Skip to main navigation
Skip notifications
Access to POEMs and Essential Evidence Plus will no longer be included in CMA membership as of Dec. 1, 2023.
Search
Arthroscopy better than personalized physical therapy in young people with femoroacetabular impingement syndrome
Clinical Question
Do patients with femoroacetabular impingement syndrome have better quality of life when treated arthroscopically or with personalized physical therapy?
Bottom line
In this unblinded study, young adults with femoroacetabular impingement syndrome (FMIS) treated arthroscopically had slightly greater improvement in quality of life after 12 months than patients treated with personalized physical therapy, but had more adverse events. 2b
Reference
Study design: Randomized controlled trial (single-blinded)
Funding: Government
Setting: Outpatient (specialty)
Synopsis
FMIS is a painful nonarthritic hip disorder that occurs mainly in young adults and is associated with structural abnormalities of the hip joint. These authors conducted a Cochrane Review several years ago and found no high-quality evidence to guide therapy, so they decided to conduct their own study. They randomized patients to receive personalized physical therapy (PPT; n = 177) or arthroscopy (n = 171). The PPT was based on a consensus of opinions as to what constituted best practice (ie, not evidence-based). This consisted of 4 main elements: baseline assessment; patient education; specific exercises tailored to the patient and adjusted based on response; and analgesia including intra-articular corticosteroid injections. For the arthroscopically treated patients, the surgeons (27 separate surgeons) reshaped bony abnormalities and repaired labral and cartilage defects. After surgery, the patients used crutches and underwent physical therapy that was based on the surgeons' usual practice and was distinctly different from the PPT. Physical therapists did not cross over between the 2 treatment groups to avoid contamination. The primary outcome, assessed 12 months after intervention, was a self-reported quality-of-life composite score that assessed symptoms; function; physical activity; job-related concerns; and social, emotional, and lifestyle concerns. The minimum clinically important difference for this composite score is 6.1 points. Over the course of the study, 27 patients assigned to surgery received no intervention; among the patients assigned to PPT, 14 also had surgery and 9 received no intervention. Following current convention, the researchers analyzed the data based on the original allocation (intention to treat). At the end of the study, the patients in each group had significant improvement. However, the patients treated surgically had slightly greater improvement that was more than the minimum clinically important difference. One-fourth of the surgically treated patients experienced numbness in the groin, leg, or foot compared with none of the PPT-treated patients. Additionally the surgically treated patients were more likely to experience other adverse events, including infections, unscheduled appointments, and wound problems.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
Good poem
Seems like a decision aid would be needed to help patients compare the potential for harm versus benefit, of having surgery.
See above
limited study and not blinded / big issue here with bias
If you are young and athletic it is unlikely that you will get enough improvement to allow high level sporting activity without surgery. Of course there are risks but most athletes will try to do whatever is necessary to get back to sport and arthroscopy gives them the best shot
The title of the POEM is misleading in suggesting that the surgical option is “better” without also stating it had more adverse effects (which is only mentioned afterwords in the “bottom-line”).
The heading, which is the only thing busy drs often read, needs to be updated to reflect the minimal increase in benefit with the significant increase in adverse effects. Also it would be nice to see the NNT & NNH to further clarify whether the surgical option is truly advantageous over the personalized physiotherapy treatment. Thank you
The problem in Nova Scotia is accessing orthopedic surgery consultation in a timely manner. Given the years of waiting for elective assessment and treatment by an orthopod this information is mostly of only theoretical usefulness.
What prognostic factors could help determine who would benefit from arthroscopic treatment versus personalized physical therapy?
Excellent