C L I N I C A L F E AT U R E S

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Operative Treatment of Femoroacetabular Impingement

DOI: 10.3810/psm.2014.09.2082

Michael D. Hellman, MD Andrew J. Riff, MD Rachel M. Frank, MD Bryan D. Haughom, MD Shane J. Nho, MD, MS Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL

Abstract: Femoroacetabular impingement is a common pathologic disorder of the hip that causes pain and has been implicated in the development of early osteoarthritis in young adults. This disorder includes 2 different subtypes: cam impingement and pincer impingement. When nonsurgical treatment methods fail, surgical options are indicated. These options have been increasingly investigated over recent years and show promising results. Several surgical techniques have been described, including surgical dislocation of the hip, mini-open procedures, hip arthroscopy, and periacetabular osteotomies. Nevertheless, the preferred mode of surgical management of femoroacetabular impingement remains a source of controversy. Only short-term and midterm outcome data are available regarding the efficacy of these surgical techniques. This review details 5 approaches for surgical management of femoroacetabular impingement: open surgical dislocation, a combined arthroscopic and open approach, hip arthroscopy, a mini-open anterior approach, and periacetabular osteotomy. It focuses specifically on surgical technique, outcomes, and their efficacy in treatment of femoroacetabular impingement. Keywords: hip arthroscopy; femoroacetabular impingement; osteotomy; cartilage; labrum

Introduction

Correspondence: Shane J. Nho, MD, MS, Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, 1611 W Harrison Street, Suite 300, Chicago, IL 60611. Tel: 708-236-2701 Fax: 708-492-5525 E-mail: [email protected]

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Femoroacetabular impingement (FAI) is a pathologic disorder characterized by abnormal contact of the hip joint secondary to abnormal morphology of either the femoral head–neck junction or the acetabular rim that causes pain and stiffness, and predisposes patients to early osteoarthritis. Femoroacetabular impingement has 2 subtypes: cam impingement and pincer impingement. Cam impingement refers to abnormal shear forces on the acetabular cartilage that stem from abnormal morphology of the femoral head–neck junction including decreased headto-neck ratio, asphericity of the femoral head, and femoral neck retroversion. Pincer impingement refers to linear contact between the acetabular rim and the femoral head–neck junction that stems from abnormal acetabular morphology, including anterosuperior acetabular rim overhang, acetabular retroversion, acetabular protrusion, and coxa profunda.1 Numerous etiologies have been suggested including genetic factors, the type of activity (eg, basketball, football, and hockey), a history of pediatric hip disease (eg, slipped capital femoral epiphysis or Legg-Calvé-Perthes disease), and prior hip fracture.2 Although the causes of these structural alterations are not completely understood, cam and pincer impingent have demonstrated specific age and gender predilections. Cam impingement more commonly affects young, athletic males, whereas pincer impingement more commonly affects active, middle-aged females. Although it was

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Operative Treatment of Femoroacetabular Impingement

first described as a clinical entity in 2001,3 substantial advances have been made in the diagnosis and treatment of FAI over the past decade.4 After diagnosis, the initial management of symptomatic FAI typically consists of a period of relative rest, a trial of a nonsteroidal anti-inflammatory drug, and physical therapy focusing on strengthening, manual techniques, and neuromuscular retraining. However, for significantly symptomatic individuals who have failed a trial of 3 months of nonsurgical measures, surgical intervention may be necessary. The goals of FAI surgery are to perform adequate osteoplasty of both pincer and cam lesions, to repair or debride any labral pathology, and to address chondral lesions. The primary goal is osteoplasty of any impinging cam or pincer lesions. If this step is not properly performed, the patient is likely to have continued pain and may require a revision operation.5 Based on their experience, surgeons must decide how much bone should be removed without causing iatrogenic microinstability. Intraoperatively, the surgeon should perform dynamic impingement testing by visualizing the lesions both directly and fluoroscopically to determine the appropriate extent of the osteoplasty. Labral injuries must also be assessed while performing FAI surgery and addressed with either repair or debridement. When possible, labral repair or refixation is preferred to labral debridement,6,7 which should be reserved for extremely frayed and degenerative tears that are unable to be repaired. Recently a few studies have reported on labral reconstruction as an option for a severely damaged labrum.6,7 Preliminary results have been quite promising, with good graft survivorship and improved patient hip scores.8 With further investigation, this technique may soon become more mainstream for severe labral destruction. Chondral lesions should be assessed, and their treatment tailored to the size and severity of the lesion. Cartilage treatment options include mosaicplasty, microfracture, osteochondral allograph transplantation, and autologous chondrocyte implantation.9 Unfortunately, these techniques have not been thoroughly studied in the hip and have not shown very promising results. The literature has reported an inverse relationship between the amount of cartilage damage and clinical outcomes following FAI surgery.7,10,11 If a patient has extensive cartilage damage in the setting of FAI, the gold standard remains total hip arthroplasty (THA). It is recommended that any patient with joint space , 2 mm should not undergo hip preservation surgery and should instead be considered a candidate for THA.7 Five techniques for performing femoroacetabular impingement surgery are reviewed in this article: open

surgical dislocation, a combined arthroscopy and open approach, a mini-open anterior approach, hip arthroscopy, and a periacetabular osteotomy. Each technique has advantages and disadvantages, and no single technique has been found to be far superior to the others. Each technique, including its outcomes and complications, is reviewed in this article.

Material and Methods

A literature search of the Cochrane database of systematic reviews, PubMed, and Ovid Medline was conducted. Inclusion criteria were full-text English-language articles published from 1980 to 2013. The following search terms were used: surgical dislocation AND impingement AND hip; combined approach AND impingement AND hip; miniopen AND impingement AND hip; Heuter AND impingement; osteotomy AND impingement; hip arthroscopy AND impingement; rim trimming AND impingement AND hip; and osteochondroplasty AND impingement AND hip. The relevancy of the abstract of each study that was found in the search was assessed by 2 authors. Studies were included if they were peer reviewed, focused on surgical outcomes, used a standardized outcomes measurement tool, and described a chondrolabral or osteoplasty procedure of the hip (femoral and/or acetabular). Any disagreement about their relevancy was discussed by the reviewers, and a consensus was determined. Ultimately every study that met all criteria listed was fully evaluated by the 2 authors, and the 50 most relevant studies reporting on operative treatment for femoroacetabular treatment were mutually determined.

Results

The numbers of articles found are as follows: 271 for the search terms surgical dislocation AND impingement AND hip; 10 for combined approach AND impingement AND hip; 9 for mini-open AND impingement AND hip; 2 for Heuter AND impingement; 98 for osteotomy AND impingement; 289 for hip arthroscopy AND impingement; 16 for rim trimming AND impingement AND hip; and 55 for osteochondroplasty AND impingement AND hip. After cross-referencing each search, a total of 548 articles were found. The 50 most relevant articles that matched all inclusion criteria were included in our review.

Surgical Hip Dislocation

Surgical hip dislocation, initially performed by Ganz and colleagues in 1992, constituted the first surgical technique used to treat FAI.12 Although this operation is still commonly

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Hellman et al

used today, it has decreased in popularity following the development of less invasive techniques. The patient is placed in the lateral decubitus position and a standard KocherLangenbeck incision is made. A trochanteric flip osteotomy is utilized to facilitate anterior hip dislocation. The short external rotators typically remain intact to the piriformis fossa and the posterior aspect of the great trochanter. The main division of the deep branch of the medial femoral circumflex, the primary blood supply to the femoral head, crosses posterior to the tendon of obturator externus and anterior to the tendons of the superior gemellus, obturator internus, and the inferior gemellus before perfusing the capsule, neck and head.13 Because the short external rotators are left intact, the head is protected from avascular necrosis. Once the hip has been dislocated, the articular cartilage and labrum may be inspected. A femoral and acetabular osteoplasty may also be performed. The main benefit of this operation is that it gives a 360° view of both the femoral head and the acetabulum. No other operation provides such broad visualization for performing an osteoplasty and addressing chondral defects. The mean length of hospital stay after a surgical hip dislocation is 3 days.10 Toe-touch weight bearing is required for 4 to 8 weeks after surgery to allow for the osteotomy to heal. After weight-bearing restrictions are removed, physical therapy is initiated. Outcomes following surgical hip dislocation have been extensively studied and show promising results. Beck et al10 reported results of 19 of patients treated with surgical hip dislocation, and noted that 13 of the 19 were rated as good or excellent using Merle d’Aubigné hip score at an average follow-up of 4.7 years postoperatively. Kempthorne et al14 found significant improvements in 53 patients’ scores on the Western Ontario and McMaster Universities Arthritis Index (35 points, P = 0.0039) at 4-years follow-up. Furthermore, Bedi et al15 reported a significant difference between preoperative and postoperative radiographs in 30 patients who underwent surgical hip dislocation. The extendedneck lateral alpha angle was reduced by a mean of 21.2° (30.7%, P  , 0.05), the anterior femoral head-neck offset was improved by 6.56 mm (108%, P , 0.05), and the beta angle was increased by a mean of 18.35°. Athletes with FAI undergoing this surgical procedure have also been studied and have shown promising results. Bizzini et al16 reported on the return to play in a series of 5 professional hockey players. The average return to unrestricted practice without symptoms was 6.7 months. Players were able to participate in their first competitive game after 114

a mean of 9.6 months. Preoperative range-of-motion recovery was obtained at 10.3 months. At an average follow-up of 2.7 years, 3 of the 5 players had returned to their prior level of competition. More recently, Naal et al17 reported on the return to play in 22 male athletes with a mean follow-up of 45.1 months after surgical hip dislocation. At follow-up, 95% of the patients were competing professionally, and 82% were satisfied with their hip surgery. The primary drawbacks associated with surgical hip dislocation include the prolonged convalescence period and the moderate rate of surgical complications. Patients who undergo surgical hip dislocation are typically limited to partial weight bearing for 4 to 8 weeks and are not released to full activity until 4 months after surgery.18 In their initial experience of 213 cases, Ganz and colleagues reported a “major” complication rate of 3.3%, which included sciatic neurapraxia, osteotomy site nonunion, and Brooker grade III heterotopic ossification.12 Complications that are most commonly reported in association with surgical hip dislocation include persistent bursitis secondary to hardware at the osteotomy (26%), osteotomy nonunion (3%–20%), failure of labral refixation (3%–8%), and Brooker grade IV heterotopic ossification (3%) (Table  1).19–23 Of note, a systematic review of 11 series of surgical hip dislocation reported no cases of avascular necrosis following surgical hip dislocation.24 Finally, surgical hip dislocation has a moderate reoperation rate. Sink and colleagues25 published reoperation results at an average 27 months postoperation for 44 patients (52 hips) who underwent surgical hip dislocation for treatment of FAI, and they reported that 15 patients required a subsequent operation following surgical hip dislocation (9 for trochanteric screw removal, 5 for arthroscopic scar debridement, and 1 periacetabular osteotomy). Clohisy and collegues22 reported rates of conversion to THA varying between 0% and 26% in a systematic review of 11 series of surgical hip dislocation.

Combined Arthroscopy and Anterior Approach

A combined hip arthroscopy and anterior approach was developed in response to the high complication rate associated with the surgical hip dislocation technique. Many practitioners felt that a more minimally invasive approach could permit adequate visualization of the impingement lesion and avoid complications related to the trochanterotomy.26 This approach utilizes one to two 5-mm peritrochanteric portals and an incision similar to the classic Hueter in the Sariali

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Operative Treatment of Femoroacetabular Impingement

Table 1.  Common Complications Open surgical dislocation Combined arthroscopy and open Mini-open

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Arthroscopy

Bernese periacetabular osteotomy

• Persistent bursitis (26%) • Osteotomy nonunion (3-20%) • Brooker grade IV heterotopic ossification (3%) • Transient lateral femoral cutaneous nerve palsy (6%) • Transient perineum numbness (6%) • Brooker grade I–II heterotopic ossification (11%) • Mild transient meralgia paresthetica (20%) • Transient femoral nerve palsy (2%) • Transient lateral femoral cutaneous nerve palsy (10–11%) • Asymptomatic heterotopic ossification (3%) • Labium majus skin necrosis/tear (1%) • Osteotomy non-union (1–24%) • Symptomatic hardware (12–28%) • Symptomatic heterotopic ossification (6–8%)

anterolateral approach. Traction is required for arthroscopic visualization of the joint, including the deep aspects of the acetabulum and labrum. The posterior aspects of the joint can be visualized by arthroscopy, and the anterior portion can be directly visualized through the incision. Advocates of this approach describe the advantage of performing a diagnostic scope at the beginning of the case compared with proceeding directly to an open procedure. Chondral lesions are difficult to assess on magnetic resonance imaging, and a diagnostic scope may demonstrate evidence of advanced chondral wear that might preclude additional hip preservation surgery.27 Postoperatively, patients are restricted to protected weight bearing with crutches for approximately 5 to 7 days. Patients typically initiate physical therapy at 1 week postoperatively, and may resume impact sports at approximately 6 months.26,27 The combined arthroscopy and anterior approach has shown very good early results.28 Laude et al26 showed good results in 100 hips that underwent a combined arthroscopy and anterior approach for symptomatic impingement. At a mean follow-up of 6 months, the Christensen nonarthritic hip score increased by 29.1 points (P , 0.0001). Clohisy et al29 reviewed 35 patients who underwent a combined arthroscopy and anterior approach with an average follow-up of 2 years. The average modified Harris Hip Score improved 23.6 points and the UCLA activity score improved 2.3 points between preoperative and final follow-up evaluations. Further, Lincoln et al27 found significant changes between preoperative and postoperative radiographs. The alpha angle decreased an average of 21.2° (P , 0.01) and the head–neck offset increased an average of 7.7 mm (P , 0.01). Complications associated with this combined approach include superficial infections (3%), deep infections (1%),

occult femoral neck fracture (1%), deep vein thrombosis (1%), asymptomatic heterotopic ossification (11%), transient lateral femoral cutaneous nerve palsy (6%), and transient perineum numbness (6%; Table 1).26,27,29

Mini-Open Femoroacetabular Osteoplasty Technique

Mini-open femoroacetabular osteoplasty is a technique that has been proposed to provide patients with the benefit of a minimally invasive procedure without hip traction. The incision is usually 4 cm distal to the anterior superior iliac spine overlying the tensor fascia lata muscle. The capsule is opened with an I-shaped capsulotomy allowing for adequate exposure to perform osteoplasty, repair, or debridement of the labrum, and to address any chondral lesions. This approach also provides direct visualization of the anterior hip while performing a dynamic impingement range-of-motion test intraoperatively.30 Patients are typically sent home with partial weight bearing on crutches for 6 weeks. After that, patients begin an aggressive physical therapy program.14,30 Results following the mini-open femoroacetabular osteoplasty technique have been good to excellent. Parvizi et al30 reported on 265 consecutive patients who had undergone femoroacetabular osteoplasty for symptomatic impingement. Range of motion in these patients improved from 89° of flexion and 8.6° of internal rotation preoperatively to 118° of flexion and 39° of internal rotation postoperatively (P  , 0.001). Further, Ribas et al31 reported significant improvements in Merele d’Aubigne-Postel and WOMAC scores in 105 patients at 3-year follow-up. Recently, Cohen et al32 reported on return to competitive play in 47 athletes who underwent a mini-open femoroacetabular osteoplasty for symptomatic impingement. The average return to full activity was 4 to 6 months postoperatively. At a mean follow-up of 22 months, all but 2 patients reported clinical improvement; 55% of the patients reported a return to their specific preoperative sports, and 18 patients reported an increase in their preoperative activity level. The main pitfall of this approach is the poor visualization of both the inferoposterior labrum and central compartment chondral lesions.14 Impingement lesions and associated labral and chondral lesions are rare in this area; thus, advocates of this technique argue that the benefits significantly outweigh this limitation. Mild transient meralgia paresthetica is the most common complication after this operation, with reported rates of approximately 20%.30,32,33 All complications reported thus far in the literature have been transient, and no major complications have been described (Table 1).

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Hip Arthroscopy

Hip arthroscopy has become the most widely used operation for FAI. Techniques continue to evolve and are enabling effective and comprehensive treatment of this condition. Hip arthroscopy is especially appealing to a younger and more active patient population that desires a quicker return to activity and a more cosmetic scar. Typically, two to three 5-mm portals are used to access the hip joint. At our institution, we start the patient in traction and perform a large transverse capsulotomy. After establishing a capsulotomy, we address the cartilage, labrum, and any pincer lesions. We then remove traction and complete a T-shaped capsulotomy down the anterolateral head–neck junction to address any cam lesions (Figure 1). Recently, we have been performing capsular closure, and our unpublished data have demonstrated that this has a positive trend toward better outcomes, including patient satisfaction and Harris Hip Score. Many experienced hip arthroscopists are currently advocating more extensile intra- and extracompartmental exposures with T-shaped capsulotomies. This allows for views of the femur and acetabulum that are similar to those in the open techniques described.34 Most of these surgeries are performed on an outpatient basis. Patients are asked to perform flat foot weight bearing for about 2 weeks. Physical therapy is started the first week. Short-term and midterm studies have shown promising results for the arthroscopic management of FAI. Byrd et al35 reported on 100 prospectively collected patients at 2-year follow-up after hip arthroscopy for symptomatic impingement. The median improvement of the modified Harris Hip Score was 21.5 points, with 79 patients reporting good to excellent results. Many studies have also shown excellent outcomes after hip arthroscopy for FAI in an athletic population. Philippon et al36 reported on 45 professional athletes with a mean follow-up of 1.6 years after hip arthroscopy for the treatment of symptomatic hip impingement; 93% returned to professional play and 78% remained active at the professional level at 1.6 years. Nho et al37 reported on 47 elite athletes undergoing hip arthroscopy for FAI; 79% of patients were able to return to play after hip arthroscopy at an average of 9.4 months. Of these, 92.3% were able to return to the same level of competition. At 2-year follow-up, 24 remained at the same level of play. Finally, Alradwan et al38 reported in a systematic review that, overall, 92% of athletes undergoing hip arthroscopy for symptomatic impingement returned to play, and 88% returned to their previous level of competition. These clinical benefits seen in patients undergoing hip arthroscopy translate into improved 116

quality of life. Malviya and colleagues39 reported that among 612 patients who underwent hip arthroscopy, quality-of-life scores improved 76.6% of patients, remained unchanged in 14.4%, and deteriorated in 9.0%. One of the primary drawbacks associated with hip arthroscopy is the steep learning curve required to adequately perform this operation. The most common cause of failed arthroscopic surgery is residual bony lesions requiring revision operations.5,27 Large retrospective studies have been performed reviewing complication rates of hip arthroscopy. The overall rate appears to be very low, ranging from 0.5% to 5.0%.33,37,38 Clarke et al40 reported on complication rates in 1054 consecutive hip arthroscopies; 15 (1.4%) complications were reported including septic arthritis, transient sciatic nerve palsy that resolved in 2 to 3 hours postoperatively, transient femoral nerve palsy that resolved in 6 hours postoperatively, and trochanteric bursitis. Other studies have reported complications including lateral femoral cutaneous nerve palsy, asymptomatic heterotopic ossification, labium majus skin necrosis/tearing, pudendal neurapraxia, and femoral neurapraxia (Table 1).20 Harris and colleagues41 reported an overall reoperation rate of 6.3% with a 2.9% conversion rate to THA at mean 2.0 years in their systematic review of 92 series of hip arthroscopy for FAI. In light of this low rate of complication, improved scar cosmesis, and quicker Figure 1.  Pre- and postoperative radiographs of a patient with cam-type FAI who underwent a hip arthroscopy with femoral osteochondroplasty. A) Preoperative anteroposterior pelvic radiograph. B) Preoperative 90° Dunn lateral radiograph. C) Postoperative anteroposterior pelvic radiograph. D) Postoperative 90° Dunn lateral radiograph. Note the difference in the head–neck junction especially on the lateral view.

Abbreviation: FAI, femoroacetabular impingement.

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Operative Treatment of Femoroacetabular Impingement

recover, hip arthroscopy is presently favored for lesions that can be treated either open or arthroscopically. The majority of patients with FAI can now be effectively managed with hip arthroscopy; however, the shortcomings of hip arthroscopy must be recognized. Bedi and colleagues15 compared the extent of radiographic correction attainable with both open and arthroscopic techniques. Although hip arthroscopy rendered an improvement that was comparable to that of open techniques with regard to the extended-neck lateral alpha angle and the anterior femoral head–neck offset, the magnitude of correction of the anteroposterior alpha angle was significantly greater in the open compared with the arthroscopic group. The authors concluded that arthroscopy offers equivalent results for anterior lesions; however, the open approach is more powerful for correction of superolateral or posterosuperior loss of femoral offset, as these areas are difficult to visualize and access arthroscopically. Furthermore, they advocated the open approach for global overcoverage (ie, profunda or protrusio). Although Bedi and colleagues recommend consideration of open treatment for posterior impingement, it should be noted that the majority of patients of with FAI have lesions located in either the anterosuperior or anteroinferior quadrants (86% and 94% in 2 series).42,43 Further research is needed to definitively establish the indications and limitations or arthroscopic and open techniques.

seen only in the superolateral parts of the acetabular rims. Peters et al49 found a significant improvement in the Harris Hip Score at 1-year follow up from 54 to 86. Improvement in radiographic measurements was also noted, with 96% of retroverted patients having radiographically anteverted or neutral acetabulum at the time of the final follow-up. Athletes undergoing periacetabular osteotomy for femoroacetabular impingement have not yet been studied. Further, there are no studies that look at return to competitive play. Until these issues are studied, it is very difficult to counsel athletic patients on this surgical procedure. The primary drawbacks associated with periacetabular osteotomy are related to its surgical morbidity. Hospital stays are significantly longer than with the other techniques described. Patients have more extensive postoperative pain and experience more significant blood loss intraoperatively. Additionally, major complications are common for this operation and occurred in 6% to 37% of cases. The most common complications include heterotopic ossification, wound hematomas, nerve palsies, intraarticular osteotomies, loss of fixation, and malreductions. Further, 12% to 28% of patients require a reoperation due to symptomatic hardware. Nonunion rates as high as 24% have been reported (Table 1).49 With this relatively high complication profile, this operation remains indicated only for select cases of pincer-type FAI.

Bernese Periacetabular Osteotomy

Both open and arthroscopic hip preservation surgery appear to be effective options for FAI. Each technique described above has its advantages and disadvantages (Table 2). Ng et al33 performed a comparative systematic review in 2010 and Matsuda et al50 did the same in 2011. They both compared outcomes and complications following surgical hip dislocation, mini-open, and arthroscopic approaches for FAI. It was concluded that all approaches were effective in pain relief and improvement in function with short-term and midterm follow-up. Open surgical dislocation was found to have a high incidence of major complications, and the miniopen approaches had a greater incidence of meralgia paresthetica. Arthroscopy showed equivalent clinical outcomes with a lower rate of major complications when performed by experienced surgeons. Overall, no technique to date has shown an overwhelming superiority over the others. The literature consists of only level III and level IV evidence, and no prospective randomized controlled trials have been performed yet. Further, only short-term and midterm outcomes have been reported. Nevertheless, in light of the presently available evidence

The periacetabular osteotomy has been extensively described for hip dysplasia but has limited use in the setting of FAI. Indications for a Bernese periacetabular osteotomy include correction of pincer-type rim impingement secondary to a retroverted acetabulum and posterior-wall insufficiency.44,45 A Smith-Peterson approach is used to access the hip. Osteotomies are performed in the same manner and sequence as described for treatment of acetabular dysplasia. Reorientation of 10° to 20° is achieved through flexion and internal rotation of the acetabular fragment.46 Biplanar fluoroscopy is often required to verify correct anteversion positioning of the acetabulum.47 Patients are partial weight-bearing with crutches for the first 6 week after surgery and then full weight-bearing with 1 crutch for the second 6 weeks after surgery.48 Siebenrock et al44 showed good to excellent results in 26 of 29 patients with an average follow-up of 30 months.44 The average Merle d’Aubigné score improved from 14.0 points to 16.9 points at follow-up. The crossover sign was eliminated in all but 4 patients. In these remaining 4, it was

Conclusion

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Table 2.  FAI Techniques: Pros and Cons Open surgical dislocation Combined arthroscopy and open

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Mini-open

Arthroscopy

Pros

Cons

• 360° view of femoral head and acetabulum • No hip traction • Diagnostic arthroscopy performed first to justify beginning a more invasive procedure • Direct visualization while performing dynamic impingement testing • Does not require a greater trochanter osteotomy • Relatively minimally invasive • Direct visualization while performing dynamic impingement testing • No hip traction • Does not require a greater trochanter osteotomy • Relatively minimally invasive • Least invasive operation • More rapid recovery

• Requires a greater trochanter osteotomy • Relatively invasive • Requires hip traction

Bernese periacetabular osteotomy • Excellent visualization of both the acetabulum and the hip joint • No hip traction

• Only able to intraoperatively assess the superior and anterior femoral head–neck junction • Requires hip traction • Steep learning curve to perform this operation • Relatively invasive • Relatively high complication rate

Abbreviation: FAI, femoroacetabular impingement.

showing a lower rate of major complications and equivalent outcomes for patients with anterior impingement lesions, hip arthroscopy is the preferred mode of surgical treatment for the majority of patients with FAI. The current literature supports operative treatment of symptomatic impingement as a tool to relieve pain and to enable patients to return to their previous functional levels. The long-term impact of these surgeries and the prevention of early osteoarthritis remain unanswered.

Conflict of Interest Statement

Michael D. Hellman, MD, Andrew J. Riff, MD, Rachel M. Frank, MD, Bryan D. Haughom, MD, and Shane J. Nho, MD, MS, have no conflicts of interest to declare.

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Operative treatment of femoroacetabular impingement.

Femoroacetabular impingement is a common pathologic disorder of the hip that causes pain and has been implicated in the development of early osteoarth...
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