Abstract

Femoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery or with physiotherapist-led conservative care. To compare the clinical effectiveness and cost-effectiveness of hip arthroscopy with best conservative care. The UK FASHIoN (full trial of arthroscopic surgery for hip impingement compared with non-operative care) trial was a pragmatic, multicentre, randomised controlled trial that was carried out at 23 NHS hospitals. Participants were included if they had femoroacetabular impingement, were aged ≥ 16 years old, had hip pain with radiographic features of cam or pincer morphology (but no osteoarthritis) and were believed to be likely to benefit from hip arthroscopy. Participants were randomly allocated (1 : 1) to receive hip arthroscopy followed by postoperative physiotherapy, or personalised hip therapy (i.e. an individualised physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre using a central telephone randomisation service. Outcome assessment and analysis were masked. The primary outcome was hip-related quality of life, measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed by intention to treat. Between July 2012 and July 2016, 648 eligible patients were identified and 348 participants were recruited. In total, 171 participants were allocated to receive hip arthroscopy and 177 participants were allocated to receive personalised hip therapy. Three further patients were excluded from the trial after randomisation because they did not meet the eligibility criteria. Follow-up at the primary outcome assessment was 92% (N = 319; hip arthroscopy, n = 157; personalised hip therapy, n = 162). At 12 months, mean International Hip Outcome Tool (iHOT-33) score had improved from 39.2 (standard deviation 20.9) points to 58.8 (standard deviation 27.2) points for participants in the hip arthroscopy group, and from 35.6 (standard deviation 18.2) points to 49.7 (standard deviation 25.5) points for participants in personalised hip therapy group. In the primary analysis, the mean difference in International Hip Outcome Tool scores, adjusted for impingement type, sex, baseline International Hip Outcome Tool score and centre, was 6.8 (95% confidence interval 1.7 to 12.0) points in favour of hip arthroscopy (p = 0.0093). This estimate of treatment effect exceeded the minimum clinically important difference (6.1 points). Five (83%) of six serious adverse events in the hip arthroscopy group were related to treatment and one serious adverse event in the personalised hip therapy group was not. Thirty-eight (24%) personalised hip therapy patients chose to have hip arthroscopy between 1 and 3 years after randomisation. Nineteen (12%) hip arthroscopy patients had a revision arthroscopy. Eleven (7%) personalised hip therapy patients and three (2%) hip arthroscopy patients had a hip replacement within 3 years. Study participants and treating clinicians were not blinded to the intervention arm. Delays were encountered in participants accessing treatment, particularly surgery. Follow-up lasted for 3 years. Hip arthroscopy and personalised hip therapy both improved hip-related quality of life for patients with femoroacetabular impingement syndrome. Hip arthroscopy led to a greater improvement in quality of life than personalised hip therapy, and this difference was clinically significant at 12 months. This study does not demonstrate cost-effectiveness of hip arthroscopy compared with personalised hip therapy within the first 12 months. Further follow-up will reveal whether or not the clinical benefits of hip arthroscopy are maintained and whether or not it is cost-effective in the long term. Current Controlled Trials ISRCTN64081839. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 16. See the NIHR Journals Library website for further project information.

Highlights

  • F urther reading on this trial is available in the trial protocol by Griffin et al.,[1] by Griffin et al.[2,3] and Wall,[4] trial non-operative intervention report by Wall trial feasibility et al.[5] and trial reports results article by Griffin et al.[6]Until recently, there was little understanding of the causes of hip pain in young adults

  • We have shown that offering hip arthroscopy to patients with femoroacetabular impingement (FAI) syndrome leads to better clinical outcomes at 12 months than best conservative care

  • Conclusion of the feasibility study and pilot trial We showed that a robust randomised controlled trial (RCT) of hip arthroscopy compared with best conservative care for patients with FAI syndrome was feasible, that patients and clinicians were willing to participate, that we were able to obtain ethics and research and development (R&D) approval at multiple sites, and that the trial procedures we developed worked well

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Summary

Introduction

F urther reading on this trial is available in the trial protocol by Griffin et al.,[1] by Griffin et al.[2,3] and Wall,[4] trial non-operative intervention report by Wall trial feasibility et al.[5] and trial reports results article by Griffin et al.[6]Until recently, there was little understanding of the causes of hip pain in young adults. A feasibility and pilot study commissioned by the Health Technology Assessment programme (reference 10/41/02) was completed.[2,3] It comprised (1) a pre-pilot phase, including patient and clinician surveys and interviews, and a systematic review of non-operative care; (2) a workload survey of hip arthroscopy for FAI; (3) development of best conventional care and arthroscopic surgery protocols; (4) a pilot RCT to measure recruitment rate; and (5) an integrated programme of qualitative research to understand and optimise recruitment.[2,3]. Femoroacetabular impingement syndrome is an important cause of hip pain in young adults It can be treated by arthroscopic hip surgery or with physiotherapist-led conservative care. FAI syndrome leads to progressive damage within the joint, including the acetabular labrum and articular cartilage, and is associated with the development of osteoarthritis of the hip. Non-operative treatments for FAI syndrome include exercise-based packages of conservative care delivered by a physiotherapist

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