Young adults who present with disabling hip pain related to femoroacetabular impingement (FAI) are a rapidly growing cohort of orthopedic patients. Clinical interest in FAI has intensified since 2003, after FAI was identified as a mechanism that could lead to early hip arthritis. As a result of the confluence of these 2 trends, improving early detection and treatment of FAI is a high priority for hip specialists.
In the past, treatment focused on open procedures for restoration of the structural abnormalities around the hip and treatment of labral and cartilage pathology. Now the emphasis is on management of select patients with early FAI — average age about 30 years — through less invasive approaches that include hip arthroscopy.
Rafael J. Sierra, M.D., is an orthopedic surgeon who specializes in young hip issues in the Division of Adult Reconstruction of the Department of Orthopedic Surgery at Mayo Clinic. He explains: "While we still use hip arthroscopy for typical problems around the hip such as removing loose bodies and repairing traumatic labral tears, our practice is changing. Over the past 3 years, practice has been shifting toward treatment of the hip with FAI."
More than 30,000 hip arthroscopies were performed in the United States in 2008. That number is expected to increase consistently at an average annual growth rate of more than 15%, exceeding 70,000 procedures by 2013.
Notes Bruce A. Levy, M.D., sports medicine and arthroscopy specialist and Dr. Sierra's colleague in young hip cases: "Although hip arthroscopy has been performed for well over 15 years, it has now hit the forefront of orthopedic practice because of the recognition of FAI and the fact that some cases of FAI can be treated with hip arthroscopy. The enthusiasm for hip arthroscopy itself is aided by the rapid development of hip-specific arthroscopic instrumentation."
In experienced hands, select cases of FAI can be successfully treated by hip arthroscopy. "Even so, our group works as a team to take a well-considered approach to hip arthroscopy," Dr. Levy says. "And because of our extensive experience treating young hip disorders, we recognize the open procedure still plays an important role."
Mayo surgeons team with sports medicine rehabilitation experts early, before FAI surgery. The team credits this early, synergistic melding of specialties — adult reconstructive surgery, arthroscopy, and sports medicine physical therapy — with its high success rates.
In this team model, surgeons have the capacity to perform a full open procedure, a full arthroscopy, or a combined arthroscopy and mini-open technique, as conditions indicate. Therapists can individualize a rehab plan before the surgery, optimizing chances for immediate compliance.
Notes Joseph J. Eischen, a physical therapist in the Sports Medicine Center: "By seeing patients before their surgery, I can motivate them to comply immediately after surgery with a stepwise program that is specifically designed to their condition and their surgery. It's a really good system that really helps patients."
To choose a technique, the team discusses all aspects of the physical examination findings, patient symptoms, and radiographic criteria. They pay special attention to the main components of FAI that determine approach: labral pathology and bony abnormalities, including whether acetabular version and normal femoral head sphericity are normal.
Explains Dr. Levy: "A patient with a large structural abnormality of the hip joint is typically treated with an open technique. If there are structural abnormalities that we believe can be corrected safely arthroscopically, then we proceed. Safety must always guide selection of technique."
To advance care of FAI, 2 initiatives are under way at Mayo Clinic: screening teens for FAI and conducting clinical trials.
It is unclear who is predisposed to FAI and when onset occurs. An FAI screening program aimed at detecting patients at risk may help answer these questions. Performed as part of a teen's preparticipation sports physical, the prototype identifies teens with hip stiffness and limitation of motion. X-rays and MRIs reveal tissue and bone defects.
The screen has the potential to provide much-needed information about the natural history of FAI and to affect youths' lives by detecting potentially damaging changes in the hip early, just as did screening for scoliosis.
One weakness in FAI surgical decision making is the lack of comparative outcome data on arthroscopic vs open techniques. Long-term follow-up data for open surgery are available, but only 1 or 2 years of outcome data have been published for arthroscopic procedures. Mayo is filling the data gap by designing a randomized clinical trial comparing the 2 techniques.