Hip Preservation Surgery
Number: 0736
Table Of Contents
PolicyApplicable CPT / HCPCS / ICD-10 Codes
Background
References
Policy
Scope of Policy
This Clinical Policy Bulletin addresses hip preservation surgery, including:
- Femoro-acetabular surgery
- Hip arthroscopy
- Pelvic osteotomy
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Medical Necessity
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Aetna considers femoro-acetabular surgery, open or arthroscopic, for the treatment of hip impingement syndrome medically necessary for persons who fulfill all the following criteria:
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Diagnosis of definite femoro-acetabular impingement (FAI) defined by appropriate imaging studies (X-rays, MRI or CT scans), showing labral pathology (e.g. partial or full thickness labral tearing or labral damage) with one or more of the following:
- cam impingement (alpha angle greater than 50 degrees)
- pincer impingement (acetabular retroversion or coxa profunda) (center edge angle greater than or equal to 40 degrees), or
- pistol grip deformity (non-spherical femoral head shape); and
- Moderate to severe symptoms typical of FAI (hip or groin pain that is worsened by flexion activities (e.g., squatting or prolonged sitting) that significantly limits activities, with duration of at least 6 months where diagnosis of FAI has been made as above; and
- Positive impingement sign with sudden pain on 90 degree hip flexion with adduction and internal rotation or extension and external rotation; and
- Failure to respond to all available conservative treatment options including: activity modification (e.g., restriction of athletic pursuits and avoidance of symptomatic motion), pharmacological intervention (e.g., non-steroidal anti-inflammatory drugs [NSAIDS]), injections of local anesthetics into the joint) and physiotherapy. The treatment should be for at least 12 weeks in the past year with at least 6 weeks being formal physiotherapy (in-person with a licensed physical therapist not virtual). Physical therapy (PT) needs to be confirmed either by the actual PT notes, or by documentation in the member claims history; and
- Absence of advanced osteoarthritis change on pre-operative X-ray (Tonnis grade 2 or more) or severe cartilage injury (Outerbridge grade III or IV); and
- Absence of joint space narrowing on plain radiograph of the pelvis. Joint space is not less than 2 mm wide anywhere along the sourcil; and
- Member does not have generalized joint laxity especially in diseases connected with hypermobility of the joints, such as Marfan syndrome and Ehlers-Danlos syndrome; and
- Member does not have osteogenesis imperfecta; and
- All other potential sources of hip pain have been ruled out.
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Aetna considers hip arthroscopy to repair a labral tear medically necessary for:
- Traumatic labral tears causing mechanical symptoms; or
- An adjunct to FAI surgery.
Note: Iliopsoas tendon release surgery, capsular repair and capsular release surgery are considered integral to the primary procedure and not separately reimbursable.
Note: Aetna recognizes that revision hip arthroscopy for FAI may be required, though infrequently, and any case would need documentation as to the reasons for failure of the prior surgery and the potential benefits of the proposed revision surgery, based on the criteria for FAI surgery listed above.
Note: For purposes of this policy, Aetna will consider the official written report of complex imaging studies (e.g., CT, MRI, myelogram). If the operating surgeon disagrees with the official written report, the surgeon should document that disagreement. The surgeon should discuss the disagreement with the provider who did the official interpretation, and there should also be a written addendum to the official report indicating agreement or disagreement with the operating surgeon.
Note: CPT Code 29860 - Diagnostic hip arthroscopy is generally not covered as it is not medically necessary (hip arthroscopy should only be performed with radiologically proven pathology that meets the above criteria), but if at the time of surgery the radiologically proven pathology is not found, then 29860 may be billed.
Note: CPT Code 29862 - Debridement during hip arthroscopy is considered integral to the FAI surgery codes 29914/5/6 and would therefore not be covered. Arthroscopic debridement of the hip as an isolated procedure is considered experimental, investigational , or unproven as its efficacy has never been proven.
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Aetna considers pelvic osteotomy (e.g., peri-acetabular osteotomy (PAO)) medically necessary for a diagnosis of acetabular dysplasia (not borderline dysplasia) for persons who fulfill all of the following criteria:
- LCEA (Lateral Center Edge Angle) of less than 20 degrees and/or Tonnis Angle (Acetabular Index) over 12 degrees; and
- No or at most mild osteoarthritis of the hip (Tonnis 0 or 1); for members with moderate or worse arthritis (Tonnis 2 or 3), the procedure would be considered not medically necessary; and
- Minimum 6 months of symptoms; and
- Age under 45.
Aetna considers pelvic osteotomy in skeletally immature children medically necessary for a diagnosis of acetabular dysplasia.
Note: Arthroscopic surgery in concert with an osteotomy would be assessed using the medical necessity criteria noted above for arthroscopic surgery of the hip.
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Medically Necessary Procedures
Medically necessary procedures, when above criteria are met, include:
- Femoro-acetabular surgery, open or arthroscopic, for the treatment of hip impingement syndrome;
- Hip arthroscopy to repair a labral tear for traumatic labral tears causing mechanical symptoms or an adjunct to FAI surgery;
- Repair of complete gluteus medius tears;
- Hip arthroscopy for removal of foreign bodies;
- Hip arthroscopy for the removal of loose bodies when no significant osteoarthritis is present (Tonnis 0 or 1);
- Hip arthroscopy for synovectomy in limited instances of inflammatory arthritis, when no significant osteoarthritis is present (Tonnis 0 or 1);
- Endoscopic tenotomy (or lengthening) for iliopsoas tendinopathy following total hip arthroplasty with the failure of at least 6 weeks of formal in-person physical therapy in the past year, and at least 1 therapeutic injection (steroid with or without local anesthetic) with significant but temporary benefit in the past 6 months.
Aetna considers arthroscopic hip surgery experimental, investigational, or unproven for all other indications.
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Experimental, Investigational, or Unproven
Aetna considers the following procedures experimental, investigational, or unproven for the following indications because its effectiveness for these indications has not been established:
- Autologous osteochondral mosaicplasty in combination with femoral neck osteochondroplasty for the treatment of FAI
- Capsular plication
- Debridement or repair of the ligamentum teres when provided as an adjunct to FAI surgery
- Hip arthroscopy to repair degenerative labral tears (e.g., due to early osteoarthritis)
- Hip arthroscopy to treat members with acetabular dysplasia, without addressing the dysplasia via osteotomy
- Labrum reconstruction for the treatment of FAI Note: Labral reconstruction uses a graft to reconstruct the native labrum. This is distinct from a labral repair, which is to repair the torn tissue by sewing it back together and/ or to its attachment site.
- The following procedures are considered experimental, investigational, or unproven when provided as an adjunct to FAI surgery because they have not been proven to improve the outcomes of FAI surgery:
- Anterior-inferior iliac spine decompression
- Debridement of trochanteric bursitis;
- Hip microfracture;
- Lesser trochanteric resection;
- Repair of partial gluteus medius tears. Note: Repair of complete gluteus medius tears is considered medically necessary.
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Related CMS Coverage Guidance
This Clinical Policy Bulletin (CPB) supplements but does not replace, modify, or supersede existing Medicare Regulations or applicable National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs). The supplemental medical necessity criteria in this CPB further define those indications for services that are proven safe and effective where those indications are not fully established in applicable NCDs and LCDs. These supplemental medical necessity criteria are based upon evidence-based guidelines and clinical studies in the peer-reviewed published medical literature. The background section of this CPB includes an explanation of the rationale that supports adoption of the medical necessity criteria and a summary of evidence that was considered during the development of the CPB; the reference section includes a list of the sources of such evidence. While there is a possible risk of reduced or delayed care with any coverage criteria, Aetna believes that the benefits of these criteria – ensuring patients receive services that are appropriate, safe, and effective – substantially outweigh any clinical harms.
Code of Federal Regulations (CFR):
42 CFR 417; 42 CFR 422; 42 CFR 423.
Internet-Only Manual (IOM) Citations:
CMS IOM Publication 100-02, Medicare Benefit Policy Manual; CMS IOM Publication 100-03 Medicare National Coverage Determination Manual.
Medicare Coverage Determinations:
Centers for Medicare & Medicaid Services (CMS), Medicare Coverage Database [Internet]. Baltimore, MD: CMS; updated periodically. Available at: Medicare Coverage Center. Accessed November 7, 2023.
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Related Policies
Background
Hip impingement syndrome, also known as femoro-acetabular impingement (FAI) syndrome, is a recently accepted pathological condition that primarily affects young and middle-aged adults. It is characterized by hip pain felt mainly in the groin and can result in chronic pain and decreased range of motion in flexion and internal rotation. Femoroacetabular impingement (FAI) occurs as a result of friction in the hip joint caused by abnormal contact between the femoral head and the rim of the acetabulum (hip socket). Over time, the repetitive contact can cause damage to the articular or labral cartilage, which may lead to degenerative joint disease.
Femoro-acetabular impingement syndrome has been reported to be associated with progressive osteoarthritis of the hip. History, physical examination, as well as supportive radiographical findings, including evidence of articular cartilage damage, acetabular labral tearing, and early-onset degenerative changes, can aid in diagnosing this condition. Several pathological changes of the femur and acetabulum are known to predispose individuals to develop FAI syndrome.
The three types of FAI include excessive acetabular covering (pincer type), non-spherical femoral head (cam type), or a combination of the two. The two basic mechanisms of FAI are cam impingement (most common in young athletic males) and pincer impingement (most common in middle-aged women). This classification is based on the type of anatomical anomaly contributing to the impingement process. Cam impingement is a type of impingement in which the femoral head is aspherical, which prevents it from rotating smoothly inside the acetabulum (i.e., femoral cause). Pincer impingement is a type of impingement in which extra bone extends out over the normal rim of the acetabulum (i.e., acetabular cause). Cam impingement is the result of an abnormal morphology of the proximal femur, usually at the femoral head-neck junction, while pincer impingement is the result of an abnormal morphology or orientation of the acetabulum (Kassajian et al., 2007). These changes can be found on conventional radiography, magnetic resonance imaging (MRI), and computed tomography (CT) examinations (Beall et al., 2005; Bredella and Stoller, 2005).
Characteristic magnetic resonance arthrographic findings of cam FAI entail large alpha angles and cartilage lesions at the antero-superior position and osseous bump formation at the femoral neck (Pfirrmann et al., 2006). The alpha angle is a measurement of the hip ball (femoral head and neck junction) to determine how much cam impingement exists. The severity of the impingement increases along with the degree of the alpha angle.
Characteristic magnetic resonance arthrographic findings of pincer FAI include a deep acetabulum and postero-inferior cartilage lesions (Pfirrmann et al., 2006). The term coxa profunda refers to a deep acetabulum with excessive acetabular coverage, also referred to as "deep socket." A center edge angle greater than or equal to 40 degrees has been found to be a reliable predictor of pincer impingement (Kutty et al., 2012). The center edge angle is the angle formed by a vertical line and a line connecting the femoral head center with the lateral edge of the acetabulum. A normal center edge angle varies between 25º and 39º (Tannast et al., 2007).
Management of individuals with FAI ranges from conservative therapies (e.g., modification of activities to reduce excessive motion and burden on the hip, the use of non-steroidal anti-inflammatory drugs, and discontinuation of activities associated with the painful hip movement) to surgery (e.g., peri-acetabular osteotomy, hip dislocation, and debridement). Conservative measures, including physical therapy, restriction of activities, core strengthening, improvement of sensory-motor control, and nonsteroidal anti-inflammatories, are the mainstays of nonsurgical treatment (Samora et al., 2011).
The main goal of surgical treatment for this condition is to improve the clearance for motion at the hip joint and lessen the femoral thrust against the acetabular rim. Surgical treatments for treating FAI include arthroscopic or open surgery and hip replacement. Arthroscopic surgery involves the insertion of an arthroscope and small surgical instruments through several small skin incisions into the joint for examination, shaving of bone spurs, or removal of damaged cartilage as needed. Open surgery is performed when large defects are present. Hip replacement is necessary when no articular cartilage is present.
Surgical intervention usually focuses on improving the clearance for hip motion and alleviation of femoral abutment against the acetabular rim. Peri-acetabular osteotomy entails an incision over the front of the hip. With the aid of fluoroscopy, the surgeon cuts through the pelvic bones (i.e., ilium, ischium, and pubis) around the acetabulum to free it from its original position. When the surgeon is satisfied with the new location of the acetabulum (facing the right direction with good coverage), it is secured with 3 to 6 screws. From the same incision, the surgeon can also access the hip joint to debride extra bone from the head/neck as needed. Hip dislocation and debridement are usually performed through an incision over the side of the hip, where the surgeon can dislocate the hip after preserving the vascular supply to the head. After exposing the femoral head and acetabulum, the surgeon can debride extra bone that contributes to the impingement. After removal of bone and damaged tissue, the greater trochanter is re-attached to the femur with screws.
It has been suggested that the surgical trauma sustained during the open procedure for the treatment of FAI syndrome may make it difficult for high-level/professional athletes to return to professional sports. As a result, an arthroscopic approach to treat FAI syndrome has been developed (Philippon and Schenker, 2006).
The iliopsoas (or hip flexors) refers to the combination of the psoas major and the iliacus muscles at their inferior ends, where they join together and form a common tendon that attaches onto the lesser trochanter of the thigh bone (femur). Iliopsoas impingement occurs when the muscle and tendon of the iliopsoas become inflamed and tight, causing an audible snap or click when the iliopsoas tendon moves over the labrum and femoral head. The tightness of the iliopsoas causes rubbing against the labral cartilage and may cause irritation, pain, and tearing.
Iliopsoas tendon release (tenotomy) is a surgical procedure that may be performed to provide relief of tension by a partial release and lengthening of the tendon. This procedure can be performed in a natural hip or after total hip arthroplasty. A tenotomy is the total or partial severing of a tendon to allow lengthening.
Ayeni et al. (2012) systematically reviewed the clinical literature to determine the consistently reported indications for arthroscopic management of femoroacetabular impingement (FAI). The indications for FAI surgery reported in the literature included a positive impingement sign, symptoms or pain for more than 6 months, and a series of positive special tests. Commonly reported radiographic indicators for arthroscopic FAI management included the following: results from a computed tomography scan or magnetic resonance imaging, cam or pincer lesions evident on anteroposterior and/or lateral radiographs, loss of sphericity of the femoral neck, acetabular retroversion, magnetic resonance arthrography, reduction in head-neck offset, an alpha angle greater than 50°, and coxa profunda.
Guidance on arthroscopic femoroacetabular surgery for hip impingement syndrome from the National Institute for Health and Clinical Excellence (NICE, 2011) found evidence is adequate for symptom relief in the short- and medium-term. The consultation documents stated, however, that additional research is needed on patient selection and long-term outcomes specifically related to the development of osteoarthritis. The Committee noted that the available evidence was from observational studies. The guidance stated that, while this was considered adequate for the present recommendation, further studies would be useful. The Committee stated that they recognized the difficulties of comparative research and acquisition of long-term data on this procedure. The guidance noted that the British Hip Society is establishing a registry for arthroscopic femoroacetabular surgery for hip impingement syndrome and stated that clinicians should submit details of all patients undergoing femoroacetabular surgery for hip impingement syndrome to the registry once it is available. The guidance noted that a prime purpose of the registry is to provide data on the long-term outcomes of the procedure. The guidance also stated that it is important that both the registry and other studies report details of patient selection to allow a clear understanding of these outcomes.
Matsuda et al. (2011) performed a systematic evidence review to analyze the current approaches to the surgical management of symptomatic femoroacetabular impingement (FAI), including open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. A total of 18 peer-reviewed treatment outcome studies met the inclusion criteria with a minimum 1-year follow-up of the surgical treatment of skeletal pathoanatomy and associated chondrolabral pathology in skeletally mature patients with FAI. There were 6 open surgical dislocation, 4 mini-open, and 8 arthroscopic studies, all with Levels of Evidence III or IV. The only prospective studies were in the arthroscopic category. Outcome data were extracted and analyzed with respect to surgical efficacy, failure rates, and complications. The authors concluded that the open dislocation, mini-open, and arthroscopic methods for treating symptomatic FAI are effective in improving pain and function in short-term to midterm studies and are relatively safe procedures. The authors said that the historical gold standard of open dislocation surgery had a comparatively high major complication rate primarily because of trochanteric osteotomy-related issues. The mini-open method showed comparable efficacy but a significant incidence of iatrogenic injury to the lateral femoral cutaneous nerve in some studies. The authors found that the arthroscopic method had surgical outcomes equal to or better than the other methods with a lower rate of major complications when performed by experienced surgeons. A critique of the systematic evidence review by Matsuda et al. conducted by the Centre for Reviews and Dissemination (CRD, 2011) concluded that Matsuda et al.'s conclusions should be treated with caution, given potential bias in the review process, inclusion of weak study designs, limited statistical data, and wide variation in the included studies. The CRD noted that most studies of femoroacetabular surgery included in Matsuda et al.'s systematic evidence review did not report confidence intervals, and only one study provided power calculations and defined clinically meaningful changes in outcomes. The CRD stated that, given that most studies of FAI surgery were case series and no explicit methods were used to assess studies for quality, the potential for bias was substantial, as differences in participants, interventions, and outcomes made it difficult to interpret the clinical relevance and reliability of the results. The CRD noted that the three different surgical options reviewed by Matsuda et al. were compared indirectly in potentially different populations, which made it difficult to interpret the findings. The CRD (2011) concluded that, given the potential biases in the review by Matsuda et al. (searching, data extraction, and quality assessment), inclusion of weak study designs, limited statistical data, and wide variation in the included studies, Matsuda et al.'s conclusions should be treated with caution.
Observational studies have demonstrated substantial improvements in symptoms with femoroacetabular surgery; however, observational studies may overestimate the actual degree of improvement from surgery. Studies of arthroscopy for shoulder impingement demonstrate the potential for observational studies to overestimate the benefit of an orthopedic intervention when compared to controlled clinical trials (compare Odenbring et al., 2008; Ketola et al., 2009). In addition, further research is needed on the structural variants that contribute to hip pain; one study failed to find an association in the community between one of the structural variants treated by arthroscopic hip surgery and hip joint pain (Gosvig et al., 2010; EMSCG, 2010).
The number of published studies of FAI surgery has increased exponentially over time. Haviv et al. (2011) reviewed publications on FAI over the past decade and found an exponential increase in the number of publications on FAI over time; the authors found, however, that there has been no corresponding increase in the quality of published studies.
A number of studies have reported positive short- and mid-term outcomes. In a case-series study of 213 treated hips, including 19 patients who underwent simultaneous inter-trochanteric osteotomy with a minimum follow-up of 2 years, Ganz and colleagues (2001) reported that most patients had an improved range of motion as well as a reduction in pain following surgical dislocation of the hip. In another case-series study (22 patients; 29 hips), Siebenrock et al. (2003) examined if symptomatic anterior FAI due to acetabular retroversion can be treated effectively with a peri-acetabular osteotomy. Follow-up ranged from 24 months to 49 months (average of 30 months). These investigators reported that peri-acetabular osteotomy produced a good or excellent result in 26/29 (90%) of hips. In a third case-series study, Murphy et al. (2004) evaluated a group of 23 hips in 23 patients treated by surgical debridement for impingement: 22 patients were treated by full surgical dislocation, and 1 patient was treated by relief of impingement without dislocation. Follow-up ranged from a minimum of 2 years to 12 years. These researchers reported that at 5.2 years' follow-up after debridement of the hip, 15/23 (65%) of patients had functioning hips and had not required further surgery.
In a retrospective case series, Larson and Giveans (2008) assessed the early outcomes of arthroscopic management of FAI, reporting good to excellent results in 75 percent of patients. A total of 96 consecutive patients (100 hips) with radiographically documented FAI were treated with hip arthroscopy, labral debridement or repair/refixation, proximal femoral osteoplasty, or acetabular rim trimming (or some combination thereof). Outcomes were measured with the impingement test, modified Harris Hip Score, Short Form 12, and pain score on a visual analog scale (VAS) pre-operatively and post-operatively at 6 weeks, 3 months, and 6 months, as well as yearly thereafter. Pre-operative and post-operative radiographical alpha angles were measured to evaluate the adequacy of proximal femoral osteoplasty. There were 54 male and 42 female patients with up to 3 years' follow-up (mean of 9.9 months). The mean age was 34.7 years. Isolated cam impingement was identified in 17 hips, pincer impingement was found in 28, and both types were noted in 55. Thirty hips underwent labral repair/refixation. A comparison of pre-operative scores with those obtained at the most recent follow-up revealed a significant improvement (p < 0.001) for all outcomes measured: Harris Hip Score (60.8 versus 82.7), Short Form 12 (60.2 versus 77.7), VAS for pain (6.74 cm versus 1.88 cm), and positive impingement test (100% versus 14%). The alpha angle was also significantly improved after resection osteoplasty. Complications included heterotopic bone formation (6 hips) and a 24-hour partial sciatic nerve neurapraxia (1 hip). No hip went on to undergo repeat arthroscopy, and 3 hips have subsequently undergone total hip arthroplasty. The authors concluded that arthroscopic management of patients with FAI results in significant improvement in outcome measures, with good to excellent results being observed in 75% of hips at a minimum 1-year follow-up. However, alteration in the natural progression to osteoarthritis and sustained pain relief as a result of arthroscopic management of FAI remain to be seen.
Ilizalitturi et al. (2008) reported on short-term follow-up of an uncontrolled cohort of 19 patients with cam femoroacetabular impingement. The authors reported a modest improvement in the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score from preoperatively to 2 years post-operatively (mean of 82 points pre-operatively to mean of 89 points post-operatively). The authors concluded that "long-term follow-up is needed to fully understand the results of surgical intervention for the treatment of FAI."
In a preliminary report, Philippon et al. (2008) reported on the treatment of FAI in the adolescent population. Between March 2005 and May 2006, a total of 16 patients (aged 16 years or younger) underwent hip arthroscopy for FAI. There were 14 females and 2 males, with 1 patient undergoing a bilateral procedure. Five patients had isolated pincer impingement, 2 had isolated cam impingement, and 9 had mixed pathology. All patients had labral pathology. Seven patients were treated with suture anchor repair of the labrum, and 9 with partial labral debridement. Subjective data were collected from each patient during their initial visit and at follow-up after surgery. Subjective data included the modified Harris Hip Score (MHHS), patient satisfaction, and hip outcome score (HOS) activities of daily living (ADL) and sports subscales. The mean age at the time of arthroscopy was 15 years old (range of 11 to 16 years). The mean pre-operative MHHS was 55 (range of 33 to 70), HOS ADL was 58 (range of 38 to 75), and HOS sport score was 33 (range of 0 to 78). The mean time from injury to surgery was 10.6 months (range of 6 weeks to 30 months). The mean time to follow-up was 1.36 years (range of 1 to 2 years). The mean post-operative MHHS improved 35 points to 90 (range of 70 to 100; p = 0.005), post-operative HOS ADL improved 36 points to 94 (range of 74 to 100; p = 0.001), and post-operative HOS sport score improved 56 points to 89 (range of 58 to 100; p = 0.001). The mean patient satisfaction score was 9 (range of 9 to 10). The authors concluded that hip arthroscopy for FAI in the adolescent population produces excellent improvement in function and a high level of patient satisfaction in the short term.
Philippon and colleagues (2009) reported the outcomes following hip arthroscopy for FAI with associated chondrolabral dysfunction. These investigators prospectively enrolled 122 patients who underwent arthroscopic surgery of the hip for FAI and met the inclusion criteria for this study. Patients with bilateral hip arthroscopy, avascular necrosis, and previous hip surgery were excluded; 10 patients refused to participate, leaving 112 in the study (62 women and 50 men). The mean age of the patients was 40.6 years (95% confidence interval (CI) 37.7 to 43.5). At arthroscopy, 23 patients underwent osteoplasty only for cam impingement, 3 underwent rim trimming only for pincer impingement, and 86 underwent both procedures for mixed-type impingement. The mean follow-up was 2.3 years (2.0 to 2.9). The mean MHHS improved from 58 to 84 (mean difference = 24 (95% CI 19 to 28)), and the median patient satisfaction was 9 (1 to 10). Ten patients underwent total hip replacement at a mean of 16 months (8 to 26) after arthroscopy. The predictors of a better outcome were the pre-operative modified HHS (p = 0.018), joint space narrowing greater than or equal to 2 mm (p = 0.005), and repair of labral pathology instead of debridement (p = 0.032). The authors concluded that hip arthroscopy for FAI, accompanied by suitable rehabilitation, gives a good short-term outcome and high patient satisfaction.
Byrd and Jones (2009) prospectively assessed 200 patients (207 hips) who underwent arthroscopic correction of cam impingement from December 2003 to October 2007, using a MHHS. The minimum follow-up was 12 months (mean of 16 months; range of 12 to 24 months); no patients were lost to follow-up. The average age was 33 years, with 138 men and 62 women. A total of 158 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 MHHS was 20 points; 0.5% converted to total hip arthroplasty. There was a 1.5% complication rate. The authors stated that the short-term outcomes of arthroscopic treatment of cam-type FAI are comparable to published reports for open methods, with the advantage of a less invasive approach.
Bardakos and Villar (2009) investigated the effect of several radiological parameters, each indicative of a structural aspect of the hip joint, on the progression of osteoarthritis. Pairs of plain antero-posterior pelvic radiographs, taken at least 10 years apart, of 43 patients (43 hips) with a pistol-grip deformity of the femur and mild (Tönnis grade 1) or moderate (Tönnis grade 2) osteoarthritis were reviewed. Of the 43 hips, 28 showed evidence of progression of osteoarthritis. There was no significant difference in the prevalence of progression between hips with initial Tönnis grade 1 or grade 2 osteoarthritis (p = 0.31). Comparison of the hips with and without progression of arthritis revealed a significant difference in the mean medial proximal femoral angle (81 degrees versus 87 degrees, p = 0.004) and the presence of the posterior wall sign (39% versus 7%, p = 0.02) only. A logistic regression model was constructed to predict the influence of these two variables in the development of osteoarthritis. Mild-to-moderate osteoarthritis in hips with a pistol-grip deformity will not progress rapidly in all patients. In one-third, progression will take more than 10 years to manifest, if ever. The individual geometry of the proximal femur and acetabulum partly influences this phenomenon. A hip with cam impingement is not always destined for end-stage arthritic degeneration.
Horisberger et al. (2010) prospectively followed a cohort of 105 hips (88 patients; 60 males, 28 females) who underwent arthroscopic surgery for symptomatic cam or mixed femoroacetabular impingement. At a minimum follow-up of 1.3 years (average, 2.3 years; range, 1.3 to 4.1 years), all clinical outcome measures improved. Nine patients (8.6%) underwent total hip arthroplasty during follow-up.
Gedouin et al. (2010) reported on outcomes of arthroscopic surgery for hip impingement in 111 hips in 110 patients (78 male, 32 female; mean age of 31 years). A total of 65 patients showed no radiographic sign of osteoarthritis, and 36 showed grade-1 early osteoarthritis on the Tönnis scale. The investigators reported that the mean WOMAC score rose from 60.3 pre-operatively to 83 (p < 0.001) at a mean 10 months' follow-up (range of 6 to 18 months); 77% of patients were satisfied or very satisfied with their result. The investigators noted that patients with early osteoarthritis had significantly lower WOMAC and satisfaction scores than those free of osteoarthritis. Operative crossover to open surgery for femoroacetabular impingement occurred in one case. Five patients (4%) had total hip replacement or resurfacing. There were 7 complications (6%): 3 cases of heterotopic ossification, 1 of crural palsy, 1 of pudendal palsy, 1 of labium majus necrosis, and 1 non-displacement stress fracture of the femoral head/neck junction. There was no palsy of the territory of the lateral cutaneous nerve of the thigh.
The labrum is a ring of fibrocartilage (fibrous cartilage) around the edge of the articular (joint) surface of a bone. In a case series study, Philippon et al. (2010) examined the indications for and outcomes of arthroscopic labral reconstruction in the hip by use of ilio-tibial band (ITB) autograft. Between August 2005 and May 2008, the senior author performed 95 arthroscopic labral reconstructions using an ITB autograft in patients with advanced labral degeneration or deficiency. There were 47 patients (32 men, 15 women; mean age 37 years, range of 18 to 55 years) who had undergone surgery at a minimum of 1 year previously and met the inclusion criteria. The mean time from the onset of symptoms to labral reconstruction was 36 months (range of 1 month to 12 years). Subsequent total hip arthroplasty was performed in 4 patients (9%). Follow-up was obtained in 37 of the remaining 43 patients. The mean time to follow-up was 18 months (range of 12 to 32 months). The mean modified Harris Hip Score (MHHS) improved from 62 (range of 35 to 92) pre-operatively to 85 (range of 53 to 100) post-operatively (p = 0.001). Median patient satisfaction was 8 out of 10 (range of 1 to 10). Patients who were treated within 1 year of injury had higher modified Harris Hip Scores than patients who waited longer than 1 year (93 versus 81, p = 0.03). The independent predictor of patient satisfaction with outcome after labral reconstruction was age. The authors concluded that these findings showed that patients who have labral deficiency or advanced labral degeneration had good outcomes and high patient satisfaction after arthroscopic intervention with acetabular labral reconstruction. Lower satisfaction was associated with joint space narrowing and increased age. Patients who waited longer than 1 year from the time of injury to surgery had lower function at follow-up than those treated in the first year. The study by Philippon et al. (2010) was a case series that examined arthroscopic labral reconstruction in the hip by use of ilio-tibial band autograft in patients with advanced labral degeneration or deficiency. It is unclear how many of the studied cases involved hip impingement syndrome/femoro-acetabular syndrome.
A controlled study of FAI surgery compared FAI surgery with resection of the torn labrum to FAI surgery with reattachment of the labrum to the acetabular rim (Espinosa et al., 2006). Espinosa and co-workers (2006) examined if labral re-fixation after treatment of FAI affects the clinical and radiographical results. These investigators retrospectively reviewed the clinical and radiographical results of 52 patients (60 hips) with FAI who underwent arthrotomy and surgical dislocation of the hip to allow trimming of the acetabular rim and femoral osteochondroplasty. In the first 25 hips, the torn labrum was resected (group 1); in the next 35 hips, the intact portion of the labrum was re-attached to the acetabular rim (group 2). At 1 and 2 years post-operatively, the Merle d'Aubigné clinical score and the Tönnis arthrosis classification system were used to compare the two groups. At 1-year follow-up, both groups showed a significant improvement in their clinical scores (mainly pain reduction) compared with their pre-operative values (p = 0.0003 for group 1 and p < 0.0001 for group 2). At 2-year follow-up, 28% of the hips in group 1 (labral resection) had an excellent result, 48% had a good result, 20% had a moderate result, and 4% had a poor result. In contrast, in group 2 (labral re-attachment), 80% of the hips had an excellent result, 14% had a good result, and 6% had a moderate result. Comparison of the clinical scores between the two groups revealed significantly better outcomes for group 2 at 1-year (p = 0.0001) and 2-year (p = 0.01) follow-up. Radiographical signs of osteoarthritis were significantly more prevalent in group 1 than in group 2 at 1-year (p = 0.02) and at 2-year (p = 0.009) follow-up. The authors concluded that patients treated with labral re-fixation recovered earlier and had superior clinical and radiographical outcomes when compared with patients who had undergone resection of a torn labrum. These investigators noted that the results must be considered preliminary, but they recommend re-fixation of the intact portion of the labrum after trimming of the acetabular rim during surgical treatment of FAI. Furthermore, they stated that long-term follow-up will be needed to evaluate if the use of this technique results in improved functional outcomes and a reduction in the prevalence of symptomatic osteoarthritis in affected patients.
Nho et al. (2011) reported on a case series showing that arthroscopic treatment of femoroacetabular impingement in a mixed group of high-level athletes resulted in a significant improvement in hip functional outcome: 78% of athletes were able to return to play at 1 year, and 73% of athletes were able to play at 2-year follow-up. High-level athletes who underwent arthroscopic treatment of femoroacetabular impingement (rim trimming, labral refixation or debridement, femoral osteochondroplasty) with a minimum of 1-year follow-up were retrospectively identified. All patients completed hip-specific outcome scores (Modified Harris Hip Score [MHHS] and Hip Outcome Score [HOS]) at baseline and most recent follow-up. Forty-seven patients with an average age of 22.8 ± 6.2 years met the study criteria with a mean follow-up of 27.0 ± 5.5 months. Thirty-three patients (70.2%) were available for follow-up. The level of competition was 27.7% varsity high school, 53.2% college, and 19.1% professional athletes. There were statistically significant improvements in the mean MHHS score (pre-operative, 68.6 ± 12.8; post-operative, 88.5 ± 17.7; p = 0.002) as well as the HOS score (pre-operative, 78.8 ± 11.3; post-operative, 91.4 ± 14.0; p = 0.03). There was a significant improvement in the alpha angle, with 76.4° ± 14.5° pre-operatively and 51.4° ± 11.7° post-operatively (p = 0.0003). Seventy-nine percent of patients were able to return to play after hip arthroscopy at a mean of 9.4 ± 4.7 months (range of 4 to 26 months); of those patients, 92.3% were able to return to the same level of competition. At 2-year follow-up, 73% of patients were able to return to play.
Byrd and Jones (2011) also found that most athletes treated with arthroscopic hip surgery were able to resume their activities. The authors reported on a case series of 200 patients identified who underwent arthroscopic management of FAI, participated in athletic activities, and had achieved a minimum 1-year follow-up. The authors stated that there was 100% follow-up at an average of 19 months (range of 12 to 60 months). A total of 116 athletes had achieved 2-year follow-up. For the entire cohort, the average age was 28.6 years (range of 11 to 60 years) with 148 males and 52 females. There were 159 cam, 31 combined, and 10 pincer lesions. There were 23 professional, 56 inter-collegiate, 24 high school, and 97 recreational athletes. The male:female ratio was 2.8:1 among cam lesions and 1:1 among pincer lesions. The median pre-operative score was 72, with a post-operative score of 96, and the median improvement was 20.5 points, which was statistically significant (p < 0.001). The authors reported that 95% of professional athletes and 85% of inter-collegiate athletes were able to return to their previous level of competition. There were 5 transient neurapraxias (all resolved) and 1 minor heterotopic ossification. One athlete (0.5%) underwent conversion to total hip arthroplasty, and 4 (2%) underwent repeat arthroscopy. For the group with a minimum 2-year follow-up, the median improvement was 21 points with a post-operative score of 96.
Schilders et al. (2011) reported that labral repairs achieved superior results to labral resection. The investigators reviewed 151 patients (156 hips) with FAI and labral tears who had been treated arthroscopically. These were subdivided into those who had undergone a labral repair (group 1) and those who had undergone resection of the labrum (group 2). In order to ensure the groups were suitably matched for comparison of treatment effects, patients with advanced degenerative changes (Tönnis grade greater than 2, lateral sourcil height less than 2 mm, and Outerbridge grade 4 changes in the weight-bearing area of the femoral head) were excluded, leaving 96 patients (101 hips) in the study. At a mean follow-up of 2.44 years (2 to 4), the mean modified Harris hip score in the labral repair group (group 1, 69 hips) improved from 60.2 (24 to 85) pre-operatively to 93.6 (55 to 100), and in the labral resection group (group 2, 32 hips) from 62.8 (29 to 96) pre-operatively to 88.8 (35 to 100). The mean modified Harris hip score in the labral repair group was 7.3 points greater than in the resection group (p = 0.036, 95% confidence interval [CI]: 0.51 to 14.09). Labral detachments were found more frequently in the labral repair group and labral flap tears in the resection group. The investigators reported that no patient in the study group required a subsequent hip replacement during the period of follow-up. The investigators concluded that this study shows that patients without advanced degenerative changes in the hip can achieve significant improvement in their symptoms after arthroscopic treatment of femoroacetabular impingement. The authors stated that this evidence also suggests that labral repair, where appropriate, provides a superior result to labral resection.
There are limited data on the efficacy of FAI surgery in adolescents. Fabricant et al. (2012) reported on a small, retrospective case series of FAI surgery in adolescents. The investigators retrospectively reviewed the records of 27 hips in 21 patients 19 years of age or younger who underwent arthroscopic treatment for FAI between 2007 and 2008. From the records, the investigators extracted demographic data, operative details, complications, and pre-operative and post-operative MHHS and the HOS. The minimum follow-up was 1 year (average of 1.5 years; range of 1 to 2.5 years). The investigators reported that the modified HHS improved by an average of 21 points, the activities of daily living subset of the HOS improved by an average of 16 points, and the sports outcome subset of the HOS improved by an average of 32 points. The investigators stated that all patients' self-reported ability to engage in their pre-operative level of athletic competition improved. In 24 hips that underwent cam decompression, the mean alpha angle improved from 64° ± 16° to 40° ± 5.3° post-operatively. The investigators concluded that they found short-term improvements in HOS and HHS with no complications for arthroscopic treatment of FAI in their cohort of adolescent athletes.
There is emerging evidence of the efficacy of FAI surgery in older patients. Javed and O'Donnell (2011) reported on a small retrospective case series of FAI surgery in patients over 60 years of age. The investigators reviewed the clinical outcome of arthroscopic femoral osteochondroplasty for cam femoroacetabular impingement performed between August 2005 and March 2009 in a series of 40 patients over 60 years of age. The group comprised 26 men and 14 women with a mean age of 65 years (60 to 82). The mean follow-up was 30 months (12 to 54). The mean modified Harris hip score improved by 19.2 points (95% CI: 13.6 to 24.9; p < 0.001), while the mean non-arthritic hip score improved by 15.0 points (95% CI: 10.9 to 19.1; p < 0.001). Seven patients underwent total hip replacement after a mean interval of 12 months (6 to 24 months) at a mean age of 63 years (60 to 70). The investigators reported that the overall level of satisfaction was high, with most patients indicating that they would undergo similar surgery in the future to the contralateral hip, if indicated. No serious complications occurred.
Philippon et al. (2012) reported on a case series of patients aged 50 years and older who underwent hip arthroscopy for femoro-acetabular impingement. Between 2006 and 2008, prospectively collected data were retrieved from the authors' database on 153 patients aged 50 years or older undergoing hip arthroscopy for FAI. Data collected included range of motion, MHHS, HOS for activities of daily living, HOS for sports, and Short Form 12 score. Survivors were defined as patients not requiring total hip replacement (THR). Survivorship was analyzed by use of the Kaplan-Meier method. The authors reported that THR was required after the arthroscopic treatment in 20% of patients (31 of 153). At 3 years (with data available in 64 patients), patients with greater than 2 mm of joint space had survivorship of 90%, whereas those with 2 mm or less had survivorship of 57% (p = 0.001). In the patients who did not require THR, the MHHS improved from 58 to 84. The HOS for activities of daily living improved from 66 to 87 (p = 0.001), and the HOS for sports improved from 42 to 72 (p = 0.001). The physical component of the Short Form 12 improved from 38 to 49 (p = 0.001), whereas the mental component did not change (54 pre-operatively vs. 53 post-operatively, p = 0.53). Median patient satisfaction was 9. The authors concluded that, on the basis of early results, patients with greater than 2 mm of joint space can expect improvement over pre-operative status in pain and function after hip arthroscopy for FAI. In patients aged 50 years or older with 2 mm of joint space or less and low pre-operative MHHSs, early conversion to THR was seen.
There is evidence that persons with advanced joint space narrowing do not improve with FAI surgery. Between September 2004 and April 2008, Larson et al. (2011) treated 210 patients (227 hips) with FAI and a minimum 12-month follow-up (mean of 27 months). Group FAI consisted of 154 patients (169 hips) without radiographic joint space narrowing, whereas Group FAI-OA consisted of 56 patients (58 hips) with pre-operative radiographic joint space narrowing. The authors collected Harris hip scores (HHS), Short Form-12 (SF-12), and pain scores on a visual analog scale (VAS) pre-operatively and post-operatively. The authors reported that score improvements were better for Group FAI compared with Group FAI-OA. The overall failure rate was greater for Group FAI-OA (52%) than for Group FAI (12%). The authors found that, although patients with less than 50% joint space narrowing or greater than 2 mm joint space remaining on pre-operative radiographs had improved scores throughout the study, they observed no score improvements at any time with advanced pre-operative joint space narrowing. The authors found that greater joint space narrowing, advanced MRI chondral grade, and longer duration of pre-operative symptoms predicted lower scores.
A number of reviews have evaluated the published data on FAI surgery, indicating positive results. A systematic evidence review (Stevens et al., 2010) judged the evidence for femoroacetabular surgery as fair quality. Wettstein and Dienst (2006) stated that the early results after hip arthroscopy for the treatment of FAI syndrome are very promising. Guanche and Bare (2006) stated that arthroscopic treatment of FAI syndrome caused by an abnormal head-neck offset improves symptoms, restores hip morphology, and may arrest the progression toward degenerative joint disease in some patients. They noted that early results showed that if debridement of the impinging lesion and injured labrum is performed in the setting of normal femoral and acetabular articular surfaces, the results are promising.
Chládek and Trc (2007) noted that in the case of primary surgery for FAI, short- and middle-term results so far obtained are promising, and forthcoming long-term results will show whether, and for how many years, this therapy is able to postpone the necessity of total hip arthroplasty. Standaert et al. (2008) stated that although a connection between anatomical abnormalities of the hip and the development of osteoarthritis has been recognized for some time, there are limited data on the natural history of FAI and no long-term studies on the effect of surgical treatment. Samora et al. (2011) concluded that the literature is replete with short-term evidence to support surgical treatment; however, there are currently no long-term prospective data or natural history studies examining the implications of FAI and effects of early intervention.
Longo et al. (2010) completed a systematic computerized literature search on hip arthroscopy. The authors found that almost all studies reporting on the outcome of hip arthroscopy are of moderate scientific quality, and the evidence-based knowledge regarding results of hip arthroscopy arises from studies with a short-term follow-up period. The authors stated that the future of hip arthroscopy will require better visualization, access, instrumentation, and implants, with longer follow-up studies to prove its equivalence to or superiority over arthrotomy. The authors concluded that preliminary studies support the use of hip arthroscopy as an alternative to arthrotomy with enormous therapeutic potential.
Beaule et al. (2009) stated that FAI is a recognized cause of hip pain and osteoarthritis in young adults. The clinical presentation of this pathology is quite varied in terms of the underlying deformity, patient age, and the degree of cartilage damage. Open hip surgery with surgical dislocation is the gold standard for treating femoral deformities and the damaged acetabular labral complex; however, less invasive techniques such as hip arthroscopy and arthroscopy combined with limited anterior hip arthrotomy may provide comparable outcomes with less surgical morbidity. Unresolved issues include the indications for acetabular rim trimming with labral refixation in the presence of acetabular retroversion and/or delaminated acetabular cartilage. Other issues involve the use of arthroplasty in older patients and/or in those with significant cartilage damage. The authors concluded that surgery should be tailored to treat individual patients' abnormal hip morphology and should address the major underlying impinging deformities.
In a review on arthroscopic treatment of FAI, Tzaveas and Villar (2009) stated that FAI is a recently recognized pathological entity. Arthroscopic treatment, as a modern and minimally invasive technique, has become an attractive and promising treatment. Also, Larson and associates (2009) noted that improved techniques and longer-term outcomes studies will further define the optimal role of hip arthroscopy.
Macfarlane and Haddad (2010) noted the increasing number of studies of FAI in the published literature. The authors reviewed the etiology, pathophysiology, clinical features, diagnosis, and treatment of FAI. Search terms included femoro-acetabular impingement, arthroscopic treatment, open treatment, etiology, and pathophysiology. The search was limited to articles published in English. All articles were read in full by the authors and selected for inclusion based on relevance to the article. An increasing number of studies relating to FAI have been produced in the 10 years since its recognition. A range of clinical and radiological features have been described. Surgical management can be performed using a number of techniques, with promising results from various studies. Early treatment with open surgery has paved the way for less invasive and arthroscopic approaches, with short-to-medium term data reporting favorable functional results for arthroscopic treatment of FAI. Thus, the results of long-term studies are awaited.
Katz and Gomoll (2007) examined recent trends in the use of arthroscopic surgical techniques to address musculoskeletal problems. These investigators focused on arthroscopic approaches to problems of the hip, wrist, elbow, and ankle. They noted that hip arthroscopy is permitting novel, minimally invasive approaches to the management of FAI, labral tears, loose bodies, and chondral lesions. Complications of arthroscopic procedures occur very rarely. However, they stated that virtually all the literature on arthroscopy outcomes comes from small uncontrolled studies.
- the quality of the literature assessing outcomes after surgical treatment of labral tears and FAI,
- patient satisfaction after open or arthroscopic intervention, and
- differences in outcome with open or arthroscopic approaches.
Computerized literature databases were searched to identify relevant articles from January 1980 to May 2008. Studies were eligible for inclusion if they had a level I, II, III, or IV study design and if the patient population had a labral tear and/or FAI as the major diagnosis. Patients with severe pre-existing osteoarthritis or acetabular dysplasia were excluded. Of the 19 articles with reported outcomes after surgery, none used a prospective study design and 1 met the criteria for level III basis of evidence. Open surgical dislocation with labral debridement and osteoplasty is successful, with a good correlation between patient satisfaction and favorable outcome scores. The studies reviewed support that 65% to 85% of patients will be satisfied with their outcome at a mean of 40 months after surgery. A common finding in all series, however, was an increased incidence of failure among patients with severe pre-existing osteoarthritis. Arthroscopic treatment of labral tears is also effective, with 67% to 100% of patients being satisfied with their outcomes. The authors found that, although open surgical dislocation with osteoplasty is the historical gold standard, the scientific data do not show that open techniques have outcomes superior to arthroscopic techniques.
In an evaluation of the afore-mentioned systematic evidence review by Bedi et al, the Centre for Reviews and Dissemination (2009) stated that the validity of the studies included in this systematic review was not assessed and the studies were of poor quality study design, so the reliability of their results is uncertain. The CRD concluded that Bedi et al.'s conclusions reflected the data presented, but the potential for various biases in the review made their reliability unclear.
A systematic evidence review prepared by the Health Care Insurance Board of the Netherlands (CVZ, 2010) found no prospective comparative studies of surgery for femoroacetabular hip impingement syndrome. The systematic evidence review noted that evidence consists largely of retrospective case-series, which are heterogeneous in terms of patient populations, treatment and outcomes.
- define the level of evidence regarding hip impingement surgery;
- determine whether the surgery relieves pain and improves function;
- identify the complications; and
- identify modifiable causes of failure (conversion to total hip arthroplasty).
These investigators searched the literature between 1950 and 2009 for all studies reporting on surgical treatment of FAI. Studies with clinical outcome data and minimum 2-year follow-up were analyzed. A total of 11 studies met criteria for inclusion – 9 were Level IV and 2 were Level III. Mean follow-up was 3.2 years; range of 2 to 5.2 years. Reduced pain and improvement in hip function were reported in all studies. Conversion to total hip arthroplasty was reported in 0% to 26% of cases. Major complications occurred in 0% to 18% of the procedures. Current evidence regarding FAI surgery is primarily Level IV and suggests the various surgical techniques are associated with pain relief and improved function in 68 to 96% of patients over short-term follow-up. The authors stated that long-term follow-up is needed to determine survivorship and impact on osteoarthritis progression and natural history.
Ng et al. (2010) also reviewed the published evidence on the surgical treatment of FAI. A total of 23 reports of case studies on the surgical treatment of FAI were identified and 1 systematic review was conducted. This review of 970 cases included 2 level III studies, and 20 level IV studies. One randomized controlled trial (level I study) (citing Espinosa et al, 2006) was found, comparing labral repair to labral debridement. The authors found that those patients with Outerbridge grade III or IV cartilage damage seen intra-operatively or with pre-operative radiographs showing greater than Tonnis grade I osteoarthritis appear to have worse outcomes with treatment for FAI. The authors found 2 studies that directly compared labral re-fixation with labral debridement; the authors stated that this evidence appears to support labral re-fixation. Although several studies reported post-operative osteoarthritis findings, the authors found that it is too soon to predict whether progression of osteoarthritis is delayed or halted.
A review by ARIF (2010) concluded that the main limitation with the data identified in reviews of femoroacetabular surgery for hip impingement syndrome was that it had been derived from retrospective case series, limiting the conclusions one can draw about the effectiveness of arthroscopic surgery for hip impingement and/or hip pain compared with any conventional approach overall and within any particular subgroups.
An assessment by Public Health Wales (Webb, 2010) found that the available evidence from systematic reviews is mainly of level III (case series) and level IV (expert opinion/formal consensus) type and is suggestive of short term improvements in outcomes with both open and arthroscopic surgical procedures. The assessment found that small prospective cohort studies also confirm outcome improvement. The assessment stated that most studies documented decreased pain and improved function in the majority of patients with short term follow-up. However, long term follow up studies were not found. The assessment stated that predictors of treatment outcome and the efficacy of various surgical techniques need to be established in well-designed clinical trials.
A systematic evidence review commissioned by the Washington State Healthcare Authority (Dettori et al., 2011) found "no data to assess the short- or long-term efficacy of FAI surgery compared with no surgery." The assessment found "no evidence that one specific treatment resulted in better outcomes than another (surgery versus no surgery, labral debridement versus refixation, osteoplasty versus no osteoplasty)." The assessment identified several case series that reported improvement in pain, patient-reported and clinician-reported hip outcome scores, patient satisfaction, and return to normal activities following FAI surgery. "However, whether this improvement is a result of the surgery, or the postoperative rehabilitation, or the change in activity subsequent to the surgery, or placebo is not known." The assessment found "no data available to assess long-term effectiveness of FAI surgery compared with no surgery." The assessment stated that "there are no data yet published to test the hypothesis that FAI surgery prevents or delays hip osteoarthritis or the need for total hip arthroplasty." The Washington State Health Technology Clinical Committee (2011) concluded that the current evidence on surgery for femoroacetabular impingement syndrome demonstrates that there is insufficient evidence to cover. The committee stated that it considered all the evidence, including the comprehensive report, public comments, and utilization data, and gave greatest weight to the evidence it determined, based on objective factors, to be the most valid and reliable.
There is new emerging evidence of the long-term effectiveness of FAI surgery. Meftah et al. (2011) reported on long-term outcomes of arthroscopic labral debridement. The investigators reported on fifty consecutive patients who underwent hip arthroscopy and labral debridement with a mean follow-up of 8.4 years. Patients' pre-operative Harris Hip Scores and co-existing pathologies such as FAI, dysplasia, or arthritis were recorded as variables. Post-operative Harris Hip Score and satisfaction at final follow-up were recorded as outcomes. The authors reported that good or excellent results were achieved in 62% of cases (58% in patients with untreated FAI and 19% in patients with arthritis). Failures included 2 cases that were converted to total hip replacement (4.5 and 5.2 years after the index procedure) due to advancement of arthritis and 1 case of repeat arthroscopy for cam decompression. Patients with no co-existing pathology had significantly higher satisfaction and Harris Hip Scores. The authors noted that almost all of the patients with low postoperative Harris Hip Scores had arthritic changes, and that arthritis had a significant correlation with low post-operative Harris Hip Scores and satisfaction. The authors found that co-existing pathology, especially arthritis and untreated FAI, can result in inferior outcomes. The authors concluded that arthroscopic labral debridement of symptomatic tears in selected patients with no co-existing pathology can result in favorable long-term results. The authors found that arthritis is the strongest independent predictor of poor outcomes.
Previously published long-term data come from Byrd and Jones (2010), who investigated the response to hip arthroscopy in a consecutive series of patients with 10 years of follow-up. Since 1993, the authors assessed all patients undergoing hip arthroscopy prospectively with a modified Harris Hip Score pre-operatively and then post-operatively at 3, 12, 24, 60, and 120 months. A cohort of 50 patients (52 hips) was identified who had achieved 10-year follow-up and represent the substance of this study. The authors reported that there was 100% follow-up of these patients. The average age of the patients was 38 years (range of 14 to 84 years), with 27 males and 23 females. The median improvement was 25 points (pre-operative, 56 points; post-operative, 81 points). Fourteen patients were converted to total hip arthroplasty (THA), and 2 died. Four patients underwent repeat arthroscopy. There were 2 complications in 1 patient. The presence of arthritis at the time of the index procedure was an indicator of poor prognosis. The authors concluded that this study substantiates the long-term effectiveness of arthroscopy in the hip as treatment for various disorders, including labral pathology, chondral damage, synovitis, and loose bodies. The authors found that arthritis is an indicator of poor long-term outcomes with these reported methods.
In summary, there is currently sufficient evidence to support the short- and mid-term effectiveness of surgery (open or arthroscopic) for the treatment of individuals with FAI syndrome. However, there is a lack of evidence that surgical intervention slows the rate of progression to osteoarthritis of the hip in these patients.
A systematic review of the evidence for FAI surgery (Harris et al., 2013) found that study methodological quality, analyzed using the Modified Coleman Methodology Score (MCMS), was poor.
Clohisy et al. (2013) stated that FAI surgery is at the development level, with only case series supporting the intervention. The authors stated that recently published systematic reviews of the literature indicate that the current evidence regarding FAI surgery primarily consists of level IV studies. These studies support the clinical efficacy of FAI surgery, with most patients reporting reduced pain, improved function, and a better quality of life after surgical intervention for symptomatic FAI. Similar to the data supporting many surgical interventions, these data have limitations, however, in that the study cohorts are relatively small, the surgical interventions are varied, and the follow-up duration is short- to midterm. The authors stated that, in the scheme of an ideal introduction of a new intervention, FAI surgery is at the development level, with only case series supporting the intervention. The authors stated that, to bolster the strength of clinical evidence regarding FAI surgery, larger clinical studies are needed to compare surgical and nonsurgical hip rehabilitation interventions, identify the predictive factors of treatment outcomes, and determine the long-term impact of FAI surgery on joint survivorship and disease modification, that is, the delay or prevention of secondary osteoarthritis.
The United Kingdom Feasibility study of a trial of Arthroscopic Surgery for Hip Impingement compared with Non-operative care (UK FASHIoN) is a large-scale multi-center pilot project funded by the Health Technology Assessment Program, a division of the National Institute for Health Research (NIHR) of the National Health Service in the United Kingdom. The study began in March 2012, with a planned 18-month study period. The research team seeks to establish the feasibility of a randomized controlled trial (RCT) comparing hip arthroscopy with the so-called best nonsurgical care for symptomatic FAI.
Currently, there is insufficient evidence regarding the use of capsular plication as a treatment for FAI. Larson et al. (2014) reported that capsular plication was a predictor of improved outcomes with revision arthroscopic surgery for residual FAI. The authors reviewed patients who underwent arthroscopic hip revision for residual FAI. The authors evaluated pathomorphological findings, intra-operative findings, and pre-operative and post-operative MHHS, SF-12, and pain on a VAS values. The authors compared outcomes after revision arthroscopic FAI correction with outcomes of a matched cohort who underwent primary arthroscopic FAI correction. A total of 79 patients (85 hips) with a mean age of 29.5 years underwent arthroscopic revision FAI correction (mean follow-up of 26 months). The labrum was debrided (27 hips), repaired (49 hips), or reconstructed (7 hips). Two labrums were stable and required no treatment. The authors compared the results of revision arthroscopic FAI correction with those of 220 age- and sex-matched patients (237 hips) who underwent primary arthroscopic FAI correction (mean follow-up of 23 months). The mean improvement in outcome scores after revision FAI correction was 17.8 (MHHS), 12.5 (SF-12), and 1.4 (VAS) points compared with 23.4 (MHHS), 19.7 (SF-12), and 4.6 (VAS) points after primary arthroscopic FAI correction. The mean improvement was significantly better in the primary cohort compared with the revision cohort (p < 0.01 for MHHS, SF-12, and VAS values). Good/excellent results were achieved in 81.7% of the primary cohort and 62.7% of the revision cohort (p < 0.01). The authors reported that capsular plication (p = 0.032), greater post-operative head-neck offset (p = 0.024), sub-spine/anterior inferior iliac spine (AIIS) decompression (p = 0.014), and labral repair/reconstruction (p = 0.009) were significant predictors for better outcomes after revision surgery.
Bedi and colleagues (2011) noted that advances in the ability to treat various soft-tissue and osseous pathologic conditions of the hip arthroscopically have been predicated on an improved exposure of the pathology of the central, peripheral, and peri-trochanteric compartments. The management of the capsule is critical and must allow for improved exposure without compromising stability and kinematics of the hip. Described approaches have included capsulectomy, limited capsulotomy, extensile capsulotomy, capsular plication, and capsular shift. The selected approach must consider various factors, including symptomatic complaints, underlying hyper-laxity, specific mechanical pathology, and surgical expertise. Universally using a single technique without consideration of the complex mechanical and anatomic factors unique to each patient may result in incomplete treatment of the pathoanatomy or iatrogenic instability.
- capsulotomy or capsulectomy without closure,
- capsulotomy with closure, and
- capsular plication.
Two independent reviewers performed a systematic review of the literature using PubMed and the reference lists of related articles by means of defined search terms. Relevant studies were included if these criteria were met:
- written in English,
- Levels of Evidence I to V,
- focus on capsule and its role in hip stability, and
- human studies and reviews.
Articles were excluded if they evaluated
- total hip arthroplasty constructs using bony procedures or prosthetic revision,
- developmental dysplasia of the hip where re-orientation osteotomies were used,
- syndromic instability, and
- traumatic instability with associated bony injury.
By use of the search method described, a total of 5,085 publications were reviewed, of which 47 met appropriate criteria for inclusion in this review. Within this selection group, there were multiple publications that specifically addressed more than 1 of the inclusion criteria. Relevant literature was organized into the following areas:
- capsular anatomy, biomechanics, and physiology;
- the role of the capsule in total hip arthroplasty stability;
- the role of the capsule in native hip stability; and
- atraumatic instability and capsulorrhaphy.
The authors concluded that as the capsule-ligamentous stabilizers of the hip continue to be studied, and their role defined, arthroscopic hip surgeons should become facile with arthroscopic repair or plication techniques to restore proper capsular integrity and tension when indicated.
In a cohort study, Skendzel et al. (2014) determined if patients with narrow joint spaces had inferior outcomes at a post-operative minimum of 5 years and if they had a higher conversion rate to total hip arthroplasty (THA). The hypothesis was that patients with less than or equal to 2-mm joint spaces would report inferior outcomes and that patients with greater than 2-mm joint spaces would have improved survivorship (no conversion to THA). Between March 2005 and January 2008, prospectively collected data were analyzed for patients older than 18 years of age undergoing hip arthroscopic surgery for FAI. Radiographic measurements of joint space were collected, and hips were grouped as having preserved (greater than 2 mm) or limited (less than or equal to 2 mm) joint space. Outcome measures included the WOMAC, MHHS, HOS for activities of daily living (ADL) and sports-specific (HOS-ADL and HOS-SS), and SF-12. There were 559 patients in this study, and 466 (83%) were contacted: 54 patients with limited joint spaces (86%) converted to THA, while only 63 patients with preserved joint spaces (16%) converted to THA. The mean survival time for patients with preserved joint spaces was 88 months (95% CI: 85 to 91 months), and the mean survival time for patients with limited joint spaces was 40.0 months (95% CI: 33.7 to 46.3 months) (p = 0.0001). Complete follow-up outcome data were available on 323 patients, none of whom had THA, with a mean follow-up of 73 months. The mean post-operative HOS for ADL and sports were significantly better in patients with preserved joint spaces (82 versus 62 [p = 0.012] and 77 versus 47 [p = 0.003], respectively) compared with those with limited joint spaces at a mean of 73 months post-operatively (range of 60 to 97 months). The authors concluded that hip arthroscopic surgery for FAI resulted in significantly better outcomes and activity levels at minimum 5-year follow-up in patients with preserved joint spaces. Hips with limited joint spaces converted to THA earlier than did those with preserved joint spaces.
Frank et al. (2014) noted that hip capsular management after hip arthroscopic surgery for FAI is controversial. These researchers compared the clinical outcomes of patients undergoing hip arthroscopic surgery for FAI with T-capsulotomy with partial capsular repair (PR; closed vertical incision, open inter-portal incision) versus complete capsular repair (CR; full closure of both incisions). The hypothesis was that there would be improved clinical outcomes in patients undergoing CR compared with those undergoing PR. Consecutive patients undergoing hip arthroscopic surgery for FAI by a single fellowship-trained surgeon from January 2011 to January 2012 were prospectively collected and analyzed. Inclusion criteria included all patients between ages 16 and 65 years with physical examination and radiographic findings consistent with symptomatic FAI, with a minimum 2-year follow-up. For analysis, patients were matched according to sex and age ± 2 years. Primary clinical outcomes were measured via the HOS-ADL and HOS-SS subscales, the MHHS, patient satisfaction (measured on a visual analog scale [VAS]), and clinical improvement at baseline, 6 months, 1 year, and 2 years. Statistical analysis was performed utilizing Student paired and unpaired t-tests, with p < 0.05 considered significant. A total of 64 patients were included in the study, with 32 patients (12 males, 20 females) in each group. The average follow-up was 29.9 ± 2.6 months. There were no significant demographic differences between the groups. The CR group demonstrated significantly superior outcomes in the HOS-SS at 6 months (PR: 63.8 ± 31.1 versus CR: 72.2 ± 16.1; p = 0.039), 1 year (PR: 72.7 ± 14.7 versus CR: 82.5 ± 10.7; p = 0.006), and 2.5 years (PR: 83.6 ± 9.6 versus CR: 87.3 ± 8.3; p < 0.0001) after surgery. Patient satisfaction at final follow-up was significantly better in the CR group (PR: 8.4 ± 1.0 versus CR: 8.6 ± 1.1; p = 0.025). Both groups demonstrated significant improvements in the HOS-ADL (PR: 64.6 ± 17.0 to 90.7 ± 8.4 [p < 0.0001]; CR: 66.1 ± 15.7 to 92.1 ± 7.9 [p < 0.0001]) and HOS-SS (PR: 39.4 ± 23.9 to 83.6 ± 9.6 [p < 0.0001]; CR: 39.1 ± 24.2 to 87.3 ± 8.3 [p < 0.0001]) at final follow-up. There were no significant differences between the groups in the HOS-ADL at any time point. There were no significant differences in the MHHS between the groups at final follow-up (PR: 82.5 ± 5.0 versus CR: 83.0 ± 4.4; p = 0.364). The overall revision rate was 6.25%; all patients (n = 4) who required revision arthroscopic surgery were in the PR group (13% of 32 patients), while no patients in the CR group required revision surgery. The authors concluded that while significant improvements were seen at 6 months, 1 year, and 2.5 years of follow-up regardless of the closure technique, patients who underwent CR of the hip capsule demonstrated superior sport-specific outcomes compared with those undergoing PR. There was a 13% revision rate in the PR group, but no patients in the CR group required revision surgery. They stated that while longer-term outcome studies are needed to determine if these results are maintained over time, these data suggested improved outcomes after CR compared with PR at 2.5 years after hip arthroscopic surgery for FAI.
This study provided Level 3 evidence. The authors stated that "This study had several limitations, including its retrospective nature and relatively short-term follow-up period of 29.9 months. In addition, the outcome instruments utilized in this study, including the MHHS and HOS, represent limitations to this study. The MHHS is limited because of its ceiling effects, as it was initially designed as a disease-specific score for hip osteoarthritis. Although a validated hip-specific outcome instrument, the HOS is limited, as it is a patient-reported outcome score but not patient-derived. The authors currently use validated hip-specific outcome scores such as the International Hip Outcome Tool (iHOT-12, iHOT-33); however, these data were not used at the time of data collection for the present study. The other potential limitation is that PR was performed initially, and then the senior author (S.J.N.) transitioned to CR, which may suggest an improvement in the overall surgical technique. The transition happened over a relatively short period of time, and no other variables were introduced in the surgical technique. As noted by multiple authors, the suggested learning curve for competency in hip arthroscopic surgery is 30 cases, and as the senior author had performed over 500 hip arthroscopic procedures before the initiation of this study, a learning curve was likely not a relevant factor in the overall outcomes found in this study. The patient characteristics and procedures performed were similar in both groups, including operative duration, and the only difference was the status of the closure. As noted, over this time period, patients were only included in the study after meeting strict inclusion/exclusion criteria, with the goal of eliminating variables that may have confounded the results; however, this may have resulted in selection bias. This study also had several strengths, including the use of age- and sex-matched study groups, the use of multiple validated hip-specific outcome scores, and the use of both 6-month and 1-year data for all patients, allowing for comparisons and trending of outcomes over time. Overall, this is the first study to directly compare partial capsular closure to complete capsular closure after hip arthroscopic surgery for FAI in age- and sex-matched cohorts. Utilizing these preliminary short-term outcome data, the authors recommend performing complete capsular closure in all appropriate patients undergoing hip arthroscopic surgery for FAI. Future long-term studies are needed to determine if these results are maintained over time."
Wang and colleagues (2021) stated that it remains controversial whether abnormal femoral version (FV) affects the outcomes of hip arthroscopic surgery for FAI or labral tears. In a systematic review, these researchers examined the outcomes of hip arthroscopic surgery for FAI or labral tears in patients with normal versus abnormal FV. Embase, PubMed, and the Cochrane Library were searched in July 2020 for studies reporting the outcomes after primary hip arthroscopic surgery for FAI or labral tears in patients with femoral retroversion (less than 5°), femoral anteversion (greater than 20°), or normal FV (5° to 20°). The primary outcome was the MHHS, and secondary outcomes were the VAS for pain, HOS-SSS, NAHS, failure rate, and patient satisfaction. The difference in pre-operative and post-operative scores (Δ) was also calculated when applicable. Included in this review were 5 studies with 822 patients who underwent hip arthroscopic surgery for FAI or labral tears; there were 166 patients with retroversion, 512 patients with normal version, and 144 patients with anteversion. Patients with retroversion and normal version had similar post-operative MHHS scores (MD, 2.42 [95% CI: -3.42 to 8.26]; p = 0.42) and ΔmHHS scores (MD, -0.70 [96% CI: -8.56 to 7.15]; p = 0.86). Likewise, the patients with anteversion and normal version had similar post-operative MHHS scores (MD, -3.09 [95% CI: -7.66 to 1.48]; p = 0.18) and ΔmHHS scores (MD, -1.92 [95% CI: -6.18 to 2.34]; p = 0.38). Regarding secondary outcomes, patients with retroversion and anteversion had similar ΔNAHS scores, ΔHOS-SSS scores, ΔVAS scores, patient satisfaction, and failure rates to those with normal version, although a significant difference was found between the patients with retroversion and normal version regarding post-operative NAHS scores (MD, 5.96 [95% CI: 1.66 to 10.26]; p = 0.007) and post-operative HOS-SSS scores (MD, 7.32 [95% CI: 0.19 to 14.44]; p = 0.04). The authors concluded that the findings of this review indicated that abnormal FV did not significantly influence outcomes after hip arthroscopic surgery for FAI or labral tears. Moreover, these researchers stated that a higher level of evidence is still needed to support these findings. Level of Evidence = IV.
The authors stated that this systematic review had several drawbacks. First, considering that Botser et al. (2012) found an MD of 8.9° for FV between CT and MRI measurements, FV evaluated using different techniques in this review might result in a difference in FV values. Second, the various definitions of the proximal femoral axis in the studies might also have led to different FV values. Third, some of the data used for meta-analysis were calculated based on estimation, and the data on each FV group remained limited, which could also have introduced uncertainty into the pooled outcomes. Fourth, although no significant difference was found in radiographic data, the majority of radiographic findings were from the study by Hartigan et al. (2017), which only included 59 patients each in the normal version and retroversion groups. Fifth, the percentage of patients who underwent the same surgical procedures was different among the included studies, which might have introduced heterogeneity to the outcomes.
Ferreira and associates (2021) stated that previous systematic reviews examining outcomes of hip arthroscopic surgery have reported meaningful improvements in patient outcomes and low complication rates. However, these conclusions were based upon a series of small observational studies. The ability of observational studies to provide a true estimate of the effect of hip arthroscopic surgery for FAI is limited; randomized controlled trials (RCTs) are needed to establish whether hip arthroscopic surgery is effective. Owing to the marked increase in the number of hip arthroscopies, there is a need to summarize evidence from RCTs on the effectiveness of hip arthroscopic surgery for patients with FAI. In a systematic review with meta-analysis, these researchers examined the effectiveness of hip arthroscopic surgery for the treatment of FAI. They carried out electronic database searches in Medline, Embase, SPORTDiscus, CINAHL, Cochrane Central Register for Controlled Trials (CENTRAL), Web of Science, Scopus, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov from their inception to July 10, 2019. These investigators included RCTs comparing hip arthroscopic surgery to a placebo/sham surgery and other non-operative comparators (e.g., no intervention, physiotherapy, etc.). Two authors independently selected studies, rated risk of bias, extracted data, and judged overall certainty of evidence using GRADE. Hip-specific quality of life (QOL) at 12 months was the primary outcome. They identified 3 RCTs (n = 650 participants). There was high certainty evidence from 3 RCTs (n = 574 participants) that hip arthroscopic surgery provided superior outcomes compared to non-operative care for hip-specific QOL at 12 months (MD: 11.02 points, 95% CI: 4.83 to 17.21). Low-quality evidence suggested that arthroscopic surgery provided similar outcomes to non-operative care for hip-specific QOL at 24 months (MD: 6.3, 95% CI: -6.1 to 18.7). The authors concluded that hip arthroscopic surgery for FAI provided superior outcomes compared to non-operative care at 12 months, but not at 24 months. Moreover, these researchers stated that although hip arthroscopic surgery provided superior outcomes to non-operative care, it is possible that it is not superior to a placebo; therefore, placebo-controlled trials are urgently needed to determine the efficacy of hip arthroscopic surgery.
In a systematic review and meta-analysis, Bastos and co-workers (2021) examined the effects of surgical treatment compared to conservative treatment in FAI syndrome in the short-, medium-, and long-term. The following databases were searched on September 14, 2020: Medline, Embase, CENTRAL, Web of Science, and PEDro. There were no date or language limits. The methodological quality assessment was performed using the PEDro scale, and the quality of the evidence followed the GRADE recommendation. The outcomes pain, disability, and adverse effects were extracted. Of 6,264 initial studies, 3 met the full-text inclusion criteria. All studies were of good methodological quality. Follow-up ranged from 6 months to 2 years, with 650 participants in total. The meta-analyses found no difference in disability between surgical versus conservative treatment, with a mean difference (MD) between groups of 3.91 points (95% CI: -2.19 to 10.01) at 6 months, MD of 5.53 points (95% CI: -3.11 to 14.16) at 12 months, and 3.8 points (95% CI: -6.0 to 13.6) at 24 months. The quality of the evidence (GRADE) varied from moderate to low across all comparisons. The authors concluded that there is moderate-quality evidence that surgical treatment is not superior to conservative treatment for FAI syndrome in the short term, and there is low-quality evidence that it is not superior in the medium term. Level of Evidence = Ia.
Labral Reconstruction for the Treatment of Femoro-Acetabular Impingement Syndrome
Boykin and colleagues (2013) stated that FAI has been well characterized as a cause of hip pain and resultant damage to the acetabular labrum. It has become increasingly clear that an intact labrum is essential for normal joint mechanics, hip stability, and preservation of the articular cartilage. Elite athletes with a hypoplastic or irreparable labrum present a difficult clinical challenge. In a case-series study, these researchers assessed clinical outcomes and determined if elite athletes are able to return to a high level of function and sport after labral reconstruction. They performed a retrospective review of a prospectively collected registry that identified 21 elite athletes (23 hips) with an average age of 28.0 years (range of 19 to 41 years) who underwent an arthroscopic ilio-tibial band labral reconstruction. Concomitant procedures included femoral and acetabular osteoplasty in all patients and micro-fracture in 9 of 23 hips. Clinical outcomes were assessed with the MHHS, HOS, the SF-12, and patient satisfaction (on a scale from 1 to 10). Return to play was determined, as well as the level of return to play, based on sport-specific statistics. Two patients progressed to arthroplasty. There were 2 revisions in this group of patients, both for lysis of capsulo-labral adhesions in which the graft was found to be well integrated at the time of surgery. The rate of return to play was 85.7% (18/21), with 81% (17/21) returning to a similar level. Subjective follow-up was obtained from 17 of the remaining 19 patients (89%), with an average follow-up of 41.4 months (range of 20 to 74 months). The average MHHS improved from 67 to 84 (p = 0.026) and the average HOS Sport sub-score from 56 to 77 (p = 0.009). The overall median patient satisfaction with outcome was 8.2 (range of 3 to 10). The authors concluded that arthroscopic labral reconstruction using an ipsilateral ilio-tibial band autograft provided good short-term clinical outcomes, high patient satisfaction, and a satisfactory level of return to play in a select group of elite athletes. This was a small (n = 21), retrospective study with short-term (average of 41.4 months) results. Level of Evidence = IV.
In a cohort study, Domb et al. (2014) compared the clinical outcomes of arthroscopic labral reconstruction (RECON) with those of arthroscopic segmental labral resection (RESEC) in patients with FAI of the hip. Between April 2010 and March 2011, all prospectively gathered data for patients with FAI who underwent arthroscopic acetabular labral reconstruction or segmental resection with a minimum 2-year follow-up were reviewed. A total of 11 cases in the RECON group were matched to 22 cases in the RESEC group according to the preoperative Non-Arthritic Hip Score (NAHS) and sex. The patient-reported outcome scores (PROs) used included the NAHS, the HOS, and the MHHS. Statistical analyses were performed to compare the change in PROs in both groups. There was no statistically significant difference between groups regarding the pre-operative NAHS (p = 0.697), any of the other pre-operative PROs, or demographic and radiographic data. The mean change in the NAHS was 24.8 ± 16.0 in the RECON group and 12.5 ± 16.0 in the RESEC group. The mean change in the HOS-activities of daily living (HOS-ADL) was 21.7 ± 16.5 in the RECON group and 9.5 ± 15.5 in the RESEC group. Comparison of the amount of change between groups showed greater improvement in the NAHS and HOS-ADL for the RECON group (p = 0.046 and 0.045, respectively). There was no statistically significant difference in the mean changes in the rest of the PROs, although there were trends in all in favor of the RECON group. All PROs in both groups showed a statistically significant improvement at follow-up compared with pre-operative levels. The authors concluded that arthroscopic labral reconstruction is an effective and safe procedure that provided good short-term clinical outcomes in hips with insufficient and non-functional labra in the setting of FAI. Again, this was a small (n = 11) study with short-term (minimum of 2 years) results. Level of Evidence = III.
In a systematic review, Ayeni et al. (2014) explored and identified the reported indications and outcomes in patients who undergo labral reconstruction of the hip joint. The electronic databases Embase, Medline, and PubMed were searched for all available dates up to July 2013. A further hand search of the reference sections of the included studies was done. Two reviewers searched, screened, and evaluated the included studies for data quality using the Methodological Index for Non-Randomized Studies (MINORS) Scale. Data were also abstracted in duplicate, and agreement and descriptive statistics were presented. There were 5 eligible studies (3 case series, 1 prospective cohort, and 1 retrospective chart review) with a total of 128 patients, and an average 11/16 quality on the MINORS score included in this review. All patients were diagnosed with FAI and underwent labral reconstruction; 94 patients were assessed at follow-up (73.4% survivorship) between a reported mean range of 10 and 49 months. There was variability between the studies with regard to the graft types utilized (ilio-tibial band, Gracilis tendon, Ligamentum teres), surgical approaches [open (18.7%) versus arthroscopic (81.3%)], and the reported outcome measures. Overall, improvement was observed in the PROs and functional scores (MHHS, HOS, UCLA, NASH, and SF-12). The failure rate or conversion to THA rate in all available patients was 20%. The most common indication for labrum reconstruction was a young, active patient with minimal arthritis and a non-salvageable or deficient labrum. Other indications included instability, pain, and hypotrophic dysfunctional labrum. The authors concluded that based on the current available evidence, hip labrum reconstruction is a new technique that shows short-term improvement in PROs and functional scores post-operatively. The main indication for reconstruction was a deficient labrum due to previous surgical excision or irreparable tears in young patients with no significant arthritis. They stated that long-term follow-up results with higher quality studies are still lacking based on this review.
White and Herzog (2015) stated that in the last 10 years, the understanding of the anatomy and function of the hip joint has continuously evolved, and surgical options for the hip have significantly progressed. Originally, surgical treatment of the hip primarily involved resection of damaged tissue. Procedures that maintain and preserve proper hip anatomy, such as labral repair and femoro-acetabular impingement (FAI) correction, have shown superior results in terms of pain reduction, increased function, and ability to return to activities. Labral reconstruction is a therapeutic option that uses a graft to reconstruct the native labrum. The technique and outcomes of labral reconstruction have been described relatively recently, and labral reconstruction is a cutting-edge procedure that has shown promising early outcomes. These investigators reviewed the literature on hip labral reconstruction. They examined the indications for labral reconstruction, surgical technique and graft options, and surgical outcomes that have been described to date. The authors concluded that labral reconstruction provided an alternative therapeutic option for challenging intra-articular hip problems; it restored the original anatomy of the hip and has the potential to preserve the longevity of the hip joint. This technique is an important tool in the orthopedic surgeon’s arsenal for hip joint treatment and preservation. Moreover, these researchers stated that long-term outcomes are needed to ascertain the longevity of this procedure.
White et al. (2016) presented minimum 2-year outcomes in patients who underwent a modified technique for arthroscopic labral reconstruction using ilio-tibial band allograft tissue and a front-to-back fixation. From April 2011 to July 2012, all consecutive arthroscopic labral reconstruction patients were included in this Institutional Review Board-approved, prospective case-series study. Inclusion criteria were arthroscopic ilio-tibial band allograft labral reconstruction performed by a single surgeon, age greater than or equal to 16 years at the time of arthroscopy, and a minimum of 2 years of follow-up. Patients completed subjective questionnaires both pre-operatively and post-operatively, including MHHS, the Lower Extremity Function Score (LEFS), VAS pain scores, and patient satisfaction. A modified front-to-back fixation technique for labral reconstruction was used. A total of 152 hips (142 patients) met the inclusion criteria for this study; 131 hips (86.2%) had complete follow-up at a minimum of 2 years, and 21 hips (13.8%) were lost to follow-up or had incomplete data during the study period; 70 hips had concomitant procedures performed: 27 microfracture, 30 chondroplasty, 26 psoas release, 5 os acetabuli resection, and 3 Ganz osteotomy. Overall, 18 hips (13.7%) required revision procedures at a mean of 17 months (range of 1 to 37) after the labral reconstruction. In the remaining 113 hips, there was significant improvement in all outcome measures from pre-operative to most recent follow-up (p < 0.0001). The mean MHHS improved by 34 points (p < 0.0001), and the mean LEFS improved by 27 points (p < 0.0001). The mean VAS pain score improved by 3 points at rest (p < 0.0001), 4 points with average pain with daily activities (p < 0.0001), and 5 points with sport (p < 0.0001). Patients reported an overall satisfaction of 9 (range of 1 to 10). The authors concluded that arthroscopic ilio-tibial band allograft labral reconstruction of the hip showed promising outcomes at minimum 2-year follow-up. Level of Evidence = IV.
Khan et al. (2016) provided a comprehensive review and summary of the research published in Arthroscopy: The Journal of Arthroscopic and Related Surgery and The American Journal of Sports Medicine (AJSM) related to hip arthroscopy for FAI. A comprehensive review was conducted in duplicate of Arthroscopy and AJSM from February 2012 to February 2015 for all articles related to FAI, and a quality assessment was completed for all included studies. Clinical outcomes were dichotomized into short-term (less than 6 months) and mid-term (less than 24 months) outcomes, and values were pooled when possible. These researchers identified 60 studies in Arthroscopy and 44 studies in AJSM, primarily from North America (78.8%), that predominantly assessed clinical outcomes after arthroscopic hip surgery (46.1%); 71% of Arthroscopy studies and 20.5% of AJSM studies were Level IV evidence. The MHHS was used by 81.5% of included studies. Pooled weighted mean MHHS values after arthroscopic surgery for FAI showed improvements at the mid-term from 60.5 points (range of 56.6 to 83.6) to 80.5 points (range of 72.1 to 98.0) out of a possible 100 points. Pooled weighted outcomes for labral repair showed mean MHHS improvements from 63.8 points (range of 62.5 to 69.0) pre-operatively to 86.9 points (range of 85.5 to 89.9) up to 24 months post-operatively. The authors concluded that this comprehensive review of research published in Arthroscopy and AJSM over the past 3 years identified a number of key findings. Arthroscopic intervention resulted in improvements in functional outcomes at both the short-term and mid-term for patients with symptomatic FAI in the absence of significant existing degenerative changes. They stated that labral repair may result in improvements over labral debridement. The most commonly used outcome score was the MHHS for objective assessment of surgical success. They stated that there is a need for continued focus on improvement of methodological quality and reporting of research pertaining to FAI.
Rathi and Mazek (2017) conducted a retrospective study to evaluate the clinical effectiveness of arthroscopic acetabular labral reconstruction using fascia lata allograft. The study included 10 patients who underwent the procedure between January 2013 and October 2015, with a minimum follow-up of 12 months (mean follow-up 22.9 months). The primary aim was to assess improvements in pain and function, as well as to monitor for complications or the need for subsequent surgical intervention. All patients reported subjective improvement in both pain and functional status postoperatively. The mean modified Harris Hip Score (mHHS) improved significantly from a preoperative average of 58 to a postoperative average of 95. The mean change in mHHS was 36 points, and the average patient satisfaction score was 9.5 out of 10. Importantly, there were no cases of radiographic progression of osteoarthritis, and none of the patients required revision surgery or conversion to total hip arthroplasty during the follow-up period. The authors concluded that arthroscopic labral reconstruction using fascia lata allograft is a safe and effective technique that yields excellent short-term clinical outcomes. Moreover, by restoring the labral seal, the procedure may help preserve joint integrity and prevent further cartilage degeneration in patients with deficient or previously resected labral tissue. This study is limited by several methodological factors that constrain its interpretability and generalizability. Most notably, the study features a small sample size, which reduces statistical power and limits the ability to detect subtle differences or perform subgroup analyses. The follow-up duration, while meeting a minimum one-year threshold, is relatively short for assessing long-term graft durability, joint preservation, or progression to arthroplasty. Additionally, the absence of a control group—such as patients undergoing labral repair or alternative reconstruction techniques—precludes comparative analysis and weakens the strength of the conclusions. The study design is retrospective and single-center, introducing potential selection bias and limiting external validity. Furthermore, the authors did not stratify outcomes based on variables such as degree of chondral damage, capsular management, or patient activity level, all of which may significantly influence postoperative recovery and functional outcomes.
Carreira et al. (2018) investigated the clinical efficacy of arthroscopic acetabular labral reconstruction using a fascia lata allograft introduced via a novel shuttle technique. The primary objective was to describe this technique and evaluate its outcomes at a minimum of two years postoperatively. The shuttle method facilitates graft delivery and fixation without requiring intra-articular manipulation of the free graft end, potentially simplifying the procedure and reducing technical demands. From a cohort of 693 hip arthroscopies performed between 2010 and 2014, 34 patients met inclusion criteria for labral reconstruction using this technique. At a minimum two-year follow-up, 91.2% of patients were available for evaluation. Among these, 12.9% eventually converted to total hip arthroplasty at an average of 27.9 months postoperatively. For the remaining patients, statistically significant improvements were observed across multiple validated outcome measures: the modified Harris Hip Score (mHHS) improved from 64.0 to 84.6, SF-12 Physical from 38.9 to 49.0, SF-12 Mental from 49.5 to 55.6, iHOT-12 from 36.4 to 68.1, HOS-ADL from 62.6 to 81.6, and HOS-Sports Subscale from 32.9 to 65.7. The study concluded that arthroscopic labral reconstruction using a fascia lata allograft and shuttle technique is a safe and effective option for managing irreparable labral pathology, yielding durable improvements in function and quality of life at two years. No major adverse events were reported, and outcomes were comparable to other labral reconstruction cohorts despite the presence of concomitant intra-articular pathology. The study presents several drawbacks that temper the strength of its conclusions. The relatively small sample size of 34 patients limits the statistical power and generalizability of the findings, particularly when considering the heterogeneity of hip pathology and patient demographics. Although the study reports favorable outcomes at a minimum two-year follow-up, this duration is insufficient to assess long-term graft durability, joint preservation, or progression to total hip arthroplasty. The absence of a control group—such as patients undergoing labral repair or alternative reconstruction techniques—precludes direct comparison and limits the ability to attribute observed improvements solely to the shuttle technique or graft choice. Additionally, the study does not stratify outcomes based on key variables such as degree of chondral damage, capsular management, or patient activity level, all of which may significantly influence postoperative recovery and functional outcomes. Finally, as a single-center study, the results may reflect institutional or surgeon-specific practices that are not broadly applicable.
In a systematic review, Trivedi and colleagues (2019) examined the evidence for the current indications and outcomes of arthroscopic labral reconstruction of the hip; the secondary objective was to assess the role of arthroscopic labral reconstruction in the management of reparable labral tears. The systematic review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using a PRISMA checklist. Studies published between June 2009 and June 2018 that examined outcomes after arthroscopic labral reconstruction with a minimum of 1 year of follow-up were included. A total of 11 studies met the inclusion and exclusion criteria, and 373 patients were identified. Of the 11 studies, 9 reported that an irreparable labrum was their indication for reconstruction, with 8 reporting that this was ultimately determined intra-operatively. Substantial variability in surgical technique, graft choice, and concurrent pathology was found. All 11 studies used at least 1 validated functional outcome metric to assess surgical outcomes, with all studies reporting improvement greater than the minimal clinically important difference. Donor-site pain was the most common complication, although it was reported in only 2 studies. Reported rates of revision surgery and conversion to arthroplasty were low (range of 0% to 9.1% for both). The authors concluded that all 11 studies included in this systematic review reported clinically significant functional improvements after arthroscopic labral reconstruction and low rates of complications, revision surgery, and progression of arthritis, although graft types and concomitant procedures confounded the findings. The most common indication for reconstruction was a deficient labrum on intra-operative evaluation. The 6 studies that examined patient satisfaction reported favorable results, with a range of 6.73 to 8.7. Level of Evidence = IV.
The systematic review is constrained by several methodological limitations inherent to the included literature. Most notably, the majority of the studies reviewed were Level IV case series, lacking control groups and randomization, which limits the strength of the evidence and precludes definitive conclusions regarding efficacy. There was substantial heterogeneity across studies in terms of surgical technique, graft type, patient selection criteria, and outcome measures, making direct comparisons difficult and reducing the internal validity of the review. Additionally, the follow-up duration varied widely, with many studies reporting only short- to midterm outcomes, thereby limiting insight into long-term joint preservation and durability of reconstruction. The review also did not perform a meta-analysis, which could have provided quantitative synthesis and strengthened the statistical interpretation of pooled outcomes. Finally, the lack of standardized definitions for terms like “irreparable labrum” or “poor tissue quality” also introduces variability in interpretation.
Domb and co-workers (2019) stated that labral reconstruction has demonstrated short-term benefit for the treatment of irreparable labral tears. Nonetheless, there is a scarcity of evidence for mid-term outcomes of this treatment. In a cohort study, these researchers hypothesized that arthroscopic segmental reconstruction in the setting of irreparable labral tears would show improvement in PROs and high patient satisfaction at minimum 5-year follow-up. They also hypothesized that primary labral reconstruction (PLRECON) would result in similar improvement in PROs at minimum 5-year follow-up when compared with a matched-pair primary labral repair (PLREPAIR) control group. Data from February 2008 to April 2013 were retrospectively reviewed. Patients were included if they underwent hip arthroscopy for segmental labral reconstruction in the setting of irreparable labral tear and FAI, with minimum 5-year follow-up for mHHS, NAHS, HOS-SS, patient satisfaction, and VAS for pain. Exclusion criteria were Tonnis OA grade of greater than 1, prior hip conditions, or workers' compensation claims. PLRECON cases were matched in a 1:3 ratio to a PLREPAIR control group based on age ± 5 years, sex, and BMI ± 5 kg/m². A total of 28 patients were eligible for the study, of which 23 (82.14%) had minimum 5-year follow-up. These investigators found significant improvement from pre-operative to latest follow-up in all outcome measures recorded: 17.8-point increase in mHHS (p = 0.002), 22-point increase in NAHS (p < 0.001), 25.4-point increase in HOS-SS (p = 0.003), and a 2.9-point decrease in VAS pain ratings (p < 0.001). Mean patient satisfaction was 7.1 out of 10. In the nested matched-pair analysis, 17 patients who underwent PLRECON were matched to a control group of 51 patients who underwent PLREPAIR. PLRECON demonstrated comparable survivorship and comparable improvements in all PROs with the exception of patient satisfaction (6.7 versus 8.5, p = 0.04). The authors concluded that hip arthroscopy with segmental labral reconstruction resulted in significant improvement in PROs at minimum 5-year follow-up. PLRECON reached comparable functional outcomes when compared with a benchmark PLREPAIR control group but demonstrated lower patient satisfaction at latest follow-up. Level of Evidence = III.
The authors stated that this study had several drawbacks. First, it was based on a former segmental labral reconstruction technique, and these investigators had since employed a novel and likely far superior reconstruction technique. Second, although these researchers employed a matched-pair study design, this trial was non-randomized. As such, confounding variables may have influenced these findings. Third, this study was also retrospective, which introduced some bias; however, this bias was limited given the prospective collection of all data. Fourth, analysis was based on a single high-volume surgeon who specialized in hip preservation, which limited the generalizability of these findings. Longer follow-up is also needed to determine the durability of these findings. Fifth, the decision between labral reconstruction and repair, in both primary and revision cases, was based on the senior author’s expertise, which may have introduced bias. Although no significant differences were found between arthroscopic findings and procedures—with the obvious exception of labral pathology and treatment—these variables were not incorporated into the matching process, thus introducing potential confounding bias. Based on the small sample size for revision reconstruction, sub-analysis in a matched-pair design was not possible for this population of patients. Finally, since conversion to THA was considered an endpoint outcome, post-operative scores for these patients were not included in the PRO analysis.
Maldonado et al. (2019) conducted a consensus study aimed at delineating the current practices and preferences among high-volume hip arthroscopists regarding labral reconstruction. The objective was to clarify indications, graft selection, and surgical techniques used in both primary and revision hip arthroscopy. The study surveyed 12 surgeons who each performed between 50 and 5000 hip arthroscopies annually. The findings revealed that labral reconstruction was generally not recommended in primary cases unless the native labrum was deemed irreparable due to factors such as hypoplasia, calcification, or poor tissue quality. In contrast, all respondents endorsed reconstruction over debridement in revision settings. Regarding graft selection, the overwhelming majority (91.7%) preferred allografts over autografts. Segmental reconstruction was favored over circumferential approaches, and most surgeons opted to excise the native labrum rather than augment it. This study highlights a strong consensus among experienced surgeons that labral reconstruction plays a critical role in restoring hip joint function when the native labrum is unsalvageable, particularly in revision procedures.
This study had a number of drawbacks. As a consensus-based survey study, its findings are inherently subjective, relying on the opinions and clinical preferences of a small group of 12 high-volume hip arthroscopists. This limited sample size restricts the generalizability of the conclusions, as the perspectives may not reflect broader surgical practices or those of lower-volume or less specialized surgeons. Additionally, the study does not incorporate clinical outcome data, making it impossible to correlate the reported preferences with patient-centered results such as functional improvement or complication rates. The absence of standardized definitions for terms like “irreparable labrum” or “poor tissue quality” also introduces variability in interpretation. Finally, the cross-sectional design captures a snapshot in time and may not account for evolving techniques or shifting paradigms in labral preservation versus reconstruction.
Al Mana et al. (2019) presented an updated systematic review of the indications and outcomes of open and arthroscopic labral reconstruction. Due to the increasing popularity and recognition of the arthroscopic procedure in recent years, these investigators examined changes in indications, graft selection, and improvement in outcomes within the last 5 years. A total of 9 eligible studies (6 case series, 1 cohort, and 2 retrospective comparative studies) with a total of 234 patients (265 hips), and an average 12/16 (non-comparative studies) and 20/24 (comparative studies) quality on the MINORS score were included in this review. All patients underwent labral reconstruction, whether as primary surgery or revision (76% versus 24%, respectively). There were 244 hips examined at final follow-up (92%) with a reported mean range of 12 to 61 months. There were more graft variabilities found in this study compared with the previous review (ITB allograft, gracilis tendon autograft, indirect head of rectus femoris autograft, semitendinosus allograft, peroneus brevis allograft, labrum allograft, ligamentum capitis femoris). Surgical approaches differed (open 7.9% [previously 18.7%], arthroscopic 86% [previously 81.3%], arthroscopic assisted mini-open technique [AAMOT] 6%). Overall, improvement was observed in the patient-reported outcomes and functional scores, with variability in their statistical significance. The failure rate or conversion to THA decreased compared with the previous review (20% versus 9.5% [conversion to THA was 5.7% and revision surgery rate was 3.8%]). Indications for labrum reconstruction remained similar (i.e., young, active patients with no or minimal arthritis [Tonnis 0 to 1], irreparable or ossified labrum, and hypotrophic less than 2 mm or dysfunctional hypertrophic labrum greater than 8 mm). According to recent evidence, hip labrum reconstruction is a new technique that showed short- and mid-term improvement in patient-reported outcomes and functional scores postoperatively. The primary indication for reconstruction remained similar over time. The failure rates and/or conversion to THA appeared to have decreased over time. Long-term follow-up with higher quality studies was not available in the literature based on this review. Level of Evidence = II.
The authors stated that this review had several drawbacks. Variation in clinical outcome measures and discrepancies in follow-up durations among studies did not allow for data pooling. The available evidence was also noted to be predominantly observational in design (6 case series, 2 retrospective comparative, and 1 prospective cohort studies), lacking studies with high-quality levels of evidence.
Bessa et al. (2020) noted that the acetabular labrum plays a major role in hip function and stability. The gold standard treatment for labral tears is labral repair, but in cases where tissue is not amenable to repair, reconstruction has been demonstrated to provide superior outcomes compared to debridement. Many types of grafts have been used for reconstruction with good to excellent outcomes. Autograft options include ITB, semitendinosus, and indirect head of the rectus femoris tendon, while allografts have included fascia lata and gracilis tendon allografts. These researchers stated that as allografts are not always readily available and have some inherent disadvantages, they examined indications for labral reconstruction and summarized outcomes, complications, and re-operation rates following arthroscopic labral reconstruction with autografts. They carried out a systematic review of the literature using 6 databases (PubMed, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Google Scholar) to identify studies reporting outcomes for arthroscopic labral reconstruction utilizing autografts, with a minimum follow-up of 1 year. Study design, patient demographics, autograft choice, complications, donor site morbidity, re-operation rates, conversion to THA, and patient-reported outcomes were extracted and reported. A total of 7 studies were identified for inclusion with a total of 402 patients (173 females, age range of 16 to 72; follow-up range of 12 to 120 months). The most commonly reported functional outcome score was the MHHS, which was reported in 6 of 7 studies. Pre-operative MHHS ranged from 56 to 67.3 and improved post-operatively to a range of 81.4 to 97.8. Conversion to THA and re-operation rates ranged from 0 to 13.2% and 0 to 11%, respectively. The most common indication for labral reconstruction was an irreparable labrum. Autografts utilized included ITB, hamstring tendons, indirect head of the rectus femoris, and capsular tissue. The authors concluded that arthroscopic autograft reconstruction of the acetabular labrum resulted in significant improvement in the short- and mid-term patient-reported outcomes for properly selected patients presenting with pain and functional limitation in the hip due to an irreparable labral injury.
The authors stated that the drawbacks of this systematic review included the level of evidence of the retrospective level III and IV studies included, which were also limited to short- and mid-term outcomes of relatively small patient sample sizes. These researchers stated that prospective and randomized trials, with longer follow-up and larger sample sizes, would be preferred for a more comprehensive and reliable assessment of arthroscopic labral reconstructions. Such design, including randomization of graft choice, would permit the comparison of different graft choices and their impact on outcomes and donor site morbidity. Specifically, the most interesting comparisons would be hamstring and ITB grafts with grafts such as the indirect head of the rectus femoris tendon that may be harvested without causing donor-site complications.
Rahl and associates (2020) stated that the acetabular labrum is critical to the maintenance of hip stability and has been found to play a key role in the preservation of the hip fluid seal. For irreparable labral damage, arthroscopic labral reconstruction is an evolving technique that has been shown to decrease hip pain and restore function. In a systematic review and meta-analysis, these investigators provided a comprehensive review of current literature for arthroscopic hip labral reconstruction, with a focus on determining if outcomes differ between autograft or allograft tissue. PubMed and Scopus online databases were searched with the key terms "hip," "labrum," "reconstruction," and "graft" in varying combinations. Procedures performed, complications, failures, and functional outcome measures were included in this analysis. The inverse variance method was used to calculate pooled estimates and 95% confidence intervals (CIs). A total of 8 studies with 537 hips were included. Mean age was 37.4 years (95% CI: 34.5 to 40.4 years), and mean follow-up time was 29 months (95% CI: 26 to 33 months). Survivorship after autograft reconstruction ranged from 75.7% to 100%, as compared with 86.3% to 90.0% in the allograft cohort. In the autograft cohort, failures included 0% to 13.2% conversion to THA and 0% to 11.0% revision hip arthroscopy. Failures in the allograft cohort included 0% to 12.9% THA conversion, 0% to 10.0% revision arthroscopy, and 0% to 0.8% open revision surgery. Based on 6 studies, the mHHS improved by a mean of 29.0 points after labral reconstruction (p < 0.0001). The authors concluded that arthroscopic hip labral reconstruction resulted in clinically significant improvements in patient-reported outcomes (PROs). The findings of this analysis indicated that there are no significant differences in outcomes based on graft type alone. A number of factors may determine graft choice, including patient preference, surgeon experience, operative time, morbidity, and cost. Proper patient selection based on age and severity of degenerative joint disease will also optimize outcomes after labral reconstruction.
The authors stated that this systematic review had several drawbacks. First, the studies had heterogeneous patient populations and lacked control groups. Many patients had previous surgery on the operative hip, and the labral reconstruction often contained concurrent procedures that were highly variable. Second, the total sample size contained in this review was not as robust as other systematic reviews, given the emerging growth of this procedure. A larger patient population would allow for a more conclusive analysis of outcomes. Third, most studies contained in this study were retrospective reviews.
Maldonado et al. (2020) noted that labral reconstruction has been advocated as an alternative to debridement for the treatment of irreparable labral tears, showing favorable short-term results. However, literature is scarce regarding outcomes and return-to-sport in the non-elite athletic population. In a case-series study, these investigators reported minimum 1-year clinical outcomes and the rate of return-to-sport in athletic patients who underwent primary hip arthroscopy with labral reconstruction in the setting of FAI syndrome and irreparable labral tears. Data were prospectively collected and retrospectively analyzed for patients who underwent an arthroscopic labral reconstruction between August 2012 and December 2017. Patients were included if they identified as an athlete (high school, college, recreational, or amateur); had follow-up on the following PROs: mHHS, NAHS, HOS-SS, and VAS; and completed a return-to-sport survey at 1 year post-operatively. Patients were excluded if they underwent any previous ipsilateral hip surgery, had dysplasia, or had prior hip conditions. The proportions of patients who achieved minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for mHHS and HOS-SS were calculated. Statistical significance was set at p = 0.05. There were 32 (14 females) athletes who underwent primary arthroscopic labral reconstruction during the study period. The mean age and BMI of the group were 40.3 years (range of 15.5 to 58.7 years) and 27.9 kg/m² (range of 19.6 to 40.1 kg/m²), respectively. The mean follow-up was 26.4 months (range of 12 to 64.2 months). All patients demonstrated significant improvement in mHHS, NAHS, HOS-SS, and VAS (p < 0.001) at the latest follow-up. Additionally, 84.4% achieved MCID and 81.3% achieved PASS for mHHS, and 87.5% achieved MCID and 75% achieved PASS for HOS-SS. VAS pain scores decreased from 4.4 to 1.8, and the satisfaction with surgery was 7.9 out of 10; the rate of return-to-sport was 78%. The authors concluded that at minimum 1-year follow-up, primary arthroscopic labral reconstruction, in the setting of FAI syndrome and irreparable labral tears, was associated with significant improvement in PROs in athletic populations; return-to-sport within 1 year of surgery was 78%. Level of Evidence = IV.
The authors stated that this study had several drawbacks. First, this was a non-randomized study with no control group. As such, confounding variables may have influenced these findings. Second, the retrospective nature introduced some bias. Third, this study included a single high-volume hip preservation surgeon, which may limit the generalizability of the results, especially since hip arthroscopy and particularly labral reconstruction have been recognized as procedures with steep learning curves. Fourth, the labral treatment decision algorithm was based on the senior author’s expertise, which may have introduced bias. Fifth, some patients who had surgery during this study period did not allow their surgical data to be used in research and statistical analysis, and this omission could have influenced the results. Sixth, this analysis included only patients who indicated participation in sports 1 year prior to surgery. Some athletes who were unable to participate in sports before surgery due to hip pain may have been excluded from analysis, which could have influenced these findings and conclusions. Seventh, as this study analyzed short-term follow-up, long-term studies are needed to examine the durability of the results.
Wu and colleagues (2020) noted that FAI is a common cause of hip pain and even tearing of the acetabular labrum in young adults and athletes; therapeutic options include arthroscopic labral debridement (LD) or labral repair (LR). In a systematic review and meta-analysis, these researchers compared the clinical outcomes of arthroscopic LD versus LR. A total of 5 studies were acquired from PubMed, Medline, Embase, and Cochrane Library. Data were extracted by 2 of the co-authors independently and were analyzed by RevMan 5.3. Mean differences (MDs), odds ratios (ORs), and 95% CIs were calculated. Cochrane Collaboration's Risk of Bias Tool and Newcastle-Ottawa Scale were used to assess risk of bias. A total of 4 observational studies and 1 prospective randomized study were examined. The methodological quality of the trials indicated a low-to-moderate risk of bias. The pooled results of NAHS, failure rate of surgeries, and complications showed that the differences were not statistically significant between the 2 approaches. The difference of mHHS, VAS score, and satisfaction rate was statistically significant between LD and LR intervention, and LR treatment was more effective. Sensitivity analysis proved the stability of the pooled results, and there were too few included articles to verify the publication bias. The authors concluded that hip arthroscopy with either LR or LD was an effective treatment for symptomatic FAI. The difference of mHHS, VAS score, and satisfaction rate was statistically significant between LD and LR, and arthroscopic LR could re-create the suction-seal effect, potentially reduce micro-instability, which demonstrated a trend toward better clinical efficacy and comparable safety compared with LD. The arthroscopic LR technique is recommended as the optimal choice for acetabular labrum tear with FAI. Moreover, these researchers stated that larger, multi-center, high-quality randomized controlled trials (RCTs) with longer follow-up are needed to verify the outcomes of this meta-analysis.
The authors stated that this study had several drawbacks. First, the small sample size might have affected the significant difference between the 2 surgical procedures. Second, the retrospective design and the patient cohorts were not similar because one group had a fixable labrum and the other did not, which may have increased the clinical heterogeneity among trials. Third, this study only included 3 articles for conducting a funnel plot, and the publication bias could not be ignored. Lastly, the included studies were mostly observational studies and not RCTs, and they largely relied on retrospectively collected data, resulting in a high risk of selection bias.
In a case-series study, Scanaliato et al. (2020) determined the return-to-play rates and hip-specific outcomes in athlete hips with FAI syndrome treated with circumferential labral reconstruction (CLR). All consecutive patients who underwent CLR from January through December 2016, performed by the senior surgeon with complete 2-year outcome scores, were identified. The hips of 57 non-athletes who underwent CLR were excluded from analysis, as were 165 patients who underwent labral repair (LR) and 4 patients who underwent labral debridement (LD). Outcome measures were completed by patients within 1 week prior to surgery and between 22 and 26 months post-operatively. A total of 30 patients met the inclusion criteria for this study. They participated in regular, competitive athletic events and had magnetic resonance arthrography (MRA)-confirmed labral tears, and non-surgical measures had failed. Of the 30 patients, 5 (16.7%) participated in cutting sports; 5 (16.7%), asymmetrical or overhead sports; 4 (13.3%), contact sports; 13 (43.3%), endurance sports; and 3 (10.0%), flexibility sports. Moreover, 25 of 30 (83.3%) were high-level athletes; both primary (n = 23) and revision (n = 7) procedures were included. As determined by iHOT-12 score, 28 of 30 patients (93.3%) met PASS, whereas 30 of 30 (100%) achieved substantial clinical benefit and exceeded the MCID for their operative hip. In addition, 23 of 30 patients (76.6%) met PASS, whereas 30 of 30 (100%) achieved substantial clinical benefit and exceeded MCID for the operative hip as determined by the VAS pain score. Of 30 patients, 26 (86.7%) were able to return to play. The mean time to return to play was 6.6 months (standard deviation [SD] of 2.4 months). The authors concluded that the 2-year outcomes in this population of athletes undergoing CLR for FAI syndrome showed a statistically and clinically significant improvement in PROs, a statistically and clinically significant reduction in pain, and an overall return-to-play rate of 86.7%. The Level of Evidence of this study was IV. The study had a number of drawbacks. The sample size was relatively small, with only 30 athletes included, and just 7 undergoing revision procedures, which limits statistical power and the ability to perform robust subgroup analyses. The absence of a control group—such as patients undergoing labral repair or segmental reconstruction—precludes direct comparison and weakens the ability to attribute outcomes specifically to the circumferential technique. Additionally, while return-to-sport rates were reported, the study did not assess sport-specific performance metrics or long-term durability of the reconstruction, which are particularly relevant in athletic populations. The retrospective nature of the data collection also introduces potential for selection and recall bias. Finally, the study did not stratify outcomes based on graft type, degree of chondral damage, or capsular management, all of which may influence postoperative recovery and functional outcomes.
White et al. (2020) examined outcomes of complete, primary, arthroscopic hip labral reconstruction among patients aged 40 years and older compared to primary labral repair and to patients aged 30 to 39 years who underwent complete, primary labral reconstruction. All arthroscopic labral reconstruction patients between March 2010 and June 2015 who were 30 to 65 years old or arthroscopic labral repair (LR) patients between June 2009 and June 2015 who were 40 to 65 years old were recruited; mHHS, LEFS, and VAS for average pain were collected pre-operatively and at minimum 2-year follow-up. Failures were defined as the need for revision ipsilateral hip surgery. The rate of conversion to total hip arthroplasty (THA) (a subset of failures) was assessed separately. A total of 363 hips met the inclusion criteria among 343 patients. Follow-up was available for 312 hips (86.0%), and the average time to follow-up was 4.2 years (range of 2.0 to 8.5 years). After adjusting for differences in follow-up time between groups, hips in the 40+ repair group were 3.29 times more likely to fail than hips in the 40+ reconstruction group (relative risk [RR] = 3.29, 95% CI: 1.25 to 8.69, p = 0.02), and there was no difference in failure rate for hips in the 40+ reconstruction group compared to the 30 to 39 reconstruction group (RR = 0.58, 95% CI: 0.18 to 1.89, p = 0.37). The rate of conversion to THA was not meaningfully different among the 3 groups. Among hips that did not fail treatment, average mHHS improvement was 35 points, and both labral reconstruction groups saw a greater mHHS improvement than 40+ labral repairs (p = 0.01 and p < 0.01). The authors concluded that labral reconstruction led to a lower failure rate, greater average improvement in mHHS, and equivalent post-operative PRO scores compared to LR among patients aged 40 years and older in this cohort, and outcomes of labral reconstruction were similar among patients aged 40 years and older compared to patients aged 30 to 39 years. Complete labral reconstruction may be particularly advantageous in patients aged 40 years and older.
The authors stated that this study had several drawbacks. First, while these researchers adjusted for the differences in follow-up time between treatment groups through the use of a log-Poisson regression model, this model may not adequately control for the impact of calendar time, and by association, the surgeon’s learning curve and changes in operative technology, on the results. There may also be additional confounding variables that were not measured or accounted for in this analysis. Second, it was possible that the 51 hips where follow-up was unavailable had different outcomes than the group for which post-operative outcomes were assessed. Third, the results of this analysis were only generalizable to patients with similar characteristics to the study population, which in this case included patients aged 30 years and older with minimal or no cartilage pathology who had no prior hip procedures. Finally, the results of this study were likely surgeon-specific and may be impacted by surgeon-specific preferences. A single high-volume hip specialist performed all surgeries that were included in this study. It is important to note that labral reconstruction, in particular, is technically demanding and requires proficiency in hip arthroscopy techniques; thus, results may not be generalizable to other patients or other surgeons.
Vap (2020) noted that the surgical treatment of labral deficiency has generated a tremendous amount of discussion and controversy among hip arthroscopists. The surgical reconstruction of the labrum has been viewed as the natural next step, after debridement and repair, in the advancement of the ability to treat patients with hip labral pathology. However, the indications for labral replacement and the profile of patients who would benefit from this complex intervention are still under debate. Every hip arthroscopist must have the technical ability to perform reconstruction when indicated. Repair or debridement does not always achieve the best patient outcome.
Lodhia et al. (2021) provided a comprehensive review of graft options for hip labral reconstruction, focusing on the evolving role of this technique in managing irreparable labral pathology. The authors highlighted the increasing prevalence of hip arthroscopy and the growing recognition of the labrum’s biomechanical importance in maintaining joint stability and fluid pressurization. The review synthesized current evidence on both autograft and allograft use, emphasizing that both options have demonstrated favorable outcomes in restoring native hip biomechanics. Autografts, such as iliotibial band or gracilis tendon, offer the advantage of biological compatibility and intraoperative availability but carry the risk of donor site morbidity. Allografts, including fascia lata and anterior tibialis tendon, eliminate donor site concerns and provide abundant tissue, though they may be limited by cost and availability. The authors noted that recent studies support the use of labral reconstruction not only in revision settings but also in select primary cases where the native labrum is nonfunctional or absent. Ultimately, the choice of graft should be individualized based on patient factors, surgeon experience, and resource availability, with the overarching goal of restoring native hip biomechanics and joint function. This review has several important drawbacks. As a narrative rather than systematic review, the methodology lacks the rigor of predefined inclusion criteria, structured data extraction, and bias assessment, which introduces the potential for selection bias and limits reproducibility. The review aggregates findings from heterogeneous studies that vary widely in surgical technique, graft type, patient demographics, and outcome measures, making direct comparisons difficult and reducing the strength of any generalized conclusions. Furthermore, the absence of quantitative synthesis, such as meta-analysis, precludes statistical evaluation of graft efficacy or complication rates. The review also does not stratify outcomes based on primary versus revision procedures or account for confounding variables such as chondral damage or capsular management. As a result, while the article provides a broad overview of graft options and theoretical considerations, it stops short of offering evidence-based guidance on optimal graft selection or technique.
Jimenez et al. (2021) stated that labral reconstruction has shown promise for the treatment of irreparable labral tears in high-level athletes. The literature is scarce regarding outcomes and timing of return-to-sports (RTS) in these patients. In a cohort study, these investigators reported minimum 2-year PRO scores and RTS characteristics for high-level athletes undergoing primary labral reconstruction for irreparable labral tears and compared clinical results with a matched control group of athletes undergoing labral repair. Data were prospectively collected and retrospectively reviewed for high school, college, and professional athletes who underwent a primary arthroscopic labral reconstruction between January 2010 and June 2018. Minimum 2-year PROs were compared for the mHHS, Nonarthritic Hip Score (NAHS), and Hip Outcome Score-Sport Specific Subscale (HOS-SSS), as well as the VAS pain score, patient satisfaction, and RTS. The percentages of patients achieving the Patient Acceptable Symptom State (PASS) and MCID for the mHHS (PASS, greater than 74 points; MCID, greater than 8 points) and HOS-SSS (PASS, greater than 75 points; MCID, greater than 6 points) were also recorded. These patients were propensity score matched in a 1:3 ratio to other high-level athletes undergoing labral repair. A total of 17 high-level athletes with primary arthroscopic labral reconstruction were included with a median follow-up time of 37.1 months (95% CI: 37.2 to 60.3 months). They demonstrated significant improvement from pre-operatively to the latest follow-up for mHHS, NAHS, HOS-SSS, and VAS for pain (p < 0.05). Furthermore, patients achieved PASS/MCID for mHHS at high rates (PASS, 84.2%; MCID, 68.4%). Athletes were able to RTS-specific training at a median of 3.33 months (95% CI: 3.07 to 4.71 months) and RTS at a median of 6.2 months (95% CI: 5.08 to 11.98 months); 14 (82.4%) of reconstructions and 29 (82.8%) of repairs either RTS or decided not to do so for reasons unrelated to the hip. PROs, RTS rate, and PASS/MCID rates were similar between the labral reconstruction group and a control labral repair group (p > 0.05). The authors concluded that primary arthroscopic labral reconstruction for irreparable labral tears was associated with significant improvement in PROs and high rates of RTS in high-level athletes. These results were comparable with those of a control group of athletes undergoing labral repair. Level of Evidence = III.
In a case-series study, Soares et al. (2022) examined mid-term outcomes of arthroscopic hip labral augmentation for labral insufficiency after previous hip arthroscopy. Patients were identified from a prospectively collected database who underwent arthroscopic hip labral augmentation between January 2011 and January 2017 with a minimum 3-year follow-up. Pre- and post-operative PRO scores were compared and included the 12-Item Short Form Health Survey physical and mental component summaries, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), mHHS, and Hip Outcome Score (HOS) (Activities of Daily Living [ADL] and Sport). Post-operative Tegner Activity Scale and patient satisfaction (1-10) scores were also evaluated. The minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) between the pre-operative and minimum 3-year follow-up scores were calculated. A total of 88 patients (39 men, 49 women) underwent revision hip arthroscopy with labral augmentation. The average age was 32.8 ± 11 years. Of these, 77 patients (88%) were available for the minimum 3-year follow-up. The survivorship (absence of conversion to THA) at 3 years and 5 years was 93% at both time points, with a mean survival time of 8.5 years (95% CI: 8.0 to 8.9); 11 patients (14%) required revision arthroscopic surgery for continued pain. Revisions occurred at a mean of 2.6 ± 1.4 years after augmentation. The mean follow-up was 5.2 ± 1.2 years (range of 3 to 9 years). For patients not requiring subsequent surgery (n = 61), all PRO measures significantly improved, which included a 20-point increase in HOS-ADL (MCID, 82%; PASS, 72%) and mHHS (MCID, 78%; PASS, 70%). The median post-operative Tegner score was 4 (range of 1 to 10). The median post-operative patient satisfaction score was 9 out of 10 (range of 1 to 10). The authors concluded that arthroscopic hip labral augmentation was a successful therapeutic option for patients with labral insufficiency after previous hip arthroscopy, showing improved PROs and survivorship of 93% at 3 years and 5 years. This technique provided a valuable labral preservation option when addressing hip labral pathology when viable native labral tissue remains. Level of Evidence = IV.
Scanaliato et al. (2022) conducted a comparative study evaluating long-term outcomes of primary arthroscopic labral repair versus complete labral reconstruction (CLR) in patients undergoing hip preservation surgery. The primary objective was to assess the durability and efficacy of both techniques at a minimum of five years postoperatively. The study included 84 patients—42 who underwent labral repair and 42 who underwent CLR—matched by age, sex, and body mass index. Notably, the reconstruction cohort presented with more severe preoperative pathology, including higher rates of prior surgery and worse baseline patient-reported outcomes. Despite these differences, both groups demonstrated statistically and clinically significant improvements across all outcome measures, including the modified Harris Hip Score (mHHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL), and International Hip Outcome Tool–12 (iHOT-12). At final follow-up, there were no significant differences in outcome scores between the two cohorts. Additionally, both groups achieved high rates of patient satisfaction and return to activity, with no significant difference in revision or conversion to arthroplasty. The authors concluded that complete labral reconstruction offers durable, long-term outcomes comparable to labral repair, even in patients with more complex pathology. These findings support the use of CLR as a viable primary treatment option when the native labrum is nonviable or irreparable. The study is subject to several limitations. The non-randomized design introduces selection bias, as treatment allocation was likely influenced by intraoperative assessment of labral viability rather than standardized criteria. This limits the ability to attribute differences in outcomes solely to the surgical technique. Additionally, while the study reports durable improvements in both cohorts, it does not account for confounding variables such as degree of chondral damage, capsular management, or patient activity level, all of which may significantly influence postoperative recovery and long-term joint preservation. The study also lacks detailed stratification by graft type or reconstruction technique, which could affect outcomes within the reconstruction group. Furthermore, although the five-year follow-up is commendable, loss to follow-up may have introduced attrition bias, potentially skewing results toward more favorable outcomes. These limitations underscore the need for prospective, randomized studies with standardized protocols and comprehensive stratification to better delineate the comparative efficacy of labral repair versus reconstruction.
In a multi-center study, Bodendorfer et al. (2022) reported minimum 2-year follow-up PRO measures in patients undergoing labral repair (LR), segmental labral reconstruction (SLR), or circumferential labral reconstruction (CLR) in the primary setting; and compared minimum 2-year follow-up PRO measures among these groups. These investigators carried out a retrospective review of a prospectively maintained multi-center database of patients undergoing hip arthroscopy. Inclusion criteria were patients undergoing hip arthroscopy for treatment of labral tear and femoroacetabular impingement (FAI) syndrome between January 2014 and October 2017, and completion of minimum 2-year post-operative outcome scores. Exclusion criteria were patients undergoing revision hip surgery, labral treatment limited to debridement, lateral center-edge angle of less than 20°, osteoarthritis (Tonnis grade of greater than 1), slipped capital femoral epiphysis, workers' compensation status, and patients undergoing concomitant gluteus medius and/or minimus repair. Labral reconstruction patients were matched (1:3) with labral repair patients on age, sex, and body mass index (BMI). The labral reconstruction group was further stratified into SLR and CLR groups. Patient demographic characteristics and clinical outcomes including Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sport Subscale, mHHS, International Hip Outcome Tool, and visual analog scale (VAS) for pain were analyzed, as well as achievement of the MCID. A p-value of less than 0.05 indicated statistical significance. A total of 416 patients were included (LR, n = 312; SLR, n = 53; CLR, n = 51). The age, BMI, and sex of the matched cohort were 42.3 ± 11.2 years, 24.7 ± 3.7, and 55.0% female. At a minimum of 2 years after hip arthroscopic surgery, no differences were found in pre-operative, post-operative, or the delta VAS for pain, mHHS, Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sport Subscale, or International Hip Outcome Tool. Subsequently, the proportion of patients achieving the MCID and the PASS at latest follow-up were analyzed. This analysis revealed that no significant differences in the rate of MCID or PASS achievement for any outcome measure existed based on labral treatment. The authors concluded that in this study on labral treatment in the primary setting, patients undergoing LR, SLR, and CLR demonstrated no difference in pre-operative or post-operative scores, nor the proportion of patients achieving clinically significant outcome improvement. The Level of Evidence of this study was III. The study was limited by several methodological drawbacks. The retrospective design inherently introduces selection bias, particularly in the allocation of patients to different surgical interventions, which was not randomized and likely influenced by intraoperative findings and surgeon preference. Additionally, the multicenter nature of the study, while enhancing generalizability, also introduces heterogeneity in surgical technique, perioperative protocols, and rehabilitation strategies, all of which may confound outcome comparisons. The study also lacks granular data on important covariates such as degree of chondral damage, capsular management, and patient activity level, which could significantly influence postoperative outcomes. Furthermore, although the follow-up period of two years provides meaningful short-term data, it is insufficient to assess long-term joint preservation or conversion to arthroplasty. These limitations underscore the need for prospective, randomized studies with standardized protocols to more definitively compare labral preservation versus reconstruction strategies.
In a retrospective, comparative study, Maldonado et al. (2022) compared a minimum of 2-year follow-up PROs in patients who underwent revision hip arthroscopy for acetabular circumferential labral reconstruction (CLR) and segmental labral reconstruction (SLR) using propensity-matched groups, in the setting of irreparable labral tear. Prospectively collected data were retrospectively reviewed for patients who underwent revision hip arthroscopy from April 2010 to September 2018. Patients were included if they underwent labral reconstruction and had pre-operative and minimum 2-year PROs. Patients unwilling to participate, with Tonnis grade of greater than 1, or hip dysplasia were excluded. Patients in the CLR group were propensity-matched on the basis of age, sex, BMI, and Tonnis grade to patients in the SLR group in a 1:1 ratio. A total of 26 hips (25 patients) with CLR were propensity-matched to 26 hips (26 patients) with SLR. The mean follow-up time was 25.92 and 27.78 months for the CLR and SLR, respectively (p = 0.845). Groups reported comparable findings for sex (p = 0.773), age (p = 0.197), BMI (p = 0.124), pre-operative Tonnis grade (p = 0.124), lateral center-edge angle (p = 0.144), and alpha angle (p = 0.264), and comparable improvement for all PROs at minimum 2-year follow-up. Patient satisfaction was similar (p = 0.612). Rates of achievement for the MCID and PASS were comparable. The authors concluded that following revision hip arthroscopy, patients who underwent CLR or SLR for complete and segmental irreparable labral tears, respectively, reported significant and comparable post-operative improvement for all PROs and rate of achievement for the MCID and PASS at a minimum 2-year follow-up. Level of Evidence = III.
In an editorial commentary, Khalil and Lynch (2022) stated that the arena of hip arthroscopy has seen leaps in practices over the last 10 years, evolving from surgical debridement of the labrum to improvements in techniques that now allow repair, augmentation, and circumferential reconstruction. However, as the operating theater continues to change its act, so too must the pre-operative choreography. Recent advancements in the understanding of pre-operative risk factors for failure of primary labral repair have identified the diminutive or hypoplastic labra on pre-screening MRI as a negative predictor of success. While this quantitative assessment predicts the anatomical coverage of the labrum, these researchers were still limited in their ability to qualify the latter's tissue substance pre-operatively. Ossified or degenerative labra may not have the inherent functional capacity to restore the suction seal of the hip in a primary repair setting. The authors stated that “If the applause from the audience failed to reach a significant threshold, we must re-think our act, and that begins with the choreography.” They stated that the next step in hip arthroscopy is determining if a primary augmentation or reconstruction, in lieu of primary repair, warrants further consideration. Until we develop reliable methods of quantifying and qualifying the labral tissue, both pre-operatively and optimally, we should establish backup for surprises encountered while on the stage.
In an editorial commentary, Kaplan (2023) stated that hip labral "width" should be defined as the distance from the chondro-labral junction to the tip of the labrum in triangular cross-section. "Height" should refer to the distance from the joint surface to the peri-labral recess (perpendicular to the width). "Length" is the distance from the anterior end of the labrum, adjacent to the anterior transverse acetabular ligament (TAL), to the posterior end of the labrum, adjacent to the posterior TAL (as may be relevant in reconstructions). Most studies of labral size focus on width, as it is thought to most contribute to the suction seal effect and hip stability. Magnetic resonance imaging (MRI) most accurately measures labral width. Labral width at the time of surgery should be considered its maximal size; the labrum is reduced in size after repair. Hypoplastic labrums may result in worse outcomes after hip arthroscopy, and hyperplastic labrums may result in higher scores than normoplastic labrums in patients with primary FAI syndrome. The author concluded that diminutive labral width is a relative indication for labral reconstruction. Moreover, the author noted that “I do think labrum width may contribute to outcomes; but am not yet ready to make treatment decisions based solely on labral size. For our field to reach this point, we will need additional compelling biomechanical studies, as well as prospective investigations.”
In a systematic review, Curley et al. (2023) reported the mid- to long-term patient-reported outcomes (PROs) following hip labral reconstruction. These investigators carried out a literature search of the PubMed, Embase, and Cochrane Library databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for clinical studies reporting mid- to long-term PROs at a minimum of 5 years of follow-up following arthroscopic hip labral reconstruction. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. Data collection included study characteristics, demographics, indications, radiographic metrics, peri-operative findings, surgical technique, baseline and most recent PROs, and subsequent surgeries. A total of 4 studies met inclusion criteria, with 182 hips (age range of 27.9 to 38.7 years) undergoing labral reconstruction in primary and revision hip surgery with a minimum of 5 years of follow-up. There were 3 Level-III studies and 1 Level-IV study, with an average MINORS score of 16.6. All studies cited labral tissue characteristics as a factor for surgical indications, including the quality and/or size of the labrum; 3 studies performed segmental labral reconstructions, while another study employed a circumferential technique. Varying grafts were selected, including hamstring autograft/allograft, ligamentum teres autograft, ilio-tibial band autograft, and tensor fascia lata autograft. All studies showed improved PROs from baseline to most recent follow-up, with 4 studies reporting modified Harris Hip Score (mHHS) values that increased from baseline (range of 58.9 to 66.8) to most recent follow-up (range of 80.1 to 86.3). After labral reconstruction, rates of revision arthroscopy ranged from 4.8% to 13.3%, and conversion to THA ranged from 1.6% to 27%. The authors concluded that improved PROs were observed in all studies at a minimum of 5 years of follow-up, suggesting that labral reconstruction could offer durable results beyond short-term follow-up. While surgical indications for all studies included labral tissue characteristics, differing graft selection and surgical techniques were utilized across studies, limiting the ability to determine an optimal treatment approach.
Autologous Osteochondral Mosaicplasty in Combination with Femoral Neck Osteochondroplasty
Gungor et al. (2015) stated that although FAI syndrome is included in the etiology of lesions involving the acetabular labrum and acetabular cartilage, it is one of many possible reasons behind osteochondral lesions in the femoral head. These researchers presented clinical findings and outcomes of 2 cases with osteochondral defects and cam type impingement of femoral head. Both cases underwent autologous osteochondral mosaicplasty along with femoral osteochondroplasty following controlled hip dislocation. Harris hip scores improved significantly post-operatively and MRI showed an adequate graft union and formation of a healthy chondral surface at the final assessment. The authors concluded that autologous osteochondral mosaicplasty of parafoveal region defects and femoral neck osteochondroplasty combination may be an effective treatment method for young patients with FAI syndrome. These preliminary findings need to be validated by well-designed studies.
Capsular Plication
Capsular plication is an arthroscopic procedure that involves suturing the ligaments around the joint for greater hip stability.
Wada et al. (2012) stated that Kabuki syndrome is characterized by distinctive facial features, skeletal anomalies, persisting fingertip pads with dermatoglyphic abnormalities, post-natal growth deficiency and mental retardation. These investigators reviewed their results in the operative treatment of hip dislocations in patients with Kabuki syndrome. Between 2001 and 2009, a total of 7 dislocated hips (3 unilateral and 2 bilateral hips) in 5 patients (all girls) were operatively treated at the authors institution. The operative treatment consists of open reduction, femoral derotation varus osteotomy, pelvic osteotomy (Salter in 1 and incomplete peri-acetabular osteotomy in 6 hips) and capsular plication. The age of the patients at the time of surgery ranged from 2.4 to 5.7 years, with an average of 3.6 years. The follow-up post-operative period ranged from 3.2 to 6.3 years, with an average of 5.0 years. At the final follow-up, all patients reported no click and no pain, and showed well-contained hips by radiographs. All 7 hips were graded as Severin class I to II. One patient presented as having habitual dislocation of the hip 4.4 years after surgery. Computed tomographic (CT) scans revealed posterior acetabular wall deficiency, which was not corrected by the antero-laterally directed Salter osteotomy. The incomplete peri-acetabular osteotomy provided sufficient postero-lateral coverage of the acetabulum. The authors concluded that operative treatment combining open reduction, femoral derotation varus and incomplete peri-acetabular osteotomies, and capsular plication provided successful results in patients with Kabuki syndrome who had the characteristics of hip instability such as ligamentous laxity, muscular hypotonia and posterior acetabular wall deficiency.
Domb et al. (2013) noted that the role of hip arthroscopy in the treatment of patients with dysplasia is unclear because of the spectrum of dysplasia that exists. Patients with borderline dysplasia are generally not candidates for peri-acetabular osteotomy because of the invasive nature of the procedure. However, arthroscopy in dysplasia has had mixed results and has the potential to exacerbate instability. These researchers hypothesized that patients with borderline dysplasia will demonstrate post-operative improvement, high satisfaction rates, and low re-operation rates after a surgical approach that includes arthroscopic labral repair augmented by capsular plication with inferior shift. Between April 2008 and November 2010, patients less than 40 years old who underwent hip arthroscopy for symptomatic intra-articular hip disorders, with a lateral center-edge (CE) angle greater than or equal to 18° and less than or equal to 25°, were included in this study. Patients with Tonnis grade 2 or greater, severe hip dysplasia (CE less than or equal to 17°), and Legg-Calve-Perthes disease were excluded. Patient-reported outcome scores, including the modified Harris Hip Score (mHHS), non-arthritic hip score (NAHS), hip outcome score-sport-specific subscale (HOS-SSS), hip outcome score-activity of daily living (HOS-ADL), and visual analog scale (VAS) for pain, were obtained in all patients pre-operatively and at 1, 2, and 3 years post-operatively. Revision surgery and complications were recorded for each group. A total of 26 patients met the criteria to be included in the study. Of these, 22 (85%) patients were available for follow-up. The mean (± standard deviation) length of follow-up for this cohort was 27.5 ± 5.5 months (range of 17 to 39), and the average age was 20 years (range of 14 to 39). The mean lateral CE angle was 22.2° (range of 18° to 25°), and the mean Tonnis angle was 5.8° (range of 0° to 17°). There was significant improvement in all patient-reported outcome scores (mHHS, NAHS, HOS-SSS, and HOS-ADL) (p < 0.0001). There was a significant improvement in VAS scores from 5.8 to 2.9 (p < 0.0001). Overall patient satisfaction was 8.4 out of 10; 17 patients had good/excellent results (77%); and 2 patients required revision arthroscopy. The authors concluded that patients with borderline dysplasia have often fallen into a gray area between arthroscopy and peri-acetabular osteotomy, and viable treatment options have remained scarce. They stated that the current study demonstrated favorable results at 2-year follow-up for an arthroscopic approach that includes labral repair augmented by capsular plication with inferior shift.
Peterlein et al. (2013) stated that the treatment of hip instability in patients with Down syndrome is challenging. These investigators have performed different pelvic osteotomies and corrections at the proximal femur for this indication. This retrospective study was conducted to evaluate the clinical and radiological outcome of each intervention. All in all, 166 patients with Down syndrome were treated at the authors’ orthopedic department during the observation period. Problems related to the hip joint were diagnosed in 63 of those patients. Only patients who underwent surgery were included in this study. The charts and X-rays of these 31 patients were evaluated with respect to the following parameters: incidence of the hip problem, concomitant diseases, temporal progress, kind of operation method and date, duration of stay in the hospital, after-care, follow-on surgery related to complications, AC angle, CE angle, ACM angle, CCD angle, index of migration according to Reimers, classification of Bauer and Kerschbauer, and general morphology of the femoral head. The group was compared with an age-matched group of 21 patients with hip dysplasia. Those patients underwent the same sort of operation in the same year. In the Morbus Down group, these researchers performed surgery for preservation of the hip in 49 cases. This included 13 osteotomies according to Chiari, 11 triple osteotomies according to Tonnis, 10 corrections by femoral varus derotation osteotomy, 8 pelvic osteotomies according to Pemberton, 5 pelvic osteotomies according to Salter, and 2 open reductions of the hip. With respect to the moment of surgery, these researchers detected 3 peaks of age. There was no difference in the course of disease and quantity of complications between the groups. Satisfactory results concerning clinical and radiological outcomes were achieved predominantly by complete re-directional acetabular osteotomies; 50% of the patients who were solely treated by femoral varus derotation osteotomy needed follow-on surgery in the form of pelvic osteotomy. Comparison of pre-operative and post-operative range of motion (ROM) of the hip joint between groups detected capsular insufficiency, increased ligamentous laxity, and muscular hypotonia in patients with Down syndrome. Comparison of pelvic radiographs demonstrated significant improvement concerning measured angles in both groups. Pre-operative values with respect to AC angle and CE angle were demonstrated to be lower in the hip dysplasia group (p < 0.01); whereas values for ACM angle were comparable between groups. The authors concluded that hypermobility and secondary dislocation of the hip joint is a common problem in patients with Down syndrome, which often requires surgical intervention at an early stage. According to the authors’ data and clinical results, they suggested a complete re-directional acetabular osteotomy in combination with capsular plication for treatment of this challenging condition.
Rosenbaum et al. (2013) reported on the case of a 24-year-old military policeman who underwent arthroscopic femoral neck osteoplasty and labral repair of his right hip following failed conservative management of femoro-acetabular impingement (FAI). His post-operative course was complicated by recurring posterior instability of his right hip, initially presenting as a posterior dislocation on post-operative day 19. Iatrogenic disruption of the hip's static stabilizers in the setting of underlying coxa valga was the likely culprit. Although anterior dislocation following hip arthroscopy has been described, posterior dislocation has not. Further, these investigators identified a successful and less-invasive approach to the treatment of this complication, in the form of a spica cast. Prior cases pertaining to post-arthroscopy hip instability have only described operative interventions, such as capsular repair and plication, as effective revision procedures.
Uchida et al. (2014) noted that in addition to the underlying shallow acetabular deformity, a patient with hip dysplasia has a greater risk of developing a labral tear, a cam lesion, and capsular laxity. This combination of abnormalities exacerbates joint instability, ultimately leading to osteoarthritis. Unsurprisingly, only repairing the acetabular labrum remains controversial, and the outcome is unpredictable. In this technical note, with video, these researchers demonstrated an entirely endoscopic approach for simultaneously repairing the most common mechanical abnormalities found in moderate hip dysplasia: labral repair, cam osteochondroplasty, capsular plication, and shelf acetabuloplasty using an autologous iliac bone graft.
Chandrasekaran et al. (2015) stated that atraumatic instability or micro-instability of the hip is a recognized cause of groin pain and hip instability. Risk factors include female sex, ligamentous laxity, and borderline dysplasia. Arthroscopically, the joint may distract easily, and there may be associated ligamentum teres tears and laxity of the capsule on manual probing. The use of arthroscopic capsular plication in this cohort of patients has shown good to excellent results. Biomechanically, a capsular plication aims to create an imbrication and inferior shift of the capsule to augment the screw-home mechanism of the capsule-ligamentous structures and thereby improve stability in extension and external rotation. These investigators detailed the step-by-step surgical technique of arthroscopic capsular plication, in addition to the indications, pearls, and pitfalls of the technique.
Larson et al. (2015) presented outcomes in a series of patients with Ehlers-Danlos syndrome (EDS)-hypermobility type who underwent hip arthroscopy for associated hip pain and extreme capsular laxity. A retrospective chart review identified 16 hips with confirmed EDS-hypermobility type that underwent hip arthroscopy for continued pain and capsular laxity. All patients had complaints of "giving way" and pain, an easily distractible hip with manual traction under fluoroscopy, and a patulous capsule at the time of surgery. No patient had osseous evidence of acetabular hip dysplasia or prior confirmed hip dislocation. Outcomes were evaluated pre-operatively and post-operatively with the mHHS, the 12-Item Short Form Health Survey (SF-12), and a VAS for pain. Evidence of symptomatic FAI was found in 15 hips (93.8%). The 16th hip had subjective giving way with a positive anterior impingement test and was easily distractible, had a labral tear, and had a patulous capsule at the time of surgery. The mean follow-up period was 44.61 months (range of 12 to 99). The mean pre-operative lateral CE angle was 31.8° (range of 25° to 44°), and the mean Tonnis angle was 3.6° (range of -2° to 8°). Mean femoral version measured on CT scans was 19.2° (range of -4.0° to 31.0°). Of the hips, 13 underwent primary arthroscopy and 3 underwent revision. All hips underwent hip arthroscopy with an inter-portal capsular cut only and arthroscopic capsular plication. There were 13 labral repairs, 2 labral debridements, 8 rim resections, 15 femoral resections, 2 psoas tenotomies, and 1 micro-fracture. Improved stability with an inability to distract the hip with manual traction under fluoroscopy was noted in all hips after plication. The mean alpha angle pre-operatively was 58.7° on antero-posterior radiographs and 63.6° on lateral radiographs compared with 47.4° and 46.1°, respectively, post-operatively. There were significant improvements for all outcomes (mHHS, p = 0.002; SF-12 score, p = 0.027; and VAS score, p = 0.0004). The mean mHHS, SF-12 score, and VAS score were 45.6 points, 62.4 points, and 6.5 points, respectively, pre-operatively compared with 88.5 points, 79.3 points, and 1.6 points, respectively, at a mean follow-up of 45 months. No EDS patients were lost to follow-up or excluded from analysis. The mean improvement in mHHS from pre-operatively to post-operatively was 42.9 points, and there were no iatrogenic dislocations. One patient underwent further revision arthroscopy for recurrent pain, subjective giving way, and capsular laxity. The authors concluded that FAI and extreme capsular laxity can be seen in the setting of EDS. Although increased femoral version was common, acetabular dysplasia was not common in this study. They stated that meticulous capsular plication, arthroscopic correction of FAI when present, and labral preservation led to dramatic improvements in outcomes and subjective stability without any iatrogenic dislocations in this potentially challenging patient population.
The authors stated that this study had several drawbacks. First, as with any study reporting on a rare genetic disorder, the sample size was small (n = 16 hips). This trial was retrospective in nature, with all of the inherent limitations of such a study. However, although the study was a retrospective review, all data were collected prospectively. Furthermore, the mHHS has been reported to be a suboptimal outcome measure for patients undergoing hip arthroscopy because of a ceiling effect. However, this was among the few outcome measures obtained for patients earlier in the cohort and thus was used along with the SF-12 and VAS scores for all patients. Moreover, ROM measures were not carried out consistently with a goniometer (even though, in general, there was typically little change); thus, pre-operative and post-operative ROM measures were not reported. Additionally, although a mean follow-up period of 45 months was a reasonable early-term to mid-term follow-up length for most studies, the 1-year minimum follow-up and challenging nature of this patient population, as well as the underlying connective tissue disorders, warrant long-term follow-up to better examine the long-term effectiveness of the procedure performed. There was also no way to know which portion of the procedure performed (i.e., plication, labral repair, or FAI correction) resulted in the most substantial improvement in outcomes. Lastly, although it could be argued that this approach was not generalizable to other more common patient populations, this trial reported an effective treatment strategy at early follow-up for patients with hip pain and generalized soft-tissue laxity. In addition, some investigators have argued that there is a lack of distinction between EDS-HT and generalized hypermobility syndrome, and in this regard, the described approach might be applicable to patients with generalized hypermobility syndrome and ligamentous laxity. However, further study is needed to support this suggestion.
Levy et al. (2015) stated that the most commonly reported reasons for persistent hip pain after hip arthroscopy are residual FAI, dysplasia and dysplasia variants, or extra-articular impingement. There are some cases in which the underlying osseous pathomorphology has been appropriately treated, and the cause of persistent hip pain can be soft-tissue injuries such as chondrolabral tears or capsular abnormalities. Capsular defects after hip arthroscopy may suggest an alteration of the biomechanical properties of the ilio-femoral ligament and lead to iatrogenically induced hip instability. There are a growing number of biomechanical and clinical studies showing the importance of capsular management during hip arthroscopy. The authors described the work-up, examination under anesthesia, diagnostic arthroscopy, and technique of capsular plication for iatrogenic instability of the hip.
Mei-Dan et al. (2015) noted that symptomatic anterior instability of the hip is typically iatrogenic in nature and poses a challenging problem for the orthopedist. With early recognition, capsular repair and plication are often effective in restoring stability. Cases involving multiple instability episodes or those with delayed presentation, however, may have patulous and deficient capsular tissue, precluding successful capsulorrhaphy. Capsular reconstruction may play an important role in restoring stability in these difficult cases. The authors presented an arthroscopic technique for ilio-femoral ligament reconstruction, using Achilles tendon allograft, to address instability of the hip due to anterior capsular deficiency.
There is inadequate evidence that microfracture improves the outcomes of femoroacetabular impingement (FAI) surgery. An editorial (Lubowitz et al., 2016) commenting on a systematic review of microfracture with FAI surgery noted that we are unable to determine from these studies whether improvements in pain are due to the microfracture or the FAI surgery.
Hip arthroscopy may be necessary for a traumatic labral tear that is causing mechanical symptoms (e.g., unstable tear in a good quality labrum, such as may occur in a younger patient with traumatic etiology). However, degenerative tears are usually a sign of early osteoarthritis, and there is a lack of adequate evidence that arthroscopic repair of degenerative tears improves clinical outcomes. Most peer-reviewed published medical literature regarding the repair of torn labrum is in the context of hip impingement. There are a few studies of isolated repair of torn labrum in patients with dysplasia and bony impingement, and these are mostly case series (level IV evidence). In an evidence review, Haddad et al. (2014) stated that "It seems logical to repair an unstable tear in a good quality labrum with good potential to heal in order potentially to preserve its physiological function. A degenerative labrum, on the other hand, may be the source of discomfort, and its preservation may result in persistent pain and the added risk of failure of re-attachment. The results of the present study do not support routine refixation for all labral tears."
Anterior-Inferior Iliac Spine Decompression During Femoro-Acetabular Impingement Surgery
Sharfman and colleagues (2016) stated that the anterior inferior iliac spine (AIIS) has variable morphology that correlates with hip range of motion (ROM). Sub-spinal impingement is an extra-capsular cause of femoroacetabular impingement (FAI) and is clinically significant because it results in decreased ROM and groin pain with flexion-based activity. In symptomatic patients with AIIS extension to or below the acetabular rim, AIIS decompression is considered part of an FAI corrective procedure. A consistent exposed bony area on the anterior and infero-medial aspect of the AIIS serves as a "safe zone" for resection, allowing for decompression while preserving the origin of the rectus femoris tendon. This surgical note described a technique for AIIS decompression. The goal for low AIIS osteoplasty is to resect the AIIS to 2 burr widths (using a 5.5-mm burr) above the acetabular rim, achieving an 11-mm clearance and creating a type I AIIS. The resultant flat anterior acetabular surface between the most antero-inferior prominent point of the AIIS and the acetabular rim allows for free movement of the hip joint without impingement. Careful execution of AIIS decompression can alleviate clinical symptoms of FAI and restore function to the hip joint. However, there is limited evidence regarding the effectiveness of anterior inferior iliac spine decompression.
Bohnsack (2018) examined the clinical value of complete arthroscopic decompression of the impinging sub-spinal soft tissues and resection of the hypertrophic bone formation between the anterior hip capsule and AIIS or decompression of a hypertrophic AIIS. Indications were painful anterior hip impingement and decreased hip flexion following a hypertrophic osseous sub-spinal deformation. Contraindications were the absence of clinical symptoms or decreased anterior hip function despite radiological osseous sub-spinal hip impingement. The surgical technique involved hip arthroscopy in a supine position on an extension table, treatment of possible intra-articular hip pathologies in the central or peripheral compartment, and arthroscopic visualization of the hypertrophic impinging soft tissues below the AIIS, followed by decompression using a shaver or radio-frequency (RF) device. Complete arthroscopic resection of the hypertrophic AIIS parts and the osseous sub-spinal deformation was performed using a high-speed burr under fluoroscopic control. Post-operative management entailed early functional rehabilitation with full weight-bearing and unlimited hip motion; 3 weeks of ossification prophylaxis; and 8 weeks of limitation for jumping and running sports activities. The authors concluded that there are no comparative studies or medium- and long-term study results in the literature for arthroscopic AIIS decompression. However, currently published case series showed an improvement in the determined scores.
Michal and associates (2020) evaluated the clinical outcomes after arthroscopic sub-spinal decompression in patients with hip impingement symptoms and low AIIS, and assessed the presence of low anterior inferior iliac spine on the pre-operative radiographs of patients with established sub-spinal impingement diagnosed intra-operatively. A retrospective analysis of patients who underwent arthroscopic sub-spinal decompression was performed. The indications for surgery were FAI or sub-spinal impingement. Pre-operative radiographs were assessed for anterior inferior iliac spine type. Intra-operative diagnosis of low anterior inferior iliac spine was based on the level of anterior inferior iliac spine extension relative to the acetabulum and the presence of reciprocal labral and chondral lesions. In patients where low anterior inferior iliac spine was not diagnosed on pre-operative radiographs, the pre-operative radiographs were re-read retrospectively to assess missed signs of low anterior inferior iliac spine. A total of 34 patients underwent arthroscopic sub-spinal decompression between 2012 and 2015. They were followed for a median of 25 months (range of 13 to 37 months). Intra-operatively, grade 2 anterior inferior iliac spine was found in 27 patients, and grade 3 anterior inferior iliac spine was found in 7 patients; modified Harris Hip Score (MHHS), Hip Outcome Score (HOS), and Hip Outcome Score-Sport Specific Subscale (HOSS) scores increased from median (range) pre-operative scores of 55 (11 to 90), 48 (20 to 91), and 20 (0 to 80) to 95 (27 to 100), 94 (30 to 100), and 91 (5 to 100), respectively (p < 0.0001, p = 0.001, p < 0.0001, respectively). Pre-operative diagnosis of low AIIS was made in 6 of 34 patients via anteroposterior (AP) radiographs. On retrospective analysis of pre-operative radiographs, signs of low AIIS were still not observed in 21 of 34 (61.8%) patients. The authors concluded that arthroscopic sub-spinal decompression of low AIIS yielded significantly improved outcome measures and high patient satisfaction at a minimum of 13 months follow-up. Low AIIS was often under-diagnosed on AP pelvis and lateral frog radiographs, and if left untreated, may result in unresolved symptoms and failed procedures. This was a retrospective study with a small sample size (n = 34) and short-term follow-up (13 months). Level of Evidence: IV.
Tateishi and co-workers (2020) evaluated the additional effect of AIIS decompression on knee extensor and hip flexor strength and compared functional outcomes after arthroscopic FAI correction with and without AIIS decompression. A total of 60 patients who underwent arthroscopic FAI correction surgery were divided into 2 groups matched for AIIS morphology: 31 patients who underwent arthroscopic FAI surgery only (without AIIS decompression) (FAI group) (AIIS Type I; n = 5, Type II; n = 26, Type III; n = 0) and 29 patients who underwent arthroscopic FAI surgery with AIIS decompression (AIIS group) (AIIS Type I; n = 5, Type II; n = 24, Type III; n = 0). Knee extensor and hip flexor strength were evaluated pre-operatively and at 6 months after surgery; patient-reported outcome (PRO) scores using MHHS, NAHS, and iHOT-12 were obtained pre-operatively and at 6 months after surgery. In the AIIS group, there was no significant difference between knee extensor strength pre- and post-operatively (non-significant). In the AIIS group, hip flexor strength was significantly improved post-operatively compared to pre-operative measures (p < 0.05). In the FAI group, there were no significant improvements regarding muscle strength (non-significant). While there were no significant differences in pre-operative and post-operative MHHS and NAHS between both groups (MHHS; non-significant, NAHS; non-significant), the mean post-operative iHOT-12 in the FAI group was inferior to that in the AIIS group (p < 0.01). The revision surgery rate for the AIIS group was significantly lower compared with that in the FAI group (p < 0.05). The authors concluded that anterior inferior iliac spine decompression, as part of an arthroscopic FAI corrective procedure, had a lower revision surgery rate and did not compromise knee extensor and hip flexor strength, and it improved clinical outcomes comparable to FAI correction without AIIS decompression. They stated that AIIS decompression for FAI correction improved post-operative PRO scores without altering the muscle strength of the hip flexor and knee extensor. Level of Evidence: III.
The authors stated that this study had several drawbacks. This was a retrospective study with all the inherent limitations of such a study design. There were many cases in which rehabilitation follow-up was limited in the authors’ hospital because many surgery cases have come from all over the country. Selection bias existed in this study because a number of patients were excluded, as they were seen at clinic sites where dynamometer testing was not performed. In addition, the sample size was relatively small (n = 29 for patients who underwent arthroscopic FAI surgery with AIIS decompression), and the follow-up was short term (6 months). These researchers stated that further studies are needed to evaluate the longer-term effects of various surgical procedures on hip function and muscle strength in a larger number of patients. It was unclear whether the addition of an AIIS decompression had an effect on the ultimate outcome other than the muscle strength measures noted previously. Post-operative inflammation of the origin of the direct head of the rectus femoris may theoretically exist and affect patient function as well. Imaging studies, such as MRI, may be necessary to examine the effect of AIIS decompression on the origin of the rectus femoris. Finally, it was difficult to distinguish whether the most important cause of revision was due to AIIS impingement or residual FAI.
Computer-Assisted Hip Arthroscopic Surgery for Femoro-Acetabular Impingement
Kobayashi and colleagues (2018) noted that precise osteochondroplasty is key for success in hip arthroscopic surgery, especially for FAI caused by cam or pincer morphology. In this Technical Note, these researchers presented computer-assisted hip arthroscopic surgery for FAI, including pre-operative planning by virtual osteochondroplasty and intra-operative computer navigation assistance. The important concept of this technique is that navigation assistance for osteochondroplasty is based on planning made by computer simulation analysis. The navigation assistance allows surgeons to perform neither too much nor too little osteochondroplasty. Specifically, computer simulation was used to identify the impingement point. Virtual osteochondroplasty was then performed to determine the maneuvers that would improve ROM. Thereafter, the planning data were transported to a CT-based computer navigation system that directly provided intra-operative assistance. The authors concluded that computer-assisted technology including pre-operative simulation, virtual osteochondroplasty planning, and intra-operative navigation assistance may promote precise hip arthroscopic surgery for FAI.
The authors stated that there are several limitations, risks, and disadvantages in the clinical application of computer-assisted techniques. First, radiation exposure by CT is considerable, although CT evaluation may be needed for a diagnosis of FAI morphology in detail regardless of computer-assisted techniques application. In addition, surgeons need certain time and fluoroscopic guides for the navigation registration process. Furthermore, it should be noted that surgeons need additional skin incision for setting the navigation device in the distal femur. They must take notice of interference between the femur and navigation device, which possibly induces the error of the navigation system. The appropriateness of pre-operative planning should be considered. Furthermore, surgeons need to validate the accuracy of the navigation system itself compared with the pre-operative planned model.
Hip Arthroscopy for Repair of Degenerative Acetabular Labral Tear
Lim et al. (2020) stated that recently, a hypertrophic labrum has been reported in the absence of hip dysplasia, which could possibly contribute to an acetabular labral tear. In a cohort study, these researchers compared the clinical outcomes and complications, including the incidence of iatrogenic acetabular labrum and cartilage injury, in patients with tears of hypertrophic versus morphologically normal acetabular labra over a minimum follow-up period of 2 years and examined the morphologic changes at follow-up CT arthrography in the two groups. Between January 2010 and December 2016, a total of 20 patients (22 hips) with a hypertrophic labrum underwent arthroscopic hip surgery. A total of 22 patients (22 hips) without a hypertrophic labrum were assigned to the control group based on matching criteria, including age, sex, body mass index (BMI), labral tear, and labral repair. Clinical outcomes were assessed with the visual analog scale (VAS) score, UCLA activity scale score (University of California, Los Angeles), and modified Harris Hip Score (mHHS). Radiologic outcomes were assessed through serial radiography; patients were followed for at least 2 years. The mean age at surgery was 42 years. The most common cause of arthroscopic surgery in the study group was an isolated acetabular labral tear without any bony structural abnormalities (68.2%, 15 of 22 hips). All improvements in both groups were statistically significant at the last post-operative follow-up (p < 0.001). Although the radiologic and clinical outcomes were not significantly different between the groups, the complication rates, including iatrogenic labral perforations and cartilage injury, were significantly higher in patients with hypertrophic acetabular labral tears (9 versus 3, p = 0.042). The patient-reported satisfaction scores at the last post-operative follow-up were 8.4 and 7.9 in the study and control groups, respectively (p = 0.351). The authors concluded that the high rates of patient-reported satisfaction and the clinical outcomes following arthroscopic repair in both groups were encouraging. These researchers stated that arthroscopic treatment in patients with hypertrophic acetabular labral tears should be carefully performed to prevent iatrogenic injury during the surgery, and isolated hypertrophic labral tears can have good results after repair. Level of Evidence = III. This was a small study (n = 20 for patients with a hypertrophic labrum who underwent arthroscopic hip surgery) with early/mid-term follow-up (2 years). Well-designed studies with larger sample sizes and long-term follow-up are needed to validate these findings.
In a retrospective, single-surgeon, single-center study, Torres-Perez et al. (2020) examined functional outcomes and 8-year survival after hip arthroscopy in patients with degenerative hip disease. This trial included 102 patients who underwent a hip arthroscopy procedure between August 2007 and October 2011. Each subject completed 3 questionnaires at final follow-up: HOS-ADL, HOS-SS, and mHHS. A total of 39 patients (40 hips) were included in this analysis. The mean age was 43.1 ± 9.9 years with a 3-year minimum follow-up (75.43 ± 25.2 months). Younger patients and those with a shorter duration of symptoms obtained significantly higher HOS-SS and mHHS scores. Patients who had undergone previous lumbar spinal surgery obtained significantly worse HOS-ADL scores. Patient acceptable symptom state was achieved in 23 patients (57.5%) for mHHS, 22 patients (55%) for HOS-ADL, and 25 patients for HOS-SS scores; no major complications were observed. Only 4 patients had minor complications. Mean survival time was 97.1 months (95% CI: 85.1 to 109.1 months), with a survival rate at 8 years of 69% (95% CI: 53% to 85%). The authors concluded that these findings suggested that hip arthroscopy was a safe procedure with acceptable functional outcomes after a long follow-up. Moreover, these researchers stated that care should be taken when treating patients with prior lumbar surgery. Level of Evidence = IV.
In a case-series study, Moon et al. (2020) examined the minimum 2-year outcomes of hip arthroscopy for FAI and concomitant labral tears in Asian patients. Patients who underwent hip arthroscopy for both FAI and concomitant labral tears between January 2012 and December 2017 were included. Patients with hip osteoarthritis (OA) of Tonnis grade 2 or greater, previous hip surgery, or those followed for less than 2 years were excluded. Clinical assessments were performed using the mHHS, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the rates of achieving threshold values of minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) at the latest follow-up. Plain radiographs were acquired pre- and post-operatively for radiologic assessments. A total of 73 patients (90 hips; 58 male, 15 female; mean age of 34.4 years) who underwent hip arthroscopy for FAI and concomitant labral tears were enrolled; 43 hips (47.8%) had cam-type, 7 (7.8%) had pincer-type, and 40 (44.4%) had mixed-type FAI. The mean follow-up duration was 5.2 years. In cam- and mixed-type FAI hips, the mean α angle significantly decreased from 66.7 ± 8.28° pre-operatively to 44.9 ± 3.78° post-operatively (95% CI: 19.6° to 22.8°; p < 0.001). The mean mHHS and WOMAC scores increased from 74.8 ± 13.2 and 75 ± 12.7 pre-operatively to 93 ± 8.1 (95% CI: 15.4 to 20.9; p = 0.001) and 89.4 ± 8.4 post-operatively (95% CI: 11.8 to 17; p = 0.001), respectively; 74 hips (82.2%) crossed the MCID, and 85 hips (94.4%) achieved the PASS. There were 2 cases of pudendal nerve palsy and 1 case of sciatic nerve palsy; no additional surgeries were required. The authors concluded that hip arthroscopy could be an effective treatment for FAI and concomitant labral tears in Asian patients, as shown in this study, with improved patient-reported outcome (PRO) scores and re-operation rates. Moreover, these researchers stated that longer-term studies with larger cohorts are needed. Level of Evidence = IV.
Hip Arthroscopy for Repair of FAI with Borderline / Mild Acetabular Dysplasia
Nawabi et al. (2016) noted that the outcomes of hip arthroscopy in the treatment of dysplasia are variable. Historically, arthroscopic treatment of severe dysplasia (lateral center-edge angle [LCEA] less than 18°) resulted in poor outcomes and iatrogenic instability. However, in milder forms of dysplasia, favorable outcomes have been reported. In a cohort study, these researchers compared outcomes after hip arthroscopy for femoroacetabular impingement (FAI) in borderline dysplastic (BD) patients compared with a control group of non-dysplastic patients. Between March 2009 and July 2012, a BD group (LCEA, 18° to 25°) of 46 patients (55 hips) was identified. An age- and sex-matched control group of 131 patients (152 hips) was also identified (LCEA, 25° to 40°); patient-reported outcome (PRO) scores, including the modified Harris Hip Score (mHHS), the Hip Outcome Score-Activity of Daily Living (HOS-ADL), the Hip Outcome Score-Sport Specific Subscale (HOS-SS), and the iHOT-33, were collected pre-operatively and at 1 and 2 years post-operatively. The mean LCEA was 22.4° ± 2.0° (range of 18.4° to 24.9°) in the BD group and 31.0° ± 3.1° (range of 25.4° to 38.7°) in the control group (p < 0.001). The mean pre-operative alpha angle was 66.3° ± 9.9° in the BD group and 61.7° ± 13.0° in the control group (p = 0.151). Cam decompression was performed in 98.2% and 99.3% of cases in the BD and control groups, respectively; labral repair was performed in 69.1% and 75.3% of the BD and control groups, respectively, with 100% of patients having complete capsular closure performed in both groups. At a mean follow-up of 31.3 ± 7.6 months (range of 23.1 to 67.3 months) in unrevised patients and 21.6 ± 13.3 months (range of 4.7 to 40.6 months) in revised patients, there was significant improvement (p < 0.001) in all PRO scores in both groups. Multiple regression analysis did not identify any significant differences between groups. Importantly, female sex did not appear to be a predictor for inferior outcomes; 2 patients (4.3%) in the BD group and 6 patients (4.6%) in the control group required revision arthroscopy during the study period. The authors concluded that favorable outcomes could be expected after the treatment of impingement in patients with BD when labral refixation and capsular closure were performed, with comparable outcomes to non-dysplastic patients. These researchers stated that further follow-up in larger cohorts is needed to prove the durability and safety of hip arthroscopy in this challenging group and to further examine potential sex-related differences in outcome. Level of Evidence = III. Moreover, the authors stated that the drawbacks of this study included its relatively small sample size (n = 46). In addition, follow-up was limited to a mean of 33 months, which may limit the ability to assess whether the treatment effect is maintained going forward.
In a cohort study, Zimmerer et al. (2020) analyzed the clinical outcomes of patients with different subtypes of BD hips who underwent arthroscopic surgery. These investigators examined patients with an LCEA between 18° and 25° who underwent arthroscopic treatment for FAI syndrome between January 2015 and December 2016. A hierarchical cluster analysis was performed to identify hip morphologic subtypes according to radiographic parameters, including the LCEA, femoro-epiphyseal acetabular roof (FEAR) index, anterior and posterior wall indices (AWI and PWI), Tonnis angle, alpha angle, and femoral neck-shaft angle. In addition, the iHOT-12 and a VAS for pain were applied pre-operatively and at follow-up, and the results were compared among the different clusters. Previously reported MCID and PASS values were used to determine clinically significant improvements. A total of 40 patients were identified. Of these, 36 patients were available for evaluation at a mean follow-up of 43.8 months. In total, 4 sex-independent clusters with different morphologic patterns of the hip were identified: cluster 1, unstable anterolateral deficiency (FEAR index greater than 2°, AWI less than 0.35); cluster 2, stable anterolateral deficiency (FEAR index less than 2°, AWI less than 0.35); cluster 3, stable lateral deficiency (FEAR index greater than 2°, normal AWI and PWI); and cluster 4, stable posterolateral deficiency (FEAR index less than 2°, PWI less than 0.85). At follow-up, clusters 1, 2, and 3 showed significantly improved iHOT-12 (p < 0.0001) and VAS pain (p < 0.0001) scores, while cluster 4 showed no significant improvements. The MCID of 15.2 points was achieved by all patients in clusters 2 and 3, by 63% of patients in cluster 1, and by 23% of patients in cluster 4. Clusters 2 and 3 differed significantly from clusters 1 and 4 (p = 0.02). A post-operative PASS score of 60 was achieved by all patients in cluster 3, by 86% of patients in cluster 2, by 63% of patients in cluster 1, and by 20% of patients in cluster 4. The differences between the groups were statistically significant (p = 0.01). The authors concluded that arthroscopic surgery yielded good results in the treatment of stable BD of the hip with anterolateral and lateral deficiency. In contrast, BD of the hip with acetabular retroversion showed no improvements after arthroscopic therapy. These investigators stated that this study underlined the need for an accurate analysis of all possible radiological signs to adequately classify borderline dysplastic hips. Level of Evidence = III.
The authors stated that this study has several drawbacks. First, the number of patients per cluster was small; thus, the results must be confirmed with larger group sizes. A post-hoc power analysis using GPower with power (1-β) set at 0.80 and α at 0.05 revealed that, based on the mean, a sample size of approximately 85 would be needed to obtain statistical power. Another drawback was the lack of a control group of patients who underwent peri-acetabular osteotomy (PAO) to treat borderline hip dysplasia. Controlled trials would help determine whether PAO is superior to arthroscopy for unstable borderline hip dysplasia. This study examined radiographic parameters without the use of advanced imaging modalities (MRI or CT). However, the different radiological signs were often sufficient for recognizing the different morphologic conditions and can be used to stratify groups. The clustering analysis considered only acetabular version. These researchers did not consider the influence of either cam morphology or femoral version. Furthermore, in this study population, no capsular repair was performed because little evidence was available for capsular closure during the investigated period of time. Presently, capsular closure or plication is routinely performed, and the effect on the outcome in this special patient group should be further analyzed. Finally, this study entailed a minimum follow-up period of 2 years, and whether these results would persist over time is unknown, especially since dysplasia can result in an early onset of arthrosis.
In a systematic review, Tang and Dienst (2020) examined the current approaches and clinical outcomes in the surgical management of concomitant mild acetabular dysplasia and FAI. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) method, the PubMed and Medline databases were searched in March 2019 for studies that reported on surgical outcomes in hips with concomitant mild acetabular dysplasia and FAI. Studies published in English that focused on the surgical outcomes after hip arthroscopy, open surgery, or PAO of concomitant acetabular dysplasia and FAI, in which the LCEA of all subjects was between 15° and 25°, were included. Articles that included subjects with LCEA of less than 15°, with a minimum follow-up duration of less than 1 year, had fewer than 5 subjects, or were not original articles were excluded. The initial search yielded 748 studies, and 5 studies met the inclusion criteria. All these 5 studies focused on hip arthroscopic treatment for patients with concomitant mild acetabular dysplasia and FAI; 3 studies had Level-III evidence, whereas 2 studies had Level-IV evidence. The mean patient age range across the studies was 29.8 to 49.6 years, and the female-to-male ratio was 1.14. Improved PROs (HOS-ADL, HOS-SS, mHHS, SF-12 Physical Component Summary, WOMAC) at a minimum 2-year follow-up were obtained in 4 of the 5 studies; 2 of these 4 studies had a comparative cohort of patients with FAI with normal acetabular coverage, and there was no significant difference in the post-operative outcomes and secondary procedure rate between patients with mild acetabular dysplasia and those with normal acetabular coverage. The authors concluded that the findings of this systematic review showed that improved PROs can be obtained with hip arthroscopy in the treatment of concomitant mild acetabular dysplasia and FAI at a minimum 2-year follow-up. Level of Evidence = IV.
Endoscopic Tenotomy (or Lengthening) for Iliopsoas Tendinopathy Following Total Hip Arthroplasty
Gedouin and Huten (2012) noted that there have been numerous recommendations for the management of iliopsoas tendinopathy secondary to hip replacement: medical treatment, cup replacement, and open or arthroscopic tenotomy. In a retrospective case-series study, these investigators reported on a series of 10 endoscopic iliopsoas tenotomies. Arthroplasty comprised 5 primary conventional total prostheses, 2 large head diameter metal-metal models, 1 resurfacing, and 1 revision arthroplasty. All patients underwent clinical (Postel-Merle d'Aubigne [PMA], WOMAC), imaging (X-ray, CT, scintigraphy), and biological assessment. A total of 7 cases showed mechanical impingement (6 involving the anterior edge of the cup and 1 a cement fragment); the other 3 involved large femoral components (2 large head diameter models, 1 resurfacing). The infiltration test was positive in 8 cases out of 9. Endoscopic iliopsoas tenotomy for recurrence was performed in dorsal decubitus on an ordinary table, under fluoroscopy, using 2 approaches (inferior for the endoscope, superior for the instruments) converging on the lesser trochanter. There were no complications. At a mean follow-up of 20 months (range of 12 to 60 months), the mean pain grade was 5.5 (range of 4 to 6); 8 patients showed complete relief, and 2 showed partial relief (2 atypical cases). The mean PMA score was 16.9 (range of 15 to 18), and the mean WOMAC score was 84 (range of 60 to 95). Muscle force was recovered at a mean of 3.25 months (range of 0.5 to 6); 8 patients were very satisfied, 1 satisfied, and 1 moderately satisfied. The authors concluded that this technique was much less invasive than implant replacement; the post-operative course was shorter than for open tenotomy, and the technique was simpler than arthroscopic tenotomy, with a lower risk. Subsequent cup change, where necessary, was not compromised. Level of Evidence = IV.
Guicherd et al. (2017) stated that impingement between the acetabular component and the iliopsoas tendon is a cause of anterior pain following total hip replacement (THR). Treatment can be non-operative, endoscopic or arthroscopic, or by open revision of the acetabular component. Few studies have assessed these options. In a prospective, multi-center study, these researchers hypothesized that endoscopic/arthroscopic treatment would provide rapid pain relief with a low rate of complications. This trial included 64 endoscopic or arthroscopic tenotomies for impingement between the acetabular component and the iliopsoas tendon, performed in 8 centers. The mean follow-up was 8 months, with a minimum of 6 months and no loss to follow-up. The Oxford score, patient satisfaction, anterior pain, and iliopsoas strength were assessed at the last follow-up. Complications and revision procedures were collated; 44% of patients underwent rehabilitation. At the last follow-up, 92% of patients reported pain alleviation. The Oxford score, muscle strength, and pain in hip flexion showed significant improvement. The complications rate was 3.2%, with complete resolution. The mean hospital length of stay (LOS) was 0.8 nights. In 2 cases, arthroscopy revealed metallosis, indicating revision of the acetabular component. The only predictive factor was acetabular projection on oblique view. Rehabilitation significantly improved muscle strength. The authors concluded that endoscopic or arthroscopic tenotomy for impingement between the acetabular component and the iliopsoas tendon following THR significantly alleviated anterior pain in more than 92% of cases. The low complications rate made this the treatment of choice in cases of failure of non-operative management. Arthroscopy also re-oriented diagnosis in cases of associated joint pathology. Projection of the acetabular component on pre-operative oblique view was the most predictive criterion, guiding treatment.
The authors stated that the main drawback of the present study was its multi-center design, which introduced treatment bias (e.g., injection tests were not systematic). It also led to inter-observer variation, which might undermine correlation with specific pre-operative parameters. There was also a significant difference between radiologists and surgeons in interpreting CT images in terms of anterior cup projection; reliable anatomic landmarks need to be defined. Surgeons may have been alerted by prior clinical findings, and radiologists may have lacked information regarding what anatomic abnormality to look for.
Bell et al. (2019) noted that iliopsoas impingement following total hip arthroplasty (THA) occurs in up to 4.3% of patients, resulting in functional groin pain. Operative treatment historically has included open iliopsoas tenotomy or acetabulum revision. These researchers described a large, retrospective, single-surgeon series of patients treated with endoscopic iliopsoas tenotomy for iliopsoas impingement following THA to examine the effectiveness and risks. This trial included a consecutive series of 60 patients with iliopsoas impingement following THA treated with endoscopic iliopsoas tenotomy. Outcomes assessed were resolution of pain, change in Hip Outcome Score (HOS), and complications. Radiographs were reviewed by a musculoskeletal radiologist to evaluate component positioning and to compare with a control cohort. At the last follow-up (mean of 5.5 months), 93.3% of patients had resolution of pain. The HOS ADL subscale mean was 57.5 (range of 10.9 to 89.3, SD of 18.8) pre-operatively and 71.6 (range of 14.1 to 100, SD of 26.1) post-operatively (p = 0.005). The HOS sports subscale mean was 37.3 (range of 0 to 83.3, SD of 24.0) pre-operatively and 58.1 (range of 0 to 100, SD of 33.2) post-operatively (p = 0.002). One complication was reported, a post-operative hematoma managed conservatively. Body mass index (BMI) and increased offset were associated with iliopsoas symptoms following THA in this series. The authors concluded that endoscopic iliopsoas tenotomy following THA had a 93.3% resolution of pain, clinically important improvements in HOS, and a low rate of complications.
The authors stated that the limitations of this retrospective study included a small sample size (n = 60) and the lack of cross-table lateral views to evaluate acetabular prominence. Objective hip flexion strength data were not recorded before or after tenotomy in a systematic manner, so this could not be evaluated. These researchers stated that further research regarding changes in hip flexion strength after tenotomy would be beneficial, as this was a concern patients had prior to surgery. Selection bias was also a limitation of this study, which these researchers attempted to limit by including all patients who underwent psoas tenotomy. They stated that a larger control group sample size would likely have increased the study power. There were 5 patients who did not have a pre-operative iliopsoas injection to confirm diagnosis; however, similar results were observed when those 5 patients were excluded from the analysis.
Shapira et al. (2019) stated that non-operative and operative management of iliopsoas impingement (IPI) is commonly performed following THA. In a systematic review, these investigators compared patient-reported outcomes (PROs) following conservative treatment, iliopsoas tenotomy, and revision arthroplasty in patients presenting with IPI following THA. PubMed and Embase databases were searched for studies regarding IPI following THA. Studies were included if IPI following THA was treated with conservative management, an iliopsoas tenotomy, or acetabular component revision and included PROs. A total of 11 studies were selected for review, and there were 280 hips treated for IPI following THA. Harris Hip Scores (HHS) reported for the conservative group, the iliopsoas tenotomy group, and the cup revision group were 59.0 pre-operatively to 77.8, 58.0 pre-operatively to 85.4, and 58.1 pre-operatively to 82.4 at the latest follow-up, respectively. The iliopsoas tenotomy cohort also demonstrated superior post-operative functional outcomes using the WOMAC, MRC score, Oxford Hip Score, and PMA pain score. Patients who had a revision exhibited higher Oxford Hip Scores, higher MRC scores, and lower VAS pain scores post-operatively. The authors concluded that management of IPI following THA included non-operative measures, iliopsoas tenotomy, or acetabular component revision. Patients have been shown to experience favorable PROs at the latest follow-up, with an apparent advantage for surgical treatment. Compared to revision arthroplasty, iliopsoas tenotomy resulted in a lower overall rate of complications with less severe complication types; thus, iliopsoas tenotomy should be considered as a second line of treatment for patients who failed conservative measures. Revision arthroplasty should be reserved for recalcitrant cases. Level of Evidence = IV.
The authors stated that this systematic review had several drawbacks. First, there was heterogeneity in the selected studies with respect to the dispersion of the reported PROs. Second, none of the articles reported on a control group who did not experience IPI following THA, limiting the level of evidence of the selected studies. Third, these researchers acknowledged that there was a selection bias inherent in some of the reviewed studies, as the surgeon’s decision-making process in performing a tenotomy versus revision was only elucidated in 3 studies. Fourth, although these investigators included 3 studies regarding outcomes on patients who underwent conservative management, it was likely that outcomes following conservative management were under-reported in the literature.
Moreta et al. (2021) noted that one of the causes of groin pain following THA is impingement of the iliopsoas tendon. In a retrospective study, these researchers presented their findings with outside-in arthroscopic tenotomy for iliopsoas impingement following THA. They reviewed the findings of 12 patients who were treated between 2009 and 2016 with a minimum follow-up of 2 years. Anterior acetabular component prominence was measured on a true lateral hip radiograph. A trans-capsular tenotomy was carried out near the edge of the acetabular component via an outside-in arthroscopic approach. The primary clinical outcomes evaluated were groin pain, assessed with a visual analog scale (VAS), and the Harris Hip Score (HHS). Secondary outcomes included strength of hip flexion, measured with the Medical Research Council (MRC) scale. All patients had groin pain improvement, although 1 patient continued to have moderate pain. The mean VAS score was significantly lower post-operatively (1.08) than pre-operatively (6.2) (p < 0.001). The mean HHS improved from 58.8 (range of 37 to 76) to 86.1 (range of 59 to 98) (p = 0.001). The average post-operative MRC scale was 4.58. The mean anterior prominence was 7.25 mm (range of 3 to 12 mm). In patients with less than 10 mm of component prominence, tenotomy provided groin pain resolution in all cases (n = 8). In patients with 10 mm or larger of prominence, symptoms resolved in 3 out of 4 cases. The authors concluded that outside-in arthroscopic iliopsoas release provided a high rate of success with no complications in this study, even in patients with moderate acetabular component prominence. Moreover, these investigators stated that further studies are needed to examine the use of MRI in iliopsoas impingement following THA.
The authors stated that although to their knowledge this was the largest series of patients with a transcapsular tenotomy, they recognized that this study had several drawbacks. In particular, the small sample size (n = 12) and the mixed population (hemispherical cups or threaded cups) were likely responsible for some differences not reaching statistical significance. Another drawback was that the mean follow-up was relatively short.
Tassinari et al. (2021) described the clinical outcomes of 16 patients with iliopsoas impingement following primary THA, treated with an arthroscopic tendon release. A total of 16 patients (11 females, 5 males), with a mean age of 57.8 ± 11.1 years (age at THA: 54.4 ± 11 years) and a diagnosis of iliopsoas impingement following primary THA, were treated with the Wettstein tenotomy. Pre-operatively, every patient underwent a diagnostic ultrasonography (US)-guided peritendinous injection and a CT scan. Every patient was clinically evaluated using the WOMAC score. Subjective pain relief and active hip flexion strength were measured. No complications related to arthroscopy were detected. Every cup was prominent, with a mean axial overhang of 13 ± 4.8 mm (range of 5 to 20 mm). At a mean follow-up of 27 ± 20.1 months (range of 6 to 48 months), the WOMAC score was 83.7 ± 10.1 points. A total of 13 patients out of 16 (81.3%) had complete pain relief; 14 patients out of 16 (88%) regained full active hip flexion strength at the final follow-up; 1 patient was scheduled for cup revision after 6 months due to persistent symptomatology. No demographic data or CT measurements regarding cup position statistically influenced the outcome. The authors concluded that when preceded by an appropriate diagnosis, arthroscopic tenotomy proved safe and effective for iliopsoas impingement, regardless of the magnitude of cup protrusion. Moreover, these researchers stated that this retrospective, limited case series did not allow definitive conclusions. They stated that prospective, matched studies are needed to point out the advantages and indications of this procedure, particularly in comparison with the endoscopic technique.
The authors stated that the present cohort study shared the same limits as the previously published literature: retrospective design, small numbers, and the lack of direct comparison between different techniques. Furthermore, quantitative evaluation of hip strength was also not performed.
In a retrospective cohort study, Viamont-Guerra et al. (2021) reported outcomes of endoscopic iliopsoas tenotomy (EIT) in patients with iliopsoas tendinopathy following THA and examined if improvements in clinical scores were associated with acetabular cup anteversion measured on plain radiographs or overhang measured using established and alternative CT-based methods. These investigators examined patients who underwent EIT for iliopsoas tendinopathy following THA (2014 to 2017), performed between the lesser trochanter and psoas valley. Indications were groin pain during active hip flexion, exclusion of other complications, and no pain relief after 6 months of conservative treatment. Pre-tenotomy inclination and anteversion were measured on radiographs; sagittal and axial overhang were measured on CT scans on slices passing through: (Method 1) prosthetic head center and (Method 2) anterior margin of the acetabular cup. Modified HHS (mHHS), Oxford Hip Score (OHS), and level of groin pain were recorded at 12 or more months. Wilcoxon signed-rank tests were used to compare pre- and post-tenotomy scores, and intra-class correlation coefficients (ICCs) were used to evaluate inter-method agreement. Participants comprised 16 men (17 hips) and 32 women (33 hips), aged 60.8 ± 10.5 years at EIT. For the 30 (60%) hips that had pre-tenotomy CT scans, axial and sagittal overhang were, respectively, 3.4 ± 3.7 mm and 4.6 ± 4.6 mm using Method 1, compared with 3.9 ± 3.9 mm and 6.9 ± 5.0 mm using Method 2. Inter-method agreement was good for axial (ICC, 0.67; p < 0.001) and sagittal (ICC, 0.68; p < 0.001) overhang. At a minimum of 1 year after EIT, 3 hips had cup and stem revision, and 1 hip had isolated cup revision, leaving 46 hips for clinical assessment. No complications were noted. The mHHS improved by 26 ± 19 (p < 0.001), and the OHS improved by 20 ± 11 (p < 0.001). A total of 26 hips (57%) achieved the patient acceptable symptom state for mHHS, whereas 42 hips (91%) achieved the patient acceptable symptom state for OHS. Post-tenotomy groin pain was slight in 15%, mild in 17%, and moderate in 11%. Regression analyses revealed no associations between clinical scores and overhang/anteversion. The authors concluded that for patients with iliopsoas tendinopathy following THA, endoscopic iliopsoas tenotomy granted clinically important improvements of mHHS in 76% and OHS in 89%, despite moderate residual groin pain in 11%. Improvements in clinical scores did not appear to be associated with the extent of cup overhang or anteversion in the cases for which adequate pre-operative imaging was available. Level of Evidence = IV.
Valenzuela and O'Donnell (2021) noted that iliopsoas impingement is an under-diagnosed cause of groin pain following total hip arthroplasty (THA), being responsible for 4.4% of cases. Non-surgical treatment may be effective in approximately 50% of cases. Endoscopic surgery has gained popularity as an option for non-responsive patients because of its non-invasive characteristics, faster recovery, and encouraging results. In a retrospective review, these researchers compared 2 different sites of endoscopic psoas tenotomy performed following THA: at the edge of the acetabulum (AR) versus at the lesser trochanter (LT). They examined prospectively collected data from a single-surgeon case series. A total of 35 iliopsoas tenotomy cases that had 24 months or longer follow-up were identified. There were 21 tenotomies at the lesser trochanter. Demographic data, pre-operative as well as post-operative pain, modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) scores, strength, and patient satisfaction data were collected and analyzed. The average age at the time of surgery was 62 years. The mean follow-up for the LT group was 49.11 months and 42.42 months for the AR group. Pain decreased significantly for both groups (p < 0.001). Both mHHS and NAHS showed superiority in the LT group; however, this difference did not reach significance (p = 0.06). LT patients showed better strength, with 71.42% of them having normal strength at the latest follow-up, compared with 41.6% in the AR group. There were no complications in either group. The authors concluded that the findings of this study supported arthroscopic/endoscopic surgical management for patients with iliopsoas impingement following THA, which was not responsive to non-surgical treatment. Both tenotomy techniques led to improved symptoms in a high percentage of patients and had no early or late complications. However, tenotomy at the LT consistently showed less post-operative pain, better strength, and higher functional scores in comparison with the AR group, although these results did not reach statistical significance. Moreover, these researchers stated that although these results suggested that both approaches were reliable surgical options, with a trend for better outcomes for the LT group, a larger, prospective study is needed to definitively determine which technique is superior.
The authors stated that this study had several drawbacks. First, data were collected retrospectively; thus, some data points were missing. Second, many mHHS and NAHS pre-operative values were not collected; however, patients consistently had scores above the patient acceptable symptom state (PASS), with better results reported for the LT group. Third, specific radiographical assessment of the degree of acetabular prominence was not carried out.
In a systematic review, Coulomb et al. (2022) examined the technique, results, and complications of arthroscopic iliopsoas tenotomies either on native hips or THA. This systematic review was carried out using 3 databases: PubMed, Embase, and the Cochrane Library from January 2000 to December 2018 in accordance with the PRISMA procedure. The literature search, data extraction, and quality assessment were performed by 2 independent reviewers. Surgical technique, clinical outcomes, recurrences, and complication rates were evaluated. Out of 115 studies reviewed, 20 concerned native hips and 8 articles focused on THA; 3 levels of release were described. For native hips, the recurrence rate was higher for central compartment than peripheral or lesser trochanter releases. Complication rates were similar for hip arthroscopy but remained low in all series. Loss of strength was examined mainly using the Medical Research Council (MRC) muscle scale. Most studies noted strength recovery. MRI analysis of muscle atrophy was greater for lesser trochanter than for central compartment release but unrelated to loss of strength. The complication rate was low for tenotomy following THA, with heterotopic ossification being the most common complication. The authors concluded that central compartment releases resulted in the highest rate of recurrence due to incomplete release. Peripheral releases had a potential risk of vascular injury. The lesser trochanteric approach had the disadvantage of not having direct access to the joint. The main difficulty with THA lay in the diagnosis of cup/iliopsoas impingement. Diagnostic tests with infiltration should be made before iliopsoas release to prevent its failure. Cup protrusion of over 8 mm was a potential indication for acetabular revision. This review identified 8 studies of iliopsoas tenotomy following THA. These researchers noted that the studies analyzed had low statistical power, as most of them were grade-4 and a few of them were grade-3. This was explained by the low frequency of pathologies related to the iliopsoas tendon that did not allow for larger series. Given the low level of scientific proof (grade-3 or grade-4), the validity of the conclusions was questionable.
The authors stated that this analysis had several drawbacks. First, the heterogeneity of the evaluation scales in the articles (HHS, OHS, WOMAC) raised the problem of measurement bias. Second, the populations in the series under study were not comparable (e.g., different countries, age, gender, athletic), which may have led to a selection bias. Third, due to its methodology, a literature review may be the cause of non-communication of certain results. This “file drawer” effect may be responsible for a publication bias.
In a retrospective study, Nikou et al. (2023) examined the outcome of arthroscopic treatment for iliopsoas impingement following THA 2 years after surgery using patient-reported outcomes (PROs). A total of 12 patients (13 hips) were included from a local hip arthroscopy registry. Patients completed web-based PROs pre-operatively and at a minimum of 2 years post-operatively. The PROs included the International Hip Outcome Tool short version (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS), the European Quality of Life-5 Dimensions Questionnaire (EQ-5D), the Hip Sports Activity Scale (HSAS) for physical activity level, the visual analog scale (VAS) for overall hip function, and a single question regarding overall satisfaction with the surgery. The mean age was 64.4 years (± 15.1 SD), mean BMI was 26.6 (± 4.3 SD), and mean follow-up time was 49.8 months (± 25 SD). Comparing PROs pre-operatively with 2-year follow-up showed an improvement for many of the PROs used. The PRO scores were iHOT-12 (24.9 versus 34.5, p = 0.13), HAGOS subscales (symptoms 38.2 versus 54.5, p = 0.05; pain 36 versus 53, p = 0.04; sport 14.1 versus 35.1, p = 0.03; daily activity 31 versus 47.5, p = 0.04; physical activity 21.8 versus 24, p = 0.76; QOL 24 versus 35, p = 0.03), EQ-VAS (57.9 versus 58, p = 0.08), EQ-5D (0.34 versus 0.13, p = 0.07), and VAS for overall hip function (43.1 versus 46.2, p = 0.14). A total of 10 out of the 12 patients (83%) were satisfied with the intervention. The authors concluded that patients undergoing surgery for iliopsoas impingement following previous THA showed improved self-reported hip function, with most patients satisfied with treatment.
The authors stated that this study had several drawbacks. It was a retrospective analysis of prospectively collected data. The small patient sample (n = 12) imposed certain limitations regarding the conclusions that could be drawn from this study. A power analysis was not conducted before analysis, as this was a retrospective study, which meant that there was a significant possibility of type-II error. However, to the knowledge of the authors, this was one of the few current studies examining results after arthroscopic psoas tenotomy following THA using recommended PROs for hip arthroscopy patients. Although a thorough search was executed with both the local registry data as well as a search in the hospital registers, there was still a risk that not all patients were found. However, the risk was deemed to be small. Another drawback of this study was the short follow-up of 2 years. A longer follow-up could be warranted to strengthen conclusions regarding the long-term effects of this method. Another aspect was that the radiological analysis was performed by only 1 surgeon without any inter- or intra-observer agreement analysis of the radiological findings, potentially limiting the accuracy of the radiological values registered. Furthermore, the hip flexion muscle strength pre- and post-operatively was not measured; thus, it was not possible to examine the effect of iliopsoas tenotomy on hip flexion muscle strength.
Hip Arthroscopy with Labral Reconstruction or Augmentation
In a systematic review, Lee et al. (2024) examined patient-reported outcomes (PROs) and survivorship in patients undergoing revision hip arthroscopy with labral reconstruction or augmentation. These investigators carried out a systematic review with the following key words: (revision) AND (hip OR femoroacetabular impingement) AND (arthroscopy OR arthroscopic) AND (reconstruction OR augmentation OR irreparable). PubMed, Cochrane Trials, and Scopus were searched in October 2022 using the criteria established in the PRISMA guidelines. Studies were included if they involved patients undergoing revision hip arthroscopy with labral reconstruction or augmentation and reported pre-operative and post-operative PROs at a minimum of 2 years follow-up. Only original research studies were included. Survivorship was defined as a non-conversion to total hip arthroplasty (THA). Outcomes present in 3 or more studies underwent further statistical analysis with forest plots. Heterogeneity of studies was examined using the I² statistic. A total of 5 studies were reviewed, including 359 revision hip arthroscopies (335 with complete follow-up) with a follow-up that ranged from 2.2 to 5.2 years. A total of 4 studies reported on outcomes after revision labral reconstruction, and 1 study reported on labral augmentation; 2 out of 5 included studies evaluated for statistical significance between pre-operative and post-operative outcomes; 3 out of 5 studies reported a rate of at least 70% for achieving minimal clinically important difference (MCID) in at least 1 PRO. At minimum 2 years follow-up, survivorship ranged from 93.5% to 100%. The authors concluded that patients who underwent revision hip arthroscopy with labral reconstruction or augmentation showed improvement in PROs with mixed rates of achieving clinical benefit and rates of survivorship at minimum 2 years follow-up ranging from 93.5% to 100%. Level of Evidence = IV.
Kim et al. (2024) stated that there is a paucity of aggregate data documenting mid- to long-term outcomes of patients following hip arthroscopy with labral reconstruction. In a systematic review, these investigators examined mid- to long-term outcomes in patients after undergoing either primary or revision hip arthroscopy with labral reconstruction for the treatment of irreparable labral tears. They searched PubMed, Cochrane, and Scopus databases in May 2022 with the following keywords: "hip arthroscopy," "labral reconstruction," "irreparable," "labrum," "reconstruction," "five-year," "midterm," "5 year," "long-term," "10 year," "ten-year," and "femoroacetabular impingement," using the PRISMA guidelines. Mid-term was defined as a mean 5-year follow-up, and long-term was defined as a mean 10-year or longer follow-up. For each included study, the demographic, radiographic, intra-operative, and surgical variables, as well as PROs, psychometric thresholds, and secondary surgeries were recorded. Forest plots were created for PROs that were reported in 3 or more studies; heterogeneity was examined using I² values. Out of 463 initial articles, 5 studies including 178 hips with primary and 41 hips with revision surgeries were included. One study had an average 5-year follow-up, 3 studies had a minimum 5-year follow-up, and 1 study had a minimum 10-year follow-up. The most common indications for hip arthroscopy with labral reconstruction were irreparable labral tears. The most common PRO was the modified Harris Hip Score (mHHS), which was reported in all 5 studies. The mean pre-operative mHHS ranged from 58.9 to 66, and the mean post-operative mHHS at minimum 5-year follow-up ranged from 80.2 to 89. The pre-operative and post-operative mHHS for the single long-term follow-up study were 60 and 82, respectively. All 5 studies showed significant improvements in reported PROs. All 5 studies reported secondary surgery rates, with 1 study reporting rates at both 5- and 10-year follow-up. Conversion to THA ranged from 0% to 27%, while overall secondary surgery rates ranged from 0% to 36%. The authors concluded that the findings of this systematic review showed that patients undergoing primary and revision hip arthroscopy with labral reconstruction experienced favorable outcomes and high rates of clinical benefit and survivorship at mid- to long-term follow-up. Level of Evidence = IV.
The authors stated that this review had several drawbacks. First, these researchers included patients undergoing labral reconstruction with a variety of surgical techniques, graft choices, and sizes of reconstruction, which may have confounded outcomes. Second, the wide study period of some studies may have failed to capture trends of improving surgical techniques, including capsular closure, which could have influenced patient outcomes. Third, these investigators included patients who underwent both primary and revision hip arthroscopy, which added to the heterogeneity of the group studied. Fourth, multiple studies from the same institution were included, and the same patients may have been included in multiple studies. Fifth, this review incorporated non-randomized studies, which limited external validity and introduced selection bias into the study. Sixth, the number of studies screened for inclusion in this review was constrained by the comprehensive but finite set of search terms used. Seventh, these researchers did not report complication rates, which was influenced by the limited data and lack of emphasis on operative complications in the studies reviewed.
Domb et al. (2024) noted that hip arthroscopy has shown effectiveness as a treatment for femoroacetabular impingement (FAI) in adult patients, with promising long-term outcomes; however, there is a paucity of data on the adolescent population. In a nested, propensity-matched analysis, these investigators reported on survivorship and PROs at a minimum 10-year follow-up in adolescent patients who underwent hip arthroscopy for FAI and labral tears and compared the survivorship and outcomes of this population with those of a nested, propensity-matched adult control group. Data regarding adolescent patients who underwent primary hip arthroscopy between February 2008 and January 2012 were reviewed. Patients with a minimum 10-year follow-up for the mHHS, NAHS, HOS-SSS, iHOT-12, and VAS for pain were eligible. The exclusion criteria were previous ipsilateral hip conditions or surgical procedures, a Tonnis grade of greater than 1, or dysplasia. In the sub-analysis, adolescent patients were matched to young adult patients using a 1:1 ratio based on sex, BMI, Tonnis grade, LCEA, labral treatment, capsular treatment, and additional procedures carried out during the surgery. A total of 74 patients (61 female and 13 male; 74 hips) with a mean (and standard deviation [SD]) age of 16.7 ± 1.4 years and a minimum follow-up of 10 years were included. The latest follow-up occurred at a mean of 125.4 ± 5.3 months (range of 120.0 to 144.1 months). Significant improvement in all PROs from baseline and 100% survivorship were observed at the 10-year follow-up. In the sub-analysis, 58 adolescent hips were propensity-matched to 58 young adult hips. The adolescent group had higher post-operative scores for the HOS-SSS (p = 0.021), NAHS (p = 0.021), and iHOT-12 (p = 0.042) than the young adult group. Patient satisfaction at the latest follow-up was also significantly higher in the adolescent group (p = 0.00061). The rate of survivorship free from conversion to THA was similar between the adolescent and control groups (100% versus 96.6%; p = 0.200). The authors concluded that adolescents undergoing hip arthroscopy for the treatment of FAI and labral tears showed excellent outcomes and a high rate of survivorship. These outcomes were superior to those observed in a matched adult group. The findings of this study indicated that hip arthroscopy in adolescents was a safe procedure that resulted in improvement in outcomes at long-term follow-up. Level of Evidence = IV.
Endoscopic Tendon Release for Iliopsoas Impingement After Total Hip Arthroplasty
Park et al. (2023) noted that iliopsoas tendinopathy (IPT) can cause persistent groin pain and result in dissatisfaction following total hip arthroplasty (THA). In a single-center study, these investigators reported the characteristics, incidences, risk factors, and treatment outcomes of IPT following THA. They reviewed primary THAs carried out between January 2012 and May 2018. Clinical and radiographic analyses were conducted on 1,602 THAs (1,370 patients). Patient characteristics, component sizes, inclination and anteversion angles, and antero-inferior cup prominence (8 mm or greater) were compared between the groups with and without IPT. Changes in teardrop to lesser trochanter (LT) distance were measured to estimate changes in leg length and horizontal offset caused by THA. Logistic regression models were used to identify the risk factors for IPT, which was identified in 53 hips (3.3%). Patients with IPT had greater leg lengthening (12.3 versus 9.3 mm; p = 0.001) and a higher prevalence of antero-inferior cup prominence (5.7% versus 0.4%; p = 0.002). There was no significant difference in inclination, anteversion, and horizontal offset change between the two groups. In multivariate analyses, greater leg lengthening, prominent acetabular cup, female sex, and higher BMI were associated with IPT. All patients reported improvement in groin pain after arthroscopic tenotomy, while 35.7% with non-operative management reported improvement (p < 0.001). The authors concluded that symptomatic IPT occurred in 53 (3.3%) of the 1,602 primary THAs. These researchers stated that these findings suggested that leg lengthening, as well as a prominent acetabular cup in THAs, could be associated with the development of IPT; and arthroscopic tenotomy was effective in relieving groin pain caused by IPT.
Lambrey et al. (2023) stated that the occurrence of iliopsoas impingement (IPI) following THA is a proven risk factor for negative outcomes. Endoscopic or arthroscopic tenotomies of the iliopsoas offer a surgical solution with short-term results that have already been validated in prospective, multi-center series. In a continuation of a prospective, multi-center study, these investigators reviewed patients at more than 5 years of follow-up to evaluate the stability of the results over time. They hypothesized that endoscopic/arthroscopic tenotomies would allow stable medium-term resolution of the painful symptoms of IPI; the secondary hypothesis was that medium-term survival would be satisfactory. Patients were contacted via multiple channels to obtain an Oxford score, evaluate for satisfaction, psoas irritation, and daily pain on a visual analog scale (VAS). Of 64 patients in the original study, 57 were contacted. The Oxford score at the last follow-up was 40.7 ± 7.7 (range 12 to 48). There was a significant difference between the Oxford scores pre-operatively, at 8 months, and at the last follow-up. The mean satisfaction out of 10 was 8.0 ± 2.1 (range 1 to 10). These researchers found 84% satisfaction at 5 years compared to 83% at 8 months. The VAS was 2.1 ± 2.3 (range 0 to 10). A straight leg psoas sign was present in 19.6% (10/51) of patients at 5 years, compared to 15.6% (8/51) at 8 months. The sign disappeared in 4 cases, while it re-appeared during the interval in 6 cases. The survival rate was 91.2% (95% CI: 80.2 to 96.3) at 5 years. The authors concluded that endoscopic/arthroscopic iliopsoas tenotomies represented a permanent medium-term solution for the treatment of IPI following THA. The existence of a force differential or an acetabular overhang did not appear, within a certain limit, to impact the results in the mid-term.
In a case-series study, Finsterwald et al. (2024) examined the effectiveness of endoscopic iliopsoas tendon release (IPR) at the LT in patients with IPI following THA. Between November 2017 and March 2021, a consecutive series of 36 patients were treated with endoscopic IPR for diagnosed IPI. Subjects included had acetabular cup position confirmed by functional imaging (OPS, Corin, Pymble, NSW), typical clinical symptoms of IPI, and a positive response to diagnostic injection. Clinical assessment included validated patient-reported outcome measures (PROMs) along with hip flexion strength and active range of motion (ROM) at different time points up to 2 years follow-up, as well as surgical complications. A total of 36 consecutive patients (11 men) with a mean age of 62 ± 12 years were included in this trial. All participants had failed non-operative management. Dynamic CT assessment was available in 89% of the patients, edge loading was reported in 10%, and variable cup overhang was reported in 50%. Clinically, PROMs were significantly improved at every time point when compared with pre-operative values (p < 0.001), showing the biggest improvement within the first 4 weeks following surgery. At the 6-month follow-up, peak isometric hip flexion strength on the operated side was 20% lower than the contralateral side (p < 0.001). The failure rate of the procedure was 2.8% (1 case). Linear regression showed no association between cup overhang and clinical outcomes. The authors concluded that endoscopic IPR at the LT was a safe and reproducible technique associated with significant and immediate improvement in pain, functional outcomes, and high patient satisfaction. With minimal short-term weakness, no complications, and only a single revision, even in cases with cup malposition and/or edge loading, these investigators believed that endoscopic IPR could be considered as one of the first-line operative options in patients with symptomatic IPI, irrespective of component position.
In an editorial that accompanied the aforementioned study by Finsterwald et al. (2024), Cuellar et al. (2024) stated that IPI pathology is one of the causes of persistent pain following THA. It is reported as occurring in approximately 4% of cases; this may be significantly greater in cases of post-arthroplasty pain of unknown etiology. Inflammation is a result of impingement of the tendon against the acetabular component. This may occur with antero-inferior prominence when the cup is properly positioned in anteversion or when the cup is oversized. Other causes of impingement include a cup-reinforcement ring or acetabular cage, a collared femoral component, screws penetrating through the ilium, cement extrusion, anterior wall hypoplasia, or increased femoral offset. When conservative treatment does not achieve the best outcome, the two main therapeutic options are psoas tenotomy or revision of the cup component. Tenotomy can be carried out either arthroscopically or by an open approach and may be considered the best option for many patients, even in cases with anterior component prominence, as it is less invasive, presents fewer complications, and has faster recovery.
Erard et al. (2024) reported 5-year outcomes of endoscopic iliopsoas tenotomy in patients with IPT following THA and examined if clinical scores were associated with cup position. Patients who underwent endoscopic iliopsoas tenotomy for IPT following THA (2014 to 2017) were contacted. Indications for endoscopic iliopsoas tenotomy after THA were groin pain during active hip flexion, exclusion of other causes of groin pain, and no pain relief after 6 months of conservative treatment. Pre-tenotomy cup inclination and anteversion were measured on radiographs; axial and sagittal cup overhang were measured on CT scans; Oxford Hip Score (OHS), mHHS, and groin pain were also assessed. The initial cohort comprised 16 men (17 hips) and 31 women (32 hips), aged 60.7 ± 10.6 years. Cup inclination and anteversion were, respectively, 46.2 ± 6.2° and 14.6 ± 8.4°, while axial and sagittal cup overhang were, respectively, 4.4 ± 4.0 mm and 6.9 ± 4.5 mm. At 5 years or longer follow-up, 4 hips underwent cup and stem revision, 2 underwent isolated cup revision, and 1 underwent secondary iliopsoas tenotomy. OHS improved by 23 ± 10, and mHHS improved by 31 ± 16. Post-tenotomy groin pain was slight in 20.0%, mild in 17.5%, and moderate in 12.5%. Regression analyses showed that the net change in mHHS decreased with sagittal cup overhang (β = -3.1; 95% CI: -4.6 to -1.7; p < 0.001); however, there were no associations between cup position and net change in OHS. The authors concluded that endoscopic iliopsoas tenotomy provided good mid-term clinical outcomes in patients with IPT following THA. In addition, improvements in mHHS were found to decrease with increasing sagittal cup overhang in cases for which adequate pre-operative imaging was available.
Giai Via et al. (2024) noted that hip replacement surgery is highly effective in relieving pain and improving mobility in patients with various hip conditions; however, some patients develop groin pain following surgery, often due to IPI, which can be challenging to diagnose. Conservative treatments are initially recommended; however, when these approaches are not effective, surgical interventions may be needed. In a systematic review, these investigators examined the clinical outcomes, success and failure rates, revision rates, as well as complications associated with arthroscopic and endoscopic surgery for IPI, thus providing a comprehensive understanding of the effectiveness and risks of these surgical interventions. This review was carried out according to PRISMA guidelines, including a thorough search of 5 main databases: PubMed, Scopus, Embase, Medline, and Cochrane. Eligible studies were evaluated according to pre-defined criteria for levels of evidence (LoE), with retrospective studies assessed using the Coleman Methodology Score (mCMS). Among the 16 included studies, 431 patients with 434 hips underwent either endoscopic or arthroscopic tenotomy. Both techniques showed favorable outcomes, with arthroscopic tenotomy reporting slightly higher success rates than endoscopic tenotomy. Common complications included mild pain and occasional infections, with recurrence observed in some cases. Both techniques offered direct visualization of prosthetic components and potential preservation of psoas function. The authors concluded that arthroscopic and endoscopic iliopsoas tenotomy were effective treatments for alleviating symptoms and improving hip function in patients with IPI following THA.
Hip Arthroscopy for the Treatment of Ehlers Danlos Syndrome
In a case-series study, Rosinsky et al. (2020) reported on minimum 2-year outcomes of patients undergoing arthroscopic ligamentum teres reconstruction (LTR). These researchers reviewed their institutional registry for all patients undergoing LTR between December 2012 and February 2016. LTR was indicated for a fully torn or dysfunctional ligamentum teres with symptomatic multi-directional instability not treatable by osteotomy or capsular plication alone. Demographic data, pre-operative clinical and radiographic measures, as well as intra-operative data were recorded. Patient-reported outcome measures (PROMs) including the modified Harris Hip Score (mHHS), the Non-Arthritic Hip Score (NAHS), a visual analog scale (VAS) score for pain, and patient satisfaction were recorded pre-operatively and annually post-operatively. Revision arthroscopies and conversions to total hip arthroplasty (THA) were recorded. A total of 12 reconstruction procedures were performed in 10 patients during the study period. Minimum 2-year follow-up was available for 9 patients (11 hips). The mean follow-up time was 44.27 months (range of 24 to 72 months). There were 7 female and 2 male patients, and the mean age was 30.34 years (range of 17.23 to 43.68 years); 2 hips underwent conversion to THA at a mean of 21.12 months. For the remaining patients, significant improvements were observed in the mHHS (from 44.1 to 71.8), NAHS (from 47.5 to 78.6), and VAS score (from 7.8 to 3.6) (p < 0.05). The average patient satisfaction rating was 7.88 (range of 4 to 10). A sub-analysis of 5 patients (7 hips) with a diagnosis of Ehlers-Danlos syndrome (EDS) showed a higher failure rate in this group. The authors concluded that although LTRs were indicated and carried out only in a select group of patients, the procedure could provide meaningful improvement in PROMs, pain reduction, and patient satisfaction. However, most patients undergoing LTR at present have underlying factors that significantly mitigate their prognosis, such as EDS or failed previous surgery. Because these patients represent a subset of patients with complex hip pathologies in whom treatment is difficult, the expectations of surgery should be set accordingly. Level of Evidence = IV.
Schubart et al. (2024) stated that patients with EDS often experience high rates of joint subluxations and dislocations, and associated pain that may require surgical interventions. Orthopedic surgical management is challenging in this population, and patients will often undergo multiple unsuccessful surgeries. Outcomes data specific to patients with EDS are sparse in the orthopedic surgery literature. In a scoping review, these investigators examined the evidence and outcomes for orthopedic surgery specifically for the EDS population. They searched PubMed, Medline, Embase, The Cochrane Library, Cochrane Controlled Register of Trials (CENTRAL), CINAHL, and Scopus from their inception to February 28, 2024, for all studies that reported outcomes for orthopedic surgery in patients with EDS. Two reviewers independently determined study eligibility, rated study quality, and extracted data. Methodology followed the PRISMA extension for scoping reviews (PRISMA-ScR). The studies in this scoping review included Level III (retrospective cohort and case control) and Level IV (case series) evidence. The literature search yielded a total of 71 citations published between 1990 and 2023. All were primary studies—38 were single-case studies, 14 were case-series studies, and 19 were retrospective cohort studies. No randomized clinical studies or systematic reviews were identified. Overall, the reported findings for the various anatomical sites and procedures indicated that surgery outcomes were inconsistent. This review highlighted the need for future studies to examine if currently established surgical approaches for various orthopedic conditions offer long-term clinical benefit in patients with EDS. This is clearly a challenging diagnosis, and more rigorous clinical studies are needed to identify optimal treatment approaches. The authors concluded that this review found little evidence-based research to guide optimal surgical treatment in EDS. These researchers stated that established surgical techniques that have been shown to be successful in the wider orthopedic population should be studied to determine their effectiveness in the EDS population.
These investigators stated that future research is needed to determine the incidence and prevalence of orthopedic manifestations that may require surgical interventions, the short-term and long-term outcomes of conservative management and surgery, as well as the rate of complications associated with each procedure. Ideally, future studies should include accurate diagnosis of the specific type of EDS studied, using stated criteria. Studies are needed to understand the stages of progression to surgery, including the effectiveness of physiotherapy and other non-surgical interventions. Studies are also needed to determine the effectiveness of post-surgical rehabilitation plans, ideally identifying measurable functional parameters of outcomes that are of practical relevance.
- observational studies, cohort studies, and randomized controlled trials (RCTs);
- describing more than 5 patients with a mean age over 18 years and GJH;
- undergoing arthroscopy of the hip;
- reporting patient-reported outcome measures (PROMs), return-to-sport, or complications/re-operations; and
- published in English.
Of the 517 articles identified, 10 studies meeting all selection criteria were included. Included studies reported significant improvements in a range of different functional and pain-based PROMs. Most patients (25.0% to 97.0%) in each study achieved a clinically important improvement post-operatively in at least 1 PROM. No complications were described in any of the 4 studies reporting this metric. One study each found an association between GJH and an increased risk of post-operative deep gluteal syndrome and iliopsoas tendinitis. The rate of revision arthroscopy ranged from 0% to 11.4%, and only 2 patients in a single study of 11 hips required conversion to total hip arthroplasty (THA). No statistically significant differences were reported between patients with and without GJH with respect to any of the described outcomes. The authors concluded that patients with GJH may achieve good outcomes following hip arthroscopy with respect to PROMs, peri-operative complications, re-operation, and return-to-sport. With effective labral repair and capsular closure, outcomes achieved in patients with GJH were comparable to those reported in patients without hypermobility. Level of Evidence = IV.
The authors stated that the principal drawback of this review was the inability to conduct a formal meta-analysis comparing outcomes in GJH and non-GJH across different studies due to heterogeneity between studies. Included studies employed a wide range of different PROMs, used various Beighton score cut-offs to define GJH, reported varying surgical techniques and indications, and described cohorts with different demographic characteristics. These sources of heterogeneity made pooling outcomes challenging and would limit the reliability of any formal meta-analysis.
Outcomes of Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Obese Patients
In a retrospective, comparative study. Berzolla et al. (2025) examined PROs and survivorship in obese patients undergoing hip arthroscopy for FAI syndrome (FAIS) at 10-year follow-up. This trial reviewed data of patients who underwent arthroscopy for FAIS from 2011 to 2013. Participants were evaluated at baseline, 1 month, 6 months, 1 year, 2 years, 5 years, and 10 years using the MHHS and NAHS. Subjects were categorized on the basis of BMI into normal, over-weight, and obese cohorts; MCID and PASS were calculated for both PROs. Improvements from baseline were analyzed, and differences between groups were evaluated while controlling for age. Survival to revision surgery was assessed with Kaplan-Meier survival curves. A total of 144 patients (65.2% women) with a mean age of 38.8 ± 13.0 years and an average follow-up of 11.6 years (rang of: 10.0 to 13.8) were included, and categorized into normal weight (59.7%), over-weight (26.4%), and obese (13.9%). All groups showed significant improvement in PROs at 10 years compared to baseline (p = 0.007). Obese subjects had lower post-operative scores (MHHS: 72.8 versus 90.1; p = 0.009; NAHS: 68.4 versus 88.6; p = 0.003) and improvement in scores from baseline (MHHS: 23.4 versus 37.7; p = 0.013; NAHS: 18.4 versus 40.0; p = 0.004) at 10-year follow-up, as well as lower achievement of MHHS PASS (60.0% versus 87.2%; p = 0.015), NAHS PASS (50.0% versus 89.5%; p < 0.001) and NAHS MCID (70.0% versus 93.0%; p = 0.008). Obese patients also had a higher rate of conversion to THA (17.4% versus 3.3%; p = 0.012). The overall complication rate was 4.2% compared to 10% in the obese group, with obese patients experiencing a superficial infection more frequently (p = 0.002). The authors concluded that although obese patients still exhibited significantly improved outcomes compared to baseline, at 10-year follow-up they had inferior outcomes compared to non-obese patients and higher rates of conversion to THA. Level of Evidence = III.
Periacetabular Osteotomy
In a case-series study, Rosinsky et al. (2020) reported on minimum 2-year outcomes of patients undergoing arthroscopic ligamentum teres reconstruction (LTR). These researchers reviewed their institutional registry for all patients undergoing LTR between December 2012 and February 2016. LTR was indicated for a fully torn or dysfunctional ligamentum teres with symptomatic multi-directional instability not treatable by osteotomy or capsular plication alone. Demographic data, pre-operative clinical and radiographic measures, as well as intra-operative data were recorded. Patient-reported outcome measures (PROMs) including the modified Harris Hip Score (mHHS), the Non-Arthritic Hip Score (NAHS), a visual analog scale (VAS) score for pain, and patient satisfaction were recorded pre-operatively and annually post-operatively. Revision arthroscopies and conversions to total hip arthroplasty (THA) were recorded. A total of 12 reconstruction procedures were performed in 10 patients during the study period. Minimum 2-year follow-up was available for 9 patients (11 hips). The mean follow-up time was 44.27 months (range of 24 to 72 months). There were 7 female and 2 male patients, and the mean age was 30.34 years (range of 17.23 to 43.68 years); 2 hips underwent conversion to THA at a mean of 21.12 months. For the remaining patients, significant improvements were observed in the mHHS (from 44.1 to 71.8), NAHS (from 47.5 to 78.6), and VAS score (from 7.8 to 3.6) (p < 0.05). The average patient satisfaction rating was 7.88 (range of 4 to 10). A sub-analysis of 5 patients (7 hips) with a diagnosis of Ehlers-Danlos syndrome (EDS) showed a higher failure rate in this group. The authors concluded that although LTRs were indicated and carried out only in a select group of patients, the procedure could provide meaningful improvement in PROMs, pain reduction, and patient satisfaction. However, most patients undergoing LTR at present have underlying factors that significantly mitigate their prognosis, such as EDS or failed previous surgery. Because these patients represent a subset of patients with complex hip pathologies in whom treatment is difficult, the expectations of surgery should be set accordingly. Level of Evidence = IV.
Schubart et al. (2024) stated that patients with EDS often experience high rates of joint subluxations and dislocations, and associated pain that may require surgical interventions. Orthopedic surgical management is challenging in this population, and patients will often undergo multiple unsuccessful surgeries. Outcomes data specific to patients with EDS are sparse in the orthopedic surgery literature. In a scoping review, these investigators examined the evidence and outcomes for orthopedic surgery specifically for the EDS population. They searched PubMed, Medline, Embase, The Cochrane Library, Cochrane Controlled Register of Trials (CENTRAL), CINAHL, and Scopus from their inception to February 28, 2024, for all studies that reported outcomes for orthopedic surgery in patients with EDS. Two reviewers independently determined study eligibility, rated study quality, and extracted data. Methodology followed the PRISMA extension for scoping reviews (PRISMA-ScR). The studies in this scoping review included Level III (retrospective cohort and case control) and Level IV (case series) evidence. The literature search yielded a total of 71 citations published between 1990 and 2023. All were primary studies—38 were single-case studies, 14 were case-series studies, and 19 were retrospective cohort studies. No randomized clinical studies or systematic reviews were identified. Overall, the reported findings for the various anatomical sites and procedures indicated that surgery outcomes were inconsistent. This review highlighted the need for future studies to examine if currently established surgical approaches for various orthopedic conditions offer long-term clinical benefit in patients with EDS. This is clearly a challenging diagnosis, and more rigorous clinical studies are needed to identify optimal treatment approaches. The authors concluded that this review found little evidence-based research to guide optimal surgical treatment in EDS. These researchers stated that established surgical techniques that have been shown to be successful in the wider orthopedic population should be studied to determine their effectiveness in the EDS population.
These investigators stated that future research is needed to determine the incidence and prevalence of orthopedic manifestations that may require surgical interventions, the short-term and long-term outcomes of conservative management and surgery, as well as the rate of complications associated with each procedure. Ideally, future studies should include accurate diagnosis of the specific type of EDS studied, using stated criteria. Studies are needed to understand the stages of progression to surgery, including the effectiveness of physiotherapy and other non-surgical interventions. Studies are also needed to determine the effectiveness of post-surgical rehabilitation plans, ideally identifying measurable functional parameters of outcomes that are of practical relevance.
Appendix
Arthroscopic hip surgery may be medically necessary for the following additional indications:
- Acute fractures of the femoral head or acetabulum; or
- Malunion of a previous intraarticular fracture; or
- Persons with chronic (3 or more months duration), persistent hip pain or dysfunction due to avascular necrosis or loose bodies; or
- Limited synovectomy for chronic inflammatory arthritides (e.g., rheumatoid arthritis, psoriatic arthritis, Lyme arthritis), benign neoplastic disorders (e.g., osteochondromatosis and pigmented villonodular synovitis), recurrent hemarthrosis (e.g., hemophilia), or septic arthritis; or
- Ligamentum teres injuries; or
- Synovial biopsy.
Note: Aetna considers psoas tendon release an integral part of femoroacetabular impingement syndrome surgery.
Tönnis Classification of Osteoarthritis by Radiographic Changes
Grade 0: No signs of OA
Grade 1: Increased sclerosis, slight joint space narrowing, no or slight loss of head sphericity
Grade 2: Small cysts, moderate joint space narrowing, moderate loss of head sphericity
Grade 3: Large cysts, severe joint space narrowing, severe deformity of the head
Outerbridge Classification
Grade 0: normal cartilage
Grade I: cartilage with softening and swelling
Grade II: a partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameter
Grade III: fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cm
Grade IV: exposed subchondral bone
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