Nonoperative management of femoroacetabular impingement in adolescents: clinical outcomes at a mean of 5 years: a prospective study

Key points

1. 0172% of hips were managed with activity modification and physical therapy alone, without progressing to injection or surgery
2. 02Mean modified Harris Hip Score improved from 69.6 at baseline to 89.5 at 5-year follow-up
3. 03Outcomes were similar across all treatment groups (activity modification, injection, arthroscopy) at 5 years (P > .6)
4. 04Outcomes were also similar regardless of FAI type (cam, pincer, combined) at 5 years (P = .08 for mHHS)
5. 0571% of patients returned to the same or a different sport or activity at follow-up

How it was conducted

Design

Prospective cohort study, Level of evidence 2

Participants

100 patients (133 hips) enrolled; 51 patients (69 hips) with mean 5-year follow-up; 62% female, mean age 15 years

Setting

Single academic pediatric sports medicine practice, Rady Children's Hospital, San Diego, California

Intervention

Stepwise nonoperative protocol: activity modification and physical therapy, then image-guided steroid injection if needed, then arthroscopic surgery if still symptomatic

Primary outcomes

Modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) at 1, 2, and 5 years

Follow-up

Mean 61.6 +/- 7.9 months (range 43.4 to 76.4 months)

What they found

• Mean mHHS improved from 69.6 +/- 12.9 at baseline to 86.8 +/- 14.8 at 1 year (P < .001), 90.4 +/- 9.8 at 2 years (P = .03), and 89.5 +/- 10.8 at 5 years
• Mean NAHS improved from 75.5 +/- 15.2 at baseline to 85.2 +/- 17.4 at 1 year (P = .01), 88.5 +/- 11.6 at 2 years, and 88.1 +/- 12 at 5 years
• No significant difference in mHHS or NAHS between treatment groups (activity modification, injection, arthroscopy) at 5-year follow-up (P > .6)
• Proportion of hips meeting MCID for mHHS (8-point improvement): 74% activity modification group, 71% injection group, 75% arthroscopy group; no significant difference (P = .99)
• No significant difference in mHHS or NAHS between FAI types at any time point (P = .08 at 5 years for mHHS)
• No significant drop in mHHS or NAHS between the 2-year and 5-year time periods (P > .3)
• 12 of 69 hips (17%) ultimately required arthroscopic surgery; 11 of these 12 had surgery within 2 years
• 71% of patients returned to the same or a different sport or activity; of those who quit, 57% (8/14) did so for reasons unrelated to hip pain

Limitations

• Significant loss to follow-up at 5 years: 48% of originally enrolled symptomatic hips were unavailable, which could bias results toward better outcomes
• No radiographic arthritis progression data were collected, so long-term joint health effects of nonoperative management remain unknown
• No a priori power calculation was performed and the study was underpowered for risk stratification to identify which patients benefit most from nonoperative treatment
• Results are not generalizable to adults; the study population was exclusively adolescents (mean age 15 years) at a single pediatric center

Why it matters

For patients

Most adolescent patients with hip impingement pain can expect meaningful, lasting relief with activity modification and physical therapy, without needing surgery in the majority of cases.

For clinicians

A stepwise nonoperative protocol is a reasonable first-line approach for adolescent FAI syndrome, with surgical outcomes at 5 years comparable to conservative management in those who do progress to arthroscopy.

For readers

This study fills a gap in the literature by providing 5-year outcome data for nonoperative FAI treatment in adolescents, a group previously studied almost exclusively with surgical cohorts.