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

High satisfaction and low conversion rate to total hip arthroplasty after hip arthroscopy for femoroacetabular impingement syndrome and risk factors affecting survival at long-term follow-up

PURPOSE

Studies evaluating the long-term survival rate, patient satisfaction, and conversion to total hip arthroplasty (THA) are limited. The aim of this study was to evaluate satisfaction and hip survival at a minimum 10-year follow-up in patients following hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

A total of 164 patients underwent hip arthroscopy for FAIS between 2007 and 2012; of these, 76 (49 men and 27 women; mean age, 40.7 ± 11.2 years; range, 15-69 years) patients could be clinically examined or reached by phone or email and included in the study. Prospectively collected data of these patients who followed for a minimum of 10 years were retrospectively analysed. Patients who had previous trauma or surgery on the hip or were younger than 15 years were excluded. Of the 76 patients, 37 (48.7%) had mixed type, where 29 (38.2%) had cam and 10 (13.2%) had pincer type FAIS. Patient demographics, Tonnis grade for osteoarthritis and intraoperative findings were reviewed. Outcome measures of interest included reoperations (re-arthroscopy, conversion to THA), patient satisfaction, ability to return to sports, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), modified Harris Hip Score (mHHS) and some possible factors associated with conversion to THA.

RESULTS

The mean follow-up was 12.4 ± 1.8 (10-16 years). Twenty-one per cent required conversion to THA, with a mean time requiring THA of 4.8 ± 1.7 years (2-8 years). Mean age of the patients requiring THA was 47.8 ± 8.2 years. Two (2.6%) patients required re-arthroscopy. Fifty-eight (76.3%) patients did not undergo any revision surgery or other treatments. Forty-seven (61.8%) patients were completely satisfied with the results, where 5 (6.6%) patients were very satisfied and 4 (5.3%) patients were satisfied. Overall satisfaction rate was 73.7%. Mean postoperative mHHS score was 76.5 ± 15.5 and the mean WOMAC score was 84.0 ± 16.0. Return-to-sports rate was 85%, and the return to the old sport level was 67.1%. Age over 40 years (p = 0.004), a Tonnis Grade >1 (p < 0.001) and a full-thickness acetabular chondral lesion (p = 0.001) were identified as factors for failure and conversion to THA.

CONCLUSIONS

Hip arthroscopy for FAIS resulted in high satisfaction of patients who did not eventually require THA. Higher rates of conversion to THA were seen in older patients, patients treated with higher Tonnis grade and full-thickness acetabular chondral lesions.

LEVEL OF EVIDENCE

Level IV, case series.

Arthroscopic Management of Femoroacetabular Impingement: Current Concepts

Background: Femoroacetabular impingement (FAI) is a common cause of hip pain and dysfunction, especially in young and active individuals, and it may require surgical management for associated labral tears and cartilage damage. The management of FAI has advanced radically over the last few years, and hip arthroscopy has gained a leading role. However, despite the increasing number of published research and technological advancements, a comprehensive systematic review summarising current evidence is still missing. Methods: All the clinical studies investigating the arthroscopic management of FAI were accessed. Only studies with a minimum of six months of follow-up were considered. The 2020 PRISMA guidelines were followed. In December 2024, PubMed, Web of Science, and Embase were accessed without time constraints. Results: The present systematic review included 258 clinical investigations (57,803 patients). The mean length of follow-up was 34.2 ± 22.7 months. The mean age was 34.7 ± 5.3, and the mean BMI was 25.1 ± 2.0 kg/m2. Conclusions: The present systematic review updates current evidence on patients who have undergone arthroscopic surgery for FAI, updating and discussing current progress in managing labral injuries and patient selection, emphasising outcomes and pitfalls. Progress in surgery and improvement in eligibility criteria, as well as current controversies and prospects, were also discussed.

Postoperative alpha angle seems to be important for the achievement of clinical significance at a minimum 5-year follow-up after primary hip arthroscopy

The purpose of the present study was to clarify whether there is an association of postoperative alpha value with functional scores or progression of osteoarthritis at X-rays at the midterm after arthroscopic treatment of femoroacetabular impingement (FAI) syndrome with femoral osteoplasty, labral repair or debridement and rim trimming. A retrospective review of prospectively gathered data from 2013 to 2017 was performed. All patients who underwent first-time unilateral hip arthroscopy for FAI resection with 5-year follow-up were included. Patient-reported outcomes included the modified Harris Hip Score (mHHS) and Visual Analog Scale for Pain (Pain VAS). The progression of osteoarthritis (Tönnis grade) and radiological parameters (alpha angle, lateral center-edge angle [LCEA] and head-neck offset) were evaluated. A receiver operating characteristic (ROC) analysis was used to evaluate the correlation between significant variables and achievement of patient-acceptable symptomatic state (PASS) and degree of osteoarthritis. We identified 52 patients with a minimum 5-year follow-up (average, 6.7 years). The average patient age was 33.9 ± 11.5 years. There were 19 (36.5%) female patients. The mHHS improved from 60.1 ± 13.4 before surgery to 86.8 ± 14 after surgery (P < 0.001). The Pain VAS decreased from 6.21 before surgery to 2 after surgery (P < 0.001). Overall, 69% achieved the PASS for mHHS. The ROC curve for postoperative alpha angle demonstrated acceptable discrimination between patients achieving a fifth-year PASS value and those who did not have an area under the curve of 0.72. Patients having a postoperative alpha angle of ≤48.3° achieved the fifth-year PASS value at a significantly higher rate than patients having a postoperative alpha angle of >48.3° (P = 0.002). The postoperative alpha angle is a predictor of the achievement of the fifth-year PASS value for the mHHS. A threshold of ≤48.3° had a sensitivity of 0.75 and a specificity of 0.69 to predict positivity. Level of evidence IV.

Hip Arthroscopy for Femoroacetabular Impingement-Associated Labral Tears: Current Status and Future Prospects

Femoroacetabular impingement (FAI) has emerged as a common cause of hip pain, especially in young patients. While the exact cause of FAI is unknown, it is thought to result from repetitive microtrauma to the proximal femoral epiphysis leading to abnormal biomechanics. Patients typically present with groin pain that is exacerbated by hip flexion and internal rotation. Diagnosis of FAI is made through careful consideration of patient presentation as well as physical exam and diagnostic imaging. Use of radiographs can help diagnose both cam and pincer lesions, while the use of MRI can diagnose labral tears and cartilage damage associated with FAI. Both non-operative and surgical options have their role in the treatment of FAI and its associated labral tears; however, hip arthroscopy has had successful outcomes when compared with physical therapy alone. Unfortunately, chondral lesions associated with FAI have had poorer outcomes with a higher conversion rate to arthroplasty. Capsular closure following hip arthroscopy has shown superior clinical outcomes and therefore should be performed if possible. More recently, primary labral reconstruction has emerged in the literature as a good option for irreparable labral tears. While non-operative management may have its role in treating patients with FAI, hip arthroscopy has developed a successful track record in being able to treat cam and pincer lesions, chondral damage, and labral injuries.