Monday, September 28, 2009

Articles supporting FAI and Labral Tear Surgery

In my quest to make my voice heard regarding insurance companies (UHC) policy on FAI surgery, I am compiling articles supporting surgery for FAI and labral tears. Please make your voice heard as well, call, write letters, emails etc. I have contacted a patient advocate regarding this matter and she suggested that we contact our members of Congress, letting them know what is going on.

What she did point out regarding the policy is the following:
The thing that nags at me about the new policy is this: "Although arthroscopic hip surgery for FAI is a procedure that is not subject to FDA regulation, devices and instruments used during the surgery require FDA approval. A search of the FDA 510(k) database revealed over 500 arthroscopes approved for marketing (product code HRX); however, the available studies did not provide sufficient information to determine which 510(k) approvals correspond to the instruments used."

So they can't tell which FDA approvals correspond to which device, so therefore they refuse to pay for any device, even if it's FDA approved? This is a major cop-out.

Another thing:
One more thing you might want to know. They cite to a Hayes brief. Hayes is a company that writes this garbage for insurance companies and justifies not paying for things. Any time you see Hayes, you know it's a biased assessment.


J Bone Joint Surg Br. 2009 Jan;91(1):16-23.
Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up.
Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA.
Steadman Hawkins Research Foundation, Vail, Colorado 81657, USA.
Over an eight-month period we prospectively enrolled 122 patients who underwent arthroscopic surgery of the hip for femoroacetabular impingement and met the inclusion criteria for this study. Patients with bilateral hip arthroscopy, avascular necrosis and previous hip surgery were excluded. Ten patients refused to participate leaving 112 in the study. There were 62 women and 50 men. The mean age of the patients was 40.6 yrs (95% confidence interval (CI) 37.7 to 43.5). At arthroscopy, 23 patients underwent osteoplasty only for cam impingement, three underwent rim trimming only for pincer impingement, and 86 underwent both procedures for mixed-type impingement. The mean follow-up was 2.3 years (2.0 to 2.9). The mean modified Harris hip score (HHS) improved from 58 to 84 (mean difference = 24 (95% CI 19 to 28)) and the median patient satisfaction was 9 (1 to 10). Ten patients underwent total hip replacement at a mean of 16 months (8 to 26) after arthroscopy. The predictors of a better outcome were the pre-operative modified HHS (p = 0.018), joint space narrowing >or= 2 mm (p = 0.005), and repair of labral pathology instead of debridement (p = 0.032). Hip arthroscopy for femoroacetabular impingement, accompanied by suitable rehabilitation, gives a good short-term outcome and high patient satisfaction.

J Pediatr Orthop. 2008 Oct-Nov;28(7):705-10.
Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report.
Philippon MJ
, Yen YM, Briggs KK, Kuppersmith DA, Maxwell RB.
Steadman Hawkins Research Foundation, Vail, CO 81657, USA.
BACKGROUND: Hip arthroscopy is becoming a more popular method of treatment of pediatric hip disorders. We report on the treatment of femoroacetabular impingement (FAI) in the adolescent population. METHODS: Between March 2005 and May 2006, 16 patients (aged 16 years or younger) underwent hip arthroscopy for FAI. There were 14 female adolescents and 2 male adolescents, with 1 patient undergoing a bilateral procedure. Five patients had isolated pincer impingement, 2 had isolated cam impingement, and 9 had mixed pathology. All patients had labral pathology. Seven patients were treated with suture anchor repair of the labrum and 9 with partial labral debridement. Subjective data were collected from each patient during their initial visit and at follow-up after surgery. Subjective data included the modified Harris hip score (MHHS), patient satisfaction, and hip outcome score (HOS) activities of daily living (ADL), and sports subscales. RESULTS: The mean age at the time of arthroscopy was 15 years old (range, 11-16 years). The mean preoperative MHHS was 55 (range, 33-70), HOS ADL was 58 (range, 38-75), and HOS sport was 33 (range, 0-78). The mean time from injury to surgery was 10.6 months (range, 6 weeks-30 months). The mean time to follow-up was 1.36 years (range, 1-2 years). The mean postoperative MHHS improved 35 points to 90 (range, 70-100; P = 0.005), postoperative HOS ADL improved 36 points to 94 (range, 74-100; P = 0.001), and postoperative HOS sport score improved 56 points to 89 (range, 58-100; P = 0.001). The mean patient satisfaction score was 9 (range, 9-10). CONCLUSIONS: Hip arthroscopy for FAI in the adolescent population produces excellent improvement in function and a high level of patient satisfaction in the short-term.

Knee Surg Sports Traumatol Arthrosc. 2007 Jul;15(7):908-14. Epub 2007 May 4.
Femoroacetabular impingement in 45 professional athletes: associated pathologies and return to sport following arthroscopic decompression.
Philippon M, Schenker M, Briggs K, Kuppersmith D.
Clinical Research, Steadman Hawkins Research Foundation, 181 W Meadow Dr. St. 1000, Vail, CO 81657, USA.
Femoroacetabular impingement (FAI) occurs when an osseous abnormality of the proximal femur (cam) or acetabulum (pincer) triggers damage to the acetabular labrum and articular cartilage in the hip. Although the precise etiology of FAI is not well understood, both types of FAI are common in athletes presenting with hip pain, loss of range-of-motion, and disability in athletics. An open surgical approach to decompressing FAI has shown good clinical outcomes; however, this highly invasive approach inherently may delay or preclude a high level athlete's return to play. The purpose of this study was to define associated pathologies and determine if an arthroscopic approach to treating FAI can allow professional athletes to return to high-level sport. Hip arthroscopy for the treatment of FAI allows professional athletes to return to professional sport. Between October 2000 and September 2005, 45 professional athletes underwent hip arthroscopy for the decompression of FAI. Operative and return-to-play data were obtained from patient records. Average time to follow-up was 1.6 years (range: 6 months to 5.5 years). Forty two (93%) athletes returned to professional competition following arthroscopic decompression of FAI. Three athletes did not return to play; however, all had diffuse osteoarthritis at the time of arthroscopy. Thirty-five athletes (78%) remain active in professional sport at an average follow-up of 1.6 years. Arthroscopic treatment of FAI allows professional athletes to return to professional sport.

J Arthroplasty. 2009 Sep;24(6 Suppl):114-9.
Labral disease associated with femoroacetabular impingement: do we need to correct the structural deformity?
Nepple JJ
, Zebala LP, Clohisy JC.
Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
In this study, we compared the clinical results of arthroscopic partial labral resection to augmentation of this procedure with limited open osteochondroplasty for the treatment of symptomatic femoroacetabular impingement. Two consecutive cohorts were evaluated: (a) group I, arthroscopic treatment of labrum and articular cartilage, and (b) group II, hip arthroscopy augmented with limited osteochondroplasty of the femoral head-neck junction. Group I (23 hips) and group II (25 hips) patients had no difference in age, labral disease patterns, osteoarthritis grade, or chondromalacia. Mean follow-up was slightly longer in group I. The modified Harris Hip Score showed a trend toward higher values in group II. A 10-point improvement was more common in group II, and fewer group II patients required subsequent surgery. These preliminary data suggest that patients with cam femoroacetabular impingement may have improved clinical outcomes when the impingement deformity is corrected.

J Bone Joint Surg Br. 2008 Dec;90(12):1570-5.
Early outcome of hip arthroscopy for femoroacetabular impingement: the role of femoral osteoplasty in symptomatic improvement.
Bardakos NV, Vasconcelos JC, Villar RN.
The Richard Villar Practice The Wellington Hospital, London, England.
There is a known association between femoroacetabular impingement and osteoarthritis of the hip. What is not known is whether arthroscopic excision of an impingement lesion can significantly improve a patient's symptoms. This study compares the results of hip arthroscopy for cam-type femoracetabular impingement in two groups of patients at one year. The study group comprised 24 patients (24 hips) with cam-type femoroacetabular impingement who underwent arthroscopic debridement with excision of their impingement lesion (osteoplasty). The control group comprised 47 patients (47 hips) who had arthroscopic debridement without excision of the impingement lesion. In both groups, the presence of femoroacetabular impingement was confirmed on pre-operative plain radiographs. The modified Harris hip score was used for evaluation pre-operatively and at one-year. Non-parametric tests were used for statistical analysis. A tendency towards a higher median post-operative modified Harris hip score was observed in the study group compared with the control group (83 vs 77, p = 0.11). There was a significantly higher proportion of patients in the osteoplasty group with excellent/good results compared with the controls (83% vs 60%, p = 0.043). Additional symptomatic improvement may be obtained after hip arthroscopy for femoroacetabular impingement by the inclusion of femoral osteoplasty.

Arthroscopy. 2008 May;24(5):540-6. Epub 2008 Jan 7.
Arthroscopic management of femoroacetabular impingement: early outcomes measures.
Larson CM, Giveans MR.
Minnesota Sports Medicine, Eden Prairie, Minnesota 55344, USA.
PURPOSE: The purpose of this study was to evaluate the early outcomes of arthroscopic management of femoroacetabular impingement (FAI). METHODS: Ninety-six consecutive patients (100 hips) with radiographically documented FAI were treated with hip arthroscopy, labral debridement or repair/refixation, proximal femoral osteoplasty, or acetabular rim trimming (or some combination thereof). Outcomes were measured with the impingement test, modified Harris Hip Score, Short Form 12, and pain score on a visual analog scale preoperatively and postoperatively at 6 weeks, 3 months, and 6 months, as well as yearly thereafter. Preoperative and postoperative radiographic alpha angles were measured to evaluate the adequacy of proximal femoral osteoplasty. RESULTS: There were 54 male and 42 female patients with up to 3 years' follow-up (mean, 9.9 months). The mean age was 34.7 years. Isolated cam impingement was identified in 17 hips, pincer impingement was found in 28, and both types were noted in 55. Thirty hips underwent labral repair/refixation. A comparison of preoperative scores with those obtained at most recent follow-up revealed a significant improvement (P < .001) for all outcomes measured: Harris Hip Score (60.8 v 82.7), Short Form 12 (60.2 v 77.7), visual analog score for pain (6.74 v 1.88 cm), and positive impingement test (100% v 14%). The alpha angle was also significantly improved after resection osteoplasty. Complications included heterotopic bone formation (6 hips) and a 24-hour partial sciatic nerve neurapraxia (1 hip). No hip went on to undergo repeat arthroscopy, and three hips have subsequently undergone total hip arthroplasty. CONCLUSIONS: Arthroscopic management of patients with FAI results in significant improvement in outcomes measures, with good to excellent results being observed in 75% of hips at a minimum 1-year follow-up. Alteration in the natural progression to osteoarthritis and sustained pain relief as a result of arthroscopic management of FAI remain to be seen. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

J Bone Joint Surg Am. 2007 Apr;89(4):773-9.
Quality of life following femoral head-neck osteochondroplasty for femoroacetabular impingement.
Beaulé PE, Le Duff MJ, Zaragoza E.
Division of Orthopaedic Surgery, University of Ottawa, Ottawa Hospital General Campus, 501 Smyth Road, Suite 5004, Ottawa, ON K1H 8L6, Canada.
BACKGROUND: Femoroacetabular impingement has been recently described as a common cause of hip pain and labral tears in young adults. We evaluated the early clinical results and quality of life after osteochondroplasty of the femoral head-neck junction for the treatment of femoroacetabular impingement. METHODS: Thirty-seven hips in thirty-four patients with persistent hip pain and a mean age of 40.5 years underwent surgical dislocation of the hip and osteochondroplasty of the femoral head-neck junction for the treatment of camtype femoroacetabular impingement. All of the patients had had preoperative evidence of pathological changes in the labrum on imaging. The clinical course and the quality of life were assessed postoperatively. RESULTS: The mean score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) increased from 61.2 points preoperatively to 81.4 points at a mean of 3.1 years postoperatively (p < 0.001), the mean University of California at Los Angeles (UCLA) activity score increased from 4.8 to 7.5 points (p < 0.001), the mean Short Form-12 (SF-12) physical component score increased from 37.3 to 45.6 points (p < 0.001), and the mean SF-12 mental component score increased from 46.4 to 51.2 points (p = 0.031). None of the hips underwent additional reconstructive surgery. There were no cases of osteonecrosis. Nine patients underwent screw removal from the greater trochanter because of persistent bursitis. Six of the thirty-four patients were dissatisfied with the outcome. CONCLUSIONS: Cam-type femoroacetabular impingement is associated with insufficient concavity at the anterolateral head-neck junction and with pathological changes in the labrum. Osteochondroplasty of the femoral head-neck junction following surgical dislocation of the hip joint is safe and effective and can provide a significant improvement in the overall quality of life of most patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

I will post these as a start, and keep this as a work in progress. But right now it has been a VERY long day and my bed is calling me, as will my alarm clock in less than 5 hours!

Saturday, September 26, 2009

Just When Things Were Getting Ugly.....

If you don't have a lot of time to read this post, I will post the gist of my visit with Dr K yesterday in one line:

"I think I need to go in and look around to see what is going on"

If you have the time, here are the details:

I had the PRP injection into the joint capsule about 3 1/2 weeks ago. It has not helped a bit. I am still having pain with walking, walking uphill etc (same as always)
As is the topic of many posts on my blog as well as responses to comments and personal emails, hip arthoscopy is very specialized and has a steep learning curve. What he is finding is that as his technique has changed slightly, patients are doing a lot better. He is not having any trouble from the "newer" patients, but the "older" patients are having issues. He did say that he knows a lot more now than he did when he did my surgeries (great!) One of the differences now is that he is stitching the capsule closed after he cuts it, instead of just approximating the edges. This was one of the things I learned when I observed him operating on one of my patients last year. I just re-read that post, he had mentioned that it puts less stress on the anterior structures and reduces tendonitis.

He has said from the beginning that he thought it was the capsule, I didn't agree. He thinks so bc I was in external rotation and that puts pressure on the anterior capsule. My MRI shows something wrong with the capsule, so did my ultrasound (during the PRP injection), my clinical signs do not. I have pain with flexion, pain with adduction, pain with internal rotation. No pain with external rotation, very little and seldomly pain in the posterior part of the joint. If I had pain in the posterior part he would think it could be ligamentum teres pain. I explained that I often sit or stand in external rotation, it is the most comfortable. He flipped through the MRI a few times and really didn't see anything of concern. He said he doesn't think it is my psoas, I agreed.
He sat down, sighed and said "so what do you want to do?", so I said "can you just cut it off? I really can't deal with this anymore". He laughed and said "should I amputate above the pelvis? you may look funny like that" so this went on a little.

Then he said it:
"I think I need to go in and have a look"
My heart stopped for a second and I got a little tear eyed I think. I said "You want to do an exploratory scope?" He said he doesn't think we have any other choice/ solution. He thinks that when I got up that day way back in June and had pain, I must have torn through some scar tissue, it then kind of flipped over and got stuck in the joint and now healed down like that.I was quiet for a long time (which is unlike me). I looked REALLY upset, and I think he was nervous that I would break down and lose it, so he said "do you want to try one more injection". Fine, what do I have to lose at this point. So we went over what I had injected in the past and what worked, what didn't. Do I want to inject the psoas? HELL NO, that was the worst one ever! So we agreed that injecting the joint would be a good idea since I had 2 days of relief last time, and since I have a "hole" in the capsule, it will leak out into the psoas anyway, so we are killing 2 birds with one stone. Fine.

So he left the room to dictate his note, I changed and went out to get the Rx from him. I walked around the corner to his receptionist and he followed me a minute later and said that he remembers we had discussed Synvisc a while ago. Anyway, he said at the time get the cortisone first and then we'll see. We ended up with the PRP then. So now he said try the Synvisc, it can be done with the cortisone.

As I drove home through crazy Manhattan, Friday afternoon traffic, I felt defeated. I was really sad, and angry, and anxious and a million other feelings all at once. I hope I can make the right decision on this and return to my prior level of function.

Tuesday, September 22, 2009

United Healthcare's new FAI Ruling

It has been brought to my attention that UHC has made a ridiculous ruling, basically trying to screw us all out of getting our symptomatic hips fixed and allowing us to return to a normal life. I am currently compiling information to prove that their ruling is wrong, unfair, and based on a small number of articles which state that further research needs to be conducted in FAI. they neglected to include the other articles which show that FAI surgery is successful. Below is their take on the issue. Please feel free to write, call, email etc the people at UHC and voice your opinion. If you would like the names of specific people to email (i.e VP and president of HR, medical director), please email me, or leave your email in the "comments" section of this post.

This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use and distribution are prohibited. This information is intended to serve only as a general reference resource regarding our Medical Policies and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on these Medical Policies in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. The enrollee's specific benefit documents supercede these policies and are used to make coverage determinations. These Medical Policies are believed to be current as of the date noted.
Confidential and Proprietary, © UnitedHealthcare, Inc. 2009
Femoroacetabular Impingement Syndrome
Technology Assessment

Approved By
Approval Date
Medical Technology Assessment Committee

After evaluating relevant benefit document language (exclusions or limitations), refer to Coverage sections of this document to determine coverage.
This policy describes surgical treatment for femoroacetabular impingement (FAI).
All reviewers must first identify member eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this policy.
Coverage RationaleSurgical treatment, both arthroscopic and open, for femoroacetabular impingement (FAI) syndrome is unproven. This includes the arthroscopic or open procedure itself, removal of any bony and soft tissue pathology including resection of excessive acetabular bone coverage, resection of femoral head-neck junction, labral repair with or without grafting, and debridement or shaving of articular cartilage. At the present time, there is insufficient evidence of long-term efficacy and safety. Long-term, randomized controlled trials are needed to help clinicians better understand the diagnosis and make effective recommendations for treatment.Centers for Medicare and Medicaid Services (CMS): Medicare does not have a national coverage policy for femoroacetabular impingement surgery. Local Coverage Determinations (LCDs) does not exist at this time. Accessed May 11, 2009.
Regulatory Requirements
U.S. Food and Drug Administration (FDA): Although arthroscopic hip surgery for FAI is a procedure that is not subject to FDA regulation, devices and instruments used during the surgery require FDA approval. A search of the FDA 510(k) database revealed over 500 arthroscopes approved for marketing (product code HRX); however, the available studies did not provide sufficient information to determine which 510(k) approvals correspond to the instruments used.Additional information is available at: Accessed August 3, 2009.
Research Evidence
BackgroundFemoroacetabular impingement (FAI), formerly called acetabular rim syndrome or cervicoacatebular impingement, is the main cause of early damage to the acetabular labrum and articular cartilage of the hip, particularly in young, active patients and high-level athletes. In patients with FAI, limitation of both flexion and internal rotation occur at the hip joint as a result of premature pathologic contact between the skeletal prominences of the acetabulum and the femur. FAI generally occurs in one joint; however, in rare cases both hips can be involved. Surgical treatment has been utilized to improve the clearance for motion at the hip joint and lessen the femoral thrust against the acetabular rim. If left untreated, FAI may lead to osteoarthrosis of the hip. (ECRI, 2008)FAI is common in patients presenting with low back pain, cartilage damage, hip pain, loss of range of motion, disability, and sport hernias. Most patients can be diagnosed with a good history, physical examination, plain x-ray, and magnetic resonance imaging. The three types of FAI include the following (ECRI, 2008; NHS 2007): 1) cam impingement due to an aspherical portion of the femoral head-neck junction (i.e., femoral cause) which is most common in young athletes;2) pincer impingement due to focal or wide-ranging excessive coverage of the ball or femoral head (i.e., acetabular cause) which is most common in athletic, middle-aged women; 3) mixed pincer and cam impingement which is the most common type of FAI. Clinical EvidenceA systematic review by Bedi et al. (2008) reviewed 19 articles to determine the quality of the literature assessing outcomes after surgical treatment of labral tears and femoroacetabular impingement (FAI), patient satisfaction after open or arthroscopic intervention, and differences in outcome with open or arthroscopic approaches. The studies reviewed support that 65% to 85% of patients are satisfied with their outcome at a mean of 40 months after surgery. A common finding in all series, however, was an increased incidence of failure among patients with substantial pre-existing osteoarthritis. Arthroscopic treatment of labral tears is also effective, with 67% to 100% of patients being satisfied with their outcomes. The authors concluded that the quality of literature reporting outcomes of surgical intervention for labral tears and FAI is limited. Although open surgical dislocation with osteoplasty is the historical gold standard, the scientific data does not show that open techniques have outcomes superior to arthroscopic techniques.In a prospective observational study, Tanzer and Noiseux (2004) examined the role of FAI in hip disorders. For this study, 38 patients who had labral tears detected during hip arthroscopy and who had radiographic evidence of FAI were followed prospectively after arthroscopic removal of the torn portion of the labrum. Labral tear development was acute as evidenced by a twisting episode or well-defined precipitating event for 19 (50%) patients, insidious or gradual onset of worsening symptoms for 12 (32%), and due to major trauma as evidenced by a violent impact or dislocation for 7 (18%). In 16 (43%) of these patients, arthritic changes were identified on radiographs taken after arthroscopy. Damage associated with acetabular tears included femoral or global arthritic changes in 7 (18%) patients, anterior acetabular arthritic changes in 6 (16%), and femoral chondral lesions in 3 (8%). At 1 year of follow-up of 24 (63%) patients, mechanical symptoms had resolved completely in all patients; however, only 6 (25%) of these patients no longer had pain. The authors concluded that although arthroscopy for hip impingement is promising, future studies are needed to determine if correction of the anterior hip impingement, early in the natural history of the disease, may delay or prevent end-stage arthritis. This study is limited by small sample size with short term follow-up and a non controlled study design.In a prospective study by Peters and Erickson (2006), 30 hips (29 patients) with femoro-acetabular impingement underwent debridement through a greater trochanteric flip osteotomy and anterior dislocation of the femoral head. Cam (femoral based) impingement was noted in 14 hips; pincer (acetabular based) impingement in 1hip; and combined cam and pincer impingement in 15 hips. Mean patient age was 31 years. The mean duration of clinical and radiographic follow-up was 32 months. All patients were followed according to a prospective protocol, with Harris hip scores and plain radiographs obtained preoperatively and at 6 months, 1 year, and annually for a minimum of 2 years. The mean Harris hip score improved from 70 points preoperatively to 87 points at the time of final follow-up. In 18 hips, severe damage of the acetabular articular cartilage that had not been appreciated on preoperative plain radiographs or magnetic resonance arthrography was noted on arthrotomy. Eight of these 18 hips subsequently had radiographic evidence of progression of the osteoarthritis, and 4 of the 8 hips required or were expected to soon require conversion to a total hip arthroplasty to treat progressive pain. The authors concluded that surgical dislocation and debridement of the hip for the treatment of femoro-acetabular impingement in hips without substantial damage to the articular cartilage can reduce pain and improve function. This study is limited by its uncontrolled study design and small sample size.Sampson (2005) conducted a retrospective study of arthroscopic hip surgery for FAI, which reported results for 156 patients, some of whom underwent bilateral arthroscopic surgery. The ages of these patients ranged from 14 to 75 years, and most were between the ages of 20 and 40 years. Symptoms were generally mild and included somewhat reduced range of motion (ROM), poor tolerance of prolonged sitting, and inability to participate in sports. For the majority of patients, pain relief was 50% in 6 to 12 weeks, 75% in 5 months, and 95% in 1 year. Patients no longer needed crutches after 2 to 4 weeks. After follow-up ranging up to 22 months, 3 (2%) patients opted for total joint replacement due to continued pain. The average follow-up period and protocol for follow-up were not reported. This study is limited by its retrospective design, heterogenous patient population which limits the generalization of this data to other populations or who is best suited for the procedure, and lack of defined follow-up period and protocols.An uncontrolled study by Larson and Giveans ( 2008) on 96 patients (100 hips), was conducted to evaluate the early outcomes of arthroscopic management of femoroacetabular impingement (FAI). There were 54 male and 42 female patients with a mean age was 34.7 years. The surgical procedures performed were 26 (26%) proximal femoral osteoplasties, 21 (21%) acetabular rim trimmings, and 53 (53%) combination osteoplasties and trimmings. Patients also underwent labral debridement and repair or refixation as needed. At a mean of 10 months follow-up compared with baseline, mean pain score decreased from 6.7 to 1.9, mean Harris Hip score increased from 61 to 83, and mean SF-12 quality-of-life score increased from 60 to 78. All of these improvements were statistically significant (P<0.001). n="19" name="
References and Resources
ResourcesAmerican College of Rheumatology (ACR) [website]. Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43(9):1905-1915. Available at: Accessed June 1, 2009.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 Oct;24(10):1135-45.ECRI Institute. Hotline Response. Surgical Treatment of Femoroacetabular Impingement. June 2008.Hayes, Inc. Health Technology Brief. Arthroscopic Hip Surgery for Femoroacetabular Impingement (FAI). Lansdale, PA: Hayes, Inc.; July 18, 2008.Ilizaliturri VM Jr, Orozco-Rodriguez L, Acosta-RodrE, 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.Larson CM, Giveans MR. Arthroscopic management of femoroacetabular impingement: early outcomes measures. Arthroscopy. 2008;24(5):540-546.National Institute for Health and Clinical Excellence (NICE). Open femoro-acetabular surgery for hip impingement syndrome. Interventional Procedure Guidance 203. London, UK: NICE; January 2007a. Available at: Accessed May 1, 2009.National Institute for Health and Clinical Excellence (NICE). Arthroscopic femoro-acetabular surgery for hip impingement syndrome. Interventional Procedure Guidance 213. London, UK: NICE; March 2007b. Available at: Accessed May 1, 2009. National Library for Health (NLH). NHS Evidence. Surgery for Femoroacetabular Impingement. 2007. Available at: Accessed June 1, 2009.Peters CL, Erickson JA. Treatment of femoro-acetabular impingement with surgical dislocation and din young adults. J Bone Joint Surg Am. 2006 Aug;88(8):1735-41. Philippon MJ, Yen YM, Briggs KK, Kuppersmith DA, Maxwell RB. Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report. J Pediatr Orthop. 2008 Oct-Nov;28(7):705-10.Philippon MJ, Stubbs AJ, Schenker ML, Maxwell RB, et al. Arthroscopic Management of femoroacetabular impingement; Osteoplasty technique and literature review. Am J Sports Med. 2007; 35(9):1571-1580.Sampson TG. Arthroscopic treatment of femoroacetabular impingement. Tech Orthop. 2005;20(1):56-62.Stahelin L, Stahelin T, Jolles BM, Herzog RF. Arthroscopic offset restoration in femoroacetabular cam impingement: accuracy and early clinical outcome. Arthroscopy. 2008;24(1):51-57.Tanzer M, Noiseux N. Osseous abnormalities and early osteoarthritis: the role of hip impingement. Clin Orthop Relat Res. 2004;(429):170-177.
New Policy.

The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this policy are for reference purposes only. Listing of a service code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.CPT Codes:
Unlisted procedure, pelvis or hip joint
Unlisted procedure, arthroscopy

Friday, September 18, 2009

When Will It Ever End

I haven't updated in a while bc things have been status quo since my PRP injection, no better no worse, just plain old shitty. To add insult to injury, I was sitting in my car yesterday with that leg in slight internal rotation. I went to reach into the back seat and the hip went further into internal rotation and I felt an awful ripping/ tearing in my hip. I immediately felt really nauseas too. Now it is super sore and stiff and really painful. My hope is that it was scar tissue tearing (I imagine there is a ton in that hip) but in the past when I have torn through scar tissue my hip felt better.

Today I have been really uncomfortable, I have pain and burning in the groin, sitting in the car was really uncomfortable. Walking is really uncomfortable. I don't know what the hell happened but needless to say I am scared shitless. I see BK next week, if this hasn't gone away by then I will be this much closer to losing it completely.

To all my Jewish readers, happy new year!

Wednesday, September 2, 2009

PRP Injection...done

After much anticipation, and 3 months after my problem started, I had my PRP injection. But not without snafus!

My appointment was at 11am. at 11:45 the radiologist came out and asked me if I knew if BKs office arranged for the PRP machine (centrifuge) to be brought over. Umm, I would assume so given all the trouble it had been to arrange this. He said he hadn't seen the rep from the company around but knew she was over at HSS, so she was "in the neighborhood".

At around 12:15 the rep arrived with the machine. We began getting the injection underway close to 12:45.

First, the radiologist, using ultrasound, checked out the hip. He could see the debrided labrum and where bone had been shaved, as well as "reduced echo" on the anterior joint capsule. He then took blood from my arm, 10cc. For some reason, this was more uncomfortable than normal. He handed the blood to the rep who spun it down for 5 minutes and then placed 3 cc of plasma into another syringe. The radiologist then injected this into the area around the capsule and the muscles and tendons. He went through the muscles a few times leaving me pretty sore. It has been 11 hours and my thigh really hurts. I just want to climb into bed and sleep for 12 hours!

I really really hope this works!

What I learned from the rep (who was super sweet) is that there are different kinds of PRP, this specific one is called ACP, autologous conditioned plasma.

I am still not 100% what the differences are but I am working on learning more. The rep is emailing me some info tomorrow!