Innovation is the aurulent gleam of scientific efforts, it's the shine that the scientific community so desires to share and spread, and there is no question about the role that insight plays in this endeavour.
Roughly all major contributions in science play out fairly similarly, an expert figures out something through hard work or maybe sheer luck (paired with knowledge of the subject of course) and then they study the phenomenon/entity/reaction/mechanism/substance meticulously, publish a finding of what they think their observations mean and the community then picks it up, re-interpret it in a few additional ways (maybe try to replicate it) and find some practical real-life applications of said information.
Our story begins with one such insight (rather a well-studied and inferred solution) towards a rather difficult problem. Before Reinhold Ganz and colleagues figured out a safe way to dislocate the hip joint (by preserving the medial femoral circumflex artery, yep big sciency words for a vessel that supplies blood to the ball of the hip), osteonecrosis of the femoral head was a big issue (death of the ball of the hip; because no blood supply) and there wasn't much data on the morphology of the inside of the hip joint.
Their innovation helped them to visualize a lot of hips *wink wink* (~600! of them) and conclude a lot of previously inconclusive trains of thought. One of the major suppositions they made was "Femoroacetabular Impingement is a cause of osteoarthritis of the Hip".
Sounds saucy no? and it actually was for the time! because of the underlying credibility and the amount of attention it got. and for good reason too, even I wouldn't doubt if an expert said that "I looked at 6000 watermelons and I found that the wonky ones taste better", I'd totally buy and recommend the wonky and lopsided ones.
This is what went down in this case as well, a whole hoard of centres and hospitals started offering preventative surgery and the logic was simple 'if it causes arthritis, removing the 'impingement' would prevent it'.
Great if it did, isn't it? but it didn't!
And now we'll see why? but first, let's understand a bit about what FAI-S actually is.
To avoid too much medical jargon, I'll state it simply in layperson terms:
1. What it is: Is a disorder of pain and disability (particularly around the Hip), defined by a triad of symptoms, clinical signs and imaging findings.
- What this means: In order to say that a person has FAI-Syndrome they must have
Some symptoms: position or motion-related disability and pain (around the hip, groin, front/back of the thigh, butt, knee or lower back) maybe some mechanical stuff as well (clicking, locking, stiffness, laxity).
Some signs: FADIR, Flex. IR, ROM restrictions, FABER distance reduction, walking stability, reduced single leg control, some tenderness *(mostly what your HCP is concerned with)
Some radiological findings: Soft tissue pathology (labral tears) on MR imaging, CAM or Pincer morphology (seen on Pelvic imaging or hip radiographs and angular measurements using Dunn view or Frog lateral view) *(again mostly what your HCP is concerned with)
Only after these findings can we say that its FAI-Syndrome.
2. What we don't say anymore:
What this means: You probably don't have and shouldn't be labelled as having FAI-Syndrome unless you have all the 3 previously mentioned criteria met. If not, you just have a Cam or Pincer morphology (especially in absence of pain).
*cam and pincer morphology isn't pathology*
3. What is the prognosis (future course and outcome):
Functionally; the outcomes of Conservative and Surgical management are moderate at best at 1-2 years. With surgical treatment reaching significant functional improvements a bit early.
To roughly put it in numbers, with only 57% of athletes return to sport, and of those that do only 30% return to optimal performance.
*Don't be discouraged by this, a physical-rehab-led management program tailored to more personalized goals and needs can lead to much better outcomes (with or without surgical intervention).
Equipped with this information, let's head back to our story of how a seemingly obvious solution didn't work as we thought it would.
So, what went wrong?
The plan was simple if you saw cam morphology just snip it away and voila! Osteoarthritis prevented.
If only it were that easy. The fundamental problem with reductionist problem-solving is that a few key elements could be missed.
And thus they were, jumping to a solution made the community forget a simple question "What we saw in people with pain present otherwise as well and if it is can we attribute causation to what we saw?"
In simpler words, if we examine pain-free people and find cam morphology is it really 'THE' cause of pain?
And that is exactly what studies later found (hence the change in terminology). (ref. ref. ref.)
Prevalence of cam morphology: 49% of athletes without pain, 65% of all athletes regardless of symptoms.
Prevalence of Soft tissue pathology: 56% of subjects tested.
Only chondral (joint surface) abnormalities were seen majorly in people with pain (64% and less in pain-free individuals 12%)
- What it means: There is some truth (technically) to the findings of Ganz and colleagues, that is, CAM morphology is somewhat associated with people having Hip Osteoarthritis,
BUT!.... changing (surgically removing) it is likely not going to prevent or delay the onset of Osteoarthritis in those individuals as well.
To explain and summarize the story and the image above (ref.) it all went down like this:
Scientists found a safe way (without killing the hip) of dislocating the joint surgically, leading to better visualization of what was happening there and a better understanding of the structures (normal and supposedly abnormal alike).
The publication led to the emergence of the idea that FAI is the root of all evil in the hip, if we burn (surgically remove) it, all will be solved.
Further, follow-up studies and comparative data to pain-free individuals showed that surgical outcomes were disappointing beyond the short term and many people without pain had the same morphological features, then the question emerged "did FAI really exist?"
Thus formed a consensus statement (The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome)) and we figured that it does exist but on what term? (remember the criteria?)
And finally the point we are at today, a point where we are able to make more informed decisions and produce much better outcomes.
With a better understanding of the pathology and the prevalence of imaging findings in the asymptomatic population, a more precise definition of FAIS (triad of symptoms, signs, and imaging), and the recognition that not all patients require surgery.
&
Thus this becomes an example of how hype comes with expectations and cools down with objective research justifying (in my own head) the saying that
"if it sounds too good to be true, it probably is".
For more go to Physio Explored Blogs
Disclaimer: This blog is for educational purposes only.
Comments