Hip Arthroscopy for Femoroacetabular Impingement Syndrome Reduces the Risk for Developing Hip Osteoarthritis: A Systematic Review

Purpose

To perform a systematic review to directly compare hip arthroscopy and nonoperative treatment for femoroacetabular impingement syndrome (FAIS) with outcomes including the risk for developing hip osteoarthritis (OA) or undergoing total hip arthroplasty (THA) later in life.

Methods

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by searching PubMed, the Cochrane Library, and Embase to identify studies directly comparing hip arthroscopy and nonoperative treatment for FAIS. The search terms used were as follows: hip AND arthroscopy AND “femoroacetabular impingement” AND (osteoarthritis OR arthroplasty) . Studies with a follow-up time <2 years were excluded. Outcomes measured were incidence rates for OA progression and THA conversion following treatment.

Results

Six studies (1 Level I, 2 Level II, 3 Level III) met inclusion criteria, with a total of 622 hips that underwent arthroscopy and 1,424 hips that underwent nonoperative treatment (control). Mean patient age ranged from 28.2 to 42.2 years in the arthroscopy group and 28.1 to 42.2 years in the control group. Mean follow-up ranged from 2.0 to 12.5 years. OA incidence rates ranged from 10.8% to 28.0% in the arthroscopy group and from 7.1% to 48.0% in the control group. Two studies found a significantly lower rate of OA in the arthroscopy group ( P <.001 and P =.005), 1 study had less articular damage in the arthroscopy group at follow-up ( P <.001), and 1 study showed a greater proportion of patients who progressed to Tönnis grade 3 changes in the arthroscopy group at follow-up ( P <.001). THA conversion rates ranged from 0.9% to 7.0% in the arthroscopy group and from 0.0% to 10.5% in the control group. One study showed a significantly lower rate of conversion to THA in the arthroscopy group ( P =.035).

Conclusions

There is some evidence that patients with FAIS who undergo hip arthroscopy may have a lower rate of progression of OA and conversion to THA compared to similar patients initially treated nonoperatively.

Level of Evidence

Level III, systematic review of Level I-III studies.

Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain and dysfunction, particularly among young and active individuals. If left untreated, FAIS may contribute to progressive damage to the hip joint, ultimately leading to the development of hip osteoarthritis (OA) or the need for total hip arthroplasty (THA). Hip arthroscopy (HA) has emerged as a widely used surgical intervention for the treatment of FAIS, aimed at alleviating symptoms, improving function, and potentially modifying the disease’s progression.

HA has been shown to improve outcomes in patients with FAIS, with multiple studies showing significant improvement in patient-reported outcomes ^, as well as a high rate of return to play in athletes. ^, Nonoperative management, including physical therapy, pain management, activity modification, and intra-articular injections, has also been effective in the short term. A prospective study by Pennock et al. reported an 82% success rate in adolescents treated nonoperatively over a mean 2-year follow-up. However, long-term results in adolescent patients treated nonoperatively for FAIS are limited, and many of these adolescent patients will undergo surgery if they wish to remain active. A 2022 meta-analysis reported HA was superior to conservative treatment in both short- and long-term outcomes in adult patients. However, the impact of HA on hip OA progression and the need for THA in the future remains unclear. The purpose of this study was to perform a systematic review to directly compare hip arthroscopy and nonoperative treatment for FAIS with outcomes including the risk of developing hip OA or undergoing THA later in life. The authors hypothesized that patients with FAIS undergoing hip arthroscopy would have a lower risk of developing hip OA and a lower likelihood of undergoing THA in the future than patients with FAIS treated nonoperatively.

Methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers (D.P., J.D.) searched PubMed, Embase, and the Cochrane Library up to January 19, 2025. The electronic search strategy used was the following: hip AND arthroscopy AND “femoroacetabular impingement” AND (osteoarthritis OR arthroplasty) . A total of 1,239 studies were reviewed by title and/or abstract to determine study eligibility based on inclusion criteria. Furthermore, reference lists for studies that met inclusion criteria were reviewed to see if any further studies were identified that met inclusion criteria. In cases of disagreement, a third reviewer (M.J.K.) made the final decision. Inclusion criteria included any studies directly comparing HA and nonoperative treatment for FAIS with outcomes, including the risk of developing hip OA or undergoing THA in the future. Studies were only included with the presence of a control group, either patients’ contralateral hips or a comparison group of individuals with FAIS who did not undergo hip arthroscopy. Studies were excluded if they did not include a control group, had a follow-up duration of less than 2 years, or lacked clinical/radiologic outcomes between hips with FAIS undergoing hip arthroscopy versus nonoperative management. Data extraction from each study was performed independently and then reviewed by a third author (M.J.K.). There was no need for funding or a third party to obtain any of the collected data. Risk of bias for 3 randomized studies ^,^, was assessed according to the Cochrane Collaboration’s risk of bias tool, which incorporates an assessment of randomization, blinding, completeness of outcomes data, selection of outcomes reported, and other sources of bias.

Risk of bias for the 3 remaining nonrandomized studies ^,^, was assessed according to the Risk of Bias in Non-randomized Studies of Interventions risk of bias tool, which incorporates an assessment of bias due to confounding, selection of participants, deviations from intended interventions, completeness of outcomes data, selection of outcomes reported, and other sources of bias. Cohen’s κ score was calculated to determine the level of intraobserver agreement between reviewers. A score of <0.20 indicates poor agreement; 0.21-0.40, fair agreement; 0.41-0.60, moderate agreement; 0.61-0.80, good agreement; and 0.81-1.00, very good agreement.

Reporting Outcomes

The data regarding level of evidence, number of hips, control group type, patient demographics, follow-up period, and rates of progression to hip OA and/or conversion to THA for each study were extracted manually by the authors. Metrics for measuring the progression of OA varied across the studies. The metrics included Tönnis grades, ^,^, joint space width, and scoring hip osteoarthritis with magnetic resonance imaging (SHOMRI) scores.

Study Methodology Assessment

The Modified Coleman Methodology Score (MCMS) was used to evaluate study methodology quality. The MCMS has a scaled potential score ranging from 0 to 100. Scores ranging from 85 to 100 are excellent, 70 to 84 are good, 55 to 69 are fair, and less than 55 are poor. The primary outcomes assessed by the MCMS are study size and type, follow-up time, attrition rates, number of interventions per group, and proper description of study methodology.

Statistical Analysis

Continuous variables were reported as a range across studies. Incidence rates for hip OA progression and conversion to THA were calculated for each study. Fisher exact tests and Kaplan-Meier analyses were used to calculate P values within each study, and P <.05 was used to determine significance.

Results

Six studies ^,^,^,^,^, (1 Level I, 2 Level II, 3 Level III) met inclusion and exclusion criteria ( Fig 1 ). A total of 2,046 hips with FAIS were included in this systematic review ( Table 1 ), of which 622 underwent hip arthroscopy and 1,424 underwent nonsurgical treatment (control group). Two studies ^, used the contralateral hip as a control. Four studies ^,^,^, used patients with FAIS who were treated nonoperatively as a control. Mean follow-up duration ranged from 2.0 to 12.5 years. The authors reviewed the patient populations in each study to avoid including duplicate patient data and ensure the accuracy of the data set.

Image, AltText currently not available — Fig 1

Table 1

Studies Included

Study	LOE	Control Group	N	Patient Age, y	% Male	Follow-Up, y
Griffin et al., 2022	II	PHT	HA: 157 C: 162	NR	NR	3
Husen et al., 2023	III	Nonop	HA: 132 C: 982	HA: 28.2 ± 7.9 (12.5-41.0) C: 28.1 ± 9.0 (6.5-39.1)	HA: 35.6 C: 30.9	12.5 ± 4.7 (5.0-23.4)
Palmer et al., 2025	II	PT	HA: 112 C: 110	NR (18-60)	NR	3.2
Mansell et al., 2018	I	PT	HA: 65 C: 14	HA: 30.3 ± 7.2 (20-52) C: 29.4 ± 8.2 (23-48)	HA: 59.1 C: 57.1	2
Lamo-Espinosa et al., 2024	III	CL Hip	HA: 56 C: 56	42.2 ± 9.2 (NR)	NR	2.7
Ramkumar et al., 2024	III	CL Hip	HA: 100 C: 100	33.8 ± NR (17-53)	54	12

NOTE. N refers to the number of hips that were included in each treatment group. Patient age and follow-up period are reported as mean ± standard deviation (range) (if reported).

C, control treatment group; CL, contralateral; HA, hip arthroscopy treatment group; LOE, level of evidence; PHT, personalized hip therapy; PT, physical therapy; Nonop, nonoperative treatment; NR, not reported.

Progression of Osteoarthritis

Four studies ^,^,^, reported on the incidence of hip OA progression ( Table 2 ). The incidence rates of OA progression ranged from 10.8% to 28.0% in the HA group and from 7.1% to 48.0% in the control group. Two of the 4 studies ^, indicated a significantly lower rate of OA progression (based on Tönnis grade) in the HA group compared to the control group ( P <.001 and P =.005 ). One study calculated SHOMRI scores and demonstrated significantly better SHOMRI scores in favor of HA ( P <.001), with significantly less articular cartilage damage at 38 months postintervention compared to nonoperatively treated patients. One study showed that the HA group was associated with increased joint space width deterioration on radiographs, and an increased proportion of HA patients (12/56, 21.4%) progressed to Tönnis grade 3 changes compared to the control group (0/45, 0%) ( P <.001).

Table 2

Progression to Hip Osteoarthritis

Study	OA Progression Group HA	OA Progression Group C	P Value
Husen et al., 2023	35/132 (26.5%)	346/982 (35.2%)	<.001
Ramkumar et al., 2024	28/100 (28.0%)	48/100 (48.0%)	.005
Palmer et al., 2025	13/53 (24.5%)	21/48 (43.8%)	.058
Mansell et al., 2018	7/65 (10.8%)	1/14 (7.1%)	.999