SummaryBackgroundFemoroacetabular 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 the...

Femoroacetabular impingement is a well-documented cause of hip pain. There is, however, increasing evidence for the presence of a previously unrecognised impingement-type condition around the hip - ischiofemoral impingement. This is caused by abnormal contact between the lesser trochanter of the femur and the ischium, and presents as atypical groin and/or posterior buttock pain. The symptoms are gradual in onset and may be similar to those of iliopsoas tendonitis, hamstring injury or bursitis. The presence of ischiofemoral impingement may be indicated by pain caused by a combination of hip extension, adduction and external rotation. Magnetic resonance imaging demonstrates inflammation and oedema in the ischiofemoral space and quadratus femoris, and is distinct from an acute tear. To date this has only appeared in the specialist orthopaedic literature as a problem that has developed after total hip replacement, not in the unreplaced joint.

The benefit of arthroscopy of the hip in the treatment of femoroacetabular impingement (FAI) in terms of quality of life (QoL) has not been reported. We prospectively collected data on 612 patients (257 women (42%) and 355 men (58%)) with a mean age at the time of surgery of 36.7 years (14 to 75) who underwent arthroscopy of the hip for FAI under the care of a single surgeon. The minimum follow-up was one year (mean 3.2 years (1 to 7)). The responses to the modified Harris hip score were translated using the Rosser Index Matrix in order to provide a QoL score. The mean QoL score increased from 0.946 (-1.486 to 0.995) to 0.974 (0.7 to 1) at one year after surgery (p < 0.001). The mean QoL score in men was significantly higher than in women, both before and one year after surgery (both p < 0.001). However, the mean change in the QoL score was not statistically different between men and women (0.02 (-0.21 to 0.27) and 0.04 (-0.16 to 0.87), respectively; p = 0.12). Linear regression analysis revealed that the significant predictors of a change in QoL score were pre-operative QoL score (p < 0.001) and gender (p = 0.04). The lower the pre-operative score, the higher the gain in QoL post-operatively (ρ = -0.66; p < 0.001). One year after surgery the QoL scores in the 612 patients had improved in 469 (76.6%), remained unchanged in 88 (14.4%) and had deteriorated in 55 (9.0%).

We describe one- to three-year results of a novel use of fibrin glue in the treatment of cartilage damage by arthroscopy in the hip. This technique uses the microfracture technique and fibrin adhesive to bond delaminated articular cartilage to the underlying subchondral bone. This is generally performed in conjunction with treatment of underlying pathology such as femoroacetabular impingement. Patients were assessed using the modified Harris Hip Score (MHHS) pre- and post-operatively, and statistical significance determined by Student's t-test. We report the mid-term results of 43 patients with femoroacetabular impingement who have undergone this technique for re-attachment of delaminated chondral flaps. There was a statistically significant improvement in MHHS at a mean of 28 months (16 to 42 months) after surgery (p<0.0001). The MHHS for pain improved significantly from 21.8 (95% CI 19.0 to 24.7) pre-operatively to 35.8 (95% CI 32.6 to 38.9) post-operatively (p<0.0001). The MHHS for function also showed significant, although more modest, improvements from 40.0 (95% CI 37.7 to 42.3) pre-operatively to 43.6 (95% CI 41.4 to 45.8) post-operatively (p=0.0006). There were three patients who had early (within 12 months of the index procedure) revision arthroscopy for iliopsoas pathology. Arthroscopic repair of delaminated acetabular articular cartilage using fibrin adhesive is a useful technique in the treatment of early cartilage damage. We have seen encouraging mid-term results, although further studies are warranted.

Patient reported outcome measures (PROMs) are used to gauge clinical performance. The PROMs outcome programme at our centre achieves a preoperative data capture rate of 99%. This falls to 90.6%, 89%, 83% and 79% at the six-week, six-month, one-year and two-year time points, respectively. The study aims were to determine factors associated with patients who did not respond to outcome questionnaires following total hip replacement (THR), and the potential implications this may have when assessing patients following THRs. During the first year of the PROMs programme, 1,322 patients underwent unilateral primary THR at our institution. Of these, 1,311 completed preoperative questionnaires. Thirty-eight patients (2.9%) died within two years of surgery and have been excluded. For the remaining 1,273 patients, we identified those who did not return postoperative questionnaires at each of our review time points. Younger age, lower baseline EQ5D and Oxford Hip scores (OHS) were significantly associated with non-response (p<0.001). Patients with lower satisfaction scores, OHS and EQ5D scores, were less likely to respond to subsequent questionnaires. A significant association between non-response and deprivation (p<0.001) was demonstrated. Our findings suggest that the more satisfied patients are over-represented and our reported outcome results are better than they would have been if all patients had responded. This phenomenon may apply to studies where those categorised as "lost to follow-up" represent a subset of patients who have disengaged due to poor outcome or satisfaction.

Introduction The Elective Orthopaedic Centre in Epsom has an established patient reported outcome measures programme, into which all patients are enrolled. Postoperative complications, Oxford hip/knee scores (OHS/OKS) and EQ-5D™ (EuroQol, Rotterdam, Netherlands) scores are collected up to the second postoperative year. Our population is ageing and the number of joint replacements being performed on the very elderly is rising. The aim of this study was to investigate the outcome of joint replacements in a nonagenarian population. Methods Our dataset was reviewed retrospectively for a cohort of nonagenarians undergoing either a primary total hip replacement (THR) or total knee replacement (TKR) between April 2008 and October 2011. Postoperative complications, mortality rates and functional outcomes were compared with those of a time matched 70-79-year-old cohort. Results Nonagenarians requiring a THR presented with a lower preoperative OHS (p=0.020) but made a greater improvement in the first postoperative year than the younger cohort (p=0.040). The preoperative OKS was lower for nonagenarians than for the control group (p=0.022). At one and two years after TKR, however, there was no significant difference between the age groups. The nonagenarians had a greater risk of requiring a blood transfusion following both THR (p=0.027; 95% confidence interval [CI]: 1.11-5.75) and TKR (p=0.037; 95% CI: 1.08-16.65) while the latter cohort also required a longer stay than their younger counterparts (p=0.001). Mortality rates were higher in the nonagenarian group but these were in keeping with the life expectancy projections identified by the Office for National Statistics. Conclusions Over a two-year period, the functional outcome and satisfaction rates achieved by nonagenarians following a THR or TKR are comparable with 70-79-year-olds.

In this large, prospective series of patients we have demonstrated the positive impact of arthroscopic surgery for FAI in both the athletic and non-athletic population. Arthroscopic management of FAI is thus not the sole domain of the athletic patient. Non-athletes can do just as well.

The amount of fluid that may be lost into the soft tissues during hip arthroscopic surgery is unknown. We measured the volumes of irrigation fluid infused, operating time, fluid pressures and volumes of fluid recovered in 36 therapeutic hip arthroscopies. We excluded those where fluid was lost to the floor, leaving 28 patients. The majority were undergoing surgery for the treatment of femoroacetabular impingement. In 5 patients an intra-articular contrast medium was instilled, in order to establish the likely location of any extravasated fluid. The mean operating time was 68 minutes (31 to 120), and the mean infusion pressure was 46 mm Hg (30 to 70). The mean volume of infused fluid was 9677 ml (95% confidence interval (CI) 7715 to 11638) and the mean volume of fluid recovered was 8544 ml (95% CI 6715 to 10373). The mean fluid extravasation loss into the peri-articular tissues was 1132 ml (95% CI 808 ml to 1456 ml). There was a significant correlation between the volume of extravasated fluid and both the length of operation and the volume of infused fluid used. We had no adverse events in our series. During arthroscopic hip surgery more than a litre of irrigation fluid may be extravasated into the soft tissues. In order to reduce problems related to this we attempt to keep operating times low, and maintain intra-operative fluid pressures as low as possible.