Arthroscopy debate moves to hips

Hip arthroscopy is one of the most popular treatments for managing pain associated with femoroacetabular impingement (FAI) but as more patients are being offered the costly procedure, experts are saying its use has escalated beyond the evidence.

Writing in the MJA this week Professor Flavia Cicuttini, Head of the musculoskeletal unit and head of rheumatology at Melbourne’s Alfred Hospital, said hip arthroscopy rates had escalated rapidly in recent years but despite its popularity, no one had proven that the surgery offered any benefit over non-surgical options in the long term.

Drawing heavy comparisons to the story that played out with arthroscopy for knee OA (read here), Professor Cicuttini and colleagues said that while studies had shown that arthroscopy improved FAI related pain in the short to medium term, it still remained unclear just how much of that symptomatic improvement was driven by a placebo effect.

What’s more, evidence showed that the percentage of pain improvement achieved by the procedure was similar to that of sham surgery for degenerative meniscal tears in osteoarthritic knees.

“We don’t really know what we should be doing with someone who has severe groin pain and FAI … the literature doesn’t help us, there are no head-to-head studies of surgical versus non surgical therapy,” she told the limbic.

“It may make sense to change the shape of the bone…but it’s worrying that we don’t really know if people would have got better with other interventions like activity modification.”

She noted that the evidence that suggested the procedure was beneficial for FAI was based on case series in young patients who were followed for relatively short periods.

“It’s quite disturbing most of the people in those studies were under the age of 40 and some even in their 20’s … No one is going to do a hip replacement [in the follow up] no matter what in that age group.”

Amid a background of virtually no high quality evidence to support its use, Professor Cicuttini remains cautious about recommending the procedure.

Until that evidence is clear, she suggests that patients should try simple analgesia, graded exercise, and activity modification for at least six months before resorting to surgery.

“It may be that the people with pain that doesn’t settle down [over time] are the ones that need the surgery,” she said.

According to Professor Cicuttini one of the most pressing questions that needed answering was whether the surgery prevented arthritis.

However, she said it would take years for studies to determine if arthritis had been prevented, particularly given the relatively young age of the patients the surgery was typically offered to.

The researchers also noted that the irregular shapes that identified impingement was present in about 25% of asymptomatic adults in the general community and might well be normal variations of certain activities and lifestyle.

“FAI isn’t a different disease – it’s probably part of the OA, it’s on the pathway so changing the shape of the bone may not modify OA risk,” said Professor Cicuttini.

She said that as more is understood about hip OA, there would likely be a shift away from treatment and a greater push to towards prevention in early adolescence.

This was because early evidence suggested that factors such as exercise in childhood, adolescence and early adulthood could influence bone shape that could result in FAI, and potentially OA down the track.

“What’s interesting is the little data that’s out there suggests that there are FAI changes on x-ray in about 9% of men but if you have been an elite basket baller and were doing a lot of exercise as you were growing up your risk of FAI is 90%,” observed Professor Cicuttini.

“For active young adults in their 20’s-40’s who end up being treated for FAI, activity modification may result in greater long-term benefits than surgery,” she said.

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