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:
- That surgical treatment was significantly better than nonoperative treatment.
- That there is no difference in clinical outcomes between different surgical techniques for FAI.
- That re-operations and complications would be higher following surgical dislocation and mini-open techniques vs. arthroscopic techniques.
- 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.
Conclusions
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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