Mansell, Am J Sports Med 2018 - Arthroscopic Surgery or Physical Therapy for Patients with Femoroacetabular Impingement Syndrome: A Randomized Controlled Trial with 2-Year Follow-Up - Article Summary

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

Mansell, Marchant, et al.·Am J Sports Med·2018·214 citations·RCT

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.

Methods

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

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).
2 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.
20 (33.3%) patients who underwent surgery and 4 (33.3%) who did not undergo surgery were medically separated from military service at 2 years.

Conclusions

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.

Supplemental

Arthroscopic Surgery or Physical Therapy for Patients with Femoroacetabular Impingement Syndrome: A Randomized Controlled Trial with 2-Year Follow-Up.

Mansell, Marchant, et al.Am J Sports Med2018214 citationsRCT