Hip preservation surgery for the treatment of nonarthritic or prearthritic conditions has increased in popularity and utility over the last decade. The goal of hip preservation surgery is to decrease pain, improve function, and ideally delay or prevent the onset of early osteoarthritis. As we continue to expand the use of hip preservation surgery, it behooves us to continue to investigate the appropriate indications for hip preservation surgery and identify potentially modifiable factors that can influence the outcomes of these procedures.
The question that is raised by Fabricant et al. is whether femoral version is a modifiable variable that affects outcomes of hip preservation surgery. It is a continuation of previous investigations from this research group that has been investigating the role of femoral version on outcomes after hip arthroscopy1,2.
A basis for this concern regarding the role of femoral version on outcomes after hip arthroscopy can be traced to work by Tönnis and Heinecke that found an association between relative decreases in femoral version and increases in the prevalence of hip osteoarthritis3. Those authors demonstrated that patients with elevated femoral anteversion had increased hip internal rotation, whereas patients with relative femoral retroversion had increased hip external rotation. That manuscript also indicated a relationship between the presence of hip pain and the degree of femoral version, with pain being greatest at the extremes of both anteversion and retroversion. The authors’ expert opinion was that operative treatment of excessive femoral version could be used to decrease pain and prevent early osteoarthritis.
A prior study by Fabricant et al. examined the influence of femoral version on outcomes after arthroscopic psoas lengthening1. They determined that patient-reported outcome scores were inferior in patients undergoing psoas lengthening with femoral anteversion of >25° compared with those with normal version or relative retroversion. However, this association of inferior clinical outcomes after psoas release with increased anteversion was not reproduced in the studies by Ferro et al.4 and Jackson et al.5, although there was some variability in methodologies across these studies.
Another prior study from the research group of Dr. Fabricant, by Kelly et al.2, examined the influence of femoral version on the effect of arthroscopic cam decompression on postoperative improvement of hip internal rotation. They found that although preoperative internal rotation was influenced by the degree of femoral neck anteversion, improvements in hip internal rotation seen after cam decompression were independent of femoral neck version. On the basis of the results of that study, the authors suggested that decreased femoral anteversion may not be an independent determinant of impingement.
In the current study by Fabricant et al., the authors performed a retrospective review of registry data to try to identify an association between femoral version and patient-reported outcomes in patients treated with arthroscopic hip preservation surgery. They found significant improvements by at least the MCID (minimal clinically important difference) in each outcome score for most of the patients within the entire cohort. Although the group with relative femoral retroversion (<5° anteversion) had clinically meaningful postoperative improvements, these were of significantly smaller magnitude compared with those in the normal version and excessive anteversion groups. The authors did not find any association of outcome scores with combined acetabular and femoral version as defined by the McKibbin index.
To my knowledge, prior to the submission of the manuscript by Fabricant et al. there had been no published studies that assessed the relevance of excessive femoral version as it applies to patient selection for arthroscopic hip preservation surgery. Recently, both Ferro et al.4 and Jackson et al.5 have published manuscripts that demonstrated similar patient-reported functional outcomes after hip arthroscopy for labral tears and femoroacetabular impingement regardless of femoral version. The three studies had different criteria for classifying excessive femoral version and variations in study design. However, the study by Fabricant et al. was the only one that revealed that the odds of improving by at least the MCID were lower in the decreased version group compared with the normal version group.
On the basis of the recently published data, it does not appear that excessive femoral anteversion or retroversion should be considered an absolute contraindication for arthroscopic correction of femoroacetabular impingement4,5. Currently, the determinants for patient selection for open treatment of excessive anteversion or retroversion are Level-V evidence (expert opinion)4. Fabricant et al. are encouraged to continue their investigations of excessive femoral version in order to determine objective criteria for patient selection for arthroscopic hip preservation surgery versus open surgical reconstruction.
↵* The author received no payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. Neither the author nor his institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
- Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated