Monday, February 11, 2019

Hip Arthroscopy Outperforms PT for Femoroacetabular Impingement

Arthroscopic surgery may be superior to physical therapy for patients with femoroacetabular impingement (FAI), according to a U.K.-based study in The BMJ. FAI, which affects roughly one-fifth of the general population, is characterized by adverse morphology causing the femoral neck to impact against the acetabular rim; this predisposes patients to premature degeneration of the joint.

Over 200 adults with symptomatic, confirmed FAI were randomized to either physical therapy plus activity modification or arthroscopic surgery to remove the impinging femoral and acetabular bone. The primary outcome — a 100-point score on an activities of daily living measure at 8 months post-randomization — favored the surgery group by 10 points. Secondary outcomes, including sports and depression scores, also favored the surgery group.

The researchers caution: "Although arthroscopic hip surgery seems superior to physiotherapy and activity modification, patients must be informed of the potential risks and benefits of surgery, including the risk of no improvement. Up to a half of patients may not achieve a clinically important improvement after surgery; hence accurate patient selection is critical to optimizing treatment outcomes." They note, for example, that osteoarthritis may negatively affect the surgery's outcomes.

My Take:
The full article is available for free from The BMJ (The British Medical Journal) CLICK HERE.

Manipulation of the femoral head is an excellent alternative to the arthroscopic surgery and can be combined with physical therapy for much improved outcomes. Clinically, I find that manipulation will also provide good temporary relief for a torn labrum as well, but ultimately a labral tear will require surgery.

The conservative approach is to try manipulation and physical therapy for up to three months. If significant improvement is not achieved then arthroscopic surgery can be performed before osteoarthritis becomes a factor. Most surgeons agree that the window for successful surgery closes around six months after symptoms appear.

It is interesting to note that the results of this study on hip surgery are the opposite of similar studies on knee and shoulder surgery. Please review my blog “No Surgery for Subacromial Pain Syndrome” posted last Friday. Outcomes for hip surgery traditionally are better than surgery on the knee or shoulder. Just look at the recovery times for people you know having a hip replacement versus those having a knee replacement.

Bottom Line:
Whenever possible take the conservative route first to rehabilitate a joint rather than operate. In the worst case scenario, the rehabilitation prior to surgery will improve outcomes even if the therapy fails and surgery is still required. Obviously, the better outcome is to avoid the surgery altogether.

Source: February 12, 2019 New England Journal of Medicine

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