Femoro-acetabular impingement (FAI): Is there still a place for open surgery?

Background: Femoroacetabular impingement (FAI) is a dynamic hip dysfunction caused by morphological alterations of the acetabulum, femoral head-neck junction, or femoral torsion. If left untreated, the resulting labral and chondral damage may progress to premature coxarthrosis in young, active populations.

Objective: This review evaluates the diagnostic imaging requirements for FAI and defines the specific clinical indications for arthroscopic versus open surgical interventions, including pelvic and femoral osteotomies.

Key Points: Diagnosis requires standardized pelvic radiographs and arthro-MRI to quantify acetabular coverage (Lateral Center Edge angle >33°), alpha angles, and torsional deformities. While conservative management is the initial approach, surgical intervention is indicated upon failure. Hip arthroscopy is effective for labral repair and focal osteochondroplasty but has limitations in addressing global acetabular retroversion or significant torsional abnormalities. Open surgical dislocation provides circumferential joint access for complex cam morphologies and focal retroversion (<30%). For global acetabular retroversion (>30%), periacetabular osteotomy (PAO) demonstrates superior long-term joint survivorship compared to rim trimming. Femoral derotation osteotomy is specifically indicated for impingement secondary to femoral retroversion (<0°) or excessive anteversion (>35°).

Conclusion: Surgical management of FAI must be tailored to the specific morphological deformity. While arthroscopy is a primary minimally invasive option, open surgical dislocation, PAO, and femoral osteotomy remain essential for correcting global version abnormalities and complex femoral deformities to optimize clinical outcomes and joint preservation.