February 2016

Skipping hip surgery: FAI responds to conservative care

In the moment: Sports medicine

2ITMsports_iStock34142360-copyBy John C. Hayes

A pilot study has found that conservative management of femoroacetabular impingement (FAI) can provide improvements in pain and function equivalent to those usually achieved with surgery.

The study, epublished in January by the Journal of Science in Medicine and Sport, joins a growing effort by researchers to evaluate treatment options for FAI other than the traditional approaches used by orthopedic surgeons.

Future studies may establish that there is a population of FAI patients that could be conservatively managed and avoid surgery, said principal study author Alexis A. Wright, PhD, assistant professor and assistant chair of the Department of Physical Therapy at High Point University in North Carolina.

Fifteen patients (11 women) with FAI were randomized to two groups: eight patients received a combination of manual therapy and supervised exercise, plus advice on home exercise; seven patients received advice and home exercise alone. Outcomes included self-reported average pain and physical function as measured by the Hip Outcome Score (HOS).

After seven weeks, the researchers found no statistically significant differences between the two groups in either measure and also that outcomes were equivalent to what is found in the surgery literature.  Functional outcomes under the HOS Activities of Daily Living subscale went from 74.3% at baseline to 81.1% for the therapy group, and from 73.8% to 85.1% for the home group. Mean pain scores fell from 39.9 to 22.3 on a 100-point scale for the therapy group and from 39.1 to 21.1 for the home group.

“What this suggests is that, in this patient population, conservative treatment measures might be useful; even the ones with stretches and very basic strengthening exercises did show improvement,” Wright said.

Although there are few published studies of conservative FAI management, Wright said there is a precedent in studies of shoulder impingement, which have found that the condition can be managed without surgery in its early stages. Unfortunately, the opportunity for early therapy is usually missed in FAI because the diagnosis is made an average of three years after the onset of symptoms. At that point, the patient is usually referred to an orthopedist and the solution is surgery.

“I do think we’re fighting an uphill battle,” Wright said of those who think conservative management might be a good option for FAI. “Once [patients] have in their mind that surgery is the only option, they are less likely to respond to or try physical therapy measures.”

Improved clinical criteria so FAI is diagnosed earlier, along with studies that demonstrate to clinical therapists which nonsurgical measures might work, may help, Wright said.

Devyani Hunt, MD, an associate professor of orthopedic surgery at Washington University in St. Louis, MO, said her group’s research on conservative management of FAI and other hip pathologies has led to change in management of patients.

Today at Hunt’s facility it is common for such patients to receive conservative therapy and they may benefit from it even if they do proceed to surgery, she said. Conservative therapy, for example, can treat biomechanical issues associated with FAI and thus improve surgical outcomes, although there are no published data on this.

Their approach is to provide basic protocols for FAI but give therapists the option to vary the regimen because hip pathology can reflect a combination of factors for each patient, Hunt said. Wright et al’s study, which examined different approaches to conservative therapy, adds to the evidence on which therapists base their treatment decisions, Hunt said. Larger studies are still needed, she added.

Although the High Point and St. Louis groups both found improved function and pain with conservative therapy, each group also found that more than half of conservatively treated patients went on to surgery. Part of this may reflect the needs and expectations of individual patients.

For example, Wright said one of the patients in her study was a Division I track and field athlete, for whom the improvements associated with conservative care did not allow him to compete at a high level. He was one of those who went on to surgery, Wright said.

Sources:

Wright AA, Hegedus EJ, Taylor JB, et al. Non-operative management of fe­moro­acetablar impingement: A pros­pective, randomized controlled clinical trial pilot study. J Sci Med Sport 2016 Jan 6. [Epub ahead of print].

Hunt D, Prather H, Harris Hayes M, Clohisy JC.  Clinical outcomes analysis of conservative and surgical treatment of patients with clinical indications of prearthritic, intra-articular hip disorders. PM R 2012;4(7):479-487.

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