The Arthroscopic Correction of Underlying Femoroacetabular Impingement: Multi-faceted Clinical Implications and Outcomes Evaluation
Creators: name: Filan, David
Publisher: name: Royal College of Surgeons in Ireland
Year: 2025
Subjects: classificationCode: 320226
subject: Surgery
classificationCode: 320216
subject: Orthopaedics

description: <strong>Background: </strong>The arthroscopic management of symptoms associated with femoroacetabularimpingement (FAI) is a progressively evolving field, and still in its relative infancy. As the clinical indications of FAI have dramatically expanded over the past 20 years, so too has the incidence of hip arthroscopy (HA), now considered the treatment ofchoice for the surgical management. Although the increased focus on outcomes, as reported from the perspective of the patient, has proved invaluable in ascertaining who is most likely to benefit from this intervention, the optimal technique to define and measure clinical improvement is variable. While consensus at a group level and through systematic reviews and meta-analyses has highlighted certain demographics that may be deemed contraindicative to a successful outcome, on an individual case-by-case scenario the benefits which HA can offer are still evolving and should be considered relative to the desires and expectations of the patient. Advancing and refining surgical techniques including capsular repair, treating patients with underlying dysplasia or with evidence of established osteoarthritis, and optimal timing for managing patients with bilateral symptoms, remains controversial. 
<strong>Methods: </strong>This thesis is based on prior published work. Data was reviewed from a prospectively maintained institutional HA registry, comprised of patients undergoing hip arthroscopy for symptomatic FAI. Each of the included papers had a specified research question. Chapter 2 describes and substantiates a technique to evaluate clinical improvement post-operatively, known as the Percentage of Possible Improvement (POPI). This technique involves quantifying a percentage threshold of minimal clinically important improvement based on the scope of potential for possible improvement in an athletic cohort. This technique is also included in Chapters 3, 4 and 7, which contain a representative sample of athletes for which this technique is proposed. Chapter 3 evaluates the impact of chronic hip impingement and subsequent hip arthroscopy on both physical and mental components of generalised well-being in an athletic population, investigating a description of health overall. Chapter 4 focuses on patients with dual pathology (namely FAI and inguinal 
13 disruption) and the effectiveness of alleviating the symptomatic consequences of both pathologies with one procedure (HA). Chapter 5 is a matched-control study evaluating the long-term outcomes of a minimally invasive preservation procedure in patients typically not indicated for arthroscopy (namely advanced osteoarthritis, OA). Chapter 6 is a comparative cohort study assessing the impact of incorporating routine capsular repair as part of the standard surgical. Chapter 7 focuses on the management of patients with bilateral symptoms and investigates the outcomes of a novel, accelerated time period between staged procedures. 
<strong>Results: </strong>The POPI technique represents a more versatile method of determining MCID, which negates the ceiling effect of PROMs. In this study &gt;40% of athletes were unable to achieve MCID (using a traditional MCID calculation technique) due to high baseline scores in both mHHS and SF36, while 0% of athletes were unable to achieve a percentage change MCID, allowing for a more comprehensive assessment of all surgically operated cases. A larger proportion of cases achieved MCID in the PCS (56.9%) compared to the MCS (28.7%). At 2 years post-HA both PCS and MCS were significantly worse in those cases not continuing to play their sport. Rates of achieving MCID for both PCS and MCS was also significantly poorer when continuing to play was not achieved. In cases of dual pathology (FAI and ID), 89% of cases did not require additional groin surgery where the hip arthroscopy for the FAI component was performed as the index procedure. PROMs, rates of achieving MCID and satisfaction are similar where HA alone or HA and separate groin repair are performed. In the presence of advanced OA, survivorship is lower (57.1% compared to 87%) and these patients are 4.1 times more likely to undergo THA compared to controls. However, where THA is avoided at 10 years post-HA, 78% of OA cases report their current state as satisfactory, with significant improvements in mHHS and SF36 observed. Routinely repairing the hip capsule did not result in significantly different PROMS, rates of achieving MCID or rates of revision surgery compared to non-repaired capsule at 2 years, at a group level. There was however a lower repeat HA rate in those younger patients with a repaired capsule. For athletes with bilateral FAI, improvement in PROs and CTP ratesfollowing accelerate staged HA (1-week) are comparable with a delayed duration  between procedures and with those case-control matched athletes undergoing unilateral arthroscopy at 2-years. 
<strong>Conclusion: </strong>The impact of HA for FAI has implications which can be considered multi-faceted. Measuring clinical improvement using a percentage of possible improvement is more inclusive. While an arthroscope may not improve all aspects of overall health (emotional wellbeing), there are instances where HA for FAI alone can improve atypical pathologies – symptoms stemming from ID and OA. Routine capsular repair did not significantly alter PROs at 2 years. Accelerated staged HA 1-week apart is a safe and effective procedure for those athletes with bilateral FAI.