Perspective

Many patients with FAI may benefit from hip arthroscopy

Investigator says evidence is growing that confirms it is an outpatient hip preservation surgery for a common condition.

KOHALA COAST, Hawaii — Arthroscopic hip surgery may be advantageous for many — but not all — patients with femoroacetabular impingement, according to an orthopedist from the Kaiser-Permanente West Los Angeles Medical Center.

“FAI [Femoroacetabular impingement] may arguably now be the number one indication for hip arthroscopy,” Dean K. Matsuda, MD, said during his presentation at Orthopedics Today Hawaii 2010. He noted that surgeons should scrutinize suspected cases of labral tears as many will have FAI or dysplasia.

“Open and arthroscopic procedures that address the structural deformities and the labrochondral pathology appear to be effective at reducing pain and improving function in short- to mid-term outcome studies,” he said. “And because numerous studies show better outcomes with less cartilage damage, early management in the context of hip preservation surgery seems appropriate. The arthroscopic option [also] offers advantages of outpatient minimally invasive surgery which is attractive to this generally young and active group of patients.”

Kaiser recommendations

supine arthroscopic view of the right hip
A supine arthroscopic view of the right hip in a 30-year-old mixed martial artist who had bilateral cam-pincer FAI with coxa profunda. He underwent single-staged bilateral arthroscopic FAI surgery that also included global rim reductions and femoral head-neck resection osteoplasties. A labral reconstruction with gracilis autograft was performed on this hip (replacing an ossified labrum), whereas a labral refixation was done on the left hip.

Images: Matsuda DK

In a 2008 new technology review, Matsuda and colleagues compared studies that examined FAI treated with either open or arthroscopic surgery. Although a definitive position statement could not be made based on the limited quantity and quality of studies at that time, they found that both procedures improved symptoms and restored function. The investigators recommended that arthroscopic surgery may be offered for the management of symptomatic impingement in patients without advanced arthritis who failed conservative treatment. The group also recommended that skilled arthroscopic hip surgeons should perform the procedure in order to optimize patient outcomes.

Matsuda cited a more recent systematic review by John Clohisy and colleagues that showed significant improvement in symptoms and activity level with FAI surgery in general without making direct comparisons between open and arthroscopic options. Matsuda and his colleagues have a large, multicenter prospective arthroscopic FAI surgical outcome study underway.

Symptomatic FAI

Matsuda said that the expanding peer-reviewed literature supports arthroscopic hip surgery as beneficial for most patients with symptomatic FAI. Some patients have bilateral symptomatic FAI, and although he encourages them to have one hip done at a time, some prefer single-staged bilateral surgery. In that case, arthroscopic — rather than open — surgery makes this a viable option.

Recent research has also indicated that patients with FAI and osteoarthritis should have fairly mild arthritis in order to expect good results with the procedure. Some studies have shown that patients should have at least 2 mm of remaining joint space. Matsuda said that the key is to individualize treatment recommendations, know when to refer for arthroplasty options, and set proper patient expectations.

“I tell any of the patients who have joint space narrowing that this is a temporizing procedure that may forestall an eventual hip replacement,” he said. “This is an evolving field for a common condition and we are learning who we can truly help and who we can not.”

Matsuda shared some examples. “Most would agree that a 20-year-old athlete with symptomatic FAI may derive real benefit from FAI surgery. I do not believe arthroscopic FAI surgery helps in the setting of advanced arthrosis, so I do not operate on that subgroup. But until further research clarifies several unknowns, I believe a 20-year-old with mild joint narrowing and painful FAI is a reasonable surgical candidate. So is the 50-year-old patient suffering from painful FAI who has seen several joint replacement surgeons and has been told she does not need a hip replacement because she has no arthritis; she, too, may benefit from arthroscopic surgery.”

Matsuda told Orthopedics Today that he has also treated adolescent FAI in patients as young as 12, and thinks this subgroup has the potential to obtain the best outcomes if the surgery is performed before significant cartilage damage occurs.

Dysplasia, asymptomatic FAI

A supine arthroscopic view of the left hip
A supine arthroscopic view of the left hip in a 31-year-old patient with dysplasia and cam FAI. Arthroscopic labral repair (without rim trimming) and femoral osteoplasty were performed. (Note the labral repair and the cam lesion before arthroscopic osteoplasty). She then underwent a staged open periacetabular osteotomy 8 weeks later.

While some studies have shown that hip arthroscopy can be helpful for patients with FAI with dysplasia, others have argued against treating these patients with the procedure. Matsuda said that surgeons must make a proper diagnosis to determine whether patient has impingement, dysplasia or both.

“With dysplasia, the key is to avoid making a shallow socket more shallow by rim trimming or removing a hypertrophic labrum and potentially destabilizing the hip,” he said. Borderline or mild dysplasia may do well with conservative labral debridement, labral repair or even labral reconstruction. “And, if indicated, a staged periacetabular osteotomy (PAO) could follow an arthroscopic labral repair or reconstruction without having to open the joint or potentially destabilize the hip by taking down the reflected head of the rectus femoris.”

Another hot topic is whether the procedure can be useful for patients with asymptomatic FAI. “Dr. Reinhold Ganz has stated that the connection between FAI and secondary osteoarthritis is compelling enough to merit prophylactic surgery, ‘as there is not a better time than time zero’ to address this pathology,” Matsuda said.

“I do not currently operate on asymptomatic FAI,” Matsuda said. “With that said, I am not sure that it is wrong to operate on perhaps a young athlete, and we may learn that this may be a subgroup of patients that may benefit from prophylactic surgery. If so, the arthroscopic option is again attractive.”

However, he emphasized, “We are treating patients, not X-rays or alpha angles” — and that not all patients with classic FAI findings on X-rays develop symptoms.

A look toward the future

He predicted that FAI surgery will continue to evolve toward minimally invasive techniques and that the indications for FAI surgery will become more refined. Matsuda also said that emerging imaging technologies, such as delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC), may help identify patients that, despite normal joint spacing, may have biochemical alterations that may negatively impact their outcomes regardless of the treatment.

“I think that improved tools and techniques will permit more widespread application of hip arthroscopy,” Matsuda said. He also noted that the American Academy of Orthopaedic Surgeons has stated hip arthroscopy is growing rapidly and the number of procedures will double by 2013. – by Gina Brockenbrough

Reference:
  • Matsuda DK. Update on hip arthroscopy. Presented at Orthopedics Today Hawaii 2010. Jan. 10-13, 2010. Kohala Coast, Hawaii.
  • Dean K. Matsuda, MD, can be reached at Southern California Permanente Medical Group, Kaiser West Los Angeles Medical Center, 6041 Cadillac Ave., Los Angeles, CA; 323-857-4477; e-mail: dean.k.matsuda@kp.org.

Perspective

I agree with him. We do not know if prophylactic surgery for FAI is indicated. We continue our research to determine factors which may predispose patients to chondral/labral dysfunction and FAI. With the development of a screening protocol, we may be able to identify patients who are at increased risk of injury and provide them with programs to reduce the risk of injuries requiring surgery.

Labral tears with chondral/labral dysfunction are my main indication for hip arthroscopy. There is a very strong association between chondral/labral dysfunction and FAI. Therefore, FAI is one of my main indications for hip arthroscopy.

— Marc J. Philippon, MD
Orthopedic Surgeon and Partner, Steadman Hawkins Clinic, Vail, Colo.

KOHALA COAST, Hawaii — Arthroscopic hip surgery may be advantageous for many — but not all — patients with femoroacetabular impingement, according to an orthopedist from the Kaiser-Permanente West Los Angeles Medical Center.

“FAI [Femoroacetabular impingement] may arguably now be the number one indication for hip arthroscopy,” Dean K. Matsuda, MD, said during his presentation at Orthopedics Today Hawaii 2010. He noted that surgeons should scrutinize suspected cases of labral tears as many will have FAI or dysplasia.

“Open and arthroscopic procedures that address the structural deformities and the labrochondral pathology appear to be effective at reducing pain and improving function in short- to mid-term outcome studies,” he said. “And because numerous studies show better outcomes with less cartilage damage, early management in the context of hip preservation surgery seems appropriate. The arthroscopic option [also] offers advantages of outpatient minimally invasive surgery which is attractive to this generally young and active group of patients.”

Kaiser recommendations

supine arthroscopic view of the right hip
A supine arthroscopic view of the right hip in a 30-year-old mixed martial artist who had bilateral cam-pincer FAI with coxa profunda. He underwent single-staged bilateral arthroscopic FAI surgery that also included global rim reductions and femoral head-neck resection osteoplasties. A labral reconstruction with gracilis autograft was performed on this hip (replacing an ossified labrum), whereas a labral refixation was done on the left hip.

Images: Matsuda DK

In a 2008 new technology review, Matsuda and colleagues compared studies that examined FAI treated with either open or arthroscopic surgery. Although a definitive position statement could not be made based on the limited quantity and quality of studies at that time, they found that both procedures improved symptoms and restored function. The investigators recommended that arthroscopic surgery may be offered for the management of symptomatic impingement in patients without advanced arthritis who failed conservative treatment. The group also recommended that skilled arthroscopic hip surgeons should perform the procedure in order to optimize patient outcomes.

Matsuda cited a more recent systematic review by John Clohisy and colleagues that showed significant improvement in symptoms and activity level with FAI surgery in general without making direct comparisons between open and arthroscopic options. Matsuda and his colleagues have a large, multicenter prospective arthroscopic FAI surgical outcome study underway.

Symptomatic FAI

Matsuda said that the expanding peer-reviewed literature supports arthroscopic hip surgery as beneficial for most patients with symptomatic FAI. Some patients have bilateral symptomatic FAI, and although he encourages them to have one hip done at a time, some prefer single-staged bilateral surgery. In that case, arthroscopic — rather than open — surgery makes this a viable option.

Recent research has also indicated that patients with FAI and osteoarthritis should have fairly mild arthritis in order to expect good results with the procedure. Some studies have shown that patients should have at least 2 mm of remaining joint space. Matsuda said that the key is to individualize treatment recommendations, know when to refer for arthroplasty options, and set proper patient expectations.

“I tell any of the patients who have joint space narrowing that this is a temporizing procedure that may forestall an eventual hip replacement,” he said. “This is an evolving field for a common condition and we are learning who we can truly help and who we can not.”

Matsuda shared some examples. “Most would agree that a 20-year-old athlete with symptomatic FAI may derive real benefit from FAI surgery. I do not believe arthroscopic FAI surgery helps in the setting of advanced arthrosis, so I do not operate on that subgroup. But until further research clarifies several unknowns, I believe a 20-year-old with mild joint narrowing and painful FAI is a reasonable surgical candidate. So is the 50-year-old patient suffering from painful FAI who has seen several joint replacement surgeons and has been told she does not need a hip replacement because she has no arthritis; she, too, may benefit from arthroscopic surgery.”

Matsuda told Orthopedics Today that he has also treated adolescent FAI in patients as young as 12, and thinks this subgroup has the potential to obtain the best outcomes if the surgery is performed before significant cartilage damage occurs.

Dysplasia, asymptomatic FAI

A supine arthroscopic view of the left hip
A supine arthroscopic view of the left hip in a 31-year-old patient with dysplasia and cam FAI. Arthroscopic labral repair (without rim trimming) and femoral osteoplasty were performed. (Note the labral repair and the cam lesion before arthroscopic osteoplasty). She then underwent a staged open periacetabular osteotomy 8 weeks later.

While some studies have shown that hip arthroscopy can be helpful for patients with FAI with dysplasia, others have argued against treating these patients with the procedure. Matsuda said that surgeons must make a proper diagnosis to determine whether patient has impingement, dysplasia or both.

“With dysplasia, the key is to avoid making a shallow socket more shallow by rim trimming or removing a hypertrophic labrum and potentially destabilizing the hip,” he said. Borderline or mild dysplasia may do well with conservative labral debridement, labral repair or even labral reconstruction. “And, if indicated, a staged periacetabular osteotomy (PAO) could follow an arthroscopic labral repair or reconstruction without having to open the joint or potentially destabilize the hip by taking down the reflected head of the rectus femoris.”

Another hot topic is whether the procedure can be useful for patients with asymptomatic FAI. “Dr. Reinhold Ganz has stated that the connection between FAI and secondary osteoarthritis is compelling enough to merit prophylactic surgery, ‘as there is not a better time than time zero’ to address this pathology,” Matsuda said.

“I do not currently operate on asymptomatic FAI,” Matsuda said. “With that said, I am not sure that it is wrong to operate on perhaps a young athlete, and we may learn that this may be a subgroup of patients that may benefit from prophylactic surgery. If so, the arthroscopic option is again attractive.”

However, he emphasized, “We are treating patients, not X-rays or alpha angles” — and that not all patients with classic FAI findings on X-rays develop symptoms.

A look toward the future

He predicted that FAI surgery will continue to evolve toward minimally invasive techniques and that the indications for FAI surgery will become more refined. Matsuda also said that emerging imaging technologies, such as delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC), may help identify patients that, despite normal joint spacing, may have biochemical alterations that may negatively impact their outcomes regardless of the treatment.

“I think that improved tools and techniques will permit more widespread application of hip arthroscopy,” Matsuda said. He also noted that the American Academy of Orthopaedic Surgeons has stated hip arthroscopy is growing rapidly and the number of procedures will double by 2013. – by Gina Brockenbrough

Reference:
  • Matsuda DK. Update on hip arthroscopy. Presented at Orthopedics Today Hawaii 2010. Jan. 10-13, 2010. Kohala Coast, Hawaii.
  • Dean K. Matsuda, MD, can be reached at Southern California Permanente Medical Group, Kaiser West Los Angeles Medical Center, 6041 Cadillac Ave., Los Angeles, CA; 323-857-4477; e-mail: dean.k.matsuda@kp.org.

Perspective

I agree with him. We do not know if prophylactic surgery for FAI is indicated. We continue our research to determine factors which may predispose patients to chondral/labral dysfunction and FAI. With the development of a screening protocol, we may be able to identify patients who are at increased risk of injury and provide them with programs to reduce the risk of injuries requiring surgery.

Labral tears with chondral/labral dysfunction are my main indication for hip arthroscopy. There is a very strong association between chondral/labral dysfunction and FAI. Therefore, FAI is one of my main indications for hip arthroscopy.

— Marc J. Philippon, MD
Orthopedic Surgeon and Partner, Steadman Hawkins Clinic, Vail, Colo.