Derek Ochiai, MD; Dean K. Matsuda, MD , 2025-05-06 17:57:00
Key takeaways:
- Patients with asymptomatic FAI should be informed of the likelihood of future hip issues.
- The known risks of prophylactic FAI surgery are not outweighed by the potential benefits.
Recognized as a cause of chronic hip pain, femoroacetabular impingement has been reportedly caused by cam and pincer anatomic abnormalities.
However, the published literature has shown even individuals who are asymptomatic can have these abnormalities. Because femoroacetabular impingement (FAI) is believed to predispose individuals to the development of early osteoarthritis, orthopedic surgeons have questioned whether prophylactic FAI surgery should be performed in patients who have these abnormalities but are asymptomatic.
Healio invited experts to weigh in on whether prophylactic surgery for FAI has any benefits when performed in patients who have cam and pincer abnormalities but are asymptomatic.
Derek H. Ochiai, MD
A common phrase among hip arthroscopy surgeons is, “I don’t operate on asymptomatic hips.”
In the early 2000s, hip arthroscopy was sometimes a brutal operation, and the damage done to the labrum, articular cartilage and capsule during the procedure was sometimes more extensive than the damage being addressed. Thankfully, those days are over. Hip arthroscopy is a safe, reproducible operation that can effectively treat FAI.
Source: Derek H. Ochiai, MD
FAI can progress to hip arthritis if left untreated. However, this does not happen to everybody. I have personally seen patients symptomatic with FAI and labral tears in their 70s with no symptoms until just prior to presentation. Also, I have seen patients in their late 20s who had large cam bumps (high alpha angles) that have already progressed to hip arthritis, such that the only reasonable surgical procedure is hip replacement. If we cannot predict the natural history of FAI, is it not safer to not correct it if there is not a clinical problem? Sure, it is “safer,” but as hip preservation surgeons, is that the best treatment?
Prophylactic surgery for FAI is already being done. A study by Ibrahim Azboy, MD, and colleagues showed most patients with bilateral hip FAI morphology who underwent unilateral arthroscopy on the symptomatic hip quickly experienced symptoms on the contralateral hip, which led to a second hip arthroscopy being performed. However, the researchers had to cut the study cohort by 10%, as these patients underwent bilateral hip FAI surgery while only being symptomatic in one hip.
Source: Derek H. Ochiai, MD
Let us do a thought exercise on a man with a high alpha angle hip. If a patient presented with the hip radiograph in Figure 1 at 20 years of age, having failed conservative treatment, had pain with prolonged sitting, no chondral damage on MRI and a positive Arlington test, hip arthroscopy is easy to justify. But what if they had successful hip surgery on their right hip (Figure 2), but noticed limitations in motion in their left hip without pain? Is hip arthroscopy “prophylactic” then? Figures 3 and 4 show preoperative and successful postoperative radiographs of a left hip where the patient had no complaints of hip pain.
What if the patient came in worried because their father had to have a hip replacement at age 45 years due to an untreated FAI? In 2025, can we tell that patient without hesitation that it is better to wait for his hip to be painful for him, when we know pain can be a lagging indicator for chondral damage? A recent study of patients aged 14 to 25 years presented by Dean K. Matsuda, MD, FAAOS, FAANA, and colleagues at the American Academy of Orthopaedic Surgeons Annual Meeting showed that patients with alpha angles greater than 75° had a greater than 50% chance of having high grade acetabular articular cartilage damage. We also know that longer duration of symptoms is a predictor of inferior results with FAI treatment, and what can be a shorter duration of symptoms than zero?
Source: Derek H. Ochiai, MD
If a 16-year-old woman presents because their mother has dysplasia requiring periacetabular osteotomy, and the daughter has a lateral center-edge angle (LCEA) of 12°, most surgeons who perform periacetabular osteotomy would operate, because the best time for treatment is before chondral damage. I completely agree with that, even though I have seen former professional athletes who present with hip pain in their 50s who also had an LCEA of 12°. The exceptions only prove the rule.
Waiting for hip FAI to cause pain, especially when the alpha angle is 75° or more, does not optimize outcomes, and, in those patients, they should at least be informed of the likelihood of hip issues in the future. Based on that conversation, if they ask if they should have prophylactic hip surgery, the answer in 2025 should be absolutely, unequivocally maybe, but their insurance also probably will not cover it.
Source: Derek H. Ochiai, MD
References:
For more information:
Derek H. Ochiai, MD, of Nirschl Orthopaedic Center, can be reached at teamsurgeon@gmail.com or on X at @DrDerekOchiai.
Dean K. Matsuda, MD
I do not, at present and in general, support prophylactic surgery for FAI.
I am not sure I can make anyone better than asymptomatic, whereas any treatment, surgical or otherwise, might generate symptoms. Moreover, surgical and anesthetic complications may occur that could be devastating, especially in younger patients. My general philosophy is to treat patients who are symptomatic, not imaging findings. FAI morphology does not necessarily mean FAI pathology.
But to be fair, the potential benefit of prophylactic FAI surgery is not to make better postoperative radiographs, but to prevent future irreversible hip degeneration. Therein lies the issue: If credible evidence demonstrates significantly less future arthrosis with prophylactic surgery, then some degree of surgical risk may be justifiable. Although 10% to 74% of studied asymptomatic populations have FAI morphology, we still do not know the natural history of FAI and if surgical intervention significantly lowers the risk for future arthritis in these patients.
Although about 10% of my surgeries are simultaneous bilateral arthroscopy for FAI, these are patients with flexion-induced pain in both hips. The more common scenario is the patient with unilateral symptoms despite often bilateral FAI morphology. When patients ask about their other hip, I counsel my patients that their hip is at risk, and to contact us if that hip becomes symptomatic so that we can perform further diagnostic workup and possible surgical intervention if indicated and desired. I have had some patients obtain annual radiographs even while asymptomatic to monitor the joint space. An asymptomatic hip in the presence of a high alpha angle and/or already with Tnnis grade 1 radiographic findings, especially if showing interval joint narrowing, should, in my book, be followed with interval visits, and my threshold to offer elective hip arthroscopy would be lower.
Although current evidence does not support routine prophylactic surgery for FAI, for every rule, there may be exceptions with varying levels of merit. Of these listed below, I have so far only operated on the asymptomatic hip for the first example.
- Asymptomatic FAI with contralateral FAI-induced total hip replacement. I have offered prophylactic surgery on a few patients in hopes that this might prevent the future need for bilateral hip arthroplasties.
- A patient with asymptomatic FAI with radiographic joint narrowing or interval progressive narrowing (still greater than 2 mm remaining joint width) and/or MRI demonstrating early chondrosis.
- An adolescent or young adult patient with asymptomatic FAI with a high alpha angle, perhaps greater than 75°.
- A patient with recalcitrant osteitis pubis/core muscle injury with asymptomatic FAI with highly constrained hip range of motion, which has been reported to be associated with and causative of athletic osteitis pubis.
A systematic review on prophylactic FAI surgery in adult patients could not find a single study from 840 references meeting their eligibility criteria. They concluded that, with the exception I listed as number 1, which had limited evidence, there is a lack of available evidence to support prophylactic surgery for FAI. That said, clinical equipoise may be hindering our ability to fully investigate this topic and arrive at an evidence-based recommendation. Thus, at present, because we do not know if prophylactic FAI surgery does appreciably prevent future coxarthrosis, and because we do know that symptoms and complications can occur with any procedure, the known risk is not outweighed by the potential benefit.
Reference:
For more information:
Dean K. Matsuda, MD, FAAOS, of Premier Hip Arthroscopy, can be reached at saltandlight777@hotmail.com.
References:
Sources/Disclosures
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Expert Submission
Disclosures:
Ochiai reports receiving royalties from ConMed.Matsuda reports receiving support from Zimmer Biomet Holdings Inc.; being the committee chair for the ISHA Hip Preservation Society; and being on the editorial or governing board for Healio | Orthopedics Today.
