BlueCross BlueShield of Tennessee Medical Policy Manual

Surgical Treatment of Femoroacetabular Impingement

DESCRIPTION

Femoroacetabular impingement (FAI) results from localized compression in the joint due to an anatomical mis-match between the head of the femur and the acetabulum. This decreased clearance between the femoral neck and the hip socket results in development of bone spurs, cartilage breakdown, pain, and decreased joint mobility. Symptoms of impingement typically occur in young to middle-aged active adults prior to the onset of advanced osteoarthritis but may be present in younger patients with developmental hip disorders. The objective of surgical treatment of FAI is to improve symptoms and reduce future damage to the joint.

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

TÖNNIS Classification of Osteoarthritis by Radiographic Changes

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 head deformity

 

There is a lack of evidence to evaluate the effect of surgical treatment in other conditions to improve acute and chronic pain or health outcomes.

SOURCES

BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2017). Surgical treatment of femoroacetabular impingement. (7.01.118). Retrieved October 17, 2017 from BlueWeb. (46 articles and/or guidelines reviewed)

Degen, R. M., Fields, K. G., Wentzel, C. S., Bartscherer, B., Ranawat, A. S., Coleman, S. H., et al. (2016). Return-to-play rates following arthroscopic treatment of femoroacetabular impingement in competitive baseball players. The Physician and Sportsmedicine, 44 (4), 385-390. Abstract retrieved December 1, 2016 from PubMed database.

Harris, J., Erickson, B., Bush-Joseph, C., & Nho, S. (2013). Treatment of femoroacetabular impingement: a systematic review. Current Reviews in Musculoskeletal Medicine, (2013), 6, 207-218. (Level 2 evidence)

Khan, M., Habib, A., de Sa, D., Larson, C. M., Kelly, B. T., Bhandari, M., et al. (2016). Arthroscopy up to date: Hip femoroacetabular impingement. Arthroscopy, 32 (1), 177-189. Abstract retrieved February 4, 2016 from PubMed database.

Kuhns, B. D., Frank, R. M., & Pulido, L. (2015). Open and arthroscopic surgical treatment of femoroacetabular impingement. Frontiers in Surgery, 2 (63), 1-16. (Level 5 evidence - Independent study)

National Institute for Health and Clinical Excellence. (2011, September). Open femoro-acetabular surgery for hip impingement syndrome. Retrieved October 3, 2011 from http://www.nice.org.

National Institute for Health and Clinical Excellence. (2011, September). Arthroscopic femoro-acetabular surgery for hip impingement syndrome. Retrieved October 3, 2011 from http://www.nice.org.

Nwachukwu, B., Rebolledo, B., McCormick, F., Rosas, S., Harris, J., & Kelly, B. (2016). Arthroscopic versus open treatment of femoroacetabular impingement: a systematic review of medium-to long-term outcomes. American Journal of Sports Medicine, 44 (4), 1062-1068. Abstract retrieved October 18, 2017 from PubMed database.

Sansone, M., Ahlden, M., Jonasson, P., Thomee, C., Sward, L., Ohlin, A., et al. (2016). Outcome after hip arthroscopy for femoroacetabular impingement in 289 patients with minimum 2-year follow-up. Scandinavian Journal of Medicine & Science in Sports, 2016 Jan 21. Doi: 10.111/sms.12641. [Epub ahead of print]. Abstract retrieved February 4, 2016 from PubMed database.

Winifred S. Hayes, Inc. Medical Technology Directory. (2017). Arthroscopic hip surgery for femoroacetabular impingement. Retrieved October 18, 2017 from www.Hayesinc.com/subscribers (60 articles and/or guidelines reviewed)

Zhang, D., Chen, L., & Wang, G. (2016). Hip arthroscopy versus open surgical dislocation for femoroacetabular impingement. Medicine, 95 (41), e5122. (Level 2 evidence)

ORIGINAL EFFECTIVE DATE:  2/12/2012

MOST RECENT REVIEW DATE:  11/9/2017

ID_BA

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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