Arthroscopic management may be advantageous for many patients with
Today Hawaii 2009, Dean K. Matsuda, MD, discussed the indications
and technique for arthroscopic management of femoroacetabular impingement (FAI)
and described his experience as a patient who underwent this treatment.
I think that FAI is here to stay, Matsuda said. If you
are thinking labral tear, think FAI. Isolated labral tears are relatively
uncommon. Both open and arthroscopic procedures [in] short-term studies appear
to be effective at pain relief and activity restoration. [There are] better
outcomes in patients with less cartilage damage, suggesting earlier surgical
intervention may be appropriate.
He added, The arthroscopic procedure offers real advantages for
most FAI patients as it is a truly outpatient minimally invasive procedure that
addresses the pathology of the open dislocation surgery while offering a more
rapid rehabilitation. This is very appealing to this, especially athletic,
group of patients.
Critical new technology review
In an extensive literature review of studies on open and arthroscopic
treatment for hip impingement, Matsuda and colleagues found insufficient
evidence to determine definitive treatment guidelines for FAI. We need
more and higher level evidence studies, he said.
However, We found, by and large, that the outcome instruments
showed improvement in both the arthroscopic and open studies in terms of
improved pain relief and activity level. The jury is still out on arthritis
The review indicated better outcomes for patients with less cartilage
damage, the importance of labral preservation, similar successful outcomes
between open and arthroscopic surgery, and fewer complications with
The recommendations were to proceed with elective surgery in
symptomatic patients without advanced osteoarthrosis who have failed
conservative treatment, Matsuda said.
arthroscopic rim trimming while viewing two adjacent monitors (arthroscopic
and fluoroscopic) to ensure precision rim resection.
Images: Matsuda DK
How much arthritis?
For patients with symptomatic FAI, arthroscopic treatment may provide a
good fit for these relatively young athletic patients desiring minimally
With arthrosis, again, the jury is still out on this, but I think
we can say that for advanced arthrosis, this does not have a place, he
said. For relatively mild arthrosis, in fact, this may have a role. I
make sure that my patients who have FAI with mild osteoarthrosis understand
that this is a temporizing procedure and it is not going to keep them from
needing an eventual hip replacement.
He performs an arthroscopic labral repair in patients with FAI and
dysplasia and a femoral osteoplasty, if necessary.
Dr. [Joel] Matta and I recently talked about this; we think that
perhaps there is a role for staged arthroscopic labral repair followed by a
later periacetabular osteotomy, so that the reflected head of the rectus
femoris (a potential hip stabilizer) need not be taken down, Matsuda
Arthroscopic treatment for patients with asymptomatic FAI remains a hot
topic. As the evidence mounts that untreated FAI may progress to hip arthritis,
Reinhold Ganz, MD, told Matsuda that he would operate on some asymptomatic hips
in active patients if they have the bony dysmorphisms of FAI.
supine arthroscopic view after rim trimming and labral refixation
(arrowhead) and before resection osteoplasty of the femoral head-neck
junction (arrow) with a bur to restore more normal offset. Note that the
traction is released and the labrum nicely contacts the femoral head,
re-establishing a fluid seal.
While Matsuda does not perform arthroscopic surgery in asymptomatic
patients, he said that it may be of merit for some young athletic patients.
Matsuda cited a recent review by Victor M. Ilizaliturri, MD, which found
a 1.5% complication rate for arthroscopic FAI surgery. The procedure was deemed
to be relatively safe when performed by experienced hip arthroscopic surgeons.
While Ilizaliturris literature review found no cases of avascular
necrosis (AVN), Matsuda said the rate of AVN may be underreported in the
literature. He emphasized that comprehensive arthroscopic management of FAI is
not to be confused with basic hip arthroscopy.
As a technically challenging procedure, We owe it to our patients
to do it well and do it often or refer to those who do.
He also stated that arthroscopic surgery for FAI is not simply labral
debridement. He has treated many symptomatic patients who have had labral
debridement by other surgeons.
Orthopedic surgeons should have a high index of suspicion for FAI in
patients referred with labral tears, he said. Also, be aware
of getting referred patients who have normal X-rays, because often
they will not be normal but have FAI, Matsuda said.
Speaking from experience
Early outcomes of his own bilateral arthroscopic FAI surgeries revealed
an asymptomatic hip and a hip with an intermittent activity-related ache and
I have had my ACL reconstructed and, comparatively, the
arthroscopic hip surgeries were much easier surgery to get through, he
Matsuda added that his hips had severe delamination of acetabular
cartilage. One hip that is occasionally still painful after basketball suggests
it is not a shortcoming of the surgery but an impetus to diagnose and treat
patients before they have as much cartilage damage, he said.
For the procedure, Matsuda places patients in a supine position. He uses
limited traction and a fluoroscopic templating technique that he developed for
precision rim trimming.
During the rim trimming, he takes down the labrum if necessary and
performs labral refixation. He has used the iliotibial band for labral
reconstruction, but currently prefers the gracilis tendon autograft.
He then performs a femoral head/neck resection osteoplasty without
traction and dynamically tests the hip to ensure eradication of ongoing
impingement. He performs this via two portals.
For more information:
- 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:
He has intellectual property rights with ArthroCare.
- Matsuda DK. Arthroscopic management of femoroacetabular
impingement. Presented at Orthopedics Today Hawaii 2009. Jan.
11-14, 2009. Kohala Coast, Hawaii.