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AUSTRALIAN experts say there is a “concerning lack of data” to support the use of hip arthroscopy in the management of femoroacetabular impingement (FAI), but a leading orthopaedic surgeon says that the procedure is a safe and cost-effective treatment for the painful condition.
In a Perspectives article in the MJA, Professor Flavia Cicuttini, Head of the Musculoskeletal Unit at Monash University’s Department of Epidemiology and Preventive Medicine, and co-authors wrote that there had been no randomised controlled trials comparing the efficacy of hip arthroscopy with either non-surgical management or sham surgery in the management of FAI.
The authors wrote that surgical correction of the hip bone shape was a “biologically plausible approach” to reducing hip pain and slowing the progression to hip osteoarthritis (OA), but that there was limited evidence to support the use of this procedure.
“There are no data available to help the clinician determine which, if any, patients may benefit from surgery for either improving symptoms or preventing development of hip OA,” the authors wrote.
Speaking in an MJA InSight podcast, Professor Cicuttini emphasised that her group’s call was for more evidence.
“The evidence is lacking – [we are] not really saying what we should [or should not] do,” Professor Cicuttini said. “If you look at the data at the moment, there are some randomised controlled trials but they … are comparing two different surgical procedures, and the conclusions are that pain improves. That is a fair conclusion, but we don’t know what would happen if we didn’t operate because we know that in joint pain … there is a very strong placebo effect. The more invasive the procedure, the stronger the effect.”
Associate Professor David Campbell, president of the Arthroplasty Society of Australia, said that the article confused the uncommon painful clinical condition of FAI with a common radiological appearance of many hips with cam morphology. FAI was not a condition that could be diagnosed on radiological findings alone, he said.
“X-rays do show hip bone morphology, and in a small minority of patients this may be associated with pain. The diagnosis must include symptoms and clinical signs,” Professor Campbell said, pointing to the 2016 international consensus statement on FAI.
“FAI surgery, both arthroscopic and open, does [aim to correct bone shape as the MJA authors say], but also, importantly, we aim to repair the damage to the labrum, articular cartilage and ligaments which has already occurred. It is the deterioration in these structures which leads to OA,” he said.
“The bone shape has been present probably from around the age of 10–12 years. It is not painful. The hip only becomes painful when associated soft tissue damage develops. It is the repair of this pathology that relieves pain.
“Level 1 trials are being performed, and they are very expensive and time consuming,” he said.
Professor Campbell said that he acknowledged the need for higher level evidence, and noted that six randomised controlled trials were underway. He said that Australian authors had also published a study earlier in 2017 comparing hip arthroscopy with community-based conservative treatment and found marked improvement in patients after surgery, and no improvement with conservative management.
“Typical of new technology, there is a lag between controlled studies and peer-reviewed publications and then some years before systematic reviews, which is evident in this paper,” Professor Campbell said, noting that arthroscopic surgery for FAI was first performed in 2002.
“There is overwhelming positive, international peer-reviewed evidence that surgery for FAI is safe, efficacious and very cost effective,” he said, adding that the procedure was supported by every Western country apart from Australia.
“Sadly, the Australian Government funding rules have recently halted a study which has already been funded to the tune of $1.2 million, so basically FAI surgery in our country has been put on hold.”
In Australia, the number of procedures performed has dramatically declined after the federal government revised the Medicare Benefits Schedule item to exclude FAI as an indication for hip arthroscopy from November 2016.
Professor Cicuttini said it was important to heed the lessons of knee arthroscopy, which was commonly used in the management of knee pain in OA until a 2002 randomised controlled trial found arthroscopic intervention to be no better than a placebo procedure.
“We have gone through this with knee arthroscopy, and there are very significant lessons to be learnt,” she told MJA InSight. She said that further investment was needed to better understand FAI and hip osteoarthritis, given the increasing number of hip arthroscopies being performed worldwide.
Professor Cicuttini said that evidence for non-surgical therapies for FAI was also lacking, but added that a short term NSAID or intra-articular steroid injection may be helpful.
“But … the key seems to be modifying activities,” she said. “So, early referral to a physiotherapist is very important.”
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As a clinician, past patient and now someone involved in research in this area.
Please review the results of the FASHion (UK) study as well as the FAIT (UK) trials.
Matt – This is not a a sham – unless you have clear evidence for your comment, its your opinion.
I am 13 years post surgery and I am very happy with my level of function and sports involvement.
I agree with the comment in the right hands, this surgery works well to produce significant outcomes – Like any other surgical procedure.
The history of surgery for knee meniscus tears, spinal fusions (and the MANY overhyped devices that injured patients over the years), and shoulder impingement “correction” show one clear path.
Surgeons are too biased to gauge the utility of their treatments. And the financial incentives make the problem even worse. Not only do they make money on the surgery, but they also draw consultancy fees and maintain cozy financial relations with the companies who make the devices for the surgeries…
Multiple studies have already shown dismal results on FAI. The publishing surgeons have tried to massage the abstracts to emphasize the positive. Look up the actual success rates for FAI surgery and take a close look at the metrics and the numbers.
It’s only a matter of time before this procedure is declared the sham that it is.
Hip arthroscopy in the right hands and in the right patient at the right time is a safe, efficacious and minimally invasive technique, which allows key-hole access to the native hip joint and periarticular structures facilitating an increasing array of therapeutic and diagnostic procedures. The future for this technique is bright and expanding despite any changes in the winds in the short-term.
As in all surgical spheres, specialist surgical skill, a well functioning multidisciplinary team, appropriate and timely patient selection and counselling is key to good outcomes.
I predict recent changes in the MBA to be short-lived, yet of significant impact upon patients, with prolonged suffering, delayed and thus less efficacious joint preserving procedures in those few endowed, and otherwise avoidable early joint arthroplasty in the many.
“Hip arthroscopy surgeons have been at the forefront of gathering evidence regarding the value of FAI surgery.” Now that wouldn’t be surprising, given that they make a lot of money from the procedure! And of course, they wouldn’t be a teeny bit biased in their research by that vested interest?
n=1
Truly glad you had a great perceived response and no complication but this is not science.
“Torn’ labrums are commonly seen in people with no pain ie: highly adaptable in an optimal context.
They hurt more when you are told they are there and need to be ‘fixed’. We now know that the model that equates tissue damage with pain and reliable, direct outcomes of interventions is not only flawed, but it leads to harms in a significant proportion. There are terrifically robust (and safe) explanations in pain science which is a field of science you could build a plane on. Worth a look if and when your pain returns or your other hip starts to hurt.
As one who suffered severe pain, to the point of fainting due to a torn labrum I am very much in favour of arthroscopy for this condition. Certainly a better option for me than hip replacement. Certainly worth further investigation.
One question Mr O’Donnell.
Would you allow a child of yours to get on a plane built using the equivalent level of science you are using to support these surgical interventions? (PS … I wouldn’t .)
Professor Cicuttini recommends “early referral to a physiotherapist is very important”, but the only RCT on physiotherapy (a pilot) showed only minor apparent benefit. Certainly, there was much smaller improvement with physiotherapy than with surgery. Long term conservative care has been shown to be not only far less effective, but also more expensive than surgery.
It should also be noted that as a result of various changes to the MBS over recent years, there are no reliable statistics available regarding the number of hip arthroscopies performed in Australia since 2015.
Finally, although there is said to be insufficient evidence for FAI surgery, there are literally hundreds of published outcome studies (many from Australia), systematic reviews, a published comparison between conservative care and surgery (again, an Australian study) and evidence from the Danish Hip Arthroscopy Registry which almost all point to substantial benefit in reduction of pain and improvement in function and activity for up to 10 years and more following surgery. The first RCTs have finished recruiting patients and are likely to be published within 12-18 months. Hip arthroscopy surgeons have been at the forefront of gathering evidence regarding the value of FAI surgery.
Whatever happened to ‘first, do no harm’? I can produce many case studies of serious harms. Even without recognised complications there is the subtle problem of perpetuating pain itself via encouraging perceptions of damage needing to be ‘fixed’. This is a fuel source for contextually vulnerable maladaptive neurobiological processes.
The existing sham controlled trials provide basis for a moratorium on funding of such interventions for pain and pain related disability. Has surgery scored a goal for direct benefit yet?