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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