Collins, J, Ward, J and Youm,T. Is Prophylactic Surgery for Femoro-Acetabular Impingement Indicated? A Systematic Review. Am J Sports Med 2014 42: 3009
Background
- Degenerative joint disease of the hip is a prevalent disorder that plays a major role in patients’ quality of life as well as overall health care costs.
- Primary osteoarthritis affects between 3% and 6% of adults.
- Approximately 0.015% of adults in the USA with symptomatic osteoarthritis eventually undergo surgical intervention.
- Since 1965, it was proposed that subtle morphological changes of the hip, now known as femoro-acetabular impingement (FAI), may contribute to degenerative hip changes.
- FAI can lead to abnormal contact forces within the hip joint, potentially causing osteoarthritis.
The Review
The authors did a systematic review to determine if prophylactic surgical intervention for asymptomatic patients with radiographic evidence of FAI is warranted to prevent early degenerative joint disease of the hip.
They also wished to answer several questions including;
- What is the prevalence of FAI in the asymptomatic population?
- What is the natural history of FAI if left untreated?
Methods
- A systematic search was performed from 1965 to 2013 in PubMed and EMBASE.
- Inclusion criteria were studies comparing asymptomatic adult patients with radiographic evidence of FAI treated with prophylactic hip arthroscopic surgery versus conservative management.
- A total of 840 references were identified from the searches.
Results
- Although valid points were discussed, no trials were identified that met the inclusion criteria for this review.
- To date, there are no prospective randomised studies that show that FAI leads to early osteoarthritis or earlier total hip arthrosis. Furthermore, there are no prospective randomised studies that demonstrate that surgery to correct FAI prevents the development of early osteoarthritis. There is conflicting data in the literature in regards to the progression of degenerative joint disease in the presence of FAI.
- There is a lack of available evidence to support surgical intervention for the treatment of FAI in asymptomatic patients. Limited evidence suggests that asymptomatic patients who have previously undergone total hip arthroplasty for FAI-induced osteoarthritis of the contralateral hip are at a significantly increased risk for early degenerative joint disease.
- There is some evidence to suggest that arthroscopic treatment of symptomatic FAI can be beneficial to patients even beyond 50 years of age. If surgery is undertaken, worse outcomes and a significantly higher failure rate have been shown when joint space narrowing of >0.2 mm is present. Further research is needed to better clarify surgical indications.
Take Home Message for Physios/Patients
- FAI is relatively common in asymptomatic patients, with prevalence rates up to 74% of the population.
- Clearly, recommending prophylactic surgery for every patient with FAI would pose a surgical risk to the general population and place a huge burden on the NHS
- At this point, a review of the literature shows that surgical correction for FAI in the properly selected symptomatic patient can improve pain and function.
- However, we cannot assure patients based on clinical evidence that surgical correction for FAI, whether symptomatic or asymptomatic, will necessarily allow them to avoid osteoarthritis and future hip replacement.Thanks for reading,
Annika Williams
Senior Physiotherapist