As the condition (hip impingement) is only being recently recognized as a cause of
hip pain which can progress to hip arthritis in young adults, the treatment strategies
are still evolving. In the initial stages, it would be appropriate to consider conservative
treatment including physiotherapy, painkillers and activity modification.
If the symptoms persist, it would be appropriate to consider surgical option. When
Ganz initially suggested this condition as a cause of hip pain, he advised surgery
using a technique known as "surgical dislocation" of the hip. In this exposure, the
hip joint is completely exposed (see picture below). While this still may be needed
in some cases, the surgical exposure is extensive and carries certain morbidities
including non-union of the trochanteric fragment.
To decrease the complications associated with the Ganz “surgical dislocation” of
the hip, further modifications of treatment techniques are evolving including a combined
procedure (using a combination of mini-open procedure and hip arthroscopy) as well
as treatment through hip arthroscopy.
With the mini-open approach, through a small incision over the front of the upper
thigh, the surgeon exposes the hip joint. Usually this is done after the surgeon
has done a preliminary examination of the hip joint through key hole surgery. The
mini-open technique allows the surgeon to do procedures like removal of the bony
Hip arthroscopy is a technically more challenging procedure when compared with a
knee arthroscopy. However, with the advances in the technique of hip arthroscopy
and instrumentation, treatment strategies are also evolving which makes it possible
for at least some impingement pathologies to be treated entirely through hip arthroscopy.
Whatever the surgical technique may be, the treatment essentially entails creating
better clearance for the ball of the hip joint. The bump in the anterolateral aspect
of the ball is removed and/or the over covered part of the acetabulum is excised.
The labral tear is often debrided but in some cases, the labrum could be repaired.
While studies have shown that many patients gain short term improvement in their
symptoms, the symptom relief is not universal. One of the main negative predictors
of symptoms relief is presence of arthritic changes or damage to the surface lining
of the hip joint.
At this stage, there is lack of data to say whether surgical treatment of hip impingement
can delay or prevent the progression to hip arthritis.
The following are some relevant selected scientific references:
1.Femoroacetabular impingement syndrome: an under recognized cause of hip pain and
J Rheumatol. 2010 Jul;37(7):1395-404.
Reid GD, Reid CG, Widmer N, Munk PL.
Department of Medicine,University of British Columbia, Vancouver, British Columbia,
Abstract: Acetabular dysplasia is well recognized as a potential predisposing factor
to the development of hip osteoarthritis (OA). In the orthopedic literature, other
dysmorphic and orientation abnormalities of the femoral head, femoral head-neck junction,
and the acetabulum have been reported, with increasing frequency in recent years,
under the term femoroacetabular impingement syndrome (FAI). The studies have shown
a clear association of these structural anomalies with patients' symptoms and signs,
radiographic and pathologic abnormalities, and the development of degenerative hip
arthritis. FAI is now believed to be a very important predisposing factor for the
development of degenerative hip arthritis, particularly in younger adults. Although
the results of longterm studies are awaited, the hope is that early surgical intervention
in patients with FAI will change the course or prevent the development of hip OA.
It is well documented that early recognition of potential FAI surgical candidates,
before OA is advanced, determines the postsurgical outcome. FAI has not been reported
in the rheumatology literature, but since patients with FAI likely often initially
present to rheumatology clinics for assessment of hip pain, it is important for rheumatologists
to be aware of this condition and refer to orthopedics when appropriate. The objective
of this review is to provide an outline of the basic concepts of FAI, including clinical
presentation and radiographic findings, so that rheumatologists become more familiar
with this important emerging entity.
2. Efficacy of Surgery for Femoroacetabular Impingement: A Systematic Review.
Am J Sports Med. 2010 May 20. [Epub ahead of print]
Ng VY, Arora N, Best TM, Pan X, Ellis TJ.
The Ohio State University.
Abstract: BACKGROUND: Recent case studies on the surgical treatment of femoroacetabular
impingement (FAI) have introduced a large amount of clinical data. However, there
has been no clear consensus on its efficacy. HYPOTHESIS: The current literature can
be clarified to address 4 questions: (1) Does treatment for FAI succeed in improving
symptoms? (2) In which subset of patients should treatment for FAI be avoided? (3)
Is labral refixation superior to simple resection? (4) Does treatment for FAI alter
the natural progression of osteoarthritis in this group of typically young patients?
STUDY DESIGN: Systematic review. METHODS: Twenty-three reports of case studies on
the surgical treatment of FAI were identified and a systematic review was conducted.
Data from each study were collected to answer each of the 4 focus questions. RESULTS:
This review of 970 cases included 1 level II evidence trial, 2 level III studies,
and 20 level IV studies. Based on patient outcome scores and effect size, all studies
demonstrated improvement of patient symptoms. Up to 30% of patients will eventually
require total hip arthroplasty; those patients with Outerbridge grade III or IV cartilage
damage seen intraoperatively or with preoperative radiographs showing greater than
Tonnis grade I osteoarthritis will have worse outcomes with treatment for FAI. Only
2 studies directly compared labral refixation with labral debridement. Several studies
reported postoperative osteoarthritis findings; only a minority of these patients
had progression of their osteoarthritis. CONCLUSION: Surgical treatment for FAI reliably
improves patient symptoms in the majority of patients without advanced osteoarthritis
or chondral damage. Early evidence supports labral refixation. It is too soon to
predict whether progression of osteoarthritis is delayed. CLINICAL RELEVANCE: These
results may be used to help predict the outcome of surgical treatment of FAI in different
patient populations and to assess the need for labral refixation.
3. Combined hip arthroscopy and limited open osteochondroplasty for anterior femoroacetabular
J Bone Joint Surg Am. 2010 Jul;92(8):1697-706.
Clohisy JC, Zebala LP, Nepple JJ, Pashos G.
Department of Orthopaedic Surgery, Washington University School of Medicine, Barnes-Jewish
Hospital, St. Louis, MO 63110, USA.
Abstract: BACKGROUND: A variety of surgical techniques have been introduced for the
treatment of femoroacetabular impingement, but clinical outcome studies of less-invasive
treatment with a minimum duration of follow-up of two years are limited. The purpose
of this study was to evaluate the early clinical and radiographic outcomes of combined
hip arthroscopy and limited open osteochondroplasty of the femoral head-neck junction
for the treatment of cam femoroacetabular impingement. METHODS: We performed a retrospective
review of our first thirty-five patients (thirty-five hips) in whom cam femoroacetabular
impingement had been treated with combined hip arthroscopy and limited open osteochondroplasty.
Thirty-five patients (twenty-eight men and seven women) with an average age of thirty-four
years and a minimum duration of follow-up of two years were analyzed. The modified
Harris hip score was utilized to assess hip function. The Tönnis osteoarthritis grade
and the alpha angle were determined to assess osteoarthritis progression and deformity
correction, respectively. RESULTS: The average modified Harris hip score improved
from 63.8 points preoperatively to 87.4 points at the time of the last follow-up.
Twenty-nine (83%) of the thirty-five patients had at least a 10-point improvement
in the Harris hip score, and 71% had a score of >80 points. The average alpha angle
was reduced from 58.6 degrees preoperatively to 37.1 degrees at the time of follow-up
when measured on cross-table lateral radiographs, from 63.9 degrees to 37.8 degrees
when measured on frog-leg lateral radiographs, and from 63.1 degrees to 44.8 degrees
when measured on anteroposterior radiographs. Two patients had osteoarthritis progression
from Tönnis grade 0 to grade 1. Minor complications included one superficial wound
infection, one deep vein thrombosis, and four cases of asymptomatic Brooker grade-I
heterotopic ossification. There were no femoral neck fractures or cases of femoral
head osteonecrosis, and no hip was converted to an arthroplasty. CONCLUSIONS: Early
results indicate that combined hip arthroscopy and limited open osteochondroplasty
of the femoral head-neck junction is a safe and effective treatment for femoroacetabular
impingement. In our small series, most patients had symptomatic relief, improved
hip function, and enhanced activity after two years of follow-up.
4. Open treatment of femoroacetabular impingement is associated with clinical improvement
and low complication rate at short-term followup.
Clin Orthop Relat Res. 2010 Feb;468(2):504-10.
Peters CL, Schabel K, Anderson L, Erickson J.
Department of Orthopaedic Surgery, University of Utah School of Medicine, 590 Wakara
Way, Salt Lake City, UT 84108, USA.
Abstract: BACKGROUND: Since the modern description of femoroacetabular impingement
(FAI) a decade ago, surgical treatment has become increasingly common. Although the
ability of open treatment of FAI to relieve pain and improve function has been demonstrated
in a number of retrospective studies, questions remain regarding predictability of
clinical outcome, the factors associated with clinical failure, and the complications
associated with treatment. QUESTIONS/PURPOSES: We therefore described the change
in clinical pain and function after open treatment, determined whether failure of
treatment and progression of osteoarthritis was associated with Outerbridge Grade
IV hyaline cartilage injury, and described the associated complications. METHODS:
We retrospectively reviewed all 94 patients (96 hips) (55 males and 39 females; mean
age, 28 years) who underwent surgical dislocation for femoroacetabular impingement
between 2000 and 2008. Seventy-two of the 96 hips had acetabular articular cartilage
lesions treated with a variety of methods, most commonly resection of damaged hyaline
cartilage and labral advancement. Patients were followed for a minimum of 18 months
(mean, 26 months; range, 18-96 months). RESULTS: Mean Harris hip scores improved
from 67 to 91 at final followup. Six of the 96 hips (6%) were converted to arthroplasty
or had worse Harris hip score after surgical recovery. Four of these six had Outerbridge
Grade IV acetabular cartilage lesions and two had Legg-Calvé-Perthes disease or slipped
capital epiphysis deformities. Two hips (2%) had refixation of the greater trochanter.
CONCLUSIONS: At short-term followup, open treatment for femoroacetabular impingement
in hips without substantial acetabular hyaline cartilage damage reduced pain and
improved function with a low complication rate. Treatment of Outerbridge Grade IV
acetabular cartilage delamination remains the major challenge. LEVEL OF EVIDENCE:
Level IV, therapeutic study. See Guidelines for Authors for a complete description
of levels of evidence.
5. Combined arthroscopic and modified open approach for cam femoroacetabular impingement:
a preliminary experience.
Arthroscopy. 2009 Apr;25(4):392-9.
Lincoln M, Johnston K, Muldoon M, Santore R.
Orthopedic Medical Group, San Diego, California 92123, USA.
Abstract: PURPOSE: We report our case series of patients undergoing surgical treatment
(femoral osteoplasty) for symptomatic cam femoroacetabular impingement (FAI). Clinical
results using a modified Heuter anterior approach combined with adjunctive hip arthroscopy
are presented. METHODS: A chart review of 16 hips (14 consecutive patients) was conducted.
Radiographic parameters (alpha angle, head-neck offset, and Tönnis grade) were compared
preoperatively and postoperatively. Clinical features (range of motion, provocative
testing, and Harris hip score) were assessed. RESULTS: At 2.0 years, mean hip flexion
improved from 94.1 degrees to 110.0 degrees (P < .01) and internal rotation from
7.1 degrees to 12.3 degrees (P = .02). The mean alpha angle improved from 64.5 degrees
to 43.3 degrees (P < .01), whereas the mean femoral head-neck offset improved from
1.9 to 9.6 mm (P < .01). The mean Harris hip score improved from 63.8 to 76.1 (P
= .01). No deterioration in overall radiographic Tönnis grades was present at last
follow-up. CONCLUSIONS: The combination of hip arthroscopy with a limited anterior
approach (Heuter) is a useful technique for patients with cam or cam-dominant FAI
lesions. We believe the limited anterior approach with open osteoplasty presents
a reasonable alternative to arthroscopic methods of osteoplasty with minimal drawbacks
in the event that total hip arthroplasty is indicated in the future. LEVEL OF EVIDENCE:
Level IV, therapeutic case series.
6. Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement.
Clin Orthop Relat Res. 2009 Mar;467(3):739-46. Byrd JW, Jones KS.
Nashville Sports Medicine Foundation, 2011 Church Street, Suite 100, Nashville, TN
Abstract: Cam-type femoroacetabular impingement is a recognized cause of intraarticular
pathology and secondary osteoarthritis in young adults. Arthroscopy is reportedly
useful to treat selected hip abnormalities and has been proposed as a method of correcting
underlying impingement. We report the outcomes of arthroscopic management of cam-type
femoroacetabular impingement. We prospectively assessed all 200 patients (207 hips)
who underwent arthroscopic correction of cam impingement from December 2003 to October
2007, using a modified Harris hip score. The minimum followup was 12 months (mean,
16 months; range, 12-24 months); no patients were lost to followup. The average age
was 33 years with 138 men and 62 women. One hundred and fifty-eight patients (163
hips) underwent correction of cam impingement (femoroplasty) alone while 42 patients
(44 hips) underwent concomitant correction of pincer impingement. The average increase
in Harris hip score was 20 points; 0.5% converted to THA. We had a 1.5% complication
rate. The short-term outcomes of arthroscopic treatment of cam-type femoroacetabular
impingement are comparable to published reports for open methods with the advantage
of a less invasive approach.
7. Femoroacetabular impingement treatment using arthroscopy and anterior approach.
Clin Orthop Relat Res. 2009 Mar;467(3):747-52. Laude F, Sariali E, Nogier A.
CMC Paris V, 36 boulevard saint Marcel, 75005, Paris, France.
Abstract: Femoroacetabular impingement (FAI) has been identified as a common cause
of hip pain in young adults. However, treatment is not well standardized. We retrospectively
reviewed 97 patients (100 hips) who underwent osteochondroplasty of the femoral head-neck
for FAI using a mini-open anterior Hueter approach with arthroscopic assistance.
The mean age of the patients was 33.4 years. The labrum was refixed in 40 hips, partially
excised in 39 cases, completely excised in 14 cases, and left intact in seven. Six
patients were lost to followup, leaving 91 (94 hips) with a minimum followup of 28.6
months (mean, 58.3 months; range, 28.6-104.4 months). We assessed patients clinically
using the nonarthritic hip score (NAHS). One patient had a femoral neck fracture
3 weeks postoperatively. At the last followup, the mean NAHS score increased by 29.1
points (54.8 +/- 12 preoperatively to 83.9 +/- 16 points at last followup). Eleven
hips developed osteoarthritis and subsequently had total hip arthroplasty. The best
results were obtained in patients younger than 40 years old with a 0 Tönnis grade.
Refixation of the labrum did not correlate with a higher NAHS score (87 +/- 11 with
refixation versus 82 +/- 19 points without) at the last followup. The technique for
FAI treatment allowed direct visualization of the anterior femoral head-neck junction
while avoiding surgical dislocation, had a low complication rate, and improved functional