Key takeaways:
- Sufferers with asymptomatic FAI needs to be knowledgeable of the chance of future hip points.
- The recognized dangers of prophylactic FAI surgical procedure aren’t outweighed by the potential advantages.
Acknowledged as a reason for persistent hip ache, femoroacetabular impingement has been reportedly brought on by cam and pincer anatomic abnormalities.
Nonetheless, the printed literature has proven even people who’re asymptomatic can have these abnormalities. As a result of femoroacetabular impingement (FAI) is believed to predispose people to the event of early osteoarthritis, orthopedic surgeons have questioned whether or not prophylactic FAI surgical procedure needs to be carried out in sufferers who’ve these abnormalities however are asymptomatic.
Healio invited consultants to weigh in on whether or not prophylactic surgical procedure for FAI has any advantages when carried out in sufferers who’ve cam and pincer abnormalities however are asymptomatic.
Derek H. Ochiai, MD
A typical phrase amongst hip arthroscopy surgeons is, “I don’t function on asymptomatic hips.”
Within the early 2000s, hip arthroscopy was generally a brutal operation, and the harm achieved to the labrum, articular cartilage and capsule in the course of the process was generally extra intensive than the harm being addressed. Fortunately, these days are over. Hip arthroscopy is a secure, reproducible operation that may successfully deal with FAI.
Supply: Derek H. Ochiai, MD
FAI can progress to hip arthritis if left untreated. Nonetheless, this doesn’t occur to everyone. I’ve personally seen sufferers symptomatic with FAI and labral tears of their 70s with no signs till simply previous to presentation. Additionally, I’ve seen sufferers of their late 20s who had giant cam bumps (excessive alpha angles) which have already progressed to hip arthritis, such that the one affordable surgical process is hip substitute. If we can not predict the pure historical past of FAI, is it not safer to not right it if there’s not a medical drawback? Positive, it’s “safer,” however as hip preservation surgeons, is that the most effective remedy?
Prophylactic surgical procedure for FAI is already being achieved. A research by Ibrahim Azboy, MD, and colleagues confirmed most sufferers with bilateral hip FAI morphology who underwent unilateral arthroscopy on the symptomatic hip rapidly skilled signs on the contralateral hip, which led to a second hip arthroscopy being carried out. Nonetheless, the researchers needed to lower the research cohort by 10%, as these sufferers underwent bilateral hip FAI surgical procedure whereas solely being symptomatic in a single hip.
Supply: Derek H. Ochiai, MD
Allow us to do a thought train on a person with a excessive alpha angle hip. If a affected person offered with the hip radiograph in Determine 1 at 20 years of age, having failed conservative remedy, had ache with extended sitting, no chondral harm on MRI and a constructive Arlington check, hip arthroscopy is straightforward to justify. However what if they’d profitable hip surgical procedure on their proper hip (Determine 2), however observed limitations in movement of their left hip with out ache? Is hip arthroscopy “prophylactic” then? Figures 3 and 4 present preoperative and profitable postoperative radiographs of a left hip the place the affected person had no complaints of hip ache.
What if the affected person got here in fearful as a result of their father needed to have a hip substitute at age 45 years as a consequence of an untreated FAI? In 2025, can we inform that affected person with out hesitation that it’s higher to attend for his hip to be painful for him, after we know ache is usually a lagging indicator for chondral harm? A latest research of sufferers aged 14 to 25 years offered by Dean Ok. Matsuda, MD, FAAOS, FAANA, and colleagues on the American Academy of Orthopaedic Surgeons Annual Assembly confirmed that sufferers with alpha angles higher than 75° had a higher than 50% probability of getting excessive grade acetabular articular cartilage harm. We additionally know that longer length of signs is a predictor of inferior outcomes with FAI remedy, and what is usually a shorter length of signs than zero?
Supply: Derek H. Ochiai, MD
If a 16-year-old lady presents as a result of their mom has dysplasia requiring periacetabular osteotomy, and the daughter has a lateral center-edge angle (LCEA) of 12°, most surgeons who carry out periacetabular osteotomy would function, as a result of the most effective time for remedy is earlier than chondral harm. I fully agree with that, despite the fact that I’ve seen former skilled athletes who current with hip ache of their 50s who additionally had an LCEA of 12°. The exceptions solely show the rule.
Ready for hip FAI to trigger ache, particularly when the alpha angle is 75° or extra, doesn’t optimize outcomes, and, in these sufferers, they need to a minimum of be told of the chance of hip points sooner or later. Primarily based on that dialog, in the event that they ask if they need to have prophylactic hip surgical procedure, the reply in 2025 needs to be completely, unequivocally perhaps, however their insurance coverage additionally most likely is not going to cowl it.
Supply: Derek H. Ochiai, MD
References:
For extra data:
Derek H. Ochiai, MD, of Nirschl Orthopaedic Middle, might be reached at teamsurgeon@gmail.com or on X at @DrDerekOchiai.
Dean Ok. Matsuda, MD
I don’t, at current and on the whole, assist prophylactic surgical procedure for FAI.
I’m not positive I could make anybody higher than asymptomatic, whereas any remedy, surgical or in any other case, may generate signs. Furthermore, surgical and anesthetic issues might happen that may very well be devastating, particularly in youthful sufferers. My common philosophy is to deal with sufferers who’re symptomatic, not imaging findings. FAI morphology doesn’t essentially imply FAI pathology.
However to be truthful, the potential advantage of prophylactic FAI surgical procedure is to not make higher postoperative radiographs, however to stop future irreversible hip degeneration. Therein lies the problem: If credible proof demonstrates considerably much less future arthrosis with prophylactic surgical procedure, then some extent of surgical danger could also be justifiable. Though 10% to 74% of studied asymptomatic populations have FAI morphology, we nonetheless have no idea the pure historical past of FAI and if surgical intervention considerably lowers the chance for future arthritis in these sufferers.
Though about 10% of my surgical procedures are simultaneous bilateral arthroscopy for FAI, these are sufferers with flexion-induced ache in each hips. The extra frequent situation is the affected person with unilateral signs regardless of typically bilateral FAI morphology. When sufferers ask about their different hip, I counsel my sufferers that their hip is in danger, and to contact us if that hip turns into symptomatic in order that we will carry out additional diagnostic workup and attainable surgical intervention if indicated and desired. I’ve had some sufferers receive annual radiographs even whereas asymptomatic to watch the joint house. An asymptomatic hip within the presence of a excessive alpha angle and/or already with Tnnis grade 1 radiographic findings, particularly if exhibiting interval joint narrowing, ought to, in my ebook, be adopted with interval visits, and my threshold to supply elective hip arthroscopy can be decrease.
Though present proof doesn’t assist routine prophylactic surgical procedure for FAI, for each rule, there could also be exceptions with various ranges of benefit. Of those listed beneath, I’ve up to now solely operated on the asymptomatic hip for the primary instance.
- Asymptomatic FAI with contralateral FAI-induced complete hip substitute. I’ve provided prophylactic surgical procedure on just a few sufferers in hopes that this may stop the longer term want for bilateral hip arthroplasties.
- A affected person with asymptomatic FAI with radiographic joint narrowing or interval progressive narrowing (nonetheless higher than 2 mm remaining joint width) and/or MRI demonstrating early chondrosis.
- An adolescent or younger grownup affected person with asymptomatic FAI with a excessive alpha angle, maybe higher than 75°.
- A affected person with recalcitrant osteitis pubis/core muscle harm with asymptomatic FAI with extremely constrained hip vary of movement, which has been reported to be related to and causative of athletic osteitis pubis.
A scientific assessment on prophylactic FAI surgical procedure in grownup sufferers couldn’t discover a single research from 840 references assembly their eligibility standards. They concluded that, with the exception I listed as number one, which had restricted proof, there’s a lack of obtainable proof to assist prophylactic surgical procedure for FAI. That mentioned, medical equipoise could also be hindering our skill to completely examine this subject and arrive at an evidence-based advice. Thus, at current, as a result of we have no idea if prophylactic FAI surgical procedure does appreciably stop future coxarthrosis, and since we do know that signs and issues can happen with any process, the recognized danger just isn’t outweighed by the potential profit.
Reference:
For extra data:
Dean Ok. Matsuda, MD, FAAOS, of Premier Hip Arthroscopy, might be reached at saltandlight777@hotmail.com.
References:
Sources/Disclosures
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Professional Submission
Disclosures:
Ochiai reviews receiving royalties from ConMed.Matsuda reviews receiving assist from Zimmer Biomet Holdings Inc.; being the committee chair for the ISHA Hip Preservation Society; and being on the editorial or governing board for Healio | Orthopedics In the present day.
