Arthroscopic femoro-acetabular surgery for hip impingement syndrome: consultation

 

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE

Interventional Procedure Consultation Document

Arthroscopic femoro-acetabular surgery for hip impingement syndrome

Hip impingement syndrome may restrict movement of the hip joint and can be painful. It is associated with an unusual shape of the hip socket (acetabulum) and/or the head of the thigh bone (femoral head). Arthroscopic hip-preservation surgery aims to reshape the hip joint by removing parts of cartilage or bone through a minimally invasive operation.

The National Institute for Health and Clinical Excellence is examining arthroscopic femoro–acetabular surgery for hip impingement syndrome and will publish guidance on its safety and efficacy to the NHS in England, Wales, Scotland and Northern Ireland. The Institute’s Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisers, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about arthroscopic femoro–acetabular surgery for hip impingement syndrome.

This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

  • comments on the preliminary recommendations
  • the identification of factual inaccuracies
  • additional relevant evidence.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.

The Advisory Committee will then prepare draft guidance which will be the basis for the Institute’s guidance on the use of the procedure in the NHS in England, Wales, Scotland and Northern Ireland.

Closing date for comments: 19 December 2006
Target date for publication of guidance: March 2007

 

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

 

1 Provisional recommendations
   
1.1 Current evidence on the safety and efficacy of arthroscopic femoro–acetabular surgery for hip impingement syndrome does not appear adequate for this procedure to be used without special arrangements for consent and for audit or research.
   
1.2 Clinicians wishing to use arthroscopic femoro–acetabular surgery for hip impingement syndrome should take the following actions .
  • Inform the clinical governance leads in their Trusts.
  • Ensure that patients understand the uncertainty about the procedure’s safety and efficacy, and provide them with clear written information. In addition, use of the Institute’s information for patients (‘Understanding NICE guidance’) is recommended (available from www.nice.org.uk/IPG XXX publicinfo). [[details to be completed at publication]]
  • Audit and review clinical outcomes of all patients having arthroscopic femoro–acetabular surgery for hip impingement syndrome (see section 3.1)
   
1.3 The procedure should only be performed by surgeons with specialist expertise in arthroscopic hip surgery.
   
1.4 The natural history of hip impingement syndrome and the selection of patients for this procedure are uncertain; further research on these issues will be useful. The Institute may review the procedure upon publication of further evidence.

 

2 The procedure
   
2.1 Indications
 
2.1.1 Hip impingement (femoro–acetabular impingement) is a result of abnormality in the femoral head, acetabulum or both. Impingement can be caused by jamming of an abnormally shaped femoral head into the acetabulum during forceful motion (especially flexion), or as the result of contact between the acetabular rim and the femoral head–neck junction. Its precise relationship with osteoarthritis of the hip is unclear, but it may lead to the development of osteoarthritis.
   
2.1.2 Symptoms of hip impingement may include restriction of movement, ’clicking‘ of the hip joint and pain. Symptoms may occur or be exacerbated during hip flexion resulting from sporting activity, or after prolonged sitting.
   
2.1.3 Treatment for hip impingement usually begins with a trial of conservative treatment, including modification of activity to reduce excessive motion and burden on the hip. Non-steroidal anti-inflammatory drugs may be useful for pain control. Patients with associated osteoarthritic degeneration may require a total hip replacement.

 

2.2 Outline of the procedure
2.2.1 Arthroscopic femoro–acetabular surgery for hip impingement syndrome aims to improve clearance of the hip movement and to alleviate femoral abutment against the acetabular rim. The procedure is carried out under general anaesthesia. The hip is sublaxed using leg traction. An arthroscope and surgical instruments are inserted into the hip through two or three portals. Any non-spherical sections of the femoral head and prominent sections of the anterior femoral neck are resected, to improve the offset of the femoral neck and increase clearance in the joint. Labral lesions are debrided using a shaver or radiothermal device, and femoral and acetabular osteoplasty are achieved where necessary with a burr. The range of motion and any residual impingement are evaluated.

 

2.3 Efficacy
   
2.3.1 Efficacy outcomes were poorly reported in the two studies identified; assessments were mostly qualitative.
   
2.3.2 In one case series of 158 patients undergoing arthroscopic femoro–acetabular surgery, resolution of impingement signs on clinical evaluation was reported in nearly all patients. In the majority of patients, pain was reduced by 50% at 3 months, 75% at 5 months and 95% at 1 year (the study did not specify how pain reduction was measured). Overall, 2% (3/158) of patients required a total hip replacement at a mean follow-up of 22 months. In another case series of 10 patients, the mean non-arthritic hip score on the McCarthy scale improved from 75 points to 95 points at 14 months’ follow-up.
   
2.3.3

The Specialist Advisers highlighted that specialist scores for evaluation of clinical outcomes have not yet been developed. Significant improvement in symptoms, and delay or prevention of total hip replacement may be useful measures.

 

2.4 Safety
   
2.4.1 The evidence on safety was based on one case series. A pathological non-displaced fracture that required closed pinning occurred in 1 of 158 patients (<1%) undergoing arthroscopic femoro–acetabular surgery for hip impingement.
   
2.4.2 The Specialist Advisers considered the key safety outcomes to be similar to those for any arthroscopic hip intervention and may include infection, deep vein thrombosis, hip fracture and late-onset avascular necrosis of the femoral head.

 

3 Further information
3.1

This guidance requires that clinicians undertaking the procedure make special arrangements for audit. The Institute has identified relevant audit criteria and is developing an audit tool (which is for use at local discretion), which will be available when the guidance is published.

   
3.2 The Institute is also developing guidance on open femoro–acetabular surgery for hip impingement syndrome (www.nice.org.uk/ip_243).

 

Bruce Campbell

Chairman, Interventional Procedures Advisory Committee

December 2006

 

Appendix: Sources of evidence

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

‘Interventional procedure overview of arthroscopic femoro–acetabular surgery for hip impingement syndrome’, September 2006.

Available from: www.nice.org.uk/ip365overview.

 

 

This page was last updated: 29 January 2011