International Orthopaedics (SICOT) (2015) 39:417422

DOI 10.1007/s00264-014-2574-9

ORIGINAL PAPER

Femoroacetabular impingement syndromeefficacy of surgical

treatment with regards to age and basic diagnosis
Petr Chldek & Martin Muslek & Tom Tr &
Petr Zahradnk & Petr Kos

Received: 24 June 2014 / Accepted: 18 October 2014 / Published online: 8 November 2014
# SICOT aisbl 2014

Abstract
Purpose The aim of this study was to assess the outcome of
hip preserving surgery for femoroacetabular impingement
relative to the condition resulting in FAI and to the patients
age at the time of the surgery.
Methods With the conditions for exclusion duly met, enrolled
in our study were a total of 100 hip joints (83 operated on with
the aid of SHD, 17 with AMIS). The minimum follow-up
period was 12 months, and the mean follow-up time was three
years four months. WOMAC and NAHS questionnaires were
used as rating instruments. To analyse the significance of the
differences relative to the age at the time of surgery and to the
basic diagnosis leading to FAI and subsequently to surgical
operation we used non-parametric forms of analysis of variance (Friedman test and Kruskal-Wallis test), i.e., comparisons of the patients pre-operative and postoperative states,
estimation of the rate of improvement in the postoperative
functional skills in relation to the age at the time of surgery
and/or relative to the basic diagnosis necessitating surgical
intervention, with respect to statistical significance at the level
of p<0.05.
Results As testing of our cohort of patients and results analysis showed, the youngest group (<30 years) compared with
the rest of the cohort shows greater postoperative improvement and consequently also a better surgical result. Proof was
also obtained that the diagnosis leading to surgery for FAI has

P. Chldek (*) : T. Tr : P. Kos

Paediatric and Adult Orthopaedics and Traumatology, Department of
Orthopaedics, 2nd School of Medicine, Charles University, Teaching
Hospital in Motol, Prague, Czech Republic
e-mail: chladek.ortopedie@gmail.com
M. Muslek : P. Zahradnk
Faculty of PT and Sports in Prague, Charles University, Prague,
Czech Republic

no effect on the patients pre- or postoperative state or on the

degree of improvement.
Conclusions The results of the study affirm the relevance of
hip preserving surgery, especially in younger-aged groups.
Keywords Femoroacetabular impingement . Results .
Surgical hip dislocation . Anterior mini-invasive approach

Introduction
The diverse causes that alter the hip joint cartilage ultimately
lead to only one resulthip osteoarthritis. The causes of hip
joint degeneration may, in each particular phase of the disease,
change, overlap and complement one another. This is entirely
true of the femoroacetabular impingement syndrome (hereinafter FAI), a condition arising from a mechanical conflict
between the hip joint socket and, put in a simplified way, the
femoral head [15]. We distinguish primary FAI, i.e. no
history of hip joint involvement before FAI appeared, Perthes
disease, i. e. avascular necrosis before growth plate cessation,
slipped capital femoral epiphysis in anamnesis (hereinafter
SCFE) and avascular necrosis of the femoral head after
growth plate cessation (hereinafter AVN). In the last three
cases FAI is considered as a sequel of them, therefore we
can call it a secondary FAI. The concept of hip osteoarthritis
developing as a result of mechanical conflict between the end
of the femoral head and that of acetabulum is fairly recent [4,
6, 7]. Since we adopted this concept of hip osteoarthritis
development at our centre, we have been using surgical treatment for FAI since 2005. And it is the presentation of our
cohort of those FAI patients who underwent surgery for their
predicament that constituted the subject of this study.
With regard to the extensive nature of the surgery required
and to merely short-term and medium-term results in world
literature [8, 9], our first operations of this kind were confined

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International Orthopaedics (SICOT) (2015) 39:417422

to cases where conceivable failure would not have had any

major negative impact on the surgical patients state of health.
Furthermore, their inclusion in the standard repertoire of surgical procedures was conditional upon a study of literature
pertaining not only to the operations mentioned below but also
to hip joint blood supply [1012]. Other prerequisites included a study of vascular supply during anatomical autopsy in
preparation for the surgery [13], and a prospective outcomerating study of the surgical patients.

Table 2 Surgical hip dislocation (SHD) patients

Diagnosis
Age

Primary FAI

Perthes disease

SCFE

AVN

< 30 years
3040 years
> 40 years

8
15
20

15
3
1

6
0
1

9
3
2

Primary FAI implies no history of hip joint involvement. Perthes

disease implies avascular necrosis before growth plate cessation
SCFE slipped capital femoral epiphysis in anamnesis, AVN avascular
necrosis of the femoral head (after growth plate cessation)

Aim
The aim of our study was to assess the outcome of a hip
preserving surgery in a cohort of patients relative to the
primary diagnosis and relative to age. We hypothesized that
the surgery for FAI would offer the patient alleviation of
subjective complaints and improvement of functional skills
regardless of the patients age and the basic diagnosis leading
to FAI.

Material
Experience in hip preserving surgery rests on our own cohort
of 136 hip joints with FAI operated on with surgical hip
dislocation (hereinafter SHD), and 54 hip joints treated
using the anterior mini-invasive surgery (hereinafter
AMIS) approach (Table 1).
For the purpose of meeting the study aim, i.e. assessment of
the outcome of hip preserving surgery, all patients after surgery for FAI were asked to complete the Western Ontario and
McMasters Universities Arthritis Index (hereinafter
WOMAC) and non arthritic hip score (hereinafter NAHS)
questionnaires [14, 15] designed to rate their functional affection before and after the operation at a minimum of 12 months
postoperatively. Excluded from the study were patients with
incomplete documents/questionnaires, and those examined
for FAI solely arthroscopically (owing to nonstandard results
with the learning curve in constant progress) [16]. Nor were
enrolled patients treated for FAI with osteochondroplasty of
the head-neck junction during Ganz Bernese periacetabular
osteotomy [17] indicated for concurrent acetabular dysplasia
Table 1 Total number of hip joints (patients) treated for FAI
Approach Number of hip
joints

(Number of
patients)

Male

SHD
AMIS

(119)
(49)

84 (72) 52 (47)
25 (23) 29 (26)

136
54

Female

SHD surgical hip dislocation, AMIS anterior mini-invasive surgery

(because the outcome was influenced by difficulties arising

from structural instability more than from FAI).
Enrolled in the study were patients surgically treated between October 11, 2005 and June 30, 2012 by means of SHD
or AMIS. This cohort was statistically assessed during autumn
2013 so that, after all the due exclusions, what remained were
83 hip joints resolved with the aid of SHD (Table 2) and 17 hip
joints treated by means of AMIS (Table 3). The minimum
duration of the study then was 12 months, with the average
period of three years four months (range, 12 months to seven
years eight months).
The exact number of participants in either group, classified
by age and diagnosis, treated with SHD are given in Table 2.
The exact numbers of age-related, AMIS-treated participants
are stated in Table 3.

Methods
WOMAC and NAHS questionnaires were used as rating
instruments for pain perception and/or functional skills. The
patients were asked to complete both diagnostic instruments
prior to and at a set time after surgery. Since the data from the
two questionnaires were scored on the Likert scale and are
consequently of the ordinal data type, we decided to use nonparametric procedures (techniques) for data analysis.
To analyse the significance of differences in pain
perception/functional skills of patients operated on for FAI
(using both SHD and AMIS) relative to age at the time of the
surgery, we used the Friedman test for both questionnaires
[18] as a nonparametric technique of two-way analysis of
variance. The actual design of this two-way analysis took
the following form: 3 (age groups: <30, 3040, >40)2
(periods of time: preoperative, postoperative).
Table 3 Anterior miniinvasive surgery (AMIS)
patients

Age

Number

< 30 years
3040 years
> 40 years

0
3
14

International Orthopaedics (SICOT) (2015) 39:417422

419

Table 4 Descriptive statistics of differences in preoperative and postoperative scores of pain perception rated with WOMAC and NAHS
Age (years)

<30
3040
>40

WOMAC before/after

Difference before/after

NAHS before/after

Difference before/after

Mean/SD

Mean /SD

Mean dif.

Mean/SD

Mean/SD

Mean dif.

73.2713.39
74.646.67
70.8210.33

89.0510.22
85.439.87
82.6212.27

15.78*
10.79
11.80

56.6110.71
54.869.34
50.6511.48

70.128.96
65.3911.13
62.1513.17

13.51
10.52
11.5

*p<0.05

For the comparison of differences in pain perception/

functional skills both before and after surgery using the
WOMAC and NAHS questionnaires between particular diagnoses (primary FAI, Perthes disease, SCFE, AVN) in SHD
patients we used the one-way nonparametric Kruskal-Wallis
analysis of variance. The defined factor levels represented the
above listed diagnoses.
Relative to the two aims of the study, the statistical significance of the difference in the procedures employed was set at
p<0.05. To express the practical significance of differences in
the effect size formula, we used Cohens coefficient d, the
acceptable level of which was set at d>0.7 [19]. NCSS2007
statistical software was used to complete statistical analysis
[20].

Results
Comparison of differences in preoperative and postoperative
scores of pain perception/ functional skills in patients operated
on for FAI (using SHD and AMIS together) relative to age
group rated with WOMAC and NAHS questionnaires

significance was as follows: d<30,3040 =0.79, d<30,>40 =0.72

and d3040,>40 =0.13. As for the NAHS results, no significant
differences were found in the mean pain perception unlikeness
though, once again, the category of patients <30 years showed
the best results, i.e. 13.51 points on average. Interestingly
enough, both questionnaires showed the least difference, albeit of no practical or statistical significance, in the age bracket
of 3040 years (see Table 4, Graphs 1 and 2).
As follows from our cohort testing, the youngest group
(<30 years) compared with the other patients presents greater
postoperative improvement and consequently also a better
surgical result.

Comparisons of differences in pain perception/functional

skills in patients before SHD surgery for each particular
diagnosisprimary FAI, Perthes disease, SCFE,
AVNthan after surgery and comparisons of differences
in the scores for each of the diagnoses

Assessment of age-related changes in the pain perception

score revealed, in statistical and practical terms, a significantly
greater difference in the WOMAC questionnaire in the youngest group of patients (up to 30 years) where the practical

Comparisons of the results of pain perception/functional skills

between primary FAI, Perthes disease, SCFE, and AVN in
SHD patients showed no statistically significant difference in
any of the parameters (Table 5, Graphs 3 and 4).
Hence, the results of our cohort of patients offer the following statistical proof, namely, a condition necessitating
surgery for FAI has no effect on preoperative or postoperative
state assessment or on the degree of improvement.

Graph 1 Mean differences in preoperative and postoperative scores for

each age group (WOMAC). *p<0.05

Graph 2 Mean differences in preoperative and postoperative scores for

each age group (NAHS). *p<0.05

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International Orthopaedics (SICOT) (2015) 39:417422

Table 5 Descriptive statistics of preoperative pain perception differences for each diagnosis
Diagnosis

FAI
M.Perthes
SCFE
AVN

WOMAC before/after

Difference before/after

NAHS before/after

Difference before/after

Mean/SD

Mean/SD

Mean dif.

Mean/ SD

Mean/ SD

Mean dif.

75.558.53
68.8314.25
72.9811.34
75.0214.65

87.8110.39
86.6210.38
87.499.33
91.15 12.02

12.26
17.79
14.51
16.12

56.0610.50
52.3511.47
55.0510.73
61.576.55

67.8311.58
67.510.15
67.788.85
73.146.98

11.76
15.14
12.73
11.57

SCFE slipped capital femoral epiphysis, AVN avascular necrosis of the femoral head

In our view, the outcome of hip preserving surgery depends

entirely on the state in which we find the joint at the time of
surgery. The procedure is determined primarily on the establishment of accurate and early diagnosis [21, 22]. The hip pain
is not necessarily an initial symptom. Consequently, the clinical picture of FAI may differ as to the character of complaints
and to the time of their onset. Trouble is more likely to arise in
secondary FAI, in more expressed CAM or PINCER lesions,
in reaction to major exertion, particularly in sports. It should
be stressed, though, that often it is not hip joint pain that makes
the patient seek medical advice, very often it is low back pain,
and not only in our experience [23].
Complications constitute an important chapter in rating the
outcome of hip preserving surgery, not only because this is an
elective operation representing, for a number of fellow surgeons and centres, a method of choice waiting for complaints
to worsen and for subsequent joint replacement.
Avascular necrosis of the femoral head is probably the
gravest FAI surgery-specific complication. It may be caused
by wrong management of flip osteotomy of the greater trochanter (with proximal involvement of fossa trochanterica, or
by failure to respect the course of lateral retinacular vessels
and their intraosseous inlets (Fig. 1) (vigorous treatment of
lateral CAM lesion).
Femoral neck fracture is also a major complication as it
may ultimately result in conversion to hip replacement,

although equally so it may heal without any consequences at

all. The cause again may rest in vigorous treatment of a CAM
lesion, which is why resection of at most 30 % of the neck
width is allowed [24]. Greater trochanter osteosynthesis failure may be attributable to the patients non-compliance but
also to an excessively lateral course of osteotomy. Nerve
injuries (direct or traction type) resulting in paresis are also a
major complication. Potential victims are sciatic nerve, femoral nerve and pudendal nerve (even contralateral in the case of
arthroscopy) and lateral femoral cutanous nerve (regularly
when using the anterior approach, rarely so in arthroscopy).
Haemorrhage is obviously a threat in Ganz periacetabular
osteotomy and hardly a problem in surgical hip dislocation.
Other non-specific but major complications include deep
wound infection and deep vein thrombosis.
Compared with other studies [8, 9, 2528], the number of
our participants under study is adequate. The average number
of surgically treated hip joints in the studies published was 45
(14112). The total average score change in all the rated
operations for FAI was 13.19 points (WOMAC) and 12.14
points (NAHS). Relative to the surgical approach, the score
change was more significant in SHD (WOMAC 14.03, NAHS
12.55), and less so in the AMIS approach (WOMAC 8.56,
NAHS 9.71). With respect to studies using WOMAC scoring,
our results are comparable, too; relative to NAHS they are
equally plausible (arthroscopically Phillipon and Brunner 14
and 31.3 points resp., using the combined approach 29.1
points; Laude) [26, 28, 29].

Graph 3 Mean differences in preoperative and postoperative pain perception scores for each diagnosis (WOMAC)

Graph 4 Mean differences in preoperative and postoperative pain perception score for each diagnosis (NAHS)

Discussion

International Orthopaedics (SICOT) (2015) 39:417422

Fig. 1 Intraosseous inlet of lateral retinacular vessels (pincette)

The proportion of failure is derived from the definition of

this category, different, as it is, from author to author. We
regarded as demonstrable failure either the need for hip replacement or score worsening in at least one of the questionnaires (WOMAC, NAHS).
With respect to the above criteria, we failed at a rate of
4.8 % (4/83) in SHD, in the AMIS approach, i.e. at 11.8 %
(2/17). Out of this number, conversion to hip replacement after
SHD was necessary in 3.6 % (3/83) and after AMIS in 5.9 %
(1/17). Hence, compared with literary data, the percentage of
our failures is below average, whereby Clohisy reports 11.1 %
(026 %), similarly as his percentage of conversions to hip
replacement is 9.3 % (026 %) (8).
More or less concurrently with other authors, we had no
major complications in our cohort (0 % AVN, 0 % greater
trochanter pseudoarthrosis, prolonged healing only twice, no
deep infection) except for sciatic nerve paresis in two female
patients, in either case associated with spinal conduction anaesthesia. The first was ipsilateral and fully resolved in
nine months, the second patient suffered transient contralateral
paresis of three days duration.

Conclusion
The outcome of our study affirmed the sense of hip preserving
surgery in adults. While it was the youngest group of patients
that had the best results of surgical treatment for FAI, the
condition leading to FAI and to subsequent surgical treatment
had no effect on the outcome of surgery.
The selection of the right kind of patients for hip preserving
surgery would in itself make a separate chapter [30]. The
recommended limit for preserving at least 50 % of the joint
space or at least 2 mm [7] for the hip preserving intervention to
be performed without any risk of failure deserves respect,
though not blind respect. Thus all patients who underwent
hip preserving surgery via the SHD approach had joint space
in the recommended limit, in contrast to six of them who
underwent AMIS approach and were out of that range. The
question always is what the patient expects from the operation

421

and what we can offer him/her. The patients expectation quite

individually comprises many variables, i.e. pain or movement
restriction tolerance, vocational position, sporting career
phase or just longing for an active way of life, etc. For our
part, the offer of help ought to be as wide as possiblefrom
conservative approaches with warning of the risks involved
and recommendation of relevant restrictions such as will not
overreach the patients tolerance, to mini-invasive treatment
with lesser morbidity but also with lesser scope for consistent
correction of existing impediments, up to major reconstructive
operations where increased morbidity is offset by more scope
for optimum management of all defects and lesions.
Acknowledgments Supported by a Grant of the Ministry of Health and
General Teaching Hospital Prague Motol 00064203 and PRVOUK
P039.

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