A new systematic review suggests that surgery, compared to physiotherapy alone, provides better results for people with symptomatic FAI. However, a combined approach of physical therapy and surgery gives the best long-term results.
In this post we will examine this systematic review and see what conclusions can be drawn from the systematic review and what changes we need to make to our clinical practice.
What is Femoroacetabular Impingement?
Femoroacetabular Impingement Syndrome (FAI) is a movement-related disorder of the hip in which premature contact between the acetabulum and the proximal femur causes pain and functional disorders. There are different types of FAI that can be broken down into three different morphologies. A CAM impact describes a flattening or convexity of the femoral head and occurs more frequently in men. A PINCER describes an overlap of the femoral head by the acetabulum, in which the acetabular rim extends either generally or focally beyond the typical amount and occurs more frequently in women. The third type is believed to be the most common (although this is discussed) and is a MIXED type with elements of both cam and pincer impact.
Align your hip and knee exercises for better results
It is believed that these morphologies are quite common in the general population, however only a fraction of them become problematic and develop FAI syndrome. According to a systematic review, the development of the syndrome is likely to be multifactorial, so the presence of morphology alone does not mean that pain and impairment will develop.
There is debate about what is the best management strategy for FAI. The most common treatment is arthroscopic surgery, which involves reshaping or trimming the bones depending on the morphology of the impact. However, there are some limitations to the surgery because the hip ROM does not improve in the frontal plane, resulting in persistent impairment of activities such as climbing stairs. This is one of the key roles physiotherapy plays in treating FAI, with strengthening the hips and knees playing a critical role in improving functional outcomes after surgery.
Some studies suggest that conservative management provided patients with equally good, if not better, results for the operation. In particular, Casertelli et al. (2016) and the UK FASHIoN study suggest that individualized exercises to strengthen the hip and knee, as well as proprioception, give good results and prevent the need for surgery by reducing exposure to surgical complications.
A new systematic review published this week in the Orthopedic Journal of Sports Medicine attempted to advance our understanding of which approach to FAI should be taken. a conservative or surgical approach. This review was specifically aimed at examining short-term results.
Methodology of the systematic review
This systematic review makes a reasonable contribution to reporting on the methodological approach used. The PRISMA guidelines have been followed by the authors of the paper and the search strategy and research question are clearly available to the reader. However, more could have been done to fully publicize the search strategy. A short, abbreviated version of the keywords used is available, which is disappointing as it prevents criticism. The databases used for verification go beyond Cochrane's recommendations, which can be clearly seen, and a transparent process is available in the PRISMA flow chart
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The research question that was to be answered with this systematic overview was:
"Is there a difference in the patient-reported results of patients with femoroacetabular dysplase who underwent surgery compared to conservative management with physical therapy?"
The study selection and data collection is more detailed than the search strategy, which offers a reasonable scope for the evaluation of the process. Only two reviewers were used to extract and select the studies used in the review, rather than the recommended three. This means that there was no third reviewer available to deliver a judgment if there were disagreements between the two reviewers. It's unclear what the two did when there was a disagreement.
CONSORT, TIDieR, CERT and the Cochrane Risk of Bias Tool were all used to ensure evidence-based requirements for both physical and surgical studies and to assess the risk of bias. A total of three (n = 3) studies were used in the review, which included results for 650 patients. Two of the studies were rated as good with a minimal risk of bias, while one study found a high risk of bias for a single center due to poor reporting and a cross-over study design. All studies could not be blinded due to the nature of the procedures to be assessed.
It must be taken into account that all studies waited a long time between randomization and the operation (~ 3 months) and the assessment of the short-term results in relation to the time of randomization. None of the included studies related to the now popular capsule-locking surgical procedure, which initial studies show that it improves outcomes compared to the approaches used in this systematic review.
Results and analysis
The outcome measures used in the review were iHOT-33 (all three studies), HOS-ADL and HOS-Sport. Sufficient heterogeneity of the results made it possible to carry out a meta-analysis with an SMD.
If one looks specifically at the physiotherapeutic interventions, there are large differences in the included studies and no standardization in the choice of treatment. Similarities in approach include home exercise schedules that consist primarily of hip strengthening and neuromuscular control and training sessions that focus on avoiding the impact position.
The overall operation improves the iHOT-33 and HOS-ADL values more than physiotherapy alone. There was no difference in outcome between the treatment groups after 6 months. Those who transitioned from physical therapy to surgery had better results than any individual treatment group.
Clinical implications
There is not enough high quality, unbiased data to enable definitive conclusions to be drawn in answering this specific research question. What we can say is that post-operative physiotherapy surgery that focuses on hip and knee proprioception and strengthening exercises is currently producing the best results for patients. There are also pointers to aid in the use of training sessions designed to prevent patients from getting into an impact position.
