Hip arthroscopy: an evidence-based approach
Authors: Karen K Briggs, Ioanna K Bolia
Journal: The Lancet (2018)

It started with the knee, then the shoulder, then the ankle, and now it is the hips' turn. Instead of open surgery, arthroscopic surgery of the hip joint can be used to repair structural damage. Arthroscopic surgery is considered to be less invasive than an open procedure, and the intact tissues are minimally exposed and not traumatised. This approach can lead to quicker recovery and early return to function and activity, with fewer complications.1Matsuda DK Carlisle JC Arthurs SC Wierks CH Philippon MJ Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement.Arthroscopy. 2011; 27: 252-269Summary Full Text Full Text PDF PubMed Scopus (203) Google Scholar For the hip, arthroscopy spares the cutting of the ligamentum teres and reduces damage to the capsular structures by avoiding dislocation. The literature has also supported the idea of hip arthroscopy as a less invasive method of repairing the damage caused by femoroacetabular impingement.2Kierkegaard S Langeskov-Christensen M Lund B et al.Pain, activities of daily living and sport function at different time points after hip arthroscopy in patients with femoroacetabular impingement: a systematic review with meta-analysis.Br J Sports Med. 2017; 51: 572-579Crossref PubMed Scopus (61) Google Scholar, 3Minkara AA Westermann RW Rosneck J Lynch TS Systematic review and meta-analysis of outcomes after hip arthroscopy in femoroacetabular impingement.Am J Sports Med. 2018; (published online Jan 1.)DOI:10.1177/0363546517749475Crossref Scopus (136) Google Scholar Femoroacetabular impingement, originally described by Ganz and colleagues,4Ganz R Parvizi J Beck M Leunig M Nötzli H Siebenrock KA Femoroacetabular impingement: a cause for osteoarthritis of the hip.Clin Orthop Rel Res. 2003; 417: 112-120PubMed Google Scholar is abnormal bony morphology of the femoral head–neck junction, rim of the acetabulum, or both. This abnormal bone results in impingement and decreased space within the joint, causing damage to the intra-articular structures. Although numerous case series and cohort studies have shown that arthroscopic treatment of femoroacetabular impingement-related intra-articular damage reduces symptoms and returns patients to activity with high patient satisfaction, no phase 1 trials had been done.2Kierkegaard S Langeskov-Christensen M Lund B et al.Pain, activities of daily living and sport function at different time points after hip arthroscopy in patients with femoroacetabular impingement: a systematic review with meta-analysis.Br J Sports Med. 2017; 51: 572-579Crossref PubMed Scopus (61) Google Scholar, 3Minkara AA Westermann RW Rosneck J Lynch TS Systematic review and meta-analysis of outcomes after hip arthroscopy in femoroacetabular impingement.Am J Sports Med. 2018; (published online Jan 1.)DOI:10.1177/0363546517749475Crossref Scopus (136) Google Scholar, 5Menge TJ Briggs KK Dornan GJ McNamara SC Philippon MJ Survivorship and outcomes 10 years following hip arthroscopy for femoroacetabular impingement: labral debridement compared with labral repair.J Bone Joint Surg Am. 2017; 99: 997-1004Crossref PubMed Scopus (191) Google Scholar, 6Öhlin A Sansone M Ayeni OR et al.Predictors of outcome at 2-year follow-up after arthroscopic treatment of femoro-acetabular impingement.J Hip Preserv Surg. 2017; 4: 224-230Crossref PubMed Google Scholar, 7Skendzel JG Philippon MJ Briggs KK Goljan P The effect of joint space on midterm outcomes after arthroscopic hip surgery for femoroacetabular impingement.Am J Sports Med. 2014; 42: 1127-1133Crossref PubMed Scopus (117) Google Scholar The results from the UK FASHIoN study, reported in The Lancet by Damian Griffin and colleagues,8Griffin DR Dickenson EJ Wall P et al.Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial.Lancet. 2018; 391: 2225-2235Summary Full Text Full Text PDF PubMed Scopus (296) Google Scholar provide this needed evidence. Griffin and colleagues compare hip arthroscopy with a structured physical therapy programme (personalised hip therapy) for the treatment of hip symptoms due to femoroacetabular impingement in 348 patients. 12 months after randomisation, hip arthroscopy resulted in superior clinical benefit compared with conservative treatment (mean difference in International Hip Outcome Tool score 6·8, 95% CI 1·7–12·0; p=0·0093). Although this patient sample might seem small, the authors should be commended on completing this study with this number of patients. Today's health-care consumers tend to have abundant knowledge about their medical issues. Patients often come to the office asking for a specific treatment. There is also variability between the surgeons' training background and experience. These factors make randomised trials difficult to complete; not only is it challenging to recruit patients, but the expense of these types of studies makes them nearly impossible to do in orthopaedics. UK FASHIoN is not the only phase 1 study of hip arthroscopy. As the Article mentions, a recent study9Mansell NS Rhon DI Meyer J Slevin JM Marchant BG Arthroscopic surgery or physical therapy for patients with femoroacetabular impingement syndrome: a randomized controlled trial with 2-year follow-up.Am J Sports Med. 2018; 46: 1306-1314Crossref PubMed Scopus (116) Google Scholar in a military population showed no difference between hip arthroscopy and conservative care; however, there was a large crossover rate and power was limited in some analyses. The study by Griffin and colleagues is the first to establish the efficacy of hip arthroscopy versus physical therapy in the medical literature. The authors randomly assigned more than 50% of the available patients and provided a conservative treatment protocol, which included an assessment, injections, education, and exercise. Although the conservative protocol produced inferior outcomes, there were no differences in general health measures. The patients in the conservative group also had individualised care, which might have led to improvement in the patients' overall general health, even if their hip-related quality of life did not improve. The use of hip arthroscopy has grown exponentially over the past 15 years. As it has grown, indications have expanded, as well as providers. This development has led to much scepticism from surgeons and insurers, and much work remains to provide adequate evidence and science supporting hip arthroscopy. Diagnosis of femoroacetabular impingement has always been debated. In arthroscopy, one can actually view the impingement taking place and stress being applied to the tissue, but the radiographic angle used to diagnose cam impingement can be increased in asymptomatic individuals. More work is therefore needed to solidify the diagnosis of femoroacetabular impingement. The number of total hip arthroplasty procedures continues to increase, especially in younger individuals, and there is a need for early intervention to slow this trend. Limitations and challenges of this analysis are clearly stated in the Article. Surgical intervention was delayed in some cases, so not all patients had the same length of follow-up. To determine if the treatment effect is maintained, longer follow-up is needed on all patients. A clear path exists for the advancement of hip arthroscopy. Its proponents should recognise the importance of this study and look to support others of equal quality, and should take lessons from the knee and shoulder; for instance, taking out the meniscus did not slow the rate of total knee arthroplasties. There is now an opportunity for the hip arthroscopy community to continue this path and provide evidence for patients that will lead to better outcomes, reduced cost, and patient satisfaction, which should be the goal. We declare no competing interests. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trialHip arthroscopy and personalised hip therapy both improved hip-related quality of life for patients with femoroacetabular impingement syndrome. Hip arthroscopy led to a greater improvement than did personalised hip therapy, and this difference was clinically significant. Further follow-up will reveal whether the clinical benefits of hip arthroscopy are maintained and whether it is cost effective in the long term. Full-Text PDF Open Access