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


Participant Characteristics

The participation rate in the survey of current practices was 100%. The participants had a mean of 12.3 years of practice and performed an annual mean of 249 arthroscopies (range, 100 to 500+), with an estimated total number of arthroscopic hip procedures of 52,580 during their career.

Survey of Current Practices

A 100% response rate was attained for the survey of current practices, and consensus was attained for the scope of this best practice statement including preoperative management and identification of ideal patients for arthroscopic management (93.3%), intraoperative practices including intraoperative bone resection (100%), and postoperative management including rehabilitation (86.7%).

Notable variability in the nonsurgical and surgical management was observed. In eight institutions where more than one surgeon performed hip arthroscopy for FAI, 50% indicated their department did not use a shared standard for conservative care trials before surgical management. In addition, 62.5% (5/8) did not use a shared standard for the surgical or postoperative management of FAI.

Delphi Round 1

All Delphi rounds achieved a 100% response rate. The first consensus round produced 27 items, including 12 preoperative, 12 intraoperative, and 3 postoperative protocols (Table 6, Supplemental Digital Content,

Interventions that were near consensus (70% to 79% agreement) include: full duration of conservative treatment is not required in patients with the following characteristics: (1) after marginal or substantial improvement after intraarticular injections and (2) large pincer-type deformities in the absence of osteoarthritic changes. In addition, (3) arthroscopic management should not be performed (contraindication) in the presence of a femoral head extrusion index >25% and a high MRI chondral grade. Last, continuous passive motion should be recommended to patients with revisions with adhesions.

Delphi Round 2

The following Delphi round resulted in consensus for 15 additional recommendations, including four preoperative, six intraoperative, and five postoperative protocols (Table 6, Supplemental Digital Content, However, the items that were near-consensus included the following: (1) mechanical symptoms should make you less likely to require the full duration of conservative treatment which would be typically recommended based on the surgeon-specific protocols implemented for such patients (given the lack of standardization), and contraindications to the arthroscopic management of FAI include (2) osteogenesis imperfecta and (3) hypermobility with dysplastic features. Of note, 60% of the participants strongly agreed (20%) or agreed (40%) that a preoperative physical therapy session, also known as prehabilitation, should be recommended before patient's having surgery.

Delphi Round 3

In the final round, interventions which did not reach consensus were modified by revising the voting items and broadening or narrowing the statement as necessary. This subsequently led to the addition of 10 recommendations, including five intraoperative and five postoperative practices (Table 6, Supplemental Digital Content, Of note, 100% agreement was obtained to generally define a large cam-type deformity as an alpha angle >65° (33% strongly agree; 67% agree), although other variables such as loss of head-neck offset may also play a role in such a definition.

Subsequently, all recommendations were summarized in a final checklist organized by the treatment phase (Figure 2). One hundred percent of participants agreed to support the publication of these BPG.

Figure 2.

Chart showing the final best practice guidelines checklist. FAI = femoroacetabular impingement. OA = osteroarthritis, PT = physical therapy, ROM = range of motion, VR12 = Veterans RAND 12 Item Health Survey