Medical Policy
7.01.109 Surgical Treatment of Femoroacetabular Impingement
Original MPC Approval: 08/12/2009
Last Review: 09/19/2011
Last Revision: 09/19/2011
Description
Femoroacetabular impingement (FAI) is a structural abnormality in the hip joint that results in articulation abnormality of the femoral head and the acetabular rim. During flexion, altered mechanics result in compression of the labrum and / or articular cartilage in the acetabulum, with tearing and inflammation. Degenerative joint disease develops with inflammation, hip and groin pain, and decreased range of motion on flexion and internal rotation. Two different types of impingement, known as cam impingement, and pincer impingement, have been identified. In cam impingement, there is an asymmetric or nonspherical contour of the femoral head or neck that abuts against the acetabulum, resulting in cartilage damage and detachment from the subchondral bone. Pincer impingement is an overcoverage of the acetabulum that pinches and injures the labrum. The two types of impingement may occur singly or together. Impingement with damage to the labrum and / or acetabulum is felt to be a contributing factor to development of osteoarthritis of the hip, and that a significant percentage of patients with primary hip osteoarthritis may have been caused by FAI. The disease mainly appears to affect young to middle-aged adults, particularly those who engage in strenuous athletic activity.
Treatment of FAI is usually initiated with conservative therapies, including reduced activity and non-steroidal anti-inflammatory drugs. Physical therapy is usually not done because it aggravates the condition. Surgery is considered for patients that do not improve with conservative management.
The surgical technique for correcting the structural defects was first performed using an open technique that involved complete disarticulation of the hip joint. More recently, an arthroscopic technique is used wherein the femoral head is distracted from the joint to the point where the surgeon can inspect the articular surfaces thoroughly, and perform the necessary resection of overhanging acetabulum, trim torn labrum, and / or debride the cam area of the femoral head.
Policy
Open or arthroscopic surgery to treat femoroacetabular impingement is considered medically necessary. (See Provider Guidelines).
Policy Guidelines
Provider Guidelines
The following conditions are applicable to possible candidates for femoroacetabular impingement surgery:
- Adolescent patients should be skeletally mature with closed growth plates. Adult patients should be too young to be considered an appropriate candidate for total hip arthroplasty.
- The patient is unresponsive to conservative therapy for at least three months.
- There is no evidence of advanced osteoarthritis, defined as Tonnis grade II or III, or joint space less than 2 mm.
- There is no evidence of severe chondral damage (Outerbridge grade IV)
References
This policy statement relates only to the services or supplies described herein. Coverage will vary from contract to contract and by line of business and should be verified before applying the terms of the policy.