Cam-Type Femoroacetabular Impingement

This is a case of **rapid progression to osteoarthritis following hip arthroscopy** - likely representing **patient selection error** rather than technical failure. The critical issue is that this patient had **pre-existing Tonnis grade 1 OA** and has now progressed to **Tonnis grade 2 OA** within 18 months, suggesting **advanced chondral damage was present at the time of initial surgery**. Tonnis grade 2 OA is a **contraindication to revision hip arthroscopy**. The patient needs counseling about **conservative management to delay THA** given his young age (28 years), as THA in patients less than 55 has a **15-20% revision rate at 15 years** (AOANJRR data). **Assessment of 'Failed' Arthroscopy:** **Patient selection error:** Pre-operative Tonnis grade 1 OA is a **relative contraindication** to hip arthroscopy - should have prompted detailed counseling about risk of progression. The pre-operative MRI (if performed) likely showed Outerbridge grade III-IV changes that predicted poor outcome. **Poor prognostic factors** in this case: (1) Tonnis grade 1 pre-operatively, (2) Rapid progression to grade 2 (suggests advanced cartilage damage), (3) Young age with early OA (mechanical factors, ? genetics). **Technical factors to assess**: Was adequate femoral osteochondroplasty performed (post-op alpha angle should be less than 50°)? Was labral repair performed vs debridement? Any iatrogenic cartilage damage during surgery? **Current Status - Tonnis Grade 2 OA:** **Tonnis grading system**: Grade 0 (normal), Grade 1 (sclerosis, slight narrowing, marginal osteophytes), Grade 2 (small cysts, moderate narrowing, moderate sclerosis), Grade 3 (large cysts, severe narrowing, deformity). This patient has **Grade 2** with joint space 2mm (normal 4-6mm), subchondral sclerosis, early cysts. **MRI Outerbridge IV** (exposed bone) in anterosuperior acetabulum confirms advanced cartilage loss. **Revision arthroscopy is contraindicated** - Tonnis ≥2 and Outerbridge IV predict failure of further joint preservation surgery. **Management - Conservative to Delay THA:** Given age 28 years, goal is to **delay THA as long as possible** to reduce lifetime revision burden. **Conservative measures**: (1) **Activity modification** - avoid high-impact activities (running, jumping), low-impact exercise encouraged (cycling, swimming, walking), weight management critical, (2) **Physiotherapy** - hip ROM exercises, core strengthening, gait training to reduce antalgic pattern, (3) **Pharmacological** - regular paracetamol, NSAIDs (celecoxib 200mg daily, PPI cover), tramadol for breakthrough pain, (4) **Intra-articular corticosteroid injection** - may provide 3-6 months symptom relief (triamcinolone 40mg or methylprednisolone 40mg), temporary measure, repeat 6-monthly maximum, (5) **Walking aids** - single point stick reduces hip joint load by 20-30%. **Counseling About THA:** **Timing**: THA indicated when conservative measures fail and pain affects quality of life/function. **No absolute age cutoff**, but younger age increases lifetime revision risk. **THA outcomes in young patients**: 90-95% survivorship at 10 years, but **15-20% revision rate at 15 years in patients less than 55** (AOANJRR data). **Revision burden**: If THA performed at age 30, likely requires 2-3 revisions over lifetime (revisions at 50, 65, 80). **Each revision more complex** with bone loss, worse outcomes. **Goal**: Delay THA by even 5-10 years significantly reduces lifetime revision burden. **Patient Communication:** Address devastation about 'failed' surgery with empathy: (1) Explain this likely **patient selection issue** not technical failure - advanced cartilage damage pre-existed surgery, (2) Hip arthroscopy has **limitations** - does not regenerate cartilage, only addresses mechanical impingement, (3) Rapid progression suggests **aggressive disease biology**, (4) At 28 years, delaying THA critical to reduce lifetime surgeries, (5) Many patients manage symptoms conservatively for years before THA needed. Discuss **realistic timeline**: Try conservative measures 12-24 months, if pain disabling despite maximal conservative treatment, consider THA.