Surgeon Willingness to Participate in Randomized Controlled Trials for the Treatment of Femoroacetabular Impingement

Preoperative Magnetic Resonance Imaging Offers Questionable Clinical Utility, Delays Time to Hip Arthroscopy, and Lacks Cost-Effectiveness in Patients Aged ≤40 Years With Femoroacetabular Impingement Syndrome: A Retrospective 5-Year Analysis

PURPOSE

To assess the clinical utility of preoperative magnetic resonance imaging (MRI) and quantify the delay in surgical care for patients aged ≤40 years undergoing primary hip arthroscopy with history, physical examination, and radiographs concordant with femoroacetabular impingement syndrome (FAIS).

METHODS

From August 2015 to December 2020, 1,786 consecutive patients were reviewed from the practice of 1 fellowship-trained hip arthroscopist. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of conservative management, or concomitant periacetabular osteotomy. After nonoperative treatment options were exhausted and a surgical plan was established, patients were stratified by those who presented with versus without MRI. Those without existing MRI received one, and any deviations from the surgical plan were noted. All preoperative MRIs were compared with office evaluation and intraoperative findings to assess agreement. Demographic data, Hip Disability and Osteoarthritis Outcome Score (HOOS)-Pain, and time from office to MRI or arthroscopy were recorded.

RESULTS

Of the patients indicated by history, physical examination, and radiographs alone (70% female, body mass index 24.8 kg/m², age 25.9 years), 198 patients presented without MRI and 934 with MRI. None of the 198 had surgical plans altered after MRI. Patients in both groups had MRI findings demonstrating anterosuperior labral tears that were visualized and repaired intraoperatively. Mean time from office to arthroscopy for patients without MRI versus those with was 107.0 ± 67 and 85.0 ± 53 days, respectively (P < .001). Time to MRI was 22.8 days. No difference between groups was observed among the 85% of patients who surpassed the HOOS-Pain minimal clinically important difference (MCID).

CONCLUSION

Once indicated for surgery based on history, physical examination, and radiographs, preoperative MRI did not alter the surgical plan for patients aged ≤40 years with FAIS undergoing primary hip arthroscopy. Moreover, preoperative MRI delayed time to arthroscopy. The necessity of routine preoperative MRI in the young primary FAIS population should be challenged.

What can we learn from surveys? A systematic review of survey studies addressing femoroacetabular impingement syndrome

The purpose of this study was to systematically review the methodology, response rate and quality of survey studies related to femoroacetabular impingement (FAI) syndrome. A search was conducted on three databases (PubMed, EMBASE, MEDLINE) for relevant studies from database inception to 27 January 2020. Data extracted included study and survey characteristics, as well as response rates. The quality of the included studies was also assessed using a previously published quality assessment tool. Data were analysed with means, ranges, standard deviations, 95% confidence intervals and bivariate analysis. Eleven studies (13 surveys) were included in this review out of a total of 1608 initial titles found. Surveys were most often administered via the Internet (72%) to orthopaedic surgeons (54%). The mean response rate was 70.4%. The mean quality score was moderate 13.3/24 (SD ±4.3). The criterion that most often scored high was ‘clearly defined purpose and objectives’ (11/11). The most common survey topic investigated surgeons’ knowledge regarding FAI diagnosis and management (n = 7). In addition, bivariate analysis between quality score and response rate showed no significant correlation (Spearman’s rho = −0.090, P = 0.85). Overall, survey studies related to FAI syndrome most often use Internet-based methods to administer surveys. The most common target audience is orthopaedic surgeons. The topics of the surveys most often revolve around orthopaedic surgeons’ knowledge and opinions relating to the diagnosis and management of FAI syndrome. The response rate is high in patient surveys and lower in larger surgeon surveys. Overall, the studies are of moderate quality.

Nonoperative Management Prior to Hip Arthroscopy for Femoroacetabular Impingement Syndrome: An Investigation Into the Utilization and Content of Physical Therapy

BACKGROUND

There has been a significant increase in surgeries for femoroacetabular impingement syndrome in recent years, but little is known about the use of physical therapy prior to surgery.

OBJECTIVES

To investigate the use of physical therapy prior to hip arthroscopy for femoroacetabular impingement syndrome, by assessing the number of visits and use of exercise. A secondary objective was to evaluate whether comorbidities prior to surgery were associated with the use of physical therapy.

METHODS

In this retrospective observational cohort study, eligible participants between the ages of 18 and 50 years undergoing hip arthroscopy between 2004 and 2013 in the Military Health System were included. Patients were categorized based on whether they saw a physical therapist for their hip in the year prior to surgery. For physical therapy patients, dosing variables were identified, including total number of visits and visits that included an exercise therapy procedure code.

RESULTS

Of 1870 participants, 1106 (59.1%) did not see a physical therapist for their hip prior to surgery. For those who did, the median number of visits was 2. Only 220 (11.8%) had 6 or more unique visits with an exercise therapy procedure code. Exercise was coded in 43.4% to 63.0% of the total visits in each individual course of care (mean, 52.3%). There was an association between substance abuse and exercise utilization. No other comorbidities were associated with physical therapy or exercise therapy utilization.

CONCLUSION

Physical therapy was not commonly used before undergoing arthroscopic hip surgery by patients seeking care in the Military Health System. Further research is needed to understand the reasons for poor utilization and better define failed nonoperative management.

LEVEL OF EVIDENCE

Therapy, level 2b. J Orthop Sports Phys Ther 2019;49(8):593-600. Epub 15 May 2019. doi:10.2519/jospt.2019.8581.

Nonoperative Management of Femoroacetabular Impingement: A Prospective Study

BACKGROUND

The literature has given little attention to the nonoperative management of femoroacetabular impingement (FAI) syndrome despite a rapidly expanding body of research on the topic.

PURPOSE

To perform a prospective study utilizing a nonoperative protocol on a consecutive series of patients presenting to our clinic with FAI syndrome.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Between 2013 and 2016, patients meeting the following criteria were prospectively recruited in a nonoperative FAI study: no prior hip surgery, groin-based pain, a positive impingement test, and radiographic FAI syndrome. The protocol consisted of an initial trial of rest, physical therapy, and activity modification. Patients who remained symptomatic were then offered an image-guided intra-articular steroid injection. Patients with recurrent symptoms were then offered arthroscopic treatment. Outcome scores were collected at 12 and 24 months. Statistical analysis was performed to identify risk factors for the need for operative treatment and to determine patient outcomes based on FAI type and treatment.

RESULTS

Ninety-three hips (n = 76 patients: mean age, 15.3 years; range, 10.4-21.4 years) were included in this study and followed for a mean ± SD 26.8 ± 8.3 months. Sixty-five hips (70%) were managed with physical therapy, rest, and activity modification alone. Eleven hips (12%) required a steroid injection but did not progress to surgery. Seventeen hips (18%) required arthroscopic management. All 3 groups saw similar improvements in modified Harris Hip Score ( P = .961) and nonarthritic hip score ( P = .975) with mean improvements of 20.3 ± 16.8 and 13.2 ± 15.5, respectively. Hips with cam impingement and combined cam-pincer impingement were 4.0 times more likely to meet the minimal clinically important difference in modified Harris Hip Score ( P = .004) and 4.4 times more likely to receive surgical intervention ( P = .05) than patients with pincer deformities alone. Participants in team sports were 3.0 times more likely than individual sport athletes to return to competitive activities ( P = .045).

CONCLUSION

A majority (82%) of adolescent patients presenting with FAI syndrome can be managed nonoperatively, with significant improvements in outcome scores at a mean follow-up of 2 years.

CLINICAL RELEVANCE

A nonoperative approach should be the first-line treatment for young active patients with symptomatic FAI syndrome.

Arthroscopic Surgery or Physical Therapy for Patients With Femoroacetabular Impingement Syndrome: A Randomized Controlled Trial With 2-Year Follow-up

BACKGROUND

Arthroscopic hip surgery has risen 18-fold in the past decade; however, there is a dearth of clinical trials comparing surgery with nonoperative management.

PURPOSE

To determine the comparative effectiveness of surgery and physical therapy for femoroacetabular impingement syndrome.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients were recruited from a large military hospital after referral to the orthopaedic surgery clinic and were eligible for surgery. Of 104 eligible patients, 80 elected to participate, and the majority were active-duty service members (91.3%). No patients withdrew because of adverse events. The authors randomly selected patients to undergo either arthroscopic hip surgery (surgery group) or physical therapy (rehabilitation group). Patients in the rehabilitation group began a 12-session supervised clinic program within 3 weeks, and patients in the surgery group were scheduled for the next available surgery at a mean of 4 months after enrollment. Patient-reported outcomes of pain, disability, and perception of improvement over a 2-year period were collected. The primary outcome was the Hip Outcome Score (HOS; range, 0-100 [lower scores indicating greater disability]; 2 subscales: activities of daily living and sport). Secondary measures included the International Hip Outcome Tool (iHOT-33), Global Rating of Change (GRC), and return to work at 2 years. The primary analysis was on patients within their original randomization group.

RESULTS

Statistically significant improvements were seen in both groups on the HOS and iHOT-33, but the mean difference was not significant between the groups at 2 years (HOS activities of daily living, 3.8 [95% CI, -6.0 to 13.6]; HOS sport, 1.8 [95% CI, -11.2 to 14.7]; iHOT-33, 6.3 [95% CI, -6.1 to 18.7]). The median GRC across all patients was that they "felt about the same" (GRC = 0). Two patients assigned to the surgery group did not undergo surgery, and 28 patients in the rehabilitation group ended up undergoing surgery. A sensitivity analysis of "actual surgery" to "no surgery" did not change the outcome. Twenty (33.3%) patients who underwent surgery and 4 (33.3%) who did not undergo surgery were medically separated from military service at 2 years.

CONCLUSION

There was no significant difference between the groups at 2 years. Most patients perceived little to no change in status at 2 years, and one-third of military patients were not medically fit for duty at 2 years. Limitations include a single hospital, a single surgeon, and a high rate of crossover. Registration: NCT01993615 ( ClinicalTrials.gov identifier).

Femoroacetabular Impingement Surgery Is on the Rise-But What Is the Next Step?

Surgery for femoroacetabular impingement (FAI) has been advocated for correction of cam and pincer hip joint morphology. Surgery for FAI was first pioneered by Myers et al, who surgically treated FAI by open dislocation. Arthroscopy was then introduced in 2005 by Sampson. Arthroscopy has continued to develop since then, with the intent of providing pain relief and improving function in patients with FAI. This Viewpoint discusses the escalating popularity of FAI surgery, the widespread acceptance of this relatively new surgical procedure, and next steps for determination of who benefits from this treatment. J Orthop Sports Phys Ther 2016;46(6):406-408. doi:10.2519/jospt.2016.0605.

Systematic Reviews Keep Arthroscopy Up to Date

Sometimes systematic reviews seem overprevalent, and some systematic reviews can be "inconclusive," which does not improve clinical decision making. On the other hand, systematic reviews can make a positive impact on patient outcomes by summarizing clinically relevant literature for arthroscopic surgeons and related researchers.

Editorial Commentary: The Demise of Randomized Controlled Trials in Hip Arthroscopy?

Hip arthroscopists asked to participate in randomized controlled trials are reluctant to offer treatment without correction of osseous deformities but may be more willing to enroll patients in studies on management of capsulolabral structures.