Hip Arthroscopy - CAM 772
Description
General Information
- It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.
- The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.
Purpose
This guideline addresses the following elective, non-emergent, arthroscopic hip repair procedures, including: diagnostic arthroscopy, femoroacetabular impingement (FAI), labral repair only; CAM, pincer, CAM & pincer combined; synovectomy, biopsy, or removal of loose or foreign body.
Scope
Open, non-arthroplasty hip repair surgeries are performed as dictated by the type and severity of injury and/or disease.
Surgical indications are based on relevant clinical symptoms, physical exam, radiologic findings, and response to non-operative, conservative management when medically appropriate.
Special Note
In order for surgeries to be considered medically necessary there must be clear medical records that demonstrate a clear surgical plan that matches the request for surgery.
GENERAL REQUIREMENTS
- Elective arthroscopic surgery of the hip may be considered if the following general criteria are met:
- There is clinical correlation of the individual’s subjective complaints with objective exam findings and/or imaging (when applicable)
- Individual has limited function (age-appropriate activities of daily living [ADLs], occupational, athletic)
- Individual is medically stable and optimized for surgery and any treatable comorbidities are adequately medically managed such as diabetes, nicotine addiction, or an excessively high BMI. There should also be a shared decision between the patient and physician to proceed with arthroscopic hip surgery when comorbidities exist as it pertains to the increased risk of complications.
- Individual does not have an active local or systemic infection
- Individual does not have active, untreated drug dependency (including but not limited to narcotics, opioids, muscle relaxants) unless engaged in treatment program
- Clinical notes should address:
- Symptom onset, duration, and severity
- Loss of function and/or limitations
- Type and duration of non-operative management modalities (where applicable)
- Non-operative management must include TWO or more of the following, unless otherwise specified:
- Physical therapy or properly instructed home exercise program
- Rest or activity modification
- Ice/Heat
- Protected weight bearing
- Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics
- Brace/orthosis
- Weight optimization
- Corticosteroid injections
Policy
INDICATIONS
Diagnostic or operative arthroscopy of the hip is considered MEDICALLY NECESSARY when performed in conjunction with periacetabular osteotomy (PAO)(1-3) OR as indicated in the following sections:
Diagnostic Hip Arthroscopy
All requests for diagnostic hip arthroscopy will be considered and decided on a case-by-case basis and are rarely deemed MEDICALLY NECESSARY.
However, on occasion, diagnostic hip arthroscopy is considered MEDICALLY NECESSARY when ALL of the following criteria are met:
- At least 6 months of hip pain with documented loss of function
- Indeterminate radiographs AND Magnetic Resonance Imaging (MR)I findings
- No radiographic findings of any of the following:
- Significant arthritis (joint space < 2 mm on X-ray or subchondral edema on MRI)(3)
- Femoroacetabular impingement (non-spherical femoral head or prominent head-neck junction (pistol-grip deformity), alpha angle > 50 degrees, overhang of the anterolateral rim of the acetabulum, posterior wall sign, prominent ischial spine sign, acetabular protrusion, or retroversion of acetabulum with a center edge (CE) angle > 35° degrees and/or cross-over sign)(4)
- Hip dysplasia (lateral center edge angle < 20 degrees, anterior center edge angle < 20 degrees, Tönnis angle > 15 degrees or femoral head extrusion index > 25%), unless combined with concomitant periacetabular osteotomy(1,3)
- Fractures of the femoral head or acetabulum
- Labral tear (on MRI or MR arthrogram)
- Pigmented villonodular synovitis (PVNS) or synovial chondromatosis
- Intra-articular loose body
- Adductor tear or hamstring tear
- Pubic edema or osteitis pubis
- Gluteus medius or minimus tear
- Ischiofemoral impingement (narrowed ischiofemoral and quadratus femoris spaces)
- Failure of at least 12 weeks of non-operative treatment, including at least two of the following:
- Rest or activity modifications/limitations
- Ice/heat
- Protected weight bearing
- Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
- Brace/orthosis
- Physical therapy or properly instructed home exercise program
- Weight optimization
- Corticosteroid injection
- No cortisone injection within 3 months of surgery(5,6)
Labral Tears and Femoroacetabular Impingement (FAI)
Labral Repair
Arthroscopic labral repair is considered MEDICALLY NECESSARY when ALL of the following criteria are met(3,4,7):
- Hip or groin pain in positions of flexion and rotation that may be associated with mechanical symptoms of locking, popping, or catching
- Positive provocative test on physical exam with pain at the hip joint with flexion, adduction, and internal rotation (FADIR test)
- Acetabular labral tear on MRI, with or without intra-articular contrast
- No evidence of significant hip joint arthritis, defined as joint space narrowing 2 mm or less or Tönnis grade 3 or evidence of severe or advanced dysplasia unless combined with concomitant periacetabular osteotomy
- Weight-bearing X-rays are not required
- Failure of at least 6 weeks of non-operative treatment, including at least two of the following:
- Physical therapy or properly instructed home exercise program
- Rest or activity modification
- Ice/heat
- Protected weight bearing
- Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics
- Weight optimization
- Corticosteroid injection
- No cortisone injection within 3 months of surgery(5,6)
CAM, Pincer, Combined CAM & Pincer Repair
Arthroscopic CAM, pincer or combined CAM and pincer repair is considered MEDICALLY NECESSARY when ALL of the following criteria are met (3,4,7,8):
- Positional hip pain
- Skeletally mature patient [partial or complete closure of the proximal femoral physis]
- BMI < 40 (9); Individuals with BMI > 40 will be reviewed on a case-by-case basis
- Positive impingement sign on physical exam (hip or groin pain with flexion, adduction, and internal rotation (FADIR test) (10)
- ANY of the following radiograph, CT and/or MRI findings of FAI:
- Non-spherical femoral head or prominent head-neck junction (pistol-grip deformity) with alpha angle > 50 degrees indicating CAM impingement (see radiographic measurement appendix)(4)
- Overhang of the anterolateral rim of the acetabulum, posterior wall sign, prominent ischial spine sign, acetabular protrusion, or retroversion with a center edge (CE) angle > 35° and/or cross-over sign indicating pincer deformity (see radiographic measurement appendix)(4)
- Combination of CAM and pincer criteria
- No evidence of significant hip joint arthritis, defined as joint space narrowing 2 mm or less or a Tönnis Grade 3 or evidence of severe or advanced hip dysplasia (see Grading Appendix) unless combined with concomitant periacetabular osteotomy (See Background Additional Notes) (11)
- Radiographic images show no evidence of severe or advanced hip dysplasia (see Grading Appendix) unless combined with concomitant periacetabular osteotomy**
- Failure of at least 6 weeks of non-operative treatment, including at least two of the following (12):
- Physical therapy or properly instructed home exercise program
- Rest or activity modification
- Ice/heat
- Protected weight bearing
- Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics
- Weight optimization
- Corticosteroid injection
- No cortisone injection within 3 months of surgery (5,6)
Arthroscopy for Synovectomy, Biopsy, or Removal of Loose or Foreign Body
Arthroscopic synovectomy, biopsy, removal of loose or foreign body, or a combination of these procedures may be medically necessary when the following criteria in either section are met (3):
Section One
- X-ray, MRI, or CT evidence of acute post-traumatic intra-articular foreign body or displaced fracture fragment
Section Two
- When ALL of the following criteria are met:
- Hip pain associated with grinding, catching, locking, or popping
- Physical examination demonstrates painful range of motion of the hip
- Radiographs, CT, and/or MRI demonstrate synovial proliferation, calcifications, nodularity, inflammation, pannus, or a loose body
- Failure of at least 12 weeks of non-operative treatment, including at least two of the following:
- Physical therapy or properly instructed home exercise program
- Rest or activity modification
- Ice/heat
- Protected weight bearing
- Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics
- Weight optimization
- Corticosteroid injection
- No cortisone within 3 months of surgery (5,6)
There is no evidence to support hip arthroscopy for FAI and/or labral tear in an asymptomatic individual and there is a high prevalence of abnormal radiographs found in asymptomatic individuals (14): 33% of asymptomatic hips have a cam lesion, 66% of asymptomatic hips have a pincer lesion, and 68% of asymptomatic hips have a labral tear. (2,4)
*Even though hip dysplasia, as well as symptomatic FAI and labral tears are believed to be precursors to hip arthritis, arthroscopy is not indicated solely for the treatment of osteoarthritis of the hip and rarely indicated for severe dysplasia, unless combined with concomitant periacetabular osteotomy. However, individuals with borderline dysplasia (lateral center-edge angle [LCEA], 18 degrees to 25 degrees), that require arthroscopic procedures appear to do as well as those with no evidence of dysplasia. (1,4,7)
Grading Appendix
Tonnis Classification of Osteoarthritis by Radiographic Changes(13)
| Grade |
Description |
| 0 |
No signs of osteoarthritis |
| 1 |
Mild: Increased sclerosis, slight narrowing of the joint space, no or slight loss of head sphericity |
| 2 |
Moderate: Small cysts, moderate narrowing of the joint space, moderate loss of head sphericity |
| 3 |
Severe: Large cysts, severe narrowing or obliteration of the joint space, severe deformity of the head |
Hip Dysplasia
Defined as any of the following criteria (1,4,7):
- Lateral center edge angle < 20 degrees
- Anterior center edge angle < 20 degrees
- Tönnis angle > 15 degrees
- Femoral head extrusion index > 25%
- Borderline dysplasia (lateral center-edge angle [LCEA], 18d degrees to 25 degrees)
Radiographic Measurement Index(18)
Alpha Angle
- Alpha angle was measured on the AP pelvis and Dunn 45 degrees radiographs. First, a Mose circle was placed around the circumference of the femoral head. A line was drawn from the center of the femoral head down the center of the femoral neck. A line was then drawn connecting the center of the femoral head to the point of the Mose circle where the head goes out of round. The angle bisecting these two lines was the alpha angle
- An alpha angle of 55 degrees (Dunn 45 degrees) or greater or an alpha angle of 50 degrees (AP pelvis) was defined as cam morphology
Femoral Head Intrusion
- Femoral head extrusion index was measured as the proportion (%) of laterally uncovered femoral head versus the femoral head (horizontal distance)
- A femoral head extrusion index greater than 25% defined dysplasia
Global Acetabular Retroversion
- Global acetabular retroversion was defined by the presence of a prominent ischial spine sign or posterior wall sign
- Prominent ischial spine sign: Visible ischial spine medial to the iliopectineal line on AP pelvis radiograph
- Posterior wall sign: Center of the femoral head lateral to the posterior wall of the acetabulum
Lateral Center Edge Angle
- Lateral center edge angle was measured after multiple lines were drawn on the AP pelvis radiograph. First, a Moses circle was placed around the circumference of the femoral head. Next, a line was drawn connecting the ischial tuberosities. A perpendicular line was then drawn up through the center of the femoral head from the ischial tuberosity line. Then, a line was drawn from the center of the femoral head to the most lateral aspect of the sourcil. The angle bisecting the latter two lines was the lateral center edge angle
- A lateral center edge angle less than 20 degrees defines dysplasia, 20 to 25 degrees borderline dysplasia, 26 to 39 degrees normal, and greater than 40 degrees lateral over coverage pincer impingement
- Lateral over coverage was defined as a lateral center edge angle greater than 40 degrees
Outcomes of Surgical Management of Borderline Hip Dysplasia (1):
- Study Design: Systematic review.
- Target Population: Patients with borderline hip dysplasia (LCEA 18-25°).
- Key Factors: This review aimed to define patient outcomes following hip arthroscopy and/or periacetabular osteotomy (PAO). It included data from 13 studies with 505 patients, showing post-operative improvement in patient-reported outcomes (PROs). The study reported a high reoperation rate, including both arthroscopic and open revision procedures, and emphasized the need for more robust studies on both specific arthroscopic techniques and open procedures.
Indications for Hip Arthroscopy (3):
- Study Design: Clinical review.
- Target Population: Patients undergoing hip arthroscopy for various hip conditions.
- Key Factors: The study discusses the indications for hip arthroscopy, which include labral tears, chondral defects, and loose bodies. It highlights the development of hip-specific arthroscopic instrumentation and improved techniques that have expanded the indications for hip arthroscopy. The review also emphasizes the importance of appropriate patient selection and understanding the indications to optimize outcomes and minimize complications.
Best Practice Guidelines for Hip Arthroscopy in Femoroacetabular Impingement (8):
- Study Design: This study utilized a Delphi process and nominal group technique to establish best practice guidelines (BPG) for hip arthroscopy in femoroacetabular impingement (FAI) syndrome. The process involved three iterative rounds of surveys and discussions among 15 experienced hip arthroscopists from 14 institutions in North America.
- Target Population: The target population included patients with FAI syndrome, which occurs due to abnormal contact between the proximal femur and acetabulum during hip joint motion. This condition can lead to labral tears, cartilage damage, and joint degeneration.
- Key Factors: The study aimed to reduce variability in clinical practice by developing consensus-based guidelines for preoperative, intraoperative, and postoperative management of FAI. The guidelines included 27 preoperative recommendations, 15 intraoperative practices, and 10 postoperative protocols. Consensus was reached on various aspects such as the avoidance of opioid prescription preoperatively, the importance of labral repair or refixation during surgery, and the inclusion of a structured postoperative rehabilitation protocol. The study highlighted the importance of patient selection, noting that certain characteristics like older age, longer duration of symptoms, and presence of arthritic changes could predict inferior outcomes.
Analysis of Evidence
Shared Findings:
- All three studies emphasize the importance of appropriate patient selection to optimize outcomes and minimize complications. (1,3,8)
- They highlight the successful treatment of labral tears and the importance of labral repair or refixation during surgery. (1,8)
- The studies agree on the need for structured postoperative rehabilitation protocols to improve patient outcomes. (3,8)
Differing Findings:
- Outcomes of Surgical Management of Borderline Hip Dysplasia emphasizes the high reoperation rate in patients with borderline hip dysplasia and the need for more robust studies on both specific arthroscopic techniques and open procedures. (1)
- Best Practice Guidelines for Hip Arthroscopy in Femoroacetabular Impingement focuses on developing consensus-based guidelines to reduce variability in clinical practice, highlighting the importance of avoiding opioid prescription preoperatively and including structured postoperative rehabilitation protocols. (8)
- Indications for Hip Arthroscopy discusses the expanded indications for hip arthroscopy due to the development of hip-specific arthroscopic instrumentation and improved techniques. (3)
In summary, while all three studies highlight the importance of patient selection and structured postoperative rehabilitation, they differ in their focus on guidelines development, reoperation rates, and the expansion of indications for hip arthroscopy.
References
1. Barton C, Scott E, Khazi ZM, Willey M, Westermann R. Outcomes of Surgical Management of Borderline Hip Dysplasia: A Systematic Review. Iowa Orthop J. 2019;39(2):40-48. Accessed September 12, 2024. http://www.ncbi.nlm.nih.gov/pubmed/32577106
2. Jamil M, Dandachli W, Noordin S, Witt J. Hip arthroscopy: Indications, outcomes and complications. International Journal of Surgery. 2018;54:341-344. doi:10.1016/j.ijsu.2017.08.557
3. Ross JR, Larson CM, Bedi A. Indications for Hip Arthroscopy. Sports Health. 2017;9(5):402-413. doi:10.1177/1941738117712675
4. O’Rourke RJ, El Bitar Y. Femoroacetabular Impingement. StatPearls. Published online June 26, 2023. https://www.ncbi.nlm.nih.gov/books/NBK547699/
5. Aamer S, Tokhi I, Asim M, et al. Postoperative Infection Following Hip Arthroscopy in Patients Receiving Preoperative Intra-articular Injections: A Systematic Review and Meta-Analysis. Cureus. Published online June 4, 2024. doi:10.7759/cureus.61649
6. Wang D, Camp CL, Ranawat AS, Coleman SH, Kelly BT, Werner BC. The Timing of Hip Arthroscopy After Intra-articular Hip Injection Affects Postoperative Infection Risk. Arthroscopy - Journal of Arthroscopic and Related Surgery. 2017;33(11):1988-1994.e1. doi:10.1016/j.arthro.2017.06.037
7. Mella C, Villalón IE, Núñez Á, Paccot D, Díaz-Ledezma C. Hip arthroscopy and osteoarthritis: Where are the limits and indications? SICOT J. 2015;1:27. doi:10.1051/sicotj/2015027
8. Lynch TS, Minkara A, Aoki S, et al. Best Practice Guidelines for Hip Arthroscopy in Femoroacetabular Impingement: Results of a Delphi Process. Journal of the American Academy of Orthopaedic Surgeons. 2020;28(2):81-89. doi:10.5435/JAAOS-D-18-00041
9. Parvaresh K, Rasio JP, Wichman D, Chahla J, Nho SJ. The Influence of Body Mass Index on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: Five-Year Results in 140 Patients. American Journal of Sports Medicine. 2021;49(1):90-96. doi:10.1177/0363546520976357
10. Pålsson A, Kostogiannis I, Ageberg E. Combining results from hip impingement and range of motion tests can increase diagnostic accuracy in patients with FAI syndrome. Knee Surgery, Sports Traumatology, Arthroscopy. 2020;28(10):3382-3392. doi:10.1007/s00167-020-06005-5
11. Lei P, Conaway WK, Martin SD. Outcome of Surgical Treatment of Hip Femoroacetabular Impingement Patients with Radiographic Osteoarthritis: A Meta-analysis of Prospective Studies. Journal of the American Academy of Orthopaedic Surgeons. 2019;27(2):E70-E76. doi:10.5435/JAAOS-D-17-00380
12. Casartelli NC, Bizzini M, Maffiuletti NA, et al. Exercise Therapy for the Management of Femoroacetabular Impingement Syndrome: Preliminary Results of Clinical Responsiveness. Arthritis Care Res (Hoboken). 2019;71(8):1074-1083. doi:10.1002/acr.23728
13. Kovalenko B, Bremjit P, Fernando N. Classifications in Brief: Tönnis Classification of Hip Osteoarthritis. Clin Orthop Relat Res. 2018;476(8):1680-1684. doi:10.1097/01.blo.0000534679.75870.5f
14. Mannava S, Geeslin AG, Frangiamore SJ, et al. Comprehensive Clinical Evaluation of Femoroacetabular Impingement: Part 2, Plain Radiography. Arthrosc Tech. 2017;6(5):e2003-e2009. doi:10.1016/j.eats.2017.06.011
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