Hip Surgery Procedures for Treatment of Femoroacetabular Impingement Syndrome – Re-review Final evidence report October 22, 2019 Health Technology Assessment Program (HTA) Washington State Health Care Authority PO Box 42712 Olympia, WA 98504-2712 (360) 725-5126 www.hca.wa.gov/hta [email protected] Hip Surgery Procedures for Treatment of Femoroacetabular Impingement Syndrome – Re-review Provided by: Aggregate Analytics, Inc. Prepared by: Andrea C. Skelly, PhD, MPH Erika D. Brodt, BS Shelby Kantner, BA October 22, 2019 WA – Health Technology Assessment October 22, 2019 This technology assessment report is based on research conducted by a contracted technology assessment center, with updates as contracted by the Washington State Health Care Authority. This report is an independent assessment of the technology question(s) described based on accepted methodological principles. The findings and conclusions contained herein are those of the investigators and authors who are responsible for the content. These findings and conclusions may not necessarily represent the views of the HCA/Agency and thus, no statement in this report shall be construed as an official position or policy of the HCA/Agency. The information in this assessment is intended to assist health care decision makers, clinicians, patients and policy makers in making sound evidence-based decisions that may improve the quality and cost- effectiveness of health care services. Information in this report is not a substitute for sound clinical judgment. Those making decisions regarding the provision of health care services should consider this report in a manner similar to any other medical reference, integrating the information with all other pertinent information to make decisions within the context of individual patient circumstances and resource availability. Hip surgery for femoroacetabular impingement syndrome: final evidence report Page i WA – Health Technology Assessment October 22, 2019 Contents Executive Summary ....................................................................................................................................... 1 1 Appraisal ................................................................................................................................................. 1 1.1 Background and Rationale ............................................................................................................... 1 1.2 Contextual Questions ....................................................................................................................... 1 1.3 Research Key Questions ................................................................................................................... 2 1.4 Key considerations highlighted by clinical experts .......................................................................... 3 1.4.1 What is the prevalence of FAI? How frequent is it? ............................................................... 3 1.4.2 What is the etiology and natural history of FAI? .................................................................... 6 1.5 Outcomes Assessed ......................................................................................................................... 8 1.6 Washington State Utilization Data ................................................................................................... 8 1.6.1 Findings ................................................................................................................................... 9 2 Background ........................................................................................................................................... 10 2.1 History of Femoroacetabular Impingement as a Diagnosis: Epidemiology and Burden of Disease ....................................................................................................................................................... 10 2.2 Mechanism of Femoroacetabular Impingement ........................................................................... 11 2.3 Classification of Femoroacetabular Impingement ......................................................................... 11 2.4 Technologies & Interventions ........................................................................................................ 12 2.4.1 Non-operative Treatment ..................................................................................................... 12 2.4.2 Operative Treatment ............................................................................................................. 12 2.5 Indications and Contraindications ................................................................................................. 13 2.6 Potential Complications/Harms of FAI surgery .............................................................................. 14 2.7 Clinical Guidelines .......................................................................................................................... 14 2.8 Previous Systematic Reviews & Health Technology Assessments ................................................. 18 2.9 Medicare and Representative Private Insurer Coverage Policies .................................................. 26 3 The Evidence ........................................................................................................................................ 34 3.1 Methods of the Systematic Literature Review .............................................................................. 34 3.1.1 Objectives .............................................................................................................................. 34 3.1.2 Contextual Questions ............................................................................................................ 34 3.1.3 Research Key Questions ........................................................................................................ 34 3.1.4 Inclusion/Exclusion Criteria ................................................................................................... 34 3.1.5 Data Sources and Search Strategy ........................................................................................ 37 3.1.6 Data Extraction ...................................................................................................................... 39 3.1.7 Quality Assessment: Risk of Bias, QHES evaluation & Overall Strength of Evidence, ........... 39 3.1.8 Analysis .................................................................................................................................. 41 Hip surgery for femoroacetabular impingement syndrome: final evidence report Page ii WA – Health Technology Assessment October 22, 2019 4 Results .................................................................................................................................................. 42 4.1 Contextual Questions ..................................................................................................................... 42 4.1.1 Contextual Question 1 .......................................................................................................... 42 4.1.2 Contextual Question 2 .......................................................................................................... 65 4.2 Key Question 1: Efficacy and effectiveness ................................................................................... 75 4.2.1 Number of studies retained .................................................................................................. 75 4.2.2 Operative vs. Non-operative Treatment ............................................................................... 77 4.2.3 Operative vs. Operative Treatment ...................................................................................... 92 4.3 Key Question 2: Safety ................................................................................................................. 109 4.3.1 Number of studies retained ................................................................................................ 109 4.3.2 Randomized controlled trials .............................................................................................. 109 4.3.3 Comparative cohort studies ................................................................................................ 113 4.3.4 Case series ........................................................................................................................... 117 4.4 Key Question 3: Differential Efficacy and Safety in Subpopulations ........................................... 127 4.4.1 Number of studies retained ................................................................................................ 127 4.4.2 Operative vs. Non-operative Treatment ............................................................................. 127 4.5 Key Question 4: Cost Effectiveness .............................................................................................. 128 5 Strength of Evidence (SOE) ................................................................................................................. 138 5.1 Strength of Evidence Summary for Key Question 1: Efficacy Results for Operative (Arthroscopy) versus Non-operative (Physiotherapy) Treatment ...................................................................... 139 5.2 Strength of Evidence Summary for Key Question 2: Safety Results with a Focus on Operative Treatment. 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