title: What Are the Risk Factors for Revision Surgery After Hip Arthroscopy for Femoroacetabular Impingement at 7-year Followup?
abstract: BACKGROUND
  In recent years, surgical treatment of symptomatic femoroacetabular impingement (FAI) has been increasingly performed using arthroscopy. Bony pathomorphologies and damage to the labrum as well as cartilage defects can be addressed with comparable results to open surgery with overall less surgery-related complications. Despite the increasing importance of hip arthroscopy, however, reports on midterm clinical and radiographic outcomes and comparison to open surgical hip dislocation are scarce.
  
  
  OBJECTIVE
  (1) What are the clinical and radiographic outcomes at a mean 7-year followup; (2) what is the cumulative 7-year survivorship, using the endpoints of THA, progression of osteoarthritis according to Tönnis, or poor clinical outcome with a Merle d'Aubigné score of less than 15 points, of hips with symptomatic FAI treated arthroscopically; and (3) what factors were associated with revision surgery?
  
  
  METHODS
  Between 2003 and 2008 we performed a total of 62 arthroscopic procedures (60 patients) for FAI. For the same indication, we also performed 571 surgical hip dislocations during that time. Standardized treatment was femoral offset correction, acetabular rim trimming, or both and treatment of labral or chondral defects. An arthroscopic approach was generally used if the pathomorphology was located in the anterosuperior quadrant of the hip and was gradually used for more complex cases. We excluded 10 hips (10 patients) in which the standardized treatment was not achieved and no offset correction or acetabular rim trimming was performed. Of the remaining 52 hips (50 patients), 39 hips underwent isolated femoral offset correction, four hips isolated acetabular rim trimming, and nine hips both procedures. At a mean followup of 7 years (range, 5-11 years), the Merle d'Aubigné clinical score was obtained and plain radiographs were examined (Tönnis grade, heterotopic ossification, lateral center-edge [LCE] angle, acetabular index [AI], extrusion index, alpha angle, and pistol grip deformity). Cumulative survivorship was calculated according to Kaplan-Meier using conversion to THA, progression of osteoarthritis (one or more Tönnis grades), or poor clinical outcome (Merle d'Aubigné score < 15 points) as endpoints. Cox regression analysis was used to identify univariate factors associated with revision surgery.
  
  
  RESULTS
  At last followup we detected a significant but possibly not clinically relevant increase in Merle d'Aubigné scores from preoperative levels to latest followup (14 ± 1 versus 16 ± 2, mean difference 2 points with a 95% confidence interval [95% CI] -3 to 7, p < 0.001). Six hips showed progression of osteoarthritis. Cumulative survivorship (hips free from conversion to THA, progression of osteoarthritis, or poor clinical outcome) of hips treated with hip arthroscopy for FAI at a mean followup of 7 years was 81% (95% CI, 68%-95%). Two patients (two hips, 4%) underwent THA at 7 and 9 years, respectively. An increased preoperative acetabular coverage (LCE angle, AI), increased offset in the superior portion of the femoral neck (pistol grip deformity), and a remaining pistol grip deformity postoperatively were associated with revision surgery. Any treatment of the labrum did not influence the outcome. Factors associated with failure could not be identified.
  
  
  CONCLUSIONS
  In this series of patients with arthroscopic treatment of symptomatic FAI, hip arthroscopy resulted in an intact hip without progression of osteoarthritis and with a Merle d'Aubigné score of ≥ 15 points in 81% of patients at 7-year followup. Increased acetabular coverage and femoral pistol grip deformity were risk factors for revision surgery.
  
  
  METHODS
  Level IV, therapeutic study.
authors.affiliation: Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
authors.forename: Pascal Cyrill
authors.initials: PC
authors.lastname: Haefeli
authors.affiliation: Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
authors.forename: Christoph Emanuel
authors.initials: CE
authors.lastname: Albers
authors.affiliation: Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
authors.forename: Simon Damian
authors.initials: SD
authors.lastname: Steppacher
authors.affiliation: Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
authors.forename: Moritz
authors.initials: M
authors.lastname: Tannast
authors.affiliation: Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. lorenz.buechler@insel.ch.|Department of Orthopaedic Surgery, Inselspital, Murtenstrasse, 3010, Bern, Switzerland. lorenz.buechler@insel.ch.
authors.forename: Lorenz
authors.identifier: http://orcid.org/0000-0002-6779-6432
authors.initials: L
authors.lastname: Büchler
mesh_terms: D000077:Acetabulum / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects; D001182:Arthroscopy / Q000009:adverse effects*; D001696:Biomechanical Phenomena; D004185:Disability Evaluation; D018450:Disease Progression; D057925:Femoracetabular Impingement / Q000150:complications / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D005269:Femur / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006617:Hip Dislocation; D006621:Hip Joint / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015207:Osteoarthritis, Hip / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D010027:Osteotomy; D016016:Proportional Hazards Models; D020127:Recovery of Function; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult