Abstract

Background
The role of hip arthroscopic intervention for Femoroacetabular impingement (FAI)
is evolving with increasing ability to deal with impingement lesions and repair the
chondrolabral tears. Initially, the procedure was thought to be most appropriate for
treatment of athletes but the objective benefits in terms of return to sport at the
same level were not considered. Moreover, any benefit in terms of overall quality of
life, and potential efficacy of arthroscopic treatment in non-athletes has not been
clarified. Currently, this procedure is still very new, and most published studies
involve retrospective analysis of small numbers of patients and do not give an
accurate picture of the frequency and severity of complications, in particular the
potential to delay the need the have hip replacement.

Aim
The aim of this thesis is to establish the benefit of hip arthroscopic intervention for
FAI by answering pertinent questions about the procedure:
• Is it effective in terms of improvement in quality of life?
• Is it beneficial for non-athletes?
• Is it possible for athletes to return to sport at the same level?
• What is the short-term complication rate?
• Does it defer the need to have hip replacement in the future?
Methods
This thesis is based on four original published papers in various peer-reviewed
journals that address the above questions.

Results
Does hip arthroscopic intervention improve quality of life (QoL) of patients with
FAI?
This publication reported the largest single-surgeon series, at the time of
publication, and was the first to consider QoL outcomes. In a series of 612 patients
at a mean follow-up of 3.2 years, we found that the QoL improved significantly after
surgical intervention in 77%, remained unchanged in 14% and deteriorated in 9%
of patients. The significant predictors of change in QoL were preoperative QoL
scores and female gender.
Is hip arthroscopic intervention for FAI only for athletes?
In this prospective comparative study the trend for improvement in hip scores after
surgery was compared between athletes and non-athletes and we found that, while
the athletes had a significantly better score at six weeks, there were no significant
differences between the two groups after one year. This study was the first
prospective comparative study to look at these two groups of patients and
demonstrated that arthroscopic surgery may be an appropriate treatment for FAI in
both athletes and non-athletes.
Does hip arthroscopic intervention for FAI improve the outcome in athletes?
In this prospective comparative study we noted that both the training and time in
competition improved approximately three-fold after surgery, with a mean time to
return to sport at the same level of 5.4 months. Professional athletes (4.2 months)
recovered more quickly than recreational athletes (6.8 months). A greater
proportion of the professional athletes (88%) returned to their pre-injury level of
sport than the recreational athletes (73%). Prior to this study, objective measures
of return to sport were lacking, and there had been no prospective comparative
studies of recovery time in professional and recreational athletes.
What is the short-term complication rate?
The national hospital episode statistics data on short-term complications after hip
arthroscopy showed that, in 6395 hip arthroscopies performed in England between
April 2005 and Jan 2013, the 30-day readmission rate was 0.5%; the 90-day
incidence of deep vein thrombosis (DVT) was 0.08% and of pulmonary embolus
(PE) 0.08%; and the 90-day mortality rate was 0.02%.
Does it defer the need to have hip replacement in the future?
In this series of 6395 hip arthroscopies, 680 patients (10.6%) underwent total hip
replacement (THR), at a mean of 1.4 years after the index operation. Female
patients had a 1.68 times (95% CI, 1.41 to 2.01) higher risk of conversion to THR
than male patients, and patients aged 50 years or older had a 4.65 (95% CI, 3.93
to 5.49) times higher risk of requiring hip replacement than patients younger than
50 years. Kaplan-Meier survival analysis revealed an eight-year survival of 82%;
while Cox proportional hazard analysis, adjusting for age, gender and Charlson
comorbidity score, revealed an eight-year survival of 86%.

Conclusion
Arthroscopic surgery for FAI improves QoL, is beneficial for non athletes as well as
athletes, enables athletes to return to their professional level of function and may
delay the need for total hip replacement. These papers have helped, not only in
establishing the outcome of surgery but also in identifying the patients who would
benefit from intervention. This information is critical to the clinicians’ understanding
of both the success of the intervention and limitations of the technique. Important
information has been generated from this work that will be helpful during
preoperative counselling, when it is imperative to obtain properly informed consent.