FAI's Hip Damage Not Abated by Arthroscopy

Major Finding: Early arthroscopic surgery does not have any effect beyond short-term pain relief.

Data Source: Prospective study of 20 patients with marked intraoperative chondral lesions; mean follow-up 3 years.

Disclosures: None.

Arthroscopic surgery for femoroacetabular impingement did not eliminate the need for total hip arthroplasty in 10 of 20 patients with advanced chondral lesions. The joint had to be replaced within 3 years of undergoing the less-extensive procedure.

The “discouraging” data indicate that arthroscopic surgery in patients with femoroacetabular impingement (FAI) involving more severe, generalized chondral lesions (grade II or greater on the Outerbridge scale) does not obviate the need for total hip arthroplasty (THA) or even lengthen the interval before the joint replacement procedure is required. “It seems obvious that these patients should not be treated by arthroscopic means,” reported Dr. Monika Horisberger and her associates of the University Hospital Basel (Switzerland).

They looked at 150 patients with cam and mixed FAI. Of these, “20 patients showed intraoperative marked chondral lesions of Outerbridge grade II or greater not restricted to the direct impingement zone, and were therefore included in the study,” they wrote (J. Arthro. 2010 Feb. 11 [doi:10.1016/j.arthro.2009.09.003

Preoperatively, according to the Tönnis classification, “[nine] hips had grade I osteoarthritis, [six] had grade II osteoarthritis, and [five] had grade III osteoarthritis.” The mean age was 47.3 years (range, 22-65 years) and the mean follow-up was 3.0 years (range, 1.5-4.1 years). Half of the patients were male, and one patient died of causes unrelated to the study.

Intraoperatively, all 20 patients were found to have “marked” generalized chondral damage as well as labral lesions. “Grade IV chondral lesions were localized at the impingement zone (ventral-cranial acetabulum) in 14 cases (70%) and at the corresponding femur in 3 cases (15%),” wrote the authors. “Microfracturing was performed in these areas in a total of 15 cases (75%).”

At the study's end, total hip arthroplasty had already been performed in eight patients, and two patients were scheduled to undergo the procedure after the study's conclusion. Preoperatively, three of these patients had Tönnis grade I osteoarthritis, two had grade II osteoarthritis, and five had grade III osteoarthritis. A higher preoperative Tönnis grade increased the risk for subsequent THA significantly (P = .03).

The remaining nine patients who had not undergone THA and were not planning the surgery did experience significant improvements in range of motion (internal rotation improved from 0.25 degrees preoperatively to 24.5 degrees following arthroscopy, P less than .001), flexion (from 110.8 to 125.0 degrees; P = .005) and pain on the visual analog scale (from 6.0 to 1.8; P = .002).

However, the authors said, it is unclear whether the index surgery slowed the degenerative process for the long term or whether a major part of improvement might have been because of the effect of articular debridement or therapy for labral tears rather than the correction of the causative lesion.

Dr. Horisberger conceded that the study does have weaknesses: Nevertheless, “If preoperative examinations underestimate the real extent of chondral damage found on arthroscopy, particularly if extended grade IV lesions at the femoral head are seen, THA should be recommended without further joint-preserving treatment attempts,” they asserted.

Major Finding: Early arthroscopic surgery does not have any effect beyond short-term pain relief.

Data Source: Prospective study of 20 patients with marked intraoperative chondral lesions; mean follow-up 3 years.

Disclosures: None.

Arthroscopic surgery for femoroacetabular impingement did not eliminate the need for total hip arthroplasty in 10 of 20 patients with advanced chondral lesions. The joint had to be replaced within 3 years of undergoing the less-extensive procedure.

The “discouraging” data indicate that arthroscopic surgery in patients with femoroacetabular impingement (FAI) involving more severe, generalized chondral lesions (grade II or greater on the Outerbridge scale) does not obviate the need for total hip arthroplasty (THA) or even lengthen the interval before the joint replacement procedure is required. “It seems obvious that these patients should not be treated by arthroscopic means,” reported Dr. Monika Horisberger and her associates of the University Hospital Basel (Switzerland).

They looked at 150 patients with cam and mixed FAI. Of these, “20 patients showed intraoperative marked chondral lesions of Outerbridge grade II or greater not restricted to the direct impingement zone, and were therefore included in the study,” they wrote (J. Arthro. 2010 Feb. 11 [doi:10.1016/j.arthro.2009.09.003

Preoperatively, according to the Tönnis classification, “[nine] hips had grade I osteoarthritis, [six] had grade II osteoarthritis, and [five] had grade III osteoarthritis.” The mean age was 47.3 years (range, 22-65 years) and the mean follow-up was 3.0 years (range, 1.5-4.1 years). Half of the patients were male, and one patient died of causes unrelated to the study.

Intraoperatively, all 20 patients were found to have “marked” generalized chondral damage as well as labral lesions. “Grade IV chondral lesions were localized at the impingement zone (ventral-cranial acetabulum) in 14 cases (70%) and at the corresponding femur in 3 cases (15%),” wrote the authors. “Microfracturing was performed in these areas in a total of 15 cases (75%).”

At the study's end, total hip arthroplasty had already been performed in eight patients, and two patients were scheduled to undergo the procedure after the study's conclusion. Preoperatively, three of these patients had Tönnis grade I osteoarthritis, two had grade II osteoarthritis, and five had grade III osteoarthritis. A higher preoperative Tönnis grade increased the risk for subsequent THA significantly (P = .03).

The remaining nine patients who had not undergone THA and were not planning the surgery did experience significant improvements in range of motion (internal rotation improved from 0.25 degrees preoperatively to 24.5 degrees following arthroscopy, P less than .001), flexion (from 110.8 to 125.0 degrees; P = .005) and pain on the visual analog scale (from 6.0 to 1.8; P = .002).

However, the authors said, it is unclear whether the index surgery slowed the degenerative process for the long term or whether a major part of improvement might have been because of the effect of articular debridement or therapy for labral tears rather than the correction of the causative lesion.

Dr. Horisberger conceded that the study does have weaknesses: Nevertheless, “If preoperative examinations underestimate the real extent of chondral damage found on arthroscopy, particularly if extended grade IV lesions at the femoral head are seen, THA should be recommended without further joint-preserving treatment attempts,” they asserted.

Major Finding: Early arthroscopic surgery does not have any effect beyond short-term pain relief.

Data Source: Prospective study of 20 patients with marked intraoperative chondral lesions; mean follow-up 3 years.

Disclosures: None.

Arthroscopic surgery for femoroacetabular impingement did not eliminate the need for total hip arthroplasty in 10 of 20 patients with advanced chondral lesions. The joint had to be replaced within 3 years of undergoing the less-extensive procedure.

The “discouraging” data indicate that arthroscopic surgery in patients with femoroacetabular impingement (FAI) involving more severe, generalized chondral lesions (grade II or greater on the Outerbridge scale) does not obviate the need for total hip arthroplasty (THA) or even lengthen the interval before the joint replacement procedure is required. “It seems obvious that these patients should not be treated by arthroscopic means,” reported Dr. Monika Horisberger and her associates of the University Hospital Basel (Switzerland).

They looked at 150 patients with cam and mixed FAI. Of these, “20 patients showed intraoperative marked chondral lesions of Outerbridge grade II or greater not restricted to the direct impingement zone, and were therefore included in the study,” they wrote (J. Arthro. 2010 Feb. 11 [doi:10.1016/j.arthro.2009.09.003

Preoperatively, according to the Tönnis classification, “[nine] hips had grade I osteoarthritis, [six] had grade II osteoarthritis, and [five] had grade III osteoarthritis.” The mean age was 47.3 years (range, 22-65 years) and the mean follow-up was 3.0 years (range, 1.5-4.1 years). Half of the patients were male, and one patient died of causes unrelated to the study.

Intraoperatively, all 20 patients were found to have “marked” generalized chondral damage as well as labral lesions. “Grade IV chondral lesions were localized at the impingement zone (ventral-cranial acetabulum) in 14 cases (70%) and at the corresponding femur in 3 cases (15%),” wrote the authors. “Microfracturing was performed in these areas in a total of 15 cases (75%).”

At the study's end, total hip arthroplasty had already been performed in eight patients, and two patients were scheduled to undergo the procedure after the study's conclusion. Preoperatively, three of these patients had Tönnis grade I osteoarthritis, two had grade II osteoarthritis, and five had grade III osteoarthritis. A higher preoperative Tönnis grade increased the risk for subsequent THA significantly (P = .03).

The remaining nine patients who had not undergone THA and were not planning the surgery did experience significant improvements in range of motion (internal rotation improved from 0.25 degrees preoperatively to 24.5 degrees following arthroscopy, P less than .001), flexion (from 110.8 to 125.0 degrees; P = .005) and pain on the visual analog scale (from 6.0 to 1.8; P = .002).

However, the authors said, it is unclear whether the index surgery slowed the degenerative process for the long term or whether a major part of improvement might have been because of the effect of articular debridement or therapy for labral tears rather than the correction of the causative lesion.

Dr. Horisberger conceded that the study does have weaknesses: Nevertheless, “If preoperative examinations underestimate the real extent of chondral damage found on arthroscopy, particularly if extended grade IV lesions at the femoral head are seen, THA should be recommended without further joint-preserving treatment attempts,” they asserted.