Arthroscopic hip surgery yielded better outcomes vs physiotherapy and activity modification for FAI

Superior outcomes were seen in patients who underwent arthroscopic hip surgery for symptomatic femoroacetabular impingement compared with patients who were placed in physiotherapy and activity modification, according to a recently published study.

Perspective from Dean K. Matsuda, MD

“Our multicenter, randomized controlled trial compared physiotherapy and activity modification with arthroscopic hip surgery for patients with femoroacetabular impingement syndrome,” Antony J. R. Palmer, MA, BMBCh, DPhil, FRCS (Tr & Orth), told Healio.com/Orthopedics. “Arthroscopic hip surgery proved superior at improving patient-reported symptoms 8 months after randomization. Arthroscopic hip surgery appears to be effective and safe, but further research is needed to identify which patients are most likely to benefit. Also, it is not known whether treatment offers sustained benefit with disease-modifying potential, which will be addressed with long-term follow-up of this cohort.”

Palmer and colleagues performed an assessor blinded, pragmatic, randomized controlled trial of patients with symptomatic FAI in which 100 patients were assigned to receive arthroscopic hip surgery and 88 patients were assigned to a program of physiotherapy and activity modification. Patients who received physiotherapy were given a goal-based program to improve core stability and movement control. Patients who received arthroscopic surgery underwent surgery to excise the bone that impinged during hip movements and then patients received routine postoperative care. The hip outcome score activities of daily living (HOS ADL) subscale at 8 months after randomization with a minimum clinically important difference between the intervention groups of nine points was the main outcome measure. Other outcomes included other patient-reported outcome measures and clinical assessment.

Results showed the mean HOS ADL was 78.4 points for patients who received arthroscopic hip surgery and was 69.2 points for patients who were assigned to the physiotherapy program. After the baseline HOS ADL, age, sex and study site were adjusted, the mean HOS ADL was 10 points higher in patients who underwent arthroscopic hip surgery compared with patients in the physiotherapy program group. There were no serious adverse events in either intervention group. – by Monica Jaramillo

Disclosures: Palmer reports he received funding from the Royal College of Surgeons of England and Dunhill Medical Trust. Please see the full study for a list of all other authors’ relevant financial disclosures.

Perspective

Dean K. Matsuda, MD

With about half of hip osteoarthritis caused by FAI, the comparison of best practice conservative care (with physical therapy as a key component) with hip arthroscopy is an important topic. Three randomized controlled studies (RCTs) have emerged, of which the FAIT study is the most recent. FAIT is an assessor-blinded, pragmatic, multicenter RCT, which concluded both physical therapy (PT) and hip arthroscopy groups had safe and significant improvement, but hip arthroscopy was more effective with significantly more improvement in pain, function (primary patient-reported outcome - HOS ADL) and hip flexion range.

The first published RCT on this topic concluded there was no significant difference between PT and hip arthroscopy groups of military patients at 2 years post-randomization. However, that single-center study has been discounted mainly because of its high 70% crossover rate (patients randomized to PT group that then opted for surgery), in essence comparing a hip arthroscopy group with 95% surgery rate to a PT group with 70% surgery rate. The Centre for Evidence-based Medicine suggests a crossover rate greater than 20% may invalidate results.

The next RCT was the FASHIoN study. The FAIT and FASHIoN RCTs, albeit with time from randomization of 8 and 12 months, respectively, are more robust and less flawed, with larger study populations, multicenter designs with experienced hip arthroscopic surgeons and relatively low crossover rates (3% and 8%, respectively). Both studies reported statistically and clinically significant improvement (albeit with wide variability and small effect sizes) in favor of hip arthroscopy for the treatment of symptomatic FAI.

So, what do I conclude so far? On balance, arthroscopic hip surgery seems superior to physiotherapy in the treatment of symptomatic FAI. However, both PT and hip arthroscopy may benefit patients as relatively safe treatments, not all patients will improve with either treatment (We know this, but our patients need to know this, too), and it seems reasonable to encourage PT as a first-line treatment option which may, in some instances, be sufficient. I look forward to ongoing and future high-quality investigations to better define which patients will benefit most, or not at all, from each option.

References:

Faucett SC, et al. Am J Sports Med. 2018;doi: 10.1177/0363546518777483.

Griffin DR, et al. Lancet. 2018; doi:10.1016/S0140-6736(18)31202-9.

Palmer AJR, et al. BMJ. 2019;doi:10.1136/bmj.l185.

Rhon DI, et al. Am J Sports Med. 2018;doi:10.1177/0363546518777482.

Dean K. Matsuda, MD

Orthopedics Today Editorial Board Member

Disclosures: Matsuda reports no relevant financial disclosures.

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Sources/Disclosures

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Source:

Palmer AJR, et al. BMJ. 2019;doi:10.1136/bmj.l185.