With about half of hip osteoarthritis caused by FAI, the comparison of best practice conservative care (with physical therapy as a key component) with hip arthroscopy is an important topic. Three randomized controlled studies (RCTs) have emerged, of which the FAIT study is the most recent. FAIT is an assessor-blinded, pragmatic, multicenter RCT, which concluded both physical therapy (PT) and hip arthroscopy groups had safe and significant improvement, but hip arthroscopy was more effective with significantly more improvement in pain, function (primary patient-reported outcome - HOS ADL) and hip flexion range.
The first published RCT on this topic concluded there was no significant difference between PT and hip arthroscopy groups of military patients at 2 years post-randomization. However, that single-center study has been discounted mainly because of its high 70% crossover rate (patients randomized to PT group that then opted for surgery), in essence comparing a hip arthroscopy group with 95% surgery rate to a PT group with 70% surgery rate. The Centre for Evidence-based Medicine suggests a crossover rate greater than 20% may invalidate results.
The next RCT was the FASHIoN study. The FAIT and FASHIoN RCTs, albeit with time from randomization of 8 and 12 months, respectively, are more robust and less flawed, with larger study populations, multicenter designs with experienced hip arthroscopic surgeons and relatively low crossover rates (3% and 8%, respectively). Both studies reported statistically and clinically significant improvement (albeit with wide variability and small effect sizes) in favor of hip arthroscopy for the treatment of symptomatic FAI.
So, what do I conclude so far? On balance, arthroscopic hip surgery seems superior to physiotherapy in the treatment of symptomatic FAI. However, both PT and hip arthroscopy may benefit patients as relatively safe treatments, not all patients will improve with either treatment (We know this, but our patients need to know this, too), and it seems reasonable to encourage PT as a first-line treatment option which may, in some instances, be sufficient. I look forward to ongoing and future high-quality investigations to better define which patients will benefit most, or not at all, from each option.
Faucett SC, et al. Am J Sports Med. 2018;doi: 10.1177/0363546518777483.
Griffin DR, et al. Lancet. 2018; doi:10.1016/S0140-6736(18)31202-9.
Palmer AJR, et al. BMJ. 2019;doi:10.1136/bmj.l185.
Rhon DI, et al. Am J Sports Med. 2018;doi:10.1177/0363546518777482.
Dean K. Matsuda, MD
Orthopedics Today Editorial Board Member
Disclosures: Matsuda reports no relevant financial disclosures.