Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trialBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l185 (Published 07 February 2019) Cite this as: BMJ 2019;364:l185
- Antony J R Palmer, NIHR academic clinical lecturer in trauma and orthopaedics1,
- Vandana Ayyar Gupta, trial manager1,
- Scott Fernquest, DPhil student and clinical research fellow1,
- Ines Rombach, medical statistician2,
- Susan J Dutton, lead medical statistician2,
- Ramy Mansour, consultant musculoskeletal radiologist3,
- Simon Wood, senior sports physiotherapist3,
- Vikas Khanduja, consultant orthopaedic surgeon4,
- Tom C B Pollard, consultant orthopaedic surgeon5,
- Andrew W McCaskie, professor of orthopaedic surgery and head of department6,
- Karen L Barker, professor of physiotherapy1,
- Tony J M D Andrade, consultant orthopaedic surgeon5,
- Andrew J Carr, Nuffield professor of orthopaedic surgery and head of department1,
- David J Beard, professor of musculoskeletal and surgical science and co-director of surgical intervention trials unit1 7,
- Sion Glyn-Jones, professor of orthopaedic surgery1
- on behalf of the FAIT Study Group
- 1Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre, Oxford OX3 7LD, UK
- 2Centre for Statistics in Medicine, NDORMS, University of Oxford, UK
- 3Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- 4Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- 5Royal Berkshire NHS Foundation Trust, Reading, UK
- 6Division of Trauma and Orthopaedic Surgery, University of Cambridge, UK
- 7Royal College of Surgeons Surgical Intervention Trials Unit, NDORMS, University of Oxford, Oxford, UK
- Correspondence to: A J R Palmer @ajrpalmer on Twitter) (or
- Accepted 7 January 2019
Objective To compare arthroscopic hip surgery with physiotherapy and activity modification for improving patient reported outcome measures in patients with symptomatic femoroacetabular impingement (FAI).
Design Two group parallel, assessor blinded, pragmatic randomised controlled trial.
Setting Secondary and tertiary care centres across seven NHS England sites.
Participants 222 participants aged 18 to 60 years with symptomatic FAI confirmed clinically and with imaging (radiography or magnetic resonance imaging) were randomised (1:1) to receive arthroscopic hip surgery (n=112) or a programme of physiotherapy and activity modification (n=110). Exclusion criteria included previous surgery, completion of a physiotherapy programme targeting FAI within the preceding 12 months, established osteoarthritis (Kellgren-Lawrence grade ≥2), and hip dysplasia (centre-edge angle <20 degrees).
Interventions Participants in the physiotherapy group received a goal based programme tailored to individual patient needs, with emphasis on improving core stability and movement control. A maximum of eight physiotherapy sessions were delivered over five months. Participants in the arthroscopic surgery group received surgery to excise the bone that impinged during hip movements, followed by routine postoperative care.
Main outcome measures The primary outcome measure was the hip outcome score activities of daily living subscale (HOS ADL) at eight months post-randomisation, with a minimum clinically important difference between groups of 9 points. Secondary outcome measures included additional patient reported outcome measures and clinical assessment.
Results At eight months post-randomisation, data were available for 100 patients in the arthroscopic hip surgery group (89%) and 88 patients in the physiotherapy programme group (80%). Mean HOS ADL was 78.4 (95% confidence interval 74.4 to 82.3) for patients randomised to arthroscopic hip surgery and 69.2 (65.2 to 73.3) for patients randomised to the physiotherapy programme. After adjusting for baseline HOS ADL, age, sex, and study site, the mean HOS ADL was 10.0 points higher (6.4 to 13.6) in the arthroscopic hip surgery group compared with the physiotherapy programme group (P<0.001)). No serious adverse events were reported in either group.
Conclusions Patients with symptomatic FAI referred to secondary or tertiary care achieve superior outcomes with arthroscopic hip surgery than with physiotherapy and activity modification.
Trial registration ClinicalTrials.gov NCT01893034.
Contributors: AJRP and SGJ designed the study, and the protocol was developed with VAG, IR, SJD, SW, TCBP, AWM, KLB, AJMDA, AJC, and DJB. IR and SJD performed the statistical analyses. AJRP, VAG, SF, RM, SW, VK, TCBP, AJMDA, and SGJ recruited patients and acquired data. AJRP, VAG, SF, IR, and SGJ drafted the manuscript. All authors revised manuscript drafts, approved the final manuscript, and contributed intellectually important content. SGJ attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. SGJ is the guarantor of the paper and takes responsibility for the integrity of the work from inception to published article.
Funding: The study was funded by Arthritis Research UK and the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (previously the Biomedical Research Unit). The University of Oxford sponsored the study. The Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences coordinated the study via the Surgical Intervention Trials Unit from the Royal College of Surgeons (England) Surgical Trials Initiative. The study was supported by the Thames Valley Comprehensive Local Research Network, which operates as part of the National Institute for Health Research Comprehensive Clinical Research Network in England. The views expressed in this report are those of the authors and do not necessarily reflect the views of the funders.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from Arthritis Research UK and NIHR Oxford Biomedical Research Centre for the submitted work. The researchers and funders were independent. AJRP received funding from the Royal College of Surgeons of England and Dunhill Medical Trust. Unrelated to the submitted work, VK received support from Stryker and Smith and Nephew for educational consultancy, AA received support from Stryker, Smith and Nephew, and Zimmer Biomet for lectures, and SGJ received research grants and fees for lectures from Zimmer Biomet, Corin, and ConMed, and research grants from Neurotechnics, Johnson and Johnson, and Siemens.
Ethical approval: The trial protocol was approved by Health Research Authority, National Research Ethics Services Committee South Central–Berkshire (REC reference: 13/SC/0154) and local research and development departments at each participating site.
Data sharing: Anonymised patient level data can be made available on reasonable request after approval from the trial management committee and after signing a data access agreement. Proposals should be directed to the corresponding author. Consent was not obtained for data sharing, but the presented data are anonymised and the risk of identification is low.
Transparency: The lead author (SGJ) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.
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