Clinical UM Guideline

 

Subject: Surgical Treatment of Femoroacetabular Impingement Syndrome
Guideline #: CG-SURG-68 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018

Description

This document addresses surgical procedures for the treatment of femoroacetabular impingement syndrome (FAIS), an anatomical abnormality of the hip in which there is abnormal contact between the acetabular rim of the pelvis and the femoral head.  This may be due to either osseous abnormalities of the acetabulum or femur where the femoral neck transitions to the head, or at extremes of joint flexibility in individuals with normal morphology.  Over time, contact may result in damage to joint cartilage, potentially leading to degenerative joint disease.  Surgical treatment may involve an open approach, arthroscopic surgery, or a combination of the two.

This document also addresses the use of capsular plication, a surgical method used to tighten redundant tissue surrounding a joint, which has been proposed as an accompanying procedure to FAIS surgery.

Note: For more information regarding capsular plication, please see:

Clinical Indications

Medically Necessary:

Surgical treatment of femoroacetabular impingement syndrome is considered medically necessary when all of the following criteria have been met:

  1. Individual exhibits signs and symptoms of femoroacetabular impingement syndrome, including hip pain (primarily in the groin) that interferes with activities of daily living; and
  2. Radiographs or 3D computed tomography confirm diagnosis of femoroacetabular impingement syndrome, with evidence of cam impingement (alpha angle greater than 50 degrees), pincer impingement (acetabular retroversion or coxa profunda), or both; and
  3. Individual has failed conservative therapy for a duration of at least 6 months, including:
    1. Activity modification, with restriction of athletic pursuits, if any, that include avoidance of symptomatic movements; and
    2. Treatment with NSAIDs or acetaminophen; and
  4. There is no other explanation for pain; and
  5. Individual has minimal degenerative changes of the hip joint (Tönnis grade 1 or less).

Not Medically Necessary:

Surgical treatment of femoroacetabular impingement syndrome is considered not medically necessary when the criteria above have not been met.

The use of capsular plication for the treatment of femoroacetabular impingement syndrome is considered not medically necessary under all circumstances.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

27299

Unlisted procedure, pelvis or hip joint [when specified as open procedure for femoroacetabular impingement syndrome (FAIS), other than capsular plication]

Note: capsular plication is considered Not Medically Necessary.

29914

Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion)

29915

Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion)

29916

Arthroscopy, hip, surgical; with labral repair [when repair of the labral tear is associated with FAIS]

29999

Unlisted procedure, arthroscopy [when specified as an arthroscopic hip procedure for FAIS, other than capsular plication]

Note: capsular plication is considered Not Medically Necessary

 

 

ICD-10 Diagnosis

 

 

All diagnoses [no specific diagnosis code for femoroacetabular impingement syndrome; may include, but is not limited to, the following]

M25.551-M25.559

Pain in hip

M25.851-M25.859

Other specified joint disorders, hip

M76.20-M76.22

Iliac crest spur

   
Discussion/General Information

Background

FAIS is a condition where there is abnormal contact between the acetabular rim (pelvic portion of the hip joint, or “socket”) and the femoral head (leg portion of the hip joint, or “ball”).  This contact causes abnormal wear and cartilage damage that, over time, may result in lesions of the labrum and adjacent acetabular cartilage.  This damage may develop into degenerative joint disease, also known as osteoarthritis.

FAIS may be due to trauma, surgery, developmental deformity, or underlying disease.  It is more common in young active individuals in whom a proximal femur abnormality is aggravated by activity involving excessive range of motion of the hip joint. 

Treatment for FAIS includes non-steroidal anti-inflammatory drugs (NSAIDs), rest and restriction of activity.  Surgery has been proposed to both assess and repair chondral damage, and potentially to reduce bony acetabular or femoral prominences which may be causing impingement.  Surgical methods may involve an open approach (e.g., peri-acetabular osteotomy, hip dislocation and debridement, etc.) to improve hip clearance, decrease abutment of hip and femur and address chondral lesions.  For some types of FAIS, less invasive hip arthroplasty procedures may be utilized.  Another option is a combination of open and arthroscopic procedures (that is, mini-open anterior arthrotomy).

Rationale

Currently there are only a small number of studies in the peer-reviewed published literature addressing the clinical outcomes of either the open or arthroscopic surgical approaches for the treatment of for FAIS.

The largest study to date involved 200 subjects with cam-type impingement with a minimum follow-up of 1 year (Byrd, 2009).  The authors report that 83% of the subjects had significant improvements in Harris Hip Scores (HHS) at their last follow-up visit.  Only 3 subjects reported significant surgery-related complications, all of which resolved clinically.

In 2010, Horisberger and others reported on a case series study of subjects undergoing arthroscopic FAIS repair.  This study involved 88 individuals with 105 hips treated.  The authors reported that at a minimum of 1.3 years (mean 2.3 years) all of the participants, with the exception of the 5 that progressed to receive a total hip replacement (THA), had significant improvement in all measures, including Non-arthritic Hip Score (NAHS), range of flexion and internal rotation, pain and alpha angle.  Positive anterior impingement was noted in 92% of subjects preoperatively and in 7% of non-THA subjects postoperatively.  No major complications were reported.

A prospective case series study by Philippon et al. of 112 subjects demonstrated significant improvement in modified HHS (MHHS), outcome scores for activities of daily living (ADLs) and sports, and non-arthritis hip score measures (2009).  Their multivariate analysis of their data indicated three independent factors of post-operative improvement were pre-operative MHHS, joint space narrowing less than 2.0 mm, and labral repair rather than debridement.  It should be noted that the authors found that subjects who were significantly older (58 vs. 39 years old) had a much higher likelihood of undergoing total hip replacement within 2 years of FAIS surgery.

Byrd and others conducted a retrospective case series study which enrolled 100 consecutive subjects followed for at least 2 years (2011).  They report that the median improvement on the HHS was 21.5 points (p<0.001), with 79 subjects reporting either good or excellent results.  Subjects with fair or poor results (n=21) still had a median improvement of 12 points, which was also significant (p<0.04).  It was noted that the fair and poor performers had worse baseline measures, had a greater incidence of femoral acetabular or bipolar lesions, and were older than the good and excellent outcome subjects.  No revision surgeries were required for any subject.  However, 6 subjects needed subsequent arthroscopic procedures for persistent or recurrent symptoms.  Complications included one transient neurapraxia of the pudendal nerve, one transient neurapraxia of the lateral femoral cutaneous nerve, both which resolved uneventfully, and one mild case of heterotopic ossification.  Byrd noted that there was fairly significant damage in 92% of subjects.  Acetabular articular damage was reported in 97 subjects, femoral damage in 23, and labral tears in 92 subjects.  This was of major concern, indicating a need for better recognition of FAIS and perhaps earlier intervention.   

Larson and colleagues described a prospective cohort study with 96 subjects enrolled (2008).  These subjects were followed for a mean of 9.9 months following FAIS surgery.  The authors report significant improvement in all outcome measures, including HHS, SF-12 Quality of Life (QOL) questionnaire, visual analog pain score, and positive impingement test. 

A retrospective case series study by Espinosa and colleagues (2006) included 52 subjects with FAIS who underwent arthrotomy and open surgical hip displacement.  In a post-hoc analysis, the authors grouped the subjects into 2 groups: 25 with resected labrum and 35 who had the labrum reattached.  The authors report that both groups had significantly improved outcomes including pain and Merle d’Aubingné score.  However, no improvement in range of motion was found in either group.  The labral reattachment group was found to have significantly improved overall Merle d’Aubingné scores when compared to the resection group (50% vs. 15% improvement at 2 years [p=0.001]), as well as greatly improved pain scores (73% vs. 59% [p=0.0009]).  Radiographic data found that the reattachment group had significantly less evidence of osteoarthritic progression than the resection group (p=0.0027).  The authors note several significant weaknesses in this study, including lack of randomization, the use of standard measures whose sensitivity is inadequate to detect subtle changes associated with osteoarthritis, and the sequential nature of the cohort studied.  They noted that at least some of the benefits found may be due in part to improvements in surgical technique and experience of the surgeons.

Nho (2011) described a retrospective case series study involving 47 high-level athletes who had undergone FAIS surgery.  Thirty-three subjects (70.2%) were available for follow-up at a mean of 27 months.  Intraoperative findings included labral tear in 97.9% (46/47) and capsular synovitis in 91.5% (43/47) of subjects.  The cartilage in all subjects was reported to be abnormal.  There were statistically significant improvements in the mean MHHS score (p=0.002) as well as the Hip Outcome Score (p=0.03).  Hip flexion demonstrated a statistically significant improvement (p=0.02), but internal and external rotation at final follow-up did not (p=0.11 and p=0.75, respectively).  A total of 79% of subjects (26/33) were able to return to play after FAIS surgery at a mean of 9.4 ± 4.7 months (range, 4-26 months) and of those, 92.3% were able to return to the same level of competition.  Only 5 subjects were unable to return to competition due to persistent hip pain.  There was a significant improvement in the alpha angle reported (p=0.0003).  No significant differences were observed between the preoperative and postoperative Tönnis angle (p=0.98) or center-edge angle (p=0.07).  The authors self-identify several limitations in this study, including its small sample size, retrospective nature, and loss to follow-up.  However, it is the first to demonstrate improvements in radiographic indicators including alpha, Tönnis, and center-edge angles.  Use of these indicators may be useful in future studies.

A retrospective case series study evaluated the outcomes in 45 professional athletes with FAIS undergoing treatment with an arthroscopic surgical method (Philippon, 2007).  The authors reported that 35 (78%) of the subjects returned to their professional athletics within 1.6 years.  Five subjects (11%) required reoperation, with lysis of adhesions in 3, and for symptoms of osteoarthritis in 2.  The results of this study indicate that a significant number of concurrent surgeries for other conditions were done along with FAIS surgery, including repair of acetabular and femoral head chondral defects, labral grafting, ligamentum teres avulsion repair, and removal of loose bodies.  Additionally, the study population consisted of highly active and motivated subjects who were all professional athletes, making the generalizability of these results limited.

Brunner and colleagues (2009) described the results of a prospective case series study that involved 53 recreational athletes diagnosed with FAIS.  After a mean follow-up of 2.4 years, the authors reported a significant increase in athletic activity and range of motion in addition to a significant decrease in pain when compared to pre-operative data.

There are no randomized or controlled studies published that address this procedure and the remainder of the available literature is composed of small case series studies.  Nonetheless, surgical treatment of FAIS has become a commonly accepted procedure, in part because the orthopedic community recognizes that specific, objectively visible mechanical disruption of the hip joint occurs in this syndrome and may be improved with surgical repair.  Expert opinion and uncontrolled case series suggest that for relatively young active people for whom no other options exist, surgical treatment for FAIS improves quality of life and pain symptoms, and may help avoid the development of hip osteoarthritis.  The criteria presented in the medically necessary section above are based upon the selection criteria presented in the published literature as well as upon expert opinion.

Capsular Plication

The use of capsular plication has been proposed for the treatment of FAIS.  This procedure involves the use of sutures to tighten redundant capsular tissue around the hip with the intent of decreasing capsular volume and increasing hip stability.  At this time, there are a limited number of published studies available addressing this technique. 

A small retrospective case series study of 16 hips with Ehlers-Danlos Syndrome and associated FAI has been reported by Larson (2015).  Subjects underwent capsular plication and arthroscopic correction procedures, with 13 primary arthroscopy procedures and three revisions.  Mean follow-up period was 44.61 months (range, 12 to 99 months).  The mean alpha angle preoperatively was 58.7° on anteroposterior radiographs and 63.6° on lateral radiographs vs. 47.4° and 46.1°, respectively, postoperatively.  There were significant improvements for all outcomes (MHHS p=0.002; SF-12 score p=0.027).  The mean improvement in MHHS from preoperatively to postoperatively was 42.9 points, and there were no iatrogenic dislocations.  One subject underwent further revision arthroscopy for recurrent pain, subjective giving way, and capsular laxity.  Limitations of this study include a retrospective design and small size.  Additional investigation into the benefits of this procedure is warranted.

At this time, the safety and efficacy of capsular plication has not been established.

References

Peer Reviewed Publications:

  1. Bardakos NV, Vasconcelos JC, Villar RN. Early outcome of hip arthroscopy for femoroacetabular impingement: the role of femoral osteoplasty in symptomatic improvement. J Bone Joint Surg Br. 2008; 90(12):1570-1575.
  2. Beaulé PE, Le Duff MJ, Zaragoza E. Quality of life following femoral head-neck osteochondroplasty for femoroacetabular impingement. J Bone Joint Surg Am. 2007; 89(4):773-779.
  3. Beck M, Leunig M, Parvizi J, et al. Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Clin Orthop Relat Res. 2004; (418):67-73.
  4. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br. 2005; 87(7):1012-1018.
  5. Bedi A, Chen N, Robertson W, Kelly BT. The management of labral tears and femoroacetabular impingement of the hip in the young, active patient. Arthroscopy. 2008; 24(10):1135-1145.
  6. Brunner A, Horisberger M, Herzog RF. Sports and recreation activity of patients with femoroacetabular impingement before and after orthroscopic osteoplasty. Am J Sports Med. 2009; 37(5):917-922.
  7. Byrd JW, Jones KS. Arthroscopic management of femoroacetabular impingement: minimum 2-year follow-up. Arthroscopy. 2011; 27(10):1379-1388.
  8. Byrd JW, Jones KS. Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement. Clin Orthop Relat Res. 2009; 467(3):739-746.
  9. Byrd JW, Jones KS. Hip arthroscopy for labral pathology: prospective analysis with 10-year follow-up. Arthroscopy. 2009; 25(4):365-368.
  10. Espinosa N, Rothenfluh DA, Beck M, et al. Treatment of femoro-acetabular impingement: preliminary results of labral refixation. J Bone Joint Surg Am. 2006; 88(5):925-935.
  11. Fabricant PD, Heyworth BE, Kelly BT. Hip arthroscopy improves symptoms associated with FAI in selected adolescent athletes. Clin Orthop Relat Res. 2012; 470(1):261-269.
  12. Gédouin JE, May O, Bonin N, et al.; French Arthroscopy Society. Assessment of arthroscopic management of femoroacetabular impingement. A prospective multicenter study. Orthop Traumatol Surg Res. 2010; 96(8 Suppl):S59-S67.
  13. Graves ML, Mast JW. Femoroacetabular impingement: do outcomes reliably improve with surgical dislocations? Clin Orthop Relat Res. 2009; 467(3):717-723.
  14. Haviv B, Singh PJ, Takla A, O'Donnell J. Arthroscopic femoral osteochondroplasty for cam lesions with isolated acetabular chondral damage. J Bone Joint Surg Br. 2010; 92(5):629-633.
  15. Horisberger M, Brunner A, Herzog. Arthroscopic treatment of femoroacetabular impingement of the hip: a new technique to access the joint. Clin Orthop Relat Res. 2010; 468(1):182-190.
  16. Ilizaliturri VM Jr, Orozco-Rodriguez L, Acosta-Rodríguez E, Camacho-Galindo J. Arthroscopic treatment of cam-type femoroacetabular impingement: preliminary report at 2 years minimum follow-up. J Arthroplasty. 2008; 23(2):226-234.
  17. Ilizaliturri VM Jr, Nossa-Barrera JM, Acosta-Rodriguez E, Camacho-Galindo J. Arthroscopic treatment of femoroacetabular impingement secondary to paediatric hip disorders. J Bone Joint Surg Br. 2007; 89(8):1025-1030.
  18. Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement: early outcomes measures. Arthroscopy. 2008; 24(5):540-546.
  19. Larson CM, Stone RM, Grossi EF, et al. Ehlers-Danlos syndrome: arthroscopic management for extreme soft-tissue hip instability. Arthroscopy. 2015; 31(12):2287-2294.
  20. Murphy S, Tannast M, Kim YJ, et al. Debridement of the adult hip for femoroacetabular impingement: indications and preliminary clinical results. Clin Orthop Relat Res. 2004; (429):178-181.
  21. Nho SJ, Magennis EM, Singh CK, Kelly BT. Outcomes after the arthroscopic treatment of femoroacetabular impingement in a mixed group of high-level athletes. Am J Sports Med. 2011; 39 Suppl:14S-19S. 
  22. Peters CL, Erickson JA. Treatment of femoro-acetabular impingement with surgical dislocation and débridement in young adults. J Bone Joint Surg Am. 2006; 88(8):1735-1741.
  23. Philippon M, Schenker M, Briggs K, Kuppersmith D. Femoroacetabular impingement in 45 professional athletes: associated pathologies and return to sport following arthroscopic decompression. Knee Surg Sports Traumatol Arthrosc. 2007; 15(7):908-914.
  24. Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. J Bone Joint Surg Br. 2009; 91(1):16-23.
  25. Siebenrock KA, Schoeniger R, Ganz R. Anterior femoro-acetabular impingement due to acetabular retroversion. Treatment with periacetabular osteotomy. J Bone Joint Surg Am. 2003; 85-A(2):278-286.
  26. Tanzer M, Noiseux N. Osseous abnormalities and early osteoarthritis: the role of hip impingement. Clin Orthop Relat Res. 2004; (429):170-177.
  27. Wright AA, Naze GS, Kavchak AE, et al. Radiological variables associated with progression of femoroacetabular impingement of the hip: a systematic review. J Sci Med Sport. 2015; 18(2):122-127.
Index

FAIS
Femoroacetabular impingement syndrome
Femoro-acetabular impingement syndrome

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History

Status

Date

Action

Reviewed

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review.

New

11/02/2017

MPTAC review. Initial document development. Moved content of SURG.00109 Surgical Treatment of Femoroacetabular Impingement Syndrome to new clinical utilization management guideline document with the same title.