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


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

In This Article


Consensus Participants

Fifteen surgeons, who are dedicated hip arthroscopists, with various levels of experience representing 14 institutions in the North American region were asked to join this initiative, and all 15 agreed to participate. Participants were selected based on multiple criteria including (1) extensive previous research in FAI, (2) clinical experience and training in hip arthroscopy for FAI, and (3) leadership positions in orthopaedic sports medicine organizations.

Overview of the Delphi and the Nominal Group Technique

The structure of this initiative replicated the methodology used for previously published BPG in the peer-reviewed orthopaedic literature and Centers for Disease Control and Prevention in state and local public health programs.[25–30] Consensus was established with the Delphi technique and nominal group approach. Given the existing lack of evidence in the literature for FAI, no American Academy of Orthopaedic Surgeons consensus exists, thus necessitating the need of expert opinion with this validated approach.

The Delphi technique is a validated system for establishing formal consensus by the repeat administration of recommendations or consensus items which are revised during iterative rounds based on participant feedback and collaborative discussions.[31–36] Accordingly, participants may revise their responses during the process[31,34] (Figure 1). Similar to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, this initiative was structured to address the areas of reporting required by the Delphi technique (Table 1, Supplemental Digital Content,[35] In addition, the nominal group technique relies on a small group discussion which comprises four main aspects: (1) an unbiased facilitator who moderates the discussion processed, (2) nonleading, impartially phrased statements which are constructed to elicit responses from group members, (3) participants with expertise in a specific field who are tasked with producing, discussing, and prioritizing suggestions from the collective group, and finally, (4) anonymous voting on the proposed ideas during iterative rounds.[30,37]

Figure 1.

Chart showing Delphi and nominal group technique process

Survey of Current Practices

An online survey consisting of 24 questions (Qualtrics platform) was administered to participating surgeons in May 2017 (Table 2, Supplemental Digital Content, Participants were queried about the total years in practice and the number of annual hip arthroscopies and were asked to select the scope of this consensus initiative. In addition to inquiring about current preoperative, intraoperative, and postoperative practices surgeons use during their current practice, participants were asked whether every member of their department used a shared standard for preoperative conservative care and surgical management of FAI.

Delphi/Nominal Group Technique Round 1

A peer-reviewed meta-analysis and systematic review of the literature[24] was conducted to assess preoperative treatment procedures, risk factors associated with success or failure of arthroscopic intervention, intraoperative practices, and postoperative protocols including rehabilitation. A total of 31 studies were included, with a total enrollment of 1,911 patients (1,981 hips).[24] Furthermore, a subsequent systematic review and meta-analysis of 22 clinical studies assessing return-to-play after hip arthroscopy was conducted, including 1,296 patients (1,442 hips).[38] The guidelines published by the Oxford Center for Evidence-Based Medicine were used to assess levels of evidence.[39]

The results of the current practice survey and systematic literature review were provided to participants in the first online round that was completed in June 2017. This secondary survey consisted of 14 main consensus items (Table 3, Supplemental Digital Content,, which was created by the primary authors using the results of the literature review and participant feedback.

The inclusion or exclusion of each consensus item or recommendation is dependent on responses to a 4-point Likert scale consisting of four options: strongly agree, agree, disagree, and strongly disagree, as used in previously published orthopaedic guidelines.[25,26] A neutral option was specifically not provided as outlined in the published Best Practice Guidelines initiatives. Consensus is reached when any item attains ≥80% agreement or disagreement, whereas near consensus is considered 70% to 79% agreement or disagreement.

Delphi/Nominal Group Technique Round 2 to 3

The results of the first Delphi round were presented to participants, and revisions to items near consensus were incorporated based on feedback elicited in the previous round (Table 4, Supplemental Digital Content, Furthermore, additional items garnered from the literature review were progressively introduced because of the extensive time commitment required during these rounds. The final consensus items were presented at the annual meeting of the American Orthopaedic Society of Sports Medicine in July 2017 (Table 5, Supplemental Digital Content, Live voting was completed using Poll Everywhere (San Francisco, CA) to ensure anonymity.