Orthopaedic surgeons continually seek to refine techniques to improve their patients’ surgical outcomes. Surgical treatments for femoroacetabular impingement (FAI) syndrome are no exception, and careful patient selection is also critical to the success of these interventions. In the June 17, 2020 issue of The Journal, Ceylan et al. analyzed a single-surgeon prospective database to identify risk factors for treatment failure after a particular hip-preservation surgery known as mini-open femoroacetabular osteoplasty (FAO). In this study, the authors defined “failure” as the eventual need for a total hip arthroplasty (THA) over a minimum 2-year follow-up.
The 749 procedures studied were performed between 2004 and 2016 and involved treatment of the femur, acetabular rim, labrum, and chondral surfaces if necessary. Labral repair was performed on all hips that had adequate healthy tissue, while those that did not were treated with partial or total excision of the labrum.
Sixty-eight hips (9%) underwent THA. The patients who did not need a hip replacement were significantly younger (mean age of 33 years vs nearly 42) and were operated on after the surgeon had more experience. Other significant differences among the failure group included the duration of symptoms (twice as long, at 3.6 years), higher preop alpha angles, and a higher percentage of total labral resections performed.
Radiographic evidence of hip dysplasia was also a significant risk factor for failure, along with labral hypertrophy and acetabular retroversion (both of which may be considered proxies for volume-deficient acetabuli). After adjusting for covariates, Ceylan et al. found that less surgeon experience, older patient age, prolonged preoperative symptoms, increased medial joint space narrowing and Tonnis grade, and developmental hip dysplasia were all associated with a higher risk of failure after FAO surgery.
Although these findings do not represent results using the most up-to-date arthroscopic techniques for FAI treatment, they do highlight characteristics that can and should be discussed with patients with FAI when the subject of expected surgical outcomes arises during shared decision making.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
Many orthopaedists wonder whether—or under what circumstances—arthroscopy confers any clinical benefit in treating hip osteoarthritis. A prospective matched-pair analysis by Chandrasekaran et al. in the June 15, 2016 Journal of Bone & Joint Surgery suggests that arthroscopy does not help prevent the eventual conversion to total hip arthroplasty (THA) in hips with Tönnis grade-2 arthritis (moderate narrowing of the joint space with moderate loss of femoral-head sphericity).
The authors compared two-year outcomes from 37 patients with Tönnis grade-2 hip osteoarthritis who had a hip arthroscopy performed with outcomes from matched cohorts of 37 Tönnis grade-0 and 37 grade-1 hips on which arthroscopy was also performed. In all cases, arthroscopy sought to address symptomatic intra-articular hip disorders refractory to nonoperative management. The cohorts were matched to minimize the confounding effects of age, sex, and BMI on the outcomes.
There were no significant differences among the groups with respect to four patient-reported outcome measures (including the modified Harris hip score), VAS pain scores, and patient satisfaction levels. However, Tönnis grade-2 hips had a significantly higher conversion rate to THA compared to the other two matched cohorts. In absolute terms, a subsequent THA was required for 3 hips in the Tönnis grade-0 group, 5 in the Tönnis grade-1 group, and 15 in the Tönnis grade-2 group.
From this finding, the authors conclude that “hip arthroscopy has a limited role as a joint preservation procedure in select patients with Tönnis grade-2 osteoarthritis…Hip arthroscopy can effectively restore the labral seal and address impingement, but patients may continue to experience symptoms associated with the osteoarthritis.”