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Randomized Controlled Trial
. 2018 May;46(6):1306-1314.
doi: 10.1177/0363546517751912. Epub 2018 Feb 14.

Arthroscopic Surgery or Physical Therapy for Patients With Femoroacetabular Impingement Syndrome: A Randomized Controlled Trial With 2-Year Follow-up

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Randomized Controlled Trial

Arthroscopic Surgery or Physical Therapy for Patients With Femoroacetabular Impingement Syndrome: A Randomized Controlled Trial With 2-Year Follow-up

Nancy S Mansell et al. Am J Sports Med. .

Abstract

Background: Arthroscopic hip surgery has risen 18-fold in the past decade; however, there is a dearth of clinical trials comparing surgery with nonoperative management.

Purpose: To determine the comparative effectiveness of surgery and physical therapy for femoroacetabular impingement syndrome.

Study design: Randomized controlled trial; Level of evidence, 1.

Methods: Patients were recruited from a large military hospital after referral to the orthopaedic surgery clinic and were eligible for surgery. Of 104 eligible patients, 80 elected to participate, and the majority were active-duty service members (91.3%). No patients withdrew because of adverse events. The authors randomly selected patients to undergo either arthroscopic hip surgery (surgery group) or physical therapy (rehabilitation group). Patients in the rehabilitation group began a 12-session supervised clinic program within 3 weeks, and patients in the surgery group were scheduled for the next available surgery at a mean of 4 months after enrollment. Patient-reported outcomes of pain, disability, and perception of improvement over a 2-year period were collected. The primary outcome was the Hip Outcome Score (HOS; range, 0-100 [lower scores indicating greater disability]; 2 subscales: activities of daily living and sport). Secondary measures included the International Hip Outcome Tool (iHOT-33), Global Rating of Change (GRC), and return to work at 2 years. The primary analysis was on patients within their original randomization group.

Results: Statistically significant improvements were seen in both groups on the HOS and iHOT-33, but the mean difference was not significant between the groups at 2 years (HOS activities of daily living, 3.8 [95% CI, -6.0 to 13.6]; HOS sport, 1.8 [95% CI, -11.2 to 14.7]; iHOT-33, 6.3 [95% CI, -6.1 to 18.7]). The median GRC across all patients was that they "felt about the same" (GRC = 0). Two patients assigned to the surgery group did not undergo surgery, and 28 patients in the rehabilitation group ended up undergoing surgery. A sensitivity analysis of "actual surgery" to "no surgery" did not change the outcome. Twenty (33.3%) patients who underwent surgery and 4 (33.3%) who did not undergo surgery were medically separated from military service at 2 years.

Conclusion: There was no significant difference between the groups at 2 years. Most patients perceived little to no change in status at 2 years, and one-third of military patients were not medically fit for duty at 2 years. Limitations include a single hospital, a single surgeon, and a high rate of crossover. Registration: NCT01993615 ( ClinicalTrials.gov identifier).

Keywords: arthroscopic surgery; femoroacetabular impingement; military medicine; physical therapy.

Comment in

  • Randomized Controlled Trial of Hip Arthroscopy Surgery vs Physical Therapy: Response.
    Rhon DI, Marchant BG, Mansell NS. Rhon DI, et al. Am J Sports Med. 2018 Jul;46(8):NP38-NP39. doi: 10.1177/0363546518777482. Am J Sports Med. 2018. PMID: 29953288 No abstract available.
  • Randomized Controlled Trial of Hip Arthroscopy Surgery vs Physical Therapy: Letter to the Editor.
    Faucett SC, Nepple JJ, Andrade T, Aoki S, Bedi A, Bharam S, Brick MJ, Byrd JWT, Cakic JN, Cascio BM, Christoforetti J, Clohisy JC, Domb B, Dumont G, Ellman MB, Harris JD, Kelly BT, Krych AJ, LaPrade RF, Larson C, Laskowski JR, Levy BA, Lynch TS, Martin HD, Mather C 3rd, Miyamoto RG, Nho SJ, O'Donnell JM, Philippon MJ, Price MR, Ranawat AS, Rodriguez MC, Safran MR, Said HG, Salata MJ, Sampson T, Stubbs AJ, Uchida S, Villar RN, Willimon SC, Wolf A, Wong I, Wuerz TH, Yen YM. Faucett SC, et al. Am J Sports Med. 2018 Jul;46(8):NP35-NP38. doi: 10.1177/0363546518777483. Am J Sports Med. 2018. PMID: 29953289 No abstract available.

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