Outcome of Hip Impingement Surgery

Does Generalized Joint Hypermobility Matter?

Florian D. Naal,*yz MD, Aileen Müller,z MD, Viju D. Varghese,§ MD,
Vanessa Wellauer,k Franco M. Impellizzeri,k PhD, and Michael Leunig,z MD
Investigation performed at the Schulthess Clinic, Zurich, Switzerland

Background: Generalized joint hypermobility (JH) might negatively influence the results of surgical femoroacetabular impinge-
ment (FAI) treatment, as JH has been linked to musculoskeletal pain and injury incidence in athletes. JH may also be associated
with worse outcomes of FAI surgery in thin females.
Purpose: To (1) determine the results of FAI surgery at a minimum 2-year follow-up by means of patient-reported outcome mea-
sures (PROMs) and failure rates, (2) assess the prevalence of JH in FAI patients and its effect on outcomes, and (3) identify other
risk factors associated with treatment failure.
Study Design: Cohort study; Level of evidence, 3.
Methods: We included 232 consecutive patients (118 females; mean age, 36 years) with 244 hips surgically treated for symptom-
atic FAI between 2010 and 2012. All patients completed different PROMs preoperatively and at a mean follow-up of 3.7 years.
Satisfaction questions were used to define subjective failure (answering any of the 2 subjective questions with dissatisfied/very
dissatisfied and/or didn’t help/made things worse). Conversion to total hip replacement (THR) was defined as objective failure.
JH was assessed using the Beighton score.
Results: All PROM values significantly (P \ .001) improved from preoperative measurement to follow-up (Oxford Hip Score: 33.8 to
42.4; University of California at Los Angeles Activity Scale: 6.3 to 7.3; EuroQol25 Dimension Index: 0.58 to 0.80). Overall, 34% of
patients scored 4 on the Beighton score, and 18% scored 6, indicating generalized JH. Eleven hips (4.7%) objectively failed and
were converted to THR. Twenty-four patients (10.3%) were considered as subjective failures. No predictive risk factors were iden-
tified for subjective failure. Tönnis grade significantly (P \ .001) predicted objective failure (odds ratio, 13; 95% CI, 4-45). There was
a weak inverse association (r = 20.16 to 20.30) between Beighton scores and preoperative PROM values. There were no significant
associations between Beighton scores and postoperative PROM values or subjective failure rates, but patients who objectively
failed had lower Beighton scores than did nonfailures (1.6 vs 2.6; P = .049).
Conclusion: FAI surgery yielded favorable outcomes at short- to midterm follow-up. JH as assessed by the Beighton score was
not consistently associated with subjective and objective results. Joint degeneration was the most important risk factor for con-
version to THR. Although statistical significance was not reached, female patients with no joint degeneration, only mild FAI defor-
mity, and higher Oxford scores at the time of surgery seemed to be at increased risk for subjective dissatisfaction.
Keywords: femoroacetabular impingement; FAI; hypermobility; hip impingement surgery; risk factors; outcome

Today, surgical treatment of femoroacetabular impingement
(FAI) has matured to a routine intervention. Outcomes at
*Address correspondence to Florian D. Naal, MD, Department of
Orthopaedic Surgery, Schulthess Clinic, Lengghalde 2, 8008 Zurich,
Switzerland (email: florian.naal@gmail.com).
y
Technical University of Munich, Munich, Germany.
z
Department of Orthopaedic Surgery, Schulthess Clinic, Zurich,
Switzerland.
§
Department of Orthopaedic Surgery, Christian Medical Center,
Vellore, India.
k
Department of Research and Development, Schulthess Clinic,
Zurich, Switzerland.
One or more of the authors has declared the following potential con-
flict of interest or source of funding: AFOR Stiftung supported this study.
The American Journal of Sports Medicine, Vol. 45, No. 6
DOI: 10.1177/0363546516688636
Ó 2017 The Author(s)
short- to midterm follow-up are favorable, and success rates
are reported to be around 80% using either hip arthroscopy
or open procedures.7,13-15,20 Several risk factors for failure
(ie, total hip replacement [THR]) or subjective dissatisfaction
have been identified. While older age and increased joint
degeneration at the time of surgery seem to be the most
important negative predictors, the effects of other factors,
such as higher body mass index (BMI) or sex, are less
clear.5,13,20,21
Generalized joint hypermobility (JH) might be another
factor that could negatively influence the results of surgi-
cal FAI treatment. JH has been recognized as a risk factor
for musculoskeletal pain and injury incidence in ath-
letes.1,8,16,19,22,23 Also, it was thought that FAI surgery in
thin and hypermobile females could be associated with
worse outcomes.13 The reason for this could be that, in
JH, even normal or almost-normal joints impinge at

1309
1310 Naal et al
TABLE 1
Preoperative Patient Demographicsa
Type of Surgery Mean Age, y Mean BMI, kg/m2
Surgical hip dislocation (n = 35) 30.3 23.9
Mini-open surgery (n = 67) 38.9 24.5
Hip arthroscopy (n = 130) 35.6 23.7
a
BMI, body mass index.
a certain point, and FAI correction makes these joints even
more mobile.11,13,24 Recently, the prevalence of JH in FAI
patients has been reported to be high; more than 30% of
the individuals scored 4 on the Beighton score, the
instrument most frequently used to determine JH.3,11 Nev-
ertheless, the association between JH and outcomes of FAI
surgery is not widely known.
Considering the aforementioned, this study aimed to (1)
determine the results of FAI surgery at a minimum 2-year
follow-up by means of patient-reported outcome measures
(PROMs) and failure rates, (2) assess the prevalence of
JH in FAI patients and its effect on outcomes, and (3) iden-
tify other risk factors associated with treatment failure.
METHODS
Between 2010 and 2012, a total of 283 patients (298 hips)
were surgically treated for symptomatic FAI by 2 senior
surgeons at our institution. This retrospective cohort study
included 232 of those consecutive patients (244 hips) with
complete follow-up data. The demographics of the nonre-
sponders did not differ from those of the study cohort.
There were 118 women (51%) and 114 men (49%). The
mean age (6SD) was 35.8 6 11.4 years, and the mean
body mass index (BMI) was 24.0 6 3.6 kg/m2. Thirty-five
patients underwent surgical hip dislocation (SHD), 67
underwent mini-open surgery using an anterolateral
approach, and 130 underwent hip arthroscopy. Indication
for either type of surgery was dependent on the surgeon’s
preference (one surgeon performed only mini-open sur-
gery) and on the severity of deformity (SHD in cases with
more severe FAI deformity). Patients in the SHD group
were younger, and more male patients underwent open
surgery (Table 1). Beighton scores and BMI did not differ
(P . .05) between the 3 groups. Center-edge (CE) and
alpha angles were significantly (P \ .01) lower in the hip
arthroscopy group. Twenty-three of the hips had at least
1 previous surgery (hip arthroscopy in 9, pelvic osteotomy
for dysplasia in 8, femoral osteotomy in 3, and SHD in 1).
The diagnosis of FAI was based on standardized parame-
ters that have been described in detail previously.13 Briefly,
a cam component was defined by an alpha angle .50° and
a pincer component by global (coxa profunda or protrusio)
or focal (crossing sign) acetabular (AC) overcoverage. Accord-
ingly, 59% had mixed-type FAI, 20% had pincer-type
FAI, and 21% had cam-type FAI. All patients underwent
The American Journal of Sports Medicine
Female Mean Center-Edge Mean Alpha
Patients, % Angle, deg Angle, deg
31.4 34.3 60.5
37.3 33.1 60.1
63.1 30.3 56.0
standardized radiographic examinations, including antero-
posterior pelvis and cross-table lateral hip radiographs and
MRIs with intra-articular gadolinium contrast. The following
parameters were determined: Tönnis grade, lateral CE angle,
AC roof angle, extrusion index, presence of AC overcoverage,
and the alpha angle.
All patients completed the Oxford Hip Score (OHS),6
EuroQol–5 Dimension (EQ-5D),4 and University of Califor-
nia at Los Angeles (UCLA) Activity Scale12 preoperatively
and at follow-up. At follow-up, the patients also completed
the self-reported version of the Beighton score,3,11 a ques-
tion inquiring about subjective satisfaction (‘‘How satisfied
are you with the result of surgery?’’: very satisfied, satis-
fied, neither satisfied nor dissatisfied, dissatisfied, very
dissatisfied), and a question inquiring about the global
treatment outcome (‘‘the hip operation’’: helped a lot,
helped, helped only little, didn’t help, made things worse).
Reoperations and conversions to THR were noted prospec-
tively. Conversion to THR was defined as objective failure.
Subjective failure was defined by answering any of the 2
subjective questions with dissatisfied/very dissatisfied
and/or didn’t help/made things worse. The local ethical
committee approved the study, and all patients provided
written informed consent.
Statistical Analysis
To determine the results of FAI surgery at a minimum 2-
year follow-up, pre- and postoperative values were com-
pared using the paired t test. Failure rates were reported
as percentages. To assess the prevalence of JH in FAI
patients and its effect on outcomes, data were presented
as percentage of patients scoring in each category of the
response options and correlations (Pearson moment product
coefficient) between Beighton scores and PROMs, radio-
graphic parameters, and failure rates. To identify other
risk factors associated with treatment failure, all the
parameters differing between failure and nonfailure were
analyzed using logistic regression with forward conditional
selection. Odds ratios were calculated with 95% CIs. The
magnitude of difference was expressed using the effect
size calculated as Cohen d (difference/baseline SD) and
interpreted using the following benchmarks: 0.2 to 0.5,
small; 0.5 to 0.8, medium; .0.8, large. Analyses were per-
formed with the use of SPSS version 17 (IBM Corp). Unless
otherwise stated, all values are expressed as mean 6 SD.
AJSM Vol. 45, No. 6, 2017 Joint Hypermobility and FAI Surgery 1311

TABLE 2
Changes in PROMs and Radiographic Parameters From Preoperative Measurement to Follow-upa

Parameter Preoperative Follow-up Cohen d P Value

OHS (0-48) 33.8 6 7.7 42.4 6 6.6 1.1 \.001

UCLA (0-10) 6.3 6 2.3 7.3 6 1.8 0.4 \.001
EQ-5D Index (–0.59 to 1) 0.58 6 0.24 0.80 6 0.22 0.9 \.001
EQ-5D VAS (0-100) 66.4 6 18.4 76.7 6 17.7 0.6 \.001
Center-edge angle, deg 31.6 6 7.1 30.1 6 5.6 0.2 \.001
Acetabular roof angle, deg 3.0 6 5.7 3.7 6 4.8 0.1 \.001
Extrusion index 16.8 6 7.3 18.3 6 6.0 0.2 \.001
Alpha angle, deg 57.7 6 9.8 42.7 6 5.4 1.5 \.001
Tönnis grade, %
0 86.7 81.5 — .133
1 8.9 13.2 — .134
2 4.5 5.3 — .677

a
Data are reported as mean 6 SD unless otherwise indicated. EQ-5D, EuroQol–5 Dimensions; OHS, Oxford Hip Score; PROMs, patient-
reported outcome measures; UCLA, University of California at Los Angeles Activity Scale; VAS, visual analog scale.

RESULTS
Mean follow-up was 3.7 years (range, 2-5 years). Nine
major revisions (3.6%) were performed at a mean of 14
months (range, 3-29 months) after index surgery (7 after
hip arthroscopy, 1 after SHD, and 1 after mini-open sur-
gery), all for residual FAI or intra-articular adhesions.
One minor revision (secondary tractus closure due to
dehiscence) was necessary after SHD. Overall, 11 hips
(4.7%) objectively failed and were converted to THR at
a mean of 24 months (range, 7-45 months) after index sur-
gery (6 had arthroscopy, 5 had mini-open surgery). Seven
of the converted hips had Tönnis grades 2 or 3 before
FAI surgery, 3 hips had Tönnis grade 1, and 1 hip had
Tönnis grade 0.
PROM values significantly improved from preoperative
measurement to follow-up (Table 2). CE, AC roof, and
Figure 1. Distribution of Beighton scores (range, 0-9) in fem-
alpha angles significantly decreased (Table 2). Effect sizes
oroacetabular impingement patients. Scores 4 are usually
were small for CE angle, AC roof angle, extrusion index,
considered as cutoff defining generalized joint hypermobility.
and UCLA Activity Scale. The effect size of the remaining
parameters and PROMs ranged from medium to large.
Overall, 34.3% of the patients scored 4 on the Beighton SHD. Patients with subjective failure did not differ from
score, and 18.0% scored 6, indicating generalized JH nonfailures in BMI, age, Beighton scores, and most radio-
(Figure 1). The mean Beighton score was 2.5 6 2.7. graphic parameters. Patients with subjective failure had
Patients with previous hip surgery did not differ in significantly (P = .038) higher OHS values before surgery
Beighton scores from those patients without. Female (36.4 vs 32.7) and lower (P = .006) mean Tönnis grades
patients had significantly (P = .009) higher Beighton scores (0.04 vs 0.21). While there were more female than male
than did male patients (3.0 vs 1.9). There was a weak patients (58.3% vs 41.7%) in the subjective failure group,
inverse association (P \ .05) between Beighton scores this difference did not reach statistical significance (P .
and preoperative PROM values (r = 20.16 to 20.30). There .2) in relation to the entire cohort. All PROM values at
were no significant associations between Beighton scores follow-up and change scores were significantly lower in
and postoperative PROM values and subjective failure the subjective failure group (OHS: 35.4 vs 42.4; UCLA:
rates. Subgroup analyses according to the surgical 6.5 vs 7.3; EQ-5D Index: 0.65 vs 0.80; EQ-5D visual analog
approach used showed similar results. Patients who objec- scale: 62.0 vs 76.7; P \ .01 for all).
tively failed (ie, conversion to THR) had significantly lower Group comparisons demonstrated that patients who
Beighton scores than did the nonfailures (1.6 vs 2.6; P = objectively failed were significantly older, had significantly
.049). lower preoperative OHS values, significantly higher Tön-
Overall, 24 patients (10.3%) subjectively failed. Of nis grades, lower Beighton scores, and higher BMI (Table
these, 15 (62.5%) underwent hip arthroscopy as index sur- 3). Effect sizes were medium to large. Radiographically,
gery, 5 (20.8%) had mini-open surgery, and 4 (16.7%) had failures had higher CE angles and lower extrusion indices
1312 Naal et al The American Journal of Sports Medicine

TABLE 3
Differences Between Objective Failures and Nonfailuresa

Parameter Failure Nonfailure Cohen d P Value

Preoperative OHS (0-48) 28.2 6 7.3 33.4 6 8.1 0.7 .039

Beighton score (0-9) 1.6 6 1.4 2.6 6 2.7 0.7 .049
Age, y 43.0 6 8.5 35.4 6 11.4 0.9 .030
BMI, kg/m2 26.1 6 4.5 23.9 6 3.5 0.5 .060
Preoperative center-edge angle, deg 36.5 6 6.1 31.5 6 7.1 0.8 .037
Preoperative extrusion index 7.1 6 8.9 17.2 6 7.1 1.1 \.001
Preoperative Tönnis grade 0, % 9.1 90.7 \.001

a
Failure was defined as conversion to total hip replacement. BMI, body mass index; OHS, Oxford Hip Score.

TABLE 4
Predictive Risk Factors for Objective and Subjective Failure According to Logistic Regression Analysisa

Objective Failures Subjective Failures

Variable P Value Odds Ratio (95% CI) P Value Odds Ratio (95% CI)

Age .224 1.1 (0.9-1.2) .529 1.0 (0.9-1.0)

BMI .105 1.2 (1.0-1.4) .502 0.9 (0.8-1.1)
Sex .678 1.4 (0.3-7.3) .749 0.8 (0.3-2.6)
Beighton score .802 1.0 (0.7-1.3) .778 1.0 (0.8-1.2)
Tönnis grade \.001 13.3 (3.9-45.2) .274 0.3 (0.0-2.5)
Preoperative outcome scores
OHS .322 0.9 (0.8-1.1) .165 1.1 (1.0-1.2)
UCLA .122 0.7 (0.5-1.1) .951 1.0 (0.7-1.3)
EQ-5D Index .397 0.1 (0.0-12.6) .676 0.5 (0.0-13.9)
EQ5-D VAS .171 1.0 (1.0-1.1) .478 1.0 (1.0-1.1)

a
BMI, body mass index; EQ-5D, EuroQol–5 Dimensions; OHS, Oxford Hip Score; UCLA, University of California at Los Angeles Activity
Scale; VAS, visual analog scale.

before surgery (Table 3). There were no significant differ-
ences in AC roof angles. Logistic regression analysis did
not identify any predictive variable for subjective failure.
Tönnis grade significantly (P \ .001) predicted objective
failure (Table 4).
DISCUSSION
Generalized JH has been linked to musculoskeletal pain
and a higher injury incidence in an active popula-
tion.1,8,16,19,22,23 Besides other known risk factors, JH might
be associated with worse results after surgical FAI treat-
ment.11,13,24 Therefore, assessing the possible association
between JH and the results of FAI surgery is important.
Before interpreting the present results, several limita-
tions have to be considered. First, the study sample is
not uniform since patients undergoing 3 different surgical
approaches to treat FAI were included. The indication for
a specific approach was dependent on the preference of
one surgeon and on the severity of the deformity, leading
to selection bias that is reflected in the demographics of
the different groups. While meaningful comparisons
between approaches are therefore not possible, this cohort
nevertheless reflects the clinical reality. Furthermore,
subgroup analyses showed similar results related to JH,
that is, only weak or no associations between the Beighton
score and PROM values. Second, Beighton scores were not
assessed before surgery but at follow-up; however, it is
unlikely that generalized joint mobility changes over the
course of a few years. Third, logistic regression analysis
identified some potential risk factors for subjective and
objective failure that showed wide ranges of overlapping
CIs. Therefore, these factors did not reach statistical sig-
nificance. This is a result of the relatively small number
of failures; studies with larger numbers of patients and
failures are required to identify other possible risk factors
for poor results.
In general, surgical FAI treatment yielded favorable
outcomes. All PROM values significantly increased, and
the scores at follow-up compare well to values reported in
the literature.7,13-15,20,21 The conversion rate to THR
(defined as objective failure in this series) is 4.5% at 3.7
years, similar to the results of previous reports.13,15,20,21
Nevertheless, contrary to what we expected, we could not
find conclusive associations between the outcomes and
JH. In line with previous studies, the prevalence of JH
was high in the present cohort.2,11 Depending on the
Beighton cutoff score used, 34% (4) or 18% (6) of the
individuals were diagnosed with JH. While hypermobile
hip joints might have the risk of persistent impingement
AJSM Vol. 45, No. 6, 2017
after FAI correction, Beighton scores did not correlate with
PROM values or radiographic parameters. Moreover,
higher Beighton scores seemed to be protective in terms
of objective failure (significantly lower Beighton scores in
the THR conversion group). These observations could be
explained in 2 ways: Either generalized JH does indeed
not substantially affect the outcomes of FAI surgery, or
the Beighton score is not a suitable instrument to assess
hip joint hypermobility. While these explanations are
rather speculative, further research seems warranted to
investigate whether higher Beighton scores indeed indi-
cate hypermobility of the hip joint itself. A significant asso-
ciation between Beighton scores and hip range of motion
(flexion and rotation in flexion) was previously found in
a small series.11
For objective failures (ie, conversion to THR), we could
identify 1 well-known predictive risk factor and some other
factors that significantly differed from patients without con-
version. The most important negative predictor was the
Tönnis grade. Patients with Tönnis grade 1 or higher at
the time of FAI surgery had a 13-fold increased risk for con-
version to THR compared with patients with Tönnis grade
0. Patient age of 40 years or older has been frequently con-
sidered as a significant negative predictor.15,20,21 Our
results confirm these observations; patients requiring
THR were significantly older than were those without con-
version (43 vs 35 years). The effect of overweight is some-
what controversial in the literature. In a large series of
FAI patients treated with SHD, lower BMI values were
associated with THR conversion and revision surgery.13
Peters et al17 did not find an increased risk of poorer out-
comes based on BMI but identified age as a risk factor. Step-
pacher et al20 showed that being overweight was a risk
factor for failure after SHD. Gupta et al5 also reported
a 2-fold increased THR and revision rate in obese FAI
patients when compared with normal-weight counterparts,
but probably due to the small sample size, these differences
did not reach statistical significance. Our data suggest that
overweight might be another risk factor for objective failure
but not for subjective failure. Therefore, in summary,
patients older than 40 years presenting with early joint
degeneration (ie, Tönnis grade .0) and higher BMI should
be considered as high-risk candidates for early objective fail-
ure after FAI surgery, irrespective of the surgical approach
used. This conclusion also explains the observation that
none of the THR conversions were performed after SHD.
SHD was mainly performed in younger men with more
severe FAI deformity but less joint degeneration. In an older
patient with early degeneration, one would be more
reserved with the indication for SHD. In such cases, hip
arthroscopy or mini-open approaches might be considered
as ‘‘palliative’’ treatment options; however, ‘‘stretching’’
indications can yield a high risk of early failure.
While the risk factors for THR conversion are relatively
uniform in the literature, it is difficult to understand why
surgery yields subjectively unsatisfactory outcomes in a rel-
evant proportion of patients, despite favorable radio-
graphic results and the absence of the above-mentioned
risk factors. Finding reasons for this can be difficult, and
identifying other predictive risk factors is mandatory.
Joint Hypermobility and FAI Surgery 1313
The present results suggest a vague picture of such kind
of patients being relatively young and female, having no
joint degeneration and less deformity, and having a quite
well-functioning hip joint at the time of surgery. It might
be a combination of higher expectations in such patients,
and it may also be a false or borderline diagnosis of FAI
yielding a lack of improvement after surgical treatment.
The interdependence of fulfilled expectations and patient
satisfaction after FAI surgery has been highlighted.9 It is
important to focus future work on patient selection pro-
cesses and a clear exclusion of sources of groin pain other
than FAI (such as muscle imbalance, sportsman’s groin,
inguinal hernia, etc), particularly in cases with only mild
deformity.10,18
Overall, FAI surgery yielded favorable outcomes in terms
of PROM values and failure rates at short- to midterm follow-
up. Generalized JH as assessed by the Beighton score had no
conclusive associations with subjective and objective results.
This might be related to the fact that JH is not linked to the
outcome of FAI surgery or that the Beighton score is not
a suitable tool to determine hypermobility of the hip joint
itself. In line with previous investigations, joint degeneration,
older patient age, and overweight were associated with THR
conversion. Future research is warranted to identify reasons
for subjective dissatisfaction. Female patients with no joint
degeneration, only mild FAI deformity, and quite well-
functioning hip joints at the time of surgery seem to be at
increased risk.
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