; P < .001). No differences in return-to-sport rate (P = .411), duration after return (P = .265), or highest attempted level of sport resumed (P = .625) were found between patients who underwent labral repair versus debridement.Conclusion:Collegiate-level athletes who underwent hip arthroscopy for FAIS returned to sport at high and predictable rates, with endurance athletes possibly returning to sport at lower rates than all other sport types. Surgical procedures may be influenced by sport type, but the rate of return to sport between athletes who underwent labral debridement versus labral repair was similar.

Mini-Open Femoroacetabular Osteoplasty: Risk Factors for Failure and Conversion to Hip Arthroplasty.

Surgical treatment of femoroacetabular impingement (FAI) has been increasing over the past decade with reports of favorable results in alleviating patient symptoms. However, progression of osteoarthritis in these patients may necessitate total hip arthroplasty (THA) for the treatment of unresolved or recurrent hip pain and accompanying disability. Identifying the risk factors for disease progression and treatment failure can help orthopaedic surgeons to select the appropriate patients for joint-preservation procedures and allow more informative discussions. With use of the prospective database of hip-preservation surgery at our institution, 652 patients (324 men and 328 women) with FAI who had undergone femoroacetabular osteoplasty (FAO) between December 2004 and April 2016 were identified. Treatment failure was defined as the need for THA. At the latest follow-up, 68 (9.08%)of 749 hips had undergone THA because of the recurrence of symptoms and the development of osteoarthritis. The groups of patients who had or had not undergone conversion to THA were compared with respect to age, sex, body mass index (BMI), surgeon experience, duration of preoperative symptoms, preoperative and postoperative alpha angles, radiographic parameters of hip dysplasia, a perioperative chondral lesion, labral abnormalities and interventions, acetabular retroversion, and severity of osteoarthritis (Tönnis grade). The mean age (and standard deviation) at the time of the index FAO was 41.9 ± 10.5 years for patients who had had a failure of FAO, compared with 33.4 ± 11.1 years for those who had not. Risk factors for treatment failure included a longer mean symptomatic period before the FAO procedure, older age, higher mean BMI, the presence of hip dysplasia, acetabular retroversion, higher preoperative alpha angle, a full-thickness acetabular chondral lesion, Tönnis grade-1 and 2 osteoarthritis, labral hypertrophy, and total labral resection during FAO. The rate of failure was related to the experience of the surgeon, with fewer failures occurring in the later years of surgery as compared with the earlier years. The present study identified a number of variables that influence the outcome of FAO. Surgeons performing hip-preservation procedures should be aware of these risk factors for failure, and a more cautious approach is recommended for patients with these risk factors. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes for Surgical Treatment of Femoroacetabular Impingement in Adults.

To assess the outcomes of modern techniques for arthroscopic surgery in the treatment of femoroacetabular impingement. While initially approached by means of open surgical hip dislocation, recent literature has shown generally good outcomes of arthroscopic treatment for femoroacetabular impingement. Modern advances in hip arthroscopy technique and implants now allow for labral repair or reconstruction when indicated. Arthroscopic treatment of femoroacetabular impingement results in significant improvements in patient pain and function, with low complication rates and high patient satisfaction. A majority of improvements in these patients occur within 1 to 2years post-operatively. Hip arthroscopy for femoroacetabular impingement yields the best results in patients without significant arthritis or hip dysplasia.

Predictors of Failure After Surgical Treatment of Femoroacetabular Impingement: Results of a Multicenter Prospective Cohort of 621 Hips

Objectives: Surgical treatment of femoroacetabular impingement attempts to improve patients’ symptoms through treatment of intra-articular labrochondral pathology and correction of underlying bony deformity. The purpose of the current study was to determine independent predictors of failure after surgical treatment of femoroacetabular impingement in a large prospective multicenter cohort study. Methods: A prospective cohort study of the surgical treatment of FAI was performed. A total of 760 hips undergoing primary surgical treatment of FAI were enrolled across seven surgeons. Patient characteristics, baseline patient reported outcomes (PROs), imaging findings, intraoperative pathology, and surgical treatments were prospectively recorded. A total of 621 hips (81.6%) with minimum one year follow-up were included in the current study (mean 4.3 years). The mHHS was assessed relative to the minimally clinically important difference (MCID, 8 points) and patient acceptable symptom state (PASS, 74 points). Univariate analyses were performed to identify factors significantly associated with failure. Multivariate logistic regression was performed to identify independent predictors of failure. Results: A total of 621 hips undergoing surgical treatment of FAI were assessed at a mean 4.2 years postoperatively. This cohort had a mean age of 29.8 and included 56.8% females. Multivariate logistic regression identified independent predictors of each failure definition. Failure A (THA) was independently associated with increasing age, acetabular microfracture (both p&lt;0.001), and femoral head chondroplasty (p=0.02). Failure B (THA or revision surgery) was independently associated only with lower preoperative mHHS (p&lt;0.001) (p=0.01). A lower failure C (clinical failure) was independently associated with participation in competitive athletics (p=0.01), BMI (p&lt;0.001), and male gender (p&lt;0.001). Conclusion: This large multicenter cohort demonstrates the outcomes of FAI treatment at a mean of 4.3 years postoperative. Rates of THA and revision surgery were 4.0% and 6.9%. An additional 14.8% of patients demonstrates clinical failure based on patient-reported outcomes.

Surgical Treatment for FAI: Arthroscopic and Open Techniques for Osteoplasty.

To review the relevant literature and techniques regarding arthroscopic and open treatment of femoroacetabular impingement (FAI). To discuss both the senior authors' preferred method of arthroscopic and open treatment of FAI. Routine treatment of FAI has moved away from open techniques and is more focused arthroscopic methods. Arthroscopic treatment of FAI has more recently focused on differing techniques of hip access and capsular management. Open techniques still have a role in FAI, but indications for open management are focused on cases with more severe pathology. While arthroscopic techniques have shown better outcomes in the short term and higher return to play, it is not without risk and is a procedure with a steep learning curve. In cases of complex joint pathology, such as FAI coupled with dysplasia or Legg-Calve-Perthes, arthroscopy may be not indicated and an open approach preferred. We outline various techniques for both arthroscopic and open treatment of FAI and their outcomes when possible.

Capsular closure positively affects the functionnal outcome of femoroacetabular Impingement treatment using the extracapsular outside-in approach

Purpose To evaluate early clinical outcomes and complication rates of the outside-in extracapsular approach for the treatment of femoroacetabular impingement (FAI) and to assess the effect of capsular closure on the functional outcome. Methods A consecutive series of hip arthroscopies performed for surgical treatment of FAI using the Ouside-In approach with minimum 2 years follow-up were assessed. Any complications during early, intermediate or long-term follow were identified and recorded. Linear regression models were used to estimate the influence of capsular closure on the functional outcome. Results Sixty-four hips in 57 patients were analyzed at the time of final follow-up of 34.17 months (range 24 to 53). Functional outcome measurements showed an improvement from the preoperative to the last follow-up: 63.5 ± 11.0 to 88.1 ± 11.2 for mHHS, 63.1 ± 13.8 to 86.4 ± 13.4 for NAHS. All PROs showed a statistically significant improvement at final follow-up compared with preoperative levels. Capsular closure leads to a significantly improved clinical outcome ( P > 0.05). No major complications occurred. One case of postoperative tensor fascia latae atrophy was documented. Conclusion Hip arthroscopy in the management of FAI with an extra-articular starting point (Outside-In) is a safe technique with functional results and postoperative morbidity comparable to previous reported techniques. Side to side capsular closure at the end of the procedure might positively affect the final functional outcome.

Surgical treatment of femoroacetabular impingement after slipped capital femoral epiphysis.

Femoroacetabular impingement (FAI) post slipped capital femoral epiphysis (SCFE) may lead to degenerative changes on the hip. We have reviewed the current procedures in the literature, aiming to correct the SCFE to prevent FAI and the ones that treat FAI post SCFE. The trends of managing moderated or severe SCFE is to correct the displacement by reduction and fixation with articular hematoma decompression in unstable hips and Dunn modified procedure even for unstable and stable situations. However, after FAI is settled, the options are osteochondroplasty by arthroscopy or surgical hip dislocation, associated or not to subtrocanteric osteotomy. Femoroacetabular impingement may occur in mild slips and certainly occur in cases of moderate and severe slips. The initial management depends on the severity and the stability of the slip.The modified Dunn procedure is a good option for the treatment of unstable SCFEs. Gentle closed reduction with capsulotomy (Parsch) may be considered whenever the surgeon is not comfortable with the modified Dunn procedure.Hips with open physis and stable moderate or severe SCFE, the modified Dunn procedure can be indicated. Cases with closed physis are managed with intertrochanteric osteotomy combined with osteoplasty.In the presence of symptomatic FAI secondary to SCFE, one should consider arthroscopic osteoplasty or surgical hip dislocation (with or without osteotomies) as treatment options.

Postoperative Imaging after Impingement Surgery.

AbstractIn addition to the patient's medical history and clinical evaluation, conventional radiographs and magnetic resonance imaging (MRI) are important tools to indicate appropriate conservative treatment or even revision surgery in patients with symptoms after surgical management of femoroacetabular impingement (FAI). We present an overview of current evidence in postoperative imaging after impingement surgery. Undercorrection of the underlying osseous FAI configuration is the most frequent indication for revision surgery within the first 2 years after index FAI surgery. Femoral neck fractures, iatrogenic chondral injuries, early conversion to total hip arthroplasty, loose bodies, and heterotopic ossifications are rare but typical early complications after surgical treatment of FAI. Abnormal MRI findings after FAI surgery such as intra-articular adhesions, labral tears, cartilage defects, and anterior capsular defects are common findings in both asymptomatic and symptomatic postoperative patients. Avascular necrosis of the femoral head is an extremely rare complication after surgical treatment of FAI.

Predictors of the clinical outcome and survival without degenerative arthritis after surgical treatment of femoroacetabular impingement

The main purposes of the present study were to evaluate the functional improvement, to identify the predictors of the clinical outcome after open surgical management of femoroacetabular impingement (FAI) in mid-term, and to determine 5-year survival rate. In this retrospective study, the clinical data of 33 patients (34 hips) were evaluated. Sex, age, body mass index (BMI), type of FAI, duration of symptoms up to surgical treatment, internal rotation of the affected hip, improvement of the Harris hip score (HHS) in the first 2 years, joint space narrowing evaluated radiographically and classified according to Kellgren-Lawrence classification, and any labral tear were the independent variables. Harris hip score and degenerative arthritic changes at the latest follow-up were identified as outcome measures. Univariate and multivariate analyses were performed. The mean post-operative follow-up was 6 years. Harris hip scores at the latest follow-up were significantly worse in patients with a pre-operative age >35 years, BMI ≥25kg/m2, internal rotation of the hip ≤10°, grade 1 or 2 joint space narrowing, labral tear, and <15 points improvement of the HHS at the first 2 years follow-up. According to multivariate analysis; major predictors of the outcome were BMI, labral tear, and improvement of the HHS at the first 2 years. A pre-operative BMI ≥25kg/m2, labral tear, and <20 points improvement of the HHS in the first 2 years of surgery should be considered as the major predictors of the clinical outcome after open surgical management of idiopathic FAI.

Surgical treatment of femoroacetabular impingement following slipped capital femoral epiphysis

ObjectivesThe purpose of this study was to evaluate the existing literature from 2005 to 2016 reporting on the efficacy of surgical management of patients with femoroacetabular impingement (FAI) secondary to slipped capital femoral epiphysis (SCFE).MethodsThe electronic databases MEDLINE, EMBASE, and PubMed were searched and screened in duplicate. Data such as patient demographics, surgical technique, surgical outcomes and complications were retrieved from eligible studies.ResultsFifteen eligible level IV studies were included in this review comprising 261 patients (266 hips). Treatment groups included arthroscopic osteochondroplasty, surgical hip dislocation, and traditional open osteotomy. The mean alpha angle corrections were 32.14° (standard deviation (sd) 7.02°), 41.45° (sd 10.5°) and 6.0° (sd 5.21°), for arthroscopy, surgical hip dislocation, and open osteotomy groups, respectively (p < 0.05). Each group demonstrated satisfactory clinical outcomes across their respective scoring systems. Major complication rates were 1.6%, 10.7%, and 6.7%, for arthroscopy, surgical dislocation and osteotomy treatments, respectively.ConclusionIn the context of SCFE-related FAI, surgical hip dislocation demonstrated improved correction of the alpha angle, albeit at higher complication and revision rates than both arthroscopic and open osteotomy treatments. Further investigation, including high-quality trials with standardised radiological and clinical outcome measures for young patients, is warranted to clarify treatment approaches and safety.Cite this article: K. O. Oduwole, D. de Sa, J. Kay, F. Findakli, A. Duong, N. Simunovic, Y. Yi-Meng, O. R. Ayeni. Surgical treatment of femoroacetabular impingement following slipped capital femoral epiphysis: A systematic review. Bone Joint Res 2017;6:472–480. DOI: 10.1302/2046-3758.68.BJR-2017-0018.R1.