IS ARTHROSCOPIC HIP SURGERY EVER A GOOD IDEA FOR FAI? Study Compares Arthroscopic Surgery to Conservative Treatment

 

Introduction

In a recent study from the British journal, The Lancet, researchers measured the effectiveness of conservative treatment of Femoroacetabular Impingement (“FAI”) and compared it to arthroscopic hip surgery.[1]  Although the researchers concluded that arthroscopic surgery was more effective than conservative treatments, like any study, sometimes you have to lift the hood and look at the fine print to see the whole picture. A careful analysis of the study actually shows us that neither treatment method offered to study participants was that promising and in fact, the difference between the two options is nominal at best.  What the study missed is offering participants an effective conservative treatment that is customized for each individual based on their specific muscle imbalances and movement dysfunction. This is the only way to truly get out of chronic hip pain and alleviate symptoms from FAI.

Nonetheless, proponents of arthroscopic surgery will cite this study as evidence that arthroscopic surgery is the gold standard for treating this condition.  It’s happening already:

Because of this,  I dove into the raw data head first to give you an alternative (and reasonable I believe) interpretation of what the study actually tells us.

Methods Used in the Study

The study involved 348 study participants, of which 171 received hip arthroscopic surgery and 177 received “personalized hip therapy.” The surgeries were performed by senior surgeons who were trained and experienced in hip arthroscopy.  In respect to “personalised hip therapy,” the researchers administered four components: (1) an assessment of pain, function, and range of hip motion; (2) patient education; (3) an exercise programme taught in the clinic and repeated at home; and (4) help with pain relief, which usually included steroid injections when pain prevents performance of the exercise programme.

A year later, the study participants were given a questionnaire, the International Hip Outcome Tool (iHot-33), on hip-related quality of life.  When the researchers analyzed this data, the study found that the group receiving hip arthroscopy responded more positively on the iHot-33 questionnaire.  As we’ll see, the iHot-33 is not a reliable tool to measure the efficacy of either treatment method and even assuming it was, the difference in scores is nominal and therefore insignificant.

The iHot-33 Test

The study used the iHot-33 test to assess the effectiveness of hip surgery versus conservative treatment.  This method uses a subjective questionnaire asking individuals to rate certain lifestyle factors related to (1) symptoms and functional limitations, (2) sports and recreational activities, (3) job-related concerns and (4) social, emotional and lifestyle concerns.[2]   A year after treatment was received, study participants were administered the test and asked to mark their responses on a Visual Analog Scale (non-numbered scale) ranging from ‘extremely difficult’ to ‘no problems at all.’  The mean of each group is then calculated and compared.

Can a subjective questionnaire provide us enough information to decide whether surgery is an appropriate treatment option?  Being someone with chronic hip pain, don’t you yourself know how variable each day, let alone, every hour can be in respect to severity of pain? Also, how do we think someone who received hip surgery will answer questions about hip discomfort as compared to someone who performed exercises for a few months? Take a look at more examples of questions that appear on the test to decide for yourself.  For now, the most important thing is for you to understand what the test is and how it’s scored.

The Difference in iHot-33 Scores Between Groups is Nominal

According to the study, “iHOT-33 provides a 100-point score, with 100 representing no pain and perfect function, and lower scores indicating pain and poor function. The instrument has been validated in a relevant population for this trial, and has a minimum clinically important difference of 6·1 points.”  In other words, only a difference of 6.1 points between the two groups would provide any indication that one method is more effective than the other.   In the intention-to-treat analysis (total number of patients in each group at beginning of study irrespective if they followed the study’s instructions), there was a 6.8 point difference in favor of the hip arthroscopic group and in the per-protocol analysis (number of patients that followed the study’s instructions), there was an 8.2 point difference in favor of the hip arthroscopic group.

So, in the calculation for all study participants, the difference in group scores was only .7 points higher than the minimally significant threshold and when the researchers measured the difference between those study participants who followed the study’s instructions, the difference was only 2.1 points higher than the minimally significant threshold.  With this data, the researchers concluded that “[t]hese results are consistent with the hypothesis that hip arthroscopy is more clinically effective than best conservative care.”  Technically this is correct since the arthroscopic group did respond to questions more positively than the conservative treatment but how much weight can truly be given to this statistic when the difference is a mere .7 and 2.1 points higher than the minimally significant threshold.

When a research study is provided with a handsome grant, lasts six years (research began in 2012) and is published in a prestigious journal such as The Lancet, I can see how the results of the study can be exaggerated.   However, even if we were to review this data in favor of arthroscopic surgery, the only reasonable interpretation of the results is that surgery is barely more effective than conservative treatment and of course, at a much greater cost.

The Subjective Improvements in the Conservative Group are Impressive

The “mean iHOT-33 scores had improved from 39·2 (SD 21) to 58·8 (27) for participants in the hip arthroscopy group, and from 35·6 (18) to 49·7 (25) in the personalised [sic] hip therapy group.” The scores in the arthroscopic group increased 19 points while the conservative treatment group increased by 14 points.  If we’re going to give any weight to the iHot-33 questionnaire, then we cannot ignore the significant improvement in the conservative treatment group, especially since we don’t know the quality of the exercises provided.

According to the study,  “Personalised hip therapy has four core components: an assessment of pain, function, and range of hip motion; patient education; an exercise programme taught in the clinic and repeated at home, that has the key features of individualisation, progression, and supervision; and help with pain relief, which could include one X-ray or ultrasound-guided intra-articular steroid injection when pain prevents performance of the exercise programme.” If you’ve read my information page on FAI or my personal FAI hip story, you’ll know what my position is on physical therapy and steroid injections when it comes to chronic hip pain associated with FAI.

The only true way to improve symptoms is to address individual muscle imbalances and movement dysfunctions and usually, the best person to work with is someone who’ve had and resolved their hip pain without surgery.  Although it’s doubtful that this study had this type of intervention, it’s promising to see study participants in the conservative treatment group still make significant progress in their rehabilitation and this should provide some insight for those considering surgery.  I’m willing to surmise that the results of the study would be very different if a more appropriate rehabilitation protocol focusing on movement function was provided to the study participants.

The Study did not Consider Alternative Variables for its Results

The study itself acknowledges that “the observed effect of hip arthroscopy over conservative care might be attributable to the surgical procedure, the placebo effect of surgery (given the unblinded nature of this trial), post-surgical rehabilitation, or a combination of these factors.” If receiving major surgery does not trigger the placebo effect, I’m not sure what does.   Additionally, if the individuals receiving arthroscopic surgery received effective post-surgery rehabilitation, it is certainly a possibility that the rehabilitation, and not the surgery, is the driving factor behind the inflated iHot-33 scores in the arthroscopic group.

 

Conclusion

Ultimately, average iHOt-33 scores were 58.8 in the arthroscopy group after surgery and 49.7 in the conservative group (out of 100) after therapy.  If you were told your pain would go from a 4 to a 6 (out of 10) after surgery, would you do it? What if you were told that your pain would go from a 3.5 to a 5 after 12 months of physical therapy, would you do that instead?  Neither of these options seem too attractive and that is because neither of these methods are effective at treating FAI or chronic hip pain.

The only way to truly resolve your hip pain is to improve your own individualized movement dysfunction and correct any specific muscle imbalances you may have.  For some, this may be due to a severe anterior pelvic tilt accompanied with weak abdominals and dysfunctional hip flexors while for others the main factor may be extremely underactive glute muscles and dysfunctional internal rotation of the hip musculature.  The possibilities are endless and I highly doubt that the study participants in the personalized hip therapy group received this type of detailed assessment of their movement dysfunction.  The key is to figure out what your specific conditioned movement dysfunction is and fix it. This is the only route to pain-free hips and it is completely under your control.

More information on FAI :

FAI and Hip Labral Tears Information Page. 

Free FAI Recovery eBook.

My FAI Story Part I, Part II and Part III.

[1] https://www.thelancet.com/action/showPdf?pii=S0140-6736%2818%2931202-9

[2] https://www.physio-pedia.com/International_Hip_Outcome_Tool_(iHOT)