Revision Surgery and Progression to Total Hip Arthroplasty After Surgical Correction of Femoroacetabular Impingement: A Systematic Review

Abstract

Background:

Femoroacetabular impingement (FAI) is a major cause of hip pain in young adults and athletes. Surgical treatment of FAI is recommended in cases of failed nonoperative treatment that have the typical clinical and radiographic findings. At present, the role of risk factors for revision surgery and progression to total hip arthroplasty (THA) in patients with FAI is still unclear.

Purpose:

To investigate the possible association between (1) rate of revision and progression to THA and (2) patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

The present systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In October 2020, the main online databases were accessed. All articles concerning surgical correction for selected patients with FAI were accessed. Patient characteristics, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores were assessed. The outcomes of interest were the possible association between these variables and the rate of revision and subsequent progression to THA using a multivariate analysis through the Pearson product-moment correlation coefficient.

Results:

Data from 99 studies (9357 procedures) were collected. The median follow-up was 30.9 months (interquartile range, 24.0-45.0). The mean ± SD age was 33.4 ± 9.3 years; mean body mass index (BMI), 24.8 ± 4.8; percentage right side, 55.8% ± 8.0%; and percentage female sex, 47.5% ± 20.4%. The overall rate of revision was 5.29% (351 of 6641 patients), while the rate of subsequent progression to THA was 3.78% (263 of 6966 patients). Labral debridement (P < .0001), preoperative acetabular index (P = .01), and BMI (P = .03) all showed evidence of a statistically positive association with increased rates of THA. No other statistically significant associations were found between patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, or pre- and postoperative scores and the rate of revision and/or progression to THA.

Conclusion:

Although surgical procedures to treat FAI led to satisfactory outcomes, there was a revision rate of 5.29% in the 9357 procedures in the present systematic review. The rate of progression to THA after a median follow-up of 30 months was 3.78%. Patients who have a higher BMI and/or have a pathologic acetabular index and/or undergo labral debridement during correction of FAI are more at risk for a subsequent THA. We advocate additional education of this patient population in terms of expected outcomes and suggest surgical labral repair instead of debridement if needed.

Keywords

femoroacetabular impingement revision surgery total hip arthroplasty risk factors

In patients with femoroacetabular impingement (FAI), anatomic abnormalities of the femoral head and/or the acetabulum produce pathologically high contact forces between the femur and the acetabulum. FAI can be a cause of activity limitation, decreased hip function, and significant hip pain, especially in young adults and athletes, because of cartilage and labral damage.^38,39 These repetitive insults to the cartilage and labrum result in early hip degeneration and osteoarthritis¹⁰⁶; 79% of patients with osteoarthritis of the hip displayed subtle developmental changes on radiographs obtained before adulthood.^38,48 FAI can be classified into 3 types depending on the origin of the pathology, being on the femur (cam), acetabulum (pincer), or both (mixed). In previous cross-sectional studies of 4151 individuals, 19.6% of men and 5.2% of women exhibited a pistol grip deformity of the proximal femur, which was defined by calculating the triangular index.⁴² Surgery is indicated in symptomatic patients with clinical and radiographic findings of FAI whose nonoperative treatment has failed for a minimum of 3 months.⁶² In these patients, surgical options include femoral osteochondroplasty to improve the femoral head-neck offset; debridement, repair, or reconstruction of the labrum; and/or removal of an excessive acetabular rim.^31,66,79 Ganz et al³⁹ first described the technique of surgical hip dislocation for the treatment of FAI in 2003, and several studies have shown good clinical outcomes using this technique.^5,91 Given the long operating and recovery time of open hip dislocation surgery, a mini-open anterior technique was developed by Clohisy and McClure,²⁰ who accessed the hip joint through a Hueter approach. Over the past few years, arthroscopic management of FAI has become popular, with a decrease in complications and faster recovery.^60,83,97

All surgical interventions aim to improve patients’ activity levels, relieve hip pain, and restore natural hip function. The various surgical techniques for management of FAI are all successful (surgical hip dislocation, mini-open, arthroscopy), but data on rates of revision and progression to total hip arthroplasty (THA) are limited. So far, prognostic factors for surgical outcome for FAI are still unclear. Thus, the present systematic review investigated the risk factors for revision surgery and progression to THA in patients who underwent surgery for symptomatic FAI. A multivariate analysis was conducted to investigate the association between (1) rate of revision and progression to THA and (2) patient characteristics, type of lesion, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores.

Methods

Search Strategy

The present systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.⁷⁷ We followed the PICO protocol for the preliminary search:

P (problem): FAI

I (intervention): surgical correction

C (comparator): generalities, type of intervention, radiographic parameters, tests, scores

O (outcomes): revision rate and progression to THA

Literature Search

Two authors (F.M., A.B.) independently performed the literature search in October 2020, accessing the following databases with no time constraints: PubMed, Embase, Google Scholar, and Scopus. The following keywords were used in combination: hip, FAI, femoroacetabular impingement, arthroscopy, mini-open, open, surgery, dislocation, treatment, therapy, cam, pincer, mixed, labral, acetabulum, femur, pelvis, pain, debridement, repair, reconstruction, THA, complications, pain. The resulting titles and eventually the abstracts were screened by the 2 authors. The full text of the articles of interest was accessed. The references were also screened. Disagreements between the authors were solved by a third senior author (M.B.).

Eligibility Criteria

All the articles concerning surgical correction for patients with FAI were accessed. To be eligible for inclusion, articles had to report the rate of revision and/or progression to THA at last follow-up. Any kind of surgical intervention that did not involve THA was considered revision surgery. According to the authors language capabilities, articles in English, Italian, French, German, and Spanish were considered. Articles of level 1 to 4 according to the Oxford Centre of Evidenced-Based Medicine were considered.⁵⁵ Data from national registries were not considered. Reviews, letters, expert opinion, case reports, and editorials were not eligible. Animal, biomechanical, and cadaveric studies were also not considered. Articles regarding revision settings were not eligible. Studies with data based on combined treatments, as well as those focusing on rehabilitation protocols, were excluded. Studies including adjuvants or innovative surgical procedures were excluded. The studies were included regardless of the surgical exposure (arthroscopic, mini-open, open). Studies treating skeletally immature patients were included, as were those describing outcomes in patients who were obese. Studies with data on patients >60 years old or with clear evidence of advanced hip degeneration (Tönnis grade III) were not included. Case series of <10 patients were also excluded. Only studies reporting quantitative data under the outcomes of interest were analyzed.

Data Extraction

Data extraction was performed by 2 authors (F.M., A.B.). Data from the following endpoints were collected:

Generalities: author and publication year, journal, type of study, follow-up duration, number of patients and procedures, mean age, body mass index (BMI), sex, side of surgery, return to sport

Type of intervention: labral debridement, labral repair, labral reconstruction

Radiographic parameters: femoral offset (millimeters), acetabular inclination (Tönnis angle), α-angle (anteroposterior, groin-lateral), β-angle, sharp angle, center-edge angle, anterior center-edge angle, lateral center-edge angle, acetabular index, Tönnis grade, caudocranial femoral coverage (percentage), anterior coverage (percentage), posterior coverage (percentage), crossover sign, and joint space (medial, foveal, lateral)

Physical examination: range of motion (flexion, extension, abduction, adduction, internal and external); anterior, lateral, and posterior impingement test (percentage positive)

Pre- and postoperative scores: Harris Hip Score, modified Harris Hip Score, Non-arthritic Hip Score, 12-Item Short Form Health Survey (SF-12; physical and mental subscales), Hip Outcome Score (activities of daily living and sport-specific subscales), International Hip Outcome Tool–12 and −33, and visual analog scale

The present work investigated whether the aforementioned endpoints were associated with the rate of revision and subsequent progression to THA. Thus, every endpoint was independently analyzed, and its association with revision and progression to THA was assessed.

Methodological Quality Assessment

The methodological quality assessment was made through the Coleman Methodology Score (CMS).²³ The CMS analyzes studies under several items: number of patients, follow-up, type of surgical approach, and study design, as well as descriptions of diagnosis, surgical technique, and postoperative rehabilitation. Furthermore, outcome criteria, the procedure of assessing outcomes, and a description of the sample selection process are evaluated. The quality is scored from 0% (poor) to 100% (excellent), with values >60% considered satisfactory.

Statistical Analysis

The statistical analyses were performed by the main author (F.M.). For the analytical statistics, STATA software (Version 16; StataCorp) was used. The Shapiro-Wilk test was performed to investigate data distribution. For normal data, mean and standard deviation were calculated. For nonparametric data, median and interquartile range were calculated. Multiple pairwise correlations using the Pearson product-moment correlation coefficient (r) were performed to investigate the association between the endpoints were accomplished. According to the Cauchy-Schwarz inequality, the final effect ranks between +1 (positive linear correlation) and −1 (negative linear correlation). Values of 0.1 < | r | < 0.3 and 0.3 < | r | < 0.5 and | r | > 0.5 were considered to have poor, moderate, and strong correlation, respectively. Possible associations with the outcomes of interest were evaluated for each endpoint. Overall significance was evaluated using the χ² test. A linear regression of the statistically significant correlations was made, and added-variable plots were displayed. Values of P > .05 were considered statistically significant.

Results

Search Results

The literature search resulted in 1174 articles. Initially, 509 articles were excluded because of duplication; 529 articles were then excluded because of the following: type of study (n = 187), nonoperative techniques (n = 91), combined treatments (n = 47), adjuvants and/ or innovative surgeries (n = 41), language limitations (n = 22), uncertain data (n = 7), or other (n = 134). A further 37 articles were excluded because they did not match the topic of interest or report quantitative data under the outcomes of interest. Finally, 99 articles were included for analysis: 3 randomized clinical trials, 36 prospective studies, and 60 retrospective studies. The literature flowchart is shown in Figure 1.

Figure 1.

Flowchart of the literature search.

Methodological Quality Assessment

The CMS evidenced the overall limited quality of the studies. Indeed, 60% of studies were retrospective, 36% prospective, and only 3% were randomized trials. Eligibility criteria and rehabilitation protocols were frequently not indicated. General health measures were rarely cited. The procedure of assessing outcomes was often biased or not clearly described. The study size and mean follow-up were well-reported in most studies. The descriptions of diagnoses and surgical techniques were also commonly well-described. The overall CMS was 64.7 points (range, 40-85), attesting to the acceptable quality of the methodological assessment of the present study (Table 1).

Table 1

Generalities of the Included Studies and Demographic Baseline of the Patients^a

First Author	Year	Journal	Study Design	CMS	Treatment	Mean Follow-up, mo	Procedures, No.	Mean Age, y	Female, %
Anwander¹	2017	Clin Orthop Rel Res	Retrospective	68	Open	Resection, 156.0; reattachment, 144.0	60 (resection, 25; reattachment, 35)	Resection, 29; reattachment, 29	Resection, 24; reattachment, 37
Bardakos²	2008	J Bone Joint Surg Br	Retrospective	61	Arthroscopy	12.0	71	34.3	47.9
Beaulé³	2007	J Bone Joint Surg Am	Retrospective	54	Open	37.2	37	40.5
Beck⁴	2011	J Bone Joint Surg Am	Retrospective	53	Open	12.0	50	32.0	44.0
Beck⁵	2004	Clin Orthop Rel Res	Retrospective	40	Open	56.4	19	36.0
Bedi⁶	2011	Am J Sports Med	Prospective	53	Arthroscopy	10.9	10	25.9
Bellotti⁷	2016	Hip Int	Retrospective	53	Mini-open	104.4	296
Boone⁸	2012	HSS J	Retrospective	70	Open	46.8	22	44.0	31.8
Botser⁹	2014	Am J Orthop	Prospective	72	Arthroscopy	14.3	18	20.1	100.0
					Open	16.2	5	18.1
Bryan¹⁰	2016	Am J Sports Med	Prospective	82	Arthroscopy	Younger, 51.6; older, 46.8	201	Younger, 37; older, 60	68.7
Büchler¹¹	2013	Arthroscopy	Retrospective	61	Arthroscopy	15.0	66	33.8;	74.2
					Open	17.5	135	31.2	32.6
Byrd¹²	2009	Clin Orthop Relat Res	Prospective	79	Arthroscopy	16.0	207	33.0	31.0
Byrd¹³	2011	Am J Sports Med	Prospective	76	Arthroscopy	19.0	200	28.6	26.0
Byrd¹⁵	2009	Arthroscopy	Prospective	70	Arthroscopy	120.0	26	46.0	50.0
Byrd¹⁶	2016	Arthroscopy	Retrospective	70	Arthroscopy	30.0	244 (122, study; 122, control)	Study, 15.9; control: 36.8	Study, 53.3; control, 41.8
Camenzind¹⁷	2015	J Hip Pres Surg	Retrospective	66	Open	Reconstruction: 38.0; control: 42.0	27 (reconstruction, 13; control, 14)	Reconstruction, 36; control, 25	Reconstruction, 38.5; control 21.4
Chaudhary¹⁸	2015	Indian J Orthop	Retrospective	61	Open	24.8	16	28.3	31.3
Cho¹⁹	2015	Hip Pelvis	Retrospective	57	Open / mini-open	>24	13	45.0	53.8
Cohen²²	2012	Am J Sports Med	Retrospective	59	Mini-open	22	66	32.0	31.8
Comba²⁵	2016	Muscles Ligaments Tendons J	Prospective	72	Arthroscopy	91.0	42	38.0	37.7
Degen²⁶	2017	Arthroscopy	Retrospective	66	Arthroscopy	Study, 36.1; control, 34.1	346 (study, 38; control, 306)	Study, 16; control, 31	Study, 47; control, 46.3
Domb²⁷	2017	Am J Sports Med	Retrospective	68	Arthroscopy	Tönnis 0, 70.0; Tönnis 1, 72.6	124 (Tönnis 0, 62; Tönnis 1, 62)	Tönnis 0, 41.9; Tönnis 1, 42.3	59.7
Domb²⁸	2014	Am J Sports Med	Retrospective	66	Arthroscopy	Reconstruction, 26.4; resection, 30.0	33 (11, reconstruction; 22, resection)	Reconstruction, 33.0; resection, 38.8	Reconstruction, 36.4; resection, 36.4
Domb²⁹	2015	Arthroscopy	Prospective	77	Arthroscopy	Study, 32.8; control, 33.1	104 (study, 52; control, 52)	Study, 54.8; control, 20.3	65.4
Domb³⁰	2013	Arthroscopy	Prospective	68	Open	24.8	10	19.0	80.0
					Arthroscopy	25.5	20	19.6	80.0
Espinosa³¹	2006	J Bone Joint Surg Am	Retrospective	61	Open	24.0	60	30.0	36.5
Ezechielia³²	2016	Technol Health Care	Prospective	63	Mini-open	15.0	72 (group A, 56; group B, 15)	Group A, 32.1; group B, 28.5	47.2
Fabricant³³	2015	J Bone Joint Surg Am	Retrospective	67	Arthroscopy	21.0	37	28.0	41.0
							149	30.0	50.0
							57	29.0	58.0
Flores³⁴	2018	Orthop J Sports Med	Prospective	72	Arthroscopy	Early, 15.5; late, 13.1	60 (early, 30; late, 30)	Early, 37.2; late, 35.3	Early, 50.0; late, 43.3
Frank³⁵	2014	Am J Sports Med	Retrospective	64	Arthroscopy	29.9	64 (partial capsular closure, 32; complete capsular closure, 32)	32.8	62.5
Fukui³⁶	2015	Arthroscopy	Retrospective	75	Arthroscopy	40.0	102	35.0	50.0
Fukui³⁷	2015	Bone Joint J	Retrospective	64	Arthroscopy	42.0	28	34.0	42.9
Gedouin⁴⁰	2010	Orthop Traum Surg Res	Retrospective	58	Arthroscopy	15.6	38	36.0	13.2
Gicquel⁴¹	2014	Orthop Traum Surg Res	Prospective	64	Arthroscopy	55.2	53	31.0	62.7
Gupta⁴⁴	2016	Am J Sports Med	Prospective	77	Arthroscopy	28.9	595	38.04	61.7
Gupta⁴⁵	2014	Am J Sports Med	Prospective	71	Arthroscopy	28.3	47	37.18	40.4
Haefeli⁴⁶	2017	Clin Orthop Relat Res	Retrospective	72	Arthroscopy	84.0	52	35.0	89.0
Hartigan⁴⁹	2017	J Hip Pres Surg	Retrospective	64	Arthroscopy	42.0	69	43.6	36.9
Hartmann⁵⁰	2009	Arch Orthop Trauma Surg	Retrospective	56	Arthroscopy	15.0	34	31.1	48.5
Hatakeyama⁵¹	2018	Am J Sports Med	Retrospective	69	Arthroscopy	42.5	45	Success, 20; failure, 47	Success, 59; failure, 91
Honda⁵²	2020	Knee Surg Sports Traumatol Arthrosc	Retrospective	66	Arthroscopy	Young, 31.8; middle, 30.9	84	Younger, 30.9; middle, 56.7	Young, 46; middle, 67
Horisberger⁵³	2010	Arthroscopy	Prospective	56	Arthroscopy	36.0	20	47.3	20.0
Horisberger⁵⁴	2010	Clin Orthop Relat Res	Prospective	69	Arthroscopy	27.6	105	40.9	30.5
Hufeland⁵⁶	2016	Arch Orthop Trauma Surg	Retrospective	64	Arthroscopy	66.3	44	34.3	45.5
Ilizaliturri⁵⁷	2007	J Bone Joint Surg Br	Prospective	61	Arthroscopy	30.0	14	30.6	53.8
Ilizaliturri⁵⁸	2008	J Arthroplasty	Prospective	60	Arthroscopy	24.0	19	34.0	42.1
Krych⁶¹	2013	Arthroscopy	Prospective, Randomized	76	Arthroscopy	32.0	36	Repair, 38; debridement, 39	100.0
LaFrance⁶³	2015	J Hip Pres Surg	Prospective	71	Arthroscopy	PRP, 18.5; control, 23.3	35	PRP, 34.4; control, 34.9
Larson⁶⁴	2009	Arthroscopy	Retrospective	63	Arthroscopy	Group 1, 21.4; group 2, 16.5	71 (group 1, 36; group 2, 39)	Group 1, 31; group 2, 27	Group 1, 26.5; group 2, 37.8
Larson⁶⁵	2012	Am J Sports Med	Prospective	79	Arthroscopy	42.0	94	Group 1, 32; group 2, 28	Group 1, 38.6; group 2, 42
Levy⁶⁷	2017	Am J Sports Med	Retrospective	49	Arthroscopy	31.2	84 (atypical, 28; typical, 56)	Atypical 35.8; typical 35.2	Atypical 64; typical 64
Levy⁶⁸	2017	Am J Sports Med	Retrospective	67	Arthroscopy	24.0	51	26.3	56.7
Maldonado⁶⁹	2018	Am J Sports Med	Retrospective	65	Arthroscopy	IFL, 42.5; control, 43.9	743 (IFL, 351; control, 392)	IFL, 27.8; control, 34.1	IFL, 82.3; control, 70.7
Maldonado⁷⁰	2019	Arthroscopy	Retrospective	57	Arthroscopy	CLT, 59.7; control, 51.4	72 (CLT, 18; control, 54)	CLT, 41.2; control, 41.1	50.0
Mardones⁷²	2016	Muscles Ligaments Tendons J	Retrospective	61	Arthroscopy	48.0	17	33.5	73.3
Matsuda⁷³	2015	J Hip Pres Surg	Prospective	69	Arthroscopy	>24	145 (focal, 127; global, 18)	Focal, 39.8; global, 37.2	Focal 52; global, 33
McConkey⁷⁴	2019	J Pediatr Orthop	Prospective	60	Arthroscopy	24.0	36 (bilateral, 24; unilateral, 12)	Bilateral, 15.7; unilateral, 16.5	Bilateral, 58.3; unilateral, 58.3
Mohan⁷⁶	2017	Arthroscopy	Retrospective	69	Arthroscopy	34.0	57	17.8	66.0
Moriya⁷⁸	2017	J Orthop Surg Res	Retrospective	61	Arthroscopy	28.0	23	59.3	73.9
Murphy⁷⁹	2004	Clin Orthop Relat Res	Prospective	71	Open	62.4	23	35.4	43.5
Naal⁸⁰	2012	Am J Sports Med	Retrospective	68	Open	60.7	233	30.0	40.0
Naal⁸¹	2011	Am J Sports Med	Retrospective	59	Open	45.1	30	19.7	0.0
Nawabi⁸²	2016	Am J Sports Med	Prospective	62	Arthroscopy	31.3	207 (BD, 55; control, 152)	BD, 29.8; control, 29.6	BD, 47.8; control, 55.7
Nho⁸³	2011	Am J Sports Med	Retrospective	61	Arthroscopy	27.0	47	22.8	28.0
Nielsen⁸⁴	2014	BMC Musc Dis	Prospective	72	Arthroscopy	>24	117	37.0	59.0
Novais⁸⁵	2014	J Pediatr Orthop	Retrospective	41	Open	21.6	29	17.0	31.0
Palmer⁸⁷	2012	Arthroscopy	Retrospective	72	Arthroscopy	46.0	185	40.2	50.7
Perets⁸⁸	2017	Arthroscopy	Prospective	67	Arthroscopy	35.7	11	14.7	100.0
Perets⁸⁹	2018	Arthroscopy	Retrospective	62	Arthroscopy	49.1	60	19.5	80.0
Perets⁹⁰	2018	J Bone Joint Surg Am	Retrospective	68	Arthroscopy	Obese, 71.6; control, 71.3	148 (obese, 74; control, 74)	44.2	Obese, 60.8; control, 60.8
Peters⁹¹	2006	J Bone Joint Surg Am	Prospective	60	Open	32.0	30	31.0	44.8
Peters⁹²	2010	Clin Orthop Relat Res	Retrospective	58	Open	26.0	96	28.0	41.5
Philippon⁹³	2009	J Bone Joint Surg Br	Prospective	71	Arthroscopy	27.6	112	40.6	55.4
Philippon⁹⁴	2012	Arthroscopy	Retrospective	64	Arthroscopy	36.0	60	15.0	69.0
Philippon⁹⁵	2007	Knee Surg Sports Traumatol Arthrosc	Retrospective	65	Arthroscopy	19.2	45	31.0	6.7
Philippon⁹⁶	2012	Arthroscopy	Retrospective	60	Arthroscopy	37.5	153	57.0	52.9
Philippon⁹⁸	2010	Am J Sports Med	Retrospective	62	Arthroscopy	24.0	28	27.0	0.0
Polesello⁹⁹	2014	Hip Int	Retrospective	62	Arthroscopy	73.2	26	34.6	12.5
Polesello¹⁰⁰	2009	Rev Bras Ortop	Retrospective	48	Arthroscopy	27.0	28	34.0	33.0
Rafols¹⁰¹	2015	Arthroscopy	Prospective, Randomized	84	Arthroscopy	24.0	57	Group 1, 34.2; group 2, 36.5	47.4
Rego¹⁰²	2018	Int Orthop	Retrospective	62	Arthroscopy	44.0	102	34.0	47.0
					Open	76.0	96	31.0	40.0
Rhee¹⁰³	2016	Arch Orthop Trauma Surg	Prospective, Randomized	85	Arthroscopy	Group A, 32.3; group B, 31.8	37 (group A, 19; group B, 18)	Group A, 33.8; group B, 34.6	59.5
Roos¹⁰⁴	2017	Rev Bras Ortop	Retrospective	60	Arthroscopy	29.1	41	36.1	13.0
					Open	52.0	17	35.8	31.3
Sanders¹⁰⁵	2017	Knee Surg Sports Traumatol Arthrosc	Retrospective	65	Arthroscopy	30.0	46	42.4	67.4
Sansone¹⁰⁷	2015	Orthop J Sports Med	Retrospective	72	Arthroscopy	12.3	115	25.0	18.0
Sansone¹⁰⁸	2017	Sc J Med Sci Sports	Prospective	77	Arthroscopy	25.4	359	37.0	34.3
Sansone¹⁰⁹	2016	J Hip Pres Surg	Prospective	74	Arthroscopy	12.8	80	47.0	23.0
Singh¹¹²	2010	Arthroscopy	Prospective	66	Arthroscopy	22.0	27	22.0
Sink¹¹³	2013	Clin Orthop Relat Res	Retrospective	61	Open	27.0	52	16.2	84.1
Skendzel¹¹⁴	2014	Am J Sports Med	Retrospective	63	Arthroscopy	73.0	383	37.0
							63	46.0
Skowronek¹¹⁵	2017	Indian J Orthop	Retrospective	66	Open	45.0	39	29.3	35.9
Stake¹¹⁶	2013	Am J Sports Med	Prospective	61	Arthroscopy	24.0	42 (WC, 21; control, 21)	39.0	WC, 15; control, 15
Steppacher¹¹⁷	2014	Clin Orthop Relat Res	Retrospective	70	Open	72.0	97	32.0	43.0
Tjong¹¹⁸	2016	Orthop J Sports Med	Retrospective	46	Arthroscopy	24.0	23	Return, 44; not return, 43.7	Return, 47; not return, 53
Tjong¹¹⁹	2017	Arthroscopy	Prospective	62	Open	37.2	106	38.1	58.0
Tran¹²⁰	2013	ANZ J Surg	Retrospective	61	Arthroscopy	14.0	41	15.7	14.7
Wang¹²¹	2011	Orthop Surg	Retrospective	51	Arthroscopy	11.6	21	37.1	57.1
Wu¹²²	2019	J Orthop Surg Res	Retrospective	55	Mini-open	44.0	39	43.6	47.2
Zingg¹²³	2013	Arch Orthop Trauma Surg	Prospective	68	Arthroscopy	12.0	23	27.6	21.7
					Open	12.0	15	28.9	26.7

BD, borderline dysplastic; CLT, complete labral tear; CMS, Coleman Methodology Score; IFL, iliopsoas fractional lengthening; PRP, platelet-rich plasma; WC, workers’ compensation.

Patient Demographics

Data from 9357 procedures (8897 patients) were collected. The median follow-up was 30.9 months (interquartile range, 24.0-45.0). The mean ± SD age was 33.4 ± 9.3 years; mean BMI, 24.8 ± 4.8; percentage right side, 55.8% ± 8.0%; and percentage female sex, 47.5% ± 20.4%. Baseline characteristics are shown in Table 1.

Outcomes of Interest

The overall rate of revision was 5.29% (351 of 6641 patients), while the rate of subsequent progression to THA was 3.78% (263 of 6966 patients). Labral debridement showed evidence of a statistically significant positive and strong association with an increased rate of progression to THA (r = 0.77; P < .0001). Equally, a higher preoperative acetabular index showed evidence of a statistically significant positive and strong association with an increased rate of progression to THA (r = 0.89; P = .01). The BMI at baseline showed evidence of a statistically significant positive and moderate association with an increased rate of THA (r = 0.43; P = .03). No other statistically significant associations were found between patient characteristics, type of lesion, type of intervention, radiographic parameters, physical examination, or pre- and postoperative scores and the rate of revision and/or progression to THA. The added-variable plots of these regressions are shown in Figure 2. The multivariate analysis including all the endpoints is shown in Appendix Table A1 (available in the online version of this article).

Figure 2.

Added-variable plots of the associations: acetabular index, body mass index, and labral debridement.

Discussion

FAI is a frequent and well-recognized cause for hip pain, joint damage, and early-onset osteoarthritis in young adults and athletes. Over the past few decades, better understanding of the pathophysiology and natural course of FAI has led to earlier identification and improved treatment options for this condition. The present study described the rates of revision and THA progression after surgical treatment of FAI, identifying some variables associated with increased rates of progression to THA. The overall revision rate after surgical treatment of FAI was 5.29%, and 3.78% of 9357 procedures progressed to THA. To date, this is the largest systematic review to analyze revision and progression rates after surgical treatment of FAI, including a total of 99 studies. According to the main results of the present study, BMI at baseline, labral debridement, and acetabular index were significantly associated with an increased rate of progression to THA. No other statistically significant associations were identified between patient characteristics, type of lesion, type of intervention, radiographic parameters, physical examination, or pre- and postoperative scores and the rate of revision and/or progression to THA.

Surgical hip dislocation for the treatment of FAI—including labral repair, labral debridement, femoral osteochondroplasty, and acetabuloplasty—leads to improvements in hip range of motion, radiographic parameters, and clinical outcomes comparable with those of hip arthroscopy.^30,80,91,117 Surgical treatment for FAI, regardless of the technique, improves hip function, with 68% to 96% of patients reporting good to excellent results after a minimum follow-up of 2 years.²¹

One of the main findings of our study was an overall revision rate of 5.29% after surgical treatment of FAI (open hip dislocation, mini-open, and arthroscopic). These findings are similar to those from a registry study from the United Kingdom, which showed a revision hip arthroscopy rate of 4.5% at a mean 1.7 years.⁷¹ In a systematic review of >6000 patients, the reoperation rate was 6.3% at a mean 1.6 years, and the most common reason for revision surgery was progression to THA.⁴⁷

No or mild hip osteoarthritis, labral repair, young age, and limited cartilage damage have been associated with good clinical outcomes, with a progression to THA in 0% to 26% of the cases.²¹ A systematic review compared outcomes and rates of progression to THA between surgical hip dislocation and arthroscopy⁸⁶: 7% of the hips were converted to a THA after a maximum follow-up of 12 years in the open group, as compared with 9.5% after 8.1 years in the arthroscopic group, with no statistical difference between them. Byrd and Jones^14,15 reported THA progression rates between 0% and 29% at 2 years after hip arthroscopy. Schairer et al¹¹⁰ used population-level data of State Ambulatory Surgery Databases and State Inpatient Databases for California and Florida from 2005 to 2012 to examine the progression rate of THA within 2 years after hip arthroscopy. They found an overall progression rate of 12.4% within 2 years after hip arthroscopy, with a significant difference between age groups. In patients <40 years old, the progression rate to THA was 3.0%, which is comparable with our findings of a 3.78% progression rate in patients with a mean age of 33.9 years. The rate of THA progression decreased steadily over time from 14.3% in 2005 to 10.3% in 2010.¹¹⁰

Age seems to be a risk factor for THA progression: patients aged >50 years exhibited a progression rate of about 20%.^71,110 This contrasted with the findings of the present systematic review, where age was not significantly associated with a higher rate of THA progression. Differences between our results and the findings of others might be explained by the fact that we included all types of surgical treatment for FAI, instead of focusing on arthroscopic procedures; other potential reasons include the type of data used, the type of analysis conducted (registry vs systematic), and the younger age of the patients in our study.

BMI at baseline was significantly associated with an increase in the rate of THA progression at a mean follow-up of 38 months. These findings confirm previous results, which found that obesity is an independent risk factor for THA progression after hip arthroscopy at a mean follow-up of 2 years.¹¹⁰ In addition, Gupta et al⁴³ and Collins et al²⁴ confirmed, in small case series studies, that obesity is associated with higher rates of THA progression after arthroscopic procedures. Our results showed that BMI was a risk factor for THA progression, regardless of the surgical technique.

We were also able to show that the preoperative acetabular index was significantly associated with an increased rate of progression to THA. So far, no studies showed an association between the preoperative acetabular index and the progression rate to THA. However, high lateral center-edge angles and low acetabular indices, which require more complex surgical techniques for adequate treatment, are associated with higher rates of revision surgery.⁵⁹

Furthermore, we found that labral debridement was associated with an increase in the rate of THA revision for the 3 major surgical techniques analyzed in the present investigation. Schilders et al¹¹¹ demonstrated superior outcomes after labral repair as compared with labral debridement in 96 patients with a mean follow-up of 2 years. This was confirmed by Larson et al⁶⁵ in a case-control study, with better Harris Hip Score, SF-12, and visual analog scale outcomes in the labral repair group. Menge et al⁷⁵ compared 79 patients who underwent labral repair and 75 patients who underwent labral debridement at a mean follow-up of 10 years: no difference in clinical outcomes between the techniques was evident. However, when controlling for acetabular microfracture, Menge et al reported that labral debridement was associated with a significantly higher risk of progression to THA, confirming our findings.

This study presents several limitations. Although we have carefully followed recommended guidelines for the preparation of systematic reviews, the overall quality of the studies was low. Most of the studies were retrospective, and eligibility criteria and rehabilitation protocols were not frequently reported. The overall CMS of 64 shows acceptable quality. The mean follow-up of the studies was 30 months, which is longer than most previous studies, but revision and progression rates are likely to increase with long-term follow-up. Given these premises, the risk of biased results is moderate to high; thus, data from the present study must be interpreted with caution. The purpose of the present study was to investigate whether the aforementioned endpoints are associated with the rate of revision and subsequent progression to THA. Thus, every endpoint was investigated independently, and its risk of recurrence in revision and progression to THA was assessed. We did not perform any comparison between endpoints and their overall effect on the surgical outcomes. This may represent a limitation of the present study. However, in the current literature, there is a multitude of studies focusing on several aspects of FAI correction, evaluating and comparing all the endpoints and their effect on the surgical outcomes. Future studies should overcome these limitations, and high-quality investigations with longer follow-up should be performed.

Conclusion

Surgical treatment for FAI leads to satisfactory outcomes. In this systematic review of 99 studies and 9357 procedures, we found an overall revision rate of 5.29% after surgical treatment. After a median follow-up of 30 months, the progression rate to THA was 3.78%. Patients were at higher risk for a subsequent progression to THA if they had a high BMI, a pathologic acetabular index, or labral debridement during correction of FAI. Therefore, we do advocate additional education of this patient population in terms of its expected outcomes and surgical labral repair instead of simple debridement if needed and technically feasible.

Supplemental Material

sj-pdf-1-ajs-10.1177_03635465211011744 – Supplemental material for Revision Surgery and Progression to Total Hip Arthroplasty After Surgical Correction of Femoroacetabular Impingement: A Systematic Review

Supplemental material, sj-pdf-1-ajs-10.1177_03635465211011744 for Revision Surgery and Progression to Total Hip Arthroplasty After Surgical Correction of Femoroacetabular Impingement: A Systematic Review by Filippo Migliorini, Nicola Maffulli, Alice Baroncini, Jörg Eschweiler, Markus Tingart and Marcel Betsch in The American Journal of Sports Medicine

Footnotes

Acknowledgements

The authors thank Michael Berner for his support and motivation during the study conceptualization. They also thank Paolo Aretini, PhD, for his consistent support and motivation during the statistical analyses.

Submitted September 8, 2020; accepted December 22, 2020.

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

An online CME course associated with this article is available for 1 AMA PRA Category 1 Credit™ at . In accordance with the standards of the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The American Orthopaedic Society for Sports Medicine that authors, editors, and planners disclose to the learners all financial relationships during the past 12 months with any commercial interest (A ‘commercial interest’ is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients). Any and all disclosures are provided in the online journal CME area which is provided to all participants before they actually take the CME activity. In accordance with AOSSM policy, authors, editors, and planners’ participation in this educational activity will be predicated upon timely submission and review of AOSSM disclosure. Noncompliance will result in an author/editor or planner to be stricken from participating in this CME activity.

ORCID iDs

Filippo Migliorini

Nicola Maffulli

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