Arthroscopy noted as a viable treatment for femoroacetabular impingement

HOLLYWOOD, Fla. — Arthroscopic management of femoroacetabular impingement may be an appropriate option for many cases, according to a study presented here.

The findings were presented by J.W. Thomas Byrd, MD, at the 2010 Annual Meeting of the Arthroscopy Association of North America.

According to Byrd, the results accomplished with arthroscopic femoroacetabular impingement (FAI) management were “at least comparable” to published reports of open methods, with the advantages of being a less invasive approach.

“Femoroacetabular impingement is a common cause of joint pathology, and I think cam impingement in particular has a proclivity for active, young adult males,” Byrd said. “These are people who are pushing their bodies beyond their diminished physiological limits.”

J.W. Thomas Byrd

Factors that have an impact on the overall success of the procedure include patient positioning and portal placement, Byrd said. Proper portal placement is crucial for assuring access to the site in an atraumatic fashion. Furthermore, he added it is important to properly identify the pathology by documenting damage indicative of the impingement, warranting its correction.

Byrd noted that patient selection is also critical in the successful arthroscopic management of FAI, stressing that reasonable joint preservation and reasonable patient expectations should be a significant factor. Delay, however, could be troublesome.

“You can certainly have impingement morphology without having impingement pathology, so I do not think every abnormal radiograph needs immediate surgical intervention,” he said. “The flip side of that is: I think it is ill-advised to delay intervention for a protracted period of time in the presence of worsening symptoms. I think our observations … support this need for intervention.”

Next to poor patient selection, Byrd stressed, improper or poor visualization “is the root of all evil in hip arthroscopy,” saying it is imperative to fully visualize the abnormal bone before undergoing the corrective process.

Study methods and parameters

Byrd said the purpose of his study was to report the results of early experience in the arthroscopic management of FAI.

Patients undergoing hip arthroscopy were prospectively assessed with a modified Harris Hip score at 3, 12, 24, 60 and 120 months. Thus far, Byrd said, 752 patients have undergone arthroscopic correction of FAI. The study he presented consisted of the first 100 such patients to have a 2-year follow-up.

For this 100-patient cohort, Byrd reported 63 cam, 18 pincer and 19 combined lesions. There were 97 acetabular articular lesions, 53 grade 4, 39 grade 3 and five grade 1; 23 femoral lesions, 11 grade 4, 11 grade 3 and one grade 2; and 92 labral tears.

Arthroscopic ability

In all, the median improvement was 20 points, with a preoperative score of 65 and a postoperative score of 85. Seventy-nine of the results recorded were good or excellent, he reported. Those with associated femoral lesions did at least as well, with a median improvement of 23 points.

Eighteen patients underwent microfracture, with a median improvement of 21 points: preoperative score, 64; postoperative score, 85.

“None of these patients were converted to a toal hip arthroplasty, and from my perspective I think that suggests that we are doing a pretty good job in selecting the right patients for the operation,” he said. “However, six of these patients underwent repeat arthroscopy, which suggests that our early technical skills needed improvement.” – by Robert Press

References:

• Byrd JWT, Jones KS. Arthroscopic management of femoroacetabular impingement with two year follow-up. Paper SS-30. Presented at the 2010 Annual Meeting of the Arthroscopy Association of North America. May 20-23, 2010. Hollywood, Fla.
• Byrd JTW. Why my results are better than yours: femoroacetabular impingement of the hip. Presented at the 2010 Annual Meeting of the Arthroscopy Association of North America. May 20-23, 2010. Hollywood, Fla.

• J.W. Thomas Byrd, MD, can be reached at Nashville Sports Medicine Foundation, Baptist Medical Plaza I, 2011 Church St., Suite 100, Nashville, TN 37203; 615-284-5800; e-mail: byrd@nsmoc.com.
• Disclosure: Byrd is a consultant and research assistant for Smith & Nephew Endoscopy and a consultant and stock owner for A2 Surgical.

I agree with Dr. Byrd. With symptomatic FAI, timely surgical intervention may in fact be conservative care; an arthroscopic one even more so. The outcomes from this study are consistent with those of a soon-to-be published comparative systematic review. [1] Arthroscopic surgery for symptomatic FAI had equal or better short- to midterm outcomes compared to the open dislocation and mini-open methods with a lower rate of major complications when performed by experienced surgeons. (An important caveat may reside within those last few words). I anticipate gravitation towards the arthroscopic and the mini-open method with adjunctive arthroscopy in the surgical management of this condition. Hip arthroscopy may not only be a viable but perhaps preferable treatment for many patients with FAI.

– Dean K. Matsuda, MD
Orthopedics Today editorial board member
Los Angeles, CA

• 1. Matsuda DK, Carlisle JC, Arthurs S, Wierks CH, Philippon MJ. Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy. In press.

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