Thursday, June 27, 2013

Outcomes of Surgical Techniques for Hip Impingement, FAI, Surgery

New exciting research is available on surgical outcomes comparing several techniques. Hip impingement (femoroacetabular impingement, FAI) is characterized by bony deformities on the femoral head/neck and/or the acetabulum (hip socket). Some bony lesions may require open hip surgery with dislocation to address large, global lesions. Many CAM and/or pincer lesions can be addressed arthroscopically. But how much do the outcomes vary depending on the various techniques used by hip surgeons?

A recently published article included a review of 29 clinical outcome studies (most of them categorized with level 4 scientific evidence) with a minimum 2-year follow-up. All in all, there were 2,369 study participants of which 60% were male and 40% female. On average, the patients had shown symptoms of hip pathology for over two years before treatment was initiated.

The different types of surgeries performed were:
  •  mini-open (11% of all hips)
  •  arthroscopy plus mini-open (6.1%)
  •  open surgical dislocation (24%)
  •  arthroscopy (59%)

The authors of the review article made the following hypotheses:
  1. That surgical treatment was significantly better than nonoperative treatment.
  2. That there is no difference in clinical outcomes between different surgical techniques for FAI.
  3. That re-operations and complications would be higher following surgical dislocation and mini-open techniques vs. arthroscopic techniques.
  4. That labral refixation/repair would have significantly better outcomes than labral debridement.

Let’s look at the results and which hypotheses proved to be correct and which not (based on the evidence at hand, not saying that it was perfectly sound scientific data).

Hypothesis 1: Nonoperative vs. operative treatment
This hypothesis was confirmed. At final follow-up, the nonarthritic hip score (NAHS) was significantly better when surgical treatment was performed to treat femoroacetabular impingement (FAI) than if no surgery was performed. Range-of-motion measurement was performed in 6 studies (1 nonoperative, 5 operative). Following nonoperative treatment, flexion decreased 7° and internal rotation (IR) increased 0.6® at two-years after the treatment. However, in the operative groups, flexion and IR increased 10.3° and 11.8° respectively with arthroscopy (two studies); 10° and 18.9° with mini-open (one study); 12° and 3° with surgical dislocation (one study); 15.9° and 5.2° with arthroscopy plus mini-open (one study)

Hypothesis 2: Clinical outcomes of surgical treatment
This hypothesis was not confirmed. Inconsistent outcome measures and outcomes were observed, but, all surgical treatments resulted in statistically significant and clinically relevant improvements in outcomes. There are a lot of different comparisons and measurements. Without diving into every singly number and scenario, the improvements in NAHS or modified Harris Hip Score (mHHS) appear to correspond to the pre-surgical score of a patient group undergoing a specific type of procedure.

For example, prior to surgery, patients undergoing surgical dislocation had significantly higher mHHS than those undergoing arthroscopy, mini-open and arthroscopy plus mini-open. At two years following surgery, patients undergoing surgical dislocation still had significantly higher mHHS than those undergoing arthroscopy, mini-open and arthroscopy plus mini-open.

Hypothesis 3: Re-operations and complications
The hypothesis was confirmed. There were 361 (14.4% rate) overall re-operations. 349 were unplanned and 12 were planned for removal of plates and screws. 190 hardware removal operations were performed following surgical dislocation (178 unplanned and performed for pain; 12 planned). Seventy-eight patients ended up with a total hip replacement (3.1% rate).

There were significantly more re-operations performed following surgical dislocation vs. arthroscopy, mini-open and arthroscopic plus mini-open. There were significantly more re-operations following arthroscopic plus mini-open vs. arthroscopy and mini-open.

Other re-operations performed included repeat arthroscopy for pain/diagnosis with lists of adhesions and debridement (39), repeat femoral bone/cartilage shaving (15 [11 after open surgical dislocation or mini-open, 4 after arthroscopy), iliotibial band release (8), hip resurfacing (4), hematoma removal (4), incision and drainage for deep infection (2), neuroma excision (1) and 18 other non-specified re-operations.

In addition, there were significantly more conversions to total hip replacement after surgical dislocation vs. arthroscopy and as well as after arthroscopic plus mini-open vs. arthroscopy and after mini-open vs. arthroscopy.

Complications were not common. Heterotopic ossification (bone formation) was the most common after surgical dislocation (15%), followed by mini-open (13%), arthroscopy plus mini-open (3.3%) and arthroscopy (less than 1%). Major complications such as fracture were extremely rare (in total 2 fractures).

Hypothesis 4: Labral repair vs. labral debridement
The hypothesis was confirmed. Four studies demonstrated significantly better clinical outcomes at 2 to 3.5 years following labral repair vs. debridement. However, 4 other studies demonstrated no difference in outcomes.  I explain the concepts of repair and debridement and more details on pros and cons from other published studies in my book The Entrepreneurial Patient: A Patient’sGuide to Hip Impingement.

In conclusion, what does a patient need to know? There are successes with all types of surgeries. However, this review of research does draw a few important conclusions. It does appear that doing something is better than doing nothing when it comes to addressing hip impingement, FAI. It also appears that arthroscopic surgery results in fewer re-operations and that labral repairs provide better long-term outcomes.

The most important thing is to find out which type of operation works the best for your specific situation and then find a surgeon who is highly specialized in the area of the particular surgery you need. That said I think it’s safe to say the research review shows that if your impingement is a “simple” CAM/pincer, labral tear situation, arthroscopy is the way to go.

Then, there is the question of what a reasonable patient expectation and the definition of a successful hip impingement surgery is - but that's a different story. You can read more about expectations from surgery to address hip impingement and common scoring systems of surgical outcomes in my book.

See you next time for more interesting research and my widespread wisdoms!

Source: Treatment of femoroacetabular impingement: a systematic review. Joshua D. Harris. Brandon J. Erickson. Charles A. Bush-Joseph. Shane J. Nho. Curr Rev Musculoskelet Med. Published online June 7, 2013.

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