Arthroscopy useful in treating FAI, labral tears

Femoroacetabular impingement (FAI), labral tears, and other hip disorders are not new conditions in athletes, but orthopaedists’ ability to diagnose and treat them continues to evolve, said J.W. Thomas Byrd, MD, during a session at the American Orthopaedic Society for Sports Medicine’s 2010 Specialty Day.

“In the past, many of these athletes fell off our radar screen,” he said. “Many of these disorders went unrecognized and untreated. Athletes were simply resigned to living within the constraints of their symptoms, which usually meant giving up their competitive athletic careers.”

Today, noted Dr. Byrd, orthopaedists are using new techniques—such as arthroscopic surgery and sophisticated rehabilitation protocols—to manage these conditions successfully.

Arthroscopy and the impact of arthritis
Dr. Byrd reviewed the results of three studies with 10-year follow-up for which he served as the lead author. In a prospective analysis of a consecutive series of 50 patients, the median improvement was 25 points on the Modified Harris Hip (MHH) scale after hip arthroscopy. The average age of the patients was 38 years (range, 14 to 84 years).

According to Dr. Byrd, the study substantiates the long-term effectiveness of arthroscopy in the hip as a treatment for various disorders including labral pathology, chondral damage, synovitis, and loose bodies. The presence of arthritis was an indicator of poor outcomes, he said. Of the approximately 25 percent of patients who had undergone total hip arthroplasty (THA) by the time the 10-year follow-up was conducted, nearly 80 percent had arthritis.

In another prospective analysis, 52 hip arthroscopy procedures were performed on a consecutive series of 50 patients with labral pathology. The mean patient age was 46 years (range, 17 to 84 years).

“In that study, 29 patients were treated for a tear of the acetabular labrum,” explained Dr. Byrd. “These patients represented the substance of the study.”

The researchers found that the median improvement in MHH scores was 29 points when comparing preoperative and postoperative scores.

“We found that 83 percent of patients without arthritis continued to show substantial improvement at 10-year follow-up,” he said, adding that the results of this study also pointed to arthritis as an indicator of poor long-term outcomes.

“We found that 88 percent of patients with arthritis subsequently had THA,” he said.

In another study of 15 patients (average age, 32 years; range 14 to 70 years) with chondral damage, labral tears, arthritis, osteonecrosis, loose bodies, or synovitis due to athletic activities, 13 had returned to sport a decade after hip arthroscopy was performed.

The median improvement in MHH scores was 45 points (from 51 preoperatively to 96, on the 100-point scale), with 87 percent of the athletes returning to their sport.

“We concluded that arthroscopy for hip injuries in athletes can lead to substantial improvement with durable results,” he said.

Managing FAI, labral tears
Dr. Byrd noted that treatment of FAI has transitioned from open to less invasive arthroscopic procedures, mirroring a similar transition in knee surgery.

“Except for the most severe cases, FAI is amenable to arthroscopic intervention,” he said. “Much more published data on the results of arthroscopic management of FAI in athletes exist compared to data on open management of FAI.”

Dr. Byrd referred to a study conducted by Asheesh Bedi, MD, and fellow researchers in which computerized literature databases were reviewed for studies involving patients diagnosed with labral tears and/or FAI.

“The investigators found that open surgical dislocation with labral débridement and osteoplasty is successful, with 65 percent to 85 percent of patients satisfied with their outcome at 40 months after surgery,” said Dr. Byrd. “Researchers found that arthroscopic treatment of labral tears is also effective, with between 67 percent and 100 percent of patients reporting satisfaction with their outcomes.”

Rehabilitation andcomplications
The more complicated the procedure, said Dr. Byrd, the more sophisticated the rehabilitation strategies must become. With extensive bony correction of FAI, he said, rehabilitation must emphasize mobilization to reduce the risk of adhesions. In patients who have undergone labral repairs, however, care must be taken to protect the repair site during early healing.

“Our rehabilitation strategies are basically empirical,” he said. “We are starting to see some good basic science work that will help direct our rehabilitation strategies.

“We must also remember that new treatment strategies create new complications,” continued Dr. Byrd. “Fractures, stiffness, and heterotopic ossification are all potential complications of more extensive reconstructive arthroscopic procedures.

“We have come a long way in hip arthroscopy, but we still have a long way to go,” he added.

Dr. Byrd reported the following disclosures: Smith & Nephew Endoscopy and A2 Surgical.

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

Bottom line

• Arthroscopic techniques and sophisticated rehabilitation protocols can be used to help athletes with FAI, labral tears, and other hip disorders return to activity.
• Studies have found that the presence of arthritis may be an indicator of poor outcomes after arthroscopy.

References

1. Byrd JWT, Jones KS: Prospective analysis of hip arthroscopy with 10-year follow-up. Clin Orthop Relat Res, 2010; 468(3):741.
2. Byrd JWT, Jones KS: Hip arthroscopy for labral pathology: Prospective analysis with 10-year follow-up. Arthroscopy, 2009; 25(4); 365-368.
3. Byrd JWT, Jones KS: Hip arthroscopy in athletes: 10-year follow-up. Am J Sports Med, 2009; 37:2140-2143.
4. Bedi A, Chen N, Robertson W, et al: The management of labral tears and femoroacetabular impingement of the hip in the young, active patient. Arthroscopy, 2008; 24(10):1135-1145.