Clinical Sports Medicine Update

Arthroscopic Versus Open Treatment of Femoroacetabular Impingement


A Systematic Review of Medium- to Long-Term Outcomes Benedict U. Nwachukwu,*y MD, MBA, Brian J. Rebolledo,y MD, Frank McCormick,z MD, Samuel Rosas,z BS, Joshua D. Harris,§ MD, and Bryan T. Kelly,y|| MD Investigation was performed at the Hospital for Special Surgery, New York, New York, USA Background: Surgical treatment of symptomatic femoroacetabular impingement (FAI) aims to improve symptoms and potentially delay initiation of hip osteoarthritis and prevent progression to end-stage hip osteoarthritis and possible total hip arthroplasty (THA). Hip arthroscopy and open surgical hip dislocations are the 2 most common surgical approaches used for this condition. Purpose: To perform a comparative systematic review to determine whether there is a significant difference in clinical outcomes and progression to THA between hip arthroscopy and open surgical hip dislocation treatment for FAI at minimum medium-term follow-up. Study Design: Systematic review and meta-analysis. Methods: A systematic review of the MEDLINE database by use of the PubMed interface was performed. Minimum mean followup for included studies was set at 36 months. English-language studies with a minimum mean medium-term time frame evaluating outcome after arthroscopic or open treatment of FAI were included. Independent t tests, Kaplan-Meier survival analysis, and weighted mean pooled cohort statistics were performed. Results: A total of 16 studies met inclusion criteria. There were 9 open surgical hip dislocation studies and 7 hip arthroscopy studies. Open studies included 600 hips at a mean follow-up of 57.6 months (4.8 years; range, 6-144 months). Arthroscopic studies included 1484 hips at a mean follow-up of 50.8 months (4.2 years; range, 12-97 months). With THA as an outcome endpoint, there was an overall survival rate of 93% for open and 90.5% for arthroscopic procedures (P = .06). Advanced age and preexisting chondral injury were risk factors for progression to THA after both treatments. Direct comparison among diseasespecific outcome instruments between the 2 procedures was limited by outcome measure heterogeneity; however, both treatments demonstrated good outcomes in their respective scoring systems. Notably, hip arthroscopy was associated with a higher general health-related quality of life (HRQoL) score on the 12-Item Short-Form Survey physical component score (P \ .001). Conclusion: Both hip arthroscopy and open surgical hip dislocation showed excellent and equivalent hip survival rates at medium-term follow-up with hip-specific outcome measures, demonstrating equivalence between groups. However, hip arthroscopy was shown to have superior results regarding general HRQoL in comparison to open treatment. An increased understanding of the natural history of FAI remains warranted, with further studies needed to assess long-term outcomes for patients with FAI. Keywords: femoroacetabular impingement; hip arthroscopy; open surgical hip dislocation; total hip arthroplasty

*Address correspondence to Benedict U. Nwachukwu, MD, MBA, Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA (email: nwachukwub y Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA. z LESS Institute, Sports Medicine Department, Fort Lauderdale, Florida, USA. § Houston Methodist Orthopaedics and Sports Medicine, Houston, Texas, USA. || Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA. The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

Femoroacetabular impingement (FAI) is a well-described structural abnormality of the hip involving either the femur (cam), the acetabulum (pincer), or both.2 When symptomatic, these osseous malformations are a common cause of pain and have been implicated in progression to chondrolabral lesion and early hip osteoarthritis.39 Treatment of FAI is thought to delay the onset of osteoarthritis by promoting increased joint stability and decreasing abnormal contact stresses across the hip joint.13-15 As such, interventions to address FAI are commonly referred to as ‘‘hip joint preserving,’’2,5,22 and the efficacy of these interventions is typically assessed based on improvement in patient symptoms and delayed progression to total hip arthroplasty (THA).25

The American Journal of Sports Medicine, Vol. 44, No. 4 DOI: 10.1177/0363546515587719 Ó 2015 The Author(s)


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Open surgical hip dislocation has long been the standard surgical modality for treating FAI.4 However, technical advances have enabled an arthroscopic approach for treatment of FAI. Prior systematic reviews comparing hip arthroscopy and surgical dislocation and reporting short-term outcomes have suggested that hip arthroscopy and open surgical treatment may have comparable efficacy but that arthroscopic procedures have a decreased complication risk.9,24,33 Since these early reviews, there have been further studies of open and arthroscopic FAI treatment reporting on patients with longer term followup. Studies with longer follow-up provide the opportunity to examine the joint-preserving capabilities attributable to these procedures by evaluating progression to THA and sustained clinical outcome improvement. To our knowledge, no prior study has reviewed the medium- to long-term efficacy of hip arthroscopy and open surgical hip dislocation in the treatment of FAI. The purpose of this study was to determine the efficacy of hip arthroscopy and open surgical hip dislocation for hip joint preservation at minimum mean medium-term follow-up. Specifically, we compared patient-reported outcome measures (PROMs) and progression to THA within the identified studies. We hypothesized that treatment of FAI results in significant improvements in PROMs after both hip arthroscopy and open surgical hip dislocation; secondarily, we hypothesized that both approaches would provide comparable clinical improvement and hip joint preservation.

METHODS Search Strategy A systematic review of the MEDLINE database was performed in October 2014 using the PubMed interface. The review was performed by use of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with a PRISMA checklist.27,28 A simple search was conducted with the phrase ‘‘femoroacetabular impingement.’’ Inclusion criteria were English language, therapeutic clinical outcome study, primary treatment of FAI, and minimum mean follow-up of 3 years. Thus, non–English language studies, non–clinical outcome studies, non–FAI-specific studies, and short-term studies (defined as mean follow-up \3 years) were excluded (Figure 1). Publications excluded as non– clinical outcome studies were review articles, technique articles, biomechanical studies, imaging/diagnostic studies, cadaveric studies, and opinion articles. Study authorship and study patient populations were crosschecked to prevent patient data duplication, with longer term studies preferentially included in such a situation. To ensure that no studies were omitted, the references for each included study were also reviewed and prior similar systematic reviews9,24,33,38 were assessed for eligible studies. This extended search did not produce additional studies. Our final study population consisted of 16 studies.{ Eight studies1,3,7,16,29-31,41 were related to open surgical {

References 1, 3, 7, 16, 18, 20, 21, 23, 29-32, 36, 37, 40, 41.

Treatment of Femoroacetabular Impingement


Figure 1. Flow chart illustration of study inclusion and exclusion criteria. FAI, femoroacetabular impingement. hip dislocation; 7 studies18,20,23,32,36,37,40 were related to hip arthroscopy. One study21 described an open approach with arthroscopic assistance and was classified accordingly as an open study.

Data Collection General demographic data were included for each study in our review. Data points of interest included study population composition (age, sex, follow-up timeframe), surgical technique, study population conversion to THA, and conversion timeframe along with included clinical outcome scores preoperatively and at final follow-up.

Statistical Analysis Pooled cohort analysis was performed for both procedures across all included studies and applied to demographic data, patient outcomes, and survival data. Weighted analysis was only applied to outcome instruments that were reported in 2 or more studies. Pooled cohort analysis was performed by use of a weighted mean of the number of hips contributed by each individual study to the overall cohort. Hip survival for arthroscopic and open procedures was determined by use of THA as an endpoint, and Kaplan-Meier survival estimate was performed according to method described by Kaplan and Meier.19 Independent t tests were performed to compare the mean weighted scores for outcome instruments that had been reported for both treatment modalities. Analyses were performed with Stata (version 12.1; StataCorp).

RESULTS Study Characteristics Nine open surgical hip dislocation and 7 hip arthroscopy studies were included in our comparative review. The

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TABLE 1 Characteristics of Identified Studiesa

Study (Year) Open Surgical Hip Dislocation Steppacher et al41 (2014) Boone et al7 (2012) Naal et al30 (2012) Naal et al31 (2011) Graves and Mast16 (2009) Laude et al21 (2009) Beaule et al1 (2007) Beck et al3 (2004) Murphy et al29 (2004) Hip Arthroscopy Polesello et al37 (2014) Skendzel et al40 (2014) Larson et al20 (2012) Malviya et al23 (2012) Palmer et al32 (2012) Philippon et al36 (2012) Horisberger et al18 (2010)

Mean Follow-up (range), mo


Country of Origin

Clin Orthop Relat Res HSS J Am J Sports Med Am J Sports Med Clin Orthop Relat Res Clin Orthop Relat Res J Bone Joint Surg Am Clin Orthop Relat Res Clin Orthop Relat Res

Switzerland USA Switzerland Switzerland USA France USA, Canada Switzerland USA

72 46.8 60.7 45.1 38 58.3 37.2 56.4 62.4

(60-84) (12-96) (24-120) (12-79) (6-67) (28.6-104.4) (25.2-60) (48-62.4) (24-144)

Hip Int Am J Sports Med Am J Sports Med J Bone Joint Surg Br Arthroscopy Arthroscopy Arthroscopy

Brazil USA USA UK USA USA Switzerland

73.2 73 42 38.4 46 42 36.0

(60-96) (60-97) (24-72) (12-84) (36-70) (24-60) (18-49.2)

Mean Time to THA If Applicable, mo

Surgical Timeframe

Level of Evidence

No. of Hips

Mean Age, y

48 22.8 33.6 NA NR 40 NA 37.2 76.8-114

2001-2003 2002-2011 2003-2005 2003-2008 2000-2003 1999-2004 2001-2003 1996-1997 NA

4 4 4 4 4 4 4 4 4

97 22 233 30 48 94 34 19 23

32 44 30 19.7 33 33.4 40.5 36 35.4

NR 31.6 12 NA 17.7 NA 16.8

2002-2007 2005-2008 2004-2007 2005-2009 2005-2008 2005-2008 2004-2007

4 3 3 4 4 4 4

26 466 94 612 201 65 20

34.6 39.6 30 36.7 40.2 15 47.3


NA, not applicable; NR not reported; THA, total hip arthroplasty. Journal abbreviations: Am J Sports Med, American Journal of Sports Medicine; Clin Orthop Relat Res, Clinical Orthopaedics and Related Research; Hip Int, Hip International; HSS J, HSS Journal; J Bone Joint Surg, Journal of Bone and Joint Surgery (Am, American; Br, British). b

majority of open studies (n = 5) originated from Europe, while the majority of arthroscopic studies (n = 4) originated from North America. Open studies included 600 hips in 519 patients at a mean follow-up of 57.6 months (4.8 years; range, 6-144 months). Arthroscopic studies included 1484 hips in 1461 patients at a mean follow-up of 50.8 months (4.2 years; range, 12-97 months). The average age of the open cohort was 32.1 years (range, 14-56 years) and 36.7 years (range, 13-87 years) for the arthroscopic patients. Both open and arthroscopic treatments of FAI were performed more commonly in men (open, 64.0%; arthroscopic, 53.9%) (Table 1).

Patient Survival Conversion to THA was used as an endpoint to define patient survival in both populations. For open procedures, 42 hips (7%) converted to THA during a maximum followup period of 12 years (range, 6-144 months); thus, the overall survival rate was 93%. In those hips converting to THA, the mean time to conversion was 3.9 years. The most commonly identified risk factors for conversion to THA in open studies were older age and preexisting chondral lesions or osteoarthritis. Increased body mass index and technical factors at the initial surgery were also identified as increasing the risk of converting to THA. After arthroscopic treatment of FAI, 141 hips (9.5%) converted to THA during a maximum follow-up period of 8.1 years (range, 12-97 months); thus, the overall survival rate was 90.5%. The difference in survival between the 2 treatment groups was not statistically significant (P = .06). Increased age and clinical factors associated with degenerative joint disease were associated with conversion to THA in arthroscopic

Figure 2. Kaplan-Meier survival analysis for open surgical hip dislocation and arthroscopic treatment of femoroacetabular impingement with progression to total hip arthroplasty as an endpoint. patients. Female sex was also noted to increase the risk of conversion to THA after hip arthroscopy. Figure 2 demonstrates a Kaplan-Meier survival estimate for both procedures based on reported conversion and survival times for the identified studies. Survival data suggest that conversion to THA may occur more quickly after hip arthroscopy

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Treatment of Femoroacetabular Impingement


TABLE 2 Patient-Reported Outcomes in Identified Studiesa Outcome Instrument (Best-Worst Possible Score) Preoperative instrument scores HOS-SSS (100-0) Merle D’Aubigne´–Postel (18-0) mHHS (100-0) NAHS (100-0) SF-12 PCS (100-0) VAS (0-10) Postoperative instrument scores HOS-ADL (100-0) HOS-SSS (100-0) Merle D’Aubigne´–Postel (18-0) mHHS (100-0) NAHS (100-0) SF-12 PCS (100-0) SF-12 MCS (100-0) UCLA (10-0) VAS (0-10) WOMAC pain (0-100) WOMAC stiffness (0-100) WOMAC function (0-100) Change in pre- and postoperative score HOS SSS Merle D’Aubigne´–Postel mHHS NAHS SF-12 PCS VAS

Open Surgical Hip Dislocation Average Score (No. of Hips)

Hip Arthroscopy Average Score (No. of Hips)

— 14.2 (187) — — —

45.3 (531) — 59.6 (557) 55.3 (221) 45.1 (560) 6.4 (295)

89.6 (263) 77.1 (263) 16.9 (187) — — 48.2 (394) 52.8 (394) 7.6 (416) — 10.3 (330) 15.9 (330) 9.6 (330)

— 77.5 (531) — 83.0 (557) 78.2 (221) 58.4 (560) — — 2.1 (321) — — —

— 12.7 — — — —

132.2 — 123.4 122.9 113.3 -4.3

a HOS, Hip Outcome Score (ADL, activities of daily living; SSS, sports-specific subscale); mHHS: modified Harris Hip Score; NAHS, NonArthritic Hip Score; SF-12, 12-Item Short-Form Survey (MCS, mental component scale, PCS, physical component scale); UCLA, University of California, Los Angeles activity index; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Universities Arthritis Index.

compared with open procedures; however, in the longer term, both procedures appear to have similar survival.

Patient Outcomes The Merle D’Aubigne´–Postel instrument was most commonly used in open studies (n = 4; 187 hips). Mean preoperative Merle D’Aubigne´–Postel score was 14.2, and postoperatively this score improved to 16.9 (range of instrument, 0-18). No other outcome instrument was sufficiently administered both preoperatively and postoperatively to allow calculation of outcome score improvement. The Hip Outcome Score (HOS), the University of California, Los Angeles (UCLA) activity scale, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were the most commonly administered disease-specific outcome instruments administered to patients postoperatively after open hip procedures. Mean weighted scores for available outcome instruments are reported in Table 2. The modified Harris Hip Score (mHHS; n = 3; 557 hips) and the HOS (n = 2; 531 hips) were the most commonly administered disease-specific outcome instruments after hip arthroscopy. Both instruments were administered with sufficient frequency both pre- and postoperatively to

allow calculation of mean improvement after hip arthroscopy. The mHHS instrument score improved from 59.6 to 83.0 (range of instrument, 0-100), while the HOS sportsspecific subscale (HOS-SSS) score improved from 45.3 to 77.5 (range of instrument, 0-100) (the HOS activity of daily living score was infrequently reported). Postoperative HOS-SSS was the only disease-specific outcome instrument commonly reported for both open and arthroscopic procedures; no statistically significant difference was noted in the 2 procedures based on this outcome instrument (open, 77.1; arthroscopic, 77.5; P = .16). In addition to disease-specific outcome instruments, general health-related quality of life (HRQoL) measures were commonly reported after both open and arthroscopic treatment of FAI. The 12-Item Short-Form Survey (SF-12) was the most commonly used. On the SF-12 physical component score (SF-12 PCS), arthroscopic patients demonstrated higher scores (open, 48.2; arthroscopic, 58.4; P \ .001).

DISCUSSION Pain relief and hip joint preservation are the goals of surgical treatment for FAI; however, there is limited evidence to support the long-term benefit of treating this condition

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with a surgical approach. Furthermore, the longer term comparative benefits of open versus arthroscopic treatment for FAI are not well documented. We confirmed our hypotheses that the surgical treatment of FAI results in sustained medium- to long-term benefit and that the clinical efficacy of open surgical hip dislocation and hip arthroscopy is comparable. Identified studies demonstrate a high rate of hip survival at medium- to long-term follow-up with a non–statistically significant survival advantage for open procedures (93% in open surgery vs 90.5% in hip arthroscopy). With regard to patient-reported outcome, both open and arthroscopic FAI treatments demonstrate good to excellent postoperative disease-specific outcome scores; however, there appears to be improved general HRQoL benefits for hip arthroscopy. Several prior reviews have addressed the surgical treatment of FAI, yet a limited number of reviews have compared arthroscopic and open treatment, with no prior comparative review specifically investigating longer term follow-up. Clohisy et al12 performed a descriptive systematic review of any FAI surgical outcomes for studies published up to 2009; the authors concluded that treatment of FAI provides successful short-term outcome, but they did not delineate between arthroscopic and open treatment modalities in their study. Botser et al9 performed a comparative review of studies published up to 2010 reporting on open and arthroscopic techniques for treating FAI. The authors noted that open and arthroscopic approaches improved patient outcomes; however, elite athletes demonstrated superior return to sporting activity after arthroscopic hip surgery. The study was limited by shorter term follow-up times (mean, 20.7 months for arthroscopic and 30.5 months for open) and lack of analysis for hip survival. Matsuda et al24 similarly reviewed studies published up to 2009 and found that clinical efficacy was comparable among surgical treatment options for FAI, but the complication rate for arthroscopic procedures was lower. Their review, however, required only that studies have a minimum 1-year follow-up and as such was limited in scope of analysis. Furthermore, although Matsuda et al reported a range for THA conversion, they did not conduct a pooled analysis and comparison. Papalia et al33 performed a descriptive review of treatment options for FAI, noting that due to a lack of longer term outcomes and homogeneity in measures, no firm conclusion could be made with regard to clinical superiority of either treatment option. The present systematic review builds on prior reviews and, to our knowledge, is the first review of medium- to long-term outcomes for FAI treatment. We defined medium-term outcome as longer than 3 years and longterm outcome as longer than 8 years. We found that after open treatment of FAI, there appears to be a nonsignificant increase in hip survival in the medium term compared with arthroscopic treatment. This finding may be explained by the fact that patients undergoing hip arthroscopy in the identified studies were older on average (open, 32.1 years; arthroscopic, 36.7 years). The incidence of osteoarthritis and chondral defects is likely to be higher in these patients, and thus they may be more predisposed for progression to THA. Age and arthritis previously

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have been identified as increasing the patient’s risk for conversion to THA and experiencing poor outcomes after hip arthroscopy.25 As well, a technical component may be associated with this observed higher rate of conversion to THA after hip arthroscopy. Evidence suggests that poor correction of FAI may predispose a hip to osteoarthritis progression.6,11,26 Given the significant learning curve associated with hip arthroscopy,17 it is possible that technical factors related to surgical experience in these early studies contributed to decreased hip survival. Finally, it is also possible that open approaches provide a level of FAI correction not easily reproduced with arthroscopic techniques. In the medium term, both open and arthroscopic FAI corrections are associated with good hip survival. Further studies are needed to understand the longterm survival benefit of both surgical approaches and the effect related to the natural history of FAI. In the present study we analyzed patient-reported outcome measures in the identified studies. Although we found some intraprocedural consistency in outcome reporting, there was little consistency in disease-specific reporting instruments between open and arthroscopic studies. Open hip studies most frequently reported the Merle D’Aubigne´–Postel outcome instrument and arthroscopic studies most frequently reported the HOS and mHHS. We noted overlap in reporting of HOS-SSS across the 2 surgical techniques, and there was no statistically significant difference in this outcome instrument. This finding is noteworthy, as prior studies have suggested that in the short term, undergoing arthroscopic FAI correction is associated with improved ability to return to sports.8 Our finding may suggest that by the time of medium-term followup, there is no longer a sport-specific advantage associated with hip arthroscopy. Interestingly, we also found a statistically significant difference in general HRQoL between open and arthroscopic FAI treatment (110.2 points for hip arthroscopy). Previously identified minimum clinically important difference (MCID) values for orthopaedic procedures using the SF-12 PCS have ranged from 3.2 to 6.1.10,34,35 More work is needed to investigate the general HRQoL advantage for hip arthroscopy identified in this review. Our finding may be related to an increased morbidity generally associated with open procedures and/or a lengthier postoperative recovery for these patients. The current review has several limitations. By limiting the scope of our search to a minimum mean medium-term follow-up, we limit the number of potentially included studies. While the quality of included evidence is likely higher as a result, a limited number of studies are available to form the basis for our reported observations. Study findings and conclusions are also limited by the quality of the available data. Various studies that we found, especially those reporting on open procedures, did not include preoperative outcome reporting and as such the degree of outcome improvement could not be calculated nor could a preoperative functional baseline comparison be made across open and arthroscopic patient populations. Similarly, radiographic parameters were often not paired with clinical outcomes, and thus we could not assess differences in radiographic FAI correction between the 2 surgical

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procedures. Additionally, we did not use qualitative inclusion/exclusion criteria due to the low number of expected included studies. As the evidence base becomes more robust, a similar review can be repeated with an emphasis on inclusion of high-quality evidence. Finally, in addition to being limited by the heterogeneity of research techniques used, this study is limited by a likely heterogeneity in surgical techniques. The included studies originated from various countries throughout Europe and the Americas across various timeframes. As such, disparate surgical techniques may affect the outcomes attributable to each included study.

CONCLUSION Both hip arthroscopy and open surgical hip dislocation demonstrate excellent and comparable hip survival rates at medium-term follow-up. Clinical outcome measures similarly demonstrate equivalence, although hip arthroscopy results in a significantly improved general HRQoL. Continued research is needed to demonstrate the long-term benefits of surgical treatment of FAI and to improve our understanding of the natural history of the disease. An online CME course associated with this article is available for 1 AMA PRA Category 1 CreditTM at In accordance with the standards of the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The American Orthopaedic Society for Sports Medicine that authors, editors, and planners disclose to the learners all financial relationships during the past 12 months with any commercial interest (A ‘commercial interest’ is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients). Any and all disclosures are provided in the online journal CME area which is provided to all participants before they actually take the CME activity. In accordance with AOSSM policy, authors, editors, and planners’ participation in this educational activity will be predicated upon timely submission and review of AOSSM disclosure. Noncompliance will result in an author/editor or planner to be stricken from participating in this CME activity.

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Arthroscopic Versus Open Treatment of Femoroacetabular Impingement: A Systematic Review of Medium- to Long-Term Outcomes.

Surgical treatment of symptomatic femoroacetabular impingement (FAI) aims to improve symptoms and potentially delay initiation of hip osteoarthritis a...
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