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Bilateral Femoroacetabular Impingement

What is the Fate of the Asymptomatic Hip?

Azboy, Ibrahim, MD; Ceylan, Hasan Huseyin, MD; Groff, Hannah, BA; Vahedi, Hamed, MD; Parvizi, Javad, MD, FRCS

Clinical Orthopaedics and Related Research®: May 2019 - Volume 477 - Issue 5 - p 983–989
doi: 10.1097/CORR.0000000000000699

Background Bilateral symptomatic femoroacetabular impingement (FAI) is common. However, the fate of asymptomatic hip in patients with the radiographic diagnosis of bilateral FAI and unilateral symptoms remains unknown.

Questions/purposes (1) What is the likelihood of the asymptomatic hip becoming painful in patients with unilateral symptoms but with radiographic evidence of bilateral femoroacetabular impingement? (2) What radiological and clinical factors are associated with the development of symptoms in an asymptomatic hip diagnosed with FAI?

Methods A longitudinally maintained institutional FAI database was queried to collect relevant data for this retrospective study. To answer our research questions, we created a cohort of patients with bilateral radiographic signs of FAI but only unilateral symptoms at the time of initial presentation. Between 2004 and 2016, a senior surgeon (JP) at one institution treated 652 patients for hip pain determined to be from FAI, a diagnosis we made based on clinical symptoms, physical exam, and diagnostic imaging. We excluded 95 patients (15%) because of inadequate data or other diagnoses, which left 557 patients. Of those, 170 patients (31%) had bilateral radiological diagnosis of FAI, and 88 (52%) of them had bilateral hip symptoms, and so were excluded. Of the remaining 82 patients, eight (10%) underwent bilateral FAI surgery under the same anesthetic despite having only unilateral symptoms, leaving 74 for analysis in this study. Patients were followed with annual clinic visits, or contacted by phone and electronically. We defined onset of symptoms using a modified Harris Hip Score (mHHS) or the University of California at Los Angeles (UCLA) activity scale, and used a logistic regression model to identify factors associated with the development of symptoms.

Results Of the 74 patients with bilateral FAI and an asymptomatic hip at initial presentation, 60 (81%) became symptomatic at a mean 2 years (range, 0.3–11 years) followup. Of these 60 patients, 43 (72%) eventually underwent subsequent surgical intervention. After controlling for potential confounding variables such as sex, age, BMI, history of trauma we identified that reduced neck-shaft angle (r = -0.243, p = 0.009), increased lateral center-edge angle (r = 0.123, p = 0.049), increased alpha angle (r = 0.069, p = 0.025), and younger age (r = -0.071, p = 0.046) were associated with the development of symptoms in the contralateral hip. With the numbers available, none of the other examined variables such as sex, BMI, history of trauma, psychiatric condition, employment, Tönnis grade, Tönnis angle, crossover sign, type of impingement, and joint congruency were found to be associated with symptom progression.

Conclusions Bilateral FAI may be observed about one-third of patients. Most patients with unilateral symptomatic FAI and radiographic diagnosis of bilateral FAI in this cohort became symptomatic relatively quickly and most of them underwent subsequent surgical intervention in the contralateral hip. Reduced neck-shaft angle, increased lateral center-edge angle, increased alpha angle, and younger age were associated with symptom development in the contralateral hip. Hip preservation surgeons may use the finding of this study to counsel patients who present with bilateral FAI but only unilateral symptoms about the natural history of their condition.

Level of Evidence Level III, therapeutic study.

I. Azboy , Department of Orthopaedics and Traumatology, Istanbul Medipol University School of Medicine, Istanbul, Turkey

I. Azboy, H. H. Ceylan, H. Groff, H. Vahedi, J. Parvizi, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA

J. Parvizi, Rothman Institute, 125 S 9th St. Ste 1000, Philadelphia, PA 19107, USA, Email:

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

One of the authors certifies that he (JP) has received or may receive personal fees during the study period, an amount of USD 100,001 to USD 1,000,000 from Corentec (Morristown, NJ, USA); less than USD 10,000 from MicroGen DX (Orlando, FL, USA); less than USD 10,000 from DataTrace (Towson, MD, USA); less than USD 10,000 from Elsevier (Philadelphia, PA, USA); less than USD 10,000 from Jaypee Publishers (London, UK); less than USD 10,000 from Slack Incorporated (Thorofare, NJ, USA); and less than USD 10,000 from Wolters Kluwer (Alphen aan den Rijn, Netherlands). One of the authors certifies that he (JP) has stock ownership in Parvizi Surgical Innovations (Philadelphia, PA, USA); Hip Innovation Technology (Boca Raton, FL, USA); Cross Current Business Intelligence (Newtown, PA, USA); Alphaeon (Irvine, CA, USA); Joint Purification Systems (Solana Beach, CA, USA); Ceribell (Mountain View, CA, USA); MedAp, Physician Recommended Nutriceuticals (Blue Bell, PA, USA); PRN Veterinary (Blue Bell, PA, USA); MDValuate (Centennial, CO, USA); Intellijoint (Waterloo, Ontario, Canada); and MicroGenDx (Orlando, FL, USA). One of the authors certifies that he (JP) he is a consultant to Zimmer Biomet (Warsaw, IN, USA), ConvaTec (Deeside, UK), CeramTec (Plochingen, Germany), Corentec (Morristown, NJ, USA), Ethicon (Somerville, NJ, USA), and Tenor (San Francisco, CA, USA).

Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

Received May 30, 2018

Accepted February 06, 2019

© 2019 Lippincott Williams & Wilkins LWW
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