Best Practice Guidelines for Hip Arthroscopy in Femoroacetabular Impingement

Results of a Delphi Process

T. Sean Lynch, MD; Anas Minkara, MD; Stephen Aoki, MD; Asheesh Bedi, MD; Srino Bharam, MD; John Clohisy, MD; Joshua Harris, MD; Christopher Larson, MD; Jeffrey Nepple, MD; Shane Nho, MD, MS; Marc Philippon, MD; James Rosneck, MD; Marc Safran, MD; Allston J. Stubbs, MBA, MD; Robert Westermann, MD; J.W. Thomas Byrd, MD

Disclosures

J Am Acad Orthop Surg. 2020;28(2):81-89. 

In This Article

Abstract and Introduction

Abstract

Background: Treatment algorithms for the arthroscopic management of femoroacetabular impingement (FAI) syndrome remain controversial because of a paucity of evidence-based guidance. Consequently, notable variability in clinical practice exists between different practitioners, necessitating expert consensus. The purpose of this study is to establish best practice guidelines (BPG) using formal techniques of consensus building among a group of experienced hip arthroscopists driven by the results of a systematic review and meta-analysis. The scope of these guidelines includes preoperative recommendations, intraoperative practices, and postoperative protocols.

Methods: The validated Delphi process and the nominal group technique (NGT), used by the Centers for Disease Control and Prevention and the peer-reviewed orthopaedic literature, were used to formally derive consensus among 15 surgeons in North America. Participants were surveyed for current practices, presented with the results of a meta-analysis and systematic literature review, and asked to vote for or against the inclusion of nonleading, impartially phrased items during three iterative rounds while preserving the anonymity of participants' opinions. Agreement greater than 80% was considered consensus, and items near consensus (70% to 80% agreement) were further queried using the NGT in a moderated group session at the American Orthopaedic Society for Sports Medicine annual meeting.

Results: Participants had a mean of 12.3 years of practice (range: 1 to 29 years) and performed an annual mean of 249 (range 100 to 500+) hip arthroscopies, with a combined total of approximately 52,580 procedures. Consensus was reached for the creation of BPG consisting of 27 preoperative recommendations, 15 intraoperative practices, and 10 postoperative protocols. The final checklist was supported by 100% of participants.

Conclusion: We developed the first national consensus-based BPG for the surgical and nonsurgical management of FAI. The resulting consensus items can serve as a tool to reduce the variability in preoperative, intraoperative, and postoperative practices and guide further research for the arthroscopic management of FAI.

Introduction

Femoroacetabular impingement (FAI) syndrome occurs because of abnormal contact between the proximal femur and acetabulum during hip joint motion and may subsequently lead to an increased risk of osteoarthritis in certain hip pathoanatomies.[1–9] The resulting repetitive injury, occurring from a variety of athletic and other daily activities, may also lead to labral tears, cartilage damage, and joint degeneration.[1–8,10] The initial results of the arthroscopic management of FAI were published in a preliminary report consisting of 158 patients, in which only 2.5% of patients experienced complications.[11] Although hip arthroscopy for FAI represents the surgical evolution of the mini-open or surgical dislocation approach, proper patient selection for this minimally invasive intervention is essential for successful surgical outcomes.[12] The arthroscopic approach presents both unique challenges to the surgeon[13,14] and shared complications with the traditional technique.[15]

Hip arthroscopists must rely on expert opinion to guide the appropriate intervention based on patient characteristics because of the paucity of evidence-based guidance in the current literature. Consequently, notable variability exists in treatment protocols between institutions and surgeons. The World Health Organization has highlighted the importance of developing standardized interventions for patient safety using evidence-based processes and best practice initiatives.[16]

The current generalized approach dictates a trial of nonsurgical care and rehabilitation before surgery to improve hip stability and neuromuscular control.[17–21] However, this global approach to nonsurgical management may confer benefit to only select patients with FAI with milder deformities and those willing to modify their activities.[21,22] Subsequently, if patients are selected to undergo surgery, certain characteristics may predict inferior outcomes such as older age, longer duration of symptoms, presence of arthritic changes, and worse preoperative pain and functional scores.[12,23]

This national initiative uses a combination of both published literature and the experience and perspective of an expert group. The purpose of this study is to formally develop consensus-based best practice guidelines (BPG) for hip arthroscopy driven by a meta-analysis,[24] a systematic review,[24] and a group of experienced hip arthroscopists. We hypothesize that formal guidelines can be developed for preoperative recommendations, intraoperative practices, and postoperative protocols using the Delphi and nominal group technique.

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