Hip Arthroscopy for Femoroacetabular Impingement

By James Rosneck, MD

A 16-year-old high school wrestler presented with hip pain that had been present for five years. This pain was symmetric in character but slightly worse on the right and had been accompanied by bilateral loss of motion for as long as he could remember. Despite competitive wrestling, he denied any specific traumatic event that correlated with initiation of symptoms. Until presentation, his treatment had consisted of decreasing wrestling volume and workout intensity. Unfortunately, those modifications along with physical therapy had not alleviated his symptoms. He became unable to wrestle.

On examination, he had a loss of internal rotation, pain at the extremes of motion, and positive bilateral anterior impingement tests. He had no soft tissue tenderness.

Femoroacetabular impingement

Anteroposterior pelvis and lateral view radiographs of the hip revealed that our patient had bilateral femoroacetabular impingement (FAI). Ganz first described FAI as a condition resulting from overcorrection of the dysplastic hip with periacetabular osteotomy (PAO). Patients who presented with recurrent symptoms after PAO were treated with an osteochondroplasty, or reshaping of their femoral neck at the head-neck junction, and their symptoms resolved.

FAI causes an abnormal abutment of the femoral neck on the acetabular rim. This repetitive abutment may lead to tearing of the hip labrum and a painful hip joint. Apart from post-PAO situations, the true cause of this anatomic variation is elusive. Some research indicates that the anatomy progresses over time in high-level athletes, possibly as a type of functional adaptation over the course of skeletal maturation. This indicates a buildup of clinically asymptomatic microtrauma, which may cause asymmetric closure of the proximal femoral physis. Another theory proposes a genetic cause, as these patients will often also have relatives who had hip issues at a young age.

Technique and results

Given the patient’s failed conservative measures, progressive symptoms, and imaging revealing FAI and a labral tear, we discussed and then proceeded with surgical treatment. Hip arthroscopy was performed in the supine position. The joint was accessed under fluoroscopic guidance utilizing a special table allowing hip distraction. After placing trocars, we completed a diagnostic routine, including evaluation of the labrum. Our patient had a torn labrum with an associated loose piece of acetabular bone (os acetabula) as part of his impingement pattern.

AP radiograph of the pelvis shows the os acetabula (blue arrow) as part of impingement pattern

We removed this piece and secured the repaired labrum to the prepared acetabular bone behind the ossicle with four suture anchors. Once we were satisfied with the repair, the hip was reduced under direct visualization to ensure appropriate position.

Arthroscopic view of repaired labrum secured to acetabular bone with suture anchors (orange arrow) after the ossicle has been resected.

At this point, we commenced the femoral portion of the procedure. The femoral-sided impingement (cam lesion) was contoured to a more normal offset. Intermittent fluoroscopy and direct visualization ensured adequate restoration of the convexity of the head-neck junction.

Arthroscopic view of femoral-sided impingement (green arrow) after contouring

The patient entered an intensive physical therapy program starting postoperative day one and returned to wrestling six months later. He noted significant improvement in his pain and range of motion compared with his preoperative status.

Hip arthroscopy helps athletes return to sport

Over the past 10 to 15 years, we have seen a rapid increase in our understanding of the evaluation, diagnosis and treatment of nonarthritic hip disorders, thanks to several studies including those performed at Cleveland Clinic Sports Health. The advent and advancement of hip arthroscopy has spearheaded this explosion of knowledge. Hip arthroscopy has been shown to help athletes of all levels return to sport or desired activity with significant improvement in their symptoms. Our understanding of and ability to treat and educate patients will only improve as we follow our patients’ clinical outcomes over time.

Dr. Rosneck is staff in Cleveland Clinic Sports Health.