Nonsurgical Versus Surgical Management of Femoroacetabular Impingement

What Does the Current Best Evidence Tell Us

Ian Gao, MD; Marc R. Safran, MD


J Am Acad Orthop Surg. 2021;29(10):e471-e478. 

In This Article

Randomized Controlled Trials

The previous literature on hip arthroscopy for the treatment of FAI was limited by lower level evidence that consisted mostly of case series.[22] However, recently, there have been higher level evidence studies with several randomized controlled trials comparing the outcomes of hip arthroscopy versus PT for the treatment of FAI (summarized in Table 1).[35–37]

Hip Arthroscopy Versus Physical Therapy

The first randomized controlled trial comparing hip arthroscopy versus PT for the treatment of FAI was performed by Mansell et al.[35] They randomized 80 patients (58.8% men, mean age 30.1 years) with symptomatic FAI in a military cohort to either formal PT treatment (40 patients) or hip arthroscopy treatment (40 patients). Both groups had similar baseline characteristics, and at the 2-year follow-up (with 77.5% follow-up), both groups had notable improvements in HOS and iHOT scores, but no notable difference between the two groups was observed, suggesting equal outcomes between PT versus hip arthroscopy for the treatment of FAI. However, there are major concerns that limit the conclusions of this study.[38] First, a very high crossover rate was observed because 70% of patients assigned to the PT group crossed over to the hip arthroscopy group. Second, there was an underpowered "as treated" analysis: after accounting for crossover and loss to follow-up, only 11 patients were left in the PT group. Third, gains in patient-reported outcomes after surgery were diminished and not consistent with the previous published results in the literature: the study reported mean improvements of 7.4 in HOS-ADL, 4.7 in HOS-SS, and 20.9 in iHOT after surgery, but the previous literature has shown much higher mean improvements of 23.6 in the HOS-ADL, 41.3 in the HOS-SS, and similar trends in the iHOT after surgery.[22] Fourth, patients with less than 2 years of follow-up were included in the primary analysis of the study. Finally, the generalizability of the study is questionable because there was only one surgeon in the study at one center, and all patients were military service members. The military cohort brings unique issues, in that recovery after surgery could lead to a loss of disability benefits, and this could negatively affect the outcomes.[38]

Subsequent randomized controlled trials have shown different results. The UK FASHIoN study (Full Randomized Controlled Trial of Arthroscopic Surgery for Hip Impingement Versus Best CoNventional) by Griffin et al[36] was a multicenter (23 hospitals in the UK with 27 surgeons and 43 physical therapists), assessor-blinded randomized controlled trial that randomized 348 patients to either receive hip arthroscopy (171 patients) or formal PT (177 patients) for the treatment of FAI. The mean age of patients was 35.3 ± 9.6 years, and the baseline characteristics between the two groups were similar. At the 12-month follow-up (with 92% follow-up), both groups had notable improvement in iHOT scores (39.2 ± 21 preoperative to 58.8 ± 27 postoperative for hip arthroscopy group, 35.6 ± 18 pretreatment to 49.7 ± 25 posttreatment in PT group), but the mean difference in iHOT scores (adjusted for impingement type, sex, baseline iHOT score, and center in the primary intention-to-treat analysis) between the two groups was 6.8 (P = 0.0093) in favor of hip arthroscopy compared with PT, which exceeded the MCID of 6.1. Fourteen patients (8%) who were randomized to PT treatment crossed over to hip arthroscopy treatment, and no patients allocated to surgery crossed over to PT treatment. In the hip arthroscopy group, 6 (4.3%) serious adverse events were noted: one patient had a hip joint infection that required further surgery and ultimately THA, one patient had scrotal hematoma requiring readmission, one patient required an overnight admission, two patients had superficial wound infections that required oral antibiotics, and one patient had a fall that was unrelated to surgery. In the PT group, there was 1 (0.7%) serious adverse event: one patient developed biliary sepsis that was unrelated to treatment. To date, this is the largest randomized controlled trial comparing hip arthroscopy versus PT for FAI treatment, and the results showed that both hip arthroscopy and PT improved patient outcomes, but hip arthroscopy led to a greater improvement in outcomes. The large number of patients, centers, surgeons, and physical therapists in this study gives its findings improved generalizability over the previous randomized controlled trial discussed.

Another randomized controlled trial, the FAIT study (FAI Trial) by Palmer et al,[37] was a multicenter (7 centers in the UK), assessor-blinded trial that randomized 222 patients with symptomatic FAI to receive either hip arthroscopy (112 patients) or PT (110 patients). The mean age of patients was 36.2 ± 9.7 years, and the mean baseline HOS-ADL score was 65.9 ± 18.7. At the 8-month follow-up (with 85% follow-up), mean HOS-ADL score was 78.4 for the hip arthroscopy group and 69.2 for the PT group. After adjusting for baseline characteristics, the mean HOS-ADL was 10.0 points higher in the hip arthroscopy group compared with the PT group (P < 0.001), which exceeded the MCID of 9. Other patient-reported outcomes measures including HOS-SS, NAHS, Oxford Hip Score (OHS), iHOT, Copenhagen Hip and Groin Outcome Score (HAGOS), UCLA, PainDetect, EQ-5D, and HADS depression score were markedly higher in patients who received hip arthroscopy compared with those who received PT (P < 0.05). Four patients (3.6%) who were randomized to PT treatment crossed over to hip arthroscopy treatment. In the surgery group, there were 3 (3%) complications: one patient had superficial wound infection that resolved with oral antibiotics, and two patients had injury to the lateral femoral cutaneous nerve. No patients had serious adverse events. This trial also showed that hip arthroscopy achieved superior outcomes compared with PT for the treatment of symptomatic FAI.

Arthroscopic Osteochondroplasty With or Without Labral Repair Versus Lavage With or Without Labral Repair

A recent randomized controlled trial by Ayeni et al[39] called the FIRST study (FAI Randomized Controlled Trial) demonstrated the efficacy of surgical correction of FAI with cam and/or pincer resection, comparing arthroscopic osteochondroplasty with or without labral repair versus arthroscopic lavage of the hip joint with or without labral repair. The study had 214 male and female patients aged 18 to 50 years (mean age 36.0 years) with nonarthritic FAI suitable for surgical management across 10 centers in Canada, Finland, and Denmark. Patients were randomized to receive either arthroscopic osteochondroplasty with resection of their cam and/or pincer lesion or to receive arthroscopic lavage with washing out of the hip joint with 3 L of normal saline. In both groups, surgeons repaired the labrum if it was mechanically unstable once probed (88.3% of patients had a labral tear, of which 60.3% were repaired). Baseline characteristics were similar in both groups, and there was relatively equal proportion of labral tears and impingement type in both groups. At 1-year postoperative, the primary outcome of patient-reported pain on Visual Analog Scale improved in both groups, but no significant difference was observed between the groups (mean difference, 0.11; 95% CI, −7.22 to 7.45; P = 0.98). Secondary outcomes of SF-12 score, EQ-5D index, and iHOT score also did not show significant differences between the groups at 1 year postoperative. However, at 2 years postoperative, the authors found that there were significantly fewer reoperations in the osteochondroplasty group (8/105) than in the lavage group (19/104) (OR, 0.37; 95% CI, 0.15 to 0.89; P = 0.026), and the primary reasons for revision surgery were hip pain (55.6%) and reinjury of the labrum (40.7%), suggesting that the correction of FAI morphology with osteochondroplasty (with or without labral repair) was a more effective surgical treatment for FAI than lavage (with or without labral repair) was in minimizing recurrence of FAI-related symptoms.