Physiotherapy or Surgery? Which is better for the treatment of Femoroacetabular impingement? (FAI)

A recent study has concluded that surgical management of FAI gives improved outcomes over a conservative programme with physiotherapy. This is an important study because it was a randomised controlled trial which means that patients who agreed to be part of the study were randomly allocated to treatment with either surgery or physiotherapy. These patients were recruited from a number of different centres. This type of study is the most valid in terms of a scientific investigation. After a follow-up of one year patients were re-evaluated to assess their outcomes and the patients who had undergone arthroscopic surgery had a better outcome than those who had only had physiotherapy.

This study was published in the Lancet earlier this year (Lancet 2018; 391: 2225–3). It reinforced my feelings regarding the management of FAI and it was gratifying to see the results, particularly as we contributed a number of patients to the study from University College London Hospitals.

A further study from Oxford with a similar design has also been completed with similar conclusions.
This does not of course mean that physiotherapy is not important as part of the management of FAI, but it indicates that in the presence of an identified morphological abnormality of the hip, when symptoms persist, patients should be referred for surgery to address the underlying abnormality.
Although there have been a number of studies indicating that arthroscopic surgery is effective in improving pain and function in patients with FAI these recent studies provide the most definitive information we have to date to indicate the effectiveness of arthroscopic intervention. It is also important that we have this information as hip arthroscopy has been under scrutiny as a procedure and with regards to the NHS commissioning this as a treatment these studies provide good evidence that the treatment is effective.

Recently I was at the main international meeting related to hip preservation surgery, the International Society for Hip Arthroscopy and Hip Preservation, in Melbourne Australia. From the presentations and discussions at this meeting it is clear that a lot of the failures associated with hip arthroscopy are related to not making a clear diagnosis and surgery not being performed adequately to address the underlying abnormality. Hip dysplasia remains a significant reason for failure of hip arthroscopy, but it is apparent that a lot of surgeons who only perform hip arthroscopy are now recognising the poor outcomes of surgery when this diagnosis is not recognised.

Arthroscopic surgery for FAI remains a complex procedure, not only in terms of being clear about the diagnosis but the surgery to correct the abnormal shape of the hip is not easy and requires an extensive surgical learning curve with exposure to a large number of cases. In my view this requires a specialised hip practice to see sufficient cases and interpret the imaging findings in conjunction with patient symptoms.

Ultimately, I think it is likely that now we are clear that arthroscopy is effective for FAI, centres will be established where there is a sufficient number of cases for expertise to be built up. This is already very much the case in the NHS but increasingly will have to be similar in the private sector, so as to ensure patients are seeing a surgeon with the appropriate expertise for their condition.