Over the last few years, a surgical industry worth billions of dollars has sprung up around operating on hips with impingement or a syndrome called FAI (FemoroAcetabular Impingement). In my Colorado office, I have a practice full of the walking wounded patients who fell for this song and dance and now have new problems created by the surgery. So it’s not surprising to see yet another study that shows again, that all of these orthopedic surgeries may be operating on an MRI phantom.
What is FAI?The idea behind FAI is that either the ball or the socket of the hip has a bone spur or is misshapen and this causes labral tears and arthritis. The labrum is the lip of the ball and socket joint, and arthritis happens when the cartilage wears down, and the bone begins to deteriorate. The solution, say armies of orthopedic surgeons, is to reshape the hip joint, shave off the cartilage, and stitch up the labrum.
The number of hip arthroscopy procedures performed by orthopedic surgeons in the USA increased 18-fold between 1999 and 2009. What’s bizarre about this explosion in hip surgery is that there is no high-level evidence that the procedure is effective when used to treat FAI. In fact, everything published to date is lower level research. Given the egg on the face of the orthopedic surgical community regarding the placebo known as knee meniscus surgery, it’s right to ask whether there is the same ticking time bomb hidden in arthroscopic hip surgery. Meaning, are billions of dollars a year and countless patient complications being wasted on surgeries that will eventually be determined to be nothing more than invasive placebos?
Is FAI Itself a Mirage or Ghost?
The diagnosis of FAI is made almost exclusively on MRI imaging. There is no single blood test or highly reliable physical exam finding that can rule in or out that a patient has the problem. Hence, for this diagnosis to be real, there must be a very clear demarcation line between those with abnormal MRI findings who have pain and those without those findings who have no pain. So does that clear line in the MRI sand exist? NO.
As an example, one recent study showed that almost half of patients have findings of FAI on their MRIs and other things such as labral tears and have no hip pain or functional problems. Another study showed that one of the types of bone spurs that orthopedic surgeons like to remove in hip arthroscopy surgeries was protecting the joint and preventing the formation of arthritis! So given these studies that cast doubt on the usefulness of MRI in hip pain diagnosis, let’s look at the new research.
The New Research that Further Questions Whether FAI is Real
The new study looked at 63 normal patients with no pain or hip issues and 63 who had an MRI diagnosis of FAI and hip pain. A hole or damage in the cartilage and/or labral abnormality was present on average in 57% of asymptomatic volunteers, compared with 80% of symptomatic patients! So while patients with FAI were more likely to have cartilage and labral abnormalities, almost 6 in 10 patients without FAI or any hip pain had them as well! So there was no clear demarcation of MRI findings between pain-free and symptomatic patients! This study and the others cited, raise serious doubts about the wisdom of using MRI measurements as the reason to operate on sore hips.The upshot? These days, if you develop hip pain that won’t remit, you’re just an MRI and a cursory exam away from getting your entire hip anatomy remodeled by an orthopedic surgeon on the belief that this will help your hip pain. This is despite continued research that many of us without any hip pain have FAI, labral tears, or lost cartilage. What all of this research is saying is that despite our current penchant for operating on MRI findings, hip pain is a much more complicated thing and the MRI only tells part of the story. So if you’ve been told you need arthroscopic hip surgery, please get a second opinion from a provider who offers precise image-guided PRP and stem cell work, as these procedures can be very successful when the problem is caught early. Also, make sure that every exam of your hip also includes an extensive examination of your low back!