RIP Hip Impingement Surgery?
POSTED ON 3/23/2018 IN Hip BY Christopher Centeno
OK, let's be honest here. The research base behind the world's most common orthopedic surgical procedures is blowing up or, more accurately, falling down. It's been an absolutely awful run for common procedures like knee debridement, meniscectomy, rotator cuff repair, and other common surgeries that make up many billions in annual healthcare spending in the U.S. Frankly, I was just waiting for hip arthroscopy to blow up as well, as it's always seemed like a dumb idea. Now those chickens have come home to roost in a recent high-level research study that shows it's no better than physical therapy. Hip surgeons, hold the hate mail please...
What Is FAI and How Do Surgeons "Fix it"?
FAI stands for femoral acetabular impingement, aka "hip impingement." The idea is that evil bone spurs on the ball or socket bones of the hip joint are destroying cartilage. In addition, some patients just have bad anatomy. Hence, surgeons can go in and remove the evil bone spurs and reshape the hip to try and prevent arthritis. This surgery has gone from relatively unknown to the most common hip surgery other than joint replacement in just the last decade. FAI procedures have opened the door to an explosion of hip surgeries. However, does the procedure work? Who knows? Surgeons began operating on hips well before a single high-level research study comparing it to conservative care was ever published.
It's Covered by My Insurance, and Top Athletes Get This Surgery, so It Must Work!
Regrettably, your insurance will still cover a plethora of elective orthopedic surgeries that have been shown in high-level research to be ineffective. Why? It takes about a decade or more for a procedure to go from being shown to be ineffective for it to be no longer covered by insurance companies. For example, the world's most common orthopedic knee surgery is called meniscectomy. We've known that it doesn't work for several years. Yet your insurance carrier will still pony up payment. In fact, that will likely happen for another five years before most carriers drop or severely limit coverage. How about top athletes who get this surgery? Yep, that's true. However, in medicine, the results of high-level research trials trump all, including big athletes. Hopefully, this new study will begin to change the minds of trainers, athletes, and agents.
The First Hip Arthroscopy RCT on FAI
First, it's insane that we've been performing this amazingly invasive procedure for a decade and we don't have a single high-level study to show that it works better than doing nothing. How invasive is this surgery? Well, pulling traction on the hip causes the major nerve in the hip to go off-line. I've also shown several cases of severe tissue injury based on damage done by the surgery. This hip FAI surgery study was a randomized controlled trial. That means that 80 patients were randomly assigned to either the hip surgery or physical therapy groups. The patients in the physical therapy group could cross over into the surgery group if they felt they still needed care. At the end of two years, there was no significant difference in functional or pain scores between the surgery and physical therapy groups. There were quite a few patients who crossed over to surgery, but these patients were accounted for in the final analysis. Most patients perceived little to no change in the status of their hip at two years, and one-third of military patients were not medically fit for duty at two years. The biggest limitation of the study was that this was a single surgeon in a single hospital and that there were many patients that crossed over into the surgery group. However, given that their careers were on the line (one-third of these patients had to leave the military due to this problem), that's not surprising because neither group of patients reported "home run" results.
This Study Will Piss Off Surgeons and Orthopedic Device Reps
OK, this is not a perfect trial, but it's ridiculous that it's the only RCT that we have on hip FAI surgery compared to PT or sham. While orthopedic surgeons will scream that we need more data for orthobiologics (which is true), their own much more invasive surgical procedures often have no high-level research support. My mother has a saying for this, "the pot calling the kettle black." Surgeons will argue, with some justification, that this trial needed more surgeons, more patients, and more sites. In addition, because a significant number of patients were allowed to cross over into the surgery group, this muddied the waters. All of this is true but doesn't change the observation that hip FAI surgery performed poorly.
The Beginning of the End for Hip Arthroscopy Treatment for FAI?
My best, educated guess is that this study is the beginning of the end for hip surgery for FAI. Why? This is exactly the way things began for meniscus surgery. A single, well-done trial showed it wasn't effective. Surgeons then screamed that the trial had issues. Then another one came out that was better and then another. Now the mantra is that the procedure doesn't work for all patients, but just select patients. The problem is that nobody seems to agree which patients. In addition, each failure of a major surgical procedure opens the door for much less invasive injection therapy using imaging guidance (interventional orthopedics [IO]) to take a shot at treating that same population. What is IO? See my video below:
Why Is Hip FAI Surgery a Dumb Idea (IMHO)?
Most of modern orthopedic surgery is based on the structural model of pain, meaning that bad structure causes the problem, so we need to fix that structure surgically. The problem is that while sometimes this is true (mostly in acute traumatic injuries), oftentimes this is a huge oversimplification of why patients have chronic pain. That often involves nerves and inflammatory chemicals as well. Hence, when someone's hip hurts and we have an MRI showing that there is a bone spur, lopping off the bone spur surgically when the pain may be caused by something else entirely makes little sense. In addition, bone spurs are caused by excessive load, so we're likely to be treating a symptom of a problem rather than a problem. See my video below about bone spurs:
In particular, bone spurs around the hip are often caused by changes in the way the forces hit the joint. Take a look at my hip video below to better understand how this works:
The upshot? This trial shows what I expected to see. Hip impingement surgery wasn't any more effective than physical therapy. On the other hand, more research is needed. Having said that, I would personally never get hip arthroscopy surgery if my hip hurt and an MRI showed impingement and a labral tear—not a chance!
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