Is surgery a guarantee of improvement for FAI?

If you're considering surgery for FAI, you've probably heard some very optimistic numbers around success rates for arthroscopic hip surgery. Physicians can sometimes convey the idea (intentionally or unintentionally) that the surgery is a surefire way to fix your hip pain. If you're seriously considering the surgery, it'll be helpful to take a look at the medical research that's been done on actual outcomes for this procedure.

In this post, we'll look more closely at studies that claim high success rates, and we'll look at what recent research says about actual patient satisfaction with FAI surgery. 

At the bottom of this page, you'll also find a list that we intend to keep updated on high quality studies on FAI surgery satisfaction rates.

 

Some studies say that FAI surgery works really well

In this study for example, Arthroscopic Femoroplasty in the Management of Cam-type Femoroacetabular Impingement, 83% of patients were reported to have had improvement from surgery for cam and mixed (cam and pincer) impingement.  

The study notes that the average improvement for those who got improvement was 20 points on the Harris Hip Score. The range of scores went from -17 (meaning someone got much worse) to +60 (meaning someone felt much better).

On the face, a study like this sounds very promising, but the reality is much different if you take a closer look.

 

...But let's take a closer look at FAI surgery success scoring

Looking at that study, everything sounds very promising. However we need to look closer at the Harris Hip Score questionnaire to understand what "improvement" really means. 

The Harris Hip Score is a series of questions that get answered pre and post-operation. In general, to be considered a successful hip surgery, the patient must score at least 20 points higher post-op than they did pre-op. It is also a flawed metric that does not align with a patient's definition of success. The way the points are tallied does not actually line up with what a person with hip pain would consider success! 

Let's look at a key question related to this: "how difficult is it to get 20 points?"

The answer is NOT VERY. Let's take a look together.

Open the Harris Hip Score so you can follow along and test this out yourself. The very first question is about pain. Go ahead and fill in that you're "marked pain" (one step better than the very worst). Scroll down and look at your score. You should see 10. 

 

(If you'd like a video walk through of this section, please watch this YouTube video).

 

Now select the "mild pain" answer. This one corresponds to having moderate levels of pain for non-average/daily activities.  You may still be taking aspirin as a gentle pain killer to function. Now scroll down and look at your score. You have just earned 20 points. Would still having pain and needing to take pain killers be considered a success for you?

You could also select "none or ignores it" as your answer and see your score jump to a total of 44 points! Imagine if at follow up your doctor asks you, "how is the pain?" and you say, "Well, it's still there, still annoying, but I can ignore it and move on with my life." You just earned top marks and the surgery would be a smashing success.

Now reset your questionnaire and look at the section on "limp." Select "severe" and look at your score. You should see a zero. Then select "slight." Scroll down. You just earned 3 points.

So let's say you go from marked pain with a severe limp down to mild pain with a slight limp. Is that a success to you? It's an improvement of 23 points; the surgery is considered an absolute unquestioned success based on the Harris Hip Score.

 

So let's say you go from marked pain with a severe limp down to mild pain with a slight limp. Is that a success to you? It's an improvement of 23 points; the surgery is considered an absolute unquestioned success based on the Harris Hip Score.

 

The reality in this study is that the improvement in quality of life did not need to be very pronounced for the surgery to be considered a success.

You have to ask yourself whether this level of "improvement" is (1) worth the expense and time and (2) whether this kind of improvement supports or undermines the idea that surgery is actually addressing the root cause of the problem.

 

How can you measure success of FAI surgery better? Patient expectations versus outcomes...

If metrics like the Harris Hip Score don't accurately reflect the expectations and desires of patients, the easiest way to get patients' opinions is to find out about their satisfaction.

Another study done in 2012 called Fulfilment of patient-rated expectations predicts the outcome of surgery for femoroacetabular impingement looked at 86 patients' experience with surgery to fix their FAI. They studied the patient motivations and expectations for surgery to see how motivations and expectations affected the patients' outcomes.

In this study, the patients had very common, familiar motivations for surgery.

The top most important reason to get surgery was to alleviate pain. The second and third were preventing worsening of the situation and improvement in physical capabilities respectively.

57% of the patients expected their hip pain would get "much better" and that a further 40% expected it to be "better" post-surgery. 46% expected their ability to do sport to be "much better," and 37% expected it to be "better."

These are pretty normal expectations. People want to get their lives back! They want to get back to activities they love without hip pain. 

 

Does surgery for FAI get you back to your activities?

fai surgery satisfaction graph

Illustration from Fulfilment of patient-rated expectations predicts the outcome of surgery for femoroacetabular impingement

In the study mentioned above, the results were not good after 12 months. Patients were asked whether their expectations were met by the surgery. As you can see in the graph to the left, there was a lot of disappointment.

56% of patients did not have their expectations met for hip pain. 61% were disappointed by the improvement in sport. 53% were disappointed in terms of general function. 33-45% were disappointed in terms of independence, mental well-being, and walking capacity. 

For those who are interested in returning to their sports, the numbers are very disconcerting. 61% of the patients did NOT have their expectations met in terms of sport.

Even general function failed to deliver for 53% of the patients! That means more than half were disappointed in the outcome in terms of general daily life.

 

How did patients rate the overall effectiveness of surgery?

29% believed it helped a lot. We can say these people were probably pretty satisfied. But what about the others?

39% thought it helped some. That means the surgery didn't actually solve all their issues.

21% said it helped only a little. For 1 out of 5 patients in this study, this would probably not be considered successful (though it's debatable).

9% said it did not help at all. This is definitely not a good outcome.

2% reported that it made things worse.  This would be the worst outcome of all.

To reiterate, only 29% though the surgery was a big help. 71% thought it was somewhat of a help down to the worst-case scenario of the surgery making things worse. More than half were disappointed by their improvement in daily function and sports.

Those are not stellar results.

 

Do recent studies show that patients are satisifed with surgery for FAI?

A study published in 2016, Multicenter outcomes of arthroscopic surgery for femoroacetabular impingement in the community hospital setting, looked at patient satisfaction after 2 years.

At the 2 year mark, only 64% of patients were satisfied. The study concludes that "arthroscopic surgery for symptomatic femoroacetabular impingement in the community setting provides safe and successful outcomes." 

If you only read the conclusion, you might think the study really strongly supports the use of surgery for FAI. But let's put the results into perspective.

36% of the patients were not satisfied. That's roughly one out of every three people in that study not satisfied with the surgery. 

It's also interesting to realize that being "satisfied" may not mean the surgery actually improved the patient's quality of life. Dr. David Hanscom, MD., a spinal surgeon, shares a very interesting statistic in his book on the perils of spine surgery that is relevant. In one study, 16% of patients who had poor results from surgery said they would choose to do the surgery again.

While the surgery may not even improve the situation, people can still be "satisfied" that they tried the only option that was presented to them. 

This is very likely to be influencing hip surgery satisfaction rates as well.

 

 

If you'd like a more in-depth analysis of this study, you can check out the article here. 

 

Conclusion

As you can see from studies like these, surgery for FAI does not seem to be anywhere near as successful as reported earlier in the medical literature.

These recent studies suggest that dissatisfaction and unmet expectations are extremely likely with surgery for FAI. In one study, over half the patients were disappointed by improvements in daily life and in sport. In another, 36% were disappointed overall by the surgery.

Based on these outcomes, surgery for FAI should be considered only very cautiously and as a last resort.

In addition, we believe that these disappointing numbers are one more indication that the underlying theories for FAI may not be accurate. You may want to read more on FAI and arthritis and FAI bone shapes and pain.

 

List of studies related to surgical outcomes for femoroacetabular impingement

We feel it's especially important to stay informed on the latest studies on the success rates of hip arthroscopy for FAI. As we come across more studies on surgical success rates for femoroacetabular impingement, we will update this list.

Fulfilment of patient-rated expectations predicts the outcome of surgery for femoroacetabular impingement (Jan. 2013)

Multicenter outcomes of arthroscopic surgery for femoroacetabular impingement in the community hospital setting (July 2016)

 

Real stories from people who have had hip surgery

This playlist of videos features interviews with real people who have gotten surgery for their hips. You'll get their honest insights on the process they went through and the lessons they learned following surgery. 

 

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