In this issue of ORTHOPEDICS, Dr Byrd discusses the importance of patient selection in arthroscopic hip surgery and its use in adolescents and athletes.
In addition to being less invasive, what advantages exist for arthroscopy vs open treatment methods?
The obvious advantage of arthroscopy is that it is less invasive. However, the arthroscopic approach to femoroacetabular impingement is much more than just the technique. Arthroscopy precisely defines the secondary damage that accompanies femoroacetabular impingement and thus is part of the treatment algorithm for determining that bony correction of the impingement is necessary. Many patients may have impingement morphology without impingement pathology. What this means is that many people who have oddly shaped hips pursue long, active lifestyles and never develop problems. Keep in mind that impingement is not a cause of hip pain. Impingement is simply a morphologic condition that predisposes the joint to the secondary damage that then results in the accompanying symptoms.
Is there any single strong predictor of symptoms of femoroacetabular impingement?
Probably the strongest predictor for femoroacetabular impingement is simply maintaining an index of suspicion. When a young adult presents with hip joint pain, the most common lesion is damage to the acetabular labrum. However, it is not normal for the labrum to tear, even in the presence of highly physical activities, and the most likely underlying culprit is a component of femoroacetabular impingement. In dancers and groups where flexibility is a premium, dysplasia may be more common because individuals with dysplasia exhibit more mobility. This mobility may be an advantage, right up to the point that the labrum and other joint structures start to break down.
When is arthroscopy not a good option for the treatment of femoroacetabular impingement?
J.W. Thomas Byrd
On average, in the hands of a surgeon experienced with arthroscopic management of impingement, most cases can be treated by this method. Having said that, there are many circumstances where the open approach is still clearly the best. Cases that require a concomitant acetabular or proximal femoral osteotomy and some extreme cases of global overcoverage are performed open.
How important is patient selection in the management of femoroacetabular impingement arthroscopically?
Like many operations, patient selection is probably the most important factor in the success of the procedure. First, does the problem require surgery at all, and is it matched for an arthroscopic solution? Second, does the patient have reasonable expectations for the given severity of damage that is being addressed? Ultimately, the success of the procedure is determined by the level of patient satisfaction, and it is important that their expectations can be reasonably met. Lastly, the patient must be ready for the rehabilitation and recovery that is necessary for a successful outcome. I tell patients that surgery is the easy part; I will take care of that for them. It is the rehabilitation and recovery effort on their part that can take 4 months or longer.
What techniques, if any, have been developed to address femoroacetabular impingement and osteoarthritis in athletes?
Numerous techniques have been developed that aid in addressing femoroacetabular impingement and osteoarthritis in athletes. Our clinical assessment skills are getting better, and imaging technology is improving to detect the damage accompanying femoroacetabular impingement. In our experience, >90% of athletes and nonathletes alike already have grade III and grade IV articular damage at the time of arthroscopic intervention. This tells us that we are intervening late in the disease course. Earlier intervention would be preferable, although we have to be cautious about not recommending surgery in asymptomatic individuals. Instruments are available for reshaping the acetabulum and the femoral head to correct the impingement problem. The labrum has been found to have excellent healing capacity, and labral repair techniques have really blossomed. Our biggest challenge remains what to do about the articular surface. Microfracture has been a tried-and-true method, but it is still imperfect. Numerous articular cartilage restorative techniques remain in the works.
Is hip arthroscopy a safe procedure in adolescents with femoroacetabular impingement?
Impingement can first start to manifest itself in adolescence, shortly after skeletal maturity. This is especially true among athletes who are pushing their bodies beyond the diminished physiologic limits imposed by femoroacetabular impingement. Substantial secondary damage is sometimes encountered, even among teenagers. Arthroscopy is just as safe in this population as in mature adults. Of course, numerous precautions are necessary in those who have not yet reached skeletal maturity. The eventual outcome of impingement has usually not been fully determined yet, and any surgery must take into account the risk of altering skeletal growth.
Is there any way to predict the future occurrence of osteoarthritis following hip arthroscopy?
Although no precise statistical data exists, the risk of future osteoarthritis is probably most closely tied to the severity of articular damage at the time of arthroscopic intervention. Thus, earlier detection and intervention still seems preferable once someones problem has declared itself.
What is on the horizon for the arthroscopic treatment of femoroacetabular impingement?
The 2 biggest technical challenges with treatment of impingement are the precision with which the bony correction is performed and knowing exactly what is the right amount of bone to remove. Computer assistance in assessing the morphology of the impingement problem and intraoperative navigation for its correction are on the immediate horizon. Presently, we are forced to make these surgical corrections freehand, and no one knows exactly the precise amount of bone to remove. Computer assistance is close in the future. We do not perform joint replacement surgery without preoperative templates and intraoperative jigs. In the near future, computer assessment will be our templating, and computer navigation will be our intraoperative jigs. It will not be long before we reflect back on these days when we performed this freehand. We are doing okay, but we can and need to do much better.
Dr Byrd is from Nashville Sports Medicine Foundation, Nashville, Tennessee.
Dr Byrd is a consultant for Smith & Nephew Endoscopy and A2 Surgical, has received research support from Smith & Nephew Endoscopy, and owns stock in A2 Surgical.
Correspondence should be addressed to: J.W. Thomas Byrd, MD, Nashville Sports Medicine & Orthopaedic Center, 2011 Church St, Ste 100, Nashville, TN 37203 (firstname.lastname@example.org).