Arthroscopic hip impingement surgery may lead to pain relief and activity restoration

Surgeons should rule out impingement in suspected labral tears and referral cases.

Arthroscopic management may be advantageous for many patients with femoroacetabular impingement.

At Orthopedics 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.”

OT Hawaii 2009

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 prevention.”

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 arthroscopic procedures.

“The recommendations were to proceed with elective surgery in symptomatic patients without advanced osteoarthrosis who have failed conservative treatment,” Matsuda said.

Matsuda performs arthroscopic rim trimming
Matsuda performs 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 invasive surgery.

“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 said.

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.

A supine arthroscopic view after rim trimming and labral refixation
A 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.

Complications

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 Ilizaliturri’s 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 occasional click.

“I have had my ACL reconstructed and, comparatively, the arthroscopic hip surgeries were much easier surgery to get through,” he said.

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: dean.k.matsuda@kp.org. He has intellectual property rights with ArthroCare.
Reference:
  • Matsuda DK. Arthroscopic management of femoroacetabular impingement. Presented at Orthopedics Today Hawaii 2009. Jan. 11-14, 2009. Kohala Coast, Hawaii.

Arthroscopic management may be advantageous for many patients with femoroacetabular impingement.

At Orthopedics 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.”

OT Hawaii 2009

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 prevention.”

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 arthroscopic procedures.

“The recommendations were to proceed with elective surgery in symptomatic patients without advanced osteoarthrosis who have failed conservative treatment,” Matsuda said.

Matsuda performs arthroscopic rim trimming
Matsuda performs 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 invasive surgery.

“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 said.

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.

A supine arthroscopic view after rim trimming and labral refixation
A 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.

Complications

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 Ilizaliturri’s 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 occasional click.

“I have had my ACL reconstructed and, comparatively, the arthroscopic hip surgeries were much easier surgery to get through,” he said.

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: dean.k.matsuda@kp.org. He has intellectual property rights with ArthroCare.
Reference:
  • Matsuda DK. Arthroscopic management of femoroacetabular impingement. Presented at Orthopedics Today Hawaii 2009. Jan. 11-14, 2009. Kohala Coast, Hawaii.