Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial
Authors: Damian R Griffin, Edward J Dickenson, Peter D H Wall, Felix Achana, Jenny L Donovan, James Griffin, Rachel Hobson, Charles E Hutchinson, Marcus Jepson, Nick R Parsons, Stavros Petrou, Alba Realpe, Joanna Smith, Nadine E Foster, Siobhan Stevens, Elke Gemperle-Mannion, Jaclyn Brown, Marc Philippon, Martin Beck, John O'Donnell, David Robinson, Ivor Hughes, David Hunter, Kim Bennell, Christopher Edward Bache, Callum McBryde, Angelos Politis, Marcus Bankes, Marc George, Gavin Bartlett, Mark Norton, Tim Board, Aslam Mohammed, Asim Rajpura, Michael Cronin, Wael Dandachli, Johan Witt, Stephen Eastaugh-Waring, Max Fehily, Darren Fern, Richard Field, Giles Stafford, Aresh Hashemi-Nejad, Tahir Khan, Venu Kavathapu, Nigel Kiely, John Paul Whitaker, Paul Latimer, Sanjeev Madan, Ajay Malviya, Sanjeev Patil, Manoj Ramachandran, Seb Sturridge, Phillip Thomas, Craig White, Matthew Wilson, Mark Williams, Emma Jones, Simon Baker, Joanna Stanton, Charlotte Nicholls, Alison Smeatham, Lucie Gosling, Katte MacFarlane, Fraser Pressdee, Gareth Dickinson, Karen Boulton, Jill Goss, Rina Venter, Jamila Kassam, Rachel Simmons, Kathryn Poll, Thomas Bergmann, Margaret Pilkington, Jo Armstrong, Daniel Wright, Philippa Dolphin, Kelly Bainbridge, Miles Callum, Anthony Lewis, Evonne Smith, Veronica Cornes, Joanna Benfield, Katie Monnington, Emma Stewart, Steven Borrill, Megan Pinches, Sam Dawson, Noel Harding, Matthew Willis, Dani Moore, Andrew MacCauley, David Cooke, Rebecca Fleck, Julliet Ball, Peter Morrison, Michael Kennedy, Sylvia Turner, Charlotte Bryant, Kirsten Harris, Rebecca McKeown, Louise Clarkson, Alison Lewis, Rebecca Rowland-Axe, Anna Grice, Gayle Githens-Mazer, Helen Aughwan, Faye Moore, Eleanor Keeling, Justine Amero, Stephanie Atkinson, Lynne Graves, Anna Fouracres, Fiona Hammonds, Jas Curtis, Lisa Brackenridge, Tracey Taylor, Christine Dobb, Joanna Whitworth, Thelma Commey, Vasanti Limbani, Heather Maclintock, Alanna Milne, Claire Cleary, Helen Murray, Maria Dubia, Abdulkerim Gokturk, Rachel Bray
Journal: The Lancet (2018)

BackgroundFemoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery, including reshaping the hip, or with physiotherapist-led conservative care. We aimed to compare the clinical effectiveness of hip arthroscopy with best conservative care.MethodsUK FASHIoN is a pragmatic, multicentre, assessor-blinded randomised controlled trial, done at 23 National Health Service hospitals in the UK. We enrolled patients with femoroacetabular impingement syndrome who presented at these hospitals. Eligible patients were at least 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. Patients with bilateral femoroacetabular impingement syndrome were eligible; only the most symptomatic hip was randomly assigned to treatment and followed-up. Participants were randomly allocated (1:1) to receive hip arthroscopy or personalised hip therapy (an individualised, supervised, and progressive physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre and was done by research staff at each hospital, using a central telephone randomisation service. Patients and treating clinicians were not masked to treatment allocation, but researchers who collected the outcome assessments and analysed the results were masked. The primary outcome was hip-related quality of life, as measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed in all eligible participants who were allocated to treatment (the intention-to-treat population). This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN64081839, and is closed to recruitment.FindingsBetween July 20, 2012, and July 15, 2016, we identified 648 eligible patients and recruited 348 participants: 171 participants were allocated to receive hip arthroscopy and 177 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% (319 of 348 participants). At 12 months after randomisation, mean iHOT-33 scores had improved from 39·2 (SD 20·9) to 58·8 (27·2) for participants in the hip arthroscopy group, and from 35·6 (18·2) to 49·7 (25·5) in the personalised hip therapy group. In the primary analysis, the mean difference in iHOT-33 scores, adjusted for impingement type, sex, baseline iHOT-33 score, and centre, was 6·8 (95% CI 1·7–12·0) in favour of hip arthroscopy (p=0·0093). This estimate of treatment effect exceeded the minimum clinically important difference (6·1 points). There were 147 patient-reported adverse events (in 100 [72%] of 138 patients) in the hip arthroscopy group) versus 102 events (in 88 [60%] of 146 patients) in the personalised hip therapy group, with muscle soreness being the most common of these (58 [42%] vs 69 [47%]). There were seven serious adverse events reported by participating hospitals. Five (83%) of six serious adverse events in the hip arthroscopy group were related to treatment, and the one in the personalised hip therapy group was not. There were no treatment-related deaths, but one patient in the hip arthroscopy group developed a hip joint infection after surgery.InterpretationHip 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 than did personalised hip therapy, and this difference was clinically significant. Further follow-up will reveal whether the clinical benefits of hip arthroscopy are maintained and whether it is cost effective in the long term.FundingThe Health Technology Assessment Programme of the National Institute of Health Research.