BRAZILIAN ORTHOPEDISTS' OPINIONS AND PERCEPTIONS ON FEMOROACETABULAR IMPINGEMENT

ABSTRACT Objective: To assess the opinion of Brazilian orthopedists surgeons on the diagnosis and treatment of femoroacetabular impingement (FAI). Methods: A questionnaire was sent to several orthopedic societies around the world, including the Sociedade Brasileira de Ortopedia e Traumatologia (SBOT). This questionnaire was sent electronically and included questions on many topics related to FAI. Results: 253 Brazilian orthopedists responded the questionnaire. Sixty-eight point nine percent worked in private practice and 23.1% in academic institutions. Pain during hip rotation was the most important finding in the clinical history according to 81.8% of the respondents and the anterior impingement sign was the most important finding in the physical examination according to 88.2%. Initial treatment was physiotherapy according to 86.2%. Surgical treatment was hip arthroscopy according to 38.8%, and via surgical hip dislocation for 14.7%. Conclusion: Brazilian orthopedists' opinions on FAI are similar to their international colleagues. There is considerable discrepancy in the answers provided, demonstrating a need for future investigation on FAI, in order to institute proper treatment and diagnosis protocols. Level of Evidence V. Expert Opinion.


INTRODUCTION
Femoroacetabular impingement (FAI) is recognized as a cause of hip pain and as a predisposing factor for early-onset osteoarthritis in young patients. 1,2 This disease is characterized by abnormal conflict between the femoral head and the acetabulum due to abnormal anatomy of the femoral head-neck junction (cam type), which is aspherical, and/or acetabular overcoverage (pincer type), resulting in injury to the labrum and articular cartilage. 3,4 Treatment is initially conservative, and in cases of failure surgery is indicated. 5 Surgical correction can be performed via an open or arthroscopic approach. However, there are few studies with adequate documentation on clinical and radiographic indications for the surgical correction of impingement, both via arthroscopy and via open surgery. Moreover, there is insufficient data to determine the natural history of femoroacetabular impingement. 6 Given the shortage of scientific data on FAI incidence, epidemiology, prevalence and treatment methods, it is essential to understand the perceptions of orthopedic surgeons to serve as a guideline for future research and to better understand the treatment indications. This study aimed at comparing the opinion of Brazilian orthopedists with orthopedists around the world on the diagnosis, treatment and scientific evidence of FAI by means of a questionnaire.

MATERIAL AND METHODS
This study was approved by the local scientific committee (identification 13-404). A group formed by a statistician and orthopedic surgeons was responsible for determining key areas of interest to be reached. This group was called IN-FOCUS (InterNational Femoroacetabuar Impingement Optimal Care Update Survey). 7 Prior orthopedic questionnaires were reviewed to ensure that all the items were appropriate and understood. 8 The questions were adapted to examine the respondent's level of understanding in relation to diagnosis, surgical indication (arthroscopic or open), and the scientific data from the literature on femoroacetabular impingement. The survey involved a 'redundancy sample' in which several new surgeons were interviewed until no new item was required in the questionnaire. 9 The survey was pretested to guarantee its validity with an independent group of four orthopedic surgeons specialized in treating hip disorders in young adults and to ensure that the questionnaire was tenable in the search for perceptions related to FAI. Sections related to epidemiology, treatment options, diagnosis and quality of available scientific evidence were refined through the surgeons' feedback, seeking an improvement in content, ease of comprehension and understanding of the survey.
Invitations were sent by email to the members of several international orthopedic societies, including the Sociedade Brasileira de Ortopedia e Traumatologia [Brazilian Society of Orthopedics and Traumatology (SBOT)]. The survey was conducted through the SurveyMonkey website. The invitations were resent twice two weeks apart in order to increase the response rate. Restrictions were applied to ensure that each partner would answer the questionnaire only once.

Statistical analysis
All the answers were organized and analyzed on the actual Sur-veyMonkey website. Categorical data were presented as percentages. Since some questions had multiple correct answers, not all questions add up to 100%. In addition, the respondents could skip questions without answering them.

Demographic results
Two hundred fifty-three members of the SBOT answered the questionnaire, representing 28.1% of international responses. In the international study, most of the orthopedists who answered the questionnaire were from Europe (40.7%), followed by South America (29.3%) and North America (14.0%). Most of the Brazilian respondents work in private practice (68.9%) and in academic institutions (23.1%). Table 1 shows the answers of the orthopedists from around the world compared to the Brazilian answers.

Clinical evaluation
The most important finding in the clinical history of a patient with FAI is pain during hip rotation according to 81.8% of respondents, followed by groin pain (50.7%). The most important finding in the physical examination is the anterior impingement sign (pain upon internal rotation-adduction-flexion) according to 88.2% of physicians, followed by the C sign (33.5%). In the respondents' opinion radiographic confirmation of the diagnosis is achieved through magnetic resonance imaging (75.9%), radiography alone (35.0%), computed tomography (26.6%) and intra-articular injection of anesthetic (9.85%). In the diagnosis of cam type FAI, the most important radiographic measurement was considered: the head-neck offset (40.9%) and the alpha angle (37.4%). In the diagnosis of pincer type FAI, the most important radiographic measurement was considered: crossover sign (43.84%), center-edge angle (30.0%) and acetabular inclination (26.6%); 21.2% of respondents were uncertain about the answer.

DISCUSSION
In the present study we evaluated Brazilian orthopedists' opinions of FAI, and compared them with colleagues around the world. The Brazilian answers were very similar to international answers, demonstrating that Brazil is at the forefront of hip preservation surgery. In analyzing the academic background of the questionnaire respondents we can see that hip pain treatment is performed mainly by orthopedists specialized in arthroplasty, sports medicine and trauma. We also found that only 26. is considered an essential finding in the patient's clinical history and the anterior impingement sign essential in the physical examination. As regards diagnostic imaging, 75.9% consider MRI essential. A difference found between Brazilians and foreigners is the use of intra-articular infiltration as a diagnostic method. . New questionnaires could assess the cause of this discrepancy. We believe that the decision on which technique to use is not only related to the surgeon's option, but also to the availability of materials at each facility. The evaluation of the surgeons' opinion on scientific evidence related to FAI shows that many aspects related to the treatment of this condition still require further scientific research. In analyzing the international data of the IN-FOCUS study, we believe that knowledge of FAI is at a "turning point". 7 According to McCulloch et al., 12 the evolution of surgical techniques follows a pre-established innovation cycle model. Under this concept, new surgical techniques are developed by pioneers, usually trendsetters who develop the basic concepts of the technique. Over time, indications expand, there is a refinement of the technique and clinical studies begin. At this moment, there is a rapid turnaround with an increase in the number of surgeons using the technique. We believe that FAI is at this "turning point". Our study has some limitations. Questionnaires were sent in English, which may have limited the response of some Brazilian orthopedists not familiar with this language. Furthermore, some physicians may not be familiar with survey webpages such as SurveyMonkey, which may have curtailed some surgeons, particularly the older ones. In the future, similar Brazilian surveys should be conducted in Portuguese either face to face or by conventional mail with the aim of reducing these biases.

CONCLUSION
The diagnosis and treatment of FAI has been growing exponentially in Brazil and in the world, but diagnostic criteria, surgical indications and treatment methods remain controversial. Perceptions of Brazilian orthopedists are similar to the opinions of international surgeons.