Title: Prehabilitation for patients undergoing hip arthroscopic surgery for Femoro-acetabular impingement syndrome- a feasibility study
Funder: Health Education England

Abstract: Background Femoro-acetabular impingement syndrome (FAIS), resulting from abnormal acetabular or femoral head/neck morphology is a well-known pathological entity found in young active adults, and is considered a pre-disposing factor for early onset of osteoarthritis. Patients with FAIS often have pain, stiffness and functional limitations. A recent epidemiological study (n=200, aged 16-65 years) reported a high prevalence of FAIS (47%) within the UK population. Hip arthroscopy is often recommended when conservative management (e.g. physiotherapy, analgesia) has failed to address the symptoms. Although hip arthroscopy has demonstrated improved outcomes for patients with FAIS, the road to recovery can be lengthy due to soft-tissue trauma sustained during the procedure and pre-existing muscle strength deficits associated with FAIS. Additionally, delay in the diagnosis and referral to appropriate secondary or tertiary centres for surgical intervention may lead to the severity of the symptoms and further deconditioning of the individual. Given the above, pre-operative intervention or 'prehabilitation' may optimise an individual's function and quality of life prior to the surgical intervention to subsequently enhance post-operative recovery and improve patient outcomes.Aim To evaluate the feasibility, suitability and acceptability of a novel prehabilitation programme for FAIS to inform a future definitive randomised control trial to assess effectiveness. Methods Sixty patients with FAIS will be recruited and randomly allocated to one of 2 treatment arms: Prehabilitation (intervention group) or usual care (control group). The intervention group will attend one face-to-face educational session to improve knowledge, health behaviours and manage patient expectations. They will commence 8 weeks of pre-operative exercise intervention aiming to improve muscle strength, proprioception, range of motion, cardiovascular fitness and address co-existing musculoskeletal pathologies. Interventions will be delivered face-to-face and at home, remotely monitored using Physitrack app. Intensity and complexity of exercises will be gradually increased depending on each participant's individual progress as judged by the treating Physiotherapist. Fidelity of intervention delivery will be analysed using self-reported checklist completed by the treating physiotherapists. The usual care group will be advised to continue with their normal activities and maintain a record of their analgesia consumption, daily activities and any other interventions they receive (e.g., exercises, acupuncture) during the intervention period in a patient diary. Both groups will be provided with standard post-operative care. The planned primary outcome measure is International Hip Outcome Tool (iHOT-12). Outcome measures will be collected at baseline, at the end of the prehabilitation period before surgery and at 6 weeks, 6 months and 1 year post-operatively.Implications and DisseminationThe role of exercise interventions prior to hip arthroscopy is unclear. This study will evaluate the feasibility, suitability and acceptability of a novel prehabilitation programme within an NHS setting and inform the design of a future large-scale trial testing the effectiveness of prehabilitation in patients undergoing hip arthroscopy. The results of this study will be disseminated to improve awareness and engagement of all key stakeholders in preparation for the future trial. The study results will be shared with the research and scientific community via peer-reviewed publications, open access repositories and scientific meetings and conferences.

Lay abstract: TitlePre-operative treatment for patients undergoing keyhole surgery of the hip for femoro-acetabular impingement syndrome -a feasibility studyBackgroundFemoroacetabular impingement syndrome (FAIS) is where extra bone grows on the bones that form the hip joint, giving it an abnormal shape. This condition is common in young adults (aged 16-50) and can lead to damage of the lining of the hip joint (labrum) and cartilage and early onset of osteoarthritis causing stiffness and loss of function. The majority of patients with FAIS experience pain and problems with movement affecting their daily life as well as their physical and mental wellbeing. This can be frustrating in a young and active population. It also affects the economy of the nation as patients in this age group are the major workforce of any country. Two large scale research studies have demonstrated that keyhole surgery (hip arthroscopy) which is 'looking at the affected area using a tiny camera inserted through a keyhole incision', can improve quality of life in the shorter term. However, the road to recovery can be long and difficult for patients. Problems occur because of the pre-existing deficits in muscle strength, length of time muscles are out of action, and also because of damage to muscles and tissues during surgery. One possible solution to this problem is to prepare the patient before surgery by helping them with exercises, patient education, psychological support and pain management. This is called 'prehabilitation'. A prehabilitation programme has been shown to help patients make a better recovery after joint replacement surgery. There has not been much research investigating prehabilitation for FAIS specifically in the NHS. The aim of this study, therefore, will be to assess if a prehabilitation programme is feasible in an NHS care setting for patients undergoing hip arthroscopy. This study will then be able to inform a future larger study to test if prehabilitation for FAIS can improve patient outcomes.MethodsMy plan is to conduct a feasibility study to address the following issues before progressing to a full trial in the future: Is the study feasible in an NHS setting? Specifically: Will we have enough participants for the study? What difficulties may arise during the study? To determine if the intervention is acceptable to both patients and Physiotherapists.Patient & Public InvolvementA focus group was organised with patients and relatives invited through the Cambridge Young Adult Hip Service to understand the general perception of the research idea, and design of the programme, as well as their views onhow best to deliver the programme. The focus group made the following key recommendations which I have incorporated into the feasibility study: Introduce a patient education programme alongside prehabilitation to provide a greater understanding of the effect of surgery and manage expectations. Introduce a patient information leaflet explaining the importance of prehabilitation and how it differs from traditional physiotherapy. Prehabilitation that can be delivered face-to-face and as a home exercise programme. Prehabilitation that utilises apps and tele-rehabilitation to monitor and progress exercises and improve adherence.Additionally, feedback from four reviewers assisted in drafting the lay summary. The PPI panel will co-design the prehabilitation leaflet and will be co-authors in developing the training manual.Two PPI members will form the advisory panel who will oversee the study.DisseminationThe results of this study will be disseminated to patients, research community and the public and will inform the design of a definitive trial. Advice from the PPI panel will be sought to identify suitable avenues for dissemination and they will be invited to contribute to the design of dissemination materials for which they will receive acknowledgements.

Research activity codes: 6.4 SURGERY
Health categories: MUSCULOSKELETAL