OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent BMJ study, the following commentary comes from Matthew R. Schmitz, MD, FAOA.
Femoroacetabular impingement (FAI) syndrome continues to be a hot topic in the orthopaedic community. The first two decades of this century have seen huge increases in the number of hip arthroscopies performed in the US and UK,1,2 most of those to treat FAI. In the February 7, 2019 issue of BMJ, Palmer et al., reporting on behalf of the Femoroacetabular Impingement Trial (FAIT), published preliminary findings from a multicenter randomized controlled trial comparing arthroscopic hip surgery to activity modification and physiotherapy for symptomatic FAI.3
The trial randomized 222 patients with a clinical diagnosis of FAI into each cohort (110 in the physiotherapy group and 112 in the arthroscopy group). Follow-up assessments were performed by clinicians blinded to the treatment arm, and attempts were made to standardize both interventions. The participants will eventually be followed for 3 years, but this early report evaluated outcomes 8 months after randomization, with follow-up data available for >80% of patients in both groups.
Baseline characteristics with regard to demographics, radiographic findings, and clinical measurements were similar between the two groups. After adjusting for multiple potential confounders, the authors found that the mean Hip Outcomes Score Activities of Daily Living (HOS ADL) was 10 points higher in the arthroscopy group than in the physiotherapy group, exceeding the prespecified minimum clinically important difference (MCID) of 9 points. The MCID was reached in 51% of surgical patients compared to 32% in the therapy cohort. In addition, the patient acceptable symptomatic state (PASS)—defined as a HOS ADL ≥87 points—was achieved in 48% of surgical patients and only 19% of therapy patients. Relative to the physiotherapy group, the arthroscopic group also had better hip flexion and superior results in a variety of commonly used hip patient-reported outcomes scores.
The 8-month data from this study show that there is a real improvement in patient function and reported outcomes from arthroscopic management for FAI. It will be important, however, to follow these patients for the entire 3 years of the FAIT study to show whether these improvements persist. It should also be emphasized that only half of the patients treated with surgical management achieved MCID at the 8-month point. That finding supports what I tell patients in my young-adult hip-preservation clinics, which seems relevant as baseball season starts: There are rarely any home runs in arthroscopic hip surgery. There are mainly singles and doubles that we hope to stretch into doubles and triples. Still, it appears that even those base hits with arthroscopic surgery are better than the physiotherapy alternative—at least in the early innings of the game.
Matthew R. Schmitz, MD, FAOA is an orthopaedic surgeon specializing in adolescent sports and young adult hip preservation at the San Antonio Military Medical Center in San Antonio, TX. He is also a member of the JBJS Social Media Advisory Board.
- Maradit Kremers H, Schilz SR, Van Houten HK et al. Trends in Utilization and Outcomes of Hip Arthrocopy in the United States Between 2005 and 2013. J Arthroplasty 2017; 32:750-5.
- Palmer AJ, Malak TT, Broomfield J, et al. Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2018. BMJ Open Sport Exerc Med 2016;2:e000082
- Palmer AJ, Gupta VA, Fernquest S, et al. Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicenter randomized controlled trial. BMJ 2019; 364:l185
The September 16, 2015 JBJS study by Robinson et al. offers clear proof that many of our patients are sensitive to price when it comes to choosing where to go for arthroscopic surgery of the knee or shoulder. This phenomenon began at least a decade ago when employers began shifting the cost burden of health care coverage onto their employees. The findings from Robinson et al. confirm the increasing strength of this effect.
The authors analyzed administrative data from the California Public Employees’ Retirement System (CalPERS) to evaluate the impact of so-called “reference-based benefits” on patient choice for the setting of arthroscopy—hospital-based outpatient departments or freestanding ambulatory surgery centers (ASCs). Reference-based benefits require patients to pay the cost differential between an insurer-established “contribution limit” and the actual price charged by a facility.
Within two years of shifting to reference-based benefits, CalPERS-covered patients increased their utilization of ASCs by 14.3% for knee arthroscopy and by 9.9% for shoulder arthroscopy, with corresponding decreases in the use of hospital-based facilities. Meanwhile, CalPERS reduced overall spending on these procedures by 13%, and there were no significant before-and-after differences in 90-day complication rates.
These findings lead one to ask what added benefits patients receive from hospital-based outpatient surgery — Is it a safer environment or more convenient? Are the results more predictable? I think not, and on that basis the added charges are not justified.
Now that Robinson et al. have provided us with hard data on the impact of surgical-setting charges on patient behavior, we need to think about providing additional information that our patients would find helpful. We should, for example, move forward with increasing transparency on surgery fees and charges for outpatient visits, imaging, and durable medical goods. The time is right for us to do our part in eliminating this “black box” aspect of orthopaedic care.
At the same time, as commentators Kern Singh and Junyoung Ahn note, because payers will continue to define value according to their criteria, “orthopaedic surgeons should increase their involvement in this process to ensure the balance between outcome benefits and associated costs.”
Marc Swiontkowski, MD
The April 1, 2015 JBJS features a level II prognostic study that analyzes registry data from 243 patients (mean age: 29) who underwent arthroscopic surgery to correct femoroacetabular impingement (FAI). Almost everyone experienced clinically important and statistically significant post-arthroscopy improvements in patient-reported outcomes. However, those with relative femoral retroversion (<5° anteversion) prior to surgery experienced smaller magnitudes of improvement than those with normal or increased femoral version.
Researchers found no association between the participants’ McKibbin index (calculated from both femoral and acetabular version) and patient-reported outcomes.
According to the authors and to commentator Keith Baumgarten, MD, these results indicate that surgeons should not consider femoral retroversion to be an absolute contraindication to arthroscopic correction of FAI. However, while the findings may help orthopaedists offer prognostic counseling to young and middle-aged adults who are considering arthroscopy for FAI, the authors say the findings “may not be externally valid in adolescents,” who represent a substantial percentage of patients diagnosed with this hip condition.