Hip Arthroscopy and Capsular Closure for a Labral Tear with FAI
Follow the case of a 21-year-old collegiate hockey goalie who presents with a 2-year history of left hip and groin pain that worsens with squatting, sitting, driving, and running. He also experiences popping and clicking during hip flexion and reports aching after a game.
Anant Dixit, MD; Sundeep Saini, DO; and John P. Salvo Jr., MD
Femoroacetabular impingement (FAI) describes the pathologic articulation between the acetabular rim and the femoral head-neck junction. FAI is implicated in the development of hip labral tears. If left untreated, it can lead to progression to hip osteoarthritis. [1-4] Advancements in hip arthroscopy have allowed for the reliable and effective treatment of FAI, resulting in an increase in rates of arthroscopic hip surgery. [5-7]
FAI is marked by subtle anatomic abnormalities that lead to increased mechanical loading during hip range of motion . More specifically, FAI can be classified into 3 morphologic subcategories:
- CAM-type deformities
- Pincer-type deformities
- Mixed-type deformities
A CAM-type deformity is a femoral-based disorder characterized by a decreased femoral offset at the head-neck junction.  The impingement of the aspherical femoral head causes repetitive microtrauma to the otherwise normal acetabular rim and labrum as it prematurely enters the hip joint during range of motion. [9, 10] This results in a characteristic “inclusion-type” delaminating injury to the chondral surface with concomitant labral tearing at the transition-zone cartilage.  Intraoperative findings have demonstrated a higher prevalence of CAM-type deformities in male patients compared with female patients (94.6% vs 84.5%), and a corresponding decrease in flexion, internal rotation, and external rotation. 
A pincer-type deformity occurs with acetabular overcoverage, secondary to excessive bony rim or labral overhang.  Repetitive engagement between the abnormal acetabular rim and the femoral head results in “impaction-type” injuries and degenerative tearing of the labrum.  These deformities are associated with focal rim lesions or global overcoverage caused by acetabular retroversion, coxa profunda, or coxa protrusio. 
A mixed-type deformity is the most common form of impingement and is a combination of CAM- and pincer-type morphologies.  Approximately 90% of patients with underlying labral pathology have concomitant femoral and/or acetabular deformities.  A study by Allen et al  further demonstrated a 42% incidence of focal acetabular rim deformities in a population of 201 hips with symptomatic CAM lesions.
Plain radiography can be used to quantify the aforementioned morphologic changes. Commonly obtained radiographs include:
- Anteroposterior (AP) pelvis view
- Frog-leg lateral view
- 45° Dunn lateral view
CAM-type deformities most commonly manifest along the anterosuperior head-neck junction and are best visualized on the 45° Dunn lateral view.  The alpha angle is formed between a line drawn from the center of the femoral neck and a line extending from the center of the femoral head to the aspherical tangent of the anterosuperior head-neck junction.  The cutoff for abnormal alpha angles is variable and has been described to be as low as 42°. 
The center-edge angle is measured on the AP view and is formed between a line drawn vertically through the center of the femoral head and a line drawn from the center of the femoral head and the superolateral aspect of the acetabulum.  Values less than 25° are consistent with inadequate acetabular coverage. 
Acetabular version can be determined by tracing the anterior and posterior walls of the acetabulum along an AP radiograph. A crossover sign represents the anterior acetabular wall crossing the posterior wall. This is indicative of a retroverted acetabulum and a pincer deformity. 
Non-operative therapy is still considered the first-line treatment modality for patients who present with symptomatic FAI.  Initial management includes a trial of:
- Non-steroidal anti-inflammatory medication
- Activity modification
- Physical therapy focused on core strengthening and avoidance of deep flexion with internal rotation
Patients with continued pain may be offered an intra-articular anesthetic and steroid injection.
This regimen has demonstrated success in an adolescent population, with 82% reporting significant improvement in outcome scores at 2-years of follow-up.  In a similar study with 72 adults, 71.2% of patients reported satisfactory results with non-operative therapy; however, 69.2% of patients were still limited in their activities and 40.4% were still considering surgery. 
Hip arthroscopy remains a powerful tool for the treatment of intra-articular pathology that is recalcitrant to non-surgical intervention. Multiple studies have demonstrated excellent clinical outcomes following arthroscopic hip labral repair in the setting of femoral and/or acetabular osteoplasty for symptomatic FAI. [21-24] Recently, increased focus has been placed on anatomic capsular repair during hip arthroscopy in an attempt to restore the native hip rotational profile and prevent iatrogenic instability. [25-27]
A 21-year-old collegiate hockey goalie presented with a 2-year history of left hip and groin pain. The patient complained that the pain worsened with squatting, sitting, driving, and running. He described the pain as intermittently sharp and noted that it ached after games. He complained of popping and clicking during hip flexion.
The patient underwent extensive physical therapy with his athletic trainer, during which he had no pain with core exercises. Despite focused physical therapy and a trial of non-steroidal anti-inflammatory medications, his symptoms persisted.
Of note, the patient presented with similar symptoms in his contralateral hip and had undergone right hip arthroscopy, labral repair, femoroplasty, acetabuloplasty, and capsular closure 3 months prior.
- Normal gait
- Positive “C sign”
- Range of motion: Flexion 100°; internal rotation 5° (at 90°of flexion); external rotation 45° (at 90° of flexion)
- 5/5 strength in hip flexion and abduction
- Positive anterior impingement and subspine impingement tests
- Positive lateral rim impingement signs
- Labral tear
- Hip osteoarthritis
- Iliopsoas tendon disorders
- Loose bodies
- Core muscle injury
- Lumbar spine radiculopathy
- Trochanteric bursitis
- Iliotibial band syndrome
- Hip adductor strain
Weight-bearing AP, lateral, false profile, 45° Dunn view hip radiographs (Figure 1)
- Tonnis 0
- Positive CAM-type deformity: alpha angle of 87.9°
- Positive crossover
- Lateral CE angle of 34.1°
Direct MRI arthrogram (Figure 2)
- Labral tear
- CAM-type deformity
Figure 1. Preoperative radiographs: Frog-leg lateral view (left), false profile view (center) demonstrating a center-edge angle of 34.1°, and a 45° Dunn view (right) demonstrating an alpha angle of 87.9°.
Figure 2. MRI arthrogram demonstrating a labral tear with a CAM-type deformity.
- Symptomatic labral tear with CAM-type deformity.
After the procedure was explained to him, the patient consented to undergo left hip arthroscopy for labral repair, femoroplasty, and acetabuloplasty.
He was positioned supine on a commercially available hip-traction table, which allowed for adequate hip joint distraction (Figure 3). Appropriate distraction across the hip joint is required to address labral pathology.
Anterolateral and modified-anterior portals were introduced, and a capsulotomy was performed. A horizontal capsulotomy, connecting the anterolateral and modified anterior portals, was performed to allow sufficient passing of instruments in the hip.
Figure 3. Distraction of the hip joint and establishment of the initial anterolateral portal under fluoroscopic guidance.
Technique: Central Compartment
- Diagnostic arthroscopy confirmed a full-thickness acetabular labral tear from the 10 o’clock (medial) to the 1 o’clock (lateral) position (Figure 4).
- The labrum was mobilized and elevated from the acetabular rim and a burr was used to perform an acetabuloplasty.
- A bony bed was prepared along the acetabular rim and suture anchors were placed on the rim, adjacent to the labral tear.
- Vertical mattress sutures were used to restore labral anatomy and the suction-seal effect.
Figure 4. The labral tear is demonstrated.
Technique: Peripheral Compartment
- Examination of the peripheral compartment was performed without hip distraction.
- Suction-seal effect of the repaired labrum was confirmed (Figure 5).
- The CAM lesion was identified arthroscopically, and the level of resection was confirmed with fluoroscopy (Figure 6). The bony prominence on the anterolateral femoral neck was consistent with the “inclusion-type” pattern of articular cartilage delamination and labral tear.
- A burr was used to contour the proximal femoral neck, and the measured resection was confirmed with fluoroscopy (Figures 7-8).
- A dynamic examination was performed to ensure resolution of the CAM-type impingement.
- The capsule was closed with 3 simple, side-to-side sutures (Figure 9).
Figure 5. The level of resection was confirmed with the use of fluoroscopy.
Figure 6. A burr was used to perform a resection of the bony prominence.
Figure 7. Fluoroscopic confirmation of appropriate bony resection of the CAM-type lesion.
Figure 8. Suction-seal effect of the repaired labrum was confirmed arthroscopically.
Figure 9. The hip capsular repair was performed with 3 side-to-side sutures.
Postoperative rehabilitation following arthroscopic treatment of FAI with labral repair consists of the following 4 phases:
Phase I – Immediate Protective Phase
The primary goal during this phase is to gradually restore range of motion and flexibility while diminishing acute postoperative pain and inflammation.
Weeks 0 to 4
- Partial (50%) weight-bearing with crutches
- Encourage, but limit, hip flexion to 90° with passive range of motion
- Avoid hyperextension or external rotation greater than 30°
Phase II – Moderate Protection Phase
During this time, exercises should focus on restoring range of motion and normalizing gait.
Weeks 4 to 6
- Crutch use is weaned; full weight-bearing is started as gait normalizes
- Gradual increase in hip rotation (internal/external rotation)
- Proprioception/balance exercises to prevent muscular inhibition
- Low-impact aerobic exercises initiated
- Bilateral leg press with eventual progression to unilateral leg press
Phase III – Advanced Exercises Phase
The primary focus during this phase is to continue increasing the range of motion and to progressively increase muscle strength and endurance.
Weeks 7 to 8
- All stretching and flexibility exercises continued to restore full passive range of motion
- May begin full squats
- Continued focus on core strengthening with prong/side planks
- Lunges performed in single plane and then advanced to triplanar lunges
Phase IV – Return to Activity Focus
During this time, increased focus should be placed on optimizing neuromuscular control, balance, and proprioception. Muscular and cardiovascular endurance should be restored while gradually increasing demands on the hip.
Weeks 9 to 11
- Begin pool running
- Initiate dynamic balance exercises and single leg body squats
- May begin running and sports-specific drills
- May initiate plyometric exercises once running is pain-free
Return to competition is based on full, pain-free range of motion, hip strength equal to the contralateral side, and the ability to perform a single leg stance while the pelvis remains level.
FAI in the setting of labral pathology is a common cause of hip pain in the athlete and the active, pre-arthritic population. Although non-operative intervention can provide satisfactory outcomes, its effect on pain level and return to activity remains controversial. 
In a recent multicenter, randomized control trial, the FASHIoN group demonstrated improved patient-reported outcomes at 12 months following hip arthroscopy for the treatment of FAI when compared with personalized hip physiotherapy programs.  Furthermore, patients who elected to undergo surgical intervention after experiencing symptoms for more than 2 years preoperatively had lower patient satisfaction scores and higher rates of revision surgery than patients who had symptoms for less than 2 years before hip arthroscopy. 
These findings suggest that non-operative therapy remains a viable option for most patients given its low-risk profile. However, hip arthroscopy may provide more favorable results in patients at higher risk for disease progression.
A recent systematic review highlighted an improvement in patient-reported outcome scores following hip arthroscopy for the treatment of FAI with labral pathology . Lee et al  supported these findings at long-term follow-up, demonstrating that anatomic restoration of the labrum was associated with improvement of clinical symptoms. Multiple studies examining return to play in professional athletes have also shown favorable results. Specifically, professional basketball players demonstrated a 100% return rate to their previous levels of competition, followed by professional baseball (95%), football (87%), and hockey (67%) players. [29-32]
Despite the success of hip arthroscopy in the treatment of FAI, the progression of osteoarthritis and recurrent hip instability remain common causes for poor outcomes and revision surgery. Menge et al  demonstrated that patients with increased age, decreased (< 2mm) preoperative joint space, or intraoperative acetabular microfracture were at an increased risk for conversion to total hip arthroplasty.
Multiple biomechanical studies have shown the role of the hip capsule in restoring native hip biomechanics. [25, 26] Therefore, the release or limited repair of the hip capsule following arthroscopy has been hypothesized as a potential cause for recurrent hip microinstability or subluxation.
In a study comparing partial capsular repair and complete capsular repair, patients who underwent the former experienced lower outcomes scores at all time points and 13% required revision surgery.  Furthermore, in a cohort of 20 patients who required revision surgery for symptomatic instability following hip arthroscopy, capsular repair resulted in satisfactory outcomes at 2 years follow up.  This suggests that capsular repair may have a restorative effect on the native hip rotational profile preventing postoperative microinstability and pain.
Overall, FAI can be effectively treated arthroscopically with femoral and/or acetabular osteoplasty and labral repair, resulting in improved pain and function. Although short-term results are promising, additional long-term studies of complete capsular repair should be explored.
Anant Dixit, MD, is a sports medicine fellow at The Rothman Institute, Philadelphia, Pennsylvania. Sundeep Saini, DO, is a PGY-4 orthopaedic surgery resident at Rowan University School of Osteopathic Medicine, Stratford, New Jersey. John P. Salvo Jr., MD, is a Clinical Associate Professor of Orthopaedic Surgery at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
Sports Medicine Editor, Rothman Institute Grand Rounds
The authors have no disclosures relevant to this article.
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