Could be surgery to correct Femurol Acetabular Impingement Syndrome. FAI surgery is relatively emerging. Somewhat controversial as to efficacy, FAI surgery is any # of similar corrective procedures (not all yet standardized) to address labral tears of the socket (pincer defect) or abnormal cartliage around the femoral head (cam defect). More often than not, these are done arthroscopically. Basically either problem or a combination of both can cause an impingement or clicking of the ball and socket on internal rotation. Cam defects most commonly affect young athletic males. FAI can cause nuisance pain, but no clear research shows that not doing surgical repair is not really any more cause for alarm or need for Total Hip Replacement years down the road. Basically, the verdict is still out on FAI surgery, but it is the ortho surgery de jour and I would not be surprised if that is the extent of his problems. I am not a physician....but I did stay at a holiday inn last night.
http://www.aetna.com/cpb/medical/data/700_799/0736.html
Clinical Policy Bulletin:
Femoro-Acetabular Surgery for Hip Impingement Syndrome
Number: 0736
Policy
Aetna considers femoro-acetabular surgery, open or arthroscopic, for the treatment of hip impingement syndrome experimental and investigational because its clinical value has not been established.
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. 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 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 the result 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; while characteristic magnetic resonance arthrographic findings of pincer FAI include a deep acetabulum and postero-inferior cartilage lesions (Pfirrmann et al, 2006).
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). 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 is usually performed through an incision over the side of 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.
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. They concluded that peri-acetabular osteotomy is an effective way to re-orient the acetabulum in young adults with symptomatic anterior FAI as a result of acetabular retroversion. 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. The authors concluded that surgical debridement of the hip effectively treats hips with impingement and without considerable secondary arthrosis or instability.
In a non-randomized controlled, 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 although the results must be considered preliminary, 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 use of this technique results in improved functional outcomes and a reduction in the prevalence of symptomatic osteoarthritis in affected patients.
The National Institute for Health and Clinical Excellence (NICE, 2007a) published an assessment of open femoro-acetabular surgery for hip impingement syndrome. It stated that current evidence on the safety and efficacy of open femoro-acetabular surgery for hip impingement syndrome does not appear adequate for this procedure to be used without special arrangements for consent and for audit or research. While the Specialist Advisers to NICE noted that there is some evidence of short-term pain reduction, there are no long-term efficacy data to show if the procedure slows degenerative changes. The NICE assessment also noted that few of the studies reported in any detail on the safety of the procedure.
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).
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. This is in agreement with the observations of Wettstein and Dienst (2006) who stated that the early results after hip arthroscopy for the treatment of FAI syndrome are very promising.
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 authors concluded that the generally weak designs of studies performed to date compromises the strength of recommendations that can be made regarding the role of arthroscopic surgical techniques in clinical practice.
The National Institute for Health and Clinical Excellence (NICE, 2007b) also released an assessment of arthroscopic femoro-acetabular surgery for hip impingement syndrome. It stated that that current evidence on the safety and efficacy of arthroscopic femoro-acetabular surgery for hip impingement syndrome does not appear adequate for this procedure to be used without special arrangement for consent and for audit or research. It noted that the natural history of hip impingement syndrome and the selection of patients for this procedure are uncertain; further research on these issues is needed. Furthermore, the Specialist Advisers to NICE noted that validated scores for evaluation of clinical outcomes have not yet been developed. Significant improvement in symptoms and delay or prevention of total hip replacement may be useful outcome measures for future studies.
Larson and Giveans (2008) assessed the early outcomes of arthroscopic management of FAI. 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 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 outcomes 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.
In this regard, Chládek and Trc (2007) noted that in the case of primary surgery for FAI, short- and middle-term results so far obtained are promising, but only long-term results will show whether, and for how many years, this therapy is able to postpone the necessity of total hip arthroplasty. Furthermore, 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.
In a review on the management of labral tears and FAI in young, active patients, Bedi and colleagues (2008) determined (i) the quality of the literature assessing outcomes after surgical treatment of labral tears and FAI, (ii) patient satisfaction after open or arthroscopic intervention, and (iii) 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 only 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 concluded that the quality of literature reporting outcomes of surgical intervention for labral tears and FAI is limited. 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 aformentioned 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.
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. This was a small study with short-term follow-up; its findings need to be validated by studies with larger sample size and long-term follow-up.
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. This was a non-randomized study without a comparison group; its main drawback was that it was a short-term study -- it is unclear how this procedure will affect the long-term outcome of the hip joint. Also, it is unclear if some of these patients were included in earlier reports by the same investigator group (Philippon and Schenker, 2006). Another drawback was the referral nature of the study population, which limited the authors' ability to carry out objective post-operative follow-up examination.
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 were 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.
Beaulé 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 patient's abnormal hip morphology and should address the major underlying impinging deformities. However, this article did not provide any clinical data on the effectiveness and long-term outcomes of various types of surgery in treating this condition. Furthermore, Beaulé et al stated that "because the indications for and techniques of arthroscopic treatment of pincer-type impingement are still evolving, great caution should be exercised when one is considering trimming the acetabular rim, which is technically demanding and can create a dysplastic acetabulum if there is overcorrection".
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.
In summary, there is currently insufficient evidence to support the effectiveness of surgery (open or arthroscopic) for the treatment of individuals with FAI syndrome. Furthermore, there is a lack of evidence that surgical intervention slows the rate of progression to osteoarthritis of the hip in these patients.
Sounding like a routine follow up procedure from last year's surgery.
Sounding like a routine follow up procedure from last year's surgery.
