Nonoperative Management of Femoroacetabular Impingement: A Prospective Study

Hip Arthroscopy for Femoroacetabular Impingement in Adolescents: 10-Year Patient-Reported Outcomes

BACKGROUND

Previous studies have demonstrated hip arthroscopy to be an effective treatment for femoroacetabular impingement (FAI) in individuals 18 years of age and older. Long-term outcome data in the adolescent population, however, are limited.

PURPOSE

To report 10-year outcomes after hip arthroscopy in adolescents with symptomatic FAI.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Prospectively collected data were analyzed on adolescent patients younger than 18 years of age who had hip arthroscopy between March 2005 and 2009 with a minimum 10-year follow-up. Patients were included if they were diagnosed with symptomatic FAI and an associated labral tear that was treated with repair. Patients were excluded if they had previous hip procedures, acetabular dysplasia (lateral center-edge angle, <20°), avascular necrosis, previous hip fracture or dislocation, or Legg-Calve-Perthes disease, or refused to participate. The primary patient-reported outcome measure was the Hip Outcome Score (HOS) Activities of Daily Living (ADL) subscale. In addition, the HOS-Sport, modified Harris Hip Score (mHHS), 12-Item Short Form Health Survey (SF-12), and patient satisfaction were collected. Failure was defined as patients having to undergo revision arthroscopy.

RESULTS

There were 60 patients (70 hips) who met inclusion criteria and had a 10-year follow-up. The mean age of the cohort was 16 ± 1.2 years, with 21 male and 49 female hips. Seven hips (10%) required revision hip arthroscopy. All revisions occurred in female patients and were associated with global laxity as well as longer duration of symptoms before time of surgery. At a mean follow-up of 12 years (range, 10-14 years), patients who did not undergo revision surgery had significant improvements from preoperatively to postoperatively in HOS-ADL (from 64 to 92; P < .01), HOS-Sport (from 40 to 86; P < .01), mHHS (from 56 to 88; P < .01), and SF-12 Physical Component Summary (from 41 to 54; P < .01). The median patient satisfaction was 10 out of 10 (very satisfied).

CONCLUSION

Hip arthroscopy for FAI with labral repair resulted in excellent patient-reported outcomes and satisfaction at a minimum of 10 years of follow-up. There was a 10% rate of revision surgery, which was associated with global laxity and longer duration of symptoms before surgery, which should be considered in patient selection.

Femoroacetabular Impingement Syndrome

Femoroacetabular impingement (FAI) syndrome is one of the most rapidly evolving etiologies of hip pain. The 2016 Warwick Agreement consensus statement defined FAI syndrome as a triad of symptoms, signs, and radiographic findings. Cam morphology is more likely in athletes and is associated with repetitive hip loading in maximal flexion during adolescence. Much less is known about the development of pincer morphology. Physical therapy improves pain and function, justifying a trial before pursuing surgery. Musculoskeletal injections are utilized for FAI syndrome, but the evidence is limited. Arthroscopic surgery for FAI syndrome can correct the morphological changes and address the underlying soft tissue injuries. Recent studies evaluated reliable indicators of surgical outcomes, the most reliable of which is the presurgical presence of osteoarthritis. Recent studies demonstrate the efficacy of surgery, but with the risk of complication and no guarantee of a return to the same level of sport.

Do currently prescribed exercises reflect contributing pathomechanics associated with femoroacetabular impingement syndrome? A scoping review

OBJECTIVE

Research reports limited, mixed evidence on the effectiveness of physiotherapy management in the treatment of femoroacetabular impingement (FAI) syndrome. The purpose of this review was to (1) identify what therapeutic exercises are being utilized in the non-surgical management of patients with FAI syndrome; (2) map the extent to which reported exercises reflect contributory pathomechanics associated with FAI syndrome.

DESIGN

Scoping Review.

METHODS

MEDLINE, PubMed, CINAHL, SPORTDiscus, and PEDRO electronic databases were searched for studies that implemented a non-surgical, exercise-based treatment approach in patients with FAI syndrome. Exercises were extracted and analyzed according to elements recognized as contributing to the pathomechanics associated with FAI syndrome.

RESULTS

24 studies fulfilled the inclusion criteria. 453 exercises were extracted. Uniplanar exercises accounted for 338/453 or 74.6% of all reported exercises whereas triplanar exercises accounted for 21/453 or 4.6% of all exercises. Non-weight bearing exercises accounted for 220/453 or 48.6% of all exercises.

CONCLUSION

The majority of therapeutic exercises were classified as sagittal, uniplanar exercises, utilizing a concentric exercise approach. These findings highlight that exercises utilizing triplanar, eccentric hip control, in a single limb weightbearing position are considerably underrepresented.

Arthroscopy versus nonoperative treatment of symptomatic femoroacetabular impingement syndrome: A systematic review and meta-analysis

BACKGROUND

Presently, hip arthroscopy is a widely adopted surgical intervention for the treatment of femoroacetabular impingement (FAI). However, there is insufficient evidence regarding which between arthroscopy and nonoperative treatment is more optimal for symptomatic FAI.

METHODS

MEDLINE, Embase, Web of Science, and the Cochrane Library were systematically searched for studies that compared arthroscopy and nonoperative interventions for FAI treatment from inception to August 4, 2020. We included studies that directly compared surgical and nonsurgical treatment for symptomatic FAI and excluded those that did not use arthroscopic treatment as a surgical technique and studies performed on patients with concomitant diagnoses instead of pure FAI. We compared the following clinical outcome scores at 6 and 12 months of follow-up: International Hip Outcome Tool 33 (iHOT-33), hip outcome score (HOS), EuroQol-visual analog scale (EQ-VAS), modified Harris hip score (mHHS), and nonarthritic hip score (NAHS).

RESULTS

Five studies totaling 838 patients were included in the qualitative and quantitative synthesis; 382 patients underwent hip arthroscopy, and 456 patients were treated by nonoperative interventions. At 6 months of follow-up, there were no statistically significant differences in iHOT-33 ratings (mean difference [MD] = 7.92, P = .15), HOS (MD of HOS-ADL = 5.15, P = .26 and MD of HOS-Sports = 2.65, P = .79, respectively), and EQ-VAS (MD = 1.22, P = .76) between the 2 treatment strategies. At 12 months of follow-up, the arthroscopy group had a greater mean improvement in iHOT-33 score than the conservative treatment group (MD = 8.42, P = .002), but there was no difference between the groups in terms of mHHS rating (MD = -0.24, P = .83) and NAHS (MD = -2.08, P = .09).

CONCLUSION

Despite arthroscopy being associated with significantly superior iHOT-33 scores after 12 months of follow-up, we were unable to discern the difference between the treatment strategies using other scoring methods, such as HOS, EQ-VAS, mHHS, and NAHS. Further studies will be needed to conclusively determine if 1 strategy is superior to the other for treating FAI.

Rate of Surgery and Baseline Characteristics Associated With Surgery Progression in Young Athletes With Prearthritic Hip Disorders

Background:

Prearthritic hip disorders (PAHD), such as femoroacetabular impingement (FAI), acetabular dysplasia, and acetabular labral tears, are a common cause of pain and dysfunction in adolescent and young adult athletes, and optimal patient-specific treatment has not been defined. Operative management is often recommended, but conservative management may be a reasonable approach for some athletes.

Purpose:

To identify (1) the relative rate of progression to surgery in self-reported competitive athletes versus nonathletes with PAHD and (2) baseline demographic, pain, and functional differences between athletes who proceeded versus those who did not proceed to surgery within 1 year of evaluation.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

An electronic medical record review was performed of middle school, high school, and college patients who were evaluated for PAHD at a single tertiary-care academic medical center between June 22, 2015, and May 1, 2018. Extracted variables included patients’ self-reported athlete status, decision to choose surgery within 1 year of evaluation, and baseline self-reported pain and functional scores on Patient-Reported Outcomes Measurement Information System (PROMIS) domains, the Hip disability and Osteoarthritis Outcome Score (HOOS), and the modified Harris Hip Score.

Results:

Of 260 eligible patients (289 hips), 203 patients (78%; 227 hips) were athletes. Athletes were no more likely to choose surgery than nonathletes (130/227 hips [57%] vs 36/62 hips [58%]; relative risk [RR], 0.99 [95% CI, 0.78-1.25]). Among athletes, those who proceeded to surgery over conservative care were more likely to be female (81% vs 69%; RR, 1.34 [95% CI, 0.98-1.83]) and had more known imaging abnormalities (FAI: 82% vs 69%, RR, 1.47 [95% CI, 1.09-1.99]; dysplasia: 48% vs 27%, RR, 1.44 [95% CI, 1.16-1.79]; mixed deformity: 30% vs 10%, RR, 2.91 [95% CI, 1.53-5.54]; known labral tear: 84% vs 40%, RR, 2.79 [95% CI, 2.06-3.76]). Athletes who chose surgery also reported worse baseline hip-specific symptoms on all HOOS subscales (mean difference, 10.8-17.7; P < .01 for all).

Conclusion:

Similar to nonathletes, just over half of athletes with PAHD chose surgical management within 1 year of evaluation. Many competitive athletes with PAHD continued with conservative management and deferred surgery, but more structural hip pathology and worse hip-related baseline physical impairment were associated with the choice to pursue surgery.

Short-term Clinical Outcomes of Hip Arthroscopy Versus Physical Therapy in Patients With Femoroacetabular Impingement: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background:

Both physical therapy (PT) and surgery are effective in treating femoroacetabular impingement (FAI), but their relative efficacy has not been well established until recently. Several randomized controlled trials (RCTs) comparing the early clinical outcomes of these treatments have been published, with contradictory results.

Purpose/Hypothesis:

The purpose of this study was to perform a meta-analysis of RCTs that compared early patient-reported outcomes (PROs) of hip arthroscopy versus PT in patients with symptomatic FAI. The hypothesis was that surgical treatment of FAI leads to better short-term outcomes than PT.

Study Design:

Systematic review; Level of evidence, 1.

Methods:

In March 2019, a systematic review was performed to identify RCTs comparing hip arthroscopy and PT in patients with symptomatic FAI. A total of 819 studies were found among 6 databases; of these, 3 RCTs met eligibility (Griffin et al, 2018; Mansell et al, 2018; and Palmer et al, 2019). All 3 RCTs reported international Hip Outcome Tool--33 (iHOT-33) scores, and 2 reported Hip Outcome Score (HOS)–Activities of Daily Living (ADL) and HOS-Sport results. In a random-effects meta-analysis, between-group differences in postintervention scores were assessed according to intention-to-treat and as-treated approaches. Quality was assessed with CONSORT, CERT, TiDieR, and the Cochrane Collaboration tool.

Results:

The 3 RCTs included 650 patients with FAI; the mean follow-up ranged from 8 to 24 months. All studies reported PRO improvement from baseline to follow-up for both PT and surgery. The quality of the Griffin and Palmer studies was good, with minimal bias. In the Mansell study, a 70% crossover rate from PT to surgery increased the risk of bias. The meta-analysis demonstrated improved iHOT-33 outcomes with surgery compared with PT for intention-to-treat (mean difference [MD], 11.3; P = .046) and as-treated (MD, 12.6; P = .007) analyses. The as-treated meta-analysis of HOS-ADL scores favored surgery (MD, 12.0; P < .001), whereas the intention-to-treat analysis demonstrated no significant difference between groups for HOS-ADL (MD, 3.9; P = .571).

Conclusion:

In patients with FAI, the combined results of 3 RCTs demonstrated superior short-term outcomes for surgery versus PT. However, PT did result in improved outcomes and did not appear to compromise the surgical outcomes of patients for whom therapy failed and who progressed to surgery.

Return to Sport After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: a Comprehensive Review of Qualitative Considerations

PURPOSE OF REVIEW

Arthroscopic hip surgery for femoroacetabular impingement syndrome has evolved over time and has resulted in significantly improved clinical outcomes. These outcomes can be measured by clinical and radiographic metrics. Return to sport is commonly used as an outcome measure, not only in terms of overall rate but also type of sport, level of competition, and timing of return, as its quantitative definition continues to develop. Qualitative research methods can highlight the patient-derived themes that affect an athlete's individual return to sport pathway, and can augment the existing methods of outcome reporting. We will specifically review the qualitative research that has been performed on evaluating return to sport after arthroscopic hip surgery for femoroacetabular impingement syndrome.

RECENT FINDINGS

Current evidence finds a high overall rate of return to sport at 87-93% after arthroscopic hip surgery for femoroacetabular impingement syndrome. The available qualitative research in this body of literature, which is limited, has found three main overarching themes behind athletes' decision and ability, or inability, to return to sport: self-efficacy, social support, and resetting expectations. Athletes experience high rates of return to sport and athletic performance after arthroscopic hip surgery for femoroacetabular impingement syndrome. This review highlights the qualitative considerations for these athletes in their overall readiness to return to sport, and its utility for treating physicians as we interact with these athletes both pre- and post-operatively. Further research is required to elucidate any further overarching themes that may be prevalent in different levels of competition.

Running with Femoral Acetabular Impingement: Operative Vs Nonoperative Treatment

A 31-year-old female lawyer presents with right hip pain starting approximately 3 years ago and worsening over the past 2 to 3 months. She is an avid runner, running 20 to 30 miles weekly, and noticed that her pain started after a running program training for the marathon. Her pain is primarily over the lateral aspect of her hip with some radiation into the groin. The pain is made worse with impact exercises such as running and made better with walking and cycling. She has done physical therapy for the past 3 months without any significant improvement. She has not had any injections or taken anti-inflammatories because of a history of gastric ulcer disease. On physical examination she has mild tenderness over her right greater trochanter and her range of motion tests are full in terms of flexion, internal rotation, and external rotation. She has a positive FADIR (flexion-adduction-internal rotation) impingement that causes both groin and lateral hip pain. Radiograph of the right hip revealed preservation of the joint space and an anterior cam lesion with reduced offset at the femoral head neck junction. Magnetic resonance imaging (MRI) of the right hip revealed a tear at the anterior superior labrum at the 1 to 2 o'clock position along with subjacent bone marrow edema in the femoral head that is likely reactive. Computed tomography (CT) scan of the right hip confirmed a combined cam and pincer type femoral acetabular impingement of the right hip with overcoverage of the femoral head. There was 15° of femoral anteversion and the coronal lateral center of edge angle (LCEA) is 34°. Dr. Peter Moley argues that a focused rehabilitation program to restore strength and motor control of the deep hip stabilizers will provide optimal functional recovery. Dr. Jakub Tatka argues that right hip arthroscopy with labral repair and possible osteochondralplasty are indicated in order to prevent early hip arthritis and prevent long-term sequela of femoral acetabular impingement.

Return to Sport After Femoroacetabular Impingement Surgery and Sport-Specific Considerations: a Comprehensive Review

PURPOSE OF REVIEW

Recent advancements in surgical technology and techniques have improved functional results for operative treatment of femoroacetabular impingement syndrome (FAIS). Few studies have comprehensively evaluated the literature regarding return to sport criteria, timing, level, and rates. The purpose of this study was to review recent studies regarding return to play after surgical correction of FAIS. We will specifically evaluate the level of return to play and look to compare pre- and postoperative competition levels when available. We will also analyze timing of return to play from injury to surgery. Additionally, we will elucidate any sport-specific criteria that may determine readiness for return.

RECENT FINDINGS

Athletes with FAIS treated non-operatively have a low rate of return to sport and are often functionally limited in their level of performance. Surgical management of FAIS includes hip arthroscopy as well as open techniques. Current literature suggests a high rate of return to sport after contemporary surgery for FAIS at 87-93% overall. Rate of return to the same level of competition following surgery for FAIS is 55-83% in pooled studies. Limited evidence is available comparing postoperative rehabilitation protocols and timing of return among different sports. Operative treatment of FAIS results in high rates of return to sport and functional performance. The results of this study may help educate patients preoperatively in regard to the likelihood of functional return to sport and sport-specific considerations. Further research evaluating rehabilitation protocols and return criteria may better elucidate timing intervals for patients to maximize function while limiting complications.

Femoroacetabular impingement in young adults: assessment and management

Femoroacetabular impingement is a cause of hip pain in young adults as a result of premature dynamic contact between the femur and acetabulum that occurs within the physiological range of hip motion. Diagnosis is made by patient history, clinical examination and radiographic findings. Cross-sectional imaging with computed tomography and magnetic resonance arthrography may be necessary in selected patients. Femoroacetabular impingement can be treated non-operatively with physiotherapist-led conservative care including analgesia and intra-articular steroid injections. Arthroscopic hip surgery aiming to restore pain-free functional range of movement and repair damaged labrum can help in selected patients with no pre-existing osteoarthritis. This review outlines the clinical assessment, investigations and management of femoroacetabular impingement in young adults.

Operative Versus Nonoperative Treatment of Femoroacetabular Impingement Syndrome: A Meta-analysis of Short-Term Outcomes

PURPOSE

To compare the outcomes of patients with femoroacetabular impingement (FAI) syndrome treated with hip arthroscopy versus those treated with physical therapy alone.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched from inception to February 15, 2019. All randomized controlled trials (RCTs) that compared operative versus nonoperative treatment in the management of FAI for a minimum 6-month follow-up period were included. The primary outcome was the International Hip Outcome Tool 33. The CLEAR NPT (Checklist to Evaluate a Report of a Nonpharmacological Trial) was used to evaluate the methodologic quality of included studies.

RESULTS

Three RCTs (Level I) were included with a total of 650 patients (323 randomized to surgery and 327 randomized to physical therapy), follow-rate of 90% (583 patients, 295 operative and 288 nonoperative), and average of 11.5 months' follow-up. Regarding participation, 222 of 350 patients (63%) in the FAIT (Femoroacetabular Impingement Trial) study, 348 of 648 (54%) in the FASHIoN (Full UK RCT of Arthroscopic Surgery for Hip Impingement Versus Best Conservative Care) study, and 80 of 104 (77%) in the study by Mansell et al. agreed to participate. The mean age was 35 years, and 51.5% of patients were male patients. All 3 RCTs represented high methodologic quality and a low risk of bias. The frequency-weighted mean follow-up period was 10 months. A meta-analysis of the 3 randomized trials showed that patients treated with operative management had improved preoperative-to-postoperative change scores on the International Hip Outcome Tool 33 compared with the nonoperative group (standardized mean difference, 3.46; 95% confidence interval, 0.07-6.86; P < .05). One study reported on the achievement of clinically relevant outcomes at the individual level, with 51% of the operative group and 32% of the nonoperative group achieving the minimal clinically important difference and with 48% and 19%, respectively, achieving the patient acceptable symptomatic state for the Hip Outcome Score-Activities of Daily Living.

CONCLUSIONS

The results of this meta-analysis show that patients with FAI syndrome treated with hip arthroscopy have statistically superior hip-related outcomes in the short term compared with those treated with physical therapy alone.

LEVEL OF EVIDENCE

Level I, meta-analysis of Level I RCTs.