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!


Anonymous said...

hi susie...2 things...
1. reading your first abstract (2009 Phillipon) you think that some of us who had labral debridement first and then a revision with the osteoplasty and labral tear are somewhat "screwed". it looks as if earlier HA utilized a lot more debridement and less repair.
2. i may be part of clohisy's data in that one study...hard to tell but i have been enrolled in several of his studies since 2007. of course...given my situation...maybe i am the one that messed up the data!

Susie said...

I definitley think we are screwed, or at least "more screwed" than someone who "got it right the first time".The amount of trauma to the joint/ joint capsule is tissue increased, scar is inceased. I dont know what I think bat long term effects of debridement vs repair, I need to find more timme to do more research.

Kate.Mich said...

Thank you Susie for everything that you do. I really really hope you are able to make a significant impact against UHC. Is there anything I can do to help? Maybe take pictures of me stuck on the floor at work with a 1st grader pulling me up because my hip hurts and I'm stuck?!? haha (kinda funny, not really..)

Susie said...

Send letters, call, write to your congressman abt it. I still want to write a "generic" letter for everyone to use but have not had a chance between vacation and some work issues but will soon! I also think my anxiety level is kind of high bc I am having this injection on Friday as a "last chance" type thing.

Kate.Mich said...

I wish you luck tomorrow with your injection. I really hope it gives you some relief. You have so much more knowledge of this stuff than me, so a letter with all of your knowledge would be amazing. I am going to start using some of the information you have posted as well as other files from the yahoo forums to send to Harvard Pilgrim. I'm just at a loss.

Chronic said...

I'm struggling with the same thing - I have my information with Phillipon to be evaluated for his repair surgery but I really question if this is even effective. I'm 42. have you heard of people getting a hip replacement to avoid all this labral tear mumbo jumbo?

Susie said...

chronic- unless yo have advanced arthritis, no one will replace your hip. I have had very successful surgeyr on one hip, It has been 2 1/2 years since I had it done and it is perfect. I had 1 1/2 good years on the right and it is now acting up again, many people have had successful surgery. Have you been watching the world series? A-rod, Chase Utley, Bret Myers to name a few....

Chronic said...

I personally know 3 people who have had the surgery from philipon and all question its effectiveness - as if it's a delay before they can receive the hip replacement. A delay that involves a 6 month healing process. Those sports figures all have teams of people working to rehab them.

Anonymous said...

Hi Susie,
I'm glad I found your blog! I had an arthroscopy for FAI with a femorolpasty and microfracture procedures one year and nine months ago. Two weeks ago, unbelievably, I received an email from my surgeon's office (Dr. Byrd) that UHC has denied my claim and I owe them in full for the procedure! I'm shocked and very angry about this...I was never notified by either UHC or the doc's office that there was any problem with coverage, and now suddenly almost 2 years later I find this out. Of course my appeals deadline has long since passed by. Right now I'm in the process of trying to get my file from UHC. Dr. Byrd's office tells me it's all on me -- I "should have known" -- and they want their 10K ASAP. This is so out of left field that I can't even believe it. My surgery was covered and paid for, and then apparently later denied, and no one told me. Dealing with UHC to get info about this so far is a nightmare. They're denying my claim due to the femoroplasty being unproven, yet supposedly they had no policy about it at the time of my surgery.
Any sugestions for me, or perhaps a good contact at UHC other than the customer service reps that are giving me all the wrong info? Thanks so much!

HFHF: Authors said...

Not sure the frequency that this blog is updated. Right now I'm struggling to get AETNA to cover my FAI Labral Tear. Has Anyone had any luck with this?

jkozora said...

My wife is also experiencing extreme pain from a hip labral tear. Our government Tri-Care insurance managed by Tri-West is also refusing to cover as their rules consider it unproven. Unbelievable considering they have spent thousands over the past year and a half trying to diagnose her pain. Now that the problem is found they refuse to cover the arthroscopy surgery to fix it. My wife used to walk 3-4 miles a day and now is bound to a chair most of the day. I appealed Tri-West's decision but was denied. Like all other I too wish something could be as this is how I discovered this web site.

Anonymous said...

Hey jkozora, I'm a TriWest patient with the same problem. I saw your post from January 2011 and would be grateful to know if you and your wife had success getting surgery covered? I hope she's gotten some relief somehow. Ariel

OTmom said...

I am 39 and trying to get FAI/cam impingement hip arthroscopy with labral tear repair. I have found several fantastic surgeons and AETNA is denying saying there are plenty of in-network physicians (they haven't taken it to the next level yet of denying the surgery; which will be their next step I'm sure). Love any advice.

Susie said...

OTmom, unfortunately I have not heard of anyone having success with Aetna. It is horrible. I believe there may be a cass action lawsuit in the making. There r other posts on my blog abt Aetna. I suggest u find them and spk w others who have Aetna. What U can do is have Aetna pay for the labral repair and u pay for the FAI component of the surgery if u r desperate.