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Author reply to “Regarding ‘Operative Versus Nonoperative Treatment of Femoroacetabular Impingement Syndrome: A Meta-analysis of Short-Term Outcomes’”

      We thank Kim et al. for their comments regarding our article.
      • Dwyer T.
      • Whelan D.
      • Shah P.S.
      • Ajrawat P.
      • Hoit G.
      • Chahal J.
      Operative versus nonoperative treatment of femoroacetabular impingement syndrome: A meta-analysis of short-term outcomes.
      We sought to perform a meta-analysis of treatment outcomes in patients with femoroacetabular impingement syndrome (FAIS) comparing operative and nonoperative treatment. When possible, we focused on 12-month outcomes given that this is the time frame of important clinical decision making such as evaluation of surgical success and return to sport.
      • Ishoi L.
      • Thorborg K.
      • Kraemer O.
      • Holmich P.
      Return to sport and performance after hip arthroscopy for femoroacetabular impingement in 18- to 30-year-old athletes: A cross-sectional cohort study of 189 athletes.
      ,
      • Sardana V.
      • Philippon M.J.
      • de Sa D.
      • et al.
      Revision hip arthroscopy indications and outcomes: A systematic review.
      However, the included study by Palmer et al.
      • Palmer A.J.R.
      • Ayyar Gupta V.
      • Fernquest S.
      • et al.
      Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: Multicentre randomised controlled trial.
      only reported outcomes after 8 months of randomization. These results were included in our meta-analysis after a post-protocol decision, and we do agree that it induces a degree of clinical heterogeneity in our analyses. Although we also agree a 6-month pooled analysis would have been a complementary adjunct to our article, we would argue that 6-month outcomes do not provide significant value in clinical decision making postoperatively.
      • Shin J.J.
      • de Sa D.L.
      • Burnham J.M.
      • Mauro C.S.
      Refractory pain following hip arthroscopy: Evaluation and management.
      Kim et al. also questioned our pooling of adjusted and unadjusted mean differences in International Hip Outcome Tool 33 (iHOT-33) scores. We agree with the authors that under ideal circumstances, we would not have combined unadjusted and adjusted data. However, Palmer et al.
      • Palmer A.J.R.
      • Ayyar Gupta V.
      • Fernquest S.
      • et al.
      Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: Multicentre randomised controlled trial.
      reported only adjusted mean differences between treatment groups, whereas Mansell et al.
      • Mansell N.S.
      • Rhon D.I.
      • Marchant B.G.
      • Slevin J.M.
      • Meyer J.L.
      Two-year outcomes after arthroscopic surgery compared to physical therapy for femoracetabular impingement: A protocol for a randomized clinical trial.
      reported only unadjusted mean differences. Griffin et al.
      • Griffin D.R.
      • Dickenson E.J.
      • Wall P.D.H.
      • et al.
      Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): A multicentre randomised controlled trial.
      reported confidence intervals only for their adjusted mean differences and gave an unadjusted point estimate, which was higher than their adjusted mean difference. If we had used the unadjusted mean difference in our analysis, the pooled treatment effect would have more substantially favored surgery over nonoperative care, not the opposite, as Kim et al. suggest. If estimates and confidence intervals had been available for all studies, we would have included only unadjusted differences.
      Kim et al. also critique our use of a fixed-effects model for pooling results. We do not share the same view that a random-effects model is always more appropriate, and in fact, their stated consensus of avoiding fixed effects in medical research is not borne out in the literature.
      • Wang X.
      • Liu S.
      • Zhao X.
      • Fang E.
      • Zhao X.
      The value of C-reactive protein as an independent prognostic indicator for disease-specific survival in patients with soft tissue sarcoma: A meta-analysis.
      • Wei F.
      Does an extreme age (>/=80 years) affect outcomes in patients after liver cancer surgery? A meta-analysis.
      • Becker M.
      • Buhn S.
      • Breuing J.
      • et al.
      The role of icodextrin in peritoneal dialysis: Protocol for a systematic review and meta-analysis.
      • Becker C.
      • Lecheler L.
      • Hochstrasser S.
      • et al.
      Association of communication interventions to discuss code status with patient decisions for do-not-resuscitate orders: A systematic review and meta-analysis.
      • Zhang X.
      • Wang C.
      • Dou Q.
      • Zhang W.
      • Yang Y.
      • Xie X.
      Sarcopenia as a predictor of all-cause mortality among older nursing home residents: A systematic review and meta-analysis.
      • Lynch T.S.
      • O'Connor M.
      • Minkara A.A.
      • Westermann R.W.
      • Rosneck J.T.
      Biomarkers for femoroacetabular impingement and hip osteoarthritis: A systematic review and meta-analysis.
      Previous statistical guides have advocated for the use of fixed-effects models provided that the I2 value indicates low heterogeneity across studies, as well as when the relative number of subjects included in the meta-analysis is small.
      • Higgins J.P.
      • Thompson S.G.
      • Deeks J.J.
      • Altman D.G.
      Measuring inconsistency in meta-analyses.
      ,
      • Hedges L.V.
      • Olkin I.
      Statistical methods for meta-analysis.
      Additionally, it is well documented that the use of random-effects models will disproportionately give higher weight to studies with smaller sample sizes,
      • Borenstein M.
      • Hedges L.V.
      • Higgins J.P.
      • Rothstein H.R.
      A basic introduction to fixed-effect and random-effects models for meta-analysis.
      which in our study would be the least generalizable trial with the most methodologic concerns.
      • Dwyer T.
      • Whelan D.
      • Shah P.S.
      • Ajrawat P.
      • Hoit G.
      • Chahal J.
      Operative versus nonoperative treatment of femoroacetabular impingement syndrome: A meta-analysis of short-term outcomes.
      ,
      • Mansell N.S.
      • Rhon D.I.
      • Marchant B.G.
      • Slevin J.M.
      • Meyer J.L.
      Two-year outcomes after arthroscopic surgery compared to physical therapy for femoracetabular impingement: A protocol for a randomized clinical trial.
      Ultimately, our meta-analysis found statistically significant improvement in patient-reported outcomes among surgically treated FAIS patients, as shown by their pooled iHOT-33 scores. The iHOT-33 is a robustly developed, valid, reliable, and responsive patient-reported outcome measure for health-related quality of life specifically for patients with FAIS.
      • Mohtadi N.G.
      • Griffin D.R.
      • Pedersen M.E.
      • et al.
      The development and validation of a self-administered quality-of-life outcome measure for young, active patients with symptomatic hip disease: The International Hip Outcome Tool (iHOT-33).
      Given the breadth of the iHOT-33 and its consistent performance with external psychometric evaluation,
      • Kemp J.L.
      • Collins N.J.
      • Roos E.M.
      • Crossley K.M.
      Psychometric properties of patient-reported outcome measures for hip arthroscopic surgery.
      we do believe that these results are generalizable to patient-reported hip-related outcomes. However, these results are inclusive of only 3 studies with relatively small sample sizes and do not include objective clinical measures such as strength and stability—a limitation well stated within our article. Clarity as to the true treatment differences, especially with long-term outcomes, will be derived only from future, well-powered randomized controlled trials.

      Supplementary Data

      References

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