1. Lancet. 2018 Jun 2;391(10136):2225-2235. doi: 10.1016/S0140-6736(18)31202-9. Epub
2018 Jun 1.

Hip arthroscopy versus best conservative care for the treatment of
femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised
controlled trial.

Griffin DR(1), Dickenson EJ(2), Wall PDH(2), Achana F(3), Donovan JL(4), Griffin 
J(3), Hobson R(3), Hutchinson CE(2), Jepson M(4), Parsons NR(3), Petrou S(3),
Realpe A(5), Smith J(6), Foster NE(7); FASHIoN Study Group.

Collaborators: Stevens S, Gemperle-Mannion E, Brown J, Philippon M, Beck M,
O'Donnell J, Robinson D, Hughes I, Hunter D, Bennell K, Bache CE, McBryde C,
Politis A, Bankes M, George M, Bartlett G, Norton M, Board T, Mohammed A, Rajpura
A, Cronin M, Dandachli W, Witt J, Eastaugh-Waring S, Fehily M, Fern D, Field R,
Stafford G, Hashemi-Nejad A, Khan T, Kavathapu V, Kiely N, Whitaker JP, Latimer
P, Madan S, Malviya A, Patil S, Ramachandran M, Sturridge S, Thomas P, White C,
Wilson M, Williams M, Jones E, Baker S, Stanton J, Nicholls C, Smeatham A,
Gosling L, MacFarlane K, Pressdee F, Dickinson G, Boulton K, Goss J, Venter R,
Kassam J, Simmons R, Poll K, Bergmann T, Pilkington M, Armstrong J, Wright D,
Dolphin P, Bainbridge K, Callum M, Lewis A, Smith E, Cornes V, Benfield J,
Monnington K, Stewart E, Borrill S, Pinches M, Dawson S, Harding N, Willis M,
Moore D, MacCauley A, Cooke D, Fleck R, Ball J, Morrison P, Kennedy M, Turner S, 
Bryant C, Harris K, McKeown R, Clarkson L, Lewis A, Rowland-Axe R, Grice A,
Githens-Mazer G, Aughwan H, Moore F, Keeling E, Amero J, Atkinson S, Graves L,
Fouracres A, Hammonds F, Curtis J, Brackenridge L, Taylor T, Dobb C, Whitworth J,
Commey T, Limbani V, Maclintock H, Milne A, Cleary C, Murray H, Dubia M, Gokturk 
A, Bray R.

Author information: 
(1)University of Warwick, Coventry, UK; University Hospitals of Coventry and
Warwickshire NHS Trust, Coventry, UK. Electronic address:
damian.griffin@warwick.ac.uk.
(2)University of Warwick, Coventry, UK; University Hospitals of Coventry and
Warwickshire NHS Trust, Coventry, UK.
(3)University of Warwick, Coventry, UK.
(4)University of Bristol, Bristol, UK.
(5)University of Warwick, Coventry, UK; University of Bristol, Bristol, UK.
(6)University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK.
(7)Arthritis Research UK Primary Care Centre, Research Institute for Primary Care
and Health Sciences, Keele University, Keele, UK.

Comment in
    Lancet. 2018 Jun 2;391(10136):2189-2190.

BACKGROUND: Femoroacetabular 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.
METHODS: UK 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.
FINDINGS: Between 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.
INTERPRETATION: 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 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.
FUNDING: The Health Technology Assessment Programme of the National Institute of 
Health Research.

Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access
article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights
reserved.

DOI: 10.1016/S0140-6736(18)31202-9 
PMCID: PMC5988794
PMID: 29893223  [Indexed for MEDLINE]